Eur J Trauma Emerg Surg DOI 10.1007/s00068-015-0508-x

REVIEW ARTICLE

Clinician‑performed abdominal sonography E. Dickman1 · M. O. Tessaro2 · A. C. Arroyo1 · L. E. Haines1 · J. P. Marshall1 

Received: 18 November 2014 / Accepted: 2 March 2015 © Springer-Verlag Berlin Heidelberg 2015

Abstract  Introduction  Point-of-care ultrasonography is increasingly utilized across a wide variety of physician specialties. This imaging modality can be used to evaluate patients rapidly and accurately for a wide variety of pathologic conditions. Methods  A literature search was performed for articles focused on clinician-performed ultrasonography for the diagnosis of appendicitis, gallbladder disease, small bowel obstruction, intussusception, and several types of renal pathology. The findings of this search were summarized including the imaging techniques utilized in these studies. Conclusion  Clinician performed point-of-care sonography is particularly well suited to abdominal applications. Future investigations may further confirm and extend its utility at the bedside. Keywords  Point-of-care ultrasonography · Renal colic · Appendicitis · Cholecystitis · Small bowel obstruction · Intussusception

Introduction Clinician-performed bedside sonography is perfectly suited to the task of assessing the abdominal organs and cavity.

* E. Dickman [email protected] 1

Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY 11219, USA

2

Division of Paediatric Emergency Medicine, The Hospital for Sick Children, Toronto, ON M5G1X8, Canada



The presence of easy to visualize structures has lead to the wide adoption of bedside abdominal sonography for several diseases and has completely replaced some previously common invasive procedures such as diagnostic peritoneal lavage and culdocentesis. Clinician-performed sonography is a standard part of medical education, with many medical schools offering fairly comprehensive training as part of their undergraduate curriculum. This article reviews the literature and techniques for some of the most common organ-specific abdominal applications of clinician-performed sonography.

Renal The use of renal ultrasonography (RUS) has been studied in many clinical scenarios, including renal colic, traumatic injury to the kidneys and bladder, infection, and acute renal failure [1–9]. Increasingly, clinicians utilize this technology to diagnose their patients at the bedside. As opposed to traditional RUS performed in the Radiology Department, point-of-care (POC) RUS is used to answer a specific clinical question and entails a physician performing the ultrasound and interpreting the acquired images in real time. Other attractive features of POC RUS include that the test is repeatable if the patient’s condition changes and there is no ionizing radiation exposure. This last attribute is of particular importance for pregnant and pediatric patients. Often times, these ultrasounds can be performed in a more expeditious manner than imaging in the Radiology Department, which may lead to a shorter time-to-diagnosis. The use of clinician-performed sonography is supported by the American College of Emergency Physicians [10], and many other specialists have begun incorporating sonography into their practice.

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Fig. 1  A longitudinal view of a normal right kidney. Note the hypoechoic renal cortex (short arrow) and the hyperechoic collecting system (long arrow)

Fig. 2  A longitudinal view of a kidney with moderate hydronephrosis. Note the hypoechoic renal cortex (short arrow) and the hyperechoic collecting system with anechoic fluid in the center (long arrow)

To date, many of the studies assessing the accuracy of POC RUS have enrolled patients with possible hydronephrosis. Caronia et al. studied the ability of Internal Medicine residents to correctly perform and interpret limited RUS after undergoing a 5-h training module and three supervised sonographic examinations. The residents subsequently demonstrated a sensitivity of 94 % and a specificity of 93 % for the detection of hydronephrosis compared to technologist-performed exams interpreted by Radiologists [11]. While these results are encouraging, data from other studies have not been as favorable. Multiple studies have been performed to assess emergency physicians’ (EPs) abilities to detect hydronephrosis using POC RUS, with sensitivities ranging from 72 to 97 % and specificities of 73–83 % [3, 12–15]. A recent study involving EPs with a wide range of clinical and sonographic experience demonstrated a sensitivity and specificity of 73 and 73 %, respectively. In a subgroup analysis, EPs who had also completed an Emergency Ultrasound fellowship had sensitivity and specificity of 93 and 81 %, respectively [16]. Computed tomography (CT) is often performed when there is a clinical suspicion for renal colic. This is done in order to evaluate for other diagnoses, determine stone location, and to measure stone size, as size is a predictor of spontaneous stone passage. Ultrasonography can be utilized to visualize stones in the proximal and distal ureter. Ultrasound is less effective in visualizing stones in the midureter due to overlying bowel gas. However, the degree and presence of hydronephrosis can be assessed using sonography (Figs. 1, 2). In a retrospective study, Goertz demonstrated that stone size correlated with the degree of hydronephrosis, and ureteral stones ≥5 mm (and therefore less likely to pass spontaneously) were more likely to cause

