• Am J Emerg Med · Mar 2021

    Is "pain before vomiting" useful?: Diagnostic performance of the classic patient history item in acute appendicitis.

    • Toshihiko Takada, Ryota Inokuchi, Hongja Kim, Sho Sasaki, Kazuhiko Terada, Hajime Yokota, Shinya Hattori, Wakako Mikami, Tadao Kubota, and Shunichi Fukuhara.
    • Department of General Medicine, Shirakawa Satellite for Teaching And Research (STAR), Fukushima Medical University, 2-1 Toyochi Kamiyajiro, Shirakawa, Fukushima 961-0005, Japan; Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Yoshida Konoe-cho, Sakyo-ku, Kyoto 606-8501, Japan. Electronic address: ttakada@water.ocn.ne.jp.
    • Am J Emerg Med. 2021 Mar 1; 41: 84-89.

    BackgroundIn most surgical textbooks, it has been stated that pain almost always precedes vomiting in patients with appendicitis. However, the usefulness of this classic history item, "pain before vomiting", has been investigated in only one study nearly 50 years ago, in which the cause of abdominal pain could not be identified in more than 40% of patients. Accordingly, our objective was to evaluate the performance of pain before vomiting for the diagnosis of acute appendicitis in patients who presented with both acute abdominal pain and vomiting.MethodsA retrospective chart review of adult outpatients with abdominal pain and vomiting at three acute care hospitals was performed. The reference standard for appendicitis was a CT scan evaluated by two radiologists. Diagnostic performance of pain before vomiting and the value it added to the Alvarado score were evaluated.ResultsAmong 310 patients, 24 patients were diagnosed with appendicitis. Diagnostic performance of pain before vomiting was a sensitivity of 95.8% (95% confidence interval [CI] 79.8-99.3) and a specificity of 16.6% (95% CI 12.6-21.4). When combined with the Alvarado score, it ruled out appendicitis in an additional 12% (increased from 32% to 44%) of patients without any false negatives.Conclusions"Pain before vomiting" is useful for ruling out appendicitis in patients with abdominal pain and vomiting.Copyright © 2020 Elsevier Inc. All rights reserved.

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