The diagnostic role of sonar and CT-

scan in suspected acute abdominal

process

Dr P J Nel (Surgery)
Dr R Minne (Radiology)
British Medical Journal 1925
A correspondence by Ralph Hopton:

Sir Berkeley Moynihan for years past has

consistently advised medical men to have nothing to
do with the non-operative treatment of appendicitis,
however apparently trivial the case
The wise man waits for an established character
before he lends; and the medical man can only wait,
examine, and re-examine
Here lies real ground for research, especially by
men in general practice. May it be well lit !
The Acute Abdominal Process

Defined as a clinical syndrome characterised

by the onset of sudden severe abdominal
pain requiring emergency medical or surgical
treatment
5% of emergency department patients have
acute abdominal pain
American College of Radiology
appropriateness criteria
But what about clinical accumen?

CT superior to clinical evaluation acute abdominal

pain
90-96% vs 60-76%
12-40% negative-finding appendicectomy rate
Clinical evaluation almost 100% sensitive
Specificity 73%
A third of acute diverticulitis are missed clinically
Acute cholecystitis triad
What about the costs?

Routine use of CT is cost-effective

15% of appendicectomies unnecesary
$741 million in total hospital charges
Use of CT with 5% reduction translates to $494
million savings
What about radiation exposure?

Annual background radiation dose in USA is 3

mSv
Standard abdominal CT is 10 mSv
A 10 mSv CT exam in a 25 year old person is
associated with a risk of induced cancer in 1 in 900
with fatal cancer 1 in 1800
Lifetime cancer risk is 1 in 3
Diagnostic benefit needs to outweigh
Low vs standard dose
The 4 modalities

Conventional chest and abdominal

radiography
3 view acute abdominal films
50% accuracy with 4% treatment change
Not for appendicitis work-up
0.1 to 1 mSv
The 4 modalities

Ultrasound examination
Available, low costs, no radiation
Graded compression technique
56% useful information, 13 % increase in correct
diagnosis, 22% alteration in treatment
The 4 modalities

CT examination
Rapid, spesific and sensitive
Radiation exposure
Iv contrast and nephrotoxicity
The 4 modalities

Magnetic resonance imaging

No ionizing radiation
High resolution does not require contrast
Long examination times, lower to 15 minutes
Poor data in the acute abdomen
Recommended in pregnant women
IV, oral, rectal contrast
Acute appendicitis

The false-positive appendicitis

The false-negative appendicitis
Clinical findings
Appropriate imaging
Ultrasound, CT or both
Hernanz-Shulman Radiology 2010 April
Toorenvliet
 Acute diverticulitis

Clinical diagnosis sensitive in 64%, thus 26% of diagnosis

missed
90% will have diverticulitis left
CT and US not significantly different accuracies
CT important in differentiating from Colon cancer
Acute cholecystitis

5 % of acute abdominal pain in ED

Clinical triad rare
Tokyo guidelines for severity (grades)
1. One local sign, one systemic sign and
confirmatory imaging (mild)
2. Mild inflammatory changes adjacent to the
gallbladder and no organ dysfunction
(moderate)
3. Cholecystitis combined with MODS (severe)
Bowel Obstruction

Small bowel obstruction

Cause related to treatment
Conventional radiography vs CT
Transitition point for cause
Internal hernias
Colonic obstruction
Cancer, volvulus and diverticulitis
CT exam of choice
Perforated viscus

Conventional radiography is insensitive for

air pockets small than 1mm and only 33%
sensitive for air pockets 1-13mm
CT can predict actual site of perforation in
85% of cases
Ultrasound useful too
Sensitivity of 92% and specificity 53% with overall
accuracy of 88%
Bowel ischaemia

CT angiogram modality of choice

Differentiates between venous and arterial
occlusions
CT signs
Bowel wall changes
Pneumatosis cystoides intestinalis
Sensitivities and specificities comparable
with angiogram
Contrast enhanced doppler US also useful
What is the place of a diagnostic
laparoscopy then?

Golash 2005
SAGES 2007
Peris 2009
Uranus 2010
Dominguez 2011
THUS
No clear recommendations
No clear guidelines
 References

American College of Radiology ACR Appropriateness Criteria 2008

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