Is bedside ultrasound performed by an emergency physician safe for diagnosis and discharge from emergency department of patients with suspected renal colic?
Date First Published:
January 17, 2014
Last Updated:
January 17, 2014
Report by:
Francis Fournier, PGY-4 Resident (Université Laval)
Three-Part Question:
In [patients with suspected acute renal colic, no fever and normal serum creatinine level], is [bedside ultrasound performed by an emergency physician along with outpatient follow-up or imaging] safe for diagnosis and discharge when compared to [traditional emergency department urinary tree imaging (intravenous pyelograpy or CT-scan)]
Clinical Scenario:
A 34 years old man presents to the emergency department at 11:00PM with severe left flank pain and vomiting which began abruptly 4 hours ago. The patient is not known for any health problem nor does he take any medication. He denies fever of chills. You suspect obstructing renal colic. His creatinine level is normal. You administer him NSAIDs and opioid medication, which relieves his pain. You wonder if this patient can safely be discharged at home if your bedside ultrasound is reassuring, with outpatient imaging and follow-up.
Search Strategy:
The search was performed on October 20th, 2013.
Search Details:
MEDLINE (through PubMED)
"Renal Colic/ultrasonography"[Mesh]
EMBASE
renal AND ('colic'/exp OR colic) AND bedside AND ('ultrasound'/exp OR ultrasound)
"Renal Colic/ultrasonography"[Mesh]
EMBASE
renal AND ('colic'/exp OR colic) AND bedside AND ('ultrasound'/exp OR ultrasound)
Outcome:
No BestBETs review was found on this subject.
No Cochrane review was found on this subject.
www.clinicaltrials.org was searched for an ongoing trial on this topic. 4 trials were found to be relevant on this subject.
MEDLINE: one paper was found to be relevant to the question. One paper cited in this article was also found to be relevant and was included for analysis.
EMBASE: 17 articles were screened for relevance. Of those, 4 papers were found to be relevant to the question.
A total of 6 studies were found to be relevant to the question
No Cochrane review was found on this subject.
www.clinicaltrials.org was searched for an ongoing trial on this topic. 4 trials were found to be relevant on this subject.
MEDLINE: one paper was found to be relevant to the question. One paper cited in this article was also found to be relevant and was included for analysis.
EMBASE: 17 articles were screened for relevance. Of those, 4 papers were found to be relevant to the question.
A total of 6 studies were found to be relevant to the question
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Bedside ultrasound and the assessment of renal colic: a review Dalziel, P.J. and V.E. Noble June 8th, 2012 USA | Review. Studies included below | ||||
| Bedside emergency department ultrasonography plus radiography of the kidneys, ureters, and bladder vs intravenous pyelography in the evaluation of suspected ureteral colic Henderson, S.O., et al. 1998 USA | Pts between 18 and 65 y.o. presenting with symptoms of ureteral colic. Exclusion: Pregnant patients, allergy to contrast, creatinine > 1.8 mg/dl. | Prospective observational study KUB x-ray, 500 ml bolus of normal saline, BUS and formal IVP study. Positive for nephroureterolithiasis if hydronephrosis on BUS or calcification on KUB |
Sensitivity of KUB + BUS | 97,1% (CI = 93.1-100%) | 1-tVarious ultrasound training and experience 2-tGold standard is IVP 3-tAll degrees of hydronephrosis considered equally positive 4-tHigh sensitivity possibly because of NS bolus prior to exam 5-tLow specificity (resolution of colic in the time between BUS and IVP? False positive caused by bolus?) 6-tNo outcome data on false negative (n=2) patients (delayed nephrograms |
| Specificity | 58.9% (CI = 43.5-74.3%) | ||||
| PPV | 80.70% | ||||
| NPV | 92.00% | ||||
| Bedside renal ultrasound in the evaluation of suspected ureterolithiasis Moak, J.H., M.S. Lyons, and C.J. Lindsell 2012 USA | Patients awaiting for CTscan for presumed renal colic. Pregnant patients, younger than 18 y.o., in custody or unable to consent were excluded |
Prospective observational Likelihood of acute ureterolithiasis on VAS, based on clinical findings and UA, on BUS and on CTscan Clinically significant change determined to be 20% |
Modification of likelihood by more than 20% based on BUS | 30.8% of cases (CI = 22.5-40.6%) | 1-tMajority of physicians evaluating likelihood were residents in training 2-tHigh NPV for stones >= 5 mm only |
| Modification of likelihood by more than 20% based on CTscan | 51.4% of cases (CI = 41.6-61.1%) | ||||
| Sensitivity of BUS compared to CT for any stone | 76.3% (CI = 59.4-88.0%) | ||||
| Specificity of BUS compared to CT for any stone | 78.3% (CI = 66.4-86.9%) | ||||
| PPV of BUS compared to CT for any stone | 65.9% (CI = 50.0-79.1%) | ||||
| NPV of BUS compared to CT for any stone | 85.7% (CI = 74.1-92.9%) | ||||
| Sensitivity of BUS compared to CT for stones >= 5mm | 90.0% (CI = 54.1-99.5%) | ||||
| Specificity of BUS compared to CT for stones >= 5mm | 63.9% (CI = 53.4-73.2%) | ||||
| PPV of BUS compared to CT for stones >= 5mm | 20.4% (CI = 10.3-35.8%) | ||||
| NPV of BUS compared to CT for stones >= 5mm | 98.4% (CI = 90.3-99.9%) | ||||
