ª Springer Science+Business Media New York 2015
Abdominal
Imaging
Impact of CT in elderly patients presenting
to the emergency department with acute
abdominal pain
Carly S. Gardner,1 Tracy A. Jaffe,2 Rendon C. Nelson2
1
The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1473, Houston, TX 77030-4009, USA
2
Duke University Medical Center, 2301 Erwin Road, Box 3808, Durham, NC 27710, USA
Abstract
Purpose: The purpose of the study was to document the
clinical impact of CT in elderly patients presenting to the
emergency department (ED) with abdominal pain.
Methods: This retrospective IRB-approved study from 2006
to 2013 evaluated 464 patients ‡80 years (mean 89 years,
range 80–100: M150, W314), who presented to the ED with
acute abdominal symptoms and underwent CT. CTs were
divided into those negative and positive for actionable
findings, defined as potentially requiring a change in surgical
or medical management. Physician diagnosis, treatment
plan, and disposition before and after CT were reviewed in
the electronic medical record to assess CT influence on
management and disposition. CT diagnosis was confirmed
with final clinical diagnosis, surgical intervention, pathology,
and follow-up. Descriptive statistics were used.
Results: CTs were positive in 55%. The most common
diagnoses were SBO (18%), diverticulitis (9%), non-ischemic
vascular-related emergency (6%), bowel ischemia (4%),
appendicitis (3%), and colonic obstruction (2%). These
diagnoses were clinically unsuspected prior to CT in 43%
(p < 0.05), with significant difficultly in diagnosing SBO
(p < 0.05), diverticulitis (p < 0.01), and colonic obstruction
(p < 0.01). Positive CT results influenced treatment plans in
65%, surgical in 48%, and medical in 52%. Disposition from
the ED was significantly affected by CT (p < 0.001), 65% of
admissions with positive CT (p < 0.001) and 63% of
discharges with negative CT (p < 0.001).
Conclusion: Utilization of abdominopelvic CT in geriatric
patients presenting to the ED with acute abdominal
symptoms strongly influences clinical management and
significantly affects disposition. As the US population
ages, the clinical impact of emergent CT in the elderly will
intensify.
Correspondence to: Carly S. Gardner; email: csgardne@gmail.com
Abdom Imaging (2015)
DOI: 10.1007/s00261-015-0419-7
Key words: Abdominal pain—CT—Emergency
department—Elderly
Acute abdominal pain is one of the most common reasons for
older patients to present to the emergency department (ED)
in the United States [1]. The ability to accurately and effec-
tively determine the cause of abdominal pain decreases with
advancing patient age [2–4]. Because elderly patients require
more time and resources, they often have prolonged ED
visits, longer wait times before seeing a physician and un-
dergo additional laboratory testing [5–7]. The evaluation of
abdominal pain in the elderly may be confounded by late
and/or atypical presentation, limitations in history taking
and physical exam, unreliable vital signs and laboratory
values [8–14]. Furthermore, acute abdominal pain in the
elderly is more commonly due to life-threatening vascular
and surgical emergencies than in younger populations [4, 15–
18]. Van Geloven et al. [17], moreover, found that mortality
was particularly high (17%) in those over age 80 admitted to
the hospital through the ED with abdominal pain.
As the U.S. population continues to age, it is estimated
that 20% of Americans will be over the age of 65 by 2030,
with the fastest growing subset over the age of 85 years
[12]. There is national concern regarding the appropri-
ateness of imaging in the era of healthcare reform and cost-
effectiveness. This dramatic growth in the elderly
population has put imaging in the spotlight. CT utilization
in the ED has increased at an annual rate of 14%, from
2.7 million exams in 1995 to 16.2 million exams in 2007
[19]. In parallel, the Emergency Medicine literature
stresses the importance of early, liberal imaging in the
elderly population and advocates a low threshold for
hospital admission in elderly patients with undifferenti-
ated abdominal pain [20].

