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Introduction In this study, the hematological and inflammatory parameters of patients admitted to the emergency department with abdominal pain were examined and predictive values were determined. Methods A total of 12682 patients who applied to Sakarya Training and Research Hospital adult emergency service with abdominal pain between 01/01/2019-31/12/2019 were included in the study. Patients were divided into groups, as follows: Group 1: Patients discharged from the emergency room, Group 2: Patients who were hospitalized from the emergency department and discharged without surgery, Group 3: Patients who were hospitalized from the emergency department and underwent surgery. Results A total of 12682 patients were included in the study. In the operated group the median CRP level (23.1 [0.1-377.4] mg/dL) was the highest, the mean WBC number (13.8±6.2 K/µL) was the highest, the median lymphocyte percentage (12.8 [0.2-55.6] %) was the lowest, the median neutrophil number (9.9 [1.0-43.8] K/µL) was the highest, the mean platelet number (254.2±88.1 K/µL) was the highest, the median neutrophil/lymphocyte ratio (6.1 [0.5-425.2]) was the highest and the median platelet/lymphocyte ratio 143.9 [16.9-2019.4] was the highest. Conclusions Our large-scale study shows that hematological-inflammatory parameters, which are routinely studied in patients presenting with abdominal pain, can be used to distinguish patients who will be discharged from the emergency service and those who require hospitalization.
Acute abdominal pain is described as a symptom that begins within a week and indicates an emergency.1 Abdominal pain constitutes approximately 10% of the symptoms of the patients who apply to the emergency department.2 Besides, emergency department physicians may have difficulties due to the wide variety of diseases in the differential diagnosis of abdominal pain.2 It is complicated to make an absolute diagnosis for patients presenting with abdominal pain in the emergency department; moreover, researchers confirm that most patients are discharged from the emergency room without any diagnosis.3,4 Emergency surgery may be required in cases presenting with acute abdominal pain, but sometimes the patient may need to be followed up for a while after hospitalization to decide on surgical treatment.5 It is of great relevance for emergency doctors to ascertain whether patients with abdominal pain require surgery or not.6
Hematological parameters and C-reactive protein (CRP) are assisting laboratory parameters in the diagnosis of acute abdomen, which is required in practically all patients presenting to the emergency department with abdominal pain.7 Some of the hematological parameters and CRP are elevated in case of infection or inflammatory conditions.8 These rapidly synthesized acute phase proteins neutralize the acute phase antigens; moreover, at the same time the tissue repair process is initiated by controlling tissue damage.9 Acute phase reactants reach their peak within 24 to 48 hours.10
It should be explained whether hematological and inflammatory parameters can be predictors for surgical decisions in patients presenting to the emergency department with abdominal pain. In this study, the hematological and inflammatory parameters of patients admitted to the emergency department with abdominal pain were examined and predictive values were determined. In this way, these determined values can help physicians to predict acute surgical intervention.
Study setting
This research is a single-center retrospective study. A total of 12682 patients who applied to Sakarya Training and Research Hospital adult emergency service with abdominal pain between 01/01/2019-31/12/2019 were included in the study. The study protocol was approved by the local ethics committee of Sakarya School of Medicine [IRB No:71522473/050.01.04-14828/108].
Patients and study design
According to the International Classification of Diseases codes, the patients who applied to the emergency department with the diagnosis codes R10 and its subgroups such as, R10.0-R10.1-R10.2-R10.3-R10.4 were scanned through the hospital automation system. These applying patients within the specified date range, i.e., 11447 patients discharged from the emergency department, 777 hospitalized, and 458 operated patients were divided into the following groups:
·Group 1: Patients discharged from the emergency room
·Group 2: Patients who were hospitalized from the emergency department and discharged without surgery
·Group 3: Patients who were hospitalized from the emergency department and underwent surgery.
Inclusion and exclusion criteria for the study were as follows:
Inclusion criteria
·Patients over 18 years of age who presented to the adult emergency department with abdominal pain and had the diagnosis code R10.0-R10.1-R10.2-R10.3-R10.4
·Patients whose tests were complete at emergency admission
Exclusion criteria
·Patients who were referred from another hospital and hospitalized without applying to the emergency department
·Patients admitted due to trauma
·Pregnant patients
·Patients who died without surgery in the emergency department or ward
·Patients admitted to the obstetrics emergency department
·Pneumonia, cellulitis, renal colic and so on. Patients with a definite diagnosis could not be included in the study
Clinical characteristics and laboratory data: The necessary data for this study were obtained from our hospital's information system and patient observation files. Complaints of patients at the admission to the emergency room, laboratory results (hematological, biochemical), information about discharge from the emergency department, hospitalization requirements, and surgical requirements in the hospital were recorded. Neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), derived NLR ratio (d-NLR) were calculated as follows:
·NLR=ratio of neutrophil count to lymphocyte count.
