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... It also involves radiation exposure, and allergic reactions to the contrast medium are a possibility. [9][10][11] An Alvarado score ≥ 7 is useful to identify those patients who have a higher probability of acute appendicitis and therefore would require a surgical consultation or further diagnostic imaging. ...
Background: Ultrasonographic scores for appendicitis to determine if, combined with Alvarado scores, they can increase the sensitivity and specificity of the diagnosis of appendicitis.Methods: All cases of abdominal pain suggestive of appendicitis presented between 2013 and 2015 were analysed. An Alvarado score was obtained. All patients underwent ultrasound, and an ultrasonographic score was determined, including the appendicitis classical findings.Results: Two hundred and fifty-one patients with abdominal pain in the right lower quadrant were analysed. Appendicitis was confirmed in 211 (84%) patients. For these patients, the average Alvarado score was 7.95/10 (±1.25) vs. 5.7/10 (± 1.11) for patients who did not have appendicitis (p < 0.001). In patients with confirmed appendicitis, the average ultrasonographic score was 2.48/6 (± 1.06) vs. 0.6/6 (± 0.92) for patients who did not have acute appendicitis (p < 0.001). The ultrasonographic score has a sensitivity of 90% and a specificity of 87% with only two parameters. The combination of the Alvarado and ultrasonographic scores decreased the percentage of negative appendectomies to 2.36% and increased the area under the curve by 0.970.Conclusions: The sum of the Alvarado and ultrasonographic scores provides an efficient alternative for diagnosing abdominal pain suggestive of appendicitis and predicts which patients should undergo surgery with good certainty.
... Generally, CT scan is the accepted imaging modality, however, ultrasound may have a role in women at risk for other pelvic pathologies , in pregnancy and in children [41]. 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]. ...
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 challenge to the ED physician is to delineate which patient population is best served by a CT to rule out appendicitis. Presently, there are no published strategies to suggest which patients should undergo CT scan to confirm appendicitis despite the repeated call for guidelines [6,1617181920. In this review, we develop guidelines for CT scanning based on Alvarado clinical scores for patients with suspected and confirmed cases of appendicitis who have undergone CT scans. ...
Appendicitis is part of the differential of an acute abdomen and can be a difficult diagnosis to make. Strategies to suggest which patients presenting to the emergency department (ED) should undergo computed tomography (CT) scan to confirm appendicitis have not been addressed. We develop guidelines for CT scanning based on Alvarado clinical scores for patients with suspected and confirmed cases of appendicitis.
A retrospective review of 150 charts of patients aged 7 and older who presented with abdominal pain to the ED of a 392-bed acute care facility over a 6-month period were evaluated by ED physicians and underwent CT to rule out appendicitis. Patient demographics, presenting signs, and symptoms were documented. Using the scoring system for appendicitis, developed by Alvarado, each chart was retrospectively scored. The Alvarado scores were correlated with positive pathology findings, as well as Alvarado scores with a negative CT scan. Equivocal scores, having neither high sensitivity nor specificity for appendicitis were calculated.
Computed tomography scans with Alvarado scores of 3 or lower were performed in 37% (55/150) of patients to rule out appendicitis. The sensitivity of Alvarado scores 3 or lower for not having appendicitis was 96.2% (53/55), and the specificity 67% (2/3). Patients with Alvarado scores 7 or higher had an incidence of acute appendicitis of 77.7% (28/36). The sensitivity of Alvarado scores 7 or higher for appendicitis was 77% (28/36), and the specificity 100% (8/8). The sensitivity of equivocal Alvarado scores, defined as scores of 4 to 6, for acute appendicitis was 35.6% (21/59), and the specificity 94% (36/38). The sensitivity and specificity of CT scans in patients with equivocal Alvarado scores remained high, at 90.4% and 95%, respectively.
