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53 Emergency Sonography of the Gallbladder: Is Measurement of the Common Bile Duct Necessary?
Research Forum Abstracts
52
Emergency Department Patients Evaluated by Bedside Biliary Ultrasonography: Does Radiology Ultrasonography Alter Disposition?
Conway DG, Baden E, Anderson K, Summers S/SAUSHEC, Brooke Army Medical Center, Fort Sam Houston, TX
Conclusion: During routine ED evaluation, omission of CBD measurement during routine US of the gallbladder is unlikely to result in missed gallbladder pathology requiring cholecystectomy.
54
Estimating Stomach Volume With Bedside Ultrasound
Lindberg P, Jin L, Beck E, Villines D, Foster T/Chicago College of Osteopathic Medicine, Chicago, IL; University of Chicago, Chicago, IL; Advocate Health Care, Chicago, IL; Lutheran General Hospital, Chicago, IL
Study Objective: The primary objective is to determine if radiology biliary (GB) ultrasonography changes the disposition of adult emergency department (ED) patients who already received emergency physician-performed bedside GB ultrasonography. The secondary objective was to determine how much radiology GB ultrasonography increases the ED length of stay. Methods: We conducted a prospective, observational study on a convenience sample of adult ED patients presenting with a chief complaint of abdominal pain suspicious for biliary disease. Bedside GB ultrasonography was performed by emergency medicine residents and attending physicians at an academic institution. The emergency physician assessed for gallstones, a sonographic Murphy’s sign, gallbladder wall thickening, and pericholecystic fluid. The emergency physician then recorded the diagnosis, disposition, and the time on a structured data collection form prior to radiology GB ultrasonography. After the radiology GB ultrasonography, the emergency physician recorded the radiology findings, the final disposition of the patient, and the time the radiology report was received. Results: Fifty-one patients were enrolled and received bedside and radiology GB ultrasonography. Eleven patients (21%) were diagnosed with acute cholecystitis. All eleven of these cases were detected on bedside GB ultrasonography. Twenty-2 patients (43%) were diagnosed with cholelithiasis on bedside GB ultrasonography. Only 2 patients (4%, 95CI 1.1-13) had their diagnosis & disposition changed based on the radiology GB ultrasonography. These 2 patients were diagnosed with cholelithiasis on bedside GB ultrasonography, but the radiology GB ultrasonography was normal. Agreement between bedside GB ultrasonography and radiology GB ultrasonography was excellent (K⫽ 0.92, 95CI 0.8-1.0). Length of stay was increased by an average of 101 minutes, with a median of 93 minutes waiting for the radiology GB ultrasonography. Conclusion: In this single center study, radiology GB ultrasonography increased the ED length of stay without significantly altering the disposition of ED patients with suspected biliary disease who already received bedside GB ultrasonography. With adequate training, bedside GB ultrasonography has the potential to be an acceptable, stand-alone study that may improve ED throughput.
Study Objectives: The volume of stomach contents in the emergency department is often important to clinical management, yet there is currently no accepted objective means of their estimation. Here we test the idea that bedside ultrasound can reliably predict CT-estimated stomach volumes. Methods: Fifty emergency department patients were recruited with informed consent after their treating physician determined they required a CT. Using bedside ultrasound, we measured the gastric antral area within 30 minutes of CT and before reviewing their CT-determined stomach volume. Using CT-determined stomach volume of 30mL as a gold standard, we compared bedside ultrasound-determined predictions of stomach emptiness with predictions based on classic recommendations for oral intake. Correlation and simple regression were performed to analyze the relationship between antral area and gastric volume. Sensitivity, specificity and receiver operating characteristic analysis were performed to determine discriminatory and diagnostic capability. Analysis was performed using SPSS®18 (Chicago, IL, 2009) and statistical significance was determined at pⱕ 0.05. Results: Antral area is a significant predictor of gastric volume (B ⫽ 16.46; t ⫽ 6.247, p ⫽ 0.000). Overall, antral area was a good predictor of whether the abdomen was empty or full (AUC ⫽ 0.863, p ⫽ 0.000). Sensitivity was optimal between the 9.2 - 10.9 cm2 range. An antral area of 10 cm2 gave a sensitivity of 78.26% and specificity of 84.61% for predicting a volume of 30 mL as measured by CT (AUC ⫽ 0.847, p ⫽ 0.000). History was not a significant predictor of gastric volume (B ⫽ 16.46; t ⫽ 6.239, p ⫽ 0.898). History gave a sensitivity of 78.26% and specificity of 53.84% for predicting a volume ⬎30 mL as measured by CT (Figure 3; AUC ⫽ 0.636, p ⫽ 0.113). Conclusion: Ultrasound measurements of gastric antral area less than or equal to 10 cm2 were as sensitive as history for volume greater than 30mL and were more specific, potentially allowing speedier treatment of patients requiring conscious sedation.
