Predictive Score in Diagnosing Acute Colonic Diverticulitis at the Emergency Department: A retrospective study

doi:10.21203/rs.3.rs-3757183/v1

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Predictive Score in Diagnosing Acute Colonic Diverticulitis at the Emergency Department: A retrospective study

https://doi.org/10.21203/rs.3.rs-3757183/v1

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Background: Acute diverticulitis was one of the common misdiagnoses among patients with acute abdominal pain in the emergency department (ED). The gold standard for diagnosing acute diverticulitis is a computerized tomography (CT) scan. Currently, no standard criteria have been established for diagnosing acute diverticulitis clinically. Therefore, the development of the predictive score for the diagnosis of acute diverticulitis will guide the physician in making a diagnosis and increase the appropriateness of the CT scan.

Method: A single-center retrospective study, conducted in adult patients aged more than 18 years who presented with acute abdominal pain at the ED, aimed to establish a predictive score for diagnosing acute diverticulitis. A multivariate logistic regression analysis was used to identify essential factors for the diagnosis of acute diverticulitis. The Akaike information criterion (AIC) was calculated to identify significant predictive factors for the probability of diagnosing acute diverticulitis and presented in a nomogram.

Results: There were 424 patients that fulfilled the inclusion criteria and 72 patients (17%) were diagnosed with acute diverticulitis. The significant predictive factors for the diagnosis of acute diverticulitis were age (adjust odd ratio (adj.OR) 1.03, 95% Confidence IntervaI (CI): 1.02-1.05), duration 24-72 hr (adj.OR 1.96, 95% CI: 0.97-3.95), duration >72 hr (adj.OR 3.22, 95% CI: 1.24-8.33), watery diarrhea (adj.OR 2, 95% CI: 0.97-4.15), nausea (adj.OR 0.43, 95%CI: 0.17-1.09), vomit (adj.OR 0.4, 95% CI: 0.11-1.38), right lower quadrant (RLQ) or left lower quadrant (LLQ) pain (adj.OR 3.48, 95% CI: 1.79-6.79), history of diverticulum (adj.OR 8.42, 95% CI: 3.61-19.63), LLQ tenderness (adj.OR 0.78, 95% CI: 0.36-1.7) and anorexia (adj.OR 0.23, 95% CI: 0.09-0.56). The seven clinical predictive variables for diagnosis acute diverticulitis of the nomogram consisted of 1) age, 2) nausea, 3) vomiting, 4) RLQ or LLQ pain, 5) duration of abdominal pain, 6) watery diarrhea, and 7) history of diverticulum. The total score of 135 was likely to diagnose acute diverticulitis with a sensitivity of 81.69% and a specificity of 70.94 %. The Area under the curve was 0.84. The secondary outcome, there were no signs, symptoms, or laboratory findings associated with complicated diverticulitis.

Conclusion: Significant predictive factors for diagnosis of acute diverticulitis were age, absence of nausea, absence of vomiting, RLQ or LLQ pain, duration of abdominal pain, watery diarrhea and history of diverticulum.

predictive score

diagnosis

acute diverticulitis

acute abdominal pain

Abdominal pain is one of the most common reasons for emergency department (ED) visits, accounting for approximately 5–10% of all ED visits. Abdominal problems can present with uncommon or unusual presentations and hence, are challenging to diagnose for ED physicians.⁽¹⁾ Some patients with abdominal pain are often diagnosed with nonspecific acute abdominal pain. Acute diverticulitis is one of the most common diagnoses in this group (1–3%) and one of the most frequently missed diagnoses.⁽²⁾

Inflammation and infection of the diverticulum causes acute colonic diverticulitis affecting approximately 10–25% of individuals. It has a high incidence and mortality rate in European countries.⁽³⁾ but less common in Asian countries although mortality rate is still high. In Thailand, the data collected from hospitals across the country from 2009 to 2010 found that the mortality rate of acute diverticulitis was 3.8%. One of the factors identified causing this increased mortality rate was delayed diagnosis.⁽⁴⁾

Currently, there are limit study data for diagnosing acute diverticulitis, which mimic other abdominal diseases. The gold standard for diagnosing acute diverticulitis and assessing its severity is an abdominal computerized tomography (CT) scan. It also helps in making differential diagnoses for other conditions. However, CT scan also has disadvantages because the patient must be exposed to radiation and contrast agents, which increases the risk of contrast-induced nephropathy (CIN).⁽⁵⁾ Furthermore, CT scan is not available in many hospitals in Thailand, particularly in rural area. Therefore, establishing a predictive score for diagnosis will increase the accuracy of diagnosis and guide physicians in considering the use of CT scan and making early diagnosis.

