From the Guidelines
For a 71-year-old female with left groin pain for 4 days, I strongly recommend ordering a CT scan of the abdomen and pelvis with IV contrast within 24 hours, as this will provide the most comprehensive assessment of the disease process and aid in stratifying patients for appropriate therapy 1. The urgency depends on several factors that should be assessed during your clinical evaluation, including red flags such as fever, severe unremitting pain, signs of bowel obstruction, pulsatile mass, or neurological deficits, which would warrant immediate imaging. In the absence of these concerning features, a non-urgent CT of the abdomen and pelvis with contrast within 1 day is appropriate. This timeframe balances the need to diagnose potentially serious conditions while avoiding unnecessary emergency resources. The differential diagnosis for groin pain in an elderly female includes hernia, hip pathology, lymphadenopathy, vascular issues like aneurysm, gynecological conditions, and urinary tract problems. A CT scan can effectively evaluate these possibilities, particularly to rule out serious conditions like incarcerated hernia, abscess, or vascular complications. Before ordering, complete a thorough physical examination and consider basic laboratory tests including CBC, CRP, and urinalysis to help guide your imaging approach. It is also important to note that the use of CT-scan with IV-contrast in elderly patients with suspected diverticulitis is recommended to confirm the diagnosis and to distinguish complicated from non-complicated diverticulitis, and to promptly plan the correct treatment 1. Additionally, the risk of contrast-induced acute kidney injury (CI-AKI) should not discourage the use of CT scan with IV-contrast in elderly patients, as recent studies have shown that the risk of CI-AKI is not significantly higher in patients with chronic kidney disease 1. Alternative diagnostic approaches, such as US, MRI, or CT-scan without IV-contrast, may be considered in patients who cannot undergo CT-scan with IV-contrast, but the evidence is insufficient to recommend them as the first-choice examination 1. The importance of CT imaging in elderly patients with suspected acute left colonic diverticulitis is highlighted by the fact that CT results influenced treatment plans in 65% of patients, with significant changes in diagnosis and management 1. Therefore, a CT scan of the abdomen and pelvis with IV contrast is the recommended imaging modality for a 71-year-old female with left groin pain for 4 days, as it provides the most accurate diagnosis and guides appropriate treatment. Key points to consider when ordering a CT scan include:
- Evaluating for red flags that warrant immediate imaging
- Completing a thorough physical examination and basic laboratory tests
- Considering alternative diagnostic approaches in patients who cannot undergo CT-scan with IV-contrast
- Weighing the benefits and risks of CT scan with IV-contrast in elderly patients with suspected diverticulitis.
From the Research
Urgency of CT Scan for 71 y/o Female with L Groin Pain
- The patient's symptoms of left groin pain for 4 days may indicate a potential deep venous thrombosis (DVT) [ 2 ]
- A study published in Emergency Radiology in 2017 found that timely detection of pelvic DVTs on CT scans can have serious implications for patient management, morbidity, and mortality [ 2 ]
- The study highlighted the importance of including the pelvic veins in the search pattern of radiologists reviewing CT scans of the abdomen and pelvis [ 2 ]
- Given the patient's age and symptoms, an urgent CT scan may be warranted to rule out a potential DVT, as the 90-day mortality rate for patients diagnosed with pelvic DVTs on CT scans was found to be 21% [ 2 ]
- The study suggests that detection of unsuspected pelvic DVTs on CT scans can be a potentially life-saving diagnosis, emphasizing the need for prompt imaging and diagnosis [ 2 ]