Routine Abdominal X-Rays in the Emergency Department 381

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Radiología. 2015;57(5):380---390

www.elsevier.es/rx

UPDATE IN RADIOLOGY

Routine abdominal X-rays in the emergency

ଝ

department: A thing of the past?

a,∗ b c

J.M. Artigas Martín , M. Martí de Gracia , C. Rodríguez Torres ,

c d

D. Marquina Martínez , P. Parrilla Herranz

Radiología de Urgencias, Servicio de Radiodiagnóstico, Hospital Universitario Miguel Servet, Zaragoza, Spain

Radiología de Urgencias, Servicio de Radiodiagnóstico, Hospital Universitario La Paz, Madrid, Spain

Servicio de Radiodiagnóstico, Hospital Universitario Miguel Servet, Zaragoza, Spain

Servicio de Urgencias, Hospital Universitario Miguel Servet, Zaragoza, Spain

Received 2 January 2015; accepted 22 June 2015

KEYWORDS Abstract The large number of abdominal X-ray examinations done in the emergency depart-

Abdomen; ment is striking considering the scant diagnostic yield of this imaging test in urgent disease. Most

Plain films; of these examinations have normal or nonspecific findings, bringing into question the appropri-

Emergencies; ateness of these examinations. Abdominal X-ray examinations are usually considered a routine

Diagnosis; procedure or even a ‘‘defensive’’ screening tool, whose real usefulness is unknown. For more

Indications; than 30 years, the scientiﬁc literature has been recommending a reduction in both the number

Appropriateness of examinations and the number of projections obtained in each examination to reduce the

dose of radiation, unnecessary inconvenience for patients, and costs.

Radiologists and clinicians need to know the important limitations of abdominal X-rays in the

diagnostic management of acute abdomen and restrict the use of this technique accordingly.

This requires the correct clinical selection of patients that can beneﬁt from this examination,

which would allow better use of alternative techniques with better diagnostic yield, such as

ultrasonography or computed tomography.

PALABRAS CLAVE Radiografía del abdomen en Urgencias. ¿Una exploración para el recuerdo?

Abdomen;

Radiografía; Resumen La escasa rentabilidad diagnóstica de la radiografía de abdomen en patología

Urgencias; urgente contrasta con el elevado número de exploraciones que se realizan. La mayoría arroja

Diagnóstico; hallazgos normales o inespecíﬁcos, lo que cuestiona la idoneidad de su indicación. Suele

ଝ

Please cite this article as: Artigas Martín JM, Martí de Gracia M, Rodríguez Torres C, Marquina Martínez D, Parrilla Herranz P. Radiografía

del abdomen en Urgencias. ¿Una exploración para el recuerdo? Radiología. 2015;57:380---90. ∗

Corresponding author.

E-mail address: [email protected] (J.M. Artigas Martín).

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Routine abdominal X-rays in the emergency department 381

considerarse un procedimiento rutinario o incluso una herramienta ‘‘defensiva’’de cri-

Indicaciones; bado, cuya utilidad real se desconoce. Desde hace más de 30 anos,˜ se recomienda en la liter-

Adecuación atura cientíﬁca reducir tanto el número de exploraciones como el de proyecciones realizadas,

en aras a disminuir dosis de radiación, molestias innecesarias para los pacientes y costes.

Radiólogos y clínicos deben conocer las importantes limitaciones de la radiografía de abdomen

en el manejo diagnóstico de la patología abdominal aguda y restringir su empleo. Para ello, es

imprescindible una adecuada selección clínica de los pacientes candidatos a estudio de imagen,

que permite un empleo ágil de técnicas alternativas más rentables como la ecografía o la

tomografía computarizada.

