Abstract
This second Guideline for Reasonable and Appropriate Care in the Emergency Department (GRACE-2) from the Society for Academic Emergency Medicine is on the topic “low-risk, recurrent abdominal pain in the emergency department.” The multidisciplinary guideline panel applied the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding four priority questions for adult emergency department patients with low-risk, recurrent, undifferentiated abdominal pain. The intended population includes adults with multiple similar presentations of abdominal signs and symptoms recurring over a period of months or years. The panel reached the following recommendations: (1) if a prior negative computed tomography of the abdomen and pelvis (CTAP) has been performed within 12 months, there is insufficient evidence to accurately identify populations in whom repeat CTAP imaging can be safely avoided or routinely recommended; (2) if CTAP with IV contrast is negative, we suggest against ultrasound unless there is concern for pelvic or biliary pathology; (3) we suggest that screening for depression and/or anxiety may be performed during the ED evaluation; and (4) we suggest an opioid-minimizing strategy for pain control. EXECUTIVE SUMMARY: The GRACE-2 writing group developed clinically relevant questions to address the care of adult patients with low-risk, recurrent, previously undifferentiated abdominal pain in the emergency department (ED). Four patient-intervention-comparison-outcome-time (PICOT) questions were developed by consensus of the writing group, who performed a systematic review of the literature and then synthesized direct and indirect evidence to formulate recommendations, following GRADE methodology. The writing group found that despite the commonality and relevance of these questions in emergency care, the quantity and quality of evidence were very limited, and even fundamental definitions of the population and outcomes of interest are lacking. Future research opportunities include developing precise and clinically relevant definitions of low-risk, recurrent, undifferentiated abdominal pain and determining the scope of the existing populations in terms of annual national ED visits for this complaint, costs of care, and patient and provider preferences.
| Original language | English (US) |
|---|---|
| Pages (from-to) | 526-560 |
| Number of pages | 35 |
| Journal | Academic Emergency Medicine |
| Volume | 29 |
| Issue number | 5 |
| DOIs | |
| State | Published - May 2022 |
Keywords
- abdominal pain
- analgesia
- anxiety
- computed tomography
- depression
- emergency department
- low-risk
- opioid
- recurrent
- ultrasound
ASJC Scopus subject areas
- Emergency Medicine
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In: Academic Emergency Medicine, Vol. 29, No. 5, 05.2022, p. 526-560.
Research output: Contribution to journal › Article › peer-review
}
TY - JOUR
T1 - Guidelines for Reasonable and Appropriate Care in the Emergency Department 2 (GRACE-2)
T2 - Low-risk, recurrent abdominal pain in the emergency department
AU - Broder, Joshua S.
AU - Oliveira J. e Silva, Lucas
AU - Bellolio, Fernanda
AU - Freiermuth, Caroline E.
AU - Griffey, Richard T.
AU - Hooker, Edmond
AU - Jang, Timothy B.
AU - Meltzer, Andrew C.
AU - Mills, Angela M.
AU - Pepper, Joan D.
AU - Prakken, Steven D.
AU - Repplinger, Michael D.
AU - Upadhye, Suneel
AU - Carpenter, Christopher R.
