Diagnostic imaging for acute abdominal pain in an Emergency Department in Italy

  • Giovanni Marasco
  • Filippo Maria Verardi
  • Leonardo Henry Eusebi
  • Sonia Guarino
  • Alessandra Romiti
  • Amanda Vestito
  • Franco Bazzoli
  • Mario Cavazza
  • Rocco Maurizio ZagariEmail author


Imaging plays a key role in the diagnostic work-up of patients with non-traumatic acute abdominal pain (AAP) in emergency department (ED). We aimed to evaluate the use and diagnostic performance of imaging techniques in adult patients with AAP in an ED in Italy. Patients with non-traumatic AAP admitted at the ED of S. Orsola-Malpighi University Hospital of Bologna (Italy) from the 1st to the 30th November 2016 were included. Demographic and clinical data, data on radiological procedures and discharge diagnosis were collected. Sensitivity and specificity for detecting acute diseases were assessed using the discharge diagnosis from the ED as reference standard. Of the 578 patients (female 52.8%, mean age 51.3 years) admitted to the ED for AAP, 433 (74.9%) underwent abdominal imaging. The most frequent techniques used were abdominal plain radiography and ultrasonography (US), performed in 38.4% and 37.9% of patients, respectively, followed by computed tomography (CT) in 28% of patients. Plain radiography yielded a sensitivity of 28% and specificity of 91.1%; the sensitivity increased to 79.4% in patients with small bowel obstruction. Ultrasonography’s sensitivity and specificity were 61.8% and 98.4%, respectively; the sensitivity of US reached 85.2% and 90% in patients with acute cholecystitis/biliary colic and urolithiasis, respectively. The sensitivity and specificity of CT were 87.8% and 92.9%, respectively. Plain radiography is still overused in the diagnostic work-up of AAP in ED in Italy, despite its unsatisfactory sensitivity. Ultrasonography and CT has a higher sensitivity and should be used as first-level imaging in most patients.


Non-traumatic acute abdominal pain Emergency department Imaging Ultrasound 



This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Compliance with ethical standards

Conflict of interest

The authors of this manuscript declare relationships with the following companies: RMZ has served as a speaker, a consultant and an advisory board member for Allergan, and as a speaker for Malesci and Takeda. FB has served as a speaker, a consultant and an advisory board member for Allergan and as a speaker for Malesci.

Statement of human and animal rights

All procedures performed in studies involving human participants were in accordance with the ethical standards of the Ethical Committee of the S.Orsola-Malpighi hospital of Bologna (date of approval: 16th May 2017) and with the 1975 Declaration of Helsinki. This article does not contain any studies with animals performed by any of the authors.

Informed consent

Being a retrospective study, informed consent was not required by the Ethical Committee and was not obtained from patients.


