Date: November 26, 2025

Reference: Ray et al. Emergency Department Visit Frequency Among Adults with Chronic Abdominal Pain: Findings From the 2023 US National Health Interview Survey. AEM November 2025.

Guest Skeptic: Dr. Kirsty Challen is a Consultant in Emergency Medicine in the UK and an evidence-based medicine advocate. She’s a seasoned knowledge translator with her PaperinaPic infographics.  

Case: You are mid-shift in what feels like the never-ending winter of emergency medicine, and you hear the sigh as your resident picks up the chart of the next patient to be seen. Wondering if the resident requires coffee or support, you ask what is wrong. “I’m good, it’s just this is the third patient with acute worsening of abdominal pain they’ve had for years that I’ve seen this week. What’s going on?”

Background: Abdominal pain is a frequent reason for presentation to the emergency department (ED), generating over 13 million visits in the US in 2022. As emergency care providers, we are taught to think of the worst-case diagnoses (aneurysmal, ischaemic, an ectopic pregnancy, appendicitis, etc). Once the “bad stuff” is excluded, it’s tempting to breathe a sigh of relief and “not my concern”.

However, there is an estimated population prevalence of chronic abdominal pain of around 22 per 1,000 person-years. According to the International Association for the Study of Pain, this is defined as abdominal pain without a clear diagnostic explanation that lasts for 3 months or more. Often, patients with these symptoms have been diagnosed with “functional” abdominal pain, although more recent terminology uses “Disorders of Gut-Brain Interaction”.

Managing patients with acute-on-chronic pain syndromes in the ED can be very challenging, particularly if continuity of care is lacking for their chronic condition. This has been addressed to some extent by the GRACE-2 guidance on managing recurrent low-risk abdominal pain, which de-emphasizes repeated routine imaging and recommends opioid-minimizing strategies for symptom management.

Clinical Question: Do people with chronic abdominal pain have higher rates of ED utilization than those without?

Reference: Ray et al. Emergency Department Visit Frequency Among Adults with Chronic Abdominal Pain: Findings From the 2023 US National Health Interview Survey. AEM November 2025.

  • Population: Adult respondents to the National Health Interview Survey 2023 who completed the question on demographics, pain, healthcare seeking behaviours, disability, mental health, past medical history and social determinants of health.
    • Exclusion: The entire survey excludes people without a permanent household address, active-duty military personnel or civilians on military bases, and residents of long-term care facilities. For this study, the authors also excluded people reporting a history of cancer, Crohn’s disease and ulcerative colitis and those who were pregnant.
  • Exposure: Chronic abdominal pain (CAP) was defined by the authors as reporting pain “most days” or “every day” over the prior three months, and being “bothered by” abdominal, pelvic or genital pain “somewhere between a little and a lot” or “a lot” over the prior three months.
  • Comparison: Adults without chronic abdominal pain.
  • Outcomes:
    • Primary Outcome: ED visits in the prior 12 months.
    • Secondary Outcomes: Mental health status, physical comorbidities, disability, and social determinants of health.
  • Type of Study: Secondary analysis of a cross-sectional interview study.

Dr. Michael Ray

This is an SGEMHOP, and we are pleased to have the lead author on the episode. Dr. Michael Ray is an Assistant Research Professor, Department of Emergency Medicine at George Washington University School of Medicine & Health Sciences. Known as a pain researcher. Clinically practiced as a chiropractor in an outpatient setting, which led to an interest in chronic pain and transition to academia.

Authors’ Conclusions: This nationally representative analysis suggests that individuals with CAP have significantly higher ED utilization and face greater burdens of disability, mental health conditions, comorbidities, and SDOH-­related barriers. These findings highlight the potential value of addressing BioPsychoSocial factors to reduce ED reliance and support comprehensive care for CAP patients.

Quality Checklist for Observational Study:

  1. Did the study address a clearly focused issue? Yes
  2. Did the authors use an appropriate method to answer their question? Yes
  3. Was the cohort recruited in an acceptable way? Unsure
  4. Was the exposure accurately measured to minimize bias? Unsure
  5. Was the outcome accurately measured to minimize bias? Unsure
  6. Have the authors identified all important confounding factors? Unsure
  7. Was the follow-up of subjects complete enough? N/A
  8. How precise are the results? The numbers are large, so they are likely to be reasonably precise, but formal measures of uncertainty, such as credible intervals, aren’t presented in the paper.
  9. Do you believe the results? Yes 
  10. Can the results be applied to the local population? Yes
  11. Do the results of this study fit with other available evidence? Yes
  12. Funding of the Study? National Research Scientist Award via George Washington University, and the Authors declared no conflicts of interest.