N1 - Funding Information: The GRACE-2 writing group included emergency physicians from geographically diverse academic medical centers in the United States and Canada, including those with research methodology expertise and content expertise in the diagnosis and treatment of abdominal pain, opioid pain medications, and mental health. In addition, the panel included a patient representative and a board-certified psychiatrist with career specialization in pain management. As discussed in the limitations, the writing group did not include other specialists engaged in the care of patients with recurrent abdominal pain, although the guideline was submitted for external review by such groups. Future GRACE guidelines should consider inclusion of these stakeholders throughout the writing process. The Society for Academic Emergency Medicine (SAEM) supported the development of this guideline. The GRACE-2 writing group included emergency physicians from geographically diverse academic medical centers in the United States and Canada, including those with research methodology expertise and content expertise in the diagnosis and treatment of abdominal pain, opioid pain medications, and mental health. In addition, the panel included a patient representative and a board-certified psychiatrist with career specialization in pain management. As discussed in the limitations, the writing group did not include other specialists engaged in the care of patients with recurrent abdominal pain, although the guideline was submitted for external review by such groups. Future GRACE guidelines should consider inclusion of these stakeholders throughout the writing process. The Society for Academic Emergency Medicine (SAEM) supported the development of this guideline. From May 2020 until August 2021, the GRACE-2 writing group met monthly. The group applied the Grading of Recommendations Assessment Development and Evaluation (GRADE) methodology, a stepwise process that includes development of systematic reviews of priority questions; assessment of certainty in the evidence at the outcome level by explicit consideration of the GRADE criteria; and development of recommendations using the GRADE Evidence-to-Decision (EtD) framework. Recommendations are assigned direction (for, against, or either) and strength (strong vs. conditional/weak [the latter used interchangeably in GRADE]; Figure 1).59–67 The methodologists had previously received GRADE training, and all writing group members were encouraged to watch online video content describing the GRADE methodology and its application to GRACE.68 All group members disclosed conflicts of interest using SAEM standard methods. No member of the group disclosed a significant conflict requiring management. The GRACE-2 writing group deliberated extensively about the population of interest for this clinical practice guideline and focused on definitions of “low-risk,” “undifferentiated,” “recurrent,” and “negative CTAP” throughout the development of the guideline. Table 1 summarizes definitions developed and used by the GRACE-2 writing group. The GRACE-2 writing group identified clinically important outcomes of interest (identification of potentially life-threatening diagnosis, abdominal surgery or other invasive procedure within 30 days, hospital and intensive care unit [ICU] admission rates within 30 days, mortality within 30 days, and return ED visit within 30 days) and then sought to describe a patient population at low-risk of these. The selection process for clinically important outcomes is discussed in more detail later in this document and in Appendix S2. In considering low risk, the GRACE-2 writing group identified specific populations that would not meet this definition and chose to exclude them prospectively. Excluded populations had the following characteristics and conditions: <18 years of age or age 65 years or older, pregnancy, acute trauma within 7 days, organ transplantation, immunosuppression, abdominal surgery within 30 days, active cancer, inflammatory bowel disease, previous bowel obstruction, and severe active psychiatric illness (specifically psychosis/mania). The writing group debated using the term “non–high risk,” as the exclusion of the above assumed high-risk populations does not necessarily define the remainder as low risk. Without an evidence-based quantitative measure of risk, the writing group chose instead to adopt low risk as a convenient shorthand, rather than as an assertion. The GRACE-2 writing group discussed the possibility of excluding other patients whose evaluation might be challenging and who therefore might be at increased risk of missed acute abdominal pathology without the use of extensive testing. Populations considered, but ultimately not excluded from, the guideline included undomiciled patients, patients with traumatic brain injury, non–English-speaking patients, patients with other communication barriers, and patients without a primary care physician, which could limit follow-up opportunities to evaluate causes of abdominal pain not pursued in the ED. Ultimately the GRACE-2 writing group chose not to exclude these populations, erring on the side of creating a clinical practice guideline with the broadest possible application. Excluding these patient populations could also introduce inequities in guidelines for the delivery of care (e.g., providing different guidance for emergency physicians caring for patients speaking different languages or those with socioeconomic disparities). Individual physicians may consider these patient populations to be at higher risk. The GRACE-2 writing group debated the definition of recurrent abdominal pain, which was not clearly defined within the literature in relationship to ED patients. We defined recurrent as indicating two or more prior similar episodes within a period of 12 months, with the time elapsed from the first episode to the