Diagnostic errors related to acute abdominal pain in the. Patients with abdominal pain from a presumed renal source should undergo a noncontrast ct of the abdomen and pelvis for initial imaging, according to the acr score8. Diagnosis of acute appendicitis in adults abdominal imaging. Table 31 outlines the typical time course associated with different diseases causing abdominal pain. Diagnostic imaging of acute abdominal pain in adults american. The obturator sign was positive, with increased pain, level 4, in the right lower quadrant. Pdf imaging of nontraumatic acute abdominal pain in adults. Nontraumatic acute abdominal pain aap is one of the most common symptoms in. Oct 01, 2009 therefore, imaging plays an important role in the treatment of patients with acute abdominal pain. The elderly, the immunocompromised, women of childbearing age, and patients with prior abdominal surgeries are at a. The causes of abdominal pain and its pathophysiology, the evaluation of the adult with abdominal pain in the emergency department, and the evaluation of abdominal pain related to trauma is discussed elsewhere. The most common causes of acute abdomen are appendicitis, biliary colic, cholecystitis, diverticulitis, bowel obstruction, visceral perforation. Likely clinical diagnosis imaging recommendation comments.
Acute appendicitis aa is among the most common causes of lower abdominal pain leading patients to attend the emergency department and the most common diagnosis made in young patients admitted to the hospital with an acute abdomen. Nontraumatic acute abdominal pain aap is one of the most common symptoms in adults presenting to the emergency department ed. In children with rlq pain suggestive of acute appendicitis, us is the first line imaging method due to its relatively high sensitivity and specificity and lack of ionizing radiation score9. Patient cases illustrate the differential diagnosis and management of an often misdiagnosed cause of severe acute abdominal pain. Imaging of nontraumatic abdominal emergencies in adults. Related articles ct suite preparedness, chest imaging guidance, and covid19s breast imaging impact. It has been shown that routine diagnostic imaging lowers the nar to 1.
Evaluation of abdominal pain in the emergency department. Although it is oftentimes held for a purely surgical problem, two thirds of patients do not require operative management. The actual diagnostic workup of a patient with acute abdominal pain presenting to the ed varies greatly between hospitals and physicians. Imaging plays a key role in the diagnostic workup of patients with nontraumatic acute abdominal pain aap in emergency department ed. Evaluation of acute abdominal pain in adults sarah l. Evaluating abdominal pain requires an approach that relies on the. Objective diagnostic errors in the emergency department ed are harmful and costly. The provider has taken a history, performed a physical exam, and obtained laboratory tests.
Diagnostic pitfalls and accuracy of diagnosis in acute abdominal pain article in scandinavian journal of gastroenterology 4110. Her abdomen was diffusely tender, with significant tenderness to deep palpation in the right upper quadrant at first. In haemodynamically stable patients with acute severe and generalized abdominal pain, mdct is now the preferred imaging test and gives invaluable diagnostic information, also in unstable patients after stabilization. Five percent of patients presenting to the er with acute abdominal pain have acute cholecystitis. Assessment of acute abdomen differential diagnosis of.
The diagnosis, however, can be obscure and therefore some centres support the use of routine imaging in the form of us andor ct scanning. It may be the sole indicator of the need for surgery and must be attended to swiftly. Acute nontraumatic abdominal pain in adult patients. May 29, 2009 conclusions imaging plays an increasingly important role in diagnosis of etiology of acute abdomen ct is widely used in several acute abdominal indications. The sensitivity is 95% to 96% and specificity is 98%. American college of radiology appropriateness criteria.
Tomorrow, ill go over the laboratory and imaging diagnosis of abdominal pain. An imaging guide to abdominal pain mdedge family medicine. Acute appendicitis features a characteristic march of symptoms. Evaluation of abdominal pain in the emergency department hartmut gross, m. Assessing abdominal complaints without imaging correctly identifies the etiology in only 43% to 59% of cases, and scoring algorithms do little to improve this accuracy. Digital rectal examination in patients with acute abdominal pain. When patients present with acute nontraumatic abdominal pain, knowing what disorders and which imaging modalities to consider is essential. Abrief discussion of the common causes of acute abdominal emergencies with the appropriate and uptodate usage of imaging diagnostic strategies and techniques with illus.
