- Abdominal pain is one of the most common patient presentations in general practice.
- A significant increase in referrals to diagnostic imaging was noted between 2002–05 and 2009–12 for patients presenting with abdominal pain – around 1 in every 3 patients presenting with abdominal pain was referred for imaging.1
- Diagnostic imaging is often not indicated or helpful for investigating chronic abdominal pain.
- Diagnostic imaging tests are not without risks – including exposure to ionising radiation and a risk of false positives and incidental findings.
Patient history and physical examination
A thorough patient and family history combined with a physical examination focusing on the common causes of abdominal pain can help to establish a provisional diagnosis, and identify any red flags.2 Results can then guide an appropriate diagnostic strategy, which may include imaging.2,3
Chronic and recurrent abdominal pain usually persists for more than 3 months, and can be continuous or intermittent.4 For patients with chronic or recurrent abdominal pain, baseline laboratory tests may also be required, such as urinalysis, full blood count (FBC), urea and electrolytes, liver function tests (LFT), erythrocyte sedimentation rate (ESR), amylase and lipase.4,5
Red flags for further investigation
- anorexia/weight loss
- pain that awakens your patient
- blood in stools or urine
- abnormal mass or organomegaly
Further investigations may be required if your patient has:4
- abnormal test results
- any red flag symptoms
- any specific clinical findings of concern.
Is imaging justified by medical need?
A careful assessment and justification of medical need should be made.6 Given the risks and costs associated with unnecessary imaging – it is best to limit imaging referrals for investigation of chronic abdominal pain to situations where it is likely to usefully inform a diagnosis or influence patient management.7
It is ideally the joint responsibility of the referring doctor and radiologist to determine if the benefits of imaging outweigh the risks. Therefore, if possible (or in complex cases) it can be beneficial to consult with a radiologist when ordering a medical imaging test.
Risks associated with medical imaging tests include:
- exposure to ionising radiation (for X-ray and computed tomography [CT])6
- false positives or false negatives7
- incidental findings8
- extra costs to your patient.
Guidelines for imaging
The WA Department of Health Diagnostic Imaging Pathways (DIP) are clinical guidelines developed in consultation with GPs, specialist clinicians and radiologists. These pathways guide appropriate imaging choices, and are organised by organ system and suspected diagnosis.
Use our Diagnostic imaging in clinical practice fact sheet to learn more about using the DIP guidelines to guide decisions about whether to refer your patient for diagnostic imaging.
- Britt H, Miller GC, Valenti L, Henderson J, Gordon J, Pollack AJ, Bayram C, Wong C. Evaluation of imaging ordering by general practitioners in Australia, 2002–03 to 2011–12. BEACH (Bettering the Evaluation and Care of Health). Sydney: Sydney University Press: 2014 (accessed 25 February 2015)
- Silen W. Harrison's principles of internal medicine. 18 ed. New York: The McGraw-Hill Companies, 2012.
- WA Department of Health. Diagnostic Imaging Pathways. Pathway diagram abdominal pain (chronic). Government of Western Australia. Department of Health, 2015 (accessed 2 March 2015)
- Greenberger N. Chronic and recurrent abdominal pain. Merck Manual Professional Version. Whitehouse Station, NJ: Merck Sharp & Dohme Corp, 2013 (accessed 16 April 2015)
- Assessment of chronic abdominal pain. BMJ Best Practice. 2015 (accessed 7 April 2015).
- WA Department of Health. Diagnostic Imaging Pathways. About imaging: general principles in requesting imaging investigations. Government of Western Australia. Department of Health, 2015 (accessed 2 March 2015)
- Grimes DS, KF. Refining clinical diagnosis with likelihood ratios. Lancet 2005;365:1500–05
- Berland LL, Silverman SG, Gore RM, et al. Managing incidental findings on abdominal CT: white paper of the ACR incidental findings committee. J Am Coll Radiol 2010;7:754–73