current episode being greater than or equal to 30 days. For comparison, the criteria for recurrent abdominal pain established by Rome IV for irritable bowel syndrome (IBS) require abdominal pain on average at least 1 day per week in the past 3 months, with symptoms beginning at least 6 months prior to diagnosis.69 These criteria are based on a survey of U.S. adults with no previous physician diagnosis of an abdominal disorder, defining ≥90th percentile as abnormal. Our definition of recurrent pain was based on the consensus that recurrence was not intended to address repeated short-term presentations with an acute and evolving new abdominal syndrome. Such presentations may not represent a low-risk condition and likely require evaluation for evolving surgical disease such as appendicitis or bowel obstruction. GRACE-2 is not intended to apply to patients who have not yet undergone evaluation of potential causes of their abdominal pain. Medical workup for undifferentiated recurrent abdominal pain may be indicated, as patients may have serious and treatable causes such as malignancy, inflammatory bowel disease, nephrolithiasis, abdominal vascular disease, and endometriosis. GRACE-2 addresses patients who, despite prior medical evaluation for the cause of pain, have not had a cause identified. Ongoing or repeated medical evaluations may have risks and benefits that should be balanced, such as cost, radiation exposure, and identification of incidental findings prompting further workup with uncertain benefit. The GRACE-2 writing group also considered whether to include within the guideline those patients for whom the cause of recurrent abdominal pain has been identified or is very likely (differentiated pain), such as those with pancreatitis, inflammatory bowel disease, or nephrolithiasis. These populations may suffer the consequences of repeated radiation exposure from imaging and other negative effects of recurrent ED presentations that the clinical practice guideline is intended to address. However, ultimately we felt that existing guidelines from specialty organizations such as the American College of Gastroenterology,53 the American College of Obstetrics and Gynecology,70 the American Urological Association,50 the American College of Radiology,51 and the American College of Emergency Physicians55,56 could provide sufficient disease-specific recommendations for management of these patients. Our search strategies, described later in this document, were not intended to capture these populations. However, some literature retrieved by the searches included patients with these conditions, and some publications were included as they provided context for comparison of outcomes in patients with undifferentiated abdominal pain in the ED. Patients with a history of nephrolithiasis, for example, may present with other abdominal conditions such as appendicitis and vascular pathology. Studies describing the yield of repeated CTAP in these populations could be relevant to those with more undifferentiated abdominal pain. We addressed the guideline to patients with previously undifferentiated abdominal pain despite workup. “Previously undifferentiated” indicates no clear etiology identified (e.g., cholelithiasis, Crohn’s disease, pancreatitis). “Workup” refers to commonly available laboratory and imaging tests that are often used in combination in the ED setting to identify the cause of abdominal pain, such as complete blood count (CBC), hepatic function tests, lipase, urinalysis, human chorionic gonadotropin (when appropriate), ultrasound, and CTAP with intravenous (IV) contrast. We considered multiple descriptors of a prior CTAP. Negative CTAP was defined as not demonstrating pathological abnormalities, related or unrelated to the current presentation. For example, evidence of prior surgery such as staples, or benign abnormalities such as renal cysts, would be allowed. “Normal” was considered but not selected, as this could be construed as not including asymptomatic, nonpathological, and/or incidental findings such as anatomic variants. Normal also would exclude expected postoperative findings such as surgical clips, as these are not normal human anatomy. “Nondiagnostic” was considered but not adopted, as this might be interpreted to mean that the CTAP image quality was not sufficient for evaluation or that structures of interest were not visualized within the field of view. “No acute findings” was not adopted, as some nonacute findings such as abdominal aortic aneurysm or chronic inflammatory findings might explain ongoing or recurrent abdominal pain. The GRACE-2 writing group discussed whether a patient with undifferentiated abdominal pain should be considered to have been adequately evaluated if previous CTAP had been performed without IV contrast. CTAP performed with IV contrast is more likely to detect some causes of abdominal pain including vascular dissections and occlusions and conditions requiring enhancement for diagnosis, such as small malignancies or abscesses.71 In clinical practice, some patients may not receive IV contrast for reasons such as contrast allergy, inadequate vascular access, or renal dysfunction. IV contrast is not required for evaluation of all conditions, and emergency physicians routinely consider the context of each individual patient’s differential diagnosis. When abdominal pain remains undifferentiated despite previous workup using CTAP without IV contrast, physicians should consider the limitations of noncontrast CTAP in relationship to the differential diagnosis to determine whether CTAP with IV contrast is indicated. For application of the guideline, we chose to study yield of repeat CTAP within 1 year of a previous CTAP for recurrent, undifferentiated abdominal pain. Clinician judgment must be applied because pathological conditions may develop at different rates, and therefore the differential