Utility of point-of-care ultrasound in patients with suspected diverticulitis in the emergency department

Development of an ultrasound-based clinical decision rule to rule-out diverticulitis

The concern for diverticulitis often leads to the use of computed tomography (CT) scans for diagnosis. We aim to develop an ultrasound-based clinical decision rule (CDR) to confidently rule-out the disease without requiring a CT scan. We analyzed data from a prospective study of adult emergency department (ED) patients with suspected diverticulitis who underwent both bedside ultrasound (US) and CT. Patient history, physical examination, laboratory findings, and US results were used to create a CDR via a recursive partitioning model designed to prioritize sensitivity, with a loss matrix heavily penalizing false negatives. We calculated the test characteristics for this CDR (TICS-Rule) and assessed the potential reduction in CT scans and ED length of stay. Data from 149 patients (84 female; mean age 58 ± 16) were used to develop the TICS-Rule. The final model integrates US diagnosis of simple and complicated diverticulitis, along with variables of heart rate, age, history of diverticulosis, vomiting, and leukocytosis. Negative US results and a heart rate below 100 effectively excluded diverticulitis. The sensitivity increased from 54.5% (32.2-75.6) in the US alone to 100% (84.6-100%) for complicated diverticulitis in the model. The TICS-Rule missed no cases of complicated diverticulitis but one case of simple diverticulitis. The median time from ED greeting to US interpretation was 103 min (IQR 62-169), compared to 285 min (IQR 229-372) for CT. The TICS-Rule uses a combination of negative US and heart rate less thanQ1 100 to exclude diverticulitis without the need for a CT scan. Integration of the TICS-Rule offers a promising enhancement to clinical decision-making while reducing both CT use and ED length of stay.

Left side jejunal diverticulitis: US and CT imaging findings

Small bowel jejunoileal diverticulosis is an uncommon and usually asymptomatic condition. Complications may occur such as acute diverticulitis including infection or perforation, bleeding, small bowel obstruction and volvulus. Herein we report a case of a 76 years-old woman with acute left side abdominal pain and tenderness. A clinical suspected diagnosis of colonic diverticulitis was formulated. She underwent Ultrasound that revealed a collapsed small bowel loop with a large sac-like out-pouching lesion with mixed content (fluid and pockets of air) associated to hyperechogenicity of perilesional fat. Because of the atypical US findings, the patient underwent abdominopelvic CT that confirmed that the large sac-like out-pouching was a jejunal inflamed diverticulum. The patient underwent emergency surgery. Radiologist should be aware of imaging findings of jejunoileal diverticulitis in order to achieve a prompt diagnosis.

Point of Care Abdominal Ultrasound

Abdominal pain is a common emergency department complaint, and point-of-care ultrasound (POCUS) of the abdomen is increasingly being utilized to evaluate clinical manifestations. It aids in accurate diagnoses and assists in procedures, particularly in emergency and critical care settings. Imaging is often required to confirm the etiology of abdominal pain. POCUS provides the benefit of avoiding radiation exposure and enables quicker diagnosis compared to computed tomography scans. There is growing evidence of the diagnostic accuracy for numerous abdominal POCUS applications, including appendicitis, intussusception, diverticulitis, gastric ultrasound and contrast-enhanced ultrasound.

Emergency medicine updates: Acute diverticulitis

INTRODUCTION

Acute diverticulitis is a condition commonly seen in the emergency department (ED). Therefore, it is important for emergency medicine clinicians to be aware of the current evidence regarding the diagnosis and management of this disease.

OBJECTIVE

This paper evaluates key evidence-based updates concerning acute diverticulitis for the emergency clinician.

DISCUSSION

Diverticulitis is a complication of diverticulosis and most commonly affects the sigmoid and descending colon in Western countries. History and examination can suggest the diagnosis, with abdominal pain and tenderness in the left lower quadrant being the most common symptom and sign, respectively. Change in bowel habits and fever may also occur. Laboratory testing may demonstrate leukocytosis or an elevated C-reactive protein. Imaging options can include computed tomography (CT) of the abdomen and pelvis with intravenous contrast, magnetic resonance imaging (MRI), or ultrasound (US), though most classification systems for diverticulitis incorporate CT findings. While the majority of diverticulitis cases are uncomplicated, complications may affect up to 25% of patients. Treatment of complicated diverticulitis requires antibiotics and surgical consultation. Antibiotics are not required in select patients with uncomplicated diverticulitis. Appropriate patients for supportive care without antibiotics should be well-appearing, have pain adequately controlled, be able to tolerate oral intake, be able to follow up, have no complications, and have no immunocompromise or severe comorbidities.

CONCLUSIONS

An understanding of literature updates can improve the ED care of patients with acute diverticulitis.