moderate to severe hydronephrosis [17]. However, this conclusion needs to be prospectively validated. Edmonds et al. studied patients with suspected ureterolithiasis who underwent RUS in search of five specific findings: (1) a visualized stone in the ureter, (2) a renal intraparenchymal stone, (3) abnormal ureteral jets, (4) hydronephrosis, and (5) perinephric fluid. If none of these findings were present, the study was considered “normal” and these patients were subsequently found to require urologic intervention in just 0.6 % of cases [5]. Yan et al. enrolled patients with presumed renal colic, and using sonography, patients were assessed for a ureteral or intrarenal stone, hydronephrosis, perinephric fluid, periureteral stranding, or abnormal or absent ureteral jets. If none of these findings were present, 0 % of patients had a urologic intervention at 90 days [4]. Of note, both the Edmonds and the Yan studies had the RUS performed by ultrasound technicians and interpreted by Radiologists. Riddell et al. [18] retrospectively studied patients who had undergone RUS performed by EPs and found that all patients with a ureteral stone >5 mm had either hydronephrosis, microscopic hematuria, or both. This would identify the group of patients who would most likely require urologic intervention to assist with stone expulsion. While RUS is not as useful as CT for detecting other pathology which may be causing a patient’s flank pain, CT is costly, contributes to extended length of stay, and involves significant radiation exposure, particularly in the many patients who have repeat episodes of renal colic. Traumatic injuries are the leading cause of morbidity and mortality in patients between 1–44 years of age [19], and renal trauma occurs in 8–10 % of patients who have sustained abdominal trauma [20]. Imaging is indicated to assess for injury to the genitourinary (GU) tract

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if a patient has gross hematuria, any hematuria and hemodynamic instability, a deceleration injury, suspected other intraabdominal or pelvic injuries, or any degree of hematuria in the setting of penetrating trauma. Jalli et al. studied the use of RUS to diagnose traumatic renal injuries. The authors found that RUS had a sensitivity and specificity of 48 and 96 %, respectively. They conclude that due to the low sensitivity, RUS should not be used as the sole imaging modality when assessing traumatically injured patients for renal insults [6]. McGahan similarly found a sensitivity and specificity of 67 and 99.8 %, respectively, for detection of renal traumatic injury when ultrasonography was compared to CT [21]. Recently, Wu et al. [7] reported the first case of bedside sonography being utilized for the diagnosis of a traumatic bladder rupture. However, at this time, CT remains the standard for the diagnosis of traumatic injuries to the GU tract. Pyelonephritis is a commonly encountered infection. While many patients will improve with antibiotics, Chen et al. recommend RUS to assess for any significant abnormalities which might predict a complicated course for the patient. In their study, 39.6 % of patients had an abnormality detected with imaging [8]. RUS performed by EPs was used to detect hydronephrosis, abscess, and stones. Detection of one or more of these abnormalities was deemed significant enough to alter patient management. Patients who present with acute kidney injury (AKI) have traditionally undergone imaging of the GU tract. This practice has come into question recently, as the incidence of a discrete post-renal obstruction as the cause of AKI is relatively low. Podoll and colleagues found that in the 810 ultrasounds performed to assess patients with AKI, hydronephrosis, suggestive of an obstructive cause, was found in only 5 % of patients. Clinical history suggestive of finding an obstructive cause for AKI included flank pain, history of urolithiasis, or a pelvic mass such as an enlarged prostate [9]. Licurse described risk factors for hydronephrosis in patients with AKI: a history of hydronephrosis, nonblack race, recurrent urinary tract infections, diagnosis consistent with obstruction, no exposure to nephrotoxic medications, no evidence of congestive heart failure, and no prerenal azotemia. Patients who did not have one or more of these risk factors were unlikely to have an obstructive process as the cause of their AKI [22]. However, if imaging is to be performed, the American College of Radiology recommends RUS as the first-line imaging modality [23]. Technique Sonographic imaging of the GU tract includes both kidneys and the bladder. A dilated ureter may be visualized proximally at the junction with the renal pelvis or distally, as it inserts into the posterior wall of the bladder. As with other

