Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Abdominal pain and constipation
Treatment:  Inpatient admission
The inpatient admission was not medically necessary.

The patient is a female child with medical history significant for prematurity and constipation (and multiple visits to the emergency department [ED] for stool evacuation) that presented to the ED midday with five-day history of diffuse abdominal pain and mild lower back pain.  She failed treatment with three different laxatives.  Her last stool was five days prior.  She had no fevers or vomiting, but she reported nausea. 

The patient's vital signs included temperature 37.1, heart rate 86, respiratory rate 20, and blood pressure 115/62.  Examination was significant for regular heart rate and rhythm, clear lungs, minimally distended abdomen, diffusely mild tenderness to palpation without rebound or guarding, no hepatosplenomegaly, and non-focal neurologic exam.  Initially, a plain x-ray was obtained, revealing a non-obstructive bowel gas pattern and small stool burden.  Urinalysis was unremarkable except for moderate ketones.  Because her tenderness was predominantly in the right lower quadrant and because the left ovary could not be visualized, computed tomography (CT) of the abdomen was obtained revealing mild bibasilar dependent atelectasis, normal appendix, trace free pelvic fluid, and a dominant left ovarian follicle.  Laboratory studies were obtained as well as a Surgery consultation.  Complete blood count was unremarkable.  Metabolic panel was significant for mild metabolic acidosis (carbon dioxide [CO2] 21) and mildly increased total bilirubin (1.6).  Abdominal and pelvic ultrasounds were non-contributory.  She continued to have abdominal pain, even in sleep, but she was able to jump comfortably.  Surgery had no recommendations for surgical intervention.  The patient was treated with two enemas and watched for a while in the ED, with plans for discharge.  The enemas were not thought to be effective, but later staff was told she had a large diarrhea stool in the ED prior to receiving the enemas. 

However, by late morning the next day, she was still experiencing severe pain, rated ten out of ten (10/10).  She was treated with Toradol, and her case was discussed with Gastroenterology.  At this point, she was admitted for pain control and bowel clean-out.  Admission orders included Zofran as needed, probiotic, Zantac, nothing by mouth (NPO), maintenance intravenous (IV) fluids, ongoing consultations, and abdominal ultrasound to assess the gallbladder.  Ultrasound of the right upper quadrant was obtained and was negative for gallbladder disease.  She did well overnight, with no bowel clean-out and non-compliant with the NPO order.  Repeat x-ray revealed minimal stool burden.  Her pain was manageable with mild medications, and she was able to tolerate a diet.  Gastroenterology (GI) consulted formally, with recommendations to increase Zantac to twice daily and trial simethicone.  She was deemed stable for discharge on those medications, as well as twice daily Miralax. 

This female patient with known history of constipation presented to the ED with abdominal pain, at times rated 10/10.  Comprehensive imaging and laboratory evaluation failed to reveal a cause.  While in the ED, she had a large diarrhea stool (as a result of the multiple medications taken at home) even before receiving the enemas. Both GI and Surgery were consulted for recommendations.  She was admitted for management of pain and bowel clean-out.  While it was not unreasonable to monitor her for resolution or progression of the abdominal pain, she was overall hemodynamically stable, with no vomiting, no evidence of dehydration, no evidence of severe or significant intra-abdominal pathology, and no acute infectious symptoms.  She did not require acute inpatient admission and could have been safely managed at a lower level of care.