The impact of introducing a no oral contrast abdominopelvic CT examination (NOCAPE) pathway on radiology turn around times, emergency department length of stay, and patient safety

Optimizing Outpatient Oral Contrast Use in Abdominal CT-A Radiology Pandemic Response Initiative to Reduce Patient Time in the Waiting Room and Reduce Costs, While Improving Patient Experience

Purpose: The aim was to reduce outpatient wait time and improve patient experience by optimising oral contrast use. Methods: Our multidisciplinary stakeholder collaboration implemented two simultaneous interventions: (1) Creation of 'oral contrast policy', limiting recommended indications. (2) Creation of a new shorter oral contrast regime (30 vs 60 min). We conducted a retrospective service evaluation of oral contrast use in outpatient (OP) abdominal CT at baseline and post-intervention. Patient wait times were measured and per-patient cost-savings were reported. An image quality review was performed by 2 blinded abdominal radiologists. Patient experience was evaluated with a standard voluntary survey. Statistical analysis was performed comparing baseline and evaluation outcomes using Chi-square or Fisher Exact test for categorical variables and Student's t-test or ANOVA for continuous data. Results: Over 1-month periods, OP CT scans were assessed in baseline (pre-pandemic) n = 575, baseline (pandemic) n = 495 and post-intervention n = 545 groups. Oral contrast use reduced from 420/575, 73.0% at baseline to 178/545, 32.7% post intervention. The turn-around time reduced by 15.8 minutes per patient from 70.3 to 54.5 minutes, P < .001 (Interventions 1 and 2). The diagnostic quality did not differ between the oral contrast regimes (Intervention 2, P = 1.0, P = .08). No repeat CTs were needed due to lack of oral contrast (Intervention 1) or poor opacification (Intervention 2). There was oral contrast cost reductions of 69.1-78.4% (P < .001). Patients reported their overall experience was improved post-intervention (Interventions 1 and 2). Conclusions: Optimising the CT oral contrast service through judicious use and a shorter regime, reduced patient wait times, improved patient experience and preserved diagnostic quality.

Quality assurance for non-contrast CT of the abdomen and pelvis during a period of supply chain disruption leading to iodinated contrast shortage in the emergency department setting

Objectives

Iodinated contrast media (ICM) shortage crisis due to COVID-19 lockdowns led to a need for alternate imaging protocols consisting of non-contrast computed tomography (CT) for abdominal complaints and related trauma indications in emergency department (ED) settings. This quality assurance study aims to evaluate clinical outcomes of protocol modifications during ICM shortage and identify potential imaging misdiagnosis of acute abdominal complaints and related trauma.

Material and Methods

The study included 424 ED patients with abdominal pain, falls, or motor vehicle collision (MVC)-related trauma who had non-contrast CT of the abdomen and pelvis in May 2022. We accessed the initial complaint, order indication, non-contrast CT results, any acute or incidental findings, and any follow-up imaging of the same body region with their results. We evaluated their association utilizing Chi-squared tests. We assessed sensitivity, specificity, and positive/negative predictive values using follow-up scan confirmation.

Results

Across initial complaint categories, 72.9% of cases were abdominal pain, and 37.3% received positive findings. Only 22.6% of patients had follow-up imaging. Most confirmed original reports were for abdominal pain. We also found three reports of missed findings. There were significant associations between complaint categories and initial non-contrast CT report results (P < 0.001), as well as initial complaint categories and whether the patient received follow-up imaging or not (P < 0.004). No significant associations were found between follow-up imaging results and initial report confirmation. Non-contrast CT had 94% sensitivity and 100% specificity, with positive and negative predictive values 100% and 94%, respectively.

Conclusion

Rate of missed acute diagnoses using non-contrast CT for patients presenting to the ED with acute abdominal complaints or related trauma has been low during the recent shortage, but further investigation would be needed to verify and quantify the implications of not routinely giving oral or intravenous contrast in the ED.

Positive oral contrast material for CT evaluation of non-traumatic abdominal pain in the ED: prospective assessment of diagnostic confidence and throughput metrics

OBJECTIVE

Evaluate the impact of positive oral contrast material (POCM) for non-traumatic abdominal pain on diagnostic confidence, diagnostic rate, and ED throughput.

