To study the epidemiology and clinical profile of adult patients with acute abdominal pain attending tertiary care hospital

Introduction: Acute abdomen is a very common problem in emergency department. Aims and Objectives: This study aims to find out the clinical and epidemiology profile of acute abdominal pain among patients attending emergency department of Santosh Medical College Ghaziabad. Materials and Methods: A tertiary care hospital based, cross-sectional study was conducted from January 2018April 2019 2018, among patients presenting with acute abdominal pain to Santosh Medical College Ghaziabad, India. Data was entered on a standard data collection sheet after obtaining a written informed consent. Results: Out of 1200 patients admitted via the Emergency Department at the Hospital, 200 (16.6%) were admitted with atraumatic acute abdominal pain. Out of 200, 120(60%) were due to Surgical causes and 80 due to non-surgical causes. Most consistent symptom and sign were pain abdomen and abdominal tenderness respectively. Acute cholecystitis was the most common etiology of acute abdominal pain (35.8% cases), followed by, Renal Stones (30.5%), Acute Appendicitis (17.5%) and Intestinal Obstruction (16.67%) respectively. Conclusion: About 16.60% of all emergency admissions were due to acute abdominal pain and about 60.0% of all atraumatic acute abdominal pain was due to surgical cause. Acute cholecystitis was the most common cause of surgical abdominal pain.


Introduction
Acute Abdominal Pain (AAP), is frequently defined as pain with nontraumatic origin and of less than five days duration. 1 Abdominal pain is one of the most common complaints in a medical emergency room and accounts up to 6-10% of Emergency room visits. 2 Due to varied clinical spectrum of presentation, diagnosis and management of abdominal pain is a significant challenge.
Acute abdomen can have heterogeneous clinical and temporal presentation lasting from hours to days. Thus, acute abdominal pain can range from non-specific, undifferentiated and benign etiologies like psychogenic pain to life threatening emergencies like aortic dissection. [3][4][5][6] Acute appendicitis, Gastroenteritis and abdominal trauma are common causes of pain abdomen adults less than 18 years of age. Appendicitis, Intestinal obstruction, cholecystitis, diverticulitis are frequently seen offenders in mid-age population and elderly. Acute Gastritis, Cardiac and some metabolic emergencies can also present as acute abdominal pain. [7][8][9][10] Ultrasound and Computed Tomography are widely used radiological modalities to augment diagnostic accuracy of history and clinical examination in the setting of abdominal pain. 6 This study aimed to find clinical and epidemiological spectrum of atraumatic acute abdominal pain in OPD and emergency department of a medical college in Western Uttar Pradesh.

Materials and Methods
A cross Sectional study was done in the Department of General Surgery, Santosh Medical College and Hospital, Ghaziabad from January 2018 to April 2019. A total of 200 patients with pain abdomen were enrolled in the study. Patients presenting with acute abdominal pain, age of above 18 years, of both the sex and all with co-morbidities were included. Patients with perforation peritonitis, all types of malignancies, trauma and of paediatric age group (<18 years) were excluded from the study. Ethical clearance was obtained from Institutional Ethical Committee. A written and informed consent was taken from patients before enrolling them for study.
A structured questionnaire format was used to elicit detailed history (onset, duration, character of pain, radiation, intensity, periodicity, type, etc.) and examination (guarding, rigidity, rebound tenderness, distortion in abdominal anatomy, lump, scar, shape of abdomen, pigmentation). Basic blood investigations were done for all patients. Radiological investigations like ultrasonography (USG) and computer tomography (CT) scan were done on appropriate indication, the patients were asked about the severity of pain and it was objectively assessed with Visual Analogue Scale (VAS) of 0 to 10.
The assessment of pain was done on the basis of a detailed history and examination which included history of onset and duration.
Pain relief was given through the oral route if mild or parenterally when severe. The patients were followed up until discharge from admission in ward and the final diagnosis at discharge was noted.

Statistical analysis
Data was entered in MS-EXCEL and the variables identified were analyzed. Descriptive statistical analysis was carried out in the present study. Statistical testing was conducted with the statistical package for the social science system (SPSS) version 17.0. Continuous variables were presented as mean ± SD and categorical variables were presented as absolute numbers and percentages. The comparison of normally distributed continuous variables between the groups was performed using Student's t test. Nominal categorical data between the groups were compared using Chi-squared test or Fisher's exact test as appropriate. P = <0.05 was considered statistically significant.

