Adverse events are rare among adults 50 years of age and younger with flank pain when abdominal computed tomography is not clinically indicated according to the emergency physician

Abstract

Objective: Many emergency physicians (EPs) order ''confirmatory'' abdominal computed tomography (CT) in young flank pain patients, despite a high clinical suspicion of renal colic and the risk of radiation exposure. We measured the adverse outcome rate among flank pain patients identified as not requiring abdominal CT by the EP on a data form, regardless of whether CT was eventually ordered. Our secondary objective was to describe diagnoses other than renal colic identified by CT in this population. Methods: We conducted a prospective observational study at two community EDs. We asked staff EPs to complete a data sheet on patients ages 18 to 50 years with a first episode of flank pain, recording 1) if the flank pain was consistent with renal colic and 2) if the EP felt abdominal CT was indicated. Adverse outcomes (defined a priori as urgent surgical procedures, disability, or death) were assessed by research assistants at 4 weeks using telephone follow-up and a hospital records search. Results: We enrolled 389 patients; 353 completed follow-up (91%). The average age was 38.8 years, and 72.0% were male. Of 212 patients identified in the ''CT not indicated'' group, 2 had another diagnosis identified (unruptured diverticulitis and a ruptured ovarian cyst), but none had adverse outcomes (95% CI 0-1.4). Conclusions: Adverse events were rare (, 1.5%) among patients , 50 years old with flank pain when CT was not required according to the clinical assessment of the EP. Future research should assess the adverse outcomes of withholding CT in low-risk patients using a larger patient sample. RÉ SUMÉObjectifs: De nombreux mé decins d'urgence (MU) demandent une tomodensitomé trie (TDM) abdominale de « confirmation » chez les jeunes patients qui ressentent une douleur du flanc, malgré une forte pré somption de colique né phré tique et le risque d'exposition au rayonnement. Nous avons mesuré le taux de ré sultats dé favorables parmi les patients qui ressentaient une douleur du flanc et chez qui une TDM abdominale n'é tait pas né cessaire selon le MU sur le formulaire de donné es, peu importe qu'une TDM ait é té demandé e plus tard ou non. L'objectif secondaire é tait de dé crire les autres diagnostics que celui de la colique né phré tique, ré vé lé s par la TDM chez les patients concerné s. Mé thode: Nous avons mené une é tude d'observation prospective, dans deux services d'urgence (SU) communautaires. Nous avons demandé aux MU de remplir une fiche de donné es sur les patients â gé s de 18 à 50 ans, chez qui il s'agissait de la premiè re crise de douleur du flanc, en notant 1) si la douleur du flanc é tait compatible avec la colique né phré tique et 2) si, à leur avis, la TDM abdominale é tait indiqué e. Les é vé nements indé sirables (dé finis a priori comme une intervention chirurgicale d'urgence, l'incapacité ou la mort) ont é té é valué s, au bout de 4 semaines, par des adjoints à la recherche, au moyen d'un entretien té lé phonique de suivi et d'un examen des dossiers mé dicaux hospitaliers. Ré sultats: Au total, 3...

Ultrasound vs. Computed Tomography for Severity of Hydronephrosis and Its Importance in Renal Colic

“…Most patients who present to the ED with renal colic have few adverse events within a follow-up period of 180 days 16–40. We chose to perform follow up at 30 days based on the recommended trial of medical expulsion therapy of 4–6 weeks 8,10,41,42.…”

A different view of the sonographic classification of the appendix

“…Also, in a population of patients suspected of having appendicitis, a considerable number of children present with recurrent abdominal pain of other origins. These children could be exposed to CT radiation at every recurrent episode of abdominal pain if the use of CT were the protocol suggested for such clinical presentation [18,21,29]. Moreover, the cost of sonography is lower than that of CT. Transabdominal US has been performed as an imaging modality in patients with suspected appendicitis because sonography can rapidly help distinguish patients with appendicitis requiring computed tomography or surgery from those with a normal appendix.…”

What are the clinical effects of the different emergency department imaging options for suspected renal colic? A scoping review

“…Summary of current evidence A total of 21 publications addressed this question via different methods, including 8 retrospective studies, 7 prospective observational studies, 4 systematic reviews, and 2 RCTs (Table 2 in Supplement B). 2,6,12,15,[21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37] Only 1 study directly compared immediate CT to delayed CT in patients who were clinically improving in the EDand neither group had any alternative diagnoses considered lifethreatening. 28 "Alternative diagnoses" were not standardized and were not always clearly defined as dangerous, emergent, or urgent.…”

“…32,36 Of the studies, 2 defined young patients as those aged 18-50 years, and found no dangerous alternative diagnoses when clinicians suspected uncomplicated renal colic (95% CI 0-1.5% and 0-3%). 25,36 The range of 0%-9% reflects the heterogeneity of clinical contexts and patient characteristics: cohorts with older patients or less-strict inclusion criteria-such as in retrospective studies-had higher rates of dangerous alternative diagnoses.…”