Transcript Let*s Talk about Oral Contrast

Non-traumatic abdominal pain
CT imaging review
CESAR SOTO
PGY -2
STONY BROOK UNIVERSITY HOSPITAL
Abdominal pain
 28 year old male with no significant past medical
history comes to ED 2 days worsening , migrating
lower abdominal pain, low grade fevers and nausea,
no vomiting, no dysuria/discharge, no travel history.
The patient looks uncomfortable, tachycardic and
was found to be febrile.
 What kind of imaging do you want to order?
ACR recommendations
 Meta-analysis of 7 studies
 Non-Contrast Abd CT
 Sensitivity of 92% and Specificity of 96%
 Oral and IV Contrast CT
 Sensitivity of 100% and Specificity 98%
 No Oral, ONLY IV contrast
 Sensitivity of 100% and Specificity of >97%
What about in the ER?
 311 patients, retrospective study
 16 had acute appendicitis
 0 patients needed repeat CT scan
 30 day follow up identified no cases significant
surgical problems identified, NO cases of
appendicitis were missed
1992 patients
retrospective
study
 4 patients (0.2%) – required repeat CT (with oral
contrast)
 1193 (59.8%) were interpreted as “negative”
 113 (17.6%) were acute appendicitis

Sensitivity of CT without oral was 100% with specificity of
99.5%
What about in perforation?
 In same study 111 cases of diverticulitis (17.9%)
 1 case out of those 1992 (0.05%) required repeat CT with
oral contrast as well as rectal contrast .
 Contrast was only used to CONFIRM perforation
Abdominal pain w/ fever
 What about someone same patient with LLQ
abdominal pain and fevers?
 Still want oral contrast?
 What do you worry about?
Diverticulitis
Diverticulitis
What about IBD?
 What about a patient who may have inflammatory
bowel disease?
 Many similar complications when compared to
diverticulitis
More words…
Last Case
 What about a patient who has history of abdominal
surgeries, is on opioids for chronic back pain, sent
from outside NH who has not had a BM in 11 days,
no vomiting, no fevers, mild abdominal distention
and mild general abdominal tenderness.
 Oral contrast important?
 Is it needed to rule out complications of SBO?
 99 patients with suspected SBO, retrospective study
 105 CT scans (6 patients had 2 CT scans) – 56% had SBO
 Non Contrast CT –
 Sensitivity 88.1% and specificity 77%
 Contrast enhanced CT
 Sensitivity 87.6% and specificity of 82.6%
Last study I promise
 Why not just give oral contrast, only 2 additional
hours!
 From the Emergency Radiology Journal, Leverson at
al study


1014 ED patient oral contrast CT vs 987 IV only contrast CT
Found no statistical difference between the two groups
(p<0.001) – no patient had repeat CT with oral contrast
ED length of stay dropped by 97.7 minutes
 Average ED visit– about $ 500 each additional 30 mins
 That’s more than $1500 per patient

Summary
 Oral contrast is generally not required, however, if
there’s time, it may add to the diagnosis
 In non acute patients, saves time, money and
resources
 May be appropriate in 1-4% of cases for more
“detailed anatomical discrepancy” – but NOT
significantly better at making the diagnosis
References

American College of Radiology. http://www.acr.org/

Atri , M, et al. Multidetector helical CT in the evaluation of acute small bowel obstruction: comparison of
non-enhanced (no oral, rectal or IV contrast) and IV enhanced CT. Eur J Radiol. 2009 Jul;71(1):135-40.

Glauser J, et al. Emergency department experience with nonoral contrast computed tomography in the
evaluation of patients for appendicitis. J Patient Saf. 2014 Sep;10(3):154-8.

Levenson, RB, et al. Eliminating routine oral contrast use for CT in the Emergency Department: Impact on
patient throughput and diagnosis. Emergency Radiology. 2012 Dec; 19 (6): 513-517.

Payor A, et al. Efficacy of Noncontrast Computed Tomography of the Abdomen and Pelvis for Evaluating
Nontraumatic Acute Abdominal Pain in the Emergency Department. J Emerg Med. 2015 Aug 22. pii: S07364679(15)00684-8.

Rawson, J.V, et al. When to Order Contrast-Enchanced CT. Am Fam Physician. 2013 Sep 1;88(5):312-316.

Stafford RE, et al. Oral contrast solution and compute d tomography for blunt abdominal trauma: a
randomized study. Arch Surg. 1999 Jun;134(6):622-6.

Uyeda JW, et al. Evaluation of Acute Abdominal Pain in the Emergency Setting Using Computed
Tomography Without Oral Contrast in Patients with Body Mass Index Greater Than 25. J Comput Assist
Tomogr. 2015 Sep-Oct;39(5):681-6.