Ultrasound evaluation of patients with acute abdominal pain in the emergency department

Transcription

1 Ultrasound evaluation of patients with acute abdominal pain in the emergency department Poster No.: C-2584 Congress: ECR 2012 Type: Authors: Keywords: DOI: Educational Exhibit A. A. Falticeanu, A.-M. Alecsa-Lupu, C. Balan; Iasi/RO Pathology, Statistics, Diagnostic procedure, Ultrasound, Emergency, Abdomen /ecr2012/C-2584 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 12

2 Learning objectives To process and evaluate data of routine use ultrasound and its findings in patients presented in the emergency department with acute abdominal pain syndrome. This study attempts a correlation between ultrasonographical data obtained in the radiology department of the emergency room and the diagnostic suspicions based on their preliminary clinical examination of the patient upon its arrival in the medical unit. Our main objective is to emphasise the utmost importance of a good collaboration between emergency medicine specialists and radiology specialists in the emergency department. Background Abdominal pain may be minor and of no great significance, the characteristics of the pain - location, timing, duration - bearing a high importance in diagnosing its cause. As a successful treatment depends both on the time between the appearance of symptoms and presentation in the emergency room, and the amount of time between the arrival at the hospital and setting a positive diagnosis, ultrasound has an increasingly important role in the initial evaluation of the patient. Today, in most trauma centres, the abdominal ultrasonography is recognised as a first-line investigation in abdominal pain syndrome. Between 1 January 2011 and 31 march 2011, in the Emergency Unit at the Clinical Hospital "Sf. Spiridon" Iasi, a number of 310 patients presented with acute abdominal pain syndrome and were recommended an ultrasound examination. Keeping in mind that CT examinations are highly accurate in finding the underlying cause of the acute abdominal pain, there are also disadvantages of this procedure: CT is static, compared to small, portable ultrasound equipment that now offers bedside and roadside assessment, takes longer to arrange and perform and is not always possible, particularly in acutely ill and unstable patients. Page 2 of 12

3 Some of the main advantages of using the ultrasound evaluation in the emergency deprtment are that sonography it is a non-invasive procedure, it has a low dose of radiation, and small, portable equipment is now widely available, offering bedside and roadside assessments. Its interactive character often guides the examiner towards a possible incriminating pathology, especially in cases like trauma, bowel inflammation or acute cholecystitis; the possibility to step out of usual protocols may direct the physician directly to the cause of the pain. Along its course, an ultrasound examination may encounter restraints, such as insufficient preparation of the patient and lack of patient history in cases of trauma or other fast installing conditions. The accuracy of the results depends on the skills and experience of the imaging specialist, as well as on communication attributes of the entire medical team. Images for this section: Page 3 of 12

4 Fig. 1: Small amount of free fluid young male after trauma. Emergency Department Radiology, Clinical Emergency Hospital Sf. Spiridon Iasi, Medical University of Iasi/ Romania 2011 Fig. 2: Cholecystitis in young woman with previously known small-dimension gallbladder lithiasis. Emergency Department Radiology, Clinical Emergency Hospital Sf. Spiridon Iasi, Medical University of Iasi/Romania 2011 Page 4 of 12

5 Imaging findings OR Procedure details Our retrospective study focused on gathering and comparing, over a period of three months (1 st January until 31 March 2011) ultrasonographic findings in patients presenting to the emergency department with acute abdominal pain, in relation with the preliminary diagnostic suspicion that followed an initial clinical examination carried out by emergency medicine specialists. The scanning equipment consisted of an ultrasound system with two arrays available: a convex array transducer (2-5MHz) and a linear array transducer (6-9 MHz). The total number of patients presenting in the emergency department with abdominal pain, that were recommended an ultrasound examination, was 310, out of which 168 already had a specific diagnostic suspicion as underlying cause of the pain at the moment of the abdominal ultrasound recommendation. The most common preliminary diagnostics after the clinical examination in the emergency room were biliary colic 16%, partial bowel obstructions 11%, appendicitis 11%, pancreatitis 10%, and renal colic 8% (Fig. 3-Table 1). We noticed a slightly higher percentage of pathological findings in this category (88.09 %) than in patients without any preliminary diagnostic stated in the charts at the moment of the recommendation for ultrasonography (75.35 %). The most frequent positive ultrasonographic findings which could be considered responsible for determining the abdominal pain were in hepatic (70 cases) and renal (42 cases) pathologies, followed closely by intestinal (30 cases) and biliary (37 cases) pathologies (Fig. 4-Table 2). From the observed modifications of the liver, nearly 50% had steatosis, with 25% adding a hepatomegaly. In 6 cases we noted the appearance of simple cysts, of small dimensions, probably not related to the abdominal pain- while in 2 cases the aspect suggested hydatic cysts. Nodular lesions were found in 14 cases - 5 typical target-sign lesions, 2 with haemangioma typical aspect and 7 hepatic nodules with non-specific characteristics. Page 5 of 12

