Elliot K. Fishman M.D.
Johns Hopkins Hospital

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" Our study shows that the use of CT increased the physicians level of diagnostic certainty, reduced the rate of hospital admissions by 24%, led to more timely surgery in 11% of patients, ruled out significant disorders in 26% of cases, and provided an alternative diagnosis for the patients symptoms in 26% of patients.” 
Impact of Abdominal CT on the Management of Patients Presenting to the Emergency Department with Acute Abdominal Pain
Rosen MP et al
AJR 2000;174:1391-1396

" CT performed in the emergency department increases the physicians level of certainty, reduces hospital admission rates by 23.8%, and leads to more timely surgical intervention."
Impact of Abdominal CT on the Management of Patients Presenting to the Emergency Department with Acute Abdominal Pain
Rosen MP et al
AJR 2000;174:1391-1396

“ The objective of our study was to prospectively determine how CT affects physicians diagnostic certainty and management decisions in the setting of patients with nontraumatic abdominal complaints presenting to the emergency department.”
Abdominopelvic CT Increases Diagnostic Certainty and Guides Management Decisions: A Prospective Investigation of 584 Patients in a Large Academic Center
Abujudeh HH, Thrall JH et al
AJR 2011; 196:238-243

“ The most common diagnoses were renal colic (119/584, 20.4%) and intestinal obstruction (80/584, 13.7%). CT altered the leading diagnosis in 49% of the patients (284/584) and increased mean physician diagnostic certainty from 70.5% to 92.2%. The management plan was changed by CT in 42% (244/583). Surgery was planned for 79 patients before CT, whereas hospital discharge was planned for 25.3% of these patients (20/79) after CT.”
Abdominopelvic CT Increases Diagnostic Certainty and Guides Management Decisions: A Prospective Investigation of 584 Patients in a Large Academic Center
Abujudeh HH, Thrall JH et al
AJR 2011; 196:238-243

“In conclusion, in this large perspective investigation, performance of an abdominal CT in the emergency department for patients with nontraumatic abdominal complaints increased the physicians diagnostic certainty and changed planned management decisions.”
Abdominopelvic CT Increases Diagnostic Certainty and Guides Management Decisions: A Prospective Investigation of 584 Patients in a Large Academic Center
Abujudeh HH, Thrall JH et al
AJR 2011; 196:238-243

“ Of 1571 adults referred to CT for clinically suspected acute appendicitis, a CT diagnosis of appendicitis was made in 23.6%, compared with 31.6% who had an alternative cause for symptoms identified at CT.”
Alternative Diagnoses to Suspected Appendicitis at CT
Pooler BD et al.
Radiology 2012; 265:733-742

“ In 406 patients in whom a specific alternative diagnosis was recorded by the treating clinician after CT was performed, the final clinical diagnosis was in agreement with the initial CT diagnosis 94.3% of the time.”
Alternative Diagnoses to Suspected Appendicitis at CT
Pooler BD et al.
Radiology 2012; 265:733-742

“ In 704 patients for whom CT results did not suggest a specific diagnosis, the treating clinician did not arrive at a specific diagnosis 82.7% of the time.”
Alternative Diagnoses to Suspected Appendicitis at CT
Pooler BD et al.
Radiology 2012; 265:733-742

“To determine how physicians’ diagnoses, diagnostic uncertainty, and management decisions are affected by the results of computed tomography (CT) in emergency department settings.”
CT in the Emergency Department: A Real-Time Study of Changes in Physician Decision Making 
Pandharipande PV et al.
Radiology. 2016 Dec;281(3):835-846.

“In this prospective, multicenter study, we found that, for common referral indications for CT in the emergency department (ie, abdominal pain, chest pain and/or dyspnea, and headache), physicians frequently changed their leading diagnosis (51%, 42%, and 24% of patients with abdominal pain, chest pain and/or dyspnea, and headache, respectively), diagnostic confidence (median increase of 25%, 20%, 13%), and admission decisions (25%, 19%, and 19% of patients with abdominal pain, chest pain and/or dyspnea, and headache, respectively) after CT results were available.”
CT in the Emergency Department: A Real-Time Study of Changes in Physician Decision Making 
Pandharipande PV et al.
Radiology. 2016 Dec;281(3):835-846.

“For common referral indications to CT in emergency department settings, physicians’ diagnoses and admission decisions change frequently after CT and diagnostic uncertainty is alleviated; these findings suggest that current ordering practices are clinically justified.”
CT in the Emergency Department: A Real-Time Study of Changes in Physician Decision Making 
Pandharipande PV et al.
Radiology. 2016 Dec;281(3):835-846.

