Changes

January 2025 — this is a new CKS topic. The evidence base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence.

Update

Goals

To support primary healthcare professionals to:

• Decide whether emergency admission is required. 
• Diagnose the underlying cause of abdominal pain.
• Treat people with abdominal pain in primary care when appropriate.
• Admit or refer people with abdominal pain when appropriate. 

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

NICE quality standards

No NICE quality standards were found during the review of this topic.

QIPP — Options for local implementation

No QIPP indicators were found during the review of this topic.

What is it?

• Acute abdominal pain is abdominal pain of less than 7 days duration.
• Acute abdomen is a clinical syndrome with acute abdominal pain that is severe and of rapid onset. 
• Non-specific abdominal pain (NSAP) is acute abdominal pain of less than 7 days duration where no diagnosis is reached after examination and baseline investigations. 
  • Causes include gynaecological conditions, irritable bowel syndrome (IBS), gastroenteritis, and abdominal wall pain.

[RCS, 2014; WHO, 2023; Yew, 2023] 

What causes it?

• Acute abdominal pain may be due to an acute condition or a consequence of a chronic condition. 
  • In one large study of people presenting to the emergency department with recent abdominal pain, 20 conditions accounted for up to 70% of the causes, but more than 150 aetiologies were diagnosed. 
• Causes of abdominal pain can broadly be categorized as: 
  • Gastrointestinal.
  • Genitourinary.
  • Gynaecological or obstetric.
  • Hepatobiliary and pancreatic.
  • Other causes. 
• The most common causes of acute abdomen are: 
  • Appendicitis.
  • Biliary colic.
  • Cholecystitis.
  • Diverticulitis.
  • Non-specific abdominal pain. 
  • Renal colic.

[Yew, 2023; BMJ Best Practice, 2024a]

How common is it?

• Abdominal pain is the ninth most common reason for consultation in primary care with a prevalence of 2.8% [Viniol, 2014; Price, 2022]. 
  • It is estimated that acute abdominal pain accounts for 9% of childhood visits to primary care [Reust, 2016].
  • It is reported in 5% of people attending emergency departments [Cartwright, 2008].
• A systematic review and meta-analysis of abdominal pain in primary care found that [Viniol, 2014]:
  • The most common causes were:
    • Gastroenteritis (7.2–19.7%).
    • Irritable bowel disease (2.6–13.3%). 
    • Urological (5.3%).
    • Gastritis (5.2%).
  • Around 1 in 10 people had an acute potentially life-threatening cause requiring immediate therapy, with the following causes: 
    • Biliary/pancreatic disorders (4.0%).
    • Diverticulitis (3.0%).
    • Appendicitis (1.9%).
    • Neoplastic diseases (1.0%).
  • In around one-third of people, the underlying cause could not be specified.
• An observational cohort study that looked at the 1-year cumulative incidence of diagnoses among people aged 40 years or over with newly recorded abdominal pain in primary care found that [Price, 2022]:
  • The four conditions most frequently diagnosed were:
    • Upper gastrointestinal problems (gastro-oesophageal reflux disease, hiatus hernia, gastritis, oesophagitis, and gastric/duodenal ulcer).
    • Diverticular disease.
    • Gallstones.
    • Urinary tract infection.
  • In over 70% of people the cause of abdominal pain remained unexplained.   
• Acute appendicitis is one of the most common acute abdominal emergencies [RCS, 2014].
  • In 2021/22 in England, over 50,000 people were treated for acute appendicitis in hospital [NHS Digital, 2022].  
  • The overall lifetime risk of developing appendicitis is 7–8%. 
• Non-specific abdominal pain (NSAP) comprises 13-40% of all surgical admission with abdominal pain [RCS, 2014].

What is the prognosis?

• The prognosis of acute abdominal pain depends on the cause, which can range from a mild self-limiting condition (for example, gastroenteritis, constipation, or viral illness) to a life-threatening surgical emergency (for example, appendicitis).  
  • The cause is usually benign, however in up to 10% of cases in emergency departments (less in primary care) there is a severe or life-threatening cause, or surgical intervention is necessary. 
• Overall 1-year mortality rates in people with acute abdominal pain are approximately 3% in general practice.

