Diagnostic Accuracy of Ultrasonography in Choledocholithiasis Taking Intraoperative Findings as Gold Standard
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Abstract:
INTRODUCTION: It is very important to find a a non invasive, less time consuming and relatively easy modality,
non operator dependent and available even remote areas for the common bile duct stones (choledocolithiasis) in
symptomatic patients. Instant diagnosis will lead to prompt decision making for treatment strategies that will
ultimately decrease the morbidity.
OBJECTIVE: To determine the diagnostic accuracy of ultrasonography in detection of Choledocholithiasis in
suspected patients taking intraoperative findings as gold standard.
STUDY DESIGN: Descriptive Cross sectional Study
SETTING: Department of Radiology, Jinnah postgraduate Medical Center, Karachi
DURATION: Six months study from Feb 2020 onwards.
SUBJECTS AND METHODS: All patients with age 30-60 years of either gender having clinically suspected with
duration of symptoms of more than or equal to 7 days were enrolled. The ultrasound was performed and presence of
CBD diameter of > 7 mm on US was taken as CBD stones. Presence of CBD stones intra operatively was noted.
RESULTS: Mean age of the patients was 51.29 ±7.03 years. There were 75 (62%) females and 46 (38%) males.
Overall diagnostic accuracy of ultrasonography was found to be 89.25%. Sensitivity was found to be 80.48%,
specificity 93.75%, PPV 86.84% and NPV 90.36%.
CONCLUSION: The diagnostic accuracy of ultrasonography was found satisfactory in detection of
Choledocholithiasis in suspected patients taking intraoperative findings as gold standard.Keywords:
Gold standard (test)
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To identify an optimal imaging strategy for the accurate detection of urgent conditions in patients with acute abdominal pain.Fully paired multicentre diagnostic accuracy study with prospective data collection.Emergency departments of two university hospitals and four large teaching hospitals in the Netherlands.1021 patients with non-traumatic abdominal pain of >2 hours' and <5 days' duration. Exclusion criteria were discharge from the emergency department with no imaging considered warranted by the treating physician, pregnancy, and haemorrhagic shock.All patients had plain radiographs (upright chest and supine abdominal), ultrasonography, and computed tomography (CT) after clinical and laboratory examination. A panel of experienced physicians assigned a final diagnosis after six months and classified the condition as urgent or non-urgent.Sensitivity and specificity for urgent conditions, percentage of missed cases and false positives, and exposure to radiation for single imaging strategies, conditional imaging strategies (CT after initial ultrasonography), and strategies driven by body mass index and age or by location of pain.661 (65%) patients had a final diagnosis classified as urgent. The initial clinical diagnosis resulted in many false positive urgent diagnoses, which were significantly reduced after ultrasonography or CT. CT detected more urgent diagnoses than did ultrasonography: sensitivity was 89% (95% confidence interval 87% to 92%) for CT and 70% (67% to 74%) for ultrasonography (P<0.001). A conditional strategy with CT only after negative or inconclusive ultrasonography yielded the highest sensitivity, missing only 6% of urgent cases. With this strategy, only 49% (46% to 52%) of patients would have CT. Alternative strategies guided by body mass index, age, or location of the pain would all result in a loss of sensitivity.Although CT is the most sensitive imaging investigation for detecting urgent conditions in patients with abdominal pain, using ultrasonography first and CT only in those with negative or inconclusive ultrasonography results in the best sensitivity and lowers exposure to radiation.
Abdominal ultrasonography
Supine position
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To determined the accuracy of ultrasound in diagnosis of acute appendicitis in children keeping histopathology as gold standard.A prospective evaluations of all ultrasound for appendicitis from January 1, 2014, to June 15, 2017, was conducted at our hospital. A diagnostic protocol was implemented to reduce radiation exposure employing US as the initial imaging modality followed by CT for non-diagnostic US studies in patients with an equivocal clinical presentation. The imaging, operative findings, and pathology of 223 patients (females 80, males 143, age less than 14years) with diagnosed appendicitis were collected. The sensitivity, specificity, predictive value, and negative appendectomy rate were also analyzed. All those patients which had subjected to surgery were included to evaluate the true result of ultrasound in diagnosis of appendicitis.Of the 223 pediatric appendectomies performed in this time period, a total of 192 (86%) were diagnosed by ultrasound. The histopathology of 8 was normal (3.6%), CT done in 11 and three was normal. The negative appendectomy rate was 3.6%. US were the sole imaging modality in all patients.In the diagnosis of acute appendicitis in children, ultrasound is useful and accurate mode, which results in a significant decrease in negative appendectomies with no increase in the number of CT scans. This has important implications in the reduction of childhood radiation exposure.cross sectional validation.
