EFSUMB Position Paper: Recommendations for Gastrointestinal Ultrasound (GIUS) in Acute Appendicitis and Diverticulitis

Abstract

An interdisciplinary task force of European experts summarizes the value of gastrointestinal ultrasound (GIUS) in the management of acute appendicitis and diverticulitis. Based on an extensive literature review, clinical recommendations for these highly common diseases in visceral medicine are presented.In patients with acute appendicitis, preoperative sonography has been established as a routine procedure in most European countries for medical and legal reasons. Routine sonography in these patients may reduce the rate of unnecessary surgery by half. The sensitivity, specificity, and accuracy of ultrasound reach values above 90 % and are equivalent to CT and MRI. However, the high operator dependence may be a problem, for example in point-of-care ultrasound in emergency departments. Structured training programs, quality controls and standardized ultrasound reporting should be increasingly implemented.In the case of suspected acute diverticulitis, “ultrasound first” should also be a basic element in the approach to all patients. Sonography can confirm the diagnosis and allows early risk stratification. As treatment strategies have become less aggressive and more tailored to the stage of diverticulitis, accurate staging has become increasingly important. GIUS and CT have proven to have similar sensitivity and specificity. Especially in cases of uncomplicated diverticulitis, GIUS will be the one and only imaging procedure. CT may work as a backup and has particular advantages for diverticulitis located in the distal sigmoid, inflammation deep in the small pelvis and insufficient ultrasound scanning conditions. This step-up approach (ultrasound first and CT only in case of a negative or inconclusive ultrasound result) has proven to yield the best accuracy.

EchoScopy in scanning abdominal diseases; a prospective single center study

“…The main disadvantages and limitations are the small screen size (the CDI window cannot be changed during Vscan™ exam-ination to cover the whole area of a larger lesion) and lack of pulse-wave and continuous Doppler to evaluate the blood flow velocities. It has to be pointed out that CDI plays a crucial role in the differential diagnosis of abdominal focal lesions [2,[80][81][82][83][84].…”

EFSUMB Gastrointestinal Ultrasound (GIUS) Task Force Group: Celiac sprue and other rare gastrointestinal diseases ultrasound features

“…Asymptomatic small bowel diverticula normally cannot be delineated from normal bowel loops by sonography. In cases of acute jejunoileal diverticulitis sonographic criteria are similar to those of acute colonic diverticulitis [17,84]: 1) Short segmental bowel-wall thickening (>5 mm); 2) diverticular outpouchings from the affected bowel wall; 3) surrounding hyperechoic tissue changes.…”

“…• on the value of intestinal ultrasound for the diagnosis, differential diagnosis and follow-up of rare inflammatory and neoplastic diseases, not mentioned in the previous chapters of the EFSUMB GIUS recommendations and WFUMB position papers [11,12,14,15,17,20,21].…”

“…The value of GIUS for diagnosis, differential diagnosis, and follow-up in celiac sprue and other rare and miscellaneous diseases of the gastrointestinal tract is much less known and largely dependent on the individual clinical experience of the examiner. The European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) has published general guidelines and recommendations on gastrointestinal ultrasound [14], inflammatory bowel disease (IBD) [15], perianal applications [16], appendicitis and diverticulitis [17] and other bowel emergencies [11,12,18], as well as functional GIUS [19].…”

State of the art in the teaching of digestive ultrasound

“…Since then, technological US advancements and increased skills of sonographers, most of them gastroenterologists, broadened its use to diagnosis and monitoring several intestinal diseases, in particular inflammatory bowel disease (IBD). Systematic reviews and meta-analyses have shown that GIUS, Computed Tomography scan (CT) and Magnetic Resonance Imaging (MRI) have similar accuracy for the evaluation of IBD [2][3][4][5], and currently GIUS is recommended by several international guidelines as the first examination in patients with abdominal complaints to detect appendicitis, diverticulitis, bowel occlusion and inflammatory bowel diseases [6][7][8][9]. The advantages of GIUS over other imaging techniques are its relatively low cost, the widely available equipment and potential prompt use and the lack of contraindications or harmful conditions such as ionizing radiation or claustrophobia [10].…”