Assessment and management of recurrent abdominal pain in the emergency department, 2019, Daniels et al

Andy

Andy

Retired committee member
Not a recommendation.
Recurrent abdominal pain accounts for a significant proportion of attenders and high impact users in the emergency department. Due to the heterogeneity of presentation and the broad spectrum of possible causes, abdominal pain presents as a significant clinical challenge within the emergency department, particularly as distress and pain are commonly elevated. Patients in this group are routinely prescribed opiate-based interventions and repeated investigations in a ‘better safe than sorry’ culture which saturates the field of persistent physical symptoms. This approach is contributing to the growing problem, and fuelling a cycle of repeated attendance and failure to resolve. This article reviews the current clinical and psychophysiological understanding of recurrent abdominal pain, critiquing guidelines and approaches to diagnosis and management. We offer an alternative evidence-based biopsychosocial approach using the mnemonic ‘ERROR’, recommending five steps to assessment and clinical management of recurrent abdominal pain in the emergency department.
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Paywall, https://emj.bmj.com/content/early/2019/12/06/emermed-2019-209113.full
Scihub, https://sci-hub.se/10.1136/emermed-2019-209113
 
It's another piece from Joleen, on the NICE guideline development committee!

"To suggest that any symptomatic experience is purely biomedical is scientifically refutable and lacking in credibility. Modern medicine has moved towards the biopsychosocial model of health, acknowledging the complex reciprocal interactions between multiple systems at physiological, psychosocial and environmental levels"

The arrogance is amazing. I really should stop reading this stuff.....
 
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MEMarge said:
It's another piece from Joleen, on the NICE guideline development committee!

"To suggest that any symptomatic experience is purely biomedical is scientifically refutable and lacking in credibility. Modern medicine has moved towards the biopsychosocial model of health, acknowledging the complex reciprocal interactions between multiple systems at physiological, psychosocial and environmental levels"

The arrogance is amazing. I really should stop reading this stuff.....
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And yet these psychosocial factors are so nebulous that the conclusion that an illness is (supposedly) a conversion reaction is reached only when no biomedical cause can be found. Which is entirely consistent with there being no conversion reaction whatsoever and a 100% biomedical cause because absence of evidence is not evidence of absence.
 
strategist said:
And yet these psychosocial factors are so nebulous that the conclusion that an illness is (supposedly) a conversion reaction is reached only when no biomedical cause can be found. Which is entirely consistent with there being no conversion reaction whatsoever and a 100% biomedical cause because absence of evidence is not evidence of absence.
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Yes exactly, at what point do they come up with a "tool" they are willing to blind test on a group of mixed illness patients and declare which ones are conversion disorder as opposed to a known and previously diagnosed physical illness.

I'm pretty sure the Lancet or the BMJ would be willing to publish their findings if they got it right 50% of the time on a tiny sub set of say two people.

Surely if conversion disorders are easy to diagnose they should be able to apply the conversion disorder questionnaire without performing a single biomedical test or physical examination.

No doubt if the results turned out that every patient was a cancer patient and they had declared a number of them conversion disorder the BMJ or Lancet would snap their hands of for the paper to show that psychological factors cause cancer.
 
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I don't understand why there are psychologists involved in this area at all. They have no medical knowledge, so should not be advising on how to assess abdominal pain.

So their 5 step 'ERROR' acronym stands for:
E: exclude medical emergency
R: review attendance and care plan (look for frequent attenders)
R: record relevant factors (meaning psychological factors)
O: offer a credible explanation for pain (tell them it's not biological)
R: Refer on (to be fair, this includes further medical tests, but also pain and psychology clinics)

That looks like a pathway that encourages pushing people off onto pyschs as soon as nothing obvious is found, especially if they've attended before.
 
Trish said:
That looks like a pathway that encourages pushing people off onto pyschs as soon as nothing obvious is found, especially if they've attended before.
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Something I read recently that I had never taken in before is that, in practice (not theory), there isn't a single gynaecological condition which constitutes an emergency. (I'm not including obstetrics in that statement.)
 
The underlying premise implicit in the above abstract (in more general terms than just abdominal pain) is that there is a large category of people who respond to life's difficulties with any of a host of physical symptoms that are not in fact any real pathology as understood in ordinary medical terms. We all already know that they believe this.

Beyond the idea of mental phenomena as cause of symptoms there is entirely no explanation for how this happens or why. One presumes strong emotions are involved and/or lack of skill in coping with the vagaries of life. This is an entirely subjective judgment on their part and based on nothing more than the distress a person presents with because they are ill and being 'handled' and are often well aware of it.