Histopathology
Gold standard (test)
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Introduction
Choledocholithiasis is a very common condition worldwide and is associated with significant morbidity and mortality. Previously, the diagnosis of choledocholithiasis was made by transabdominal ultrasonography (TAS) followed by endoscopic retrograde cholangiopancreatography (ERCP) if suspicious of choledocholithiasis. Unfortunately, the sensitivity of TAS is low. On the other hand, ERCP carries a high risk of complications and should strictly be reserved only for therapeutic purposes. In the last two decades, endoscopic ultrasound (EUS) has been increasingly used in the diagnosis of suspected choledocholithiasis. Previous studies have shown EUS to be highly accurate compared to transabdominal ultrasound, but at the same time has a much lower complication rate than ERCP.
Objective
Primary Objectives:
• To determine the sensitivity, specificity, positive predictive value, and negative predictive value of EUS in the diagnosis of CBD stones in University Malaya Medical Centre
• To compare the accuracy of EUS vs T AS in patients (who have undergone both procedures) in the diagnosis of CBD stones. Secondary Objective:
• To assess the positive and negative predictive values of EUS depending on the individual's probability for choledocholithiasis.
• To identify the baseline demography of the patients with conftrrned choledocholithiasis and predactive factors for the diagnosis of choledocholithiasas.
Methods
This is a retrospective study where all patients with suspected choledocholithiasis who underwent both EUS and TAS from 2011 to 2016 were recruited. The baseline demography, symptoms, biochemistry, TAS finding and EUS findings were recorded. The final diagnosis of choledocholithiasis was made based on ERCP finding and clinical outcome following a minimum six-month follow up and subsequently the sensitivity, specificity, positive predictive value and negative predictive value for EUS and T AS were calculated.
Results
192 patients were recruited. 93{48.4%) had choledocholithiasis. EUS has the sensitivity of 95.7% and 84.8% specificity; TAS has 41.9% sensitivity and 88.9% specificity.
Conclusions
Endoscopic ultrasonography (EUS) remains high accuracy for detecting choledocholithiasis compared to transabdominal ultrasonography (TAS). In our study, none of the predictors (Age, Ethnicity, Gender, Abdominal pain, Elevated GOT, ALP, AST, ALT, WBC and Amylase) were found to be associated with choledocholithiasis.
Endoscopic Ultrasound
Endoscopic ultrasonography
Transabdominal ultrasound
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To evaluate the diagnostic accuracy of ultrasonography in pediatric acute appendicitis.In this cross-sectional study, 230 children aged 5-15 years with the diagnosis of acute appendicitis were studied. This study included the evaluation of demographic indices, ultrasound findings at diagnosis, and then comparing the results with the description of the patient's procedure and the pathology report of these patients. Patients who did not undergo ultrasound before surgery or their ultrasound did not include the evaluation of appendicitis or their pathologic report was not available were excluded.Overall, we have included a total number of 230 children with clinical diagnosis of acute appendicitis among whom there were 121 (52.6%) girls and 109 (47.4%) boys with mean age of 11.44 ± 2.90 years. Preoperative ultrasound report showed that 51.3% were normal and 48.7% had acute appendicitis. 34.8% had normal appendix and 65.2% had a pathological diagnosis of acute appendicitis. The sensitivity and specificity of ultrasound in these children were 58% and 68%, respectively. Positive and negative predictive values were 77% and 46%, respectively. The area under curve (AUC) was 0.853 (CI 95% 0.788-0.917) indicating a test with moderate accuracy.According to the obtained results, abdominal ultrasonography is of acceptable diagnostic accuracy in pediatric patients with acute appendicitis. The use of auxiliary techniques in ultrasound would increase the sensitivity and specificity in the diagnosis of acute appendicitis in children.
