Plain abdominal radiographs and acute abdominal pain

Role of contrast-enhanced serial/spot abdominal X-rays in perioperative follow-up of patients undergoing abdominal surgery: An observational clinical study

BACKGROUND

Many imaging methods such as ultrasonography, computed tomography (CT), magnetic resonance imaging, and endoscopy are used to identify the problems or complications that occur in the perioperative period and to determine the appropriate therapeutic approach. Specialists at surgical clinics and intensive care units sometimes need diagnostic procedures that can give quick results or reveal unexpected results. In particular, rapid on-site evaluation of patients followed under intensive care conditions has several advantages.

AIM

To determine the problems developing in patients in the perioperative period by contrast-enhanced abdominal X-ray (CE-AXR), revealing their current status or defining the effectiveness of CE-AXR.

METHODS

The files of the patients who underwent hepatopancreatobiliary or upper gastrointestinal surgery, whose CE-AXR film was taken, were reviewed retrospectively. Abdominal X-ray radiographs taken after ingestion of a water-soluble contrast agent (iohexol, 300 mg, 50 cc vial) and its application in a drain, nasogastric tube, or stent were evaluated. The contribution of the data obtained in patients who underwent CE-AXR to the diagnosis, follow-up, and treatment processes and the effectiveness of the application were investigated.

RESULTS

CE-AXR was applied to 131 patients in our clinic, most of whom underwent hepatopancreatobiliary or upper gastrointestinal surgery. It was determined that the data obtained from CE-AXR films taken in 98 (74.8%) of the patients contributed to the diagnosis, treatment, and follow-up expectations and positively affected the clinical processes.

CONCLUSION

CE-AXR is a simple procedure that can be applied anywhere, especially in intensive care patients and at bedside, with a portable X-ray device. The simplicity of the procedure, less radiation exposure for the patients, less time wastage, reduction in the CT and endoscopy procedure burden and costs, quick results, rapid assessment of the situation, and enabling the monitoring of processes with repetitive procedures are important advantages. X-rays taken will be useful in terms of being a reference value during the follow-up period of the patient and determining the situation in medicolegal processes.

Are We Following iRefer Guidelines From the Royal College of Radiology When Requesting Abdominal X-rays?

Background Abdominal radiography is one of the most routinely performed radiological investigations in hospitals. It is one of the initial investigations done in hospitals. Numerous studies have shown that abdominal X-rays have low sensitivity in several conditions such as acute abdominal pain. Methodology This study aims to first identify whether the Royal College of Radiology guidelines are being adhered to while requesting abdominal X-rays and, second, to identify the number of unnecessary requests made in the Betsi Cadwaladr health board. This is a retrospective audit of abdominal X-ray request data collected between the 1st and 23rd of August 2022. Data were collected from the electronic radiology record system. iRefer guidelines by the Royal College of Radiology were used as a reference to compare the requests made, and data were then analysed accordingly. Data are reported descriptively using percentages. Data analysis was done using SPSS version 20 (IBM Corp., Armonk, NY, USA). Results Of the total 242 abdominal X-rays noted, 89.67% of requests were according to the iRefer guidelines while 10.33% of requests were not. A total of 73.14% of cases were suspected to have an intestinal obstruction, and the positivity rate for the same was only 12.39%. Conclusions The majority of the requests followed the guidelines. However, there is an urgent need to develop local guidelines to reduce needless abdominal X-rays.

Abdominal Pain in the Emergency Department: How to Select the Correct Imaging for Diagnosis

Abdominal pain is a common presenting complaint in the emergency department, and utilization of diagnostic imaging is often a key tool in determining its etiology. Plain radiography has limited utility in this population. Computed tomography (CT) is the imaging modality of choice for undifferentiated abdominal pain. Ultrasound and magnetic resonance imaging may be helpful in specific scenarios, primarily in pediatrics and pregnancy, and offer the benefit of eliminating ionizing radiation risk of CT. Guidance for imaging selection is determined by location of pain, special patient considerations, and specific suspected etiologies. Expert guidance is offered by the American College of Radiology Appropriateness Criteria^® which outlines imaging options based on location of pain.

Ultra-low dose CT abdomen and pelvis for the detection of acute abdominal pathology in the emergency room: initial experience from an academic hospital

PURPOSE

The aim of this study is to describe our initial experience using ULDCT performed in the emergency room in the evaluation of acute abdominal pathology.

METHODS

Data from consecutive patients who underwent ULDCT for assessment of bowel obstruction, free intraperitoneal air, unexplained abdominal pain, or fecal loading for constipation between June 1, 2016 and March 31, 2017 was retrospectively assessed. Demographic data, radiation dose, CT findings, and clinical outcomes including performance of full dose contrast-enhanced CT (CECT), hospitalization, and surgery was collected. Concordance of ULDCT to CECT was calculated.

RESULTS

ULDCT was performed in 325 patients (188 women and 137 men; mean age, 65.1 years). ULDCT detected acute abdominal pathology in 134/325 (41.2%), and in 89/134 (66.4%) it was concordant with the clinical working diagnosis. The average dose length product (DLP) was 101.6 mGy cm (range 51.7-614; median, 82.6). CECT was performed in 44/325 patients (13.5%). In 7/44 (15.9%), CECT identified discordant findings which likely impacted management. A greater proportion of patients were admitted to hospital after a positive ULDCT 99/137 (72.3%), compared to those with a negative study 81/188 (43.1%); p < 0.0001(Chi², 27.30). Of those admitted to hospital, 11/99 (11.1%) with positive ULDCT had surgery compared to 1/81 (1.2%) with a negative ULDCT; p < 0.008 (Chi², 6.98).

