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Sensitivity of emergency bedside ultrasound to detect hydronephrosis in patients with computed tomography-proven stones.

ABSTRACT: Non-contrast computed tomography (CT) is widely regarded as the gold standard for diagnosis of urolithiasis in emergency department (ED) patients. However, it is costly, time-consuming and exposes patients to significant doses of ionizing radiation. Hydronephrosis on bedside ultrasound is a sign of a ureteral stone, and has a reported sensitivity of 72-83% for identification of unilateral hydronephrosis when compared to CT. The purpose of this study was to evaluate trends in sensitivity related to stone size and number.This was a structured, explicit, retrospective chart review. Two blinded investigators used reviewed charts of all adult patients over a 6-month period with a final diagnosis of renal colic. Of these charts, those with CT evidence of renal calculus by attending radiologist read were examined for results of bedside ultrasound performed by an emergency physician. We included only those patient encounters with both CT-proven renal calculi and documented bedside ultrasound results.125 patients met inclusion criteria. The overall sensitivity of ultrasound for detection of hydronephrosis was 78.4% [95% confidence interval (CI)=70.2-85.3%]. The overall sensitivity of a positive ultrasound finding of either hydronephrosis or visualized stones was 82.4% [95%CI: 75.6%, 89.2%]. Based on a prior assumption that ultrasound would detect hydronephrosis more often in patients with larger stones, we found a statistically significant (p=0.016) difference in detecting hydronephrosis in patients with a stone ≥6 mm (sensitivity=90% [95% CI=82-98%]) compared to a stone <6 mm (sensitivity=75% [95% CI=65-86%]). For those with 3 or more stones, sensitivity was 100% [95% CI=63-100%]. There were no patients with stones ≥6 mm that had both a negative ultrasound and lack of hematuria.In a population with CT-proven urolithiasis, ED bedside ultrasonography had similar overall sensitivity to previous reports but showed better sensitivity with increasing stone size and number. We identified 100% of patients with stones ≥6 mm that would benefit from medical expulsive therapy by either the presence of hematuria or abnormal ultrasound findings.

SUBMITTER: Riddell J

PROVIDER: S-EPMC3935794 | biostudies-other | 2014 Feb

REPOSITORIES: biostudies-other

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Project description:Study objectiveReduced-dose computed tomography (CT) scans have been recommended for diagnosis of kidney stone but are rarely used in the emergency department (ED) setting. Test characteristics are incompletely characterized, particularly in obese patients. Our primary outcome is to determine the sensitivity and specificity of a reduced-dose CT protocol for symptomatic ureteral stones, particularly those large enough to require intervention, using a protocol stratified by patient size.MethodsThis was a prospective, blinded observational study of 201 patients at an academic medical center. Consenting subjects underwent both regular- and reduced-dose CT, stratified into a high and low body mass index (BMI) protocol based on effective abdominal diameter. Reduced-dose CT scans were interpreted by radiologists blinded to regular-dose interpretations. Follow-up for outcome and intervention was performed at 90 days.ResultsCT scans with both regular and reduced doses were conducted for 201 patients, with 63% receiving the high BMI reduced-dose protocol. Ureteral stone was identified in 102 patients (50.7%) of those receiving regular-dose CT, with a ureteral stone greater than 5 mm identified in 26 subjects (12.9%). Sensitivity of the reduced-dose CT for any ureteral stone was 90.2% (95% confidence interval [CI] 82.3% to 95.0%), with a specificity of 99.0% (95% CI 93.7% to 100.0%). For stones greater than 5 mm, sensitivity was 100% (95% CI 85.0% to 100.0%). Reduced-dose CT identified 96% of patients who required intervention for ureteral stone within 90 days. Mean reduction in size-specific dose estimate was 18.6 milligray (mGy), from 21.7 mGy (SD 9.7) to 3.4 mGy (SD 0.9).ConclusionCT with substantial dose reduction was 90.2% (95% CI 82.3% to 95.0%) sensitive and 98.9% (95% CI 85.0% to 100.0%) specific for ureteral stones in ED patients with a wide range of BMIs. Reduced-dose CT was 96.0% (95% CI 80.5% to 99.3%) sensitive for ureteral stones requiring intervention within 90 days.