53
55
Emergency Sonography of the Gallbladder: Is Measurement of the Common Bile Duct Necessary?
Becker BA, Mervis E, Chin E, Fox JC, Anderson C, Oshita R, Menchine M, Hata S, Stacy A, Nguyen N/University of California Irvine, Orange, CA
Study Objectives: Measurement of the common bile duct (CBD) is considered an integral part of gallbladder sonography, but can be difficult especially for novice sonographers. This study examined the incidence of isolated CBD dilation in patients with suspected gallbladder pathology and the need for universal sonographic CBD measurement in ruling out acute gallbladder disease. Methods: This was a retrospective chart review performed on all patients undergoing a cholecystectomy at University of California Irvine Medical Center between July 2000 and June 2010. All included patients received a pre-operative gallbladder ultrasound (US) including CBD measurement. Each ultrasound was also evaluated for presence or absence of sonographic Murphy’s sign (SMS), gallbladder wall thickening (GWT) and pericholecystic fluid (PCF). A “positive” US was defined as a scan including at least 1 of SMS, GWT or PCF, regardless of CBD diameter. Contemporary lab values were collected, including white blood cell count, aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, total/direct bilirubin and lipase. Post-operative gallbladder pathology reports were obtained as the gold standard for final diagnoses. Results: A total of 734 charts were reviewed with 667 included. 634 of these demonstrated a pathology-confirmed diagnosis of cholecystitis (95.1%). 417 cases demonstrated normal CBDs with diameters less than or equal to 6 mm (62.5%) and 250 cases demonstrated dilated CBDs with diameters greater than 6 mm (37.5%). Of the cases with a dilated CBD, 26 (10.4%) demonstrated a “positive” US with normal labs, 72 (28.8%) demonstrated an otherwise normal US with at least 1 lab value above the accepted normal range, and 152 (60.8%) demonstrated both a “positive” US and at least 1 lab abnormality. There were only 2 (0.8%, 95% CI 0.1-2.9%) cases of dilated CBD that occurred in isolation without either a “positive” US or lab abnormality.
Volume , . : October
Cardiac Index Measurements by Emergency Physicians Using Bedside Ultrasound Compared to Pulse Contour Analysis and Echocardiographer
Dinh V, Ko S, Rao R, Bansal R, Nguyen H/Loma Linda University Medical Center, Loma Linda, CA
Study Objective: Measuring cardiac index (CI) in the emergency department (ED) setting may facilitate resuscitation of the critically ill patients. In this study, our objective was to compare CI measurements obtained by emergency physicians using standard bedside ultrasound to those CI measured by pulse contour analysis of noninvasive blood pressure measurements at the finger tip (the accepted reference standard for this study). Additionally, we compared a subset of CI measurements by the emergency physician to a certified echocardiographer. Methods: This study was a prospective observational cohort that was performed over a 2-month period at a university tertiary-care ED, enrolling a convenience sample of adult patients. CI was measured by 2 emergency physicians and an echocardiographer using the Z. One Ultra ultrasound system (Zonare Medical System, Inc, Mountainview, Calif) with an upgraded cardiac software package. CI was also measured by an independent study personnel using the Nextfin pulse contour analysis cardiac index system (BMEye, Amsterdam, the Netherlands). Measurements obtained by the emergency physician were blinded to measurements obtained by Nexfin and echocardiographer. All ultrasound measurements of CI were verified by a cardiologist. Pearson correlation, percentage difference, and BlandAltman analyses were performed. Results: Fifty-six patients were enrolled, with 53 patients, age 49.5 ⫹ 20.6 years, having acceptable ultrasound cardiac views obtained by the emergency physician. The echocardiographer obtained CI measurements on ten of the 53 patients. Cardiac, respiratory, and gastrointestinal were the most common presenting diagnostic categories. The average CI was 2.37 ⫹ 0.73 L/min/m2, 2.48 ⫹ 0.39 L/min/m2, and 3.33 ⫹ 0.92 L/min/m2 for emergency physician, echocardiographer, and Nexfin measurements, respectively. The correlation between emergency physician ultrasound
Annals of Emergency Medicine S195
52
Emergency Department Patients Evaluated by Bedside Biliary Ultrasonography: Does Radiology Ultrasonography Alter Disposition?
