Langenbeck's Archives of Surgery

https://doi.org/10.1007/s00423-020-01884-1

SYSTEMATIC REVIEWS AND META-ANALYSES

Routine versus selective computed tomography in non-traumatic

acute abdominal pain: meta-analysis of randomised trials
Shahab Hajibandeh 1,2 & Mohamed Loutfi 2 & Shahin Hajibandeh 3 & Adel Abulkhir 4 & Sheik Rehman 1 &
Moustafa Mansour 2 & Reza Arsalani Zadeh 4

Received: 8 February 2020 / Accepted: 15 April 2020

# Springer-Verlag GmbH Germany, part of Springer Nature 2020

Abstract
Purpose To compare the routine vs. selective use of computed tomography (CT) in patients presenting with non-traumatic acute
abdominal pain (AAP) to a surgical service.
Methods We conducted a systematic review of literature and meta-analysis of outcomes according to PRISMA statement
standards to compare the routine vs. selective use of CT in adult patients presenting with non-traumatic AAP.
Results Analysis of 722 patients from 4 randomised controlled trials showed no difference between the routine CT and selective
CT groups in terms of proportion of correct diagnoses (OR 1.36,95% CI 0.89, 2.07, P = 0.15), mortality (RD 0.03, 95% CI −
0.08, 0.02, P = 0.27] and length of hospital stay (LOS) [MD − 0.26, 95% CI − 2.07, 1.55, P = 0.78).
Conclusions The routine use of CT does not improve the proportion of correct diagnoses and mortality compared to selective use
of CT in adult patients with non-traumatic AAP. The available evidence regarding the influence of routine CT on LOS may be
subject to type 2 error. These findings, however, may not apply to the elderly patient with AAP and further studies are required.

Keywords Abdominal pain . Emergencies . Tomography . X-ray computed

Introduction younger patients [3–5], contributing to higher morbidity and

Acute abdominal pain (AAP) is a common surgical emergen-
cy requiring admission to hospital [1, 2]. The initial clinical
assessment of patients with AAP allow the surgeon to estab-
lish relevant differential diagnoses; however, making an accu-
rate early diagnosis is often very difficult, necessitating further
laboratory and radiological investigations. The accuracy of the
preliminary diagnosis of the underlying cause for acute abdo-
men is less reliable in elderly patients (age > 65) compared to
* Shahab Hajibandeh
shahab_hajibandeh@yahoo.com
1
Department of General Surgery, Glan Clwyd Hospital,
Rhyl, Denbighshire, UK
2
Department of General Surgery, North Manchester General Hospital,
Northern Care Alliance NHS Group, Manchester, UK
3
Department of General Surgery, Sandwell and West Birmingham
Hospitals NHS Trust, Birmingham, UK
4
Department of General Surgery, Royal Bolton Hospital, Bolton, UK
mortality in these group of patients [6]. This highlights the
importance of early accurate and thorough investigation of
AAP in all patients, especially the elderly, to reduce morbidity
and mortality.
The use of computed tomography (CT) to investigate AAP
has increased significantly over the past few years. In some
countries, a routine early CT is commonly used in the triage of
patients presenting with AAP while in other countries, triage
of such patients is based mainly on clinical findings supported
by plain radiography and CT if indicated on clinical grounds.
CT can diagnose a wide range of acute abdominal conditions
[7–12], facilitating early diagnosis and management, which
can potentially reduce the risk of morbidity and mortality
and shorten the length of hospital stay. The benefits of routine
use of CT in patients presenting with AAP to reduce hospital
admissions and shorten hospital length of stay (LOS) and its
impact on patients’ morbidity and mortality have been
controversial.
We performed a systematic review of literature and meta-
analysis of outcomes to compare the routine and selective use
of CT in patients presenting with non-traumatic AAP.

