Routine abdominal X-rays in the emergency department: A thing …webcir.org/.../2017/1_febrero/esp/rx_abdomen_eng.pdf · 2017-02-13 · Routine abdominal X-rays in the emergency department

Radiología. 2015;57(5):380---390

www.elsevier.es/rx

UPDATE IN RADIOLOGY

Routine abdominal X-rays in the emergency

department: A thing of the past?�

J.M. Artigas Martín a,∗, M. Martí de Graciab, C. Rodríguez Torres c,D. Marquina Martínez c, P. Parrilla Herranzd

a Radiología de Urgencias, Servicio de Radiodiagnóstico, Hospital Universitario Miguel Servet, Zaragoza, Spainb Radiología de Urgencias, Servicio de Radiodiagnóstico, Hospital Universitario La Paz, Madrid, Spainc Servicio de Radiodiagnóstico, Hospital Universitario Miguel Servet, Zaragoza, Spaind Servicio de Urgencias, Hospital Universitario Miguel Servet, Zaragoza, Spain

Received 2 January 2015; accepted 22 June 2015

KEYWORDSAbdomen;Plain films;Emergencies;Diagnosis;Indications;Appropriateness

Abstract The large number of abdominal X-ray examinations done in the emergency depart-

ment is striking considering the scant diagnostic yield of this imaging test in urgent disease. Most

of these examinations have normal or nonspecific findings, bringing into question the appropri-

ateness of these examinations. Abdominal X-ray examinations are usually considered a routine

procedure or even a ‘‘defensive’’ screening tool, whose real usefulness is unknown. For more

than 30 years, the scientific literature has been recommending a reduction in both the number

of examinations and the number of projections obtained in each examination to reduce the

dose of radiation, unnecessary inconvenience for patients, and costs.

Radiologists and clinicians need to know the important limitations of abdominal X-rays in the

diagnostic management of acute abdomen and restrict the use of this technique accordingly.

This requires the correct clinical selection of patients that can benefit from this examination,

which would allow better use of alternative techniques with better diagnostic yield, such as

ultrasonography or computed tomography.

© 2015 SERAM. Published by Elsevier España, S.L.U. All rights reserved.

PALABRAS CLAVEAbdomen;Radiografía;Urgencias;Diagnóstico;

Radiografía del abdomen en Urgencias. ¿Una exploración para el recuerdo?

Resumen La escasa rentabilidad diagnóstica de la radiografía de abdomen en patología

urgente contrasta con el elevado número de exploraciones que se realizan. La mayoría arroja

hallazgos normales o inespecíficos, lo que cuestiona la idoneidad de su indicación. Suele

� Please cite this article as: Artigas Martín JM, Martí de Gracia M, Rodríguez Torres C, Marquina Martínez D, Parrilla Herranz P. Radiografía

del abdomen en Urgencias. ¿Una exploración para el recuerdo? Radiología. 2015;57:380---90.∗ Corresponding author.

E-mail address: [email protected] (J.M. Artigas Martín).

2173-5107/© 2015 SERAM. Published by Elsevier España, S.L.U. All rights reserved.

Documento descargado de http://www.elsevier.es el 11/02/2017. Copia para uso personal, se prohíbe la transmisión de este documento por cualquier medio o formato.

Routine abdominal X-rays in the emergency department 381

Indicaciones;Adecuación

considerarse un procedimiento rutinario o incluso una herramienta ‘‘defensiva’’de cri-

bado, cuya utilidad real se desconoce. Desde hace más de 30 anos, se recomienda en la liter-

atura científica reducir tanto el número de exploraciones como el de proyecciones realizadas,

en aras a disminuir dosis de radiación, molestias innecesarias para los pacientes y costes.

Radiólogos y clínicos deben conocer las importantes limitaciones de la radiografía de abdomen

en el manejo diagnóstico de la patología abdominal aguda y restringir su empleo. Para ello, es

imprescindible una adecuada selección clínica de los pacientes candidatos a estudio de imagen,

que permite un empleo ágil de técnicas alternativas más rentables como la ecografía o la

tomografía computarizada.

© 2015 SERAM. Publicado por Elsevier España, S.L.U. Todos los derechos reservados.

Introduction

The evaluation of a healthcare technology is a complextask whose objective is to balance the actual benefits forthe patient and the possible risks, disadvantages and costsderived from its implementation. The radiological settingincludes five levels referring progressively to technical qual-ity, diagnostic yield, diagnostic and therapeutic impact andhealth progression.1 Parameters such as image resolutionare useful to evaluate the first level while sensitivity andspecificity or predictive value are useful to evaluate thesecond being relatively easy up to this point to verifyprogression with respect to the previous standard. Mak-ing progress in the evaluation process is extremely difficultespecially in techniques consolidated by use, for which thereare no defined evaluation guidelines and where scientificevidence can be of low quality or non-existent. In practiceit is assumed that an examination is useful when the resultmodifies clinical management, to confirm or rule out a diag-nostic choice or else to stage the risk of a potentially serioussituation.2 When radiology is used routinely as a ‘‘rubberstamp’’ to be stamped on every patient1 it is difficult toprove its effectiveness, since there is no previous clinicalquestion to answer. Also an examination that does not con-tribute any information can only contribute confusion (e.g.,incidental or unspecific findings).3 The following pages areintended to show how abdominal radiography (AR) in theemergency setting is an example in the negative way of allthe above: an imaging modality consolidated by use of whoseclinical usefulness there is little scientific evidence---or ifthere is any evidence there is negative evidence---in spiteof which it maintains a long list of possible clinical appli-cations that everyday reality surpasses broadly making it aroutine for every patient that goes to the emergency ser-vices (ES) with abdominal symptomatology regardless of itscharacteristics and the degree of severity. Radiologists andclinicians alike need to know the important limitations of ARto detect acute pathologies with the promptness and pre-cision of other image modalities basically ultrasounds andcomputed tomographies (CT). They must resort to the lat-ter regardless of the AR result when the clinical contextsuggests a serious pathology. In mild cases, the remote prob-ability of positive findings also advises against the use ofAR.

