Tag Archives: diagnosis

Impact of Ultrasound on Medical Imaging: 1967–2021

Posted on by
Reply

In 1967, a weekly feature for medical school seniors was the ‘bullpen’ in the Charity Hospital amphitheater. Students were assigned a patient and given 30 minutes to do a history and physical exam and then present their differential diagnosis and recommendations to an attending. Diagnosis was almost exclusively based on the history and physical examination. Laboratory studies were generally confined to basic electrolytes, a CBC, urinalysis, sputum stains, and a chest x-ray.

This prepared me well for internship and residency on the Osler Medical Service at Johns Hopkins Hospital. Interns were on call 24 hours a day for 6 days a week and usually spent 16 to 18 hours a day attending patients at the bedside.

On Osler, there were no computers and handwritten or typed paper records hung on a chart rack. The wards were not air-conditioned, and yellow curtains separated each of the 28 beds. There were no patient monitors, IV pumps, or respirators, and interns performed all of the basic lab work on their patients. Nursing care was excellent; the house staff and nurses worked as a team caring for the patients. Lack of technology was compensated for by close and direct interaction with the patients and their families, and the practice of medicine was extremely satisfying and filled with empathy and compassion.

The patient was the object of all of our attention. In the late 1960s, imaging was limited and played a relatively minor role in diagnosis and management. Defensive medicine was not a concern.

Following my internal medicine residency at Hopkins, I spent the next 3 years in the immunology branch of the National Cancer Institute in Bethesda. The research centered on the new field of bone marrow transplantation and treatment of graft vs. host disease.1 Whole-body radiation prepared candidates for transplantation and my experience in dealing with near-lethal doses of radiation led me to pursue a career in radiation oncology.

After completing a residency in general and therapeutic radiology in 1975, I joined the staff of the Ochsner Clinic in New Orleans, practicing a combination of radiation therapy and general radiography and fluoroscopy. Imaging was film-based, with studies hung on multipanel viewboxes for interpretation and a hot light for image processing. Cases were dictated directly to a transcriptionist in a cubicle next to the reading room and were typed and signed in real time. The daily workload included 40 to 50 barium studies along with numerous oral cholecystograms, intravenous urograms, and chest and bone radiographs. Specialized imaging consisted of polytomography, penumoencephalography, lymphangiography, and angiography. Evaluation of the aorta, runoff vessels, and carotid vessels was performed by direct puncture. Women’s imaging consisted of xeromammograms, hysterosalpingography, and pelvimetry. Image-guided intervention was nonexistent.

That year, ultrasound was in its early clinical development and I acquired a machine and placed it in the radiation therapy department and began scanning patients from the nearby emergency department. At that time there were no other sectional imaging modalities (CT was not yet available for clinical use.).

A large part of the challenge of ultrasound was learning anatomy in a completely new way. As a result, my groundwork in understanding sectional anatomy came from ultrasound. Ultrasound, unlike CT and MR, permitted imaging not only in standardized axial planes but allowed scan planes in virtually any orientation, requiring a very detailed knowledge of anatomy.

In 1976, upon the retirement of Dr. Seymour Ochsner, I became Chair of the department at Ochsner. This provided me with an opportunity to re-equip the department at a time that the entire field of imaging was undergoing immense change. With ultrasound, new findings were being reported regularly2, and the overall quality of ultrasound images often exceeded those of early body CT scans.

The development of Doppler ultrasound in the late 1970s further expanded the applications of ultrasound, although prior to the introduction of color Doppler, this was mainly of interest to vascular surgeons, and diagnosis was based on waveform analysis rather than imaging.

An important technological development at the end of the 1970s was real-time ultrasound, leading to the rapid development of new applications in obstetrical, abdominal, pediatric, and intraoperative imaging3,4.

Developments in computers in the early 1980s led me to an opportunity to participate in the development of exciting new technologies, including a breakthrough involving ultrasound and providing a method to image Doppler information. Working with a small company in Seattle and a large prototype device, we generated the first images of blood flow in the abdomen and peripheral vessels using color Doppler5,6. Color Doppler, by allowing Doppler information to be shown in an image rather than as a waveform, was important in getting radiologists interested in Doppler. Today, color Doppler is an integral part of the ultrasound examination.

