Abstract
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Objective
Abdominal pain is the most common emergency department (ED) chief complaint, with many patients experiencing recurrent episodes due to non–life-threatening etiologies such as disorders of gut-brain interaction. This pilot study aimed to characterize patients with recurrent low-risk abdominal pain, focusing on pain severity, management, biopsychosocial factors, opioid use, and 30-day return visits.
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Methods
This prospective, observational pilot study enrolled adult ED patients with recurrent abdominal pain at a single academic center between July 2022 and June 2023. Inclusion required at least one similar episode in the prior year with symptom resolution between episodes. Exclusions included unstable clinical status or high-risk conditions. Patient-reported outcomes, social determinants of health, and clinical data were collected. Primary outcomes included pain severity, opioid use, and 30-day return visit rates.
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Results
A total of 101 participants were enrolled (mean age, 43.7 years; 65.3% female; 69.3% Black). Pain severity was high (triage pain score, 7.1±2.6). Frequent prior computed tomography imaging was noted in 56.4% of participants. Opioids were administered in 50 participants (49.5%), while Patient-Reported Outcomes Measurement Information System (PROMIS)-29 scores highlighted risks of anxiety (T-score, 56.0±11.1) and pain interference (T-score, 60.8±8.2). Return visits occurred in 11 participants (10.9%) within 30 days.
-
Conclusion
In this pilot study, patients with recurrent low-risk abdominal pain showed high symptom burden and healthcare utilization. Targeted interventions addressing biopsychosocial factors and improving pain management are needed to reduce ED revisits and improve outcomes.
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Keywords: Abdominal pain; Emergency department; Opioid use; Social determinants
Capsule Summary
What is already known
Abdominal pain is the most common emergency department chief complaint, with many patients experiencing recurrent episodes due to non–life-threatening etiologies such as disorders of gut-brain interaction.
What is new in the current study
This study investigates the characteristics and outcomes of patients presenting with recurrent low-risk abdominal pain with a focus on pain severity, biopsychosocial factors, opioid use, and 30-day return visits. Our findings highlight the high symptom burden and frequent healthcare utilization among this patient population, as well as gaps in pain management and communication regarding the cause of symptoms. The study underscores the need for tailored interventions that address biopsychosocial contributors in order to improve management strategies in the emergency department.
INTRODUCTION
Abdominal pain is the most common reason for emergency department (ED) visits in the United States, accounting for approximately 7 million visits per year [
1]. For many patients, abdominal pain is not a one-time event but a recurrent symptom with repeat episodes and multiple ED visits. Approximately 15% to 34% of patients with recurrent abdominal pain qualify as super-utilizers, defined as having four or more ED visits per year [
2]. The causes of recurrent abdominal pain are highly heterogeneous including structural disease such as chronic pancreatitis, diverticulitis, and inflammatory bowel disease and nonstructural causes such as disorders of gut-brain interaction [
3–
5]. Patients with recurrent abdominal pain often undergo multiple diagnostic studies such as laboratory tests, computed tomography (CT) scans and ultrasounds. As a result, visits for ED patients with abdominal pain are resource-intensive and costly [
6]. In addition, 44% to 59% of ED abdominal pain patients are treated with opioid analgesics, which are associated with adverse events [
7]. Patients presenting with low-risk abdominal pain often exhibit symptoms that closely resemble more acute, high-risk conditions, resulting in similar diagnostic workups that expose them to unnecessary iatrogenic radiation, extensive laboratory testing, significant healthcare costs, and prescription of opioid medications, which can contribute to dependence, adverse side effects, and long-term misuse [
8,
9]. These patients could be more effectively managed in an outpatient setting using a biopsychosocial approach that emphasizes longitudinal care, addresses underlying psychosocial contributors, and promotes lifestyle modification, all while reducing the strain on EDs and conserving critical acute care resources. Given the significant patient stress, cost, and overall burden on the healthcare system, patients with recurring episodes of abdominal pain highlight a gap in the healthcare system, contributing to unmet patient needs. The objective of this study was to characterize patients with recurrent abdominal pain and describe their symptoms, the use of opioid analgesia, the efficacy of pain control, and the frequency of 30-day ED return visits.