organs of interest, the kidneys should be scanned in two orthogonal planes. In order to obtain a true longitudinal view of the kidney, the transducer may need to be rotated 10–15° from the body’s long axis. The probe should be moved anteriorly and posteriorly in order to ensure that the entire organ is visualized. The probe is then rotated 90° in order to view the kidney in a transverse axis. The probe is moved in a superior–inferior plane in order to scan through the entire kidney. This process is performed for both kidneys, while keeping in mind that the left kidney is more posterior and slightly superior when compared to the right kidney. The bladder is also visualized using both a longitudinal and transverse approach. It is again important to image the entire organ in order to ensure that a stone at the uretero-vesicular junction is not overlooked. Ultrasound findings The kidneys should be assessed for hydronephrosis. The presence of any masses, including simple and complex cysts, can also be determined, although this is not typically the focus of clinician-performed sonography. Cysts are usually located on the inferior or superior pole of the kidney. Peri-pelvic cysts can be mistakenly identified as hydronephrosis. However, as opposed to hydronephrosis, the anechoic collection will not extend to the calyces. In the bladder, the presence or absence of ureteral jets can be assessed, as can any evidence of intra-vesicular mass or blood clots, as well as stones at the uretero-vesicular junction, depending on the experience of the sonographer. The use of POC RUS appears to be best suited to patients presenting with signs and symptoms suggestive of renal colic, particularly if used in conjunction with other clinical findings. Further studies which incorporate RUS are necessary in order to develop algorithms for the assessment of patients with possible ureterolithiasis if there is a desire to decrease CT utilization.

Biliary Abdominal pain is the most common chief complaint in patients presenting to the emergency department (ED). It has been reported that up to one-third of all patients with abdominal pain presenting to the ED may have biliary pathology [24, 25]. Biliary pathology may cause a variety of symptoms-from the classic right upper quadrant pain to epigastric, flank, back, or shoulder pain, or even isolated nausea and vomiting. Unfortunately, the history, physical examination, and laboratory findings have all been shown to provide poor predictive value in diagnosing biliary pathology, and the best tools are a high clinical suspicion and diagnostic imaging [26]. For the patient

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with suspicion of biliary pathology, right upper quadrant ultrasound (RUQUS) has emerged as the first-line imaging modality because it has the highest sensitivity for detecting gallstones and exposes the patient to no ionizing radiation. POC RUQUS has become an indispensible tool for the clinician in the evaluation of upper abdominal pain. Results of this test can help to rearrange a differential diagnosis and to guide additional testing. EPs have been shown to have a sensitivity and specificity for detecting gallstones of 86–96 and 88–97 %, respectively. This resembles the pooled sensitivities and specificities in data gathered from radiologists (84 and 99 %, respectively) [27]. Radiologists demonstrated a 94 % sensitivity and a 84 % specificity in the sonographic diagnosis of acute cholecystitis [28]. One study showed that RUQUS performed by EPs had a 91 % sensitivity and a 66 % specificity for making the diagnosis. Remarkably, these numbers were obtained with no additional training prior to the initiation of the study [29]. Teaching the clinician to perform this study is relatively straightforward and it has been demonstrated that a clinician can become competent after performing and interpreting as few as 25 scans [30]. Because it requires an average of only 10 min, RUQUS has been shown to decrease ED length of stay [31]. Despite the relative ease and time benefits of this examination, care must be taken in the identification of stones. This is particularly true for small stones in the neck of the gallbladder, which can be challenging for even the most experienced sonographer. The astute clinician will remember that biliary disease remains ultimately a clinical diagnosis and not just a sonographic diagnosis. RUQUS is indicated for any patient in whom the history, physical examination, or laboratory findings raise the possibility of biliary pathology. The primary goal is to visualize gallstones. The secondary goal is to observe for signs of acute cholecystitis. A tertiary goal is to measure the common bile duct (CBD) to assess for dilation that would suggest biliary obstruction. Technique The RUQUS is best performed by first positioning the patient in the left lateral decubitus position. This position usually allows for better visualization of the gallbladder. Additionally, the patient is asked to take a deep breath whereupon the gallbladder moves inferiorly and is therefore more easily visualized. A low frequency, curvilinear probe is the best choice for this exam due to its better penetrating ability. The probe should be placed in the patient’s epigastrium in a longitudinal orientation with the probe marker directed cephalad. An infracostal sweep laterally toward the patient’s right side should allow the clinician to find the gallbladder (Fig. 3). The gallbladder may be tucked up under the patient’s ribs. In this case, the ultrasound beam can be

