Clinical Imaging 90 (2022) 32–38

Contents lists available at ScienceDirect

Clinical Imaging
journal homepage: www.elsevier.com/locate/clinimag

Musculoskeletal and Emergency Imaging

Delays in imaging diagnosis of acute abdominal pain in the

emergency setting
Alana Fruauff, Christopher Trepanier, Hiram Shaish, Lyndon Luk *
Columbia University Irving Medical Center, Department of Radiology, 622 West 168th Street, New York, NY 10032, United States of America

A R T I C L E I N F O A B S T R A C T

Keywords: Acute abdominal pain is a common cause of ED visits and often requires imaging to identify a specific diagnosis.
Delayed diagnosis Prompt and appropriate imaging plays a crucial role in patient management and leads to improved patient
Abdominal radiographs outcomes, decreased hospital stay, and improved ED workflow. There are many cases of abdominal pain in the
Oral contrast
ED with delayed diagnosis and management secondary to a combination of institutional policies and knowledge
Contrast-induced acute kidney injury
deficits in current imaging guidelines. Inappropriate use of abdominal radiographs, use of oral contrast for CT
abdomen and pelvis, and concern for iodinated contrast-induced acute kidney injury are three of the more
commonly encountered roadblocks to prompt imaging diagnosis of abdominal pain. The purpose of this review is
to discuss why these potential causes of delayed diagnosis occur and how radiologists can help improve both
imaging and ED workflow by utilizing the most up-to-date imaging guidelines such the American College of
Radiology (ACR) Appropriateness Criteria and ACR Manual on Contrast Media to assist clinicians working in the
emergency setting.

1. Introduction computed tomography (CT), and concern for contrast-induced acute

Acute nontraumatic abdominal pain is a non-specific, but common
complaint encountered in the emergency department (ED). Approxi­
mately 4–10% of ED visits are for acute abdominal pain, of which one-
third never have a diagnosis established.1,2 The evaluation of acute non-
traumatic abdominal pain in the ED has changed significantly over the
past several decades due to improvements in quality, speed, and avail­
ability of radiology imaging modalities.3 The range of pathology that
can manifest as acute abdominopelvic pain is extremely broad and re­
quires the proper imaging approach in narrowing differential diagnosis
and guiding patients to appropriate medical and surgical management.
Thorough understanding of evidence-based imaging guidelines and a
streamlined approach in performing imaging leads to efficient diagnosis
and treatment, improved outcomes, decreased hospital length of stay,
and overall cost of stay.4,5
In reality, there are many cases of abdominal pain in the ED with
delayed diagnosis and management secondary to knowledge deficits in
current imaging guidelines. The goal of this manuscript is to review
three of the more commonly encountered potential radiology causes of
delayed diagnosis of abdominal pain in the emergency setting (inap­
propriate use of abdominal radiographs, oral contrast use with
kidney injury) and provide up to date recommendations for both radi­
ologists and clinicians to provide more timely patient care.
2. Abdominal radiographs in acute abdominal pain
Many patients presenting to the ED with abdominal pain first un­
dergo an abdominal radiograph (AR), which has long been considered a
primary initial imaging modality in part because they are low cost and
quick to obtain.6 There is a wide body of evidence that ARs are limited
by poor diagnostic yield, poor interobserver agreement, and inaccuracy
in diagnosing common clinical conditions, including bowel obstruction
and pneumoperitoneum (Figs. 1-4).7,8 In a retrospective study con­
ducted by Ho Anh, et al., AR was found to have a sensitivity of 49% for
diagnosing bowel obstruction.9 CT is not only more sensitive at identi­
fying bowel obstruction, but it can also lead to identification of the
location and cause of obstruction. This additional information can be
essential to patient management and determining which patients need
emergent surgery and which can be conservatively managed. Delay in
surgery can result in complications such as intestinal ischemia and
strangulation with associated increased morbidity and mortality.10
Mortality rate is further increased in elderly patients, who often have

