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

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.

The utility of the abdominal series in the emergency setting: a retrospective review

PURPOSE

The abdominal series (AXR) remains a frequently ordered test in the emergency department (ED), despite existing literature questioning its utility. The aim of this study was to characterize the use of the AXR in the ED by quantifying how often it is ordered and the frequency of subsequent imaging. Additionally, a time estimate in ED associated with the AXR was quantified. We hypothesized that there would be a low clinical utility of the AXR, and long associated time period spent in the ED.

METHODS

A retrospective audit of AXRs performed in the ED from January to December 2019 was performed. The local picture archiving and communication system (PACS) and electronic medical record were used to collect the variables.

RESULTS

Of 701 AXRs, 438 (62.4%) were reported normal, and 263 (37.6%) were abnormal. A Chi Squared test showed that the two variables (abdominal series result and follow up imaging completion) were significantly related, with p < 0.001. However, the effect size was small (Nagelkerke R square = 0.022). The average time spent in the ED for these patients was 7.27 h, and the average time between the AXR being ordered and interpreted was 1.31 h.

CONCLUSION

The majority of AXRs were reported as normal. Our results showed that AXR had a statistically significant, but low clinically significant predictive ability on subsequent imaging ordering. This supports our hypothesis that the AXR is of low clinical utility with respect to the rate of ordering follow up imaging. The AXR also translated to a quantifiable time interval during the patient's stay in ED. Minimizing overuse of the AXR may result in a decrease in patient duration in the ED.

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.

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

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

Evaluation and disposition of older adults presenting to the emergency department with abdominal pain

BACKGROUND

Abdominal pain is the most common chief complaint in US emergency departments (EDs) among patients over 65, who are at high risk of mortality or incident disability after the ED encounter. We sought to characterize the evaluation, management, and disposition of older adults who present to the ED with abdominal pain.

METHODS

We performed a survey-weighted analysis of the National Hospital Ambulatory Medical Care Survey (NHAMCS), comparing older adults with a chief complaint of abdominal pain to those without. Visits from 2013 to 2017 to nationally representative EDs were included. We analyzed 81,509 visits to 1211 US EDs, which projects to 531,780,629 ED visits after survey weighting. We report the diagnostic testing, evaluation, management, additional reasons for visit, and disposition of ED visits.

RESULTS

Among older adults (≥65 years), 7% of ED visits were for abdominal pain. Older patients with abdominal pain had a lower probability of being triaged to the "Emergent" (ESI2) acuity on arrival (7.1% vs. 14.8%) yet were more likely to be admitted directly to the operating room than older adults without abdominal pain (3.6% vs. 0.8%), with no statistically significant differences in discharge home, death, or admission to critical care. Ultrasound or CT imaging was performed in 60% of older adults with abdominal pain. A minority (39%) of older patients with abdominal pain received an electrocardiogram (EKG).

CONCLUSIONS

Abdominal pain in older adults presenting to EDs is a serious condition yet is triaged to "emergent" acuity at half the rate of other conditions. Opportunities for improving diagnosis and management may exist. Further research is needed to examine whether improved recognition of abdominal pain as a syndromic presentation would improve patient outcomes.

Clinical utility of plain-film abdominal radiographs for inpatients outside standard working hours in a large university teaching hospital

INTRODUCTION

Plain film abdominal radiographs (PFAs) are frequently the initial investigation ordered for patients with abdominal symptoms. However, increasing use of emergency ultrasound and availability of emergency CT raises the question of whether PFA remains an appropriate first line investigation. We investigated the impact of out of hours (OOH) PFAs on inpatient management.

METHODS

All consecutive PFAs over an 8-week period were included to determine the impact on patient management. OOH was classified as from 5pm to 9am Monday to Friday, weekends and bank-holidays. PACS and hospital records were accessed to determine patient pathways. The institution is a tertiary referral centre with 850 acute beds and serves a population of 950,000.

