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Department of Emergency Medicine University of Pennsylvania Health System. Discerning the Helpful From the Hedge: Imaging Tips for Abdominal Emergencies. Angela M. Mills, MD March 5, 2012. Disclosures. None related to this talk Allere, Inc. Research Funding

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slide1

Department of Emergency

Medicine

University of Pennsylvania Health System

Discerning the Helpful From the Hedge: Imaging Tips for Abdominal Emergencies

  • Angela M. Mills, MD
  • March 5, 2012
disclosures
Disclosures

None related to this talk

  • Allere, Inc.
    • Research Funding
  • Siemens Health Care Diagnostics
    • Research Funding
  • EM Clinics of North America
    • Honorarium
hedge h j
Hedge (hĕj)

n.

4. An intentionally noncommittal or ambiguous statement.

v.intr.

3. To avoid making a clear, direct response or statement.

The American Heritage® Dictionary of the English Language

overview
Overview
  • Epidemiology
  • Right upper quadrant pain
  • Pelvic pain
  • Right lower quadrant pain in pregnancy
  • Contrast for suspected appendicitis
slide7

13.9% all ED pts

Kocher et al. Ann Emerg Med. 2011.

slide10

RUQ Pain:

Is It Acute Cholecystitis?

ultrasound
Ultrasound

“…Recommend HIDA scan if there is concern for acute cholecystitis”

acute cholecystitis
Acute Cholecystitis
  • EMBU comparable to Rad
    • Sensitivity 87% vs. 83%
    • Specificity 82% vs. 86%
    • Prior studies sensitivity 84-98%
  • CT sensitivity 75%
    • Perforation, emphysematous chole, alternative diagnoses

Summers et al. Ann Emerg Med. 2010.

Privette et al. EMCNA. 2011.

slide13
HIDA
  • Nonfilling of GB suggestive of AC
    • GB normally visualized within 30 mins
  • Sensitivity 90-100%
  • Specificity 85-90%

Privette et al. EMCNA. 2011.

Blaivas et al. J Emerg Med. 2007.

slide14
99 pts, ED US and HIDA
  • Agreement 77%
  • 80% (12/15) +HIDA but –US, path agreed with US
  • 5 pts with normal HIDA but +US, path agreed with US

Blaivas et al. J Emerg Med. 2007.

other hida indications
Other HIDA Indications
  • Symptoms of biliary dyskinesia (chronic acalculous cholecystitis)
  • Biliary tree anomalies
  • Evaluation of bile leak post chole
  • Sick ICU patient
    • GN sepsis and unreliable exam
    • Unexplained leukocytosis on TPN

Lambie et al. Clin Rad. 2011.

hida limitations
HIDA Limitations
  • Does not image other structures
  • High bilirubin (>4.4 mg/dL) can ↓ sensitivity
  • Recent eating or fasting for 24 hrs
  • False negatives (filling in 30 min) in 0.5%
    • Filling between 30-60 mins associated with false-negative rates of 15-20%
  • False-positive results (10-20%)

Blaivas et al. J Emerg Med. 2007.

slide17

Gallstones

www.cartoonstock.com

slide18

Pelvic Pain:

Is It Ovarian Torsion?

computed tomography
Computed Tomography

“…Recommend US if there is concern for ovarian torsion”

Chiou et al. J US Med. 2007.

slide20
100% OT had abnormal ovary on CT

CT with normal ovaries rules out torsion

Moore et al. Emerg Rad. 2009.

us for ovarian torsion
US for Ovarian Torsion
  • Abnormal flow
    • Sensitivity 44%, Specificity 92%
    • PPV 78%, NPV 71%
  • Accuracy 71%

Bar-On et al. Fertil Steril. 2010.

Chiou et al. J US Med. 2007.

us for toa
US for TOA
  • Sensitivity 56-93%
  • Specificity 86-98%
  • Only prospective study showed Sensitivity 56%, Specificity 86%

Lee et al. J Emerg Med. 2011.

Tukeva et al. Rad. 1999.

ct for toa
CT for TOA
  • No studies to evaluate Sens/Spec
  • Ovarian masses, dilated tubes, free fluid equally seen CT and US
  • Fat stranding better seen on CT
  • May be more difficult to differentiate pyosalpinx from T-O complex or abscess by CT

Horrow et al. US Quart. 2004.

ct for toa25
CT for TOA

Hiller et al. JRM. 2005.

slide26

Cat Scan

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us for appendicitis
US for Appendicitis

“…Recommend MRI if there is concern for acute appendicitis”

us for appendicitis29
US for Appendicitis
  • Systematic review 14 studies (adults)
    • Sensitivity 81%, Specificity 80%
  • Appendix not seen 25-35% of time
    • Positive when diameter >6-7mm
  • False negatives with perforation, retrocecal or tip inflammation only

Eresawa et al. Ann Int Med. 2004.

Horn et al. EMCNA. 2011.

Kessler et al. Rad. 2004.

slide31
Systematic review
  • Imaging after normal or inconclusive US in pregnancy
    • CT: Sensitivity 86%, Specificity 97%
    • MRI: Sensitivity 80%, Specificity 99%

Basaran et al. Ob Gyn Surv. 2009.

mri vs ct in pregnancy
MRI vs. CT in Pregnancy
  • MRI has NPV 98% for acute abd pain
  • Both show alternative diagnoses
  • Retrospective study 1998-2005 greater increase in abd CT in pregnancy
    • 22%/yr/1,000 deliveries vs. 13%/yr
    • Suspected appy most common indication

Oto et al. Abd Imaging. 2009.

Goldberg-Stein et al. Am J Roentgenol. 2011.

slide34
No consensus for imaging algorithm for abd pain in pregnancy
  • Radiology survey
    • 96% respondents perform CT when benefit/risk ratio is high
    • MRI preferred 1st trimester
    • CT preferred 2nd / 3rd trimesters

Jaffe et al. Am J Roentgenol. 2007.

contrast
Contrast
  • Oral
    • Limits resp misregistration, motion artifacts
      • Development of fast multidetector CT
    • Protocols: 60-90 mins to opacify bowel
  • IV
    • Highlights differences btwn soft tissues
    • Risk of CIN, allergic reaction

Holmes et al. Ann EM. 2004.

Stuhlfaut et al. Rad. 2004.

slide37
Retrospective, 183 pts
    • 81 oral contrast, 102 no oral contrast
    • Stat sig increased ED LOS
      • 358 vs. 599 min, p<0.001
    • Difference of 241 min >> 90 min

Huynh et al. Emerg Rad. 2004.

slide38
Systematic review of 23 studies
    • 19/23 prospective, total 3474 patients
      • 1510 patients no oral contrast
    • Final dx by path or clinical follow up

Anderson et al. Am J Surg. 2005.

slide39
7-study systematic review
    • 1060 patients
    • Final dx at surgery or min 2 week f/u
    • Noncontrast = no oral or IV
  • Sensitivity 93%, Specificity 96%
    • Comparable to prior published reviews

Hlibczuk et al. Ann Emerg Med. 2010.

slide40

Questions

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