Evaluation Of The Common Findings Of Emergency Abdominal X-rays (a Case Study Of University Of Nigeria Teaching Hospital Ituku Ozalla).

 Plain abdominal radiographs are commonly requested for acute medical emergencies on patients with non-specific abdominal symptoms and signs. Whether plain abdominal radiography contributes to therapeutic decision making or disposition remains questionable particularly in the case of a negative result, the additional value of plain abdominal radiographs most especially in emergency situations is disputed. 

The study is a retrospective research design aimed at evaluating the common findings of emergency abdominal x-rays (A Case Study of University of Nigeria Teaching Hospital Ituku- Ozalla). The Subjects used for the study were those who underwent abdominal x-ray examination as an emergency investigation.

The result showed that more males (66.1%) than females (33.9%) were referred for emergency abdominal x-rays and patients with specific or non-specific abdominal pain (24.6%) were the major reason for clinical referral while bleeding PUD (1.5%) was the least common reason for referral of patients for emergency abdominal x-rays. However, patients greater than 60 years of age (30.77%) formed the age group of patients with the highest incidence of clinical referrals whereas patients between 1-10 years (7.69%) formed the age group with the least incidence of clinical referrals. The commonest radiological finding in patients undergoing emergency abdominal x-rays is normal bowel distribution pattern n=47 (74.60%). Thus an estimated diagnostic yield of emergency abdominal x-rays done for the study showed that n=49 (37.69%) was positive while n=51 (39.23%) was negative. There was also no significant association between the diagnostic outcome and gender or age (P>0.05).

Title Page…………………………………………………………….…………..i

Approval Page…………………………………………………….…..…….…..ii

Certification…………………………………………………………………….iii

Dedication………………………………………………………..…….……….iv

Acknowledgement……………………………………………..………………..v

Abstract…………………………………………………………………….…..vi

Table of Content……………………………………………………………….vii

Lists of Tables……………………………………………………………...….xii

Lists of Figures…………………………………………………………..…....xiii

CHAPTER ONE – Introduction

1.1 Background of the Study……………………………………………………1

1.2 Statement of Problem……………………………………………………….3

1.3 Purpose of Study………………………………………..………………….4

1.3.1 Objectives of study………………………………..……………………....4

1.4 Significance of the Study……………………………………………………4

1.5 Scope of Study………………………………….………………………….5

1.6 Operational Definition of Terms……………………………………………5

CHAPTER TWO - Literature Review

2.1 Review of Related Literature…………………………..………………………7

2.2 Theoretical Background……………………………………………………17

2.2.1 Anatomy of the Abdomen…….……………………………………….….17

2.2.1.1 Regions and planes of the abdomen………..………………….…….…18

2.2.1.3 Anatomy  summary  chart- four  quadrant abdomen……………………20

2.2.1.4 Abdominal radiography………………………………………………….23

2.2.1.5 Clinical  indication  requiring  abdominal x- ray…………………………24   

2.2.1.6 Clinical indication requiring abdominal x-ray in emergency conditions………………………………………………………………………….24

CHAPTER THREE - Research Methodology

3.1 Research Design…………………………….………………………….38

3.2 Scope of Study……………………………………………………….….38

3.3 Source of Data………………………………………………………….38

3.4 Sample Size…………………………….……………………………….38

3.5 Inclusion Criteria……………………………….……………………….39

3.6 Exclusion Criteria……………………………………………………….39

3.7 Method  and  procedure  for  data collection………………………….39 

CHAPTER FOUR - Data Analysis and Presentation

4.1 Data Analysis……………………….…………………………….…….40

4.2 Data Presentation…………………………………………………….…41

CHAPTER FIVE - Discussion and Implication of the Results, Summary of findings, Conclusion, and Recommendations

5.1Discussion and Implication of the Results…………...………………….…45

5.2 Summary of findings………………………………………………………48

5.3 Recommendations………………….…..………………….………………48

5.4 Areas of Further Research……………..…………………..………………49

5.5 Limitations…………………………………………………………………49

5.6 Conclusion…………………………………………………………………48

APPENDIX – Data of patients referred for emergency abdominal x-ray at the University of Nigeria Teaching Hospital Ituku- Ozalla from January 2011 to May 2013.

