Panamerican Journal of Trauma, Critical Care & Emergency Surgery

Register      Login

VOLUME 9 , ISSUE 2 ( May-August, 2020 ) > List of Articles

Original Article

Performance of Noncontrast Multidetector Computed Tomography Compared with a Reference Standard (Surgery/Pathology or Clinical Follow-up) in Diagnosing Acute, Nontraumatic Abdominal Pain

Milena Alcázar, Maria Del Pilar Gutierrez, Santiago Rojas, Tatiana Suarez, Carlos Morales

Citation Information : Alcázar M, Gutierrez MD, Rojas S, Suarez T, Morales C. Performance of Noncontrast Multidetector Computed Tomography Compared with a Reference Standard (Surgery/Pathology or Clinical Follow-up) in Diagnosing Acute, Nontraumatic Abdominal Pain. Panam J Trauma Crit Care Emerg Surg 2020; 9 (2):91-96.

DOI: 10.5005/jp-journals-10030-1287

License: CC BY-NC 4.0

Published Online: 18-11-2020

Copyright Statement:  Copyright © 2020; The Author(s).


Introduction: Computed tomography (CT) with intravenous (IV) contrast is the method of choice for diagnosing and selecting treatments for surgical pathologies in patients visiting the emergency room (ER) for acute, nontraumatic abdominal pain. However, there are risks, high costs, and delays in medical attention associated with this modality. Studies have suggested performance of CT without venous contrast for diagnosing appendicitis. Nevertheless, no methodologically rigorous studies have evaluated CT without IV contrast performance when used as the main diagnostic tool for patients with acute abdominal pain. Objective: This study aims to evaluate the diagnostic performance of noncontrast abdominal CT and compare it with a reference standard (surgery/pathology or clinical follow-up) to detect surgical diseases in patients with acute abdominal pain. Design: This is a cross-sectional, diagnostic test study. Place: Hospital Universitario San Vicente Foundation (Medellín, Colombia). Materials and methods: This is a cross-sectional convenience sample diagnostic test study of consecutively selected patients who underwent noncontrast CT of the abdomen. All patients were those who presented to the ER with abdominal complaints. All patients who consented underwent a noncontrast and IV contrast CT scans. Two radiologists with different levels of expertise independently evaluated the noncontrast tomography images to specify the diagnostic findings. Final diagnoses were collected independently from the patients’ clinical histories. Patients who did not undergo surgery, their clinical histories were reviewed during hospitalization. Those who were not hospitalized had their clinical course obtained by telephone 2 weeks after being discharged. Results: Of the 157 included patients, 19.1% underwent surgery because of an acute pathology. For noncontrast abdominal contrast tomography, values of 93.3% sensitivity (95% CI 82.7–100), 96.8% specificity (95% CI 93.4–100), 87.5% PPV (95% CI 74.4–100), 98.4% NPV (95% CI 95.8–100), 29.6 LR+ (95% CI 11.24–78.1), 0.07 LR− (95% CI 0.02–0.26), and 97.4% diagnostic accuracy were obtained. The interobserver concordance had a kappa value of 0.88. Conclusion: Noncontrast abdominal CT performs well in differentiating medical vs surgical diseases in patients with acute abdominal pain.

