In addition to those with a specific diagnosis requiring admission, the following patients should be seriously considered as candidates for hospitalization: Those who appear ill; any elderly or immunocompromised (including HIV-positive) patient (with or without comorbidity) in whom the diagnosis is unclear; younger, healthy patients in whom the diagnosis is unclear and any potentially serious cause of abdominal pain has not been comfortably excluded; intractable pain or vomiting; acute or chronic altered mental status; inability to follow discharge or follow-up instructions; undomiciled, living in shelter, or otherwise lacking social supports; excessive alcohol or other drug use.
NONSPECIFIC ABDOMINAL PAIN A substantial number of patients who are discharged with the diagnosis of NSAP are initially admitted as suspected appendicitis. This may be the reason that there appears to be an unexplained predominance of RLQ pain among patients discharged with the diagnosis of NSAP.
Although this entity is poorly understood pathophysiologically, follow-up among patients discharged from the ED with this diagnosis has found that nearly 90 percent are better or asymptomatic at 2 to 3 weeks.11 Similarly, follow-up of patients discharged from inpatient services with the diagnosis of NSAP has shown that about 80 percent have no further problems and are asymptomatic at 5 years. Of the remainder, about one-third are rehospitalized, of whom one-third have appendicitis. Some of these individuals probably had early appendicitis on their prior admission, with spontaneous resolution due to disimpaction of the appendiceal lumen. 43 Among this group, it is plausible that some later developed recurrent appendicitis that did not resolve and went on to appendectomy. The remaining two-thirds of patients who were neither rehospitalized nor asymptomatic turned out to have "benign" gynecologic and colonic problems, most commonly irritable bowel. 4445
The key to confirming NSAP as a working diagnosis is reexamination in 24 h, repeated as necessary if patients remain symptomatic. Whether this occurs on the inpatient service, in the ED observation unit, or at home depends upon the culture of the institution, the clinician's degree of uncertainty about the diagnosis, and the presence of facilities for reliable outpatient follow-up.
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