Utility of Abdominal Ultrasounds in the Investigation of Non-Specific ...

Utility of Abdominal Ultrasounds in the
Investigation of Non-Specific
Abdominal Complaints in Adults in the
Primary Care Setting: A Retrospective
Chart Review
Devon Turner, B.Sc.(H), M.D. PGY-2
Family Medicine Teaching Unit
Royal Victoria Regional Health Centre
Department of Family and Community Medicine
University of Toronto

Acknowledgement
• Dr. Parbtani for his expert advice,
coaxing and support
• RVH Research Ethics Board for their
advice and expedited review
• REQIP (BCFHT) for their support
Declarations
• This study was not funded by any external
commercial agencies
• The study team/authors have no conflict of
interest to declare

Background
• Abdominal complaints represent one of
the most common reasons for seeking
care in the outpatient setting (1).
• Often the symptoms are vague which
prompts providers to “cast a wide net” in
the diagnostic pathway.

Background
• Abdominal ultrasounds are frequently used to
discern the diagnosis, but their utility is unclear,
unless there is a specific diagnostic suspicion,
e.g. biliary or renal pathology (2,3).
• Abdominal ultrasounds are known to detect
extraneous information:
• Speets et. al. determined an “incidental
finding” rate of 43% among ultrasounds
performed for specific RUQ pathology
(4,6)

Research Question
• Is abdominal ultrasonography an
appropriate diagnostic tool in the
investigation of non-specific abdominal
complaints?

Methods
• Study Design: retrospective chart
review
• Patient population: adult patients of one
of 5 community family medicine
practice, including a resident teaching
unit

Inclusion Criteria
• adults age 18 or older
• ultrasound indication is some variant of
vague symptomatology: generalized
pain, cramping, bloating, malaise
• ultrasound report available
• follow up progress notes available

Exclusion Criteria
• age less than 18
• pregnancy
• ultrasound related to a cancer diagnosis
• ultrasound ordered for purposes of
surgery
• ultrasound performed specifically for
biliary or renal pathology

Assessment of Ultrasounds
• Assessed ultrasound results based on:
• utility of ultrasound
• adverse utility of ultrasound
• These are not mutually exclusive

Criteria for Utility
• An ultrasound was deemed worthwhile if
any of the following conditions were met:
• detection of relevant findings
• findings that establish a diagnosis
• findings that lead to a referral for
definitive management
• findings that lead to further imaging
based on a clinically relevant finding
• definitive management was initiated

Criteria for Adverse Utility
• An ultrasound was deemed to have an
adverse utility if any of the following
conditions were met:
• did not meet utility criteria
• sole outcome is patient reassurance or
“normal ultrasound”
• detection of irrelevant findings
• benign anatomical variants
• increased healthcare utilization based on
irrelevant finding

Results
• 180 ultrasounds reviewed
• 36 ultrasounds assessed
Average Age
51 +/- 37
Gender
Female 26
Male 10

Results
Assessment Number % Overlap
Utility 7* 19
Adverse Utility 31 (29) 86 (81)
2
z-test ** z = 5.01, p < 0.001
* four of those meeting utility criteria did so by establishing an abnormality in the
pelvis
** statistical significance determined after data were converted to mutual
exclusivity

Conclusions
• Limitations of study design limit the
impact of these results, but they suggest
more judicious use of this imaging
modality is warranted.
• Results are compelling enough to warrant
further, more rigorous study into this
area; may substantially reduce cost and
improve clinical care

Limitations
• Small sample size
• “One” site
• Assessment instrument arbitrarily devised by
investigator
• Included but did not separate both resident and
independently-licensed physicians in the study
• No specialist input
• Unable to distinguish between abdominal and
abdomial/pelvic ultrasounds

Discussion: Utility
19% of the ultrasounds met the criteria for utility
Ultrasound
Number
Reason for meeting clinical utility
1 fatty liver with resolution
2 fibroid*
3 ovarian cyst*
4 ovarian cyst*
5 ovarian cyst*
6 cholelithiasis
7 intra-hepatic bile duct dilatation
*study design did not allow for separation of some pelvic and abdominal
ultrasounds

Discussion: Adverse Utility
86% of the ultrasounds met the criteria for adverse utility
Criterion for Adverse Utility
Frequency of
Occurrence
Percentag
e
Irrelevant findings 13 36.1
Lack of clinically relevant findings 30 83.3
Patient reassurance sole outcome 2 5.5
Referral generated based on incidental
finding 0 0
Follow-up imaging based on incidental
finding 0 0

Discussion
• Abdominal ultrasound yielded fairly low rate
of utility, with many of these being for pelvic
complaints:
• for which there is a more focused test
• for which the role of physical exam is
unclear

Discussion
• Very high rate of adverse utility was
noted:
• suggests inappropriate use of
ultrasound
• concern about “falsely reassuring” the
patient is present, though we do not
have research to support or refute this

Conclusions
• Research results not compelling enough
to change care or impose restrictions on
use, but warrants more judicious use of
this imaging modality.
• Results are compelling enough to warrant
further, more rigorous study into an area
that may substantially reduce cost and
improve clinical care

References
1. Kroenke K, Mangelsdorff AD. Common symptoms in ambulatory care: incidence,
evaluation, therapy and outcome. Am J Med, 1989. 86: 262-266.
2. 2012 Canadian Association of Radiology Referral Guidelines.
www.car.ca/en/standards-guidelines/guidelines.aspx. Section G: Gastrointestinal
system.
3. 2012 Canadian Association of Radiology Referral Guidelines.
www.car.ca/en/standards-guidelines/guidelines.aspx. Section H: Urological,
adrenal and genitourinary systems.
4. Speets AM, Hoes AW, van der Graaf Y et al. Upper abdominal ultrasound in
general practice: indications, diagnostic yield and consequences for patient
management. Fam Pract, 2006. 23: 507-511.
5. Connor SE, Bannerjee AK. General Practitioner requests for upper abdominal
ultrasound: their effect on clinical outcome. Br J Radiol, 1998. 71: 1021-1025.
6. Speets AM, Kalmijn S, Hoes AW et al. Yield of abdominal ultrasounds in patients
with abdominal pain referred by general practitioners. Eur J Gen Pract. 2006. 12:
135-137.