  1. 1.
    Gans SL, Pols MA, Stoker J et al (2015) Guideline for the diagnostic pathway in patients with acute abdominal pain. Dig Surg 32:23–31. CrossRefGoogle Scholar
  2. 2.
    van Randen A, Laméris W, Luitse JSK et al (2011) The role of plain radiographs in patients with acute abdominal pain at the ED. Am J Emerg Med 29:582–589.e2. CrossRefGoogle Scholar
  3. 3.
    Laméris W, van Randen A, van Es HW et al (2009) Imaging strategies for detection of urgent conditions in patients with acute abdominal pain: diagnostic accuracy study. BMJ 338:b2431. CrossRefGoogle Scholar
  4. 4.
    Hastings RS, Powers RD (2011) Abdominal pain in the ED: a 35 year retrospective. Am J Emerg Med 29:711–716. CrossRefGoogle Scholar
  5. 5.
    Rosen MP, Sands DZ, Longmaid HE et al (2000) Impact of abdominal CT on the management of patients presenting to the emergency department with acute abdominal pain. Am J Roentgenol 174:1391–1396. CrossRefGoogle Scholar
  6. 6.
    Smith JE, Hall EJ (2009) The use of plain abdominal X-rays in the emergency department. Emerg Med J 26:160–163. CrossRefGoogle Scholar
  7. 7.
    Dubuisson V, Voïglio EJ, Grenier N et al (2015) Imaging of non-traumatic abdominal emergencies in adults. J Visc Surg 152:S57–S64. CrossRefGoogle Scholar
  8. 8.
    van Randen A, Laméris W, van Es HW et al (2011) A comparison of the Accuracy of Ultrasound and Computed Tomography in common diagnoses causing acute abdominal pain. Eur Radiol 21:1535–1545. CrossRefGoogle Scholar
  9. 9.
    McNamara R, Dean AJ (2011) Approach to acute abdominal pain. Emerg Med Clin N Am 29:159–173. CrossRefGoogle Scholar
  10. 10.
    Gangadhar K, Kielar A, Dighe MK et al (2016) Multimodality approach for imaging of non-traumatic acute abdominal emergencies. Abdom Radiol 41:136–148. CrossRefGoogle Scholar
  11. 11.
    MacKersie AB, Lane MJ, Gerhardt RT et al (2005) Nontraumatic acute abdominal pain: unenhanced helical CT compared with three-view acute abdominal series. Radiology 237:114–122. CrossRefGoogle Scholar
  12. 12.
    Caporale N, Morselli-Labate AM, Nardi E et al (2016) Acute abdominal pain in the emergency department of a university hospital in Italy. United Eur Gastroenterol J 4:297–304. CrossRefGoogle Scholar
  13. 13.
    Hong MDR, Sexton MDR, Sweet MDB et al (2015) Comparison of START triage categories to emergency department triage levels to determine need for urgent care and to predict hospitalization. Am J Disaster Med 10:13–21. CrossRefGoogle Scholar
  14. 14.
    Mattson B, Dulaimy K (2017) The 4 Quadrants: acute pathology in the abdomen and current imaging guidelines. Semin Ultrasound CT MRI 38:414–423. CrossRefGoogle Scholar
  15. 15.
    Campbell JP, Gunn AA (1988) Plain abdominal radiographs and acute abdominal pain. Br J Surg 75:554–556CrossRefGoogle Scholar
  16. 16.
    Zeina A-R, Shapira-Rootman M, Mahamid A et al (2015) Role of plain abdominal radiographs in the evaluation of patients with non-traumatic abdominal pain. Isr Med Assoc J 17:678–681Google Scholar
  17. 17.
    Nagurney JT, Brown DFM, Chang Y et al (2003) Use of diagnostic testing in the emergency department for patients presenting with non-traumatic abdominal pain. J Emerg Med 25:363–371. CrossRefGoogle Scholar
  18. 18.
    Expert Panel on Gastrointestinal Imaging: CD, Scheirey CD, Fowler KJ et al (2018) ACR appropriateness criteria® acute nonlocalized abdominal pain. J Am Coll Radiol 15:S217–S231. CrossRefGoogle Scholar
  19. 19.
    Velissaris D, Karanikolas M, Pantzaris N et al (2017) Acute abdominal pain assessment in the emergency department: the experience of a Greek University Hospital. J Clin Med Res 9:987–993. CrossRefGoogle Scholar
  20. 20.
    Fagerström A, Paajanen P, Saarelainen H et al (2017) Non-specific abdominal pain remains as the most common reason for acute abdomen: 26-year retrospective audit in one emergency unit. Scand J Gastroenterol 52:1072–1077. CrossRefGoogle Scholar
  21. 21.
