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Sonography of acute appendicitis
Abstract
Graded compression sonography is an established imaging modality in the clinical setting of acute right lower quadrant pain or to diagnose acute appendicitis because of its easy assessability, noninvasiveness, real-time imaging. However, the ability to accurately diagnose appendicitis can be affected by several factors including operator dependence, deeper-located appendix, and obesity or muscularity of the patient. However, adjuvant techniques utilizing advanced equipment and accumulated operator's experience to conventional graded compression sonography will yield more frequent detection of the vermiform appendix and more accurate results of acute appendicitis on sonography. This article introduces adjuvant techniques and various know-how of real field in the detection of the vermiform appendix and diagnosis of acute appendicitis.
... [2][3][4][5][6][7][8][9] There is currently some debate about the best imaging modality or combination of modalities to accurately and costeffectively diagnose the condition. Studies have variously advocated ultrasound in all presentations, 10 as a first-line modality, [11][12][13] and even inappropriate as it delays treatment. 14 Pershad et al. found that performing ultrasound on all children with suspected appendicitis was the most cost-effective diagnostic approach. ...
... 37,46 The development of complementary techniques such as posterior manual compression, where the sonographer's left hand provides anterior force to the patient's right lower back above the ileum in order to reduce the distance to a high frequency transducer allow better identification of deeper appendices. 12 When utilising the bladder as an acoustic window or a right posterior approach for retro-caecal appendices, a lower frequency curvilinear transducer can be useful without using compression. 5 This lower frequency transducer may be helpful when dealing with obese children where a body mass index greater than 85th percentile has been shown to result in significantly lower diagnostic accuracy with sonography. ...
... The appendix is most commonly retro-ileal, but a retro-caecal location has been reported in 5-28% of cases, making identification by ultrasound technically difficult due to artefact from overlying bowel gas/faeces (Fig. 5). 12,46,51 The lack of a visible appendix makes determining diameter and other previously mentioned criteria impossible to assess, highlighting the potential diagnostic use of more readily visible secondary signs of appendicitis. ...
Sonography is an important clinical tool in diagnosing appendicitis in children as it can obviate both exposure to potentially harmful ionising radiation from computed tomography scans and the need for unnecessary appendicectomies. This review examines the diagnostic accuracy of ultrasound in the identification of acute appendicitis, with a particular focus on the the utility of secondary sonographic signs as an adjunct or corollary to traditionally examined criteria. These secondary signs can be important in cases where the appendix cannot be identified with ultrasound and a more meaningful finding may be made by incorporating the presence or absence of secondary sonographic signs. There is evidence that integrating these secondary signs into the final ultrasound diagnosis can improve the utility of ultrasound in cases where appendicitis is expected, though there remains some conjecture about whether they play a more important role in negative or positive prediction in the absence of an identifiable appendix.
... A total of 55 adult (age was equal or greater than 15 years old) patients with clinically suggested appendicitis due to acute pain over the RLQ, and without trauma or pregnancy, underwent ultraso- (7,8) . The results of sonographic examination were discussed with the consultant surgeons. ...
... In recent years, ultrasonography has achieved an important place in the diagnosed of acute appendicitis. US has the highest diagnostic reliability for acute appendicitis in children (77.7% sensitivity and 94.8% specificity) compared with other techniques (4,8,11) . In adult patients, the sensitivity of US is 75~90%. ...
... The corresponding specificity is 73~98%. The accuracy is between RLQ: right lower quadrant values are about 92% and 63%, respectively (2,7,8,10) . ...
... The presence of free fluid also afforded a sensitivity of 53% and a PPV of 95% (See Figure 4c). The presence of free fluid is widely known as a secondary feature, and it could often be suggestive of an abdominal condition but not specific for appendicitis [26,27]. In this study, approximately 50% of cases presented free fluid showed an absence of a distinctly visualized appendix. ...
Acute appendicitis it a quite common abdominal disorder and considered as a difficult diagnosis. An accurate diagnosis is essential to prevent any complication from delayed surgical intervention. Aim: To evaluate the diagnostic accuracy of ultrasound in acute appendicitis cases in Saudi Arabia compared with histopathology. Moreover, to determine whether there is a correlation between the accuracy of ultrasound in acute appendicitis and the sonographers’ expertise. Methods: A retrospective study was conducted, including patients who admitted to the emergency room with clinical symptoms of suspected acute appendicitis and underwent ultrasound examinations. Diagnostic features, including diameter of the appendix ≥7 mm, free fluid, lack of compressibility, no appendix seen, normal appearance, and thick wall, were recorded for each patient. Results: Only 61 of the 132 patients in the study were accurately diagnosed with the use of ultrasound. Just 44 of them were diagnosed with appendicitis (true positives) and 17 without appendicitis (true negatives). However, 69 patients who had positive histopathologic results received a negative ultrasound diagnosis (false negatives), and 2 patients with negative histopathologic findings had a positive ultrasound diagnosis (false positives). There was no significant association between the accuracy of the ultrasound diagnosis and the years of experience of the sonographers. Conclusion: a low level of diagnostic accuracy was demonstrated when utilizing ultrasound to diagnose cases of acute appendicitis. In addition, no association was found between the years of experience of the sonographer conducting the examination and the diagnosis of acute appendicitis.
... The features of a blind ending tubular appendage that is non compressible, non-peristaltic with a diameter of 6mm and the appendix wall hyperemia on a color Doppler are characteristic findings. Obstructive and complicated cases of appendicitis are characterized by appendicoliths, pericaecal inflammation and free fluid collection in the pelvic cavity [5,6]. ...
... The features of a blind ending tubular appendage that is non compressible, non-peristaltic with a diameter of 6mm and the appendix wall hyperemia on a color Doppler are characteristic findings. Obstructive and complicated cases of appendicitis are characterized by appendicoliths, pericaecal inflammation and free fluid collection in the pelvic cavity [5,6]. ...
... The features of a blind ending tubular appendage that is non compressible, non-peristaltic with a diameter of 6mm and the appendix wall hyperemia on a color Doppler are characteristic findings. Obstructive and complicated cases of appendicitis are characterized by appendicoliths, pericaecal inflammation and free fluid collection in the pelvic cavity [5,6]. ...
... This suggests the high predictive value of ultrasound in diagnosing AA and as such USS diagnosis of AA can be relied upon most of the time particularly regarding operative decision. Some reports have varied ultrasound accuracy with age, gender and body mass index (BMI) [20][21][22][23]. The effect of body weight is with regard to the influence of excessive abdominal wall fat in the obese obscuring adequate visualization by USS while that of gender owes largely to the wide array of gynecological conditions such as ovarian cyst, pelvic inflammatory disease and ectopic pregnancy that may either mimic, obscure or coexist with AA [23][24][25][26]. ...
BACKGROUND: Surgery for pain in the right lower quadrant of the abdomen remains a clinical dilemma. Acute appendicitis is considered one of the commonest surgical emergencies. Correct diagnosis and prompt treatment are required to reduce the development of complications. Ultrasound has been shown to be of value in the diagnosis of acute appendicitis with sensitivity varying from one study to another.
