Page 122 - Registrar Orientation Manual 2016

Reference:
1257
Effective date:
7 July 2015
Expiry date:
6 July 2018
Page:
5 of 35
Title:
Imaging Guidelines
Type:
Clinical Guideline
Version:
02
Authorising initials:
Abdominal Pain
General Principles
General principles in the use of imaging for abdominal pain include:
Patients with “surgical abdomens” do not always require imaging and imaging should not need to be done to “prove” a patient with abdominal pain has a surgical problem before they are seen.
Registrars cannot request that imaging must be performed before they make a clinical assessment.
Plain Film Radiology
Plain film radiology (PFR) has a limited role and should only be used for specific indications. In an unselected population with acute abdominal pain PFR rarely alters clinical management.
Utilising PFR for 'non-specific abdominal pain' is unlikely to yield a positive finding. Significantly, unrelated or incidental pathology can be identified and alter clinical management erroneously.
Evidence and consensus indications for PFR in the investigation of acute abdominal pain include:
• suspected bowel obstruction or ileus
• suspected bowel perforation
• ingested foreign body, and
• severe abdominal pain or tenderness of unknown origin requiring opiate analgesia
The National Community Radiology Access Criteria have the following indications for PFR:
• diagnosis of constipation where patient history is unobtainable (eg, patient with autism)
• follow-up of radio-opaque renal tract stones with a kidney, ureter, bladder (KUB) X-ray
They note referral for community X-ray not typically indicated:
• acute abdomen: discuss with acute surgical services or emergency services
• vague central abdominal pain
• suspected colorectal neoplasm
• suspected constipation (other than in specific patient groups as above)
Ultrasound
In young patients (<40) ultrasound is usually preferred to CT to minimise radiation exposure. In women with lower abdominal pain pelvic ultrasound should always be considered first.
In RUQ pain and suspected cholecystitis ultrasound should usually be requested first.
CT Scanning
CT scans must not be requested by registrars to avoid seeing or delay seeing patients in ED.
Unless a surgical SMO has recommended it, CT abdomen for patients with abdominal pain under other services will not be performed without a team SMO to radiology SMO discussion.
The ‘Choosing Wisely’ recommendations include:
CT scans are not necessary in the routine evaluation of children with abdominal pain.
Don’t do CT for the evaluation of suspected appendicitis in children until after ultrasound has been considered as an option.
For a patient with functional abdominal pain syndrome (as per ROME III criteria) CT scans should not be repeated unless there is a major change in clinical findings or symptoms.
MRI
MRI is rarely needed except for specific indications and should only be done after specialist review and usually a discussion in the MDT (for example staging pelvic tumours before surgery).
Clinical urgency: Depends on the acuity. After 2200 hours, requests will need to be discussed with the on call radiology registrar. If a patient does not have signs of an acute abdomen imaging can usually be deferred until the following morning.