As the subset of elderly patients grows, the utilization
of resources such as CT in the ED becomes increasingly
important. The incidence of CTs in elderly patients pre-
senting with abdominal symptoms is as high as 59% [21].
In one study, CT of the abdomen and pelvis was shown
to alter decision-making in elderly patients, changing
diagnosis in 45% of patients and increasing the diag-
nostic confidence of emergency physicians in 81% of
patients [22]. Another study published in 2007 demon-
strated no significant change in disposition in the elderly
population undergoing CT compared with those under-
going physical examination alone [21]. Physical exam
findings, however, have been shown to be unreliable for
predicting or excluding clinically significant disease in the
elderly with abdominal pain [20], thereby stressing the
importance of CT. The purpose of this study is to eval-
uate and explore the clinical impact of CT imaging of the
abdomen and pelvis in patients 80 years or older pre-
senting to the ED with acute abdominal symptoms.
Materials and methods
Patient selection
Institutional Review Board approval was obtained and
patient consent waived for this HIPAA-compliant, ret-
rospective study. A retrospective review of electronic
medical records from January 2006 to January 2013
identified 464 geriatric patients age 80 years or older who
underwent a CT scan of the abdomen and pelvis after
presenting to the ED with acute abdominal symptoms.
An age of 80 years old was selected given previous
studies suggesting that mortality in this patient subset
was particularly high [17, 23]. Patients with traumatic
indications were excluded from the study. For instance, a
patient undergoing CT of the abdomen and pelvis for
abdominal pain in the setting of a fall or trauma was
excluded. Patients with known malignancy presenting
with acute abdominal symptomatology were included.
For example, a patient with colon cancer undergoing CT
of the abdomen and pelvis because of concern for acute
intestinal obstruction or perforation would be included
in the study. In the event that a patient underwent more
than one abdominal and pelvic CT in the ED, either
during the same or different encounters, the scan from
the earliest or first visit was selected.
CT imaging technique
Acquisition parameters at our institution for abdominal
and pelvic CT imaging in these patients includes helical
mode, 120 kVp, beam pitch 0.8–1.375, automated tube
current modulation (noise index for GE systems 15–22
HU from 0.625 mm images, reference mA for Siemens
systems 200), minimum tube current 100–150 mAs, and
reconstructed section thickness and interval of 5 mm.
Administration of intravenous (IV) contrast material was
C. S. Gardner et al.: Impact of CT in elderly patients
150 mL (Isovue 300, 300 mg L/mL) injected at a rate of
3 mL/s. Coronal reformatted images (section thickness
and interval of 3 mm) are reconstructed from 0.6 to
0.625-mm thick axial sections during the portal venous
phase acquisition. According to institution protocol over
this time period, a positive oral contrast agent, diluted
diatrizoate meglumine (Gastrografin 2%; Schering) was
administered, 30 mL mixed in 450 mL of water for the
following indications: abdominal pain, small bowel ob-
struction, abscess, pancreatitis, and enteric fistula or
leak.
Review of clinical history and imaging
Demographic data including age and gender were col-
lected. The electronic medical record was reviewed by
one radiologist (CSG) for diagnosis, treatment plan, and
disposition before and after imaging.
Determining pre-CT diagnosis
The pre-CT diagnosis was identified by review of the
emergency physician note in the electronic medical re-
cord. The pre-CT diagnosis was defined as the primary
diagnosis under the initial assessment and plan for the
patient prior to CT imaging. If no diagnosis was listed by
the emergency physician before obtaining the CT, the
study indication or reason for CT was used as the prin-
cipal pre-CT diagnosis. For instance, a study indication
of ‘‘rule out sbo’’ was classified as a pre-CT diagnosis of
small bowel obstruction, and an indication of ‘‘left flank
pain, hematuria’’ was classified as a pre-CT diagnosis of
renal/ureteral stone. If more than one diagnosis was
recorded in the ED note, the first or leading diagnosis
listed in the differential was considered to represent the
emergency physician’s pre-CT diagnosis.
Determining post-CT diagnosis
The post-CT diagnosis was based on final interpretation
of the CT. CT report interpretations were categorized
into those positive and negative for actionable findings.
Actionable findings were defined as those potentially
requiring a change in either surgical or medical man-
agement. Examples of actionable findings included small
bowel obstruction, bowel ischemia or perforation, ob-
structing renal stone, diverticulitis, appendicitis, and
vascular emergency such as aortic dissection, aneurysm
rupture, and acute arterial or venous thrombosis. Newly
diagnosed malignancy was not considered an actionable
