Diagnostic Imaging Pathways - Abdominal Plain X-Ray (Indications)
Population Covered By The Guidance
This pathway provides guidance on the indications for a plain abdominal radiograph in adult patients.
Date reviewed: January 2012
Date of next review: January 2015
Published: January 2012
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|SYMBOL||RRL||EFFECTIVE DOSE RANGE|
|Minimal||< 1 millisieverts|
- Indications for plain abdominal radiograph are
- Suspected bowel obstruction
- Suspected perforation
- Suspected foreign body
- Mod-severe undifferentiated abdominal pain
- Renal tract calculi follow-up
Indications For Plain Abdominal Radiograph
- Eisenberg et al (1982) established the futility of indiscriminate use of AXRs showing 53.7% fewer AXRs could be performed if strict guidelines were followed. A prospective study by Thomas et al showed that about 77% films were normal, increasing to 84% if unrelated or unsuspected findings were considered. Even 25 years later, AXRs continue to be overused. Kellow et al (2008), in their retrospective study of 874 patients presenting to the Emergency Department, showed that 81% had normal or non-specific abdominal radiograph results
- In their review of 277 cases, Lee showed that plain abdominal radiographs were not helpful in 57% and were misleading in another 1%
- A few recent studies have shown that guidelines, as laid by the Royal College of Radiologists, are not being followed and a majority of plain abdominal radiographs requested on acute medical emergencies is still inappropriate ,,
- The appropriate conditions for requesting a AXR as suggested by Jelinek et al are
- Bowel obstruction or paralytic ileus
- Renal /ureteric/bladder calculus
- Ingested foreign body
- Penetrating injury
- In this prospective trial , the authors were able to demonstrate a 50% reduction in the PAR requests and a further 16% reduction in inappropriate imaging by following the above indications
- Similar indications were suggested by Eisenberg et al in their prospective study. They recommended the following criteria
- Patients with moderate or severe abdominal tenderness
- Patients without moderate or severe abdominal tenderness, with high clinical suspicion of bowel obstruction, renal-ureteric calculi, trauma, ischemia, or gallstones if ultrasound is unavailable)
- They demonstrated that following the above guidelines could have avoided around 53% of AXRs, as mentioned above
- Smith et al conducted a systematic review of literature to suggest indications for AXRs. They suggested the following indications
- Rothrock et al, in their prospective study, showed that the presence of any of the following features-prior abdominal surgery, foreign body ingestion, abnormal bowel sounds, abdominal distension, or peritoneal signs-was 93% sensitive and 40% specific in predicting diagnostic or suggestive radiographs in patients with major disease. The positive and negative predictive values were 11% and 99%, respectively
- Levine and Chiu both have supported the use of AXR in pneumoperitoneum
- Plain abdominal radiographs have little or no role in diagnosis or further investigation of gastrointestinal haemorrhage, peptic ulcer, appendicitis, urinary tract infection or non-specific abdominal pain ,,,,
- There is mixed evidence for the use of AXR in trauma. Some studies suggest that AXRs are neither useful nor cost-effective in stab wounds to the abdomen ,, while others favour AXRs in a trauma setting ,
- Greene, in his review article, makes the following recommendations for the appropriate use of plain radiographs in an emergency department
- Avoid radiography for conditions unlikely to be associated with radiographic signs
- Avoid radiography in women of reproductive age group, unless a strong indication exists, and only after pregnancy has been excluded
- Avoid radiography where it will not lead to a change in management
- If radiography is indicated, request only a supine abdomen or a supine abdomen and erect chest x-ray. A complimentary view is to be requested only after reviewing the initial film
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- Eisenberg R, Heineken P, Hedgcock MW et al. Evaluation of plain abdominal radiographs in the diagnosis of abdominal pain. Ann Intern Med. 1982;97:257-61. (Level II evidence). View the reference
- McCook TA, Ravin CE, Rice RP. Abdominal radiography in the emergency department: A prospective analysis. Ann Emerg Med. 1982;11(1):7-8. (Level II evidence)
- Kellow ZS, MacInnes M, Kurzencwyg D, Rawal S, Jaffer R, Kovacina B, et al. The role of abdominal radiography in the evaluation of the nontrauma emergency patient. Radiology. 2008;248(3):887-93. (Level III evidence)
- Lee P. The plain x-ray in acute abdomen : a surgeon's evaluation. Br J Surg. 1976;63:763-6. (Level III evidence)
- Karkhanis S, Medcalf J. Plain abdomen radiographs: the right view? Eur J Emerg Med. 2009;16(5):267-70. (Level III evidence)
- Morris-Stiff G, Stiff R, Morris-Stiff H. Abdominal radiograph requesting in the setting of acute abdominal pain: temporal trends and appropriateness of requesting. Ann R Coll Surg Engl. 2006;88(3):270-4. (Level II evidence). View the reference
- Feyler S, Williamson V, King D. Plain abdominal radiographs in acute medical emergencies: an abused investigation? Postgrad Med J. 2002;78(916):94-6. (Level II evidence).
