CT Abd/Pelv and contrast

[Jeff698]

When do you order contrast? PO? Rectal? IV?

What type of push back do you get from radiology if not using every type of contrast known to man?

Our radiologists basically want PO contrast for anything below the diaphragm that doesn't happen to be a kidney stone protocol.

Led by one of my partners, I've recently started using IV contrast only for just about everything other than appendicitis in adults, in which case I'll give the radiologists their rectal contrast. I'm having a hard time overlooking the large amounts of evidence that PO contrast isn't needed for most things and the HUGE amount of time it takes for my EMERGENT studies.

What are y'all doing for:

Appys (adults and children)
Divertics
Obstructions
Undifferentiated pain that requires advanced imaging
Abscesses

Take care,
Jeff

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[DrMom]

I can't think of the last time I've ordered oral or rectal contrast.

 

[deleted65604]

In residency, every scan got PO contrast and turned every single CT scan into a minimum 4 hour ordeal, causing massive log-jam in the ER.

I worked at a different ER where all "rule out appies" got rectal and IV contrast.

At my current community job, the radiologists just ask for IV contrast for everything except kidney stones.

 

[docB]

My guys still want po. I have long thought this was because none of them trained on the 64s and have never been taught how to look at the non-con hi res scans that you're supposed to be able to read without po contrast.

 

[Apollyon]

I can't think of the last time I've ordered oral or rectal contrast.

Then you're living in the 21st century, and don't be surprised if you go elsewhere and the radiologists don't care - I mean, don't give a flying **** or rat's ass that you say that they should be able to read this study with or that study without, because, as mentioned above, many radiologists were trained a different way.

And what do you do for obstruction studies? I know of no surgeons or radiologists that can definitively dx a transition point without the contrast.

 

[southerndoc]

We can order them however we want, but generally we always use PO and IV contrast for abdominal CT's. I'm not sure what type of PO contrast we're using, but we only wait 1 hour from drinking contrast before we do the CT. By that time the patient's labs are back and they've received their liter of fluids (I always give a liter when doing a CT with IV contrast unless they have CHF).

 

[GeneralVeers]

Our radiologists still want 2-hour Oral prep on ALL abdominal pain, the exception is for Appy which is "drink and go".

So for B.S. abdominal pain, diverticulitis, obstruction, or mass they want the po contrast.

I've gone to making my indication for the scan "rule out appy" on every abdominal pain, regardless of what kind of pain they have. That way I get the scans quicker, and get people out of the department.

The only abdominal pain for which I do the 2-hour prep is obstruction. Oral contrast is useful to help determine the location of obstruction, and if there's any concomitant perforation.

 

[kungfufishing]

Noncontrast for appy.

Noncontrast or IV for diverticulitis, occasionally PO is requested by rads.


IV contrast for undifferentiated concerning pain or anytime I think there is a point to seeing the vessels.

Usually IV or noncontrast for SBO - will do PO sometimes when I think there may be some issue with figuring out a true transition point.

 

[Jeff698]

We can order however we want but our rads guys want PO on most everything. I've recently been just ordering IV and seem to be getting fine reads, albeit with the expected hedge about lack of PO contrast. They're at least answering my question from an EM standpoint and allowing me to make decisions.

I've been feeling a bit guilty about forcing rads to read a study without the information they feel they need (despite oodles of their own literature saying they don't). Then I look at my waiting room and order IV only.

I've also been wondering about the utility of knowing the exact location of the transition zone for SBOs. I know the surgeons always want to know but what decisions are made solely on this information? Most are being managed, at least initially AFAIK, with conservative treatment.


Take care,
Jeff

 

[roja]

Almost all of those, IV. If the radiologists want bowel wall enhancement, they give them water right before the scan.

 

[Stitch]

What are y'all doing for:

Appys (adults and children)
Divertics
Obstructions
Undifferentiated pain that requires advanced imaging
Abscesses

Take care,
Jeff

IV
Don't see these, though if it came up I'd probably go IV
IV, but only if the surgeon wants it. They don't always.
It depends on the pain, but most of the time just IV
IV

Like Dr. Mom says, I've hardly ever ordered PO or rectal, though for intussusception our guys often do soluble contrast enemas (but not a CT).

 

[Apollyon]

I've been feeling a bit guilty about forcing rads to read a study without the information they feel they need (despite oodles of their own literature saying they don't). Then I look at my waiting room and order IV only.

As I said above, that's how people trained. Risks from oral contrast are very low (an undetected esophageal perf? Yeah, right.) - apart from clinical deterioration while drinking it (which, in itself is not much of an issue, because, if someone crumps, that trumps the CT), and that, in itself, can be ameliorated with an NG tube.

It is not just to tell another practitioner how to do their job because of new data - if some of these people have been practicing for more than 10 years, looking for appys and obstructions with PO contrast, you cannot expect the same level of correct diagnosis without PO. The oodles of data are from people in residency, with someone over-reading all of their studies. The medicine changes, and the newer people do it the newer way (which is correct for today only), but the people who are doing it the way that was correct back then are going to continue that way.

