Assessment of the Adult Patient Presenting With Knee Pain a Review Article

Abstruse

Purpose

Abdominal pain is the most common reason for surgical referral. Imaging, aids early on diagnosis and treatment. All the same unnecessary requests are associated with increased costs, radiations exposure and increased length of stay. Pathways can meliorate the quality of the diagnostic process. The aim of this systematic review was to identify the current testify for diagnostic pathways and their utilise of imaging and effect on concluding outcomes.

Data sources

A systematic search of Embase, Medline and Cochrane databases was performed using keywords and MeSH terms for abdominal hurting.

Study selection

All papers describing a pathway and published between Jan 2000 and January 2017 were included.

Data extraction

Information was obtained virtually the use of imaging, complications and length of stay. Quality assessment was performed using MINORS and Level of Evidence.

Results

X articles were included, each describing a different pathway. 5 studies based the pathway on literature reviews lonely and v studies on the results of their prospective study. Of the latter five studies, iv showed that routine imaging increased diagnostic accuracy, merely without showing a reduction in length of stay, complication rate or bloodshed. None of the studies included evaluated apply of hospital resources or costs.

Conclusion

Pathways incorporating routine imaging will improve early diagnosis, but has not been proven to reduce complexity rates or hospital length of stay. On the basis of this systematic review conclusions can therefore not be drawn about the pathways described and their do good to the diagnostic procedure for patients presenting with intestinal hurting.

Background

Up to 10% of all presentations to the emergency department (ED) are patients presenting with abdominal pain. The differential diagnosis is very broad and covers multiple specialties [1]. Rapid and accurate diagnosis is of importance to commencement treatment as presently as possible to ensure the best possible consequence. The standard diagnostic processes for a patient presenting with abdominal pain to ED includes; taking a clinical history and performing a physical examination and additional work-up in the form of blood tests, urine and if considered necessary obviously X-rays. The apply of boosted imaging, especially computed tomography (CT) scanning, for this group of patients has increased over the terminal decade, because of the well-described diagnostic accuracy [2–four]. This increase in the use of this CT scans has downsides, it can atomic number 82 to college costs and a delay in diagnosis due to waiting times. The risks also include contrast allergies, contrast induced nephropathy and ionising radiation exposure. A study published last twelvemonth, reviewing the care around patients presenting with abdominal hurting to our establishment over the last decade, showed that use of CT scans increased from 26.0% in 2004 to 45.0% in 2014 and an increasing proportion of these scans are negative for acute surgical pathology (17.3% in 2004 compared with 34.4% in 2014) [5].

Introductions of clinical pathways are common and aim to amend patient care. They can reduce inter-clinician decision variation, improve quality of intendance and maximise the outcomes for patients [six, 7]. The European Pathways Association (EPA) developed 5 criteria to define a clinical pathway: (one) an explicit statement of the goals and key elements of care based on prove, all-time practice, and patients' expectations and their characteristics; (2) the facilitation of the communication among the team members and with patients and families; (three) the coordination of the care procedure past coordinating the roles and sequencing the activities of the multidisciplinary intendance team, the patients and their relatives; (4) the documentation, monitoring, and evaluation of variances and outcomes and (5) the identification of the appropriate resource [8]. A pathway to diagnose patients presenting with new intestinal hurting to the ED could be helpful to better patient care and multidisciplinary communication and to guide doctors in the ED about when to use imaging.

Study objectives

The aim of this systematic review was to evaluate studies describing diagnostic pathways, particularly with respect to use of imaging, for patients presenting with abdominal hurting and the issue of these pathways on diagnostic accuracy, and last outcomes such as morbidity, mortality and length of stay.

Methods

A systematic review was performed using Preferred Reporting Items for Systematic.

Reviews and Meta-Analyses (PRISMA) to identify, select and critically appraise relevant research while minimising bias. The PRISMA statement was used to cheque the manuscript for its completeness and accuracy [9].

Search strategy

We performed an extensive literature search of the Medline, Cochrane and EMBASE databases from 1 January 2000 to 31 January 2017 using the MeSH term 'acute abdomen' OR the keywords 'abdominal pain' OR acute abdomen. Nosotros limited the search to papers including adults and articles written in English, Spanish, French, German or Dutch. Titles and abstracts were examined to determine the relevance of the information past ii authors. Full text was obtained for the studies that were relevant on the basis of title and abstract. These were again reviewed by the same 2 authors and a concluding inclusion pick was fabricated.