CONCLUSION

With its high clinical yield and similar radiation dose, ULDCT appears as a suitable alternative to abdominal radiography for the detection of select acute abdominal pathology in the emergency room.

Diagnostic imaging for acute abdominal pain in an Emergency Department in Italy

Imaging plays a key role in the diagnostic work-up of patients with non-traumatic acute abdominal pain (AAP) in emergency department (ED). We aimed to evaluate the use and diagnostic performance of imaging techniques in adult patients with AAP in an ED in Italy. Patients with non-traumatic AAP admitted at the ED of S. Orsola-Malpighi University Hospital of Bologna (Italy) from the 1st to the 30th November 2016 were included. Demographic and clinical data, data on radiological procedures and discharge diagnosis were collected. Sensitivity and specificity for detecting acute diseases were assessed using the discharge diagnosis from the ED as reference standard. Of the 578 patients (female 52.8%, mean age 51.3 years) admitted to the ED for AAP, 433 (74.9%) underwent abdominal imaging. The most frequent techniques used were abdominal plain radiography and ultrasonography (US), performed in 38.4% and 37.9% of patients, respectively, followed by computed tomography (CT) in 28% of patients. Plain radiography yielded a sensitivity of 28% and specificity of 91.1%; the sensitivity increased to 79.4% in patients with small bowel obstruction. Ultrasonography's sensitivity and specificity were 61.8% and 98.4%, respectively; the sensitivity of US reached 85.2% and 90% in patients with acute cholecystitis/biliary colic and urolithiasis, respectively. The sensitivity and specificity of CT were 87.8% and 92.9%, respectively. Plain radiography is still overused in the diagnostic work-up of AAP in ED in Italy, despite its unsatisfactory sensitivity. Ultrasonography and CT has a higher sensitivity and should be used as first-level imaging in most patients.

A Study on the Use of Abdominal X-Ray in an Emergency Department

Objective

1) To study the current use of abdominal X-rays (AXR) in our emergency department (ED). 2) To evaluate the clinical predictors for positive AXR findings.

Methods

During the 40 days study period, all patients who had taken abdominal X-rays were included. The attending doctor filled in a questionnaire on demographic data, clinical features and outcome. The three radiologists who participated in this study reported the films and consultant emergency physicians then commented on the appropriateness of the request. The clinical features, which were predictive of positive radiological findings, were sorted out using univariate analysis.

Results

64 patients were included in the 40 days study period. The rate for AXR request was 3.4 per 1000 patients. The most common presenting complaints were abdominal pain (85.9%) and constipation (45.3%). The most frequent clinical findings were abdominal distension (35.9%) and hyperactive bowel sound (31.3%). Only two of the clinical features, including vomiting and rebound tenderness, were found to have significant correlation with positive X-ray findings. Most of the AXR requests and interpretations by ED doctors were considered to be appropriate.

Acute appendicitis in young children less than 5 years: review article

Despite wide spread availability of sophisticated diagnostic imaging, acute appendicitis in pre-school children remains a diagnostic challenge. Most of these children present late, often with complications e.g. appendicular perforation, abscess formation and peritonitis and as result hospital stay is prolonged and is associated with increased morbidity and mortality.The purpose of this article is to review peculiar features of acute appendicitis in preschool children.

Pediatric abdominal radiograph use, constipation, and significant misdiagnoses

OBJECTIVE

To determine the proportion of children diagnosed with constipation assigned a significant alternative diagnosis within 7 days (misdiagnosis), if there is an association between abdominal radiograph (AXR) performance and misdiagnosis, and features that might identify children with misdiagnoses.

STUDY DESIGN

We conducted a retrospective cohort study of consecutive children <18 years who presented to a pediatric emergency department in Toronto, between 2008 and 2010. Children assigned an International Statistical Classification of Diseases and Related Health Problems 10th Revision code consistent with constipation were eligible. Misdiagnosis was defined as an alternative diagnosis during the subsequent 7 days that resulted in hospitalization or an outpatient procedure that included a surgical or radiologic intervention. Constipation severity was classified employing text word categorization and the Leech score.

RESULTS

3685 eligible visits were identified. Mean age was 6.6 ± 4.4 years. AXR was performed in 46% (1693/3685). Twenty misdiagnoses (0.5%; 95% CI 0.4, 0.8) were identified (appendicitis [7%], intussusception [2%, bowel obstruction [2%], other [9%]). AXR was performed more frequently in misdiagnosed children (75% vs 46%; P = .01). These children more often had abdominal pain (70% vs 49%; P = .04) and tenderness (60% vs 32%; P =.01). Children in both groups had similar amounts of stool on AXR (P = .38) and mean Leech scores (misdiagnosed = 7.9 ± 3.4; not misdiagnosed = 7.7 ± 2.9; P = .85).

CONCLUSIONS

Misdiagnoses in children with constipation are more frequent in those in whom an AXR was performed and those with abdominal pain and tenderness. The performance of an AXR may indicate diagnostic uncertainty; in such cases, the presence of stool on AXR does not rule out an alternative diagnosis.

