The NTAP Trap: Age Can Mask Abdominal Ills
The NTAP Trap: Age Can Mask Abdominal Ills
Increased pressure from MCOs to justify number of studies ordered must not result in misdiagnosis of life-threatening disease process
Concerns regarding patients presenting with non-traumatic abdominal pain (NTAP) have risen in recent years as hospitals and physicians face growing medical necessity concerns under managed care.
At the same time, the frequency of NTAP as a presenting problem has remained high while patients continue to be difficult to diagnose in the emergency setting, says Robert Bitterman, MD, JD, director of risk management and managed care with Carolinas Medical Center in Charlotte, NC.
This presenting complaint can be especially complicated if the patient’s ability to express the degree and locality of pain is compounded by age factors or an apparent unwillingness to cooperate with a triage team.
Young children and the very elderly are more likely than other patients to mislead emergency physicians when assessing the seriousness of NTAP, says Joel R. Gernsheimer, MD, director of emergency medicine residency at New York City’s Lincoln Medical and Mental Health Center.
There are no conclusive statistics available to support this claim. But the tendency for even the most experienced emergency physicians to "misread the markers of a serious, rapidly deteriorating condition linked to something like appendicitis in these patients can be fairly high," Gernsheimer says.
Managed care raising concerns
The primary obstacle is that the responses to pain and initial examination at the opposite extremes of age usually don’t fit the classic textbook models, Gernsheimer observes.
Typical perineal signs such as abdominal tenderness, rebound, or guarding may or may not indicate a serious underlying condition. In addition, pain thresholds among the very young or old vary considerably and are not good surface indicators of morbidity.
Therefore, physicians are advised to employ a narrower set of assumptions concerning the susceptibility of these patients to age-related morbidity, Gernsheimer warns. Conducting a complete and thorough history and physical is mandatory, he adds.
But in completing the history and physical, don’t automatically rule out acute conditions that are not commonly age-associated, such as primary intussusception in infants. Although rare in most children, these disorders may be present, he adds.1
Physicians are being advised to take special precautions in reaching a diagnosis with these patients. These steps should include:
• Resorting to a surgical consultation early in the process. This step is advised as early as possible, especially when ruling out the existence of a gall bladder infection or intestinal obstruction, Gernsheimer says. In children, the occurrence of an external hernia or primary volvulus could be responsible in the presence of acute pain. Excessive crying and discomfort, even vomiting and fever, aren’t sufficient to warrant a conclusive diagnosis. In elderly patients, abdominal guarding or rebound may signal common gastritis or medication-induced caustic irritation. But the signs can also mask early stages of peritonitis or worse, a leaking aortic aneurysm, observes Peter R. McNally, DO, chief of gastroenterology at Eisenhower Army Medical Center in Augusta, GA.
• Conducting serial exams to evaluate for worsening morbidity. Experienced physicians are likely to err on the side of caution and hold the NTAP patient for observation prior to making a final diagnosis, Gernsheimer says. Place the patient in a holding area and recheck the signs every half hour or hour. Gernsheimer advises. Serious conditions usually manifest themselves early. But these assumptions aren’t fool-proof. "Two hours later, something that initially looked like benign acidity may have finally evidenced as something far worse," he notes. (For a partial list of pain symptoms by rate of development, see the chart on page 109.)
• Considering circumstances external to the case. One factor that may warrant holding the patient for a serial exam might include the hour in which the case presents. "If that patient shows up in the middle of the night, even if the pain is vague and non-specific, I’d take it as a sign that something may or may not be wrong," Gernsheimer says. Fifty percent of the time, NTAP turns out to be nothing more than dyspepsia, McNally says. But consider your patient mix. If your hospital serves a predominantly low-income community, the likelihood is greater that many patients will be uninsured and lack good primary care. The ability to obtain early diagnosis and intervention from a primary care physician for serious conditions might also be lacking, resulting in acute flare-ups. Physicians should consider these factors when weighing the nature of each case, McNally advises.
• Avoiding misconceptions regarding age factors in patients. Believing that children are for some reason more vulnerable than adults to diseases or that the elderly are more accepting of medications also can get you in trouble, McNally warns. Painting in these broad strokes about patients can adversely color your assessments, he adds. They can blur your judgment when trying to intelligently assess crampy, colicky signs of pain as something critical. The signs may actually indicate something benign, McNally says. In elderly patients especially, episodes of caustic medication-related irritation are common. But they can obscure something far worse underlying the chief complaint, he adds.
Weigh the value of ancillary testing as a diagnostic tool. Lab testing to determine perineal inflammation or perfusion is often valuable. However, these tests are not reliable in reaching intelligent conclusions regarding an underlying condition by themselves, Gernsheimer says.
Complete blood counts (CBCs) and urinalyses, which are routinely performed in evaluating NTAP, aren’t reliable because their findings often account for other, unrelated factors in the blood or urine, including a vaginal discharge.
Some studies show that as many as 40% of patients suffering from acute appendicitis had normal white blood cell counts within the 10,000-cell range, Gernsheimer says. On the other hand, simple stress or dehydration can account for an elevated white count. "An infection can also overwhelm white cells and result in a lower-than-normal reading," he adds.
Reference
1. Gupta J, Gernsheimer J, Golden J. Acute abdominal pain and vomiting in a 10-year-old girl. Ann Em Med 1997; 303:322-328.
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