The role of surgeon-performed ultrasound in the management of the acute abdomen

Abstract

The overall objective of this thesis was to evaluate the effects of bedside surgeon-performed ultrasound on the diagnostic accuracy and management of the patient admitted to the emergency department for abdominal pain.

Methods: We randomized 800 patients who attended the emergency department at Stockholm South General Hospital, Sweden, for abdominal pain, to either receive or not receive surgeon-performed ultrasound as a complement to routine management. The patients were followed up by a telephone interview after six weeks and by a registry follow-up after two years. Outcome measures included proportion of correct diagnoses, the number of complementary investigations, admission rate, time for surgery if required, time consumption at the emergency department and at hospital if admitted, self-rated patient satisfaction at the Emergency Department and at follow-up, health condition at follow-up, health consumption and mortality at six week and two year follow-up. Diagnostic accuracy and need of further examinations and admissions were measured in specific subgroups as well as timing of surgery among patients with peritonitis.

Results: Several benefits were seen in the group receiving US. Diagnostic accuracy was significantly higher in the group examined with ultrasound (65% versus 57%, p=0.027). The number of ordered complementary US examinations was considerably higher in the group who did not receive bedside US (9% versus 28%, p < 0.001). The admission rate was lower in the ultrasound group (43% versus 50%, p = 0.04) and the proportion of patients requiring surgery submitted for surgery directly from the emergency department was higher in the ultrasound group (34% versus 16%, p = 0.01). Self-rated patient satisfaction was slightly higher in the ultrasound group when leaving the emergency department but equal after six weeks. There was no difference found in the two-year health consumption or mortality between the groups.

Regarding sub group analyses increased diagnostic accuracy of bedside US was seen in the patients with Body Mass Index>25(67% versus 54%, p=0.02), elevated C-reactive protein (63% versus 52%,p=0.047), peritonitis (74% versus 54%, age 30-59 years(68% versus 58%, p=0.042) and/or upper abdominal pain(72% versus 52%, p=0.045). Other benefits such as decreased need of further examinations and/or fewer admissions were seen in all groups except the patients with a first diagnosis of appendicitis where the outcomes were equal between the intervention groups. Among patients with peritonitis admitted for surgery the decision about surgery was taken while still at the emergency department for 61 % in the ultrasound group and 19 % in the control group, p= 0.003.

Conclusion: The results we have shown in our large randomized study, following up patients on a short- and long-term basis, is that US performed bedside by the surgeon on duty when a patient seeks care for abdominal pain, can increase diagnostic accuracy, decrease the need of further examinations, decrease admission frequency and increase self-rated patient satisfaction. There are benefits of different kinds in nearly all subgroups and the health consumption and mortality on a long term basis are equal. The method is well worth recommending for implementation as a routine for evaluation of the acute abdomen in the ED.