Abdominal Pain and Emergency Department Evaluation

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EMERGENCY OBSERVATION MEDICINE

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ABDOMINAL PAIN AND EMERGENCY DEPARTMENT EVALUATION Louis G. Graff IV, MD, FACEP, and Dave Robinson, MD, MS, FACEP

Abdominal pain is the most common chief complaint of patients in emergency departments (EDs). It comprises 8% of the 100 million ED visits each year.I3,26 Some patients with abdominal pain experience a catastrophic event, such as ruptured abdominal aortic aneurysm. Most patients with abdominal pain have a minor problem, such as dyspepsia. Overall, 20% to 25% of patients with abdominal pain are found to have a serious condition requiring acute care hospital admission.20The most common surgical emergency is appendicitis. Since Fitz’s report of the surgical treatment of appendicitis in 1886,”j early diagnosis and operation has been found to prevent appendicitis perforation. This avoids acute complications (such as abscess formation and sepsis) and delayed complications (such as scar formation with episodes of bowel obstruction and infer ti lit^).^^ Those patients who are not admitted usually are treated, released from the ED, and do well. Lukens et alZ5reported that only 3% of abdominal pain patients discharged from the ED require admission during the following 3 weeks. Yet, in the primary care setting, an average of 1.32 visits are required to adequately complete these patients’ work-up, with half found after evaluation to have a diagnosis of nonspecific abdominal pain.23Gold and Azevedo17reported that the abdominal pain work-up generated more use of ancillary services than all other ambulatory complaints studied. Identifying and managing abdominal pain is a dilemma for several reasons: first, the definitive diagnosis is often obscure, with an unconfirmed or uncertain diagnosis reported in over 40% of patients.*Failure to confirm a diagnosis results in further testing and, often, return visits to the primary care provider or the

From the Department of Emergency Medicine, University of Connecticut School of Medicine, Farmington; the Observation Unit, Department of Emergency Medicine, New Britain General Hospital, New Britain, Connecticut (LGG); the Department of Emergency Medicine, University of Texas-Houston Health Science Center; and the Diagnostic Observation Center, Hermann Memorial Hospital, Houston, Texas (DR)

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ED despite good long-term prognoses; second, the burden for establishing a diagnosis and the large differential of presenting symptoms often obligates the ED to repeat many of the tests or broaden the differential diagnosis of those presenting with persistent pain. The difficulty in identifying the origin of abdominal pain results in large numbers of negative work-up, unnecessary surgeries, increased cost, and a burden on patient and hospital resources; third, the physician often faces the dilemma of when to declare the patient safe for discharge and conclude the work-up in a timely manner despite a negative work-up or an unclear diagnosis. A methodological approach to abdominal pain, including judicious test ordering and the use of a period of observation, can reduce or eliminate the dilemmas previously mentioned. TRADITIONAL APPROACH

The traditional approach in the ED to the patient with acute abdominal pain is similar to the evaluation of any ED patient. The physician performs a history and physical examination, then orders stat testing, such as a complete blood count, urinalysis, and radiograph. Two to 3 hours after the patient’s arrival, the physician discharges those patients who are judged to have a benign condition and admits to the hospital patients who have a serious disease. A thorough history is the initial step in the ED evaluation of the patient with acute abdominal pain. The location of the pain is important in forming a differential diagnosis. Right upper quadrant pain suggests gallbladder disease or hepatitis; right lower quadrant pain suggests acute appendicitis or, in women, ovarian or tuba1 problems. The quality of the complaint may suggest the cause of the condition. Burning pain may be due to gastritis or peptic ulcer. Sharp, penetrating pain can be secondary to acute pancreatitis. The severity of the pain may not have any relationship to the seriousness of the condition. Acute nephrolithiasis is described as severe, incapacitating pain, yet for most patients the condition is not serious, and they spontaneously pass their stone. The duration of the pain can also be a clue to diagnosis. Acute appendicitis evolves over 1to 2 days. Other conditions, such as a ruptured ovarian cyst, are a sudden event. The timing of the pain can aid the physician. Pain that begins after eating suggests peptic ulcer disease; pain that begins 2 weeks after menstruation suggests ovulation disorder of mittleschmertz. The context of the pain can also aid in the evaluation of patients with abdominal pain. Pain that begins during physical activity may be secondary to a rectus abdominal muscle tear and hematoma. Associated signs and symptoms can also be helpful in clarifying the diagnosis. Patients with acute appendicitis usually have anorexia, nausea, and vomiting; patients with mittelschmertz may have pain in the same location as appendicitis but usually do not have the associated symptoms of anorexia, nausea, and vomiting. The patient’s age and gender deserve special focus from the physician during the initial evaluation. Patients at the extremes of age often present atypically and require even greater attention to details of the history to avoid missing the diagnosis. The very young cannot express themselves to the physician about what their symptoms are or where pain is located. The elderly may not be able to express themselves as well as when they were younger, especially those with Alzheimer’s disease. They also do not mount as vigorous an inflammatory response, which usually is the source of many of the findings of their illness. women with abdominal pain have a much more complex differential diagnosis than men. Women may have pregnancy-related problems, and they