[Cartwright, 2008; RCHM, 2024; Tans, 2024]

How should I assess a person with acute abdominal pain?

• Abdominal pain is diagnosed with a combination of history, physical examination, imaging, and laboratory results.
• Assess vital signs — measure blood pressure, pulse rate, temperature, and capillary refill time. 
  • Fever suggests infection, although absence does not rule it out, especially in people who are older or immunocompromised. 
    • Fever at the onset of acute illness is less likely to indicate a surgical cause for acute abdominal pain, whereas fever after the onset of vomiting or pain is consistent with developing peritonitis.
  • Tachycardia and orthostatic hypotension suggest hypovolemia. 
• Take a history and ask about:
  • The location of the pain. 
  • The onset, duration, severity, progression, radiation, and quality of pain.
    • Chronic, intermittent acute abdominal pain is less likely to be related to a surgical cause than a first episode of acute pain. 
  • Associated symptoms — for example, fever, nausea or vomiting, constipation, cough, shortness of breath, sore throat, urinary symptoms, and colic.
    • Constipation is the symptom with the highest positive predictive value for bowel obstruction. 
    • Colic is associated with several diseases although the location may help diagnosis. The absence of colic can help rule out cholecystitis; fewer than 25% of people with acute cholecystitis present without right upper quadrant pain or colic.
  • Red flag features. 
  • Any previous episodes of similar pain.
    • This may suggest recurrent conditions (for example, cholecystitis, pancreatitis, or diverticulitis). 
    • A history of recurrent upper abdominal pain that worsens suddenly may indicate a perforated ulcer. 
  • Exacerbating or relieving factors — for example, medicines, eating, movement.  
  • A change in bowel habit.
  • Any urinary features — for example, dysuria, frequency, haematuria, or strangury. 
  • Presence or absence of anorexia. 
  • History of trauma or bleeding. 
  • Previous medical and surgical history. 
  • Medication history including over-the-counter mediations. 
  • Travel history.
  • For women, their menstrual history, abnormal menstrual bleeding, sexual history, contraception used, current pregnancy status, gynaecological problems, and presence of any vaginal discharge.
  • Smoking status, alcohol consumption, and use of illegal substances. 
  • Family history of abdominal pain.
• Perform an abdominal examination guided by the location of pain. This should include:
  • Inspection 
    • People with peritonitis tend to lie very still, while people with renal colic may be unable to. 
    • Presence of abdominal scars from previous surgery may aid the diagnosis. 
    • The contour of the abdomen may indicate generalised distension or local bulges (bowel obstruction, herniae, or masses).
    • Skin changes (particularly over hernias) can identify strangulation with erythema, discolouration, or ulceration. Other skin changes including periumbilical ecchymosis (Cullen's sign) or flank ecchymoses (Grey Turner's sign) may be seen due to haemorrhagic extravasation in acute pancreatitis. 
    • Signs of dehydration, anaemia, or jaundice.
    • In children look for signs of lethargy or unusual activity (moving around in discomfort).
  • Auscultation 
    • Small or large bowel obstruction — if examined early there may be hyperactive 'tinkling' bowel sounds. If the person presents later there may be reduced or absent bowel sounds, often in combination with a markedly distended abdomen. 
    • Bowel sounds may be absent in people with a perforated viscus, haemoperitoneum, or other conditions with peritoneal inflammation. 
    • A succussion splash may be heard indicating the presence of a gastric outlet obstruction. 
  • Percussion — if this causes pain, peritoneal inflammation may be present. Check also for shifting dullness which can be associated with ascites. 
  • Palpation — check for:
    • Focal or generalized tenderness.
    • Percussion or rebound tenderness. 
    • Guarding or rigidity — a rigid abdomen with reflex involuntary guarding implies severe peritoneal irritation indicating a likely perforation.
    • Palpable faeces.
    • Abdominal masses including herniae. 
• Other examinations that may be appropriate include:
  • Chest auscultation may reveal increased vocal resonance and reduced breath sounds consistent with pneumonia, or reduced heart sounds and/or a pericardial rub associated with pericarditis. 
  • Digital rectal examination (DRE) in people with lower abdominal pain — this may reveal faecal impaction, a palpable mass, or blood in the stool. 
    • DRE is of limited value in the diagnosis of undifferentiated abdominal pain and should be used selectively in people with colonic symptoms.
  • A pelvic examination in people with pelvic pain — this may reveal vaginal discharge. The presence of cervical motion tenderness and peritoneal signs increase the likelihood of ectopic pregnancy or other gynaecologic complications, such as salpingitis or a tubo-ovarian abscess. 
  • Note: rectal or vaginal examination is rarely indicated in children. 
  • Inspection and palpation of the scrotum and testicles — tenderness can signify epididymitis or testicular torsion. For more information see the CKS topic on Scrotal pain and swelling.
• Specific signs associated with abdominal pain include: 
  • Carnett's sign — increased pain when a supine patient flexes the abdominal wall by lifting the head and shoulders off the examination table in people with abdominal wall pain.
  • McBurney's sign — right lower quadrant abdominal tenderness and localised rebound tenderness if appendix is anterior.  
  • Murphy's sign — right upper quadrant tenderness with arrest of inhalation during palpation in people with cholecystitis.
    • However, it is only present in 65% of adults with cholecystitis and is particularly unreliable in older patients. 
  • Psoas sign — passive extension of the right thigh with the person in the left lateral position elicits pain in the right lower quadrant in people with appendicitis. 
  • Rovsing's sign — pain in the right lower quadrant after palpating the left lower quadrant.  
  • Obturator sign — passive internal rotation of the flexed right thigh elicits pain in the right lower quadrant in people with appendicitis. 
  • Note: psoas sign, Rovsing's sign, and obturator sign have low sensitivity for appendicitis, but modestly increase the likelihood of appendicitis when present. 
• Be aware that abdominal pain often presents atypically in older people, people who are immunocompromised, people who are living with obesity, and pregnant women.  
• Arrange appropriate investigations.