Introduction Diagnostic approach to patients with acute

abdominal symptomatology

The evaluation of a healthcare technology is a complex

task whose objective is to balance the actual beneﬁts for

Pain is the most constant clinical manifestation of acute

the patient and the possible risks, disadvantages and costs

abdomen condition and a common cause for going to the ES

derived from its implementation. The radiological setting 4 --- 6

in adults. The medical history, the physical examination

includes ﬁve levels referring progressively to technical qual-

and lab tests are the starting point of its clinical study and

ity, diagnostic yield, diagnostic and therapeutic impact and

usually enough in mild cases. In the remaining cases although

health progression. Parameters such as image resolution

they can give clues about the nature and location of the

are useful to evaluate the ﬁrst level while sensitivity and

causal process they often yield unspeciﬁc results that need

speciﬁcity or predictive value are useful to evaluate the 5

to be completed with image tests. Such tests should provide

second being relatively easy up to this point to verify

ideally either in positive or negative signiﬁcant information

progression with respect to the previous standard. Mak-

for the therapeutic decision. A positive result establishes a

ing progress in the evaluation process is extremely difﬁcult

diagnosis (e.g., intestinal obstruction [IO]), or its etiology

especially in techniques consolidated by use, for which there

(e.g., peritoneal adhesion) and location (e.g., distal ileum),

are no deﬁned evaluation guidelines and where scientiﬁc

and it even allows us to stage its severity (e.g., closed-loop

evidence can be of low quality or non-existent. In practice

obstruction with signs of intestinal ischemia). A reliable neg-

it is assumed that an examination is useful when the result

ative result promotes an early discharge from the ES avoiding

modiﬁes clinical management, to conﬁrm or rule out a diag-

admissions and unnecessary expenses. When correctly indi-

nostic choice or else to stage the risk of a potentially serious

cated and performed timely a decisive image examination

situation. When radiology is used routinely as a ‘‘rubber

improves diagnostic accuracy, promotes surgical indication,

stamp’’ to be stamped on every patient it is difﬁcult to

planning and approach, speeds up the discharge or admission

prove its effectiveness, since there is no previous clinical

decision-making process, reduces hospital stays, improves

question to answer. Also an examination that does not con- 7,8

service quality and diminishes morbimortality. On the con-

tribute any information can only contribute confusion (e.g.,

trary image modalities add little value, or even subtract

incidental or unspeciﬁc ﬁndings). The following pages are

value, in patients with mild symptomatology, candidates to

intended to show how abdominal radiography (AR) in the 2,5

clinical management or when the modality selected is not

emergency setting is an example in the negative way of all

the right one---situations that only increase the dose of radi-

the above: an imaging modality consolidated by use of whose

ation, the time spent in the ER and the patient’s discomfort

clinical usefulness there is little scientiﬁc evidence---or if 5

and healthcare costs.

there is any evidence there is negative evidence---in spite

Acute abdominal pain can be associated to a vari-

of which it maintains a long list of possible clinical appli- 5

able degree of severity and be due to multiple causes.

cations that everyday reality surpasses broadly making it a

Apendicitis, IO, diverticulitis, cholecystitis, renal colic,

routine for every patient that goes to the emergency ser-

acute intestinal pathology---including ischemia and perfora-

vices (ES) with abdominal symptomatology regardless of its

tion---pancreatitis or gynecological disorders are diagnoses

characteristics and the degree of severity. Radiologists and

that need to be taken into consideration whose frequency

clinicians alike need to know the important limitations of AR

varies in the different publications and epidemiological pro-

to detect acute pathologies with the promptness and pre-

ﬁles. Although one in 3 patients who go to the ER due

cision of other image modalities basically ultrasounds and

to abdominal pain is discharged without identifying any

computed tomographies (CT). They must resort to the lat- 3,4,7,9

causes, expediting those discharges requires decisive

ter regardless of the AR result when the clinical context

image modalities (Fig. 1). The diagnostic management of

suggests a serious pathology. In mild cases, the remote prob-

acute abdomen differs from one country to another with

ability of positive ﬁndings also advises against the use of

two major trends, early use of CT or clinical examina-

AR.

tion complemented with simple radiography and ultrasound

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382 J.M. Artigas Martín et al.

Figure 1 Thirty-seven (37) year old male presenting with abdominal pain and impaired intestinal rhythm with reduced gas fecal

emission. (a) Abdominal radiography (AR) in decubitus supine position showing a pattern of anodyne gas with a slightly dilated small

intestine loop in the left superior quadrant/ﬂank (arrow). (b) The AR in bipedalism shows multiple hydroaerial levels (arrow heads)

with very few gas in the colon indicative of small intestine occlusion. A CT was performed (not shown) giving normal results. After

24 h the clinical condition resolved spontaneously.

