Persistently High Rates of Abdominal Computed Tomography Imaging Among Patients With Inflammatory Bowel Disease Who Present to the Emergency Department

Abstract

Background Recent guidelines recommended judicious use of abdominal computed tomography (CT) in the emergency department (ED) for inflammatory bowel disease. Trends in CT utilization over the last decade, including since the implementation of these guidelines, remain unknown. Methods We performed a single-centre, retrospective study between 2009 and 2018 to assess trends in CT utilization within 72 h of an ED encounter. Changes in the annual rates of CT imaging among adults with IBD were estimated by Poisson regression and CT findings by Cochran-Armitage or Cochran-Mantel Haenszel tests. Results A total of 3000 abdominal CT studies were performed among 14,783 ED encounters. CT utilization increased annually by 2.7% in Crohn’s disease (CD) (95% confidence interval [CI], 1.2 to 4.3; P = 0.0004), 4.2% in ulcerative colitis (UC) (95% CI, 1.7 to 6.7; P = 0.0009) and 6.3% in IBD unclassifiable (95% CI, 2.5 to 10.0; P = 0.0011). Among encounters with gastrointestinal symptoms, 60% with CD and 33% with UC underwent CT imaging in the final year of the study. Urgent CT findings (obstruction, phlegmon, abscess or perforation) and urgent penetrating findings alone (phlegmon, abscess or perforation) comprised 34% and 11% of CD findings, and 25% and 6% of UC findings, respectively. The CT findings remained stable overtime for both CD (P = 0.13) and UC (P = 0.17). Conclusion Our study demonstrated persistently high rates of CT utilization among patients with IBD who presented to the ED over the last decade. Approximately one third of scans demonstrated urgent findings, with a minority demonstrating urgent penetrating findings. Future studies should aim to identify patients in whom CT imaging is most appropriate.

Perceived value of computed tomography imaging for patients with inflammatory bowel disease in the emergency department: a Canadian survey

“…Importantly, a proportion of physicians overestimated the rates of IBD complications, particularly in UC where IBD complications are rare. 6 , 18 , 20 , 26 , 27 Most published studies report rates of obstructive and penetrating complications of less than 5% each on APCT imaging in the ED. 6 , 20 , 26 , 27 These rates are much lower than the perceived rates reported by emergency physicians and surgeons in our study.…”

“… 6 , 20 , 26 , 27 These rates are much lower than the perceived rates reported by emergency physicians and surgeons in our study. In CD, disease complications detected by APCT imaging are more common, 6 , 18 , 19 , 22–26 , 28 with most published series reporting rates of obstructive complications of 10–27%, 7–10% for septic complications, but less than 5% for penetrating complications. 6 , 18 , 19 , 23–25 , 27 , 28 Interestingly, 32% of gastroenterologists and 55% of emergency physicians in our study underestimated the proportion of imaging studies with obstructive complications, while 44% of gastroenterologists and 77% of surgeons overestimated the proportion of imaging studies with septic complications and 69% of surgeons and 34% of emergency physicians overestimated the proportion of imaging studies with perforation.…”

“…For analytic purposes, we converted the data from questions pertaining to the perceived proportion of APCT imaging findings into dichotomous groups using cut-offs based on the average rates of each IBD finding reported in the literature 6 , 18–20 , 23–25 , 27 , 28 . Cut-offs included >50% for inflammation alone, ≤25% for bowel obstruction, ≤10% for septic complication, and ≤5% for perforation for CD and ≥75% for inflammation alone, ≤10% for bowel obstruction, ≤10% for septic complication, ≤10% for megacolon, and ≤5% for perforation for UC.…”

“…Despite the increased awareness of the potential harms of APCT imaging, the rates of APCT utilization have continued to rise over the past two decades among patients with IBD in the ED. 18 , 19 Furthermore, only a minority of patients with IBD who undergo APCT imaging have urgent penetrating or structuring complications (abscesses, phlegmon, perforation, or obstruction) suggesting that APCT imaging is not always necessary. 18–26 To better understand physicians’ preferences and perceived practices regarding APCT utilization in the IBD population, we performed a national survey of gastroenterologists, surgeons, and emergency physicians.…”

The effect of the size of gold nanoparticle contrast agents on CT imaging of the gastrointestinal tract and inflammatory bowel disease

“…7,8 In one Canadian study, CT was performed in 17-22% of IBD patients presenting to emergency rooms. 9 CT is an X-ray based, whole body imaging technique that is relatively inexpensive, simple to use, and fast (image acquisition time <5 s). The speed of CT systems makes imaging of IBD patients easier by minimizing motion artifacts from bowel movement.…”