Study selection

All studies describing a pathway for diagnosing intestinal pain or a specific diagnosis causing abdominal hurting (e.m. appendicitis or diverticulitis) and that fulfilled at least a majority of the EPA criteria for a clinical pathway were included.

Data extraction

3 authors screened each written report and extracted information independently using standard format. Consensus was reached by discussion. The following data was extracted from each report: first writer's last name; publication year; number of patients; study blueprint; the described pathway and use of additional imaging and final outcomes (complications, mortality and length of stay) and if the pathway was prospectively tested by the authors of the included study. For the use of imaging, ii categories were used to describe the frequency of the apply of this modality, selective or routine. If specific criteria for the use of imaging were described, this was described every bit selective use. While routine meant that nearly all patients underwent some form of imaging.

Quality assessment

In ascertainment of PRISMA guidelines, the methodological quality of the studies was assessed using the Methodological Alphabetize for Not-Randomised Studies (MINORS) every bit the included studies were all of different pattern [10, eleven]. The maximum score for a non-comparative study is sixteen and for a comparative study, 24. The Oxford Centre for Evidence-based Medicine, Levels of Evidence was also used [12]. Quality cess was independently performed by two authors and consensus was reached by discussion and if considered necessary a third writer was consulted. In order to assess the complexity of the included pathways, all four authors were asked to rank the pathways included every bit; easy, medium or hard to follow and the number of decision and terminate points in each pathway were calculated to give each a score. The authors ranking of the pathway were and so compared with these score. Furthermore, the take a chance of bias was assessed for each included report and summarised [9].

Results

Written report choice

A total of 1839 citations were identified using our search criteria in Embase and 3953 in Medline. Duplicates were removed leaving the total at 4655 articles. The championship and abstracts of these articles were reviewed by two authors, the majority of the studies were excluded as they did not mention a diagnostic procedure of patients with abdominal pain in either the title or the abstruse. The full text was obtained for 136 articles, from these a further 126 articles were excluded every bit they did non describe a pathway every bit described past the EPA criteria. This lead to a total of 10 papers included in this review (Fig. 1). A summary of the proposed pathways is shown in Tables 1 and 2.

Figure i

Flow diagram of study search and inclusion.

Figure 1

Flow diagram of written report search and inclusion.

Table ane

Included studies characteristics, quality assessment and pathway summary

	Year publication	Written report type	Level of evidence	MINORS	Complexity pathway	Assessment specifics	Role of US	Role of CT
Ng et al.	2002	RCT	1b	due north/a	Medium	Standard	–	Routine
Lameris et al.	2009	Prospective cohort	1b	16	n/a	Urgent vs. non-urgent	Routine	Selective
Scott et al.	2015	Prospective accomplice	1b	14	Low	Low/intermediate/high gamble appendicitis	Selective	Selective
Toorenvliet et al.	2010	Prospective cohort	1b	11	Low	Suspected appendicitis	Routine	Selective
Majewski et al.	2000	Prospective accomplice	3b	11	Medium	Standard	Routine	Selective
Gans et al.	2014	Literature review	5	n/a	High	Urgent vs non-urgent	Routine	Selective
Karul et al.	2013	Literature review	five	n/a	Medium	Suspected appendicitis	Routine	Selective
Lyon et al.	2006	Literature review	v	n/a	Medium	Standard, focussed on elderly patient	Selective	Selective
Trentzsch et al.	2011	Literature review	5	n/a	Loftier	Subdivided per probable diagnosis	Routine	Selective
Mayumi et al.	2015	Literature review	v	north/a	Medium	Urgent vs. non-urgent	Selective	Routine

	Yr publication	Study type	Level of prove	MINORS	Complexity pathway	Cess specifics	Role of The states	Role of CT
Ng et al.	2002	RCT	1b	n/a	Medium	Standard	–	Routine
Lameris et al.	2009	Prospective cohort	1b	16	due north/a	Urgent vs. non-urgent	Routine	Selective
Scott et al.	2015	Prospective accomplice	1b	14	Low	Low/intermediate/high risk appendicitis	Selective	Selective
Toorenvliet et al.	2010	Prospective cohort	1b	11	Low	Suspected appendicitis	Routine	Selective
Majewski et al.	2000	Prospective cohort	3b	11	Medium	Standard	Routine	Selective
Gans et al.	2014	Literature review	5	n/a	High	Urgent vs non-urgent	Routine	Selective
Karul et al.	2013	Literature review	five	due north/a	Medium	Suspected appendicitis	Routine	Selective
Lyon et al.	2006	Literature review	5	n/a	Medium	Standard, focussed on elderly patient	Selective	Selective
Trentzsch et al.	2011	Literature review	5	due north/a	High	Subdivided per likely diagnosis	Routine	Selective
Mayumi et al.	2015	Literature review	5	n/a	Medium	Urgent vs. non-urgent	Selective	Routine

RCT, randomised controlled trial; n/a, not applicative.

