Limits...
Do we really need additional contrast-enhanced abdominal computed tomography for differential diagnosis in triage of middle-aged subjects with suspected biliary pain.

Hwang IK, Lee YS, Kim J, Lee YJ, Park JH, Hwang JH - Medicine (Baltimore) (2015)

Bottom Line: Retrospectively, pre-contrast phase and multiphase CT findings were reviewed and the detection rate of findings suggesting disease requiring significant treatment by noncontrast CT (NCCT) was compared with cases detected by multiphase CT.Approximately 70% of total subjects had a significant condition, including 1 case of gallbladder cancer and 126 (68.8%) cases requiring intervention (122 biliary stone-related diseases, 3 liver abscesses, and 1 liver hemangioma).Biliary stones and liver space-occupying lesions were found equally on NCCT and multiphase CT.Calculated probable rates of overlooking acute cholecystitis and biliary obstruction were maximally 6.8% and 4.2% respectively.

View Article: PubMed Central - PubMed

Affiliation: From the Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si (IKH, YSL, JK, J-HH); Department of Internal Medicine, Wonkwang University College of Medicine, Wonkwang University Sanbon Hospital, Gunpo (IKH) and Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, Republic of Korea (YJL, JHP).

ABSTRACT
Enhanced computed tomography (CT) is widely used for evaluating acute biliary pain in the emergency department (ED). However, concern about radiation exposure from CT has also increased. We investigated the usefulness of pre-contrast CT for differential diagnosis in middle-aged subjects with suspected biliary pain.A total of 183 subjects, who visited the ED for suspected biliary pain from January 2011 to December 2012, were included. Retrospectively, pre-contrast phase and multiphase CT findings were reviewed and the detection rate of findings suggesting disease requiring significant treatment by noncontrast CT (NCCT) was compared with cases detected by multiphase CT.Approximately 70% of total subjects had a significant condition, including 1 case of gallbladder cancer and 126 (68.8%) cases requiring intervention (122 biliary stone-related diseases, 3 liver abscesses, and 1 liver hemangioma). The rate of overlooking malignancy without contrast enhancement was calculated to be 0% to 1.5%. Biliary stones and liver space-occupying lesions were found equally on NCCT and multiphase CT. Calculated probable rates of overlooking acute cholecystitis and biliary obstruction were maximally 6.8% and 4.2% respectively. Incidental significant finding unrelated with pain consisted of 1 case of adrenal incidentaloma, which was also observed in NCCT.NCCT might be sufficient to detect life-threatening or significant disease requiring early treatment in young adults with biliary pain.

Show MeSH

Related in: MedlinePlus

Flow diagram for selecting target disease and completing case report form. Only common conditions in young adults presenting with right upper quadrant or epigastric pain in the emergency department were selected. Diseases that were common in patients with older than 60 years or condition with distinct feature from biliary tract disease were excluded. Also only significant conditions requiring a surgical or medical intervention were included then the target diseases only when computed tomography (CT) is considered to be essential in making diagnosis and helpful for planning the management were selected. Finally, case report form for reviewing the CT was completed. ∗Diverticulitis, aortic dissection, mesenteric ischemia (common in elderly with mean age over 60), pancreatitis (elevation of amylase, lipase), myocardial infarction, hepatic congestion (elevation of cardiac enzyme), pulmonary embolism (d-dimer elevation), nephrolithiasis, pyelonephritis (hematuria, pyuria), perforated peptic ulcer, pneumonia (X-ray abnormality). ∗∗Herpes zoster (skin lesion), pericarditis (typical chest pain, dyspnea, EKG change). #Esophagitis, gastritis, colitis, peptic ulcer, hepatitis.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
getmorefigures.php?uid=PMC4554168&req=5

Figure 1: Flow diagram for selecting target disease and completing case report form. Only common conditions in young adults presenting with right upper quadrant or epigastric pain in the emergency department were selected. Diseases that were common in patients with older than 60 years or condition with distinct feature from biliary tract disease were excluded. Also only significant conditions requiring a surgical or medical intervention were included then the target diseases only when computed tomography (CT) is considered to be essential in making diagnosis and helpful for planning the management were selected. Finally, case report form for reviewing the CT was completed. ∗Diverticulitis, aortic dissection, mesenteric ischemia (common in elderly with mean age over 60), pancreatitis (elevation of amylase, lipase), myocardial infarction, hepatic congestion (elevation of cardiac enzyme), pulmonary embolism (d-dimer elevation), nephrolithiasis, pyelonephritis (hematuria, pyuria), perforated peptic ulcer, pneumonia (X-ray abnormality). ∗∗Herpes zoster (skin lesion), pericarditis (typical chest pain, dyspnea, EKG change). #Esophagitis, gastritis, colitis, peptic ulcer, hepatitis.