* Corresponding author.
E-mail addresses: alf9123@nyp.org (A. Fruauff), cht9138@nyp.org (C. Trepanier), hs2926@cumc.columbia.edu (H. Shaish), ll2844@cumc.columbia.edu (L. Luk).

https://doi.org/10.1016/j.clinimag.2022.06.015
Received 25 April 2022; Received in revised form 9 June 2022; Accepted 26 June 2022
Available online 29 June 2022
0899-7071/© 2022 Elsevier Inc. All rights reserved.
A. Fruauff et al. Clinical Imaging 90 (2022) 32–38

Fig. 1. Supine abdominal radiograph (A) of a 79-year-old female with diffuse abdominal pain shows air-filled, dilated small bowel in the left midabdomen and air
within the ascending and transverse colon, interpreted as ‘possible small bowel ileus’. Coronal CT of the abdomen and pelvis with IV contrast (B) shows a dilated,
fluid-filled small bowel loop with focal transition point (arrow), consistent with small bowel obstruction.

Fig. 2. Supine abdominal radiograph (A) of a 70-year-old male with history of hypertension and diabetes presenting to the ED with generalized abdominal pain
shows a diffusely dilated air-filled stomach with curvilinear lucencies along the greater curvature (white arrow). Coronal CT abdomen and pelvis with air window (B)
obtained afterwards clearly shows air throughout the wall of the stomach (black arrow), consistent with emphysematous gastritis. Intramural air within the stomach
was missed on the abdominal radiograph.

atypical or late presentations of medical conditions that may confound
timely diagnosis, which is exacerbated when AR does not readily iden­
tify a focal abnormality.11,12
ARs have low sensitivity for identifying pneumoperitoneum. One
study evaluating patients with documented visceral perforation found
that only 51% of ARs showed pneumoperitoneum.1 The sensitivity of AR
to diagnose pneumoperitoneum depends largely on the technique used.
Often ARs will exclude or incompletely visualize portions of the
abdominal cavity, such as the diaphragm, from the field of view.6 Other
common occurrences include radiographs with inadequate penetration
due to obesity, overlying artifact from clothing and external devices, and
radiographs of patients laying only in the supine position.1 If AR is ob­
tained to identify free air, a well-performed left lateral decubitus
radiograph should be obtained. Prior studies of left lateral ARs in proven
hollow viscera perforation have shown a positive detection rate of 98%,
though other studies of left lateral decubitus ARs in postoperative
pneumoperitoneum show a positive rate of 53%.13,14 CT is superior in
detecting pneumoperitoneum as it is able to detect small amounts of free
air that would not be appreciated even on well-executed ARs.6
Not only are ARs inferior at identifying pneumoperitoneum and
bowel obstruction, they also have low overall diagnostic yield. A ran­
domized clinical control study conducted by Nguyen et al. compared the
use of low dose CT (LDCT) and AR in the evaluation of patients pre­
senting to the ED with acute abdominal pain. A diagnosis was obtained
only in 21.8% of patients imaged with AR. Diagnoses made by abdom­
inal radiograph included bowel obstruction, fecal loading, and pneu­
moperitoneum. The remaining ARs were interpreted as normal or
nonspecific. In patients imaged with LDCT, a diagnosis was established
in 64.2% of patients. With LDCT, additional diagnoses of diverticulitis,
acute pancreatitis, hernias, and hydronephrosis were made.6 A similar