MATERIALS AND METHODS

ED oral contrast guidelines were changed to limit use of POCM. A total of 2,690 abdominopelvic CT exams performed for non-traumatic abdominal pain were prospectively evaluated for diagnostic confidence (5-point scale at 20% increments; 5 = 80-100% confidence) during a 24-month period. Impact on ED metrics including time from CT order to exam, preliminary read, ED length of stay (LOS), and repeat CT scan within 7 days was assessed. A subset of cases (n = 729) was evaluated for diagnostic rate. Data were collected at 2 time points, 6 and 24 months following the change.

RESULTS

A total of 38 reviewers were participated (28 trainees, 10 staff). 1238 exams (46%) were done with POCM, 1452 (54%) were performed without POCM. For examinations with POCM, 80% of exams received a diagnostic confidence score of 5 (mean, 4.78 ± 0.43; 99% ≥ 4), whereas 60% of exams without POCM received a score of 5 (mean, 4.51 ± 0.70; 92% ≥ 4; p < .001). Trainees scored 1,523 exams (57%, 722 + POCM, 801 -POCM) and showed even lower diagnostic confidence in cases without PCOM compared with faculty (mean, 4.43 ± 0.68 vs. 4.59 ± 0.71; p < 0.001). Diagnostic rate in a randomly selected subset of exams (n = 729) was 54.2% in the POCM group versus 56.1% without POCM (p < 0.655). CT order to exam time decreased by 31 min, order to preliminary read decreased by 33 min, and ED LOS decreased by 30 min (approximately 8% of total LOS) in the group without POCM compared to those with POCM (p < 0.001 for all). 205 patients had a repeat scan within 7 days, 74 (36%) had IV contrast only, 131 (64%) had both IV and oral contrast on initial exam. Findings were consistent both over a 6-month evaluation period as well as the full 24-month study period.

CONCLUSION

Limiting use of POCM in the ED for non-traumatic abdominal pain improved ED throughput but impaired diagnostic confidence, particularly in trainees; however, it did not significantly impact diagnostic rates nor proportion of repeat CT exams.

Emergency department length of stay following discontinuation of routine oral contrast material

PURPOSE

To determine the effect of discontinuing routine oral contrast material on emergency department (ED) length of stay (LOS), time from order to CT completion, and preliminary report turnaround time (TAT).

METHODS

A HIPAA-compliant, IRB-waived, single-institution, retrospective cohort study was conducted on adult patients presenting with abdominal pain to the ED from October 2015 to April 2019. Routine oral contrast material was administered prior to July 2018 and discontinued thereafter. CT workflow (ED LOS, exam completion time, report TAT) data were analyzed in a univariate analysis before and after discontinuation of oral contrast. Pre- versus post-policy data were compared with 2-sided t tests. The primary outcome was ED LOS. Data were analyzed on a process control chart and confidence limits were adjusted using established criteria.

RESULTS

There were 5020 included abdominopelvic CTs. After routine oral contrast material was discontinued, ED LOS (13.4 h vs 10.7 h, p < 0.001) and time from CT order to CT completion (2.7 h vs 2.1 h, p < 0.001) declined. However, control chart analysis revealed improvement in overall LOS preceded the policy change by 9 months, while improvement in time to CT completion coincided with the policy change. Preliminary report TAT increased by 4 min after the policy change (29 min vs. 33 min, p < 0.001).

CONCLUSIONS

Discontinuation of routine oral contrast material in the ED accelerated time to CT completion but had a minor non-significant effect on overall ED LOS. Much of the reduction in overall LOS likely was due to unrelated process improvements.

Ultrasound and CT in the Diagnosis of Appendicitis: Accuracy With Consideration of Indeterminate Examinations According to STARD Guidelines

OBJECTIVE. The objective of our study was to determine the accuracy of ultrasound (US) and CT in diagnosing appendicitis at our institution while taking into account the number of indeterminate examinations in accordance with the Standards for Reporting Diagnostic Accuracy (STARD) guidelines. MATERIALS AND METHODS. We retrospectively evaluated 790 patients who underwent US, CT, or both for evaluation of suspected appendicitis between May 1, 2013, and April 30, 2015. Patient characteristics and US and CT examination results were recorded. The reference standard was histopathology or 3 months of medical record follow-up if surgery was not performed; 3 × 2 tables were generated, and sensitivity, specificity, overall test yield, and accuracy were calculated according to STARD guidelines. For surgical cases, time to surgery (one-way ANOVA) was compared among patients who underwent US alone, CT alone, or both US and CT. RESULTS. A total of 473 of 562 US examinations had indeterminate findings (overall test yield, 15.8%); sensitivity and specificity in the 89 diagnostic examinations were 98.5% and 54.2%, respectively. Thirteen of 522 CT examinations were indeterminate (overall test yield, 97.5%); sensitivity and specificity in the remaining 509 CT examinations were 98.9% and 97.2%, respectively. Taking indeterminate studies into account, the accuracy was 13.7% for US and 95.6% for CT. The negative appendectomy rates were 17.7% (11/62) for US and 3.3% (9/276) for CT (p = 0.0002). Time to surgery was longer for patients who underwent US and CT (mean ± SD, 17.7 ± 8.9 hours) than US alone (12.9 ± 6.4 hours; p = 0.002) but was not longer for patients who underwent CT alone (16.3 ± 8.4 hours; p = 0.45). CONCLUSION. At our institution, a large proportion of US examinations are indeterminate for appendicitis. CT is the preferred first-line imaging test for evaluating appendicitis in nonobstetric adult patients.