Low-dose computed tomography versus plain abdominal radiography in the investigation of an acute abdomen

BACKGROUND

To compare low-dose abdominal computed tomography (LDCT) with plain abdominal radiography (AR) in the primary investigation of acute abdominal pain to determine if there is a difference in diagnostic yield, the number of additional investigations required and hospital length of stay (LOS).

METHODS

This randomized controlled trial was approved by the institutional review board, and informed consent was obtained. Patients presenting to the emergency department with an acute abdomen and who would normally be investigated with AR were randomized to either AR or LDCT. The estimated radiation dose of the LDCT protocol was 2-3 mSv compared to 1.1 mSv for AR. Pearson's chi-square and the independent samples t-test were used for the statistical analysis.

RESULTS

A total of 142 patients were eligible, and after exclusions and omitting those with incomplete data, 55 patients remained for analysis in the AR arm and 53 in the LDCT arm. A diagnosis could be obtained in 12 (21.8%) patients investigated with AR compared to 34 (64.2%) for LDCT (P < 0.001). Twenty-eight (50.9%) patients in the AR group required further imaging during their admission compared to 14 (26.4%) in the LDCT group (P= 0.009). There was no difference in the median hospital LOS (3.84 days for AR versus 4.24 days for LDCT, P= 0.83).

CONCLUSION

LDCT demonstrates a superior diagnostic yield over AR and reduces the number of subsequent imaging tests for a minimal cost in radiation exposure. However, there is no difference in the overall hospital LOS between the two imaging strategies.

Plain abdomen radiographs: the right view?

BACKGROUND

Plain abdomen radiographs (PAR) have limited use in the setting of the emergency department. We conducted this study to look at the appropriateness of requests and its utilization in our emergency department.

METHODOLOGY

We conducted a retrospective analysis of scanned emergency department notes between the period of December 2005 and February 2006 (3 months). Those cases with PAR requested by an emergency department doctor were recruited in this study. The documented history, examination, and provisional diagnosis in the case notes were reviewed to look at the appropriateness of the indications for requests.

RESULTS

Only 67% (50 of 75) of the requests were appropriate according to the Royal College of Radiologists guidelines with bowel obstruction/paralytic ileus, renal colic and foreign body ingestion being the common presentations. Thirty three percent (25 of 75) (95% confidence interval: 24-45) of the requests were inappropriate and could have been avoided by referring to the aforementioned guidelines.

CONCLUSION

We recommend implementing strict local protocols and guidelines for requesting PAR to reduce inappropriate requests. We also recommend staff education and awareness programs for reducing the over-utilizing of PAR.

[Acute abdomen film: is there hope of changing referring patterns?]

An abdomen radiograph (KUB) is frequently requested by ER physicians as part of the inital work-up of patients. However, other imaging studies are now routinely available in the acute setting that may make the KUB an obsolete and unnecessary examination. The first part of this study was to assess the current referral patterns for urgent KUB in our center; the improper referral pattern for KUB in terms of requests for unnecessary exams 48,5% as well as number of technical errors in terms of inadequate radiographic projection for the suspected pathology 47% were recorded. In a second part, the impact of corrective actions at one month, 2 months and 6 months was assessed and we observed a decrease of about 20% of the number of KUB scheduled by the ER physician. Our results confirm that it is possible to teach ER physicians to more appropriately order imaging studies, which should improve patient care and generate savings. Long term correction of referral patterns is possible if all actors remain involved in this process.

Abdominal radiograph requesting in the setting of acute abdominal pain: temporal trends and appropriateness of requesting

INTRODUCTION

The biannual turnover of house surgeons has long been dreaded by paramedical staff because of fears of increased workloads generated by 'untrained' junior doctors. The aim of this study was to address this issue by examining both the quantity and quality of requests made for emergency abdominal radiographs made by 'experienced' house surgeons during the month of July and by the 'novices' during August.

PATIENTS AND METHODS

All adult patients undergoing abdominal radiography (AXR) following admission as emergencies via the surgical directorate with abdominal signs were identified prospectively. The reports of the AXRs were reviewed to determine the total number of requests and the number of positive findings for the two groups. In addition, the hand-written request forms were recovered to determine the suitability of the requests according to nationally-accepted guidelines produced by the Royal College of Radiologists (RCR).

RESULTS

During the study period, a total of 252 radiographs were performed consisting of 98 in July and 154 in August. The number of unreported films in each month were similar at 11 (11.2%) and 16 (10.4%), respectively, leaving 87 reported radiographs in July and 138 in August. There was no difference in the number of radiographs with positive findings (excluding degenerative spinal disease) for July (n = 19; 22%) and August (n = 33; 24%). Of the 225 reported films, RCR guidelines were followed in only 73 (32%) of 225 cases. When guidelines were adhered to, positive findings were identified in 56 (76.7%) of 73 cases whereas when guidelines were not followed positive findings were seen in only 13/139 (8.9%) of AXRs.

CONCLUSIONS

We have demonstrated that the popular myth of the 'August syndrome' is unsubstantiated at least using the surrogate marker of abdominal radiograph requests. The worrying finding of a high number of unacceptable indications for the performance of abdominal radiographs deserves urgent attention both in terms of its financial implications and with regards reducing radiation exposure. A programme of education is proposed to emphasise the RCR guidelines with re-audit to assess adherence to the guidelines.