33
A. Fruauff et al.
Fig. 3. Supine abdominal radiograph (A) of a 52-year-old male with history of stem cell transplant, hypertension, and diabetes with low abdominal pain shows a
non-obstructive bowel gas pattern. Coronal CT abdomen and pelvis with IV contrast (B) shows diffuse submucosal edema (arrowhead) and enhancing mucosa (arrow)
throughout the small bowel. Patient was diagnosed with graft-versus-host disease and was treated with steroids.
retrospective study by Ho Anh, et al. showed 68% of ARs were read as
nonspecific, 23% of ARs were interpreted as normal, and only 10% of
ARs leading to a specific diagnostic abnormality. ARs had 0% sensitivity
in identifying appendicitis and diverticulitis, two common causes of
acute abdominal pain. CT resulted in a specific diagnosis in 80% of
cases.9
There are several reasons why ARs have low diagnostic yield. Most
abdominal disease processes do not result in specific radiographic
findings and thus, one cannot secure a definitive diagnosis. ARs also
have low soft tissue contrast; inflammatory changes that occur in most
acute processes cannot be appreciated on AR. CT has the advantage of
not only identifying a focal disease process, but also demonstrating the
extent of disease and associated complications such as abscess.6,9
Because ARs are commonly interpreted as nonspecific and do not
lead to a diagnosis, patients will often require additional imaging.
Nguyen et al. found that 50.9% of patients initially evaluated with AR
required further imaging during a hospital admission versus 26.4% of
patients initially imaged with LDCT.6 Delay in CT imaging in ED patients
who had an AR performed first can lead to disease complications and
increased risk of complications during surgery. Cournane, et al. found
that delays in obtaining CT scans were associated with longer hospital
length of stay and increased hospital costs.15 Larson et al. found that
increase in CT utilization was associated with a 53% relative risk
reduction of admission or transfer,16 supporting the notion that prompt
and appropriate use of CT enables clinicians to triage patients and
develop disposition plans more appropriately. Delay in CT imaging for
abdominal pain may be due in part to adherence to out of date practices
and unawareness of current imaging guidelines. Prior studies have
shown that the physician in charge of requesting and approving imaging
studies may have an impact on the type and number of studies or­
dered.17 Furthermore, ARs are often ordered when they are not the most
appropriate imaging modality for various acute abdominal pain sce­
narios. A recent study evaluating AR performed in 1997 ED patients
found only 11.8% of them indicated according to American College of
Radiology (ACR) guidelines.18 And while many patients may undergo
both AR and CT for abdominal pain in the ER, the AR is unlikely to
provide additional information while exposing patients to radiation.19
The diagnostic superiority of CT is captured by the ACR Appropri­
ateness Criteria, a broad set of evidence-based guidelines to assist
34
Clinical Imaging 90 (2022) 32–38
clinicians in making the appropriate decision when imaging is required
for a specific clinical condition. On the most current version of the ACR
Appropriateness Criteria, CT is categorized as “usually appropriate” for
33 of 39 (85%) separate scenarios of abdominal pain emergencies. AR is
deemed “usually appropriate” for none of the 39 scenarios.20
3. Utility of oral contrast in evaluating abdominal pain
The use of positive oral contrast agents with CT of the abdomen and
pelvis was initially considered essential for radiologists to better char­
acterize bowel abnormalities and differentiate bowel loops from fluid
collections.21 The development and widespread adoption of multi-
detector CT (MDCT), which allows for quicker acquisition times,
decreased motion artifact, and improved spatial and contrast resolution,
led to investigation into timelier imaging of ED patients with acute
abdominal pain. Several studies have shown equivalent and superior
accuracy of MDCT without oral contrast compared to MDCT with oral
contrast for patients being evaluated for several abdominopelvic pa­
thologies, including blunt trauma, appendicitis, bowel obstruction, and
acute diverticulitis (Fig. 5).5,22,23 A study of 2668 consecutive ER pa­
tients undergoing CT with oral and CT without oral contrast for
abdominal pain in two urban teaching hospitals showed only one change
in final patient diagnosis after CT with oral contrast was given after
patient recall.24 In addition, high attenuation of the bowel wall and
segmental bowel wall hypoenhancement specific to ischemia may
potentially be obscured or less evidence if positive oral contrast is
given.25,26
In addition to questionable diagnostic advantage, the use of oral
contrast can also result in significant delays in scan acquisition, ED
throughput, and prompt management, which can have adverse effects
on patient outcome and hospital length of stay. Patients in the ED are
typically instructed by clinicians to drink upwards of 1 L of barium or
water-soluble oral contrast prior to imaging, but cannot be monitored
consistently during contrast drinking. During the typical 60–90 min
delay between drinking and imaging in the ED, patients are often unable
to drink a significant amount of oral contrast, do not drink at all due to
pain and discomfort, or quickly drink a large amount of contrast just
prior to imaging, leaving the distal small bowel and colon unopacified
(Fig. 6). Fluid-filled small bowel loops in cases of complete obstruction
A. Fruauff et al. Clinical Imaging 90 (2022) 32–38

