Guidelines for Reasonable and Appropriate Care in the Emergency Department 2 (GRACE-2): Low-risk, recurrent abdominal pain in the emergency department

Joshua S. Broder, Department of Surgery, Division of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA.
Lucas Oliveira J E Silva, Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota, USA.
Fernanda Bellolio, Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota, USA.
Caroline E. Freiermuth, Department of Emergency Medicine, University of Cincinnati School of Medicine, Cincinnati, Ohio, USA.
Richard T. Griffey, Department of Emergency Medicine and Emergency Care Research Core, Washington University School of Medicine, St. Louis, Missouri, USA.
Edmond Hooker, Department of Health Services Administration, Xavier University, Cincinnati, Ohio, USA.
Timothy B. Jang, Department of Emergency Medicine, University of California Los Angeles, UCLA Santa Monica Medical Center, Torrance, California, USA.
Andrew C. Meltzer, Department of Emergency Medicine, George Washington University School of Medicine & Health Sciences, Washington, DC, USA.
Angela M. Mills, Department of Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA.
Joan D. Pepper, Patient Representative, Durham, North Carolina, USA.
Steven D. Prakken, Avance Health, Raleigh, North Carolina, USA.
Michael D. Repplinger, BerbeeWalsh Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.
Suneel Upadhye, Division of Emergency Medicine, McMaster University, Hamilton, Ontario, Canada.
Christopher R. Carpenter, Department of Emergency Medicine and Emergency Care Research Core, Washington University School of Medicine, St. Louis, Missouri, USA.

Document Type

Journal Article

Publication Date

5-1-2022

Journal

Academic emergency medicine : official journal of the Society for Academic Emergency Medicine

Volume

29

Issue

5

DOI

10.1111/acem.14495

Keywords

abdominal pain; analgesia; anxiety; computed tomography; depression; emergency department; low-risk; opioid; recurrent; ultrasound

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.

Department

Emergency Medicine

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