In the equivocal clinical presentation of appendicitis as defined by Alvarado scores of 4 to 6, adjunctive CT is recommended to confirm the diagnosis in the ED setting. If clinical presentation suggests acute appendicitis by an Alvarado score of 7 or higher, surgical consultation is recommended. Computed tomography is not indicated in patients with Alvarado scores of 3 or lower to diagnose acute appendicitis.
The Alvarado score is a clinical scoring system used in the diagnosis of acute appendicitis. This study aimed to compare the reliability of the Alvarado score and clinical judgment and to refine the score to make it easier to use.
In this prospective, randomized study, patients presenting at the authors' outpatient department with suspected appendicitis during a 1-year period were assigned in weekly alternation to either group A or group B. The group A patients were treated on the basis of their Alvarado score, and the group B patients underwent treatment based on clinical judgment. The correctness of the methods was assessed by evaluation of the final histology. Statistical comparison of the data was performed using SPSS 20.
The study investigated 269 patients (131 in group A and 138 in group B). The groups were homogeneous in terms of mean age, gender, body mass index, and American Society of Anesthesiologists score. The number of negative appendectomies was 12 (9.16 %) in group A versus 5 (3.6 %) in group B (p = 0.063). The clinical judgment had better specificity and sensitivity than the Alvarado score. For that reason, the specificity of the Alvarado score was refined using statistical methods, with weighting of certain clinical data and inclusion of new ones (e.g., ultrasound investigation). Consequently, the area under the curve by receiver operating characteristic analysis gradually increased, and the Alvarado score became more accurate.
The study findings showed clinical judgment to be more reliable in the diagnosis of acute appendicitis than the Alvarado score, but the score is a useful diagnostic aid, especially for young colleagues. The use of the new scoring system has become easier. It includes fewer criteria as well as an important and sensitive predictor: the ultrasound investigation.
AIM: To analyze the gross and microscopic features of acute appendicitis as seen in the histopathology department of a Nigerian tertiary health institution.
METHODS: The appendices of patients histologically diagnosed as acute appendicitis were used for this study. The diameter of the appendix, gross serosal features and the luminal contents were assessed. The presence or absence of mucosal microabscesses and periappendicitis were also assessed. These were all analyzed for differences in proportion using Chi square by SPSS version 16 (p is significant at <0.05).
RESULTS: Acute appendicitis accounted for 76.2% of all appendicectomy specimens received. The mean age was 25.3 years while the age range was between 4 and 67 years and the male to female ratio was 1.3:1. The highest frequency of cases was in the 21-30 year age group. The diameter of the appendix was greater than 0.8cm in about 88.2% of cases. The association between the diameter of the appendix and the diagnosis of acute appendicitis was, however, not statistically significant. The most frequent luminal finding were faecaliths (55.6%) although a large proportion of lumina were empty (33.6%). No helminthes were seen. The serosa of the appendix was shiny, dull and fibrinous/purulent in 14.7%, 39.0% and 46.3% of cases respectively. A statistically significant association was noted between these serosal appearances and the occurrence of periappendicitis. Periappendicitis was noted in 76.1% of cases where mucosal microabscesses were observed. This association was also statistically significant.
CONCLUSION: Although acute appendicitis is still the most common disorder of the appendix, there has been a shift in the peak age of occurrence at our centre from adolescence to early adulthood. A statistically significant association exists between the occurrence of peritonitis and the gross appearance of the serosa as well as with the presence of mucosal microabscesses but not with the diameter of the appendix.
KEYWORDS: acute appendicitis, serosa, diameter, microabscesses, periappendicitis
Introduction:
Non-appendiceal tumors can mimic and present with clinical features of acute appendicitis in patients of age 40 years or above. The aim of this prospective study is to investigate the incidence of right-sided (non-appendiceal) colonic tumors in patients presenting with clinical features of acute appendicitis.