Accuracy of "TICS" ultrasound protocol in detecting simple and complicated diverticulitis: A prospective cohort study

BACKGROUND

Point-of-care ultrasound (US) has been suggested as the primary imaging in evaluating patients with suspected diverticulitis. Discrimination between simple and complicated diverticulitis may help to expedite emergent surgical consults and determine the risk of complications. This study aimed to: (1) determine the accuracy of an US protocol (TICS) for diagnosing diverticulitis in the emergency department (ED) setting and (2) assess the ability of TICS to distinguish between simple and complicated diverticulitis.

METHODS

Patients with clinically suspected diverticulitis who underwent a diagnostic computed tomography (CT) scan were identified prospectively in the ED. Emergency US faculty and fellows blinded to the CT results performed and interpreted US scans. The presence of simple or complicated diverticulitis was recorded after each US evaluation. The diagnostic ability of the US was compared to CT as the criterion standard. Modified Hinchey classification was used to distinguish between simple and complicated diverticulitis.

RESULTS

A total of 149 patients (55% female, mean ± SD age 58 ± 16 years) were enrolled and included in the final analyses. Diverticulitis was the final diagnosis in 75 of 149 patients (50.3%), of whom 53 had simple diverticulitis and 22 had perforated diverticulitis (29.4%). TICS protocol's test characteristics for simple diverticulitis include a sensitivity of 95% (95% confidence interval [CI] 87%-99%), specificity of 76% (95% CI 65%-86%), positive predictive value of 80% (95% CI 71%-88%), and negative predictive value of 93% (95% CI 84%-98%). TICS protocol correctly identified 12 of 22 patients with complicated diverticulitis (sensitivity 55% [95% CI 32%-76%]) and specificity was 96% (95% CI 91%-99%). Eight of 10 missed diagnoses of complicated diverticulitis were identified as simple diverticulitis, and two were recorded as negative.

CONCLUSIONS

In ED patients with suspected diverticulitis, US demonstrated high accuracy in ruling out or diagnosing diverticulitis, but its reliability in differentiating complicated from simple diverticulitis is unsatisfactory.

Surgeon-Performed Point-of-Care Ultrasound in the Diagnosis of Acute Sigmoid Diverticulitis: A Pragmatic Prospective Multicenter Cohort Study

Background and purpose Early diagnosis and risk stratification of sigmoid diverticulitis rely heavily on timely imaging. Computerized tomography (CT), the gold standard diagnostic test, may be delayed due to resource constraints or patient comorbidity. Point-of-care ultrasound (POCUS) has an established role in trauma evaluation, and could potentially diagnose and stage acute diverticulitis, thus shortening the time to definitive treatment.  Aims This study aimed to benchmark the accuracy of surgeon-performed POCUS against CT in diagnosing and staging acute diverticulitis. A secondary aim was to evaluate the duration between the POCUS and the confirmatory CT scan report. Patients and methods A pragmatic prospective multicenter cohort study (ClinicalTrials.gov Identifier: NCT02682368) was conducted. Surgeons performed point-of-care ultrasound as first-line imaging for suspected acute diverticulitis. POCUS diagnosis and radiologic Hinchey classification were compared to CT as the reference standard. Results Of 45 patients with suspected acute diverticulitis, POCUS classified 37 (82.2%) as uncomplicated diverticulitis, four (8.8%) as complicated diverticulitis, and four (8.8%) as other diagnoses. The POCUS-estimated modified radiologic Hinchey classification was largely concordant with CT staging with an accuracy of 88.8% (95% CI, 75.95-96.2%), a sensitivity of 100% (95% CI, 90.2- 100%) and a specificity of 44.4% (95% CI, 13.7-78.8%). The positive predictive value (PPV) was 87.8% and the negative predictive value (NPV) was 100%. There was moderate agreement between CT and POCUS, with a Cohen's kappa coefficient of 0.56. The mean delay between CT and POCUS was 9.14 hours (range 0.33 to 43.5). Conclusion We examined the role of POCUS in the management of acute diverticulitis and our findings suggest that it is a promising imaging modality with the potential to reduce radiation exposure and treatment delays. Adding a POCUS training module to the surgical curriculum could enhance diagnosis and expedite the management of acute diverticulitis.

Sonographic assessment of inflammatory bowel disease in the emergency department: A case series and review of the literature

The use of sonography for diagnosing inflammatory bowel disease (IBD) has been reported in the radiology literature but is not common practice in the hands of emergency physicians (EPs). We present a series of three cases where IBD was managed by an EP using point-of-care ultrasonography (POCUS), and discuss the sonographic features of IBD including bowel wall thickening, increased blood flow on color Doppler, infiltration of surrounding fatty tissue, and presence of intraperitoneal fluid. Complications such as bowel strictures and peri-colic abscess are also described. We suggest that the use of POCUS for the assessment of IBD patients in the ED may expedite both diagnosis and treatment, as well as minimize the use of additional imaging.