Wednesday, February 2, 2011

Abdominopelvic CT Increases Diagnostic Certainty

A report from the Massachusetts General Hospital shows that abdominopelvic CT scans significantly increased diagnostic accuracy and changed patient management in a series of 584 prospectively studied non-trauma patients with abdominal pain. The paper was published ahead of print in the American Journal of Radiology.

Emergency physicians recorded their presumptive diagnoses after examining patients and before the CT scan was performed. Key findings were that CT scanning increased diagnostic certainty from 70% to 90% and resulted in changes in patient treatment plans in 42%. In addition, 25% of patients initially diagnosed with a problem thought to require surgery were discharged from the emergency department without further treatment.

The most common problems encountered were ureteral stones, bowel obstruction and no acute condition, which was thought to be the diagnosis in 77 patients before CT scanning. Post-CT scan, the number of patients with no acute condition was 174, representing a 126% increase in that finding.

The paper did not address cost or radiation exposure. Asked about radiation exposure, lead author Hani H. Abujudeh, M.D. said in an email, radiation to the patient can be decreased “…using the latest technologies [and] knowledge we have.”

A surgeon, who asked to remain anonymous, reviewed the paper and offered a different interpretation of the data. He said that based on the nearly 50% post-CT rate of change in the diagnoses of appendicitis and bowel obstruction, one could simply say that the emergency department physicians at MGH are not particularly astute diagnosticians. He went on to say that the use of CT scans for abdominal pain is so common at his hospital, “if you complain of abdominal pain to the [emergency department] triage nurse, you are given your [oral] contrast to drink while you are still in the waiting room!”

This paper will no doubt be cited as justification for the increasing use of CT scanning in the diagnosis of abdominal pain. The blogger Skeptical Scalpel has commented that the quest for diagnostic accuracy trumps concerns about radiation.

15 comments:

Anonymous said...

SS, I am not sure why you got no comments on this one. Hilarious/sad and true post.

I have been a general surgeon for a decade and have gotten the most insane consults from ER's, that indicate to me that many of the ER MD's should lose their license for gross ignorance vs. utter failure to take history and perform physical examination.

I have been consulted for RUQ pain/cholecystitis, and when I arrive, a reliable and articulate patient tells me the pain is in the LLQ, they are having diarrhea, and any clinician worth his/her NaCl should have been able to figure out that colitis vs food poisoning was the issue. (No, only surgeons can diagnose any more.) I have been called to examine patients with gallstones whose only pain was in the coccygeal area (guess that ER MD slept through his 3rd yr surgery rotation.) I saw a big ER in a big hospital once miss an incarcerated umbilical hernia with a bowel obstruction; labs showed Na of 119, so they shipped the patient to the medicine service. Finally the medical residents show up to examine the patient, and they call me. I ask the patient, why did you come to the hospital? She points to a "lump at her belly button" and "she has been having these terrible abdominal pains and vomiting" for the last 36 hours. That ER "MD" apparently did not even see the patient.

Maybe those MGH ER MDs aren't so hot. Well, some of the ones I've seen would make them look like Einstein. No wonder they want to bring on more mid-levels; things really couldn't get worse.

Skeptical Scalpel said...

Good point. I don't know why this one didn't get more comments. It might be because it first ran 2.5 years ago. Let's try an experiment. I'll tweet about it today and see if it gets a rise out of anyone. Thanks.

Seth Trueger said...

One of the first things I learned on my surgery rotation as a medical student was that patients symptoms frequently change.

And, that we should treat our colleagues with respect.

Anonymous said...

My comment at 7:11 was not intended to insult ER docs as a class. Heaven knows how stereotypes get going. Plenty of ER MDs do good work.
My point is, it is pathetic how so many physicians get out of medical school without picking up the NUMBER ONE lesson: medicine begins with the history and physical exam. And it is pathetic that economics and who knows what else, has produced this kind of stupefied medicine. When I am 80 years old, I am afraid I will just stay at home to die; I doubt there will be anybody left at the hospital who gives a hang.
Saw your article on "pain as the fifth vital sign" today in general surgery news. Gracious. The lack of common sense has reached a critical mass. Excellent point, that "symptom" does not equal "sign". Anybody who has spent time in the trenches knows that chronic users of narcotics usually are in more pain than anybody; other people's backaches go away, but their backaches/fibromyalgia/etc never do, despite gallons of Dilaudid. And their sincerity about it, beats all. Chronic narcotics are for the terminally ill -- my personal opinion.

Matthew Pirotte, MD said...