·PLR = ratio of platelet count to lymphocyte count.
·dNLR = d-NLR=ratio of neutrophil count to WBC count – neutrophil count.
Statistical analysis
The mean ± standard deviation or median, minimum, and maximum were used to summarize the descriptive data obtained from the study. Normal distribution of numerical variables was controlled with the Kolmogorov-Smirnov and Shapiro-Wilk tests.
The Mann-Whitney U test was used for the comparison of two independent samples when the numerical data were not normally distributed.
To compare more than two independent groups the One-Way ANOVA was used when the numerical variables were normally distributed and the Kruskal-Wallis test was used when numerical variables were not normally distributed. For multiple comparisons, the Tukey test was used for normally distributed variables, and the Dwass-Steel-Critchlow-Fligner was used for variables that were not normally distributed.
The Pearson-Chi square test was used to compare the differences between categorical variables.
Receiver operating characteristic (ROC) curve analysis was used to test their ability to predict operation status. MedCalc Statistical Software Trial version (MedCalc Software bvba, Ostend, Belgium; http://www.medcalc.org; 2015) software was used to calculate optimal cut-off values with the DeLong method using Youden’s index, the 95% confidence interval, and area under the curve. Other statistical analyses were performed using Jamovi project (2020), Jamovi (Version 1.6.13.0) computer software, retrieved from https://www.jamovi.org, and JASP (Version 0.14.1.0), retrieved from https://jasp-stats.org and p-value was accepted as 0.05.
A total of 12682 patients were included in the study. Among them, 11447 were discharged from the emergency department (Group 1), 777 were hospitalized but not operated (Group 2), and 458 were operated (Group 3). The ratio of males was the highest in the discharged patients (61.9%) and the lowest in the operated patients (53.1%). The mean age was the highest in the hospitalized patients (52.3±21.0 years) and the lowest in the discharged patients (43.3±18.7 years). The duration of hospital stay was higher in the operated patients (4.5 [0.0-129.0] days) than in the hospitalized patients (3.0 [0.0- 67.0] days). In the discharged group the median CRP level was (5.3 [0.0-418.4] mg/dL) the lowest, the mean white blood cell number (9.6±3.4 K/µL) was the lowest, the mean lymphocyte number (9.6±3.4 K/µL) and its percentage (2.2 [0.1-9.6] %) were the highest, the median number of neutrophils (5.6 [0.5-44.6] K/µL) was the lowest, the mean hemoglobin level (12.6±1.8 g/dL) was the highest, the mean platelet number (242.5±69.3 K/µL) was the lowest, and the mean RDW was the lowest (16.6±2.3 %), the mean platelet/lymphocyte ratio was the lowest 106.8 [14.0-2652.6], and the mean neutrophil/lymphocyte ratio (2.5 [0.2-62.4]) was the lowest. In the operated group the median CRP level (23.1 [0.1-377.4 mg/dL]) was the highest, the mean WBC number (13.8±6.2 K/µL) was the highest, the median lymphocyte percentage (12.8 [0.2-55.6] %) was the lowest, the median neutrophil number (9.9 [1.0-43.8] K/µL) was the highest, the mean platelet number (254.2±88.1 K/µL) was the highest, the median neutrophil/lymphocyte ratio (6.1 [0.5-425.2]) was the highest and the median platelet/lymphocyte ratio (143.9 [16.9-2019.4]) was the highest (Tables 1 and 2).
Receiver operating characteristics analysis was performed to determine cut-off values for several laboratory parameters to predict the operation outcome. For the whole group, the cut-off values were as follows: CRP >13.84 mg/dL, WBC >11.13 K/µL, LYM ≤1.81 K/µL, NEU >8.41 K/µL, HGB ≤11.1 g/dL, EOS ≤0.08 K/µL, PLT >267.000 /µL, RDW >15.96 %, NEU/lym >3.83, PLT/lym >133.16. For the males, the cut-off values were as follows: CRP >10.13 mg/dL, WBC >11.58 K/µL, LYM ≤1.81 K/µL, NEU >8.75 K/µL, HGB ≤13.3 g/dL, EOS ≤0.08 K/µL, PLT >262.000 /µL, RDW >15.9 %, NEU/lym >3.83, PLT/lym >126.63. For the females, the cut-off values were as follows: CRP >17.88 mg/dL, WBC >11 K/µL, LYM ≤1.83 K/µL, NEU >8.29 K/µL, HGB ≤11.1 g/dL, EOS ≤0.07 K/µL, PLT >285.400 /µL, RDW >18.5 %, NEU/lym >3.46, PLT/lym >132.58 (Table 3, Figure 1).