Methods:
A prospective data analysis of 1662 patients using appendectomy database was performed from 2005 to 2011. Patients above age 40 years or older were included. Patients were compared for demographic data, clinical presentation, radiological findings, operative technique & findings, histo-pathological findings and postoperative complications. The primary outcome was incidence of right-sided colonic (non-appendiceal) tumors presenting with features of acute appendicitis. Secondary outcomes measured were, role of diagnostic radiology, negative appendectomy rate, length of stay and changing trends in operative techniques.
Results:
From 1662 patients initially reviewed, only 179 patients (10.77%) age 40 years or above mean (56 ± 11.75), median 54 (40-89), with clinical features of acute appendicitis were included in the final analysis. F:M ratio was (1:1.06). CT scan showed in only 1 patient (1.25%, OR = 0.806, p = 0.695), suspicion of cecal tumor and underwent right hemicolectomy. Histological examination of specimen showed, 2 patients (1.11%, OR = 1.10, p = 0.47) had primary appendiceal tumors, in which one patient was histologically reported as appendiceal mucocele (mucinous cystadenoma with low-grade dysplasia), while the other one had appendeceal carcinoid (Goblet cell carcinoid). In the other tumor group one patient had metastatic involvement of appendix from ovarian tumor. The time to appendectomy in radiological group was delayed by (9.2 ± 3.7 h). 131 (73.1%) had laparoscopic while 48 (26.81%) underwent open appendectomy. The negative appendectomy rate was (1.12%) and 30 days complication rate was (11.73%, p = 0.27). Mean length of stay was 3.54 ± 2.1 days.
Conclusion:
Right-sided colonic (cecal) tumors rarely present with features of acute appendicitis. Only those patients with atypical presentation and findings should have pre-operative radiological evaluation.
Purpose:
Evaluation of the feasibility, cost-effectiveness, time of surgery, morbidities, and other/additional findings during laparoscopy for suspected appendicitis.
Methods:
Prospective evaluation of 148 laparoscopies for suspected acute appendicitis.
Results:
Laparoscopic appendectomy was safe and cost-effective. No appendiceal stump leaks or wound infections occurred. Of the patients, 4.7% developed intra-abdominal abscesses. Mean time of all procedures was 47 min: 42 min for simple appendectomies (n = 126), 67 min for perforated appendicitis (n = 15), and 75 min for converted procedures (n = 7). Twenty-one of 148 (14.2%) patients had unexpected findings instead of appendicitis: inflamed epiploic appendices (three times), inflammatory disorders of intestine (five times), intestinal adhesions (two times), ovarian cysts (six times: one time with mesenteric lymphadenitis, one time ruptured), tubo-ovarian abscess (one time), tubal necrosis (one time), adnexitis with mesenteric lymphadenitis (one time), and acute cholecystitis (one time). These diagnoses might have been missed during conventional open appendectomy and were, if necessary, treated during laparoscopy.
Conclusions:
Laparoscopic appendectomy should be recommended as standard procedure for acute appendicitis.
Traditionally, in Crohn's disease (CD), surgery has played an essential role in the treatment of complications. TNF-α-blockers have significantly improved results of conservative treatment but they do not definitely cure Crohn's disease.
Our aim was to examine the prevalence of and indications for surgical procedures in CD in our hospital.
A retrospective survey included all CD patients diagnosed in our hospital referral area during a 10-year period in 1996-2005.
Altogether 114 new patients with CD were diagnosed, 56 (49%) males, 58 (51%) fe-males. The median follow-up time was 5.0 years. In all, 31 (27%) patients underwent some sur-gical procedure, and of these, 12 (39%) underwent an emergency operation. The most common indication for surgery was bowel obstruction. The most frequent procedures were ileocolic re-section in 12 (39%) patients and small bowel resection in 10 (32%).
Almost one-third of CD patients needed surgical therapy in an early phase of their disease, and more than one-third of these underwent an emergency procedure. Obstructive symptoms were the most common indication for surgery in the early phase of CD.
