In the past, tradition dictated the routine use of plain films to screen patients with acute abdominal pain. 23 Screening acute abdominal pain patients routinely with plain films is not advisable, since the yield of positive findings that would change clinical management is low, in the range of 10 to 40 percent. 45 However, in the proper clinical setting, plain abdominal radiographs are entirely appropriate and are still considered the first test of choice. In patients with a suspected perforated ulcer or free air in the abdomen, plain films demonstrate free air, if present, in a high percentage of patients. 6 Plain films may demonstrate as little as 1 to 2 mL of air.7 In patients with suspected small bowel obstruction, plain films are the initial method of imaging. Plain films have a sensitivity for revealing high-grade small bowel obstruction of 69 to 82 percent, but, when combined with barium contrast studies, the sensitivity rate may approach 100 percent. 89 Low-grade small bowel obstruction is difficult to demonstrate on plain films and has much lower diagnostic rates.10 Other appropriate conditions for the use of plain film radiographs include moderate or severe abdominal tenderness, suspicion of bowel ischemia, ingestion of radiopaque foreign bodies, and penetrating foreign bodies, such as gunshot wounds.
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