Study design and setting

This single-center retrospective study was conducted in patients aged more than 18 years who presented with acute abdominal pain at the ED of Songklanagarind Hospital, which is a tertiary referral and academic hospital on the campus of the Prince of Songkla University in southern Thailand.

The hospital's electronic medical record database was reviewed to obtain patient data from January 2013 to October 31, 2022. The study was conducted in concordance with the declaration of the Helsinki and was performed according to Ethics Committee approval. (REC 64-354-20-4).

Study population

The inclusion criteria included patients who were older than 18 years, presented with acute abdominal pain, and underwent CT scan. The exclusion criteria were as follows: referred in-patients, pregnant patients, trauma patients, and patients with incomplete pertinent histories, physical examinations, and laboratory test data in their medical records.

The sample size was calculated based on the study by Lameris et al. (2012),⁽⁹⁾which established the clinical rules for the diagnosis of acute diverticulitis. The diagnosis of acute diverticulitis was found to have a high correlation with four symptoms, with the subacute onset of pain having the lowest odds ratio. Therefore, it was used to get the largest number of patients (n), which can determine the relationship between each factor.

The sample size was calculated using the G-power program version 3.1.9.4 for Z test: Multiple Logistic Regression, which was:

Alpha (α) = 0.05, Beta (β) = 0.20

Z _1−α/2 = 1.959964

Z _β = 0.841621

Odd ratio of factor subacute onset of pain = 2.3

N = 424 patients

Data collection

Data were collected from adult patients older than 18 years, with abdominal pain as the chief complaint and suspected to be a case of acute diverticulitis and other surgical conditions. Information gathered included medical history, physical examination, laboratory investigation, and CT scan of the whole abdomen interpreted by a radiologist. In this study, data collection started on December 1, 2021 were reviewing records from January 2013 to May 2021. However, there were insufficient data after excluding some medical records following the exclusion criteria. Hence, data collection was extended to October 31, 2022.

The information collected from the medical record was divided into five parts, namely:

Part 1: Basic information, including age, gender, and triage level

Part 2: Medical history contained information on abdominal pain, including its onset, duration, location, and pain score; associated symptoms such as nausea, vomiting, diarrhea, constipation, anorexia, and rectal bleeding; underlying disease; and history of colonic diverticulum.

Part 3: Physical Examination included vital signs, body weight, height, and abdominal examination findings, such as bowel sounds, location of abdominal tenderness, rebound tenderness, and guarding.

Part 4: Laboratory investigations included white blood cell (WBC) count, polymorphonuclear leukocyte (PMN) count, band count, and lactate level.

Part 5: Final diagnosis of possible acute diverticulitis, with its laterality, and Modified Hinchey classification as well as other diagnoses.

Outcome measure

The primary objective was to establish a predictive score for diagnosing acute diverticulitis in patients with abdominal pain at the emergency department. The secondary objective was to identify signs, symptoms, and laboratory tests associated with complicated diverticulitis.

Statistical analysis

Continuous data were reported as medians with interquartile ranges, means, and standard deviations. Categorical data were presented as counts and percentages. Categorical variables were compared using Pearson's chi-squared test, Ranksum test, Fisher's exact test, and t-test.

The study population was classified into an acute diverticulitis group and a non-acute diverticulitis group. From univariate logistic regression, the essential variables with P < 0.2 and show correlation with being acute diverticulitis were included in the multivariate logistic regression analysis. The factors were analyzed to conduct a proper model for predicting the probability of acute diverticulitis by using the Akaike information criterion (AIC). The AIC value was calculated by R studio program using the Eq. 2K – 2(log-likelihood). The lowest AIC model was deemed the proper model to predict the probability of the disease. A predictive score with probability nomogram was created. The optimal cut-off points were calculated from the best sensitivity and specificity using the receiver operating characteristic (ROC) curves and the area under the ROC curve (AUROC).

A total of 424 patients fulfilled the inclusion criteria. Patient flow through the study is presented in Fig. 1.

