- CT if there is abdominal tenderness or a seatbelt sign - Seatbelt sign- Not just abrasions! They have bruising / ecchymoses.
- With Seat Belt Sign, incidence of hollow viscus injuries (17%); splenic injuries (10%)
- Things that are easy to miss on CT scan
- Diaphragm injuries - think about in abdominal pain w/ dyspnea or chest pain
- GI tract injuries - free fluid; bowel in discontinuity
- Pancreatic injuries - difficult to tell difference between contusion and ductal injury -
- Important because these need intervention and waiting will be detrimental;
- ERCP or MRCP - definitive diagnosis
ABDOMINAL PAIN IN THE ELDERLY
- Have a low threshold for imaging elderly patients with abdominal pain
- Abdominal pain in elderly - 60-70% admitted; 30% with surgical process; 10% with return ED visits; 5% mortality
- Exam is not as reliable!!
- CT: diagnostic in 85% of people who had emergent surgical process
- Contrast? IV/ PO/ both/ CTA?- if concerned about vascular - get CTA
> Contrast allergy - only true contraindication - airway compromise
> CIN - Cr rising >0.5 mg/dL or 25% from baseline;
> Most elderly people have risk factors Cr > 1.5-2.0
> Consider no contrast - if giving contrast - HYDRATE
> Manufacture warning - no metformin 48 hrs before or after IV contrast;
> Increased risk - contraindications to metfomin, preexisting renal dysfunction
- Dilated loops of small bowel - diameter > 2.5 cm;
- >50% difference in caliber before and after transition
- Acute Obstruction Series X-rays - help if diagnostic; not so much if "normal" or "non-specific"
- If an obstruction series is nondiagnostic and you suspect bowel obstruction, get a CT
- PO contrast may add functional info, but often difficult to get into the patient... and not necessary.
- PO contrast is almost never needed in CT scanning
- Diverticulitis - fat stranding; bowel wall thickening - CT with IV contrast best image
- Appenditicits - senstivity 90% with no contrast; 100% with contrast
- Mesenteric ischemia - CT angio is the best
- Acute cholecystitis - cholesterol vs pigment stones can be seen on CT
- Ultrasound is the first best test for suspected gallbladder pathology
- Generally don't need imaging.
- Consider imaging if changing clinical picture; not typical; no classic pancreatitis risk factors (to r/o malignancy)