Scandinavian Journal of Gastroenterology

ISSN: 0036-5521 (Print) 1502-7708 (Online) Journal homepage: http://www.tandfonline.com/loi/igas20

Non-specific abdominal pain remains as the most

common reason for acute abdomen: 26-year
retrospective audit in one emergency unit

Anne Fagerström, Paavo Paajanen, Heidi Saarelainen, Mirella Ahonen-

Siirtola, Mika Ukkonen, Pekka Miettinen & Hannu Paajanen

To cite this article: Anne Fagerström, Paavo Paajanen, Heidi Saarelainen, Mirella Ahonen-Siirtola,
Mika Ukkonen, Pekka Miettinen & Hannu Paajanen (2017): Non-specific abdominal pain remains
as the most common reason for acute abdomen: 26-year retrospective audit in one emergency unit,
Scandinavian Journal of Gastroenterology

To link to this article: http://dx.doi.org/10.1080/00365521.2017.1342140

Published online: 28 Jun 2017.

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SCANDINAVIAN JOURNAL OF GASTROENTEROLOGY, 2017
https://doi.org/10.1080/00365521.2017.1342140

ORIGINAL ARTICLE

Non-specific abdominal pain remains as the most common reason for acute
abdomen: 26-year retrospective audit in one emergency unit
€ma, Paavo Paajanenb
, Heidi Saarelainenb, Mirella Ahonen-Siirtolac, Mika Ukkonend,
Anne Fagerstro
Pekka Miettinena,b and Hannu Paajanena,b
a
Department of Gastrointestinal Surgery, Kuopio University Hospital, Kuopio, Finland; bSchool of Medicine, Faculty of Health Sciences,
University of Eastern Finland, Kuopio, Finland; cDepartment of Surgery, Oulu University Hospital, Oulu, Finland; dDepartment of
Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland

ABSTRACT ARTICLE HISTORY

Objective: Distribution of diagnoses causing acute abdominal pain (AAP) may change because of Received 3 May 2017
population aging, increased obesity, advanced diagnostic imaging and changes in nutritional habits. Revised 29 May 2017
Our aim was to evaluate the diagnoses causing AAP during a 26-year period. Accepted 7 June 2017
Materials and methods: This was a retrospective cross-sectional cohort study in one emergency
department (ED) covering population about 250,000. All patients admitted to the ED in 1986, 2003 and KEYWORDS
2012 were evaluated from hospital electronic database. Demographic data, utilization of diagnostic Acute abdominal pain;
tests, surgical treatment and discharge diagnosis were analyzed. Statistical data of population aging, aging; diagnosis; time-
obesity and alcohol consumption during 1980–2012 were obtained from national registers. dependent changes
Results: The AAP patients represented 10–20% of our total ED census. The most common causes of
AAP were nonspecific abdominal pain (NSAP, 31–37%), acute appendicitis (11–23%), biliary disease
(9–11%), bowel obstruction (5–7%), acute pancreatitis (4–8%) and acute diverticulitis (1–7%). The per-
centage of NSAP remained highest throughout the study period. Decrease in the number of acute
appendicitis (from 23 to 11%; p < .0001), increase in acute diverticulitis (from 1 to 5%; p  .0001) and
acute pancreatitis (from 4 to 7%; p ¼ .0273) was observed over time. The utilization of diagnostic imag-
ing increased significantly (CT from 2 to 37% and US from 4 to 38%, p < .0001). Hospital mortality was
very low (1–2%).
Conclusions: NSAP is still the main differential diagnostic problem in the ED. Except acute appendicitis,
distribution of specific diagnoses causing AAP remained rather stable through 26-year audit.

