Ultrasound

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7266076/

Ultrasound is, in most cases, the first imaging technique used to diagnose and characterize
abdominal pathology. Sometimes, ultrasound alone or with ultrasound contrast agents can be
sufficient to make a complete diagnosis to enable management of the patient. The American
Institute for Ultrasound in Medicine (AIUM) published the following indications for abdominal
ultrasound, summarized in Tab. Tab.22(3).

Indications for abdominal ultrasound [AIUM Practice Parameter for the Performance of an
Ultrasound Examination of the Abdomen and/or Retroperitoneum.
http://www.aium.org/resources/guidelines/abdominal.pdf]
Abdominal non-traumatic emergencies

US is the most widely used imaging technique in abdominal emergencies(4). It can be used in
the setting of both acute and chronic pain. US excludes important pathology, and is sometimes
the only imaging technique required to make a full diagnosis (e.g. in biliary lithiasis or
cholecystitis). It can also guide decisions about further investigations. In the case of acute
abdominal pain, different studies have shown that US adds 40% more information than clinical
examination alone and changes the management in 20% of cases(5). Using US in patients with
acute abdominal pain can decrease the number of emergency abdominal CT examinations by a
half. The combined use of US and CT in patients with inconclusive US examinations in cases of
acute abdominal pain will reduce the percentage of missed urgent diagnoses to 6%(6).

Jaundice

Ultrasound is the imaging technique of choice in patients with jaundice. It can demonstrate
obstruction by showing dilated biliary ducts, and sometimes it can identify the cause of
obstruction. Sensitivity for the detection of choledocholithiasis varies considerably across
different centers, with values between 25% and 100% being reported(7). Endoscopic ultrasound
is the method of choice to rule out microlithiasis(8).

Urinary symptoms

Ultrasound should be used in patients with symptoms related to the urinary tract, such as
hematuria (Fig. (Fig.1).1). The most important indications for ultrasound in urinary tract infection
are to check for complications, such as nephritic foci in the kidneys or renal abscesses, or to
exclude an obstructive cause of pyelonephritis.

Sensitivity of conventional B-mode ultrasound in detecting renal tumors depends on the size
and location of the tumor. In one study the detection rate was 65% for tumors <2.5 cm and 80%
for tumors >2.5 cm(9). Contrast-enhanced ultrasound (CEUS) results are comparable to
contrast-enhanced CT for characterization of focal renal lesions. US has a sensitivity of 87.1%
and a specificity of 98.1% in diagnosing bladder tumors(10).

Palpable abnormalities, such as abdominal mass or organomegaly

Both US and CT are excellent techniques for confirming or excluding the presence of an
abdominal mass, with sensitivity and specificity higher than 95%(11). The accuracy of US in
determining the organ of origin is estimated at between 88% and 91%(11).

Elevated liver enzymes

For patients with elevated liver enzymes, ultrasound should be the first imaging technique used.
US performs well in the diagnosis of diffuse liver disease, with a sensitivity >90% for the
diagnosis of advanced liver cirrhosis with complications(12).

Follow-up of already diagnosed and documented abdominal pathology

US is recommended as a follow-up technique for ectatic abdominal aorta (diameter between 2.6
and 2.9 cm). Aneurysms with a diameter >3 cm should be examined by CT. In pancreatitis, the
first evaluation is often done by means of CT. Ultrasound is useful in follow-up since frequent
CT scans lead to excessive irradiation exposure.

Staging and evaluation of known oncologic pathology

Where there is good visualization of the liver, contrast-enhanced ultrasound has a comparable
sensitivity to contrast-enhanced CT or MRI for the diagnosis of liver metastasis. CEUS of the
liver has been shown to detect more metastases in the follow-up of colorectal metastases than
conventional B-mode US(13).

Evaluation of suspected congenital abnormalities

Congenital abnormalities can be diagnosed with both antenatal and postnatal US evaluations.
Ultrasound is typically the first imaging method used in urinary tract congenital abnormalities
because of its easy availability, non-invasiveness and the fact that it is free from ionizing
radiation. CT and MRI are indicated in complex urinary malformations to evaluate the collecting
system and vascular anatomy.

