1
|
Weinstein S, Kim DH, Fowler KJ, Birkholz JH, Cash BD, Cilenti E, Dane B, Horvat N, Kambadakone AR, Korngold EK, Liu PS, Lo BM, McCrary M, Mellnick V, Pietryga JA, Santillan CS, Zukotynski K, Carucci LR. ACR Appropriateness Criteria® Left Lower Quadrant Pain: 2023 Update. J Am Coll Radiol 2023; 20:S471-S480. [PMID: 38040465 DOI: 10.1016/j.jacr.2023.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 08/22/2023] [Indexed: 12/03/2023]
Abstract
The differential diagnosis for left lower quadrant pain is wide and conditions range from the benign and self-limited to life-threatening surgical emergencies. Along with patient history, physical examination, and laboratory tests, imaging is often critical to limit the differential diagnosis and identify life-threatening abnormalities. This document will discuss the guidelines for the appropriate use of imaging in the initial workup for patients who present with left lower quadrant pain, patients with suspected diverticulitis, and patients with suspected complications from diverticulitis. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
Collapse
Affiliation(s)
| | - David H Kim
- Panel Chair, University of Wisconsin Hospital & Clinics, Madison, Wisconsin
| | - Kathryn J Fowler
- Panel Vice-Chair, University of California, San Diego, San Diego, California
| | - James H Birkholz
- Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Brooks D Cash
- University of Texas Health Science Center at Houston and McGovern Medical School, Houston, Texas; American Gastroenterological Association
| | - Elizabeth Cilenti
- MedStar Georgetown University Hospital, Washington, District of Columbia, Primary care physician
| | - Bari Dane
- NYU Grossman School of Medicine, New York, New York
| | - Natally Horvat
- Memorial Sloan Kettering Cancer Center, New York, New York
| | | | | | | | - Bruce M Lo
- Sentara Norfolk General Hospital/Eastern Virginia Medical School, Norfolk, Virginia; American College of Emergency Physicians
| | - Marion McCrary
- Duke Signature Care, Durham, North Carolina; American College of Physicians
| | - Vincent Mellnick
- Mallinckrodt Institute of Radiology, Saint Louis, Missouri; Committee on Emergency Radiology-GSER
| | - Jason A Pietryga
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | | | - Katherine Zukotynski
- McMaster University, Hamilton, Ontario, Canada; Commission on Nuclear Medicine and Molecular Imaging
| | - Laura R Carucci
- Specialty Chair, Virginia Commonwealth University Medical Center, Richmond, Virginia
| |
Collapse
|
2
|
Rausch VH, Weinrich JM, Schön G, Sabour L, Özden C, Kaul MG, Adam G, Bannas P, Henes FO. Accuracy of preoperative CT staging of acute colonic diverticulitis using the classification of diverticular disease (CDD) - Is there a beneficial impact of water enema and visceral obesity? Eur J Radiol 2021; 141:109813. [PMID: 34116453 DOI: 10.1016/j.ejrad.2021.109813] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 05/13/2021] [Accepted: 06/02/2021] [Indexed: 11/18/2022]
Abstract
PURPOSE We evaluated the accuracy of preoperative CT in staging colonic diverticulitis (ACD) by using the classification of diverticular disease (CDD) and investigated the diagnostic impact of water enema (WE) and visceral obesity. METHODS In this retrospective study, the radiological and hospital information system was searched for patients who underwent CT for clinically suspected ACD prior to surgery between 2009 and 2019. From the initial population (n = 164), we included 155 patients (94.5 %) (85 women; mean age: 58 ± 13 years) matching the following inclusion criteria: i.) clinically suspected ACD, ii.) i.v. contrast-enhanced CT, iii.) surgery for ACD within 1 week after CT, iv.) histopathological report that proved ACD. The remaining 9 patients (5.5 %) were excluded because histopathological reports were lacking (n = 3) or CT was performed without intravenous contrast agent (n = 6). WE (+ butylscopolamine i.v.) was performed in 93 patients (group A, 60 %). 62 patients (group B, 40 %) had no WE. Visceral-to-subcutaneous fat ratio (V/S) was determined for each patient. Two radiologists blinded for final diagnosis independently staged ACD according to CDD and assessed prevalence and confidence ratings of ACD-related CT-findings: pericolonic fat stranding, covered- and free-perforation, local and generalized peritonitis, abscess. Interobserver-agreement of CT-findings were assessed and effects of WE and V/S ratio on the diagnostic accuracy of CT with surgical and histopathological findings as reference were determined by calculating a logistic regression model. RESULTS CT-staging showed high accuracy (94 %) and excellent interrater-correlation (ICC 0.96) for staging ACD. WE had no positive impact