A prospective study of ultrasonography in the diagnosis of appendicitis

Delayed appendectomy for appendicitis: causes and consequences

This study was undertaken to describe the causes and consequences of delayed diagnosis and intervention in cases of appendicitis. The hospital records of adult patients undergoing appendectomy during a 4-year period (November 1989 to November 1993) were reviewed, with concentration on 40 patients who had a delay of 72 hours or more from initial symptoms to operation. The initial medical contact points for patients were walk-in clinics and community emergency departments. Definitive care was provided in a general hospital. Patients were adults with appendicitis who underwent an operation for definitive management 72 or more hours after the onset of symptoms. Length of hospital stay, reasons for delay in diagnosis, incidence of perforation, and complications were recorded. Delay in diagnosis and treatment was attributed to factors controlled by the patient in 15 cases (27.5%) and by the physician in 25 cases (62.5%). Perforation, postoperative complications, and hospital length of stay were related to the delay in diagnosis; with delay, the mean hospital length of stay was 9 days, the incidence of perforation was 90%, and major complications were recorded in 60% of the patients. Early diagnosis and surgical management for appendicitis remains an important and, at times, elusive goal. Delays of 72 hours or more have serious consequences. Patient education and the experience, intuitiveness, and persistence of the physician are important elements to improving these findings.

The myth of the fecalith

A radiographically demonstrated fecalith is widely considered a virtually pathognomonic sign of acute appendicitis. This case report describes a patient with a clinical presentation suggestive of appendicitis and a well-defined right lower quadrant fecalith who was found to have a normal appendix at surgery. This case calls into question the venerable dogma surrounding the fecalith and highlights the necessity for the physician to continue to rely on clinical judgment in making the diagnosis of appendicitis.

The management of acute abdominal pain in children

OBJECTIVE

Acute abdominal pain is a common problem in childhood, and appendicitis is frequently diagnosed by general practitioners and doctors working in emergency departments. The objective of the present report was to determine the frequency of appendicitis in a group of children with acute abdominal pain presenting to the emergency department of a general hospital, as well as attempting to analyse the manner in which these patients were managed.

METHODOLOGY

The initial assessment in hospital (by resident hospital staff) of the study group of patients was analysed and their subsequent clinical progress documented.

RESULTS

The present report shows that the vast majority of children with acute abdominal pain do not have appendicitis and that appendicitis is significantly over-diagnosed by junior hospital doctors.

CONCLUSIONS

Appendicitis is a clinical diagnosis, best made by an experienced member of the paediatric surgical team. Frequent review, with a minimum of investigations, provides the best means of making a rational decision regarding surgery.

Conventional radiography and ultrasonography in the diagnosis of small bowel obstruction and strangulation

Ninety-six patients, 45 men and 51 women (mean age 39 years, range 13- 90 years), with clinically acute abdomen were examined by conventional abdominal radiography and ultrasonography during a period of one year. Ultrasonography was performed with a linear transducer, which permitted study of morphology and motility of small bowel loops: distention, paralysis, intramural thickening, and extraluminal fluid. Nineteen cases of mechanical obstruction (9 simple and 10 of strangulation type) were observed. In the strangulation group ultrasonographic findings were positive in 91% whereas conventional radiography solely was positive in 30%. In the simple obstruction, 89% and 78%, respectively, were correctly diagnosed by the 2 techniques. Ultrasonography is recommended as a routine examination beside conventional abdominal films in acute abdomen.

Ultrasonography to evaluate adults for appendicitis: decision making based on meta-analysis and probabilistic reasoning

OBJECTIVES

To review ultrasonography (US) test performance and to develop recommendations for the use of US to aid in the evaluation of potential appendicitis.