To describe the MR appearance of the normal appendix and the MR imaging characteristics of acute appendicitis with correlation to pathological severity.
A total of 20 volunteers participated in this study to demonstrate normal appendices by MR imaging. A total of 37 consecutive patients with clinically diagnosed acute appendicitis were also scanned. T1-weighted (T1WI) spin-echo images, T2-weighted (T2WI) fast spin-echo, and fat-suppressed spectral presaturation inversion recovery T2-weighted (T2SPIR) fast spin-echo images were obtained. The MR criteria for considering acute appendicitis were as follows: 1) thickening of the appendiceal wall with high intensity on T2WI or T2SPIR; 2) dilated lumen filled with high intensity material on T2WI or T2SPIR; and 3) increased intensity of periappendiceal tissue on T2WI or T2SPIR.
The visibility of a normal appendix on MR imaging was 90% (18/20). It appeared as a cord-like structure of medium intensity without fluid collection in the lumen. A total of 30 cases with clinically diagnosed acute appendicitis had positive MR findings and all except one were pathologically proven. The one had cecal diverticulitis. These cases demonstrated filled lumen, with a hypointense wall on T1WI and slightly hyperintense on T2WI or T2SPIR. MR findings correlated well with pathological severity, especially a thicker wall, periappendiceal high intensity, and ascites were useful for suspecting severe appendicitis.
Correct diagnosis of acute appendicitis was obtained with MRI, and correlated well with its pathological severity. MRI is a powerful alternative for diagnosing acute appendicitis especially for the patients in whom the radiation is major concern.
We wanted to review the usefulness of ultrasonography (US) for the diagnosis of appendicitis and to evaluate the diagnostic accuracy of US according to patients' and researchers' characteristics.
The relevant Korean articles published between 1985 and 2003 were included in this study if the patients had clinical symptoms of acute appendicitis. The histopathologic findings were the reference standard and the data were presented for 2 x 2 tables. Articles were excluded if patients had no sonographic signs of appendicitis according to graded-compression US. Two reviewers independently extracted the data on study characteristics. The Hasselblad method was used to obtain the combined estimates of sensitivity and specificity for the performance of US.
Twenty-two articles (2,643 patients) fulfilled all inclusion criteria. The estimate of d calculated by combining the sensitivity and specificity was 2.0054 (95% confidence interval [CI]: 1.8553, 2.1554) by a random effects model. The overall sensitivity and specificity (95% CI) were 86.7% (85.4 to 88.0), and 90.0% (88.9 to 91.2), respectively. According to the subgroup meta-analysis by patients' characteristics, the d estimate (95% CI) of dominantly younger age, male, and highly clinical suggestive group for US was 2.2388 (1.8758 to 2.6019), 2.7131 (2.2493 to 3.1770), and 2.4582 (1.7387 to 3.1777), respectively. Also, according to subgroup meta-analysis by researchers' characteristics, the d value (95% CI) for US done by diagnostic radiologists and gray-scale was 2.0195 (1.7942 to 2.2447) and 2.2630 (1.8444 to 2.6815).
This evidence suggests that US may be useful for the diagnosis of acute appendicitis, especially when patients are younger age, male, and highly clinical suggestive.
Appendicitis is a common diagnosis, but is by no means a simple one to establish. This retrospective study investigated the value of medical imaging (ultrasonography and/or computed tomography [CT]) for patients with suspected appendicitis. Negative appendicectomy rate and appendiceal perforation with or without medical imaging were used as end points for this investigation.
This study retrospectively reviewed all patients admitted in one district general hospital with suspected acute appendicitis. The patient cohort was identified from the Unit Registry and an International Classification of Diseases-based Review of medical records. The medical records were analysed, and the outcome of patients were followed up.
