Results

There were 100 consecutive patients recruited into the study available for analysis. The mean age of participants was 50 years. They admitted 68 patients for surgery, 21 for duct clearance (ERCP/MRCP), and 11 for no surgery.

Key Result

• The surgical plan was not changed often after a formal radiology US was performed.
• Primary outcome: The initial plan based upon the ED POCUS was changed 10 percent of the time after RUS was performed. See the alluvial diagram.

EBM Commentary

1. Unmasked surgeons: The surgeon in this study knew that the patient was going to have both a BUSED and RUS examination. This could have introduced some confounders depending on the surgeon’s opinion of BUSED. This issue could have been addressed by masking the surgeon to which report was from the ED and which was a formal US from the radiology department.
2. External validity: This is a small study of 11 emergency physicians and 20 surgeons performed at a single, tertiary, university-affiliated hospital in Canada. Hospitals have their own culture of practice patterns. This group of physicians may not reflect practice in other tertiary centers, smaller community hospitals, or different countries.
3. Location versus experience: Ultimately, this is not a comparison between BUSED and RUS, but between US and US. The skill to obtain and interpret an US image is operator-dependent. It can be tricky to detect gallstones in the neck of the GB or common bile duct; it is a learned skill. Sensitivity for these subtle findings goes up with experience. The difference observed in this study could be due to less-experienced versus more-experienced sonographers.

Bottom Line

An emergency physician trained in BUSED can correctly inform surgical decision-making in most cases of non-jaundiced adult patients with suspected acute biliary disease.

Case Resolution

You present the surgeon with the clinical case, including the BUSED results. The surgeon agrees the patient has acute cholecystitis and admits the patient to the surgical team for further management.

Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.

Thank you to Dr. Casey Parker, an emergency physician working in Broome, Australia, for his help with this review.