METHODS
Ethics statement
This study was approved by the Institutional Review Board of The George Washington University (No. NCR213728). Informed consent was obtained from all patients.
Study setting and design
This prospective case-cohort observational study was conducted at The George Washington University Hospital in Washington, DC, USA, from July 4, 2022, to June 1, 2023. Patients were screened for recurrent low-risk abdominal pain, excluding patients with established high-risk characteristics. Study participants completed an electronic survey to evaluate symptomatology, comorbidities, and psychosocial risk factors. In addition, an automated report generated from the electronic health record after the index visit was reviewed to assess 30-day outcomes.
Study population
Adult patients (≥18 years old) presenting to the ED with a chief complaint of abdominal pain and at least one reported episode of similar pain in the past year were screened for this study. Recurrence was defined as patients with a similar episode of abdominal pain at least 30 days before the current ED visit with a period of resolution between episodes such that pain was not continuous, i.e., episodic pain. Patients were excluded if they met any of the following criteria: altered mental status, prisoner/ward of state, pregnant, or non–English-speaking or did not meet all low-risk criteria. Low-risk criteria were established by the GRACE-2 (Guidelines for Reasonable and Appropriate Care in the Emergency Department 2) writing group [
1] and include the following: (1) stable vital signs; (2) age range of 18 to 65 years; (3) not pregnant; (4) no history or physical findings of acute abdominal pathology; (5) no acute trauma within the last 7 days; (6) no prior organ transplantation or immunosuppression; (7) no abdominal surgery within 30 days and/or active cancer; (8) no history of inflammatory bowel disease; (9) no previous bowel obstructions; and (10) no active severe psychiatric illnesses requiring urgent stabilization.
The cohort was a convenience sample enrolled by research staff who screened ED patients on weekdays from 9 AM to 7 PM. Once enrolled, participants were evaluated to assess for pain severity, frequency of symptoms, and confidence in diagnosis. Other validated scoring tools were used to assess for substance use risk (Alcohol, Smoking and Substance Involvement Screening Test, ASSIST) [
10], social determinants of health (Accountable Health Communities [AHC] health-related social needs [HRSN]) [
11], and health-related quality of life (Patient-Reported Outcomes Measurement Information System [PROMIS]-29) [
12]. Additional data on clinical outcomes, including ED management, ED disposition, ED diagnosis, and 30-day ED revisits, collected through automated electronic health record reports. The primary ICD-10 (International Classification of Diseases, 10th Revision) diagnosis code associated with this visit was also recorded.
Descriptive statistics were used to summarize demographic, clinical, and patient-reported outcome data. Continuous variables, such as pain scores (10-point numerical rating system) and PROMIS-29 T-scores, were reported as mean±standard deviation, while categorical variables, including sex, race, and opioid administration, were presented as frequencies and percentages. Associations between 30-day return visits to the ED and patient-reported outcomes were assessed using a multivariate logistic regression. The model was also adjusted for age and sex. Unadjusted and adjusted odds ratios were reviewed, as well as 95% confidence intervals (CIs). All analyses were conducted using SAS ver. 9.4 (SAS Institute Inc), with a two-tailed significance threshold of P<0.05.