Between 12 January 2004 to 27 May 2005, 168 patients' medical records were audited. The negative appendicitis rate was 6.7% and appendiceal perforation rate was 3.2%. Among them, only 20 in-patients (12%) had medical imaging (ultrasonography and/or CT scan) after clinical assessment for suspected acute appendicitis. Medical imaging had a 70% prediction rate for acute appendicitis, 20% false-negative rate, and 10% false-positive rate. Overall, the prediction rate for appendicitis by clinical assessment supplemented by laboratory tests and medical imaging at clinician's discretion was 93.2%.
Despite studies advocating routine use of medical imaging for patients with suspected acute appendicitis, this study showed that the clinical evaluation is still paramount to the management of patients with suspected acute appendicitis before considering medical imaging.
In patients with clinically suspected appendicitis, computed tomography (CT) is diagnostically accurate. However, the effect of routine CT of the appendix on the treatment of such patients and the use of hospital resources is unknown.
We performed appendiceal CT on 100 consecutive patients in the emergency department who, on the basis of history, physical examination, and laboratory results, were to be hospitalized for observation for suspected appendicitis or for urgent appendectomy. Outcomes were determined at surgery and by pathological examination in 59 patients, and by clinical follow-up two months later in 41 patients. Treatment plans made before CT were compared with the patients' actual treatment. We also determined the costs of surgery that revealed no appendicitis (from data on 61 patients), one day of observation in the hospital (from data on 350 patient-days in patients with suspected appendicitis), and appendiceal CT (from data on all pelvic CT examinations in 1996).
Fifty-three patients had appendicitis, and 47 did not. The interpretations of the appendiceal CT scans were 98 percent accurate. The results of CT led to changes in the treatment of 59 patients. These changes resulted in the prevention of unnecessary appendectomy in 13 patients, admission to the hospital for observation in 18 patients, admission to the hospital for observation before necessary appendectomy in 21 patients, and admission to the hospital for observation before the diagnosis of other conditions by CT in 11 patients. The effects of performing appendiceal CT on the use of hospital resources included the prevention of unnecessary appendectomy in 13 patients (for a savings of $47,281) and the prevention of unnecessary hospital admission for 50 patient-days (for a savings of $20,250). After the cost of 100 appendiceal CT studies ($22,800) was subtracted, the overall savings was $447 per patient.
Routine appendiceal CT performed in patients who present with suspected appendicitis improves patient care and reduces the use of hospital resources.
To determine whether diagnosis by graded compression ultrasonography improves clinical outcomes for patients with suspected appendicitis.
A randomised controlled trial comparing clinical diagnosis (control) with a diagnostic protocol incorporating ultrasonography and the Alvarado score (intervention group).
Single tertiary referral centre.
302 patients (age 5-82 years) referred to the surgical service with suspected appendicitis. 160 patients were randomised to the intervention group, of whom 129 underwent ultrasonography. Ultrasonography was omitted for patients with extreme Alvarado scores (1-3, 9, or 10) unless requested by the admitting surgical team.
Time to operation, duration of hospital stay, and adverse outcomes, including non-therapeutic operations and delayed treatment in association with perforation.
Sensitivity and specificity of ultrasonography were measured at 94. 7% and 88.9%, respectively. Patients in the intervention group who underwent therapeutic operation had a significantly shorter mean time to operation than patients in the control group (7.0 v 10.2 hours, P=0.016). There were no differences between groups in mean duration of hospital stay (53.4 v 54.5 hours, P=0.84), proportion of patients undergoing a non-therapeutic operation (9% v 11%, P=0.59) or delayed treatment in association with perforation (3% v 1%, P=0.45).
Graded compression ultrasonography is an accurate procedure that leads to the prompt diagnosis and early treatment of many cases of appendicitis, although it does not prevent adverse outcomes or reduce length of hospital stay.
Computed tomography (CT) and ultrasonography (US) do not improve the overall diagnostic accuracy for acute appendicitis.
Retrospective review.
University tertiary care center.
Seven hundred sixty-six consecutive patients undergoing appendectomy for suspected appendicitis from January 1, 1995, to December 31, 1999.
