Giri\u015f<\/strong><\/p>\nKolesistektomi, en s\u0131k ger\u00e7ekle\u015ftirilen cerrahi i\u015flemlerden birisidir. Kolesistit tan\u0131s\u0131nda fizik muayene ve laboratuvar testlerinin tek ba\u015f\u0131na tan\u0131 koydurucu olmad\u0131klar\u0131n\u0131 biliyoruz. Radyolog taraf\u0131ndan ger\u00e7ekle\u015ftirilen kapsaml\u0131 ultrason, safra kesesi patolojilerinin tan\u0131nmas\u0131nda alt\u0131n standart olarak kabul ediliyor. Ancak bir\u00e7ok hastanede, \u00f6zellikle de mesai saatleri sonras\u0131nda, radyologlar taraf\u0131ndan ultrason uygulanm\u0131yor.<\/p>\n
Acil serviste kolelitiazis ve kolesistit tan\u0131s\u0131nda yatak ba\u015f\u0131 hedefe y\u00f6nelik ultrasonografi (POCUS) kullan\u0131labiliyor. Kapsaml\u0131 ultrasona g\u00f6re POCUS daha kolay ula\u015f\u0131labilir olmas\u0131yla, ek g\u00f6r\u00fcnt\u00fcleme ihtiyac\u0131n\u0131, kons\u00fcltasyon isteme s\u00fcresini ve sonu\u00e7 olarak da hastan\u0131n acil serviste kal\u0131\u015f s\u00fcresini ve morbiditeyi azaltabiliyor.<\/p>\n
Kanada Acil Hekimleri Derne\u011fi (CAEP) POCUS uygulamas\u0131n\u0131 te\u015fvik etse de kolesistit POCUS kullan\u0131m alanlar\u0131 aras\u0131nda say\u0131lmam\u0131\u015ft\u0131r. Konuyla ilgili literat\u00fcr\u00fcn k\u00fc\u00e7\u00fck tek merkezli \u00e7al\u0131\u015fmalarla s\u0131n\u0131rl\u0131 kalmas\u0131, daha geni\u015f bir hasta pop\u00fclasyonuyla y\u00f6ntemin de\u011ferlendirilmesi ihtiyac\u0131n\u0131 do\u011furmu\u015ftur.<\/p>\n
Y\u00f6ntem<\/strong><\/p>\n\u00c7al\u0131\u015fma, 01 Aral\u0131k 2011 – 04 Aral\u0131k 2015 tarihleri aras\u0131nda Kanada\u2019daki bir akademik Acil T\u0131p Klini\u011fi\u2019ne sa\u011f \u00fcst kadran a\u011fr\u0131s\u0131yla ba\u015fvuran b\u00fct\u00fcn 17 ya\u015f \u00fczeri hastalarda, kolelitiazis ve kolesistit tan\u0131s\u0131 amac\u0131yla uygulanan POCUS \u00e7al\u0131\u015fmalar\u0131na ait kay\u0131tlar\u0131n incelenmesiyle ger\u00e7ekle\u015ftirilmi\u015f. Ultrason uygulay\u0131c\u0131lar\u0131n\u0131n tamam\u0131n\u0131n uygun e\u011fitimi alm\u0131\u015f oldu\u011fu vurgulanm\u0131\u015f. Hastal\u0131k tan\u0131s\u0131nda, varsa patoloji sonucu, bu yoksa s\u0131ras\u0131yla laparoskopi, kapsaml\u0131 ultrason ve bilgisayarl\u0131 tomografi (BT) alt\u0131n standart olarak kabul edilmi\u015f.<\/p>\n