| Bedside urinary bladder duplex ultrasonography for the detection of obstructing ureteral calculi in the emergency department Fox, J., et al. 2013 USA | Adult patients with suspected renal colic. Excluded if empty bladder or TJF =< 3 in 4 minutes. | Prospective pilot study (abstract only). Duplex BUS of the bladder. 4 minutes evaluation of RJF and TFJ. RJF =< 40% of TJF was considered positive for acute renal colic |
Sensitivity for acute ureterolithiasis of BUS compared to CTscan | 90% (67-99%) | 1-tPerformed by non-clinician research assistants 2-tLimited training 3-tSmall sample (41 pts) 4-tPilot study |
| Specificity | 67% (41-87%) | ||||
| PPV | 74% (52-90%) | ||||
| NPV | 86% (57-98%) | ||||
| Prospective validation of a current algorithm including bedside US performed by emergency physicians for patients with acute flank pain suspected for renal colic Kartal, M., et al. 2006 Turkey | Adult patients presenting to ED with unilateral flank pain Exclusions: Patients < 14, fever, pregnant, unable to give informed consent |
Prospective non-randomized clinical study Urinanalysis for RBC, BUS. Patients discharged home according to algorithm if positive BUS and positive urianalysis and outpatient follow up in urology |
#NAME? | 99/122 (81%) with confirmed stone. All but 3 discharged home w/o adverse event. Others hospitalized for various reasons | 1-tPatients with negative BUS and positive urinalaysis for RBCs were sent for radiology exam and were not discharged home. However, they seem to be the safest group for outpatient strategy 2-tNo outcome data on size of stones or need for surgical/rescue therapy for each group 3-tMain outcome is rule-in of nephroureterolithiasis rather than rule-out pathology or complex pathology |
| – BUS and + urinanalysis | 22/24 (92%) with confirmed stone | ||||
| – BUS and – urinanalysis | 11/27 (41%) with confirmed stone | ||||
| + BUS and – urinanalysis | 44/54 (81%) with confirmed stone | ||||
| Overall sensitivity of BUS | 80.70% | ||||
| Overall specificity of BUS | 37.20% | ||||
| Emergency ultrasound and urinalysis in the evaluation of flank pain Gaspari, R.J. and K. Horst 2005 USA | Adults presenting with flank pain believed to be consistent with renal colic. Exclusion: Fever, trauma, known current kidney stone, unstable vital signs and inability to provide consent. |
Prospective observational study Patients underwent CT scan, BUS and urinalaysis |
Sensitivity of BUS for HN | 86.8% (CI = 78.9-92.3%) | 1-tMost BUS performed by only 2 emergency physicians 2-tNo safety data according to BUS results 3- HN is a surrogate for diagnosis of renal colic |
| Specificity | 82.4% (CI = 74.1-88.1) |
Author Commentary:
Most studies are comparing BUS with usual methods of diagnosis (CT scan or IVP). The diagnosis accuracy of the BUS is mainly based on the presence or absence of HN. Only one study (Kartal, 2006) tries to prospectively validate the accuracy and safety of routine laboratory tests plus BUS to rule in diagnosis of renal colic. Sensitivity/specificity/PPV/NPV are used as surrogate endpoints for safety; however a low sensitivity is clinically irrelevant if stones are small or creates no complication for the patient.
Bottom Line:
Diagnosis accuracy of BUS for acute nephroureterolithiasis is highly variable depending on the protocol used and on the training of the operator. Its use appears to be safe to rule in renal colic as the most probable diagnosis and to rule out renal colic caused by a stone likely to necessitate rescue therapy. Various protocols can improve diagnosis accuracy (fluid bolus prior to BUS, KUB x-ray, bladder duplex ultrasound and urinalaysis). Definitive value of BUS for ED diagnosis of renal colic will likely be answered in upcoming clinical trials.
Abbreviations
CI : Confidence interval (95% unless otherwise specified)
KUB : Kidney, ureters and bladder
BUS : Bedside ultrasound, performed by emergency physician
IVP : Intravenous pyelography
VAS : Visual analog scale
UA : Urinanalysis
NPV : Negative predictive value
PPV : Positive predictive value
RJF : Relative jet frequency
TJF : Total jet frequency
US : Ultrasound
RBC : Red blood cells
ED : Emergency department
Abbreviations
CI : Confidence interval (95% unless otherwise specified)
KUB : Kidney, ureters and bladder
BUS : Bedside ultrasound, performed by emergency physician
IVP : Intravenous pyelography
VAS : Visual analog scale
UA : Urinanalysis
NPV : Negative predictive value
PPV : Positive predictive value
RJF : Relative jet frequency
TJF : Total jet frequency
US : Ultrasound
RBC : Red blood cells
ED : Emergency department
References:
- Dalziel, P.J. and V.E. Noble. Bedside ultrasound and the assessment of renal colic: a review
- Henderson, S.O., et al.. Bedside emergency department ultrasonography plus radiography of the kidneys, ureters, and bladder vs intravenous pyelography in the evaluation of suspected ureteral colic
- Moak, J.H., M.S. Lyons, and C.J. Lindsell. Bedside renal ultrasound in the evaluation of suspected ureterolithiasis
- Fox, J., et al.. Bedside urinary bladder duplex ultrasonography for the detection of obstructing ureteral calculi in the emergency department
- Kartal, M., et al.. Prospective validation of a current algorithm including bedside US performed by emergency physicians for patients with acute flank pain suspected for renal colic
- Gaspari, R.J. and K. Horst. Emergency ultrasound and urinalysis in the evaluation of flank pain