Methods
This systematic review was performed according to an
agreed predefined protocol. The review was conducted
and presented according to Preferred Reporting Items for
Systematic Reviews and Meta-Analyses (PRISMA) state-
ment standards [13].
Eligibility criteria
We included RCTs comparing routine vs. selective use of CT in
adult patients of any gender presenting to hospital due to non-
traumatic AAP. All patients who presented with AAP and
underwent CT scan or other imaging modalities while they
were in emergency department or any other wards were con-
sidered eligible. The patients who had CT scan in emergency
department and were discharged due to normal findings were
also considered eligible. The exclusion criteria were age <
18 years, pregnancy, acute abdominal trauma, contraindication
to iodinated contrast media and need for immediate surgery.
Intervention of interest
Routine CT was defined as CT within 24 h of presentation to
hospital with AAP regardless of clinical assessment.
Presentation to hospital was defined as either registration in
emergency department in case of direct presentation to emer-
gency department or registration in surgical assessment unit in
case of referral from community.
Comparison of interest
Selective CT was the comparison of interest, defined as CT at
the discretion of physician based on clinical assessment. Any
patient with abdominal pain allocated to this group would
have initial plain radiographs or ultrasound, and, if necessary
on clinical grounds as recognised by the on-call general sur-
geon, CT within or after 24 h, or not at all.
Outcome measures
The proportion of correct diagnoses was the primary outcome
measure. The final diagnosis established at maximum follow
up was used as reference for correct diagnosis. The secondary
outcome measures included mortality and LOS.
Literature search strategy
Two authors independently (Shahab H, ML) searched the fol-
lowing electronic databases: MEDLINE, EMBASE,
CINAHL and the Cochrane Central Register of Controlled
Trials (CENTRAL). The last search was run on 06
May 2019. Thesaurus headings, search operators and limits
Langenbecks Arch Surg
in each of the above databases were adapted accordingly. The
literature search strategy is outlined in Table 1. The biblio-
graphic lists of relevant articles and reviews were interrogated
for further potentially eligible studies. No language restric-
tions were applied in our search strategies.
Study selection
The title and abstract of articles identified from the literature
searches were assessed independently by two authors (Shahab
H, ML). The full texts of relevant reports were retrieved, and
those articles that met the eligibility criteria of our review were
selected. Any discrepancies in study selection were resolved
by discussion between the authors. An independent third au-
thor (Shahin H) was consulted in the event of disagreement.
Data collection
We created an electronic data extraction spreadsheet which
was pilot-tested in randomly selected articles and adjusted
accordingly. This included study-related data (first author,
year of publication, country of origin of the corresponding
author, journal, study design and sample size, and clinical
condition of the study participants), baseline demographic
and clinical information of the study populations (age, gender,
diagnosis) and primary (correct diagnosis) and secondary
(mortality, LOS) outcomes. Data collection was performed
independently by two authors (Shahab H, ML), and disagree-
ments were resolved by discussion. If no agreement could be
reached, a third author (Shahin H) was consulted.
Methodological quality and risk of bias assessment
Two authors (Shahab H, ML) independently assessed the meth-
odological quality and risk of bias of the included articles using the
Cochrane tool for assessing the risk of bias of randomized con-
trolled trials [14]. The Cochrane tool assesses domains including
selection, performance, detection, attrition, reporting and other
sources of bias and, for each individual domain, classifies studies
into low, unclear and high risk of bias. Disagreements were re-
solved by discussion between the reviewers. If no agreement could
be reached, a third author acted as an adjudicator.
Data synthesis and statistical analyses
For dichotomous outcome variables, we calculated the odds ratio
(OR) as the summary measure. We calculated the risk difference
(RD) when more than half of the studies had zero events in both
groups. For continuous parameters, we calculated the mean differ-
ence (MD) between the two groups. Individual patient was used as
the unit of analysis. We used intention-to-treat data from the indi-
vidual clinical studies. We used the Review Manager 5.3 software
for data synthesis [14]. Random or fixed-effects modelling was
Langenbecks Arch Surg

