Was muss der Viszeralchirurg über den Einsatz der Computertomografie in der Abklärung des akuten Abdomens wissen

Zusammenfassung

Das akute Abdomen ist ein häufiges klinisches Bild in der Notaufnahme. Nicht selten ist die Klinik unspezifisch. Die Aufgabe des Viszeralchirurgen besteht darin, unter Zeitdruck mit hoher Treffsicherheit unmittelbar lebensbedrohliche von harmlosen Ursachen zu unterscheiden. Bildgebende Verfahren nehmen heute eine zentrale Rolle in der erweiterten Diagnostik des akuten Abdomens ein. Die Computertomografie (CT) gewinnt zunehmend an Bedeutung in der Abklärung des akuten Abdomens. In der Übersichtsarbeit wird die Rolle der CT in der Diagnostik des akuten Abdomens dargestellt und ihre Wertigkeit mit der konventionellen Übersichtsaufnahme des Abdomens, der Sonografie, aber auch der Magnetresonanztomografie (MRT) verglichen. Zusätzlich werden in der Übersichtsarbeit für die Indikationsstellung zur CT relevante Aspekte wie Strahlenexposition und Kontrastmittelsicherheit thematisiert.

Abstract

The acute abdomen is a very serious yet common condition of patients presenting in the emergency department. The clinical symptoms of patients with acute abdomen are often unspecific. The responsibility of the surgeon in charge is to differentiate acute life-threatening from less serious conditions with a high level of diagnostic accuracy in a minimal period of time. Imaging represents a cornerstone in the diagnostic work-up of patients with acute abdomen. Computed tomography (CT) is increasingly utilised to detect emergency conditions in patients with acute abdomen. In this review article we aim to elaborate the role of CT in the imaging strategy for acute abdomen in comparison to conventional radiography, ultrasonography and magnetic resonance imaging. In addition, relevant factors pertaining for the indication of CT such as exposure to ionising radiation and safety of iodinated contrast media are discussed.

Schlüsselwörter

akutes Abdomen - bildgebende Verfahren - Computertomografie - Strahlenexposition - Kontrastmittelsicherheit

Key words

Acute abdomen - imaging - computed tomography - exposure to ionising radiation - safety issues for contrast media handling

