Advertisement

Delays in imaging diagnosis of acute abdominal pain in the emergency setting

      Highlights

      • Prompt radiology evaluation of acute nontraumatic abdominal pain leads to improved patient outcomes
      • Abdominal radiographs are less accurate than CT in diagnosing common causes of acute abdominal pain
      • Oral contrast does not provide significant diagnostic benefit to CT abdomen and pelvis but takes longer to perform
      • Contrast-induced acute kidney injury risk is overestimated due to results from outdated research studies
      • Reviewing up to date imaging and contrast guidelines can help limit delays in ordering the proper imaging study

      Abstract

      Acute abdominal pain is a common cause of ED visits and often requires imaging to identify a specific diagnosis. Prompt and appropriate imaging plays a crucial role in patient management and leads to improved patient outcomes, decreased hospital stay, and improved ED workflow. There are many cases of abdominal pain in the ED with delayed diagnosis and management secondary to a combination of institutional policies and knowledge deficits in current imaging guidelines. Inappropriate use of abdominal radiographs, use of oral contrast for CT abdomen and pelvis, and concern for iodinated contrast-induced acute kidney injury are three of the more commonly encountered roadblocks to prompt imaging diagnosis of abdominal pain. The purpose of this review is to discuss why these potential causes of delayed diagnosis occur and how radiologists can help improve both imaging and ED workflow by utilizing the most up-to-date imaging guidelines such the American College of Radiology (ACR) Appropriateness Criteria and ACR Manual on Contrast Media to assist clinicians working in the emergency setting.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Clinical Imaging
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Gans Sarah L.
        Plain abdominal radiography in acute abdominal pain; past, present, and future.
        Int. J. Gen. Med. 2012; 5 (annual) (pp. 525+. Gale Academic OneFile, link.gale.com/apps/doc/A344279390/AONE?u=columbiau&sid=summon&xid=797aff25. Accessed 20 Jan. 2022)
        • Mindelzun R.E.
        • Jeffrey R.B.
        Unenhanced helical CT for evaluating acute abdominal pain: a little more cost, a lot more information.
        Radiology. 1997; 205: 43-45
        • Powers R.D.
        • Guertler A.T.
        Abdominal pain in the ED: stability and change over 20 years.
        Am J Emerg Med. 1995 May; 13: 301-303
        • Rubin G.D.
        Costing in radiology and health care: rationale, relativity, rudiments, and realities.
        Radiology. 2017 Feb; 282: 333-347
        • Alabousi A.
        • Patlas M.N.
        • Sne N.
        • Katz D.S.
        Is oral contrast necessary for multidetector computed tomography imaging of patients with acute abdominal pain?.
        Can Assoc Radiol J. 2015 Nov 1; 66: 318-322
        • Nguyen L.K.
        • Wong D.D.
        • Fatovich D.M.
        • Yeung J.M.
        • Persaud J.
        • Wood C.J.
        • de Vos D.
        • Mendelson R.M.
        Low-dose computed tomography versus plain abdominal radiography in the investigation of an acute abdomen.
        ANZ J Surg. 2012; 82: 36-41
        • Garcia-Valdecasas J.C.
        • Llovera J.M.
        • DeLacy A.M.
        • Reverter J.C.
        • Grande L.
        • Fuster J.
        • Cugat E.