- Jelinek G, Bangham N. Reducing the use of plain abdominal radiographs in an emergency department. Arch Emerg Med. 1990;7:241-5. (Level II evidence). View the reference
- Smith JE, Hall EJ. The use of plain abdominal x rays in the emergency department. Emerg Med J. 2009;26(3):160-3. (Review article)
- Maglinte D, Reyes B, Harmon B, Kelvin F, Turner WW, Hage JE, et al. Reliability and role of plain film radiography and CT in the diagnosis of small-bowel obstruction. AJR Am J Roentgenol. 1996;167(6):1451-5. (Level III evidence)
- Ahn SH, Mayo-Smith WW, Murphy BL, Reinert SE, Cronan JJ. Acute nontraumatic abdominal pain in adult patients: abdominal radiography compared with CT evaluation. Radiology. 2002;225(1):159-64. (Level III evidence)
- Suri S, Gupta S, Sudhakar P, Venkataramu N, Sood B, Wig J. Comparative evaluation of plain films, ultrasound and CT in the diagnosis of intestinal obstruction. Acta Radiol. 1999;40:422-8. (Level II evidence)
- Rothrock S, Green S, Hummel C. Plain abdominal radiography in the detection of major disease in children: a prospective analysis. Ann Emerg Med. 1992 21(12):1423-9. (Level II evidence).
- Levine MS, Scheiner JD, Rubesin SE, Laufer I, Herlinger H. Diagnosis of pneumoperitoneum on supine abdominal radiographs. AJR Am J Roentgenol. 1991;156:731-5. (Level III evidence)
- Chiu YH, Chen JD, Tiu CM, Chou YH, Yen DH, Huang CI, et al. Reappraisal of radiographic signs of pneumoperitoneum at emergency department. Am J Emerg Med. 2009;27(3):320-7. (Level III evidence)
- Anyanwu A, Moalypour S. Are abdominal radiographs still overutilized in the assessment of acute abdominal pain? A district general hospital audit. J R Coll Surg Edinb. 1998;43(4):267-70. (Level III evidence)
- Campbell J, Gunn A. Plain abdominal radiographs and acute abdominal pain. Br J Surg. 1988;75(6):554-6. (Level III evidence)
- McCook T, Ravin C, Rice R. Abdominal radiography in the emergency department: a prospective analysis. Ann Emerg Med. 1982;11:7-8. (Level II evidence)
- Brewer BJ, Golden GT, Hitch DC, Rudolf LE, Wangensteen SL. Abdominal pain. An analysis of 1,000 consecutive cases in a University Hospital emergency room. Am J Surg. 1976;131(2):219-23. (Level II evidence). View the reference
- Kester D, Andrassy R, Aust J. The value and cost effectiveness of abdominal roentgenograms in the evaluation of stab wounds to the abdomen. Surg Gynecol Obstet. 1986;162(4):337-9. (Level III evidence)
- Smith DS, Bonadio WA, Losek JD, Walsh-Kelly CM, Hennes HM, Glaeser PW, et al.The role of abdominal x-rays in the diagnosis and management of intussusception. Pediatr Emerg Care. 1992 8(6):325-7. (Review article)
- Greene C.Indications for plain abdominal radiography in the emergency department. Ann Emerg Med. 1986;15(3):257-60. (Review article)
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