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have additional pelvic organs ( e g , ovary, fallopian tubes) that may develop problems. Women patients require additional vigilance from the physician in their ED evaluation to avoid missing the diagnosis. The physical examination is the second step in the initial evaluation of a patient with acute abdominal pain. With palpation, the physician can confirm if the process causing the abdominal pain is localized to one area of the abdomen. Right upper quadrant processes include cholecystitis or hepatitis; right lower quadrant process includes appendicitis, mittleschmertz, ovarian cyst, and ectopic pregnancy; left lower quadrant processes may include an obstetrical problem, such as ectopic pregnancy, or a local problem, such as diverticulitis. Auscultation may be used by the physician to identify findings such as the absence of bowel sounds with an ileus. If ascites are present, percussion can be used to identify this finding. During the initial evaluation, the emergency physician evaluates the patient with selected stat tests such as urinalysis, complete blood count, electrolytes, amylase, lipase, and liver enzymes. These findings may aid the physician in forming an initial clinical impression but usually are not diagnostic. For example, leukocytosis is consistent with acute appendicitis but is present with many other conditions as well. PROBLEM WITH THE TRADITIONAL APPROACH

After the initial history, physical examination, and diagnostic tests, disposition decisions can be difficult on many patients. If the patient has clear evidence of a specific disease, then a lengthy evaluation is not necessary. The patient is admitted or released, depending on the seriousness of the disease condition and the need for acute care hospital therapy. Many patients, however, do not have clear evidence of the cause of their acute condition after the initial evaluation. In these patients, the physician makes a probability of disease estimate.30At some threshold for probability of disease, the physician discusses with the patient his or her concern about their condition and recommends admission to the hospital.3O When the probability of disease is lower than this threshold, the physician reassures the patient and releases him or her.30The problem with a traditional ED approach, limited to admission or discharge only, is that patients must meet a higher threshold for further testing to occur. Any threshold for admission of the ED patient to the hospital is a balance between what the physician feels to be an appropriate diagnostic work-up and the use of limited hospital resources, including time. If there is a relatively high threshold for considering disease, above which the physician admits the patient, quality of care problems arise for some patients not meeting that threshold. If a patient falls below this threshold, the physician reassures them and releases them. Whereas many patients with acute appendicitis initially present with classic symptoms (i.e., migration of pain to the right lower quadrant, nausea, vomiting, and fever), just as many have nonspecific These appendicitis patients often are released home with false reassurance from the physician that they are fine, or admitted to the hospital without their diagnosis being identified. In either case, needed surgery is delayed. Appendicitis patients who are missed during the initial evaluation have few documented signs or symptoms of appendicitis. Using Alvarados’ validated appendicitis “MANTRELS” scoring system, Graff et alZofound these patients to have an average appendicitis score of 2 out of 10 points. Rusnak et a13’ examined