Kolelitiazis, safra kesesi l\u00fcmeninde posteriorda akustik g\u00f6lgelenme veren y\u00fcksek yans\u0131t\u0131c\u0131 bir ekojenik oda\u011f\u0131n varl\u0131\u011f\u0131 olarak tan\u0131mlanm\u0131\u015f. Kolesistit tan\u0131s\u0131 ise, \u015funlardan ikisinin varl\u0131\u011f\u0131nda konulmu\u015f: Pozitif sonografik Murphy bulgusu, anterior safra kesesi duvar kal\u0131nl\u0131\u011f\u0131n\u0131n >3 mm olmas\u0131 ve perikolesistik s\u0131v\u0131 varl\u0131\u011f\u0131. Koledokolitiyazis, safra kanallar\u0131nda safra ta\u015f\u0131 varl\u0131\u011f\u0131 olarak tan\u0131mlanm\u0131\u015f. B\u00fct\u00fcn koledokolitiyazis hastalar\u0131nda kolelitiazis de oldu\u011fu kabul edilmi\u015f. Tan\u0131da karars\u0131z kal\u0131nd\u0131\u011f\u0131 durumlarda sonu\u00e7lar negatif olarak yorumlanm\u0131\u015f. Bunlara ek olarak, hastalar sonraki 30 g\u00fcn i\u00e7erisinde yeniden acil servise ba\u015fvurmu\u015flarsa, detayl\u0131 bir inceleme ile kolelitiazis veya kolesistit tan\u0131s\u0131 do\u011frulanmaya \u00e7al\u0131\u015f\u0131lm\u0131\u015f.<\/p>\n
\u00c7al\u0131\u015fman\u0131n primer sonlan\u0131m\u0131, kolelitiazis ve kolesistit tan\u0131s\u0131nda POCUS\u2019un tan\u0131sal do\u011frulu\u011fu olarak se\u00e7ilmi\u015f. \u0130ki hastal\u0131k i\u00e7in de duyarl\u0131l\u0131k, \u00f6zg\u00fcll\u00fck, prediktif de\u011ferler ve olabilirlik oranlar\u0131 hesaplanm\u0131\u015f. Wilson skoru kullan\u0131larak %95 g\u00fcven aral\u0131klar\u0131 da hesaplanm\u0131\u015f.<\/p>\n
Bulgular<\/strong><\/p>\nKay\u0131tlarda 966 hasta bulunsa da bunlar\u0131n 320\u2019si m\u00fckerrer kay\u0131t, 69\u2019u ise POCUS\u2019un ba\u015fka bir nedenle uygulanm\u0131\u015f olmas\u0131 nedeniyle \u00e7\u0131kart\u0131larak, toplam 577 hasta analize dahil edilmi\u015f.<\/p>\n
Kolelitiazis a\u00e7\u0131s\u0131ndan 205 hastan\u0131n POCUS (+) oldu\u011fu g\u00f6r\u00fclm\u00fc\u015f. POCUS (+) olan gruptan 27 hastan\u0131n yanl\u0131\u015f pozitif, 9\u2019unun ise yanl\u0131\u015f negatif oldu\u011fu saptanm\u0131\u015f.<\/p>\n
Kolesistit a\u00e7\u0131s\u0131ndan 59 hastan\u0131n POCUS (+) oldu\u011fu g\u00f6r\u00fclm\u00fc\u015f. Bunlardan 12\u2019si yanl\u0131\u015f pozitifken, 23\u2019\u00fc ise yanl\u0131\u015f negatifmi\u015f. Cohen’in kappa \u00f6l\u00e7\u00fcs\u00fc 0,93 saptanm\u0131\u015f. Cohen’in kappa \u00f6l\u00e7\u00fcs\u00fcnde de\u011ferin 1\u2019e yakla\u015ft\u0131k\u00e7a daha g\u00fc\u00e7l\u00fc bir uyu\u015fma g\u00f6sterdi\u011fini hat\u0131rlayacak olursak, burada m\u00fckemmele yak\u0131n bir uyu\u015fma mevcut oldu\u011funu s\u00f6yleyebiliriz.<\/p>\n
Kolelitiazis a\u00e7\u0131s\u0131ndan duyarl\u0131l\u0131k ve \u00f6zg\u00fcll\u00fck, s\u0131ras\u0131yla, %95,2 (%95 CI %91,1-97,8) ve %93,1 (%95 CI %90,1-95,4) olarak bulunmu\u015f. Pozitif ve negatif olabilirlik oranlar\u0131 14 ve 0,05 imi\u015f. Yani \u00e7al\u0131\u015fmaya g\u00f6re POCUS\u2019un konvansiyonel ultrasona g\u00f6re kolelitiazis tan\u0131s\u0131n\u0131 do\u011fru saptama olas\u0131l\u0131\u011f\u0131, yanl\u0131\u015f saptama olas\u0131l\u0131\u011f\u0131ndan 14 kat fazla bulunmu\u015f. Negatif prediktif de\u011fer ise %97,6 (%95 CI %95,5-98,7) olarak saptanm\u0131\u015f.<\/p>\n