Diagnostic approach and management of acute abdominal pain. Generations of medical students and trainee doctors have been taught that digital rectal examination dre is an essential part of the clinical examination required in any patient with abdominal pain suspected of having abdominal or pelvic pathology. Sonography should be the first imaging technique in adult patients for the diagnosis of acute appendicitis and triage of acute abdominal pain. Lower abdominal pain is caused by lesions of the lower git or pelvic organs. Practice recommendations choose ultrasonography as the initial imaging test for patients with pain in the right upper quadrant. Download citation diagnostic imaging of acute abdominal pain in adults acute abdominal pain is a common presentation in the outpatient setting and can.
Diagnostic imaging pathways abdominal pain chronic population covered by the guidance this pathway provides guidance on imaging in adult patients with non acute abdominal pain. Diagnostic practice for acute abdominal pain at the. Guideline diagnostics in acute abdominal pain in adults. Emergency department visits for chest pain and abdominal pain. The incidence of acute abdominal pain ranges between 510% of all visits at emergency department. Therefore, the differential diagnosis of abdominal pain can be organized based on whether patients are presenting with their first episode of acute abdominal pain, a recurrent episode of acute abdominal pain, or chronicsubacute abdominal pain. In patients suspected of an urgent condition, additional imaging is. The role of laboratory data in narrowing a differential diagnosis should not be underestimated.
Start studying diagnostic imaging of acute abdominal pain in adults. Ct should be used as a complementary study for selected cases. An approach is used based on categorization of symptoms. Emergency abdominal radiology table ii suggested algorithmic imaging approach for the diagnostic workup of acute. Acute abdominal pain is a common presentation in the outpatient setting and can represent conditions ranging from benign to lifethreatening. Acute abdominal pain accounts for 710% of all emergency department accesses. Diagnosis of appendicitis in children and pregnant women is discussed separately, as are the pathogenesis, clinical manifestations, differential diagnosis, and management.
Imaging strategies for detection of urgent conditions in patients with. Acute and severe abdominal pain, however, is almost always a symptom of intra abdominal disease. Results 661 65% patients had a final diagnosis classified as urgent. Diagnostic sensitivity and specificity are 5088% and 8088%, respectively. Acute abdominal pain can represent a spectrum of conditions from benign and selflimited disease to surgical emergencies. Imaging patients with acute abdominal pain radiology. Diagnostic imaging of acute abdominal pain in adults attending kvg medical college and hospital, sullia. Ultrasonography is the initial imaging test of choice for patients presenting with right upper quadrant pain. If imaging is required, the most appropriate modality will depend on the symptoms present and the individual clinical scenario. Diagnostic imaging of acute abdominal pain in adults attending kvg. Conclusions imaging plays an increasingly important role in diagnosis of etiology of acute abdomen ct is widely used in several acute abdominal indications. Diagnostic imaging for acute abdominal pain in an emergency.
Abdominal hernia abdominal muscle wall pain abdominal pain evaluation abdominal wall pain causes acalculous cholecystitis acute abdominal pain acute abdominal pain causes in adults acute cholecystitis acute gallstone cholangitis adynamic ileus appendicitis biliary colic bowel pseudoobstruction choledocholithiasis chronic mesenteric ischemia. Our focus is acute abdominal pain in general, but we also discuss a number of frequently encountered urgent diagnoses in patients with acute abdominal pain. All imaging investigations should be justified a responsibility shared by the referrer and the imaging specialist. Assessment of acute abdomen in the emergency department mario luka csenar summary. Employing these guidelines helps providers enhance quality of care and contribute to the most efficacious use of radiology. The purpose of this study was to compare the diagnostic accuracy of contrastenhanced mri with that of contrastenhanced ct for the diagnosis of appendicitis in adolescents when interpreted by abdominal radiologists and pediatric radiologists. Diagnostic imaging in adults with chronic abdominal pain is overused. This pathway provides guidance for imaging adult patients with nontraumatic acute abdominal pain. Transabdominal ultrasound should be the firstline imaging test. The etiology of the pain may be any of a large number of processes. Abdominal pain is the primary presenting complaint of patients with acute appendicitis. Acute abdominal pain accounts for 510% of visits to the emergency department.