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Fig. 3  A longitudinal view of a normal gallbladder (thick arrow), the liver (star), and the portal triad (thin arrow)

Fig. 4  An example of acute cholecystitis. Note the large gallstone (thick arrow), with the anterior gallbladder wall thickened to 7.5 mm. The common bile duct (thin arrow) is located anterior to the larger portal vein and measures less than 6 mm in diameter from inner wall to inner wall

directed under the ribs, or the clinician may move the probe on top of the patient’s ribs, finding a window between the rib spaces. Once the anechoic (black) gallbladder is found, a slow careful sweep through the entire organ in two orthogonal directions should be performed in search of echogenic gallstones and the secondary signs of acute cholecystitis. Subsequently, the CBD should be identified and measured. Ultrasound findings Gallstones are the primary indication that the patient may have biliary pathology since 95–99 % of patients with acute

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cholecystitis will have gallstones [32]. Gallstones appear as hyperechoic (bright) objects within the lumen of the gallbladder and usually create posterior acoustic shadowing that can aid in the identification of the stones (Fig. 4). The stones are gravitationally dependent, unless impacted in the neck of the gallbladder, whereas folds or polyps in the gallbladder will not move when the patient changes position. In addition, folds and polyps usually do not cause posterior acoustic shadowing. The sonographer should be meticulous in scanning the neck of the gallbladder to ensure that there are no inconspicuous impacted stones, as these stones may be symptomatic. Also, if the gallbladder is contracted around a big stone or a collection of stones, the bile filled lumen of the gallbladder may not be visible. This is termed the “WES” (Wall, Echo, Shadow) sign because all that is visible is the echogenic gallbladder wall anterior to the strongly hyperechoic gallstone(s) and the posterior acoustic shadow behind it. Sludge may appear as a hyperechoicor hypoechoic-dependent layer within the gallbladder, and does not usually cause shadowing. Sludge may cause biliary disease, so its presence should prompt the clinician to assess for additional signs of acute cholecystitis. Gallbladder wall thickening, a dilated gallbladder, pericholecystic fluid, and a sonographic Murphy’s sign are the secondary signs of acute cholecystitis. The anterior gallbladder wall should be measured. The normal gallbladder wall should be less than 3 mm thick. A wall >3 mm is a sensitive finding for acute cholecystitis, but is not specific as this finding may be seen in numerous other conditions, as well as the post-prandial state. A dilated gallbladder with a transverse width of >5 cm can be indicative of an impacted stone [33]. Pericholecystic fluid is an uncommon finding and may be subtle in appearance, but when found it is very specific for acute cholecystitis [34]. A sonographic Murphy’s sign is considered present if pain is elicited when the gallbladder is visualized, and pressure is placed directly over the gallbladder area with the probe. A prospective study reported a positive predictive value of 92 %, for the combination of gallstones and a sonographic Murphy’s sign, whereas a combination of gallstones and gallbladder wall thickening had a positive predictive value of 95 %, for the diagnosis of acute cholecystitis. No single sign is definitive for acute cholecystitis, but the presence of multiple signs increases the likelihood of this disease [32]. An attempt to identify and measure the CBD is prudent. This is especially true in patients who present with jaundice, abnormal liver function tests, or a suspected abdominal source of sepsis. It has been reported that 25 % of patients with intra-abdominal sepsis have acute cholecystitis or cholangitis as the etiology [35]. The CBD, along with the portal vein and the hepatic artery are the components of the portal triad. Sonographically, this triad is encased in fat and connective tissue so it appears hyperechoic (bright)