finding unless considered to cause the patient’s acute
symptomatology, such as a colon cancer resulting in
large bowel obstruction. The CT results were cor-
roborated with the final diagnosis in the ED note or
discharge summary (in those admitted) and any subse-
quently available pathology, intervention, surgery or
clinical follow-up in patients admitted or referred to a
C. S. Gardner et al.: Impact of CT in elderly patients
subspecialty. Positive CT report interpretations concor-
dant with the clinical diagnosis and follow-up were given
a post-CT diagnosis. CTs with non-actionable findings,
nonspecific findings, or unconvincing findings, that were
not supported clinically, were considered negative. For
instance, a patient with an indeterminate renal cystic le-
sion would be categorized as non-actionable or negative.
Similarly, a patient with ‘‘possible bowel wall thickening
vs. under-distention’’ without any clinical support of
colitis or further workup would be considered negative.
Patients with actionable positive CT results were
subdivided into medical and surgical treatment cate-
gories, summarized in Fig. 1. Analysis of ED records was
performed to determine whether the CT results influ-
enced clinical management. Changes in medical man-
agement were defined as medication or treatment
changes and referrals to a subspecialty consultation
based on positive CT results. Changes in surgical man-
agement consisted of surgical operations and minimally
invasive procedures such as endoscopy and image-guided
percutaneous drainage or intervention.
Disposition
Anticipated disposition prior to CT imaging and final
disposition after CT imaging were recorded. Details of
anticipated disposition status prior to CT imaging were
obtained from review of the emergency physician note in
the electronic medical record and categorized into the
following: (1) anticipated admission, (2) anticipated dis-
charge, and (3) unknown or pending CT examination.
Under ‘‘disposition’’ in the initial assessment and plan of
the ED note, ‘‘likely admit’’ was categorized as an-
Elderly with CT A/P
(n=464)
CT Posi ve CT Nega ve
(n=257, 55%) (n=207, 45%)
Change in No Change in
Management Management
(n=166, 65%) (n=91, 35%)
Surgical Medical
(n=80, 48%) (n=86, 52%)
Interven onal Other Minimally
Opera ve
(n=49, 61%)
Radiology Invasive
(n=20, 25%) (n=11, 14%)
Fig. 1. Summary of CT effect on medical and surgical
management.
ticipated admission and ‘‘likely discharge’’ as anticipated
discharge. Anticipated disposition in the ED note that
was either blank, ‘‘unknown’’ or ‘‘pending CT’’ was
placed in the third category above. Final dispositions
from the ED were as follows: (1) admission, (2) dis-
charge, and (3) death.
Statistical analysis
Statistics were performed using Microsoft Excel version
12.1.3 (Microsoft, Redmond, WA) and Statistical Pro-
gram for the Social Science (SPSS, Chicago, IL) version
11.0, Windows 2000. The incidence of positive CTs, most
common indications, most common diagnoses, changes
in clinical management, and disposition were reported
along with proportions with 95% confidence intervals
(CIs). Z test was used to assess proportional differences
between pre- and post-CT diagnosis for the most com-
monly observed diagnoses. The effect of positive vs. ne-
gative CT results on disposition, admission, and
discharge rates, was compared using z test and Chi
square test with Yate’s continuity correction; p < 0.05
indicated statistical significance.
Results
Our study identified 464 geriatric patients (mean
89 years, range 80–100 years), including 150 men and
314 women who underwent a CT scan of the abdomen
and pelvis in the ED for acute abdominal symptoms.
Sixty-nine percent (321/464) of the CTs were performed
following the administration of intravenous (IV) contrast
material and 31% (141/464) were performed without IV
contrast material. The average serum creatinine, in those
who received IV contrast material, was 1.1 mg/dL (range
0.5–8.3 mg/dL) and in those who did not 1.4 mg/dL
(range 0.4–8.7 mg/dL) (p = 0.01).
The most common indications for CT were small
bowel obstruction (SBO) (83/464, 18%; 95% CI 15%–
22%), generalized abdominal pain (77/464, 17%; CI
14%–20%), non-ischemic vascular-related indications
including abdominal aortic aneurysm rupture or dissec-
tion (67/464, 14%; CI 11%–17%), diverticulitis (51/464,
11%, CI 8%–14%), renal or ureteral calculi (32/464, 7%;
CI 5%–9%), bowel ischemia (29/464, 6%; CI 4%–8%),
appendicitis (12/464, 3%; CI 1%–5%), and pancreatitis
(5/464, 1%; CI 0%–2%).
CT results were positive for actionable findings in
55% (257/464; CI 50%–60%) and negative in 45% (207/
464; CI 40%–50%). Table 1 summarizes the most com-
mon final diagnoses pre- and post-CT. Significant dif-
ferences in pre- vs. post-CT diagnosis were seen with
SBO, diverticulitis, and large bowel obstruction. No
significant difference in pre- vs. post-CT diagnosis
was found in vascular emergency, bowel ischemia, or
appendicitis. These six most common CT diagnoses
 C. S. Gardner et al.: Impact of CT in elderly patients

