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Radiología. 2015;57(5):380---390

www.elsevier.es/rx

UPDATE IN RADIOLOGY

Routine abdominal X-rays in the emergency

department: A thing of the past?夽
J.M. Artigas Martín a,∗ , M. Martí de Gracia b , C. Rodríguez Torres c ,
D. Marquina Martínez c , P. Parrilla Herranz d

a
Radiología de Urgencias, Servicio de Radiodiagnóstico, Hospital Universitario Miguel Servet, Zaragoza, Spain
b
Radiología de Urgencias, Servicio de Radiodiagnóstico, Hospital Universitario La Paz, Madrid, Spain
c
Servicio de Radiodiagnóstico, Hospital Universitario Miguel Servet, Zaragoza, Spain
d
Servicio de Urgencias, Hospital Universitario Miguel Servet, Zaragoza, Spain

Received 2 January 2015; accepted 22 June 2015

KEYWORDS Abstract The large number of abdominal X-ray examinations done in the emergency depart-
Abdomen; ment is striking considering the scant diagnostic yield of this imaging test in urgent disease. Most
Plain films; of these examinations have normal or nonspecific findings, bringing into question the appropri-
Emergencies; ateness of these examinations. Abdominal X-ray examinations are usually considered a routine
Diagnosis; procedure or even a ‘‘defensive’’ screening tool, whose real usefulness is unknown. For more
Indications; than 30 years, the scientific literature has been recommending a reduction in both the number
Appropriateness 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.
© 2015 SERAM. Published by Elsevier España, S.L.U. All rights reserved.

PALABRAS CLAVE Radiografía del abdomen en Urgencias. ¿Una exploración para el recuerdo?
Abdomen;
Radiografía; Resumen La escasa rentabilidad diagnóstica de la radiografía de abdomen en patología
Urgencias; urgente contrasta con el elevado número de exploraciones que se realizan. La mayoría arroja
Diagnóstico; hallazgos normales o inespecíficos, lo que cuestiona la idoneidad de su indicación. Suele

夽 Please cite this article as: Artigas Martín JM, Martí de Gracia M, Rodríguez Torres C, Marquina Martínez D, Parrilla Herranz P. Radiografía

del abdomen en Urgencias. ¿Una exploración para el recuerdo? Radiología. 2015;57:380---90.

∗ Corresponding author.

E-mail address: jmartigasm@gmail.com (J.M. Artigas Martín).

2173-5107/© 2015 SERAM. Published by Elsevier España, S.L.U. All rights reserved.
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Routine abdominal X-rays in the emergency department 381

considerarse un procedimiento rutinario o incluso una herramienta ‘‘defensiva’’de cri-

Indicaciones; bado, cuya utilidad real se desconoce. Desde hace más de 30 años, se recomienda en la liter-
Adecuación atura científica reducir tanto el número de exploraciones como el de proyecciones realizadas,
en aras a disminuir dosis de radiación, molestias innecesarias para los pacientes y costes.
Radiólogos y clínicos deben conocer las importantes limitaciones de la radiografía de abdomen
en el manejo diagnóstico de la patología abdominal aguda y restringir su empleo. Para ello, es
imprescindible una adecuada selección clínica de los pacientes candidatos a estudio de imagen,
que permite un empleo ágil de técnicas alternativas más rentables como la ecografía o la
tomografía computarizada.
© 2015 SERAM. Publicado por Elsevier España, S.L.U. Todos los derechos reservados.