diagnosis under consideration may differentially impact the ability of a previous CTAP to exclude pathology. For example, an abdominal aortic aneurysm is generally a slowly evolving condition (e.g., median annual growth rate is 0.22 cm for aneurysms ≤5 cm diameter; for aneurysms <4 cm diameter, maximum 6 month increase is 0.7 cm).72 Therefore, a negative CTAP as many as 12 months prior to the patient’s current presentation may be adequate to rule out aneurysm, depending on aortic size on the first evaluation. In contrast, appendicitis may evolve over an interval of just hours,73 meaning that a negative CTAP 1 month prior likely has little relevance if the patient’s current presentation suggests acute appendicitis. In one study, appendicitis was diagnosed in 6.8% of patients with a negative CTAP ≤ 1 month prior, 6.1% of those with prior CTAP between 1 and ≤6 months, and 11.5% of those with CTAP repeated between 6 and ≤12 months.46 We did not specify the requirements for available information (e.g., images, reports, summaries) to determine whether a prior CTAP was negative. Patients may present to multiple medical centers over the course of repeated evaluations, and the availability of CTAP images, complete CTAP reports, and/or summary information from the medical record or from patients (e.g., “CTAP was negative”) may vary depending on the degree of integration of medical record systems. Some studies suggest a low rate of misinterpretation of CTAP (i.e., false-negative studies resulting from human error in interpretation), so review of original images may not have a high yield if reports can be reviewed.48 To further safeguard against the possibility of missed findings, when original previous CTAP images are available, review of images as well as interpretations in the context of the patient’s presentation is prudent, before a decision to repeat CTAP. Although siloed medical record systems may be an impetus for repeat imaging, the availability of an electronic medical record system was not associated with decreased repeat CT utilization in one retrospective study.74 In the setting of suspected renal colic, visits to different EDs were associated with higher rates of repeat short-term CTAP, although the availability of images and/or reports was not evaluated.75 In summary, our working definitions of abdominal pain that is low risk, recurrent, and undifferentiated framed the profile of the patient population to guide our subsequent literature searches for relevant literature. In reality, studies applied variable inclusion criteria, which often did not specify patient risk factors, differentiated or undifferentiated etiology of pain, or the duration or frequency of signs or symptoms. The GRACE-2 writing group discussed the target population and considered management challenges, attempting to maintain the perspectives of treating physicians, health systems, and patients. We generated categories for discussion including diagnosis, treatment, and disposition. We considered a wide range of topics including risk stratification; utility of laboratory tests; utility of imaging including first-time and repeated CT/MRI/x-ray/ultrasound; endoscopy; acid suppression medications and motility agents; high-risk medications such as opioids and nonsteroidal anti-inflammatory drugs (NSAIDs); referrals to outpatient follow-up including primary care, gastroenterology, and mental health; minimum previous workup advisable before ceasing further search for physical causes of abdominal pain; best practices such as review of previous images or imaging reports before ordering additional testing; conditions that might be missed in an ED workup such as cancer, inflammatory bowel disease, interpersonal violence, or mental health conditions; and high-risk diagnoses for abdominal pain that should not be missed during an ED evaluation such as abdominal aortic aneurysm or acute appendicitis.76 Prior research finding an association between moderate to severe depression and repeat ED visits for abdominal pain prompted consideration of a more systematic approach to this topic.77 We considered the possibility of abdominal pain as a manifestation of depression and depression as a consequence of unremitting abdominal pain. The ongoing opioid epidemic in the United States, as well as clinical experience and studies noting frequent opioid prescribing in the ED setting of recurrent abdominal pain, prompted consideration of opioid use disorder screening and alternative methods of pain control.3,17–26,28–30,78–86 An important consideration for the GRACE-2 writing group was the feasibility of the guideline for physicians and patients in various practice settings. We debated including recommendations for testing for conditions such as Helicobacter pylori but noted that some forms of testing such as exhaled carbon dioxide or immunological testing might not be available within an ED time frame in some settings.87,88 Similarly, we chose not to investigate the utility of MRI of the abdomen and pelvis in the ED for patients with recurrent and undifferentiated abdominal pain, as many sites might not have availability of this testing on a regular basis. Based on 2005 data, on-site MRI was available in 66% of a random sample of U.S. EDs, but only 13% reported 24 hours/7 days per week (24/7) availability with an on-site technologist and an additional 26% with 24/7 on-call technologist. In contrast, CT is widely available (96% of surveyed U.S. EDs, with 94% reporting 24/7 access for ED patients).89 All GRACE-2 writing group members, including the patient representative, had the opportunity to submit candidate questions and outcomes of interest, using the standard PICOT format.90,91 Candidate questions shared features such as patient-oriented benefits (improved diagnosis, reduced radiation risk, cost) and impact on health system and societal resource utilization. We rank-ordered