References: Level of evidence, Oxford Centre of Evidence-based Medicine [12], MINORS, Zeng et al. 2015 [11]

Tabular array 1

Included studies characteristics, quality assessment and pathway summary

	Year publication	Report type	Level of evidence	MINORS	Complexity pathway	Assessment specifics	Function of United states of america	Role of CT
Ng et al.	2002	RCT	1b	northward/a	Medium	Standard	–	Routine
Lameris et al.	2009	Prospective accomplice	1b	16	n/a	Urgent vs. non-urgent	Routine	Selective
Scott et al.	2015	Prospective accomplice	1b	14	Low	Low/intermediate/high risk appendicitis	Selective	Selective
Toorenvliet et al.	2010	Prospective cohort	1b	eleven	Low	Suspected appendicitis	Routine	Selective
Majewski et al.	2000	Prospective accomplice	3b	11	Medium	Standard	Routine	Selective
Gans et al.	2014	Literature review	5	n/a	High	Urgent vs non-urgent	Routine	Selective
Karul et al.	2013	Literature review	v	n/a	Medium	Suspected appendicitis	Routine	Selective
Lyon et al.	2006	Literature review	5	n/a	Medium	Standard, focussed on elderly patient	Selective	Selective
Trentzsch et al.	2011	Literature review	5	n/a	High	Subdivided per probable diagnosis	Routine	Selective
Mayumi et al.	2015	Literature review	five	north/a	Medium	Urgent vs. non-urgent	Selective	Routine

	Year publication	Study type	Level of show	MINORS	Complexity pathway	Cess specifics	Part of US	Part of CT
Ng et al.	2002	RCT	1b	n/a	Medium	Standard	–	Routine
Lameris et al.	2009	Prospective cohort	1b	16	n/a	Urgent vs. non-urgent	Routine	Selective
Scott et al.	2015	Prospective accomplice	1b	xiv	Low	Low/intermediate/high take a chance appendicitis	Selective	Selective
Toorenvliet et al.	2010	Prospective cohort	1b	eleven	Low	Suspected appendicitis	Routine	Selective
Majewski et al.	2000	Prospective accomplice	3b	11	Medium	Standard	Routine	Selective
Gans et al.	2014	Literature review	5	n/a	High	Urgent vs not-urgent	Routine	Selective
Karul et al.	2013	Literature review	5	n/a	Medium	Suspected appendicitis	Routine	Selective
Lyon et al.	2006	Literature review	5	n/a	Medium	Standard, focussed on elderly patient	Selective	Selective
Trentzsch et al.	2011	Literature review	5	northward/a	High	Subdivided per probable diagnosis	Routine	Selective
Mayumi et al.	2015	Literature review	5	n/a	Medium	Urgent vs. non-urgent	Selective	Routine

RCT, randomised controlled trial; n/a, not applicative.

References: Level of evidence, Oxford Centre of Evidence-based Medicine [12], MINORS, Zeng et al. 2015 [11]

Table ii

Summary proposed algorithms

	Initial assessment	Role plain X-ray	Role of US	Role of CT	Complexity
Ng et al.	Standard	Selective	–	Routine	Medium
Lameris et al.	Urgent vs. non-urgent	Selective	Routine	Selective	–
Scott et al.	Low/intermediate/high risk appendicitis	–	Selective	Selective	Depression
Toorenvliet et al.	Suspected appendicitis	–	Routine	Selective	Depression
Majewski et al.	Standard	Routine	Routine	Selective	Medium
Gans et al.	Urgent vs. not-urgent	Selective	Routine	Selective	High
Karul et al.	Suspected appendicitis	–	Routine	Selective	Medium
Lyon et al.	Standard, focussed on elderly patient	Routine	Selective	Selective	Medium
Trentzsch et al.	Subdivided per probable diagnosis	Selective	Routine	Selective	High
Mayumi et al.	Urgent vs. non-urgent	Selective	Selective	Routine	Medium