Introduction Diagnostic approach to patients with acute

The evaluation of a healthcare technology is a complex
task whose objective is to balance the actual benefits for
the patient and the possible risks, disadvantages and costs
derived from its implementation. The radiological setting
includes five levels referring progressively to technical qual-
ity, diagnostic yield, diagnostic and therapeutic impact and
health progression.1 Parameters such as image resolution
are useful to evaluate the first level while sensitivity and
specificity or predictive value are useful to evaluate the
second being relatively easy up to this point to verify
progression with respect to the previous standard. Mak-
ing progress in the evaluation process is extremely difficult
especially in techniques consolidated by use, for which there
are no defined evaluation guidelines and where scientific
evidence can be of low quality or non-existent. In practice
it is assumed that an examination is useful when the result
modifies clinical management, to confirm or rule out a diag-
nostic choice or else to stage the risk of a potentially serious
situation.2 When radiology is used routinely as a ‘‘rubber
stamp’’ to be stamped on every patient1 it is difficult to
prove its effectiveness, since there is no previous clinical
question to answer. Also an examination that does not con-
tribute any information can only contribute confusion (e.g.,
incidental or unspecific findings).3 The following pages are
intended to show how abdominal radiography (AR) in the
emergency setting is an example in the negative way of all
the above: an imaging modality consolidated by use of whose
clinical usefulness there is little scientific evidence---or if
there is any evidence there is negative evidence---in spite
of which it maintains a long list of possible clinical appli-
cations that everyday reality surpasses broadly making it a
routine for every patient that goes to the emergency ser-
vices (ES) with abdominal symptomatology regardless of its
characteristics and the degree of severity. Radiologists and
clinicians alike need to know the important limitations of AR
to detect acute pathologies with the promptness and pre-
cision of other image modalities basically ultrasounds and
computed tomographies (CT). They must resort to the lat-
ter regardless of the AR result when the clinical context
suggests a serious pathology. In mild cases, the remote prob-
ability of positive findings also advises against the use of
AR.
abdominal symptomatology
Pain is the most constant clinical manifestation of acute
abdomen condition and a common cause for going to the ES
in adults.4---6 The medical history, the physical examination
and lab tests are the starting point of its clinical study and
usually enough in mild cases. In the remaining cases although
they can give clues about the nature and location of the
causal process they often yield unspecific results that need
to be completed with image tests.5 Such tests should provide
ideally either in positive or negative significant information
for the therapeutic decision. A positive result establishes a
diagnosis (e.g., intestinal obstruction [IO]), or its etiology
(e.g., peritoneal adhesion) and location (e.g., distal ileum),
and it even allows us to stage its severity (e.g., closed-loop
obstruction with signs of intestinal ischemia). A reliable neg-
ative result promotes an early discharge from the ES avoiding
admissions and unnecessary expenses. When correctly indi-
cated and performed timely a decisive image examination
improves diagnostic accuracy, promotes surgical indication,
planning and approach, speeds up the discharge or admission
decision-making process, reduces hospital stays, improves
service quality and diminishes morbimortality.7,8 On the con-
trary image modalities add little value, or even subtract
value, in patients with mild symptomatology, candidates to
clinical management2,5 or when the modality selected is not
the right one---situations that only increase the dose of radi-
ation, the time spent in the ER and the patient’s discomfort
and healthcare costs.5
Acute abdominal pain can be associated to a vari-
able degree of severity and be due to multiple causes.5
Apendicitis, IO, diverticulitis, cholecystitis, renal colic,
acute intestinal pathology---including ischemia and perfora-
tion---pancreatitis or gynecological disorders are diagnoses
that need to be taken into consideration whose frequency
varies in the different publications and epidemiological pro-
files. Although one in 3 patients who go to the ER due
to abdominal pain is discharged without identifying any
causes,3,4,7,9 expediting those discharges requires decisive
image modalities (Fig. 1). The diagnostic management of
acute abdomen differs from one country to another with
two major trends, early use of CT or clinical examina-
tion complemented with simple radiography and ultrasound
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382 J.M. Artigas Martín et al.