To the anonymous surgeon above: over a long career any doctor is going to have enough bad experiences with their colleagues to generate a rude comment on an Internet forum. The question is whether the aggregation of your worst experiences says anything meaningful about the specialty of Emergency Medicine. I have seen some shockingly bad decisions by individual general surgeons and have occasionally had to intervene to save a patient's life in the face of dangerous management decisions by surgical attendings and residents. I tend to view these experiences as individual rather than aggregate and I maintain the highest level of respect for my surgical colleagues. We all make mistakes and it is best to approach our jobs with a certain level of humility. Finally to reiterate what Dr. Trueger noted: many patient histories and complaints evolve or completely change during their time in the hospital.

Anonymous said...

When I wrote my comment at 1124, Dr Trueger's comment was not yet visible on Skeptical Scalpel's blog. As I said, I was not intending to insult ER MDs as a class. I had no idea anyone was looking at this post 2 years later.

But I will stick to my guns: 1) if you are a physician who fails to interview the patient or examine the patient, then you should not be a physician -- and you will get zero respect from me.
2) plenty of ERs across the country order labs/CTs/MRIs and then consult specialists for abnormalities, when they should have started out with a little H&P. Don't kid me that it isn't happening.
3) if your bosses are running you so hard that you can't practice medicine properly (the real problem with ERs, I think), then you need to quit and work somewhere else, and not be part of the problem.

-anonymous surgeon

Skeptical Scalpel said...

Sorry to have provoked or annoyed anyone. Good points by all. Discussion leads to better understanding.

Pirotte said...

If what you are saying is that "over a career that spans X years I have had Y experience with Z number of colleagues that suggest to me that those Z people are not great docs" then you have set a bar so low that anyone could jump over it. I have ALSO had experiences with surgeons that make me questions whether or not that particular surgeon should be practicing. I could also describe these experiences as "insane," or "grossly ignorant." Does that leave us anywhere helpful? No it does not. Is every case of abdominal pain something that can be figured out be a careful H+P? I wish. If you think these particular docs are so stupid then you should be thanking God, Zeus, and Zoroaster that they had the good sense to consult you -- who apparently can come in and save the day.

E. said...

Not sure what it's like at your center, but in many of the academic teaching hospitals I've been through, the surgical service would not even see the patient until a scan is done. Even if clinically it most certainly is an appendicitis.

I've lost count of the times a simple appy has turned into a ruptured one a result of imaging and consultation delays.

All this to say, I think the culture of push-backs from some surgeons has led to the "well the surgeon will ask for a scan before seeing the pt anyways" phenomenon.

Anonymous said...

Maybe I have just worked at bad hospitals. I am glad that good medicine is being practiced somewhere, even if I don't actually get to see it.

I am delighted to come and take out the appendix on a young male with leukocytosis, a good history, and RLQ peritoneal signs -- without a CT. I am also delighted to follow closely a patient with normal or normalizing wbc/diff, who clinically has viral gastroenteritis -- without a CT. I am seeing high-strung patients who run to the ER with every belly ache, and end up with 10 CTs in 4 years -- I think we are going to kill such people with malignancies. I think the surgery department should be glad to help out, and not make the CT scanner do all the work to the detriment of certain patients.

-anonymous surgeon

Skeptical Scalpel said...

There is a school of thought that suggests that perforated appendicitis is a different disease than non-perforated appendicitis. This is based on the fact that despite the advances in the diagnosis of appendicitis and the falling rates of normal appendix removal, the incidence of perforated appendicitis has remained about the same. It may be that delays in surgery really don't lead to perforations that often.

Here's a link to a paper that discusses this. http://www.ncbi.nlm.nih.gov/pubmed/17522514

Although I personally never delayed appendectomy until the next day for those patients presenting at night, there are many papers saying that it does not result in more complications. http://skepticalscalpel.blogspot.com/2010/09/delayed-appendectomy-different-kind-of.html

Pirotte said...

Anonymous surgeon it is nice to hear you say that about serial exams and management. It remains very difficult to admit a patient to the hospital for this observational strategy. The overwhelming attitude from the inpatient side is "just get the scan." It is very difficult for us in the ED to game out which docs will accept what level of uncertainty on any given day.

Skeptical Scalpel said...

Serial exams are good, but most people say they work only if the examiner is the same person each time. That of course leaves the residents out of the process since they must go home.

Anonymous said...

Pirotte -- I am aware of what the ED docs are up against. I was only giving my personal opinion. I am used to being in the minority. I left the large surgical group and came out to practice alone in the sticks for such reasons. (Maybe I am Artiger's long lost cousin?) I hate being a straight-jacketed cipher, forced to do things because the system says so.

In my situation, I naturally am the only one doing the serial exams.

I can respect the use of CT when the patient is "on the fence"; but when the case is strongly for or against appendicitis, I try to avoid the CT.

-anonymous surgeon

Skeptical Scalpel said...

As I have pointed out in previous posts, it is very difficult for surgeosn to see every patient with abdominal pain in a community non-teaching hospital. Serial exams are nice but hard to do in a solo practice.

There's also the issue of CT scanning reducing the rate of normal appendices found at surgery. I have a few posts about that too.

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