Is positive oral contrast material necessary for computed tomography in patients with suspected acute abdomen?

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"tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "161" "paginaFinal" => "166" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "I.M. González-Moreno, J.M. Plasencia-Martínez, A. Blanco-Barrio, A. Moreno-Pastor" "autores" => array:4 [ 0 => array:4 [ "nombre" => "I.M." "apellidos" => "González-Moreno" "email" => array:1 [ 0 => "im.gonzalezmoreno@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "J.M." "apellidos" => "Plasencia-Martínez" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "Blanco-Barrio" ] 3 => array:2 [ "nombre" => "A." "apellidos" => "Moreno-Pastor" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Radiodiagnóstico, Hospital General Universitario Morales Meseguer, Murcia, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Ante la sospecha de abdomen agudo, ¿es necesario el contraste oral positivo en la tomografía computarizada?" ] ] "textoCompleto" => "Clinical problemPositive oral contrast (POC) in abdominal and pelvic computed tomography (CT) is justified in patients with suspected anastomotic dehiscence or enteric fistulas.<a class="elsevierStyleCrossRefs" href="#bib0065">1,2</a> Its use in cases of non-specific acute abdominal pain is controversial and generally depends on the preferences of the institution or radiologist. However, this measure lengthens the diagnostic process, may delay surgery due to its implications for anaesthesia, promotes the development of aspiration pneumonia, increases the radiation dose and causes the patient malaise.<a class="elsevierStyleCrossRefs" href="#bib0070">2–5</a> In addition, the excellent imaging quality of current multi-detector CT equipment<a class="elsevierStyleCrossRef" href="#bib0065">1</a> and the increased rate in the population of obesity (which acts as a natural contrast element to separate the intestinal loops) improve visualisation of the abdominal viscera. These conditions are sufficient to call into question whether POC should continue to be administered to this type of patient.Clinical questionWe formulated our question according to the Patient, Intervention, Comparison, Outcomes (PICO) strategy (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Search strategy usedIn January 2018, we conducted an efficient search according to the Haynes pyramid. We searched UpToDate, National Guideline Clearinghouse, Cochrane Library, PubMed's systematic review search engine and PubMed's original study database, as well as EMBASE. To search PubMed, we used a combination of terms and Boolean operators, shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. In all other search engines, we simply used the keywords “abdominal”, “emergency”, “oral”, “contrast” and “CT”.We found 16 publications from which we selected the following by adhering to the question asked: three clinical practice guidelines corresponding to the appropriateness criteria of the American College of Radiology (ACR), three prospective original studies and six retrospective original articles.Critical reading of selected articlesAmerican College of Radiology appropriateness criteria guidelines.We found three clinical practice guidelines (CPGs) from the ACR which dealt with the management of non-traumatic acute abdominal disease. The most recent, revised in 2018, are the CPGs for patients with acute nonlocalised abdominal pain.<a class="elsevierStyleCrossRef" href="#bib0090">6</a> They consider CT to be an imaging technique of choice, normally with intravenous (IV) contrast and a single post-contrast phase. However, on the use of POC, they report that some institutions do without it due to the delay that it creates and the uncertainty of its diagnostic advantages. The CPGs in adult patients with suspected acute appendicitis<a class="elsevierStyleCrossRef" href="#bib0095">7</a> indicate that the evidence is usually against using POC, given that it does not improve diagnostic yield compared to CT with IV contrast without POC (100% sensitivity and >97% specificity), but it does increase examination duration and may be poorly tolerated and increase the radiation dose from CT. The recommendation is similar in the CPGs for clinically suspected acute diverticulitis.<a class="elsevierStyleCrossRef" href="#bib0100">8</a>Primary sourcesWe applied the QUADAS-2 (quality assessment of diagnostic accuracy studies) checklist to the references selected to evaluate their quality. Their assessment and other characteristics of the critical reading of the articles are detailed in <a class="elsevierStyleCrossRefs" href="#tbl0010">Tables 2 and 3</a>. Important aspects thereof are discussed below. They are divided by study population, since a large percentage are focused on patients with acute appendicitis.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Articles with a study population consisting of patients with suspected appendicitis:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">•A study by Anderson<a class="elsevierStyleCrossRef" href="#bib0105">9</a> evaluated how body mass index (BMI) and intra-abdominal fat affected the reliability of the reading of three radiologists in the diagnosis of acute appendicitis using a 64-slice CT scan and two diagnostic protocols: CT with IV contrast alone versus CT with POC and IV. Rates of correct diagnosis did not differ significantly between the two CT protocols and were not associated with either BMI or amount of intra-abdominal fat. As a limitation, the researchers did not independently study the effects of physique on the reliability of positive and negative diagnoses.</li><li class="elsevierStyleListItem" id="lsti0010">•Kepner et al.