Figure 1 Thirty-seven (37) year old male presenting with abdominal pain and impaired intestinal rhythm with reduced gas fecal
emission. (a) Abdominal radiography (AR) in decubitus supine position showing a pattern of anodyne gas with a slightly dilated small
intestine loop in the left superior quadrant/flank (arrow). (b) The AR in bipedalism shows multiple hydroaerial levels (arrow heads)
with very few gas in the colon indicative of small intestine occlusion. A CT was performed (not shown) giving normal results. After
24 h the clinical condition resolved spontaneously.

with CT on demand.7---10 Although the former option seems
to improve diagnostic accuracy, prospective studies have
not shown any significant differences in other measures.10
Most clinical guidelines indicate image studies depend on
the location of the pain, being the ultrasound the 1st
choice for the right upper quadrant and the pelvis, and
CT for the remaining quadrants. Laméris et al.7 attain
maximum sensitivity with a minimal radiation dose begin-
ning by AR followed by ultrasound and CT in uncertain
cases.
Simple abdomen X-ray in the emergency
room. Real use and scientific evidence
The low diagnostic yield of AR2 has been recognized since
the 1960s yet despite this its systematic use is recommended
in patients with acute abdomen pain.11 In 1982, Eisenberg
et al.12 suggested restricting AR to patients with moderate
or serious abdominal pain and in cases of clinical suspicion
of IO, urethral calculi, ischemia or vesicular pathology. With
this approach, they eliminate 53.7% of the examinations,
without any clinical repercussions. Many subsequent studies
have proven the absence of scientific basis for performing
AR to all patients with abdominal symptomatology2,5,9,13---20
---a usual practice in the ES even today when the availabil-
ity of other more refined modalities such as ultrasound and
CT is practically universal. There is no direct information
available about the use of AR in patients that go to the ER
due to abdominal pain. In most published series ARs are per-
formed in more than half of these patients regardless of the
characteristics or the intensity of the pain,14,21 surpassing
90% in some.15 These are some of the factors that promote
the unjustified use of AR: the consideration the ‘‘routine
examination’’ in the ER, the lack of control of the simple
X-ray by the radiologist and the electronic request systems
along with training deficits among new physicians and the
resistance of ‘‘senior’’ physicians to change their traditional
practices.15,18,20
During the last few years the most important radiological
societies around have been continually reducing the lists of
indications for AR included in their recommendations.22---24
In its 2011 revision the American College of Radiology
(ACR)23 eliminates abdominal pain as an indication for AR.
With a more practical approach in their Diagnostic Imaging
Pathways24 the Royal Australian and New Zealand College
of Radiologists recommend performing ARs only in cases of
suspicion of perforation or IO, ingestion of a foreign body,
unspecific moderate or serious abdominal pain and follow-
up of calculi in the urinary tract. Nevertheless even these
indications are being revised today.
Different publications place the ideal rate of AR use
due to acute abdominal pain below 10%.2,21 Implementing
the previous unrestrictive recommendations most authors
agree that the number of ARs performed could be reduced
by 50---70%, or even in larger percentages.5,9,15,17,21,25 Logi-
cally, the diagnostic yield of AR is incidental in the group of
patients where there is no indication.2,9,15
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Routine abdominal X-rays in the emergency department
The ‘‘abdominal series’’. Necessary
projections
AR in supine position must include from the thoracic
diaphragm to the obturator foramen, occasionally needing
two exposures. This is the basic projection, the start-
ing point of the so-called ‘‘abdominal series’’ that also
includes another projection ‘‘with a horizontal beam’’ in
bipedalism or lateral decubitus position and a chest X-
ray in bipedalism.23,26 The latter, performed as part of an
abdominal series, contributes useful information in 10---15%
of the cases, about the thoracic pathology (pneumonia,
pericarditis) causing abdominal symptomatology or thoracic
manifestations of an abdominal process (pleural effusion in
pancreatitis or abdominal infection). It can detect small
quantities of intraperitoneal gas better than AR in bipedal-
ism. It is recommended to maintain bipedalism or the lateral
decubitus position for at least 10 min before obtaining the
X-ray exposure to let the gas rise above the liver dome.26
Mirvis et al.27 opposed the use of AR in bipedalism in
1986 because it rises costs and contributes little useful infor-
mation. The AR in the decubitus prone position favors the
displacement of the gas in the transverse colon toward its
ascending and descending segments. Performing it is diffi-
cult in seriously ill patients where the only alternative is
often laterolateral projections of the abdomen in the supine
position with a horizontal beam, tangential to the anterior
wall for the detection of underlying gas. Today the gen-
eralized opinion is to consider the ‘‘abdominal series’’ as
superfluous whose dose of radiation and costs are similar to