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a series of cases where the appendicitis patient's diagnosis was missed in the ED and the patient sued the physician. The authors found that these patients had few clinical signs or symptoms of appendicitis at the time of their pre~entation.~~ When the initial physician misses the diagnosis of appendicitis, the patient's outcome worsens. Brender et a17 found that the initial physician missed many appendicitis presentations. The perforation rate was increased in those presentations initially missed by the physician (66.7% versus 39.5y0).~ Time delay from the initial physician evaluation until surgery was greater in perforated than in nonperforated patients (38.8 hours versus 10.5 h o ~ r s )Savrin .~ et a138found 45% of appendicitis patients with perforation had been evaluated by a physician and released home with the diagnosis missed. Schere et a139found the percentage of appendicitis patients whose diagnosis was missed by the physician was 17.6% for patients with perforation compared with 5.3% for appendicitis patients without perforation. Buchman et a19 found the diagnosis was missed in 27.1% of appendicitis patients, which resulted in 4.6 days' delay before the patient was admitted to the hospital. Cacioppo et all1 examined the changes from 1980 to 1987 as insurance payers created road blocks to patients being referred to a surgeon for evaluation. These authors found the percentage of patients not evaluated by a surgeon initially increased from 7.9% to 24.1%. Those patients not referred to the surgeon by the initial physician had 3.5 days' delay before surgery with the perforation rate increased from 26.3% to 40.5%." Traditionally, the physician has failed to diagnose appendicitis in 10% to 27% of cases with many patients experiencing adverse outcomes, such as perforation and abscess formation. When a physicians' practice is limited to admit or discharge an ED patient with abdominal pain, usage problems also arise. Physicians admit patients to the hospital who have a probability of disease greater than the threshold to admit. Some of these patients do have a serious disease, but most do not. The This average rate of false positive surgery rate ranges from 20% to 30%.31*42 results in unnecessary surgery to avoid delays in performing surgery and resulting perforation. In 1984, Berry and Malt4 summarized the first 100 years of management of appendicitis. This included a review of 23 studies with 13,848 patients and the first 100 years of experience with appendicitis at Massachusetts General Hospital, where the first appendectomy was perf~rmed.~ They concluded that low diagnostic accuracy was necessary (high false-positive surgery rate) to reduce the risk of perforation. They recommended a 23% false-positive surgery rate as the ideal balance for the s ~ r g e o nThe . ~ consequences of negative laparotomy result in a threefold waste of hospital resources, unnecessary complications to the patient, and expense to the health care system.18 Gough et all8 found the incidence of noninflammed appendices removed was 29.6% and was nearly twice as high in women than men. Postoperative complications reached 6.7%.l8 OBSERVATION: THE THIRD PATHWAY

Observation offers a third disposition pathway to address problems in quality and use. The physician does not have to release those patients with a low probability of disease; they may be evaluated further to ensure the safety of their release. The few patients with serious disease can be identified. Usage problems also can be addressed because low probability and moderate probability of disease patients do not have to be admitted after the ED evaluation. During the 10 to 12 hours of observation unit evaluation, approximately 20% of patients will be found to have a serious disease and be admitted to the hospital;

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the other 80% are safely released, avoiding hospitalization at 50% of the cost and charges of admission to the hospital. With the third pathway, the physician can be more discriminating in deciding who to commit to expensive hospitalization without unwanted risk to patient safety. Clinical changes over time illustrate the benefit of observation in patients whose diagnosis is not clear after the initial ED evaluation.20Patients with appendicitis develop more signs and symptoms during evaluation in the ED observation unit. Judging patients by the 10 point appendicitis scoring system, Graff et a P found that during 12 hours of observation the amount of clinical findings in patients with appendicitis increased from 6.8 to 7.8 points. They also found that patients without appendicitis during 12 hours of observation cleared their clinical findings with appendicitis scores decreasing from 3.8 to 1.6.20 Formation of a probability of disease estimate from clinical findings and consideration of the changes (delta) over a 12-hour period of observation (Fig. 1) clarifies the patient's diagnosis. In evaluating patients for appendicitis, Lewis et a124found serial examination was the best approach to minimize perforation risk while reducing delays to diagnosis.24To identify patients with appendicitis who present with atypical symptoms, the physician needs to decrease the threshold for extended evaluation of abdominal pain patients. Appendicitis patients whose diagnosis is initially missed have few signs and symptoms of appendicitis (Fig. 2). Observation is a