AIM: This retrospective cross-sectional study assessed the accuracy of preoperative ultrasound scan in the evaluation of patients with suspected acute appendicitis.
METHODS:One hundred-and-three adult patients with suspected acute appendicitis who underwent preoperative ultrasound scan of the abdomen and subsequently appendectomy; had the histopathology reports compared with their operative findings.
RESULTS: 103 patients whose ages ranged from 15 to 65 years with a mean age of 30.6±18 were retrospectively reviewed. Male to female ratio was 1.5:1. Seventy-five patients had ultrasound diagnosis of acute appendicitis, 68 of which correlated with histopathology. There were 16 patients with equivocal ultrasound findings while ten patients had normal scans and two patients had a misdiagnosis of ovarian cyst. Of the ten, eight had histopathological features of acute appendicitis. Sensitivity of ultrasound in this study was 90.2% while specificity was 85.6%.
CONCLUSION: Ultrasound scan in patients with suspected acute appendicitis provides a high sensitivity and specificity in the diagnosis and therefore a formidable tool for diagnosing acute appendicitis in low resource center.
... This may have been a confounding factor in these patients. 5 There was only modest correlation between accuracy the radiologist reading and the emergency physician, with accuracy favoring the emergency physicians. The basis for this counterintuitive result are not fully described but, in part, are attributed to the blinding of the radiology residents and their relative inexperience. ...
In their introduction, Gungor et al described ultrasound as a technique for evaluation of patients with low prior probability of acute appendicitis. This testing protocol for appendicitis is being proposed to challenge and perhaps replace the current standard of care for imaging, CT scanning. Specificity of CT scanning is reported in the range of 92-98% and CT is generally felt to be more accurate than ultrasonography The finding of 95.8% specificity for their method appears competitive and may be arithmetically correct but is seriously flawed. This article is protected by copyright. All rights reserved.
... The diagnosis of acute appendicitis by ultrasonography is a well-validated test with clear radiologic guidelines [6]. These describe a blind ending tubular structure in the longitudinal axis, measuring 6 mm in diameter and lacking peristaltic activity [7]. ...
Background
Ultrasound (US) is often the imaging modality of choice in women with acute right iliac fossa (RIF) pain, identifying the appendix in up to 99% of patients. The literature, however, lacks clear guidelines on how ultrasonography should be performed to maximise sensitivity and specificity in such patients. Many centres perform untargeted abdomino-pelvic scans, including organs such as the liver and spleen, which unlikely contribute to the presenting complaint. AimsWe aimed to evaluate the clinical utility of unfocussed abdominal and pelvic US in women of reproductive age with acute RIF pain. Methods
This multicentre study describes 501 women between the ages of 12 and 50, over a 3-year period from three institutions, presenting acutely with RIF pain and investigated with US abdomen and pelvis. Results5.9% of cases confirmed appendicitis sonographically. A normal appendix was visualised in 0.2%. Over 10% identified gynaecological pathology, 41% relating to the right ovary. 10.4% incidental extra-pelvic findings were unrelated to the acute clinical presentation. 0.8% of patients had extra-pelvic findings meriting further clinical assessment. Conclusion
The results herein reflect findings from high volume emergency surgical departments, demonstrating that unfocussed abdominal and pelvic ultrasounds are not an appropriate use of resources in reproductive women with RIF pain. Clinically relevant extra-pelvic US findings account for less than 1%, rarely contributing to the acute presentation. The appendix was only visualised in 6% of patients, suggesting that a focussed appendiceal and pelvic US would better assist diagnosis with a higher yield and increased sensitivity and specificity.
... The presence of pericaecal inflammatory changes such as hyperechoic fat or free fluid is often considered suggestive of but not specific for appendicitis. 8,9,10 Doppler ultrasound helps in showing the vascularity of the intestines and in the diagnosis of necrosis. 11 CT plays an important role in early diagnosis and shows hernias with their contents. ...
Inguinal hernia is the most common seen groin hernias which mostly contain bowel. The incidence of vermiform appendix in an inguinal hernia is seen in 1% of all inguinal hernia. This is known as Amyand's hernia. Appendix within a hernia can be normal or complicated by appendicitis. Most of these cases are not diagnosed preoperatively and managed during surgery. Preoperative diagnosis of these cases is so rare. Very few cases have been reported so far.
In our case, we diagnosed an inflamed appendix in a 49 years old female within right inguinal hernia by using ultrasound and confirmed it by CT scan.
... We should not forget the innate shortenings of sonography in diagnosis of acute appendicitis including its limitations in obese patients, pregnant patients, and patients with gassy bowel loops, patients with severe pain/ tenderness or guarding, uncooperative patients, patients with distorted anatomy and patients with perforated appendix. Ultrasound has also limited accuracy in detecting pelvic, retrocecal, and retroileal position appendicitis [20][21][22]. ...
Accurate early diagnosis of appendicitis can decrease its complications and minimize the mortality, morbidity and costs. This prospective study evaluates the accuracy of bedside emergency physician performed ultrasound study diagnosis in acute appendicitis.
Patients who were suspicious to have appendicitis based on their clinical findings were included and underwent emergency physician performed ultrasound study. Then they were followed up until the recognition of final diagnosis based on pathology report or identification of an alternative diagnosis. Ultrasound studies were done by post-graduate year three emergency medicine residents or emergency medicine attending physicians who were attended in a 4 h didactic and practical course and with 7.5 MHz linear probe both in longitudinal and axial axes.
Ninety-seven patients were included and analyzed. 27 (27.8 %) of patients had appendicitis according to the results of emergency physicians performed ultrasound studies. 19 (70.37 %) of them had appendicitis according to their pathologic reports too. Forty-three (44.3 %) of patients had appendicitis according to pathology reports. Only 19 (44.18 %) of them were diagnosed by emergency physicians. Emergency physician performed ultrasound study had a sensitivity of 44.18 %, specificity of 85.18 %, positive predictive value of 70.37 %, negative predictive value of 65.71 % and overall accuracy of 67.01 % in diagnosing appendicitis in patients clinically suspicious to have acute appendicitis.
Emergency physician performed bedside ultrasound has an acceptable overall accuracy but its sensitivity is low thus it can help emergency physicians to diagnose the acute appendicitis when used in conjunction with other clinical and para-clinical evaluations but not per se.
... La exploración debe comenzar con una sonda abdominal estándar (3)(4)(5), que nos dará una información global de la distribución, localización y relación con estructuras vecinas de las asas de intestino delgado y colon. Posteriormente deberemos centrar el estudio con sondas de alta frecuencia (7)(8)(9)(10)(11)(12), imprescindibles para realizar un examen detallado de los segmentos identificados previamente en los que sospechemos patología, ya que valoran con mayor resolución la pared intestinal. De hecho, durante el estudio es relativamente frecuente cambiar de una sonda a otra para obtener información complementaria de cada una de ellas. ...