Mentions: Over 2 years from January 2011 to December 2012, all patients between 20 and 50 years of age who visited the ED for biliary pain and who underwent multiphase CT with a pancreatobiliary CT protocol (PBCT) were investigated. The study was approved by the Seoul national university bundang hospital institutional review board. We thoroughly reviewed all electronic medical records. Suspected biliary pain was typically defined as: severe, steady pain located in the epigastrium or the right upper quadrant lasting >30 min; findings of abnormal liver function test (LFT) (total bilirubin ≥2 mg/dL or alkaline phosphatase or γ-glutamyl transpeptidase or aspartate aminotransferase or alanine aminotransferase >1.5 standard deviations [STD]) or right upper quadrant (RUQ) tenderness/Murphy's sign on physical examination.14,15 We excluded patients older than 50 years or younger than 20 years, those with amylase or lipase levels >3 times the upper normal limits, those with a history of malignancy or significant cardiovascular diseases, and those with advanced liver diseases. We also excluded patients who visited the ED for trauma or who had been referred due to suspected malignancy. We selected target diseases for the study based on a flow diagram (Fig. 1). Briefly, target diseases were chosen based on textbooks or journals.16–18 Consequently, 7 diseases including gallbladder (GB) stones, acute cholecystits, common bile duct (CBD) stones, acute cholangitis, liver abscess, liver mass, and pancreas mass remained as target conditions for this study. Finally, we added any incidental malignancy or significant findings not associated with pain (Fig. 1). Final diagnoses were confirmed by pathologic reports undergoing surgery or by reviewing electronic medical records during follow-up. The clinical relevance of the final diagnosis was considered to be either “significant” or “non-significant” regardless of association with pain.19 “Significant” causes were defined as a condition requiring significant therapeutic management and subclassified as Group A: life-threatening malignancy necessitating therapeutic actions, Group B: significant diseases requiring surgical or medical intervention with indubitable clinical or prognostic relevance. “Non-significant” etiologies were defined as conditions requiring only conservative management and assigned to either group C: conditions requiring clinical awareness, follow-up however not necessitating intervention, Group D: findings not requiring follow-up or further tests. All NCCTs were firstly reviewed by 2 expert radiologists (YLand JHK) according to case report form. After a washout period of 8 weeks, all PBCTs, including NCCT, were reviewed again by same radiologists. Only the initial clinical information was provided before reviews were made. Rate of NCCT was evaluated for each of the 4 groups with reference to PBCT. The primary end point was the probable rate of overlooking group A by NCCT with reference to PBCT. The secondary end point was the rate of overlooking group B by NCCT with reference to PBCT.


Do we really need additional contrast-enhanced abdominal computed tomography for differential diagnosis in triage of middle-aged subjects with suspected biliary pain.

Hwang IK, Lee YS, Kim J, Lee YJ, Park JH, Hwang JH - Medicine (Baltimore) (2015)

Flow diagram for selecting target disease and completing case report form. Only common conditions in young adults presenting with right upper quadrant or epigastric pain in the emergency department were selected. Diseases that were common in patients with older than 60 years or condition with distinct feature from biliary tract disease were excluded. Also only significant conditions requiring a surgical or medical intervention were included then the target diseases only when computed tomography (CT) is considered to be essential in making diagnosis and helpful for planning the management were selected. Finally, case report form for reviewing the CT was completed. ∗Diverticulitis, aortic dissection, mesenteric ischemia (common in elderly with mean age over 60), pancreatitis (elevation of amylase, lipase), myocardial infarction, hepatic congestion (elevation of cardiac enzyme), pulmonary embolism (d-dimer elevation), nephrolithiasis, pyelonephritis (hematuria, pyuria), perforated peptic ulcer, pneumonia (X-ray abnormality). ∗∗Herpes zoster (skin lesion), pericarditis (typical chest pain, dyspnea, EKG change). #Esophagitis, gastritis, colitis, peptic ulcer, hepatitis.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4554168&req=5