neither on diagnostic accuracy of staging, nor on confidence ratings of ACD-related CT-findings (all p > 0.5). Confidence ratings were significantly higher in examinations without WE for perforation, peritonitis as well as abscesses (all p < 0.5). Confidence ratings for the assessment of local peritonitis improved significantly with higher V/S (p = 0.049). The increase of V/S significantly correlated with the probability for correct CDD staging of ACD in CT (p = 0.023). CONCLUSION Increase of visceral obesity significantly improves accuracy of CT in preoperative staging acute colonic diverticulitis. However, independently of the degree of visceral obesity, water enema has no diagnostic benefit and may therefore be omitted. Overall, CT proves high accuracy in preoperative staging ACD using the classification of diverticular disease. LEVEL OF EVIDENCE Retrospective study, observational study.
Collapse
Affiliation(s)
- Vanessa Hanna Rausch
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, Center for Radiology and Endoscopy, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Julius Matthias Weinrich
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, Center for Radiology and Endoscopy, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Gerhard Schön
- Department of Medical Biometry and Epidemiology, University Medical Centre Hamburg-Eppendorf, Martinistrasse 52, D 20246, Hamburg, Germany.
| | - Layal Sabour
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, Center for Radiology and Endoscopy, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Cansu Özden
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, Center for Radiology and Endoscopy, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Michael Gerhard Kaul
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, Center for Radiology and Endoscopy, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Gerhard Adam
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, Center for Radiology and Endoscopy, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Peter Bannas
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, Center for Radiology and Endoscopy, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Frank Oliver Henes
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, Center for Radiology and Endoscopy, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| |
Collapse
|
3
|
Fonsi GB, Sapienza P, Brachini G, Andreoli C, De Cicco ML, Cirillo B, Meneghini S, Pugliese F, Crocetti D, Fiori E, Mingoli A. Is Lung Ultrasound Imaging a Worthwhile Procedure for Severe Acute Respiratory Syndrome Coronavirus 2 Pneumonia Detection? JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2021; 40:1113-1123. [PMID: 32894583 DOI: 10.1002/jum.15487] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 07/16/2020] [Accepted: 08/03/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES We compared 2 imaging modalities in patients suspected of having coronavirus disease 2019 (COVID-19) pneumonia. Blinded to the results of real-time reverse transcriptase polymerase chain reaction (rRT-PCR) testing, lung ultrasound (LUS) examinations and chest computed tomography (CT) were performed, and the specific characteristics of these imaging studies were assessed. METHODS From March 15, 2020, to April 15, 2020, 63 consecutive patients were enrolled in this prospective pilot study. All patients underwent hematochemical tests, LUS examinations, chest CT, and confirmatory rRT-PCR. The diagnostic performance of LUS and chest CT was calculated with rRT-PCR as a reference. The interobserver agreement of radiologists and ultrasound examiners was calculated. Ultrasound and CT features were compared to assess the sensitivity, specificity, positive predictive value, and negative predictive value. Positive and negative likelihood ratios measured the diagnostic accuracy. RESULTS Nineteen (30%) patients were COVID-19 negative, and 44 (70%) were positive. No differences in demographics and clinical data at presentation were observed among positive and negative patients. Interobserver agreement for CT had a κ value of 0.877, whereas for LUS, it was 0.714. The sensitivity, specificity, positive predictive value, and negative predictive value of chest CT for COVID-19 pneumonia were 93%, 90%, 85%, and 95%, respectively; whereas for LUS, they were 68%, 79%, 88%, and 52%. On receiver operating characteristic curves, area under the curve values were 0.834 (95% confidence interval, 0.711-0.958) and 0.745 (95% confidence interval, 0.606-0.884) for chest CT and LUS. CONCLUSIONS Lung ultrasound had good reliability compared to chest CT. Therefore, our results indicate that LUS may be used to assess patients suspected of having COVID-19 pneumonia.