7---10

with CT on demand. Although the former option seems due to abdominal pain. In most published series ARs are per-

to improve diagnostic accuracy, prospective studies have formed in more than half of these patients regardless of the

10 14,21

not shown any signiﬁcant differences in other measures. characteristics or the intensity of the pain, surpassing

Most clinical guidelines indicate image studies depend on 90% in some. These are some of the factors that promote

the location of the pain, being the ultrasound the 1st the unjustiﬁed use of AR: the consideration the ‘‘routine

choice for the right upper quadrant and the pelvis, and examination’’ in the ER, the lack of control of the simple

CT for the remaining quadrants. Laméris et al. attain X-ray by the radiologist and the electronic request systems

maximum sensitivity with a minimal radiation dose begin- along with training deﬁcits among new physicians and the

ning by AR followed by ultrasound and CT in uncertain resistance of ‘‘senior’’ physicians to change their traditional

cases. practices.15,18,20

During the last few years the most important radiological

societies around have been continually reducing the lists of

22---24

Simple abdomen X-ray in the emergency indications for AR included in their recommendations.

room. Real use and scientiﬁc evidence In its 2011 revision the American College of Radiology

(ACR) eliminates abdominal pain as an indication for AR.

2 With a more practical approach in their Diagnostic Imaging

The low diagnostic yield of AR has been recognized since

Pathways the Royal Australian and New Zealand College

the 1960s yet despite this its systematic use is recommended

11 of Radiologists recommend performing ARs only in cases of

in patients with acute abdomen pain. In 1982, Eisenberg

12 suspicion of perforation or IO, ingestion of a foreign body,

et al. suggested restricting AR to patients with moderate

unspeciﬁc moderate or serious abdominal pain and follow-

or serious abdominal pain and in cases of clinical suspicion

up of calculi in the urinary tract. Nevertheless even these

of IO, urethral calculi, ischemia or vesicular pathology. With

indications are being revised today.

this approach, they eliminate 53.7% of the examinations,

Different publications place the ideal rate of AR use

without any clinical repercussions. Many subsequent studies

2,21

due to acute abdominal pain below 10%. Implementing

have proven the absence of scientiﬁc basis for performing

2,5,9,13---20 the previous unrestrictive recommendations most authors

AR to all patients with abdominal symptomatology

agree that the number of ARs performed could be reduced

--- a usual practice in the ES even today when the availabil-

5,9,15,17,21,25

by 50---70%, or even in larger percentages. Logi-

ity of other more reﬁned modalities such as ultrasound and

cally, the diagnostic yield of AR is incidental in the group of

CT is practically universal. There is no direct information

2,9,15

patients where there is no indication.

available about the use of AR in patients that go to the ER

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Routine abdominal X-rays in the emergency department 383

The ‘‘abdominal series’’. Necessary ileum, ascites and urethral lithiasis. The correlation was low

projections to determine partial or complete obstruction of the small

intestine and its proximal, medial or distal location.

With important variations based on the sign or pathol-

AR in supine position must include from the thoracic

ogy being considered the diagnostic yield of AR is around

diaphragm to the obturator foramen, occasionally needing 2,5,17---19,21,29,30

10% and though some authors rise the percent-

two exposures. This is the basic projection, the start- 14

age of relevant ﬁndings to 15.8%, others do not ﬁnd any

ing point of the so-called ‘‘abdominal series’’ that also

signiﬁcant impacts of AR in the clinical decision-making

includes another projection ‘‘with a horizontal beam’’ in 16

process. Such yield should improve with the level of adhe-

bipedalism or lateral decubitus position and a chest X-

23,26 sion to clinical recommendations that is usually. Morris-Stiff

ray in bipedalism. The latter, performed as part of an 15

et al. in their series ﬁnd that 32% of requests abide by the

abdominal series, contributes useful information in 10---15%

standards of the Royal College of Radiologists (RCR) with

of the cases, about the thoracic pathology (pneumonia,

positive results for this group of around 76.7% as opposed to

pericarditis) causing abdominal symptomatology or thoracic 18

3.3% for patients with inadequate requests. Feyler et al.