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Initial Appendicitis Score Figure 1. Probability of appendicitis after observation: calculation from initial and change in appendicitis score. Bottom curve = 24%; second curve = 33%; third curve = 62%; fourth curve = 97%; top curve = 100%. (From Graff LG, Radford MJ, Werne CW: Probability of appendicitis before and after observation. Ann Emerg Med 20503-507,1991; with permission.)

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Figure 2. Amount of clinical findings of appendicitis in abdominal pain patients. First bar = misses (patients with appendicitis whose diagnosis is missed by the initial physician);

second bar = false positives (patients without appendicitis who are taken to surgery for suspected appendicitis; third bar = true positives (patients with appendicitis identified by initial physician).

method for the physician to perform extended evaluation of abdominal pain patients whose diagnosis might be acute appendicitis with atypical or early presentation. Nonappendicitis patients who have surgery for suspected appendicitis have many of the signs and symptoms of acute appendicitis (see Fig. 2). Observation is a method for the physician to perform extended evaluation of nonappendicitis abdominal pain patients who have many findings of appendicitis. The Observation approach provides the framework for today’s ED alternative to hospital admission. Physicians can use observation to improve their performance, decreasing false positive decisions (i.e., unnecessary surgery or hospital admission). Up through the 1960s, abdominal pain patients usually were admitted to the hospital for The physician examined the patient once per day on rounds, with only 25% of acute appendicitis patients being taken to surgery during the first 24 hours.28During the early 1970s at John Hopkins University Hospital, White et a1@showed that intensive observation (physical examinations every 8 hours rather than once per day) could nearly eliminate false positive decisions. They found the normal appendix rate decreased from 15% to 1.9% after implementing an observation program, but there was no increase in perforation (26.7% ~ ~ similar results. before and 27.5% after).43A prospective trial by T h ~ m s o nfound In this study there was a single observer’s serial examinations, hourly vital sign changes, and basic laboratory and radiographic tests of patients who present to the ED with abdominal pain.42By 12 hours, 135 of 153 patients (88.2%)completed the observation period without l a p a r ~ t o m yDuring . ~ ~ the observation period, 18 of 153 patients (11.8%)required There were no reported complications because of the delay to early surgery, and there were no return visits for abdominal pain patients discharged after observation. Since the 1970s, many other hospitals have implemented observation programs and found similar results. In Pennsylvania, a 28-hospital study of the care of appendicitis patients found normal appendicitis rates varying from 4% to 28% (mean 14%).3Hospitals with low normal appendix rates were those with formal, explicit observation program^.^ The surgeons at these hospitals followed a philosophy that appendicitis was an urgent but not critical emergency3 They judged that perforation occurs over 1 to 2 days, so a deliberate approach with

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short-term observation is safe and reasonable. Thomson et a142reviewed the literature on the evaluation of abdominal pain patients for appendicitis with and without observation. They compared the results of three studies on hospitals with explicit observation programs with the results of nine studies where there was no use of ~bservation.~~ The normal appendix rate was significantly lower where observation was the accepted approach (60%versus 20%).42 OBSERVATION AND DIAGNOSTIC IMAGING