Abdominal ultrasound
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Role of ultrasonography in diagnosis of acute appendicitis in children is being debated. This study was conducted ahead of a clinical trial and aimed to evaluate the adjunctive role of ultrasonography in this group.Retrospective chart review of consecutive children undergoing appendicectomy in an Australian tertiary children's hospital over 24 months. Two study groups were: clinical assessment and clinical assessment plus ultrasonography. The accuracy of diagnosis was compared by generating estimates for sensitivity and positive predictive value using histopathology of the appendix as the reference standard. The incremental value of ultrasonography was evaluated in subgroups of gender, age and clinical severity.Two hundred ninety-five children (170 boys, median age 10 years) were included in the study. Negative appendicectomy rate was 17.3%; 10.4% in the clinical assessment group (n = 134) and 23% in the ultrasonography group (n = 161). Overall sensitivity for diagnosis by clinical assessment (71.4%, 95% confidence interval (CI) 63.3-79.5) was not significantly different to that using adjunct ultrasonography (77.7%, 95% CI 69.7-85.7; P = 0.29). Adjunct ultrasonography was more sensitive between 7 and 11 years (81% versus 68%, P = 0.002) and possibly in girls (86% versus 73%, P = 0.1), but did not increase the sensitivity of the diagnosis in children who presented with milder symptoms and signs.Adjunct ultrasonography may not increase the overall accuracy of diagnosis of acute appendicitis in children but holds promise in certain subgroups viz. between 7 and 11 years and in girls. There is an increase in negative appendicectomies following a 'non-targeted' use of ultrasonography. Future prospective trials should take cognizance of these findings in designing the subgroup analysis.
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Clinical Diagnosis
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BACKGROUND AND OBJECTIVE: Acute appendicitis is one of the most important urgent conditions of abdominal surgery, in which, proper and on-time diagnosis may decrease the unwanted complications. In despite of diagnostic methods, a significant number of patients yet end up with negative laparotomies. Sonography can diminish the rate of these negative results. The aim of this study was to evaluate the sensitivity and specificity of sonography in diagnosis of acute appendicitis. METHODS: In a cross sectional study, 500 patients with acute abdomen and primary diagnosis of acute appendicitis were evaluated preoperatively by graded compression sonography. This study was conducted in Tabriz Imam Khomeini hospital during 12 months. Results of sonography were compared with histopathological findings after operation. FINDINGS: A hundred and sixty three males and 237 females with the mean age of 25.1±13.9 years were enrolled. Sensitivity, specificity, PPV, NPV and accuracy of abdominal sonography in diagnosis of acute appendicitis were 96.2, 93.1, 96.8, 91.9 and 95.2 percent, respectively; 97.2, 96.4, 98.3, 94.2 and 97 percent, respectively in males; and 95, 89.5, 95, 89.5 and 93.2 percent, respectively in females. The optimal cut-off point of diameter of appendix was 5.8 mm with corresponding sensitivity and specificity of 88.3% and 73%, respectively. CONCLUSION: Due to noninvasiveness, cost-effectiveness and availableness of sonography, it is proposed as a diagnostic modality. This may cause a dramatic decrease in the costs of operation and treatment of patients.
Abdominal ultrasonography
Acute abdomen
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Background: Acute appendicitis (AA) is among the most common cause of acute abdominal pain. Imaging methods, such as ultrasonography (US) and computed tomography (CT), aimed at avoiding a misdiagnosis and facilitating earlier surgery, when necessary, have become increasingly important for decreasing the morbidity of the disease. Objective: This study aimed to compare the accuracy of US and CT in the diagnosis of AA. Patients and Methods: After local ethical approval and written consent taken, 107 patients with signs and symptoms suggesting AA, selected from emergency department of Al-Azhar University Hospital, New Damietta during the period from March, 2016 to April 2017. They were 63 males and 44 females, mean age was 17.09±3.02 years. 90 (84.11%) underwent surgery, and 17 patients (15.9%) were hospitalized for clinical observation after imaging (12 patients (11.2%) were dismissed from the hospital while 5 cases (4.7%) presented with positive CT findings underwent surgery). After history taking, full clinical examination and laboratory investigations, all patients were subjected to US and CT examination. All patients were reevaluated clinically, and a correlation was made between both sets of results. Accordingly, final decision was made. Accuracy was ascertained intra-operatively for those underwent appendectomy, and the results were compared with those found by radiological examination. The results were correlated with surgical and histopathologic findings. Results: Males affected more than females, and abdominal pain was present in 100%. The sensitivity, specificity, positive predictive value, negative predictive value and overall accuracy of US in diagnosis of AA in our study were found to be 91.7 %, 77.8 %, 94.3%, 70.0% and 88.9 % respectively.The sensitivity, specificity, positive predictive value, negative predictive value and overall accuracy of CT in diagnosis of AA were 98.8 %, 88.9 %, 98.8%, 88.9% and 97.8 % respectively. Conclusion: US should be the first-line imaging modality. As US sensitivity is limited, and non-confirmed US examinations, diagnostic strategies and algorithms should focus on clinical reassessment and CT examination.
