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."
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."
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."
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."
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."
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."
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.