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

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.

Accurately evaluating for a small bowel obstruction using an abdominal radiograph, by a new method: The Bowel-Spine Ratio

INTRODUCTION

A well-established method does not exist to rule out a small bowel obstruction using an abdominal xray series with significant accuracy. The hypothesis of the study is that the ratio of an average small bowel diameter to lumbar spine diameter over 0.5 is most likely a small bowel obstruction.

METHODS

An x-ray abdominal series measurement technique was applied to 41 subjects with a chief complaint of "abdominal pain" as part of a randomized retrospective case review to predict an obstruction v. non obstruction. A total number of 81 abdominal pain subjects with a mean age of 46.7 years were selected with 40 excluded due to normal small bowel gas pattern. The subject's medical information was unknown to the authors when reading their images. The measurement technique involved averaging the largest and smallest small bowel short axis diameters with comparison to the lowest clearly visible lumbar body width. The subjects' medical course as described in the medical chart or subsequent computed tomography scans were used as the referencing standard to determine presence of obstruction vs non-obstruction.

RESULTS

This method, called the Bowel-Spine Ratio (BSR), resulted in a sensitivity of 0.882 (0.622-0.979; 95% CI), specificity of 0.957 (0.760-0.998; 95% CI), accuracy of 94.7% (80.9%-99.1%; 95% CI) and a positive likelihood ratio of 21 for predicting a small bowel obstruction.

CONCLUSION

The abdominal series Bowel-Spine Ratio is a simple yet effective technique to screen for a small bowel obstruction using limited resources and to avoid unnecessary computed tomography scans with the potential to reduce health care costs.

IMPLICATIONS FOR PRACTICE

Clinicians could have increased confidence in utilizing abdominal radiographs to evaluate for small bowel obstruction.

Clinical indications for plain abdominal radiographs: A survey study among radiographers

Background

Abdominal pain is a common complaint in the Emergency Department. Radiographers' knowledge and practices regarding clinical indications for performing abdominal examinations are crucial in the results radiographs produced.

Aim

To determine the knowledge and practices of radiographers regarding the clinical indications for performing radiographic examinations of the abdomen.

Setting

Four public hospitals in the Eastern Cape province, South Africa.

Methods

A cross-sectional study was conducted, using a convenience, all-inclusive sample of n = 85 radiographers. A hard copy self-administered questionnaire was distributed between February and June 2020. Descriptive (mean and standard deviations) and inferential (chi² test) statistics were generated using IBM® SPSS® version 26.0 software package.

Results

Knowledge of clinical indications had a mean of 59.41. All four demographics (age, years of experience, attended a short course and attended pattern recognition course) were significantly associated with overall knowledge. Additionally, short course attendance was significantly associated with most practice items, and two knowledge items (which views are done for perforation; and which view(s) demonstrate a stab abdomen). Pattern recognition was significantly associated with one knowledge item (which views are regarded as an acute abdomen).

Conclusion

Despite the lack of short courses and pattern recognition courses, radiographers' knowledge of clinical indications was good (>50%). Continuous training, accessible protocols for performing clinical indications for plain abdominal radiographic examinations for radiographers, audit, feedback and reminders to enhance protocol adherence are recommended.

Contribution

The study findings could be used to enhance knowledge and practices regarding clinical indications for plain abdominal radiographic examinations among radiographers.

The effect of erect abdomen radiography on absorbed doses to internal organs and tissues: A clinical study

BACKGROUND

As low as reasonably achievable principles (ALARA) should be applied during all X-ray examinations. In some institutions, an acute abdomen series includes both erect and supine radiography. The purpose of the study was to evaluate the effect of an erect position on absorbed dose to internal abdominal organs when compared with the supine position.

MATERIAL AND METHODS

A prospective study was undertaken where 81 patients were imaged in both supine and erect positions. The PCXMC Monte Carlo software was used to estimate individual organ doses using dose area product (DAP). Absorbed doses were calculated for the large intestines, active bone marrow, liver, lungs, small intestine, stomach, gallbladder, breasts, uterus, ovaries, urinary bladder, kidneys, testicles, and prostate.

RESULTS

The results showed a significant increase of absorbed dose by 1.4% when moving from a supine to an erect position. The testes were found to be the organs most affected by the erect position and then the urinary bladder.

CONCLUSIONS

According to the study's findings, using the erect position during abdominal radiography increases the radiation dose for all of the selected organs compared to using a supine position. Therefore, it is advised that the use of erect abdomen radiography be restricted to certain circumstances.

Diagnostic values of supine and erect abdominal radiographs for patients with acute abdomen: which is better for decision making?