Project description:PurposeMore than 1 million patients annually seek care in an emergency department for kidney stones but a minority require hospital admission or a urological procedure. We describe predictors of hospital admission or urological intervention.Materials and methodsThis secondary analysis of prospective data included patients with an obstructing ureteral stone that was confirmed by computerized tomography in an emergency department. All patients also underwent point of care limited renal ultrasound. The need for urological intervention at 90 days was assessed by a followup interview. Logistic regression was used to identify predictors of admission and urological intervention, which were further stratified by disposition. Separate regression models with and without computerized tomography findings (point of care limited renal ultrasound only) were compared using c-statistics.ResultsAmong a cohort of 475 patients with a symptomatic stone on computerized tomography 95 (20%) were admitted and 68 (72%) received an intervention. Of 380 discharged patients 66 (17%) required urological intervention. Admitted patients were more likely to have undergone a prior procedure, have evidence of kidney injury or infection, need opiate analgesia or have larger stones or hydronephrosis on point of care limited renal ultrasound. Predictors of intervention varied by disposition. However, regression models with and without computerized tomography findings demonstrated similar c-statistics. Discharged patients with larger stones, a longer pain duration at presentation and prior procedures were more likely to undergo intervention.ConclusionsIntervention was common among admitted patients but it occurred in a minority of those discharged. Predictors of intervention varied by disposition. Models incorporating computerized tomography findings were similar to those that did not incorporate such findings. These data support ultrasound first or delayed computerized tomography diagnostic pathways for patients deemed clinically suitable for discharge home.

Project description:BackgroundThe current guideline recommends patients who meet high probability criteria for choledocholithiasis to receive endoscopic retrograde cholangiopancreatography (ERCP). However, adverse events can occur during ERCP. Our goal is to determine whether endoscopic ultrasound (EUS) before ERCP can avoid unnecessary ERCP complications, especially in patients with a negative CT scan.MethodsA total of 604 patients with high probability of choledocholithiasis were screened and 104 patients were prospectively enrolled. Patients with malignant biliary obstruction, altered GI anatomy, and choledocholithiasis on CT scan were excluded. Among them, 44 patients received EUS first, and ERCP if choledocholithiasis present (EUS-first group). The other 60 patients received ERCP directly (ERCP-first group). The baseline characteristics, presence of choledocholithiasis, and complications were compared between groups. All patients were followed for 3 months to determine the difference in recurrent biliary event rate. Cost-effectiveness was compared between the two strategies.ResultsThere was no marked difference in age, sex, laboratory data, presenting with pancreatitis, and risk factors for choledocholithiasis. Overall, 51 patients (49.0%) had choledocholithiasis, which did not justify the risk of direct ERCP. In the EUS-first group, 27 (61.4%) ERCP procedures were prevented. The overall complication rate was significantly lower in the EUS-first group compared to the ERCP-fist group (6.8% vs. 21.7%, P = 0.04). The number-needed-to-treat to avoid one unnecessary adverse event was 6.71. After a 3-month follow-up, the cumulative recurrence biliary event rates were similar (13.6% vs. 15.0%, P = 0.803). EUS-first strategy was more cost-effective than the ERCP-first strategy (mean cost 2322.89$ vs. 3175.63$, P = 0.002).ConclusionsIn high-probability choledocholithiasis patients with a negative CT, the EUS-first strategy is cost-effective, which can prevent unnecessary ERCP procedures and their complications.

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Sensitivity of emergency bedside ultrasound to detect hydronephrosis in patients with computed tomography-proven stones.

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