Conway DG, Baden E, Anderson K, Summers S/SAUSHEC, Brooke Army Medical Center, Fort Sam Houston, TX
Conclusion: During routine ED evaluation, omission of CBD measurement during routine US of the gallbladder is unlikely to result in missed gallbladder pathology requiring cholecystectomy.
54
Estimating Stomach Volume With Bedside Ultrasound
Lindberg P, Jin L, Beck E, Villines D, Foster T/Chicago College of Osteopathic Medicine, Chicago, IL; University of Chicago, Chicago, IL; Advocate Health Care, Chicago, IL; Lutheran General Hospital, Chicago, IL
Study Objective: The primary objective is to determine if radiology biliary (GB) ultrasonography changes the disposition of adult emergency department (ED) patients who already received emergency physician-performed bedside GB ultrasonography. The secondary objective was to determine how much radiology GB ultrasonography increases the ED length of stay. Methods: We conducted a prospective, observational study on a convenience sample of adult ED patients presenting with a chief complaint of abdominal pain suspicious for biliary disease. Bedside GB ultrasonography was performed by emergency medicine residents and attending physicians at an academic institution. The emergency physician assessed for gallstones, a sonographic Murphy’s sign, gallbladder wall thickening, and pericholecystic fluid. The emergency physician then recorded the diagnosis, disposition, and the time on a structured data collection form prior to radiology GB ultrasonography. After the radiology GB ultrasonography, the emergency physician recorded the radiology findings, the final disposition of the patient, and the time the radiology report was received. Results: Fifty-one patients were enrolled and received bedside and radiology GB ultrasonography. Eleven patients (21%) were diagnosed with acute cholecystitis. All eleven of these cases were detected on bedside GB ultrasonography. Twenty-2 patients (43%) were diagnosed with cholelithiasis on bedside GB ultrasonography. Only 2 patients (4%, 95CI 1.1-13) had their diagnosis & disposition changed based on the radiology GB ultrasonography. These 2 patients were diagnosed with cholelithiasis on bedside GB ultrasonography, but the radiology GB ultrasonography was normal. Agreement between bedside GB ultrasonography and radiology GB ultrasonography was excellent (K⫽ 0.92, 95CI 0.8-1.0). Length of stay was increased by an average of 101 minutes, with a median of 93 minutes waiting for the radiology GB ultrasonography. Conclusion: In this single center study, radiology GB ultrasonography increased the ED length of stay without significantly altering the disposition of ED patients with suspected biliary disease who already received bedside GB ultrasonography. With adequate training, bedside GB ultrasonography has the potential to be an acceptable, stand-alone study that may improve ED throughput.
Study Objectives: The volume of stomach contents in the emergency department is often important to clinical management, yet there is currently no accepted objective means of their estimation. Here we test the idea that bedside ultrasound can reliably predict CT-estimated stomach volumes. Methods: Fifty emergency department patients were recruited with informed consent after their treating physician determined they required a CT. Using bedside ultrasound, we measured the gastric antral area within 30 minutes of CT and before reviewing their CT-determined stomach volume. Using CT-determined stomach volume of 30mL as a gold standard, we compared bedside ultrasound-determined predictions of stomach emptiness with predictions based on classic recommendations for oral intake. Correlation and simple regression were performed to analyze the relationship between antral area and gastric volume. Sensitivity, specificity and receiver operating characteristic analysis were performed to determine discriminatory and diagnostic capability. Analysis was performed using SPSS®18 (Chicago, IL, 2009) and statistical significance was determined at pⱕ 0.05. Results: Antral area is a significant predictor of gastric volume (B ⫽ 16.46; t ⫽ 6.247, p ⫽ 0.000). Overall, antral area was a good predictor of whether the abdomen was empty or full (AUC ⫽ 0.863, p ⫽ 0.000). Sensitivity was optimal between the 9.2 - 10.9 cm2 range. An antral area of 10 cm2 gave a sensitivity of 78.26% and specificity of 84.61% for predicting a volume of 30 mL as measured by CT (AUC ⫽ 0.847, p ⫽ 0.000). History was not a significant predictor of gastric volume (B ⫽ 16.46; t ⫽ 6.239, p ⫽ 0.898). History gave a sensitivity of 78.26% and specificity of 53.84% for predicting a volume ⬎30 mL as measured by CT (Figure 3; AUC ⫽ 0.636, p ⫽ 0.113). Conclusion: Ultrasound measurements of gastric antral area less than or equal to 10 cm2 were as sensitive as history for volume greater than 30mL and were more specific, potentially allowing speedier treatment of patients requiring conscious sedation.