or surpass those of low-dose CT with much less information.2
Arguments against the use of abdomen X-ray
in the emergency room
The validity and reliability of AR are very low in the assess-
ment of abdominal pathology; therefore errors are frequent,
especially in the emergency setting.9 That is why its findings
must be interpreted with caution always within the patient’s
clinical context and based on its accuracy. In the studies pub-
lished, the validity of AR in patients with acute abdominal
pain is not usually expressed through the usual parameters
of sensitivity, specificity and predictive value due to the
absence of adequate reference standards in many studies2
and to the multiplicity of signs and etiological options mak-
ing it impossible to set up the usual contingency tables
2 × 2. Most often, its diagnostic usefulness is expressed
in terms of positive findings, change of diagnosis or clini-
cal management of patients or degree in which the image
modality proves to be of diagnostic utility for the ER physi-
cian. When it comes to reliability, Markus et al.28 studied
interobserver variability in the interpretation of AR by dif-
ferent radiologists and they found an adequate concordance
in the identification of pneumobilia, renal lithiasis or pneu-
moperitoneum, and worse results in the detection of small
intestine obstruction, cholelithiasis, colitis, thumbprinting,
dilatated intestinal loops, pathological hydroair levels, nor-
mal gas pattern or masses. The worst results were for the
assessment of colon obstruction, unspecific gas patterns,
complete obstruction of the small intestine, location of
the obstruction site in the small intestine, diffused/located
383
ileum, ascites and urethral lithiasis. The correlation was low
to determine partial or complete obstruction of the small
intestine and its proximal, medial or distal location.
With important variations based on the sign or pathol-
ogy being considered the diagnostic yield of AR is around
10%2,5,17---19,21,29,30 and though some authors rise the percent-
age of relevant findings to 15.8%,14 others do not find any
significant impacts of AR in the clinical decision-making
process.16 Such yield should improve with the level of adhe-
sion to clinical recommendations that is usually. Morris-Stiff
et al.15 in their series find that 32% of requests abide by the
standards of the Royal College of Radiologists (RCR) with
positive results for this group of around 76.7% as opposed to
3.3% for patients with inadequate requests. Feyler et al.18
say that 12% of requests abide by the RCR guidelines with
an impact of their findings on clinical management in 7% of
the cases. The usefulness of AR is zero in cases of unspe-
cific abdominal pain, acute digestive hemorrhage, peptic
ulcer, apendicitis, urinary tract infection, pelvic pain, biliary
pathology, acute pancreatitis or uncomplicated constipa-
tion, among others.2,13,16,19,21
The AR detects alterations with low sensitivity
(Figs. 2 and 3) but even when it does it rarely exhausts
the diagnostic process on its own. In most publications,
the change of clinical management for patients induced
by the AR is below 10%.21 Kellow et al.16 find that with
the exception of the location of abdominal catheters, the
AR is not very useful in acute abdomen conditions and
only 3% of their patients were treated based on the AR
findings. They conclude that in general the AR does not
avoid other image modalities, as it happened in 59% of their
patients to outline the extent of the alteration, identify its
etiology, plan treatment or have a basal image to evaluate
therapeutic response. This is to say that a pathologic AR
does not provide any conclusive diagnoses in most patients
but even when it does it needs other additional image
modalities (Figs. 4 and 5).
Incidental findings are especially frequent when an incor-
rect indication is the starting point. Its assessment can
provide a wrong or inadequate clinical response diverting
the management of the patient to research lines or guide-
lines of clinical management that are far from their actual
problem, with diagnostic delays or inadequate treatments
and greater morbimortality. The percentage of wrong find-
ings for AR in some papers has been established around 19%21
and in others it has managed to surpass the useful informa-
tion in a 3:2 ratio.30
Ruling out a prevailing or especially serious condition
expedites the work of the ES while contributing to early
discharge being one of the most decisive current applica-
tions of diagnostic image modalities. This is not the case of
AR---a not very useful modality for the identification of unsus-
pected diagnoses.26 Yet despite this fact its use is frequent
as a normal screening tool. Stower et al.31 found that 60.8%
of the ARs requested in their series were meant to rule out
a serious condition. This practice causes unnecessary incon-
veniences to the patient, it is potentially dangerous and
should not be recommended. It is well known that a nor-
mal x-ray does not allow guarantee normality or precludes
a serious condition21 (Figs. 2 and 3). Seventy-two per cent
the patients with normal AR in the Kellow et al. paper16 pre-
sented some alteration when other image modalities were
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384 J.M. Artigas Martín et al.

