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

Abstract

Ann R Coll Surg Engl 2010; 92: 697-699 697Patients admitted as an emergency with abdominal pain often undergo two standard imaging studies in the acute setting, namely an erect chest and supine abdominal radiograph. The indications for the erect chest radiograph (CXR) are first to exclude free gas under the diaphragm as a result of a perforated viscus, and second to attempt to exclude an intrathoracic condition as a cause for the abdominal symptoms.The Royal College of Radiologists (RCR) recommends a CXR be performed when there is a suspected visceral perforation, to exclude air under the diaphragm. This does not supersede a thorough clinical examination and should not be done routinely for patients with abdominal pain. 1Although the cost of a CXR is relatively small at approximately £20 per film, the fact that acute abdominal pain accounts for 50% of all emergency surgical admissions 2 means that the overall costs for this investigation are significant. Furthermore, although the radiation exposure of a CXR is low at 0.2 mGy, 3 all unnecessary radiation should be avoided. In addition, from a clinical perspective, requesting investigations which are unlikely to be of any benefit in obtaining the diagnosis simply delays the commencement of treatment.The aim of this study was to address this issue by examining both the quantity and quality of requests made for emergency chest radiographs in patient presenting with abdominal symptoms. It has been suggested that changes to the training schemes of junior doctors and the increased pressure on emergency departments to manage their patients within a limited time might increase the number of unnecessary investigations performed on emergency admission patients. This, in turn, may lead to an increased number of investigations with normal results. In this study we try to analyse the role of the chest X-ray (CXR) as a diagnostic tool in patients presenting with acute abdominal pain. PATIENTS AND METHODS A retrospective study was performed of the request forms and results of all chest radiography performed on patients admitted on the emergency surgical intake with acute abdominal pain through utilisation of the prospectively maintained electronic radiology database. The indications were compared to the guidelines published by the Royal College of Radiologists (RCR) which have been adopted as the standard of care. RESULTS A total of 334 chest X-rays were identified of which only 23 (7%) had new findings. Four (1%) patients had free gas under the diaphragm. Of the CXRs, 258 (77%) were reported normal whilst 53 (16%) had old changes which were described in their hospital records and previous radiographs. Of the CXRs with new findings, only 20 were clinically significant and, of these, four (1%) were surgically significant. CONCLUSIONS The majority of CXRs performed on emergency surgical admissions with abdominal pain are unnecessary. By obtaining a clear history, performing a thorough clinical examination and following the RCR guidelines most of the CXRs could be avoided. This wo...

Atypical presentation of a large pneumothorax in a young male: A case report

“…One study trying to assess if a chest X-ray should be ordered for every patient complaining of abdominal pain, ordered a chest radiograph on all patients admitted to the surgical ward (344 patients) for abdominal pain. The results revealed that 7% had a new finding and 1% had air under the diaphragm, respectively [20]. As a result, the vast majority of the X-rays that were requested were normal.…”

Spontaneous hemopneumothorax simulating acute abdominal affections

“…3 Considering the radiation exposure and waste of resources, it has been recently recommended that chest X-ray performed on patients admitted with acute abdominal pain are mostly unnecessary. 9 However, several cardiopulmonary indications in children can certainly mimic primary abdominal diseases, ranging from the mostly seen pneumonia, pleuritis, myocarditis, and pericarditis, to the lesser seen acute mediastinitis, aortitis, and spontaneous rupture of the esophagus. 1,10 In particular lungs and pleura are important parts of RUQ and always need to be considered in RUQ pain.…”

The acute abdomen

“…Four studies have reported its sensitivity for detecting free gas in the presence of hollow viscus perforation. 1- 4 We excluded the many other studies in this area that combined multiple plain film techniques (for example, abdominal, supine, or lateral decubitus films) or looked at iatrogenic pneumoperitoneum from our analysis (table⇓). [5][6][7][8] The level of evidence put forward by these studies varied greatly, with cohort sizes ranging from seven to 94 and reported sensitivities of 40-85% (table).…”