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Appendicitis: is oral/IV contrast necessary


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Had an 18 yo female come in with periumbilical pain, positive McBurney's point, nausea and anorexia last night. She didn't look ill, but everything was pointing to appendicitis. Ultrasound was gone for the day (isn't that always the way it works out), so I played with the idea of a CT scan of the belly and pelvis.

 

Got her labs back...nada. Discussed it briefly with the attending and told the nurse to order a non-contrasted CT of the abdomen and pelvis. The attending looked puzzled and asked why I wasn't giving IV contrast for an appendicitis rule out. Good question.

 

I know this is a controversial topic, but the literature that I've seen says that with a 96% and 98% sensitivity and specificity, non-contrasted CT scans for the purpose of ruling out appendicitis are as good or better than contrasted studies. I shared this with the attending. He was so intrigued he made calls to other colleagues, including a radiologist. Most of them had heard of this practice but admitted that most clinicians in the ED use IV contrast for appendicitis, and some use both oral and IV.

 

 

Thoughts?

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Ct scans expose patients to harmful ionizing radiation. When performing an Abd/Pelvic ct to r/o appendicitis it is important to have iv/oral contrast. Although the appendix can be visualized without contrast, you also want to efficiently visualize other important structures that can be the cause of abd pain. It is not enough to visualize a problem but also see the extent of the problem. Non-contrast abd ct to r/o appendicitis may be insufficient and lead to a repeat contrast ct exposing the patient to more ionizing radiation.

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The blockage I've encountered in the past when wanting to deviate from the oral + IV route for contrast (the standard at my facilities)has always come by the radiologists. It's a slim to none chance that the techs will do the study without both, if it's appy you're looking for. If a non-con CT is done, what radiologists I've talked to will admit is that patients who are larger, and therefore have more stored fat, will have an appy light up better on non-con CT due to more fat surrounding the appy which becomes streaky/stranding when inflamed (this is what the IV contrast helps highlight, while also looking at the vasculature and any intra-abdominal abscesses). I've have to go back and do a lit search, but like you I've also seen figures similar, but I'm not sure if that's excluding oral contrast or both types of contrast. Nevertheless, radiology can do what they still feel they need to, despite what literature says- which leads me to believe that it's either not in the radiology literature to a great extent, the studies are too small in scope and number to be useful in a "prime time" setting, or the CT scanner y'all have isn't high-tech enough to pick up what it needs to without contrast. And yes, it does help to visualize what else may be lurking in the abdomen.

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I've come across four or five studies totaling 1000 participants -adults and children alike- that demonstrate both oral and iv contrast are not necessary. Sure, it's helpful to use it to rule out other intra-abdominal pathology. In the ED with true emergency cases, I would question the need for oral contrast altogether given transit time.

 

I'm inclined to agree with you TruAnomaly that radiologists are not seeing this literature. Perhaps this is just one of those things that will take some time to catch on. Contrast is indeed helpful, but why use it if the literature says otherwise? Aren't we supposed to be practicing evidence-based medicine and doing patients no harm?

 

Thanks for entertaining questions from a greenie.

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Coming from a radiology and nuclear med background myself, I agree it is not necessary. But honestly you could also turn around and just order an ultrasound if you are looking for appendicitis to spare the radiation. I have to agree with the post that says most places use oral and IV in case it isn't appendicitis, and is more useful if you see different types of masses (Ca, Benign Tumor, etc...). We tried using non contrast studies on demand for some of the doctors, but 90% of the time they would turn around and order a contrast study less than 3 hours later because the scan was indeterminate. So mainly this was a just a defensive issue that was developed to save the patient exposure, and to cut the probability of studies becoming indeterminate reads....

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What about a good H&P coupled with intellect? Why have we become slaves to testing and studies!This is part of the problem , wasteful utilization of "healthcare dollars" in this country.IMHO

 

Agreed, but when surgeons won't touch a patient without imaging and/or labwork, that's what can hinder things. At least in my hospital system, unless they have a peritonitic abdomen and/or present in shock because whatever was brewing in the belly has finally burst, they always cop to "We'll complete the consult after the CT scan". When I have a patient who comes in with that exact presentation as above and I consult surgery very early in the process, it always defaults to "We won't do anything without some objective study"

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yup, most surgeons don't want to know anything other than the result of the ct....some (rarely) actually do exams and care about labs and I know 1 peds surgeon who never ct's kids. he does an exam, takes them to the o.r., puts in a scope, if nl, he pulls out the scope and closes and leaves the healthy appendix in.