    Nural MS, Ceyhan M, Baydin A et al (2008) The role of ultrasonography in the diagnosis and management of non-traumatic acute abdominal pain. Intern Emerg Med 3:349–354. CrossRefGoogle Scholar
  22. 22.
    Cross R, Bhat R, Li Y et al (2018) Emergency department computed tomography use for non-traumatic abdominal pain: minimal variability. West J Emerg Med 19:782–796. CrossRefGoogle Scholar
  23. 23.
    Prasannan S, Zhueng TJ, Gul YA (2005) Diagnostic value of plain abdominal radiographs in patients with acute abdominal pain. Asian J Surg 28:246–251. CrossRefGoogle Scholar
  24. 24.
    Ahn SH, Mayo-Smith WW, Murphy BL et al (2002) Acute nontraumatic abdominal pain in adult patients: abdominal radiography compared with CT evaluation. Radiology 225:159–164. CrossRefGoogle Scholar
  25. 25.
    Thompson WM, Kilani RK, Smith BB et al (2007) Accuracy of abdominal radiography in acute small-bowel obstruction: does reviewer experience matter? Am J Roentgenol 188:W233–W238. CrossRefGoogle Scholar
  26. 26.
    Katz DS, Baker ME, Rosen MP et al (2013) ACR appropriateness criteria® 1 Suspected small-bowel obstruction.
  27. 27.
    Lindelius A, Törngren S, Sondén A et al (2008) Impact of surgeon-performed ultrasound on diagnosis of abdominal pain. Emerg Med J 25:486–491. CrossRefGoogle Scholar
  28. 28.
    Kiewiet JJ, Leeuwenburgh MM, Bipat S et al (2012) A systematic review and meta-analysis of diagnostic performance of imaging in acute cholecystitis. Radiology 264:708–720. CrossRefGoogle Scholar
  29. 29.
    Peterson CM, McNamara MM, Kamel IR et al (2019) ACR appropriateness criteria® right upper quadrant pain. J Am Coll Radiol 16:S235–S243. CrossRefGoogle Scholar
  30. 30.
    Riddell J, Case A, Wopat R et al (2014) Sensitivity of emergency bedside ultrasound to detect hydronephrosis in patients with computed tomography-proven stones. West J Emerg Med. Google Scholar
  31. 31.
    Watkins S, Bowra J, Sharma P et al (2007) Validation of emergency physician ultrasound in diagnosing hydronephrosis in ureteric colic. Emerg Med Australas 19:188–195. Google Scholar
  32. 32.
    Moak JH, Lyons MS, Lindsell CJ (2012) Bedside renal ultrasound in the evaluation of suspected ureterolithiasis. Am J Emerg Med 30:218–221. CrossRefGoogle Scholar
  33. 33.
    Smith-Bindman R, Aubin C, Bailitz J et al (2014) Ultrasonography versus Computed tomography for suspected nephrolithiasis. N Engl J Med 371:1100–1110. CrossRefGoogle Scholar
  34. 34.
    Kanno T, Kubota M, Sakamoto H et al (2014) Determining the Efficacy of ultrasonography for the detection of ureteral stone. Urology 84:533–537. CrossRefGoogle Scholar
  35. 35.
    Lehtimäki T, Juvonen P, Valtonen H et al (2013) Impact of routine contrast-enhanced CT on costs and use of hospital resources in patients with acute abdomen. Results of a randomised clinical trial. Eur Radiol 23:2538–2545. CrossRefGoogle Scholar
  36. 36.
    Irvin TT (1989) Abdominal pain: a surgical audit of 1190 emergency admissions. Br J Surg 76:1121–1125CrossRefGoogle Scholar
  37. 37.
    Brewer BJ, Golden GT, Hitch DC et al (1976) Abdominal pain. An analysis of 1,000 consecutive cases in a University Hospital emergency room. Am J Surg 131:219–223CrossRefGoogle Scholar
  38. 38.
    Flasar MH, Cross R, Goldberg E (2006) Acute abdominal pain. Prim Care Clin Off Pract 33:659–684. CrossRefGoogle Scholar

Copyright information

© Società Italiana di Medicina Interna (SIMI) 2019

Authors and Affiliations

  • Giovanni Marasco
    • 1
  • Filippo Maria Verardi
    • 1
  • Leonardo Henry Eusebi
    • 1
  • Sonia Guarino
    • 1
  • Alessandra Romiti
    • 1
  • Amanda Vestito
    • 1
  • Franco Bazzoli
    • 1
  • Mario Cavazza
    • 2
  • Rocco Maurizio Zagari
    • 1
    Email author
  1. 1.Department of Medical and Surgical SciencesUniversity of Bologna, Policlinico S. Orsola-MalpighiBolognaItaly
  2. 2.Emergency DepartmentS. Orsola-Malpighi HospitalBolognaItaly

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