• Literatur

• 1 Powers RD, Guertler AT. Abdominal pain in the ED: stability and change over 20 years. Am J Emerg Med 1995; 13: 301-303
• 2 Grundmann RT, Petersen M, Lippert H et al. [The acute (surgical) abdomen – epidemiology, diagnosis and general principles of management]. Z Gastroenterol 2010; 48: 696-706
• 3 Trentzsch H, Werner J, Jauch KW. [Acute abdominal pain in the emergency department – a clinical algorithm for adult patients]. Zentralbl Chir 2011; 136: 118-128
• 4 Graff L, Russell J, Seashore J et al. False-negative and false-positive errors in abdominal pain evaluation: failure to diagnose acute appendicitis and unnecessary surgery. Acad Emerg Med 2000; 7: 1244-1255
• 5 Andersson RE. The natural history and traditional management of appendicitis revisited: spontaneous resolution and predominance of prehospital perforations imply that a correct diagnosis is more important than an early diagnosis. World J Surg 2007; 31: 86-92
• 6 Ng CY, Squires TJ, Busuttil A. Acute abdomen as a cause of death in sudden, unexpected deaths in the elderly. Scott Med J 2007; 52: 20-23
• 7 Stoker J, van Randen A, Lameris W et al. Imaging patients with acute abdominal pain. Radiology 2009; 253: 31-46
• 8 American College of Radiology. ACR-SPR practice guideline for the performance of abdominal radiography (2011). Im Internet: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Abdominal_Radiography.pdf Stand: 16.05.2013
• 9 Kellow ZS, MacInnes M, Kurzencwyg D et al. The role of abdominal radiography in the evaluation of the nontrauma emergency patient. Radiology 2008; 248: 887-893
• 10 Ahn SH, Mayo-Smith WW, Murphy BL et al. Acute nontraumatic abdominal pain in adult patients: abdominal radiography compared with CT evaluation. Radiology 2002; 225: 159-164
• 11 American College of Radiology. ACR appropriateness criteria: right lower quadrant pain – suspected appendicitis (2010). Im Internet: http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/RightLowerQuadrantPainSuspectedAppendicitis.pdf Stand: 16.05.2013
• 12 Kiewiet JJ, Leeuwenburgh MM, Bipat S et al. A systematic review and meta-analysis of diagnostic performance of imaging in acute cholecystitis. Radiology 2012; 264: 708-720
• 13 van Randen A, Lameris W, van Es HW et al. A comparison of the accuracy of ultrasound and computed tomography in common diagnoses causing acute abdominal pain. Eur Radiol 2011; 21: 1535-1545
• 14 American College of Radiology. ACR appropriateness criteria: suspected small-bowel obstruction (2010). Im Internet: http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/SuspectedSmallBowelObstruction.pdf Stand: 16.05.2013
• 15 van Randen A, Lameris W, Nio CY et al. Inter-observer agreement for abdominal CT in unselected patients with acute abdominal pain. Eur Radiol 2009; 19: 1394-1407
• 16 American College of Radiology. ACR appropriateness criteria: acute (nonlocalized) abdominal pain and fever or suspected abdominal abscess (2012). Im Internet: http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/AcuteAbdominalPainFeverSuspectedAbdominalAbscess Stand: 16.05.2013
• 17 American College of Radiology. ACR appropriateness criteria: left lower quadrant pain – suspected diverticulitis (2011). Im Internet: http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/LeftLowerQuadrantPainSuspectedDiverticulitis.pdf Stand: 16.05.2013
• 18 American College of Radiology. ACR appropriateness criteria: acute pancreatitis (2010). Im Internet: http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/AcutePancreatitis.pdf Stand: 16.05.2013
• 19 American College of Radiology. ACR appropriateness criteria: right upper quadrant pain (2010). Im Internet: http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/RightUpperQuadrantPain.pdf Stand: 16. 05. 2013
• 20 Lameris W, van Randen A, van Es HW et al. Imaging strategies for detection of urgent conditions in patients with acute abdominal pain: diagnostic accuracy study. BMJ 2009; 338: b2431
• 21 Stromberg C, Johansson G, Adolfsson A. Acute abdominal pain: diagnostic impact of immediate CT scanning. World J Surg 2007; 31: 2347-2354
• 22 Ng CS, Watson CJ, Palmer CR et al. Evaluation of early abdominopelvic computed tomography in patients with acute abdominal pain of unknown cause: prospective randomised study. BMJ 2002; 325: 1387-1391
• 23 Rao PM, Rhea JT, Novelline RA et al. Effect of computed tomography of the appendix on treatment of patients and use of hospital resources. N Engl J Med 1998; 338: 141-146
• 24 Rhea JT, Halpern EF, Ptak T et al. The status of appendiceal CT in an urban medical center 5 years after its introduction: experience with 753 patients. AJR Am J Roentgenol 2005; 184: 1802-1808
• 25 Baron KT, Arleo EK, Robinson C et al. Comparing the diagnostic performance of MRI versus CT in the evaluation of acute nontraumatic abdominal pain during pregnancy. Emerg Radiol 2012; 19: 519-525
• 26 Dewhurst C, Beddy P, Pedrosa I. MRI evaluation of acute appendicitis in pregnancy. J Magn Reson Imaging 2013; 37: 566-575
• 27 Johnson AK, Filippi CG, Andrews T et al. Ultrafast 3-T MRI in the evaluation of children with acute lower abdominal pain for the detection of appendicitis. AJR Am J Roentgenol 2012; 198: 1424-1430
• 28 Tonolini M, Ravelli A, Villa C et al. Urgent MRI with MR cholangiopancreatography (MRCP) of acute cholecystitis and related complications: diagnostic role and spectrum of imaging findings. Emerg Radiol 2012; 19: 341-348
