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Gastrointestinal Ultrasound (GIUS) in Intestinal Emergencies – An

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Gastrointestinal Ultrasound (GIUS) in Intestinal Emergencies – An Published online: 2020-04-20 Guidelines & Recommendations Gastrointestinal Ultrasound (GIUS) in Intestinal Emergencies – An EFSUMB Position Paper Gastrointestinaler Ultraschall (GIUS) bei intestinalen Notfällen – Ein EFSUMB-Positionspapier Authors Alois Hollerweger1, Giovanni Maconi2,TomasRipolles3,KimNylund4, Antony Higginson5, Carla Serra6, Christoph F. Dietrich7,KlausDirks8, Odd Helge Gilja9 Affiliations ABSTRACT 1 Department of Radiology, Hospital Barmherzige Brüder, An interdisciplinary group of European experts summarizes Salzburg, Austria the value of gastrointestinal ultrasound (GIUS) in the manage- 2 Gastroenterology Unit, Department of Biomedical and ment of three time-critical causes of acute abdomen: bowel Clinical Sciences, “L.Sacco” University Hospital, Milan, Italy obstruction, gastrointestinal perforation and acute ischemic 3 Department of Radiology, Hospital Universitario bowel disease. Based on an extensive literature review, state- Doctor Peset, Valencia, Spain ments for a targeted diagnostic strategy in these intestinal 4 Gastroenterology, Haukeland University Hospital, Bergen, emergencies are presented. GIUS is best established in case Norway of small bowel obstruction. Metanalyses and prospective 5 Department of Radiology, Queen-Alexandra-Hospital, studies showed a sensitivity and specificity comparable to Portsmouth Hospitals NHS Trust, Portsmouth, United that of computed tomography (CT) and superior to plain Kingdom of Great Britain and Northern Ireland X-ray. GIUS may save time and radiation exposure and has 6 Internal Medicine and Gastroenterology, S. Orsola the advantage of displaying bowel function directly. Gastroin- University Hospital, Bologna, Italy testinal perforation is more challenging for less experienced 7 Department of General Internal Medicine Kliniken investigators. Although GIUS in experienced hands has a rela- Hirslanden Beau-Site, Salem und Permanence, Bern, tively high sensitivity to establish a correct diagnosis, CT is the Switzerland most sensitive method in this situation. The spectrum of 8 Gastroenterology and Internal Medicine, intestinal ischemia ranges from self-limited ischemic colitis Rems-Murr-Klinikum Winnenden, Germany to fatal intestinal infarction. In acute arterial mesenteric ische- 9 Haukeland University Hospital, National Centre for mia, GIUS may provide information, but prompt CT angiogra- Ultrasound in Gastroenterology, Bergen, Norway phy is the gold standard. On the other end of the spectrum, Key words ischemic colitis shows typical ultrasound features that allow ultrasound, ischemic bowel disease, gastrointestinal tract, correct diagnosis. GIUS here has a diagnostic performance bowel obstruction, perforation similar to CT and helps to differentiate mild from severe ischemic colitis. received 18.11.2019 accepted 16.03.2020 ZUSAMMENFASSUNG Eine interdisziplinäre Arbeitsgruppe von europäischen Exper- Bibliography ten gibt einen Überblick über den Wert des gastrointestinalen DOI https://doi.org/10.1055/a-1147-1295 Ultraschalls (GIUS) bei der Abklärung von 3 zeitkritischen Published online: 2020 Ursachen eines akuten Abdomens: Ileus, Perforation und Ultraschall in Med akute Darmischämie. Basierend auf einer ausgiebigen Litera- © Georg Thieme Verlag KG, Stuttgart · New York turrecherche werden Aussagen für eine zielgerichtete diag- ISSN 0172-4614 nostische Abklärung bei diesen intestinalen Notfällen präsen- Correspondence tiert. GIUS ist eine gut etablierte Methode bei der Frage nach Dr. Alois Hollerweger einem mechanischen Dünndarmverschluss. Metaanalyen und Department of Radiology, Hospital Barmherzige Brüder, prospektive Studien haben eine mit der Computertomografie Kajetanerplatz 1, 5010 Salzburg, Austria (CT) vergleichbare, gegenüber der Röntgen-Abdomen-Nativ- Tel.: ++ 43/6 62/80 88 aufnahme aber bessere Sensitivität und Spezifität gezeigt. [email protected] GIUS kann Zeit und Strahlungsdosis sparen und hat den Vor- teil einer direkten Beurteilung der peristaltischen Aktivität. Gastrointestinale Perforationen sind eine Herausforderung Hollerweger A et al. Gastrointestinal Ultrasound (GIUS)… Ultraschall in Med Guidelines & Recommendations für weniger erfahrene Untersucher. Obwohl GIUS in der Hand zwar Hinweise geben, die rasche CT-Angiografie ist aber der des erfahrenen Untersuchers bei dieser Diagnose eine relative Goldstandard. Am anderen Ende des Spektrums ermöglichen hohe Sensitivität erreicht, ist die CT die sensitivste Methode. typische Ultraschallzeichen die korrekte Diagnose der ischä- Das Spektrum der Darmischämie reicht von der selbstlimitie- mischen Kolitis. GIUS ist hier vergleichbar mit der CT und hilft renden ischämischen Kolitis bis zur fatalen