A prospective study comparing water only with positive oral contrast in patients undergoing abdominal CT scan

Consecutive adults scheduled to undergo abdominal CT with oral contrast were asked to choose between 1000 ml water only or positive oral contrast (50 ml Télébrix-Gastro diluted in 950 ml water). Two abdominal radiologists independently reviewed each scan for image quality of the abdomen, the diagnostic confidence per system (gastrointestinalsystem/organs/peritoneum/retroperitoneum/lymph nodes) and overall diagnostic confidence to address the clinical question (not able/partial able/fully able). Radiation exposure was extracted from dose reports. Differences between both groups were evaluated by Student’s t-test, Mann-Whitney-U-test or chi-square-test. Of the 320participants, 233chose water only. All baseline characteristics, image quality of the abdomen and the diagnostic confidence of the organs were comparable between groups and both observers. Diagnostic confidence in the water only group was more commonly scored as less than good by observer1. The results were as follows: the gastrointestinal system(18/233vs1/87; p = 0.031), peritoneum (21/233vs1/87; p = 0.012), retroperitoneum (11/233vs0/87; p = 0.040) and lymph nodes (11/233vs0/87; p = 0.040). These structures were scored as comparable between both groups by observer2. The diagnostic confidence to address the clinical question could be partially addressed in 6/233 vs 0/87 patients (p = 0.259). The water only group showed a tendency towards less radiation exposure. In summary, most scan ratings were comparable between positive contrast and water only, but slightly favored positive oral contrast for one reader for some abdominal structures. Therefore, water only can replace positive oral contrast in the majority of the outpatients scheduled to undergo an abdominal CT.

Positive Oral Contrast Material for Abdominal CT: Current Clinical Indications and Areas of Controversy

OBJECTIVE. The use of positive oral contrast material for abdominal CT is a frequent protocol issue. Confusion abounds regarding its use, and practice patterns often appear arbitrary. Turning to the existing literature for answers is unrewarding, because most studies are underpowered or not designed to address key endpoints. Even worse, many decisions are now being driven by nonradiologists for throughput gains rather than patient-specific considerations. Herein, the current indications for positive oral contrast material are discussed, including areas of controversy. CONCLUSION. As radiologists, we owe it to our patients to drive the appropriate use of positive oral contrast material. At the very least, we should not allow nonradiologists to restrict its use solely on the basis of throughput concerns; rather, we should allow considerations of image quality and diagnostic confidence to enter into the decision process. Based on differences in prior training and practice patterns, some radiologists will prefer to limit the use of positive oral contrast material more than others. However, for those who believe (as I do) that it can genuinely increase diagnostic confidence and can sometimes (rather unpredictably) make a major impact on diagnosis, it behooves us to keep fighting for its use.

New CT-based diagnoses of torso cancer is low in the emergency department setting

PURPOSE

The incidence of new CT-based torso cancer diagnoses and the most commonly diagnosed cancer types in the emergency department (ED) setting are unknown. The purpose of our study was to determine the incidence and types of new CT-based torso cancer diagnoses in the ED.

METHODS

A total of 19,496 CT reports including all or parts of the torso from 2017 were searched for the keywords: "mass", "tumor", "neoplasm", "malignancy", or "cancer". Each report and corresponding medical record was evaluated for presence of a new cancer. Cases were scored as no cancer, subcentimeter lung nodule, known cancer, new cancer, or suspicious, but unconfirmed for new cancer. Each mass was characterized as symptom-related or incidental.

