J Curr Surg

Journal of Current Surgery, ISSN 1927-1298 print, 1927-1301 online, Open Access

Article copyright, the authors; Journal compilation copyright, J Curr Surg and Elmer Press Inc

Journal website http://www.currentsurgery.org

Original Article

Volume 3, Number 1, June 2013, pages 13-18

Clinical Indicators for Differential Diagnosis of Acute Lower Abdominal Pain in Women of Reproductive Age

**Table 1.** Demographic Characteristic and Clinical Findings of Patients With Appendicitis, Obstetrics-Gynecological Conditions (OB-GYN), and Non-Specific Abdominal Pain (NSAP)
Characteristics	Appendicitis (n = 382)	OB-GYN (n = 97)	NSAP (n = 63)	P-value
* Kruskal-Wallis equality-of-populations rank test.
Age (yr)
> 25	169	44.2	41	42.3	27	42.9
Mean (SD)	30.1	(11.3)	28.9	(8.8)	29.9	(10.4)	0.937*
Single	193	50.8	49	51.0	33	53.2	0.943
Duration of pain (hr)
> 24	94	24.6	39	40.2	21	33.3
Mean (SD)	31.2	(32.0)	52.4	(65.9)	34.9	(37.4)	0.413*
Shifting of pain	142	31.2	6	6.2	11	17.5	< 0.001
Anorexia	43	11.3	2	2.1	6	9.5	0.010
Nausea and vomiting	200	52.4	15	15.5	20	31.8	< 0.001
Abnormal vaginal bleeding	1	0.1	28	28.9	2	3.2	< 0.001
Diarrhea	29	7.6	4	4.1	13	20.6	0.002
Temperature ≥ 37.5 °C	124	33.3	14	14.6	12	19.4	< 0.001
Pulse rate (/min)	(n = 374)	(n = 97)	(n = 62)
Tachycardia (≥ 100)	115	30.6	24	24.7	10	16.3
Mean (SD)	90.8	(15.5)	88.0	(17.4)	85.2	(17.0)	0.021
Systolic blood pressure (mmHg)	(n = 374)		(n = 97)	(n = 61)
Hypotension (< 90)	4	1.1	12	12.4	1	1.6
Mean (SD)	121.8	(15.9)	112.4	(18.5)	117.9	(14.3)	< 0.001
RLQ tender	374	97.9	71	73.2	53	84.1	< 0.001
LLQ tender	15	3.9	48	49.5	6	9.5	< 0.001
Guarding/rebound tenderness	255	66.8	34	35.1	13	20.6	< 0.001
Hematocrit (%)	(n = 336)	(n = 86)	(n = 55)
Mean (SD)	38.0	(3.9)	33.3	(6.0)	36.5	(5.9)	< 0.001*
WBC (/mm³)	(n = 292)		(n = 71)	(n = 53)
≥ 10,000	245	83.9	42	59.2	19	35.9
Mean (SD)	14,204.5	(4,638.4)	11,875.9	(4,531.9)	9,958.8	(5,200.0)	< 0.001*
Neutrophil (%)	(n = 281)	(n = 69)	(n = 51)
≥ 75	171	60.9	39	56.5	10	19.6	< 0.001
Pregnancy	7	1.8	47	48.5	3	4.8	< 0.001

Table 1. Demographic Characteristic and Clinical Findings of Patients With Appendicitis, Obstetrics-Gynecological Conditions (OB-GYN), and Non-Specific Abdominal Pain (NSAP)

Characteristics

Appendicitis (n = 382)

OB-GYN (n = 97)

NSAP (n = 63)

P-value

* Kruskal-Wallis equality-of-populations rank test.

Age (yr)

> 25

169

44.2

42.3

42.9

Mean (SD)

30.1

(11.3)

28.9

(8.8)

29.9

(10.4)

0.937*

Single

193

50.8

51.0

53.2

0.943

Duration of pain (hr)

> 24

24.6

40.2

33.3

Mean (SD)

31.2

(32.0)

52.4

(65.9)

34.9

(37.4)

0.413*

Shifting of pain

142

31.2

6.2

17.5

< 0.001

Anorexia

11.3

2.1

9.5

0.010

Nausea and vomiting

200

52.4

15.5

31.8

< 0.001

Abnormal vaginal bleeding

0.1

28.9

3.2

< 0.001

Diarrhea

7.6

4.1

20.6

0.002

Temperature ≥ 37.5 °C

124

33.3

14.6

19.4

< 0.001

Pulse rate (/min)

(n = 374)

(n = 97)

(n = 62)

Tachycardia (≥ 100)

115

30.6

24.7

16.3

Mean (SD)

90.8

(15.5)

88.0

(17.4)

85.2

(17.0)