Darminfarzierung. milde von schweren Formen zu unterscheiden. Bei der akuten arteriellen Mesenterialischämie kann GIUS Introduction diagnosis and if there are associated co-morbidities such as diabe- tes or cardiovascular, lung and neurological diseases [19]. Acute abdomen is a condition that demands urgent diagnostic In patients with a history and physical examination suspicious evaluation and treatment. Today, gastrointestinal ultrasound for SBO, blood tests and imaging are usually required to confirm (GIUS) and/or computed tomography (CT) scans are widely used the diagnosis and guide management [20]. to determine the cause of acute abdominal pain, so that targeted The clinical presentation of patients is variable and no single surgical intervention is possible in most cases and unnecessary clinical symptom is diagnostic. Abdominal pain, nausea, vomiting, surgery can be avoided [1]. absence of passage of flatus and/or feces and abdominal disten- Acute intestinal diseases account for more than one third of sion are the most common symptoms of SBO [21]. The clinical patients who present with acute abdominal pain [2, 3]. GIUS is fre- signs also vary significantly depending on the cause. For example, quently used as the initial imaging tool for diagnostic evaluation acute presentation is seen in cases of bowel incarceration or stran- of these patients [4–7]. Two of the most frequent acute intestinal gulation and prolonged symptoms in cases of malignant stric- conditions, appendicitis and diverticulitis, have already been tures. The location of obstruction may result in different presenta- covered by the taskforce group (TFG) with EFSUMB recommenda- tion with primarily vomiting in proximal SBO vs. distension and tions in gastrointestinal diseases [8]. This paper deals with the abdominal cramps in distal SBO [22]. Nevertheless, it is often other most important intestinal emergencies, namely bowel difficult to distinguish simple obstruction from strangulation [21, obstruction, gastrointestinal perforation and acute ischemic bow- 22]. el disease. Abdominal pain associated with SBO is often described as The sonographic features of other rare acute intestinal condi- crampy and intermittent. Changes in the character of the pain tions such as focal fat necrosis (omental infarction and epiploic (e. g. from intermittent pain to constant pain) may indicate the appendicitis), angioneurotic edema, Meckel’s diverticulitis, intus- development of serious complications, such as bowel wall necro- susception, and intestinal graft versus host disease have been sis or perforation. On physical examination, abdominal distention discussed elsewhere by the same TFG [9]. Specific pediatric acute is present in about 60 % of patients with less distention when the intestinal conditions are not within the scope of this paper. gastric outlet, the duodenum or proximal small bowel is obstruc- Statements about imaging signs and use of imaging methods ted. Hyperactive bowel sounds occur early and hypoactive bowel were created and voting on the statements was performed by sounds later in the disease process. Fever, tachycardia, peritoneal 16 members of the TFG in an online survey. The agreement/dis- signs, leukocytosis, and metabolic acidosis suggest complicated agreement level was scored on a five-point Likert scale as follows: disease such as vascular impairment or perforation [21]. A+: agree; A–: rather agree; I: indecisive; D–: rather disagree; D+: In this context imaging procedures like GIUS should help to disagree. address the following: 1. Confirmation or exclusion of bowel obstruction, 2. Whether small bowel dilatation/ileus is mechanical or Bowel obstruction functional, 3. Identification of the site of obstruction, General remarks and clinical presentation 4. Identification of the cause of the obstruction, Bowel obstruction is a common challenge in emergency depart- 5. Recognition of the risk of associated critical intestinal ischemia ments. In particular, small bowel obstruction (SBO), which is 4– and the need for emergency surgery, 5 fold more common than large bowel obstruction (LBO), accounts 6. The appropriateness of conservative management for patients for approximately 2 % of all visits and up to 16 % of hospital admis- not requiring immediate surgery [22, 23]. sions of patients with acute abdominal pain [10, 11]. LBO is mostly due to colonic malignancies. The most frequent cause of SBO is ad- Examination technique and sonographic signs hesions from previous surgery, in particular if complicated by peri- of bowel obstruction tonitis. These account for up to 80 % of cases, while Crohn’s disease, A 3-step examination technique is suggested: tumors, hernias and volvulus are far less common [12, 13]. Only a 1. Epigastrium: to assess the stomach subgroup (about 30–60 %) of patients with SBO will undergo 2. Left mid-abdomen:
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