Abdominal trauma

CEUS has significantly improved the diagnostic performance of US in the diagnosis of

parenchymal organ injuries, with sensitivity and specificity of >90% and up to 99% under certain
circumstances; the performance is then similiar to that of CT. CEUS can prevent overutilization
of CT(14). Ultrasound is generally used as the diagnostic tool of choice in low-energy trauma
limited to the abdomen. In a series of 57 patients with blunt abdominal trauma, the diagnostic
accuracy of ultrasound in evaluating the existence of peritoneal fluid was 91%, although it was
only 56% for the evaluation of parenchymal injury. However, another study reported
considerably better accuracy, with a value of 94.7% for the combined presence of parenchymal
injury and free peritoneal fluid(15). The different results reported may be due to differences in
experience between operators and centers. Focused Assessment with Sonography for Trauma
(FAST) shows high sensitivity up to 99% for the detection of free fluid, but the sensitivity in the
diagnosis of parenchymal injuries is poor.

Pre-transplantation and post-transplantation evaluation

Ultrasound is an additional method to CT for pre- and post-transplantation evaluations. CT is

considered the technique of choice due to its better suitability for assessing vascular structures.
US can be used in diagnosis and follow-up of non-vascular complications of transplants, such
as abscesses or the presence of free fluid.

Interventional procedures

US can be used for guiding both diagnostic and interventional procedures in abdominal
pathology. Interventional US benefits from the development of new techniques, such as fusion
imaging (a technique that uses data from two different imaging modalities to improve the quality
of information for increased diagnostic accuracy) and CEUS. The complication rate in
interventional ultrasound is low, ranging from 0.51% to 0.81% in US-guided fine needle biopsy,
although the rate ranges from 0.4% to 2.5% when a needle with a diameter over 1 mm is
used(16).

Evaluation of peritoneal or retroperitoneal fluid

Ultrasound is the method of choice for the detection, quantification and localization of peritoneal
fluid, with results superior to CT. US can detect even small amounts of fluid in the
peritoneum(17).

Abdominal emergencies in children

Ultrasound is the recommended imaging method for the diagnosis of abdominal emergencies in
newborns and young children, such as hypertrophic pyloric stenosis or intussusception. For
suspected hypertrophic pyloric stenosis, ultrasound, in experienced hands, has sensitivity and
accuracy close to 100% and a diagnostic accuracy of 97%–100% for the diagnosis of
intussusception(18). In children, ultrasound is also the technique of choice to identify treatable
abnormalities that favor upper urinary tract infections, other than vesico-ureteral reflux.
Contrast-enhanced voiding urosonography is replacing radiographic voiding cystourethrography
as the technique of choice in diagnosing vesico-ureteral reflux.

The usage of contrast-enhanced ultrasound (CEUS)

CEUS is indicated in both hepatic and non-hepatic pathology. The role of CEUS in
characterizing focal liver lesions is well-established. When US is technically satisfactory, it offers
comparable results to those of CT and MRI. A large multicenter study showed the value of
CEUS in the characterization of focal liver lesions(19). CEUS has also proved its value in renal,
pancreatic and small bowel pathology. In most of the cases evaluated by CEUS, ultrasound
contrast agents (UCA) are administered intravenously. Intracavitary administration of UCA can
also offer useful diagnostic information. UCAs can be injected in physiologic cavities, such as
the bladder for vesico-ureteral reflux or the uterine cavity for assessing tubal patency or in
pathologic cavities for the characterization of fistulae. CEUS can be used intraoperatively
especially in gastrointestinal surgery, but also in neurosurgery and interventional procedures,
such as biopsies and interstitial ablation therapies which can be guided using CEUS.

Overview of point-of-care abdominal ultrasound in emergency and critical care

https://www.researchgate.net/publication/306098607_Overview_of_point-of-
care_abdominal_ultrasound_in_emergency_and_critical_care/fulltext/
58b1400b45851503be9801a1/Overview-of-point-of-care-abdominal-ultrasound-in-emergency-
and-critical-care.pdf?origin=publication_detail

Clinical manifestations and point-of-care US

Acute abdominal pain
As a single imaging strategy, computed tomography (CT) is overall superior to US in patients
with acute abdominal pain [4]. Laméris et al. reported that conditional strategy with CT after
negative or inconclusive radiology US resulted in the highest overall sensitivity, with only 6 %
missed urgent conditions, and the lowest overall ex- posure to radiation by performing CT in
only half of adult patients with acute abdominal pain [4]. In this regard, imaging strategies
including point-of-care abdominal US must also be evaluated.