... However, in the past, its utility has been less well estab-lished for examining the gastrointestinal tract, for three main reasons: Better technological development in other diagnostic techniques, a rejection by gastroenterologists in the validity of its results, and the intestinal content itself, which has always been considered a limiting factor for exploration. However, in the last 20 years, it has been used with great diagnostic reliability to evaluate inflammatory processes of the gastrointestinal tract (1-3) such as infectious enterocolitis (4,5), diverticulitis (6)(7)(8), appendicitis (9) or ischemic colitis (10). Only in the last decade has it been accepted as a first-line technique in the diagnosis and monitoring of inflammatory bowel disease. ...
... However, in the past, its utility has been less well estab-lished for examining the gastrointestinal tract, for three main reasons: Better technological development in other diagnostic techniques, a rejection by gastroenterologists in the validity of its results, and the intestinal content itself, which has always been considered a limiting factor for exploration. However, in the last 20 years, it has been used with great diagnostic reliability to evaluate inflammatory processes of the gastrointestinal tract (1-3) such as infectious enterocolitis (4,5), diverticulitis (6)(7)(8), appendicitis (9) or ischemic colitis (10). Only in the last decade has it been accepted as a first-line technique in the diagnosis and monitoring of inflammatory bowel disease. ...
Abdominal ultrasonography has been undervalued for years as technique used in examining the gastrointestinal tract. However, thanks to the technological advances that have been seen inultrasonography probes and the use of high frequency equipment, we are able to obtain high quality images of the intestinal wall.Moreover, due to the increased sensitivity of the colour Doppler, we can detect the parietal vascularization. Finally, in recent years, intravenous ultrasonography contrast agents have been used that allow not only the inflammatory activity to be quantified but also the presence of complications with a diagnostic accuracy similar to computed tomography (CT) and full magnetic resonance (full-RM), without the associated radiation risk and at a lower cost. This article reviews the utility of abdominal ultrasonography in inflammatory bowel disease, in particular Crohn´s disease, both during initial diagnosis and follow-up of the disease; the article also reviews the ability of the technique to be used in the detection of complications (stenosis, fistulas and abscesses).
... Graded compression is used in the area that the patient identifies as the point of maximal tenderness to measure the AP diameter of the appendix. 2,3 The reported sensitivity and specificity of compression sonography were 83% and 93% respectively. 4 Sonography is especially useful in ovulating women in whom there is a higher chance of false negative appendectomy rate. ...
Case A 71-year-old gentleman attended the emergency department due to right-sided abdominal tenderness for two days. The physical examination found fever and right lower abdominal pain. The chest and abdominal radiographs were unremarkable. Sonographic examination of the right lower abdomen (Figures 1 & 2) was done. Questions 1. What is the abnormality and diagnosis? 2. What is the treatment? 3. Any further investigations if sonographic findings are inconclusive? Figure 1. Transverse scan of the right lower abdomen (with compression). Figure 2. Longitudinal scan of the right lower abdomen (with compression).
... The sensitivity and specificity of CT scan in the diagnosis of acute appendicitis are 87-100% and 91-98%, respectively [42,43]. Ultrasound is very user dependent, and results can be affected by patient body habitus, however overall sensitivity is 76-96% and specificity is 91-100% [44]. Ultrasound, with its decreased cost, lack of ionizing radiation and ability to assess ovarian pathology, has been the preferred initial imaging modality in children454647. ...
ABSTRACT: Intra-abdominal infection (IAI) is an important cause of morbidity and mortality. It is the second most commonly identified cause of severe sepsis in the intensive care unit and it has been associated with a high mortality rate. Most IAI are the result of inflammation and perforations of the gastrointestinal tract, such as appendicitis, peptic ulcer disease, and diverticulitis. Successful treatment of IAI is based on early and appropriate source recognition, containment and antimicrobial coverage. We will review the pathophysiology of IAI and provide clinical guidelines for its management.
The advent of small, affordable ultrasound machines and the widespread use of PACS systems have made imaging more accessible to anaesthetists and intensivists than ever before. This concise, highly illustrated text discusses the key aspects of radiology, examining all imaging modalities and body regions. Introductory sections review the imaging knowledge required for the FRCA exams and the role of imaging in the Pre-Operative Assessment. These are followed by chapters on each imaging modality and body region, each containing numerous illustrations, practical advice on diagnosis, and many case illustrations. Each modality chapter contains a concise introductory section on the principles of image formation. Containing over 300 scans and illustrations, and written by a multidisciplinary team of radiologists and anaesthetists, Radiology for Anaesthesia and Intensive Care, second edition, is an invaluable aid for all anaesthetists and intensivists.
Acute appendicitis is a common cause for an 'acute abdomen' and is the most common abdominal condition requiring emergency surgical intervention. Misdiagnosis is fraught with morbid complications, ranging from unnecessary surgery to appendiceal perforation, peritonitis or sepsis. In this article, we discuss the application of ultrasound to the diagnosis of appendicitis. We detail the ultrasound imaging technique, including practical tips and pitfalls, describe the sonographic criteria for the diagnosis of appendicitis, discuss the relative strengths and weaknesses of ultrasound compared with other diagnostic approaches, and review the reported performance of ultrasound in the diagnosis of appendicitis.
Acute appendicitis is always a clinical challenge to emergency physicians. Clinical examination or blood tests are notoriously unreliable in making the diagnosis, especially in the early phase of the disease. Computed tomogram can facilitate the diagnosis, however it is usually not easily accessible to emergency physicians. Bedside ultrasonography is now frequently used by emergency physicians in various situations for the assessment of patients. This study aimed at exploring the potential use of bedside ultrasonography in the diagnosis of acute appendicitis in patients presenting with right lower quadrant abdominal pain. (Hong Kong j.emerg.med. 2007;14:70-73)
Although ultrasound has been used diagnostically in patients with right lower quadrant pain and possible appendicitis since
the 1980s, there has recently been renewed interest in this technique due to increasing concerns over radiation exposure with
abdominal CT. Although overall slightly less accurate than CT for the diagnosis of appendicitis, ultrasonography has several
distinct advantages, such as lack of ionizing radiation or intravenous contrast and low cost. Keys to success for this technique
include a thorough understanding of the graded-compression technique using both grayscale and color-Doppler sonography. In
addition, the concept of “staging of appendicitis” is presented, since different treatment options may be selected for patients
who have gangrenous or perforated appendicitis, rather than the standard laparoscopic appendectomy for early uncomplicated
appendicitis. Finally, alternative diagnoses of the gastrointestinal and genitourinary tract that clinically mimic appendicitis
are discussed.