RESULTS
As shown in
Fig. 1, a total of 101 participants were included in the study with a mean age of 43.7±16.7 years. Sex distribution was predominantly female, with 66 participants (65.3%) identified as women and 34 participants (33.7%) as men. Regarding racial distribution, 70 participants (69.3%) reported being Black. Participants reported high levels of pain severity with pain on multiple days. The mean triage pain score was 7.1±2.6 and the mean pain score at time of discharge was 5.0±3.4 on a 10-point scale. Approximately half of the participants (n=50, 49.5%) were treated with opioids in the ED, while 13.9% of participants were prescribed opioids from the ED (
Table 1). When asked about their understanding of their pain, 37 participants (36.6%) reported being informed of the cause by a provider, while 22 (21.8%) indicated they were told but did not understand. A notable 26 participants (25.7%) stated they were never informed of the cause, while 2 (2.0%) were uncertain if they had been told. Additionally, 14 participants (13.9%) reported never seeking medical attention for their pain. Prior CT imaging was also noted, with 57 (56.4%) having received at least one CT scan in the past 5 years for this abdominal pain.
Table 2 provides insights into questionnaire scores among participants, focusing on metrics such as physical function and anxiety measured using the PROMIS-29 tool. Of the 101 participants who completed the assessments, the mean T-score for physical function was 43.8±10.2, indicating below-average physical functioning in the sample. Anxiety levels were elevated, with a mean T-score of 56.0±11.1, suggesting significant psychological distress. For all participants, 30-day outcomes were reviewed to assess return visits and ED course. Of the participants, 90 (89.1%) did not return to the ED during the 30-day follow-up period, while 7 participants (6.9%) returned once, and 4 participants (4.0%) returned twice.
Further analysis examined associations between return visits and clinical or demographic factors. This study found no statistically significant associations between patient-reported factors and repeat ED visits within 30 days. While trends suggest that high-impact chronic pain and financial strain may increase the likelihood of return visits, the wide CIs indicated uncertainty (
Table 3). Initial findings suggest that individuals with more frequent ED visits may have higher levels of unresolved pain or chronic conditions contributing to repeat healthcare utilization. This distribution underscores the importance of targeted follow-up and interventions to reduce frequent ED utilization among at-risk populations.
DISCUSSION
Abdominal pain is one of the most common chief complaints to US EDs and represents a heterogeneous group of diseases with a wide variety of treatments, diagnostic tests, and pain management. Patients with recurrent abdominal pain may not be offered treatment due to uncertainty of diagnosis and concerns about the dangers of opioid analgesia. In particular, patients presenting with low-risk recurrent abdominal pain often exhibit symptoms that closely mimic those of high-risk, acute conditions, leading to substantial resource utilization, including frequent imaging and emergency evaluations, despite a low likelihood of serious pathology; these patients may be more appropriately managed in the outpatient setting, where primary care providers and gastroenterologists can focus on developing long-term care plans, addressing lifestyle factors, and assessing comorbid conditions in a more sustainable and patient-centered manner. We chose to study patients presenting with low-risk abdominal pain to better characterize this patient population and validate the GRACE-2 guidelines for low-risk abdominal pain. In this study, patients with recurrent abdominal pain showed minimal improvement in pain during their ED stay. In addition, they reported high levels of pain interference with activities of daily living and often received opioids in the ED. This pattern is inconsistent with recommendations to limit opioid treatment to the lowest effective dose, and increasing dose based on severity of pain and treatment side effects for chronic noncancer pain [
13]. The high rates of opioid treatment observed among patients with low-risk recurrent abdominal pain suggest that providers may not be consistently prioritizing strategies to minimize the risk of opioid dependence; given the frequency with which these patients present to the ED, this practice places a large population at unnecessary risk for opioid-related harm despite the availability of safer, more sustainable management strategies outside the acute care setting. While trends suggest that high-impact chronic pain and financial strain may increase the likelihood of return visits, further research with larger sample sizes is needed to clarify these potential associations.
It is possible that improving diagnosis will lead to more effective care, reduced costs from repeat ED visits, and improved health outcomes for abdominal pain patients. The need for answers is one of the major motivations for patients to present to the ED. Proper education regarding a diagnosis has been shown to have a therapeutic effect [
14]. In this study, recurrent abdominal pain patients do not appear to have received effective communication regarding the cause of their pain. In comparison, those with a more serious diagnosis may be more likely to claim that they were told “what was wrong, and the cause of their pain was clear” by a doctor or medical provider.