Results: Just over 4.5 million (2.8%) of the nearly 163 million respondents reported Chronic Abdominal Pain. The chronic abdominal pain group had higher proportions of female sex (66% vs 50%) and age 55 to 64 (23% vs 15%), with similar race/ethnicity distribution.

Key Result: Reporting Chronic Abdominal Pain was associated with an increased frequency of ED attendance.

  • Primary Outcome: 1% of people with CAP reported one ED visit over the last 12 months, compared to 11.7% of people without. 16.9% had visited 2 to 4 times compared with 5.2%.
  • Secondary Outcomes: Chronic abdominal pain was associated with increased incidence of anxiety, depression, physical comorbidities, challenges accessing healthcare, economic instability and limitations in social and employment function.

  1. Recall Bias: By conducting a secondary analysis of the US National Health Interview Survey, you are obviously limited by how the original survey’s designers chose to collect the data. Much of the data depends on patients’ recollections, which we know can be flawed. People who go to the ED with their pain may well remember the days of pain more clearly than those who did not or could not seek healthcare. Do you have any information or a sense of how the NHIS measures up against other cohorts where the data can be triangulated
  2. Exclusions & Missing Data: The dataset includes many potential confounding factors, such as comorbidities and some social determinants of health. However, the entire survey excludes people without a permanent household address, and there doesn’t seem to be information around alcohol or substance use, which could plausibly be associated with chronic pain and contact with healthcare. How much do you think that challenges your findings?
  3. Outcome Measurement: The NHIS does not link ED visits to a specific presenting complaint, so some “excess” ED use among chronic abdominal pain respondents may reflect unrelated issues. In addition, modelling excluded asthma and injury. Excluding injury makes sense, but why exclude asthma?
  4. Multiple Comparisons: You acknowledge in the paper that the multiple comparisons you have done increase your risk of Type 1 error. This is where you find something that meets the criteria for statistical significance purely by chance. However, you deliberately chose not to apply a statistical adjustment, such as a Bonferroni correction. Could you talk us through that?
  5. Residual & Bidirectional Confounding: Although models adjusted for demographics, disability, mental health, PMH, and SDOH, unmeasured or imperfectly measured factors (access to specialty care, pain catastrophizing, prior imaging availability) could partly explain the associations. You note complex bidirectional relationships among CAP, mental health, disability, and SDOH that a cross-sectional model cannot fully resolve, which is an inherent limitation of observational designs. What do you think its implications might be for the individual patient and care provider?

Comment on Authors’ Conclusion Compared to SGEM Conclusion: We broadly agree with the authors’ conclusions, but would emphasize the need to be very cautious about inferring causation in either direction.

SGEM Bottom Line: Adults reporting chronic abdominal pain report more ED attendances than those without, and report higher levels of physical, psychological and social comorbidities.

Dr. Kirsty Challen

Case Resolution: You empathize with your resident, noting that it can be frustrating when patients present to the ED with chronic problems. However, you help her frame this in the context of the impact on multiple areas of the patient’s life of chronic pain.

Clinical Application: ED providers should recognize that people presenting with chronic abdominal pain are more likely to have physical and psychological comorbidities and be disadvantaged in terms of social determinants of health.

What Do I Tell the Patient? We know that patients with chronic abdominal pain often have challenges in other parts of their lives. Is there anything else we can help with?

Keener Kontest: The last episode’s winner was Scott Luce. He gave four examples of c-collars with geographic locations from the US (Aspen, Philly, Miami Jr and NY Ortho).

Listen to the SGEM podcast for this week’s question. If you know, then send an email to thesgem@gmail.com with “keener” in the subject line. The first correct answer will receive a shoutout on the next episode.

Now it is your turn, SGEMers. What do you think of this episode on chronic abdominal pain and ED utilization? What questions do you have for Michael and his team? Post your comments on social media using #SGEMHOP. The best social media feedback will be published in AEM.

Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.