Table 1. Most common diagnoses pre- and post-computed tomography (CT)

Final diagnosis Pre-CT diagnosis, n (%, CI 95%)a Post-CT diagnosis, n (%, CI 95%)* p value

SBO 34 (13, 9–17) 50 (20, 14–24) <0.05

Diverticulitis 8 (3, 1–5) 25 (10, 6–14) <0.01
Vascular emergency 16 (6, 3–9) 18 (7, 4–10) 0.65
Ischemia 5 (2, 0–4) 10 (4, 2–6) 0.18
Appendicitis 4 (2, 0–4) 8 (3, 1–5) 0.47
Large bowel obstruction 0 (0, 0–0) 6 (2, 0–4) <0.01
Totals 67 (26, 19–29) 117 (42, 36–48) <0.05

Bold values indicate statistically significant (p < 0.05)

a
Denominator is the total number of patients with CTs positive for actionable findings (n = 257)

Table 2. Summary of planned disposition (pre-CT) and final disposition (post-CT)

Disposition Planned disposition, n (%, CI 95%) Final disposition, n (%, CI 95%) Died, n (%)

Admission 190 (41, 37–46) 298 (64, 60–68) 2 (0.5)

Discharge 37 (8, 6–10) 162 (35, 31–39) –
Unknown/pending 237 (51, 46–56) 0 (0, 0–0) 2 (0.5)
Total, n (%, CI 95%) 227a (49, 45–54) 460 (99, 98–100) 4 (1)
a
Reflects the total number of patients with planned disposition, either admission or discharge.

Table 3. CT effect on disposition from the emergency department

Disposition CT negative CT positive p value

Admission, n (%, CI 95%) 103 (22, 18–26) 195 (42, 37–46) <0.001
Discharge, n (%, CI 95%) 102 (22, 17–25) 60 (13, 10–16) <0.001
Died, n (%, CI 95%) 2 (0.4) 2 (0.4) 1
Total, n (%, CI 95%) 207 (45, 41–50) 257 (55, 50–59) <0.001