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Agreed, but when surgeons won't touch a patient without imaging and/or labwork, that's what can hinder things. At least in my hospital system, unless they have a peritonitic abdomen and/or present in shock because whatever was brewing in the belly has finally burst, they always cop to "We'll complete the consult after the CT scan". When I have a patient who comes in with that exact presentation as above and I consult surgery very early in the process, it always defaults to "We won't do anything without some objective study"

 

 

what about serial exams?

 

CT's cause cancer - and CT of a young female pelvic organs is a very bad idea - hold them there, serial exams, explain ALL the risks of CT and no CT INCLUDING the risk of causing cancer! It is amazing how many people actually choose to forgo the study...... and their pain is not that bad - and they don't think that they NEED that next study to make sure nothing in wrong

 

 

As to your specific contrast question - be aware that if you with and without you are getting about 300 Xrays of the abd/pelvis -

 

 

Ltd MRI - love it - will be the future as no radiation (MRI will replace CT for a lot of studies due to the radiation exposure)

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what about serial exams?

 

Nice idea in theory, but not very practical in an ED setting when you've got 30 more in the waiting room and no open beds. We can sometimes refer for a repeat abdominal exam the next day in somebody with a reliable PCP and and a reassuring exam/labs, but with McBurney's tenderness and anorexia she is likely getting the CT. We have some great radiologists who will do an appy CT with no PO contrast, but most still want PO and IV. It's too bad ultrasound wasn't available; this would be my modality of choice with the patient the OP described.

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Agreed, but when surgeons won't touch a patient without imaging and/or labwork, that's what can hinder things. At least in my hospital system, unless they have a peritonitic abdomen and/or present in shock because whatever was brewing in the belly has finally burst, they always cop to "We'll complete the consult after the CT scan". When I have a patient who comes in with that exact presentation as above and I consult surgery very early in the process, it always defaults to "We won't do anything without some objective study"

 

As a "Old Man PA" I've grown tired of lazy churlish surgeons whose stock replies to consults are #1 why are you calling me now? or #2 Why didn't you call sooner? A good H&P for eons was the standard without hurting patients, I recall the saying if 15% of your appys are negative you aren't operating soon enough. This 100% certainty or zero defect mentality = dumbing down IMHO. Yes taking proper care of a patient can be time consuming but doing what's "right" is the standard. I still haven't come across any document that lists a CT as a must have study to DX or RX acute appendicitis.

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As a "Old Man PA" I've grown tired of lazy churlish surgeons whose stock replies to consults are #1 why are you calling me now? or #2 Why didn't you call sooner? A good H&P for eons was the standard without hurting patients, I recall the saying if 15% of your appys are negative you aren't operating soon enough. This 100% certainty or zero defect mentality = dumbing down IMHO. Yes taking proper care of a patient can be time consuming but doing what's "right" is the standard. I still haven't come across any document that lists a CT as a must have study to DX or RX acute appendicitis.

 

Agree totally.. .. Surgeons no longer read Cope's early diagnosis of the acute abdomen... And neither do insurance companies ... Much as I live to ding surgeons for becoming essentially lazy technicians, what is happening is that the payers will not pay for The operation if there is negative pathology... Unless tere was retry darn good OBJECTIVE evidence ( eg CT, MR,Ultrasound scan) which couldn't be avoided... So Eric's Peds surgeon would not get covered for the explor lap.

 

Also, this is the way it is now.. U/s has changed cardiology.. The definition of a murmur used to be what the senior guy ( resident, fellow, attending, senior attending) said it was.

Then in 1974, cardiac ultrasound became standard. And suddenly no one classified the murmur until "the u/s showed us what it was"... So now most cardiologists do not know how to really listen to a heart.

Sigh

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Ct scans expose patients to harmful ionizing radiation. When performing an Abd/Pelvic ct to r/o appendicitis it is important to have iv/oral contrast. Although the appendix can be visualized without contrast, you also want to efficiently visualize other important structures that can be the cause of abd pain. It is not enough to visualize a problem but also see the extent of the problem. Non-contrast abd ct to r/o appendicitis may be insufficient and lead to a repeat contrast ct exposing the patient to more ionizing radiation.