Managing chronic abdominal pain can require a multifaceted approach. A tailored approach that does not involve an increase in opioid analgesia is preferred. Current guidelines on the management of chronic abdominal pain include initially treating with proton pump inhibitors, first-line dietary treatments, antidiarrheals, and laxatives before turning to opioid analgesics [
15]. Such treatments may serve to improve pain score outcomes while avoiding the potential side effects of opioid analgesia. In addition, psychiatric treatments such as cognitive behavioral therapies and clinical hypnosis have been shown effective in disorders of gut-brain interaction like irritable bowel syndrome [
16]. Integrating psychotherapy in the ED alongside existing medical treatments could also be beneficial in lowering pain scores of patients with benign diagnoses. Additionally, psychiatric comorbidities have been found to be more common in patients who are frequent utilizers of the ED [
17]. A biopsychosocial approach to pain management has the potential to be beneficial for reducing pain scores and preserving ED resources.
Although socioeconomic factors were not significantly associated with repeat ED visits, trends suggest financial and social determinants may influence healthcare utilization. Financial strain was potentially linked to increased ED reliance, reflecting barriers to primary care and challenges managing chronic conditions. Prior studies have shown similar findings, identifying financial strain as being associated with the patient identifying the ED as their primary resource for obtaining care, while reporting adverse social determinants of health was correlated with actual ED visits [
18]. Employment and education showed no clear associations, although work constraints might limit outpatient follow-up, and higher education levels could lead to proactive care-seeking behavior. Physical activity showed no significant impact but remains important for overall health. These findings highlight the need for larger, more longitudinal studies to clarify these relationships. Addressing financial barriers, improving outpatient access, and strengthening social support systems may help reduce avoidable ED visits and improve outcomes.
The limitations of this study should be acknowledged. First, the single-center design conducted at an academic ED may limit the generalizability of findings to other settings or patient populations with differing demographic or clinical characteristics. Second, the use of convenience sampling during limited hours introduces selection bias, potentially excluding patients who present outside of these timeframes. Third, as a pilot study, the relatively small sample size (n=101) limits the statistical power to detect associations and draw definitive conclusions. Additionally, reliance on self-reported data for variables such as pain interference and psychosocial factors introduces the potential for recall and social desirability biases. The exclusion of non-English-speaking patients further contributes to selection bias and restricts the applicability of findings to linguistically diverse populations. Moreover, the study’s focus on outcomes within a 30-day follow-up period provides a narrow time frame that does not capture longer-term healthcare utilization or patient outcomes. Despite adjustments for age and sex, the potential for residual confounding remains, as unmeasured factors may influence the observed associations between patient-reported outcomes and ED return visits. Finally, the specificity of the inclusion criteria, which exclude patients with high-risk conditions, limits the applicability of these findings to broader populations with recurrent abdominal pain, including those with higher-risk diagnoses. Addressing these limitations in future studies will be critical to enhancing the understanding and management of recurrent abdominal pain in ED settings.
Conclusions
This pilot study emphasizes the challenges of managing recurrent abdominal pain in ED patients, revealing that those with benign diagnoses often leave the ED unsure about the cause of their pain and with less effective pain management compared to patients with serious diagnoses. These findings highlight the need for a more nuanced approach to the diagnosis and treatment of patients with recurrent low-risk abdominal pain, emphasizing the need for tailored treatment strategies that supplement analgesic approaches to pain management. Future research should investigate biopsychosocial factors to enhance therapeutic interactions and improve overall management of low-risk abdominal pain in the ED setting.
NOTES
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Author contributions
Conceptualization: ACM; Data curation: ACM; Formal analysis: all authors; Investigation: ACM; Methodology: FY, MB; Writing–original draft: all authors; Writing–review & editing: all authors. All authors read and approved the final manuscript.
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Conflicts of interest
The authors have no conflicts of interest to declare.
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Funding
The authors received no financial support for this study.
