Children with Abdominal Pain Increasingly Exposed to CT Scanning in the Emergency Room

Computed tomography (CT) imaging use in children with nontraumatic abdominal pain increased in emergency departments each year between 1999 and 2007, according to new findings.

The study’s authors found no corresponding increase in ultrasound use during the same period, in spite of research supporting it as an important diagnostic tool for assessing pediatric abdominal pain. The study’s findings were published online April 26, 2012, in the journal Radiology.

Nontraumatic abdominal pain is a typical complaint of pediatric visits to the emergency department. Physicians frequently order CT exams when abdominal pain suggests appendicitis. While CT scans provide rapid, accurate diagnosis, they expose patients to ionizing radiation--a significant concern for children due to their longer life expectancy and increased susceptibility to radiation effects.

“Our findings help give us an overall understanding of places where we can tackle disparities of use and disparities in care,” said Anastasia L. Hryhorczuk, MD, a clinical fellow from Children’s Hospital Boston (MA, USA). “Ideally, we’d like to see the same standard of care being applied across the country to protect children from unnecessary radiation exposure.”

Research has shown that step-by-step evaluations of pediatric patients, beginning with ultrasound and proceeding to CT if ultrasound is negative or uncertain, is the most accurate path for diagnosing appendicitis. Dr. Hryhorczuk and colleagues sought to determine if this strategy had been incorporated into general emergency department practices.

For the study, researchers looked at data from the US National Hospital Ambulatory Medical Care Survey (NHAMCS) to evaluate imaging utilization among children with acute abdominal pain in US emergency departments. From 1999 to 2007, there were 16,900,000 pediatric emergency department visits for acute abdominal pain. The chances of a child receiving a CT scan increased during each year of the study period, in spite of the fact that there were no statistically significant changes in ultrasound usage, numbers of patients admitted to the hospital, or numbers of patients with acute appendicitis. Only three percent of patients ultimately diagnosed with appendicitis were imaged with both ultrasound and CT.

Children evaluated in pediatric emergency departments were more than 25% less likely than those seen at general emergency departments to undergo CT imaging for abdominal pain. “In a pediatric setting, clinicians may have skills for evaluating patients that favor management without imaging, lowering CT usage,” Dr. Hryhorczuk said.

Statistical analysis demonstrated increased odds of CT use in teens, white patients, the Midwest region of the United States, urban settings, patients with private insurance, and patients who were admitted or transferred. Although the study did not investigate reasons for these variations, Dr. Hryhorczuk pointed out that CT scanners are readily available in hospitals, whereas access to ultrasound may be limited based on operator availability in some areas. The local legal climate also may play a factor in obtaining imaging exams, according to the study, as appendicitis diagnoses are a source of lawsuits in the pediatric emergency setting.

The time period of the study predates “Image Gently,” a 2008 initiative of the Alliance for Radiation Safety in Pediatric Imaging that promotes radiation safety in the imaging of children. The researchers hope that further study of NHAMCS information will provide more data on the success of this and other programs aimed at lowering medical radiation exposure in children.

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