RESULTS

At least one keyword was found in 2086 reports. Of these 706, 126 and 905 were known cancer cases, subcentimeter lung nodules, and non-cancerous cases, respectively. There were 251 confirmed new cancers and 98 suspicious cases which lacked adequate diagnostic workup. Depending on whether only definite or definite and suspicious cases were included together, the number of new cancer cases per 100 torso CT exams was 1.3 or 1.8, respectively. Gastrointestinal, lung, pancreaticobiliary, urinary, and gynecologic cancers were most common. Only 58 of the confirmed cases (23%) were deemed as incidental findings.

CONCLUSION

CT-diagnosis of new torso cancers was uncommon in our setting. Still, while extensive knowledge of cancer staging may not be necessary for ED radiologists, knowledge of the most common types of cancer including gastrointestinal, lung, pancreaticobiliary, urinary, and gynecologic cancers may improve sensitivity for these diagnoses and may expedite appropriate referrals for the newly diagnosed patients.

Emergency Radiology: Current Challenges and Preparing for Continued Growth

The escalation of imaging volumes in the emergency department and intensifying demands for rapid radiology results have increased the demand for emergency radiology. The provision of emergency radiology is essential for nearly all radiology practices, from the smallest to the largest. As our radiology specialty responds to the challenge posed by the triple threat of providing 24-7 coverage, high imaging volumes, and rapid turnaround time, various questions regarding emergency radiology have emerged, including its definition and scope, unique operational demands, quality and safety concerns, impact on physician well-being, and future directions. This article reviews the current challenges confronting the subspecialty of emergency radiology and offers insights into preparing for continued growth.

Using Body Mass Index and Bioelectric Impedance Analysis to Assess the Need for Positive Oral Contrast Agents Before Abdominopelvic CT

OBJECTIVE

The objective of this study was to determine whether body fat percentage, measured using a portable handheld bioelectric impedance analysis (BIA) device, and body mass index (BMI, weight in kilograms divided by the square of height in meters) can estimate the amount of intraabdominal and intrapelvic fat and thereby predict the need for oral contrast material before abdominopelvic CT.

SUBJECTS AND METHODS

A prospective, institutional review board-approved study consisting of 101 patients who presented to the emergency department of a level I trauma center was conducted between June 1, 2016, and July 19, 2016. A medical student calculated patients' BMI and obtained body fat measurements from a handheld BIA device. Three fellowship-trained and board-certified radiologists who were blinded to the collected data then assigned a score of 1-5 on the basis of the amount of intraabdominal and intrapelvic fat seen on CT images. A McNemar test was used to compare overall sensitivity and specificity of this method, and a weighted Fleiss kappa score was used to determine interobserver variability between the three radiologists.

RESULTS

Nearly all (97%) of the patients with high BMI (BMI ≥ 25) had sufficient amounts of intraabdominal and intrapelvic fat to allow delineation of anatomic structures without the use of oral contrast material. Of the patients with low BMI (BMI ≤ 21), 83% had inadequate amounts of fat to separate intraabdominal and intrapelvic structures. For patients with intermediate BMIs (21 < BMI < 25), BIA-determined body fat percentage of 30% or more can be used to predict whether a patient will have sufficient intraabdominal and intra-pelvic fat to obviate oral contrast material for CT.

CONCLUSION

Using BIA in addition to BMI accurately predicts amount of intraabdominal and intrapelvic fat. This information may help guide the decision to use oral contrast material in patients presenting for abdominopelvic CT.

Effects of eliminating routine use of oral contrast for computed tomography of the abdomen and pelvis: A pilot study

INTRODUCTION

Computed tomography (CT) of the abdomen and pelvis using only intravenous contrast has been shown to have a high degree of accuracy in evaluating abdominal pain. The aim of this study was to determine the effect on time to completion of study, time to radiologist read, and length of stay in the emergency department (ED) of implementing a protocol that stopped the routine use of oral contrast for CT of the abdomen and pelvis.

METHODS

This was a single-center, retrospective cohort study. All patients ≥18 years of age who presented to the ED and required a CT of the abdomen and pelvis during the hours 0700-1500 were included. There were two one-month study periods, before and after implementing a protocol that specified oral contrast should only be used for CT scans of the abdomen and pelvis if body mass index <25 kg/m² or age < 30 years, or if there was history of inflammatory bowel disease, gastrointestinal surgery, or suspected bowel malignancy.

RESULTS

During the pre- and post-implementation periods, there were 93 and 83 patients, respectively, with mean times to CT completion of 158 min and 135 min, representing a reduction of 23 min (15%). The mean lengths of stay in the pre- and post-implementation periods were 365 min and 336 min, a decrease of 29 min (8%).

