New guideline for low-risk, recurrent abdominal pain in emergency department released

A multidisciplinary panel of experts and a patient stakeholder assessed the certainty of evidence and strength of recommendations regarding four priority questions for adults presenting to the emergency department (ED) with low-risk, recurrent, undifferentiated abdominal pain.

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, they suggest against ultrasound unless there is concern for pelvic or biliary pathology;

(3) they suggest that screening for depression and/or anxiety be performed during the ED evaluation;

(4) they suggest an opioid-minimizing strategy for pain control.

To write this clinical practice guideline, the panel used Grading of Recommendations Assessment Development and Evaluation (GRADE) methodology, a framework used by 110 organizations from 19 countries for rating the quality of the best available evidence and developing transparent clinical practice recommendations.

GRACE-2 authors found that 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 clinically relevant and widely acceptable definitions of low-risk, recurrent, undifferentiated abdominal pain before quantifying the frequency of annual ED visits for this complaint, associated costs of care, and patient and provider preferences in terms of diagnostic certainty and therapeutic priorities.

"The GRACE-2 writing committee was focused on the common but challenging questions we confront every day in the emergency department. While the evidence we found was limited, we identified key areas for future research, and we hope the transparency of the process and our recommendations will help physicians and patients."

The SAEM GRACE program addresses the best practices for the care of the most common chief complaints that can be seen on the tracking board of any ED in the country, based upon research and expert consensus. These guidelines are designed with de-implementation as a guiding principle to reasonably reduce wasteful testing, provide explicit criteria to reduce foreseeable risk, while defining sensible and prudent medical care. In addition to GRACE-2 for abdominal pain, SAEM GRACE teams have previously published guidelines for recurrent, low risk chest pain and are currently working on clinical practice guidelines for acute dizziness and non-opioid substance dependence.

Recommendations

Recommendation 1: In adult ED patients with low-risk, recurrent, undifferentiated abdominal pain and prior negative computed tomography of the abdomen and pelvis (CTAP) within 12 months, there is insufficient evidence to accurately identify populations in whom repeat imaging can be safely avoided or routinely recommended in the ED. (No recommendation) [No evidence]

Recommendation 2: In adult ED patients with low-risk, recurrent, undifferentiated abdominal pain and a negative CTAP with IV contrast in the ED, we suggest against ultrasound unless there is concern for pelvic or biliary pathology. (Conditional recommendation, against) [Very low certainty of evidence]

Recommendation 3: In adult ED patients with low-risk, recurrent, undifferentiated abdominal pain, we suggest screening for depression and/or anxiety may be performed during the ED evaluation. (Conditional recommendation, either) [Very low certainty of evidence]

Recommendation 4: In adult ED patients with low-risk, recurrent, undifferentiated abdominal pain, we suggest an opioid-minimizing strategy for pain control. (Conditional recommendation, for) [Consensus, no evidence]

Read the full article at:

https://dx.doi.org/10.1111/acem.14495