Abdominal x-ray a key factor in missed appendicitis diagnoses, while CT shines
Clinicians who only collect abdominal x-rays of patients in the emergency department are likelier to miss spotting an appendicitis diagnosis. And this may present an opportunity for hospitals and radiology practices to fine-tune imaging guidance for this common condition.
A team of experts recently made this discovery after analyzing commercial claims data from nearly 124,000 patients. They found that providers missed the appendicitis diagnosis for about 6% of adults and 4.4% of children at the first ED visit. While stomach x-rays failed to pinpoint the condition, those who received CT imaging were more likely to be diagnosed on the first try, Michigan Medicine experts wrote last week in JAMA Network Open.
“There is a potential to reduce unnecessary abdominal x-rays for the evaluation of abdominal pain, and use computed tomography scans for a more select group of patients either in the emergency department or on a follow-up visit,” lead author Prashant Mahajan, MD, professor and vice-chair of emergency medicine, said in a statement issued Monday, March 16.
“We’re not saying that CT scans should be used on all cases of abdominal pain,” he added. “Instead, based on the study finding that most cases were diagnosed at the repeat visit, we hope this finding will give guidance to emergency department and other healthcare providers on when to follow up with patients, as well as when to request advanced imaging.”
In their March 9 study, Mahajan and colleagues noted that the symptoms of appendicitis are common—including abdominal pain, nausea, vomiting, fever and diarrhea. And this is one of the most frequent surgical emergencies in the U.S. However, previous analyses have found that radiologists and other docs miss the condition upward of 24% of the time. It’s also the second most common condition among pediatric patients and third most commonly cited in adult malpractice diagnoses, the authors wrote.
Looking for frequent reasons for this miss, the team found that missed appendicitis was more common in women and patients with preexisting conditions. On the imaging front, CT was the most common diagnostic radiology test among patients diagnosed with appendicitis, regardless of age. And ultrasonography was the second most common—at 9% in those diagnosed at the first visit and 22.3% at follow-up. Mahajan and colleagues noted that most of the radiologic tests, including CT, were not performed at the initial visit, but at the second encounter for patients who were not diagnosed during the first time.
For clinicians, one key takeaway is to keep an eye on abdominal pain when patients present with stomach pain and ensure there are proper channels to close the diagnosis loop and avoid costly medical errors.
“Our data suggests that patients with abdominal pain who visit the emergency department may need some form of close follow-up healthcare to enhance the diagnosis of appendicitis,” Mahajan added.
Marty Stempniak has covered healthcare since 2012, with his byline appearing in the American Hospital Association's member magazine, Modern Healthcare and McKnight's. Prior to that, he wrote about village government and local business for his hometown newspaper in Oak Park, Illinois. He won a Peter Lisagor and Gold EXCEL awards in 2017 for his coverage of the opioid epidemic.