 

^^ this. i agree. from a GI perspective, helps when we get consulted and the CT is already performed with contrast. sucks if it's not appendicitis, and then we're called to see the patient and then stuck with a CT without contrast which is useless a lot of times

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Nice idea in theory, but not very practical in an ED setting when you've got 30 more in the waiting room and no open beds. .

 

sorry if I go off a little bit here - but that is a lame excuse - I get that ER's can be insane - I have workd in some crazy bad one's, but possibly harming patients just to move them along is something that is wrong with this system, but to say that you can not offer the best care to the patient because you are two busy is just not the right excuse.... and in fact is a load-o-crap. CT radiation expsosure is going to be HUGE issue in 10,20,30 years as all these chronic complainers that have had 10, 15, 20 abd pelvis CT's courtsey of the lazy ER provider are going to get CA - although I have no idea how it would pan out in the courts I would love to have one of these Cancer patients with too many CT's sue past providers (As this is the only way that medicine is truly going to change) for their cancer - just the other week I had an trim female with a history of renal stones go to the ER with renal colic and the darn PA ordered yet another CT - when she has had five in the past 5 years and by her own report was having exactly the same renal colic as past times - WHY WHY not get a U./S to r/o bad hydro and just get her pain and hydration under control...... lazy? doesn't know better? doesn't care? I have no idea but it was wrong to do this to the patient. I told her my thoughts and that she should NEVER again let someone order a CT on her for something that she was positive was just another stone and put the fear of CANCER from the CT's firmly in her thought process......

 

 

1) don't blame the system for you not doing the best job you can do

2) don't hurt your patients

3) radiation causes cancer

4) (and this is a system issue not our's) Surgeon's need to stop relying so much on CT and more on Exam.....

 

 

sorry if I am curt or short - but this is an issue that is an interest point for me and we are actually hurting out patients with to many CT's when serial exams (or even just doing a good exam) would help and maybe eliminate some CT's

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although I have no idea how it would pan out in the courts I would love to have one of these Cancer patients with too many CT's sue past providers (As this is the only way that medicine is truly going to change) for their cancer

 

I certainly get the spirit behind the rest of your post, and in general agree, but when it comes to this point I think you'll be disappointed. Someone smarter than me please correct me if I'm wrong, but what I understand is that the civil statute of limitations would run out WELL before someone's cancer diagnosis would set in due to multiple past imaging studies. And let's say that a suit could actually be brought up- there's little to no way that it would be successful. How in the world would you actually prove in court/arbitration that out of how many scans/Xrays/other exposes to medical radiation, which ONE specifically caused the cancer? And who would you sue? Everyone who ever saw the patient at any point in their life and ordered an imaging study? Maybe if you had a PCP who solely saw the patient, and always ordered imaging studies for every little complaint they had, and later on they did develop cancer- then maybe you had a case against one provider?

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sorry if I go off a little bit here - but that is a lame excuse - I get that ER's can be insane - I have workd in some crazy bad one's, but possibly harming patients just to move them along is something that is wrong with this system, but to say that you can not offer the best care to the patient because you are two busy is just not the right excuse.... and in fact is a load-o-crap.

 

I'm sorry that you consider it lame, but it is unfortunately the truth. Believe me I'm in no way an advocate for CT's on every belly pain; I'm simply saying that skipping the CT for serial exams on every abdominal pain in an ED is pie in the sky fantasy. How long do you observe the patient in the ED for their exams? Six hours? A day? Two days? Do you admit every abdominal pain and fill your inpatient beds? If we see 40 patients with abdominal pain a day, this is simply unrealistic. As I said, if somebody has a fairly benign exam and good follow-up, they can see their PCP in the morning for a repeat exam. In an inner-city ED such as ours, a very large percentage of patients have no reliable follow-up; unfortunately if appy is a reasonable part of your differential, you are going to have to CT this patient to rule out a significant pathology. For the patients who do have a PCP, we are often stuck in the position seeing a patient who has been told by the primary they HAVE to get a CT scan for their pain after a phone conversation or quick office visit, leaving the ED to try and convince the patient otherwise if we disagree. I had a woman in her 40's sent in this weekend by her doctor for a CT scan due to her fevers and 5 minutes of LLQ pain. It took a lengthy H&P, multiple lab tests and numerous conversations with the patient that she did not need a CT scan for what was more likely ehrlichiosis.

