SGEM#367: GRACE2 – Low-Risk, Recurrent Abdominal Pain - The Skeptics Guide to Emergency Medicine

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Date: May 24th, 2022

Reference: Broder et al. Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE) 2: Low-Risk, Recurrent Abdominal Pain in the Emergency Department. AEM May 2022

Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the creator of the #FOAMed project called First10EM.com

Case: A 33-year-old male presents to the emergency department (ED) complaining of abdominal pain. He states he has had the same pain for more than 10 years, and no one has ever been able to figure out what is going on. He doesn’t have any specific symptoms today, including no fever, vomiting, diarrhea, or urinary symptoms. His vital signs are normal. His abdomen is diffusely tender, but without any surgical findings. You review his chart and note that he has had five CTs performed in the last year at your hospital alone, all of which were negative. You are worried about the cumulative radiation dose he has received but find it hard to exclude significant pathology on history and physical. After all, even patients with chronic abdominal pain can develop a new acute issue like appendicitis.

Background: The Society of Academic Emergency Medicine (SAEM) has launched an initiative called GRACE which stands for Guidelines for Reasonable and Appropriate Care in the Emergency Department.

GRACE-1

The first GRACE publication looked at low risk chest pain, and in my opinion, they filled a very valuable role. Most guidelines focus on a single emergency visit in isolation, but a patient who presents to the emergency department recurrently with the same symptoms may require a different approach. In the context of recurrent chest pain, they made eight key recommendations. The SGEM bottom line was there is moderate level of evidence that ACS can be excluded in adult patients with recurrent, low-risk chest pain using a single hs-troponin below a validated threshold without further diagnostic testing in patients who have a CCTA within the past two years showing no coronary stenosis.

The writing group of GRACE-2 wanted to look at clinically relevant questions to address the care of adult patients with low-risk, recurrent, previously undifferentiated abdominal pain in the ED. Through consensus, four questions were developed and then a systematic review of the literature was performed. This literature was then synthesized to come up with recommendations, following GRADE methodology.

GRADE stands for Grading of Recommendations, Assessment, Development, and Evaluation, it was pioneered at McMaster University, in creating rigorous, transparent, and trustworthy guidelines on common clinical problems for EM physicians that are not always directly studied in EM research activities.

There can be many presentations for low-risk abdominal pain. We have covered cannabis hyperemesis on SGEM#318 and SGEM#46 and pediatric gastroenteritis on SGEM#254.

Clinical Question: What are the recommendations for managing patients with low-risk, recurrent, previously undifferentiated abdominal pain in the ED?

Dr. Joshua Broder

Reference: Broder et al. Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE) 2: Low-Risk, Recurrent Abdominal Pain in the Emergency Department. AEM May 2022

This is an SGEMHOP episode which means we have the lead author on the show. Dr. Joshua Broder is the Residency Program Director and Vice Chief for Education In the Division of Emergency Medicine Duke University School of Medicine.

Authors’ Conclusions: “No direct evidence exists to direct the care of patients with low-risk recurrent undifferentiated abdominal pain in the ED. Improved definitions are required to better define this population, and clinically relevant outcomes of interest should be described and studied with rigorous research methodology to inform future clinical guidelines.”

Quality Checklist for a Guideline:

The study population included or focused on those in the emergency department? Yes
An explicit and sensible process was used to identify, select and combine evidence? Yes
The quality of the evidence was explicitly assessed using a validated instrument? Yes
An explicit and sensible process was used to the relative value of different outcomes? Yes
The guideline thoughtfully balances desirable and undesirable effects? Yes
The guideline accounts for important recent developments? Yes
The guidelines has been peer-reviewed and tested? Yes/No
Practical, actionable and clinically important recommendations are made? Yes
The guideline authors’ conflicts of interest are fully reported, transparent and unlikely to sway the recommendations of the guidelines? Yes

Key Recommendations: We don’t have a key result section but what we do have is the key recommendations. It is important to understand the definitions created by the guideline committee for terms “low-risk, undifferentiated and recurrent”.

Listen to the SGEM podcast to hear Josh comment on each of these four recommendations.