A pilot observational study showed that emergency physician (EP)-performed US appears to

positively impact decision-making and the diagnostic workup of patients with nonspecific
abdominal pain as determined by the nursing triage. In 128 patients, 58 (45 %; 95 % confidence
interval (CI), 36–54 %) had an improvement in diagnostic accuracy and planned diagnostic
workup using US [5]. In a randomized study including 800 adult patients with acute abdominal
pain, Lindelius et al. re- ported the utility of US performed by surgeons who underwent a 4-week
US training program. The propor- tion of correct primary diagnoses was 7.9 % higher in the
group undergoing surgeon-performed US than in the control group (64.7 vs 56.8 %; p = 0.027)
[6]. The number of US performed in the radiology department was significantly lower in the
group receiving surgeon- performed US, while there was no difference between the groups
regarding the number of ordered CT scans or other examinations [7].
Evidence on detection of each lesion causing acute ab- dominal pain with point-of-care
abdominal US is reviewed in the “Detection of abdominal and pelvic le- sions” section. Methods
for the assessment of acute ab- dominal pain with point-of-care US must be developed
according to the accumulated evidence in each abdom- inal region.

Hemoperitoneum
Abdominal US in trauma patients is typically performed with the methodology of a focused
assessment with son- ography for trauma (FAST) examination. FAST provides a quick overview
of the peritoneal cavity to detect free fluid, which is a direct sign of hemoperitoneum and an
indirect sign of organ injuries. The sensitivity and speci- ficity of FAST for the detection of free
intraperitoneal fluid were 64–98 and 86–100 %, respectively. These ran- ging results may be
explained by differences in the levels of clinical experience and in the reference standards [8].
The sensitivity may be higher, and time needed to per- form may be shorter in patients with
hemodynamic col- lapse. Wherrett et al. demonstrated that an abdominal assessment with
FAST required 19 ± 5 s in the positive group and 154 ± 13 s in the negative group (p < 0.001)
with high accuracy in 69 hypotensive blunt trauma pa- tients [9].
It is also reasonable to consider the usage of a complete or partial FAST examination in
evaluating spontaneous hemoperitoneum in non-trauma patients. The etiology of spontaneous
hemoperitoneum can vary, and the causes may be classified as gynecologic, hepatic, splenic,
vascular, or coagulopathic conditions [10]. Spontaneous hemoperitoneum frequently presents
with acute abdominal pain with or without hemodynamic collapse. In some patients, the collapse
becomes obvious after the
initial evaluation; therefore, spontaneous hemoperito- neum should be detected rapidly during
the evaluation. Case reports comment on the use of bedside US to de- tect intra-abdominal free
fluid to aid in the diagnosis of the causes; however, few original studies have explored its use
[11].
Hemoperitoneum caused by gynecologic conditions, such as rupture of the gestational sac in
ectopic preg- nancy and hemorrhage or rupture of an ovarian cyst, is common in women of
childbearing age, in whom US is selected as the primary imaging modality [10]. In a
retrospective study, Rodgerson et al. demonstrated that identifying patients with a suspected
ectopic pregnancy and fluid in Morison’s pouch by EP-performed abdom- inal US decreased the
time to diagnosis and treatment [12]. In a prospective observational study, Moore et al. reported
that ten of 242 patients with suspected ectopic pregnancy were found to have fluid in Morison’s
pouch with EP-performed abdominal US, and nine of the ten patients underwent immediate
operative intervention for ruptured ectopic pregnancy. They concluded that free intraperitoneal
fluid in Morison’s pouch in patients with suspected ectopic pregnancy may be rapidly identified
by US and predicts the need for intervention [13].
However, US is not sensitive at identifying a focus of extravasation from a vessel or organ [8].
Therefore, FAST may be an option for the initial evaluation to detect hemoperitoneum in non-
trauma patients (Fig. 1).