Epidemiology of acute appendicitis and the roles of clinical assessment, CT, US, and laparoscopy.
The negative appendectomy rate was 15.7%, and the incidence of perforated appendicitis was 14.6%. A history of migratory pain had the highest positive predictive value (91%), followed by leukocytosis greater than 12 x 10(9)/L (90.1%), CT (83.8%), and US (81.3%). The false-negative rates were 60% for CT and 76.1% for US. Emergency department evaluation took a mean +/- SD of 5.2 +/- 5.4 hours and was prolonged by US or CT (6.4 +/- 7.4 h and 7.8 +/- 10.8 h, respectively). The duration of emergency department evaluation did not affect the perforation rate, but patients with postoperative complications had longer evaluations (mean +/- SD, 8.0 +/- 12.7 h) than did those without (4.8 +/- 3.3 h) (P =.04). Morbidity was 9.1%, 6.4% for nonperforated cases and 19.8% for perforated cases. Seventy-six patients had laparoscopic appendectomy, with a negative appendectomy rate of 42.1%, compared with 15.4% for open appendectomy (P<.001). Laparoscopy, however, had minimal morbidity (1.3%) and correctly identified the abnormality in 91.6% of patients who had a normal-appearing appendix.
Migratory pain, physical examination, and initial leukocytosis remain reliable and accurate in diagnosing acute appendicitis. Neither CT nor US improves the diagnostic accuracy or the negative appendectomy rate; in fact, they may delay surgical consultation and appendectomy. In atypical cases, one should consider the selective use of diagnostic laparoscopy instead.
Objective: To evaluate the impact of appendiceal computed tomography (CT) availability on negative appendectomy and appendiceal perforation rates. Summary Background Data: Appendiceal CT is 98% accurate. However, its impact on negative appendectomy and appendiceal perforation rates has not been reported. Methods: The authors reviewed the medical records of 493 consecutive patients who underwent appendectomy between 1992 and 1995, 209 consecutive patients who underwent appendectomy in 1997 (59% of whom had appendiceal CT), and 206 patients who underwent appendiceal CT in 1997 without subsequent appendectomy. Results: Before appendiceal CT, 98/493 patients (20%) taken to surgery had a normal appendix. After CT availability, 15/209 patients (7%) taken to surgery had a normal appendix; 7 patients did not have CT, 5 patients had surgery despite a negative CT, and 3 patients had a false-positive CT. Negative appendectomy rates were lowered overall (20% to 7%), in men (11% to 5%), in women (35% to 11%), in boys (10% to 5%), and in girls (18% to 12%). Appendiceal perforation rates dropped from 22% to 14% after CT availability. CT excluded appendicitis in 206 patients in 1997 who avoided appendectomy and identified alternative diagnoses in 105 of these patients (51%). Conclusion: The availability of appendiceal CT coincided with a drop in the negative appendectomy rate from 20% to 7% in all patients, and to only 3% in patients with a positive CT. Perforation rates decreased from 22% to 14%. Appendiceal CT can be advocated in nearly all female and many male patients.
We prospectively examined 103 consecutive adults (67 women, 36 men; mean age: 58.7 years) referred for abdominal and pelvic computed tomography (CT) in whom there was no history of right lower quadrant symptoms or appendectomy. Contiguous 5-mm CT images through the pericecal region were obtained in each subject, once routine scanning was completed. Three radiologists reviewed all CT images and reached a consensus on appendiceal visualization and the quantity of intraperitoneal fat. Statistical methods were applied to the collected data to seek significant associations between a visualized appendix and the following factors: patient age, sex, intraperitoneal fat grade, and the presence of oral contrast in the cecal lumen. The appendix was definitely visualized in only 45 of the 103 patients (43.7%). Analysis of variance revealed no statistically significant correlation between a CT-demonstrated appendix and the four variables examined. The clinical implications of these findings are discussed.