manifestations of an abdominal process (pleural effusion in

say that 12% of requests abide by the RCR guidelines with

pancreatitis or abdominal infection). It can detect small

an impact of their ﬁndings on clinical management in 7% of

quantities of intraperitoneal gas better than AR in bipedal-

the cases. The usefulness of AR is zero in cases of unspe-

ism. It is recommended to maintain bipedalism or the lateral

ciﬁc abdominal pain, acute digestive hemorrhage, peptic

decubitus position for at least 10 min before obtaining the

26 ulcer, apendicitis, urinary tract infection, pelvic pain, biliary

X-ray exposure to let the gas rise above the liver dome.

27 pathology, acute pancreatitis or uncomplicated constipa-

Mirvis et al. opposed the use of AR in bipedalism in 2,13,16,19,21

tion, among others.

1986 because it rises costs and contributes little useful infor-

The AR detects alterations with low sensitivity

mation. The AR in the decubitus prone position favors the

(Figs. 2 and 3) but even when it does it rarely exhausts

displacement of the gas in the transverse colon toward its

the diagnostic process on its own. In most publications,

ascending and descending segments. Performing it is difﬁ-

the change of clinical management for patients induced

cult in seriously ill patients where the only alternative is 21 16

by the AR is below 10%. Kellow et al. ﬁnd that with

often laterolateral projections of the abdomen in the supine

the exception of the location of abdominal catheters, the

position with a horizontal beam, tangential to the anterior

AR is not very useful in acute abdomen conditions and

wall for the detection of underlying gas. Today the gen-

only 3% of their patients were treated based on the AR

eralized opinion is to consider the ‘‘abdominal series’’ as

ﬁndings. They conclude that in general the AR does not

superﬂuous whose dose of radiation and costs are similar to

2 avoid other image modalities, as it happened in 59% of their

or surpass those of low-dose CT with much less information.

patients to outline the extent of the alteration, identify its

etiology, plan treatment or have a basal image to evaluate

Arguments against the use of abdomen X-ray

therapeutic response. This is to say that a pathologic AR

in the emergency room does not provide any conclusive diagnoses in most patients

but even when it does it needs other additional image

The validity and reliability of AR are very low in the assess- modalities (Figs. 4 and 5).

ment of abdominal pathology; therefore errors are frequent, Incidental ﬁndings are especially frequent when an incor-

especially in the emergency setting. That is why its ﬁndings rect indication is the starting point. Its assessment can

must be interpreted with caution always within the patient’s provide a wrong or inadequate clinical response diverting

clinical context and based on its accuracy. In the studies pub- the management of the patient to research lines or guide-

lished, the validity of AR in patients with acute abdominal lines of clinical management that are far from their actual

pain is not usually expressed through the usual parameters problem, with diagnostic delays or inadequate treatments

of sensitivity, speciﬁcity and predictive value due to the and greater morbimortality. The percentage of wrong ﬁnd-

2 21

absence of adequate reference standards in many studies ings for AR in some papers has been established around 19%

and to the multiplicity of signs and etiological options mak- and in others it has managed to surpass the useful informa-

ing it impossible to set up the usual contingency tables tion in a 3:2 ratio.

2 2. Most often, its diagnostic usefulness is expressed Ruling out a prevailing or especially serious condition

in terms of positive ﬁndings, change of diagnosis or clini- expedites the work of the ES while contributing to early

cal management of patients or degree in which the image discharge being one of the most decisive current applica-

modality proves to be of diagnostic utility for the ER physi- tions of diagnostic image modalities. This is not the case of

cian. When it comes to reliability, Markus et al. studied A R --- a not very useful modality for the identiﬁcation of unsus-

interobserver variability in the interpretation of AR by dif- pected diagnoses. Yet despite this fact its use is frequent

ferent radiologists and they found an adequate concordance as a normal screening tool. Stower et al. found that 60.8%

in the identiﬁcation of pneumobilia, renal lithiasis or pneu- of the ARs requested in their series were meant to rule out

moperitoneum, and worse results in the detection of small a serious condition. This practice causes unnecessary incon-

intestine obstruction, cholelithiasis, colitis, thumbprinting, veniences to the patient, it is potentially dangerous and

dilatated intestinal loops, pathological hydroair levels, nor- should not be recommended. It is well known that a nor-

mal gas pattern or masses. The worst results were for the mal x-ray does not allow guarantee normality or precludes

assessment of colon obstruction, unspeciﬁc gas patterns, a serious condition (Figs. 2 and 3). Seventy-two per cent

complete obstruction of the small intestine, location of the patients with normal AR in the Kellow et al. paper pre-

the obstruction site in the small intestine, diffused/located sented some alteration when other image modalities were

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384 J.M. Artigas Martín et al.