Collapse
Affiliation(s)
| | - Paolo Sapienza
- Department of Surgery Pietro Valdoni, Sapienza University of Rome, Rome, Italy
| | - Gioia Brachini
- Department of Surgery Pietro Valdoni, Sapienza University of Rome, Rome, Italy
| | - Chiara Andreoli
- Department of Radiology, Oncology, and Pathology, Sapienza University of Rome, Rome, Italy
| | - Maria Luisa De Cicco
- Department of Radiology, Oncology, and Pathology, Sapienza University of Rome, Rome, Italy
| | - Bruno Cirillo
- Department of Surgery Pietro Valdoni, Sapienza University of Rome, Rome, Italy
| | - Simona Meneghini
- Department of Surgery Pietro Valdoni, Sapienza University of Rome, Rome, Italy
| | | | - Daniele Crocetti
- Department of Surgery Pietro Valdoni, Sapienza University of Rome, Rome, Italy
| | - Enrico Fiori
- Department of Surgery Pietro Valdoni, Sapienza University of Rome, Rome, Italy
| | - Andrea Mingoli
- Department of Surgery Pietro Valdoni, Sapienza University of Rome, Rome, Italy
| |
Collapse
|
4
|
Meyer S, Schmidbauer M, Wacker FK, Ringe KI. To Fill or Not to Fill? - Value of the Administration of Positive Rectal Contrast for CT Evaluation of Diverticular Disease of the Colon. ROFO-FORTSCHR RONTG 2021; 193:804-812. [PMID: 33535255 DOI: 10.1055/a-1339-2157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To assess the value of the administration of positive rectal contrast at CT in patients referred for suspected diverticular disease (DD) of the colon. MATERIALS AND METHODS 460 patients (253 male, 207 female; median age 62 years; interquartile range 24) with clinical suspicion of DD of the colon were included in this retrospective IRB-approved study. CT was performed with i. v. contrast only (n = 328, group M1), i. v. + positive rectal contrast (n = 82, group M2), neither i. v. nor rectal contrast (n = 32, group S1), or positive rectal contrast only (n = 19, group S2). Two readers in consensus evaluated all CT datasets concerning diagnosis of DD (yes/no) and categorized findings (classification of diverticular disease (CDD)). Sensitivity, specificity, positive (PPV) and negative (NPV) predictive values for the diagnosis of DD were calculated for all groups, using either clinical follow-up (n = 335) or intraoperative findings (n = 125) as the reference standard. In patients undergoing surgery, radiological staging of DD was correlated with the histopathology (weighted Cohen-k). RESULTS 224 patients (48.7 %) were diagnosed with DD. The sensitivity, specificity, PPV, and NPV were as follows. Group M1 / M2: 92 %/92 %, 97 %/94 %, 96 %/96 %, 94 %/89 %, respectively; group S1 / S2: 94 %/86 %, 93 %/80 %, 94 %/92 %, 93 %/67 %, respectively. Radiological staging and histopathology correlated substantially in all groups (k = 0.748-0.861). CONCLUSION Abdominal CT had a high sensitivity and specificity for the diagnosis of DD. Disease staging correlated well with the findings at surgery. Additional positive rectal contrast administration did not have a significant advantage and may therefore be omitted in patients with suspected DD. KEY POINTS · CT has a high sensitivity and specificity for diagnosis of DD.. · CT staging using the CDD algorithm correlates very well with surgery.. · Positive rectal contrast administration does not improve diagnosis and radiological staging.. CITATION FORMAT · Meyer S, Schmidbauer M, Wacker FK et al. To Fill or Not to Fill? - Value of the Administration of Positive Rectal Contrast for CT Evaluation of Diverticular Disease of the Colon. Fortschr Röntgenstr 2021; 193: 804 - 812.
Collapse
Affiliation(s)
- Simone Meyer
- Department of Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - Martina Schmidbauer
- Department of Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - Frank K Wacker
- Department of Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - Kristina Imeen Ringe
- Department of Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| |
Collapse
|