Abdominal X Rays in the Emergency Department

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Abdominal X Rays in the Emergency Department

• Dr F. Atang

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RCR Guidelines

• Acute abdominal pain ? Perforated viscus
  ?obstruction.
• Acute exacerbation of inflammatory bowel disease.
• ? Ingested (radio opaque)FB only if likely to be
  dangerous e.g. battery, cocaine wraps.
• Renal calculus.

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Not indicated routinely

• ? AAA ultrasound is investigation of choice.
• Abdominal mass ultrasound more useful, but
  barium studies may be required for GI tract.
• Acute pancreatitis CT more useful.
• Biliary disease refer for ultrasound.
• Constipation.
• GI bleed upper or lower.
• Haematuria.
• Non specific abdominal pain.

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Not indicated routinely

• If the surgeon asks for one!

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Method

• 50 case notes collected on patients who were sent
  for AXR in the ED, Leeds General Infirmary.
• October 2006 December 2006.

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Data collected

• Age.
• Sex.
• Presentation.
• Clinical impression.
• AXR indicated?
• AXR findings.
• Final diagnoses.

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Results

• Abdominal pain 24 (48)
• Abdo pain vomiting 6 (12)
• Back pain 6 (12)
• Abdo distension 4 (8)
• Haematemesis 3 (6)
• DV 3 (6)
• Abdo pain constipation 2 (4)
• Urinary retention 1 (2)
• PR bleed 1 (2)

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Clinical Impression made

• Renal calculus 11
• Bowel obstruction (SB or LB) 7
• None 7
• Gastroenteritis 5
• Constipation 3
• Upper GI bleed 4
• Ascites 2
• Hernia 2
• Pancreatitis 2
• Perforated DU 2
• Ischaemic colitis 2

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Clinical Impression contd.

• Abdominal mass 1
• Pyelonepritis 1
• Dissecting thoracic aneurysm! 1

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• All the suspected renal calculus had a KUB.
• The remaining cases all had AXR/CXR
• Except
• 1 ? Perf DU only had AXR and no erect CXR.

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X Ray findings

• Normal 35 (70)
• Not documented 4 (8)
• Large bowel dilatation 4 (8)
• Small bowel dilatation 2 (4)
• Constipation 2 (4)
• Renal calculus 1 (2)
• Sub-diaphragmatic gas (CXR) 1 (2)
• Calcified vessels (AXR) 1 (2)

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Were the guidelines followed?

• Yes 37 (74)
• No 8 (16)
• Others 5 (10)
• Not documented. (4)
• Requested by RSO before seeing patient. (1)

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Typical exposures(office of radiation protection)

• Dental bitewing 300 millirem (3 inch diameter
  area)
• Chest x-ray 20 millirem (14 x 17 inch area)
• Abdominal film 300 millirem (14 x 17)
• Lumbar spine 350 millirem (14 x 17)
• Extremity x-ray 30 millirem (8 x 10)
• Skull x-ray 100 millirem (8 x 10)
• Breast (mammogram) 175 millirads (glandular
  tissue dose)

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Problems

• Surgical team.
• Not sure of Diagnosis hence X-Ray may help.

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Closing the audit cycle

• Document everything especially the clinical
  impression.
• If requesting AXR, (or any other investigation)
  ask yourself
• what am I looking for?
• will my findings change my management?

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• Thank you