Bold values indicate statistically significant (p < 0.05)

accounted for almost half of all patients (46%, 117/257)
with positive CT results. Overall, when comparing pre-
CT vs. post-CT diagnosis, the CT results in these most
commonly encountered diagnoses were unsuspected
clinically in 43% of patients (67/117, p < 0.05). Malig-
nancy was fairly common but only accounted for the
patient’s acute symptomatology in 26% (9/35): hy-
dronephrosis secondary to malignancy (n = 3), gross
hematuria from bladder mass (n = 2), large bowel ob-
struction from rectal mass (n = 1), small bowel ob-
struction from a metastasis (n = 1), biliary
obstruction/jaundice from cholangiocarcinoma (n = 1).
Figure 1 illustrates CT influence on clinical manage-
ment. The CT results influenced management in 36% of
all patients (166/464; CI 31%–40%), and in 65% of those
with positive CT results (166/257; CI 59%–70%). CT
influenced medical management in 52% (86/166; CI
44%–60%) and surgical management in 48% (80/166; CI
40%–56%) of these patients. Eighteen percent of all pa-
tients (88/464; CI 15%–22%) had follow-up procedures,
of which 90% (80/88; CI 84%–96%) were influenced by
positive CT findings. Eleven percent (55/464) required
operative management, of which 89% (49/55) were in-
fluenced by the CT findings. Thirty-seven percent re-
quired other intervention: 23% (21/88; 20/21 or 95%
influenced by CT results) interventional radiology (14
CT or U/S guided procedures including percutaneous
drain and nephrostomy tube placement, three an-
giograms, three percutaneous biliary drainage), 8% (7/88;
7/7 or 100% influenced by CT) endoscopic retrograde
cholangiopancreatography (ERCP) or endoscopic ultra-
sound (EUS), and 6% (5/88; 4/5 or 80% influenced by
CT) colonoscopy, barium enema, or upper GI series.
Fifteen percent (15/103) of patients with positive CT
findings requiring surgical attention were treated non-
operatively due to being poor surgical candidates.
Table 2 highlights planned disposition prior to
imaging and final disposition from the ED. Admission to
the hospital from the ED occurred in 64% (298/464) and
discharge in 35% (162/464). Four patients (4/464, 1%; CI
0%–2%) died during the ED visit. Only 49% had planned
disposition prior to CT imaging. Disposition was re-
versed in 29% of patients (134/464, CI 25%–33%). In
admitted patients, 121 (26%) were unknown/pending
prior to imaging and 115 (25%) were changed after
imaging and workup from anticipated discharge to ad-
mission. These included 22 patients with negative CTs
(admitted primarily for medical and psychosocial issues)
and 93 with positive CTs. In discharged patients, 114
(25%) were unknown/pending prior to imaging and 19
(4%) were changed after imaging and workup from an-
ticipated admission to discharge. These included nine
patients with negative CTs and ten with positive CTs:
renal colic (n = 3), diverticulitis (n = 2), cystitis
C. S. Gardner et al.: Impact of CT in elderly patients
(n = 2), enlarging abdominal aortic aneurysm with en-
doleak (n = 1), bowel ischemia (n = 1), one cholecys-
titis (n = 1). Seven decided to undergo no treatment due
to comorbidities, three were treated conservatively and
non-operatively on an outpatient basis.
Table 3 illustrates the effect of CT results on final
disposition. CTs positive for actionable findings sig-
nificantly affected disposition when compared with ne-
gative CTs (p < 0.001). Patients with positive CTs were
significantly more likely to be admitted than patients
with negative CTs, 42% vs. 22%, respectively
(p < 0.001). Similarly, patients with negative CTs were
more likely to be discharged (p < 0.001). Overall, 65%
of admissions had positive CTs and 63% of discharges
had negative CTs (p < 0.001).
Discussion
As the population continues to age, the utilization of CT
imaging in elderly patients presenting to the ED becomes
increasingly important. In the elderly, physical ex-
amination and history-taking are time-consuming and
laboratory values may be unreliable [2–4, 8–14]. More-
over, many emergency medicine physicians are uncom-
fortable with physical examinations of the elderly [24],
and the ED literature promotes early, liberal use of
imaging. In our study, the most common diagnoses fol-
lowing CT were small bowel obstruction, diverticulitis,
vascular-related findings, ischemia, appendicitis, and
large bowel obstruction. Our results support those pre-
viously reported in the Emergency Medicine literature [4,
21, 22, 25].
CT results were positive in 55%. For the most com-
monly encountered diagnoses, CT results were clinically
unsuspected in 43%. This is not entirely surprising given
the diminished utility of physical examination and
laboratory values in the elderly and increased incidence