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Data availability
Data analyzed in this study are available from the corresponding author upon reasonable request.
Fig. 1.Study flowchart. MVC, motor vehicle collision.
Table 1.Demographic variables among participants (n=101)
Table 1.
|
Characteristic |
Value |
|
Age (yr) |
43.7±16.7 |
|
Sexa)
|
|
|
Male |
34 (33.7) |
|
Female |
66 (65.3) |
|
Other (transgender, nonbinary) |
1 (1.0) |
|
Racea)
|
|
|
Black |
70 (69.3) |
|
White |
21 (20.8) |
|
Asian |
2 (2.0) |
|
Other |
4 (4.0) |
|
More than one race |
1 (1.0) |
|
Prefer not to answer |
3 (3.0) |
|
Ethnicitya)
|
|
|
Hispanic or Latino |
5 (5.0) |
|
Not Hispanic or Latino |
91 (90.1) |
|
Prefer not to answer |
5 (5.0) |
|
Insurance status |
|
|
Medicaid |
34 (33.7) |
|
Medicare |
17 (16.8) |
|
Private |
25 (24.8) |
|
Uninsured |
12 (11.9) |
|
Other |
13 (12.9) |
|
Past medical history |
|
|
High blood pressure |
38 (37.6) |
|
Diabetes |
18 (17.8) |
|
Congestive heart disease |
5 (5.0) |
|
COPD |
6 (5.9) |
|
Coronary artery disease |
3 (3.0) |
|
Depression |
26 (25.7) |
|
Anxiety |
30 (29.7) |
|
Pain score (range, 0–10) |
|
|
Triage pain score |
7.1±2.6 |
|
Current pain score a)
|
6.1±2.9 |
|
Discharge pain score |
5.0±3.4 |
|
Questionnaire |
|
|
In the past 7 days, how often did you have abdominal pain? |
|
|
More than once a day |
30 (29.7) |
|
Once a day |
17 (16.8) |
|
At least 2–6 days |
36 (35.6) |
|
One day only |
14 (13.9) |
|
Never |
3 (3.0) |
|
Missing data |
1 (1.0) |
|
In the past 7 days, how much did your abdominal pain interfere with your day-to-day activities? |
|
|
Quite a bit, very much |
67 (66.3) |
|
Not at all, a little bit, or somewhat |
33 (32.7) |
|
Missing data |
1 (1.0) |
|
Prior episode of similar symptoms? |
|
|
1 Week prior |
20 (19.8) |
|
More than 1 week and less than a month |
20 (19.8) |
|
Between 1 month and 6 months prior |
33 (32.7) |
|
Between 6 months and 1 year prior |
14 (13.9) |
|
More than 1 year prior |
10 (9.9) |
|
Not sure or unable to answer |
3 (3.0) |
|
Missing data |
1 (1.0) |
|
≥ 1 CT scan in the past 5 years for this abdominal pain |
57 (56.4) |
|
Has a doctor or medical provider been able to tell you what was causing the pain? |
|
|
Yes, I was told what was wrong and the cause of my pain is clear |
37 (36.6) |
|
I was told the cause of my pain, but I do not understand |
22 (21.8) |
|
No, I was never told the cause |
26 (25.7) |
|
Uncertain if I was told the cause |
2 (2.0) |
|
I never saw a doctor |
14 (13.9) |
|
Administered medication |
|
|
Opioid in the ED |
50 (49.5) |
|
NSAIDa) in the ED |
21 (20.8) |
|
APAPa) in the ED |
39 (38.6) |
|
Alternative analgesia in the ED |
12 (11.9) |
|
ED course |
|
|
CT scan in the ED |
61 (60.4) |
|
Ultrasound in the ED |
20 (19.8) |
|
Discharged to home |
68 (67.3) |
|
Prescribed opioid analgesia at discharge |
14 (13.9) |
Table 2.Questionnaire scores among participants (n=101)
Table 2.
