CT和超音波两者对诊断女性之急性骨盆疼痛有效


  May 15, 2006 — 根据一篇发表于美国放射线医学会年会(ARRS)的回溯性研究结果,腹部和骨盆腔计算机断层(CT)和骨盆腔超音波(US)横切面影像,是诊断非怀孕妇女的急性骨盆疼痛的有效工具。
  
  为了评估CT和US在诊断急性骨盆疼痛以判断是否需要手术的效果,研究团队回顾在港景医学中心急诊部门157位曾发生骨盆疼痛的女性(平均年纪:32 ± 10岁)的相关记录。
  
  有71位先进行腹部和骨盆腔CT、有86位则是先进行骨盆腔US,得到卵巢囊肿、妇科肿块、盲肠炎或者正常等种种影像。
  
  将近三分之二的影像有阳性发现,CT和US有助于80%的病患得到最后的诊断;剩下的32位病患中,有20位随后被确认诊断或者推测罹患骨盆腔发炎或者泌尿道感染。
  
  港景医学中心放射科住院医师、主要作者Dawn Hastreiter向Medscape表示,虽然影像无法对20%的病患提供最终的诊断,但已经可以帮助医师排除其它的诊断。
  
  有33位(21%)病患在同次住院期间进行了另一种影像技术,其中8位是在US之后进行CT,有3位的CT影像改变了原本US的阴性诊断,其中一位是急性盲肠炎需立刻手术;其它25位是先进行CT,随后再进行US,有1位因而改变诊断,有5位被研究团队认为US的判读较佳。
  
  Hastreiter医师表示,CT和US两种都进行的病患人数有限,是因为当无法以一种确定诊断后才会进行另一种;在ARRS的其它报告中有类似的发现,我们认为先US再CT,比先CT再US更有助益。
  
  发表后的220天内有21位病患需要进行手术,CT和US对于手术的敏感度和预测值约为0.80,专一度和负向预测值则大于0.97。
  
  Hastreiter医师指出,此研究的高度正向意义,使医师可以对病患影像作出更佳处理,CT和US有助于帮助诊断。
  
  但是,由于这项研究的样本数少,对于哪里一种方法比较有效还不能确定,Hastreiter医师表示,我们愿意鼓励其它研究中心发表他们有关CT和US对急性骨盆腔疼痛的比较经验,来为此问题寻求一更好的答案。
  
  Hastreiter医师建议医师考量病患疑似有急性骨盆腔疼痛时的影像需求,因为单纯的泌尿道感染和无并发症的骨盆腔发炎显示的影象是正常的,对这种情况则需要相关检验数据以及医师的临床经验作判断。
  
  对于需要影像辅助诊断的病患,医师选用的方法会影响到臆断;Hastreiter医师表示,虽然US因不具放射线风险,所以较常被使用,CT已经渐渐被认为对疑似盲肠炎、疑似泌尿道结石、已知的恶性肿瘤和疑似术后并发症的病患是较佳的选择。
  
  Hastreiter医师补充,此外,急诊室医师、妇科医生、放射科医师对使用CT进行妇科诊断需要更有自信;有越来越多的证据指出,当CT显示有妇科疾病时,再使用US帮助诊断的附加价值不大。
  
  Hastreiter医师提出结论,最后,大多数的医师知道盲肠炎容易在骨盆腔超音波中被忽略,所以当超音波显示没有盲肠炎但却有疑虑时,应该即刻进行CT。
  
  作者们无任何财经关系。

CT and Ultrasound Both Effecti

By Yael Waknine
Medscape Medical News

May 15, 2006 — Abdominal and pelvic computed tomography (CT) and pelvic ultrasound (US) cross-sectional imaging are effective tools for detecting the cause of acute pelvic pain in nonpregnant women, according to the results of a retrospective study presented at the annual meeting of the American Roentgen Ray Society (ARRS) in Vancouver, British Columbia.

To assess the performance of CT and US in diagnosing acute pelvic pain and predicting the need for surgery, investigators reviewed the records of 157 women (mean age, 32 ± 10 years) who had presented with pelvic pain at the Harborview Medical Center emergency department and urgent care clinic in Seattle, Washington.

Abdominal and pelvic CT or pelvic US was performed first in 71 and 86 patients, respectively, and yielded a wide range of findings such as ovarian cysts, gynecologic masses, appendicitis, and normal studies.

Approximately two thirds of the imaging studies had positive findings, and CT and US were helpful for making the final diagnosis in 80% of patients. Twenty of the 32 remaining patients were subsequently diagnosed with confirmed or presumed pelvic inflammatory disease or urinary tract infection.

"Although imaging did not provide the final diagnosis in 20% of patients, it should be noted that the studies may have allowed the clinicians to exclude other diagnoses," lead author Dawn Hastreiter, MD, PhD, a radiology resident at Harborview Medical Center, told Medscape.

In 33 patients (21%), an opposite imaging study was performed during the same hospitalization. Of the 8 patients who had undergone US followed by CT, the CT changed the US-negative diagnosis in 3 cases, of which 1 case required surgery for emergent appendicitis. Of 25 patients who underwent CT first, subsequent US changed the diagnosis in 1 case and was considered by investigators to better reflect the diagnosis in 5 cases.

"A limited number of patients had both a CT and US if there was still a clinical question after the first imaging modality," Dr. Hastreiter said. "Similar to the findings of another paper presented at ARRS, we found that CT after US was more beneficial than US after CT."

Surgery was required in 21 patients at 0 to 220 days after presentation; the sensitivity and positive predictive value of CT and US for surgery were above 0.80, and the specificity and negative predictive value were greater than 0.97.

"The high positivity of the studies suggests that our clinicians are doing well in deciding which patients require imaging, and that CT and US are helpful in determining the diagnoses," Dr. Hastreiter pointed out.

Because of the small study sample size, it remains unclear whether either method is more effective than the other for achieving diagnoses, Dr. Hastreiter said. "We would encourage other institutions to publish their experience with CT vs US for acute pelvic pain to better answer this question."

Dr. Hastreiter advises clinicians to consider the need for imaging studies in patients presenting with acute pelvic pain. Because simple urinary tract infections and uncomplicated pelvic inflammatory disease often have normal imaging, laboratory tests and clinical history may be more effective for diagnosing these conditions.

In patients for whom imaging is indicated, the method chosen should reflect the suspected diagnosis. "Although US is often ordered because it poses no radiation risk to the patient, CT is generally believed better for patients with suspected appendicitis, suspected urinary stones, known malignancy, and suspected postsurgical complications," Dr. Hastreiter observed.

"In addition, emergency room physicians, gynecologists, and radiologists need to become more confident in the diagnosis of gynecologic conditions on CT, if a patient happens to get that study," Dr. Hastreiter added, noting that there is increasing evidence of diminished added value in the immediate term in performing US if CT demonstrates gynecologic findings.

"Finally, most physicians know that appendicitis can be missed on pelvic ultrasound, so if appendicitis is still a consideration after a negative US, CT should be performed," Dr. Hastreiter concluded.

The authors report no relevant financial relationships.

ARRS 2006 Annual Meeting: Abstract 13. Presented May 1, 2006.

Reviewed by Robert Chevrier

    
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