In a prospective study 152 consecutive patients presenting with acute abdominal pain were assessed clinically and an ultrasonographic examination was performed immediately. Of these, 16 (11 per cent) patients would normally have had an immediate ultrasonographic scan requested; routine (within 24 h of admission) ultrasonographic examination would have been requested in a further 66 (43 per cent) patients. In 70 (46 per cent) patients an ultrasonographic examination would not have been requested. Ultrasonography altered the diagnosis in one patient from probable appendicitis to cholecystitis. Ultrasonography missed one abdominal aortic aneurysm and one empyema of the gallbladder. Ultrasonography had a sensitivity of 96 per cent, a specificity of 94 per cent, a positive predictive value of 96 per cent, a negative predictive value of 94 per cent and an accuracy of 95 per cent in diagnosing appendicitis. Exactly the same values were found for the clinical diagnosis of appendicitis. The study shows that routine immediate ultrasonographic examination of the acute abdomen is rarely helpful, with the possible exception of appendicitis. Where an urgent ultrasonographic scan is necessary on clinical grounds the expertise of a radiologist is probably required, whereas in specific areas, for example in the diagnosis of right iliac fossa pain, there may be a place for training the surgical trainee.
We conducted a prospective evaluation of the normal vermiform appendix in 203 patients. Conventional CT techniques were utilized with an 8 mm slice thickness and 10 mm slice interval. The normal appendix was definitely identified in 51% of the patients studied. Computed tomographic appearance of the normal appendix is demonstrated, and potential pitfalls are described.
To better define the effectiveness of abdominal computed tomographic scanning (ACTS) in adult patients with suspected appendicitis.
Retrospective analysis.
A community teaching hospital.
Ninety-seven patients with appendicitis in the differential diagnosis, whose clinical findings were insufficient to perform surgery or to discharge from the hospital, during a 14-month period.
None.
Accuracy of ACTS, rate of appendectomies that show no appendicitis (negative appendectomy rate), and frequency of ACTS as a definitive diagnostic test.
Forty-nine of the 50 patients with appendicitis were correctly diagnosed by ACTS. Forty-three of the 47 patients without appendicitis were correctly diagnosed by ACTS. Positive predictive value was 92%, negative predictive value was 98%, and accuracy was 96%. The ACTS group had a negative appendectomy rate of 5.8% (3/52), lower than the hospital rate of 14% for the preceding 3 years. The ACTS established an alternative diagnosis in 16 patients, allowed 10 other patients to be discharged early or not admitted, and was the critical diagnostic test in 30 of the patients with appendicitis. Therefore, the ACTS played a definitive role in the treatment of 56 (57.7%) of the 97 patients.
The ACTS was an accurate test in the diagnosis of appendicitis and was of significant benefit in 57.7% of the patients studied. However, it was difficult to predict which patients were most likely to benefit. Expanded selective use of ACTS for patients with clinically indeterminate appendicitis may result in a lower negative appendectomy rate and fewer patient admissions for observation.
Computed tomography (CT) is used increasingly to diagnose acute appendicitis, despite variable technique and interpretation. We hypothesized that CT interpretation would not reflect actual clinical-pathologic findings in all demographic patient groups.
A prospective university hospital database of 625 consecutive patients (1995-1999), all of whom were operated on for appendicitis (261, or 41.8%, within 24 hours of discretionary CT), was reviewed. CT and pathology data were obtained from final, written reports. CT criteria included free fluid or air, appendiceal visualization, mesenteric fat stranding, and blurred pericecal fat. Appendix pathology included acute, gangrenous, and perforated organs. Statistics were performed with the Fisher exact test (coordinate data) and univariate analysis of variance (continuous data); multivariate analysis of variance for independent effects on dependent variable (positive CT or pathology; P <.05).