• 29 Heverhagen JT, Sitter H, Zielke A et al. Prospective evaluation of the value of magnetic resonance imaging in suspected acute sigmoid diverticulitis. Dis Colon Rectum 2008; 51: 1810-1815
• 30 International Commission on Radiological Protection. The 2007 Recommendations of the International Commission on Radiological Protection. ICRP publication 103. Ann ICRP 2007; 37: 1-332
• 31 Brenner DJ, Hall EJ. Computed tomography – an increasing source of radiation exposure. N Engl J Med 2007; 357: 2277-2284
• 32 Hall EJ, Brenner DJ. Cancer risks from diagnostic radiology. Br J Radiol 2008; 81: 362-378
• 33 Hricak H, Brenner DJ, Adelstein SJ et al. Managing radiation use in medical imaging: a multifaceted challenge. Radiology 2011; 258: 889-905
• 34 Little MP, Wakeford R, Tawn EJ et al. Risks associated with low doses and low dose rates of ionizing radiation: why linearity may be (almost) the best we can do. Radiology 2009; 251: 6-12
• 35 Tubiana M, Aurengo A, Averbeck D et al. The debate on the use of linear no threshold for assessing the effects of low doses. J Radiol Prot 2006; 26: 317-324
• 36 Barcellos-Hoff MH, Nguyen DH. Radiation carcinogenesis in context: how do irradiated tissues become tumors?. Health Phys 2009; 97: 446-457
• 37 Bundesministerium für Umwelt Naturschutz und Reaktorsicherheit. Umweltradioaktivität und Strahlenbelastung Jahresbericht 2010 (Juli 2012). Im Internet: http://doris.bfs.de/jspui/bitstream/urn:nbn:de:0221-201206278814/5/JB_Umweltradioaktivität_2010.pdf Stand 16.05.2013
• 38 Sodickson A, Baeyens PF, Andriole KP et al. Recurrent CT, cumulative radiation exposure, and associated radiation-induced cancer risks from CT of adults. Radiology 2009; 251: 175-184
• 39 Sasieni PD, Shelton J, Ormiston-Smith N et al. What is the lifetime risk of developing cancer?: the effect of adjusting for multiple primaries. Br J Cancer 2011; 105: 460-465
• 40 Zondervan RL, Hahn PF, Sadow CA et al. Body CT scanning in young adults: examination indications, patient outcomes, and risk of radiation-induced cancer. Radiology 2013; 267: 460-469
• 41 Hemme E. Dose reduction in CT. Radiol Technol 2010; 82: 196-198
• 42 Marin D, Nelson RC, Rubin GD et al. Body CT: technical advances for improving safety. AJR Am J Roentgenol 2011; 197: 33-41
• 43 McCollough CH, Bruesewitz MR, Kofler jr. JM. CT dose reduction and dose management tools: overview of available options. Radiographics 2006; 26: 503-512
• 44 Guite KM, Hinshaw JL, Ranallo FN et al. Ionizing radiation in abdominal CT: unindicated multiphase scans are an important source of medically unnecessary exposure. J Am Coll Radiol 2011; 8: 756-761
• 45 Pasternak JJ, Williamson EE. Clinical pharmacology, uses, and adverse reactions of iodinated contrast agents: a primer for the non-radiologist. Mayo Clin Proc 2012; 87: 390-402
• 46 Morcos SK, Thomsen HS. Adverse reactions to iodinated contrast media. Eur Radiol 2001; 11: 1267-1275
• 47 Lasser EC, Berry CC, Talner LB et al. Pretreatment with corticosteroids to alleviate reactions to intravenous contrast material. N Engl J Med 1987; 317: 845-849
• 48 Thomsen HS. European Society of Urogenital Radiology (ESUR) guidelines on the safe use of iodinated contrast media. Eur J Radiol 2006; 60: 307-313
• 49 Webb JA, Stacul F, Thomsen HS et al. Late adverse reactions to intravascular iodinated contrast media. Eur Radiol 2003; 13: 181-184
• 50 Bellin MF, Stacul F, Webb JA et al. Late adverse reactions to intravascular iodine based contrast media: an update. Eur Radiol 2011; 21: 2305-2310
• 51 Morcos SK, Thomsen HS, Exley CM. Contrast media: interactions with other drugs and clinical tests. Eur Radiol 2005; 15: 1463-1468
• 52 Rendl J, Saller B. Thyroid and Contrast Materials. Dtsch Arztebl 2001; 98: A402-A406
• 53 Saam T, Hess T, Kasperk C et al. [Prevalence of latent and manifest hyperthyroidism in an iodine-deficient area: non-selected patient population admitted for CT studies with iodine-containing contrast agents]. Rofo 2005; 177: 1250-1254
• 54 Stacul F, van der Molen AJ, Reimer P et al. Contrast induced nephropathy: updated ESUR Contrast Media Safety Committee guidelines. Eur Radiol 2011; 21: 2527-2541
• 55 Davenport MS, Khalatbari S, Dillman JR et al. Contrast material-induced nephrotoxicity and intravenous low-osmolality iodinated contrast material. Radiology 2013; 267: 94-105
• 56 McDonald RJ, McDonald JS, Bida JP et al. Intravenous contrast material-induced nephropathy: causal or coincident phenomenon?. Radiology 2013; 267: 106-118
• 57 Davenport MS, Khalatbari S, Cohan RH et al. Contrast material-induced nephrotoxicity and intravenous low-osmolality iodinated contrast material: risk stratification by using estimated glomerular filtration rate. Radiology 2013; 268: 719-728
• 58 Vogt B, Ferrari P, Schonholzer C et al. Prophylactic hemodialysis after radiocontrast media in patients with renal insufficiency is potentially harmful. Am J Med 2001; 111: 692-698
• 59 Marenzi G, Marana I, Lauri G et al. The prevention of radiocontrast-agent-induced nephropathy by hemofiltration. N Engl J Med 2003; 349: 1333-1340
• 60 Goergen SK, Rumbold G, Compton G et al. Systematic review of current guidelines, and their evidence base, on risk of lactic acidosis after administration of contrast medium for patients receiving metformin. Radiology 2010; 254: 261-269