Clinical Features, CT Imaging Decisions, and Yield by Age in Adult ED Abdominal Pain

Clinical Features, CT Imaging Decisions, and Yield by Age in Adult ED Abdominal Pain
Authors: Friedman AB, Adjei-Poku MN, Schadt LA, Li Y, Cappola AR, Kelz RR, Hwang U, Kowdley G, Mwinyogle A, Trueger NS
Journal: Academic Emergency Medicine, May 2026

Conclusions:

  • CT use rises with age—and so does CT yield: older adults get more CTs, and those CTs are more often actionable/positive.

  • The abdominal exam is less helpful in older adults: “tenderness” is notably less sensitive for adverse outcomes ≥60, while rebound stays highly specific across ages.

  • Clinicians didn’t report higher pretest suspicion in older adults despite higher CT positivity/admission/surgery—suggesting we may under-appreciate baseline geriatric risk and compensate with imaging rather than calibrated gestalt.

  • Practical takeaway: treat “abdominal pain in ≥60” like its own high-risk chief complaint—lower threshold for CT and serial reassessment, and don’t be falsely reassured by a soft exam.

Practice pearls:

  • In ≥60 with abdominal pain: soft exam ≠ low risk. Use age-aware thresholds for CT and observation/serial exams.

  • If rebound is present, it stays a high-specificity red flag regardless of age—but absence of tenderness is less reassuring in geriatrics.

  • This paper supports reframing workflows: consider “geriatric abdominal pain” pathways (earlier CT, lactate/UA considerations, earlier surgery consult when appropriate, aggressive reassessment/decision-to-dispo timeouts).

Results:

  • Cohort: 1,169 nontraumatic adult abdominal pain visits; 229 (19.6%) ≥60.

  • CT ordering by age:

    • 18–39: 41.7%

    • 40–59: 66.2%

    • ≥60: 70.7% (p<0.001)

  • CT diagnostic yield (acute actionable findings) by age:

    • 18–39: 18.4%

    • 40–59: 31.2%

    • ≥60: 37.7% (p<0.001)

  • Disposition/outcomes rose with age:

    • Admission: 12.1% → 28.0% → 37.6%

    • Surgery: 4.6% → 9.0% → 10.6%

  • Exam operating characteristics:

    • Abdominal tenderness sensitivity for adverse outcomes:

      • ≥60: 0.58 vs 0.73 (18–39) and 0.73 (40–59)

    • Rebound tenderness specificity remained very high: 0.98 / 0.96 / 0.98 across age groups.

  • Clinician pretest suspicion: reported as similar across age groups.

  • Differential breadth: number of potential diagnoses considered increased with age.

Methods:

  • Retrospective cohort analysis of data from a prospective cohort (single community teaching ED, southwest Baltimore; Mar 2016–Jan 2017).

  • Compared age strata (18–39, 40–59, ≥60) for: CT ordering, actionable CT findings, admission, surgery, and composite adverse outcome (actionable CT, admission, surgery, or Emergency General Surgery diagnosis).

  • Calculated operating characteristics for key H&P findings and related these plus clinician pretest suspicion to outcomes.

Friedman, A.B., Adjei‐Poku, M.N., Schadt, L.A., Li, Y., Cappola, A.R., Kelz, R.R., Hwang, U., Kowdley, G., Mwinyogle, A. and Trueger, N.S., 2026. Clinical Features, CT Imaging Decisions and Yield by Age in Adults With Abdominal Pain in the Emergency Department. Academic Emergency Medicine, 33(5), p.e70299.

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