Abdominal radiography in the emergency department: a prospective analysis

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.

Diagnostic Yield of Abdominal Radiographs in the Pediatric Emergency Department

BACKGROUND AND OBJECTIVES

Abdominal radiographs (ARs) are commonly used in the pediatric emergency department (PED). Their low diagnostic accuracy leads to overuse, excess radiation exposure, and increased resource usage. This study aims to assess the diagnostic yield of ARs in the evaluation of intraabdominal pathology in the PED.

METHODS

Retrospective, cross-sectional study of patients aged 0 to 18 years with an AR who visited the PED between 2017 and 2019. Diagnostic yield was analyzed with sensitivity, specificity, positive predictive value, negative predictive value (NPV), and likelihood ratio.

RESULTS

A total of 4288 ARs were identified, with a rate of 6%. The overall abnormal AR rate was 31%. The incidences of an abnormal AR in abdominal pain, vomiting, and constipation were 26%, 37%, and 50%, respectively. There was a 13% rate of clinically significant diagnoses. The AR diagnostic yield showed 44% sensitivity, 70% specificity, 17% positive predictive value, and 90% NPV ( P < 0.05). Unadjusted odds ratio analysis of positive AR and abdominal pain, vomiting, and constipation revealed an odds ratio of 0.68 (95% confidence interval [CI], 0.63-0.75), 1.22 (95% CI, 1.06-1.39), and 1.72 (95% CI, 1.54-1.91), respectively.

CONCLUSIONS

There is a low rate of intraabdominal pathologic processes that an AR can identify. A normal AR does not change patient management, nor does it reduce the need for further radiologic imaging. Despite a good NPV, the AR is not a useful diagnostic tool in the PED because of its limited ability to rule in or rule out clinically significant diagnoses.

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.

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.

Examining Clinical Utility of Imaging for Inpatient Palliative Care

BACKGROUND

Medicine in the final months of life is increasingly interventional, both in the manner by which life may be prolonged and symptoms may be reduced. Radiology is frequently utilized to provide diagnostic clarity and improve symptom control. As with any intervention, examining the benefit and potential harms of a procedure is required to establish its role in ongoing clinical care.

METHODS

This retrospective cohort study involved patients admitted to an inpatient palliative care unit between October 2013 and September 2014. Data were collected using clinical databases manually searched by the researchers.

RESULTS

Of 388 admissions, there were a total of 154 imaging events completed in 85 patients. Patients who had imaging performed had longer mean length of stays, more likely to be discharged home, and male. Very few imaging events (4%) occurred in the 3 days prior to death and none on the day of death. In total, 43% of imaging confirmed the clinical suspicion and management changed 42% of times. Limbs X-rays and computed tomography brain had low rates of confirming clinical suspicion (21% and 17%) and changing management (21% and 33%). There were a total of 7 complications resulting from imaging, the majority due to interventional procedures.

CONCLUSION

The use of imaging in inpatient palliative care seems to be of substantive utility, prompting alterations in management in >40% of instances. The majority of imaging occurred prior to the terminal phase of the disease and with few complications.

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.

The role of plain radiographs in patients with acute abdominal pain at the ED

OBJECTIVE

The purpose of this study was to evaluate the added value of plain radiographs on top of clinical assessment in unselected patients presenting with acute abdominal pain at the emergency department (ED).

METHODS

In a multicenter prospective trial, patients with abdominal pain more than 2 hours and less than 5 days presented at the ED were evaluated clinically, and a diagnosis was made by the treating physician. Subsequently, all patients underwent supine abdominal and upright chest radiographs, after which the diagnosis was reassessed by the treating physician. A final (reference) diagnosis was assigned by an expert panel. The number of changes in the primary diagnosis, as well as the accuracy of these changes, was calculated. Changes in the level of confidence were evaluated for unchanged diagnoses.

RESULTS

Between March 2005 and November 2006, 1021 patients, 55% female, mean age 47 years (range, 19-94 years), were included. In 117 of 1021 patients, the diagnosis changed after plain radiographs, and this change was correct in 39 patients (22% of changed diagnoses and 4% of total study population). Overall, the clinical diagnosis was correct in 502 (49%) patients. The diagnosis after evaluation of the radiographs was correct in 514 (50%) patients, a nonsignificant difference (P = .14). In 65% of patients with unchanged diagnosis before and after plain radiography, the level of confidence of that diagnosis did not change either.

CONCLUSION

The added value of plain radiographs is too limited to advocate their routine use in the diagnostic workup of patients with acute abdominal pain, because few diagnoses change and the level of confidence were mostly not affected.

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.

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.

Acute nontraumatic abdominal pain in adult patients: abdominal radiography compared with CT evaluation

PURPOSE

To compare the diagnostic yield of abdominal radiography with that of computed tomography (CT) in adult patients presenting to the emergency department with nontraumatic abdominal pain.

MATERIALS AND METHODS

Records of 1,000 consecutive patients presenting to the emergency department with acute abdominal pain from April to June 1998 were retrospectively reviewed. A total of 871 patients underwent abdominal radiography, and 188 underwent abdominal CT. The report interpretations of the abdominal radiographs and CT scans were divided into normal, nonspecific, and abnormal categories. Final discharge diagnoses were compared with the interpretations of the imaging examination results, and sensitivities and specificities of each modality were calculated and compared.

RESULTS

Interpretation of abdominal radiographs was nonspecific in 588 (68%) of 871 patients, normal in 200 (23%), and abnormal in 83 (10%). The highest sensitivity of abdominal radiography was 90% for intraabdominal foreign body and 49% for bowel obstruction. Abdominal radiography had 0% sensitivity for appendicitis, pyelonephritis, pancreatitis, and diverticulitis. Sensitivities of abdominal CT were highest for bowel obstruction and urolithiasis at 75% and 68%, respectively.

CONCLUSION

Abdominal radiographs are not sensitive in the evaluation of adult patients presenting to the emergency department with nontraumatic abdominal pain.

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.

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.

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.

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.

Efficacy of plain abdominal radiography in patients with gastrointestinal bleeding

To assess the value of plain abdominal radiography in cases of gastrointestinal hemorrhage, the records of 100 such consecutive patients were reviewed. Seventy-eight of the patients had presented to the emergency department, and 22 were inpatients. The radiologic and clinical records were scrutinized to determine the actual effect of the radiologic examination on management of the patient. Three patients had pneumoperitoneum attributed to bowel perforation, and two had confirmed bowel obstruction. In each, the clinical findings suggested the diagnosis. We found no instance of silent gastrointestinal bleeding in which plain radiography contributed important diagnostic information. We conclude that gastrointestinal bleeding is not, in itself, a valid indication for abdominal radiography.

Emphysematous pyelonephritis: an emergency indication for the plain abdominal radiograph

We report the case of a 59-year-old diabetic woman with emphysematous pyelonephritis. The patient presented with nausea, vomiting, and right flank pain of three days duration. The diagnosis was established by a plain abdominal radiograph in the emergency department. Aggressive rehydration, control of diabetes, broad-spectrum antibiotic therapy, and early right nephrectomy resulted in rapid clinical improvement. Emphysematous pyelonephritis is rare and often fatal. Survival depends on early diagnosis and aggressive combined medical and surgical management.

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.