Diagnostic value of plain abdominal radiographs in patients with acute abdominal pain

OBJECTIVE

A prospective study was performed over a 3-month period in a tertiary referral centre to evaluate the appropriateness and contribution of plain abdominal radiographs (PAR) in the diagnosis and management of adult patients presenting with acute abdominal pain.

METHODS

Forward stepwise logistic regression was used to examine the correlation between PAR findings and the final diagnosis. The Chi-squared test was used to determine any changes in patient management including requirement for surgical intervention based on PAR findings (p < 0.05).

RESULTS

Of 168 patients (246 PAR), 59 (35%) had positive findings on PAR. PAR were most sensitive in cases of intestinal obstruction (odds ratio, OR = 33.548, r = 0.561). The sensitivity was further increased if three of the following predictive signs were present: exaggerated bowel sounds (OR = 13.350, r = 0.154), abdominal distension (OR = 2.993, r = 0.234) and age over 50 years (OR = 2.301, r = 0.027). PAR were non-diagnostic in 82% of patients with acute abdominal pain (p < 0.001).

CONCLUSION

PAR do not play a major role in influencing the management of patients with acute abdominal pain without coexisting bowel obstruction.

Nontraumatic acute abdominal pain: unenhanced helical CT compared with three-view acute abdominal series

PURPOSE

To prospectively evaluate and compare the diagnostic accuracy of unenhanced helical computed tomography (CT) for patients with nontraumatic acute abdominal pain with that of traditional abdominal radiography.

MATERIALS AND METHODS

Institutional review board approval and informed consent were obtained; this study was completed before implementation of the HIPAA. Ninety-one patients (44 men; 47 women; age range, 18-84 years; mean age, 48.5 years) with acute nontraumatic abdominal pain over a 7-month period were referred by the emergency department of one institution. These patients underwent a three-view acute abdominal series (AAS) and unenhanced helical CT. AAS included an upright chest radiograph and upright and supine abdominal radiographs. Unenhanced helical CT images with 5-mm collimation were obtained from the lung bases to the pubic symphysis, without intravenous, oral, or rectal contrast material. AAS and unenhanced helical CT images were each separately and prospectively interpreted by a different experienced radiologist who was blinded to patient history and the images and interpretation of the other examination for each patient. Final diagnosis was established with surgical, pathologic, and clinical follow-up. The sensitivity, specificity, accuracy, positive predictive value, negative predictive value, and positive and negative likelihood ratios were calculated for AAS and unenhanced helical CT. Confidence intervals of 95% were calculated for each value with the standard equation for population proportions. Results of AAS and unenhanced helical CT examinations were compared with chi2 analysis.

RESULTS

Among the 91 patients examined, unenhanced helical CT yielded an overall sensitivity, specificity, and accuracy of 96.0%, 95.1%, and 95.6%, respectively. The AAS interpretations yielded an overall sensitivity, specificity, and accuracy of 30.0%, 87.8%, and 56.0%, respectively. The accuracy of unenhanced helical CT was significantly greater than the accuracy of AAS (P < .05).

CONCLUSION

AAS is an insensitive technique in the evaluation of nontraumatic acute abdominal pain in adults. Unenhanced helical CT is an accurate technique in the evaluation of adult patients with nontraumatic acute abdominal pain and should be considered as an alternative to radiography as the initial imaging modality.

Ineffectiveness of routine abdominal radiography in patients with gastrointestinal hemorrhage admitted to an intensive care unit

GOALS

To determine the utility of plain abdominal radiography in the initial evaluation of acute gastrointestinal (GI) hemorrhage in a medical intensive care unit.

BACKGROUND

Plain abdominal radiographs are frequently used in the routine evaluation of patients with GI bleeding. The utility of these studies in the intensive care unit setting is unclear.

STUDY

The study was a retrospective chart review of 71 adult subjects admitted to a medical intensive care unit with the diagnosis of GI bleeding. Subjects were excluded if they presented with peritoneal signs, received an abdominal CT scan in the 24 hours prior to admission, or were chronically treated with immunosuppressive medication. Subjects were divided into two cohorts based on whether or not they underwent plain abdominal radiography during the first hospital day. The primary study endpoints were hospital mortality, intensive care unit length of stay, and whether or not radiographic findings altered clinical management.

RESULTS

Of the 71 patients admitted with a diagnosis of GI bleeding (mean age 65.8 +/- 14.5 years, 73.2% male), 56 (79%) had a plain abdominal radiograph performed. Subjects who had a plain film did not differ significantly from those who did not in age, gender, degree of anemia, degree of coagulopathy, or in severity of illness as measured by Acute Physiology and Chronic Health Evaluation (APACHE II) score. There was no statistically significant difference in hospital mortality or intensive care unit length of stay between patients who received plain films and those who did not. In no subject (0%; 95% confidence interval, 0%-5.4%) did abdominal radiography reveal an abnormality that altered clinical management.

CONCLUSIONS

Based on our observations, plain films of the abdomen do not appear to alter clinical outcomes or management decisions for patients with GI bleeding and normal abdominal examinations who are admitted to the intensive care unit.