	Initial assessment	Office plain X-ray	Role of Usa	Role of CT	Complication
Ng et al.	Standard	Selective	–	Routine	Medium
Lameris et al.	Urgent vs. not-urgent	Selective	Routine	Selective	–
Scott et al.	Low/intermediate/high chance appendicitis	–	Selective	Selective	Depression
Toorenvliet et al.	Suspected appendicitis	–	Routine	Selective	Low
Majewski et al.	Standard	Routine	Routine	Selective	Medium
Gans et al.	Urgent vs. non-urgent	Selective	Routine	Selective	High
Karul et al.	Suspected appendicitis	–	Routine	Selective	Medium
Lyon et al.	Standard, focussed on elderly patient	Routine	Selective	Selective	Medium
Trentzsch et al.	Subdivided per probable diagnosis	Selective	Routine	Selective	High
Mayumi et al.	Urgent vs. non-urgent	Selective	Selective	Routine	Medium

Table two

Summary proposed algorithms

	Initial assessment	Role plain X-ray	Role of United states of america	Role of CT	Complexity
Ng et al.	Standard	Selective	–	Routine	Medium
Lameris et al.	Urgent vs. non-urgent	Selective	Routine	Selective	–
Scott et al.	Low/intermediate/high risk appendicitis	–	Selective	Selective	Low
Toorenvliet et al.	Suspected appendicitis	–	Routine	Selective	Low
Majewski et al.	Standard	Routine	Routine	Selective	Medium
Gans et al.	Urgent vs. not-urgent	Selective	Routine	Selective	High
Karul et al.	Suspected appendicitis	–	Routine	Selective	Medium
Lyon et al.	Standard, focussed on elderly patient	Routine	Selective	Selective	Medium
Trentzsch et al.	Subdivided per likely diagnosis	Selective	Routine	Selective	High
Mayumi et al.	Urgent vs. not-urgent	Selective	Selective	Routine	Medium

	Initial assessment	Part patently X-ray	Role of Usa	Part of CT	Complexity
Ng et al.	Standard	Selective	–	Routine	Medium
Lameris et al.	Urgent vs. non-urgent	Selective	Routine	Selective	–
Scott et al.	Low/intermediate/high risk appendicitis	–	Selective	Selective	Depression
Toorenvliet et al.	Suspected appendicitis	–	Routine	Selective	Low
Majewski et al.	Standard	Routine	Routine	Selective	Medium
Gans et al.	Urgent vs. not-urgent	Selective	Routine	Selective	Loftier
Karul et al.	Suspected appendicitis	–	Routine	Selective	Medium
Lyon et al.	Standard, focussed on elderly patient	Routine	Selective	Selective	Medium
Trentzsch et al.	Subdivided per probable diagnosis	Selective	Routine	Selective	High
Mayumi et al.	Urgent vs. non-urgent	Selective	Selective	Routine	Medium

Characteristics of the included studies

Five out of the ten included studies based their pathway based on the results of a prospective study [2, 13–16].

1 of these was a randomised controlled trial. In this written report, Ng et al. [15] compared routine versus selective CT scans for patients with acute abdominal hurting. They establish that routine CT scanning was associated with significantly less missed serious diagnoses compared with the selective imaging grouping (13% vs. 4%, P = 0.014). In the selective imaging grouping, only 11.1% had a CT scan. Length of stay was 5.3 days for the routine imaging group versus half dozen.4 days for the selective imaging group (P = 0.17). Therefore, the authors recommend routine CT scans for patients presenting with acute abdominal pain.

Two prospective cohort studies examined pathways for the management of patients with suspected appendicitis [fourteen, 16]. Toorenvliet et al. [xvi] included 802 patients with intestinal pain just mainly focused on patients with suspected appendicitis. Their pathway included routine ultrasound (U.s.a.) and selective CT scanning (17.9%). Patients with an unclear diagnosis, were re-evaluated the adjacent mean solar day and if considered necessary re-imaged. Their main outcome was the negative appendicectomy charge per unit (NAR), which was 3.3%. They concluded that routine US scan, utilize of selective CT scanning and re-assessing patient if diagnosis is unclear inside 24 h is associated with high diagnostic accuracy and low NAR for patients with suspected appendicitis. Scott el al. [14] included 464 patients with suspected appendicitis. They applied the Appendicitis Inflammatory Response (AIR) score for all patients (low adventure: AIR score <5, intermediate 5–9, high risk for appendicitis score >9), apply of additional imaging (Usa and CT scan) was at the discretion of the surgical team. Negative and positive likelihood ratios were calculated afterwards, for ruling out appendicitis with assistance of additional imaging and related to the risk of having appendicitis based on the AIR score. On the basis of their results, they adult a pathway with specific imaging modalities for patients with depression, intermediate or high risks for having appendicitis, they did not prospectively evaluate this pathway.

