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Background
Up to 10% of emergency department visits are for abdominal pain. Numerous etiologies require imaging for specific diagnosis. The American College of Radiology (ACR) Appropriateness Criteria narrative table of acute nonlocalized abdominal pain lists contrast-enhanced (CE) CT of the abdomen and pelvis (CTAP) equivalent in appropriateness to noncontrast CT (NC). However, they stipulate that IV contrast increases detection and that CTAP is generally performed with iodinated contrast media (ICM). Shanghai, China went under COVID-19 lockdown on March 27th 2022, which had ramifications for the entire world and for radiologista due to it being a key site of manufacture for ICM. General Electric Company is one of only a handful of major producers of ICM, and closure of their Shanghai factory resulted in a global shortage. In response, hospitals in the United States developed rationing protocols, research was done to demonstrate the most effective rationing techniques, and the ACR compiled resources to save ICM. Nevertheless, the reality for the radiologist interpreting examinations is that many studies that would have utilized ICM prior to the shortage are now done without it, considering only 16.2% of CTAPs were performed without ICM before the shortage. The purpose of this exhibit is to demonstrate the common and uncommon pathologies that may be diagnosed on NC CTAP for the radiologist practicing in the era of a contrast shortage.

Educational Goals / Teaching Points
After reviewing this exhibit, the radiologist will be able to diagnose a multitude of abdominal pathologies on NC CTAP and recommend the next appropriate imaging study or consultation to the referring clinician. We will also discuss our institution’s rationing policy and when CE CTAP may be most appropriate during the shortage.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
We discuss the normal and abnormal imaging appearance of various structures on NC CTAP including solid organs, bowel, and vasculature. We review a range of abdominal pathologies that may be diagnosed with NC CTAP. These include obstructive etiologies such as urolithiasis, cholecystitis, and bowel obstruction; inflammatory and infectious etiologies such as pancreatitis, enteritis, pyelonephritis, and abscess; and oncologic and idiopathic diseases. We will also comment on vascular pathology, as it may sometimes be identified on NC CT and be subsequently investigated with CE CT or MRI.

Conclusion
The reality of a globalized world, supply chain issues relating to world geopolitics, and emerging disruptive events such as COVID-19 have highlighted the need for radiologists to adapt quickly and efficiently utilize available resources to best serve patients and referring clinicians. Having a working knowledge of pathological findings on NC CTAP will arm the radiologist to deliver the best care possible for patients with acute abdominal pain in an ICM-restricted environment.