Erect chest radiography in the setting of the acute abdomen: essential tool or an unnecessary waste of resources?

Characterizing and quantifying low-value diagnostic imaging internationally: a scoping review

BACKGROUND

Inappropriate and wasteful use of health care resources is a common problem, constituting 10-34% of health services spending in the western world. Even though diagnostic imaging is vital for identifying correct diagnoses and administrating the right treatment, low-value imaging-in which the diagnostic test confers little to no clinical benefit-is common and contributes to inappropriate and wasteful use of health care resources. There is a lack of knowledge on the types and extent of low-value imaging. Accordingly, the objective of this study was to identify, characterize, and quantify the extent of low-value diagnostic imaging examinations for adults and children.

METHODS

A scoping review of the published literature was performed. Medline-Ovid, Embase-Ovid, Scopus, and Cochrane Library were searched for studies published from 2010 to September 2020. The search strategy was built from medical subject headings (Mesh) for Diagnostic imaging/Radiology OR Health service misuse/Medical overuse OR Procedures and Techniques Utilization/Facilities and Services Utilization. Articles in English, German, Dutch, Swedish, Danish, or Norwegian were included.

RESULTS

A total of 39,986 records were identified and, of these, 370 studies were included in the final synthesis. Eighty-four low-value imaging examinations were identified. Imaging of atraumatic pain, routine imaging in minor head injury, trauma, thrombosis, urolithiasis, after thoracic interventions, fracture follow-up and cancer staging/follow-up were the most frequently identified low-value imaging examinations. The proportion of low-value imaging varied between 2 and 100% inappropriate or unnecessary examinations.

CONCLUSIONS

A comprehensive list of identified low-value radiological examinations for both adults and children are presented. Future research should focus on reasons for low-value imaging utilization and interventions to reduce the use of low-value imaging internationally.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO: CRD42020208072.

Do referral guidelines recommend chest x-rays for patients with abdominal pain? A review

BACKGROUND

Chest X-rays (CXRs) are often requested for patients who present to emergency with abdominal pain, but its benefit to patient management remains unclear. Several guidelines have been developed to ensure that imaging investigations have the highest diagnostic impact. This study aims to compare referral guidelines to establish their recommendations and circumstances for recommendations regarding CXRs for patients with abdominal pain.

METHODS

A systematic search of the literature was performed using Medline (via OVID), PubMed, Google, and Google Scholar. Referral guidelines were included if they provided recommendations for imaging of abdominal pain, were based on published evidence, and were broadly utilised. Data related to their recommendations for CXR for abdominal pain was recorded and analysed.

RESULTS

Three guidelines supported the use of CXRs in the case of suspected perforation. Two guidelines included CXR for patients presenting with blunt abdominal trauma and severe abdominal pain requiring admission. One of the guidelines included use of CXRs for patients presenting with suspected small bowel obstruction, cholecystitis, and penetrating trauma. Two guidelines recorded no circumstances where the use of CXRs were recommended.

CONCLUSION

Published evidence-based guidelines allow for the use of CXRs for patients presenting with abdominal pain in very limited circumstances.

Are chest X-rays valuable for patients presenting to emergency departments with acute abdominal pain?

BACKGROUND

Emergency department patients presenting with acute abdominal pain are often prescribed a chest X-ray; however, the value of chest X-rays in acute abdominal pain is poorly understood. The aim of this study was to assess the value of chest X-rays in acute abdominal pain.

METHODS

A retrospective analysis of 944 chest X-rays performed for acute abdominal pain was conducted. Patient clinical information, radiology reports, and findings of other diagnostic investigations were also collected. MedCal® software was used to calculate diagnostic performance of chest X-rays. A Chi-Square test was used to assess the association between positive chest X-ray findings and both age and gender.

RESULTS

Of the 944 chest X-rays identified as satisfying inclusion factors, only 10 cases (approximately 1%) demonstrated pathology that was likely to be the cause of the abdominal pain. Further analysis demonstrated the following performance metrics at 95%CI: sensitivity (12.8; 8.78-17.72); specificity (100; 98.4-100); positive predictive value (100%); negative predictive value (52.76; 51.54-53.98); accuracy (55.82; 51.17-60.40).

CONCLUSION

Chest X-ray has limited sensitivity and diagnostic value in patients presenting to the emergency department with abdominal pain and does not appear to be a useful diagnostic investigation for abdominal pain.

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.

Spontaneous hemopneumothorax simulating acute abdominal affections

Spontaneous hemopneumothorax (SHP) is a rare potentially life-threatening condition that occurs in predominantly young adolescents. The resultant massive hemorrhage leading to hypovolemic shock can be a surgical emergency. It constitutes 1-12% of all spontaneous pneumothoraces and presents with two cardinal features, chest pain and dyspnea. However, the pain of SHP may be confined to the abdomen secondary to the irritation of diaphragmatic pleura, which produces signs simulating an acute abdomen. SHP masquerading as an abdominal affection is apparently regarded as extremely rare. We present a case of a 16-year-old male with SHP presenting features simulating acute gallbladder disease. After prompt diagnosis with appropriate surgical intervention, he had an uneventful recovery. Our experience emphasizes the importance of careful and thorough chest examination for each child with atypical pictures for abdominal pain to exclude possible extra-abdominal lesions, even rare as SHP.