Introduction study was to find out the possible changes of underlying

Acute abdominal pain (AAP) is defined as pain of non-trau-
matic origin with a maximum duration of 7 days [1,2]. It is
one of the most common complaints leading patient to the
emergency department (ED) accounting for up to 7–10% of
all ED visits [3,4]. AAP can be caused by a wide variety of
conditions, most common reasons have been previously non-
specific abdominal pain (20–30%), acute appendicitis
(10–20%), acute biliary disease (10%), acute diverticulitis
(5–10%) and bowel obstruction (5–10%) [5,6].
Despite a relatively high frequency, AAP may be a symp-
tom of a serious underlying disease needing immediate sur-
gical treatment. The challenging differential diagnosis may
generate both medico-legal litigation and unfavorable out-
comes. Rapid and accurate detection of urgent conditions is
vital for managing and for efficient throughput of patients.
There are only few long-term epidemiological studies of dis-
eases causing AAP [3,4]. Distribution of diagnoses causing
AAP may change over time because of population aging,
advanced diagnostic imaging, changes in dietary habits and
increased obesity of western people. The aim of the present
diagnosis causing AAP during 26-year time span comparing
the incidence percentages to our initial ED audit [7]. Our
hypothesis was that population aging, increased obesity and
alcohol consumption, and increased use of modern imaging
technology in the ED may cause changes in the diagnosis
of AAP.
Methods
Our university hospital is a 700-bed public teaching hospital
located in central Finland. The service area of tertiary care
has a population of about 880,000 living in mixed rural, sub-
urban, and city environs. The ED catchment area for AAP
patients is about 150,000–250,000 because surrounding cen-
tral and district hospitals also participate in the treatment of
AAP patients (Figure 1). The ED of university hospital uses
fully electronic patient records, including patient’s medica-
tion, diagnostic procedures and operating room data. Clinical
records and electronic database were utilized to collect data
of AAP patients’ medication on admission, laboratory values,

CONTACT Hannu Paajanen hannu.paajanen@kuh.fi Department of Gastrointestinal Surgery, Kuopio University Hospital, PL 1777, 70211 Kuopio, Finland

Equal contributorship to first author.
ß 2017 Informa UK Limited, trading as Taylor & Francis Group
2 € ET AL.
A. FAGERSTROM
Figure 1. Study flowchart. Whole university catchment area (tertiary care; n ¼ 880,000) and smaller emergency department (ED) secondary care catchment area for
the patients with AAP are presented.
imaging results, endoscopy findings, operation room records
and treatment during the hospital stay. The national popula-
tion data during 1980–2012 was retrieved from the Official
Statistics authority. This included the number of population
in Finland, the number of elderly inhabitants (>65 years old),
body mass index (BMI kg/m2) changes and alcohol consump-
tion per capita. Checklist of items of cohort studies (STROBE
statement; http://www.strobe-statement.org) was followed
when reporting the data.
The adult patients (>15 years old) with AAP were selected
from all the patients who visited the ED in years 2003
(n ¼ 6006) and 2012 (n ¼ 11,060) and compared to our previ-
ous audit in 1986 (n ¼ 4851) [7]. The research data were col-
lected from electronic records using the computer search
program. The selection of patients was based on the diagno-
sis codes indicating acute abdomen and every third case was
randomly selected into our cohort analysis (Figure 1). The
annual number of patients having AAP is quite high in the
ED, and one third of these patients represents the reliable
percentage of diagnosis distribution. Acute abdomen
was defined according to Organization Mondial de
Gastroenterologue (OMGE) as follows: acute abdomen implies
presentation of a patient to his or her doctor as an urgent
or emergency case with a history of hitherto undiagnosed
non-traumatic abdominal pain lasting less than one week
and more than 6 hours. Hernias were also included if they
caused abdominal pain [2,7]. Eligible patients were identified
and they were either self-referred or referred from primary
health care centers or by private physicians to ED. The
patients were excluded if the abdominal pain was chronic
(>1 week) or pain was not related to abdomen in the final
diagnosis. To find out specific reason for AAP, full medical
history, clinical assessment, standard laboratory tests for AAP
(haemoglobin, leucocyte count, thrombocytes, serum amyl-
ase, serum alkaline phosphatase, creatinine, liver tests,
c-reactive protein/erythrocyte sedimentation rate, human
chorion-gonacotropin and urine analysis) were performed to
every patients. Diagnostic endoscopies or imaging, such as
abdominal x-ray, ultrasound, computerized tomography and/
or magnetic resonance imaging was performed if needed. All
patients were extensively examined to find out any organic
diseases of the GI-tract or abdominal cavity. The ethical com-
mittee of the study hospital approved this register study
protocol.
All statistical analyses were performed using SPSS
Statistics 22.0. (Chicago, IL). Continuous variables were
 SCANDINAVIAN JOURNAL OF GASTROENTEROLOGY 3

Table 1. Population aging, body mass index and alcohol consumption during the study years in Finland.
Number of patients or per cents
Year 1980 2000 2010
Population 4,787,778 5,181,115 5,375,276
>65 years old (%) 577,382 (12.1) 777,198 (15) 941,041 (17.5)
BMIa > 30, females (%) 10 13 17
BMI > 30, males (%) 8 12 18
Alcohol consumption in liter of absolute alcohol 11 11 12
a
BMI: body mass index kg/m2.