Figure 1: Flow diagram for selecting target disease and completing case report form. Only common conditions in young adults presenting with right upper quadrant or epigastric pain in the emergency department were selected. Diseases that were common in patients with older than 60 years or condition with distinct feature from biliary tract disease were excluded. Also only significant conditions requiring a surgical or medical intervention were included then the target diseases only when computed tomography (CT) is considered to be essential in making diagnosis and helpful for planning the management were selected. Finally, case report form for reviewing the CT was completed. ∗Diverticulitis, aortic dissection, mesenteric ischemia (common in elderly with mean age over 60), pancreatitis (elevation of amylase, lipase), myocardial infarction, hepatic congestion (elevation of cardiac enzyme), pulmonary embolism (d-dimer elevation), nephrolithiasis, pyelonephritis (hematuria, pyuria), perforated peptic ulcer, pneumonia (X-ray abnormality). ∗∗Herpes zoster (skin lesion), pericarditis (typical chest pain, dyspnea, EKG change). #Esophagitis, gastritis, colitis, peptic ulcer, hepatitis.
Mentions: Over 2 years from January 2011 to December 2012, all patients between 20 and 50 years of age who visited the ED for biliary pain and who underwent multiphase CT with a pancreatobiliary CT protocol (PBCT) were investigated. The study was approved by the Seoul national university bundang hospital institutional review board. We thoroughly reviewed all electronic medical records. Suspected biliary pain was typically defined as: severe, steady pain located in the epigastrium or the right upper quadrant lasting >30 min; findings of abnormal liver function test (LFT) (total bilirubin ≥2 mg/dL or alkaline phosphatase or γ-glutamyl transpeptidase or aspartate aminotransferase or alanine aminotransferase >1.5 standard deviations [STD]) or right upper quadrant (RUQ) tenderness/Murphy's sign on physical examination.14,15 We excluded patients older than 50 years or younger than 20 years, those with amylase or lipase levels >3 times the upper normal limits, those with a history of malignancy or significant cardiovascular diseases, and those with advanced liver diseases. We also excluded patients who visited the ED for trauma or who had been referred due to suspected malignancy. We selected target diseases for the study based on a flow diagram (Fig. 1). Briefly, target diseases were chosen based on textbooks or journals.16–18 Consequently, 7 diseases including gallbladder (GB) stones, acute cholecystits, common bile duct (CBD) stones, acute cholangitis, liver abscess, liver mass, and pancreas mass remained as target conditions for this study. Finally, we added any incidental malignancy or significant findings not associated with pain (Fig. 1). Final diagnoses were confirmed by pathologic reports undergoing surgery or by reviewing electronic medical records during follow-up. The clinical relevance of the final diagnosis was considered to be either “significant” or “non-significant” regardless of association with pain.19 “Significant” causes were defined as a condition requiring significant therapeutic management and subclassified as Group A: life-threatening malignancy necessitating therapeutic actions, Group B: significant diseases requiring surgical or medical intervention with indubitable clinical or prognostic relevance. “Non-significant” etiologies were defined as conditions requiring only conservative management and assigned to either group C: conditions requiring clinical awareness, follow-up however not necessitating intervention, Group D: findings not requiring follow-up or further tests. All NCCTs were firstly reviewed by 2 expert radiologists (YLand JHK) according to case report form. After a washout period of 8 weeks, all PBCTs, including NCCT, were reviewed again by same radiologists. Only the initial clinical information was provided before reviews were made. Rate of NCCT was evaluated for each of the 4 groups with reference to PBCT. The primary end point was the probable rate of overlooking group A by NCCT with reference to PBCT. The secondary end point was the rate of overlooking group B by NCCT with reference to PBCT.

Bottom Line: Retrospectively, pre-contrast phase and multiphase CT findings were reviewed and the detection rate of findings suggesting disease requiring significant treatment by noncontrast CT (NCCT) was compared with cases detected by multiphase CT.Approximately 70% of total subjects had a significant condition, including 1 case of gallbladder cancer and 126 (68.8%) cases requiring intervention (122 biliary stone-related diseases, 3 liver abscesses, and 1 liver hemangioma).Biliary stones and liver space-occupying lesions were found equally on NCCT and multiphase CT.Calculated probable rates of overlooking acute cholecystitis and biliary obstruction were maximally 6.8% and 4.2% respectively.

View Article: PubMed Central - PubMed

Affiliation: From the Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si (IKH, YSL, JK, J-HH); Department of Internal Medicine, Wonkwang University College of Medicine, Wonkwang University Sanbon Hospital, Gunpo (IKH) and Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, Republic of Korea (YJL, JHP).

ABSTRACT
Enhanced computed tomography (CT) is widely used for evaluating acute biliary pain in the emergency department (ED). However, concern about radiation exposure from CT has also increased. We investigated the usefulness of pre-contrast CT for differential diagnosis in middle-aged subjects with suspected biliary pain.A total of 183 subjects, who visited the ED for suspected biliary pain from January 2011 to December 2012, were included. Retrospectively, pre-contrast phase and multiphase CT findings were reviewed and the detection rate of findings suggesting disease requiring significant treatment by noncontrast CT (NCCT) was compared with cases detected by multiphase CT.Approximately 70% of total subjects had a significant condition, including 1 case of gallbladder cancer and 126 (68.8%) cases requiring intervention (122 biliary stone-related diseases, 3 liver abscesses, and 1 liver hemangioma). The rate of overlooking malignancy without contrast enhancement was calculated to be 0% to 1.5%. Biliary stones and liver space-occupying lesions were found equally on NCCT and multiphase CT. Calculated probable rates of overlooking acute cholecystitis and biliary obstruction were maximally 6.8% and 4.2% respectively. Incidental significant finding unrelated with pain consisted of 1 case of adrenal incidentaloma, which was also observed in NCCT.NCCT might be sufficient to detect life-threatening or significant disease requiring early treatment in young adults with biliary pain.

Show MeSH
Related in: MedlinePlus