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Changing Perspectives: Plain radiography in acute abdominal pain; ancient history?

Plain radiography in acute abdominal pain; ancient history?

In the not so distant past, plain radiography of the abdomen was one of the diagnostic tools in the management of patients with acute abdominal pain. It is quick, cheap and yields less radiation exposure than a CT-scan. However, multiple large studies showed that plain radiography of the abdomen has no additional value on top of clinical assessment in the evaluation of patients with acute abdominal pain (1-3). Furthermore, plain radiography gives the false reassurance of being able to exclude major pathology, for example, free air due to a bowel perforation. Moreover, if free air is seen on plain radiography mostly an additional CT-scan of the abdomen will be obtained to decide what type of operation has to be performed.

Multiple studies showed that the highest sensitivity and lowest radiation exposure, in patients with acute abdominal pain, can be achieved by first performing an abdominal ultrasound followed by, if the ultrasound is inconclusive, a CT scan (1). Therefore, in the Dutch guidelines for acute abdominal pain, there is no room for conventional imaging of the abdomen (4). Nevertheless, many doctors are still attributing great diagnostic value to plain radiography of the abdomen in the acute setting although scientific evidence is lacking. The future will show whether plain radiography in acute abdominal pain will definitely belong to ancient history.

L. Hubers & A. Schuurman

References:

  1. Lameris et al. (2009). Imaging strategies for detection of urgent conditions in patients with acute abdominal pain: diagnostic accuracy study. BMJ, 26:2431–2431.
  2. MacKersie et al. (2005). Nontraumatic acute abdominal pain: unenhanced helical CT compared with three-view acute abdominal series. Radiology, 237:114–22.
  3. Prasannan et al. (2005). Diagnostic value of plain abdominal radiographs in patients with acute abdominal pain. Asian J Surg, 28:246–51.
  4. Gans et al. (2014) Richtlijn ‘Diagnostiek acute buikpijn bij volwassenen. Ned Tijdschr Geneeskd.158:A7494

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