Among the 352 patients who were diagnosed with another disease, the most common diagnoses were enterocolitis (20.17%), acute appendicitis (19.18%), nonspecific acute abdominal pain (11.07%), ovarian mass (7.67%), and bowel obstruction (6.48%).

Baseline patient characteristics are shown in Table 1. The median age of patients with acute diverticulitis was 63.5 years, which was significantly higher than that of patients with other diseases (p < 0.001). Male sex was significantly more affected than female sex (p = 0.001). Furthermore, majority of patients with acute diverticulitis had a history of diverticulum (P < 0.001).

Table 1

Baseline patient characteristic of patients with acute abdominal pain in the ED
Characteristic	Number of patients		P value
Characteristic	Acute diverticulitis (n= 72)	Non acute diverticulitis (n=352)	P value
Age Median (IQR)	63.5(53,72)	50 (28.8,68)	< 0.001
Sex			0.001
Female	32 (44.4)	230 (65.3)
Male	40 (55.6)	122 (34.7)
Underlying disease
Diabetes mellitus	9 (12.5)	33 (9.4)	0.554
Hypertension	22 (30.6)	82 (23.3)	0.248
CKD	4 (5.6)	12 (3.4)	0.493
Heart disease	0 (0)	18 (5.1)	0.269
Stroke/TIA	0 (0)	11 (3.1)	0.224
HIV	1 (1.4)	3 (0.9)	0.526
Autoimmune disease	3 (4.2)	5 (1.4)	0.139
Chronic liver disease	0 (0)	10 (2.8)	0.224
History of colonic diverticulum	21 (29.2)	15 (4.3)	< 0.001

Abbreviations: CKD, chronic kidney disease; TIA, transient ischemic attack; HIV, human immunodeficiency virus

Regarding the signs and symptoms, patients with acute diverticulitis did not have nausea, vomiting, or anorexia as compared to those patients without diverticulitis (p <0.001). The median duration of abdominal pain in acute diverticulitis was 48 h, which was longer than the 24 h in other abdominal diseases (p <0.001). Right lower quadrant (RLQ) or left lower quadrant (LLQ) pain was a statistically significant clinical presentation in acute diverticulitis (p <0.001). The results are shown in table 2.

Table 2

Signs and symptoms of patients with acute abdominal pain in the ED
Signs and symptoms	Number of patients		P value
Signs and symptoms	Acute diverticulitis (n = 72)	Non acute diverticulitis (n = 352)	P value
Pain (Median (IQR))	8 (6.8,9)	8 (6,9)	0.985
Fever	24 (33.3)	92 (26.1)	0.27
Duration of abdominal pain (Median (IQR))	48 (16,72)	24 (8,48)	0.002
Nausea	12 (16.9)	180 (51.3)	< 0.001
Vomiting	5 (7)	112 (31.8)	< 0.001
Migratory pain	9 (12.5)	57 (16.2)	0.542
Diarrhea	18 (25)	72 (20.5)	0.483
Type of diarrhea			0.062
Watery	13 (72.2)	65 (90.3)
Mucous	2 (11.1)	4 (5.6)
Bloody	1 (5.6)	2 (2.8)
Mucous bloody	2 (11.1)	1 (1.4)
Constipation	7 (13.7)	63 (23.9)	0.158
Anorexia	9 (20.9)	113 (54.3)	< 0.001
Rectal bleeding	3 (4.3)	6 (1.7)	0.172
Epigastrium pain	0 (0)	28 (8)	0.008
RUQ pain	1 (1.4)	19 (5.4)	0.221
LUQ pain	1 (1.4)	10 (2.8)	0.699
Lower abdomen pain	6 (8.3)	43 (12.2)	0.461
Periumbilical pain	10 (13.9)	85 (24.1)	0.081
RLQ pain	29 (40.3)	35 (9.9)	0.449
LLQ pain	23 (31.9)	132 (37.5)	< 0.001
LLQ or RLQ pain	46 (76.7)	146 (49)	< 0.001
Abbreviations: RUQ, right upper quadrant; LUQ, left upper quadrant; RLQ, right lower quadrant; LLQ, left lower quadrant

Statistically significant physical examination findings were LLQ tenderness (p <0.001), RLQ tenderness (p = 0.007), and absence of guarding (p <0.001). The results are shown in table 3.