C order computed tomography with contrast of the abdomen andor pelvis for adults with acute pain of new onset in the right or left lower quadrant, or both. Imaging for chronic abdominal pain in adults australian. Medical imaging is rapidly evolving due to advanced computer applications. Evaluation of acute abdominal pain in adults american. Diagnostic approach and management of acute abdominal pain article pdf available in acta medica indonesiana 444. Imaging of nontraumatic acute abdominal pain in adults. At a minimum, a radiologist interpreting an imaging study of a patient with acute abdominal pain should be familiar with the patients blood cell counts, liver function tests, amylase and lipase levels, and urinalysis if they are available. Upper abdominal pain is caused by lesions of the upper git.
Imaging and laboratory testing in acute abdominal pain. Guideline for the diagnostic pathway in patients with acute. If there is clinical suspicion of an urgent condition the guideline advises that additional imaging be performed. While the clinical diagnosis may be straightforward in patients who present with classic signs and symptoms, atypical presentations may result in diagnostic confusion and delay in treatment. Some documents for download on this website are in a portable. When patients present with acute nontraumatic abdominal pain, knowing what disorders. Imaging patients with acute abdominal pain rsna publications. Both the referrer and the imaging specialist should ensure all procedures are justified, with potential benefits outweighing the risks. Gangrene and perforation of the gut can occur diagnostic imaging in adults with chronic abdominal pain is overused. Gangrene and perforation of the gut can occur of symptoms in certain conditions eg, interruption of the intestinal blood supply due to a. Diagnostic imaging pathways acute abdomen overview tabpathway home population covered by the guidance. Clinical diagnosis of abdominal pain in the elderly is complicated by many factors, including diminished immune function, vague symptoms, multiple comorbidities, and normal senescent anatomic alterations. Apr 01, 2008 acute abdominal pain can represent a spectrum of conditions from benign and selflimited disease to surgical emergencies.
Acute abdominal pain is a common chief complaint in patients examined in. Records of 1,000 consecutive patients presenting to the emergency department with acute abdominal pain from april to june 1998 were retrospectively. Acute abdominal pain, defined as pain of less than a week in duration, is a common complaint among elderly patients. To compare the diagnostic yield of abdominal radiography with that of computed tomography ct in adult patients presenting to the emergency department with nontraumatic abdominal pain. Amongst other recommendations, the guideline advises the use of creactive protein and white blood cell count to differentiate urgent from nonurgent causes in an adult with acute abdominal pain presenting at the emergency department.
Acute abdominal pain is one of the most commonly encountered leading symptoms in the emergency department. An approach to the causes of acute abdominal pain in adults. Therefore, imaging plays an important role in the treatment of patients with acute abdominal pain. When fever is present, the need for quick, definitive diagnosis is considerably heightened. Severe lower left abdominal pain diagnostic imaging. Unlabelled three imaging modalities are available for the diagnosis of acute appendicitis. Be wary of early diagnostic closure and misdiagnosis of abdominal pain. Differential diagnosis of abdominal pain in adults. Acute abdominal pain in adults approach to the patient. Abdominal emergencies of hospital visits may include surgical and nonsurgical emergencies. Us should be the initial imaging study for the diagnosis of ruq pain and acute cholecystitis.
