Use CT scans judiciously

I have a patient who has had abdominal pain for 3 weeks. The child is 3 and has lost 5 pounds since it began. She’s been in the hospital once already and has had 2 ultrasounds and at least 2 x-rays of her belly without much found.

She’s had labs to rule out gluten problems, leukemia, kidney stones, urinary tract infection, mono, and liver issues. She has been seen by a GI doctor as well who has had her on reflux medication and laxatives to be sure she isn’t constipated. She’s continued to have belly pain.

This kid is not a complainer at all. When she gets blood work she just holds out her arm and even as an infant barely cried with vaccines. She is a happy child and comes from a great family who is relaxed and healthy. Her pain had been intermittent but intense when it came and was not relenting. When she developed fever last week with worsening stomach pain and tenderness now to touch her belly I sent her back to the hospital and frankly felt strongly that she needed a CT of her belly.

The family went to Children’s Hospital of Michigan where I am affiliated but when children get admitted there they see the hospitalist, which means I can advise and discuss things with the doctors there but can’t order tests myself. When I talked to the ER docs first and then later the staff physicians she was seeing and urged a belly CT, everyone resisted. They drilled me and asked what I was looking for. I answered abscess, ruptured appendicitis, bowel inflammation, small cancerous tumor intermittently obstructing the bowel. I was rebuffed by the doctors there who kept saying that ultrasound would show all of that without radiation and she had another one that showed nothing more than a few swollen lymph nodes.

I was frustrated. As the week progressed the girl’s fever progressed with temperatures up to 105 frequently and belly pain persisting. She remained in the hospital with gastrointestinal specialists and eventually infectious disease specialists seeing her. I worried we were missing something in her belly and yet no one wanted to do the CT. Finally on the sixth day of fever, she developed a rash on her hands and feet with swelling too, which was the clue we needed to figure out that she had Kawasaki’s disease. She underwent treatment and her fever was gone immediately.

I learned a lot from this patient. One of the things I learned is that even though there were 2 or 3 points in the illness where I was gung ho to get a CT scan, she really didn’t need it. I was frustrated we weren’t finding an answer and worried that we were missing something even though the ultrasounds were thorough and done by superb pediatric radiologists.

Recent studies have shown that children who get radiation from CT scans are more likely to get cancers like leukemia or brain tumors than those who did not have a scan. Even a single scan can increase risk but at times a CT scan is the best or only test to figure out what’s wrong. In this case, CT was not needed since ultrasound was able to show everything but my impatience and frustration with the absence of a clear diagnosis made me want to order it. I’m glad that the team doctors at Children’s were measured and held off.

It’s tough sometimes to hold off ordering tests. Sometimes parents are anxious and want them. Other times I’m the impatient one. Remembering that CT scans carry risks and using them judiciously only when absolutely needed is a lesson we all need to learn again and again.