Efforts to reduce children's exposure to radiation when they present in the emergency room with abdominal pain have been effective -- mostly by using ultrasound to diagnose the cause of the pain rather than CT, according to a study published November 19 in the American Journal of Roentgenology.
But the same can't be said for adults, wrote a team led by Dr. Ralph Wang of the University of California, San Francisco.
"CT use has decreased in the evaluation of abdominal pain in children, perhaps because of research findings and efforts to implement an ultrasound-first strategy for suspected appendicitis," the group noted. "In contrast, CT use has continued to increase among adults with abdominal pain in emergency departments."
It can be difficult to diagnose patients presenting in the emergency room with abdominal pain. CT offers high accuracy for diagnosing appendicitis, but it comes with radiation exposure and an increase in incidental findings. Because of these drawbacks, an effort to reduce the use of CT through an "ultrasound first" protocol has been implemented for children, but no such protocol has been put into place for adults, according to the authors.
To investigate the use of CT and ultrasound in the emergency department for abdominal pain and appendicitis in both children and adults, Wang and colleagues used data from the National Hospital Ambulatory Medical Care Survey (1997-2016). They found that CT use in children increased during the study time frame, with a peak in 2010 that then plateaued. Among adults, however, the use of CT steadily increased.
| Trends in CT and ultrasound use for abdominal pain in the emergency department | |||
| Measure | 1997-1998 | 2009-2010 | 2015-2016 |
| Percentage of ED visits for abdominal pain | |||
| Children | 5.4% | 6.3% | 7.8% |
| Adults | 8.3% | 10.9% | 12.8% |
| Percentage of CT use | |||
| Children | 1.2% | 16.6% | 14.7% |
| Adults | 3.9% | 35.6% | 37.8% |
| Percentage of ultrasound use | |||
| Children | 4.3% | 9.5% | 15.9% |
| Adults | 10.5% | 14.3% | 16.6% |
| Percentage of appendicitis diagnoses | |||
| Children | 3.4% | 3.4% | 3.7% |
| Adults | 2.3% | 1.6% | 1.1% |
The authors noted that the peak in pediatric CT use and the ensuing decrease was likely due to education efforts around managing radiation dose exposure in children.
"Although we did not prove that the research and implementation efforts actually caused this [pediatric CT use] plateau and decrease in CT, the timing of these efforts correlates well," they wrote. "Seminal articles regarding radiation dose appeared in 2007-2010, and Choosing Wisely recommendations by the American Academy of Pediatrics and American College of Radiology were disseminated in 2012-2013."
However, the dramatic increase in the use of CT among adults over the past 20 years remains a concern.
"The increase over time in CT use for adults was not associated with an increase in the proportion of diagnoses of appendicitis during visits for abdominal pain, suggesting that the increase in CT use may not benefit patients but instead results in more patients without appendicitis receiving CT," Wang and colleagues concluded.
