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No plain radiography in patients with acute abdominal pain
- Julien B.C.M. Puylaert (8 July 2009)
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Management of acute abdominal pain.
- Ajith K Siriwardena, Panagiotis Petras, Saurabh Jamdar, Santhalingam Jegatheeswaran (23 July 2009)
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Julien B.C.M. Puylaert, radiologist MCH The Hague, Netherlands, Lijnbaan 32 2512 VA The Hague
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With great interest I have read the paper by Laméris et al concerning imaging in patients with acute abdominal pain (1). They have well demonstrated that a strategy with initial ultrasound in all patients and conditional computed tomography in patients with a negative or inconclusive ultrasound is the optimal strategy. This results in the best sensitivity and minimizes radiation exposure when compared to a strategy of computed tomography in all patients. The authors also have demonstrated that the use of plain radiography is not effective and does not have a positive effect on sensitivity or specificity. Plain radiography therefore can be disregarded in patients with acute abdominal pain and ultrasound should be the initial diagnostic modality. Therefore I was somewhat amazed that both the accompanying editorial (2) and the editor choice (3) conclude from the paper that plain radiography should be the initial imaging technique in all patients, while in fact the paper has demonstrated that it is not effective. The bottom line of the paper by Laméris et al is: ultrasound in all patients with acute abdominal pain, and computed tomography for those patients in whom ultrasound cannot explain the symptoms. 1. Wytze Laméris, Adrienne van Randen, H Wouter van Es, Johannes P M van Heesewijk, Bert van Ramshorst, Wim H Bouma, Wim ten Hove, Maarten S van Leeuwen, Esteban M van Keulen, Marcel G W Dijkgraaf, Patrick M M Bossuyt, Marja A Boermeester, Jaap Stoker on behalf of the OPTIMA study group. Imaging strategies for detection of urgent conditions in patients with acute abdominal pain: diagnostic accuracy study. BMJ 2009; 338: b2431 2. Adrian K Dixon and Christopher J Watson. Imaging in patients with acute abdominal pain. BMJ 2009;338:b1678 3. Jane Smith. The rhythm method. BMJ 2009;339:b2668 Competing interests: None declared |
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Ajith K Siriwardena, Professor of Hepatobiliary Surgery Manchester Royal Infirmary, Panagiotis Petras, Saurabh Jamdar, Santhalingam Jegatheeswaran
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Dixon and Watson in their editorial on imaging in acute abdominal pain (1) reinforce the conclusions of the OPTIMA study group (2) and emphasise that a strategy of abdominal ultrasonography as a first test followed by computed tomography results in the best diagnostic sensitivity in this group. Acute radiology is well-established in the diagnostic algorithm of patients with acute abdominal pain, but an equally important and increasingly recognised aspect of assessment is to ensure that patients are seen by a sufficiently senior and appropriately experienced gastrointestinal surgeon within a short time of admission. In this regard, contemporary sub-specialisation has resulted effectively in the disappearance of the “General Surgeon”. The impetus for this specialisation is strong and includes the shortened period of training available for surgeons to attain expertise but also the parallel evidence for improved outcome when complex operations are done by appropriate specialist teams (3). The Department of Health’s guidance on centralisation of upper gastrointestinal cancer has helped change the face of surgical service provision in the UK (4): elective gastrointestinal cancer surgery is now provided by oesophago-gastric, hepato-pancreato- biliary and colorectal surgeons. These changes in service structure are substantial and are unlikely to be reversed to restore a “General Surgeon” to undertake on-call. However, it is recognised that service changes to improve the management of cancer patients should not be at the expense of disadvantaging other groups of patients and thus several practical solutions have been implemented. Consultant-level surgeons participating in an on-call service should not have concomitant elective activities but should be free to assess acute patients within 24 hours of admission. Placement of this senior experience at an early point in the management pathway is perhaps the best means to ensure that optimal tests are requested. Second, some acute patients do best with immediate surgery – for example, those with peritonitis from perforated ulcers and the current intercollegiate surgical curriculum project (ISCP) is aimed at equipping current trainees with the core skills to deal with these emergencies. However many acute general surgery patients – such as those with bowel obstruction or pancreatitis can effectively be triaged to colorectal or HPB teams by the admitting surgeon ensuring that each patient sees an appropriate specialist team. These measures, properly audited,should ensure that service changes designed to improve elective outcome can be implemented without disadvantage to emergency surgery and with the potential benefits of improved specialist input to urgent care References 1. Dixon AK, Watson CJ. Imaging in patients with acute abdominal pain. BMJ 2009; 338:b1678. 2. Laméris W, van Randen A, van Es HW, van Heesewijk JPM, van Ramshorst B, Bouma WH et al on behalf of the Optima study group. Imaging strategies for detection of urgent conditions in patients with acute abdominal pain: diagnostic accuracy study. BMJ 2009;338:b2431. 3. Birkmeyer JD, Stukel TA, Siewers AE, Goodney PP, Wennberg DE, Lucas FL et al. Surgeon volume and operative mortality in the United States. N Engl J Med 2003;349:2117-27. 4. Siriwardena AK. Centralisation of upper gastrointestinal cancer surgery. Ann R Coll surg Engl 2007;89:335-6. Competing interests: None declared |
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