Imaging the child with right lower quadrant pain and suspected appendicitis: current concepts

Acute appendicitis is the most common condition presenting with right lower quadrant pain requiring acute surgical intervention in childhood. The clinical diagnosis of acute appendicitis is often not straightforward and can be challenging. Approximately one-third of children with the condition have atypical clinical findings and are initially managed non-operatively. Complications usually result from perforation and include abscess formation, peritonitis, sepsis, bowel obstruction and death. Cross-sectional imaging with sonography and computed tomography (CT) have proven useful for the evaluation of suspected acute appendicitis in children. The principal advantages of sonography are its lower cost, lack of ionizing radiation, and ability to precisely delineate gynecologic disease. The principal advantages of CT are its operator independency with resultant higher diagnostic accuracy, enhanced delineation of disease extent in perforated appendicitis, and improved patient outcomes including decreased negative laparotomy and perforation rates.

Plain abdominal radiographs in acute medical emergencies: an abused investigation?

Plain abdominal radiographs are commonly requested for acute medical emergencies on patients with non-specific abdominal symptoms and signs. In this study 131 plain abdominal radiographs performed on the day of admission were prospectively analysed. In only 16 cases (12%) the reasons for requests conformed to the recommended guidelines by the Royal College of Radiologists. The reason for the request was stated in the case notes in only three cases. In 62 cases (47%), there was no comment made on the film by the requesting clinician. There was a discrepancy in the interpretation of the radiograph between the clinician and the radiologist in 31 cases (24%). The clinical management was influenced by plain abdominal radiographs in only nine cases (7%). The majority of plain abdominal radiographs requested on acute medical emergencies is inappropriate. There is a need to ensure guidelines are followed to prevent unnecessary exposure of patients to radiation as well as preventing expenditure on irrelevant investigations.

Abdominal pain and emergency department evaluation

By approaching the abdominal pain patient in a systematic fashion, the physician can improve his or her performance in evaluating the patient in a safe and efficient manner without extensive or redundant tests.

Contrast radiography in small intestinal obstruction, a valuable diagnostic tool?

OBJECTIVE

To investigate the diagnostic and therapeutic potential of plain abdominal radiographs and contrast radiography in patients with suspected small intestinal obstruction.

DESIGN

Retrospective study.

SETTING

General hospital, Sweden.

MATERIAL

2357 sets of plain abdominal radiographic casenotes.

MAIN OUTCOME MEASURES

Analysis of plain abdominal radiographs for small intestinal obstruction. Establishment of the time that subsequent contrast radiography medium took to reach the caecum, and its success rate.

RESULTS

Of the 2357 plain abdominal films 1599 (68%) did not show small intestinal obstruction, 425 (18%) showed intermediate obstruction, and 333 (14%) showed small intestinal obstruction. The water-soluble contrast medium reached the colon in 394/591 (67%) of the cases with intermediate or complete small intestinal obstruction. Although the contrast medium passed to the colon there was remaining abnormality with dilated small intestine in 71/212 (33%) of the cases with intermediate obstruction and in 95/143 (66%) of the small intestinal obstruction group. The time for the contrast medium to reach the colon was 3.4 hours in the normal group, 5.5 hours in the intermediate group and 8.9 hours in the obstruction group.

CONCLUSION

The plain abdominal radiographs seem to predict the success of follow-through examinations. Contrast radiography is safe and may have a therapeutic potential in small intestinal obstruction.

When appendicitis is suspected in children

Acute appendicitis is the most common condition requiring emergent abdominal surgery in childhood. The clinical diagnosis of acute appendicitis is often not straightforward because approximately one-third of children with the condition have atypical clinical findings. The delayed diagnosis of this condition has serious consequences, including appendiceal perforation, abscess formation, peritonitis, sepsis, bowel obstruction, and death. Cross-sectional imaging with ultrasonography (US) and computed tomography (CT) have proved useful for the evaluation of suspected acute appendicitis. There has been a great deal of variability in the utilization of these modalities for such diagnosis in the pediatric population. The principal advantages of US are its lower cost, lack of ionizing radiation, and ability to assess vascularity through color Doppler techniques and to provide dynamic information through graded compression. The principal advantages of CT include less operator dependency than US, as reflected by a higher diagnostic accuracy, and enhanced delineation of disease extent in a perforated appendix.

Advances in imaging of the acute abdomen

Over the last 10 years, the most significant advancement in imaging of the acute abdomen has been the development of helical CT imaging. Rapid breath-hold imaging and improved intravascular opacification have enabled radiologists to obtain volumetric data that can be viewed in smaller slice increments. Helical data can also be analyzed utilizing multiplanar and three-dimensional techniques. With its proven ability to diagnose a wide variety of conditions, CT remains the diagnostic modality of choice for imaging the surgical abdomen. There have been considerable improvements in image resolution in US with improvements in transducer technology. Ultrasonography often serves as the first study in evaluating the pediatric or female patient with right lower quadrant or pelvic pain. Computed tomography may be necessary if US is not diagnostic. Despite these technical advances, plain film radiography should be the first imaging study for suspected cases of bowel perforation or obstruction. Magnetic resonance imaging continues to evolve, with improvements in hardware and software design that allow for faster imaging, but current levels of availability in the acute setting preclude its wider use. Whereas further imaging is not necessary for patients presenting with classic signs and symptoms of various acute abdominal diseases, the atypical patient often requires careful diagnostic imaging. Close consultation between the radiologist and surgeon leads to studies appropriately tailored to meet the diagnostic challenge at hand.

Automated evidence-based critiquing of orders for abdominal radiographs: impact on utilization and appropriateness

OBJECTIVE

Inappropriate utilization of diagnostic testing has been well documented. The purpose of this study was to measure the impact of presenting real time, evidence-based critiques about the appropriateness of abdominal radiograph (KUB) orders on physician decision making.