<a class="elsevierStyleCrossRef" href="#bib0080">4</a> compared CT with IV contrast to CT with POC and IV contrast in a sample of adult patients. The diagnostic precision was similar in the two groups. The researchers even affirmed that specificity and positive predictive value were lower for studies with POC. However, in this group there was a tendency to find more alternative diagnoses, especially gynaecological diagnoses. As a limitation, the sample size was insufficient a priori.</li><li class="elsevierStyleListItem" id="lsti0015">•In the sample of paediatric patients in a study by Farrel et al.,<a class="elsevierStyleCrossRef" href="#bib0110">10</a> POC did not reach the caecum in 48% of cases and accounted for a delay of more than 90min. There were no significant differences in terms of diagnostic precision between the groups with CT with IV contrast and POC and the group with CT with IV contrast.</li><li class="elsevierStyleListItem" id="lsti0020">•In a sample of 730 patients with a BMI of less than 25, Ramalingam et al.<a class="elsevierStyleCrossRef" href="#bib0115">11</a> achieved rates of diagnostic precision similar to those in protocols with CT with IV contrast only and CT with IV contrast and POC.</li><li class="elsevierStyleListItem" id="lsti0025">•A study by Wadhwani et al.<a class="elsevierStyleCrossRef" href="#bib0120">12</a> is the only study in favour of POC: the addition of positive POC to CT with IV contrast improved the reliability of the reading of the radiologists. The study specified that if the POC reached the caecum, it usually better identified the appendix; however, the study also specified that the extent of enteral opacification did not differ significantly between protocols with a wait time of 1 or 3h following ingestion of POC.</li></ul>Articles with a study population consisting of patients with acute abdominal pain:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0030">•Kessner et al.<a class="elsevierStyleCrossRef" href="#bib0065">1</a> compared the diagnostic yield of abdominal CT with IV contrast with and without POC in patients with non-traumatic acute abdominal pain. In 96.6% of patients who did not receive POC, its absence was considered irrelevant for diagnosis, with no differences found between the two groups in terms of diagnostic capacity. One of the main limitations of the study was the design itself (nested case–control study in a cohort).</li><li class="elsevierStyleListItem" id="lsti0035">•Uyeda et al.<a class="elsevierStyleCrossRef" href="#bib0075">3</a> and Alabousi<a class="elsevierStyleCrossRef" href="#bib0085">5</a>et al. only eliminated POC from the CT protocol in patients with a BMI greater than 25. In that specific scenario, they agreed that the absence of contrast did not compromise the diagnostic efficacy of CT.</li><li class="elsevierStyleListItem" id="lsti0040">•Jensen et al.<a class="elsevierStyleCrossRef" href="#bib0070">2</a> conducted a retrospective study of a sample of oncology patients with abdominal pain assessed by means of CT with IV contrast. The researchers divided up the patients based on whether or not they used POC. They found no differences in terms of the reliability of the reading or in terms of diagnostic precision.</li></ul>Applicability and conclusionsAccording to the available evidence, the use of positive oral contrast in abdominal and pelvic CT is not recommended in cases of non-specific acute abdominal pain or suspected appendicitis. However, there is a certain amount of debate with respect to patients with a BMI <25; therefore, more studies that enrol this type of patient are needed.Authorship<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0045">1.Individual responsible for the integrity of the study: IMGM.</li><li class="elsevierStyleListItem" id="lsti0050">2.Study conception: IMGM.</li><li class="elsevierStyleListItem" id="lsti0055">3.Study design: IMGM.</li><li class="elsevierStyleListItem" id="lsti0060">4.Data collection: IMGM.</li><li class="elsevierStyleListItem" id="lsti0065">5.Data analysis and interpretation: IMGM and JMPM.</li><li class="elsevierStyleListItem" id="lsti0070">6.Statistical processing: N/A</li><li class="elsevierStyleListItem" id="lsti0075">7.Literature search: IMGM and JMPM.</li><li class="elsevierStyleListItem" id="lsti0080">8.Drafting of the paper: IMGM.</li><li class="elsevierStyleListItem" id="lsti0085">9.Critical review of the manuscript with intellectually significant contributions: IMGM, JMPM, ABB and AMP.</li><li class="elsevierStyleListItem" id="lsti0090">10.Approval of final version: IMGM, JMPM, ABB and AMP.</li></ul>Conflicts of interestThe authors declare that they have no conflicts of interest." 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The great image quality provided by multidetector computed tomography scanners, the increase in intraabdominal fat (as a natural element that provides contrast for separating the bowel loops) related with the increased prevalence of obesity in the population, and the potential drawbacks associated with the use of high-density oral contrast agents argue against the generalised us of these agents. This article aims to evaluate the effects of omitting the use of this type of oral contrast material for computed tomography examinations required in the emergency department for suspicion of acute abdominal pathology through an efficient literature search among recent publications." