Routine abdominal X-rays in the emergency department: a thing of the past?

The large number of abdominal X-ray examinations done in the emergency department is striking considering the scant diagnostic yield of this imaging test in urgent disease. Most of these examinations have normal or nonspecific findings, bringing into question the appropriateness of these examinations. Abdominal X-ray examinations are usually considered a routine procedure or even a "defensive" screening tool, whose real usefulness is unknown. For more than 30 years, the scientific literature has been recommending a reduction in both the number of examinations and the number of projections obtained in each examination to reduce the dose of radiation, unnecessary inconvenience for patients, and costs. Radiologists and clinicians need to know the important limitations of abdominal X-rays in the diagnostic management of acute abdomen and restrict the use of this technique accordingly. This requires the correct clinical selection of patients that can benefit from this examination, which would allow better use of alternative techniques with better diagnostic yield, such as ultrasonography or computed tomography.

[Multidetector computed tomography as the first diagnostic option for acute lower digestive tract bleeding in the Emergency Department]. / La tomografía computarizada multidetector como primera opción diagnóstica en la hemorragia digestiva baja aguda en Urgencias.

The wide availability, speed, safety, and diagnostic accuracy of multidetector computed tomography (MDCT) make it the first-line diagnostic tool in the study of acute bleeding of the lower digestive tract. The use of MDCT after the initial stabilization of the patient makes it possible to identify active bleeding and to determine its origin and possible cause, even when bleeding has stopped. MDCT provides information that is key to selecting the most appropriate treatment option: colonoscopy, embolization, surgery, or clinical follow-up. MDCT orients the surgical or endovascular intervention, minimizing the time, risks, and doses of radiation and of contrast agents involved in the intervention and avoiding "blind" resections associated with greater morbimortality. Although the active presence of radiologists in the Emergency Department involves some disadvantages in scheduling, it also places radiologists in a privileged position in their relations with other techniques and professionals involved in the management of acute lower digestive tract bleeding.

[Organization and management of urgent imaging]. / Organización y gestión de la radiología urgente.

Urgent imaging accounts for more than 50% of the overall activity in diagnostic imaging departments. The enormous impact of this workload makes the appropriate organization and management of urgent imaging essential. Providing urgent imaging services aims to meet the needs of urgent and critical patients from both within the hospital (wards) and outside it (emergency department). To achieve these aims, all hospitals should have a specific unit for urgent imaging. This unit should be large enough to deal with the volume of activity and it should be provided with the human, technological, structural, and organizational resources necessary to fulfill this mission.

Organización y gestión de la radiología urgente / Organization and management of urgent imaging

La demanda asistencial de radiología urgente supone más del 50% de la actividad global de los servicios de radiodiagnóstico. Esto representa un enorme impacto que hace imprescindible una adecuada organización y gestión de los mismos. La prestación de servicios de urgencias radiológicas tiene la misión de atender a las urgencias, emergencias y los pacientes críticos procedentes de los servicios clínicos, tanto externos (servicio de urgencias), como internos (servicios hospitalarios). Para el cumplimiento correcto de esta misión todos los hospitales deberían contar con una unidad específica de radiología de urgencias, apropiadamente dimensionada al volumen de actividad a desarrollar, dotada de los medios humanos, tecnológicos, estructurales y organizativos adecuados para cumplir esa misión (AU)

Urgent imaging accounts for more than 50% of the overall activity in diagnostic imaging departments. The enormous impact of this workload makes the appropriate organization and management of urgent imaging essential. Providing urgent imaging services aims to meet the needs of urgent and critical patients from both within the hospital (wards) and outside it (emergency department). To achieve these aims, all hospitals should have a specific unit for urgent imaging. This unit should be large enough to deal with the volume of activity and it should be provided with the human, technological, structural, and organizational resources necessary to fulfill this mission (AU)

La tomografía computarizada multidetector como primera opción diagnóstica en la hemorragia digestiva baja aguda en Urgencias / Multidetector computed tomography as the first diagnostic option for acute lower digestive tract bleeding in the Emergency Department

Amplia disponibilidad, rapidez, seguridad y precisión diagnóstica hacen de la tomografía computarizada multidetector la herramienta diagnóstica de primera línea en el estudio de la hemorragia digestiva baja aguda. Su empleo tras la estabilización inicial permite identificar la presencia de sangrado activo, su origen y posible etiología, incluso cuando la hemorragia ha cesado, aportando información clave para seleccionar la alternativa terapéutica idónea: colonoscopia, embolización, cirugía o seguimiento clínico. Orienta la intervención, quirúrgica o intravascular, minimizando tiempos, riesgos, dosis de radiación y de constraste, y evita resecciones «ciegas», con mayor morbimortalidad. La presencia activa del radiólogo en Urgencias, si bien asocia algunos inconvenientes horarios, lo sitúa en una posición de privilegio en relación con otras técnicas y profesionales implicados en el manejo de la hemorragia digestiva baja aguda (AU)

The wide availability, speed, safety, and diagnostic accuracy of multidetector computed tomography (MDCT) make it the first-line diagnostic tool in the study of acute bleeding of the lower digestive tract. The use of MDCT after the initial stabilization of the patient makes it possible to identify active bleeding and to determine its origin and possible cause, even when bleeding has stopped. MDCT provides information that is key to selecting the most appropriate treatment option: colonoscopy, embolization, surgery, or clinical follow-up. MDCT orients the surgical or endovascular intervention, minimizing the time, risks, and doses of radiation and of contrast agents involved in the intervention and avoiding “blind” resections associated with greater morbimortality. Although the active presence of radiologists in the Emergency Department involves some disadvantages in scheduling, it also places radiologists in a privileged position in their relations with other techniques and professionals involved in the management of acute lower digestive tract bleeding (AU)

[Radiological management of patients with multiple trauma: history and current practice]. / Manejo radiológico del paciente politraumatizado. Evolución histórica y situación actual.