DESIGN

Prospective trial where evidence-based critiques were presented to ordering clinicians in two kinds of situations: (1) a KUB was likely to have a low probability of providing useful information, or (2) an alternative view(s) was more appropriate given the clinical circumstance. There were two phases of the trial: Phase 1 was a 9-week period where evidence-based critiques were presented at the time of ordering a KUB, followed by Phase 2, a 19-week period in which orderers were randomized to receive critiques either amended to include both institutional data regarding the utility of the critiques and stronger messages about the lack of utility of the study, or the same critiques as presented in Phase 1, depending upon indication. Based upon the radiologist's report of their interpretation of the exams, the results of the examinations were scored as positive, equivocal, or negative using structured criteria.

RESULTS

299 KUBs in Phase 1 and 385 KUBs in Phase 2 received at least one critique. Cancellation rates of low yield films were low, and were similar in Phase 1 and 2, 8/258 (3%) vs. 10/283 (4%). Compliance with the recommendation for alternative view(s) was higher: 19/104 (38%) in Phase 1 vs. 96/176 (55%) in Phase 2 (p = 0.006). The results differentiated low-yield from non-low-yield films: 5% of low-yield films vs. 20% of non-low-yield films were positive in Phase 2 (p < 0.0001). Surgical physicians were less likely to cancel (p = 0.07) or to change to the suggested view(s) (p < 0.0001) than medical physicians or nurses.

CONCLUSIONS

The intervention identified clinical situations in which KUBs appeared to have a low clinical yield. In response to evidence-based critiques, providers were reluctant to cancel their order, but were more willing to change to different views. To reduce the number of inappropriate radiographic films, stronger incentives or interventions may be required.

Appendicitis

A complete understanding of the anatomy, pathophysiology, and presenting signs and symptoms of appendicitis, combined with a thorough history and physical examination, will be the most important factors in allowing the practicing emergency physician to make the correct diagnosis of acute appendicitis. For patients in which the diagnosis is less clear or for patients in high-risk groups (extremes of age, pregnant women, and immunocompromised patients) additional diagnostic testing, usually US or CT, and early surgical consultation are recommended.

Radiographic imaging modalities for the patient in the emergency department with abdominal complaints

The emergency physician should be aware of the sensitivity and specificity of any radiologic study being considered. Radiographic examinations should be used to answer specific questions raised by the history and physical examination. The need to obtain a given radiologic evaluation should be based on the potential information it may reveal and the likelihood that this information will alter patient care. This cost-effective approach minimizes unnecessary radiation exposure and has been advocated by many authorities. The emergency physician should resist the "knee jerk" tendency to order radiographs to reassure himself or herself of the safety of the patient at discharge. Documentational and legal concerns are equally invalid reasons, as is the feeling that "it's what we always order for patients with this abdominal complaint." A given study may be indicated if the yield is acceptable and treatment of the patient may be altered by the results.

Evaluation of abdominal pain in the elderly

Evaluation of the older patient presents a unique challenge to the emergency physician. The increased age of the population, a high incidence of comorbidity, general poverty of history and clinical signs in acute abdominal conditions, poor reliability of diagnostic procedures, and the variable presentations of diseases with significant morbidity and mortality summarize the problems to be encountered with the complaint of abdominal pain in the elderly. The correct diagnosis is often difficult to establish and coexisting complicating diseases influence the patient's condition and the ED management. The emergency physician must maintain a wide differential and have a low threshold for admission and more extensive evaluation in this patient population.

[Clinical standardization in acute abdominal pain]

The correct diagnosis in acute abdominal pain is necessary for adequate treatment. In several clinical studies it has been shown that, despite improvements in laboratory and technology medicine, errors occur in a considerable proportion of cases due to insufficient history-taking and clinical examination. By the introduction of a standardised and structured history and clinical examination, the diagnostic accuracy can be improved by at least 10%. The aim of this publication is to improve history-taking, clinical examination and diagnostic decision-making by exact definition of all relevant parameters. This was performed by a national clinical expert group, international standardisations were taken in consideration. The standardisation was based mainly on these existing international standardisations (World Organisation of Gastroenterology); however, revisions and corrections were necessary. In order to introduce the standardisation into clinical routine, a documentation form and a documentation program can be provided.

The acute abdomen

Acute abdomen patients present a diagnostic and therapeutic challenge to emergency clinicians. The decision to perform surgery or to treat medically is often difficult to make and requires assimilating patient information, laboratory findings, radiological studies, and DPL. The importance of careful and repetitive PE cannot be overemphasized when managing these patients. If all diagnostics performed are not definitive and the patient continues to exhibit signs of abdominal pain, it is advisable to explore the abdominal cavity while administering supportive measures. Abdominal ultrasonography is emerging as a valuable diagnostic tool for the acute abdomen patient. Laparoscopy, CT, and CAD may also prove useful in certain cases.

Delayed appendicitis from an ingested foreign body

An unusual case of acute appendicitis induced by a metal drill bit that was ingested by a 27-year-old man 3 years before presentation is reported. This foreign body lodged in the patient's appendix and developed a fecalith coating. When this fecalith coating enlarged enough to obstruct the appendiceal lumen, the patient presented with classic acute appendicitis. Foreign body-induced appendicitis is reviewed.