Results
Out of 1200 patients admitted via the emergency department at the hospital, 200 were admitted with atraumatic acute abdominal Pain. Out of 200, 120 were due to surgical causes and 80 due to non-surgical causes. Thus 10% of patients presenting to Emergency Room (ER) were admitted with surgical causes of acute abdomen. Out of 200 patients, maximum numbers of patients were present in the young age group with a percentage as high as 78.5%, followed by 30 patients in the middle age group. Only 6.5% of patients fell in the senior age group.

Clinical symptoms
Sudden onset of abdominal pain was the main clinical presentation of most of the patients. Onset was found to be Sudden among 181 (90.5%) subjects and Insidious among 19 (9.5%). colicky pain was most common with a frequency of 120 (60.0%), followed by dull Aching pain seen among 55 (27.5%) patients. Next came burning among 17 (8.5%) patients, and throbbing pain among 8 (4.0%) subjects. Prevalence of abdominal pain was found to be maximum in the right hypochondrium [n=37, (37%)], followed by right lumbar [n=48, (24%)]. Next follows left lumbar [n=25, (12.5%)] followed by epigastrium and right hypochondrium together [n=21, (10.5%)]. Right iliac and hypogastric show similar prevalence of 12 cases each (6%). Lastly follows epigastric and bilateral lumbar with n=7 (3.5%) and n=1 (0.5%) respectively. Pain in the abdomen was referred to the right shoulder in 23 (11.5%) subjects. Referred pain has quite a low prevalence in the total number of patients enrolled in the study, anorexia with pain abdomen was found among 35 (17.5%) subjects only, therefore suggestive of a very low frequency of the same in cases of pain abdomen. Vomiting was the dominant clinical feature, found among 84 (42.0%) patients, next follows fever among 46 (23.0%) subjects. A Detailed tabulated description of clinical Symptoms follows in Table 2.

Etiologic distribution
Out of 200 patients in our study: Acute Cholecystitis (n = 43), Renal Stones (n = 36), Acute Appendicitis (n = 21) and Intestinal Obstruction (n = 20) were most commonly seen Surgical diagnosis. 80 patients had non-Surgical Diagnosis. The 95% confidence Interval table and Distribution Bar diagram are presented in Table 4. Most of our patients i.e. 181 patients (90.5%) reported their pain as sudden onset while the remainder described their pain onset as gradual. The incidence of sudden onset pain here is higher than study by Jegraj M, Chanana L. et al 11 where pain was sudden in onset in 54.9% of patients. Acute onset abdominal pain when presented should always be taken as a matter of utmost concern about a potential intra-abdominal catastrophe.
As character of pain gives a clinical hint about the ongoing etiology, colicky pain with a frequency of 120 (60.0%) in the patient cohort suggest that mostly tubular structures (Gall Bladder, Kidney) related etiologies are the leading cause of acute abdominal pain, dull aching pain was seen among 55 (27.5%) patients, burning among 17 (8.5%) patients and throbbing pain among 8 (4.0%) subjects signify other abdominal viscera to be responsible due to other etiologies which are responsible for pain abdomen. Jegaraj M, Chanana L. et al 11 observed that the common types of pain included dull aching (36%), colicky (18.2%), pricking (10.2%), crushing (9.8%), and throbbing (3.4%). The variation observed likely reflected different patient distribution at various clinical centers.
In present Study, Abdominal Pain found in 100% and vomiting in 42% of the patients. This study is in concordance with study by Jain et al 12 where the commonest symptom was abdominal pain (100%) followed by vomiting (71.4%). Jegaraj M, Chanana L. et al also found that the most common symptom was abdominal pain (76.9%) followed by vomiting (57.2%). Similar Findings were observed in a study done by Berhane et al 13 the commonest symptom was abdominal pain (100%) followed by vomiting (80%). Vomiting often accompanies abdominal pain both due to mechanical causes as well as pain and psychogenic stimuli.
In this study acute cholecystitis and Renal Colic were most common causes of acute abdominal pain followed by acute appendicitis, whereas in Study by Thakur et al. 14 acute appendicitis was more common followed by cholecystitis and renal colic respectively. This might again reflect heterogeneity in clinical profile across various centers.

Conclusion
Atraumatic Acute Abdominal Pain contributes to about 16.6% of emergency admissions at this center and about 60% of it is due to surgical causes. Acute cholecystitis is most common cause of surgical acute abdomen at this centre. These findings validate comparative literature findings about clinical and epidemiology profile of abdominal pain as well as help us in addressing health infrastructure and training facilities tailored to specific etiologies in our region.
Source of funding Self.