A less successful application of ultrasound in the 1980s was in the evaluation of the breast. Early breast scanners produced quality images by scanning the breast, as the patient lay prone in a water tank. Unfortunately, breast ultrasound was promoted aggressively by many manufacturers and by the mid-1980s was discredited as a useful addition to mammography. By the mid-1990s, however, advances in breast ultrasound demonstrated an important role in the evaluation of breast masses, making ultrasound an indispensable part of breast imaging and leading to the BI-RADS breast imaging and reporting system for ultrasound7–9.

Ultrasound also has had a major impact in providing guidance for minimally invasive diagnostic procedures. Fine-needle biopsy of lesions of the liver, kidney, retroperitoneum, as well as peripheral lymph nodes and the thyroid, have become a standard part of the diagnostic workup.

A radiologist of 50 years ago would not recognize the field if he or she were to return today. In fewer than 50 years, the computer has changed the practice of medicine. More precise and early diagnosis are clear benefits of the technology of the 21st century, but are accompanied by the perils of over utilization prompted by defensive medicine with interests of the physician potentially overshadowing those of the patient.

Although the contribution of these advances has benefited countless patients, many of the rewards of the practice of medicine have been diminished. In looking back at my 50 years of practicing medicine, recalling my final grand rounds at Charity Hospital, I appreciate the diagnostic skills acquired through history and physical examination, as well as the relationship I had with my patients during my clinical years. To me, this represents the real definition of being a physician. In many cases, these simple tools were often as effective, and certainly more satisfying, than today’s tendency to view the patient as the result of an imaging test rather than a person.

Christopher R. B. Merritt, MD, is a Past President (1986–1988) of the American Institute of Ultrasound in Medicine (AIUM) where he led the development of the AIUM/NEMA/FDA Output Display Standard, and served as a founder of the Intersocietal Commission for the Accreditation of Vascular Laboratories (ICAVL).

References

  1. Merritt CB, Mann DL, Rogentine GN Jr. Cytotoxic antibody for epithelial cells in human graft versus host disease. Nature 1971; 232:638.
  2. Merritt CRB. Ultrasound demonstration of portal vein thrombosis. Radiology 1979; 133:425–427.
  3. Merritt CRB, Coulon R, Connolly E. Intraoperative neurosurgical ultrasound: transdural and tranfontanelle applications. Radiology 1983; 148:513–517.
  4. Merritt CRB, Goldsmith JP, Sharp MJ. Sonographic detection of portal venous gas in infants with necrotizing enterocolitis. AJR 1984; 143:1059–1062.
  5. Merritt CRB. Doppler colour flow imaging. Nature 1987; Aug 20; 328:743–744.
  6. Merritt CRB. Doppler color flow imaging. J Clin Ultrasound 1987; 15:591–597.
  7. Mendelson EB, Berg WA, Merritt CRB. Towards a standardized breast ultrasound lexicon, BI-RADS: ultrasound. Semin Roentgenol 2001; 36:217–225.
  8. Taylor KWJ, Merritt C, Piccoli C, et al. Ultrasound as a complement to mammography and breast examination to characterize breast masses. Ultrasound Med Biol 2002; 28:19–26.
  9. Berg WA, Blume JD, Cormack JB, et al. Combined screening with ultrasound and mammography vs mammography alone in women at elevated risk of breast cancer. JAMA 2008; 299(18):2151–2163.

Clear Reporting About Adnexal Torsion

Posted on by
1

The Challenge: “Can you please rule out torsion?” is a common request ED teams have of their radiologists and gynecologists. Unfortunately, a straightforward answer to this question is rare. The diagnosis of adnexal torsion is full of uncertainty and to make matters worse, we humans are terrible at communicating uncertainty.

Indeed, there are pathognomonic sonographic findings of torsion– whirlpool sign and/or absent flow in the setting of an enlarged, edematous ovary. But certainty is rare. Thus, many reports hedge that “torsion cannot be ruled out.”

We acknowledge that the radiologist interpreting the images is not at fault for this uncertainty. The issue is that the tool itself is imperfect. Ultrasound, as a test, is great at “ruling things in,” but quite mediocre at “ruling things out.” And torsion, as we know, is a surgical diagnosis. However, going to the OR means subjecting a patient to the potential risks of surgical complications, “tying up” healthcare resources, and is expensive.

The Crux: Most imaging is helpful to “rule in,” NOT “rule out” a diagnosis. The complexity and uncertainty of pelvic ultrasonography in the evaluation of women with acute pelvic pain in and of itself is challenging. On top of that, how do we best communicate the uncertainty of NOT seeing something – like looking for a black cat in a dark room — is it even there?