Figure 2 Thirty-four (34) year old male with pain in the lower semi-abdomen, fever and leukocytosis. (a) The AR of the abdomen

in the decubitus supine position shows no signiﬁcant alterations. (b and c) CT parasagittal images. Wall thickening of sigmoid colon

with diverticula and perforation of one of these diverticula (arrow in b) with presence of extraluminal gas and signs of adjacent fat

inﬂammation. Multiple bubbles of intraperitoneal gas of anterior location (arrow-heads in c). Perforated diverticulitis.

used; this is why they do not recommend its use to rule out modalities. Every exposure to ionizing radiation needs to be

abdominal conditions. Almost half (46%) of the cases pre- justiﬁed by a potential beneﬁt and though the dose of one AR

sented unspeciﬁc ﬁndings in the AR, and in 78% of them is not very high for an individual examination (0.7---1.3 mSv),

alterations could be later identiﬁed. Simeone et al. dis- 40 times that of a chest X-ray or 4 months of background

cover useful information through ultrasound predominantly radiation, it gains relevance from a population approach,

of biliary origin in 20% of the patients with abdominal pain above all taking into account the probability of additional

25,34,35

and a negative AR. projections. Radiation derived from conventional

The dose of radiation administered is another issue radiographies has declined during the last few years though

that should be considered when evaluating medical image the AR is still one of the four most common indications in

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Routine abdominal X-rays in the emergency department 385

Figure 3 Seventy-two (72) year old woman with abdominal pain of sudden onset. The clinical exploration shows signs of shock

and arrhythmia and in the analysis acidosis and hyperamylasemia. (a) AR with no signiﬁcant ﬁndings. (b) CT coronal image in 6 mm

maximal intensity projection showing a lumen repletion defect of the superior mesenteric artery compatible with an embolism

(arrow). Cardiomegaly (*).

this group. It is responsible for 2.93% of the radiological sensitivity of AR to diagnose IO ranges from 46% to 90.8%

procedures performed in the UK, and for 4.42% of the total in the different series, with a speciﬁcity close to 50%.

dose. The progressive accessibility from the ER to low-dose It has important limitations when it comes to determin-

and ultralow-dose CT modalities <4 and 2 mSv will probably ing the level and cause of the obstruction as well as the

34 5,39

displace the use of AR in favor of these modalities. presence of strangulation. Today the MSCT (multi-slice

The economic cost is another evaluation argument, and computed tomography) answers all questions with sensitiv-

although the AR is a relatively inexpensive modality---around ity and speciﬁcity close to 100%, and it is the initial test of

30---40 D the reduction of unnecessary examinations along choice in cases of suspicion of IO as recognized by the ACR

with other direct costs such as technician and radiologist guidelines. Also this approach is useful for cases of colon

time or indirect costs, such as a previous pregnancy tests obstruction, where the AR can be confusing or inconclusive

in young patients amount to yearly savings of around 50---60 and delay treatment. Not only does the CT perform a more

15,25

million pounds in the UK. precise diagnosis but it also provides additional information

that can modify treatment in one out of every ﬁve cases

(Fig. 5).

AR in the usual causes of abdominal pain.

Does anything change?