The ability to use high-tech tests, such as computed tomographic (CT) scanning, also illustrates the value of observation in patients whose diagnosis is not clear after the initial ED evaluation. Computed Tomography scanning has been shown to improve physician decision-making in patients with moderate probability of appendicitis. Rao et aP3 examined the effect of CT scan use on patients with moderate probability of appendicitis and found that 53 of 100 patients had appendicitis in contrast to the ED, where only 3 of 100 patients have appendicitis. Physicians prospectively recorded their disposition decisions before and after CT scan results. Computed tomographic scan imaging results decreased false negative decisions with 18 of the patients with appendicitis being observed and then taken to surgery that otherwise would have been released after their ED e v a l ~ a t i o nComputed .~~ tomographic scan imaging results also decreased false positive decisions with 13 nonappendicitis patients not taken to surgery who otherwise would have been taken to surgery after the surgeon’s initial e v a l ~ a t i o n . ~ ~ Observation enables the physician to judiciously use advanced diagnostic testing in the evaluation of abdominal pain patients. These tests are costly and not appropriate for patients whose diagnosis is clear after the initial physician evaluation. These patients should be taken to surgery right after the ED evaluation without the added cost of such testing. Advanced diagnostic tests also are not appropriate for patients whose likelihood of appendicitis is very low. Few will be found to have a positive test in such circumstances, and most of these will be false positive^.^^ OBSERVATION STRATEGIES

A successful observation strategy for abdominal pain requires safety, efficiency, and prudent use of resources. Safety is the primary goal of any successful observation program. The physician seeks to accurately detect abdominal pathology without delaying surgery. Efficiency is inherent in the observation program. Patients are evaluated with an accelerated protocol over 10 to 12 hours rather than during a 2- to 3-day hospitalization. Fewer personnel are required to provide services to the observation patient during the accelerated protocol. Duplicate physician and nursing assessments during hospitalization are avoided. In addition, the physician can often avoid expensive diagnostic testing. The patient with abdominal pain, unlike the patient with chest pain, often develops changes in their signs and symptoms during the observation period, aiding the physician in clarifying the patient’s diagnosis. Safe patient care requires good physician-to-physician communications. The emergency physician is screening 100 abdominal pain patients to find the 2 or 3 with acute appendicitis to refer to the surgeon for definitive care. The astute emergency physician must recognize the subtle changes during the abdominal pain observation period and be able to objectively categorize these changes and

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relay this information to the consultant, if needed. Delays in care or disputes in the approach to abdominal pain observation and management can occur without a defined protocol for physician communication. With a defined observation strategy, information regarding dynamic changes in the quality of pain, localization, or frequency of pain is adequately conveyed from physician to physician. Criticism toward the emergency physician regarding the administration of analgesia for abdominal pain may occur when a consultant has no serial examination information and is unable to assess the patient prior to the administration of the analgesic. An observation pathway with a defined role for the emergency physician and the consultant is designed to accurately assess dynamic changes in the patient's pain, variations in laboratory values, serial examinations, and vital signs and can improve the quality of information transferred between physicians without the withholding of necessary pain relief. Efficiency is possible with observation of abdominal pain patients. A multidisciplinary strategy for abdominal pain management from the ED provides an opportunity to reduce hospital resources while ensuring patient safety. More than one third of all patients admitted into surgical units with abdominal complaints will have complete resolution of symptoms without treatment.14 These findings have also been demonstrated in childrenI5, admitted for lower quadrant abdominal pain. Emergency department observation avoids unnecessary admissions, results in fewer laporatomies, and is not associated with increased rates of appendicular perforation.@ Prudent use of resources is possible with a predefined observation pathway that includes objective criteria to risk stratify patients over the observation period and indications for advanced testing, such as CT or US. Low-risk patients with improving criteria may be safely observed in the emergency setting without unnecessary tests. High-risk presentations have earlier surgical consultation and may avoid testing. Imprudent test ordering is especially difficult to accept at smaller hospitals that do not have 24-hour ultrasound or CT testing except to call in technicians. When the physician is not certain on the proper disposition decision, he or she can observe the patient and schedule testing in the morning. An accelerated diagnostic protocol (ADP) for abdominal pain patients can be applied to any ED (Fig. 3). The protocol includes general definition of which probability of disease patients are appropriate for observation. More specific inclusion and exclusion criteria can be included in the protocol as well. Useful criteria for acceptable risk patients for observation include: Inclusion criteria Undifferentiated abdominal pain not clarified by initial ED evaluation Mild to Moderate suspicion of appendicitis Exclusion criteria Hemodynamically unstable-hypotension, tachycardia Surgical abdomen Pain for more than 2 weeks Intoxication Advanced pregnancy (more than 20 weeks) Terminal illness Immunosuppressed, transplant patients, or chronic steroid therapy Unable to give reliable history or physical Organic brain syndrome or psychiatric illness Probability of appendicitis estimate can be made with Alvarado 10-point appendicitis scoring system' with consideration of changes over observation (see Fig. ,).I9 Decision points for surgery and advanced imaging should be