The remaining ii prospective cohort studies were for all cause acute abdominal hurting [2, xiii]. Lameris et al. [2] included 1021 patients with abdominal pain in a multicentre prospective cohort study. The methodology employed in this study was to give all patients routine assessment, plain radiography, US and CT scan, and and so to post-hoc employ eleven diagnostic pathways based on combinations of imaging. They concluded that the pathway associated with the highest diagnostic accuracy was routine U.s. and CT scans if the U.s.a. results were negative (sensitivity of 94% and specificity of 68%). Use of this pathway lead to a total of 1021 US (100%) and 501 CT scans (49.ane%). They did not prospectively evaluate this pathway and they did not address complication rate or length of stay for the included patients. In the remaining clinical cohort, Majewski et al. [13], which compared the results of single operator diagnostic laparoscopies (DL) in 120 patients with acute intestinal hurting (both traumatic and non-traumatic) compared with diagnostic accuracy and length of stay to 310 patients that were diagnosed without DL and treated past a dissimilar consultant. This study concluded that DL was associated with a diagnostic accuracy of 88.half dozen%. Length of stay was a median of 5 days in the DL group compared with six days in the control grouping (P = <0.0003). Therefore, the authors concluded that DL is accurate for diagnosing patients with both traumatic and non-traumatic abdominal pain and reduces length of stay. On the footing of their results, they designed a pathway that includes standard Us equally role of the work-upward of the patients and to go along with a DL when diagnosis is still uncertain. They did not prospectively evaluate their pathway.

Across these v clinical studies, data on diagnostic accuracy was given in four cases for the whole cohort, and ranged from 75% to 96.7%, although the latter was in suspected appendicitis only (Table 2). The 5th clinical written report reported diagnostic accuracies, per risk stratification on the ground of the AIR score [14]. Routine US followed by selective utilize of CT appeared to be associated with the highest diagnostic accuracy beyond these studies. None of the studies provided any data on complications. While bloodshed data and length of stay information was provided in three studies, comparison beyond these studies for these parameters is not warranted due to differences in patient cohorts.

The other five included studies developed a pathway based on a literature review alone. Iii were developed to aid the differentiation of acute from non-acute abdominal hurting [17–19], i was developed to improve the diagnosis of appendicitis [xx] and the last to ameliorate diagnosis of abdominal hurting in the older [21]. Three of these five concluded routine US was essential as role of the diagnostic work-upwards [17, 18, 20], ane study opted for use of routine CT scanning to assist diagnosis [19] and the concluding study concluded that imaging (CT or The states scan) may either exist required or non based on the differential diagnosis [21].

Quality assessment

The level of bear witness among the 10 included studies ranged between 1b and 5, according to the Oxford scale of level of evidence. The MINORS score could only be calculated for the studies that included patients and were non-randomised and ranged from 11 to 16 (Table 1).

The complexity assessments are summarised in Table one, there was no relevant discrepancy between the four authors and their ranking of the pathway as like shooting fish in a barrel, medium or hard to follow. Pathways that were accounted easy to follow by the authors had a lower number of end and decision points compared with the medium or difficult to read pathways (average number of cease points, respectively, 2, 6 and viii and decision points 4, 6 and 14, respectively). No complication assessment for Lameris et al. [2] study could be made equally this study describes multiple pathways.

Word

This systematic review included 10 studies describing a pathway for diagnosing patients presenting with abdominal hurting. Five studies were literature reviews describing a pathway on the basis of their search and with or without the communication of an expert steering grouping. Five studies based their pathway on the results of their prospective cohorts, two of these studies were for patients with suspected appendicitis. Effects of the introduction of the pathways on costs, complications and length of stay were scarcely reported.

Using pathways to diagnose patients presenting with abdominal hurting to the ED can be extremely valuable to reduce inter-collegial differences, improve advice, standardise use of diagnostic tools and thereby meliorate patient care. Multiple specialties (including: emergency physicians, gynaecologists, urologists, full general surgeons, etc.) can exist involved in this diagnostic process and therefore a pathway should be widely applicable to all [six, 7].