Fig. 4. Supine abdominal radiograph (A) of an 82-year-old female with diffuse upper abdominal pain shows a gastrostomy tube balloon projecting over the right
upper abdomen (arrow) and surrounding ill-defined lucencies in the right lateral abdomen (arrowheads). The radiograph was read as ‘non-obstructive bowel gas
pattern’. CT abdomen and pelvis with IV contrast sagittal and axial images (B, C) shows a large amount of subcutaneous emphysema in the anterior abdominal wall
(arrowheads) and the gastrostomy tube balloon displaced into the soft tissues (arrow).

often provide adequate intrinsic contrast and obviate the need for oral
contrast, as detailed by the ACR Appropriateness Criteria.20 Limitations
in emergency department, radiology, and transport staffing can also
increase expected imaging time, diagnosis, and disposition. Several
studies evaluating the reduction in length of stay in the ED (disposition
to inpatient admission and discharge) when omitting oral contrast from
CT of the abdomen and pelvis have shown a median reduction time
ranging from 30 to 241 min.5,22,23
Many emergency departments have opted to determine whether a
patient requires oral contrast based on body mass index (BMI). Patients
with BMI >25 are not given oral contrast for CT due to the expectation of
having more intrabdominal and intrapelvic fat as a backdrop to evaluate
bowel and other viscera, as well as more easily identifying fatty in­
flammatory changes.27
4. Nephropathy risk with iodinated IV contrast use
After the introduction of iodinated intravenous (IV) and intraarterial
contrast agents, there was suggestion that these agents could cause acute
renal dysfunction after contrast-enhanced CT (CECT). This phenomenon
was initially called contrast-induced nephropathy (CIN), but is now
referred to as contrast-induced acute kidney injury (CI-AKI) in the ACR
Manual on Contrast Media.28,29 Original studies of CI-AKI lacked suit­
able control groups and thus, any association between contrast agents
and AKI was conflated by other uncontrolled variables.30 Furthermore,
much of the early research studying CI-AKI evaluated high-osmolality
contrast media only, which has since been replaced by low-osmolality
contrast media. There have been several studies suggesting that low-
osmolality contrast media is less nephrotoxic than high-osmolality
contrast media and thus, this further conflated the association.31–33
Lastly, much of the early research behind CI-AKI was based on intra-
arterial contrast administration for cardiac angiography which carries
a much higher risk of renal injury. Conclusions drawn from initial
studies of CI-AKI have disseminated broadly in medical education and
training, leading many clinicians to avoid the use of iodinated IV
contrast if there was any concern for renal impairment.34
More recent controlled studies and meta-analyses have provided
evidence countering claims made in early studies, with most studies
finding no significant change in renal function in patients who received
IV contrast compared to those who did not.35–37 Newer research studies