Figure 2 Thirty-four (34) year old male with pain in the lower semi-abdomen, fever and leukocytosis. (a) The AR of the abdomen
in the decubitus supine position shows no significant alterations. (b and c) CT parasagittal images. Wall thickening of sigmoid colon
with diverticula and perforation of one of these diverticula (arrow in b) with presence of extraluminal gas and signs of adjacent fat
inflammation. Multiple bubbles of intraperitoneal gas of anterior location (arrow-heads in c). Perforated diverticulitis.

used; this is why they do not recommend its use to rule out
abdominal conditions. Almost half (46%) of the cases pre-
sented unspecific findings in the AR, and in 78% of them
alterations could be later identified. Simeone et al.32 dis-
cover useful information through ultrasound predominantly
of biliary origin in 20% of the patients with abdominal pain
and a negative AR.
The dose of radiation administered is another issue
that should be considered when evaluating medical image
modalities. Every exposure to ionizing radiation needs to be
justified by a potential benefit and though the dose of one AR
is not very high for an individual examination (0.7---1.3 mSv),
40 times that of a chest X-ray or 4 months of background
radiation,33 it gains relevance from a population approach,
above all taking into account the probability of additional
projections.25,34,35 Radiation derived from conventional
radiographies has declined during the last few years35 though
the AR is still one of the four most common indications in
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Routine abdominal X-rays in the emergency department 385

Figure 3 Seventy-two (72) year old woman with abdominal pain of sudden onset. The clinical exploration shows signs of shock
and arrhythmia and in the analysis acidosis and hyperamylasemia. (a) AR with no significant findings. (b) CT coronal image in 6 mm
maximal intensity projection showing a lumen repletion defect of the superior mesenteric artery compatible with an embolism
(arrow). Cardiomegaly (*).