6 As biliary pathology was concerned, 14% of all the sonography positive findings were cases of gallbladder lithiasis - one with gallbladder wall abscess, while in 4% of the cases gallbladder polyps were identified. The pancreatic pathology is rarely objectified in ultrasound evaluations, especially during the first hours of its evolution. Clear ultrasound modifications were observed in just 8 cases, with identification of 2 cases of pancreatic cysts, 2 cases of peripancreatic collections and 3 cases of nodular lesions within the pancreatic area. Only in 3 cases of the suspected pancreatitis (from a total of 17 preliminary diagnostics) free intraperitoneal fluid has been objectified on sonography in the emergency department. The renal pathology consisted mostly of pyeloureteral dilatation (15 cases) - an indirect sign of renal colic; renal calculi of small dimensions (5-7 mm) without any symptoms were identified in 9 other cases. There were 12 cases of splenomegaly, and one case of a large hydatic cyst (Fig. 8). Intestinal pathology identified through ultrasonography consisted 10 cases of targetshaped apparently solid lesions, abnormal peristalsis (reverse peristaltic movements and slow or absent peristaltic movements), as well as a number of 8 cases with pathological modifications of the appendix. Only 7 cases of adenopathies were found in ultrasonography; but visualization has sometimes been limited by excess bowel gas and large body habitus, or in patients with open wounds. Images for this section: Page 6 of 12

7 Fig. 3: Table 1: Preliminary diagnostic suspicions Page 7 of 12

8 Fig. 4: Table 2: Ultrasonographic pathological findings. Page 8 of 12

9 Fig. 5: Cholecystitis in young woman. Emergency Department Radiology, Clinical Emergency Hospital Sf. Spiridon Iasi, Medical University of Iasi/Romania 2011 Fig. 6: Incidentally found hepatic methastatis in 64 year old man. Emergency Department Radiology, Clinical Emergency Hospital Sf. Spiridon Iasi, Medical University of Iasi/ Romania 2011 Page 9 of 12

10 Fig. 7: Left kidney first degree hydronephrosis in renal colic. Emergency Department Radiology, Clinical Emergency Hospital Sf. Spiridon Iasi, Medical University of Iasi/ Romania 2011 Page 10 of 12

11 Fig. 8: Large spleen hydatic cyst. Emergency Department Radiology, Clinical Emergency Hospital Sf. Spiridon Iasi, Medical University of Iasi/Romania 2011 Page 11 of 12

12 Conclusion Although it has a limited value when used in the emergency department for finding the cause of the acute abdominal pain, due to insufficient preparation of the patients and often difficult anamnesis, sonography is a very effective, non-invasive method in the search of the underlying cause. This study focused on the most often encountered modifications during the initial ultrasound examination - hepatic and renal, followed closely by intestinal and biliary ones. In most of the cases the ultrasonographical findings corresponded with the diagnostic suspicion issued after the preliminary clinical examination, with relatively few cases of incidental findings that represented the cause of the abdominal pain. One or multiple preliminary diagnostics helped the sonographer evaluate specific areas within the abdomen, and sonography findings were recorded in a higher percentage than in cases with no mentioned etiology suspicion after the clinical examination. Also, the ability of the radiologist to integrate clinical findings in the ultrasound evaluation led to a more efficient differential diagnostic process and a better management of the patient. Personal Information References 1. J. Bates, Abdominal Ultrasound (sec. ed.), Churchill Livingstone, Mittelstaedt, Carol A., General Ultrasound, Churchill Livingstone,New York, Hagen-Ansert SL: Textbook of Diagnostic Ultrasonography, 5th Edition, Mosby, Wyatt, Jonathon; Illingworth, RN. Graham, CA. Clancy, MJ. Robertson, Oxford Handbook of Emergency Medicine. Oxford University Press, 2006 Page 12 of 12