Three pathways included in this study were for patients with suspected appendicitis [fourteen, xvi, 20]. Appendicitis is the virtually common diagnosis for patients to exist referred to full general surgery with acute abdominal hurting [22]. The diagnosis, even so, can be obscure and therefore some centres back up the use of routine imaging in the course of The states and/or CT scanning. It has been shown that routine diagnostic imaging lowers the NAR to one.vii–half-dozen.ii% [23–25]. While in hospitals where imaging is not used routinely, the NAR can be between xx.6 and 38.9% [26, 27]. 2 of the three pathways for diagnosing patients with suspected appendicitis included in this study support the use of routine US [sixteen, xx], all three studies advocated the utilize of selective CT scanning.

Of the other vii studies describing a pathway for diagnosing patients with abdominal pain, only three were based on results from a prospective report. One of them supports the use of routine CT scanning [15], one the utilize of routine U.s. followed by a CT browse if US results are negative [2] and the concluding one the use of DL when diagnosis after routine US remains unclear. Diagnostic accuracy is high in all of the iii studies due to the routine use of imaging. Even so, applying any of these three pathways will lead to a substantial increase in the number of requests for imaging while none of these studies have reported results of costs analysis, a reduction in the incidence of morbidity, mortality or length of stay. The remaining four studies based their pathways on their literature review [17–19, 21]. The use of imaging differs per study, two support the use of routine US followed by selective CT scanning [17, xviii], 1 uses both forms of imaging selectively [21] and the concluding 1 supports the utilize of selective US only routine utilise of CT scans [19].

In this study, we evaluated pathways for diagnosing patients with abdominal pain, published in peer reviewed journals. However, there are a number of pathways published on the Internet. Including UpToDate [28], which describes a pathway for diagnosing patients over 50 years of age and women of childbearing age with abdominal pain. The document has an educational approach. The American Family Doc [29] describes multiple pathways depending on the location of the pain and the characteristics of the patients, only mainly targets the full general practice setting. Lastly, the Royal College of Surgeons [xxx] describes a pathway in which they differentiate between non-urgent, intermediate and urgent patients. They suggest immediate senior (registrar or consultant) review for the urgent patient and observation with or without additional imaging for the intermediate patient. Even so, none of these pathways have been prospectively evaluated and therefore no conclusions about efficiency and reduction in morbidity, mortality or length of stay tin can exist drawn.

Evaluating the use of imaging of the x included studies, most studies recommend the utilise of routine U.s. followed past CT scanning when in that location is still diagnostic uncertainty. Notwithstanding, accurateness for US varies widely in literature, with sensitivities every bit loftier as 77–91% in countries in Western Europe [xvi, 31] where United states of america appears to exist the standard diagnostic tool. On the other paw, US accurateness is operator and infirmary dependent and pregnant lower sensitivities have been reported every bit well [32, 33]. Another issue with US is the access of information technology out of hours is infirmary dependent. Use of CT scans comes with high diagnostic accuracy [25, 34], but there are also significant limitations to routine apply of this diagnostic tool, including: costs, longer waiting times, patient radiation exposure, contrast induced nephropathy and dissimilarity allergies, for the apply of CT scans [35–37].

Part of our assessment of the described pathways was to look at the complexity of the pathways. To our cognition, in that location is no standardised assessment tool to evaluate the complexity and the quality of a pathway, therefore nosotros came up with the ranking equally previously described. Aiming for a pathway that is easy to medium to follow would be preferable, as the authors believe that implementing a difficult pathway will probable result in reduced cooperation from involved clinicians.

Limitations of this written report should exist considered. Firstly, the design of the study ways that simply published literature could be included. Secondly, difficulties arose when comparing the unlike pathways described, as a number was designed for sub-diagnosis like appendicitis, while some other focused mainly on abdominal pain in the elderly. However, the aims were to describe the pathways published in peer reviewed journals and their use of additional imaging and whether this has had an outcome on last outcomes.

Conclusion

Multiple pathways take been described for diagnosing abdominal pain. This study shows that simply a small proportion has been published in peer reviewed literature and the bulk of these pathways have not been prospectively evaluated. Nearly of the included studies support routine imaging either in the course of CT scans or routine Usa followed by CT scan when there is diagnostic uncertainty. This will improve early and accurate diagnosis for the patient presenting with abdominal pain, but has non been proven to reduce complication rate, mortality or length of stay. Besides, none of the studies included evaluated use of infirmary resource, waiting times and cost implications. Therefore, on the footing of this systematic review no recommendations can be fabricated about the use of whatever of these pathways for diagnosing patients with abdominal pain.

Funding

'This work was supported by a doctoral scholarship of the University of Otago; and a grant from the Surgical Research Trust in combination with 'phil&teds' to KB'.

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