this group.36 It is responsible for 2.93% of the radiological
procedures performed in the UK, and for 4.42% of the total
dose.37 The progressive accessibility from the ER to low-dose
and ultralow-dose CT modalities <4 and 2 mSv will probably
displace the use of AR in favor of these modalities.34
The economic cost is another evaluation argument, and
although the AR is a relatively inexpensive modality---around
30---40 D the reduction of unnecessary examinations along
with other direct costs such as technician and radiologist
time or indirect costs, such as a previous pregnancy tests
in young patients amount to yearly savings of around 50---60
million pounds in the UK.15,25
AR in the usual causes of abdominal pain.
Does anything change?
Intestinal obstruction
Around 7% of patients with acute abdominal pain will
have IO.5 Clinical evaluation has limitations in its assess-
ment but it provides information (abdominal distension,
increase of intestinal noise, vomiting, age > 50 years) which
improves the sensitivity and the predictive value of AR
when diagnosing IO (intestinal obstruction).5,14,19 Its most
frequent etiology is peritoneal adhesions and hernias, and an
early diagnosis and treatment prevent intestinal ischemia,
improving morbimortality. The IO has been one of the clas-
sic indications for AR which is diagnostic in 50---60% of the
cases, uncertain in 20---30% and confusing in 10---20%.38 The
sensitivity of AR to diagnose IO ranges from 46% to 90.8%
in the different series, with a specificity close to 50%.
It has important limitations when it comes to determin-
ing the level and cause of the obstruction as well as the
presence of strangulation.5,39 Today the MSCT (multi-slice
computed tomography) answers all questions with sensitiv-
ity and specificity close to 100%,7 and it is the initial test of
choice in cases of suspicion of IO as recognized by the ACR
guidelines. Also this approach is useful for cases of colon
obstruction, where the AR can be confusing or inconclusive
and delay treatment. Not only does the CT perform a more
precise diagnosis but it also provides additional information
that can modify treatment in one out of every five cases40
(Fig. 5).
Hollow viscus perforation
There is no scientific evidence supporting the use of AR
in cases of suspicion of visceral perforation.2 Although in
ideal conditions it can be detected through an X-ray using
a minimum of 1 cc of free intraperitoneal gas41 reality can
paint a different picture as shown by the high variability
in the figures of detection of pneumoperitoneum among the
different papers and radiographic projections used. van Ran-
den et al.13 estimate in around 15% the sensitivity of AR
to detect pneumoperitoneum; in the Baker et al. series42
X-rays detected it in 51% of the patients with proven vis-
ceral perforation, and Levine et al.43 identify it in 59% of
ARs performed in the decubitus supine position, while Keefe
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386 J.M. Artigas Martín et al.

Figure 4 Eighty-two (82) year old male with a history of chronic renal failure (serum creatinine levels: 6 mg/dl) and a right hip
prosthesis. Oral anticoagulation with a INR (International Normalized Ratio) > 5. He goes to the hospital with acute abdominal pain
radiated to his back with distention. Anemia and thrombocytopenia. (c) AR in the decubitus supine position showing signs of chronic
spondylitis and scoliosis with abundant fecal content that prevents us from performing an adequate assessment of the visceral
structures. Colon caliber-reduction at splenic flexure level simulating a ‘‘colon cut-off sign’’ (arrow). Initially a study through
computed tomography (CT) without contrast (b) is performed. The coronal multiplanar reconstruction (MPR) shows non-obstructive
left renal atrophy and an enlarged unstructured left kidney with heterogeneous attenuation secondary to non-traumatic renal
hematoma (h). Wunderlich syndrome. No causal lesion can be identified. Then an axial cut of the CT-angiography (c) is performed
and two (2) small foci of active bleeding (arrow-heads) can be identified and visible in the venous phase only. The patient remained
stable with conservative treatment and correction of his coagulopathy.

et al.44 identify it in 83% - number that goes up to 85% when
using chest radiographies and to 96% with ARs performed
in the left lateral decubitus position and that goes down to
60% and 56% with ARs performed in bipedalism and in the
decubitus supine position, respectively.45 Other papers do
not find any differences in the positive predictive value of
the clinical examination for pneumoperitoneum after per-
forming ARs.13 This low diagnostic yield, inherent to the
typical limitations of X-rays grows worse when its technical
quality is deficient, due to incomplete anatomical coverage
or exposure.42 There are diverging opinions46 but MSCT is
at present the test of choice to identify the presence,
location and etiology of intestinal perforation, which is rel-
evant information for an adequate surgical approach47---50
(Fig. 2).
Renal colic
When the clinical context is typical and in the presence of
hematuria the image modalities do not modify therapeutic
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Routine abdominal X-rays in the emergency department 387