Table 3

Physical examination findings of patients with acute abdominal pain in the ED
Signs and symptoms	Number of patients		P value
Signs and symptoms	Acute diverticulitis (n = 72)	Non acute diverticulitis (n = 352)	P value
Body temperature (\(^\circ\)C) (Mean (SD))	37.1 (0.8)	37.1(0.9)	0.791
News score (Mean (SD))	1.9 (1.9)	2.4 (2)	0.088
BMI (kg/m2) (Mean (SD))	24.5 (4.1)	23.7 (4.8)	0.249
Abdominal distention	12 (17.9)	74(21)	0.68
Bowel sound			0.089
Hyperactive	17 (23.6)	66 (18.8)
Normoactive	42 (58.3)	241 (68.5)
Hypoactive	9 (12.5)	40 (11.4)
Absent	4 (5.6)	5 (1.4)
Rebound tenderness	18 (26.1)	63 (17.9)	0.162
Guarding	26 (36.6)	59 (16.8)	< 0.001
Epigastrium tenderness	1 (1.4)	20 (5.7)	0.227
RUQ tenderness	2 (2.8)	21 (6)	0.396
LUQ tenderness	3 (4.2)	8 (2.3)	0.408
LLQ tenderness	31 (43.1)	51 (14.5)	< 0.001
RLQ tenderness	20 (27.8)	161 (45.7)	0.007
Lower abdomen tenderness	10 (13.9)	32 (9.1)	0.305
Periumbilical tenderness	3 (4.2)	30 (8.5)	0.31
Generalized tenderness	3 (4.2)	29 (8.2)	0.344
LLQ and RLQ tenderness	42 (70)	181 (60.7)	0.228
Abbreviations: BMI, body mass index; RUQ, right upper quadrant; LUQ, left upper quadrant; RLQ, right lower quadrant; LLQ, left lower quadrant

There were no laboratory investigations that revealed a statistically significant difference between acute diverticulitis and other abdominal pain. The result is shown in Table 4.

Table 4

Laboratory investigation of patients with acute abdominal pain in the ED
Laboratory investigation	Number of patients		P value
Laboratory investigation	Acute diverticulitis (n = 72)	Non acute diverticulitis (n = 352)	P value
WBC (cell/mm3) (Mean (SD))	11501 (3718.9)	12187.2 (7101.5)	0.426
WBC group (cell/mm3)			0.279
<10000	21 (29.2)	130 (36.9
10000–15000	36 (50)	141 (40.1)
>15000	15 (20.8)	81 (23)
PMN (%) (Mean (SD))	74.3 (9.9)	75.8 (12.4)	0.338
Band (%) (Mean (SD))	3.2 (7.6)	3.5 (7.9)	0.888
Lactate (mmol/L) (Mean (SD))	1.3 (0.4)	1.8 (2)	0.338
Abbreviations: WBC, white blood cells; PMN, polymorphonuclear neutrophils; lac, lactate level

Overall, the factors chosen in the multivariate logistic regression were age (p <0.001); history of diverticulum (p<0.001); duration of abdominal pain (p 0.002); type of diarrhea (P 0.062); absence of nausea (p<0.001), absence of vomiting (p<0.001); anorexia (p<0.001); RLQ or LLQ pain (p<0.001), and LLQ tenderness (p<0.001). The results of the multivariate logistic regression are shown in supplementary table 1. From the analysis by AIC, the appropriate model for the predictive probability of acute diverticulitis included age (adjust odd ratio (adj.OR) 1.03, 95% Confidence IntervaI (CI): 1.02-1.05), duration 24-72 hr (adj.OR 1.96, 95% CI: 0.97-3.95), duration >72 hr (adj.OR 3.22, 95% CI: 1.24-8.33), watery diarrhea (adj.OR 2 , 95% CI: 0.97-4.15), nausea (adj.OR 0.43, 95% CI: 0.17-1.09), vomit (adj.OR 0.4, 95% CI: 0.11-1.38),

RLQ or LLQ pain (adj.OR 3.48 , 95% CI: 1.79-6.79), history of diverticulum (adj.OR 8.42, 95% CI: 3.61-19.63). The AIC of these model was 299.9 and area under the curve was 0.84. The ROC curves of the scores are shown in Supplementary Figure 1. The AIC of the variables included in the model are shown in supplementary table 2.

