CT without borders: Comparison of diagnoses for abdominal pain from a teaching hospital in rural Kenya and a US academic medical center

Abstract

Purpose: Radiology global health opportunities are expanding as more hospitals in low- and middle-income countries utilize CT. This creates opportunities for global health program building, education, service, and research. This study determines the diagnostic yield and variety of abdominopelvic CT diagnoses for abdominal pain in a US academic medical center (UW) compared to a rural Kenyan teaching hospital (Tenwek).

Methods: A retrospective, cross-sectional sequential sample of 750 adults from both hospitals who underwent abdominopelvic CT for abdominal pain from February 2019 through July 2020 was obtained. Exclusion criteria were trauma, cancer staging, and recent hospitalization or surgery. Patient age, sex, comparison studies, use of contrast, known cancer diagnosis, and CT diagnoses were compared. Negative exam rate, acute abdomen diagnosis, and new cancer diagnosis were recorded. Statistical analysis was performed using R.

Results: 750 UW patients met inclusion criteria (mean age 53.3 ± 20 years; 442 women) and 750 Tenwek patients met inclusion criteria (mean age 52.5 ± 18 years; 394 women). 72% of UW patients had comparison imaging compared to 6% of Tenwek patients. 11% (83/750) of UW patients had a known cancer diagnosis compared to 1% (10/750) of Tenwek patients. 39% of UW patients had a negative exam compared to 23% of Tenwek patients (p < 0.001). 58% of UW patients had an acute abdomen diagnosis compared to 38% of Tenwek patients (p < 0.001). 10 of the 15 top acute abdomen diagnoses were shared, but in different order of frequency. Diagnoses unique to UW were diverticulitis, constipation, stercoral colitis, and epiploic appendagitis. Diagnoses unique to Tenwek were tuberculosis and hydatidosis. 3% of UW patients received a new cancer diagnosis (7/19 metastatic), compared to 40% of Tenwek patients (153/303 metastatic) (p < 0.001).

Conclusion: For adults undergoing CT for abdominal pain, there are differences in the prevalence of abdominal pain diagnoses, new cancer diagnosis, and negative exam rate between the rural Kenyan teaching hospital and the US academic medical center.

Keywords: Education; Global health; Outreach.

Fig. 1

Inclusion and exclusion criteria applied to achieve a sequential patient sample of 750 from each institution

Fig. 2

Tuberculosis at Tenwek Hospital: tuberculous adenitis. Coronal CT images of the abdomen and pelvis for three different patients presenting with abdominal pain. There is extensive tuberculous adenitis, with characteristic low-attenuation adenopathy in the retroperitoneum, mesentery, and pelvis (arrows) and ascites (a)

Fig. 3

Tuberculosis at Tenwek Hospital: Pott disease. Three CT images of a 20 year-old patient presenting with back and abdominal pain, with massive bilateral iliopsoas “cold” abscesses (solid arrows) and destruction of the L3/L4 endplates and disc space, resulting in gibbus deformity and paraspinal/epidural abscess (dashed arrows)

Fig. 4

Tuberculosis at Tenwek Hospital: splenic and hepatic infiltration. 30 year-old patient presenting with abdominal pain, with splenic enlargement and diffuse granulomatous infiltration (solid arrows) by tuberculosis infection (treated with splenectomy) and subtle granulomatous infiltration of the liver (dashed arrows)

Fig. 5

Abdominopelvic manifestations of hydatid disease at Tenwek Hospital. Coronal CT images with a characteristic large liver cyst with peripheral calcifications and daughter cysts (arrows), b hepatic hydatid disease with dissemination into the peritoneal cavity with cysts of various sizes (arrows), with a larger cyst simulating an ovarian mass (o) with mass effect on the uterus (u), and c hepatic and larger peritoneal cyst conglomerates indenting the urinary bladder (b)

Fig. 6

Delayed presentations are common at Tenwek Hospital, often resulting in more advanced pathology than seen in a typical US academic medical center. a Coronal CT image of a 45 year-old female with several month history of abdominal distension, with extensive peritoneal carcinomatosis related to an ulcerative gastric mass (m) resulting in omental caking (arrows) and large volume ascites (a). b Coronal CT image of a 70 year-old man with shortness of breath, with cirrhosis and a large, infiltrative hepatocellular carcinoma occluding the hepatic veins and growing into the right atrium (arrows), with large volume ascites (a). c Coronal CT image of a 65 year-old female with several months of worsening abdominal pain, with severe dilation of small bowel loops (sb) containing fecalized material (arrows), small dots of free air indicating perforation (dashed arrows) and occlusion of the superior mesenteric artery (not shown)