Diagnostic approach to patients with acuteabdominal symptomatology

Pain is the most constant clinical manifestation of acuteabdomen condition and a common cause for going to the ESin adults.4---6 The medical history, the physical examinationand lab tests are the starting point of its clinical study andusually enough in mild cases. In the remaining cases althoughthey can give clues about the nature and location of thecausal process they often yield unspecific results that needto be completed with image tests.5 Such tests should provideideally either in positive or negative significant informationfor the therapeutic decision. A positive result establishes adiagnosis (e.g., intestinal obstruction [IO]), or its etiology(e.g., peritoneal adhesion) and location (e.g., distal ileum),and it even allows us to stage its severity (e.g., closed-loopobstruction with signs of intestinal ischemia). A reliable neg-ative result promotes an early discharge from the ES avoidingadmissions and unnecessary expenses. When correctly indi-cated and performed timely a decisive image examinationimproves diagnostic accuracy, promotes surgical indication,planning and approach, speeds up the discharge or admissiondecision-making process, reduces hospital stays, improvesservice quality and diminishes morbimortality.7,8 On the con-trary image modalities add little value, or even subtractvalue, in patients with mild symptomatology, candidates toclinical management2,5 or when the modality selected is notthe right one---situations that only increase the dose of radi-ation, the time spent in the ER and the patient’s discomfortand healthcare costs.5

Acute abdominal pain can be associated to a vari-able degree of severity and be due to multiple causes.5

Apendicitis, IO, diverticulitis, cholecystitis, renal colic,acute intestinal pathology---including ischemia and perfora-tion---pancreatitis or gynecological disorders are diagnosesthat need to be taken into consideration whose frequencyvaries in the different publications and epidemiological pro-files. Although one in 3 patients who go to the ER dueto abdominal pain is discharged without identifying anycauses,3,4,7,9 expediting those discharges requires decisiveimage modalities (Fig. 1). The diagnostic management ofacute abdomen differs from one country to another withtwo major trends, early use of CT or clinical examina-tion complemented with simple radiography and ultrasound


382 J.M. Artigas Martín et al.

Figure 1 Thirty-seven (37) year old male presenting with abdominal pain and impaired intestinal rhythm with reduced gas fecal

emission. (a) Abdominal radiography (AR) in decubitus supine position showing a pattern of anodyne gas with a slightly dilated small

intestine loop in the left superior quadrant/flank (arrow). (b) The AR in bipedalism shows multiple hydroaerial levels (arrow heads)

with very few gas in the colon indicative of small intestine occlusion. A CT was performed (not shown) giving normal results. After

24 h the clinical condition resolved spontaneously.

with CT on demand.7---10 Although the former option seemsto improve diagnostic accuracy, prospective studies havenot shown any significant differences in other measures.10

Most clinical guidelines indicate image studies depend onthe location of the pain, being the ultrasound the 1stchoice for the right upper quadrant and the pelvis, andCT for the remaining quadrants. Laméris et al.7 attainmaximum sensitivity with a minimal radiation dose begin-ning by AR followed by ultrasound and CT in uncertaincases.

Simple abdomen X-ray in the emergencyroom. Real use and scientific evidence

The low diagnostic yield of AR2 has been recognized sincethe 1960s yet despite this its systematic use is recommendedin patients with acute abdomen pain.11 In 1982, Eisenberget al.12 suggested restricting AR to patients with moderateor serious abdominal pain and in cases of clinical suspicionof IO, urethral calculi, ischemia or vesicular pathology. Withthis approach, they eliminate 53.7% of the examinations,without any clinical repercussions. Many subsequent studieshave proven the absence of scientific basis for performingAR to all patients with abdominal symptomatology2,5,9,13---20

---a usual practice in the ES even today when the availabil-ity of other more refined modalities such as ultrasound andCT is practically universal. There is no direct informationavailable about the use of AR in patients that go to the ER

due to abdominal pain. In most published series ARs are per-formed in more than half of these patients regardless of thecharacteristics or the intensity of the pain,14,21 surpassing90% in some.15 These are some of the factors that promotethe unjustified use of AR: the consideration the ‘‘routineexamination’’ in the ER, the lack of control of the simpleX-ray by the radiologist and the electronic request systemsalong with training deficits among new physicians and theresistance of ‘‘senior’’ physicians to change their traditionalpractices.15,18,20

During the last few years the most important radiologicalsocieties around have been continually reducing the lists ofindications for AR included in their recommendations.22---24

In its 2011 revision the American College of Radiology(ACR)23 eliminates abdominal pain as an indication for AR.With a more practical approach in their Diagnostic ImagingPathways24 the Royal Australian and New Zealand Collegeof Radiologists recommend performing ARs only in cases ofsuspicion of perforation or IO, ingestion of a foreign body,unspecific moderate or serious abdominal pain and follow-up of calculi in the urinary tract. Nevertheless even theseindications are being revised today.