Hollow viscus perforation

Intestinal obstruction

There is no scientiﬁc evidence supporting the use of AR

Around 7% of patients with acute abdominal pain will in cases of suspicion of visceral perforation. Although in

have IO. Clinical evaluation has limitations in its assess- ideal conditions it can be detected through an X-ray using

ment but it provides information (abdominal distension, a minimum of 1 cc of free intraperitoneal gas reality can

increase of intestinal noise, vomiting, age > 50 years) which paint a different picture as shown by the high variability

improves the sensitivity and the predictive value of AR in the ﬁgures of detection of pneumoperitoneum among the

5,14,19

when diagnosing IO (intestinal obstruction). Its most different papers and radiographic projections used. van Ran-

frequent etiology is peritoneal adhesions and hernias, and an den et al. estimate in around 15% the sensitivity of AR

early diagnosis and treatment prevent intestinal ischemia, to detect pneumoperitoneum; in the Baker et al. series

improving morbimortality. The IO has been one of the clas- X-rays detected it in 51% of the patients with proven vis-

sic indications for AR which is diagnostic in 50---60% of the ceral perforation, and Levine et al. identify it in 59% of

cases, uncertain in 20---30% and confusing in 10---20%. The ARs performed in the decubitus supine position, while Keefe

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386 J.M. Artigas Martín et al.

Figure 4 Eighty-two (82) year old male with a history of chronic renal failure (serum creatinine levels: 6 mg/dl) and a right hip

prosthesis. Oral anticoagulation with a INR (International Normalized Ratio) > 5. He goes to the hospital with acute abdominal pain

radiated to his back with distention. Anemia and thrombocytopenia. (c) AR in the decubitus supine position showing signs of chronic

spondylitis and scoliosis with abundant fecal content that prevents us from performing an adequate assessment of the visceral

structures. Colon caliber-reduction at splenic ﬂexure level simulating a ‘‘colon cut-off sign’’ (arrow). Initially a study through

computed tomography (CT) without contrast (b) is performed. The coronal multiplanar reconstruction (MPR) shows non-obstructive

left renal atrophy and an enlarged unstructured left kidney with heterogeneous attenuation secondary to non-traumatic renal

hematoma (h). Wunderlich syndrome. No causal lesion can be identiﬁed. Then an axial cut of the CT-angiography (c) is performed

and two (2) small foci of active bleeding (arrow-heads) can be identiﬁed and visible in the venous phase only. The patient remained

stable with conservative treatment and correction of his coagulopathy.

44 42 46

et al. identify it in 83% - number that goes up to 85% when or exposure. There are diverging opinions but MSCT is

using chest radiographies and to 96% with ARs performed at present the test of choice to identify the presence,

in the left lateral decubitus position and that goes down to location and etiology of intestinal perforation, which is rel-

47---50

60% and 56% with ARs performed in bipedalism and in the evant information for an adequate surgical approach

decubitus supine position, respectively. Other papers do (Fig. 2).

not ﬁnd any differences in the positive predictive value of

the clinical examination for pneumoperitoneum after per- Renal colic

forming ARs. This low diagnostic yield, inherent to the

typical limitations of X-rays grows worse when its technical

When the clinical context is typical and in the presence of

quality is deﬁcient, due to incomplete anatomical coverage

hematuria the image modalities do not modify therapeutic

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Routine abdominal X-rays in the emergency department 387

Figure 5 Fifty-six (56) year-old woman at the emergency room presenting with diffuse abdominal pain and no gas or fecal

expulsion. During the examination she shows poor health with the presence of tachycardia and hypotension, abdominal silence and

‘‘loop mass’’ palpation. The AR (a) does not show any significant findings with the exception of flexure thickening in a jejunal loop

located at the left superior quadrant (arrow). (b) Computed tomography (axial view) in portal stage (70 sg) of the middle abdomen

region showing jejunal loop distention with no wall enhancement due to hypoperfusion (*) [compare it with the adjacent duodenum

(d)]. Perihepatic intraperitoneal liquid in between the loops (arrow-heads). Surgery conﬁrmed the diagnosis of intestinal obstruction

caused by bridles complicated with strangulation; 55 cm of necrotic small intestine were resected.

