A practical reporting guide that combines contrast phase, the gastrointestinal tract, solid organs, and emergency complications within one review sequence.
REPORTING SYSTEMATICS / ABDOMEN
A practical reporting guide that combines contrast phase, the gastrointestinal tract, solid organs, and emergency complications within one review sequence.
Abdomen and pelvis CT is used for many different indications, including acute abdominal pain, trauma, malignancy staging and follow-up, infection, urinary symptoms, and postoperative complications. Noncontrast, arterial, portal venous, nephrographic, and delayed phases do not depict the same diseases with equal sensitivity. The technique section is therefore clinical information that defines the limits of interpretation.
Before reviewing the examination, confirm oral or intravenous contrast administration, phase timing, scan coverage, prior surgery, and any current stoma, drain, or catheter. Particularly in emergency studies, prioritize findings that answer the clinical question while still performing a fixed second survey of the entire abdomen and pelvis.
| Do not dismiss the bowel as “normal” in one line The gastrointestinal tract requires its own search pattern, particularly in the acute abdomen. From the stomach to the rectum, assess bowel caliber, wall, contents, transition point, mesentery, vessels, and surrounding fat together. If the appendix is not visualized, state this in conjunction with the clinical context and secondary findings. |
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Instead of simply stating “dilated small-bowel loops,” assess the degree of dilation, transition point, distal collapse, closed-loop features, wall enhancement, mesenteric edema, free fluid, and signs of perforation together. The likely level of obstruction and suspected complications are more useful for clinical management in the impression.
Similarly, in inflammatory processes such as pancreatitis, diverticulitis, or appendicitis, search for collections, free air, vascular complications, and effects on adjacent organs in addition to the primary-organ finding. Rather than merely naming the diagnosis, the report should communicate disease extent and complications.
In oncologic examinations, it is important to measure the same lesions in the same plane using a similar technique, clearly identify new lesions, and reflect changes in nontarget disease in the report. Response criteria may vary by tumor type and treatment; follow the institution’s oncologic reporting standard.
Rather than labeling every small size change as progression or response, consider measurement variability and differences in phase and technique. In the impression, prioritize the overall direction of disease burden, new organ involvement, and complications.
This template should be divided into separate versions for the acute abdomen, stone protocol, and oncologic follow-up:
| INDICATION: [Clinical question] COMPARISON: [Date and examination] TECHNIQUE: [Contrast, phases, oral contrast, reconstructions, limitations] FINDINGS: Liver and portal system: [Assessment] Gallbladder and bile ducts: [Assessment] Spleen and pancreas: [Assessment] Adrenal glands: [Assessment] Kidneys, ureters, and urinary bladder: [Assessment] Gastrointestinal tract and appendix: [Assessment] Peritoneum/mesentery/retroperitoneum: [Fluid, air, collection, implant] Lymph nodes and vessels: [Assessment] Pelvic organs: [Assessment] Abdominal wall, bones, and lung bases: [Important findings] IMPRESSION: 1. [Primary diagnosis or finding answering the clinical question] 2. [Complication, extent, or second important finding] 3. [Recommendation appropriate to guidelines and clinical context, if needed] |
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The abdomen and pelvis CT impression should prioritize three questions: What is the main diagnosis or most likely explanation? What is the extent of disease? Is there a complication that changes urgent management? This triad removes unnecessary detail from the impression, particularly in the acute abdomen and oncologic patients.
If incidental findings are included in the impression, prioritize them according to clinical significance and need for follow-up. Follow-up recommendations should be consistent with current guidelines, the patient’s risk profile, and prior imaging; automatic template recommendations must be verified by a specialist.
Are contrast administration and phases correctly described? Was the initial survey for free air, active hemorrhage, ischemia, obstruction, and collections completed? Were all solid organs, the gastrointestinal tract, peritoneum, vessels, and pelvic structures assessed? Were the lung bases and bones checked? Is meaningful interval change clear? Does the impression communicate diagnosis, extent, and complications in that order?
Este contenido es educativo y no constituye asesoramiento médico específico para un paciente. Antes de firmar, el médico debe verificar y adaptar cada frase, plantilla, resultado de clasificación y recomendación teniendo en cuenta todas las imágenes, el contexto clínico, las guías vigentes y el protocolo del centro.
Open an examination-specific framework in RadPhrases, adapt it to the findings, and verify it before signing.
Explora otras listas de comprobación, expresiones y métodos sistemáticos de este tema.
