Dissections DIAGNOSIS

14 July 2009
Evidence-based Medicine for Surgeons

Imaging strategies for detection of urgent conditions in patients with acute abdominal pain:
diagnostic accuracy study
Authors: Laméris W, van Randen A, van Es WH, et al
Journal: British Medical Journal 2009;339:b2431doi:10.1136/bmj.b2431
Centre: Department of Surgery, Academic Medical Center, Amsterdam, Netherlands
Several forms of imaging, of which ultrasonography and computed tomography (CT) are the most
often used, can assist in clinical decision making in patients who present with acute abdominal
BACKGROUND pain. Indiscriminate diagnostic imaging in the emergency department has been held responsible
for an increase in hospital costs. This concern calls for a rational, evidence-based approach to
imaging in patients with abdominal pain.

RESEARCH QUESTION IN SUMMARY

Population Imaging in abdominal pain
A cohort of patients presenting Sensitivity (%) Specificity (%)
with non-traumatic abdominal pain
of acute onset, seen in 6 hospitals Number 1021
in the Netherlands.
Performance of tests in isolation
Indicator variable Clinical diagnosis 88 41
Clinical diagnosis after plain Clinical diagnosis after plain films 88 43
radiographs, ultrasound and CT
scan. Ultrasound alone 70 85
CT alone 89 77
Outcome variable
Performance as diagnostic strategies
Primary: sensitivity and specificity
for each test alone and in US in all patients; CT if US negative 94 68
diagnostic strategies.
US in all patients; CT if US inconclusive 85 76
Comparison Imaging strategies based on patient characteristics (age and BMI) or on
location of the pain did not prove superior .
As described above.

Authors' claim(s): “... Although CT is the most sensitive imaging

investigation for detecting urgent conditions in patients with abdominal
pain, using ultrasonography first and CT only in those with negative or
inconclusive ultrasonography results in the best sensitivity and lowers
exposure to radiation.”

THE TISSUE REPORT

All patients, received all tests and interventions, prospectively; herein lies the strength of this large series. Most studies that
attempt to do what this study has done, are flawed in this respect. The need to make quick decisions and move along always
hampers the design of these studies where expert opinions may not be available in short order. Assignment of the final
diagnosis was made in a blinded fashion by competent experts, assuring thereby that the calculation of sensitivities and
specificities was fair and objective. The results of the study, however, confirm what many of us, at least in India, use as the
protocol for a cost-effective diagnostic pathway in managing patients with acute abdominal pain: liberal use of ultrasound to
complement the clinical impression and selective use of CT in the subset that has eluded definitive diagnosis.

EBM-O-METER
Evidence level Overall rating Bias levels
Double blind RCT Sampling
Randomized controlled trial (RCT) Comparison
Trash Swiss Safe News-
Prospective cohort study - not randomized cheese worthy Measurement
Life's too Holds water
short for this Full of holes “Just do it”
Case controlled study
Interestingl | Novel l | Feasible l
Case series - retrospective  Ethical l | Resource saving l

The devil is in the details (more on the paper) ... 

© Dr Arjun Rajagopalan
 SAMPLING
Sample type Inclusion criteria Exclusion criteria Final score card
Simple random Non-traumatic Patients in shock  Non-traumatic abdominal pain
abdominal pain of > Pregnant women 
Stratified random Target ?
2 hrs and < 5 days'
Cluster duration  Accessible ?
Age > 18 yrs 
Consecutive Intended 1101
Convenience Drop outs 80
Judgmental Study 1021

 = Reasonable | ? = Arguable |  = Questionable

Duration of the study: Inclusion started in March 2005, and 1101 patients were included over the following 21 months

Sampling bias: The study was carried out in the Netherlands.

COMPARISON
Randomized Case-control Non-random Historical None

Controls - details
Allocation details Included patients had a medical history, physical examination, and initial laboratory
investigations. A diagnosis based on clinical evaluation and laboratory investigation was
recorded. Thereafter, patients were investigated with a full structured imaging protocol,
including upright chest and supine abdominal plain radiography, abdominal ultrasonography,
and CT. After the physician in the emergency department had assessed the plain radiographs,
a new diagnosis was recorded.
Comparability -
Disparity There were no significant differences between the 80 patients who dropped out of the study
and the included patients in terms of age, sex, or time or type of presentation.

The fully paired study design, with all imaging tests in all patients and with the panel-based final diagnosis as the
reference standard, allowed a comparison of the diagnostic accuracy of multiple imaging strategies.
Comparison bias: All patients had, a priori, all tests; this is the element that makes the study stand out from others
that attempt to do the same but fail on the score that some, but not all, patients have each of the tests carried out.

MEASUREMENT
Measurement error
Device used Device error Observer error
Gold std.

Device suited to task

Training

Scoring

Blinding
Repetition

Protocols

Y ? N

1.Final diagnosis - panel of experts * Y N ? Y Y N Y

An expert panel formed of two gastrointestinal surgeons and an abdominal radiologist with long term clinical experience
assigned a final diagnosis. The panel members had not been involved in the investigation or management of the
evaluated cases. Each panel member individually evaluated every case; data were presented in a standardized format,
including all available information collected during follow-up. Disagreements on the final diagnosis were resolved during
consensus meetings.
Measurement bias: The need to make quick decisions and move along always hampers the design of these studies
where expert opinions may not be available in short order and, necessarily, have to be carried out at a later date.
This study, addresses the issue of measurement bias squarely.

EDITOR'S NOTE: The paper is full of details and data that cannot be adequately reproduced within the limitations of
the the standardized format of ebm4s. Readers are strongly recommended to go through the full article.

© Dr Arjun Rajagopalan