Rationalising abdominal radiography in the accident and emergency department

Current abdominal X-rays practice in accident and emergency

INTRODUCTION

Previous literature reviews revealed that abdominal X-rays (AXR) performed for the accident and emergency department (A&E), had low sensitivity, high further imaging and non-alignment rate to the Royal College of Radiologists (RCR) guidelines. A study was performed to investigate the current practice with the aim of making recommendations to improve practice, which can reduce patients' radiation exposures, while can re-routing resources to other priorities.

METHODS

A study was performed in one of the UK's largest A&Es, in accordance with the RCR guidelines. All the AXR requests from A&E, regardless of the patient's age, within a 28-day period, were retrospectively assessed. Non-A&E patients and abandoned examinations due to uncooperative patients were excluded. The total number of AXR requests received by the A&E imaging department was 169, with 28/169 falling into the exclusion criteria.

RESULTS

Of the 141 included requests, five unjustified requests were correctly rejected. The remaining 136 requests were accepted and performed, though only 115/136 (84.6%) of these were justified. The most common justified and unjustified indications were obstruction and renal stones, respectively. Only 4% of reported AXR had pathological abnormalities, while 45/136 patients had further imaging.

CONCLUSIONS

The small proportion of significant findings echoed previous studies, suggesting an AXR overuse. Over 80% of non-compliant requests were performed, and awareness of the justification guidelines can be increased by clinical governance, posters, or an algorithm previously presented. The 32.4% further imaging rate recorded in this study, as opposed to the 73.7% reported in previous literature, merits attention.

IMPLICATIONS TO PRACTICE

Stopping the overuse of AXR can minimise the radiation dose received and relieve the mounting pressure in imaging and reporting, which can serve other patients who would benefit from the services otherwise.

Effective dose and image quality for different patient sizes during AP upper abdominal radiography: A phantom study

INTRODUCTION

Undertaking medical imaging examinations on obese patients can present practical challenges. Choosing optimal imaging protocols can be difficult, especially when promoting the ALARA principle. The aim of this study was to assess the effects of increasing body part thickness on image quality (IQ) and effective dose (ED) during upper abdominal radiography. A secondary aim was to determine the optimum exposure settings for larger sized patients.

METHODS

Underweight, standard, overweight and obese abdomen sizes were simulated using an anthropomorphic upper abdomen phantom, without and with additional fat layers (6, 10 and 16 cm). Phantoms were imaged using a variety of tube potentials (70-110 kVp), automatic exposure control (AEC) and a source-to-image distance of 120 cm. IQ was assessed visually using a relative visual grading analysis (VGA) method. Radiation dose was evaluated by calculating the ED using the Monte Carlo PCXMC 2.0 computer program.

RESULTS

IQ values showed a statistical reduction (p = 0.006) with increasing phantom size across all examined tube potentials. The highest IQ scores (3.3, 2.8, 2.5 and 2.2, respectively) were obtained at 70/75 kVp for all phantom thicknesses. As tube potential increased the IQ was also shown to decrease. ED showed a statistically significant increase (p < 0.001) with increasing phantom thicknesses.

CONCLUSION

Higher EDs were evident when applying lower tube potentials. Using an AEC with high tube potentials (105/110 kVp) can lead to a considerable decrease in ED with acceptable IQ when undertaking upper abdomen radiography on patients with large body part thicknesses.

IMPLICATION FOR PRACTICE

Applying higher values of tube potentials for patients who have a thicker abdomen can lead to decreased ED.

Knowledge translation: Radiographers compared to other healthcare professionals

OBJECTIVES

This narrative review examines the current status of evidence-based practice and knowledge translation in diagnostic radiography. It explores knowledge translation efforts in the allied health professions aimed at systematically implementing evidence-based practice and suggests ways that these may be applied within diagnostic radiography.

KEY FINDINGS

Knowledge translation in diagnostic radiography is in its infancy with numerous examples of key findings of rigorous studies not implemented in practice. Utilising frameworks, models and theories to systematically translate knowledge into evidence-based practice has been shown to be effective in other allied health professions. Whilst few studies in diagnostic radiography report utilising these systematic approaches to implementing evidence-based practice, those that do, show promising results. Attitudes towards evidence-based practice within diagnostic radiography are becoming more positive and it is important to use this positive shift in attitudes to create real evidence-based change in the profession.

CONCLUSION

The potential benefits of systematically translating knowledge into evidence-based practice in diagnostic radiography are wide reaching with positive implications for our patients, the profession and wider community. Leaders at all levels of radiography must work towards implementing evidence-based practice in their daily work.