Different publications place the ideal rate of AR usedue to acute abdominal pain below 10%.2,21 Implementingthe previous unrestrictive recommendations most authorsagree that the number of ARs performed could be reducedby 50---70%, or even in larger percentages.5,9,15,17,21,25 Logi-cally, the diagnostic yield of AR is incidental in the group ofpatients where there is no indication.2,9,15



The ‘‘abdominal series’’. Necessaryprojections

AR in supine position must include from the thoracicdiaphragm to the obturator foramen, occasionally needingtwo exposures. This is the basic projection, the start-ing point of the so-called ‘‘abdominal series’’ that alsoincludes another projection ‘‘with a horizontal beam’’ inbipedalism or lateral decubitus position and a chest X-ray in bipedalism.23,26 The latter, performed as part of anabdominal series, contributes useful information in 10---15%of the cases, about the thoracic pathology (pneumonia,pericarditis) causing abdominal symptomatology or thoracicmanifestations of an abdominal process (pleural effusion inpancreatitis or abdominal infection). It can detect smallquantities of intraperitoneal gas better than AR in bipedal-ism. It is recommended to maintain bipedalism or the lateraldecubitus position for at least 10 min before obtaining theX-ray exposure to let the gas rise above the liver dome.26

Mirvis et al.27 opposed the use of AR in bipedalism in1986 because it rises costs and contributes little useful infor-mation. The AR in the decubitus prone position favors thedisplacement of the gas in the transverse colon toward itsascending and descending segments. Performing it is diffi-cult in seriously ill patients where the only alternative isoften laterolateral projections of the abdomen in the supineposition with a horizontal beam, tangential to the anteriorwall for the detection of underlying gas. Today the gen-eralized opinion is to consider the ‘‘abdominal series’’ assuperfluous whose dose of radiation and costs are similar toor surpass those of low-dose CT with much less information.2

Arguments against the use of abdomen X-rayin the emergency room

The validity and reliability of AR are very low in the assess-ment of abdominal pathology; therefore errors are frequent,especially in the emergency setting.9 That is why its findingsmust be interpreted with caution always within the patient’sclinical context and based on its accuracy. In the studies pub-lished, the validity of AR in patients with acute abdominalpain is not usually expressed through the usual parametersof sensitivity, specificity and predictive value due to theabsence of adequate reference standards in many studies2

and to the multiplicity of signs and etiological options mak-ing it impossible to set up the usual contingency tables2 × 2. Most often, its diagnostic usefulness is expressedin terms of positive findings, change of diagnosis or clini-cal management of patients or degree in which the imagemodality proves to be of diagnostic utility for the ER physi-cian. When it comes to reliability, Markus et al.28 studiedinterobserver variability in the interpretation of AR by dif-ferent radiologists and they found an adequate concordancein the identification of pneumobilia, renal lithiasis or pneu-moperitoneum, and worse results in the detection of smallintestine obstruction, cholelithiasis, colitis, thumbprinting,dilatated intestinal loops, pathological hydroair levels, nor-mal gas pattern or masses. The worst results were for theassessment of colon obstruction, unspecific gas patterns,complete obstruction of the small intestine, location ofthe obstruction site in the small intestine, diffused/located

ileum, ascites and urethral lithiasis. The correlation was lowto determine partial or complete obstruction of the smallintestine and its proximal, medial or distal location.

With important variations based on the sign or pathol-ogy being considered the diagnostic yield of AR is around10%2,5,17---19,21,29,30 and though some authors rise the percent-age of relevant findings to 15.8%,14 others do not find anysignificant impacts of AR in the clinical decision-makingprocess.16 Such yield should improve with the level of adhe-sion to clinical recommendations that is usually. Morris-Stiffet al.15 in their series find that 32% of requests abide by thestandards of the Royal College of Radiologists (RCR) withpositive results for this group of around 76.7% as opposed to3.3% for patients with inadequate requests. Feyler et al.18

say that 12% of requests abide by the RCR guidelines withan impact of their findings on clinical management in 7% ofthe cases. The usefulness of AR is zero in cases of unspe-cific abdominal pain, acute digestive hemorrhage, pepticulcer, apendicitis, urinary tract infection, pelvic pain, biliarypathology, acute pancreatitis or uncomplicated constipa-tion, among others.2,13,16,19,21

The AR detects alterations with low sensitivity(Figs. 2 and 3) but even when it does it rarely exhauststhe diagnostic process on its own. In most publications,the change of clinical management for patients inducedby the AR is below 10%.21 Kellow et al.16 find that withthe exception of the location of abdominal catheters, theAR is not very useful in acute abdomen conditions andonly 3% of their patients were treated based on the ARfindings. They conclude that in general the AR does notavoid other image modalities, as it happened in 59% of theirpatients to outline the extent of the alteration, identify itsetiology, plan treatment or have a basal image to evaluatetherapeutic response. This is to say that a pathologic ARdoes not provide any conclusive diagnoses in most patientsbut even when it does it needs other additional imagemodalities (Figs. 4 and 5).