A medical emergency is an injury or illness that is acute and poses an immediate risk to a person’s life or long term health. These emergencies may require assistance from another person who should ideally be suitably qualified to do so, although some of these emergencies can be dealt with by the victim themselves. The response to an emergency medical situation will depend strongly on the situation, the patient involved and availability of resources to help them. It will also vary depending on whether the emergency occurs whilst in hospital under medical care or outside of medical care. However, plain abdominal radiographs are commonly requested for acute medical emergencies on patients with non specific abdominal symptoms and signs. Plain films are likely to remain the best and most useful methods of initial investigation for imaging gas shadows for many years to come and computed tomography scanning, isotope studies and nuclear magnetic resonance are unlikely to play any major role in the initial investigation of the acute abdomen1. During the decades that followed the discovery of x-rays, x-rays were mainly used for detecting fractures and foreign bodies and gradually for the evaluation of various other diseases such as acute abdominal pain. Approximately 4-10% of emergency department visits are due to acute abdominal pain making it one of the most encountered complaints2. The wide variety in clinical presentation of symptoms and the broad spectrum of associated diseases complicates isolation of the cause of abdominal pain which may vary from life threatening diseases requiring emergency surgery to mild self-limiting causes. An early and accurate diagnosis is essential in decision making and insufficient work up results in unnecessary interventions or delayed treatment. The use of plain abdomen radiographs (PAR) as part of the routine investigative profile to diagnose acute abdominal pain is still widely advocated at various levels of medical practice and has become ingrained in our system of management3, however earlier retrospective and prospective studies have concluded that 77-78% of PAR requested were normal increasing to 84% if unsuspected and unrelated findings were taken into account (4,5). Further studies have suggested that there is need to determine specific indications for requesting PAR in the emergency department which can effectively help to reduce numbers by at least 50%(6,7).

Plain abdominal radiography was the only diagnostic imaging modality available in 1972 and was ordered in 43% of all patients. Progressively, ultrasound and computed tomography (CT) had come into use but were barely ordered, that is in only 6.8% of all patients8. In 2007, the use of ultrasound and CT was widespread and the use of plain abdominal radiography decreased somewhat, however in the same time period, the average time patients spent at the emergency department had risen from 2.9 hours in 1992 to 4.26 hours in 2007 thus patients who had  undergone a  CT scan spent more time than those who were examined via conventional means(8,-10), hence diagnostic accuracy has significantly improved over the years with progressive advancement in technology and improved health management standards. Furthermore amidst these improvements in health care delivery services especially in emergency situations, diagnosing the underlying cause of acute abdominal conditions remains a challenge over the years. The ideal diagnostic imaging modality for evaluation of acute abdominal condition especially at emergency department should be one that can provide a balance between the highest diagnostic value and most accurate management changes on one hand and lowest radiation exposure, discomfort and duration of stay at the emergency department on the other hand while ultimately resulting in the lowest cost to the health care system. Several studies have demonstrated that a diagnosis based solely on a patient’s medical history, physical examinations and laboratory test is not reliable enough despite the fact that these aspects are essential parts of the work up of a patient presenting with acute abdominal pain, further diagnostic work up such as imaging is therefore mandatory in patients suspected of an urgent medical condition hence, this work up traditionally starts with abdominal radiography against all odds as the first diagnostic modality10, in addition , the UK and US guidelines advise consideration of abdominal radiography in case of hospital admission emergency or surgery in patients presenting with acute abdominal pain as well as three basic radiographic projections for the investigation which includes supine abdominal view combined with an erect chest film and an upright abdominal view. In the same vein, the royal college of radiologists has mapped out guidelines for the indications or symptoms requiring abdominal x-rays whether as a routine procedure or emergency case.

Whether plain abdominal radiography contributes to therapeutic decision making or disposition remains questionable particularly in the case of a negative result, the additional value of plain abdominal radiographs most especially in emergency situations is disputed However it is amidst all the backdrops and challenges associated in  emergency abdominal radiography as regards the radiation dose reception, diagnostic value and accuracy that the researcher is motivated to carry out this research to ascertain the pattern of common findings in abdominal x-ray emergency cases and further correlate these findings with the final diagnostic and prognostic outcome as well as its utilization.