This study was conducted to assess the efficacy of ultrasound in the diagnosis of acute appendicitis in clinically suspected cases of acute appendicitis. A total of 110 patients clinically suspected to have acute appendicitis admitted to the surgery departments of Golestan and Imam Khomeini hospitals, from March 2006 to 2007. Abdomino-pelvic ultrasonography with focus on RLQ ultrasonographying the graded compression technique was done. Positive ultrasonography was defined as at least one of the criteria of puylaert. The sonographic data were prospectively correlated with clinical, operative and pathological findings. Graded compression ultrasonography results were analyzed and remarked 92.7% sensitivity, 94.5% specificity, 93% accuracy, 94.4% positive predictive value and 92.5% negative predictive value. Ultrasonography is an accurate, safe and reliable method in the diagnosis of suspected cases of acute appendicitis that can help to minimize negative appendectomies and perforation rates.
The purpose of the study was to assess the diagnostic performance of MR cystography with virtual cystoscopic and multiplanar reconstructions for detection of malignant bladder tumors. Thirty-two patients with 43 bladder tumors previously confirmed by cystoscopy (mean size 2.5 cm; 0.4-9.1 cm;) were examined at 1.5 T with a three-dimensional T2-weighted turbo spin echo sequence (TR=2911 ms, TE=500 ms, echo train length 256). Virtual cystoscopic reconstructions (VC) and multiplanar reconstructions (MPR) were obtained and analyzed separately by three radiologists without knowledge of the tumor location. Intraoperative or cystoscopic findings served as standard of reference. Sensitivities and specificities were calculated using a receiver-operating characteristic analysis with five levels of confidence. Area-under-curve values were similar for MPRs (0.952), VC (0.932) and the combination of both methods (0.954). Optimal sensitivity was 92.3% for MPR and 90.7% for VC, respectively, with a specificity of 91.1% for MPR and 90.4% for VC. The combination of MPR and VC resulted in a sensitivity of 90.7% and specificity of 94.0%. MR cystography is a promising, completely non-invasive technique for the detection of bladder lesions with a high diagnostic performance.
The objective of our prospective study was to evaluate the value of various operator-dependent techniques that allow graded compression sonography to detect normal or abnormal vermiform appendix.
A total of 877 subjects were included in this study. This sample population consisted of two groups: 202 control subjects and 675 patients who were suspected of having acute appendicitis. If detection of the appendix failed after a sufficient number of trials using graded compression scanning, appropriate operator-dependent techniques were used to help graded compression scanning to increase the detectability of the appendix further. The detection rate for the appendix in both groups and the diagnostic accuracy for acute appendicitis were obtained.
The initial graded compression sonography examination depicted the appendix in 170 (84%) of 202 subjects in the control group and 601 (89%) of the 675 patients in the patient group. We then added operator-dependent techniques to graded compression sonography for the remaining patients in whom the appendix could not be detected. The additional use of the posterior manual compression technique, low-frequency convex transducer, upward graded compression technique, or left oblique lateral decubitus change of body position allowed graded compression sonography to depict the appendix in an additional 10, eight, six, and four patients in the control group, respectively, and in an additional 27, 23, 11, and seven patients in the patient group. The number of identified appendixes was increased to 198 (98%) of the 202 patients in the control group and to 669 (99%) of the 675 patients in the patient group. Graded compression sonography with operator-dependent techniques in the patient group yielded a sensitivity of 99% (319/321 patients), specificity of 99% (350/354), and an accuracy of 99% (669/675) for acute appendicitis.
The addition of various operator-dependent techniques to graded compression sonography is useful for allowing improved visualization of both normal and abnormal appendixes.
The use of radiological studies as diagnostic tools in patients with suspected acute appendicitis has increased recently. In this setting, abdominal ultrasonography is viewed as a possible means of avoiding unnecessary surgery. This retrospective study of patients who underwent laparotomy for suspected acute appendicitis was undertaken to determine the sensitivity and specificity of ultrasound in diagnosing acute appendicitis and the frequency of leucocytosis in patients in whom the diagnosis was confirmed by histology. The ultrasound and surgery registers were reviewed to identify 254 referrals for abdominal ultrasound between January 2001 and December 2002 because of a clinical suspicion of acute appendicitis. Of these cases, 223 did not proceed to surgery. The study sample comprised 31 patients who had appendectomies after abdominal ultrasonography. The ultrasound reports, pathological diagnoses and white blood cell counts of these patients were obtained and formed the basis for the analysis. A histological diagnosis was available for 30 cases, in 17 of whom appendicitis was confirmed In these patients, positive ultrasound and leucocytosis were present in five (29%) and nine (53%) respectively. Ultrasound showed 92% specificity and 29% sensitivity for the pre-operative diagnosis of appendicitis. The positive predictive value of ultrasonography (83%) was higher than that of leucocytosis (69%). The sensitivity and specificity of ultrasound and leucocytosis in this study indicate limited utility as preoperative diagnostic tools.
Bowel ultrasound has been proven to be a useful tool in the management of Crohn's disease, particularly in the assessment of intra-abdominal complications, most of which require surgery.
The National Library of Medicine has been searched for articles on the use of bowel ultrasound in Crohn's disease focusing on aspects of interest to the surgeon.
Several studies have demonstrated that bowel ultrasound may be useful to reduce the risk of unnecessary laparotomy in patients presenting acute abdomen with suspected chronic inflammatory bowel disease. Bowel ultrasound has been proven to be of value in the follow-up of Crohn's disease patients since allowing early diagnosis of intra-abdominal complications and, therefore, optimising the diagnostic and surgical approach. At followup, bowel ultrasound may accurately diagnose early postoperative complications and long-term disease recurrence. In patients submitted to conservative surgery, ultrasonography reveals changes in diseased bowel walls that may be predictive of recurrence of the disease, and hence determinant in the choice of medical treatment.
Acute appendicitis is a diagnosis that can be made on clinical symptoms and signs but can often be extremely challenging. Difficulties arise particularly when the presentation is atypical, and this can lead to untoward sequelae. In this review, we present the range of presentations of atypical appendicitis, the variety of management options and the potential value of CT.
The aim of this study was to describe the MR appearance of acute appendicitis and to determine the value of MR imaging for diagnosis of acute appendicitis.
Forty-five children (28 girls, 17 boys), 7-16 years old (mean age, 13 years old), with clinically diagnosed acute appendicitis underwent independently graded compression sonography by two radiologists. MR imaging was performed when sonography revealed acute appendicitis (observer 1, 16 [36%] patients; observer 2, 18 [40%] patients), was inconclusive (observer 1, two [4%] patients; observer 2, one [2%] patient), and was interpreted as normal (observer 1, two [4%] patients; observer 2, one [2%] patient) (n = 20). Axial T1-weighted turbo spin-echo sequences, T2-weighted turbo spin-echo sequences in the axial and coronal planes, and fat-suppressed short inversion time inversion recovery turbo spin-echo sequences in the axial plane (4-mm slice thickness) were obtained and evaluated independently by two radiologists. The ability to see acute appendicitis with MR imaging was evaluated, the appearance and morphologic changes were described, and the most accurate sequence was determined. All children in whom MR imaging was performed underwent surgery.