Incidental findings are especially frequent when an incor-rect indication is the starting point. Its assessment canprovide a wrong or inadequate clinical response divertingthe management of the patient to research lines or guide-lines of clinical management that are far from their actualproblem, with diagnostic delays or inadequate treatmentsand greater morbimortality. The percentage of wrong find-ings for AR in some papers has been established around 19%21

and in others it has managed to surpass the useful informa-tion in a 3:2 ratio.30

Ruling out a prevailing or especially serious conditionexpedites the work of the ES while contributing to earlydischarge being one of the most decisive current applica-tions of diagnostic image modalities. This is not the case ofAR---a not very useful modality for the identification of unsus-pected diagnoses.26 Yet despite this fact its use is frequentas a normal screening tool. Stower et al.31 found that 60.8%of the ARs requested in their series were meant to rule outa serious condition. This practice causes unnecessary incon-veniences to the patient, it is potentially dangerous andshould not be recommended. It is well known that a nor-mal x-ray does not allow guarantee normality or precludesa serious condition21 (Figs. 2 and 3). Seventy-two per centthe patients with normal AR in the Kellow et al. paper16 pre-sented some alteration when other image modalities were



Figure 2 Thirty-four (34) year old male with pain in the lower semi-abdomen, fever and leukocytosis. (a) The AR of the abdomen

in the decubitus supine position shows no significant alterations. (b and c) CT parasagittal images. Wall thickening of sigmoid colon

with diverticula and perforation of one of these diverticula (arrow in b) with presence of extraluminal gas and signs of adjacent fat

inflammation. Multiple bubbles of intraperitoneal gas of anterior location (arrow-heads in c). Perforated diverticulitis.

used; this is why they do not recommend its use to rule outabdominal conditions. Almost half (46%) of the cases pre-sented unspecific findings in the AR, and in 78% of themalterations could be later identified. Simeone et al.32 dis-cover useful information through ultrasound predominantlyof biliary origin in 20% of the patients with abdominal painand a negative AR.

The dose of radiation administered is another issuethat should be considered when evaluating medical image

modalities. Every exposure to ionizing radiation needs to bejustified by a potential benefit and though the dose of one ARis not very high for an individual examination (0.7---1.3 mSv),40 times that of a chest X-ray or 4 months of backgroundradiation,33 it gains relevance from a population approach,above all taking into account the probability of additionalprojections.25,34,35 Radiation derived from conventionalradiographies has declined during the last few years35 thoughthe AR is still one of the four most common indications in



Figure 3 Seventy-two (72) year old woman with abdominal pain of sudden onset. The clinical exploration shows signs of shock

and arrhythmia and in the analysis acidosis and hyperamylasemia. (a) AR with no significant findings. (b) CT coronal image in 6 mm

maximal intensity projection showing a lumen repletion defect of the superior mesenteric artery compatible with an embolism

(arrow). Cardiomegaly (*).

this group.36 It is responsible for 2.93% of the radiologicalprocedures performed in the UK, and for 4.42% of the totaldose.37 The progressive accessibility from the ER to low-doseand ultralow-dose CT modalities <4 and 2 mSv will probablydisplace the use of AR in favor of these modalities.34

The economic cost is another evaluation argument, andalthough the AR is a relatively inexpensive modality---around30---40 D the reduction of unnecessary examinations alongwith other direct costs such as technician and radiologisttime or indirect costs, such as a previous pregnancy testsin young patients amount to yearly savings of around 50---60million pounds in the UK.15,25

AR in the usual causes of abdominal pain.Does anything change?

Intestinal obstruction

Around 7% of patients with acute abdominal pain willhave IO.5 Clinical evaluation has limitations in its assess-ment but it provides information (abdominal distension,increase of intestinal noise, vomiting, age > 50 years) whichimproves the sensitivity and the predictive value of ARwhen diagnosing IO (intestinal obstruction).5,14,19 Its mostfrequent etiology is peritoneal adhesions and hernias, and anearly diagnosis and treatment prevent intestinal ischemia,improving morbimortality. The IO has been one of the clas-sic indications for AR which is diagnostic in 50---60% of thecases, uncertain in 20---30% and confusing in 10---20%.38 The

sensitivity of AR to diagnose IO ranges from 46% to 90.8%in the different series, with a specificity close to 50%.It has important limitations when it comes to determin-ing the level and cause of the obstruction as well as thepresence of strangulation.5,39 Today the MSCT (multi-slicecomputed tomography) answers all questions with sensitiv-ity and specificity close to 100%,7 and it is the initial test ofchoice in cases of suspicion of IO as recognized by the ACRguidelines. Also this approach is useful for cases of colonobstruction, where the AR can be confusing or inconclusiveand delay treatment. Not only does the CT perform a moreprecise diagnosis but it also provides additional informationthat can modify treatment in one out of every five cases40

(Fig. 5).

Hollow viscus perforation

There is no scientific evidence supporting the use of ARin cases of suspicion of visceral perforation.2 Although inideal conditions it can be detected through an X-ray usinga minimum of 1 cc of free intraperitoneal gas41 reality canpaint a different picture as shown by the high variabilityin the figures of detection of pneumoperitoneum among thedifferent papers and radiographic projections used. van Ran-den et al.13 estimate in around 15% the sensitivity of ARto detect pneumoperitoneum; in the Baker et al. series42

X-rays detected it in 51% of the patients with proven vis-ceral perforation, and Levine et al.43 identify it in 59% ofARs performed in the decubitus supine position, while Keefe



Figure 4 Eighty-two (82) year old male with a history of chronic renal failure (serum creatinine levels: 6 mg/dl) and a right hip

prosthesis. Oral anticoagulation with a INR (International Normalized Ratio) > 5. He goes to the hospital with acute abdominal pain

radiated to his back with distention. Anemia and thrombocytopenia. (c) AR in the decubitus supine position showing signs of chronic

spondylitis and scoliosis with abundant fecal content that prevents us from performing an adequate assessment of the visceral

structures. Colon caliber-reduction at splenic flexure level simulating a ‘‘colon cut-off sign’’ (arrow). Initially a study through

computed tomography (CT) without contrast (b) is performed. The coronal multiplanar reconstruction (MPR) shows non-obstructive

left renal atrophy and an enlarged unstructured left kidney with heterogeneous attenuation secondary to non-traumatic renal

hematoma (h). Wunderlich syndrome. No causal lesion can be identified. Then an axial cut of the CT-angiography (c) is performed

and two (2) small foci of active bleeding (arrow-heads) can be identified and visible in the venous phase only. The patient remained

stable with conservative treatment and correction of his coagulopathy.