CONCLUSION

A protocol without the routine use of oral contrast for CT of the abdomen and pelvis can result in improved time to completion and ED length of stay.

Removing barriers to early CT scanning in emergency and inpatient radiology

Over the last 5 years, several key trends have emerged which challenge the established paradigm of inpatient computed tomography (CT) services. Many widespread practices seem intuitive and have become dogmatic; these include pre-hydration for renal injury, holding medications which predispose to metabolic acidosis, steroid administration for allergies, oral contrast administration, and fasting. The efficacy and cost-benefit of all of these measures have been challenged by recent publications. A common theme has emerged, delaying inpatient CT scans worsens patient outcomes and increases cost.

CT for Acute Nontraumatic Abdominal Pain-Is Oral Contrast Really Required?

RATIONALE AND OBJECTIVES

This study aims to compare the diagnostic performance of abdominal computed tomography (CT) performed with and without oral contrast in patients presenting to the emergency department (ED) with acute nontraumatic abdominal pain.

MATERIALS AND METHODS

Between December 2013 and December 2014, 348 adult patients presenting to the ED of a large tertiary medical center with nontraumatic abdominal pain were evaluated. Exclusion criteria for the study were history of inflammatory bowel disease, recent abdominal operation and suspected renal colic, abdominal aortic aneurysm rupture, or intestinal obstruction. All patients underwent intravenous contrast-enhanced abdominal CT on a Philips Brilliance 64-slice scanner using a routine abdomen protocol. The study group included 174 patients who underwent abdominal CT scanning without oral contrast, recruited using convenience sampling. A control group of 174 patients was matched to the cohort groups' gender and age and underwent abdominal CT with oral contrast material during the same time period. The patients' medical records were reviewed for various clinical findings and for the final clinical diagnosis. The CT exams were initially reviewed by a senior attending radiologist to determine the exams' technical adequacy and to decide whether an additional scan with oral contrast was required. Two senior radiologists, blinded to the clinical diagnosis, later performed consensus reading to determine the contribution of oral contrast administration to the radiologists' diagnostic confidence and its influence on diagnosing various radiological findings.

RESULTS

Each group consisted of 82 men and 92 women. The average age of the two groups was 48 years. The main clinical diagnoses of the pathological examinations were appendicitis (17.5%), diverticulitis (10.9%), and colitis (5.2%). A normal CT examination was found in 34.8% of the patients. There was no significant difference between the groups regarding most of the clinical parameters that were examined. None of the examinations of all of the 174 study group patients was found to be technically inadequate, and therefore no patient had to undergo additional scanning to establish a diagnosis. The consensus reading of the senior radiologists determined that the lack of oral contrast was insignificant in 96.6% of the cases and that contrast material might have been useful in only 6 of 174 study group patients (3.4%). The radiologists found oral contrast to be helpful only in 8 of 174 control group patients (4.6%). There was no significant difference between the clinical and radiological diagnoses in both groups (study group, P = 0.261; control group, P = 0.075).

CONCLUSIONS

Our study shows that oral contrast is noncontributory to radiological diagnosis in most patients presenting to the ED with acute nontraumatic abdominal pain. These patients can therefore undergo abdominal CT scanning without oral contrast, with no effect on radiological diagnostic performance.

Source Identification and Source Control

Identifying sources of infection and establishing source control is an essential component of the workup and treatment of sepsis. Investigation with history, physical examination, laboratory tests, and imaging can in identifying sources of infection. All organ systems have the potential to develop sources of infection. However, there are inherent difficulties presented by some that require additional diligence, namely, urinalysis, chest radiographs, and intraabdominal infections. Interventions include administration of antibiotics and may require surgical or other specialist intervention. This is highlighted by the Surviving Sepsis Campaign with specific recommendations for time to antibiotics and expeditious time to surgical source control.

Small bowel diverticulitis: an imaging review of an uncommon entity

In this review, we discuss the clinical and radiologic findings of small bowel diverticulosis, which is infrequently encountered during practice and far less common than colonic diverticulosis. Small bowel diverticulosis can present with a range of emergent symptomatic complications including diverticulitis, perforation, or hemorrhage. Here, we focus on the clinical features, pathogenesis, radiologic findings, and treatment of small bowel diverticulitis. Although not routinely considered in the differential diagnosis of an acute abdomen, prospective radiologic diagnosis of small bowel diverticulitis is important and can lead to conservative treatment thus preventing unnecessary exploratory laparotomy.