The predictive scores for acute diverticulitis are shown as a nomogram in Figure 2. The probability of acute diverticulitis increases with age, watery diarrhea, duration of abdominal pain, history of diverticulum and location of RLQ or LLQ pain, which we grouped as localized pain. Patients without nausea or vomiting had a higher probability of acute diverticulitis.

The nomogram was used by summation of the points of each variable. Age was pointed by years. Nausea, vomiting, RLQ or LLQ pain, watery diarrhea and history of diverticulum were pointed by ‘yes’ or ‘no’. Duration of the symptom was divided as <24 hrs., 24-72 hrs., and >72 hrs. The total point plotted on the “total point” line will express the probability of acute diverticulitis by draw a vertical line down straight to “probability” line. For example, in the 60 years old patient (50 points) with LLQ pain (37 points), no nausea (25 points) no vomiting (27 points), duration of abdominal pain was 30 hrs. (20 points), and had history of diverticulum (65 points), the total score was 224. The probability of acute diverticulitis in this patient was about 75%.

A score greater than 135 points suggested a diagnosis of acute diverticulitis with a sensitivity of 81.69% and a specificity of 70.94%.

Score of age was increased by years. No nausea was 25 points; No vomiting was 27 points; localize pain was 37 points; duration 24-72 hr was 20 points; duration>72 hr was 35 points, watery diarrhea was 20 points and a history of diverticulum was 65 points.

The CT scan results for patients with diverticulitis are shown in supplementary table 3. Among the 72 patients, 22 and 50 had uncomplicated diverticulitis and complicated diverticulitis, respectively. However, no statistically significant differences were observed between uncomplicated and complicated diverticulitis. The secondary outcomes are presented in Table 5.

Table 5

Uncomplicated and complicated diverticulitis
Variables	Number of Patient		P value (< 0.05)
Variables	Non complicated diverticulitis (n = 22)	Complicated diverticulitis (n = 50)	P value (< 0.05)
Age (Mean (SD))	59.8 (14)	63 (14.3)	0.373
Fever	7 (31.8)	17 (34)	1
Body temperature (Mean (SD))	37.1 (0.7)	37.1 (0.9)	0.969
News score (Median (IQR))	2 (1.5,3)	1 (0,3)	0.056
Rebound tenderness	4 (19)	14 (29.2)	0.56
Guarding	10 (45.5)	16 (32.7)	0.442
WBC (Mean (SD))	12017.3 (2839.5)	11273.8 (4051.1)	0.438
Band (Median (IQR))	0 (0,0)	0 (0,1.2)	0.216
PMN
<70	4 (18.2)	12 (24)	0.67
>=70	18 (81.8)	38 (76)	0.761
Lactate (Median (IQR))	1.2 (0.4)	1.4 (0.5)	0.513
Abbreviations: WBC, white blood cells; PMN, polymorphonuclear neutrophils; lac, lactate level

Acute diverticulitis are more common in patients over 40 years old and increased with age; up to 65% of patients were over 80 years old.⁽³⁾ The median age of patients with acute diverticulitis in this study was 63.5 years old, and the likelihood of a predictive score increased with age. According to this study, acute diverticulitis was more common in male than in female sex. This result is consistent with a study from hospitals across Thailand, which found that 50.8% of cases of acute diverticulitis affected male patients.⁽³⁾ Patients with diverticulum had a higher probability of having acute diverticulitis according to the prevalence of this disease, which occurs in 10–25% of patients with diverticulum. Andweg et al. found that one or more episodes of acute diverticulitis contributes to the increased probability of this disease.⁽⁶⁾

Fever and body temperature were found to be not significant factors in this study, as was the case in a previous study in 2006⁽⁷⁾ wherein body temperature did not differ in patients with acute diverticulitis and nonspecific acute abdominal pain.

According to Andeweg’s study, nausea and vomiting were found to be negative predictors of acute diverticulitis, while absence of vomiting was found to be a predictor of acute diverticulitis.⁽⁶⁾The location of pain and tenderness in the LLQ area was a significantly better predictor of acute diverticulitis in the present study than in previous studies.^(7,8) Many studies were done in western countries, which have a high prevalence of left-side diverticulitis, so the location and tenderness of pain were LLQ. However, in Asian countries, the prevalence of right-side diverticulitis is higher⁽³⁾ that could explain the RLQ pain and tenderness in some patients. Moreover, in the present study, RLQ pain and tenderness were not significantly associated with acute diverticulitis. This could be due to other diseases can present with RLQ pain and tenderness, especially acute appendicitis. In a subgroup analysis of patients with acute diverticulitis, RLQ pain or tenderness was significantly and positively associated with right-sided diverticulitis.