et al.44 identify it in 83% - number that goes up to 85% whenusing chest radiographies and to 96% with ARs performedin the left lateral decubitus position and that goes down to60% and 56% with ARs performed in bipedalism and in thedecubitus supine position, respectively.45 Other papers donot find any differences in the positive predictive value ofthe clinical examination for pneumoperitoneum after per-forming ARs.13 This low diagnostic yield, inherent to thetypical limitations of X-rays grows worse when its technicalquality is deficient, due to incomplete anatomical coverage

or exposure.42 There are diverging opinions46 but MSCT isat present the test of choice to identify the presence,location and etiology of intestinal perforation, which is rel-evant information for an adequate surgical approach47---50

(Fig. 2).

Renal colic

When the clinical context is typical and in the presence ofhematuria the image modalities do not modify therapeutic



Figure 5 Fifty-six (56) year-old woman at the emergency room presenting with diffuse abdominal pain and no gas or fecal

expulsion. During the examination she shows poor health with the presence of tachycardia and hypotension, abdominal silence and

‘‘loop mass’’ palpation. The AR (a) does not show any significant findings with the exception of flexure thickening in a jejunal loop

located at the left superior quadrant (arrow). (b) Computed tomography (axial view) in portal stage (70 sg) of the middle abdomen

region showing jejunal loop distention with no wall enhancement due to hypoperfusion (*) [compare it with the adjacent duodenum

(d)]. Perihepatic intraperitoneal liquid in between the loops (arrow-heads). Surgery confirmed the diagnosis of intestinal obstruction

caused by bridles complicated with strangulation; 55 cm of necrotic small intestine were resected.

management in the absence of fever, durable pain ordiagnostic uncertainty. Nevertheless the great majority ofexisting clinical guidelines and recommendations indicatethe immediate performance of an imaging test.51 Such testshould confirm the presence of urethral calculi and provideinformation about its location, size and composition, aswell as the presence of urethral obstruction. In the absenceof lithiasis, it should identify alternative diagnoses suchas complicated aorta aneurism.9 The sensitivity of the ARranges from 44% to 77% in the different works publishedbeing the specificity between 71% and 87%, and MSCT is theusual standard of care.5,51,52 When image tests are indicatedthe ultrasound usually comes first in young patients yet theCT identifies the practical totality of lithiases53 and providesthe required additional information.5 The indication forAR would be limited to the follow-up of urethral lithiasisdiagnosed through CT or ultrasound.2

Acute appendicitis

ARs are performed on 50---75% of patients with suspicion ofacute clinical apendicitis,54 despite the existing scientificevidence that does not recommend it.2 A conclusive clini-cal diagnosis does not require confirmation through imagingmodalities,2,19 and in uncertain cases, the diagnostic yieldof ultrasound and CT is way much higher.55 Ultrasound is theinitial method of choice, especially in children and womenin their fertile age; the MRI is an alternative in pregnantwomen with inconclusive ultrasounds.

Diverticulitis, pancreatitis and acute cholecystitis

Acute diverticulitis does not associate useful semiology inAR this is why it does not have any indications. Whenit is necessary to confirm the diagnosis and detect possi-ble complications CT is used. Beyond the presence of a‘‘sentinel loop’’ or a ‘‘colon cut-off sign’’ that may beindicative of diagnosis of acute pancreatitis the AR does notpresent specific findings of this clinical entity so its use is notindicated. The latest review of the Atlanta guidelines56 doesnot recommend the use of image modalities including CT,during the first week, except for cases of uncertain clinical-biochemical diagnosis or to rule out alternatives such asintestinal perforation or mesenteric thrombosis. The AR isnot indicated either as the initial diagnostic modality incases of acute biliary pathology where the ultrasound is themodality of choice when suspicion of uncomplicated acutecholecystitis.4

Intestinal ischemia

Identifying gas on the intestinal wall or the portal branchesthrough the AR, classically considered a pathognomonicsign of mesenteric ischemia, is an infrequent finding thatat least denotes advanced disease.26 The growing use ofabdominal CT has allowed the visualization of portal gas inmore ‘‘benign’’ situations but its detection through X-rayassociates a high risk of ischemia and a 75% mortality, andthis is why immediate laparotomy is recommended evenin the absence of clinical signs.57 Nevertheless an AR can



Table 1 Problems derived from using abdomen radiographies in the emergency room.

• Unjustified increase of the radiation dose

• The patient is in pain

• Unnecessary increase of healthcare expenditure:

--- Direct: Obtention (tube, facilities, PACS), time of RTS and radiologist

--- Indirect: Pregnancy test in a young girl prior to performing any abdomen radiographies

--- Of opportunity: resources being destined to non-profitable techniques and modalities making other profitable ones not

available for the right patient

• Diagnostic errors due to irrelevant positive result or false negative. Incidental findings contributing to erroneous

management or delayed diagnoses

PACS: Picture Archiving and Communication System; RTS: radiodiagnosis technical specialist.

be normal even in the presence of extensive intestinalischemia26 (Fig. 3).

