Published 26 June 2009, doi:10.1136/bmj.b2431
Cite this as: BMJ 2009;338:b2431
Research
Imaging strategies for detection of urgent conditions in patients with
acute abdominal pain: diagnostic accuracy study
Correspondence to: J Stoker j.stoker "appropriate symbol here " amc.uva.nl
Objective To identify an optimal imaging strategy for the accurate
detection of urgent conditions in patients with acute abdominal pain.
Design Fully paired multicentre diagnostic accuracy study with
prospective data collection.
Setting Emergency departments of two university hospitals and four
large teaching hospitals in the Netherlands.
Participants 1021 patients with non-traumatic abdominal pain of >2
hours’ and <5 days’ duration. Exclusion criteria were discharge from
the emergency department with no imaging considered warranted by the
treating physician, pregnancy, and haemorrhagic shock.
Intervention All patients had plain radiographs (upright chest and
supine abdominal), ultrasonography, and computed tomography (CT) after
clinical and laboratory examination. A panel of experienced physicians
assigned a final diagnosis after six months and classified the
condition as urgent or non-urgent.
Main outcome measures Sensitivity and specificity for urgent
conditions, percentage of missed cases and false positives, and
exposure to radiation for single imaging strategies, conditional
imaging strategies (CT after initial ultrasonography), and strategies
driven by body mass index and age or by location of pain.
Results 661 (65%) patients had a final diagnosis classified as urgent.
The initial clinical diagnosis resulted in many false positive urgent
diagnoses, which were significantly reduced after ultrasonography or
CT. CT detected more urgent diagnoses than did ultrasonography:
sensitivity was 89% (95% confidence interval 87% to 92%) for CT and
70% (67% to 74%) for ultrasonography (P<0.001). A conditional strategy
with CT only after negative or inconclusive ultrasonography yielded
the highest sensitivity, missing only 6% of urgent cases. With this
strategy, only 49% (46% to 52%) of patients would have CT. Alternative
strategies guided by body mass index, age, or location of the pain
would all result in a loss of sensitivity.
Conclusion Although CT is the most sensitive imaging investigation for
detecting urgent conditions in patients with abdominal pain, using
ultrasonography first and CT only in those with negative or
inconclusive ultrasonography results in the best sensitivity and
lowers exposure to radiation.
=====================
Imaging in patients with acute abdominal pain
Adrian K Dixon and Christopher J Watson
BMJ 2009 338: b1678. [Extract] [Full Text]
Evaluation of early abdominopelvic computed tomography in patients
with acute abdominal pain of unknown cause: prospective randomised
study
Chaan S Ng, Christopher J E Watson, Christopher R Palmer, Teik
Choon See, Nigel A Beharry, Barbara A Housden, J Andrew Bradley, and
Adrian K Dixon
BMJ 2002 325: 1387. [Abstract] [Full Text] [PDF]
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