MR imaging revealed acute appendicitis in all cases (100%) by both observers. On T2-weighted ultra turbo spin-echo images, acute appendicitis appeared with a markedly hyperintense center, a slightly hyperintense thickened wall, and markedly hyperintense periappendiceal tissue. Unenhanced axial T2-weighted spin-echo imaging was the most sensitive sequence.
In this study group, MR imaging was a valuable technique for depiction of acute appendicitis.
To establish the frequency and natural history of ultrasonographically (US) documented spontaneously resolving appendicitis following conservative treatment.
From July 1987 to July 1997, the authors encountered 106 patients with US-diagnosed spontaneously resolving appendicitis. We retrospectively studied clinical data and US findings obtained at admission and follow-up relating to 60 patients who were treated conservatively. Over the same 10 years, 1,280 appendectomies for acute appendicitis were performed in the authors' hospital.
Of 60 patients, 23 (38%) had recurrent appendicitis after a median of 14 weeks (range, 2-254 weeks), with 16 (70%) having recurrence within 1 year of the first attack. US findings indicated that patients with an appendiceal diameter of at least 8 mm were more prone to recurrence than patients with an appendiceal diameter of less than 8 mm; the recurrence rates were 47% (21 of 45 patients) and 13% (two of 15 patients). The other parameters did not show a statistically significant difference.
Spontaneously resolving appendicitis occurs in at least one in 13 cases of appendicitis and has an overall recurrence rate of 38%, with the majority of cases reccurring within 1 year.
We evaluated the usefulness of graded compression sonography with the adjuvant use of a posterior manual compression technique for detection of the vermiform appendix and the diagnosis of acute appendicitis.
Five hundred seventy consecutive patients referred for suspected acute appendicitis were prospectively examined by original, graded compression sonography with a 5- or a 7.5-MHz linear transducer. A posterior manual compression technique was added for 85 patients whose vermiform appendix was not identified with graded compression sonography. For consensus, another experienced radiologist or a resident observer was in attendance throughout the examination. The detection rate for the vermiform appendix and the diagnostic accuracy for acute appendicitis before and after the adjuvant use of a posterior manual compression technique were obtained, respectively, and final diagnoses were established with the official radiology reports, surgical results, and clinical follow-up.
Graded compression sonography enabled visualization of the vermiform appendix in 485 (85%) of 570 patients. After the adjuvant use of a posterior manual compression technique, the vermiform appendix was found in an additional 57 of 85 patients, with the number of identified vermiform appendices increasing to 542 (95%) of 570 patients. The 57 patients with an additionally found appendix included 11 patients with acute appendicitis. The sonographic diagnosis of acute appendicitis was determined in 312 of 542 patients. Acute appendicitis was proven by surgery in 311 of 332 patients. Sonography was used to establish the diagnosis in 302 of the 311 patients with proven appendicitis; there were 10 false-positive diagnoses and nine false-negative diagnoses. One false-positive diagnosis was acquired after use of the posterior manual compression technique. These results showed more improvement than those of the probabilities for acute appendicitis with single use of graded compression sonography.
Graded compression sonography with adjuvant use of a posterior manual compression technique seems to be useful for detecting the vermiform appendix and for diagnosing acute appendicitis.
Objective:
Two hundred eleven patients with acute pain in the right lower quadrant had CT without oral or IV contrast material. The CT examination required less than 5 min to perform and interpret. We assessed the efficacy of this limited CT examination in identifying patients with acute appendicitis who required emergency laparotomy.
Subjects and methods:
Unenhanced CT of the lower abdomen was performed in 211 patients with lower abdominal pain of uncertain origin (130 women and 81 men 4-91 years old). Scans were obtained by using 10-mm collimation at 10-mm intervals from the L3 level to the symphysis pubis without IV or oral contrast material. Twenty-two to 30 images per patient were obtained, depending on the size of the patient. On average, the entire examination took less than 5 min to complete. Prospective diagnoses based on CT findings were compared with surgical results and clinical follow-up.
Results:
Unenhanced CT was an accurate imaging technique for the initial examination of patients with suspected acute appendicitis. The accuracy was 93%. The sensitivity was 87%, the specificity was 97%, the positive predictive value was 94%, and the negative predictive value was 93%.
Conclusion:
This study shows that unenhanced CT is a useful test to diagnose appendicitis in patients with acute abdominal pain in the right lower quadrant.
One hundred eighty pediatric patients with suspected appendicitis were prospectively examined with graded compression ultrasonography (US) to assess the sensitivity, specificity, and accuracy of graded compression US in the diagnosis of appendicitis in children and to compare those results with results of clinical assessment in the diagnosis of this disorder. Patients were assigned to one of three groups prior to US based on the clinical level of confidence that appendicitis was present and on the planned management decision. Of 141 patients in the low- and intermediate-clinical risk categories, 20 (14%) had appendicitis: US had a sensitivity of 100%, specificity of 97%, and accuracy of 97% in these two groups. Of 39 patients in the high-clinical risk category, 32 (82%) had appendicitis: US had a sensitivity of 81%, specificity of 86%, and accuracy of 82%. Of 52 patients with surgically proved appendicitis, the initial management decision was to discharge to home or admit for observation and further testing in 18 (35%). Results at US were positive for appendicitis in all 18 patients in the latter two categories.
A prospective study of 170 patients with suspected appendicitis was performed to assess the value of sonography in detecting the normal and abnormal appendix. The wall thickness (normal, less than or equal to 3 mm), compressibility of the appendix, and echogenicity of surrounding fat were the primary criteria used to determine the status of the appendix. Of 60 patients who underwent surgery, appendicitis was proved in 45. The remaining 110 patients who did not have surgery, contacted by telephone at the end of the study, had no clinical follow-up evidence of acute appendicitis. A normal appendix was clearly identified in 102 (82%) of 125 patients without acute appendicitis. The sensitivity of sonographic examination in detecting appendicitis was 93%, the specificity was 94%, and the accuracy was 94%. The predictive value of a positive test was 86%; that of a negative test was 98%. Ruptured appendicitis was predicted in all cases (11/11). Sonography is useful in detecting acute appendicitis and can clearly show the normal appendix more frequently than previously reported.
Computed tomography (CT) was used to prospectively evaluate 100 patients with clinical indications for acute appendicitis. Examinations were performed with the terminal ileum and cecum filled with contrast material. Acute appendicitis was diagnosed when an abnormal appendix or inflammatory changes plus an appendicolith were detected. Failure to visualize an abnormal appendix or appendicolith in the presence of pericecal inflammatory changes was considered suspicious but nonspecific. CT results were correlated with surgical and pathologic results (74 patients) and other radiologic and clinical findings (26 patients). CT helped to diagnose appendicitis (64 patients) and nonspecific right lower quadrant inflammation (five patients) and to rule out appendicitis (31 patients). CT had a 98% sensitivity, an 83% specificity, and a 93% accuracy. In 17 of 31 patients without CT evidence of appendicitis, other conditions explaining their symptoms were detected. When the clinical diagnosis is in doubt, CT can be used successfully to evaluate patients with acute appendicitis.