The radiologist plays a crucial role in the multidisciplinary management of patients with multiple trauma. In the last few decades, technological advances and changes in the healthcare culture have led to changes in the imaging work-up of multiple trauma patients, with emphasis shifting from plain-film radiography to whole-body multidetector CT. This article describes the evolution of the different protocols and the current practice in the management of patients with multiple trauma. As a member of the multidisciplinary team, the radiologist must decide on the best imaging technique and protocol for each situation in function of the technological resources available.

Decision-making process in long term acute cholecystitis.

OBJECTIVE: To demonstrate that the categorization of different therapeutic options is essential for the decision-making applied to clinical management. METHOD: This paper compares the usefulness of percutaneous echo-guided cholecystostomy as the first therapeutic option in acute long-term cholecystitis versus the exclusive surgical or clinical management. RESULT: We have analyzed the usefulness of different therapeutic options in a case of long term acute cholecystitis and we have obtained the following results: isolated intravenous antibiotic therapy (0.76), surgery (0.73) and echo-guided cholecystostomy (0.93). This last option has provided good clinical-radiological results. CONCLUSION: Decision trees are a good methodological option as support of surgical and non surgical therapeutic procedures.

Teoría de la decisión en colecistitis aguda de larga evolución / Decision-making process in long term acute cholecystitis

Objetivo: demostrar que la categorización de las diferentes opciones terapéuticas, es esencial en la aplicación clínica de la teoría de la decisión. Método: este artículo balancea la utilidad de la colecistostomía percutánea eco-dirigida como primera opción terapéutica en la colecistitis aguda de larga evolución frente al tratamiento quirúrgico o médico exclusivos. Resultados: del cálculo de las utilidades de las diferentes opciones terapéuticas ante un caso de colecistitis aguda evolucionada hemos obtenido los siguientes resultados: tratamiento médico exclusivo (0,76), intervención quirúrgica (0,73) y radiología intervencionista (0,93). Ha sido esta última opción, la que ha aportado una buena evolución clínico-radiológica. Conclusiones: los árboles de decisión representan una herramienta metodológica útil como soporte en la selección de procedimientos terapéuticos quirúrgicos o no quirúrgico (AU)

[The diagnostic performance of echography and CT in pancreatic diseases producing extrahepatic cholestasis]. / Rendimiento diagnóstico de la ecografía y TC en las enfermedades del páncreas productoras de colestasis extrahepática.

A hundred and fifty patients with jaundice and analytical suspicion of extrahepatic cholestasis were studied prospectively; history, laboratory investigation and ultrasound examination were realized. Computerized tomography was performed in 146 patients. Ultrasonography and computerized tomography findings were confirmed by CPRE o CPTH and surgery. Ultrasonography has a sensitivity of 92.6% while that of computerized tomography was 87.2% for the identification of dilated biliary ducts. The accuracy of ultrasonography was higher than the one obtained in computerized tomography in cholangiocarcinoma (sensitivity: 77.7%) and gallbladder carcinoma (sensitivity: 100%). Computerized tomography recognized choledocholithiasis (sensitivity: 83.3%) and ampullary carcinoma (sensitivity: 88.8%) with better accuracy. However for pancreatic carcinoma (sensitivity: 88.8%) and pancreatitis (sensitivity: 83.3%) both examinations had the same accuracy.

[Extrahepatic cholestasis: the echographic and CT findings]. / Colestasis extrahepática: hallazgos mediante ecografía y TC.

One hundred and fifty patients with jaundice and analytical suspicion of extrahepatic cholestasis were studied prospectively; history laboratory investigation and ultrasound examination were done in all. Computerized tomography was performed in 46 patients. Ultrasonography has a sensitivity of 92.6% while that of computerized tomography was 87.2% for the identification of dilated biliary ducts. Computerized tomography demonstrated the level of obstruction with a sensitivity of 89.1%, being most useful at the suprapancreatic and ampullary levels, while ultrasound examination had a sensitivity of 80%. The accuracy of ultrasonography was higher than the one obtained in computerized tomography in cholangiocarcinoma (sensitivity: 77%) and gallbladder carcinoma (sensitivity: 100%). Computerized tomography recognized choledocholithiasis (sensitivity: 83%) and ampullary carcinoma (sensitivity: 75%) with better accuracy. However for pancreatic carcinoma (sensitivity: 87%) and pancreatitis (sensitivity: 88%) both examinations had the same accuracy.