Figure 5 Fifty-six (56) year-old woman at the emergency room presenting with diffuse abdominal pain and no gas or fecal
expulsion. During the examination she shows poor health with the presence of tachycardia and hypotension, abdominal silence and
‘‘loop mass’’ palpation. The AR (a) does not show any significant findings with the exception of flexure thickening in a jejunal loop
located at the left superior quadrant (arrow). (b) Computed tomography (axial view) in portal stage (70 sg) of the middle abdomen
region showing jejunal loop distention with no wall enhancement due to hypoperfusion (*) [compare it with the adjacent duodenum
(d)]. Perihepatic intraperitoneal liquid in between the loops (arrow-heads). Surgery confirmed the diagnosis of intestinal obstruction
caused by bridles complicated with strangulation; 55 cm of necrotic small intestine were resected.

management in the absence of fever, durable pain or
diagnostic uncertainty. Nevertheless the great majority of
existing clinical guidelines and recommendations indicate
the immediate performance of an imaging test.51 Such test
should confirm the presence of urethral calculi and provide
information about its location, size and composition, as
well as the presence of urethral obstruction. In the absence
of lithiasis, it should identify alternative diagnoses such
as complicated aorta aneurism.9 The sensitivity of the AR
ranges from 44% to 77% in the different works published
being the specificity between 71% and 87%, and MSCT is the
usual standard of care.5,51,52 When image tests are indicated
the ultrasound usually comes first in young patients yet the
CT identifies the practical totality of lithiases53 and provides
the required additional information.5 The indication for
AR would be limited to the follow-up of urethral lithiasis
diagnosed through CT or ultrasound.2
Diverticulitis, pancreatitis and acute cholecystitis
Acute diverticulitis does not associate useful semiology in
AR this is why it does not have any indications. When
it is necessary to confirm the diagnosis and detect possi-
ble complications CT is used. Beyond the presence of a
‘‘sentinel loop’’ or a ‘‘colon cut-off sign’’ that may be
indicative of diagnosis of acute pancreatitis the AR does not
present specific findings of this clinical entity so its use is not
indicated. The latest review of the Atlanta guidelines56 does
not recommend the use of image modalities including CT,
during the first week, except for cases of uncertain clinical-
biochemical diagnosis or to rule out alternatives such as
intestinal perforation or mesenteric thrombosis. The AR is
not indicated either as the initial diagnostic modality in
cases of acute biliary pathology where the ultrasound is the
modality of choice when suspicion of uncomplicated acute
cholecystitis.4

Acute appendicitis Intestinal ischemia

ARs are performed on 50---75% of patients with suspicion of
acute clinical apendicitis,54 despite the existing scientific
evidence that does not recommend it.2 A conclusive clini-
cal diagnosis does not require confirmation through imaging
modalities,2,19 and in uncertain cases, the diagnostic yield
of ultrasound and CT is way much higher.55 Ultrasound is the
initial method of choice, especially in children and women
in their fertile age; the MRI is an alternative in pregnant
women with inconclusive ultrasounds.
Identifying gas on the intestinal wall or the portal branches
through the AR, classically considered a pathognomonic
sign of mesenteric ischemia, is an infrequent finding that
at least denotes advanced disease.26 The growing use of
abdominal CT has allowed the visualization of portal gas in
more ‘‘benign’’ situations but its detection through X-ray
associates a high risk of ischemia and a 75% mortality, and
this is why immediate laparotomy is recommended even
in the absence of clinical signs.57 Nevertheless an AR can
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388 J.M. Artigas Martín et al.

Table 1 Problems derived from using abdomen radiographies in the emergency room.
• Unjustified increase of the radiation dose
• The patient is in pain
• Unnecessary increase of healthcare expenditure:
--- Direct: Obtention (tube, facilities, PACS), time of RTS and radiologist
--- Indirect: Pregnancy test in a young girl prior to performing any abdomen radiographies
--- Of opportunity: resources being destined to non-profitable techniques and modalities making other profitable ones not
available for the right patient
• Diagnostic errors due to irrelevant positive result or false negative. Incidental findings contributing to erroneous
management or delayed diagnoses
PACS: Picture Archiving and Communication System; RTS: radiodiagnosis technical specialist.

