Abstract
Objective. To investigate the spectrum of diagnoses made by general practitioners (GPs) seeing patients with acute abdominal pain, as well as GPs’ handling of these patients. To investigate factors predictive of acute admission to hospital. Design. Descriptive study. Setting. General practices in southern Norway, autumn 2007 and spring 2008. Subjects. A total of 134 patients who were offered an acute appointment with a GP because of abdominal pain. Main outcome measures. Tentative diagnosis made and handling of the patient by the GP. Explanatory factors: pain duration, findings on clinical examination. Results. The most frequent diagnosis was non-specific pain (20%), followed by gastroenteritis (13%), appendicitis (12%), ulcer disease (11%), gynaecological disease (9%), and urinary tract problems (7%). One-quarter of patients were sent home after clinical examination without any specific action taken. One-quarter were acutely admitted to hospital, and one-quarter were treated with medication. The rest was either referred for further investigations on a non-acute basis (14%) or given a follow-up appointment with the GP (10%). Suspected appendicitis was the strongest predictor for acute admission. Rebound tenderness on clinical examination as well as pain duration for 24 hours or less also independently predicted acute hospital admission. Conclusion. GPs face the challenge of meeting a wide and inhomogeneous spectre of complaints when dealing with patients with acute abdominal pain. Three-quarters of patients are taken care of in primary care.
Hospital-based studies conclude that around half of patients admitted for acute abdominal pain turn out not to be in need of instant treatment Citation[1–4]. Some claim that investigation of these patients in hospital is resource demanding, and suggest that they should be investigated more thoroughly before admission Citation[1]. Little is known, however, about the diagnostic challenges facing the primary care physician regarding patients with acute abdominal pain. By searching relevant databases we were not able to find any studies considering the spectrum of symptoms, diagnoses, or handling of such patients in general practice. We wanted to shed some light on the area by carrying out this descriptive study. Our research questions were: What spectrum of tentative diagnoses characterises patients seen with acute abdominal pain in general practice? How are these patients handled by the primary care physician? Can predictive factors be found regarding acute admission to hospital?
Little is known of the diagnostic challenges facing GPs seeing patients with acute abdominal pain and about GPs’ handling of these patients. This descriptive study showed:
A wide spectrum of tentative diagnoses was made, and one-fifth of patients were labelled as having “non-specific pain”.
Three-quarters of patients were handled by the GP without acute hospital admission.
Suspected appendicitis, rebound tenderness on clinical examination, and short pain duration independently predicted acute admission.
Material and methods
Fifth-year medical students at the University of Oslo accomplishing their practice period in general practice in autumn 2007 and spring 2008 were on a voluntary basis asked to fill in a questionnaire when dealing with a patient with acute abdominal pain. Close to 200 students were given questionnaires, and we received 134 completed questionnaires. Patients were either seen by the GP with the student sitting in, or were first seen by the student and then by the GP and the student together. Decision on handling was always taken by the GP exclusively.
The inclusion criterion was any patient who was offered an acute appointment with the GP because of abdominal pain. Information was collected on the patient's age and sex, on duration and localization of pain, on other symptoms (nausea, diarrhoea, fever), clinical findings, performance of blood or urine tests, tentative diagnosis, and handling of the patient. More than one alternative for handling was possible for each patient.
Data were analysed using SPSS version 15.0. Pearson's chi-squared test was used to compare frequencies. Regression analysis was performed to test factors predictive for hospital admission.
Results
Two-thirds of patients were female and median age was 33.5 years (range 2 to 106). Eleven patients were seen out of office hours. One-third had experienced pain for 24 hours or less and 56% for three days or less. In all but three patients a tentative diagnosis was made. Non-specific pain was the most frequent diagnosis (20%), followed by gastroenteritis (13%), and appendicitis (12%). Other diagnoses were ulcer disease (11%), gynaecological complaints (9%), and urinary tract symptoms (7%). C-reactive protein (CRP) was measured in more than half of patients and a urine examination was carried out in one-third.
shows the handling of the 134 patients by the GPs. One-quarter were sent home after the clinical examination without any specific action taken. One-quarter were given medication treatment and one-quarter were acutely admitted to hospital. Suspected appendicitis was by far the most frequent reason for admission, comprising close to half of admissions. Pain duration for 24 hours or less was significantly associated with admission (p = 0.016, chi-squared test), as was rebound tenderness on clinical examination (p = 0.004, chi-squared test) and performance of a CRP test (p = 0.006, chi-squared test). There was no difference in age or sex between patients admitted and not admitted. Regression analyses with the patient-related factors significantly correlating with acute admission in bivariate analyses (pain duration, rebound tenderness, and suspected appendicitis) showed that each factor independently predicted acute admission. Suspected appendicitis was the strongest predictor with a standardized beta 0.49 (data not shown in table).
Table I. Patients with acute abdominal pain in general practice: action taken by physician.
shows the diagnoses made, related to the GPs’ handling of the cases. The table also lists the number of patients in each handling group with pain duration of less than 24 hours and with rebound tenderness on clinical examination.
Table II. Patients with acute abdominal pain in general practice. Diagnoses and factors predictive for hospital admission related to handling by GP (n = 134).
Discussion
The patients in this study were seen by fifth-year medical students in their six-week GP practice period, which enabled us to investigate a relatively large number of patients with acute abdominal pain within a short time span. The questionnaire was simple, and the data were easy to obtain during the consultation and seem to be thoroughly reported. In the first part of their practice period the students sit in with the doctor, and later they are allowed to investigate patients by themselves. In some of the study cases the student therefore may have ordered simple laboratory tests, such as a urine test or C-reactive protein, without consulting the GP. These patients are always seen by the GP, and decisions on handling are taken exclusively by the doctor. That the data were collected during students’ practice period is therefore unlikely to have influenced the main results of the study: the handling of patients and rate of acute hospital admission. GPs who teach medical students in their practice are experienced doctors who have completed specialist training. This may influence the results of the study, as one might expect younger GPs to be less secure in their own evaluation leading to a higher rate of admission. In a previous Norwegian study, 35% of patients seen in an out-of-hours emergency department were acutely admitted to hospital Citation[5]. This higher admission rate may reflect less experienced GPs or a selection of more seriously ill patients at the emergency department.
We may question the value of measuring CRP in more than half of the patients, as this analysis is proved not to be sensitive and specific enough to distinguish serious illness from more harmless conditions Citation[6]. Rate of acute hospital admission was significantly higher among patients where CRP had been measured. It may thus seem that the GPs decided to measure CRP when they suspected more serious disease. The present study does not enable us to evaluate the usefulness of the blood test in this setting.
GPs face the challenge of meeting a wide and inhomogeneous spectre of complaints when dealing with patients with acute abdominal pain, and diagnostic and therapeutic decisions have to be made with simple tools. The study indicates that GPs’ handling of these patients is varied, and adjusted to the specific problem raised. Even if hospital doctors complain that only half of admitted patients are in need of instant hospital treatment Citation[1], three-quarters of the patients in this study were taken care of by GPs alone. Suspicion of potentially serious disease, such as appendicitis or extra-uterine pregnancy, was the most frequent reason for acute admission. Not to refer these patients in time can be fatal, and the primary goal for GPs must be not to miss them. Any pressure on GPs to be more selective in their admissions inevitably increases the risk of delayed treatment of seriously ill patients.
Acknowledgements
Note
The authors report no conflicts of interest and no funding was necessary for this study.
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