Reassurance or Redundancy: A Retrospective Observational Study of the Clinical Utility of Abdominal Radiographs in an Australian Emergency Department

IntroductionAcute abdominal pain accounts for a significant proportion of emergency department (ED) presentations, and abdominal radiographs or X-rays (AXR) remain among the most frequently performed investigations for this presentation.Although radiographs carry a lower radiation dose than computed tomography (CT), this is offset by comparatively poor diagnostic yield, and CT has been shown to improve diagnostic accuracy and clinical outcomes in acute abdominal pain.The Royal College of Radiologists (RCR) iRefer guidelines define appropriate indications for abdominal radiographs to maximise its clinical utility and are endorsed for use in Australia by the Royal Australian and New Zealand College of Radiologists.This study aimed to assess whether abdominal radiograph requests at an Australian tertiary ED met RCR iRefer indications and whether radiograph findings informed management or led to further imaging within the same presentation. MethodsThis retrospective study reviewed all abdominal radiographs performed at the Royal Brisbane and Women's Hospital ED between 1 January and 30 June 2025, identified via the Radiology Information System.Adult patients (≥18 years) imaged for acute abdominal pain were included; those imaged to monitor known pathology were excluded.Request-form indications were compared against RCR iRefer guidelines.Clinical notes were reviewed to determine whether radiograph findings directly informed management or whether further imaging was required. ResultsOf 191 radiographs identified, 162 met inclusion criteria.The mean age was 48.3 years (range 18-99), with an approximately equal sex distribution.Overall, 85.18% (n=138) of requests were iRefer-compliant, with noncompliance (14.82%, n=24) largely attributable to inpatient-initiated and device-position check requests.The leading indications were exclusion of constipation (37.03%) and suspected bowel obstruction or volvulus (29.6%).No acute pathology was identified in 45.06% (n=73) of studies.Constipation and faecal loading were seen in 36.41%(n=59) of studies and bowel obstruction in 7.4% (n=12).Radiograph findings directly informed management in 75.9% (n=123) of cases (79 discharged, 44 admitted).Further imaging was required in 24.10% (n=39): 34 underwent CT, four underwent ultrasound, and one obtained both modalities.This further imaging identified a positive finding in 26 patients (66.6%), while 13 (33.3%)had no defined aetiology.Notably, clinically significant pathologies, including bowel obstruction, new inflammatory bowel disease, and previously undetected foreign bodies, were identified on further imaging in a subset of patients despite an initially negative or non-specific radiograph. ConclusionAbdominal radiography in this centre was largely compliant with the iRefer guidelines, but diagnostic yield was limited, and a meaningful proportion of patients required subsequent cross-sectional imaging, some of which revealed pathology not apparent on the initial radiographs.These findings support closer adherence to core iRefer indications and consideration of more selective first-line abdominal radiograph use, with earlier consideration of CT in patients with a high pre-test probability of significant pathology.