Acute abdominal pain aap is a common complaint in the emergency department ed. Optimization of diagnostic imaging use in patients with acute abdominal pain optima. Computed tomography ct is recommended for evaluating right or left lower quadrant pain. Triage and disposition acute abdominal pain frequently requires urgent. The utility of ct scan for the diagnostic evaluation of.
Abdominal ct is superior to us and is required immediately in patients with atypical clinical presentation of appendicitis and suspected perforation. Diagnostic imaging is often not indicated in patients with chronic abdominal pain. Optimization of diagnostic imaging use in patients with. We aimed to evaluate the use and diagnostic performance of imaging techniques in adult patients with aap in an ed in italy. Acute nonlocalized abdominal pain appropriateness criteria. Early severe vomiting indicates a high obstruction of the git. Imaging of nontraumatic acute abdominal pain in adults presenting. Abdominal pain, acute in adults murtaghs diagnostic. The goal of this activity is to provide information on the differential diagnosis of acute. The optima study was designed to provide the evidence base for constructing an optimal diagnostic imaging guideline for patients with acute abdominal pain at the ed. Assessment of acute abdomen in the emergency department. Many of these causes will be benign and selflimited, while others are medical urgencies or even surgical emergencies. Imaging evaluation of acute abdominal pain radiology key.
Apr 01, 2015 acute abdominal pain is a common presentation in the outpatient setting and can represent conditions ranging from benign to lifethreatening. Learn vocabulary, terms, and more with flashcards, games, and other study tools. In patients with highgrade intestinal obstruction, ultrasound evaluation of the abdomen historically had diagnostic sensitivity approaching 85%. Appropriate use of imaging for acute abdominal pain. Only studies with adult patients 18 years were eligible for. Imaging is especially helpful in the elderly with acute abdominal pain and.
Conventional radiography has limited diagnostic value in the assessment of most patients with abdominal pain. Diagnostic accuracy of mri versus ct for the evaluation of. Acr appropriateness criteria american college of radiology. Diagnostic imaging pathways acute abdomen overview. The usefulness of mri in emergency patients presenting with acute abdominal pain may be low at this time.
Acute abdominal pain gastrointestinal disorders msd. Evaluation and management of acute abdominal pain in the emergency department. Diagnostic imaging in ed varies for adults with suspected appendicitis. Diagnostic pitfalls and accuracy of diagnosis in acute. Acute abdominal pain is a common chief complaint in patients. If the patient history, physical examination, and laboratory testing do not identify an underlying cause of pain and if serious pathology remains a clinical concern, diagnostic imaging is indicated. Diagnostic imaging of acute abdominal pain in adults. Pdf optimization of diagnostic imaging use in patients. Even when imaging is indicated, ct scanning is often not the investigation of choice. When discussing which laboratory tests or imaging to order in the setting of acute abdominal pain, it is practical to organize information by disease process eg, acute appendicitis, cholecystitis. An approach is used based on categorization of symptoms with associated links to more specific pathways.
Appendicitis is the most common diagnosis for patients to be referred to general surgery with acute abdominal pain. Appendicitis is frequently diagnosed in the emergency department, most commonly using ct. Abdominal pain is usually a feature, but a pain free acute abdomen can occur, particularly in older people, children, and the immunocompromised, and in the last trimester of pregnancy. Because us and ct are widely available, radiography is rarely indicated for the examination of patients with acute abdominal pain, with the exception of select patients groupsfor example, patients with bowel obstruction. Clinical assessment is sufficient to decide on the level of urgency, but not on the specific. Imaging in the adult patient with nontraumatic abdominal pain. Imaging recommendations for evaluating select causes of acute abdominal pain in adults. Diagnostic imaging of acute abdominal pain in adults researchgate. Clinical manifestations and differential diagnosis, section on epidemiology. Appendicitis is the most common abdominal emergency. Imaging of nontraumatic acute abdominal pain in adults presenting to the emergency department. Order computed tomography with contrast of the abdomen andor pelvis for adults with acute pain of new onset in the right or.
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