of life-threatening emergencies; moreover our results
corroborate those in other studies [21, 22, 26], which
report changes in diagnosis following CT in up to 45% of
patients and highlight the central role of CT in providing
an accurate diagnosis and etiology for abdominal pain in
elderly in the ED. Small bowel obstruction and diver-
ticulitis were commonly encountered diagnoses in our
elderly population, both being more prevalent with older
age. As observed in another study focusing on the elderly
[25], malignancy was common though only resulted in
the patient’s acute symptoms in 26% of our patients; as
the population ages, we should expect and be aware of
the increased likelihood of observing malignancy on CT
scans of the abdomen and pelvis performed in the ED.
In our study, CT results affected medical and surgical
management almost equally. CT findings resulted in
medication changes, specialty consultations, and refer-
rals. Approximately, 20% of all patients undergoing CT
in our study required surgical procedures based on the
CT findings, including operative and minimally invasive
interventions. Millet et al. [27] similarly concluded that
CT in the elderly heavily influenced surgical decision-
making.
We found that CT results significantly affected over-
all final disposition (p < 0.001), admission (p < 0.001),
and discharge (p < 0.001). In fact, 65% of admitted
patients had positive CTs and 63% of discharged patients
had negative CTs. Previous studies suggested that CT
was able to alter disposition in 25%–40% of elderly pa-
tients [21, 22]. Several studies by Rosen et al. [26, 28]
showed that CT results produced a net reduction in
hospital admission of 17%–24%, in all patients, not just
elderly, coming to the ED with abdominal pain. In fact,
given that physical examination performance dra-
matically decrease with age, it is likely that the ability of
CT to affect disposition is actually higher in our older
age group of 80 years when compared with earlier
studies, which used a criteria of older than 60 and
65 years of age, respectively [21, 22]. As the subset of
elderly patients over age 80 increases exponentially
through 2030, our research suggests that the clinical
impact of CT on disposition may intensify.
The retrospective nature of this study proposed in-
herent limitations. Real-time decision-making of the
emergency medicine physician is less clear than with a
prospective study. However, by design, the structure of
the ED notes at our institution allowed relatively easy
access and assessment of the pre-CT diagnosis, treatment
plan, and anticipated disposition to adequately evaluate
the role of CT. However, subsequent admission and
discharge summaries and surgical or pathologic follow-
up were immediately available in this retrospective study
to corroborate post-CT diagnosis and CT influence on
treatment plan. Selection bias also likely occurred. We
only included patients undergoing CT for acute ab-
dominal symptoms in the ED. These patients may have
experienced more severe symptoms or had an unclear
clinical picture, in which case CT results would be more
likely to change clinical management and affect disposi-
tion. Moreover, long-term outcomes were not obtained.
We did not evaluate whether patients discharged with
negative CT results returned to the ED at a later date
with significant pathology or whether CT results affected
outcome such as survival after the ED visit. More re-
search is needed to assess the overall cost-effectiveness of
performing CT in this patient population, for instance
whether early CT imaging of elderly patients shortens
ED stays, improves throughput, and hereby contributes
to health care cost savings.
Despite these limitations, our large retrospective
study suggests that CT scanning of the abdomen and
pelvis is invaluable in guiding clinical management and
disposition in elderly patients presenting to the ED with
acute abdominal symptoms. We believe our study affirms
the clinical impact and appropriateness of emergent CT

for abdominal pain in the elderly and provides useful
insight into further research, which should focus on the
economic impact and potential savings of early CT uti-
lization of these patients in the ED. In the future, early
imaging with CT may avoid prolonged ED visits and
triage elderly patients more quickly for necessary care.
This is of increasing importance to the healthcare budget
as the population continues to age.
Conflict of interest Rendon C. Nelson: Consultant—GE Healthcare,
Inc., Consultant—Nemoto Kyorino, Ltd., and Research support—-
Bracco Diagnostics, Inc. Carly S. Gardner and Tracy A. Jaffe declare
that they have no conflict of interest.
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