Hypoperfusion and renal dysfunction

Doppler US is indicated as a tool to assess renal perfu- sion. The Doppler-based resistive index (RI) is
calculated using the following formula: (peak systolic velocity− end-diastolic velocity)/peak systolic
velocity in an inter-lobar or arcuate artery, with a normal value of 0.58 ± 0.10. It is broadly accepted that
values >0.70 are considered to be abnormal [14]. Corradi et al. reported that in normotensive polytrauma
patients without biochemical signs of hypoperfusion, a renal Doppler RI greater than 0.7 at admittance
into the emergency department was predictive of hemorrhagic shock within the first 24 h (odds ratio,
57.8; 95 % CI, 10.5–317.0; p < 0.001). However, the inferior vena cava (IVC) diameter and caval index
were not predictive in these patients. They hypothesized that most of the patients were normovolemic at
arrival [15]. Although larger comparative studies are needed, a high renal Doppler RI may be more
predictive of hemorrhagic shock than the IVC diameter and caval index [15].
A renal Doppler RI may also help in detecting early renal dysfunction or predicting short-term
reversibility of acute kidney injury (AKI) in critically ill patients [16–18]. A preliminary study
showed that a semi-quantitative as- sessment of renal perfusion using color Doppler was easier
to perform than the RI and may provide similar in- formation [16]. That study also found that
both the semi- quantitative assessment using color Doppler and the RI could be performed with
good feasibility and reliability by inexperienced operators, such as intensive care residents
following a half-day training session [16]. Doppler US may be useful in assessing renal
perfusion; however, larger studies with standardized methods are needed to confirm these
results and reveal its roles in the management of patients with AKI [19].

Detection of abdominal and pelvic lesions

Gallstone and acute cholecystitis
It is well known that radiology US is very useful for the detection of gallstones and the diagnosis
of acute chole- cystitis [20]. A systematic review and meta-analysis was conducted to compare
surgeon-performed US for sus- pected gallstone disease to radiology US or a pathological
examination as the gold standard investigation. The search criteria resulted in eight studies with
1019 patients. The pooled sensitivity was 96 % (95 % CI, 93.4–97.9 %), and the specificity was
99 % (95 % CI, 98.3–99.8 %) [21]. On the other hand, EP interpretation for the identification of
gallstones is reported to have a sensitivity of 86–96 % and specificity of 78–98 % [22].
Gallstones are found in approximately 95 % of patients with acute cholecystitis; however, the
detection of gall- stones is not specific for the diagnosis of acute cholecystitis. When performing
US, secondary findings such as gallbladder wall thickening, pericholecystic fluid, and
sonographic Murphy sign provide more specific infor- mation [20]. Summers et al. reported in a
prospective observational study with 164 enrolled patients that the test characteristics of EP-
performed US for the detection of acute cholecystitis had a sensitivity of 87 % (95 % CI, 66–97
%), specificity of 82 % (95 % CI, 74–88 %), positive predictive value of 44 % (95 % CI, 29–59
%), and negative predictive value of 97 % (95 % CI, 93– 99 %). Additionally, the test
characteristics of EP- performed US were similar to those of radiology US. Ac- cording to the
high negative predictive value, the study indicated that patients with a negative result are
unlikely to require cholecystectomy or admission within 2 weeks of their initial presentation [23].

Appendicitis
CT was found to have a superior test performance to US in the diagnosis of acute appendicitis;
however, US is recommended as the first-line imaging modality in young, female, and slender
patients in view of the radiation exposure [24]. Recent studies from the field of emergency
medicine addressed the diagnostic performance of point-of-care US performed by EPs or
pediatric EPs in the evaluation of suspected appendicitis [25–30] (Table 1). In these studies, no
visualization of the appen- dix with US was coded as a negative result, and the final diagnosis of
appendicitis was made with operative or pathology findings. Chen et al. demonstrated a high
sen- sitivity in their study, where more extensive US training was provided and the prevalence of
appendicitis was higher [25]. Several studies demonstrated the feasibility of reducing the length
of stay in the emergency department [28] and avoiding CT according to the result of a high
positive predictive value in some patients [30] when using point-of-care US as the first-line
imaging modality. To date, the diagnosis of appendicitis with point-of- care US by clinicians has
not been fully accepted. A large prospective study is necessary to investigate methods to
increase the accuracy of point-of-care US through more effective educational techniques and
safety of the addition to sequential radiology imaging [28, 30].

