Impact of clinical experience and diagnostic performance in patients with acute abdominal pain.

Background. The aims were to evaluate the importance of the formal competence of the emergency department physician, the patient's time of arrival at the emergency department, and the use of a structured schedule for investigation of patients with acute abdominal pain. Methods. Patients attending the Mora Hospital with acute abdominal pain from 1997 to 2000 were registered prospectively according to a structured schedule. Registration included history, symptoms, signs, preliminary diagnosis, surgery and final diagnosis after at least one year. Results. 3073 acute abdominal pain patients were included. The preliminary diagnosis, as compared with the final diagnosis, was correct in 54% (n = 1659). Previously, during 1996, a base-line registration of 790 patients had a 58% correct diagnoses (n = 458). A majority of the patients (n = 2699; 88%) were managed by nonspecialists. The proportion of correct diagnoses was 54% (n = 759) for pre-registrar house officers and 55% (n = 443) for senior house officers. Diagnostic performance at the emergency department was independent of patient's time of arrival. Conclusions. A structured schedule for investigation did not improve the diagnostic precision at the emergency department in patients with acute abdominal pain. The diagnostic performance was independent of the formal competence of the physician and the patient's time of arrival.

C-reactive protein and white blood cell count as triage test between urgent and nonurgent conditions in 2961 patients with acute abdominal pain.

The purpose of this article is to assess the diagnostic accuracy of C-reactive protein (CRP) and white blood cell (WBC) count to discriminate between urgent and nonurgent conditions in patients with acute abdominal pain at the emergency department, thereby guiding the selection of patients for immediate diagnostic imaging.Data from 3 large published prospective cohort studies of patients with acute abdominal pain were combined in an individual patient data meta-analysis. CRP levels and WBC counts were compared between patients with urgent and nonurgent final diagnoses. Parameters of diagnostic accuracy were calculated for clinically applicable cutoff values of CRP levels and WBC count, and for combinations.A total of 2961 patients were included of which 1352 patients (45.6%) had an urgent final diagnosis. The median WBC count and CRP levels were significantly higher in the urgent group than in the nonurgent group (12.8 ×10/L; interquartile range [IQR] 9.9-16) versus (9.3 ×10/L; IQR 7.2-12.1) and (46  mg/L; IQR 12-100 versus 10  mg/L; IQR 7-26) (P < 0.001).The highest positive predictive value (PPV) (85.5%) and lowest false positives (14.5%) were reached when cutoff values of CRP level >50  mg/L and WBC count >15 ×10/L were combined; however, 85.3% of urgent cases was missed.A high CRP level (>50  mg/L) combined with a high WBC count (>15 ×10/L) leads to the highest PPV. However, this applies only to a small subgroup of patients (8.7%). Overall, CRP levels and WBC count are insufficient markers to be used as a triage test in the selection for diagnostic imaging, even with a longer duration of complaints (>48  hours).

Accuracy of White Blood Cell Count and C-reactive Protein Levels Related to Duration of Symptoms in Patients Suspected of Acute Appendicitis.

OBJECTIVES: Low levels of white blood cell (WBC) count and C-reactive protein (CRP) have been suggested to sufficiently rule out acute appendicitis. The diagnostic value of these tests is likely to depend on the duration of complaints. The aim of this study was to evaluate the accuracy of these inflammatory markers in relation to duration of symptoms in patients suspected of acute appendicitis. METHODS: Patients suspected of having acute appendicitis were retrospectively selected from five prospective cohorts of patients with acute abdominal pain presenting at the emergency department (ED) in two European countries. Only adult patients with clinical suspicion of acute appendicitis based on medical history, physical examination, and laboratory studies at the time of registration in the original cohorts were included in this analysis. WBC count and CRP level were determined in all patients and a final diagnosis was assigned to every patient by an expert panel based on all available clinical data and follow-up. For categories based on symptom duration, the diagnostic accuracy of single and combined cutoff values was determined, and negative predictive values (NPV) and positive predictive values (PPV) were calculated. Subgroup analyses for age (<40 years or ≥40 years) and sex were performed. RESULTS: A total of 1,024 patients with clinically suspected acute appendicitis were included, of whom 580 (57%) were assigned a final diagnosis of appendicitis. No value of WBC count, CRP level, or their combination resulted in a NPV of more than 90%, regardless of the duration of symptoms. A WBC count of >20 × 10(9) /L in combination with symptoms for more than 48 hours was associated with a PPV of 100%. However, only eight of the 1,024 patients (1%) fulfilled these criteria, limiting the clinical applicability. No other cutoff level of WBC count, CRP level, or their combination resulted in a PPV of more than 80%, regardless of the duration of symptoms. In female patients, normal levels of CRP and WBC count more accurately excluded the diagnosis of appendicitis than normal levels did in male patients. CONCLUSIONS: No WBC count or CRP level can safely and sufficiently confirm or exclude the suspected diagnosis of acute appendicitis in patients who present with abdominal pain of 5 days or less in duration.

External validation of two tools for the clinical diagnosis of acute diverticulitis without imaging.

AIM: External validation and comparison of the diagnostic accuracy of two predictive tools, the emergency department triad and the clinical scoring tool in diagnosing acute diverticulitis. METHODS: Two derivation datasets were used crosswise for external validation. In addition, both tools were validated in a third independent cohort. Predictive values were reassessed and the Area Under the Curve expressed discriminatory capacity. Performance was compared by calculating positive predictive values of the emergency department triad in the validation cohorts and with a cut-off analysis for the clinical scoring tool at a positive predictive value of 90%. RESULTS: Predictive value of the emergency department triad was comparable to the clinical scoring tool. The positive predictive value of the emergency department triad (97%) decreased in the clinical scoring tool cohort (81%) and was excellent in the independent cohort (100%), identifying 24%, 20% and 14% of the patients. A smaller proportion of patients with diverticulitis could be identified with the clinical scoring tool (6%, 19% and 9%). CONCLUSION: The emergency department triad as well as the clinical scoring tool have significant predictive value in external cohorts of patients suspected of diverticulitis. These tools can be used to select patients in whom additional imaging to diagnose acute diverticulitis may be omitted.

Diagnostic pitfalls and accuracy of diagnosis in acute abdominal pain.

OBJECTIVE: To identify the differential diagnostic difficulties in acute abdominal pain at the emergency department and during hospitalization. MATERIAL AND METHODS: Patients with abdominal pain lasting for up to 7 days were registered during 1997-2000 and re-evaluated one year after discharge (n=2851). RESULTS: Diagnoses with low sensitivity at the emergency department but markedly increased sensitivity at discharge were non-specific abdominal pain with a sensitivity value at the emergency department of 0.43, appendicitis 0.80, gallstones 0.68, constipation 0.74 and peptic ulcer 0.26. Corresponding kappa-values were 0.48, 0.74, 0.84, 0.88 and 0.93, respectively. Malignancy, gynaecological complaints, dyspepsia, urinary tract infection and diverticulitis displayed fairly good concordance between the preliminary and discharge judgements, but the predictive diagnostic value was still low at discharge. Sensitivity values at discharge were 0.40, 0.75, 0.73, 0.77 and 0.83, respectively. Among 479 surgically treated patients, 104 initially received a diagnosis usually not requiring surgery and had a median delay until operation of 22 h (95% CI 30-50 h), compared with 8 h (12-18 h) for referrals. CONCLUSIONS: Non-specific abdominal pain is the main differential diagnostic problem in the emergency department also for diagnoses requiring surgery. Constipation is a diagnostic pitfall and when making this diagnosis a careful re-evaluation is necessary.