During a 4-month period, high-resolution ultrasonography (US) was used to prospectively evaluate 70 children with clinically suspected acute appendicitis. Thirty-five US scans showed a noncompressible appendix with maximal outer diameters greater than 6 mm. This finding was considered positive for the diagnosis of acute appendicitis. Thirty-one of these 35 patients had acute appendicitis documented by surgical and pathologic findings. The remaining four patients were observed, and their symptoms resolved. Thirty-five patients had US scans considered negative for appendicitis. Seventeen of these patients had US findings positive for other conditions including mesenteric adenitis, ileitis, intussusception, Crohn disease, and Burkitt lymphoma. In this series US enabled diagnosis of acute appendicitis with a sensitivity of 94%, a specificity of 89%, and a predictive accuracy of 91%. Diagnosis of acute appendicitis can be made with US with the same accuracy in children as has been previously reported in series of adult patients. The use of US in clinically ambiguous cases may allow earlier diagnosis, prevention of perforation, and decreased complications in the pediatric patient with acute appendicitis.
We reviewed the clinical and sonographic findings in 297 patients who had graded compression sonography for suspected acute appendicitis. The purpose of the study was to determine the accuracy of sonography in detecting other diseases in the 174 patients in this group who proved not to have acute appendicitis. Of the 174 patients without acute appendicitis, 93 patients (53%) were ultimately discharged with a diagnosis of abdominal pain of unknown origin. Of the 81 patients in whom specific diagnoses were established, sonography suggested the correct diagnosis in 57 patients (70%). A broad spectrum of diseases was detected, including: gynecologic diseases (35); visceral diseases, including hollow viscera and diseases of liver, pancreas, or spleen (18); and urinary tract abnormalities (four). This study suggests that sonography is useful in establishing alternative diagnoses in patients undergoing sonography for suspected acute appendicitis.
Recently ultrasonography (US) has proven effective in the diagnosis of acute appendicitis. However, the impact of US on surgical decision-making in clinical practice remains unclear. From August 1986 to July 1987, 62 patients with clinical signs of acute appendicitis received US examinations after initial clinical evaluations. According to clinical pictures, they were classified into two groups: group I, clinically typical (Alvarado's score greater than or equal to 7) and group II, clinically dubious (Alvarado's score less than or equal to 6) cases. All group I patients (n = 34) had surgery. Group II patients (n = 28) received close in-hospital observation on an every 4-hour basis for less than 24 hours. However, surgery was performed if Alvarado's score increased up to or above 7 or surgical indications became evident during observation. The pathologic reports and operative findings were retrospectively correlated with the US diagnosis. For group I patients, clinical examination without knowledge of US findings was correct in 30 (88.9%) cases, 26 (86.7%) of which were detected by US. Four (50%) of eight patients with negative US findings had acute appendicitis. In group II, 12 of 15 patients who had surgery had acute appendicitis, and 10 (83.3%) were detected by US. Two (11%) of 18 patients with negative US findings were finally proved to have acute appendicitis. The average duration from initial clinical examination to surgical decision fpr patients with acute appendicitis was 6.8 hours. There were no false-positives in either group. For patients with typical clinical presentation, US is not superior to clinical examination, and surgery is recommended even if US findings are negative.(ABSTRACT TRUNCATED AT 250 WORDS)
Ultrasound (US) examination during graded compression was performed in 60 consecutive patients with clinical signs of acute appendicitis. In 25 (89%) of 28 patients with confirmed appendicitis, the inflamed appendix was visualized by US. Perforation was predictable in six of seven patients. In 32 patients without appendicitis, the appendix was not visualized. Graded-compression US is the examination of choice if there is doubt whether an appendectomy should be performed.
In nine patients with clinical symptoms of acute appendicitis, graded-compression ultrasound (US) did not depict the appendix but instead demonstrated mural thickening of the terminal ileum and part of the colon, as well as moderately enlarged mesenteric lymph nodes. In one patient a normal appendix was removed; eight patients recovered without treatment. Infection with Campylobacter jejuni was proved in all nine patients. In four patients, an unnecessary appendectomy was avoided because of the US findings. Graded-compression US enables differentiation between acute appendicitis and Campylobacter ileocolitis, a vital differentiation, since surgery is almost certainly not indicated for the latter.
Two hundred and fifty consecutive patients with suspected appendicitis were examined with graded compression sonography. The initial diagnostic criterion for appendicitis was visualization of a noncompressible appendix; this was later modified to include the dimensions of the visualized appendix. The appendix was visualized in 91 of 250 patients (36%). Five adult patients with sonographically visible appendixes that were 6 mm or less in maximal diameter had either benign clinical follow-up (three patients) or a histologically normal appendix removed at surgery (two patients). However, two patients with appendixes measuring 6 mm in diameter and multiple appendicoliths had surgically confirmed acute appendicitis. Of 84 patients with visible appendixes measuring greater than 6 mm in maximal diameter, 78 had surgically confirmed acute appendicitis. In the remaining six, symptoms resolved spontaneously, and no surgery was required. In the absence of compelling clinical findings or an appendicolith, adult patients with maximal appendiceal diameters of 6 mm or less should undergo a period of close observation rather than immediate surgery. A diagnosis of appendicitis can be made in adult patients with persistent right lower quadrant pain and a visualized appendix greater than 6 mm in diameter.
During a 7-month period high-resolution sonography was used in the evaluation of 68 patients with an equivocal clinical diagnosis of acute appendicitis. The sonographic findings were correlated with surgical-pathologic outcome in 32 cases and with clinical follow-up in the remainder. This technique was found to be accurate in the diagnosis of acute appendicitis with a specificity of 95%, a sensitivity of 80%, and an accuracy of 90%. The predictive value of a positive test was 91%; that of a negative test was 89%. The results show that high-resolution sonography is indicated to establish the diagnosis of acute appendicitis in patients with equivocal clinical findings.
One hundred seventy consecutive patients with clinical suggestion of acute appendicitis were studied by ultrasound (US) with the examiner using the graded compression technique. In 14 patients, the only US findings consisted of enlarged mesenteric lymph nodes in combination with mural thickening of the terminal ileum. This was consistent with the findings at surgery in four patients and with the results of barium studies in seven patients. In nine of 14 patients, stool cultures were performed, eight of which were positive for Yersinia enterocolitica. None of these 14 patients finally proved to have appendicitis. In a patient with acute pain in the right lower quadrant whose appendix cannot be visualized sonographically and whose US findings consist of enlarged mesenteric lymph nodes and mural thickening of the terminal ileum, the diagnosis is probably mesenteric adenitis and acute terminal ileitis. Appendectomy should be avoided in this condition.