and is easily identifiable. The CBD is usually anterior to the portal vein (Fig. 4) and will not exhibit internal Doppler flow. Once identified, the lumen is measured from inner wall to inner wall. The normal CBD diameter is 2.5 cm in transverse diameter) and fluid-filled bowel loops proximal to the site of obstruction (Fig. 13), while bowel distal to the obstruction appears either normal or collapsed [49, 55]. Obstructed bowel also exhibits absent or decreased peristalsis, described as “to-and-fro” motion of echoes within the bowel lumen [49, 50].

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of the abdomen (where it can also be imaged from the flanks) and running transversely across the upper abdomen. Small bowel is encountered in the central abdominal areas [50]. Gas that obscures visualization can be displaced by gentle graded compression with the transducer, or by moving the patient into decubitus positions [50, 56]. An accurate sonographic assessment for SBO can be completed in under 5 min [55].

Intussusception

Fig. 13  Bedside abdominal ultrasound image revealing dilated and fluid-filled bowel loops. Arrowhead indicates bowel wall. Arrow indicates bowel content. No peristalsis occurred during min of dynamic sonographic visualization

Debate exists over the sonographic criteria for SBO. Some authors state that the cut-off of 2.5 cm for bowel dilation applies only to the jejunum, and that a diameter >1.5 cm constitutes dilated ileum. This sonographic distinction between jejunum and ileum requires recognition of the more numerous and prominent valvulae conniventes in the jejunum [55]. There is an agreement that sonography is more accurate for SBO when both dilated bowel and abnormal peristalsis are taken into account [48, 49, 55]. Both bowel dilation and decreased peristalsis can also be seen in a functional ileus, and it is suggested that observing a transition point from dilated to collapsed bowel can distinguish mechanical obstruction from ileus [47, 50]. Future studies are needed to clarify the ability of sonography to predict advanced cases likely to fail conservative measures. Preliminary works suggests the utility of some combination of bowel wall thickening, intraperitoneal free fluid, and decreasing motion of bowel content on serial sonographic examinations [56–58]. Technique Curved, phased array, and linear transducers have all proven accurate in the assessment of SBO [49, 50, 55]. With the patient in the supine position, the abdomen is interrogated in both transverse and longitudinal orientations. Large bowel is encountered along the lateral aspects

Intussusception is the most common cause of intestinal obstruction in children between 3 months to 6 years of age, and occurs in 1–4 per 1000 children [59, 60]. It occurs when a portion of bowel (the intussusceptum) telescopes into an adjacent distal bowel segment (the intussuscipiens). In children, this most commonly occurs with ileum acting as the intussusceptum and colon as the intussuscipiens, and is thought to occur when Peyer’s patches become inflamed after a viral illness and act as a lead point [61–63]. Untreated intussusception can lead to dehydration, intestinal necrosis, and death. Treatment delays are associated with decreased enema reduction success rates and the need for bowel resection [59, 64–66]. The classic clinical triad of vomiting, intermittent abdominal pain, and bloody stools has a positive predictive value of 93 % but occurs in less than 25 % of cases [59, 65, 67]. Instead, most patients present with non-specific symptoms (vomiting, abdominal pain, crying, or lethargy) that create a very wide differential diagnosis. Abdominal radiographs exhibit sensitivities of only 45–50 % for intussusception [63]. While barium contrast enema is highly accurate for this condition, its use as a screening test is limited by its invasive nature, radiation exposure, and an approximately 1 % risk of bowel perforation [63, 65–67]. Ultrasound is highly accurate for intussusception, with radiology literature indicating sensitivity between 98–100 % and specificity between 88–100 % [65, 66]. Studies of POC ultrasonography by pediatric EPs also demonstrate high accuracy for the detection of intussusception in children, with sensitivities of 85–89 % and specificities of 97–98 % [66, 68]. There are also reports of POC ultrasonography being used by EPs to diagnose intussusception in adults [60, 62]. While rare, false-positive ultrasounds for intussusception have been reported due to fecal matter, thickened bowel wall (e.g., enterocolitis), volvulus, mesenteric adenopathy, or misidentification of the kidney or psoas muscle [60, 61, 63, 65, 70]. The literature shows a higher false-negative rate for POC ultrasonography compared to radiology-performed