management in the absence of fever, durable pain or Diverticulitis, pancreatitis and acute cholecystitis

diagnostic uncertainty. Nevertheless the great majority of

existing clinical guidelines and recommendations indicate Acute diverticulitis does not associate useful semiology in

the immediate performance of an imaging test. Such test AR this is why it does not have any indications. When

should conﬁrm the presence of urethral calculi and provide it is necessary to conﬁrm the diagnosis and detect possi-

information about its location, size and composition, as ble complications CT is used. Beyond the presence of a

well as the presence of urethral obstruction. In the absence ‘‘sentinel loop’’ or a ‘‘colon cut-off sign’’ that may be

of lithiasis, it should identify alternative diagnoses such indicative of diagnosis of acute pancreatitis the AR does not

as complicated aorta aneurism. The sensitivity of the AR present speciﬁc ﬁndings of this clinical entity so its use is not

ranges from 44% to 77% in the different works published indicated. The latest review of the Atlanta guidelines does

being the speciﬁcity between 71% and 87%, and MSCT is the not recommend the use of image modalities including CT,

5,51,52

usual standard of care. When image tests are indicated during the ﬁrst week, except for cases of uncertain clinical-

the ultrasound usually comes ﬁrst in young patients yet the biochemical diagnosis or to rule out alternatives such as

CT identiﬁes the practical totality of lithiases and provides intestinal perforation or mesenteric thrombosis. The AR is

the required additional information. The indication for not indicated either as the initial diagnostic modality in

AR would be limited to the follow-up of urethral lithiasis cases of acute biliary pathology where the ultrasound is the

diagnosed through CT or ultrasound. modality of choice when suspicion of uncomplicated acute

cholecystitis.4

Acute appendicitis Intestinal ischemia

ARs are performed on 50---75% of patients with suspicion of Identifying gas on the intestinal wall or the portal branches

acute clinical apendicitis, despite the existing scientiﬁc through the AR, classically considered a pathognomonic

evidence that does not recommend it. A conclusive clini- sign of mesenteric ischemia, is an infrequent ﬁnding that

cal diagnosis does not require conﬁrmation through imaging at least denotes advanced disease. The growing use of

2,19

modalities, and in uncertain cases, the diagnostic yield abdominal CT has allowed the visualization of portal gas in

of ultrasound and CT is way much higher. Ultrasound is the more ‘‘benign’’ situations but its detection through X-ray

initial method of choice, especially in children and women associates a high risk of ischemia and a 75% mortality, and

in their fertile age; the MRI is an alternative in pregnant this is why immediate laparotomy is recommended even

women with inconclusive ultrasounds. in the absence of clinical signs. Nevertheless an AR can

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388 J.M. Artigas Martín et al.

Table 1 Problems derived from using abdomen radiographies in the emergency room.

• Unjustiﬁed increase of the radiation dose

•

The patient is in pain

•

Unnecessary increase of healthcare expenditure:

--- Direct: Obtention (tube, facilities, PACS), time of RTS and radiologist

---Indirect: Pregnancy test in a young girl prior to performing any abdomen radiographies

--- O f opportunity: resources being destined to non-proﬁtable techniques and modalities making other proﬁtable ones not

available for the right patient

•

Diagnostic errors due to irrelevant positive result or false negative. Incidental ﬁndings contributing to erroneous

management or delayed diagnoses

PACS: Picture Archiving and Communication System; RTS: radiodiagnosis technical specialist.

be normal even in the presence of extensive intestinal

26 Table 2 Proposal of indications for abdomen radiographies

ischemia (Fig. 3).

in the emergency room.

• Identiﬁcation of foreign bodies

•

Foreign bodies. Intra-abdominal catheters Location of catheters

•

Follow-up of urinary stones

•

They are cause of abdominal pain especially in pediatric age. Evolution of the obstruction

5,17

The sensitivity of the AR is 90% and its speciﬁcity 100% of • Desvolvulation control

course based on its nature. Such ﬁgures recommend keeping

its use in this clinical setting yet the AR should be reserved

•

for those cases where seeing the foreign body has clinical To develop research lines on the local, national and inter-

relevance, such as batteries or toxics, or forensic relevance, national level to clarify the guidelines for the use of AR

5,9

or else when the patient is symptomatic. An identical (Table 2) and write them in clinical guidelines and recom-

approach should be followed when monitoring abdominal mendations.

16 •

catheters. To control the demand for this type of examination as well

as the quality of reports that should not be left at the

mercy of clinicians under the consideration of a ‘‘lesser

Alternatives and patterns of action technique’’.

