The Use of Bedside Ultrasound for Gallstone Disease Care within a Community-based Emergency Department: A Confirmation Bias

Point-of-care ultrasound to diagnose acute cholecystitis in the emergency department: A scoping review

Introduction/Purpose

Ultrasound is the first-line imaging modality for suspected acute cholecystitis. This can be radiology-performed ultrasound or point-of-care ultrasound (POCUS). POCUS can potentially streamline patient assessment in the emergency department (ED). The primary objective was to evaluate the literature for the diagnostic accuracy of POCUS performed for acute cholecystitis in the ED. Secondary objectives were to assess the effect of POCUS operator training on diagnostic accuracy for acute cholecystitis, utility of POCUS measurement of the common bile duct and POCUS impact on resource utilisation.

Methods

A systematic scoping review of articles was conducted using Medline, Embase, CENTRAL and CINAHL. Original studies of adults with POCUS performed for the diagnosis of acute cholecystitis in the ED were included. The study was reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist (PRISMA-ScR).

Results

A total of 1090 publications were identified. Forty-six met the eligibility criteria. Studies were thematically grouped into categories according to specified objectives. Point-of-care ultrasound was of acceptable but variable accuracy, contributed to by the absence of a consistent reference standard and uniform training requirements. It may positively impact ED resource utilisation through reduced ED length of stay and radiology-performed imaging, whilst improving patient experience.

Conclusion

This review highlights the heterogeneity of existing research, emphasising the need for standardisation of training and reference standards in order to precisely define the utility of POCUS for acute cholecystitis in the ED and its benefits on ED resource utilisation.

Point of care biliary ultrasound in the emergency department (BUSED) predicts final surgical management decisions

Objectives

Gallstone disease is a common reason for emergency department (ED) presentation. Surgeons often prefer radiology department ultrasound (RUS) over point of care ultrasound (POCUS) because of perceived of unreliability. Our study was designed to test the hypothesis that POCUS is sufficient to guide the management of surgeons treating select cases of biliary disease as compared to RUS.

Methods

This was a prospective cohort study. Patients who presented to the ED with abdominal pain and findings of biliary disease on POCUS were included. The surgeon was then presented the case with POCUS only and recorded their management decision. Patients then proceeded to RUS, were followed through their stay, and analysis was performed to analyze the proportion of patients where the introduction of the RUS changed the management plan.

Results

100 patients were included in this study, and all received both POCUS and RUS. Depending on the surgeons’ POCUS based management decisions, the patients were divided into three groups: (1) surgery, (2) duct clearance, (3) no surgery. Total bilirubin was 34±22 mmol/L in the duct clearance group vs 8.4±6.5 mmol/L and 16±12 mmol/L in the surgery and no surgery groups, respectively (p<0.05). POCUS results showed 68 patients would have been offered surgery, 21 offered duct clearance, and 11 no surgery. In 90% of cases, the introduction of RUS did not change management. The acute care surgeons elected to operate on patients more frequently than other surgical subspecialties (p<0.05).

Conclusions

This study showed that fewer than 10% of patients with biliary disease seen on POCUS had a change in surgical decision-making based on the addition of RUS imaging. In uncomplicated cases of biliary disease, relying on POCUS imaging for surgical decision-making has the potential to improve patient flow.

Level of evidence

II Prospective Cohort Study.