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Acute pain, unstable? Exclusions? (Table 1) Send labs, hydrate, probability of disease estimate

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individualized for each hospital. The indications for surgical consultation and hospital admission include: Developed peritoneal signs or shock Worsening abdominal tenderness during the observation period Persistent pain or tenderness after observation period Focalizing tenderness Deteriorating vital signs Identification of a surgical pathology (such as ectopic pregnancy or small bowel obstruction) Worsening toxicity as defined by clinical condition, laboratory, or ancillary testing Worsening or continued high appendicitis (MANTELS) score Table 1 examines the many diagnostic testing options for the abdominal pain patient. Laboratory testing, radiography, and advanced diagnostic testing account for the majority of charges to the low-risk individual that does not require surgery. Differentiating surgical emergencies from nonsurgical emergencies often require additional testing that may result in one of two strategies; The wait and see strategy narrows the diagnosis through a series of progressively more specific tests. This ordering pattern is cost-effective but could delay care and management. Alternatively, ordering all laboratories and studies on initial presentation (shot-gunning) may provide information earlier but may incur additional costs through inappropriate ordering patterns. Table 1 illustrates the limitations of single laboratory and radiographic testing. The most frequently ordered study for abdominal pain is the complete blood count (CBC). Complete blood count elevations in the context of abdominal pain imply a more serious pathology. The CBC should never be used to make a sole diagnosis of an abdominal pathology, as nearly 11%of normal adults have elevated white blood cell (WBC) counts and 13% have left shifts. Conversely, elevated CBCs occur in only 42% to 90% of those patients with confirmed appendicitis. In a prospective trial of 382 children with appendicitis, only 13 (3.9%) had a normal CBC and no left shift, resulting in a 96% ~ensitivity.~ Unfortunately, elevated CBCs are reported with almost any infectious, inflammatory, or traumatic condition, reducing the specificity of CBC in some reports less to than 50%. Other than pregnancy testing, there are few laboratory tests that clearly are indicated for all patients. The standard electrolyte panel, consisting of serum sodium, chloride, potassium, blood urea nitrogen, and creatinine are rarely helpful in the work-up of abdominal pain except to monitor the patient's hydration status. Urinalysis is indicated in the evaluation of most patients with abdominal pain but has limited use, except in the diagnosis of urinary tract infections (UTI) in patients with urinary tract symptoms. It can be false positive in up to 30% of appendicitis cases.4oBorrero6 noted that 24 of 134 (17.9%) of symptomatic abdominal aortic aneurysms presenting to EDs were misdiagnosed as nephrolithiasis. In this trial, 12 of the 14 patients with diagnostic delays resulted from intravenous pyelograms testing6Furthermore, in a trial by Pomper et a1,3* gross hematuria was found to be a significant cause of the delay in arriving to the diagnosis of appendicitis. Plain films routinely ordered for all presenting abdominal patients are another example of an ordering practice that may no longer be necessary.'2,36 Abdominal radiographs are rarely helpful as an initial test for abdominal pain except where bowel obstruction, foreign body, or perforated viscous is an immediate concern. Even in these presentations, CT provides more information with

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Y

A Y A A A A A Y A Y A Y Y A

Lytes

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Common Testing

Abdominal aortic aneurysm Appendicitis Biliary tract disease Bowel obstruction, perforation Cholecystitis Diverticulitis Ectopic pregnancy Gastroenteritis Hernia Intestinal infarction/ischemia Ovarian torsion Pancreatitis Pelvic inflammatory disease Pyelonephritis Renal colic Testicular torsion