|
Questionnaire |
Value |
|
PROMIS-29 scorea)
|
|
|
Physical function T-score |
43.8±10.2 |
|
Anxiety T-score |
56.0±11.1 |
|
Depression T-score |
51.7±10.5 |
|
Fatigue T-score |
54.3±10.4 |
|
Sleep disturbance T-score |
55.5±9.9 |
|
Ability to participate in social activities T-score |
52.2±9.6 |
|
Pain interference T-score |
60.8±8.2 |
|
Global pain scoreb)
|
7.0±2.4 |
|
Moderate- to high-risk substance use (ASSIST score) |
|
|
Alcohol (n=61) |
9.2±8.7 |
|
Tobacco (n=31) |
14.9±9.0 |
|
Cannabis (n=33) |
14.1±9.4 |
|
Cocaine (n=4) |
14.5±10.4 |
|
Amphetamine (n=3) |
16.3±10.6 |
|
Sedative (n=2) |
12.0±0.0 |
|
Hallucinogen (n=6) |
12.3±9.9 |
|
Opioid (n=5) |
11.6±8.3 |
|
Simplified chronic pain scale |
|
|
Grade 0 (chronic pain absent) |
68 (67.3) |
|
Grade 1 (mild or bothersome chronic pain) |
17 (16.8) |
|
Grade 2 (high-impact chronic pain) |
16 (15.8) |
|
Unmet health-related social strain (AHC-HRSN score) |
|
|
Financial strain |
37 (36.6) |
|
Employment |
15 (14.9) |
|
Family and community support |
23 (22.8) |
|
Education |
21 (20.8) |
|
Physical activity |
59 (58.4) |
Table 3.Association between repeat ED visit within 30 days of index visit and patient-reported factors
Table 3.
|
Factor |
OR (95% CI) |
aOR (95% CI)a)
|
|
PROMIS-29 score |
|
|
|
Physical function T-score |
0.97 (0.92–1.04) |
0.99 (0.92–1.06) |
|
Anxiety T-score |
1.06 (0.99–1.13) |
1.06 (0.99–1.14) |
|
Depression T-score |
1.05 (0.99–1.11) |
1.05 (0.99–1.12) |
|
Fatigue T-score |
1.02 (0.96–1.08) |
1.04 (0.97–1.11) |
|
Sleep disturbance T-score |
0.99 (0.93–1.06) |
1.00 (0.94–1.07) |
|
Ability to participate in social activities T-score |
0.95 (0.89–1.02) |
0.95 (0.88–1.02) |
|
Pain interference T-score |
1.02 (0.94–1.10) |
1.03 (0.94–1.12) |
|
Global pain score |
1.36 (0.96–1.93) |
1.34 (0.95–1.90) |
|
ASSIST score |
|
|
|
Alcohol |
0.98 (0.85–1.14) |
1.02 (0.88–1.18) |
|
Cannabis |
1.04 (0.91–1.19) |
1.70 (0.21–13.82) |
|
Pain score at discharge |
1.01 (0.84–1.21) |
0.99 (0.81–1.20) |
|
Grade 0 (chronic pain absent) |
1 (Reference) |
1 (Reference) |
|
Grade 1 (mild or bothersome chronic pain) |
0.55 (0.06–4.75) |
0.60 (0.07–5.49) |
|
Grade 2 (high-impact chronic pain) |
2.01 (0.46–8.83) |
2.02 (0.43–9.57) |
|
AHC-HRSN score |
|
|
|
Financial strain |
1.49 (0.42–5.25) |
1.66 (0.45–6.18) |
|
Employment |
0.54 (0.06–4.52) |
0.71 (0.07–6.86) |
|
Family and community support |
0.72 (0.14–3.60) |
0.65 (0.12–3.41) |
|
Education |
2.42 (0.64–9.22) |
2.05 (0.51–8.27) |
|
Physical activity |
0.82 (0.23–2.87) |
0.70 (0.18–2.75) |
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, Felice Yang2