Table 2. Characteristics of adult patients with AAP.

Study years and number of patients (%)
1986 (n ¼ 639) 2003 (n ¼ 389) 2012 (n ¼ 390) p
Population 135,000 143,443 147,441 <.0001
Age >65 years 17,415 (13) 21,936 (15) 27,602 (19) <.0001
AAP/EDa visits 639/4851 (13) 1167/6006 (19) 2169/11 060 (20) <.0001
Age >65 years 119 (19) 102 (26) 124 (32) <.0001
Mean age ± SD 43 ± 20 50 ± 12 53 ± 13 <.0001
Males 297 (46) 187 (48) 178 (46) .7857
Surgical treatment 274 (43) 76 (20) 109 (28) <.0001
Mortality 12 (1.9) 6 (1.5) 5 (1.3) .7557
Imaging studies
Ultrasound 27 (4.0) 87 (22) 149 (38) <.0001
Computerized tomography 10 (1.6) 55 (14) 144 (37) <.0001
a
means patients with AAP/total emergency department visits.

expressed as mean ± standard deviation. Fisher’s exact test or bowel obstruction were more common than acute appendi-
Pearson’s v2 test was used to compare nominal data and the citis (Figure 3). Also, in the elderly, the percentage of acute
Mann–Whitney U test for nonparametric data. p values < .05 pancreatitis and diverticulitis were increased in the year 2003
were considered significant. when compared to other study years (Figure 3).

Results
The flowchart of study population is presented in Figure 1.
The overall catchment area of our university hospital is about
880,000 and the geographical catchment area of our ED for
AAP patients has increased from 135,000 to 147,000 during
26 years. Number of elderly people (>65 years old) in
Finland has increased from 12 to 18% during 26 years
(Table 1). The corresponding percentage of elderly people
(>65 years old) in our hospital area is now 21%. The number
of obese people (BMI >30 kg/m2) has also increased from 9
to 18 per cents during study years (Table 1).
The AAP patients represented 10–20% of our total ED cen-
sus (Table 2). Along with population aging in Finland, the
number of elderly patients (>65 years old) with AAP in our
hospital area has increased from 19 to 32% in 30 years
(p < .0001). The number of emergency laparotomies almost
halved (from 43 to 28%) during the study years. This
decrease was particularly evident in the patients suffering
from NSAP (from 4.1 to 0.5%; p ¼ .0002) and acute appendi-
citis (from 23 to 10%; p < .0001). The overall hospital mortal-
ity was low (< 2%) in the patients with AAP (Table 2).
The distribution of diagnoses causing AAP is demon-
strated in Figure 2. NSAP (31–37%) was the most common
reason for ED admission in every cohort year. The frequen-
cies of acute appendicitis were significantly decreased and
acute pancreatitis and diverticulitis slightly increased during
study years. In the elderly patients, NSAP was still the most
frequent diagnosis for AAP, but acute biliary disease and
Discussion
Our study indicated that NSAP is still a common exclusion
diagnosis for abdominal discomfort in all age groups. It
would be a good reason to expect that distribution of spe-
cific diagnoses causing AAP will change over time because
diagnostic imaging has been improved tremendously during
last decades [5,8,9]. The percentage of NSAP remained rather
stable in adult patients with AAP accordingly to many previ-
ous studies (Table 3). In children, up to 70% of AAP cases
may be diagnosed as NSAP [10]. The recent register-study
indicated that the incidence of NSAP has also been declining
in Finland and there were clear geographical differences in
the incidence of NSAP [11].
Psychological factors and functional disorders are very
common among NSAP patients. This acute syndrome implies
short-lived, self-limited, AAP for which no serious or definite
organic cause is ever established [10,11]. In children, NSAP
may predict adulthood organic and functional disease in
about 10% of patients [10]. Our previous study indicated that
also in adults the NSAP may predict higher mortality and
increased risk for various alimentary tract diseases during the
20-year follow-up [12]. Consequently, it can be argued that
not all cases of NSAP are self-limited, short-lived and
harmless.
Although the advanced utilization of modern imaging did
not decrease the rate of NSAP in our study, the rate of emer-
gency surgery in NSAP was greatly decreased from 4 to
0.5%. If more diagnostic serum tests (i.e. helicobacter pylori,
4 € ET AL.
A. FAGERSTROM

Figure 2. Distribution of diseases (%) causing AAP in patients aged >15 years of is presented during the study years.