The radiologic evaluation of acute abdominal pain of intestinal origin. A clinical approach

The patient with acute abdominal pain presents the attending physician with a wide and varied gamut of diagnostic possibilities. Prompt and accurate diagnosis is essential for the proper care and management of these acutely ill patients. Diagnostic radiology is often an integral part of the emergent evaluation of these patients. This article focuses on some of the key plain-film findings in the patients suffering from acute abdominal pain of intestinal causes and reviews the radiologic evaluation of several major abdominal conditions such as acute appendicitis, diverticulitis, inflammatory bowel disease, bowel ischemia, and infarction.

The natural history and clinical findings in undifferentiated abdominal pain

STUDY OBJECTIVE

This was a follow-up study of patients diagnosed in and discharged from the emergency department with undifferentiated abdominal pain to establish the natural history of this condition and to define clinical features of patients with undifferentiated abdominal pain.

SETTING

ED of a county teaching hospital.

DESIGN

Telephone survey of patients at two to three days (first contact) and again at two to three weeks (second contact) after discharge and retrospective chart review.

TYPE OF PARTICIPANTS

All patients 18 years or older discharged with the primary diagnosis of undifferentiated abdominal pain from the ED. Excluded were pregnant patients and those presenting with trauma. Patients unavailable for follow-up contact were not included in further data analysis.

MEASUREMENTS AND MAIN RESULTS

Four hundred three patients were discharged from the ED with undifferentiated abdominal pain. Of these, 307 (76.1% were available for follow-up information. The female-to-male ratio was almost 3:1. At first contact, 26.8% of all patients were pain-free and another 30% improved. At second contact, 59.1% had no pain, and an additional 28.6% reported improvement. Ten patients were hospitalized during the follow-up period for continued abdominal pain, and no deaths were attributed to abdominal conditions. The largest subgroup of patients with undifferentiated abdominal pain was female patients less than 30 years old. Epigastric pain was the most common patient complaint, with nausea second. The abdomens of most patients were nontender on examination. Abnormal laboratory and radiologic findings in patients with undifferentiated abdominal pain were few.

CONCLUSION

Patients with the diagnosis of undifferentiated abdominal pain have a benign short-term course. Almost 88% of patients were pain-free or improved by two to three weeks after their evaluation. No signs or symptoms clearly identified subgroups of patients with undifferentiated abdominal pain.

A comparative ultrasound and plain abdominal x-ray: Evaluation of non-classical clinical cases of appendicitis

A prospective study of 109 patients with non-classical symptoms of appendicitis using the standard ultrasound (US) machine and plain abdominal x-rays demonstrated that US was superior to plain x-ray with a sensitivitiy, specificity and overall accuracy of 89%, 96% and 91%, respectively as compared with plain x-ray with 48%, 93% and 67% respectively. The negative appendectomy rate was 7%. In the alternative diagnosis, plain x-ray was superior to US due to the prevalence of intestinal diseases, ureteric calculi and basal pneumonia which were best shown in plain x-rays. US was, however, most useful in detecting female pelvic pathology. It is hoped that with improved imaging expertise and the appication of high resolution US machine a higher sensitivity and accuracy can be achieved. US is therefore recommended as the first line in the imaging of non-classical cases of appendicitis. However, in areas where enteric diseases and urinary calculus are endemic, it is prudent to perform both ultrasound and plain abdominal x-rays while the patient is in the radiodiagnostic department.

Plain abdominal radiography in the detection of major disease in children: a prospective analysis

STUDY OBJECTIVE

To prospectively evaluate previously described high-yield clinical criteria for obtaining plain abdominal radiographs in the emergency evaluation of children.

DESIGN

Prospective, observational study.

SETTING

Emergency departments of a university medical center and an affiliated county hospital.

PARTICIPANTS

Three hundred fifty-four children 15 years old or younger who underwent plain abdominal radiography during a one-year period.

METHODS AND MEASUREMENTS

Physicians ordering plain abdominal radiographs completed data forms that included historical and physical examination information before viewing films. At a later date, records of all patients were reviewed for radiologist interpretation and final diagnosis. The data were analyzed to determine the sensitivity, specificity, and predictive values of previously described high-yield criteria (from a retrospective series) in detecting radiographs that were diagnostic or suggestive of "major" abdominal disease.

MAIN RESULTS

Sixty-one patients (17%) had major diseases potentially requiring procedural intervention (eg, appendicitis, ingested foreign bodies, and intussusception), whereas 296 patients (83%) had minor diseases not requiring procedural intervention (eg, gastroenteritis and nonabdominal diagnoses). The presence of any of the following features--prior abdominal surgery, foreign body ingestion, abnormal bowel sounds, abdominal distention, or peritoneal signs--was 93% sensitive and 40% specific in detecting diagnostic or suggestive radiographs in patients with major disease. Positive and negative predictive values were 11% and 99%, respectively. If only these criteria had been used to obtain radiographs, 38% of films would have been omitted (at an estimated savings of $20,000) with only two suggestive radiographs missed.

CONCLUSION

Our results suggest that restricting abdominal radiographs to patients with at least one of these five high-yield clinical features will detect most diagnostic and suggestive radiographs in children with major abdominal diseases.