35
A. Fruauff et al.
Fig. 5. IV contrast-enhanced coronal CT abdomen and pelvis without oral contrast (A) and with oral contrast (B) in two different patients presenting with right lower
abdominal pain show a dilated, fluid-filled appendix (arrows) with stranding of the surrounding periappendiceal fat. CT without oral contrast was imaged 35 min
after evaluation, while CT with oral contrast was imaged 3 h after evaluation.
Fig. 6. Coronal CT abdomen and pelvis without oral or IV contrast (A) in a 50-
year-old female presenting with right lower abdominal pain shows a dilated
appendix containing an appendicolith (arrow) and stranding of the surrounding
periappendiceal fat. IV contrast was not given due to a creatinine of >4 mg/dL.
The patient was instructed to drink oral contrast in the ER, but did not drink
any due to pain. A total of 5 h passed before the patient was imaged. Acute
appendicitis was confirmed on pathology after the patient was taken to surgery
the next morning.
have also used propensity score adjustment and propensity score
matching, which accounts for confounding variables such as sepsis,
which may affect renal function, thereby reducing confounding
bias.36,37 The most recent version of the ACR contrast manual makes a
clear distinction between contrast-associated acute kidney injury (CA-
AKI) and CI-AKI in order to differentiate a correlative relationship from
a causative one. CI-AKI is a real but rare entity that is overestimated in
clinical practice because most published series have conflated CA-AKI
with CI-AKI and attributed a correlative finding to a causative
36
Clinical Imaging 90 (2022) 32–38
relationship.24
Clinicians remain wary about the use of IV contrast and pre-
procedural hydration for CECT in abdominal pain for patients with
elevated creatinine, post renal transplant, on dialysis, or recent (within
24 h) CECT, even if the differential includes life-threatening conditions.
These and other risk factors have not been rigorously confimed and are
discussed in length by the ACR Manual on Contrast Media.29,38,39 While
most hospitals have creatinine and estimated glomerular filtration rate
(eGFR) thresholds where administration of IV contrast becomes con­
traindicated or requires communication between clinicians and radiol­
ogists, there is no universally agreed upon creatinine or eGFR threshold
for which the risk of CI-AKI makes IV contrast an absolute contraindi­
cation. Currently, there is very little evidence that IV contrast leads to
AKI in patients with an eGFR of ≥30 mL/min/1.73m2; an eGFR of ≤30
mL/min/1.73m2 is the threshold with the strongest evidence to weigh
risks and benefits of CECT. In the emergency setting, concern for CI-AKI
often results in lengthy discussions between ordering clinicians and ra­
diologists, which leads to delays in imaging acquisition and thus, a
diagnosis. Furthermore, if the initial CT scan is done without intrave­
nous contrast, critical diagnoses that could seriously change patient
management can be missed (Fig. 7). Unlike oral contrast, IV contrast has
been shown to increase the spectrum of identifiable pathology on CT of
patients with generalized abdominal pain.40 By the time a patient is
brought back for CECT, there has been even further delay in diagnosis
and treatment. MRI could be an appropriate imaging alternative to
evaluate acute abdominal emergencies, particularly in young patients
with multiple CT studies and patients with prior anaphylaxis to iodin­
ated IV contrast. However, MRI may not be available to all facilities
overnight and studies may be more difficult to interpret due to motion
artifact secondary to pain and inability to breath hold.20
5. Conclusion
Acute non-traumatic abdominal pain is a common chief complaint
encountered in the ED that often relies heavily on imaging to provide an
early and accurate diagnosis crucial for better patient outcomes. Three
practices that can lead to a delay in diagnosis discussed in this manu­
script include the inappropriate use of abdominal radiographs, the use of
oral contrast in CT, and concern for CI-AKI in patients prior to CECT. Up
A. Fruauff et al.
Fig. 7. Axial CT abdomen and pelvis pre and post-IV contrast (A, B) images of a 68-year-old male presenting with bright red blood per rectum and hypotension
showing enhancement of the abdominal aorta (arrowhead), dilated, fluid filled loops of small bowel and diffuse arterial intraluminal small bowel enhancement
(arrows), consistent with aortoenteric fistula. The patient had a complex vascular history, including endograft repair of the abdominal aorta (not pictured) and had
undergone CTA chest 6 h prior to evaluate for pulmonary embolus (negative). The clinical team was hesitant to order a second contrast-enhanced study within 24 h,
requiring a conversation between the radiologist and clinical team that took approximately 1 h to resolve.
to date knowledge of current literature and imaging guidelines such as
the ACR Appropriateness Criteria and ACR Manual on Contrast Media
should help limit delays in ordering and performance of the proper
imaging study. It is contingent upon clinicians ordering imaging studies
to evaluate patients with abdominal pain and the radiologists inter­
preting them to work together to safely and positively impact workflow.
Declaration of competing interest
The authors do not have any competing or conflicting interests to
declare in the writing and submission of this review manuscript.
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