Small bowel obstruction

The utility of surgeon-performed US for the diagnosis of bowel obstruction and early recognition
of strangulation was evaluated in the 1990s [31]. In recent years, some studies showed the
accuracy of EP-performed US for the diagnosis of small bowel obstruction. Unlüer et al.
demonstrated in a prospective study with 168 patients that the sensitivity and specificity were
97.7 % (95 % CI, 94.5–100 %) and 92.7 % (95 % CI, 87.0–98.3 %), respectively. Additionally,
the diagnostic accuracy of EP- performed and radiology-performed US were not statistically
different from one another [32]. Jang et al. demonstrated in a prospective study with 76 patients
that the sensitivity and specificity were 90.9 % (95 % CI, 74.5–97.6 %) and 83.7 % (95 % CI,
68.7–92.7 %), respectively [33]. These studies also showed that EP-performed US had a
superior test performance compared with an X-ray in the diagnosis of small bowel obstruction
[32, 33]. However, large prospective studies are needed to alter the management of small bowel
ob- struction with its use.

Gastrointestinal perforation
The diagnosis of gastrointestinal perforation is based on the evidence of pneumoperitoneum,
which is usually detected with an X-ray or CT. A US sign of pneumoperitoneum (Fig. 2) has also
been recognized following a comprehensive study on visualizing pneumoperitoneum with US
reported from Germany over 30 years ago [34]. In the 21st century, the utility of clinician-
performed US for the detection of pneumoperitoneum was reported from Asian countries.
Prospective studies have demonstrated the sensitivity and specificity to be 85–93 % and 53–
100 %, respectively [35–37]. Moreover, Chan et al. also reported that US was more sensitive
than an X-ray for the detection [36]. However, large prospective trials are needed to validate the
accuracy of this modality and whether the concept can be generalized among clinician
sonographers.

Ureterolithiasis and pyelonephritis

Pain due to ureterolithiasis is a common problem in the emergency room. CT has become the
most common initial imaging modality for suspected ureterolithiasis because of its high accuracy
[38]. However, CT exposes patients to ionizing radiation, which is especially concerning for
patients with ureterolithiasis as they are prone to recurrence and repeated imaging. Moreover,
no evidence has shown that increased CT use is associated with an improved patient outcome
[38]. The diagnostic performance of bedside US performed by EPs or medical staff members in
the diagnosis of ureterolithiasis has been prospectively studied, as shown in Table 2 [39–42].
These studies, which used CT as the reference standard, showed that the diagnostic
performance using US finding of hydronephrosis was generally modest. In one of the articles,
Herbst et al. also demonstrated that attending physicians with fellowship training had
significantly better sensitivity than all other users (93 vs 68 %) [42]. A large, multicenter,
randomized trial conducted in the USA showed that initial US performed by EPs was asso-
ciated with lower cumulative radiation exposure than initial CT, without significant differences in
high-risk diagnoses with complications, serious adverse events, pain scores, return emergency
department visits, or hos- pitalizations [38]. Although US was less sensitive than CT for the
diagnosis of ureterolithiasis, bedside US in emergency departments is justified as the initial
imaging modality. Moreover, whether the detection of the stone itself in addition to
hydronephrosis with point-of-care US actually improves the accuracy of the diagnosis requires
further investigation [43].
Acute pyelonephritis is also a common disease encountered in emergency departments. For
complicated acute pyelonephritis, such as obstructive uropathy due to ureterolithiasis, delayed
management can lead to high morbidity and mortality. Chen et al. showed that EP-performed
US was able to detect significant ab- normalities such as hydronephrosis, polycystic kidney
disease, renal abscess, and emphysematous pyelonephritis in 40 % of patients finally
diagnosed with acute pyelonephritis. The early utilization of US in emergency departments may
impact on the management of these patients or initial assessment of septic patients [44] (Fig. 3).