The language we use in ultrasound reports can further complicate the situation. This is especially true when images are interpreted out of context, and a broad differential diagnosis offered. There are incidental findings in asymptomatic patients that warrant further evaluation in the outpatient setting, and there are others that require emergent evaluation in the correct clinical context. A cyst or mass may be an incidentaloma. Torsion is not.

The verbiage used in reports carries significant weight in clinical decision-making and management. When humans read “cannot rule out xyz,” they usually interpret this (for better or worse) as “xyz should be ruled out.” And so, we would love to start a conversation about the linguistics of report-writing for female pelvic ultrasonography.

Cases: Here are a couple of clinical scenarios that illustrate our concern:

  1. A 14-year-old female patient presents to the ED with right upper abdominal and flank pain. Her ultrasound was performed to evaluate the kidneys (area where pain was originating from), however, it also demonstrated an enlarged right ovary (4.9 cm in largest dimension). The report reads “intermittent torsion cannot be excluded.” We agree; it in fact cannot. However, now intermittent torsion MUST be excluded, and we are consulted.

The patient’s lower abdominal examination is benign. Our suspicion for torsion is exceedingly low. However, ultrasound cannot rule out torsion, only surgery can rule out torsion. Now this teenager has been given an additional, unrelated stressor (“your ovary can die”) that was unlikely to ever have significant medical repercussions. To top it off, the report recommends a follow-up scan at 8–12 weeks for what appears to be a physiologic hemorrhagic corpus luteum — an additional expense and time taken from the patient and her family to follow-up.

Final Diagnosis: Pyelonephritis

  1. A 43-year-old female patient scheduled for hysterectomy later in the month presents to the ED with persistent left lower quadrant pain that has been present for several weeks. She has a long-standing history of fibroids and was diagnosed with a 5-cm anechoic left ovarian cyst 2 months ago. Ultrasonography re-demonstrates a leiomyomatous uterus and the left ovary was not visualized.

The report reads “torsion of the left adnexa could not be excluded.” Agreed, it in fact cannot. However, the reason why it cannot be excluded is not that the ovary was not visualized. Additionally, torsion could not be excluded because ultrasound is NOT a test to exclude torsion.  

On examination, there was focal tenderness and point-of-care ultrasonography confirmed its location over a pedunculated fibroid (likely degenerating). An overnight, unscheduled diagnostic laparoscopy, in this case, would’ve resulted in a reassuring adnexal evaluation and possible myomectomy, not the procedure the patient truly needed (a laparoscopic hysterectomy).

Final Diagnosis: Degenerating fibroid (noted on hysterectomy later that week)

Why now?

Prior to COVID-19, healthcare overutilization and defensive medicine were problematic. Now, with limited resources and increased demand, the burden is even higher. ER providers, gynecologists, and radiologists must work in tandem to:

  1. prioritize imaging studies when relevant,
  2. report in clear, objective language in the context of the clinical scenario, and
  3. prioritize emergency and inpatient consultations.

Why does this matter?

Most imaging is helpful to “rule in,” not “rule out” a diagnosis. Language and semantics may significantly affect management, especially in the context of less experienced providers. For patients, it may mean the difference between an unscheduled abdominal surgery or observation. In our prior commentary (1) we referenced the language used by our obstetrics colleagues wherein they acknowledge the limitations of the imaging modality and thus, we suggest the following modification to the current style of reporting:

“Ultrasound is not intended to rule out ovarian torsion.”

We understand that this suggestion, for some, is a change of established practice patterns and we would love to hear your thoughts. Please leave comments below or tweet at @StethoscopeOn and @Dmitry_Fridman to continue the conversation!

Reference

  1. Meljen V,  Fridman D. Gynecologist’s Perspective: Semantics of “Ruling Out” Ovarian Torsion. J Ultrasound Med 2020; 39:1013. Available at: https://onlinelibrary.wiley.com/doi/10.1002/jum.15175.

Vivienne Meljen, MD, is a resident, and Dmitry Fridman, MD, PhD, is an Assistant Professor of Obstetrics and Gynecology, in the Department of Obstetrics and Gynecology at  Duke University Health System in Durham, North Carolina, USA.

Interested in learning more about gynecologic ultrasound? Check out the following posts from the Scan: