Case

A 50-year-old woman presents to the emergency department (ED) complaining of epigastric pain and nausea for 36 hours. The physical examination is consistent with biliary colic and the blood work shows a mild elevation in C-reactive protein while her white blood cell count and liver function tests are normal. You perform a biliary ultrasound (US) in the ED (BUSED) which shows a gallbladder (GB) full of stones, some GB wall thickening and a positive Murphy’s sign. Will this be enough for the general surgeon, or will they want an US performed by the radiology department to make their surgical decision?

Clinical Question

What is the value of radiology-performed US (RUS) compared to BUSED in terms of the surgical decision-making in acute biliary disease?

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Background

Ultrasound is typically the first-line imaging modality for the diagnosis of acute biliary disease. ED physician-performed point of care ultrasound (POCUS) has increased in popularity over the last decade. Several small trials have compared the accuracy of POCUS versus the “gold standard” of radiology performed ultrasound. Little is known regarding whether the department in which the US is performed (ED or radiology) impacts the surgeon’s clinical decision making.

Reference: Hilsden, et al. Point of care biliary ultrasound in the emergency department (BUSED) predicts final surgical management decisions. Trauma Surg Acute Care Open. 2022;7(1):e000944.

• Population: Adult ED patients 18 years of age or older with abdominal pain whom the EM physician felt had biliary disease after performing a history, physical examination, and BUSED.
• Excluded: Cases in which surgery was completed prior to formal ultrasound imaging, there was failure to gain consent, or patient’s age was less than 18 years.
• Intervention: Surgical decision (offer surgery, endoscopic retrograde cholangiopancreatography/magnetic resonance cholangiopancreatography [ERCP/MRCP], or no surgery) based on the clinical, laboratory and BUSED data. There were 11 specially trained ED physicians and 20 surgeons.
• Comparison: Surgical decision made after formal radiology ultrasound (RUS).
• Outcome (Primary): Percentage of patients in which the management changed after RUS was performed.
• Type of Study: Observational, prospective, cohort study performed at a tertiary care center in Canada.

Authors’ Conclusions

Gallstones removed via surgery.

This prospective study has shown that in the vast majority of cases the additional information afforded by formal RUS does not alter clinical management. Point-of-care biliary ultrasound has been demonstrated to be reliable in the diagnosis of acute biliary disease and offers a safe and efficient diagnostic pathway for patients presenting in the emergency department.