0.021

Systolic blood pressure (mmHg)

(n = 374)

(n = 97)

(n = 61)

Hypotension (< 90)

1.1

12.4

1.6

Mean (SD)

121.8

(15.9)

112.4

(18.5)

117.9

(14.3)

< 0.001

RLQ tender

374

97.9

73.2

84.1

< 0.001

LLQ tender

3.9

49.5

9.5

< 0.001

Guarding/rebound tenderness

255

66.8

35.1

20.6

< 0.001

Hematocrit (%)

(n = 336)

(n = 86)

(n = 55)

Mean (SD)

38.0

(3.9)

33.3

(6.0)

36.5

(5.9)

< 0.001*

WBC (/mm³)

(n = 292)

(n = 71)

(n = 53)

≥ 10,000

245

83.9

59.2

35.9

Mean (SD)

14,204.5

(4,638.4)

11,875.9

(4,531.9)

9,958.8

(5,200.0)

< 0.001*

Neutrophil (%)

(n = 281)

(n = 69)

(n = 51)

≥ 75

171

60.9

56.5

19.6

< 0.001

Pregnancy

1.8

48.5

4.8

< 0.001

**Table 2.** Likelihood Ratio of Positive Test (LR+) of Diagnostic Indicators From Multivariable Analysis
Indicators	Appendicitis	Obstetric-gynecological conditions	Non-specific abdominal pain
Age > 25yr	1.07 (0.91 - 1.26)	0.395	1.09 (0.68 - 1.76)	0.711	0.71 (0.33 - 1.53)	0.379
Single	0.95 (0.80 - 1.12)	0.542	1.34 (0.84 - 2.14)	0.216	1.06 (0.49 - 2.30)	0.884
Duration of pain > 24 hr	1.11 (0.94 - 1.31)	0.237	0.86 (0.51 - 1.44)	0.567	0.89 (0.50 - 1.57)	0.677
Shifting of pain	1.13 (0.99 - 1.28)	0.068	0.36 (0.13 - 0.99)	0.047	0.76 (0.35 - 1.68)	0.501
Anorexia	0.98 (0.81 - 1.17)	0.792	0.34 (0.13 - 0.88)	0.027	1.66 (0.69 - 4.00)	0.258
Nausea and vomiting	1.06 (0.93 - 1.19)	0.375	0.42 (0.23 - 0.76)	0.004	0.90 (0.50 - 1.63)	0.728
Abnormal vaginal bleeding	0.23 (0.03 - 1.51)	0.125	1.15 (0.56 - 2.39)	0.701	0.24 (0.03 - 2.30)	0.217
Diarrhea	0.84 (0.63 - 1.10)	0.207	0.85 (0.32 - 2.25)	0.738	2.93 (1.55 - 5.56)	0.001
Temperature ≥ 37.5 °C	1.00 (0.88 - 1.14)	0.955	0.71 (0.38 - 1.33)	0.282	1.06 (0.54 - 2.06)	0.863
Tachycardia	0.95 (0.83 - 1.09)	0.441	1.05 (0.61 - 1.81)	0.852	1.22 (0.62 - 2.43)	0.565
Systolic BP ≤ 90 mmHg	0.88 (0.33 - 2.31)	0.792	2.08 (0.82 - 5.29)	0.124	0.78 (0.10 - 6.07)	0.816
RLQ tender	2.30 (1.17 - 4.51)	0.016	0.53 (0.31 - 0.93)	0.026	0.75 (0.31 - 1.82)	0.528
LLQ tender	0.22 (0.10 - 0.48)	< 0.001	3.59 (2.27 - 5.66)	< 0.001	0.79 (0.30 - 2.13)	0.647
Guarding/rebound tenderness	1.25 (1.10 - 1.43)	0.001	0.69 (0.42 - 1.12)	0.131	0.37 (0.19 - 0.71)	0.003
Hematocrit < 33%	0.84 (0.65 - 1.09)	0.190	1.61 (0.87 - 2.98)	0.126	0.98 (0.43 - 2.23)	0.960
WBC ≥ 10,000/mm³	1.74 (1.38 - 2.20)	< 0.001	0.38 (0.20 - 0.74)	0.004	0.36 (0.20 - 0.67)	0.001
Neutrophil ≥ 75%	1.00 (0.88 - 1.15)	0.956	1.96 (1.11 - 3.45)	0.021	0.33 (0.16 - 0.66)	0.002
Pregnancy	0.31 (0.14 - 0.69)	0.004	2.24 (1.18 - 4.25)	0.014	1.18 (0.32 - 4.29)	0.806

Table 2. Likelihood Ratio of Positive Test (LR+) of Diagnostic Indicators From Multivariable Analysis

