Detection of pneumoperitoneum on an erect chest X-ray
Date First Published:
October 27, 2000
Last Updated:
December 9, 2003
Report by:
John Butler, Consultant in Emergency Medicine (Manchester Royal Infirmary)
Search checked by:
Bruce Martin, Manchester Royal Infirmary
Three-Part Question:
In [patients with a possible perforated abdominal viscus] does [a normal erect chest X-ray] exclude [pneumoperitoneum]?
Clinical Scenario:
A 37 year old female patient attends the emergency department with a 4 hour history of epigastric pain. The patient has been taking NSAIDs for backache for the last few months. On examination they have mild tenderness in the epigastric region but no peritonism. You wonder whether an erect chest Xray is sensitive enough to exclude a perforation of an abdominal viscus in this patient.
Search Strategy:
Medline 1966-11/03 using the OVID interface via ATHENS. Including MEDLINE in progress and non-indexed citations.
Search Details:
({exp Pneumoperitoneum OR exp Intestinal perforation OR exp Abdominal pain OR exp Abdomen acute} AND {exp Radiography, thoracic}) LIMIT to human AND English
Outcome:
39 papers found of which 2 papers were relevant to the original question.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Diagnosis of pneumoperitoneum: abdominal CT vs. upright chest film. Stapakis JC, Thickman D. 1992, USA | 13 patients with known pneumoperitoneum after DPL |
Diagnostic study of upright PA chest Xray against CT scan of abdomen | Sensitivity of Chest Xray and CT scan for detection of pneumoperitoneum | CT scan demonstrated free gas in all cases | Iatrogenic pneumoperitoneum Small numbers of cases What size collection is clinically relevant? |
| Detection of pneumoperitoneum on chest radiographs: comparison of upright lateral and posteroanterior projections. Woodring JH, Heiser MJ. 1995, USA | 100 consecutive patients with pneumoperitoeum from a variety of causes |
Diagnostic study | Sensitivity of lateral upright CXR | 98% | Pneumoperitoneum form a variety of causes Only 7 patients presenting as emergencies with acute perforated abdominal viscus Gold standard for pneumoperitoneum variable |
| Difference between upright and lateral | 18% p<0.01 | ||||
| Sensitivity of upright PA chest X-ray | 80% | ||||
| Sensitivity of both XRays | 100% |
Author Commentary:
The available evidence on the sensitivity of upright abdominal chest x-rays 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 postero-anterior chest x-ray 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 x-ray or a CT scan.
Bottom Line:
An erect postero-anterior chest x-ray is not sufficiently sensitive to rule out pneumoperitoneum in patients attending emergency departments with abdominal pain.
Level of Evidence:
Level 3: Small numbers of small studies or great heterogeneity or very different population
References:
- Stapakis JC, Thickman D.. Diagnosis of pneumoperitoneum: abdominal CT vs. upright chest film.
- Woodring JH, Heiser MJ.. Detection of pneumoperitoneum on chest radiographs: comparison of upright lateral and posteroanterior projections.