Table 1 The literature search

strategy Search no. Search strategya

1 Routine: TI,AB,KW
2 Routine near 2 ct: TI,AB,KW
3 Routine near 2 computed tomography: TI,AB,KW
4 Mandatory: TI,AB,KW
5 No. 1 OR no. 2 OR no. 3 OR no. 4
6 Selective: TI,AB,KW
7 Selective near 2 ct: TI,AB,KW
8 Selective near 2 computed tomography: TI,AB,KW
9 No. 6 OR no. 7 OR no. 8
10 MeSH descriptor: [computed tomography scanner, x-ray] explode all trees
11 Computed tomography: TI,AB,KW
12 ct: TI,AB,KW
13 No. 10 OR no. 11 OR no. 12
14 abdom* near 2 pain
15 MeSH descriptor: [acute abdomen] explode all trees
16 MeSH descriptor: [abdominal pain] explode all trees
17 No. 14 OR no. 15 OR no .16
18 No. 5 AND no. 9 AND no. 13 AND no. 17
a
This search strategy was adopted for following databases: MEDLINE, EMBASE, CINAHL and the Cochrane
Central Register of Controlled Trials (CENTRAL)

used as appropriate for analysis. We report the results in a Forest
plot with 95% confidence intervals (CIs). Heterogeneity among
the studies was assessed using the Cochran Q test (χ2). We quan-
tified inconsistency by calculating I2 and interpreted it using the
following guide: 0 to 50% may represent low heterogeneity, 50 to
75% may represent moderate heterogeneity and 75 to 100% may
represent high heterogeneity.
Sensitivity analyses
To explore potential sources of heterogeneity and assess the ro-
bustness of our results, additional analyses were conducted for
outcomes that were reported by at least four studies. For each
outcome, we repeated the primary analysis using the random-
effects and fixed-effect model. In addition, we calculated the risk
ratio (RR) and risk difference (RD) for each dichotomous vari-
able. We assessed the effect of each study on the overall effect
size and heterogeneity by repeating the analysis after removing
one study at a time. In order assess the consistency of our results,
we removed the studies including patients with right lower quad-
rant pain or non-specific abdominal pain only.
Results
Results of the search
Searches of electronic databases identified 76 articles. Among
the studies that were identified through search of electronic
databases, 69 articles were not relevant to the topic of this
study and were excluded directly. The remaining 7 studies
were relevant to the topic of this study and, after assessing
their full texts, 3 more were excluded; two were additional
analyses of a previously published RCT, and one was exclud-
ed, as the comparison group in the study did not undergo
selective CT. Therefore, 4 RCT studies [15–18] enrolling
722 patients were selected for this review. Overall, 369 pa-
tients were included in the routine CT group and 353 patients
were included in the selective CT group. The included popu-
lations in the individual studies were comparable by baseline
characteristics. The literature search flow chart (PRISMA for-
mat), baseline characteristics of the included studies and base-
line characteristics and final diagnoses of the included popu-
lation are shown in Fig. 1; Tables 2 and 3, respectively.
Description of included studies
Lehtimäki 2013 [15]: This was an RCT from Finland that
included 254 patients presenting to the surgical emergency
department with acute abdominal pain of unknown cause.
Patients were randomised to routine CT or selective CT.
Patients in routine CT group underwent abdominopelvic CT
imaging within 24 h of presentation to the emergency depart-
ment. Patients in selective CT group underwent initial diag-
nostic imaging such as plain radiographs or ultrasound scans
and if necessary on clinical grounds CT scan.
Sala 2007 [16]: This was an RCT from UK that included
198 patients presenting to the on-call general surgeons with a