 

I'm in complete agreement with you regarding the repeat CT's on chronic pain patients and the overuse of radiation. We do a tremendous amount of ultrasounds in our ED, and whenever possible are using this over CT (e.g. appendix, renal colic, aortic aneurysm). We are in the middle of a study to validate the use of bedside ultrasound in flank pain patients; the hope is we can drastically cut back on the number of CT's for possible kidney stones. I would love to see a world where we can avoid radiating patients, but in our current health care system its just not realistic.

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I'm sorry that you consider it lame, but it is unfortunately the truth. Believe me I'm in no way an advocate for CT's on every belly pain; I'm simply saying that skipping the CT for serial exams on every abdominal pain in an ED is pie in the sky fantasy. How long do you observe the patient in the ED for their exams? Six hours? A day? Two days? Do you admit every abdominal pain and fill your inpatient beds? If we see 40 patients with abdominal pain a day, this is simply unrealistic. As I said, if somebody has a fairly benign exam and good follow-up, they can see their PCP in the morning for a repeat exam. In an inner-city ED such as ours, a very large percentage of patients have no reliable follow-up; unfortunately if appy is a reasonable part of your differential, you are going to have to CT this patient to rule out a significant pathology. For the patients who do have a PCP, we are often stuck in the position seeing a patient who has been told by the primary they HAVE to get a CT scan for their pain after a phone conversation or quick office visit, leaving the ED to try and convince the patient otherwise if we disagree. I had a woman in her 40's sent in this weekend by her doctor for a CT scan due to her fevers and 5 minutes of LLQ pain. It took a lengthy H&P, multiple lab tests and numerous conversations with the patient that she did not need a CT scan for what was more likely ehrlichiosis.

 

I'm in complete agreement with you regarding the repeat CT's on chronic pain patients and the overuse of radiation. We do a tremendous amount of ultrasounds in our ED, and whenever possible are using this over CT (e.g. appendix, renal colic, aortic aneurysm). We are in the middle of a study to validate the use of bedside ultrasound in flank pain patients; the hope is we can drastically cut back on the number of CT's for possible kidney stones. I would love to see a world where we can avoid radiating patients, but in our current health care system its just not realistic.

 

 

Why would a chronic pain pt even be considered for another CT scan unless the presentaion is "different" from their baseline pain. I'm still not convinced that CT scans are needed or appropriate use of time or money for acute appendicitis ,especially when the HPI clearly points to the diagnosis.

I do recall from my days in your ED "being pimped by residents and those same folks dragging their feet about coming down to see the patient" added to backlog and delays in disposition of ED patients.

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As an 11 y/o boy I woke up one morning with the worst pain of my life in my rlq. Parents took me to the pediatrician who drew labs and sent me to the ER. WBC count was sky high and the pediatric surgeon said "it's his appendix". An hour later my appendix was out, looking pink and healthy. The pathology report came back and described a healthy, noninflammed appendix. Had there been imaging available then it would have ruled out the need for an unnecessary surgery. Of course this was done before laparoscopy so I have a 2.5" surgical scar on my belly.

 

Moral of the story: Sometimes clinical suspicion is very high but still wrong. For every 99 successes you have 1 failure.

Edited by bstone
typo
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As an 11 y/o boy I woke up one morning with the worst pain of my life in my rlq. Parents took me to the pediatrician who drew labs and sent me to the ER. WBC count was sky high and the pediatric surgeon said "it's his appendix". An hour later my appendix was out, looking pink and healthy. The pathology report came back and described a healthy, noninflammed appendix. Had there been imaging available then it would have ruled out the need for an unnecessary surgery. Of course this was done before laparoscopy so I have a 2.5" surgical scar on my belly.

 

Moral of the story: Sometimes clinical suspicion is very high but still wrong. For every 99 successes you have 1 failure.

 

Which is why, as Clark alluded to earlier in the thread, it used to be accepted medical wisdom that if a surgeon was removing less than 20% of healthy appendicies in pts with a presentation like appendicitis, they simply weren't operating enough.

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