Strategies for reducing inappropriate laparotomy rate in the acute abdomen

Images

The acute abdomen: the role of computer-assisted diagnosis

CAD has been used in over 20,000 patients in an Accident and Emergency Department. Structured documentation has replaced normal case notes and a patient record is created which includes investigations and management. A copy of the documentation acts as an immediate communication to the general practitioner. The information is held on a computer and is readily accessed to produce feedback and to allow audit of any number of parameters. The results show that an improvement in diagnostic accuracy and a reduction in admissions and unnecessary laparotomies continues over 15 years. Problems have occurred; some are inherent to the system and some have been minimized as a result of a series of studies. The savings in terms of finance and facilities are considerable and the cost is small in comparison as the programs are available and the cost of hardware has diminished. It is concluded that documentation is essential. This allows the more accurate collection of information, permits analysis, acts as a method of communication and creates a detailed patient record. The use of this part of the CADA system produces a considerable improvement in the parameters used to assess satisfactory patient management. The computer diagnostic program produces a higher level of diagnostic accuracy than that obtained by doctors who are not using the system. It does not normally exceed the accuracy of the doctors who are using the structured documentation and entering the information into the computer. Other mathematical models might lead to an improvement, particularly if they were based on the diagnostic process used by a senior clinician. The method of entry of information could be facilitated by modern technology, including light pens or word sensitive computers. This would reduce the time required for completion of the documents. A number of possible improvements in the CADA system are reported and some have been studied in detail with little evidence of significant change. The computer part of the system has an educational value and presents a stimulating challenge to the junior hospital staff seeing the patient for the first time in the Accident and Emergency Department. Rapid feedback is possible and advantageous. Possibly the greatest value of the computer is in the analysis of the value of clinical features in diagnosis, which has not been easy in the past. It has also allowed precise assessment of the value of investigations in the diagnosis of patients with a suspected disease, which leads to more appropriate management and the saving of facilities.(ABSTRACT TRUNCATED AT 400 WORDS)

Evaluation of women with possible appendicitis using technetium-99m leukocyte scan

The authors evaluated the use of technetium-99m albumin colloid white blood cell (TAC-WBC) scan in women with possible appendicitis. One hundred and nine women underwent 110 TAC-WBC scans. One woman had a second scan on a separate admission and was considered two individual patients in the analysis. Twenty-six women had appendicitis, 10 of whom had a perforated appendix at surgery. The TAC-WBC scan was indeterminate (abnormal but nondiagnostic for appendicitis) in 52 women (47%), nine of whom had appendicitis. Fifty-eight scans were read as positive or negative for appendiceal pathology. There were 16 true positives, 5 false positives, 36 true negatives, and 1 false negative. The predictive value of a positive scan was 76%, and the predictive value of a negative scan was 97%. The TAC-WBC scan was positive in 62% of patients with appendicitis and negative in 43% of the patients without appendicitis resulting in an overall accuracy of 47% in the 109 women. The main value of TAC-WBC scan in women with possible appendicitis is its high negative predictive value and the main problem with the TAC-WBC scan is its high indeterminate rate.

Efficacy of plain abdominal radiography in patients with biliary tract disease

A retrospective review was performed to determine the usefulness of plain abdominal radiographs in patients presenting to the emergency department with gallbladder disease. Patients with the clinical diagnosis of biliary tract disease were divided into two groups: those with confirmed biliary tract disease and those who did not have gall bladder disease. There were no major radiologic findings (pneumoperitoneum, pneumobilia, or bowel obstruction) in any patient with biliary tract disease. No significant difference was noted in the incidence of minor radiologic findings (right upper quadrant calcification, mild ileus and right basilar atelectasis) in patients with biliary colic and acute cholecystitis. Additionally, there was no significant difference in minor findings between patients with biliary tract and nonbiliary tract disease. Plain abdominal radiographic findings were found to be nonspecific in patients with gallbladder disease and not useful in differentiating between patients with biliary colic and acute cholecystitis. Our results also suggest that plain abdominal radiographic findings are not useful in differentiating between patients with and without biliary tract disease, although the selection of patients without biliary tract disease may have biased this finding.

Modern aids to clinical decision-making in the acute abdomen

Acute abdominal pain continues to provide not only a large workload for the general surgeon but also many diagnostic and management problems. Many different techniques have been introduced over the past two decades to help in the management of the acute abdomen and this review considers their relative claims to become incorporated into the process of clinical decision-making. The evidence in support of formally structured patient interview pathways with or without computer-aided diagnostic programs is now overwhelming and should become routine. Both laparoscopy and peritoneal cytology have an important role to play in the management of patients in whom the decision to operate is in doubt, and a combination of the two would be complementary. Ultrasonography has become increasingly popular for investigating the acute abdomen, and results from specialist centres are impressive. However, the problems of operator variation and the difficulties in providing a 24-h service will probably prevent it from becoming a first-line investigation in most hospitals. Although plain radiography has been available for many years, its routine use in the management of the acute abdomen remains controversial. Recent studies have confirmed that contrast radiography is an important adjunct to decision-making, particularly in the management of large bowel obstruction, and there is increasing evidence to support its use in suspected small bowel obstruction, perforated peptic ulcer and acute diverticular disease.

Aids in the diagnosis of acute appendicitis

Methods used to improve the accuracy of diagnosis of acute appendicitis are reviewed. Laparoscopy, barium enema, ultrasonography and computer assistance have all been shown to improve accuracy, but no one method is of proven superiority. Such diagnostic aids or intensive in-hospital observation must be used to reduce the 15-30 per cent negative laparotomy rate when acute appendicitis is suspected, without increasing the incidence of appendiceal perforation.