METHODS

A meta-analysis was conducted using all English-language articles published since 1986 (17 studies; 3,358 patients) to ascertain sensitivity and specificity of US for diagnosing appendicitis in adults and teenagers. Calculation of the predictive value of US was performed for three groups of patients: group I--usually operated on (prevalence of appendicitis = 80%); group II--usually observed in hospital (prevalence = 40%); and group III--usually released home (prevalence 2%).

RESULTS

Overall sensitivity was 84.7% (95% CI: 81.0-87.8%), and specificity 92.1% (88.0-95.2). The accuracy and usefulness of US were related to the likelihood of appendicitis. In group I, a positive test was accurate [positive predictive value (PPV) = 97.6%], but a negative study could not rule out appendicitis [negative predictive value (NPV) = 59.5%]. The converse was true for group III patients (PPV = 19.5%, NPV = 99.7%). Test performance accuracy was balanced only for group II patients (PPV = 87.3%, NPV = 89.9%).

CONCLUSIONS

1) US should not be used to exclude appendicitis for patients who have "classic" signs/symptoms, due to the underlying high false-negative rate. 2) US is most useful for patients who have an indeterminate probability of disease after the initial evaluation--if US is positive, the patient should have an operation; otherwise, he or she should be observed. 3) US is not recommended for screening patients who have a low probability of appendicitis, due to the low prevalence of disease and high false-positive rate in this group.

Imaging and intervention in patients with acute right lower quadrant disease

US using graded compression plays a central role in the diagnostic work-up of acute right lower quadrant disease, but its results should always be integrated with clinical data and results of other possible radiological examinations. Direct US visualization of an inflamed appendix is solid proof of appendicitis. Pitfalls are secondary enlargement in perforated peptic ulcer, caecal carcinoma or Crohn's disease. If a normal appendix is visualized in its full length, appendicitis can be excluded. However, this is rarely the case. In practice, the only means to exclude appendicitis is to demonstrate an alternative condition, which in most cases is possible by US alone. Concomitant adynamic ileus is a valuable US finding. Abscesses related to appendicitis, Crohn's disease and colonic carcinoma respond well to percutaneous drainage, which is technically possible in 95% of cases. Some of these abscesses evacuate spontaneously to neighbouring bowel. For abscesses due to caecal diverticulitis spontaneous evacuation to the caecal lumen is the rule. For indication and drainage strategy, integration of US, CT and clinical data are indispensable. The use of US in right lower quadrant disease will not only lead to a strong improvement of diagnostic accuracy, but also to better understanding of the incidence and natural course of various conditions such as abortive appendicitis, appendiceal abscess, caecal diverticulitis, bacterial ileocaecitis and right-sided segmental infarction of the omentum.

Imaging and intervention in abdominal emergencies

While plain abdominal radiographs retain an essential place in acute abdominal emergencies, the dramatic advances in ultrasound, computed tomography and magnetic resonance imaging witnessed over the past two decades have revolutionized the practice of emergency medicine. Cross-sectional imaging techniques now play a key role in evaluating patients with abdominal emergencies, and allow confident diagnoses to be made in an ever increasing proportion of these patients. Unnecessary laparotomies are now uncommon, and a wide array of interventional radiological techniques can be used to treat abdominal emergencies without surgery.

Misdiagnosis of appendicitis in nonpregnant women of childbearing age

A retrospective case series was conducted at a teaching hospital with an emergency department (ED) census of 100,000 patients per year to identify the incidence of, and factors associated with, the misdiagnosis of appendicitis in nonpregnant women aged 15 to 45 years. There were 174 nonpregnant women identified with a pathologic diagnosis of appendicitis. Clinical features were then compared between patients misdiagnosed (seen in prior 10 days and given an incorrect diagnosis) and those who were initially diagnosed correctly. The results showed that 33% of the women with appendicitis were initially misdiagnosed. The most common misdiagnoses included pelvic inflammatory disease, gastroenteritis, and urinary infections. Misdiagnosed women more frequently exhibited diffuse and bilateral lower abdominal pain and tenderness, cervical motion, and right adnexal tenderness. Misdiagnosed women also had a lower incidence of right lower quadrant pain and tenderness, and peritoneal signs. In addition, misdiagnosis was associated with an increased incidence of perforation, abscess formation, and an increase in the total length of hospitalization. In conclusion, the incidence of misdiagnosis of appendicitis in women of childbearing age is high. Women who are misdiagnosed have less typical symptoms and physical findings and more frequent abnormal pelvic findings than those who are diagnosed correctly. Emergency physicians should be aware that atypical signs and symptoms are associated with misdiagnosed appendicitis in nonpregnant women of childbearing age.

