Regarding Constipation as Cause of Acute Abdominal Pain

To the Editor:
Congratulations to the JUCM staff for its efforts! The content of the journal is timely, relevant, and needed. As original research in urgent care increases, clinicians will look to JUCM as a source for the most important of these studies.

Until then, we must rely on data from many other sources to inform and improve our practice. JUCM features like Dr. Nahum Kovalski’s Abstracts in Urgent Care Medicine are a most welcome and excellent resource in this regard. We will always have less control over the applicability of knowledge we gain indirectly, and along these lines there was an abstract in the November issue (Constipation as Cause of Acute Abdominal Pain in Children) that deserves some comment.

The abstract pertained to a retrospective study of constipation and abdominal pain in a pediatric practice, with a final conclusion that “constipation was the most common cause of acute abdominal pain in children.”

Unfortunately, the evidence in the study does not necessarily pertain to urgent care practice or allow us to make diagnoses or other clinical decisions. Though the Results section of the paper to which the abstract review pertains does distinguish between patients with abdominal pain for less or more than three or four days, the abstracted data include cumulative numbers, and by definition, children with pain for up to two months were considered to have “acute” abdominal pain.

In addition, not mentioned in the abstract but stated in the article is that clinicians, at least sometimes, used enemas in the office and subsequent pain resolution to help with diagnosis. Beyond this, 19% of patients had no diagnosis, and there is no description of further follow-up or evaluation of any patient to determine whether any of the other diagnoses were correct— it seems that they were just assumed to be correct.

These and other methodological problems allow only one take-home point from the study: some of the doctors in that practice thought that some of the children had constipation as a cause of their abdominal pain. Unfortunately, it is not possible to validly conclude anything more specific than that.

This experience reminds me of two things.

First, we should regard all study results carefully to determine how they pertain to our practice. We should participate in education (we can get CME credit!) that focuses on the basics of analyzing studies using evidence-based medicine techniques.

The specifics and quality of our knowledge will always depend on the specifics and quality of the methods we use to acquire it. We should aspire to the highest quality; our patients deserve it.

Second, in urgent care, we can learn from the emergency medicine approach to caring for patients with acute abdominal pain. In EM, discharging patients with a definite benign diagnosis is typically avoided (“unspecified abdominal pain” is fine), and the evaluation is best explained to patients as a “work-in-progress” which continues after discharge.

Our decision-making should focus on whether a confident diagnosis can be made clinically, whether the patient’s presentation is worrisome enough to warrant further tests or consultation soon, or whether it’s benign enough wait and see if it resolves fully (which it frequently does), or subsequently declares itself clinically or rises to the level of requiring a work-up.

Constipation is certainly a valid diagnosis in a patient with these symptoms as a chief complaint, but in patients with a chief complaint of acute abdominal pain, considering using enemas to relieve the pain prior to discharge (there is no evidence supporting the validity of this approach, but it does seem to make sense), or using the “work-in-progress” approach, with a clear discussion about what to expect and other precautions, seems to be the appropriate fit considering the risk-management and clinical realities in urgent care medicine.

Joe Toscano, MD
Emergency and Urgent Care Medicine Clinician
San Jose, CA

If you have thoughts on an article that appeared in JUCM, The Journal of Urgent Care Medicine (or on issues relevant to urgent care in general), please express them in a Letter to the Editor via e-mail to editor@jucm.com or by “snail mail” to: Editor, JUCM, 2 Split Rock Road, Mahwah NJ 07430.