SGEM#398: Another Ab Gets BUSED – POCUS in the ED for Biliary Disease

Date: March 22, 2023 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 Guest Skeptic: Dr. Casey Parker is a Rural Generalist that includes in his practice emergency medicine, anesthesia, and critical care. He is also now a fully-fledged “sonologist”. Casey currently splits his time between Broome, a small rural hospital in the remote Kimberley region of Western Australia, and a large tertiary ED in sunny Perth. He has been on the SGEM#369, SGEM#326 and SGEM#217. Case: A forty-year-old woman presents to the emergency department (ED) complaining of epigastric pain and nausea for 24 hours.  The junior doctor has performed physical examination and blood work. She has some right upper quadrant (RUQ) tenderness on palpation and an elevated C-reactive protein (CRP) of 42. Her white blood cell count and liver function tests are normal. The very efficient junior doctor has arranged for a formal ultrasound, but this will be done later this afternoon, after six hours fasting. As luck would have it the admitting surgeon is currently in the ED seeing another patient. The supervising ED physician has been to a few training courses and is keen to try out his new sono-skills. This seems like a good case to try and decide if this patient has significant biliary disease such as acute cholecystitis or an impacted gallstone.  A focused Biliary US in the ED (BUSED) may be all that is required to guide the surgeon’s decision-making for this patient.  Do they need surgery, an ERCP or just analgesia and non-operative care? Background: The SGEM has reviewed the use of point of care ultrasound (POCUS) for a variety of conditions in the ED. This includes using ultrasound for small bowel obstructions (SGEM#373), shoulder dislocations (SGEM#288), appendicitis (SGEM#274), endotracheal tube placement (SGEM#249), retinal detachments (SGEM#245), skull fractures (SGEM#124), acute heart failure (SGEM#119), renal colic (SGEM#97), acute abdominal aneurysms (SGEM#94) and lumbar punctures (SGEM#41). One use of POCUS we have not covered yet is for diagnosing acute biliary disease. Ultrasound is usually the first line imaging modality for diagnosing  acute biliary disease. As demonstrated in the list of SGEM episodes, ED clinician performed POCUS has been increasing in popularity over the years.  Many small trials have compared the accuracy of POCUS to the “gold standard” of “Radiology-performed ultrasound”. The literature on POCUS for diagnosing acute biliary disease tends to compare the diagnostic accuracy of the sonography in each department.  However, little is known about the actual decision-making process after POCUS evaluation. Clinical Question: When compared to point-of-care ultrasound, what is the value of formal radiology-performed ultrasound in terms of the surgical decision-making in acute biliary disease? 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 Population: Adult ED patients 18 years of age or older with abdominal pain who the EM physician felt they had biliary disease after performing a history, physical examination, and POCUS Excluded: If surgery was completed prior to formal ultrasound imaging, failure to gain consent or age less than 18 years. Intervention: Surgical decision (offer surgery, ERCP/MRCP or no surgery) based upon the clinical, laboratory and POCUS data. The BUSED scans were performed by one of 11 specifically trained ED physicians. There were 20 surgeons 3 acute care, 4 colorectal, 4 hepatobiliary, 3 surgical oncology and 3 MIS/bariatric. Comparison: Surgical decision made after formal radiology ultrasound (RUS). Outcome: Primary Outcome: The primary outcome was the percentage of patients in which the management changed after ...