Diagnosing acute appendicitis using a nonoral contrast CT protocol in patients with a BMI of less than 25

The objective of this study was to compare the accuracy for the diagnosis of appendicitis in patients presenting to the emergency department (ED) with acute, nontraumatic abdominal pain and a body mass index (BMI) of less than 25 before and after the implementation of a nonoral contrast computed tomography (CT) protocol with intravenous contrast. The IRB approved this HIPAA-compliant retrospective study; informed consent was waived. This study included 736 adult patients with a BMI of less than 25 presenting to our ED with acute, nontraumatic abdominal pain over two distinct 6-month time periods. An oral and intravenous contrast-enhanced protocol was utilized in the first cohort (group A), and an intravenous contrast-enhanced protocol without oral contrast was utilized in the second cohort (group B). Three abdominal fellowship-trained readers retrospectively reviewed all CT studies and electronic medical records, including surgical/pathology reports that served as reference standards. Group A consisted of 359 patients; 41 patients had surgically proven appendicitis. The sensitivity and specificity of the readers for diagnosing appendicitis in group A ranged from 95.2-100 and 98.1-99.5 %, respectively. Group B consisted of 372 patients; 39 had surgically proven appendicitis. The sensitivity and specificity of the readers in group B ranged from 92.0-100 and 98.6-100 %, respectively. There were no statistically significant differences in sensitivity or specificity for CT scans performed in groups A and B. In patients with a BMI of less than 25, an intravenous contrast-enhanced CT protocol without oral contrast demonstrates similar accuracy to an intravenous contrast-enhanced protocol with oral contrast for diagnosing acute appendicitis.

Considerations in Imaging Among Emergency Department Patients With Inflammatory Bowel Disease

Patients with inflammatory bowel disease who experience abdominal pain and gastrointestinal symptoms often seek care in the emergency department (ED). These patients commonly undergo abdominopelvic computed tomography (CT) as part of their evaluation, and the rate of imaging appears to be increasing without a corresponding increase in identification of clinically actionable findings or effect on disposition. Studies demonstrate that the yield of CT tends to be fairly high. Yet, because inflammatory bowel disease is often diagnosed at an early age, these patients are repeatedly imaged during their lifetime, a subset of whom accumulate high levels of ionizing radiation exposure, increasing their risk of cancer. This compounds an already increased risk of cancer in these patients because of inflammatory bowel disease alone. Lack of intimate knowledge of a patient's disease phenotype and disease progression contributes to uncertainty in distinguishing between an inflammatory exacerbation; a complication such as obstruction, abscess, perforation, fistula, or stricture; and a noninflammatory-bowel-disease-related condition. This uncertainty can lead to overuse of imaging with CT. Limited availability of and lack of awareness of alternate imaging modalities and strategies may prevent providers from pursuing strategies that avoid ionizing radiation. In this article, we review options for imaging inflammatory bowel disease patients in the ED and attempts undertaken to risk stratify these patients, and we discuss ways in which details of a patient's disease might guide imaging decisionmaking.

Enteric Distribution of Oral Contrast in Emergency Department Patients Undergoing Abdominal-Pelvic Computed Tomography

PURPOSE

The study sought to assess the gastrointestinal (GI) distribution of oral contrast (OC) among emergency department (ED) patients and determine if contrast reaches the terminal ileum or site of pathology to assist in diagnosis.

METHODS

Retrospectively, adults undergoing abdominal-pelvic computed tomography (APCT) in the ED at 2 hospitals were identified over a 3-month period. APCTs were reviewed for location of OC. Presence, site, type of bowel pathology, and prior gastrointestinal surgery were documented. When applicable, the site of bowel pathology was evaluated for the presence or absence of OC.

RESULTS

There were 1349 exams with mean age 50.5 years (range 18-97 years), 41% male, with 530 (39%) receiving OC. In 271 of 530 (51%), OC reached the terminal ileum (TI). Bowel pathology was present in 31% of cases (165 of 530). When bowel pathology was present, 47% (77 of 165) had OC present at the pathology site. The GI tract was divided into 4 anatomic segments: OC most frequently reached pathology in stomach and duodenum (84%), but was present less frequently at sites of pathology from jejunum to TI (35%), proximal colon (57%), and distal colon (28%). In only 84 of 530 OC cases (16%) did contrast extend from the stomach to distal colon. OC administration contributed to longer mean APCT order to final report of 0.5 hours and longer mean ED length of stay of 0.8 hours compared with all patients who received APCT.

CONCLUSIONS

Optimal OC distribution is not achieved in more than half of ED patients, raising questions about the continued use of OC in the ED.