Figure 3. Distribution of diseases (%) causing AAP in the elderly patients (aged >65 years old) is presented.

lactose intolerance, celiac disease, calprotectin) would be
conducted in primary healthcare centers, then possibly the
number of NSAP patients in ED would be even more
decreased. Intra-abdominal adhesions and abdominal wall
pain are also difficult differential organic diagnoses which
may sometimes be diagnosed as NSAP at ED [13,14].
Of all patients presenting in the ED, approximately
10–15% have complaints of AAP [3,4,6]. The percentage of
AAP patients in our study was slightly higher (13–20%). This
can be explained with different admission characteristics of
hospitals in different countries. Some changes in the diagno-
ses causing AAP was observed in our study. The percentage
of acute appendicitis decreased and the number of acute
pancreatitis and diverticulitis increased slightly over time.
The wide-spread use of modern imaging technology is prob-
ably one reason for the diminishing number of appendecto-
mies in many western countries [5,9,15]. The outpatient
antibiotic use can theoretically have a decreasing influence
on the incidence of appendicitis, although we did not find
any strong correlation between the antibiotic use and acute
appendicitis [16]. In Finland, alcohol is the main reason for
acute pancreatitis [17], and alcohol use per capita has been
high (Table 1).
Changes in population aging and increase in BMI may
explain partly the increased rate of acute pancreatitis and
diverticulitis in our study. Diagnosis of AAP in older persons
 SCANDINAVIAN JOURNAL OF GASTROENTEROLOGY 5

Table 3. Distribution (%) of the ten most common diagnoses in adult patients with acute abdomen reported in six previous studies.
Ikonen de Dombal Irvin Feny€o Lehtim€aki Laurell
1983 1988 1989 2000 2013 2015
Study year n ¼ 326 n ¼ 10,682 n ¼ 1190 n ¼ 3727 n ¼ 254 n ¼ 2851
NSAP 50.3 34.0 34.9 23.8 29.5 37.1
Acute appendicitis 23.3 28.1 16.8 7.8 19.7 9.8
Acute biliary disease 9.7 9.7 5.1 9.2 6.7 10.8
Intestinal obstruction 6.7 4.1 14.8 6.6 5.5 3.2
Urinary tract disorder 3.3 2.9 5.9 6.3 4.3 6.9
Acute pancreatitis 2.6 2.9 2.4 4.9 8.7 3.2
Acute diverticulitis 0.9 1.5 3.9 4.9 13.8 4.7
Gynecological disease – 4.0 1.1 – – 3.5
Peptic ulcer 0.0 2.5 3.9 5.6 – 1.3
Malignancy – 1.5 3.0 6.4 1.6 2.2
NSAP: nonspecific abdominal pain.

is a challenge, with the age-related increase in concurrent
diseases. Both the preliminary diagnosis at the ED and the
discharge diagnosis are less reliable in elderly than in
younger patients [18]. The number of elderly people was
constantly rising in our study, which means that an increas-
ing proportion of patients admitted for AAP are elderly. The
distribution of diagnoses causing AAP was different in elderly
patients than in general population. Particularly acute biliary
disease and bowel obstruction were more common in elderly
than younger patients.
Formerly many patients thought to have an acute abdo-
men were operated. Nowadays the patients with AAP, even if
accompanied by abdominal tenderness and rigidity, will not
undergo urgent surgery but first diagnostic imaging [5,8,9].
Both CT and US are widely used in the work-up of patients
with AAP and the diagnostic specificity of AAP is highly ele-
vated [5,8,9]. For example, in Netherlands the number of
negative appendectomies has decreased from 20–30 to 5%
after modern preoperative imaging [8]. Our study also indi-
cated that diagnostic imaging is more widely used now than
in previous decades in the diagnosis of AAP.
The weakness of our study was a relatively small number
of patients and few study years during a 26-year period. We
studied, however, very carefully the discharge diagnoses and
we believe, that these reflect reliably the diseases underlying
AAP during the study years. The strength of our study was
very long time span. To conclude, our long-term analysis
indicated that NSAP is still the main differential diagnostic
problem in the ED. The distribution of specific diagnoses
causing AAP remained rather stable through 30-year audit.
More prospective data of AAP patients should be registered
to confirm causal relationship of dietary and environmental
factors causing changes in AAP.
Disclosure statement
Drs. Paavo Paajanen, Anne Fagerstro €m, Heidi Saarelainen, Mirella
Ahonen-Siirtola, Mika Ukkonen, Pekka Miettinen and Hannu Paajanen
have no conflicts of interest or financial ties to disclose.
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