Fig. 1 Study flow diagram
diagnosis of non-specific acute abdominal pain either follow-
ing self-referral to the emergency department or following
referral by their general practitioner. Patients were randomised
to early routine CT or standard practice including selective
CT. Patients in routine CT group underwent early
abdominopelvic CT imaging within 24 h of presentation to
the emergency department. Patients in selective CT group
underwent initial diagnostic imaging such as plain radio-
graphs or ultrasound scans and if necessary on clinical
grounds CT scan.
Lee 2007 [17]: This was an RCT from USA that included
152 patients presenting with acute right lower quadrant
Langenbecks Arch Surg
abdominal pain who were reviewed by the on-call general
surgeons following self-referral to the emergency department.
Patients were randomised to early routine CT or selective CT.
Patients in routine CT group underwent early abdominal and
pelvic CT scan with oral and intravenous contrast. Patients in
selective CT group underwent initial diagnostic imaging such
as plain radiographs or ultrasound scans and if necessary on
clinical grounds CT scan.
Ng 2002 [18]: This was an RCT from UK that included 118
patients presenting with acute abdominal pain who were ad-
mitted under the care of the surgical team. Patients were
randomised to early routine CT or standard practice including
selective CT. Patients in routine CT group underwent early
abdominopelvic CT imaging within 24 h of presentation to
the emergency department. Patients in selective CT group
underwent initial diagnostic imaging such as plain radio-
graphs or ultrasound scans and if necessary on clinical
grounds CT scan.
Risk of bias in included studies
The summary and results of methodological quality assess-
ment of the 4 RCTs [15–18] are demonstrated graphically in
Fig. 2. All of the included studies were judged to be of low
risk of bias in terms of random sequence generation and allo-
cation concealment. The risk of performance bias was consid-
ered to be high or unclear due to lack of information about
blinding of participants and personnel in all of the included
studies. Three of the included studies [15–17] were judged to
be of unclear risk of detection bias due to lack of information
about blinding of outcome assessment. All of the included
studies were judged to be of low risk of reporting, attrition
or other sources of bias.
Outcome synthesis
Proportion of correct diagnoses
OR analysis Proportion of correct diagnoses was reported in 4
studies [15–18], enrolling 652 patients (Fig. 3). There was no
difference in proportion of correct diagnoses between the two
groups (OR 1.36, 95% CI 0.89, 2.07, P = 0.15). A low level of
heterogeneity among the studies existed (I2 = 21%, P = 0.28).
Sensitivity analysis Removing one study at a time did not
change the direction of the effect size and the overall hetero-
geneity. The direction of the effect size remained unchanged
when RR or RD were calculated. The use of random-effects or
fixed-effect models did not affect the direction of the effect
size. Removing the studies that included patients with right
lower quadrant pain or non-specific abdominal pain only did
not change the direction of effect size and overall
heterogeneity.
Langenbecks Arch Surg

Table 2 Baseline characteristics of the included studies

Study Journal Design Clinical Intervention Comparison Definition Definition of Sample size Methodological
presentation of routine selective CT quality
CT
Total Routine Selective
CT CT

Ng 2002 BMJ RCT Patients with Routine CT Standard Early CT CT requested 118 55 63 Moderate
acute scan practice within at
abdominal with 24 h of discretion
pain selective admis- of
presenting CT sion physician
to hospital imaging based on
clinical
assess-
ment
Lee 2007 Academic RCT Patients with Routine CT Standard Early CT CT requested 152 72 80 Moderate
emer- acute right scan practice within at
gency lower with 24 h of discretion
medi- quadrant selective admis- of
cine pain CT sion physician
presenting imaging based on
to hospital clinical
assess-
ment
Lehtmiki European RCT Patients with Routine CT Standard Early CT CT requested 254 143 111 Moderate
2013 radiolo- acute scan practice within at
gy abdominal with 24 h of discretion
pain selective admis- of
presenting CT sion physician
to hospital imaging based on
clinical
assess-
ment
Sala 2007 Clinical RCT Patients with Routine CT Standard Early CT CT requested 198 99 99 Moderate
radiolo- acute scan practice within at
gy abdominal with 24 h of discretion
pain selective admis- of
presenting CT sion physician
to hospital imaging based on
clinical
assess-
ment