Foreign bodies. Intra-abdominal catheters

They are cause of abdominal pain especially in pediatric age.The sensitivity of the AR is 90% and its specificity 100%5,17 ofcourse based on its nature. Such figures recommend keepingits use in this clinical setting yet the AR should be reservedfor those cases where seeing the foreign body has clinicalrelevance, such as batteries or toxics, or forensic relevance,or else when the patient is symptomatic.5,9 An identicalapproach should be followed when monitoring abdominalcatheters.16

Alternatives and patterns of action

If the AR was a new technology today, it would be diffi-cult to justify its clinical introduction. It can be assertedwith Gans et al. that its role in adults with acute abdominalpain is null today.5 Greene proposed reducing its emer-gency use in 1986, avoiding it in clinical situations wherethe odds of radiological findings are minimal, in women infertile age, except when clearly indicated and as far aspregnancy has been ruled out, and when it is not mod-ify clinical management. He suggests avoiding performingthe abdominal series systematically and rather analyzingfirst the projection in the decubitus supine position com-plemented eventually with thorax in bipedalism, and thendeciding the need for additional projections.58 An adequateclinical analytical orientation, followed by ultrasound andCT when it is negative, is today the best management pat-tern of the urgent abdominal pathology. So until this conceptbecomes generalized, it would be convenient for radiologiststo follow these procedural guidelines, among others:

• To recognize and publicize the excessive demand, usuallyunjustified, for AR in Emergency Departments.

• To analyze the causes for its popularity among cliniciansand its possible risks (Table 1).

• To develop and implement training programs for youngphysicians and foster constructive dialog in multidisci-plinary sessions with senior physicians while promotingthe role of the radiologist as a consultant.

Table 2 Proposal of indications for abdomen radiographies

in the emergency room.

• Identification of foreign bodies

• Location of catheters

• Follow-up of urinary stones

• Evolution of the obstruction

• Desvolvulation control

• To develop research lines on the local, national and inter-national level to clarify the guidelines for the use of AR(Table 2) and write them in clinical guidelines and recom-mendations.

• To control the demand for this type of examination as wellas the quality of reports that should not be left at themercy of clinicians under the consideration of a ‘‘lessertechnique’’.

These proposals aim to rationalize the use of AR, limitits use and offer the patients alternative modalities with agreater diagnostic yield in an effort to expedite the health-care process and ultimately, reduce the dose of radiation,costs and unnecessary inconveniences.

Ethical responsibilities

Protection of people and animals. The authors declare thatno experiments with human beings or animals have beenperformed while conducting this investigation.

Data confidentiality. The authors declare that the protocolsof their institution on the publishing of data from patientshave been followed.

Right to privacy and informed consent. The authorsdeclare that in this article there are no personal data frompatients.

Authors

1. Manager of the integrity of the study: JMAM, MMDG,PPH.

2. Study idea: JMAM, PPH.3. Study design: JMAM.4. Data mining: CRT, DMM.



5. Data analysis and interpretation: CRT, JMAM.6. Statistical analysis: NA.7. Reference search: CRT, DMM, JMAM, PPH.8. Writing: JMAM, MMDG.9. Critical review of the manuscript with intellectually rel-

evant remarks: JMAM, MMDG, CRT, DMM, PPH.10. Approval of final version: JMAM, MMDG, CRT, DMM, PPH.

Conflict of interests

The authors declare no conflict of interests associated withthis article.

This work is an update to be published in the journalRadiología exclusively. No material from former reviews orjournals has been used yet some ideas and concepts werealso summed up in the summary book from the 4th Meetingof SERAU 2013 ‘‘Radiología de urgencias. La oportunidad en

la crisis’’.

References

1. Dixon A. Evidence-based diagnostic radiology. Lancet.

1997;350:509---12.

2. Smith JE, Hall EJ. The use of plain abdominal X rays in the

emergency department. Emerg Med J. 2009;26:160---3.

3. Golberg B. Department of inappropriate investigations. Br Med

J. 1977;2:1274---5.

4. Stoker J, van Randen A, Laméris W, Boermeester MA.

Imaging patients with acute abdominal pain. Radiology.

2009;253:31---46.

5. Gans SL, Stoker J, Boermeester MA. Plain abdominal radiogra-

phy in acute abdominal pain; past, present, and future. Int J

Gen Med. 2012;5:525---33.

6. Niska R, Bhuiya F, Xu J. National Hospital Ambulatory Medical

Care Survey: 2007 Emergency Department Summary. National

health statistics reports, No. 26. Hyattsville, MD: National Cen-

ter for Health Statistics; 2010. Available from: http://www.

cdc.gov/nchs/data/nhsr/nhsr026.pdf [accessed 29.11.14].

7. Laméris W, van Randen A, van Es HW, van Heesewijk JPM, van

Ramshorst B, Bouma WH, et al., on behalf of the OPTIMA study

group. Imaging strategies for detection of urgent conditions in

patients with acute abdominal pain: diagnostic accuracy study.

BMJ. 2009;338:b2431, http://dx.doi.org/10.1136/bmj.b2431

[accessed 29.11.14].

8. Ng CS, Watson CJE, Palmer CR, See TC, Beharry NA, Housden

BA, et al. Evaluation of early abdominopelvic computed tomo-

graphy in patients with acute abdominal pain of unknown cause:

prospective randomised study. Br Med J. 2002;325:4---7.

9. Hampson F. Assessment of the acute abdomen: role of the

plain abdominal radiograph. Rep Med Imaging. 2010;3:93---105,

http://dx.doi.org/10.2147/RMI.S13837.

