It would seem that despite a great many literature reviews and audits of practice,
no studies have been translated into revised recommendations by the Royal College of Radiologists for use of the abdominal plain film.
The current guidelines have little evidence base or basis from established practice.
In 2011 a multicentre prospective trial of patients in the Netherlands concluded that plain radiographs should be omitted from the routine diagnostic work up of patients with acute abdominal pain to a substantial cost saving effect (5).
It can be concluded from our data that only half of all AXR requests are appropriate and a very small number have positive results. It is possible that this is because few referrers are aware of and are adhering to the current guidance.
Similar results have been seen previously in smaller studies (6,
7).
Also highlighted by this study is that a lack of confidence in the plain AXR and its diagnostic capability exists.
Regardless of reported findings,
further investigations appear to be requested in order to adequately support or make suspected diagnoses and inform management.
This study does not advocate the complete elimination of the abdominal plain film from the clinician’s toolbox,
however a more measured approach to its requesting and a better understanding of its diagnostic capacity.
In order to fully justify the exposure of patients to a significant radiation dose,
the study should go some way to affecting their diagnosis or the confidence with which the clinicians will make that diagnosis.
It is clear from the data regarding further investigations,
that in a number of cases the AXR findings are not of relevance to the decision making process. Thus by streamlining the referral criteria to a few diagnoses that can be confidently ruled out then patients will be imaged more appropriately and in a more timely fashion. It would follow that further information should be provided with any new guidelines produced that would guide the clinician to the most appropriate alternative investigation.
As well as impacting patient care,
this can be expected to have significant cost and efficiency benefits.
From this study and evidence from other referenced material (1,3,8),
it is concluded that the abdominal plain film should only be requested for the indications listed below and that for each of these sufficient clinical information ought to be available to support the request.
Indications suggested for AXR in the patient with acute abdominal pain:
- Suspected intestinal obstruction
- Suspected colitis or complication (eg: Toxic Megacolon)
- Foreign Body
Specific indications,
of note,
that do not feature in this list:
- Perforation: only an erect CXR is clearly indicated here (2)
- Calculi: Gallstones require an Ultrasound and Renal tract stones a CT-KUB (8)
It is also inferred that this investigation appears to still be used inappropriately as part of a routine work up of patients with indistinct abdominal symptoms and this is not practice recommended by the RCR. If requested appropriately there will be a savings in:
- Patient dose
- Time,
and
- Cost.
The positive pick-up rate from plain AXR should also be seen to improve. These results are observed in a study of plain films in 2006 (9).
A program of education for referrers and subsequent re-audit should be carried out. If a re-audit were to show more appropriate requesting and a greater diagnostic yield,
it could then be concluded that central guidelines should be re-examined.