This study found that the mean WBC count, neutrophil count, and band were not significantly different between acute diverticulitis and other diseases; this result is similar to that of a previous study by Laurell et al. in 2007.⁽⁷⁾ In contrast to the study by Iyer et al. in 2014,⁽⁸⁾ leukocytosis was one of the most common findings in acute diverticulitis. However, Iyer et al. also found that leukocytosis was less common in older patients. In this study, most of the patients with diverticulitis were elderly, so they may have no leukocytosis compared with other diseases occurring in the younger group. Therefore, leukocytosis is not the laboratory investigation of choice for diagnosing acute diverticulitis. A study in 2010 found that one of the clinical decision rule for the diagnosis of acute diverticulitis was the C-reactive protein (CRP) level.⁽⁹⁾However, in our setting Songklanakarin hospital, CRP is not used in routine laboratory investigations. Therefore, there were no data showing the association between CRP and acute diverticulitis.

In this study, the predictive score for diagnosing acute diverticulitis included age, absence of nausea and vomiting, RLQ or LLQ pain, duration of abdominal pain, watery diarrhea and history of diverticulum with sensitivity of 81.69 % and a specificity of 70.94%. A previous study in 2011 developed a clinical scoring system for left-sided diverticulitis.⁽⁶⁾ The score included age, one or more episodes of abdominal pain, LLQ pain, LLQ tenderness, pain on movement, absence of vomiting, and CRP level ≥ 50 mg/L. This score had sensitivity and specificity of 75% of and 84%, respectively. Another study in 2010 identified a clinical decision rule for acute diverticulitis.⁽⁹⁾Three factors were used to predict the probability of acute left-sided diverticulitis namely; LLQ pain, absence of vomiting, and CRP ≥50 mg/L. This clinical decision rule had a sensitivity and specificity of 36% and 98%, respectively.

In this study, no significant factors were associated with complicated diverticulitis. In contrast to the study by Longstreth et al⁽¹⁰⁾ which found that BT>37.5°C, leukocytosis (>11,000 cell/mm3), neutrophilia (PMN>77%), and predominance of bands (>7%) were associated with severe disease. This may be because few patients with acute diverticulitis and most patients with complicated diverticulitis was in the less severe group (modified Hinchey class Ia and Ib).

For the primary outcome, the predictive scores for diagnosing acute diverticulitis included age, absence of nausea and vomiting, RLQ or LLQ pain, duration of abdominal pain, watery diarrhea and history of diverticulum. A predictive score greater than 135 points suggested a diagnosis of acute diverticulitis with a sensitivity of 81.69% and a specificity of 70.94%. The secondary outcomes included no signs, symptoms, or laboratory investigations associated with complicated diverticulitis.

Ethics approval and consent to participate

Ethical approval was obtained from the Human Research Ethics Commitee Faculty of Medicine, Prince of Songkla University (REC.64-354-20-4). Patient consent was waived, as approved by the Ethics Committee of the Faculty of Medicine of Prince of Songkla University, because the participants had no greater than minimum risk and the patients received standard medical care.

Consent for publication

Not applicable

Availability of data and materials

All data generated or analysed during this study are included in this published article.

Competing interests

The authors declare that they have no competing interests.

Funding

This research had no funded.

Authors’ contributions

Choasita Glawsongkram performed the literature search, study design, data collection, data analysis, and data interpretation, and manuscript writing. Wasuntaraporn Pethyabarn and Siriwimon Tantarattanapong performed a literature search, study design, and critical revision.

Acknowledgments

The authors are grateful to Ms. Kingkarn Waiyanak for article searches and retrieval, and Mr. Marzukee Mayeng of the Epidemiology Unit, Faculty of Medicine, Prince of Songkla University, for his statistical assistance.

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No competing interests reported.

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Predictive Score in Diagnosing Acute Colonic Diverticulitis at the Emergency Department: A retrospective study

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