A big part of medicine is pattern recognition; you know it because you've seen it before (and I got that from roja's boss, when she was mine). What you're saying is to change that pattern.

And a final aside to all of you going for IV contrast only - if anything, I flip your (supposed) percentages for IV and PO contrast only. The amount of CTs I order where people have a Cr >1.7 or an allergy are substantial, and the authority that some of you state about which CTs you order is interesting, because YOU are not administering it or reading it. If I ask you to close a lac for me, I'm not going to tell you to use a subcuticular stitch or chromic deep and an interrupted 5.0 Prolene. Either your radiologists are amazingly good, amazingly passive, or are doing what they want, and giving you lip service.

 

[kungfufishing]

Using our own shop as an example, this is not always the case. I work in a busy community setting in which all of our radiologists have been on the job for at least ten years. I would not consider our dept. particularly progressive, but we have changed (together) with the times in this specific area. My point is that it certainly can and does happen out in the community, I know - "good for you!" - but worth mentioning.

 

[southerndoc]

People keep mentioning the data supporting lack of oral contrast is just as good and we fault the radiologists for not allowing us to order CT's without contrast.

They aren't the only ones who are slow to adopt new treatment modalities.

How many of us still perform archaic treatments that haven't been shown to be beneficial? Steroids in sepsis patients, beta blockers in MI patients going to the cath lab (when data was only for patients receiving thrombolytics), etc.

 

[Arcan57]

I order non-con for kidney stone, IV contrast for everything else, PO+IV when the surgeon's already agreed to admit and wants it (usually hunting for transition point). Occassionally I'll do IV and PO for appy on the rail-thin (not a high percentage of my population). We have a radiology residency, so that may make things more progressive than your typical community hospital.

 

[Apollyon]

People keep mentioning the data supporting lack of oral contrast is just as good and we fault the radiologists for not allowing us to order CT's without contrast.

They aren't the only ones who are slow to adopt new treatment modalities.

How many of us still perform archaic treatments that haven't been shown to be beneficial? Steroids in sepsis patients, beta blockers in MI patients going to the cath lab (when data was only for patients receiving thrombolytics), etc.

The number one cause of litigation for radiologists is missed mass on mammo, which turns out to be a neoplasm.

Now, what is our number cause of monetary loss for EM docs? Missed MI. However, what is the number one source of litigation? Missed fractures.

Now, if a radiologist wants contrast, that is his job, and that's what he gets. He's worried about missing something (at the job I just left, there was a radiologist who had that exact same thing happen - was reading a CT, got interrupted by a phone call, and missed something), and I do NOT fault him for wanting it the way he's always had it.

What would we do if someone all of a sudden told us to not primarily close lacs, or to use Dermabond only? We wouldn't.

And I want to hear from someone who is all about IV contrast, who never orders PO - what do you do in cases with bad creatinine, or an allergy? I'd rather have PO only or non-con studies all day.

 

[zinjanthropus]

Steroids in sepsis patients

Not to divert too much...but

Is that not common at other places? Our CC peeps want steroids for severe sepsis...along with vasopression for hormone replacement in the ICU setting. We had a joint conference with them once and they did present what looked like new/credible data from the CC lit but, obviously, I can't keep up and didn't have a chance to read that lit myself.

 

[Jeff698]

Not to divert too much...but

Is that not common at other places? Our CC peeps want steroids for severe sepsis...along with vasopression for hormone replacement in the ICU setting. We had a joint conference with them once and they did present what looked like new/credible data from the CC lit but, obviously, I can't keep up and didn't have a chance to read that lit myself.

That's SO last year. 🙂

Last I've heard, and I'm sure I'll be corrected by our critical care colleagues quickly, is that steroids are of benefit only in those with adrenal insufficiency and not all sepsis patients. Much like tight glucose control, the initial promising studies haven't borne out when done on a larger, real world scale.

At last, that's my understanding.

Take care,
Jeff

 

[southerndoc]

Not to divert too much...but

Is that not common at other places? Our CC peeps want steroids for severe sepsis...along with vasopression for hormone replacement in the ICU setting. We had a joint conference with them once and they did present what looked like new/credible data from the CC lit but, obviously, I can't keep up and didn't have a chance to read that lit myself.

Latest research shows no benefit with steroids, even in patients on pressors unless there is documented adrenal insufficiency.

 

[kungfufishing]

That's SO last year. 🙂
/QUOTE]

Exactly. I do strive to practice EBM when possible (strive? that's me, a...striver) but the way it changes with the wind makes it feel like a fad.

 

[Seaglass]

IV only. PO for a transition point occasionally or for a very thin patient who needs the extra help.

 

[KidDr]

I'm in peds.
We give IV only except in very rare cases when rads requests IV + PO contrast.
And for what it's worth, we're doing fewer and fewer CTs for r/o appy---at the request of both rads and surgery, we try to start with U/S in most pts (during the day when the U/S tech is in house---overnight it's still usually a CT).