IMPLICATIONS FOR PRACTICE

Systematic approaches to knowledge translation should be adopted and reported in diagnostic radiography in order to more effectively translate knowledge into evidence-based practice.

Exploring the evidence-practice gap in the use of plain radiography for acute abdominal pain and intestinal obstruction: a systematic review and meta-analysis

AIM

Previous studies, some dating back several decades, have recommended that the use of plain abdominal radiography should be curbed, particularly with the growth of more accurate imaging modalities. However, evidence from referral data suggests that plain abdominal radiography continues to be a commonly requested examination. The aim of this review was to explore the gap between evidence and practice by re-examining the evidence using a robust methodology, investigating the diagnostic accuracy of plain abdominal radiography.

METHODS

Studies were identified from electronic databases and reference lists. Eligible studies provided data as to the sensitivity and specificity of plain abdominal radiography for either acute abdominal pain (Group A) or suspected intestinal obstruction (Group B). Version 2 of the Quality Assessment of Diagnostic Accuracy Studies was used to assess the quality of studies and hierarchical summary receiver operator characteristic curves and coupled forest plots were generated.

RESULTS

Four studies evaluated plain abdominal radiography for acute abdominal pain (Group A) and 10 for suspected intestinal obstruction (Group B). Two studies investigated both presentations and were included in both groups. Methodological quality of studies was moderately high, though incorporation bias was a common limitation. Sensitivity for Group A studies ranged from 30 to 46%, with specificity from 75 to 88%. For Group B, the range of sensitivity was 48 to 96% and specificity from 50 to 100%.

CONCLUSION

The results suggest that use of plain abdominal radiography could be substantially reduced, particularly for patients with undifferentiated acute abdominal pain. While some guidelines exist, there is sound argument for clinical decision rules for abdominal imaging to inform evidence-based clinical decision-making and radiology referrals.

The value of the erect abdominal radiograph for the diagnosis of mechanical bowel obstruction and paralytic ileus in adults presenting with acute abdominal pain

INTRODUCTION

There is discord on the value of the erect abdominal radiograph for diagnosing acute abdominal pathologies. The erect radiograph can be uncomfortable for patients in pain and increases patient radiation dose.

AIM

To determine if including the erect abdominal radiograph in plain abdominal radiography (PAR) improved diagnostic accuracy for identifying mechanical bowel obstruction and/or paralytic ileus in adults presenting with acute abdominal pain.

METHODS

PAR of 40 consecutive adults presenting with suspected bowel obstruction or paralytic ileus was retrospectively sampled and independently reviewed by two emergency department (ED) consultants and two radiology consultants for bowel obstruction and paralytic ileus across two sessions. In session 1, the assessors assessed the supine abdominal radiographs (PAR 1) and clinical details in a randomised order, and session 2, at least 6 weeks later, they assessed the supine and erect radiographs (PAR 2) and clinical details of the randomly re-ordered cases. Computed tomography was the reference standard. Pair-wise comparisons of receiver operating characteristic curves were calculated to assess for significant differences in participants' diagnostic accuracy using MedCalc 16.4.3.

RESULTS

Average sensitivity, specificity and area under the receiver operating characteristic curves (AUROC) were 69.7%, 61.0% and 0.642 for PAR 1, respectively, and 80.0%, 53.4% and 0.632 for PAR 2 respectively. For AUROC there were no significant differences (P > 0.05) between PAR 1 and PAR 2. Intra-rater and inter-rater agreement improved in PAR 2.

CONCLUSION

There was no statistically significant improvement in diagnostic accuracy when including the erect radiograph in PAR for the acute abdomen.

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.

Plain abdominal radiography in acute abdominal pain; past, present, and future

Several studies have demonstrated that a diagnosis based solely on a patient’s medical history, physical examination, and laboratory tests is not reliable enough, despite the fact that these aspects are essential parts of the workup of a patient presenting with acute abdominal pain. Traditionally, imaging workup starts with abdominal radiography. However, numerous studies have demonstrated low sensitivity and accuracy for plain abdominal radiography in the evaluation of acute abdominal pain as well as various specific diseases such as perforated viscus, bowel obstruction, ingested foreign body, and ureteral stones. Computed tomography, and in particular computed tomography after negative ultrasonography, provides a better workup than plain abdominal radiography alone. The benefits of computed tomography lie in decision-making for management, planning of a surgical strategy, and possibly even avoidance of negative laparotomies. Based on abundant available evidence, major advances in diagnostic imaging, and changes in the management of certain diseases, we can conclude that there is no place for plain abdominal radiography in the workup of adult patients with acute abdominal pain presenting in the emergency department in current practice.

