Imaging of non-traumatic acute abdominal pain in adults presenting to the emergency department.

M imaging is rapidly evolving due to advanced computer applications. Non-traumatic acute abdominal pain (AAP) is one of the most common symptoms in adults presenting to the emergency department (ED).1,2 The emergency physician should have sufficient assessment skills to triage such patients. Clinical assessment is sufficient to decide on the level of urgency, but not on the specific cause of the AAP.1 The causes of abdominal pain vary from life threatening to the self-limiting. Management decision on the basis of clinical and laboratory tests alone can result in unnecessary intervention or delayed management.2 The use of diagnostic imaging has been blamed for increasing hospital costs and length of stay in the ED.2 The underlying cause for AAP can be in the area of many different specialties’ such as surgery, gynecology, internal medicine, and urology.1 There is a need to search for a diagnostic pathway with a balance between cost, amount of radiation exposure, accuracy, patient discomfort, and duration of stay in the ED.1 The purpose of this brief report is to discuss the current practice and summarize the new trends and paradigm for imaging of AAP in adults presenting to the ED. Stoker et al3 summarized 22 different studies involving 3340 patients. He found that the most common presenting symptom was non-specific abdominal pain in 23% of all the 3340 cases followed by acute appendicitis (14%), bowel obstruction (9%), urinary tract disorders (9%), acute diverticulitis (8%), acute cholecystitis (5%), acute pancreatitis (4%), gynecologic disorder (3%), perforations (1%), and peritonitis (1%). It is rare to see a comprehensive description of the patients symptoms on the referral request from the ED. Adherence to specific guidelines helps to reduce the request for plain radiographs. In 1972, plain abdominal radiography (PAR) were the only available diagnostic imaging modality available at the ED.1 They were ordered for 43% of all presenting patients with abdominal plain.1 This rate decreased to 30% in 1992 and 21% in 2007 while ultrasound or computerized tomography were requested for 6.8% of patients in 1992 and increased up to 42% in 2007.1 Smith & Hall4 performed a structured literature review for 38 original papers concerning the use of PAR’s. They concluded that PAR’s have a limited role in the ED. Plain abdominal radiography were revealed in 10.4% of cases and some radiographs were requested to avoid criticism.4 The Royal College of Radiologists (RCR), the America College of Radiology (ACR), and the Canadian Association of Radiologists (CAR) keep updating their guidelines on radiologic procedures regularly. The number of clinical situations such as abdominal radiography were not indicated but it keeps rising with every new update. The phenomenon of requesting and performing unnecessary x-rays is a particular concern in the evolving affluent Arabian Gulf region where there are multinational expatriate health care providers who may be adopting protective attitudes. The introduction of CT scan in 1973 revolutionized the cross sectional imaging. Abdominal CT scans are supplemented with oral, rectal, and intravenous contrast media. This renders the examination invasive in nature and of high expanse. Plain abdominal radiography may be used to diagnose intestinal obstruction (Figures 1A & 1B) , but the exact cause can only be determined by contrast enhanced CT. Radiation exposure to the patient and the environment may statistically increase the cancer risk. Computerized tomography scan of the abdomen delivers an approximately 15 times the dose delivered by radiography. Low dose non-contrast CT is now the commonly used test for the investigation of renal colic.5 This evades the cost of contrast material, the possibility of allergic reactions, and decreases the cancer risk. Haller et al5 compared the performance of PAR’s on 222 patients with low dose CT. Patients who had PAR’s needed additional imaging in 38% of cases, while those who had low dose CT needed additional imaging in 4% of cases. The low dose CT delivers 4.2 mSv, less than half the radiation dose from the standard contrast enhanced CT. Even when using a 4 detector row multi-slice CT, the result of low dose CT were diagnostic in 59% compared with 20% with PAR’s.5 There is a steady rise of the number of performed CT scan worldwide raising much concern. Fortunately, there is a parallel attention to dose reduction equipment and protocols for each examination.6 On a study of 10.9 million Australians, 680211 were exposed to CT radiations. There was a significant increased cancer incidence in the exposed group.6 Acute appendicitis is the most common surgical emergency. However, negative appendectomy may reach up to 40% in women of child bearing age. Furthermore, Brief Report