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The ultrasoundtwinkling artefact’ in the diagnosis of urolithiasis

hocus or valuable point-of-care-ultrasound? A systematic review and meta-analysis

Laher, Abdullah E.a; McDowall, Jareda; Gerber, Louisa; Aigbodion, Sunday J.a; Enyuma, Callistus O.A.a,c; Buchanan, Seana; Adam, Ahmedb

European Journal of Emergency Medicine: March 01, 2019 - Volume Publish Ahead of Print - Issue - p
doi: 10.1097/MEJ.0000000000000601
Review article: PDF Only

Presentation to the emergency department with renal colic has been reported as between 6.7 and 27.9 per 1000 emergency department visits. Clinicians rely on various radiological investigations for the prompt and accurate diagnosis of urolithiasis. This review assesses the validity of the colour Doppler ultrasonographic twinkling artefact (TA) sign as a diagnostic tool for the presence of urolithiasis. A systematic search of the Cochrane Database of Systematic Reviews, Embase, PubMed, Scopus and Web of Science databases was performed (October 2018) using specific search terms. PRISMA (Preferred Reporting Items for Systematic reviews and Meta-analyses) guidelines and the QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies-2) tool were applied to rank and evaluate selected studies. Twenty-two articles that included 4389 participants were assessed. The median sample size was 102.5 (interquartile range: 47–292.5) and the age range of participants was 4–91 years. Meta-analysis of the studies that provided sufficient data resulted in a pooled sensitivity and specificity for the ultrasonographic TA sign of 88.16 [95% confidence interval (CI): 87.07–89.19%] and 79.22% (95% CI: 73.41–84.26%) respectively, with an estimated summary effect of 3.84 (95% CI: 1.08–6.60, P=0.006) in log odds ratio terms. There was significant interstudy heterogeneity as suggested by an I2-statistic of 94.51% (95% CI: 94.51–99.58) and an estimated τ2 parameter of 7.21 (SE: 7.44). Despite the suboptimal pooled sensitivity and specificity of the TA sign and the large heterogeneity between published studies, the current body of evidence suggests that the colour Doppler ultrasonography TA sign may be useful as a complementary tool in the diagnostic workup of patients with suspected urolithiasis.

aDepartment of Emergency Medicine

bDivision of Urology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

cDepartment of Paediatrics, Faculty of Medicine, University of Calabar, Calabar, Nigeria

Correspondence to Abdullah E. Laher, MBBCh, MMed, FCEM, Cert Critical Care, EDIC, DipPEC, DCH, DipAllerg, DipHIVMan, Department of Emergency Medicine, Faculty of Health Sciences, University of the Witwatersrand, 7 Jubilee Road, Parktown, Johannesburg 2193, South Africa Tel: +27 848 402 508; fax: +27 118 340 646; e-mail:

Received April 4, 2018

Accepted February 11, 2019

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