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.

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.

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.

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.

Plain abdominal radiographs and abdominal CT scans for nontraumatic abdominal pain--added value?

We conducted a retrospective descriptive study to determine the value of plain abdominal radiographs in emergency department (ED) patients also receiving abdominal computed tomography scans (CT) for the evaluation of nontraumatic abdominal, back and flank pain (NTAP). Cases were identified through radiology log books. Medical records and radiology reports were reviewed to determine whether the CT confirmed the findings of the plain abdominal radiographs, and whether the clinical course confirmed the results of either. Test characteristics for the plain abdominal radiograph and for the CT, using the clinical course including subsequent invasive procedures as the gold standard, were calculated. Of 177 patients who received CTs, 97 (55%) also received plain abdominal radiographs. Among the 74 patients who were admitted to the hospital and had complete data, the sensitivity and specificity for the plain abdominal radiographs were .43 and .75 respectively, compared to .91 and .94 for the CT scan (P(sens.) < .05, P(spec.) < .05). In 4 patients (5%), both studies failed to identify pathology shown in a subsequent procedure. In ED patients with NTAP, the plain abdominal radiograph may have some value as a screening tool; however, in patients in whom a CT is likely to be ordered anyway, a plain abdominal radiograph is unhelpful and often misleading.

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.

Colonic pseudo-obstruction: value of prone lateral view of the rectum

BACKGROUND

Collection of fluid within the rectum of patients with gas-distended bowel can simulate as obstructive lesion.

METHODS

In 12 patients with suspected distal colonic obstruction on plain radiographs, we obtained 2 additional films comprising a right lateral decubitus view of the abdomen followed by a prone lateral view of the pelvis.

RESULTS

Significant gaseous distension of the rectum was achieved in 75% of the 8 patients with pseudo-obstruction. Gaseous filling of the rectum did not occur in any patient with a structural obstructive lesion.

CONCLUSIONS

In the appropriate clinical setting this approach could exclude the presence of obstruction and avoid unnecessary barium enemas in the majority of patients with colonic pseudo-obstruction.

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.

Radiological investigation in acute diverticulitis

Optimal management of acute sigmoid diverticulitis depends on evaluation of the severity of the inflammatory process, in which radiological investigation is a useful but probably underutilized adjunct to clinical assessment. Plain abdominal radiography shows abnormalities in 30-50 per cent of patients but these tend to be non-specific and more accurate information is obtainable from a contrast enema. Although the quality of images produced by a water-soluble contrast agent is inferior to that with barium, the former is less hazardous in the presence of perforation and provides sufficient information to permit rational management decisions to be made. Ultrasonography and computed tomography (CT) are particularly useful in visualizing abscesses. They may be helpful in following the progression or resolution of suppuration and in guiding percutaneous aspiration when appropriate. Despite early reports to the contrary, CT is no more specific than a contrast enema in the diagnosis of acute diverticulitis. Radionuclide scans have little role in the routine assessment of acute diverticulitis and magnetic resonance imaging has not been adequately evaluated. Water-soluble contrast enema is safe, widely available and probably the most useful early supplementary investigation.

Reducing the use of plain abdominal radiographs in an emergency department

Plain abdominal radiographs are ordered frequently in emergency departments. Previous studies have shown that these radiographs are often requested inappropriately with little likelihood of producing useful information. This study shows that the overall number can be reduced significantly, with little risk to patients, when clear guide-lines are applied.

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.

Plain abdominal radiographs and acute abdominal pain

The records of all (5080) patients presenting to a district general hospital with acute abdominal pain over a 4-year period were examined. The contribution of abdominal radiographs to the assessment of patients with suspected appendicitis, urinary tract infection, and non-specific abdominal pain was evaluated, these conditions accounting for 48 per cent of patients with abdominal pain and 32 per cent of those with abdominal radiographs. Any positive information from these radiographs was less likely to be helpful than incidental or inconsistent (and hence potentially misleading). Because of this high 'false positive' rate it is suggested that if the initial diagnosis is suspected appendicitis, urinary tract infection, or non-specific abdominal pain, there is little value in the routine use of abdominal radiographs.

Can more efficient use be made of x ray examinations in the accident and emergency department?

Increasing workloads in our radiology department prompted a study of casualty officers' use of x ray examinations, of which there were 5463 in the period. While casualty officers were in post referrals for x ray examination did not become more selective, but skills in interpreting films improved. Overall, 4.9% of trauma radiographs were misinterpreted, but this fell from 7.1% to 2.9% during tenure of post. One in four errors was clinically important. Clinical guidelines for selective radiography produced a significant and sustained reduction in the number of x ray examinations requested by the department. Analysis of one common injury indicated that the quality of patient care was not adversely affected. The number of x ray examinations carried out in the accident and emergency department can be reduced by using guidelines, and this does not compromise the quality of patient care. Appreciable savings may be made in patients' waiting times and radiodiagnostic expenditure.