these using an online survey instrument, blinded to the submissions of other members of the group. The results of the PICOT survey are shown in Appendix S1. Box 1 details the four key priority questions. We scored outcomes of interest using an online survey with a 0-to 100-point scale (maximum importance 100), blinded to others’ scores (Appendix S2, Box 2). The chosen outcomes, while perceived as having greatest importance by the writing group, were often not reflected in outcomes measured by the identified literature. Published research instead tended to focus on readily measured process-oriented outcomes, such as frequency of positive findings on CTAP, the clinical relevance of which was not always clear. Identifying a diagnosis alone might have patient-, physician-, and system-level benefits such as alleviating the frustration of having no explanation for symptoms or providing a direction for outpatient follow-up.92,93 The absence of many of the highly rated, clinically relevant outcomes in the existing literature identifies an important target for future research. The GRACE-2 writing group divided into four subgroups, each focused on a single PICOT question for which a systematic review was executed. Medical librarians at Mayo Clinic (Rochester, MN) and Washington University (Saint Louis, MO) created and performed an individualized search strategy for each of the four PICOT questions, querying multiple databases from inception to December 2020. Databases included Ovid Medline (1946+, including epub, ahead-of-print, in-process, and other nonindexed citations), Ovid Embase (1974+), Ovid EBM Reviews and Web of Science Core Collection (1975+), Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus (1970+). The full search strategies are available in Appendix S3. Following the literature search, each subgroup screened the titles and abstracts, selecting articles for inclusion (as either direct or indirect evidence) or exclusion. Articles selected for inclusion during this initial screening were reviewed in full-text and abstracted. Each subcommittee then performed an evidence synthesis and created draft recommendations. We found zero studies directly addressing any of the selected PICOT questions, providing no direct evidence. For this reason, each subgroup synthesized pertinent indirect evidence as described below. The individual subcommittee evidence synthesis documents were then circulated among the group in July 2021 for review and commentary. The GRACE-2 writing group attempted to abstract the priority outcomes selected earlier (Box 2). When these outcomes were unavailable in the literature, each subgroup evaluated the certainty for other relevant outcomes. After the available evidence was synthesized, certainty was assessed at the outcome level by each subgroup using GRADE methodology when appropriate.59–65,94 GRADE applies eight criteria including risk of bias (methodological flaws), inconsistency (heterogeneity across studies), indirectness (studies conducted in populations other than the intended ED population), imprecision (wide confidence intervals [CIs] resulting from underpowered studies/studies with small sample sizes), publication bias, effect size magnitude, dose–response effects, and opposing bias/confounders.59 A level of certainty was assigned to each effect estimate evaluated (Figure 2). The lowest level of certainty across critical outcomes determined the overall certainty of evidence supporting the guideline recommendation. Using the GRADE EtD framework59 for each PICOT question, a methodologist presented the evidence synthesis followed by a structured group discussion of each of the framework criteria: certainty of evidence, balance of benefits and harms (desirable and undesirable effects of the intervention, balance of effects), values, resources, acceptability, feasibility, and equity. We then developed recommendations for each PICOT question (Box 3, Table 2). Recommendations for which no evidence was found received a label of “No evidence.” Note: Reproduced with permission from the GRADE Handbook. The GRADE methodology59 allows the use of indirect evidence, which was necessary because our literature search did not identify direct evidence for any PICOT question. We decided a priori that “direct evidence” must match each element of the PICOT question. If any element of the published research differed from the PICOT question, that manuscript was considered “indirect evidence.” In the GRADE evaluation, concerns for indirectness downgraded the certainty in the evidence, limiting the strength of conclusions and recommendations that were drawn. This second Guideline for Reasonable and Appropriate Care in the Emergency Department (GRACE-2) from the Society for Academic Emergency Medicine is on the topic “low-risk, recurrent abdominal pain in the emergency department.” The multidisciplinary guideline panel applied the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding four priority questions for adult emergency department patients with low-risk, recurrent, undifferentiated abdominal pain. The intended population includes adults with multiple similar presentations of abdominal signs and symptoms recurring over a period of months or years. The panel reached the following recommendations: (1) if a prior negative computed tomography of the abdomen and pelvis (CTAP) has been performed within 12 months, there is insufficient evidence to accurately identify populations in whom repeat CTAP imaging can be safely avoided or routinely recommended; (2) if CTAP with IV contrast is negative, we suggest against ultrasound unless there is concern for pelvic or biliary pathology; (3) we suggest that screening for depression and/or anxiety may be performed during the ED evaluation; and (4) we suggest an opioid-minimizing strategy for pain control. Publisher Copyright: © 2022 Society for Academic Emergency Medicine.
