Prof. Ioan Sporea
Prof. Alina Popescu
Dept. of Gastroenterology
University of Medicine
During the last few years, medical specialties have expanded their use of ultrasound to examine certain organs: the thyroid by endocrinologists, the kidneys by urologists, and the urinary bladder and prostate and abdomen by gastroenterologists. Ultrasonography is well known as a very operatordependent and time-consuming evaluation, with an average of 15 - 20 minutes for a complex case. Though generally speaking, the radiologist is largely responsible for performing imaging evaluations, echography seems to be slipping from their diagnostic algorithm, as cardiologists and gynaecologists have begun performing ultrasonic evaluation themselves. This is a positive development for patients as well as for the medical community.
The Situation in Romania
First of all, I would like to give a brief presentation of present examination models of the abdomen worldwide to illustrate this point. In the US, the UK, the Netherlands and Scandinavian countries, radiologists and ultrasonographers are exclusively involved in evaluating a patient’s abdomen by using ultrasonography and clinicians don’t perform trans-abdominal echography.
In other countries such as Germany, Italy or Romania the clinician uses echography for patient examination, allowing him to integrate the obtained data. Subsequently, in these countries the gastroenterologist, the internal medicine doctor, the endocrinologist, etc. Perform their own ultrasonic evaluation leading to a more complete patient evaluation together with anamnesis and clinical examination. In this manner, the diagnosis can be quickly obtained and therapy can be decided immediately in many cases.
Which model is better? This is not a simple question. It is hard to change a tradition and to involve different kinds of specialists in ultrasonic evaluation. Here I would like to share my personal experience as a gastroenterologist that has performed ultrasonography for over 25 years.
Firstly, I believe that echography is the next mandatory step in evaluating a patient with abdominal pain after anamnesis and clinical examination. How can we benefit from this prompt examination: by confirming or excluding a certain pathology? In this way we can diagnose a simple or already complicated gall bladder lithiasis, chronic pancreatitis, aneurism of the aorta, ascites or obstructive kidney calculus etc. Due to the immediately performed echography, we can decide which examination will follow: gastroscopy or colonoscopy, an ecoendoscopy or we can send the patient for a different imaging exploration (CT or MRI), in case the lesions found on echography can not be completely evaluated (e.g., hepatic tumours). In the near future this strategy might be changed due to contrast-enhanced ultrasound (CEUS), which allows the description of echographic lesions during the same session.
What is Proper Protocol?
Ultrasonography should always follow a clinical examination and should have a prompt diagnosis. If transferring the patient to another department for echography, time is being wasted as usually there are long waiting lists, information on the patient is being lost, not to mention the eventual delay until proper diagnosis.
In case of abdominal emergencies, echography performed by a gastroenterologist is a great asset allowing a correct diagnosis almost instantly in many cases (including difficult pathologies such as acute appendicitis, diverticulitis, intestinal occlusion, etc).
Having in mind all of these, we consider beneficial, teaching the gastroenterology resident early on to perform echography in ambulatory as well as in emergency settings or on already hospitalised patients. In Romania, as well as in Germany, the curriculum of a gastroenterology resident contains a period of training for clinical
echography, which allows him to get familiar with the echography that he will be using in his daily routine.
This aspect is mentioned in European Gastroenterology Diploma (available online at http://www.gastrohep. com/eums/), the European curriculum of the future gastroenterologist. It stipulates that 300 echographies should be performed by the gastroenterology resident together with a certain number of endoscopies. At the same time, learning to perform trans-abdominal echography will help the gastroenterologist understand echoendoscopy, which is an indispensable method of evaluation in gastroenterology.
Gastroenterology & Echography in Romania
In the gastroenterology department at Timisoara, all gastroenterologists trained during the last 15 years are using ultrasonic evaluation successfully, which allows them a proper and rapid orientation when facing emergencies, ambulatory patients or hospitalised patients. Altogether, having a great experience in echography, some members of our staff perform interventional echography: echo-guided and assisted liver biopsy (in diffuse hepato-pathologies and abdominal tumours), percutaneous ethanol injection therapy (PEIT) for hepatic tumours or radiofrequency ablation (RFA) or diagnostic and therapeutic approaches for abdominal collections. This strategy is common for the majority of gastroenterology centres in Romania.
During the last few years, the United European Gastroenterology Federation, through its annual meetings is making efforts to encourage gastroenterologists worldwide to learn ultrasound by organising postgraduate courses on how to use abdominal echography in daily practice. Therefore we have to thank Prof. Dr. Lucas Greiner from Wuppertal, Germany, director of the postgraduate course of ultrasonography from UEGW for the special efforts made within the last ten years.
Other domains in which the gastroenterologist is involved actively include supervising inflammatory bowel diseases through performant echography, as well as hepatic cirrhosis. Trans-abdominal echography examination of patients with digestive tract pathology in everyday practice, together with endoscopic and echoendoscopic data will allow not only a correct diagnosis but also a large personal experience in this type of pathology domains.
ConclusionFor the clinician who uses echography in daily clinical practice, I see the transducer as a sort of third eye for visualising the abdomen. That is why this article is meant to be a plea for gastroenterologists to learn how to use abdominal echography in daily clinical activity. For gastroenterology residents, they should be guided by the curricula of the European Gastroenterology Diploma that stipulates explicitly the fact that training for abdominal echography is part of European gastroenterologist education.