1990, The British Journal of Radiology, 63, 698-699
Ultrasound as part of a 1 -day gastroenterology clinic: advantages and problems By S. Ryan, FRCSI, A. Chua, MB, C. Clabby, SRN, P. W. N. Keeling, MD, FRCPI and E. J. Fitzgerald, MRCP, FRCR Departments of Diagnostic Imaging and Gastroenterology, St James's Hospital, Dublin 8, Ireland {Received January 1990 and in revised form March 1990) Abstract. Ultrasound was introduced into a 1-day gastroenterology clinic so that clinical assessment, endoscopy and ultrasound could be performed as appropriate in a single hospital visit. The findings in 602 patients are reported. A total of 256 (43%) patients underwent ultrasound, 35% of which showed positive findings including cholelithiasis in 12% and tumours in 7%. This system of referral for ultrasound is very convenient for patients and their general practitioner and is less costly than traditional referral methods. It is, however, time-consuming for the radiologist.
With increasing constraints on hospital resources, especially on in-patient facilities, more patients are being investigated as out-patients. In the past, several visits to the hospital for assessment, investigations and review of results were necessary. More recently, gastroenterology clinics have been established that include endoscopy with clinical assessment at a single visit (Beavis et al, 1979; Lobo & Dickenson, 1988). There have been no reports, however, of the inclusion of diagnostic imaging within this arrangement. The aim of this study was to evaluate the role of ultrasound within a 1-day gastroenterology service. We report our findings in 602 patients and present the advantages and difficulties encountered. Patients and methods Patients are referred to the 1-day gastroenterology service by their general practitioner. They attend the clinic fasting and are first assessed by a gastroenterologist, and are then referred for blood tests, endoscopy and ultrasound, as appropriate. As far as possible all procedures are carried out during the morning. The next day the gastroenterologists and radiologists meet to review the results of these investigations and a management plan is formulated for each patient. The referring doctor is notified and frequently the patient is referred back to him after only one hospital visit. Results In the first 6 months, 602 patients (aged between 14 and 85 years with a mean age of 35 years) were seen at the 1-day gastroenterology service. Presenting symptoms included dyspepsia, abdominal pain, vomiting and weight loss. Upper gastrointestinal endoscopy was undertaken where clinical diagnosis included the possibility of oesophageal, gastric or duodenal disease; 536 patients (89%) underwent endoscopy. Those patients whose history included right hypochondrial pain, subscapular pain, fat intolerance or jaundice or whose examination otherwise suggested 698
Table I. Findings of ultrasound examination of 256 patients Normal Renal cysts Gallstones Dilated common bile duct Fatty liver Ascites Tumours: Benign Malignant
165 (64%) 10 31 18 10 3 5 14
hepatic or biliary disease were referred for abdominal ultrasound examination. In addition, 22 patients with suspected lower abdominal or gynaecological disease were referred for pelvic untrasound studies. Examination of the thyroid was carried out in 15 patients and two obstetrical sonograms were performed. In all, 256 patients (43%) were referred for ultrasound examination (Table I). One hundred and sixty-five examinations (64%) were reported as normal. In a further 10 cases, a simple renal cyst, varying in size from 8 mm to 7 cm, was the only abnormality. The commonest finding in the remaining 81 patients was cholelithiasis, seen in 31 cases, all of whom had biliary symptoms. The common bile duct was dilated in 18 patients, five of whom had had cholecystectomy and in two of whom calculi were seen in the common bile duct. Fatty liver was noted in 10 cases and contributed to the final diagnosis in six of these. Ascites was diagnosed in three patients. Benign tumours were reported in five cases: four haemangiomata of the liver (all confirmed by dynamic computed tomographic (CT) studies and managed conservatively) and one small angiomyolipoma of the kidney which was resected (Table II). Fourteen patients were shown to have malignant tumours: five of the liver, four pancreatic cancers, one The British Journal of Radiology, September 1990
Ultrasound as part of a 1-day gastroenterology clinic
Table II. Findings of tumour in 19 patients Benign tumours: Liver haemangioma Renal Malignant tumours: Hepatic Pancreatic Renal Gastric Oesophageal Adrenal
Stage 1 hypernephroma, a gastric mass and a lower oesophageal tumour. These last two were seen and biopsied on endoscopy. Two adrenal tumours were reported but malignancy was confirmed in only one of these. Discussion
The introduction of ultrasound as part of a 1-day gastroenterology service has several advantages. The greatest is that it saves patients the expense and inconvenience of further visits to hospital for investigations, and when investigations are normal further out-patient department visits are avoided. General practitioners like this system. Open access to ultrasound is available to GPs in our hospital but referral to this particular clinic has the extra advantage of a gastroenterologist's opinion and, if appropriate, endoscopy. Furthermore, they promptly resume the care of many of their patients. Some reduction in administrative costs is achieved. Previous radiographs, for example, are made available on one occasion only rather than for two out-patient visits and again on the day of the ultrasound examination. Reports of ultrasound studies are available at the discussion meeting. The proportion of positive scans compares well with other out-patient studies (Colquhoun et al, 1988). This
Vol. 63, No. 753
suggests that ease of access alone did not lead to inappropriate referral for ultrasound examinations. In fact, we found that discussion of individual cases between radiologists and gastroenterologists at the time of the ultrasound scan increased the usefulness of the examination. However, flexibility is required to operate this system, as the caseload is unpredictable. Between four and 19 patients per session were referred for ultrasound with an average of 10 patients per day. The radiologist must remain available even when few patients are referred. Also, some delay may be necessary to allow patient preparation, such as bladder filling for pelvic studies. It is helpful if the ultrasound equipment is sited close to the endoscopy unit, preferably in adjoining rooms, to allow easy transfer of patients from one to another. The meeting held on the following day to discuss the patients is another call on the time of those involved. Conclusions
Ultrasound has an important role in the investigation of gastrointestinal disease. When ultrasound is introduced into a 1-day gastroenterology service, the positive yield is maintained. Though time-consuming for the radiologist, it is much more convenient for the patient and his general practitioner than traditional methods of referral for ultrasound examination. It also reduces administrative costs. We feel that this has made a valuable contribution to patient care in our hospital. References BEAVIS, A.
K.,
LA BROOY, S. &
MISIEWICZ, J.
J.,
1979.
Evaluation of one-visit endoscopic clinics for patients with dyspepsia. British Medical Journal, 1, 1387-1389. COLQUHOUN, I. R., SAYWELL, W. R. & DEWBURY, K. C ,
1988.
An analysis of referrals for primary diagnostic abdominal ultrasound to a general X-ray department. British Journal of Radiology, 61, 297-300. LOBO, A. & DICKENSON, R., 1988. Managing the dyspeptic
patient: experience of a single-visit dyspepsia clinic. Journal of the Royal Society of Medicine, 81, 212-213.
699
Ultrasound as part of a 1 -day gastroenterology clinic: advantages and problems By S. Ryan, FRCSI, A. Chua, MB, C. Clabby, SRN, P. W. N. Keeling, MD, FRCPI and E. J. Fitzgerald, MRCP, FRCR Departments of Diagnostic Imaging and Gastroenterology, St James's Hospital, Dublin 8, Ireland {Received January 1990 and in revised form March 1990) Abstract. Ultrasound was introduced into a 1-day gastroenterology clinic so that clinical assessment, endoscopy and ultrasound could be performed as appropriate in a single hospital visit. The findings in 602 patients are reported. A total of 256 (43%) patients underwent ultrasound, 35% of which showed positive findings including cholelithiasis in 12% and tumours in 7%. This system of referral for ultrasound is very convenient for patients and their general practitioner and is less costly than traditional referral methods. It is, however, time-consuming for the radiologist.
With increasing constraints on hospital resources, especially on in-patient facilities, more patients are being investigated as out-patients. In the past, several visits to the hospital for assessment, investigations and review of results were necessary. More recently, gastroenterology clinics have been established that include endoscopy with clinical assessment at a single visit (Beavis et al, 1979; Lobo & Dickenson, 1988). There have been no reports, however, of the inclusion of diagnostic imaging within this arrangement. The aim of this study was to evaluate the role of ultrasound within a 1-day gastroenterology service. We report our findings in 602 patients and present the advantages and difficulties encountered. Patients and methods Patients are referred to the 1-day gastroenterology service by their general practitioner. They attend the clinic fasting and are first assessed by a gastroenterologist, and are then referred for blood tests, endoscopy and ultrasound, as appropriate. As far as possible all procedures are carried out during the morning. The next day the gastroenterologists and radiologists meet to review the results of these investigations and a management plan is formulated for each patient. The referring doctor is notified and frequently the patient is referred back to him after only one hospital visit. Results In the first 6 months, 602 patients (aged between 14 and 85 years with a mean age of 35 years) were seen at the 1-day gastroenterology service. Presenting symptoms included dyspepsia, abdominal pain, vomiting and weight loss. Upper gastrointestinal endoscopy was undertaken where clinical diagnosis included the possibility of oesophageal, gastric or duodenal disease; 536 patients (89%) underwent endoscopy. Those patients whose history included right hypochondrial pain, subscapular pain, fat intolerance or jaundice or whose examination otherwise suggested 698
Table I. Findings of ultrasound examination of 256 patients Normal Renal cysts Gallstones Dilated common bile duct Fatty liver Ascites Tumours: Benign Malignant
165 (64%) 10 31 18 10 3 5 14
hepatic or biliary disease were referred for abdominal ultrasound examination. In addition, 22 patients with suspected lower abdominal or gynaecological disease were referred for pelvic untrasound studies. Examination of the thyroid was carried out in 15 patients and two obstetrical sonograms were performed. In all, 256 patients (43%) were referred for ultrasound examination (Table I). One hundred and sixty-five examinations (64%) were reported as normal. In a further 10 cases, a simple renal cyst, varying in size from 8 mm to 7 cm, was the only abnormality. The commonest finding in the remaining 81 patients was cholelithiasis, seen in 31 cases, all of whom had biliary symptoms. The common bile duct was dilated in 18 patients, five of whom had had cholecystectomy and in two of whom calculi were seen in the common bile duct. Fatty liver was noted in 10 cases and contributed to the final diagnosis in six of these. Ascites was diagnosed in three patients. Benign tumours were reported in five cases: four haemangiomata of the liver (all confirmed by dynamic computed tomographic (CT) studies and managed conservatively) and one small angiomyolipoma of the kidney which was resected (Table II). Fourteen patients were shown to have malignant tumours: five of the liver, four pancreatic cancers, one The British Journal of Radiology, September 1990
Ultrasound as part of a 1-day gastroenterology clinic
Table II. Findings of tumour in 19 patients Benign tumours: Liver haemangioma Renal Malignant tumours: Hepatic Pancreatic Renal Gastric Oesophageal Adrenal
Stage 1 hypernephroma, a gastric mass and a lower oesophageal tumour. These last two were seen and biopsied on endoscopy. Two adrenal tumours were reported but malignancy was confirmed in only one of these. Discussion
The introduction of ultrasound as part of a 1-day gastroenterology service has several advantages. The greatest is that it saves patients the expense and inconvenience of further visits to hospital for investigations, and when investigations are normal further out-patient department visits are avoided. General practitioners like this system. Open access to ultrasound is available to GPs in our hospital but referral to this particular clinic has the extra advantage of a gastroenterologist's opinion and, if appropriate, endoscopy. Furthermore, they promptly resume the care of many of their patients. Some reduction in administrative costs is achieved. Previous radiographs, for example, are made available on one occasion only rather than for two out-patient visits and again on the day of the ultrasound examination. Reports of ultrasound studies are available at the discussion meeting. The proportion of positive scans compares well with other out-patient studies (Colquhoun et al, 1988). This
Vol. 63, No. 753
suggests that ease of access alone did not lead to inappropriate referral for ultrasound examinations. In fact, we found that discussion of individual cases between radiologists and gastroenterologists at the time of the ultrasound scan increased the usefulness of the examination. However, flexibility is required to operate this system, as the caseload is unpredictable. Between four and 19 patients per session were referred for ultrasound with an average of 10 patients per day. The radiologist must remain available even when few patients are referred. Also, some delay may be necessary to allow patient preparation, such as bladder filling for pelvic studies. It is helpful if the ultrasound equipment is sited close to the endoscopy unit, preferably in adjoining rooms, to allow easy transfer of patients from one to another. The meeting held on the following day to discuss the patients is another call on the time of those involved. Conclusions
Ultrasound has an important role in the investigation of gastrointestinal disease. When ultrasound is introduced into a 1-day gastroenterology service, the positive yield is maintained. Though time-consuming for the radiologist, it is much more convenient for the patient and his general practitioner than traditional methods of referral for ultrasound examination. It also reduces administrative costs. We feel that this has made a valuable contribution to patient care in our hospital. References BEAVIS, A.
K.,
LA BROOY, S. &
MISIEWICZ, J.
J.,
1979.
Evaluation of one-visit endoscopic clinics for patients with dyspepsia. British Medical Journal, 1, 1387-1389. COLQUHOUN, I. R., SAYWELL, W. R. & DEWBURY, K. C ,
1988.
An analysis of referrals for primary diagnostic abdominal ultrasound to a general X-ray department. British Journal of Radiology, 61, 297-300. LOBO, A. & DICKENSON, R., 1988. Managing the dyspeptic
patient: experience of a single-visit dyspepsia clinic. Journal of the Royal Society of Medicine, 81, 212-213.
699