What are the red flags in people with acute abdominal pain?

• Medical red flags include: 
  • Signs and symptoms of sepsis — for example, fever, tachycardia, lowered temperature, and being generally unwell.
  • Generalised oedema — suspect nephrotic syndrome. 
  • Jaundice. 
  • Polyuria/polydipsia — suspect diabetic ketoacidosis.
  • Purpuric or petechial rash — suspect sepsis meningococcal disease if the person is febrile. 
  • Respiratory symptoms — for example, tachypnoea, respiratory distress, and cough. 
  • Significant dehydration (clinically or over 5% weight loss). 
• Surgical red flags include:
  • History of recent significant abdominal trauma or recent surgery. 
  • Irreducible hernia. 
  • Peritonitis (guarding, rebound tenderness, and constant dull pain exacerbated by movement). 
  • 'Red currant jelly' stool —  indicating possible intussusception. 
  • Signs and symptoms of bowel obstruction — colicky abdominal pain, absolute constipation (no stool or flatus), bilious vomiting, and hyperactive or tinkling bowel sounds.
  • Testicular or labial pain.
• Other red flags include: 
  • Abdominal distension.
  • Bilious (green) or blood-stained vomit.
  • Blood in stool. 
  • Palpable abdominal mass.
  • Severe or increasing abdominal pain.
  • Unintentional weight loss. 
• In children, red flags also include: 
  • Non-mobile or change in gait pattern due to pain.
  • Unresponsive or excessively drowsy.

What investigations should I arrange for a person with acute abdominal pain?