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Diagnosis of choledocholithiasis requires clinical manifestations and imaging examination findings suggesting a stone in the common bile duct (CBD), but these factors are not highly sensitive or specific. The choledocholithiasis management algorithm proposed by the American Society for Gastrointestinal Endoscopy (ASGE) may not be appropriate for patients who fulfill the clinical criteria for a high likelihood of choledocholithiasis. Endoscopic ultrasonography (EUS) may replace endoscopic retrograde cholangiopancreatography (ERCP) for the detection of CBD stones in all patients. The aims of this study were to determine the diagnostic yield and optimal timing of EUS in patients with an intermediate or high likelihood of choledocholithiasis requiring therapeutic ERCP.Patients with suspected choledocholithiasis who underwent EUS between June 2009 and January 2012 were retrospectively reviewed. The patients were divided into two groups based on the likelihood of choledocholithiasis according to the clinical predictors described by the ASGE guidelines: an intermediate likelihood group and a high likelihood group. The demographic data, clinical manifestations at presentation, blood test results, EUS and ERCP findings, and clinical manifestations during the follow-up period were recorded and analyzed.Ninety-three patients were enrolled in the study (52.7% in the intermediate likelihood group and 47.3% in the high likelihood group). CBD stones were detected in 22.44% of patients in the intermediate likelihood group and 38.63% of patients in the high likelihood group. EUS had a sensitivity of 100% and specificity of 80% for detection of CBD stones. An alkaline phosphatase level of > 133 mg/dL (area under the curve, 0.576) was the only factor that was significantly associated with detection of CBD stones in patients who underwent EUS > 7 days after the initial clinical presentation (odds ratio 4.87, p = 0.01).EUS is an accurate diagnostic tool for the detection of CBD stones, and can prevent the unnecessary use of ERCP. This study found that use of clinical criteria alone might not provide a good prediction of the presence of CBD stones, even in patients who fulfill the criteria for a high likelihood of choledocholithiasis.
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Abdominal ultrasonographic study is a part of the acute abdominal pain diagnosis protocol in our hospital. As an internal quality assessment, we performed a six-month prospective study, including those patients who meet one of these requirements: 1st the reason for attendance being non-traumatic abdominal pain 2nd an abdominal ultrasonography achieved at the hospital. Collected data included: demographic characteristics, presenting sign and symptoms, test results, ultrasonography, final diagnosis and treatment. Children attended to the hospital were evaluated through clinical findings to verify concordance between clinical and ultrasound diagnosis, and patients who did not stay at the hospital had telephone follow-up in 2 weeks. A total of 136 patients underwent ultrasonography (7 children did not cooperate and were discarded): 74 females and 55 males with a mean age of 9.52 years. Admission was required in 63 subjects and 66 were sent home after clinical evaluation. Abdominal ultrasonography was performed by the radiologist on duty (occasionally paediatric radiologist). Ultrasound examination, for acute appendicitis, had a sensitivity of 94.8%, specificity of 98.8%, positive predictive value of 97.3% and negative predictive value of 97.8%. Abdominal ultrasonography has showed usefulness for surgical pathology discrimination in acute abdominal pain. When ultrasonography is inconclusive, clinical follow-up and periodical ultrasonography results in a positive change in management and treatment.
Concordance
Acute abdominal pain
Abdominal ultrasonography
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Background : Laparoscopic cholecystectomy is widely used for cholelithiasis. Abdominal ultrasonography often precedes this operation and can prove diagnosis, as well as helps in showing possible complications during the perioperative period. Aim : Evaluate the description of variables of gallbladder and bile ducts present in reports of preoperative abdominal ultrasonography in cholelithiasis comparing with surgical findings. Methods : Were studied 91 patients who underwent elective laparoscopic cholecystectomy with previous abdominal ultrasonography. Variables such as identification and amount of gallstones involved were evaluated, both in preoperative ultrasonography and during surgery to evaluate sensitivity, specificity, concordance and positive and negative predictive values. Results : The reports did not mention diameter of vesicular light (98.9%), organ distension (62.6%), gallstone sizes (58.2%), wall thickness (41.8%) and evaluation of the common bile duct (39.6%). Ultrasound had high values for sensitivity, consistency and positive predictive value for identifying the presence/absence of gallstones: 98.8%, 96.7% and 97.8% respectively. As for the amount of stones, ultrasonography showed agreement in 82.7%, negative predictive value in 89.1% and specificity in 87.7%, with lower values for sensitivity (68.2%) and positive predictive value (65.2%). Conclusions : The ultrasound reports were flawed in standardization. Significant percentage of them did not have variables that could predict perioperative complications and surgical conversion.
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