53
55
Emergency Sonography of the Gallbladder: Is Measurement of the Common Bile Duct Necessary?
Becker BA, Mervis E, Chin E, Fox JC, Anderson C, Oshita R, Menchine M, Hata S, Stacy A, Nguyen N/University of California Irvine, Orange, CA
Study Objectives: Measurement of the common bile duct (CBD) is considered an integral part of gallbladder sonography, but can be difficult especially for novice sonographers. This study examined the incidence of isolated CBD dilation in patients with suspected gallbladder pathology and the need for universal sonographic CBD measurement in ruling out acute gallbladder disease. Methods: This was a retrospective chart review performed on all patients undergoing a cholecystectomy at University of California Irvine Medical Center between July 2000 and June 2010. All included patients received a pre-operative gallbladder ultrasound (US) including CBD measurement. Each ultrasound was also evaluated for presence or absence of sonographic Murphy’s sign (SMS), gallbladder wall thickening (GWT) and pericholecystic fluid (PCF). A “positive” US was defined as a scan including at least 1 of SMS, GWT or PCF, regardless of CBD diameter. Contemporary lab values were collected, including white blood cell count, aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, total/direct bilirubin and lipase. Post-operative gallbladder pathology reports were obtained as the gold standard for final diagnoses. Results: A total of 734 charts were reviewed with 667 included. 634 of these demonstrated a pathology-confirmed diagnosis of cholecystitis (95.1%). 417 cases demonstrated normal CBDs with diameters less than or equal to 6 mm (62.5%) and 250 cases demonstrated dilated CBDs with diameters greater than 6 mm (37.5%). Of the cases with a dilated CBD, 26 (10.4%) demonstrated a “positive” US with normal labs, 72 (28.8%) demonstrated an otherwise normal US with at least 1 lab value above the accepted normal range, and 152 (60.8%) demonstrated both a “positive” US and at least 1 lab abnormality. There were only 2 (0.8%, 95% CI 0.1-2.9%) cases of dilated CBD that occurred in isolation without either a “positive” US or lab abnormality.
Volume , . : October
Cardiac Index Measurements by Emergency Physicians Using Bedside Ultrasound Compared to Pulse Contour Analysis and Echocardiographer
Dinh V, Ko S, Rao R, Bansal R, Nguyen H/Loma Linda University Medical Center, Loma Linda, CA
Study Objective: Measuring cardiac index (CI) in the emergency department (ED) setting may facilitate resuscitation of the critically ill patients. In this study, our objective was to compare CI measurements obtained by emergency physicians using standard bedside ultrasound to those CI measured by pulse contour analysis of noninvasive blood pressure measurements at the finger tip (the accepted reference standard for this study). Additionally, we compared a subset of CI measurements by the emergency physician to a certified echocardiographer. Methods: This study was a prospective observational cohort that was performed over a 2-month period at a university tertiary-care ED, enrolling a convenience sample of adult patients. CI was measured by 2 emergency physicians and an echocardiographer using the Z. One Ultra ultrasound system (Zonare Medical System, Inc, Mountainview, Calif) with an upgraded cardiac software package. CI was also measured by an independent study personnel using the Nextfin pulse contour analysis cardiac index system (BMEye, Amsterdam, the Netherlands). Measurements obtained by the emergency physician were blinded to measurements obtained by Nexfin and echocardiographer. All ultrasound measurements of CI were verified by a cardiologist. Pearson correlation, percentage difference, and BlandAltman analyses were performed. Results: Fifty-six patients were enrolled, with 53 patients, age 49.5 ⫹ 20.6 years, having acceptable ultrasound cardiac views obtained by the emergency physician. The echocardiographer obtained CI measurements on ten of the 53 patients. Cardiac, respiratory, and gastrointestinal were the most common presenting diagnostic categories. The average CI was 2.37 ⫹ 0.73 L/min/m2, 2.48 ⫹ 0.39 L/min/m2, and 3.33 ⫹ 0.92 L/min/m2 for emergency physician, echocardiographer, and Nexfin measurements, respectively. The correlation between emergency physician ultrasound
Annals of Emergency Medicine S195