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Utrecht, and c Department of Radiology, Academic Medical Centre, Amsterdam, The Netherlands
E-Mail karger@karger.com
NL–1105 AZ Amsterdam (The Netherlands)
www.karger.com/dsu
E-Mail s.l.gans @ amc.uva.nl
Introduction a large variation in choice of diagnostic modalities and
treatment. Diagnostic practice varies within hospitals and
Acute abdominal pain is a common complaint of pa- within specialties, mostly lead by a doctor’s preferences.
tients presenting at the Emergency Department [1]. Ap- This guideline was developed to standardize the diag-
proximately 10% of presentations at the Emergency De- nostic pathway of patients with acute abdominal pain and
partment are because of acute abdominal pain [2]. Acute provide doctors with evidence-based support in their de-
abdominal pain can be caused by a variety of diseases cision-making process. A multidisciplinary steering
ranging from mild and self-limiting to life-threatening group developed the national guideline based on all avail-
diseases [2]. able international literature regarding the diagnostic
An early and accurate diagnosis results in more accu- pathway in patients with acute abdominal pain, making
rate management and, subsequently, leads to better out- the guideline internationally applicable.
comes. Causes for acute abdominal pain can be classified
as urgent or nonurgent. Urgent causes require immediate
treatment (within 24 h) to prevent complications; where- Methods
as for nonurgent causes, immediate treatment is not nec-
essary [2]. Most common urgent causes are acute appen- The development of this guideline was initiated by the Asso-
ciation of Surgeons of the Netherlands in collaboration with the
dicitis, acute diverticulitis, and bowel obstruction. Most Dutch societies of Radiology, Gynecology, and Obstetrics, Emer-
common nonurgent causes are nonspecific abdominal gency Physicians, Internal medicine, and the Dutch College of
pain (NSAP) and gastro-intestinal diseases. General Practitioners. Methodological support was provided by
Complaints of acute abdominal pain can be very non- the Knowledge Institute of Medical Specialists. The guideline was
specific at the start and evolve to more disease-specific drafted in accordance with the requirements of the AGREE II in-
strument (Appraisal of Guidelines for Research and Evaluation II)
symptoms over time. This increases the difficulty of an ac- (www.agreecollaboration.org), an internationally accepted instru-
curate identification of the cause of acute abdominal pain. ment for the evaluation of the quality of guidelines.
The first step in the diagnostic pathway is clinical evalua- A steering group was formed with representatives of each par-
tion. In daily practice, a preliminary diagnosis will be made ticipating society. The steering group consisted of 2 surgeons, 2
based on medical history, physical examination, and, in radiologists, an internist, a gynecologist, an emergency physician,
and a general practitioner. No specific patient group consisting of
some cases, laboratory parameters. After clinical assess- patients with acute abdominal pain exists. The patients’ views and
ment, the decision can be made to perform additional diag- preferences were therefore described based on existing literature.
nostic investigations to increase certainty of the diagnosis. The steering group identified the most important bottlenecks and
The use of additional imaging modalities such as plain divided these into areas of relevance: incidence of acute abdominal
radiography, ultrasound, and computed tomography pain, clinical diagnosis, imaging modalities, invasive diagnostic
tests, and treatment during the diagnostic pathway. Twelve clinical
(CT) has increased over the years. Only a few decades ago, questions were derived from these areas of relevance: terminology
when imaging was not widely available and its diagnostic and definitions, diagnostic accuracy of medical history, physical
accuracy was low, patients would immediately proceed to examination and laboratory parameters, difference in diagnostic
the operating theater. However, many causes can be treat- accuracy between residents and staff, additional value of consulta-
ed conservatively and do not benefit from diagnostic lap- tion of gynecologists on diagnostic accuracy, diagnostic accuracy
of outpatient re-evaluation the next day, diagnostic accuracy of
aroscopy and laparotomy [3]. laboratory parameters in differentiating urgent from nonurgent
The increase in use of diagnostic modalities also has conditions, diagnostic accuracy of conventional radiology, diag-
downsides. Imaging can lead to higher costs, a protracted nostic accuracy of ultrasound, diagnostic accuracy of computed
patient throughput at the emergency department, and an tomography (including assessment of influence of various meth-
increased risk of negative side effects such as contrast- ods of administration of contrast agents), diagnostic accuracy of
MRI, diagnostic accuracy of diagnostic laparoscopy, indications
induced nephropathy and ionizing radiation exposure. for antibiotic treatment during the diagnostic pathway, and influ-
To date, the effect of the increased use of imaging on cost ence of analgesics on the reliability of physical examination.
effectiveness of treatment of patients with acute abdomi-
nal pain remains unknown. Search
The authors performed a systematic search of the literature in
Despite the increased use of imaging modalities, acute collaboration with the literature specialist of the Knowledge Insti-
abdominal pain remains a major diagnostic challenge. tute of Medical Specialists. The Embase, Medline, and Cochrane
The underlying cause for the acute abdominal pain can be databases were searched using keywords, MESH terms, and free
in the area of many different specialties such as gynecol- text words for acute abdominal pain. The complete search strategy
ogy, surgery, internal medicine, and urology. This leads to is added in online supplementary appendix 1 (for all online suppl.
115.178.213.148 - 5/10/2017 3:00:09 AM
Laboratory investigations:
yes ± additional laboratory Laboratory
investigations/pregnancy investigations: no
test when indicated
Urgent Nonurgent
Diagnosis Consultation
other physician
Admission
Invasive Non-invasive
Acknowledgement
Conclusion
Initiative: Association of Surgeons of the Netherlands.
In Collaboration with: Netherlands Association of Internal
This review of the guideline of the diagnostic pathway Medicine, Dutch Society of Obstetrics and Gynaecology, Radio-
in patients with acute abdominal pain summarizes all the logical Society of the Netherlands, Netherlands Society of Emer-
available literature on diagnostic modalities. The guide- gency Physicians, Dutch College of General Practitioners.
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