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "En la actualidad, el número de tomografías computarizadas realizadas en el ámbito de las urgencias ha aumentado sustancialmente, y con ello la controversia sobre si realmente es útil el contraste oral positivo en todos los pacientes. La gran calidad de imagen que ofrecen los equipos de tomografía computarizada multidetector, el incremento de la grasa intraabdominal (como elemento natural de contraste para separar las asas intestinales) relacionado con el aumento de la tasa de obesidad poblacional, así como los potenciales inconvenientes que asocia el contraste oral de alta densidad son argumentos que cuestionan su uso generalizado. El propósito de este artículo es valorar el efecto de omitir el uso de este contraste oral para las TC requeridas en la urgencia por sospecha de patología abdominal aguda a partir de una búsqueda eficiente en las publicaciones recientes." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: González-Moreno IM, Plasencia-Martínez JM, Blanco-Barrio A, Moreno-Pastor A. Ante la sospecha de abdomen agudo, ¿es necesario el contraste oral positivo en la tomografía computarizada? Radiología. 2019;61:161–166." ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">PICO question \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patient \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Intervention \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Comparison \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Outcomes \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">In patients with suspected acute abdominal disease who undergo abdominal and pelvic CT, would the diagnostic yield be maintained in a protocol without POC compared to a protocol with POC? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Patient with suspected acute abdominal disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Abdominal and pelvic CT with intravenous contrast (without positive oral contrast) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Abdominal and pelvic CT with oral and intravenous contrast \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Diagnostic yield (sensitivity, specificity) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Search strategy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">[“emergency” (MeSH) OR “abdominal pain” (MeSH)] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">AND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " colspan="2" align="center" valign="top">(“oral contrast” [Title])</td><td class="td" title="table-entry " align="left" valign="top">AND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">[“sensitivity” (MeSH) OR “diagnostic imaging” (MeSH) OR “diagnosis”] \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1986227.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "All the terms listed in the “Search Strategy” row correspond to MeSH descriptors except for “oral contrast”, which we entered as an unstructured term and to which we applied the label [Title] to restrict the search." ] ] ] "descripcion" => array:1 [ "en" => "Structured PICO question and search strategy in PubMed and EMBASE search engines.<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a>" ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Year \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">LE/DR \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">N \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean age (years) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Study population \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Blinded design \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Results \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Assessment of risk of bias according to QUADAS-2 \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Kessner et al.<a class="elsevierStyleCrossRef" href="#bib0065">1</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2012 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">II/B \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">227 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Non-traumatic acute abdominal pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">POC: SENS: 100% (95% CI: 87.4–100) SPEC: 94.9% (95% CI: 86.9–98.4) Without POC: SENS 100% (95% CI: 89.3–100) SPEC: 98.6% (95% CI: 91.6–99.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Low risk \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Anderson et al.<a class="elsevierStyleCrossRef" href="#bib0105">9</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2010 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">II/B \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">303 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">43 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Suspected acute appendicitis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Reader 1: POC: OR: 1.02 (95% CI: 0.94–1.11), p=0.59 Without POC: OR: 1.02 (95% CI: 0.92–1.13), p=0.69 Reader 2: POC: OR: 0.99 (95% CI: 0.91–1.07), p=0.75 Without POC: OR: 1.05 (95% CI: 0.94–1.16), p=0.38 Reader 3: POC: OR: 0.99 (95% CI: 0.92–1.06), p=0.73 Without POC: OR: 1.06 (95% CI: 0.96–1.17), p=0.23<a class="elsevierStyleCrossRef" href="#tblfn0010">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Risk of bias \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Kepner et al.<a class="elsevierStyleCrossRef" href="#bib0080">4</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2017 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">II/B \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">348 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">48 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Suspected acute appendicitis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">There were no significant differences between the final radiological diagnosis and the final clinical diagnosis between the study group without POC (p=0.261) and the study group with POC (p=0.075). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Risk of bias \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1986225.