Usages assisting procedures

Paracentesis
US guidance enables visualization of the needle insertion site to perform paracentesis safely.
An observational cohort study using a nationally representative database was conducted to
examine the effect of US guidance on the risk of bleeding complications after paracentesis. Of
69,859 patients undergoing paracentesis, 0.8 % (n = 565) experienced bleeding complications.
After adjusting for the inpatient or outpatient procedures, the duration of hospitalization before
the paracentesis, and the admission diagnoses, US guidance reduced the risk of bleeding
complications by 68 % (odds ratio, 0.32; 95 % CI, 0.25– 0.41). The data indicated that US
guidance is associated with a decreased risk of complications after paracentesis [48]. A
randomized study with 100 enrolled patients demonstrated that the success rate of US-assisted
para- centesis performed by EPs with varying levels of experience and the traditional technique
were 95 and 65 %, respectively (p = 0.0003) [49]. Case series indicated that emergent US-
guided paracentesis may lead to a significant management change in selected unstable patients
with a positive FAST examination [50]. As mentioned above, paracentesis under US guidance is
shown to improve patient care. Furthermore, localization of the inferior epigastric artery before
paracentesis may provide a more reliable means to avoid complications [51].

Conformation of gastric tube placement

Gastric tube insertion is commonly performed in emergency and critical care settings.
Immediately after the procedure, the placement of the tube is typically evaluated using a visual
inspection of aspirate contents and auscultation with instillation of air in the tube. Additionally, a
chest X-ray is recommended in most cases to confirm correct placement. However, a chest X-
ray has issues, including radiation exposure, delayed confirmation, and cost. Several recent
studies showed that US is a potential modality to verify the placement of the gastric tube. The
methods include confirmation of the tube in the stomach [52], the stomach or duodenum with or
without instillation of normal saline mixed with air [53], and the cervical esophagus and stomach
with or without instillation of air [54] or normal saline with air [55]. The visualization can be
affected by the size of the tube [52] and volume of gas in the gastrointestinal tract [55]. If the
presence of the tip of the tube in the stomach is verified with direct visualization or an indirect
finding of dynamic fogging made by the instillation, US in addition to physical examinations
appears to be a substitute imaging modality for a chest X-ray in some patients.

Urethral catheterization
Urethral catheterization is frequently performed for a urinalysis and culture, management of
acute urinary retention, and monitoring of the urine output in emergency and critical care
settings.
If there is little certainty of the presence or amount of urine in the bladder before urethral
catheterization, then this procedure to obtain urine for an analysis and culture often needs to be
repeated. The estimation of the amount of urine using bedside bladder US has been reported to
lead to an increased success rate during the first attempt in children younger than 2 years of
age [56, 57].
In adult male patients, difficulty with standard catheterization is occasionally encountered. In
such cases, repeated and unsuccessful blind attempts can cause patient distress and damage
to the urethra, usually requiring a urological consultation. Kameda et al. mentioned in their pilot
study that transabdominal US performed by emergency medical personnel can reveal the tip of
the catheter in a part of the posterior and bulbar urethra, and US-guided catheterization with
transrectal pressure appears to be safe and useful in some male patients in whom standard
urethral catheterization is diffi- cult [58] (Fig. 4).

Conclusions
Methods for the assessment of acute abdominal pain with point-of-care abdominal US must be
developed according to the accumulated evidence in each abdominal region. To detect
hemoperitoneum, a FAST examination may be a helpful option in non-trauma patients. For the
assessment of systemic hypoperfusion and renal dysfunction, point-of-care renal Doppler US
may be an option. The utilization of point-of-care US is also considered in order to detect
abdominal and pelvic lesions. It is useful for the detection of gallstones and the diagnosis of
acute cholecystitis. It is justified as the initial imaging modality for the diagnosis of
ureterolithiasis and the assessment of pyelonephritis. It can be used with great accuracy to
detect the presence of AAA in symptomatic patients. It may also be useful for the diagnoses of
digestive tract diseases. Additionally, point-of-care US can be a modality for assisting
procedures. Paracentesis under US guidance is shown to improve patient care. US appears to
be a potential modality to verify the placement of a gastric tube. Moreover, the estimation of the
amount of urine with bladder US can lead to an increased success rate in small children. US-
guided catheterization with transrectal pres- sure appears to be useful in some male patients in
whom standard urethral catheterization is difficult. Although a greater accumulation of evidence
is needed in some fields, point-of-care abdominal US is a promising modality to improve patient
care in emergency and critical care settings.