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Detection of pneumoperitioneum on erect chest radiograph
  1. John Butler,
  2. Bruce Martin
  1. Department of Emergency Medicine, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK
  1. kevin.mackway-jones{at}man.ac.uk

Abstract

A short cut review was carried out to establish whether a normal erect chest radiograph excludes the diagnosis of perforated abdominal viscus. Altogether 37 papers were found using the reported search, of which two presented the best evidence to answer the clinical question.. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are shown in table 1. A clinical bottom line is stated.

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Report by John Butler , Specialist Registrar
 Checked by Bruce Martin, Specialist Registrar

Clinical scenario

A 37 year old female patient attends the emergency department with a four hour history of epigastric pain. The patient has been taking non-steroidal anti-inflammatory tablets for backache for the past few months. On examination she has mild tenderness in the epigastric region but no peritonism. You wonder whether an erect chest radiograph is sensitive enough to exclude a perforation of an abdominal viscus.

Three part question

In [patients with a possible perforated abdominal viscus] does [a normal erect chest radiograph] exclude [pneumoperitoneum]?

Search strategy

Medline 1966–11/01 using the OVID interface. ({exp pneumoperitoneum OR exp intestinal perforation OR exp abdominal pain OR exp abdomen acute} AND {exp radiography, thoracic}) LIMIT to human AND English.

Search outcome

Altogether 37 papers found of which two papers were relevant to the original question.

Comment(s)

The available evidence on the sensitivity of upright abdominal chest radiographs at detecting pneumoperitoneum is poor. No studies looked at patients attending the emergency department with abdominal pain. However, the available evidence suggests that an erect posteroanterior chest radiograph is not sufficiently sensitive to be used as a sNout for pneumoperitoneum in such patients. Sensitivity might be improved by performing either an erect lateral chest radiograph or computed tomography.

CLINICAL BOTTOM LINE

An erect posteroanterior chest radiograph is not sufficiently sensitive to rule out pneumoperitoneum in patients attending emergency departments with abdominal pain.

Table 1

Report by John Butler , Specialist Registrar
 Checked by Bruce Martin, Specialist Registrar

References

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