10. Sala E, Watson CJE, Beadsmoore C, Groot-Wassink T, Fan-

shawe TR, Smith JC, et al. A randomized, controlled trial of

routine early abdominal computed tomography in patients pre-

senting with non-specific acute abdominal pain. Clin Radiol.

2007;62:961---9.

11. Lee PW. The plain X-ray in the acute abdomen: a surgeon’s

evaluation. Br J Surg. 1976;63:763---6.

12. Eisenberg RL, Heineken P, Hedgcock MW, Federle M, Goldberg

HI. Evaluation of plain abdominal radiographs in the diagnosis

of abdominal pain. Ann Intern Med. 1982;97:257---61.

13. Van Randen A, Laméris W, Luitse JS, Gorzeman M, Hesselink EJ,

Dolmans DE, et al., on behalf of the OPTIMA study group. The

role of plain radiographs in patients with acute abdominal pain

at the ED. Am J Emerg Med. 2011;29:582---9.

14. Böhner H, Yang Q, Franke C, Verreet PR, Ohmann C. Simple data

from history and physical examination help to exclude bowel

obstruction and to avoid radiographic studies in patients with

acute abdominal pain. Eur J Surg. 1998;164:777---84.

15. Morris-Stiff G, Stiff RE, Morris-Stiff H. Abdominal radiograph

requesting in the setting of acute abdominal pain: temporal

trends and appropriateness of requesting. Ann R Coll Surg Engl.

2006;88:270---4.

16. Kellow ZS, MacInnes M, Kurzencwyg D, Rawal S, JAffer R,

Kovacina B, et al. The role of abdominal radiography in the

evaluation of the nontrauma emergency patient. Radiology.

2008;248:715---6.

17. Ahn SH, Mayo-Smith WW, Murphy BL, Reinert SE, Cronan JJ.

Acute nontraumatic abdominal pain in adult patients: abdom-

inal radiography compared with CT evaluation. Radiology.

2002;225:159---64.

18. Feyler S, Williamson V, King D. Plain abdominal radiographs in

acute medical emergencies: an abused investigation. Postgrad

Med J. 2002;78:94---6.

19. Prasannan S, Zhueng TJ, Gul YU. Diagnostic value of plain

abdominal radiographs in patients with acute abdominal pain.

Asian J Surg. 2005;28:246---51.

20. Artigas JM, Rodriguez C, Martí M. Radiografía simple del

abdomen. Argumentos para el no. In: Artigas JM, Martí M,

editors. Radiología de Urgencias. La oportunidad en la crisis.

Madrid: SERAU; 2013. p. 13---7.

21. Anyanwu AC, Moalypour SM. Are abdominal radiographs still

overutilized in the assessment of acute abdominal pain?

A district general hospital audit. J R Coll Surg Edinb.

1998;43:267---70.

22. The Royal College of Radiologists Guidelines Working Party.

Making the best use of clinical radiology services: refer-

ral guidelines. 6th ed; 2007, http://dx.doi.org/10.1016/0277-

5379(82)90167-5. London.

23. ACR---SPR practice parameter for the performance of abdom-

inal radiography; 2014. Website of the American College of

Radiology. Available from: http://www.acr.org/∼/media/ACR/

Documents/PGTS/guidelines/Abdominal Radiography.pdf


24. Diagnostic imaging pathways --- abdominal plain X-ray

(indications). Website of Government of Western Aus-

tralia. Department of Health. Available from: http://www.

imagingpathways.health.wa.gov.au/index.php/image-gallery/

gastrointestinal?id=60#pathway [accessed 01.12.14].

25. Jelinek GA, Banham ND. Reducing the use of plain abdomi-

nal radiographs in an emergency department. Arch Emerg Med.

1990;7:241---5.

26. Flak B, Rowley VA. Acute abdomen: plain film utilization and

analysis. Can Assoc Radiol J. 1993;44:423---8.

27. Mirvis E, Mirvis SE, Young JW, Keramati B, McCrea ES, Tarr

R. Plain film evaluation of patients with abdominal pain: are

three radiographs necessary. AJR Am J Roentgenol. 1986;147:

501---3.

28. Markus JB, Somers S, Franic SE, Moola C, Stevenson GW. Interob-

server variation in the interpretation of abdominal radiographs.

Radiology. 1989;171:69---71.

29. Jackson K, Taylor DJS, Jackson K, Taylor D, Judkins S. Emergency

department abdominal X-rays have a poor diagnostic yield and

their usefulness is questionable. Emerg Med J. 2011;28:745---9.

30. Campbell JP, Gunn AA. Plain abdominal radiographs and acute

abdominal pain. Br J Surg. 1988;75:554---6.

31. Stower M, Mikulin T, Hardcastle J, Amar S, Kean D. Evaluation of

the plain abdominal X-ray in the acute abdomen. J R Soc Med.

1985;78:630---3.

32. Simeone JF, Novelline RA, Ferrucci JT, DeLuca SA, McCabe CJ,

Mueller PR, et al. Comparison of sonography and plain films

in evaluation of the acute abdomen. AJR Am J Roentgenol.

1985;144:49---52.



33. Hart D, Hillier MC, Wall BF. Doses to patients from medical

X-ray examinations in the UK 2000 review (NRPB-W-14);

2002. United Kingdom. Available from: https://inis.iaea.org/

search/searchsinglerecord.aspx?recordsFor=SingleRecord&RN=

34005445# [accessed 01.12.14].

34. Haller O, Karlsson L, Nyman R. Can low-dose abdominal CT

replace abdominal plain film in evaluation of acute abdominal

pain. Ups J Med Sci. 2010;115:113---20.

