Pitfalls To Avoid
1. “His belly wasn’t very impressive.”
The physical examination can be misleading in many causes of abdominal pain, especially in the elderly or immunocompromised.
2. “The CBC was normal.”
All laboratory tests should be considered in the context of the potential disease process. A negative CBC in and of itself does not rule out an inflammatory or infectious process.
3. “I thought the nurse ordered the pregnancy test.”
A pregnancy test should be ordered and reviewed on women of childbearing age.
4. “X-rays of the abdomen are a thing of the past. I just go straight to CT.”
CT may provide more information depending on what disease process is most likely. However, in patients presenting with signs of perforation, foreign body ingestion, or SBO, it may be prudent to order abdominal radiographs first to potentially make the diagnosis and assist with choice of later imaging modality (nonenhanced vs. contrast enhanced CT).
5. “I wanted to get an ultrasound to evaluate a pregnant patient with flank pain and hematuria, but the urologist wanted a KUB.”
According to the ACR Appropriateness CriteriaTM, renal ultrasound is the preferred examination in pregnant patients with flank pain.
6. “The radiologist didn’t see the appendix on US, so I told the patient he could go home.”
A non-visualized appendix may be due to patient body habitus or overlying bowel gas and can be operator dependent. The negative predictive value of ultrasound for appendicitis (generally reported in the 70 - 75% range) is much lower than its positive value (above 90%). This is when the appendix is visualized. Failure to visualize the appendix on ultrasound does not rule out appendicitis, and necessitates further evaluation (usually with CT scan.) No tenderness over the appendix with ultrasound probe compression is needed in addition to a non-visualized appendix to be considered a negative US. Clinical decisions should not be based on US alone.
7. “The patient was allergic to contrast so I couldn’t order a CT.”
Contrast allergy is usually due to the intravascular administration of an iodinated agent. Intravenous contrast is not required for many CT studies. Additionally, with the advent of newer generation CT technology, some radiologists are not using intravascular (or oral contrast) for abdominal CT imaging. Knowledge of available resources and communication with the radiologist interpreting the study is key to obtaining the appropriate study for your patient.
8. “The surgeon said that the patient needed oral contrast for the abdominal CT because the bowel obstruction was so bad.”
Oral contrast is not recommended as a first line choice for patients with high-grade or complete bowel obstructions. It may be useful for patients with partial SBO.
9. “The patient only had belly pain. The work-up was negative so I let him go home. He came back three days later with a perforated appendix. He should have known to follow up with his physician.”
Every patient discharged with undifferentiated abdominal pain should be given clear instructions for follow up. This includes specific instructions on when to return to the ED if the patient’s clinical condition worsens.