Endosonography For Right‐sided and Acute Upper Intestinal Misery: the EFRAIM study

Background Acute upper abdominal pain is a frequent symptom leading to hospital admission. Objective To determine whether a primary intra‐ and extraluminal diagnostic approach enabled by endoscopic ultrasound is as effective as a conventional diagnostic algorithm of transabdominal ultrasound followed by oesophagogastroduodenoscopy. Methods A total of 240 patients who presented with acute right‐sided and/or upper abdominal pain were prospectively recruited. Exclusion criteria were chronic pain, malignancy, prior abdominal surgery, bleeding, peritonitis, and elevated liver enzymes or lipase as defined 3‐times higher than upper reference value. All patients underwent first transabdominal ultrasound and were then randomized (1 : 1) to either endoscopy followed by endoscopic ultrasound or vice versa. Patients and respective examiners were blinded to prior findings. Results A total of 223 patients were included. Endoscopic ultrasound provided a higher diagnostic yield than the combination of transabdominal ultrasound and endoscopy (62.3 vs. 50.7%; p  = 0.001). For mucosal/intraluminal lesions, we observed a very good agreement between both endoscopic modalities (kappa 0.89). The agreement for pancreatic and biliary causes was good between both ultrasound modalities (kappa 0.66). Conclusions Due to its high diagnostic yield, endoscopic ultrasound as a primary diagnostic modality appears to be a valuable option in patients with acute upper abdominal pain.