be normal even in the presence of extensive intestinal

Table 2 Proposal of indications for abdomen radiographies
ischemia26 (Fig. 3).
in the emergency room.
• Identification of foreign bodies
Foreign bodies. Intra-abdominal catheters • Location of catheters
• Follow-up of urinary stones
They are cause of abdominal pain especially in pediatric age. • Evolution of the obstruction
The sensitivity of the AR is 90% and its specificity 100%5,17 of • Desvolvulation control
course based on its nature. Such figures recommend keeping
its use in this clinical setting yet the AR should be reserved
for those cases where seeing the foreign body has clinical • To develop research lines on the local, national and inter-
relevance, such as batteries or toxics, or forensic relevance, national level to clarify the guidelines for the use of AR
or else when the patient is symptomatic.5,9 An identical (Table 2) and write them in clinical guidelines and recom-
approach should be followed when monitoring abdominal mendations.
catheters.16 • To control the demand for this type of examination as well
as the quality of reports that should not be left at the
mercy of clinicians under the consideration of a ‘‘lesser
Alternatives and patterns of action technique’’.

If the AR was a new technology today, it would be diffi-
cult to justify its clinical introduction. It can be asserted
with Gans et al. that its role in adults with acute abdominal
pain is null today.5 Greene proposed reducing its emer-
gency use in 1986, avoiding it in clinical situations where
the odds of radiological findings are minimal, in women in
fertile age, except when clearly indicated and as far as
pregnancy has been ruled out, and when it is not mod-
ify clinical management. He suggests avoiding performing
the abdominal series systematically and rather analyzing
first the projection in the decubitus supine position com-
plemented eventually with thorax in bipedalism, and then
deciding the need for additional projections.58 An adequate
clinical analytical orientation, followed by ultrasound and
CT when it is negative, is today the best management pat-
tern of the urgent abdominal pathology. So until this concept
becomes generalized, it would be convenient for radiologists
to follow these procedural guidelines, among others:
• To recognize and publicize the excessive demand, usually
unjustified, for AR in Emergency Departments.
• To analyze the causes for its popularity among clinicians
and its possible risks (Table 1).
• To develop and implement training programs for young
physicians and foster constructive dialog in multidisci-
plinary sessions with senior physicians while promoting
the role of the radiologist as a consultant.
These proposals aim to rationalize the use of AR, limit
its use and offer the patients alternative modalities with a
greater diagnostic yield in an effort to expedite the health-
care process and ultimately, reduce the dose of radiation,
costs and unnecessary inconveniences.
Ethical responsibilities
Protection of people and animals. The authors declare that
no experiments with human beings or animals have been
performed while conducting this investigation.
Data confidentiality. The authors declare that the protocols
of their institution on the publishing of data from patients
have been followed.
Right to privacy and informed consent. The authors
declare that in this article there are no personal data from
patients.
Authors
1. Manager of the integrity of the study: JMAM, MMDG,
PPH.
2. Study idea: JMAM, PPH.
3. Study design: JMAM.
4. Data mining: CRT, DMM.
Documento descargado de http://www.elsevier.es el 11/02/2017. Copia para uso personal, se prohíbe la transmisión de este documento por cualquier medio o formato.
Routine abdominal X-rays in the emergency department
5.Data analysis and interpretation: CRT, JMAM.
6.Statistical analysis: NA.
7.Reference search: CRT, DMM, JMAM, PPH.
8.Writing: JMAM, MMDG.
9.Critical review of the manuscript with intellectually rel-
evant remarks: JMAM, MMDG, CRT, DMM, PPH.
10. Approval of final version: JMAM, MMDG, CRT, DMM, PPH.
Conflict of interests
The authors declare no conflict of interests associated with
this article.
This work is an update to be published in the journal
Radiología exclusively. No material from former reviews or
journals has been used yet some ideas and concepts were
also summed up in the summary book from the 4th Meeting
of SERAU 2013 ‘‘Radiología de urgencias. La oportunidad en
la crisis’’.
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