POCUS’un kolesistit te\u015fhisi i\u00e7in duyarl\u0131l\u0131\u011f\u0131 %67,1 (%95 CI %54,9-77,9) ve \u00f6zg\u00fcll\u00fc\u011f\u00fc %97,6 (%95 CI %95,9-98,8) olarak bulunmu\u015f. Negatif prediktif de\u011feri ise %95,6 (%95 CI %93,9-96,8) olarak saptanm\u0131\u015f. Pozitif ve negatif olabilirlik oranlar\u0131 28 ve 0,34, yani POCUS\u2019un konvansiyonel ultrasona g\u00f6re kolesistit tan\u0131s\u0131n\u0131 do\u011fru saptama olas\u0131l\u0131\u011f\u0131, yanl\u0131\u015f saptama olas\u0131l\u0131\u011f\u0131ndan tam 28 kat fazla olarak tespit edilmi\u015f.<\/p>\n
\u00c7al\u0131\u015fman\u0131n her iki hastal\u0131k i\u00e7in pozitif ve negatif olabilirlik oranlar\u0131n\u0131 de\u011ferlendirdi\u011fimizde, POCUS\u2019un test sonras\u0131 olas\u0131l\u0131\u011f\u0131n\u0131 ciddi oranda art\u0131rd\u0131\u011f\u0131n\u0131 ve tan\u0131sal y\u00f6nden \u00e7ok g\u00fc\u00e7l\u00fc bir silah olabilece\u011fini g\u00f6rebiliyoruz.<\/p>\n
Tart\u0131\u015fma<\/strong><\/p>\nSonu\u00e7lar, literat\u00fcrde kolelitazis tan\u0131s\u0131nda kapsaml\u0131 ultrasonun test karakteristiklerini sunan \u00e7al\u0131\u015fmalar ile benzer g\u00f6r\u00fcn\u00fcyor. Kolesistit tan\u0131s\u0131nda POCUS\u2019un \u00f6zg\u00fcll\u00fc\u011f\u00fc kapsaml\u0131 ultrasona g\u00f6re daha y\u00fcksek bulunsa da duyarl\u0131l\u0131k ciddi oranda d\u00fc\u015f\u00fck (%67,1-94). Bu durumun nedeni olarak, ultrasonun ger\u00e7ek i\u015flevinin kolelitiazis tan\u0131s\u0131 olmas\u0131 g\u00f6steriliyor.<\/p>\n
\u00c7al\u0131\u015fman\u0131n retrospektif yap\u0131s\u0131, tek merkezli bir \u00e7al\u0131\u015fma olmas\u0131 ve ilgili tarih aral\u0131\u011f\u0131ndaki t\u00fcm hastalar\u0131 kapsamamas\u0131 k\u0131s\u0131tl\u0131l\u0131klar\u0131 aras\u0131nda. Bunun se\u00e7im yanl\u0131l\u0131\u011f\u0131na yol a\u00e7m\u0131\u015f olma potansiyeli var. Ancak \u00f6rneklem b\u00fcy\u00fckl\u00fc\u011f\u00fcn\u00fcn geni\u015fli\u011fi, kay\u0131tlar\u0131n standart olmas\u0131 ve e\u011fitimli personel taraf\u0131ndan standart formlar kullan\u0131larak de\u011ferlendirilmesi, \u00e7al\u0131\u015fman\u0131n g\u00fc\u00e7l\u00fc y\u00f6nleri olarak say\u0131l\u0131yor.<\/p>\n