• Arrange appropriate investigations depending on the results of the assessment and the suspected cause. Do not delay admission to wait for the results of investigations. 
• Consider arranging the following initial tests for people with abdominal pain:
  • Full blood count. 
  • Urea and electrolytes. 
  • Liver function test.
  • Blood glucose.
  • C-reactive protein (CRP).
  • Urinalysis. 
  • Pregnancy test — for all women of childbearing age. 
• Other investigations that may be appropriate in primary care, depending on the assessment, include:
  • Amylase and lipase levels — if pancreatitis is suspected.  
  • Chlamydia and gonorrhoea testing — for women at risk of sexually transmitted infections. 
  • Coagulation screen — if a vascular cause is suspected. 
  • Markers for specific diseases — for example, coeliac disease or inflammatory bowel disease.  
  • Quantitative faecal immunochemical testing (FIT) — for example, if malignancy is suspected.
  • Serum lactic acid levels — if acute mesenteric ischaemia is suspected. 
  • Stool culture — if an infectious cause is suspected.
• Investigations in secondary care may include:
  • Abdominal CT scan — for example, if abdominal sepsis, or bowel obstruction are suspected. 
    • First choice in people with right lower quadrant, left lower quadrant pain, left upper quadrant, or generalized abdominal pain. 
  • Abdominal MRI.
  • Abdominal X-ray — for example, if intestinal obstruction, fulminant colitis, or perforation are suspected. 
  • Abdominal ultrasound — for example, if biliary, gynaecological or renal pathology is suspected. 
    • First choice for right upper quadrant pain and suprapubic pain.
  • Colonoscopy/sigmoidoscopy.
  • ECG — in people aged over 50 years, or people aged under 50 years where appropriate. 
  • Endoscopy — if an oesophageal or gastric pathology is suspected.
  • Laparoscopy.
  • Transvaginal ultrasound — if ectopic pregnancy or endometriosis are suspected.

What are the possible gastrointestinal causes of acute abdominal pain?

• Gastrointestinal causes of acute abdominal pain include:
  • Adhesions — history of abdominal or pelvic surgery, cramp-like pain, nausea and or vomiting, constipation, absence of flatus, high-pitched bowel sounds, tenderness to abdominal palpation, involuntary guarding, tachycardia, tympanic percussion, or presence of abdominal surgical scars. 
  • Appendicitis — sudden onset, constant, severe pain often with periumbilical migration to the right lower quadrant, worse on movement. Nausea, vomiting, anorexia, fever, and diarrhoea. For more information, see the CKS topic on Appendicitis. 
    • In children aged under 5 years this may not present with classical symptoms and may include fever, vomiting, perforation or sepsis, or diarrhoea.
  • Acute diverticulitis — persistent left lower quadrant pain, fever, anorexia, nausea, vomiting, distended abdomen, or rectal bleeding or mucus. For more information, see the CKS topic on Diverticular disease. 
  • Bowel obstruction — constipation (no stool or flatus) and abdominal distension strongly suggest bowel obstruction. It is usually preceded by intermittent pain.
  • Constipation — bowel movements occurring less than three times a week, or daily bowel movements with excessive straining. Additional symptoms may include lower abdominal pain or discomfort, distension, or bloating. For more information, see the CKS topic on Constipation. 
  • Crohn's disease — family history, abdominal pain, unexplained persistent diarrhoea, anal discharge, weight loss, fatigue, or fever. For more information, see the CKS topic on Crohn's disease.
  • Perforated gastric ulcer — history of recurrent upper abdominal pain with nausea, vomiting, loss of appetite, and pain made worse by eating. Sudden onset severe upper abdominal pain with fever, nausea, and vomiting. For more information, see the CKS topic on Dyspepsia - proven peptic ulcer.
  • Gastroenteritis — nausea, vomiting, diarrhoea, or abdominal pain or cramps. For more information, see the CKS topic on Gastroenteritis.
  • Gastrointestinal cancer — consider gastrointestinal cancer if abdominal pain is accompanied by other features, such as weight loss, low haemoglobin levels, raised platelet count, nausea or vomiting, or rectal bleeding. For more information see the CKS topics on Gastrointestinal tract (upper) cancers - recognition and referral, and Gastrointestinal tract (lower) cancers - recognition and referral.
  • Dyspepsia — upper abdominal pain or discomfort, heartburn, acid reflux, and nausea and/or vomiting, typically present for 4 weeks or more. For more information, see the CKS topic on Dyspepsia - unidentified cause.
  • Incarcerated/strangulated hernia — history of hernia, cramp-like abdominal pain, painful bulge, nausea, vomiting, decreased bowel function, and distended abdomen. 
  • Infectious colitis — fever, chills, nausea, vomiting, diarrhoea, abdominal pain and distention, and malaise. 
  • Ulcerative colitis — bloody diarrhoea, fever, abdominal pain, and weight loss. For more information, see the CKS topic on Ulcerative colitis.

What are the possible genitourinary causes of acute abdominal pain?

• Genitourinary causes of acute abdominal pain include:
  • Kidney stones — abrupt onset of severe unilateral abdominal pain originating in the loin or flank radiating to the labia in women, or the groin or testicle in men. For more information, see the CKS topic on Renal or ureteric colic. 
  • Pelvic inflammatory disease — lower abdominal or pelvic pain of recent onset, usually bilateral but can be unilateral, deep dyspareunia, abnormal vaginal bleeding or discharge. For more information, see the CKS topic on Pelvic inflammatory disease. 
  • Pyelonephritis — sudden onset flank pain (usually unilateral), fever, and nausea with signs and symptoms of urinary tract infection. For more information, see the CKS topic on Pyelonephritis. 
  • Testicular torsion — acute severe unilateral scrotal pain and swelling may radiate to the groin or lower abdomen. There may be associated nausea and vomiting. For more information, see the section on Differentiating clinical features in the CKS topic on Scrotal pain and swelling.
  • Urinary tract infection — suprapubic pain or tenderness, dysuria, frequency, urgency, and nocturia. For more information, see the CKS topics on Urinary tract infection (lower) - men, Urinary tract infection (lower) - women, and Urinary tract infection - children.  

What are the possible gynaecological or obstetric causes of acute abdominal pain?

• Gynaecological or obstetric causes of acute abdominal pain include:
  • Adnexal mass — these cause abdominal pain (torsion, haemorrhage, and rupture), and are more likely to present in the first trimester. 
  • Ectopic pregnancy — vaginal bleeding with severe unilateral pelvic pain, history of recent early pregnancy, or missed last period. For more information, see the CKS topic on Ectopic pregnancy. 
  • Endometriosis — dysmenorrhoea, cyclical abdominal/pelvic/back pain, often 1–2 weeks before menstruation and during menstruation. For more information, see the CKS topic on Endometriosis. 
  • Miscarriage — lower abdominal cramping or vaginal bleeding. For more information, see the CKS topic on Miscarriage. 
  • Mittelschmerz — one-sided, sharp, and usually lasts less than a few hours in the middle of the ovulatory cycle. 
  • Ovarian cancer — consider this in a woman who has pelvic or abdominal pain on a persistent or frequent basis. For more information, see the CKS topic on Gynaecological cancers - recognition and referral. 
  • Ovarian torsion — sudden, sharp, unilateral pain often with nausea/ vomiting. 
  • Pelvic inflammatory disease —  may present with lower abdominal pain, vaginal discharge, and pyrexia, but can also present with hepatic inflammation and Fitz-Hugh Curtis syndrome. For more information, see the CKS topic on Pelvic inflammatory disease. 
  • Uterine fibroids — pelvic pain, abdominal discomfort, bowel symptoms, and heavy menstrual bleeding. For more information, see the CKS topic on Fibroids. 
• Other causes of abdominal pain in women include: 
  • Menarche.
  • Ovarian cysts.
  • Placental abruption.
  • Pre-term labour.
  • Tubo-ovarian abscesses.

What are the possible hepatobiliary and pancreatic causes of acute abdominal pain?