The mean age was 35 +/- 1 years with 46.6% being female patients. CT was done more often in women and after 1997 (both P <.05). The sensitivity and specificity of CT were 96.1% and 16.1%, respectively. The positive predictive value (PPV) and accuracy rate (A) were 90%, and 88%, respectively. After CT, the incidence of finding a normal appendix was lower (19.3% vs 12.3%, P <.05), especially if the white blood cell count (WBC) was normal (< or = 11K/microL, 6.1% vs 23.2%, P <.001). If the WBC was < or = 11K/microL with positive CT, PPV/A was 73. 7%/71.3%, whereas with WBC > 11K/microL and positive CT, PPV/A was 99.4%/93.3%. Multivariate analysis of variance showed that none of the individual variables used by the radiologist to determine a positive CT scan correlated with outcome determined by surgical pathology. A healthy appendix was predicted by a CT interpreted as negative and younger age (both P <.05), and especially by lower WBC (P <.0001), but not by gender or surgeon.
Although the negative appendectomy rate was decreased by CT, there was no correlation between CT findings and pathologically proved disease. Other factors such as more precise patient selection by clinical criteria may also be improving outcome. A positive CT scan in a patient with a normal WBC should be interpreted with caution.
Misdiagnosis of presumed appendicitis is an adverse outcome that leads to unnecessary surgery. Computed tomography, ultrasonography, and laparoscopy have been suggested for use in patients with equivocal signs of appendicitis to decrease unnecessary surgery.
To determine if frequency of misdiagnosis preceding appendectomy has decreased with increased availability of computed tomography, ultrasonography, and laparoscopy.
Retrospective, population-based cohort study of data from a Washington State hospital discharge database for 85 790 residents assigned International Classification of Diseases, Ninth Revision procedure codes for appendectomy, and United States Census Bureau data for 1987-1998.
Population-based age- and sex-standardized incidence of appendectomy with acute appendicitis (perforated or not) or with a normal appendix.
Among 63 707 nonincidental appendectomy patients, 84.5% had appendicitis (25.8% with perforation) and 15.5% had no associated diagnosis of appendicitis. After adjusting for age and sex, the population-based incidence of unnecessary appendectomy and of appendicitis with perforation did not change significantly over time. Among women of reproductive age, the population-based incidence of misdiagnosis increased 1% per year (P =.005). The incidence of misdiagnosis increased 8% yearly in patients older than 65 years (P<.001) but did not change significantly in children younger than 5 years (P =.17). The proportion of patients undergoing laparoscopic appendectomy who were misdiagnosed was significantly higher than that of open appendectomy patients (19.6% vs 15.5%; P<.001).
Contrary to expectation, the frequency of misdiagnosis leading to unnecessary appendectomy has not changed with the introduction of computed tomography, ultrasonography, and laparoscopy, nor has the frequency of perforation decreased. These data suggest that on a population level, diagnosis of appendicitis has not improved with the availability of advanced diagnostic testing.
Abdominal computed tomographic scanning (ACTS) has recently been shown to be an accurate diagnostic tool for appendicitis and may improve the negative exploration rate in our patient population.
We reviewed 224 patients evaluated for appendicitis during 1998. Forty-two patients underwent appendectomy on clinical grounds alone (Group I), 182 patients underwent ACTS (Group II), and 79 patients in Group II were explored for appendicitis. Diagnostic errors, alternative diagnoses, and perforation rates were noted.
There were five negative explorations in Group I (11.9%) and five in Group II (6.3%), resulting in a combined negative rate of 8.3%. The negative exploration rate in women was 23.5% in Group I and 5.3% in Group II (P = 0.07), producing a combined negative rate of 10.9%. Fifty-eight alternative diagnoses were made by ACTS. The ACTS made a critical difference in the management of 67% of patients over 50 years of age and in 79% of Group II patients.
The negative exploration rate for appendicitis at our institution fell from 13.6 to 8.3% with selective use of ACTS. The most striking benefit occurred in women and in patients over 50 years of age.