TATDUS yazar\u0131n\u0131n \u00e7al\u0131\u015fma i\u00e7in yorumlar\u0131; <\/strong><\/p>\nE\u011fitimli Acil T\u0131p hekimlerinin elinde, kolelitiazis tan\u0131s\u0131nda ve kolesistitin ay\u0131r\u0131c\u0131 tan\u0131da \u00f6ne \u00e7\u0131kmas\u0131nda POCUS y\u00fcksek ba\u015far\u0131yla kullan\u0131labilir. \u00c7al\u0131\u015fman\u0131n da belirtti\u011fi gibi, POCUS\u2019un Kolesistiti net olarak g\u00f6steremedi\u011fi, ancak klinik \u015f\u00fcphenin y\u00fcksek oldu\u011fu durumlarda, ileri g\u00f6r\u00fcnt\u00fcleme uygun olacakt\u0131r. Zaten g\u00fcnl\u00fck prati\u011fimizde fizik muayene ve laboratuvar testlerini hi\u00e7 kullanmadan, yaln\u0131zca ultrason ile kolesistit tan\u0131s\u0131 koymad\u0131\u011f\u0131m\u0131z\u0131 (veya tan\u0131y\u0131 d\u0131\u015flamad\u0131\u011f\u0131m\u0131z\u0131) d\u00fc\u015f\u00fcnd\u00fc\u011f\u00fcm\u00fczde, bu durum ek bir g\u00fc\u00e7l\u00fck do\u011furmuyor gibi g\u00f6r\u00fcn\u00fcyor. Acil T\u0131p uzmanlar\u0131n\u0131n klinik becerilerinin POCUS ile bu iki klinik durumu tan\u0131yabilme noktas\u0131nda geli\u015ftirilmesi, ciddi bir yarar sa\u011flama potansiyeli ta\u015f\u0131yor.<\/p>\n","protected":false},"excerpt":{"rendered":"
Kar\u0131n a\u011fr\u0131s\u0131, acil servis ba\u015fvurular\u0131n\u0131n en s\u0131k nedenlerinden birisidir. Klinik olarak bat\u0131n i\u00e7i patolojilerden \u015f\u00fcphelendi\u011fimiz vakalarda, tan\u0131ya gidebilmek i\u00e7in g\u00f6r\u00fcnt\u00fcleme tetkiklerinden yararlan\u0131yoruz.…<\/p>\n","protected":false},"author":1205,"featured_media":4201,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"inline_featured_image":false,"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"categories":[3,19,12,10014],"tags":[10049,71,86],"class_list":["post-4276","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-egitim","category-literatur-ozetleri-surekli-yayinlar","category-surekli-yayinlar","category-akademik-blog-yazisi","tag-kolelitiazis","tag-kolesistit","tag-pocus"],"acf":[],"_links":{"self":[{"href":"https:\/\/tatd.org.tr\/tatdus\/wp-json\/wp\/v2\/posts\/4276","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/tatd.org.tr\/tatdus\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/tatd.org.tr\/tatdus\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/tatd.org.tr\/tatdus\/wp-json\/wp\/v2\/users\/1205"}],"replies":[{"embeddable":true,"href":"https:\/\/tatd.org.tr\/tatdus\/wp-json\/wp\/v2\/comments?post=4276"}],"version-history":[{"count":0,"href":"https:\/\/tatd.org.tr\/tatdus\/wp-json\/wp\/v2\/posts\/4276\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/tatd.org.tr\/tatdus\/wp-json\/wp\/v2\/media\/4201"}],"wp:attachment":[{"href":"https:\/\/tatd.org.tr\/tatdus\/wp-json\/wp\/v2\/media?parent=4276"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/tatd.org.tr\/tatdus\/wp-json\/wp\/v2\/categories?post=4276"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/tatd.org.tr\/tatdus\/wp-json\/wp\/v2\/tags?post=4276"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}