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Table 1. DIAGNOSTIC STUDIES FOR COMMON ABDOMINAL PRESENTATIONS

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Helical Doppler,

Barium HCG, pr Fecal le Physical Angiogr Doppler Lipase*, ESR, CR

Angiogr C-reacti HIDA s

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little additional cost than a complete abdominal series. Using similar inclusion criteria as noted previously, Rothrock et aP6reported a 48% reduction in unnecessary radiographs without missing any major disease. Campbell et all2reviewed 5080 patients with abdominal pain and reported that if the patient presented with suspected appendicitis, UTI, or nonspecific abdominal pain, the radiographs were not likely to be helpful and may, in fact, cloud the diagnosis. Results from this trial support the conclusion that radiographs without clear indication add little to the diagnosis and may actually delay the management of abdominal pain.12 Observation of selected emergency department abdominal pain patients is imperative. Early appropriate laboratories and radiographic testing combined with observation can reduce cost and resource without jeopardizing safety. An advantage of observation pathways is that the physician has the opportunity to narrow his or her diagnosis by observation and is not obligated to shot-gun the patient at presentation. The patient with mild diffuse abdominal pain may develop focal findings in the right lower quadrant, improve, or even be found to have other pathology clarified by serial evaluations.

SUMMARY

By approaching the abdominal pain patient in a systematic fashion, the physician can improve his or her performance in evaluating the patient in a safe and efficient manner without extensive or redundant tests.

References 1. Alvardo A: A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med 15:557-564, 1986 2. Andersson RE, Hugander A, Thulin AJ: Diagnostic accuracy and perforation rate in appendicitis: Association with age and sex of the patient with appendectomy rate. Eur J Surg 158:137-141, 1992 3. Banaszak P: Clinical quality improvement in a multihospital system: The Voluntary Hospitals of America/Pennsylvania experience. Am J Med Qua1 8:56-60, 1993 4. Berry J, Malt R: Appendicitis near its century. Ann Surg 200:567-575, 1984 5. Bower RJ, Bell MJ, Temberg J L Diagnostic value of the white blood count and neutrophil percentage in the evaluation of abdominal pain in children. Surg Gynecol Obstet 152424-426, 1981 6. Borrero E, Queral LA: Symptomatic abdominal aortic aneurysm misdiagnosed as nephrouterolithiasis. Ann Vasc Surg 2145-149, 1988 7. Brender JD, Marcuse EK, Koepsell TD, et al: Childhood appendicitis: Factors associated with perforation. Pediatrics 76:301-306, 1985 8. Brewer RJ, Golden GT, Hitch DC, et a1 Abdominal pain: An analysis of 1000 consecutive cases in a hospital emergency room. Am J Surg 131:219-223, 1976 9. Buchman RG, Zuidema G D Reasons for delay of the diagnosis of acute appendicitis. Surg Gynecol Obstet 158:260-266, 1984 10. Bums RP, Cochran JL, Russell WL, et al: Appendicitis in mature patients. Ann Surg 201:695-704, 1985 11. Cacioppo JC, Diettrich NA, Kaplon G, et al: The consequences of current constraints on surgical treatment of appendicitis. Am J Surg 157276280, 1989 12. Campbell JP, Gunn AA: Plain abdominal radiographs and acute abdominal pain. Br J Surg 75:554-556, 1988