PY - 2022/5
Y1 - 2022/5
N2 - This second Guideline for Reasonable and Appropriate Care in the Emergency Department (GRACE-2) from the Society for Academic Emergency Medicine is on the topic “low-risk, recurrent abdominal pain in the emergency department.” The multidisciplinary guideline panel applied the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding four priority questions for adult emergency department patients with low-risk, recurrent, undifferentiated abdominal pain. The intended population includes adults with multiple similar presentations of abdominal signs and symptoms recurring over a period of months or years. The panel reached the following recommendations: (1) if a prior negative computed tomography of the abdomen and pelvis (CTAP) has been performed within 12 months, there is insufficient evidence to accurately identify populations in whom repeat CTAP imaging can be safely avoided or routinely recommended; (2) if CTAP with IV contrast is negative, we suggest against ultrasound unless there is concern for pelvic or biliary pathology; (3) we suggest that screening for depression and/or anxiety may be performed during the ED evaluation; and (4) we suggest an opioid-minimizing strategy for pain control. EXECUTIVE SUMMARY: The GRACE-2 writing group developed clinically relevant questions to address the care of adult patients with low-risk, recurrent, previously undifferentiated abdominal pain in the emergency department (ED). Four patient-intervention-comparison-outcome-time (PICOT) questions were developed by consensus of the writing group, who performed a systematic review of the literature and then synthesized direct and indirect evidence to formulate recommendations, following GRADE methodology. The writing group found that despite the commonality and relevance of these questions in emergency care, the quantity and quality of evidence were very limited, and even fundamental definitions of the population and outcomes of interest are lacking. Future research opportunities include developing precise and clinically relevant definitions of low-risk, recurrent, undifferentiated abdominal pain and determining the scope of the existing populations in terms of annual national ED visits for this complaint, costs of care, and patient and provider preferences.
AB - This second Guideline for Reasonable and Appropriate Care in the Emergency Department (GRACE-2) from the Society for Academic Emergency Medicine is on the topic “low-risk, recurrent abdominal pain in the emergency department.” The multidisciplinary guideline panel applied the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding four priority questions for adult emergency department patients with low-risk, recurrent, undifferentiated abdominal pain. The intended population includes adults with multiple similar presentations of abdominal signs and symptoms recurring over a period of months or years. The panel reached the following recommendations: (1) if a prior negative computed tomography of the abdomen and pelvis (CTAP) has been performed within 12 months, there is insufficient evidence to accurately identify populations in whom repeat CTAP imaging can be safely avoided or routinely recommended; (2) if CTAP with IV contrast is negative, we suggest against ultrasound unless there is concern for pelvic or biliary pathology; (3) we suggest that screening for depression and/or anxiety may be performed during the ED evaluation; and (4) we suggest an opioid-minimizing strategy for pain control. EXECUTIVE SUMMARY: The GRACE-2 writing group developed clinically relevant questions to address the care of adult patients with low-risk, recurrent, previously undifferentiated abdominal pain in the emergency department (ED). Four patient-intervention-comparison-outcome-time (PICOT) questions were developed by consensus of the writing group, who performed a systematic review of the literature and then synthesized direct and indirect evidence to formulate recommendations, following GRADE methodology. The writing group found that despite the commonality and relevance of these questions in emergency care, the quantity and quality of evidence were very limited, and even fundamental definitions of the population and outcomes of interest are lacking. Future research opportunities include developing precise and clinically relevant definitions of low-risk, recurrent, undifferentiated abdominal pain and determining the scope of the existing populations in terms of annual national ED visits for this complaint, costs of care, and patient and provider preferences.
KW - abdominal pain
KW - analgesia
KW - anxiety
KW - computed tomography
KW - depression
KW - emergency department
KW - low-risk
KW - opioid
KW - recurrent
KW - ultrasound
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U2 - 10.1111/acem.14495
DO - 10.1111/acem.14495
M3 - Article
C2 - 35543712
AN - SCOPUS:85129322704
SN - 1069-6563
VL - 29
SP - 526
EP - 560
JO - Academic Emergency Medicine
JF - Academic Emergency Medicine
IS - 5
ER -