RESULTS

A total of 758 consecutive PFAs were performed in total (58.3% male, mean age 58.1 (range 0-93)). 310 (40.9%) were requested from the emergency department (ED) and 382 (50.4%) were requested from wards. 160 (21.1%) met the criteria of OOH, of these 120 (72.2%) were from ED and 28 were on adult inpatients. Of these 28, none had a change in management based on the PFA result.

CONCLUSION

Our study suggests that OOH PFAs of inpatients are of limited clinical utility. These patients are exposed to extra radiation.

IMPLICATIONS FOR PRACTICE

We propose that OOH PFAs of inpatients should be questioned as a viable investigation due to the limited contribution they offer in managing patients, the deleterious effects they confer on the patient and the associated economic cost. Further studies are needed to assess if these results are generalizable to other large hospitals.

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.

[Identification and review of low-value clinical practices in General and Digestive Surgery]

INTRODUCTION

There are currently widespread clinical practices that, because they do not have been supported by available scientific evidence, are inappropriate for most patients. The objective of the present study was to identify and review these low-value clinical practices in General Surgery.

MATERIAL AND METHODS

A systematic review of the specialized databases and the published guidelines with identification of low-value practices in General Surgery was carried out. Of the low-value practices selected for a tertiary and university hospitals through the consensus of expert surgeons, those that do not provide clinical value were identified.

RESULTS

In a first search, 4,019 recommendations were found, of which 60 were selected because they were focused on General Surgery. After evaluation by the experts, a total of 29 clinical recommendations were selected to be implemented in a specialty service, which were divided into those corresponding to diagnostic processes (n=9), procedures and surgical technique (n=10) and of perioperative care and medication (n=10).

CONCLUSIONS

There is evidence in the literature of some clinical practices that provide little value in General Surgery. The changes referring to do-not-do these practices should be implemented in current clinical practice of this specialty.

Appropriateness of adult plain abdominal radiograph requesting in a regional Emergency Department

INTRODUCTION

Although commonly ordered, abdominal x-rays are thought to be overused and unhelpful in many emergency department patients. Our objectives were to evaluate the appropriateness of plain abdominal X-ray (AXR) requests in adult patients presenting to a Victorian regional emergency department (ED).

METHODS

A retrospective chart review was performed of all adult patients with a plain AXR requested by ED medical staff members in a regional healthcare centre in Victoria, Australia in 2016. Patient demographics, ED disposition and any further imaging results were extracted from the medical record. Indications for X-ray and clinician seniority were determined from the radiology request slips signed by the treating emergency doctor. Appropriateness of imaging was determined by comparing the indication for abdominal radiograph to local evidence-based guidelines.

RESULTS

One hundred and nine episodes of plain AXR requests met the inclusion criteria. Of these, 40 were considered inappropriate according to clinical guidelines. Overall, 36% (39/109) had normal or non-specific findings and 42% (46/109) demonstrated faecal loading, while 22% (24/109) identified pathology. Thirty-three patients had further imaging, mostly with computed tomography (CT). Junior staff members were responsible for most of the AXR requests.

CONCLUSION

In our regional hospital ED, over one third of AXRs requested for adult patients were inappropriate according to clinical guidelines. AXRs have a low diagnostic yield and frequently do not reduce the need for further imaging. The use of a clinical practice guideline and education of junior medical staff may increase the appropriate use of plain AXRs in the regional ED setting.

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.

Implementing a guideline for the request of chest and abdominal x-rays in nontrauma pathologic conditions in an ED

OBJECTIVE

The purpose of this study is to evaluate the impact of implementing a guideline for the request of chest and abdominal x-ray to reduce unnecessary examinations in nontraumatic pathologic conditions.

METHODS

We selected most common chief complaints in nontrauma pathologic conditions at emergency department (ED) and reviewed the available literature to determine the effectiveness of chest and abdominal x-rays for each one. We developed a guideline for the request of x-rays according to the chief complaints, including modulating factors derived from initial clinical evaluation. Guideline implementation was achieved through a multifaceted educational intervention. To evaluate its impact, both in the absolute number and in the adequateness of x-ray requests, we compared data obtained from patients coming to the ED at 2 different time points, October 2004 (preimplementation) and October 2005 (postimplementation).