High-resolution, real-time ultrasonography (US) with graded compression was used to evaluate 90 patients with clinically suspected acute appendicitis. US visualization of a noncompressible appendix was the primary criterion for a diagnosis of acute appendicitis. The overall sensitivity was 89%, the specificity was 95%, and the accuracy was 93%. When the results in women were analyzed separately (n = 49), the overall accuracy was 96%. Several important limitations of US scanning were encountered. There were three false-positive examinations in patients with a sonographically visible appendix whose symptoms spontaneously resolved. Another patient had a normal compressible appendix with a thin (2-mm), symmetric wall surrounded by ascites. There were three nondiagnostic studies (3%) due to inability to compress the cecum and right lower quadrant adequately because of exquisite tenderness (two patients) or massive ascites (one patient). When interpreted in light of the clinical examination, sonography should significantly reduce the rate of false-negative appendectomies, particularly in women.
Acute appendicitis, at times, is a difficult clinical diagnosis. CT can play a valuable role in selected patients with suspected appendicitis; the CT diagnosis of acute appendicitis has high positive and negative predictive values, 96% and 95%, respectively [1]. In this essay, we review the normal CT anatomy of the appendix and the right lower quadrant and illustrate the CT signs of appendicitis and important differential diagnostic entities. The CT appearance of complications of acute appendicitis is also presented, as are issues concerning examination technique and patient preparation.
To compare the accuracy of computed tomography (CT) and ultrasonography (US) in the diagnosis of acute appendicitis.
One hundred consecutive patients were examined with US and CT, and the results, independently reported, were correlated with surgical and histopathologic findings (69 patients) and data from other laboratory and clinical follow-up (31 patients).
Fifty-four patients had acute appendicitis; 46 patients did not. Analysis of the data for CT and US, respectively, revealed sensitivity, 96% versus 76%; specificity, 89% versus 91%; accuracy, 94% versus 83%; positive predictive value, 96% versus 95%; and negative predictive value, 95% versus 76%. In the 46 patients without appendicitis, an alternative diagnosis was made with CT in 22 patients and with US in 15. CT scans showed abscesses and/or phlegmons in 28% of patients with appendicitis versus 17% at US. Results of CT and US were discordant in 20 patients; CT findings were correct in 17 and US findings in three.
CT is more accurate than US in diagnosis of acute appendicitis.
The sonographic appearance of the appendix and the periappendiceal region may vary greatly in children with acute appendicitis, depending on the extent and degree of inflammation and the presence or absence of perforation. Recognition of the typical and atypical sonographic features of appendicitis can be important in its diagnosis. In this report, we illustrate the spectrum of sonographic findings in 250 children examined with the graded-compression technique because of suspected appendicitis. Sixty-three (25%) of these children were subsequently shown to have appendicitis.
To evaluate a focused, helical computed tomographic (CT) technique for imaging the appendix in patients suspected of having appendicitis.
One hundred patients prospectively underwent appendix CT examination, with use of oral and colon contrast media and contiguous, thin-collimation, helical CT imaging of the right lower quadrant. Results were correlated with the results of surgery and pathologic examination from 61 patients or from clinical follow-up in 39 patients.
CT scans were positive for appendicitis in 59 patients: true-positive in 56 patients on the basis of surgery and pathologic examination, and false-positive in two patients on the basis of clinical follow-up; in the case of the other positive scan, the clinical outcome was indeterminate. CT scans were negative for appendicitis in 41 patients: true-negative in five patients on the basis of surgery and pathologic examination, and true-negative in 36 patients on the basis of clinical follow-up. CT had a sensitivity of 100%, a specificity of 95%, a positive predictive value of 97%, a negative predictive value of 100%, and an accuracy of 98%. The normal appendix was always identified. CT helped establish alternative diagnoses in 33 of the 41 patients (80%) in whom the results of CT were negative for appendicitis.
Appendix CT examination can help diagnose or exclude appendicitis and establish an alternative diagnosis.
(55%) of 20 patients with appendicitis. Appendiceal diameter ranged between 3 and 8 mm (mean, 6 mm) in the control group and between 8 and 12 mm (mean, 10 mm) in patients with appendicitis (p < .05). Wall thickness was barely perceptible in the control population and mea- sured 2-4 mm in patients with appendicitis (p < .05). Appendicoliths were found in 10 (50%) of 20 patients with appendicitis and in none of the control patients. Pericecal inflammation was seen in 19 (95%) of 20 patients with appendicitis and abscess was seen in 10 (50%) of 20 patients. Specific signs of appendicitis. defined as either an inflamed appendix or appendicolith with asso- ciated inflammatory changes, were seen in 16 (80%) of 20 patients. CONCLUSION. Our results suggest that CT findings of the healthy appendix are dis- tinct from those of the abnormal appendix and that CT scans can be useful in diagnosing appendicitis in a pediatric population.
A cute right lower quadrant (RLQ) abdominal pain is a common chief complaint in clinical practice. The term "acute abdomen" may be applied if the onset of pain is sudden and unexpected and if the pain is present for less than 24 hr and asso- ciated with other gastrointestinal symptoms. The differential diagnosis of acute RLQ pain includes a broad spectrum of clinical entities that range from benign self-limited disorders to illnesses associated with high morbidity. In up to 30% of cases, no pathologic diagnosis is ever made and symptoms resolve spontane- ously without intervention (I). It is often diffi- cult on the basis of history and physical examination alone to separate these patients from those who require immediate surgery. The increased availability and use of CT and sonography have dramatically changed the clinical examination and treatment of patients who present with acute abdominal pain. These noninvasive imaging techniques have effec- tively replaced exploratory laparotomy as the primary means of examining patients who present with what was formerly known as a "surgical abdomen." This article will review the indications for, technique of, and imaging findings in CT and sonography of patients with acute RLQ pain.
To assess the efficacy of ultrasound (US) as part of an algorithm to establish the indication for laparotomy in patients with suspected acute appendicitis.
Prospective investigation.
University department of surgery, Germany.
669 unselected patients admitted with suspected acute appendicitis.
Clinicopathological and procedural diagnoses of the algorithm were evaluated by correlating clinical and US findings with the results of laparotomy in 171 patients of whom 143 had acute appendicitis (prevalence 21%), and clinical as well as follow up data in the remainder.
The major clinicopathological variables were accuracy and positive predictive value; the rate of negative laparotomies and that of bad diagnostic errors served as the main procedural variables.
The overall sensitivity, specificity, and accuracy of the clinical diagnosis were 0.503, 0.950, and 0.855, respectively (positive predictive value: PPV 0.734, negative predictive value: NPV 0.875), those of ultrasound: 0.797, 0.967, and 0.931 (PPV 0.870, NPV 0.946); and 0.853, 0.927, and 0.940 at the end of the algorithm (PPV 0.762, NPV 0.958). However, the algorithm would have resulted in a significant increase in the rate of unnecessary laparotomies (from 13% to 16%). A revised clinical algorithm gave an overall diagnostic accuracy of 0.940 (p < 0.001) together with a low rate of negative laparotomies (11%, p < 0.01) and a significantly reduced number of diagnostic errors (from 71 to 21, p < 0.001).
Ultrasonography enabled us to diagnose acute appendicitis in more patients more often and more quickly than clinical evaluation alone, suggesting that US may produce a better outcome. The revised clinical algorithm may be helpful in the study of US in patients with suspected acute appendicitis in prospective randomised controlled clinical trials.