        • Visa J.
        • Pera C.
        Obstructing colorectal carcinomas.
        Dis Colon Rectum. 1991 Sep; 34: 759-762
        • Thompson W.M.
        • Kilani R.K.
        • Smith B.B.
        • Thomas J.
        • Jaffe T.A.
        • Delong D.M.
        • Paulson E.K.
        Accuracy of abdominal radiography in acute small-bowel obstruction: does reviewer experience matter?.
        Am J Roentgenol. 2007 Mar; 188: W233-W238
        • Ahn S.H.
        • Mayo-Smith W.W.
        • Murphy B.L.
        • Reinert S.E.
        • Cronan J.J.
        Acute nontraumatic abdominal pain in adult patients: abdominal radiography compared with CT evaluation.
        Radiology. 2002 Oct; 225: 159-164
        • Leung A.M.
        • Vu H.
        Factors predicting need for and delay in surgery in small bowel obstruction.
        Am Surg. 2012 Apr; 78: 403-407
        • Hilton D.
        • Iman N.
        • Burke G.J.
        • Moore A.
        • O'Mara G.
        • Signorini D.
        • Lyons D.
        • Banerjee A.K.
        • Clinch D.
        Absence of abdominal pain in older persons with endoscopic ulcers: a prospective study.
        Am J Gastroenterol. 2001 Feb; 96: 380-384
        • Thorsen K.
        • Søreide J.A.
        • Kvaløy J.T.
        • Glomsaker T.
        • Søreide K.
        Epidemiology of perforated peptic ulcer: age- and gender-adjusted analysis of incidence and mortality.
        World J Gastroenterol. 2013; 19: 347-354
        • Chiu Y.H.
        • Chen J.D.
        • Tiu C.M.
        • Chou Y.H.
        • Yen D.H.
        • Huang C.I.
        • Chang C.Y.
        Reappraisal of radiographic signs of pneumoperitoneum at emergency department.
        Am J Emerg Med. 2009 Mar 1; 27: 320-327
        • Earls J.P.
        • Dachman A.H.
        • Colon E.
        • Garrett M.G.
        • Molloy M.
        Prevalence and duration of postoperative pneumoperitoneum: sensitivity of CT vs left lateral decubitus radiography.
        AJR Am J Roentgenol. 1993 Oct; 161: 781-785
        • Cournane S.
        • Conway R.
        • Creagh D.
        • Byrne D.G.
        • Sheehy N.
        • Silke B.
        Radiology imaging delays as independent predictors of length of hospital stay for emergency medical admissions.
        Clin Radiol. 2016 Sep; 71: 912-918
        • Larson D.B.
        • Johnson L.W.
        • Schnell B.M.
        • Salisbury S.R.
        • Forman H.P.
        National trends in CT use in the emergency department: 1995–2007.
        Radiology. 2011 Jan; 258: 164-173
        • Mukerji N.
        • Wallace D.
        • Mitra D.
        Audit of the change in the on-call practices in neuroradiology and factors affecting it.
        BMC Med Imaging. 2006 Apr; 6: 1-5
        • Bertin C.L.
        • Ponthus S.
        • Vivekanantham H.
        • Poletti P.A.
        • Kherad O.
        • Rutschmann O.T.
        Overuse of plain abdominal radiography in emergency departments: a retrospective cohort study.
        BMC Health Serv Res. 2019 Dec; 19: 1-7
        • Berdahl C.T.
        • Vermeulen M.J.
        • Larson D.B.
        • Schull M.J.
        Emergency department computed tomography utilization in the United States and Canada.
        Ann Emerg Med. 2013 Nov 1; 62: 486-494
      1. ACR appropriateness criteria®. ® | American College of Radiology. (n.d.). Accessed January 21, 2022, from https://www.acr.org/Clinical-Resources/ACR-Appropriateness-Criteria.