35. Hart D, Hillier MC, Shrimpton PC. Doses to patients from radio-

graphic and fluoroscopic X-ray imaging procedures in the UK

--- 2010 review (HPA-CRCE-034); 2012. United Kingdom. Avail-

able from: https://www.gov.uk/government/uploads/system/

uploads/attachment data/file/342780/HPA-CRCE-034 Doses to

patients from radiographic and fluoroscopic x ray imaging

procedures 2010.pdf [accessed 01.12.14].

36. Hart D, Wall BF. UK population dose from medical X-ray exami-

nations. Eur J Radiol. 2004;50:285---91.

37. Hart D, Wall BF. Radiation exposure of the UK population

from medical and dental X-ray examinations. Chilton, UK:

National Radiological Protection Board (NRPB); 2002. Avail-

able from: http://cloud.medicalphysicist.co.uk/nrpb w4.pdf


38. Maglinte DD, Reyes BL, Harmon BH, Kelvin FM, Turner WW Jr,

Hage JE, et al. Reliability and role of plain film radiography

and CT in the diagnosis of small-bowel obstruction. AJR Am J

Roentgenol. 1996;167:1451---5.

39. Frager D, Medwid SW, Baer JW, Mollinelli B, Friedman M. CT

of small-bowel obstruction: value in establishing the diagnosis

and determining the degree and cause. AJR Am J Roentgenol.

1994;162:37---41.

40. Taourel PG, Fabre JM, Pradel JA, Seneterre EJ, Megibow AJ,

Bruel JM. Value of CT in the diagnosis and management of

patients with suspected acute small-bowel obstruction. AJR Am

J Roentgenol. 1995;165:1187---92.

41. Miller RE, Nelson SW. The roentgenologic demonstration of

tiny amounts of free intraperitoneal gas: experimental and

clinical studies. Am J Roentgenol Radium Ther Nucl Med.

1971;112:574---85.

42. Baker SR. Unenhanced helical CT versus plain abdominal radio-

graphy: a dissenting opinion. Radiology. 1997;205:45---7.

43. Levine MS, Scheiner JD, Rubesin SE, Laufer I, Herlinger H. Diag-

nosis of pneumoperitoneum on supine abdominal radiographs.

AJR Am J Roentgenol. 1991;156:731---5.

44. Keefee EJ, Gagliardi RA. Significance of ileus in perforated vis-

cus. Am J Roentgenol Radium Ther Nucl Med. 1973;117:275---80.

45. Roh JJ, Thompson JS, Harned RK, Hodgson PE. Value of pneu-

moperitoneum in the diagnosis of visceral perforation. Am J

Surg. 1983;146:830---3.

46. Solis CV, Chang Y, De Moya MA, Velmahos GC, Fagenholz PJ.

Free air on plain film: do we need a computed tomography too.

J Emerg Trauma Shock. 2014;7:3---8.

47. Oguro S, Funabiki T, Hosoda K, Inoue Y, Yamane T, Sato M,

et al. 64-Slice multidetector computed tomography evalua-

tion of gastrointestinal tract perforation site: detectability

of direct findings in upper and lower GI tract. Eur Radiol.

2010;20:1396---403.

48. Kim HC, Yang DM, Kim SW, Park SJ. Gastrointestinal tract per-

foration: evaluation of MDCT according to perforation site and

elapsed time. Eur Radiol. 2014;24:1386---93.

49. Hainaux B, Agneessens E, Bertinotti R, De Maertelaer V,

Rubesova E, Capelluto E, et al. Accuracy of MDCT in predicting

site of gastrointestinal tract perforation. AJR Am J Roentgenol.

2006;187:1179---83.

50. Borofsky S, Taffel M, Khati N, Zeman R, Hill M. The emer-

gency room diagnosis of gastrointestinal tract perforation: the

role of CT. Emerg Radiol. 2014, http://dx.doi.org/10.1007/

s10140-014-1283-4 [Epub ahead of print].

51. Nicolau C, Salvador R, Artigas JM. Manejo diagnóstico del

cólico renal. Radiología. 2015;57:113---22, http://dx.doi.org/

10.1016/j.rx.2014.11.003.

52. Levine JA, Neitlich J, Verga M, Dalrymple N, Smith RC.

Ureteral calculi in patients with flank pain: correlation of plain

radiography with unenhanced helical CT. Radiology. 1997;204:

27---31.

53. Chan VO, Buckley O, Persaud T, Torreggiani WC. Urolithia-

sis: how accurate are plain radiographs. Can Assoc Radiol J.

2008;59:131---4.

54. Otero HJ, Ondategui-Parra S, Erturk SM, Ochoa RE, Gonzalez-

Beicos A, Ros PR. Imaging utilization in the management of

appendicitis and its impact on hospital charges. Emerg Radiol.

2008;15:23---8.

55. Van Randen A, Bipat S, Zwinderman AH, Ubbink DT, Stoker

J, Boermeester MA. Acute appendicitis: meta-analysis of

diagnostic performance of CT and graded compression US

related to prevalence of disease. Radiology. 2008;249:

97---106.

56. Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD, Sarr

MG, et al. Classification of acute pancreatitis --- 2012: revi-

sion of the Atlanta classification and definitions by international

consensus. Gut. 2013;62:102---11.

57. Nelson AL, Millington TM, Sahani D, Chung RT, Bauer C, Hertl

M, et al. Hepatic portal venous gas. The ABCs of management.

Arch Surg. 2009;144:575---81.

58. Greene CS. Indications for plain abdominal radiography

in the emergency department. Ann Emerg Med. 1986;15:

257---60.