Are we taught how to use a radiology department as medical students?

Thirty-six final year medical students and 28 senior house officers answered a questionnaire designed to evaluate their efficacy in requesting common radiological procedures and their knowledge of what the patient experiences during the investigation. Both groups revealed a significant degree of ignorance, though the house officers were better informed than the students. The need for undergraduate teaching in radiology, particularly in the role of diagnostic radiology in clinical management is discussed.

'Hunt the thimble': a study of the radiology of ingested foreign bodies

The role of radiology in the management of patients with a history of ingested foreign bodies is reviewed in a retrospective study over a 2-year period in a Children's Hospital. If radiography was confined to those children who have a clinical history suggestive of foreign body impaction in the oesophagus, a foreign body aspiration or having swallowed a button battery, the work load and unnecessary radiation arising from this practice could be halved. This study demonstrates another misuse of radiological services.

Indications for plain abdominal radiography in the emergency department

Despite the proliferation of new imaging methods, plain abdominal radiographs remain the first films ordered in a significant number of emergency department patients. Several small studies suggest that abdominal films are ordered unnecessarily. Over-ordering takes two forms: inappropriate indications and poor choice of the number and/or types of views ordered. Criteria for obtaining plain abdominal radiographs are suggested based on the likelihood of radiographic findings and the probability of a change in management resulting from the findings. Benefit versus risk in fertile women is considered. Recommendations are made for the selection of views based on clinical suspicion and initial film review. There is a need for studies using larger sample sizes to confirm these conclusions.

Evaluation of the plain abdominal X-ray in the acute abdomen

The prognostic value of an erect and supine abdominal X-ray was studied prospectively in 97 patients with an acute abdomen. Although 64 (66%) of the radiographs showed an abnormality, the surgical registrar altered his clinical diagnosis on only seven occasions and changed his management on four. A consultant radiologist was the most accurate at reporting the X-rays even without seeing the patient, whilst junior surgical and radiological staff were as accurate as each other. A surgical registrar, however, was more accurate than junior radiologists in making a diagnosis. The investigation was of immediate clinical value in only 4% of the patients, and its use could probably be limited without detriment to patients.

The erect abdominal radiograph in the acute abdomen: should its routine use be abandoned?

The value of erect and supine abdominal radiographs and erect chest radiographs was analysed prospectively in 102 consecutive patients admitted to hospital with acute abdominal symptoms. The radiographs were reported on initially by junior surgeons of the admitting team, special note being made of the value of the erect abdominal radiograph over the combination of the supine abdominal radiograph and erect chest radiograph. On the basis of information obtained from the erect abdominal radiograph alone no changes in patient management were recorded. A consultant radiologist reported on the same radiographs at a later date. In five cases the erect abdominal radiograph was thought to have contributed useful or additional information, although in four of these cases abnormal features were visible in the supine film. In three of the five cases important but subtle information was missed by junior surgeons. In five of the 102 patients information obtained from the erect abdominal radiograph was potentially misleading. The small yield of positive information, potentially misleading features, and lack of effect on surgical management suggest that the routine use of the erect abdominal radiograph in the acute abdomen should be abandoned.

Unnecessary intravenous urography in young women with recurrent urinary tract infections

Intravenous urography was evaluated in 201 young women with recurrent urinary tract infections. In 118 of 121 patients with uncomplicated recurrent infections the intravenous urogram (IVU) was normal. Insignificant abnormalities were found in only three cases. It is concluded that, in order to avoid unnecessary investigation, an additional risk indication should be present to warrant an IVU. The additional risk indications have been identified.

Abdominal radiography in the emergency department: a prospective analysis

We present a prospective analysis of 100 consecutive abdominal radiographs of 96 emergency patients who were referred to radiology with a variety of abdominal complaints. In patients with diffuse, nonspecific abdominal pain, nausea, vomiting, or gastrointestinal bleeding, 98% of the radiographs were negative or had positive findings which were unrelated to the current clinical problem. Ninety-three percent of the positive radiographs that were related to the acute problem occurred in patients with renal colic; hematuria; ingestion of foreign bodies; previously known surgical conditions, such as incarcerated hernias; intra-abdominal metastatic carcinoma; fecal impaction; or true acute abdominal syndromes.