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Ultrasound findings

Fig. 14  Bedside abdominal ultrasound image of an intussusception in cross section, demonstrating the “donut” sign of multiple concentric rings of bowel wall surrounding a central echogenic core. The arrowed line demonstrates measurement of the cross-sectional diameter of the intussusception

An intussusception seen in cross section on ultrasound appears as a mass of concentric rings and has been described as a “target”, “bulls eye”, or “donut” (Fig. 14). The hypoechoic edematous bowel walls of the intussuscipiens surround the central echogenic mucosa and mesentery of the intussusceptum [59, 62, 64]. Viewed longitudinally, an intussusception appears as “hayfork” or “sandwich” of parallel echogenic mucosal stripes, the outer two belonging to the intussusipiens and the central one representing the intussusceptum (Fig. 15). Hypoechoic bowel wall is interposed between these mucosal stripes [59, 60]. The “pseudokidney” sign is obtained with an oblique view of an intussusception, with the hypoechoic “cortex” of edematous bowel wall surrounding the echogenic “collecting system” of mucosa and mesentery [60, 61, 64]. Ileocolic intussusceptions in children are usually greater than 2 cm in transverse diameter [69]. Lesions smaller than this, especially if they are found in the left quadrants, are more likely ileoileal and should be observed in real time as they are more likely to spontaneously reduce [61]. Technique

Fig. 15  Bedside abdominal ultrasound image of an intussusception in long-axis view. In this “sandwich sign”, the stars indicate the outer bowel layers of the intussuscipiens, while the circle marks the inner bowel of the intussusceptum

ultrasonography for intussusception, suggesting that POC ultrasonography should be used as a rule-in rather than rule-out test for this condition [67]. When used successfully to rule-in intussusception, POC ultrasonography can significantly decrease time to enema reduction [65].

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Ultrasonography for intussusception is an easily learned application [59, 61, 66]. Best results are achieved with a high-frequency linear transducer and a starting depth between 4 and 7 cm [59, 61, 66]. To begin tracing the course of the large intestine for an ileocolic intussusception, the psoas muscle is identified as a landmark with the probe in the transverse orientation in the right lower quadrant [66]. An ileocolic intussusception will most commonly be seen as the probe is swept superolaterally toward the RUQ [61, 66]. Once the liver and gallbladder are seen, the probe is rotated into a longitudinal orientation and swept across the epigastrium from the RUQ to the left upper quadrant (LUQ), before being returned to a transverse orientation and swept inferiorly from the LUQ into the left lower quadrant [61, 66]. Gentle graded compression can be used to displace bowel gas [64]. If a lesion resembling an intussusception is noted, it should be scanned throughout its length in multiple planes.

Summary The thoughtful application of clinician-performed sonography has had a profound impact on the assessment of the abdomen. Physicians who utilize this technology are able to rapidly assess their patients for a variety of pathologic abdominal conditions, including hydronephrosis,

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gallbladder disease, appendicitis, small bowel obstruction, and intussusception. The high sensitivity and specificity of ultrasonography allows physicians to expeditiously “rulein” and “rule-out” these and other disease states.

Conclusion Clinician-performed ultrasonography has been demonstrated to be a safe and effective tool when performed by well-trained physicians. This accurate imaging modality can be performed at the bedside, utilizes no ionizing radiation, and is associated with a decreased length of stay, which is increasingly important in crowded EDs. Further research on sonographic applications, education and competency assessment will better delineate the limits of its applicability at the bedside. The current state of evidence, however, clearly demonstrates that clinician-performed sonography is the first-line imaging of choice for many disease processes. Conflict of interest  Dr.’s E. Dickman, M. O. Tessaro, A. C. Arroyo, L. E. Haines, and J. P. Marshall declare they have no conflict of interest. Compliance with Ethics Guidelines  This article does not contain any studies with human participants or animals performed by any of the authors.

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Clinician-performed abdominal sonography.

Point-of-care ultrasonography is increasingly utilized across a wide variety of physician specialties. This imaging modality can be used to evaluate p...
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