Table 1. The comparison of the demographic and laboratory data of the patient groups
Table 2. Multiple comparisons of the three patient groups according to several laboratory values
Table 3. Receiver operating characteristics analysis of the laboratory values of the patients who were operated or not
CRP – C-reactive protein; EOS – eosinophil; HGB– hemoglobin; LYM – lymphocyte; NEU – neutrophil; PLT – platelet; RDW – red cell distribution width; WBC – white blood cell.
Figure 1. Receiver operating characteristics
Abdominal pain is one of the most common causes of emergency room admissions and this is one of the patient groups that emergency physicians also encounter most frequently.11 Since it may be a symptom of a serious underlying disease, physicians may experience various difficulties in case of an incorrect diagnosis. In a study on overlooked and delayed diagnoses in the emergency department, it was confirmed that the majority of patients presented with abdominal pain.12 This designates that emergency physicians necessitate tools to strengthen their hands in terms of diagnosis and follow-up in abdominal pain cases.
Abdominal pain cases admitted to the emergency department may have three outcomes: those who are discharged from the emergency service, those who are hospitalized operated on, those who are hospitalized and followed up only. In our study, 9.7% of the patients who applied with abdominal pain were hospitalized, and 3.6% were operated on. Considering these data, emergency department physicians discharged approximately 90% of the patients who applied and had to identify 10% of patients in need of urgent treatment. In a study, one-year patient applications were examined and it was found that 7.7% of the patients who applied with abdominal weight were operated on.13 One of the reasons for the difference between our study and the results of this study may be that the use of imaging methods has increased today and therefore unnecessary operations have decreased. Besides, another reason for this difference may be due to the high number of applications to the emergency department over the years.
In the current medical literature, data showing the relationship between complaints and gender of patients presenting to the emergency department with abdominal pain is limited. In a study conducted, it was reported that 65% of the patients presenting with abdominal pain were women, and 24.7% of the total patients were hospitalized.2 Similarly, in our study, it was found that female patients admitted to the emergency department due to abdominal pain were more frequent, whereas 53% of the operated patients were male. The more women presenting to the emergency room and less hospitalization can be explained by the hormonal status of women and the sociocultural characteristics of the population.14
Hematological parameters and CRP are widely studied in patients presenting to the emergency department with abdominal pain. CRP rises rapidly in response to most infectious and inflammatory conditions.8 Studies analyzing CRP levels in cases of abdominal pain report conflicting results. Some studies have reported that there is little correlation between CRP values and patient outcome and that CRP alone is not useful in distinguishing patients who need surgery.15,16 In another study, it was reported that CRP can predict positive results in CT.17 In our study, it was found that CRP was significantly lower in patients who were discharged from the emergency department due to abdominal pain compared to the group of patients who were hospitalized or operated on. However, no statistically significant relationship was found between the patients' operation status and the CRP value after hospitalization. Thus, it is possible to say that the elevation of CRP detected in patients admitted to the emergency room with abdominal pain guides physicians in deciding hospitalization, but has no significant effect on the decision of surgery.
It is apprehended that the hematological parameters, such as WBC, LYM, NEU, EOS, RDW, NLR, PLR are parameters indicating inflammatory states.18.19 In our study, there was a significant difference in these parameters between the patient groups who presented with abdominal pain and were discharged, hospitalized, and operated on. Besides, the cut-off values of the relevant parameters in the operated patients were calculated. Information on calculating the cut-off values of these parameters of patients with abdominal pain is limited in the current medical literature.
Since the analysis results within the reference range cannot exclude an urgent disease, the patient history, and physical examination guide physicians.20 Even in patients with acute abdomen diagnosed after surgery, laboratory parameters may be within reference values, or even if the results of the analysis are seriously high, it does not indicate that there is an emergency in the patient.20 In a study, more than 10,000 patients who presented with acute abdominal pain were analyzed and the etiology was not determined in approximately one of three patients.21 It is known that CT has a high accuracy rate in identifying patients with the acute abdomen,22 but considering the current disadvantages of tomography due to radiation and contrast, it is seen that we need guidance and triage tools, especially in patients who do not require urgent imaging. In the presence of laboratory parameters that can be used in the triage of patients, tomography can be reduced, treatment costs can be decreased and waiting times in the emergency department can be shortened.
This study has certain limitations. First, it was designed retrospectively. Second, there were no imaging methods. Laboratory parameters may not always be correct due to human error.
Our large-scale study shows that hematological-inflammatory parameters, which are routinely studied in patients presenting with abdominal pain, can be used to distinguish patients who will be discharged from the emergency service and those who require hospitalization.
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