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "a" "nota" => "In a study by Anderson et al.<a class="elsevierStyleCrossRef" href="#bib0105">9</a> the results are expressed as a measure of association and the estimated odds ratio represents the change in the probability of identifying the caecal appendix when the body mass index increases by one unit. These results are shown for each reader with and without oral contrast. CI: confidence interval; DR: degree of recommendation; LE: level of evidence; N: sample size; OR: odds ratio; POC: positive oral contrast group; SENS: sensitivity; SPEC: specificity; Without POC: group with intravenous contrast alone." ] ] ] "descripcion" => array:1 [ "en" => "Summary of the main characteristics of the critical reading of the prospective articles and application of QUADAS-2 (quality assessment of diagnostic accuracy studies) criteria.<a class="elsevierStyleCrossRef" href="#tblfn0010">a</a>" ] ] 2 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Year \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">LE/DR \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">N \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean age (years) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Study population \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Blinded design \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Results \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Assessment of risk of bias according to QUADAS-2 \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Farrell et al.<a class="elsevierStyleCrossRef" href="#bib0110">10</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2018 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">III/C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">558 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Suspected acute appendicitis in paediatric patients \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Not reported \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">POC: SENS: 93.8% (95% CI: 84.8–98.3) SPEC: 98.5% (95% CI: 95.8–99.7) Without POC: SENS: 94.6% (95% CI: 84.9–98.9) SPEC: 98.3% (95% CI: 95.7–99.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Risk of bias \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Wadhwani et al.<a class="elsevierStyleCrossRef" href="#bib0120">12</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2016 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">III/C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">225 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">37–40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Suspected acute appendicitis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">POC: SENS: 100% (95% CI: 85.4–100) SPEC: 97.67% (95% CI: 86.2–99.8) Without POC: SENS: not calculated SPEC: 100% (95% CI: 93.4–100) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Risk of bias \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ramalingam et al.<a class="elsevierStyleCrossRef" href="#bib0115">11</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2016 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">III/C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">731 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">47–51 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Suspected acute appendicitis and BMI <25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">POC: SENS: 95.2–100% SPEC: 98.1–99.5% Without POC: SENS: 92.0–100% SPEC: 98.6–100% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Risk of bias \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">C. Jensen et al.<a class="elsevierStyleCrossRef" href="#bib0070">2</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2017 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">III/C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">267 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">56 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Acute abdominal pain in oncology patients \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">There were no significant differences between the group with POC and the group without POC in terms of the diagnostic reliability of the readers (OR: 7.20; 95% CI: 0.74–70.2, p=0.089) or the diagnosis (OR: 4.57; 95% CI: 0.41–51, p=0.22) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Uncertain applicability \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Uyeda et al.<a class="elsevierStyleCrossRef" href="#bib0075">3</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2015 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">III/C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1992 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">50.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Acute abdominal pain and BMI >25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CT Without POC: SENS: 100% SPEC: 99.5% PPV: 92% NPV: 100% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Risk of bias \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Alabousi et al.<a class="elsevierStyleCrossRef" href="#bib0085">5</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2015 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">III/C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">375 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">57 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Acute abdominal pain and BMI >25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Not reported \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Risk of bias \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1986226.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "a" "nota" => "In all studies patients were recruited consecutively. 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