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Three Part Question

In [elderly patients presenting to the Emergency Department with abdominal pain] does [CT scan]affect [clinical decision making]?

Clinical Scenario

A 75 years old man presents with acute onset of central abdominal pain. He has never
had this pain before. Abdominal examination revealed central abdominal tenderness but no guarding or masses. The general examination was unremarkable. Routine blood tests came back as normal. You request a CT scan of the patient’s abdomen as he continues to be in pain with no obvious pathology but wonder if the CT scan is a sensitive predictor of significant underlying pathology and if it will help you in clinical decision making.

Search Strategy

Midline,CINAHL,EMBASE search using OVID interface (1950- December 2013)
Using CT Scan OR Computerised Tomography scan
AND Abdominal pain
AND Elderly OR Old age OR Above 65 years
AND decision making OR Management OR need for surgery OR admit OR discharge
Limit search to English language and humans. We also searched Google and Google scholar for relevant articles and abstracts.

Search Outcome

42 studies were found. 2 of these papers were identified as relevant to this
question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Esses D et al 2004 USA	104 patients 65 years or older presenting to an urban teaching Emergency Department with non traumatic acute abdominal pain	Prospective observational cohort study of a convenience sample	CT scan altered decision to admit in 26%, the need for surgery in 12% and diagnosis in about 50%.Of 72 patients who would have been admitted before CT,23 of them were discharged when CT results were known.Out of 32 patients who would have been discharged without knowing the CT results 4 were admitted.	Diagnostic certainty doubled. Altered decision making regarding admission ,discharge or surgery. Planned surgery in 6 cases prior to CT results deemed unnecessary in 4 cases.10 patients deemed to require surgery duo to CT results 8 of them were unsuspected.	Convenience sample. Single centre 29 patients met the inclusion criteria but the attending physician chose not to include. Out of 42 attending physicians involved 40 were board certified but they had varied experience between 2-20 years.
Hustey FM et al 2005 USA	337 patients >60 years old presenting to ED with acute non traumatic abdominal pain	Prospective multicentre observational study	57% of CT scans were diagnostic for patients requiring acute surgical or medical interventions, and 85% for patients requiring acute surgical intervention	CT scan results are often diagnostic for older patients with abdominal pain	Sample bias as started by age of 60 years old

Comment(s)

CT scan is an important investigation tool in elderly patients with acute non traumatic abdominal pain presenting to the emergency department. it can improve diagnostic accuracy, it also helps in decision to admit, discharge and the need for surgery.

References

1. Esses D, Birnbaum A, Bijur P, Shah S, Gleyzer A, Gallagher DEJ Ability of CT to Alter Decision Making in Elderly Patients With Acute Abdominal Pain Am J Emerg Med 2004 Jul;22 (4):270-2.
2. Hustey FM, Meldon SW, Banet GA, Gerson LW, Blanda M, Lewis LM The use of abdominal computed tomography in older ED patients with acute abdominal pain Am J Emerg Med 2005 May;23(3):259-65