• Hepatobiliary and pancreatic causes of acute abdominal pain include: 
  • Acute pancreatitis — acute onset, constant severe mid-abdominal epigastric pain that often radiates to the back; nausea; vomiting; anorexia; and history of alcohol misuse. For more information, see the CKS topic on Pancreatitis - acute. 
  • Cholangiocarcinoma  — may present with right upper quadrant pain and associated jaundice. For more information, see the CKS topic on Jaundice in adults. 
  • Cholecystitis — sudden onset constant severe pain in the right upper quadrant pain. For more information, see the CKS topic on Cholecystitis - acute. 
  • Gallstones — right upper quadrant or epigastric pain lasting more than 30 minutes, but less than 8 hours. It is often severe and may be associated with nausea and vomiting. For more information, see the CKS topic on Gallstones.
  • Hepatic abscess — right upper quadrant pain, fever, chills, anorexia, malaise, hepatomegaly, weight loss, shortness of breath, and jaundice.
  • Hepatitis — right upper quadrant pain, fever, chills, fatigue, myalgia/arthralgia, nausea, vomiting, and jaundice. History of high-risk activities. For more information, see the CKS topics on Hepatitis B and Hepatitis C. 
  • Pancreatic cancer — consider pancreatic cancer if abdominal pain is accompanied by weight loss in people aged 60 years and over. For more information see the CKS topic on Gastrointestinal tract (upper) cancers - recognition and referral.
  • Pancreatic pseudocyst — can present as acute pain as a feature of chronic pancreatitis. For more information, see the CKS topic on Chronic pancreatitis. 

What are the possible other causes of acute abdominal pain?

• Other causes of acute abdominal pain include: 
  • Aortic dissection — severe, sharp, or tearing pain in the thorax or abdomen. Pain may also radiate to the neck or back. 
  • Diabetic ketoacidosis — abdominal pain, increased thirst, urinary frequency, dehydration, weight loss, lethargy, and confusion. For more information, see the section on Diabetic ketoacidosis in CKS topic on Diabetes - type 1.
  • Fitz-Hugh Curtis syndrome — severe right upper quadrant pain, possibly referred to the right shoulder and worse on coughing or movement. Fever, chills, headaches, malaise hiccups, night sweats, nausea and vomiting, and history of pelvic inflammatory disease. 
  • Mallory-Weiss tear — vomiting or coughing with haematemesis, retrosternal, epigastric or back pain, melaena, syncope, and dysphagia. 
  • Metabolic and toxic causes — for example, uraemia, Addisonian crisis, hypercalcaemia, inherited metabolic disorders, or heavy metal poisoning. 
    • For more information, see the CKS topic on Addison's disease, Hypercalcaemia, and Poisoning or overdose. 
  • Mesenteric ischaemia — constant periumbilical non-radiating abdominal pain with a recent history of postprandial abdominal pain. 
  • Musculoskeletal causes — for example, abdominal wall haematoma — acute pain with fever, nausea, and vomiting; there may be a lump or mass. May follow trauma, exercise, coughing, or surgical interventions. 
  • Opioid withdrawal — history of drug use, fever, chills, nausea, vomiting, abdominal pain, sweating, tremors, confusion, anxiety, muscle aches, and dilated pupils. 
  • Porphyria —  can present with abdominal pain, nausea, vomiting, peripheral neuropathy, and seizures. 
  • Psoas abscess — fever, chills, nausea, vomiting, flank or low abdominal/groin pain, malaise, and new-onset limp. Most commonly presents in people with immunosuppression. 
  • Sickle cell crisis — history of sickle cell disease, diffuse bodily pain, including abdominal pain. May be accompanied by fatigue, fever jaundice, and tachycardia. For more information, see the section on Sickle cell crisis in the CKS topic on Sickle cell disease. 
  • Trauma.
  • Typhlitis (neutropenic enterocolitis) — history of haematological malignancy and/or receiving chemotherapy or immunosuppressants; fever; abdominal pain, particularly in right lower quadrant; nausea; vomiting; and diarrhoea. 

Scenario: Management

From age 1 month onwards.

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of abdominal pain.

Unrestricted - September 2024

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.