Recommendation #1

In adult ED patients with low-risk, recurrent, undifferentiated abdominal pain and prior negative CTAP within 12-months, there is insufficient evidence to accurately identify populations in whom repeat imaging can be safely avoided or routinely recommended in the ED. (No recommendation) [No evidence]

Recommendation #2

In adult ED patients with low-risk, recurrent, undifferentiated abdominal pain and a negative CTAP with IV contrast in the ED, we suggest against ultrasound unless there is concern for pelvic or biliary pathology. (Conditional recommendation, against) [Very low certainty of evidence]

Recommendation #3

In adult ED patients with low-risk, recurrent, undifferentiated abdominal pain, we suggest screening for depression and/or anxiety may be performed during the ED evaluation. (Conditional recommendation, either) [Very low certainty of evidence]

Recommendation #4

In adult ED patients with low-risk, recurrent, undifferentiated abdominal pain, we suggest an opioid-minimizing strategy for pain control. (Conditional recommendation. [Consensus, no evidence]

Listen to the podcast to hear Josh answer our five nerdy questions.

1. Scope of the Review: There are thousands of questions I could imagine asking for this guideline. What is the role of observation and repeat exams instead of imaging? When is blood work required? What chronic therapeutic options should the emergency physician consider? Obviously, this guideline was a massive undertaking as it stands. How did you decide which questions were the most important to ask?

2. Pediatric Patients: This guideline only applies to adult patients. Those of us who work community ED or as Pediatric Emergency Medicine know many children present with abdominal pain. Are there any plans for the GRACE group to look at this issue?

3. Patient Representative: In the recommendation to screen for depression, you lean heavily of the comments of a patient representative in your group. For a scientific guideline, I think that might surprise people. Can you explain the role of the patient representative in the creation of these guidelines? Patients are all unique. I wonder how representative this one patient’s views are for the average patient.

4. Gaps in Knowledge: Clearly there are huge gaps in knowledge in this area. That could be looked at as a negative or a positive. It is an opportunity for those listening to design a study with a clinically relevant question and proper methods to answer the question. If could give future researchers one area that you think would have the biggest impact for patients, what would it be?

5. Making Guidelines without Evidence: Personally, I find it very frustrating when guidelines make strong recommendations in the absence of evidence. This guideline does a very good job discussing the absence of evidence, and explaining why recommendations were made, but it is still a difficult task without evidence. I wonder if you could comment on what you think is the best approach to writing a guideline when no evidence exists, and the clinical value of such guidelines.

Comment on Authors’ Conclusion Compared to SGEM Conclusion: We agree with the authors’ conclusion that there is no direct evidence to guide our management of patients with low risk, recurrent, undifferentiated abdominal pain.

SGEM Bottom Line: Given the lack of evidence available to guide is, there is tremendous uncertainty in the most appropriate management plan for these patients. We should be open about that uncertainty without our patients and involve them in shared decision-making to ensure that the chosen management plan matches their personal values.

Case Resolution: You discuss the potential harms and the potential benefits of repeat imaging with your patient and opt for repeat exams over a brief period of observation with rapid follow-up with his primary care provider. You treat his pain effectively with non-opioid analgesia. You discuss depression and anxiety with him, and he admits that the recurrent abdominal pain has been causing significant anxiety, but he is already addressing that with his family doctor.

Clinical Application: Although the current lack of evidence is somewhat disappointing, managing uncertainty is a core skill of emergency physicians. In some ways, the lack of clear science frees us up to use our clinical judgement and talk to our patients to develop individualized treatment plans that suit their values best.

Dr. Justin Morgenstern

What Do I Tell the Patient? Unfortunately, despite recurrent abdominal pain being a very common presentation, there is very little good science to guide us. You have been through these symptoms many times before, so you know that it is unlikely that a repeat CT scan will provide us with an answer today. However, we never want to miss anything, and there is always a chance that something new is happening today. Let’s talk about the specific risks and benefits, and then you can help me decide what is the best management plan for you.

Keener Kontest: Last weeks’ winner was Dr. Gregory Yates from Manchester. He knew muscle relaxant curare was the poison used by natives of the Amazon Basin in South America on the tips of their arrows that produced death by skeletal muscle paralysis.

Listen to the SGEM podcast for this weeks’ keener question. Send your email to TheSGEM@Gmail.com with “keener” in the subject line. The first correct answer will win a cool skeptical prize.

SGEMHOP: Now it is your turn SGEMers. What do you think of this episode on recurrent, low-risk abdominal pain? Tweet your comments using #SGEMHOP. What questions do you have for the GRACE-2 team? Ask them on the SGEM blog. The best social media feedback will be published in AEM.

Also, don’t forget those of you who are subscribers to Academic Emergency Medicine can head over to the AEM home page to get CME credit for this podcast and article.