BACKGROUND

Plain abdominal radiography including supine and erect abdominal radiographs (SAR and EAR) is a frequently used image modality for preliminary evaluation of acute abdomen. We aimed to explore which one of the SAR or EAR has a higher diagnostic value in overall diagnosis of acute abdomen, including their respective advantages over each other for the various underlying diseases.

METHODS

We retrospectively analyzed the imaging findings of plain abdominal radiography of patients with acute abdomen who received abdominal computed tomography (CT) within 24 hours at the emergency department of a medical center in northern Taiwan between October 2019 and February 2020. Final diagnosis was made by CT reports and clinical data. The relevance between the imaging findings and clinical diagnosis in the groups of SAR and EAR were compared.

RESULTS

A total of 1009 cases with acute abdomen were included, of which 341 (33.8%) underwent EAR and 668 (66.2%) underwent SAR. Among them, 820 cases had final diagnosis confirmed by CT and clinical data. In comparison of the diagnostic relevance of SAR and EAR, there were no significant difference in the overall acute abdomen, but EAR showed a better diagnostic relevance in cases with bowel obstruction than SAR did (100% vs 87.2%, p < 0.05). No statistical difference in other abdominal diseases.

CONCLUSION

There is no significant difference between SAR and EAR in evaluation of overall acute abdomen. However, EARs has a diagnostic advantage over SAR for evaluation of suspected bowel obstruction.

Mechanic ileus due to retroperitoneal migration of total hip prosthesis; A case report

Intrapelvic migration of total hip prosthesis is a rare but severe complication of total hip arthroplasty that can cause severe outcomes for elderly patients. A 78-year-old female patient was referred to our hospital with the complaint of no gas-stool excretion for 3-4 days, abdominal distension, nausea, vomiting, and a preliminary diagnosis of ileus. Computed tomography showed the migration of the left total hip prosthesis to the pelvis, causing a hematoma around the prosthesis and mechanical ileus due to the compression of the hematoma. To our knowledge, this case report is the only reported mechanic ileus due to migration of total hip prosthesis. Although postop paralytic ileus is one of the complications of total hip arthroplasty, mechanical ileus has not been described before. This case report shows that mechanical ileus might be an unreported complication of total hip arthroplasty. It should be kept in mind that mechanical ileus complications may also occur after hip arthroplasty.

Acute abdominal disease with nonspecific symptoms in the elderly: A case series

Acute stomach disease in elderly patients often lacks characteristic clinical manifestations. Presentations may differ from those in younger patients and are often complicated by concomitant diseases, delayed presentation, and misdiagnosis. Incorrect diagnosis and treatment can lead to medical-related death claims. We investigated eight cases of elderly fatality due to acute abdominal diseases in forensic autopsy cases. Although most fatalities were unwitnessed, possibly due to the characteristics of elderly individuals, recent social backgrounds, and involvement with health care, some cases of possible misdiagnosis suggested that physicians should carefully consider atypical clinical manifestations and the characteristics of elderly individuals when the managing abdominal symptoms, particularly in primary health care. Our investigation of these forensic autopsy cases indicated the particular importance of peritoneal adhesions as an unexpected cause of acute abdomen in the elderly due to strangulation ileus, even among those with no history of abdominal surgery or trauma. Diagnosis of acute stomach symptoms can be difficult in elderly patients. Pathophysiological examination and autopsy analyses can thus contribute to early-stage diagnosis and prevention of acute stomach symptoms in elderly patient populations.

Acute abdominal obstruction: Colon stent or emergency surgery? An evidence-based review

According to the American Cancer Society and Colorectal Cancer Statistics 2017, colorectal cancer (CRC) is one of the most common malignancies in the United States and the second leading cause of cancer death in the world in 2018. Previous studies demonstrated that 8%-29% of patients with primary CRC present malignant colonic obstruction (MCO). In the past, emergency surgery has been the primary treatment for MCO, although morbidity and surgical mortality rates are higher in these settings than in elective procedures. In the 1990s, self-expanding metal stents appeared and was a watershed in the treatment of patients in gastrointestinal surgical emergencies. The studies led to high expectations because the use of stents could prevent surgical intervention, such as colostomy, leading to lower morbidity and mortality, possibly resulting in higher quality of life. This review was designed to provide present evidence of the indication, technique, outcomes, benefits, and risks of these treatments in acute MCO through the analysis of previously published studies and current guidelines.

Abdominal radiographs in the emergency department: current status and controversies

This editorial is discussing about the indiscriminate use of abdominal radiographs in the emergency department in general, with focus on value of the erect abdominal radiograph for the diagnosis of mechanical bowel obstruction and paralytic ileus.

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.