• exp Abdominal Pain/, abdominal pain.tw
• exp Diagnostic Techniques, Abdominal/, exp "Laboratory Techniques and Procedures"/

• National Institute for Health and Care Excellence (NICE)
• Scottish Intercollegiate Guidelines Network (SIGN)
• Royal College of Physicians
• Royal College of General Practitioners
• Royal College of Nursing
• NICE Evidence
• Health Protection Agency
• World Health Organization
• National Guidelines Clearinghouse
• Guidelines International Network
• TRIP database
• GAIN
• NHS Scotland National Patient Pathways
• New Zealand Guidelines Group
• Agency for Healthcare Research and Quality
• Institute for Clinical Systems Improvement
• National Health and Medical Research Council (Australia)
• Royal Australian College of General Practitioners
• British Columbia Medical Association
• Canadian Medical Association
• Alberta Medical Association
• University of Michigan Medical School
• Michigan Quality Improvement Consortium
• Singapore Ministry of Health
• National Resource for Infection Control
• UK Ambulance Service Clinical Practice Guidelines
• RefHELP NHS Lothian Referral Guidelines
• Medline (with guideline filter)
• Driver and Vehicle Licensing Agency
• NHS Health at Work(occupational health practice)

• The Cochrane Library:
  • Systematic reviews
  • Protocols
  • Database of Abstracts of Reviews of Effects
• Medline (with systematic review filter)
• EMBASE (with systematic review filter)

• NIHR Health Technology Assessment programme
• The Cochrane Library:
  • NHS Economic Evaluations
  • Health Technology Assessments
• Canadian Agency for Drugs and Technologies in Health
• International Network of Agencies for Health Technology Assessment

• The Cochrane Library:
  • Central Register of Controlled Trials
• Medline (with randomized controlled trial filter)
• EMBASE (with randomized controlled trial filter)

• Bandolier
• Drug & amp; Therapeutics Bulletin
• TRIP database
• Central Services Agency COMPASS Therapeutic Notes

• Department of Health
• Health Management Information Consortium(HMIC)

• Healthtalkonline
• BMJ - Patient Journeys

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

• British National Formulary(BNF)
• electronic Medicines Compendium(eMC)
• European Medicines Agency(EMEA)
• LactMed
• Medicines and Healthcare products Regulatory Agency(MHRA)
• REPROTOX
• Scottish Medicines Consortium
• Stockley's Drug Interactions
• TERIS
• TOXBASE
• Micromedex
• UK Medicines Information

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

• Clinical accuracy.
• Consistency with other providers of clinical knowledge for primary care.
• Accuracy of implementation of national guidance (in particular NICE guidelines).
• Usability.

• The process is inclusive and any individual may participate.
• To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
• Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
• Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
• External reviewers are not paid for commenting on the draft topics.
• Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
• All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
• All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

• Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
• Stakeholders identified from the following groups are invited to review draft topics:
  • Experts in the topic area.
  • Professional organizations and societies (for example, Royal Colleges).
  • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
  • Guideline development groups where the topic is an implementation of a guideline.
  • The British National Formulary team.
  • The editorial team that develop MeReC Publications.
• Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

• Topic selection
• Scoping of topic
• Selection of clinical scenarios
• First draft internal review
• Second draft internal review
• External review
• Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

• Animal studies
• Original research is not written in English

• Sample size too small or study underpowered
• Bias evident or promotional literature
• Population not relevant
• Intervention/treatment not relevant
• Outcomes not relevant
• Outcomes have no clear evidence of clinical effectiveness
• Setting not relevant
• Not relevant to UK
• Incorrect study type
• Review article
• Duplicate reference

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

• Feasibility
  • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
• Organizational and Financial Impact Analysis
• Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
  • Eligible population
  • Current interventions
  • Likely uptake of new intervention or recommendation
  • Cost of the current or new intervention mix
  • Impact on other costs
  • Condition-related costs
  • In-direct costs and service impacts
  • Time dependencies
• Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

• Personal financial interests
• Personal family interest
• Personal non-financial interest
• Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

None.