11 gaspari r blehar d mendoza m et al use of

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11. Gaspari R, Blehar D, Mendoza M, et al. Use of ultrasound elastography for skin and subcutaneous abscesses. J Ultrasound Med 2009; 28 : 855–60. Diagnostic ultrasound 225 Soft tissue and musculoskeletal ultrasound
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12 Gastrointestinal ultrasound Introduction For years – maybe decades – gastrointestinal ultrasound has developed under the auspices of radiology departments. Specialized protocols for the ultrasound diagnosis of many gastrointestinal pathologic processes and dis- ease states have evolved over time. There has been little interest on the part of emergency and critical care clinicians to learn these applications, however, and little desire on the part of radiologists to advocate for gastrointestinal ultrasound, because frankly computed tomography (CT) is easier to obtain, is viewed as more accurate and less operator-dependent, and is perceived as standard of care. The focus on resource utilization, cost, and radiation expos- ure may change this, and indeed – especially as a screening test – there may be a substantial role for utilizing ultrasound in several common gastrointest- inal conditions. This chapter will review some of the most promising applications. Appendicitis The ultrasound diagnosis of appendicitis is certainly not new, and ultrasound is most often the first-line test in pediatrics ( Figure 12.1 ) [ 1 ]. Using ultrasound as a screening test in adults suspected of having the disease has fallen out of favor with the increased accuracy and ease in obtaining “appy protocol” CT scans [ 2 ]. However, with increased focus on cost and radiation exposure, perhaps utilizing ultrasound to rule in positive cases and reserving CT for non-diagnostic ultrasounds maybe a more effective strategy [ 3 , 4 ]. The chal- lenge is that the reported diagnostic accuracy of ultrasound for acute appen- dicitis varies greatly, with sensitivity ranges from 44% to 94% and specificity ranges from 47% to 95%. In addition, almost all of this research has looked only at scans performed by radiologists or ultrasound technologists [ 5 ] and not point-of-care provider ultrasounds. Hernia Often hernias are clinically obvious and the decision to go to the operating room is based on: 1. the ability to reduce the hernia 2. the suspicion of incarceration or strangulation Diagnostic ultrasound 227 Gastrointestinal ultrasound
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While these seem like simple decision points, it is often not so straightfor- ward. Patients with high body mass indexes (BMI) or with multiple scars as a result of repeated abdominal surgeries can be quite challenging. Studies have shown how ultrasound can assist in clinical decision making in these difficult patients [ 6 , 7 ], and pertinent ultrasound characteristics have been evaluated for their accuracy in making the diagnosis of an incarcerated hernia ( Figure 12.2 ) [ 8 ]. The findings that are included in most published scanning Figure 12.1 Appendicitis with shadowing appendicolith (A).
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