RCT randomised controlled trial, CT computed tomography

Mortality lower quadrant pain or non-specific abdominal pain only did

RD analysis Mortality was reported in 4 studies [15–18], en-
rolling 722 patients (Fig. 3). There was no difference in the
risk of mortality between the two groups (RD − 0.03, 95% CI
− 0.08, 0.02, P = 0.27). A high level of heterogeneity among
the studies existed (I2 = 88%, P < 0.00001).
Sensitivity analysis Removing one study at a time did not
change the direction of the effect size and the overall hetero-
geneity. The direction of the effect size remained unchanged
when RR or OR were calculated. The use of fixed-effect mod-
el changed the direction of the effect size in favour of routine
CT. Removing the studies that included patients with right
not change the direction of effect size and overall
heterogeneity.
LOS
MD analysis LOS was reported in 3 studies [15, 16, 18], en-
rolling 570 patients (Fig. 3). There was no difference in LOS
between the two groups (MD − 0.26, 95% CI -2.07, 1.55, P =
0.78). A moderate level of heterogeneity among the studies
existed (I2 = 71%, P = 0.03).
Sensitivity analysis We did not perform sensitivity analysis for
this outcome because it was reported by fewer than 4 studies.
 Langenbecks Arch Surg

Table 3 Baseline demographics and final diagnoses of the included population

Lehtmiki 2013 Sala 2007 Lee 2007 Ng 2002

Routine CT Selective CT Routine CT Selective CT Routine CT Selective CT Routine CT Selective CT

Mean/median age (SD/range) 53 (17) 54 (17) 59 (42–73) 57 (43–75) 35.1 (14.5) 33.3 (12.6) NR NR
Male gender 68/143 53/111 42/99 30/99 24/72 31/80 NR NR
Female gender 75/143 58/111 57/99 69/99 48/72 49/80 NR NR
Final diagnosis:
Acute appendicitis 30/143 20/111 10/99 7/99 39/72 38/80 6/55 3/63
Acute diverticulitis 22/143 14/111 12/99 12/99 NR NR 10/55 12/63
Acute pancreatitis 13/143 10/111 4/99 6/99 NR NR 4/55 4/63
Biliary disease 9/143 10/111 5/99 1/99 NR NR 4/55 7/63
Bowel obstruction 10/143 4/111 8/99 5/99 NR NR 5/55 4/63
Urological disease 6/143 7/111 3/99 6/99 NR NR 1/55 1/63
Non-specific abdominal pain 27/143 33/111 20/99 18/99 NR NR 10/55 8/63
Inflammatory bowel disease 3/143 3/111 NR NR NR NR NR NR
Colitis NR NR 4/99 4/99 NR NR NR NR
Gastroenteritis NR NR 1/99 2/99 NR NR 1/55 2/63
Malignancy 3/143 1/111 8/99 14/99 NR NR 1/55 1/63
Perforated viscus NR NR 0/99 2/99 NR NR 1/55 3/63
Vascular disease 4/143 0/111 1/99 0/99 NR NR 0/55 1/63
Thoracic disease 2/143 3/111 1/99 0/99 NR NR 2/55 2/63
Gynaecological disease NR NR 4/99 2/99 NR NR 1/55 1/63

