Plain abdominal radiography in acute abdominal pain; past, present, and future

Abstract

Several studies have demonstrated that a diagnosis based solely on a patient's medical history, physical examination, and laboratory tests is not reliable enough, despite the fact that these aspects are essential parts of the workup of a patient presenting with acute abdominal pain. Traditionally, imaging workup starts with abdominal radiography. However, numerous studies have demonstrated low sensitivity and accuracy for plain abdominal radiography in the evaluation of acute abdominal pain as well as various specific diseases such as perforated viscus, bowel obstruction, ingested foreign body, and ureteral stones. Computed tomography, and in particular computed tomography after negative ultrasonography, provides a better workup than plain abdominal radiography alone. The benefits of computed tomography lie in decision-making for management, planning of a surgical strategy, and possibly even avoidance of negative laparotomies. Based on abundant available evidence, major advances in diagnostic imaging, and changes in the management of certain diseases, we can conclude that there is no place for plain abdominal radiography in the workup of adult patients with acute abdominal pain presenting in the emergency department in current practice.

Keywords: abdominal radiography; abdominal x-ray; acute abdomen; acute abdominal pain; diagnostic imaging; emergency department.

Case 1

Free air. Notes: A 48-year-old male presented at the emergency department with pain in the entire abdomen, but concentrating in the right lower quadrant. Palpation of the entire abdomen was extremely painful and laboratory values showed elevated inflammatory parameters (leucocyte count 17.9 and C-reactive protein 43). Upright abdominal radiography showed no abnormalities. Computed tomography of the abdomen showed free intraperitoneal air and signs of appendicitis acuta. Patient underwent an emergency laparotomy, which confirmed the diagnosis of perforated appendicitis acuta.

Case 2

Urinary tract stones. Notes: A 36-year-old female presented at the emergency department with left-sided abdominal pain over the course of 6 hours. Laboratory values showed elevated inflammatory parameters (leucocyte count 15.3 and C-reactive protein 44). Based on clinical examination, the patient was suspected of having bowel obstruction or kidney stones, and an abdominal radiograph was ordered. Abdominal radiography demonstrated no abnormalities other than multiple clips related to previous bowel surgery. Computed tomography of the abdomen demonstrated hydronephrosis and signs of pyelonephritis of the left kidney due to an obstructing ureteral stone.

Case 3

Bowel obstruction. Notes: A 59-year-old female presented at the emergency department with complaints of nausea, vomiting, and abdominal pain for one day. Physical examination demonstrated abdominal tenderness in all quadrants. Laboratory values were within normal limits, with the exception of slightly raised inflammatory parameters (C-reactive protein 17, leucocyte count 8) The attending physician suspected a bowel obstruction and ordered an abdominal radiograph. Abdominal radiography showed no abnormalities in addition to minimal dilation of the small bowel. Computed tomography demonstrated dilated small bowel loops, collapsed large bowel loops, and a change in diameter due to a herniation of small bowel into the right musculus rectus abdominus. Images were suggestive of an incarcerated herniation. After reduction of herniation at the emergency department, her complaints resolved and she made an uneventful recovery.

Case 4

Ingested foreign body. Notes: A 35-year-old male presented at the emergency department with acute abdominal pain, tachycardia, and a diffusely rigid abdomen. The patient admitted having ingested eight packets of drugs three days earlier. An abdominal radiograph was done to confirm ingestion of the packets and to clarify the location and exact number of packets in need of surgical removal. At least four packets were identified on abdominal radiographs and the patient underwent a laparotomy due to signs of intoxication; eight packets of drugs were identified and surgically removed from the small bowel. Postoperatively, the patient remained tachycardic and in pain; a computed tomography scan was done 24 hours after the initial laparotomy, showing an additional five packets of drugs in the stomach and ileum.