RESULTS

In the preimplementation period, 52.7% of the patients underwent chest x-rays and 28.0% abdominal x-rays, whereas in the postimplementation period, the proportions decreased to 41.8% and 13.5%, respectively (P<.001 in both cases). The adequateness of x-ray requests improved, as shown by a reduction in the number of inappropriate x-ray examinations (absolute error reduction of 9.2%; 95% confidence interval, 7.7-10.8, and relative error reduction of 59.8%; 95% confidence interval, 49.7-69.8).

CONCLUSIONS

In our ED, implementing a specifically designed guideline for the request of chest and abdominal x-ray examinations in nontraumatic pathologic conditions reduced the absolute number of requests and the rate of inappropriate requests.

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

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

Derivation of a clinical guideline for the assessment of nonspecific abdominal pain: the Guideline for Abdominal Pain in the ED Setting (GAPEDS) Phase 1 Study

OBJECTIVE

The purpose of this study was to identify a clinical guideline for the evaluation of nonspecific abdominal pain (NSAP) using history, physical examination, laboratory analysis, acute abdominal series (AAS) radiographs, and nonenhanced helical computed tomography (NHCT) clinical predictor variables (CPVs).

SETTING

The setting of this study was at an urban emergency department (ED) with 70,000 yearly visits.

METHODS

This is an institutional review board-approved, prospective, observational study. The primary outcome variable was urgent intervention (UI), defined as a diagnosis requiring surgical or medical treatment to prevent death or major morbidity. Subjects underwent prompted history, physical, laboratory studies, AAS, and NHCT and were followed up to 6 months for ultimate diagnosis and outcome. CPVs were subjected to classification and regression tree analysis.

RESULTS

One hundred sixty-five subjects were analyzed. Thirteen percent of subjects required UI within 24 hours of presentation; an additional 34% underwent elective interventions that mitigated morbidity or mortality. Four guideline models were generated. Model 1 consisted of history and physical, with a sensitivity of 25%, a specificity of 92%, a positive likelihood ratio of 3.17, and a negative likelihood ratio of 0.81. Model 2 consisted of model 1 with laboratory, with a sensitivity of 39%, a specificity of 88%, a positive likelihood ratio of 3.25, and a negative likelihood ratio of 0.69. Model 3 consisted of model 2 with AAS, with a sensitivity of 56%, a specificity of 81%, a positive likelihood ratio of 2.94, and a negative likelihood ratio of 0.54. Model 4 comprised all inputs, including NHCT, with a sensitivity of 92%, a specificity of 90%, a positive likelihood ratio of 9.2, and a negative likelihood ratio of 0.089. NHCT was the single most accurate CPV for UI.

CONCLUSIONS

No clinical guideline was identified exclusive of NHCT that possessed adequate sensitivity for exclusion of UI. NHCT is a rational choice for decision support in the evaluation of NSAP and is likely the single most useful diagnostic adjunct available to augment the clinical evaluation.

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.

Does reporting of plain chest radiographs affect the immediate management of patients admitted to a medical assessment unit?

AIM

The purpose of our study was to investigate whether reporting of plain chest radiographs affects immediate management of patients admitted to a medical assessment unit.

MATERIALS AND METHODS

During a 3 month period we prospectively evaluated 200 patients who had a plain chest radiograph on admission. After the post on-call ward round, an independent medical specialist registrar reviewed the notes, retrieving relevant clinical details. The plain chest films were reported independently by a trainee radiologist and consultant, reaching a consensus report.

RESULTS

There was 93% agreement between trainee and consultant radiologists (95% CI=89-96%). Seventy percent had documented reports by the on-call medical team. There was disagreement between radiology and medical reports in 49% of reported films (95% CI=40-57%). The radiologist's report led to a direct change in the immediate management of 22 patients (11%).

CONCLUSION

Only 70% of films had documented reports in the clinical notes despite this being a legal requirement. Radiology reporting does cause a direct change in patient management. Chest radiographs of patients admitted to a medical admissions unit should be reported by a radiologist with the minimum of delay.