 

[TysonCook]

IV/PO here, except for stones....tech won't do the scan without rads approval...so I get lip from both the tech as well as the radiologist. If thats what they need so be it, but it hurts when you got 10+ in waiting

 

[Apollyon]

IV/PO here, except for stones....tech won't do the scan without rads approval...so I get lip from both the tech as well as the radiologist. If thats what they need so be it, but it hurts when you got 10+ in waiting

You can't get a non-con stone protocol study without rads approval, and they give you lip? Now THAT'S crazy!

 

[Hawkeye Kid]

I'm kind of in the same boat as Tyson, after training at a place where rads didn't usually insist on po contrast. It's not that I can't GET a renal stone study w/o approval, but they won't definitively call anything else. I've had discussions with the rads residents, I've asked them about their literature, etc. It all boils down to "if you want me to rule out/in diagnosis X, then you need po contrast."

Interestingly, one of the body CT guys where I trained felt (not sure about evidence for this) that the only thing you need po for is the duodenum. Right before I left, they started a protocol where CT calls for the patient, nurse gives patient contrast, pt goes to CT. Doesn't delay things at all and the radiologist gets what he needs.

 

[southerndoc]

How many here would feel comfortable ruling out an MI by EKG alone in a 50 year old hypertensive, diabetic smoker?

What we are asking radiology to do is rule out significant pathology without PO contrast is similar to asking us to rule out an MI without a troponin.

I would prefer them being comfortable ruling out significant pathology and not increasing their liability even if it means patients have to wait another hour before they get their CT. They don't tell me how to practice emergency medicine, and I never tell them how to practice radiology.

 

[Apollyon]

I would prefer them being comfortable ruling out significant pathology and not increasing their liability even if it means patients have to wait another hour before they get their CT. They don't tell me how to practice emergency medicine, and I never tell them how to practice radiology.

You and I are completely on the same wavelength here.

 

[Jeff698]

They don't tell me how to practice emergency medicine, and I never tell them how to practice radiology.

That's really the thought process I was using. When my partner switched to IV only or IV + rectal for the adult appy studies, I let her go alone for awhile. Now I'm seeing her rapid results without much grief and I'm rethinking things.

To use you're analogy, perhaps it's like them telling us to rule out an acute MI (note I didn't say anything about ultimate dispo) with EKG and two sets of negative markers 2 hours apart, something our literature supports. If I didn't like doing that, I might push back. Sort of the same thing here. Their literature says PO contrast doesn't help and might actually hurt in some cases. Their insistence on PO contrast impacts my ability to manage my department and, by extension, the patients in the waiting room I can't get to because I have a department full of people sipping their contrast.

I can't tell you I've come off the fence on this by any means. My own little inner struggle is what led me to start this thread. I really appreciate the different viewpoints on this.

Take care,
Jeff

 

[Seaglass]

How many here would feel comfortable ruling out an MI by EKG alone in a 50 year old hypertensive, diabetic smoker?

What we are asking radiology to do is rule out significant pathology without PO contrast is similar to asking us to rule out an MI without a troponin.

I would prefer them being comfortable ruling out significant pathology and not increasing their liability even if it means patients have to wait another hour before they get their CT. They don't tell me how to practice emergency medicine, and I never tell them how to practice radiology.

I would respectfully disagree. There is plenty of literature stating that the sensitivity for all types of pathology is about the same. The delay in ED through-put potentially puts other patient's at risk as they wait to be seen. It's kinda like saying that the really slow doc is OK to be really slow because that's what he needs to be to be comfortable. The world of medicine is always changing - it isn't appropriate to say "That's how we do it because that's how we've always done it and that's what makes me comfortable."

 

[southerndoc]

I would respectfully disagree. There is plenty of literature stating that the sensitivity for all types of pathology is about the same. The delay in ED through-put potentially puts other patient's at risk as they wait to be seen. It's kinda like saying that the really slow doc is OK to be really slow because that's what he needs to be to be comfortable. The world of medicine is always changing - it isn't appropriate to say "That's how we do it because that's how we've always done it and that's what makes me comfortable."

Actually I would prefer a doc be slow and not miss something than just fly through patients so fast that he's uncomfortable seeing them and misses things.

As I said before, my institution uses a 1-hour contrast. Our turnaround times for CT's with contrast is <120 mins in 80% of the time (that's our goal, which we are exceeding).

 

[deleted109597]

They don't tell me how to practice emergency medicine, and I never tell them how to practice radiology.

I'll trade you. Our radiologist are notorious for offering helpful clinical advice in their reads, regardless of how wrong it is. Think "advance catheter/ETT/Chest Tube X cm". If it were helpful I wouldn't mind it. But usually their numbers seem to come out of thin air, and sometimes, they'll put downright litigious stuff in there. I've seen "Chest tube appears to be malpositioned and needs to be replaced" in chest tubes that are neither.

 

[EM OR BUST]

All contrast studies are IV and PO where I am at, unless it is a peds pt with a rule out appy, then its Pelvis CT with only Iv contrast.