  1. Strömberg C, Johansson G, Adolfsson A. Acute abdominal pain: diagnostic impact of immediate CT scanning. World J Surg 2007;31(12):2347–2354. DOI: 10.1007/s00268-007-9233-x; discussion 2355–8.
  2. Van Randen A, Laméris W, van Es HW, et al. A comparison of the accuracy of ultrasound and computed tomography in common diagnoses causing acute abdominal pain. Eur Radiol 2011;21(7):1535–1545. DOI: 10.1007/s00330-011-2087-5.
  3. Sala E, Watson CJE, Beadsmoore C, et al. A randomized, controlled trial of routine early abdominal computed tomography in patients presenting with non-specific acute abdominal pain. Clin Radiol 2007;62(10):961–969. DOI: 10.1016/j.crad.2007.01.030.
  4. Torbati SS, Guss DA. Impact of helical computed tomography on the outcomes of emergency department patients with suspected appendicitis. Acad Emerg Med 2003;10(8):823–829. DOI: 10.1197/aemj.10.8.823.
  5. Hill BC, Johnson SC, Owens EK, et al. CT scan for suspected acute abdominal process: impact of combinations of IV, oral, and rectal contrast. World J Surg 2010;34(4):699–703. DOI: 10.1007/s00268-009-0379-6.
  6. Udayasankar UK, Li J, Baumgarten DA, et al. Acute abdominal pain: value of non-contrast enhanced ultra-low-dose multi-detector row CT as a substitute for abdominal radiographs. Emerg Radiol 2009;16(1):61–70. DOI: 10.1007/s10140-008-0743-0.
  7. MacKersie AB, Lane MJ, Gerhardt RT, et al. Nontraumatic acute abdominal pain: unenhanced helical CT compared with three-view acute abdominal series. Radiology 2005;237(1):114–122. DOI: 10.1148/radiol.2371040066.
  8. Ahn SH, Mayo-Smith WW, Murphy BL, et al. Acute nontraumatic abdominal pain in adult patients: abdominal radiography compared with CT evaluation. Radiology 2002;225(1):159–164. DOI: 10.1148/radiol.2251011282.
  9. Lehtimäki T, Juvonen P, Valtonen H, et al. Impact of routine contrast-enhanced CT on costs and use of hospital resources in patients with acute abdomen. Results of a randomised clinical trial. Eur Radiol 2013;23(9):2538–2545. DOI: 10.1007/s00330-013-2848-4.
  10. Hajian-Tilaki K. Sample size estimation in diagnostic test studies of biomedical informatics. J Biomed Inform 2014;48:193–204. DOI: 10.1016/j.jbi.2014.02.013.
  11. Altman D, Machin D, Bryant T, et al. Statistics with confidence. British Medical Journal. 2nd ed., 2005.
  12. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics 1977;33(1):158–174. DOI: 10.2307/2529310.
  13. Doyle LA, Odze RD. Inflammatory disorders of the appendix Odze RD, Goldblum JR, ed. Odze and Goldblum Surgical Pathology of the GI Tract, Liver, Biliary Tract and Pancreas. 3rd ed., Elsevier; 2015. pp. 516–517.
  14. Powers RD, Guertler AT. Abdominal pain in the ED: stability and change over 20 years. Am J Emerg Med 1995;13(3):301–303. DOI: 10.1016/0735-6757(95)90204-X.
  15. Hastings RS, Powers RD. Abdominal pain in the ED: a 35 year retrospective. Am J Emerg Med 2011(7):711–716. DOI: 10.1016/j.ajem.2010.01.045.
  16. Irvin TT. Abdominal pain: a surgical audit of 1190 emergency admissions. Br J Surg 1989;76(11):1121–1125. DOI: 10.1002/bjs.1800761105.
  17. Lukens TW, Emerman C, Effron D. The natural history and clinical findings in undifferentiated abdominal pain. Ann Emerg Med 1993;22(4):690–696. DOI: 10.1016/s0196-0644(05)81849-9.
  18. Larson DB, Johnson LW, Schnell BM, et al. National trends in CT use in the emergency department: 1995-2007. Radiology 2011;258(1): 164–173. DOI: 10.1148/radiol.10100640.
  19. Kocher KE, Meurer WJ, Fazel R, et al. National trends in use of computed tomography in the emergency department. Ann Emerg Med 2011;58(5):452.e3–462.e3.
  20. Cohan RH, Davenport MS, Dillman JR, et al. ACR Manual on Contrast Media Version 9 ACR Committee on Drugs and Contrast Media. Version 9. American College of Radiology; 2013.