CT computed tomography, NR not reported

Discussion traumatic AAP, we found no benefits of routine use of CT

We performed a systematic review of literature and meta-
analysis of outcomes to compare routine use of CT vs. selective
use of CT in patients presenting with non-traumatic AAP. We
identified 4 RCTs enrolling 722 patients. The results of analyses
suggested that there was no difference in the proportion of
correct diagnoses, mortality and LOS between the routine use
and selective use of CT in patients presenting with AAP.
The use of CT scan in patients with AAP with clinical
suspicion of diverticulitis or appendicitis has been investigat-
ed by some authors. In patients with suspected diverticulitis,
use of CT has been shown to be helpful in detecting compli-
cations to assist in therapeutic decisions [19]. In patients with
suspected acute appendicitis, use of CT has been shown to
reduce rates of negative appendicectomy and lower overall
hospital costs by preventing unnecessary admissions and sur-
gical explorations [20–22]. We know from available evidence
that CT increases the accuracy of the clinical diagnosis and
diagnostic certainty, facilitating management decisions in pa-
tients with AAP. However, whether CT should be routinely
used as the first imaging modality for patients with AAP is
controversial.
Routine use of CT in trauma has been shown to reduce
missed injury and mortality rates [23]. In terms of non-
compared to selective approach. It has been argued that selec-
tive use of CT, with ultrasonography in all patients and CT
only after negative or inconclusive ultrasonography, gives the
highest sensitivity for detecting urgent conditions. With this
selective CT strategy, it has been shown that only 50% of
patients would require CT [24].
The use of CT scan for patients presenting to emergency
department with AAP is variable among different coun-
tries. In some countries such as USA, early CT is com-
monly used in the triage of patients presenting with AAP
because admission to General Surgery setting prior to CT
scan is not a common practice. On the other hand, in many
European countries including UK, triage of patients is
based mainly on clinical findings supported by plain radi-
ography and CT scan will be done if indicated on clinical
grounds. The findings of this study may have some impli-
cations in facilitating efficient and safe referral of patients
from emergency department to General Surgery unit with-
out performing early CT in emergency department. Many
causes of AAP such as acute cholecystitis, peptic ulcer
disease or acute appendicitis may be diagnosed without a
need for CT scan; therefore, not performing CT scan in
emergency department should not necessarily delay refer-
ral of a patient to General Surgery team.
Langenbecks Arch Surg
Fig. 2 Risk of bias summary and
graph showing authors’
judgements about each risk of
bias item for randomised trials
The reported outcomes of our review should be viewed and
interpreted in the context of inherent limitations. The sample
size of this study was adequate for robust conclusions regard-
ing the correct diagnosis rate and mortality; however, the sam-
ple size was not adequate for LOS, subjecting our results to
type 2 error for this outcome. One of the included studies
included patients with acute right lower quadrant pain and
excluded patients with other forms of acute abdominal pain,
subjecting our results to potential selection bias. The included
studies had some differences in their design in terms of includ-
ed population (one study included patients with right-sided
abdominal pain and one study included patients with non-
specific abdominal pain) and time frame for performing CT
scan (one study performed CT scan within 1 h of presentation
and other 3 RCTs within 24 h of presentation). All of these can
potentially subject the results of this study to bias. Moreover,
we excluded cases that were pregnant and cases with acute
abdominal trauma, contraindication to iodinated contrast me-
dia and need for immediate surgery without delay; therefore,
the results of current study cannot be used for definite
conclusions for these subgroups. The number of eligible stud-
ies for this review was less than 10, not allowing for formal
assessment of publication bias as planned in our protocol. The
available data was not adequate to synthesise some clinically
important outcomes such as non-therapeutic surgery and
missed diagnoses. Moreover, the available data from the in-
cluded studies was not adequate to determine what proportion
of patients in the selective group already had a correct diag-
nosis by other imaging. Finally, the available data did not
allow for subgroup analysis based on the age of the patients;
therefore, we were not able to define a subgroup of patients
who may benefit from routine use of CT.
Conclusions
The best available evidence suggests that routine use of CT
does not improve the proportion of correct diagnoses and
mortality compared to selective use of CT in adult patients
with non-traumatic AAP. The available evidence regarding

a) Correct diagnosis
b) Mortality
c) Length of hospital stay
Fig. 3 Forest plots of the comparisons of outcomes between routine CT
and selective CT groups. a Correct diagnosis: event = correct diagnosis,
M-H Mantel-Haenszel methods, fixed fixed-effect model, weight: the
amount of information that each study contributes. b Mortality: event =
the influence of routine CT on LOS may be subject to type 2
error. These findings, however, may not apply to the elderly
patient with AAP and further studies are required.
Authors’ contributions Study conception and design: Shahab H,
Acquisition of data: ML, AA, SR, Shahin H, Shahab H. Analysis and
interpretation of data: SR, Shahin H, Shahab H. Drafting of manuscript:
all the authors. Critical revision of manuscript: all the authors.
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of
interest.
Ethical approval Considering the nature of this study, ethical approval
was not required.
Human and animal rights This study is a systematic review with meta-
analysis of outcomes which does not include research directly involving
human or animal participation.
Informed consent Considering the nature of this study, informed con-
sent was not required.
Langenbecks Arch Surg
death, M-H Mantel-Haenszel methods, random random-effects model,
weight: the amount of information that each study contributes. c Length
of hospital stay: IV Inverse variance; random random-effects model;
weight: the amount of information that each study contributes
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