If the AR was a new technology today, it would be difﬁ- These proposals aim to rationalize the use of AR, limit

cult to justify its clinical introduction. It can be asserted its use and offer the patients alternative modalities with a

with Gans et al. that its role in adults with acute abdominal greater diagnostic yield in an effort to expedite the health-

pain is null today. Greene proposed reducing its emer- care process and ultimately, reduce the dose of radiation,

gency use in 1986, avoiding it in clinical situations where costs and unnecessary inconveniences.

the odds of radiological ﬁndings are minimal, in women in

fertile age, except when clearly indicated and as far as Ethical responsibilities

pregnancy has been ruled out, and when it is not mod-

ify clinical management. He suggests avoiding performing Protection of people and animals. The authors declare that

the abdominal series systematically and rather analyzing no experiments with human beings or animals have been

ﬁrst the projection in the decubitus supine position com- performed while conducting this investigation.

plemented eventually with thorax in bipedalism, and then

deciding the need for additional projections. An adequate Data conﬁdentiality. The authors declare that the protocols

clinical analytical orientation, followed by ultrasound and of their institution on the publishing of data from patients

CT when it is negative, is today the best management pat- have been followed.

tern of the urgent abdominal pathology. So until this concept

becomes generalized, it would be convenient for radiologists Right to privacy and informed consent. The authors

to follow these procedural guidelines, among others: declare that in this article there are no personal data from

patients.

• To recognize and publicize the excessive demand, usually

unjustiﬁed, for AR in Emergency Departments. Authors

• To analyze the causes for its popularity among clinicians

and its possible risks (Table 1). 1. Manager of the integrity of the study: JMAM, MMDG,

• To develop and implement training programs for young PPH.

physicians and foster constructive dialog in multidisci- 2. Study idea: JMAM, PPH.

plinary sessions with senior physicians while promoting 3. Study design: JMAM.

the role of the radiologist as a consultant. 4. Data mining: CRT, DMM.

Documento descargado de http://www.elsevier.es el 11/02/2017. Copia para uso personal, se prohíbe la transmisión de este documento por cualquier medio o formato.

Routine abdominal X-rays in the emergency department 389

5. Data analysis and interpretation: CRT, JMAM. 14. Böhner H, Yang Q, Franke C, Verreet PR, Ohmann C. Simple data

6. Statistical analysis: NA. from history and physical examination help to exclude bowel

7. Reference search: CRT, DMM, JMAM, PPH. obstruction and to avoid radiographic studies in patients with

acute abdominal pain. Eur J Surg. 1998;164:777---84.

8. Writing: JMAM, MMDG.

15. Morris-Stiff G, Stiff RE, Morris-Stiff H. Abdominal radiograph

9. Critical review of the manuscript with intellectually rel-

requesting in the setting of acute abdominal pain: temporal

evant remarks: JMAM, MMDG, CRT, DMM, PPH.

trends and appropriateness of requesting. Ann R Coll Surg Engl.

10. Approval of ﬁnal version: JMAM, MMDG, CRT, DMM, PPH.

2006;88:270---4.

16. Kellow ZS, MacInnes M, Kurzencwyg D, Rawal S, JAffer R,

Conﬂict of interests Kovacina B, et al. The role of abdominal radiography in the

evaluation of the nontrauma emergency patient. Radiology.

2008;248:715---6.

The authors declare no conﬂict of interests associated with

17. Ahn SH, Mayo-Smith WW, Murphy BL, Reinert SE, Cronan JJ.

this article.

Acute nontraumatic abdominal pain in adult patients: abdom-

This work is an update to be published in the journal

inal radiography compared with CT evaluation. Radiology.

Radiología exclusively. No material from former reviews or 2002;225:159---64.

journals has been used yet some ideas and concepts were

18. Feyler S, Williamson V, King D. Plain abdominal radiographs in

also summed up in the summary book from the 4th Meeting acute medical emergencies: an abused investigation. Postgrad

of SERAU 2013 ‘‘Radiología de urgencias. La oportunidad en Med J. 2002;78:94---6.

la crisis’’. 19. Prasannan S, Zhueng TJ, Gul YU. Diagnostic value of plain

abdominal radiographs in patients with acute abdominal pain.

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