Indicators

Appendicitis

Obstetric-gynecological conditions

Non-specific abdominal pain

LR+ (95%CI)

Age > 25yr

1.07 (0.91 - 1.26)

0.395

1.09 (0.68 - 1.76)

0.711

0.71 (0.33 - 1.53)

0.379

Single

0.95 (0.80 - 1.12)

0.542

1.34 (0.84 - 2.14)

0.216

1.06 (0.49 - 2.30)

0.884

Duration of pain > 24 hr

1.11 (0.94 - 1.31)

0.237

0.86 (0.51 - 1.44)

0.567

0.89 (0.50 - 1.57)

0.677

Shifting of pain

1.13 (0.99 - 1.28)

0.068

0.36 (0.13 - 0.99)

0.047

0.76 (0.35 - 1.68)

0.501

Anorexia

0.98 (0.81 - 1.17)

0.792

0.34 (0.13 - 0.88)

0.027

1.66 (0.69 - 4.00)

0.258

Nausea and vomiting

1.06 (0.93 - 1.19)

0.375

0.42 (0.23 - 0.76)

0.004

0.90 (0.50 - 1.63)

0.728

Abnormal vaginal bleeding

0.23 (0.03 - 1.51)

0.125

1.15 (0.56 - 2.39)

0.701

0.24 (0.03 - 2.30)

0.217

Diarrhea

0.84 (0.63 - 1.10)

0.207

0.85 (0.32 - 2.25)

0.738

2.93 (1.55 - 5.56)

0.001

Temperature ≥ 37.5 °C

1.00 (0.88 - 1.14)

0.955

0.71 (0.38 - 1.33)

0.282

1.06 (0.54 - 2.06)

0.863

Tachycardia

0.95 (0.83 - 1.09)

0.441

1.05 (0.61 - 1.81)

0.852

1.22 (0.62 - 2.43)

0.565

Systolic BP ≤ 90 mmHg

0.88 (0.33 - 2.31)

0.792

2.08 (0.82 - 5.29)

0.124

0.78 (0.10 - 6.07)

0.816

RLQ tender

2.30 (1.17 - 4.51)

0.016

0.53 (0.31 - 0.93)

0.026

0.75 (0.31 - 1.82)

0.528

LLQ tender

0.22 (0.10 - 0.48)

< 0.001

3.59 (2.27 - 5.66)

< 0.001

0.79 (0.30 - 2.13)

0.647

Guarding/rebound tenderness

1.25 (1.10 - 1.43)

0.001

0.69 (0.42 - 1.12)

0.131

0.37 (0.19 - 0.71)

0.003

Hematocrit < 33%

0.84 (0.65 - 1.09)

0.190

1.61 (0.87 - 2.98)

0.126

0.98 (0.43 - 2.23)

0.960

WBC ≥ 10,000/mm³

1.74 (1.38 - 2.20)

< 0.001

0.38 (0.20 - 0.74)

0.004

0.36 (0.20 - 0.67)

0.001

Neutrophil ≥ 75%

1.00 (0.88 - 1.15)

0.956

1.96 (1.11 - 3.45)

0.021

0.33 (0.16 - 0.66)

0.002

Pregnancy

0.31 (0.14 - 0.69)

0.004

2.24 (1.18 - 4.25)

0.014

1.18 (0.32 - 4.29)

0.806

**Table 3.** Summarized Direction of Likelihood of Diagnosis (Appendicitis, Common Obstetric and Gynecological Conditions; OB-GYN, or Non-Specific Abdominal Pain; NSAP) for Each Clinical Indicators
Diagnostic indicators	Likelihood of diagnosis
Anorexia		Decrease
Nausea/vomit		Decrease
Shifting of pain		Decrease
Diarrhea			Increase
RLQ tender	Increase	Decrease
LLQ tender	Decrease	Increase
Guarding/rebound tenderness	Increase		Decrease
Pregnancy	Decrease	Increase
WBC ≥ 10,000/mm²	Increase	Decrease	Decrease
Neutrophil ≥ 75%		Increase	Decrease

Table 3. Summarized Direction of Likelihood of Diagnosis (Appendicitis, Common Obstetric and Gynecological Conditions; OB-GYN, or Non-Specific Abdominal Pain; NSAP) for Each Clinical Indicators

Diagnostic indicators

Likelihood of diagnosis

Appendicitis

OB-GYN

NSAP

Anorexia

Decrease

Nausea/vomit

Decrease

Shifting of pain

Decrease

Diarrhea

Increase

RLQ tender

Increase

Decrease

LLQ tender

Decrease

Increase

Guarding/rebound tenderness

Increase

Decrease

Pregnancy

Decrease

Increase

WBC ≥ 10,000/mm²

Increase

Decrease

Neutrophil ≥ 75%

Increase

Decrease