ACR Appropriateness Criteria® Acute Nonlocalized Abdominal Pain

Abstract

The range of pathology in adults that can produce abdominal pain is broad and necessitates an imaging approach to evaluate many different organ systems. Although localizing pain prompts directed imaging/management, clinical presentations may vary and result in nonlocalized symptoms. This review focuses on imaging the adult population with nonlocalized abdominal pain, including patients with fever, recent abdominal surgery, or neutropenia. Imaging of the entire abdomen and pelvis to evaluate for infectious or inflammatory processes of the abdominal viscera and solid organs, abdominal and pelvic neoplasms, and screen for ischemic or vascular etiologies is essential for prompt diagnosis and treatment. Often the first-line modality, CT quickly evaluates the abdomen/pelvis, providing for accurate diagnoses and management of patients with abdominal pain. Ultrasound and tailored MRI protocols may be useful as first-line imaging studies, especially in pregnant patients. In the postoperative abdomen, fluoroscopy may help detect anastomotic leaks/abscesses. While often performed, abdominal radiographs may not alter management.

The utility of abdominopelvic CT in pregnant patients with abdominal pain and a negative or inconclusive abdominal MRI

“…The differential diagnosis for abdominal pain in pregnant women is vast with common causes including ectopic pregnancy, acute appendicitis, biliary tract pathology, renal colic, and bowel pathology. Ultrasound can diagnose many of these causes, especially if used in conjunction with noncontrast MRI [6]. The utility of abdominopelvic MRI in the pregnant population has been well supported.…”

“…However, there is a role for abdominopelvic CT in the evaluation of abdominal pain in pregnant patients. The ACR appropriateness criteria mention the possible role for CT in the evaluation of pregnant women with nontraumatic abdominal pain if MRI is not readily available and ultrasound findings are equivocal or nondiagnostic [6]. In one study, there was no statistically significant difference in performance between MRI and CT in the evaluation of nontraumatic abdominal pain in pregnant patients with sensitivity 91% and 88%, specificity 85% and 90%, positive predictive value 81% and 91%, negative predictive value 94% and 85%, and diagnostic accuracy 88% and 88%, respectively [8].…”

Rapid Sequence MRI Analysis of Acute Abdominal Pain

“…Only a few of emergency cases can be diagnosed by physical and laboratory tests (2), because the differential diagnoses of AAP are wide and the most frequently encountered reasons are acute appendicitis (AA), biliary colic, cholecystitis, diverticulitis, ileus, gastrointestinal lumen perforation, pancreatitis and renal colic (3). Thus, radiological visualization is one of the most used methods for the diagnosis of the reasons for AAP (4). According to the conformity criteria of the American College of Radiology for the cases who have fever, delocalized stomach pain and lack of surgical background, the abdomen computerized tomography (CT) is the most suitable method (4).…”

“…Thus, radiological visualization is one of the most used methods for the diagnosis of the reasons for AAP (4). According to the conformity criteria of the American College of Radiology for the cases who have fever, delocalized stomach pain and lack of surgical background, the abdomen computerized tomography (CT) is the most suitable method (4). However, this methodology is rarely preferred for children and pregnant women because of the ionized radiation and contrast material usage which has nephrotoxic effects (5-7).…”

“…But there is a need for an operator and the stomach-intestine gas superposition prevents achieving high quality visualization, which are the disadvantages of the method (7,8). Besides, CT is more sensitive than US in delocalized AAP (4).…”