Conclusions: Our study shows that oral contrast is noncontributory to radiological diagnosis in most patients presenting to the ED with acute nontraumatic abdominal pain. These patients can therefore undergo abdominal CT scanning without oral contrast, with no effect on radiological diagnostic performance. 
CT for Acute Nontraumatic Abdominal Pain—Is Oral Contrast Really Required? 
Kessner R et al.
Acad Radiol 2017; 24:840–845

“In summary, the Radiology department at NYU-Langone Medical Center has, through dialogue with our Emergency Medicine section, reaffirmed the benefits of oral contrast utilization for CT scanning of ED patients. We have found that stocking the oral contrast in the ED and allowing a 45-min period for oral contrast administration coordinated with obtaining clinical and laboratory information facilitate radiologic diagnosis with a high level of confidence and accuracy. As stated by JRD Tata, it is insistence on relentless attention to detail and insistence on highest standards of quality and performance that are the keys to productivity and efficiency, most certainly not through cutting corners.”
Oral contrast utilization for abdominal/pelvic CT scanning in today’s emergency room setting
Megibow A.J. 
Abdom Radiol (2017) 42: 781. doi:10.1007/s00261-016-0941-2

“As radiologists, we owe it to our patients to drive the appropriate use of positive oral contrast material. At the very least, we should not allow non-radiologists to restrict its use solely on the basis of throughput concerns; rather, we should allow considerations of image quality and diagnostic confidence to enter into the decision process. Based on differences in prior training and practice patterns, some radiologists will prefer to limit the use of positive oral contrast material more than others. However, for those who believe (as I do) that it can genuinely increase diagnostic confidence and can sometimes (rather unpredictably) make a major impact on diagnosis, it behooves us to keep fighting for its use.
Positive Oral Contrast Material for Abdominal CT: Current Clinical Indications and Areas of Controversy 
Perry J. Pickhardt 
AJR 2020; 215:1–10

Scan Protocol Selection

• Arterial phase imaging
• Venous phase imaging
• Role of non-contrast CT
• Role of delayed phase imaging

Upper GI bleeding occurs proximal to ligament of Trietz

• Hematemesis, coffee ground vomiting, or melena

Lower GI bleeding occurs distal to ligament of Trietz

• Melena, hematochezia, positive fecal occult blood test (hemoccult) or rectal bleeding

Upper GI bleeding

• Gastric/duodenal ulcers
• Varices
• Erosive gastritis
• Erosive duodenitis
• Mallory-Weiss tear
• Malignancy

Lower GI Bleeding

• Diverticulosis
• Diverticulitis
• Angiodysplasia/AVM
• Colitis
  • Ischemic
  • Inflammatory bowel disease
  • Infectious
• Malignancy
• Anorectal disease
• Small bowel disease

Any patient with suspected upper GI bleeding should undergo endoscopy first

• Facilitates diagnosis and treatment in vast majority of patients
• Sensitivity and specificity of 92-98% and 30-100% respectively
• May need NG to assess rate of bleeding and for gastric lavage
  • If no blood in aspirate and no hematemesis, upper GI source for bleeding is unlikely

CT is not appropriate in patients with suspected upper GI bleeding

“Endoscopy is highly useful for diagnosing the cause of UGIB, with 92%–98% sensitivity and 93%–100% specificity, and enables effective treatment of bleeding in the majority of cases.” 
CT for Evaluation of Acute Gastrointestinal Bleeding 
Michael L.Wells et al.
Radiographics. 2018 Jul-Aug;38(4):1089-1107

“The major complications of acute PUD are perforation and bleeding. Intraperitoneal free air is a major sign of perforation. Intravenous contrast media extravasation into the stomach is a sign of active bleeding. High-density gastric contents, with a suspicion of blood clots, can also indicate recent bleeding and are generally found close to the bleeding site. Although many reports have described CT findings of complicated PUD, the CT findings of uncomplicated PUD have not been well documented.”
Computed tomography findings of acute gastric peptic ulcer 
Kanako Oyanagi , Takeshi Higuchi , Norihiko Yoshimura
Clinical Imaging 71 (2021) 77–82

“On imaging, it can be difficult to distinguish benign peptic ulcer disease from malignant causes of gastric outlet obstruction and biopsy is required for confirmation. Peptic ulcers can perforate and should be recognized on imaging.”
Imaging of acute gastric emergencies: a case-based review 
Jetty S et al.
Clinical Imaging 72 (2021) 97–113