It's difficult to understand how the BPS cabal can easily through a simple box ticking exercise distinguish between someone who presents with a physical illness that has no reliable test markers but requires improved medical understanding (or just further examination) and those that fit in to conversion. We know the answer here too is to simple hover up all people unfortunate enough to find themselves without an easy diagnosis. I can't help think 'conversion' is an apt term here. The BPS filling the part of the powerful figure who must convince them of their sin of unconscious pretense.

Of course there is the problem that mental processes do affect us physically so that because we know almost nothing of how, why or when they do that--the BPS premise becomes unfalsifiable. By the same token one can say well then, who's to say? Clearly, the BPS cabal think they can by virtue of a complete lack of evidence.

But (even according to many of the BPS cabal) they are real physical sensations that can even be objectively evaluated on tests (occasionally) yet are still due to some vague (as yet to be well defined) mental process. So here's a problem as I see it: how then to tell the difference between the two?

If medical technology continues to provide new ways of evaluating physical processes and their dysfunctions how are the BPS to distinguish when one is a real illness that requires medicine and the one that only requires some talk therapy about how to acquire a backbone?

In other words, when can we expect this madness to stop?
 
‘better safe than sorry’ culture which saturates the field of persistent physical symptoms
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Riiiight. Oh yeah, totally. This is definitely true and not completely made up. Doubleplusungood.

It's particularly notable that if those patients were actually followed competently in regular care, and those problems competently researched, they would almost never go to emergency medicine. Don't blame people suffering for your own damn failures.

Which to some credit the paper acknowledges, yet somehow chooses not to follow the train of thought:
An over-represented yet poorly understood group, repeat attendances within the ED are purported to be a reflection of unmet clinical need
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This is despite the availability and expertise of community self-management to help patients during these phases.
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It's almost as if those were not actually adequate and useful. Almost. Only if you apply common sense, though.
The severity of pain and purported health anxiety observed in medical populations are likely factors in precipitating ED visits pain triggers a ‘threat’ response leading to action, which for a significant minority, is an ED visit
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Especially if you aggressively reject common sense by making stuff up about pain being anything other than pain. Nobody likes pain. Pain is bad, it's disabling, it's exhausting. It doesn't care whether you think about it or not the same way you can't wish away a constant source of loud screeching noise. It's not about a "threat" at all, pain is bad in and of itself without inventing some imaginary additional meaning to it.

No idea what's going on here:
Recent reviews of recommended non-pharmacological interventions for abdominal pain have reported mixed findings for a range of psychological therapies including cognitive behavioural therapy (CBT), behavioural therapy, hypnotherapy, psychodynamic therapy and person-centred therapy26 27 33 34owever, trials are limited by the absence of the psychophysiological components which are an essential underpinning to understanding this complex presentation.
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No true BPS? The paper mentions earlier to this paragraph that a BPS model of abdominal has been around since about 1990. With absolutely nothing to show for it. 30 years and somehow this weird realization that it's both complete yet lacking any understanding. It's not as if technology or other scientific breakthroughs will make a difference here, this is a completely alternative model that could have been done as is 500 years ago if they had wanted to.

The O in ERROR stands for "offer a credible explanation for pain", which is basically the typical "rousing reassurance" nonsense, make up an explanation for the sake of giving an explanation because that's all the patient needs. An explanation, any explanation, doesn't matter if it's relevant just reassure them. What freaking arrogance.

I assume this is the same Jo Daniels as on the NICE committee. With "experts" like this...
 
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Jonathan Edwards said:
What I find remarkable is the complete lack of psychological insight.
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I never stop being amazed at this. Paper-thin caricatures of human behaviors from people clearly committing false attribution errors while pretending to take a "holistic" approach that is actually 100x more reductive than biology, which is freakishly large and covers a whole lot of ground.
 
James Morris-Lent said:
Stress doesn't even make you feel abdominal pain. So...
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Somehow even though peptic ulcers got yanked away from MUS, the ideas underlying it are still used in practice. It's mostly moved on to IBS and generic abdominal pain now, with everything else the same. Ooops, wrong doomsday prediction, the end of the world is not for 10 May, it's actually for 5 October. Just mixed up notation. Still guaranteed to happen, sell all your belongings anyway.
 
Arnie Pye said:
Something I read recently that I had never taken in before is that, in practice (not theory), there isn't a single gynaecological condition which constitutes an emergency. (I'm not including obstetrics in that statement.)
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I was thinking of something specific when I wrote the post above.

Think of testicular torsion versus ovarian torsion.

Both ought to be treated as emergencies. Since the scrotum and testicles can be seen and felt I'm sure that testicular torsion is almost certainly treated very seriously and very rapidly most of the time.

But for women, since the ovaries can't be seen the chances of not getting taken seriously are high, and women can be left to suffer in excruciating pain for weeks.
 
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