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13. Ciccone A, Allegra JR, Cochrane DG, et a1 Age related differences in diagnoses within the elderly population. Am J Emerg Med 16:43-48, 1998 14. Dedombal FT Diagnosis of Acute Abdominal Pain. Edinburgh, Churchill Livingstone, 1980, p 17 15. Drake DP: Acute abdominal pain in children. J R SOCMed 73:641-645,1980 16. Fitz RH:Perforating inflammation of the vermiform appendix, with special reference to its early diagnosis and treatment. Am J Med Sci 184321-346, 1886 17. Gold M, Azevedo D The content of adult primary care episodes. Public Health Rep 9748-57, 1982 18. Gough IR, Morris MI, Pertnikovs EI, et al: Consequences of removal of a "normal" appendix. Med J Aust 16:370-372, 1983 19. Graff LG: Observation Units: Implementation and Management Strategies. American College of Emergency Physicians, Dallas, Texas, 1999. 20. Graff LG, Radford MJ, Weme C: Probability of appendicitis before and after observation. Ann Emerg Med 20:503-507, 1991 21. Jones PF: Acute abdominal pain in children, with special references to cases not due to acute appendicitis. Br Med J 1:284-286, 1969 22. Karp MP, Caldarola VH, Cooney DR The avoidable excesses in the management of perforated appendicitis in children. J Pediatr Surg 21:506-510, 1986 23. Klinkman M: Episodes of care for abdominal pain in a primary care practice. Arch Fam Med 5:279-286, 1996 Boey J, et a1 Appendicitis: A critical review of diagnosis and 24. Lewis FR, Holcroft JW, treatment in 1,000 cases. Arch Surg 110:677434, 1975 25. Lukens TW, Emerman C, Effron D The natural history and clinical findings in undifferentiated abdominal pain. Ann Emerg Med 226904596,1993 26. McCaig LG, Stussman BJ: National Hospital Ambulatory Medical Care Survey: 1996 emergency department survey. Adv Data 293:l-20, 1997 27. McCallion J, Canning GP, Knight RV, et al: Acute appendicitis in the elderly: A 5 year retrospective study. Age Ageing 1625G260, 1987 28. Mittelpunkt A, Nora PF: Current features in the treatment of acute appendicitis: An analysis of 1,000 consecutive cases. Surgery 60:971-975, 1966 29. Mueller BA, Daling JR, Mare DE, et al: Appendectomy and the risk of tuba1 infertility. N Engl J Med 315:150G1508,1987 30. Pauker SG, Kassier JP: The threshold approach to clinical decision making. N Engl J Med 3021109-1117, 1980 31. Pena BM, Taylor GA, Lund DP, et al: Effect of computed tomography on patient management and costs in children with suspected appendicitis. Pediatrics 104:440446, 1999 32. Pomper SR, Fiorillo MA, Anderson CW, et al: Hematuria associated with ruptured abdominal aortic aneurysms. Intern Surg 80:261-263, 1995 33. Rao I'M, Rhea JT, Novelline RA, et a1 Effect of computed tomography of the appendix on treatment of patients and use of hospital resources. N Engl J Med 33% 141-146,1998 34. Reynolds SL: Missed appendicitis in a paediatric emergency department. Pediatr Emerg Care 9:l-3, 1993 35. Rothrock SG, Green SM, Dobson M, et a1 Misdiagnosis of appendicitis in non pregnant women of childbearing age. J Emerg Med 13:l-8, 1995 36. Rothrock SG, Green SM, Harding M, et al: Plain abdominal radiography in the detection of acute medical and surgical disease in children: A retrospective analysis. Pediatr Emerg Care 7281-285, 1991 37. Rusnak RA, Borer J, Fastow J S Misdiagnosis of acute appendicitis in emergency department patients: An analysis of common errors discovered after litigation. Ann Emerg Med 20455, 1991 38. Savrin RA, Clatsworthy Hw: Appendiceal rupture: A continuing diagnostic problem. Pediatrics 63:37-43, 1979 39. Schere SS, Coil J A The continuing challenge of perforating appendicitis. Surg Gynecol Obstet 150:535-538, 1980 40. Scott JH, Amin M, Harty JI: Abnormal urinalysis in appendicitis. J Urol 129:1015, 1983

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41. Sox HC. Probability theory in the use of diagnostic tests. Ann Intern Med 10460-66, 1986 42. Thomson HJ, Jones PF: Active observation in acute abdominal pain. Am J Surg 152:522-525, 1986 43. White JJ, Santillana M, Haller JA: Intensive in-hospital observation: A safe way to decrease unnecessary appendectomy. Am Surg 41:793-798,1975

Address reprint requests to Louis G. Graff IV, MD, FACEP New Britain General Hospital 100 Grand Street New Britain, CT 06050