The objective of this prospective study was to determine the accuracy in diagnosing appendicitis in children by using high-resolution graded compression sonography.
During a 7-year period, 3859 children (mean age 9.9 years) with clinically suspected appendicitis were evaluated by sonography with the graded compression technique. The ultrasound results were correlated with the intraoperative and histopathological findings or clinical outcome.
High-resolution sonography was performed in 3859 children. Of the 610 patients who underwent a laparotomy, 494 had histologically proven acute or perforated appendicitis (prevalence 13%). In these children, sensitivity, specificity and overall accuracy of sonography were 90%, 97% and 96%, respectively. The reasons for false-negative and false-positive results are discussed.
Although the use of ultrasound to diagnose acute appendicitis in children has excellent results, the decision for surgery remains a clinical one because of the continuing false-negative and false-positive results from sonography.
We evaluated the accuracy of unenhanced helical CT with enteric contrast material in the diagnosis of appendicitis in children and adults treated at a community hospital.
Over an 8-month period, 100 consecutive patients with right lower quadrant pain and suspected appendicitis were prospectively evaluated. Thin-collimation helical CT scanning was performed after administration of enteric contrast material. CT interpretations were correlated with surgical pathology (45 patients) and clinical follow-up (55 patients).
The findings of 33 CT scans were interpreted as positive for appendicitis (29 true-positives and four false-positives), and the findings of 67 were interpreted as negative for appendicitis (66 true-negatives and one false-negative). Sensitivity was 97%, specificity was 94%, accuracy was 95%, positive predictive value was 88%, and negative predictive value was 99%. In the 67 CT scans with negative findings for appendicitis, an alternative diagnosis was made for 36 patients (54%).
Unenhanced helical CT with enteric contrast material for the evaluation of appendicitis can be implemented in a community hospital. In our study, such imaging achieved excellent accuracy.
To establish the accuracy of unenhanced CT in the preoperative diagnosis of acute appendicitis.
Accuracy study, prospective and blinded.
The University Hospital.
52 patients with clinical and laboratorial manifestations of acute appendicitis. CT diagnosis was made by: presence of an abnormal appendix, appendiceal calculi with pericecal phlegmon or alterations in the pericecal appendicular site and absence of signs that may lead to other diagnosis.
Overall accuracy, comparing the tomographic aspects with the intra-operative findings and pathological reports ("gold standard").
Acute appendicitis was confirmed in 44 cases. Efficacy was 92%, sensitivity was 91%, specificity was 100%, positive predictive value was 100% and negative predictive value was 67%.
Unenhanced CT presents a similar overall accuracy to that reported by other authors who studied enhanced CT diagnosis of acute appendicitis.
To determine the accuracy of helical computed tomography (CT) without the oral, intravenous, or rectal administration of contrast material in confirming suspected acute appendicitis.
Three hundred consecutive patients referred from the departments of surgery and emergency medicine were examined for suspected acute appendicitis by using thin-section nonenhanced helical CT. All transverse CT scans were obtained in a single breath hold from the upper abdomen (T12 vertebra) to the pubic symphysis with 5-mm collimation and a pitch of 1.6. All scans were obtained without oral, intravenous, or rectal contrast material. Criteria for diagnosis of acute appendicitis included an enlarged appendix (> 6 mm) and periappendiceal inflammation. CT diagnoses were recorded prospectively. Final diagnoses were established with the results of surgical or clinical follow-up or both.
There were 110 true-positive diagnoses, 181 true-negative diagnoses (63 of which were an alternative diagnosis correctly established prospectively), five false-negative diagnoses, and four false-positive diagnoses, which yielded a sensitivity of 96%, a specificity of 99%, and an accuracy of 97%.
Nonenhanced helical CT is a highly accurate technique for diagnosing or excluding acute appendicitis. Developing experience with the technique and understanding the subtleties of interpretation can further improve diagnostic accuracy.
To investigate whether the presence or absence of gas in the appendix may be considered as additional ultrasonographic (US) criteria to rule out or confirm acute appendicitis.
The appendices in 239 control subjects, 138 patients with lower right quadrant pain without acute appendicitis, and 80 patients with acute appendicitis were prospectively evaluated for intraluminal gas with US.
The appendices in 206 (86%) control subjects showed gas at US, and those in 33 (14%) did not. The appendices in 109 (79%) symptomatic patients without acute appendicitis showed gas, and those in 29 (21%) did not. The appendices in 12 (15%) patients with acutely inflamed appendices showed gas, and those in 68 (85%) did not. The absence of gas as a criterion for acute appendicitis had a sensitivity of 85%; specificity, 79%; positive and negative predictive values, 57% and 94%, respectively; and accuracy, 81%. Gas was useful to exclude acute appendicitis in 64 (46%) symptomatic patients because the established criteria were misleading. In 19 (24%) patients, the absence of gas was useful for diagnosis of acute appendicitis because the other criteria were not convincing.
US-based detection of gas in the appendiceal lumen helps to rule out acute appendicitis, whereas the absence of gas further confirms its presence, especially in cases where established US criteria are either insufficiently present or misleading.
Acute appendicitis is a common clinical problem. Accurate and prompt diagnosis is essential to minimize morbidity. While the clinical diagnosis may be straightforward in patients who present with classic signs and symptoms, atypical presentations may result in diagnostic confusion and delay in treatment. Helical computed tomography (CT) and graded compression color Doppler ultrasonography (US) are highly accurate means of establishing the diagnosis. These imaging modalities have now assumed critical roles in the treatment of patients suspected to have appendicitis. The purpose of this article is threefold: to provide an update on new information regarding the pathophysiology, clinical diagnosis, and laparoscopic treatment of acute appendicitis; to describe the state-of-the art use of CT and US in diagnosing this disease entity; and to address the role of medical imaging in this patient population.
To evaluate the usefulness and limitations of the outer diameter of the vermiform appendix at cross-sectional ultrasonography to confirm or rule out acute appendicitis.
In a prospective study, outer appendiceal diameters in 240 control subjects and in 278 patients suspected of having acute appendicitis who did (n = 98) or did not (n = 180) have acute appendicitis were measured.
Outer appendiceal diameters in the control subjects ranged between 2 and 13 mm, and in 55 (23%) of 240 control subjects, diameters were 6 mm or more. Diameters in the symptomatic patients without acute appendicitis ranged between 2 and 11 mm, and 57 (32%) of 180 patients had diameters of 6 mm or more. Diameters of acutely inflamed appendices ranged between 6 and 30 mm. A diameter of 6 mm or more confirmed acute appendicitis with a sensitivity of 100%; a specificity of 68%; positive and negative predictive values of 63% and 100%, respectively; and an accuracy of 79%.
The outer appendiceal diameter of 6 mm or more as a sign of acute appendicitis provides high sensitivity but limited specificity. This diagnostic criterion is more useful in excluding acute appendicitis than in confirming it.
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Mesenteric adenitis and acute terminal ileitis
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