        • Hamlin D.J.
        • Burgener F.A.
        Positive and negative contrast agents in CT evaluation of the abdomen and pelvis.
        J Comput Tomogr. 1981 Jun 1; 5: 82-90
        • Stuhlfaut J.W.
        • Soto J.A.
        • Lucey B.C.
        • Ulrich A.
        • Rathlev N.K.
        • Burke P.A.
        • Hirsh E.F.
        Blunt abdominal trauma: performance of CT without oral contrast material.
        Radiology. 2004; 233: 689-694
        • Hopkins C.L.
        • Madsen T.
        • Foy Z.
        • Reina M.
        • Barton E.
        Does limiting oral contrast decrease emergency department length of stay?.
        West J Emerg Med. 2012; 13: 383-387
        • Razavi S.A.
        • Johnson J.O.
        • Kassin M.T.
        • Applegate K.E.
        The impact of introducing a no oral contrast abdominopelvic CT examination (NOCAPE) pathway on radiology turn-around times, emergency department length of stay, and patient safety.
        Emerg Radiol. 2014; 21: 605-613
        • Nakashima K.
        • Ishimaru H.
        • Fujimoto T.
        • et al.
        Diagnostic performance of CT findings for bowel ischemia and necrosis in closed-loop small-bowel obstruction.
        Abdom Imaging. 2015 Jun; 40: 1097-1103
        • Sheedy S.P.
        • Earnest IV, F.
        • Fletcher J.G.
        • Fidler J.L.
        • Hoskin T.L.
        CT of small-bowel ischemia associated with obstruction in emergency department patients: diagnostic performance evaluation.
        Radiology. 2006 Dec; 241: 729-736
        • Kielar A.Z.
        • Patlas M.N.
        • Katz D.S.
        Oral contrast for CT in patients with acute non-traumatic abdominal and pelvic pain: what should be its current role?.
        Emerg Radiol. 2016 Oct; 23: 477-481
        • Newhouse J.H.
        • RoyChoudhury A.
        Quantitating contrast medium-induced nephropathy: controlling the controls.
        Radiology. 2013 Apr; 267: 4-8
        • Committee on Drugs and Contrast Media
        • American College of Radiology (ACR)
        Manual on contrast media.
        • McDonald J.S.
        • McDonald R.J.
        • Comin J.
        • et al.
        Frequency of acute kidney injury following intravenous contrast medium administration: a systematic review and meta-analysis.
        Radiology. 2013; 267: 119-128
      2. Functional renal anatomy, renal physiology, and contrast media.
        in: Sandler C.M. Newhouse J.H. Dunnick N.R. Textbook of Uroradiology. Chapter 4. Wolters Kluwer/Lippincott Wiliams & Wilkins, Philadelphia, PA2013
        • Goldfarb S.
        • Spinler S.
        • Berns J.S.
        • Rudnick M.R.
        Low-osmolality contrast media and the risk of contrast-associated nephrotoxicity.
        Invest Radiol. 1993; 28: 7-10
        • Rudnick M.R.
        • Goldfarb S.
        • Wexler L.
        • et al.
        Nephrotoxicity of ionic and nonionic contrast media in 1,196 patients: a randomized trial—the iohexol cooperative study.
        Kidney Int. 1995; 47: 254-261
        • Luk L.
        • Steinman J.
        • Newhouse J.H.
        Intravenous contrast-induced nephropathy—the rise and fall of a threatening idea.
        Adv Chronic Kidney Dis. 2017 May 1; 24: 169-175
        • Lima F.O.
        • Lev M.H.
        • Levy R.A.
        • et al.
        Functional contrast-enhanced CT for evaluation of acute ischemic stroke does not increase the risk of contrast-induced nephropathy.
        Am J Neuroradiol. 2010; 31: 817-821
        • Davenport M.S.
        • Khalatbari S.
        • Cohan R.H.
        • Dillman J.R.
        • Myles J.D.
        • Ellis J.H.
        Contrast material-induced nephrotoxicity and intravenous low-osmolality iodinated contrast material: risk stratification by using estimated glomerular filtration rate.
        Radiology. 2013; 268: 719-728
        • McDonald J.S.
        • McDonald R.J.
        • Carter R.E.
        • Katzberg R.W.
        • Kallmes D.F.
        • Williamson E.E.
        Risk of intravenous contrast material mediated acute kidney injury: a propensity score-matched study stratified by baseline-estimated glomerular filtration rate.
        Radiology. 2014; 271: 65-73
        • Davenport M.S.
        • Cohan R.H.
        • Khalatbari S.
        • Ellis J.H.
        The challenges in assessing contrast-induced nephropathy: where are we now?.
        AJR Am J Roentgenol. 2014; 202: 784-789
        • Katzberg R.W.
        • Newhouse J.H.
        Intravenous contrast medium-induced nephrotoxicity: is the medical risk really as great as we have come to believe?.
        Radiology. 2010; 256: 21-28
        • Rosen M.P.
        • Sands D.Z.
        • Longmaid III, H.E.
        • Reynolds K.F.
        • Wagner M.
        • Raptopoulos V.
        Impact of abdominal CT on the management of patients presenting to the emergency department with acute abdominal pain.
        AJR Am J Roentgenol. 2000; 174: 1391-1396