  21. Berrington de González A, Darby S. Risk of cancer from diagnostic X-rays: estimates for the UK and 14 other countries. Lancet (London, England) 2004;363(9406):345–351. DOI: 10.1016/S0140-6736(04)15433-0.
  22. Brenner DJ, Hall EJ. Computed tomography--an increasing source of radiation exposure. N Engl J Med 2007;357(22):2277–2284. DOI: 10.1056/NEJMra072149.
  23. Romero J, Sanabria Á, Angarita M, et al. Cost-effectiveness of computed tomography and ultrasound in the diagnosis of appendicitis. 2008(1):139–147.
  24. Bennett GL, Balthazar EJ. Ultrasound and CT evaluation of emergent gallbladder pathology. Radiol Clin North Am 2003;41(6):1203–1216. DOI: 10.1016/s0033-8389(03)00097-6.
  25. Daly CP, Cohan RH, Francis IR, et al. Incidence of acute appendicitis in patients with equivocal CT findings. AJR Am J Roentgenol 2005;184(6):1813–1820. DOI: 10.2214/ajr.184.6.01841813.
  26. Seo H, Lee KH, Kim HJ, et al. Diagnosis of acute appendicitis with sliding slab ray-sum interpretation of low-dose unenhanced CT and standard-dose i.v. Contrast-enhanced CT scans. AJR Am J Roentgenol 2009;193(1):96–105. DOI: 10.2214/AJR.08.1237.
  27. Rhea JT, Halpern EF, Ptak T, et al. The status of appendiceal CT in an urban medical center 5 years after its introduction: experience with 753 patients. AJR Am J Roentgenol 2005;184(6):1802–1808. DOI: 10.2214/ajr.184.6.01841802.
  28. Platon A, Jlassi H, Rutschmann OT, et al. Evaluation of a low-dose CT protocol with oral contrast for assessment of acute appendicitis. Eur Radiol 2009;19(2):446–454. DOI: 10.1007/s00330-008- 1164-x.
  29. Keyzer C, Cullus P, Tack D, et al. MDCT for suspected acute appendicitis in adults: impact of oral and IV contrast media at standard-dose and simulated low-dose techniques. AJR Am J Roentgenol 2009;193(5):1272–1281. DOI: 10.2214/AJR.08.1959.
  30. Weir-McCall J, Shaw A, Arya A, et al. The use of pre-operative computed tomography in the assessment of the acute abdomen. Ann R Coll Surg Engl 2012;94(2):102–107. DOI: 10.1308/003588412X13171221501663.
  31. Tsushima Y, Yamada S, Aoki J, et al. Effect of contrast-enhanced computed tomography on diagnosis and management of acute abdomen in adults. Clin Radiol 2002;57(6):507–513. DOI: 10.1053/crad.2001.0925.
  32. Paulson EK, Jaffe TA, Thomas J, et al. MDCT of patients with acute abdominal pain: a new perspective using coronal reformations from submillimeter isotropic voxels. AJR Am J Roentgenol 2004;183(4):899–906. DOI: 10.2214/ajr.183.4.1830899.
  33. Chin JY, Goldstraw E, Lunniss P, et al. Evaluation of the utility of abdominal CT scans in the diagnosis, management, outcome and information given at discharge of patients with non-traumatic acute abdominal pain. Br J Radiol 2012;85(1017):e596–e602. DOI: 10.1259/bjr/95400367.
  34. Knottnerus JA, Muris JW. Assessment of the accuracy of diagnostic tests: The cross-sectional study Knottnerus JA, Buntinx F, ed. The Evidence Base of Clinical Diagnosis Theory and methods of diagnostic research. 2nd ed., BMJ Books; 2011. p. 53.
  35. Després JP, Prud'homme D, Pouliot MC, et al. Estimation of deep abdominal adipose-tissue accumulation from simple anthropometric measurements in men. Am J Clin Nutr 1991;54(3):471–477. DOI: 10.1093/ajcn/54.3.471.
  36. Wolfe JM, Smithline H, Lee S, et al. The impact of body mass index on concordance in the interpretation of matched noncontrast and contrast abdominal pelvic computed tomographic scans in ED patients with nontraumatic abdominal pain. Am J Emerg Med 2006;24(2):144–148. DOI: 10.1016/j.ajem.2005. 08.015.
  37. Uyeda JW, Yu H, Ramalingam V, et al. Evaluation of acute abdominal pain in the emergency setting using computed tomography without oral contrast in patients with body mass index greater than 25. J Comput Assist Tomogr 2015;39(5):681–686. DOI: 10.1097/RCT.0000000000000277.
PDF Share
PDF Share

© Jaypee Brothers Medical Publishers (P) LTD.