Review of the need for Abdominal X-rays in the diagnosis of acute abdominal pain- An Emergency Department Perspective

There has been a significant debate over the use of AXR as an adjunct to the diagnosis of the acute abdomen. There are only a few numbers of clinical indications for this modality of imaging, and there has been a concerted effort from the Royal College of Radiologist (RCR) to ensure that there is a reduction in the number of AXR being performed. Evidence Acquisition To study the most frequent presentation of abdominal pain to accident and emergency requiring abdominal X-ray imaging. To understand the correlation between the clinical indication for the imaging and the subsequent findings as reported by the Radiologist. To assess whether further imaging was done and if these yielded any benefit. To assess for change once interventions were instituted. Method Phase 1-100 patients were selected at random from the patients presenting with abdominal pain to Ayr Accident and Emergency during July 2014. As previously stated, the indication for the AXR was explored with any follow-up imaging that was performed. Phase 2 was carried out for the patients presenting with abdominal pain in months of December 2019- January 2020. The same methodology was used with 100 patients to investigate the indications for AXR imaging as per Phase 1, any significant findings in relation to the clinical query and the further use of other imaging modalities. The clinical indications for the imaging were also studied and audited against the IRMER and the RCR guidelines, taking into consideration any changes in the guidelines from the time of Phase 1. Results/Measures Phase1 - It was seen than in 56 cases out of the 100 cases AXR was the only imaging done with no follow-up imaging. In 44 cases there was follow up imaging with other modalities. It was also noted that only in 20 cases the indication matched with the radiological findings whilst in the vast 80% of cases there was no correlation between the indication and imaging findings. Phase 2- As can be seen, there was an improvement in the indication put in the request with a significant reduction of 7% in the? perforation? obstruction as an indication. There was also a significant reduction in the number of AXR done for renal calculi related cases (11% vs 4%). There was, however, increases in both surgery-related and acute onset abdominal pain-related cases. One of the main limitations of this form of comparison is that this only represents a cohort of patients and may not be representative of the actual trend in requesting AXR. Discussion The practice of medicine is ever-changing, and the realities of medico-legal consequences are becoming part of the way we are practising today. The tendency to over investigate and practice defensively is increasing, and this is shown clearly through this audit study Conclusion There can be more that can be done to reduce the number of AXR that are done for abdominal pain. It should be noted that there is no role for AXR in the diagnosis of undifferentiated abdominal pain. All clinicians requesting AXR should review the need for the same prior to proceeding due to the unnecessary exposure in the vast majority of cases