The diagnostic value of repetitive preoperative analyses of C-reactive protein and total leucocyte count in patients with suspected acute appendicitis

BACKGROUND

Studies have shown that C-reactive protein (CRP) and total leucocyte count (WBC) in suspected acute appendicitis analysed only on admission gave valuable information to guide the surgeon. The aim of this study was to investigate the usefulness of CRP and WBC measured repetitively before operation.

METHODS

During a 1-year period 227 patients were studied before emergency appendicectomy. CRP and WBC were analysed every 4th h. The upper limits of the reference intervals used were 9.0 x 10(9)/l for WBC and 10 mg/l for CRP.

RESULTS

Of the 227 appendicectomized patients, 170 (75%) had acute appendicitis. Sixty-six of the patients were tested on two or more occasions every 4th h. Forty-six of these patients had appendicitis; repetitive tests showed a continuing rise in CRP values but a continuing decrease in WBC. The negative appendicectomy rate among these 66 patients was 30%, which theoretically would have fallen to 19% if patients with normal results had not been subjected to surgery.

CONCLUSIONS

Repeated laboratory tests for CRP and WBC should be performed in patients with suspected acute appendicitis requested to stay for further observation. If these test results are normal, the surgeon should preferably refrain from operating but consider other differential diagnoses.

[Ultrasound diagnosis of appendicitis by surgeons--a matter of experience? A prospective study]

A number of studies have shown that ultrasound has an advantage over physical examination in the diagnosis of acute appendicitis. Most of these studies were conducted by experts in the field of ultrasonography. In this study the influence of experience on the results of the sonography of acute appendicitis were evaluated. All 203 patients admitted to our unit between December 1990 and December 1992 were examined physically and sonographically by a team of surgeons consisting of one experienced sonographer and six inexperienced surgical trainees. Laparotomy was performed in 136 patients (46%). Appendicitis was demonstrated histologically in 119 cases (39.4%). Initial clinical findings were positive in 87 (28.8%). Sonography was positive in 119 patients (39.4%). The 163 patients not operated on demonstrated other pathology on ultrasound in 60 cases (19.9%). The rate of negative laparotomies amounted to 7.2% in our study. Sensitivity and specificity for the sonographic diagnosis were 92% and 95%, respectively. They were only 81% and 80% for physical examination. Overall accuracy was 92% for sonography. Sensitivity and specificity for the inexperienced surgeons were 87% and 93%, respectively, while the experienced surgeon reached values of 97% and 98%, respectively. The results of both groups are comparable with values in the literature, suggesting that ultrasound evaluation of appendicitis is not a diagnostic tool limited to a few experienced sonographers.

Acute appendicitis in children: when does ultrasound help?

Fifty-six patients with possible appendicitis were evaluated clinically and by ultrasound. Ultrasound examination visualized the appendix in 18 of the patients evaluated and showed another pathology in six others. It was useful when the clinical picture was not clear (25 patients) as it showed an inflamed appendix in 10 patients. This was of particular value when there was another critical illness making clinical evaluation difficult (three patients), and for the diagnosis of other unsuspected pathological conditions (six patients). It did not affect the line of management when the clinical picture was clear enough to diagnose or exclude acute appendicitis.

Peritoneal aspiration cytology as a diagnostic aid in acute appendicitis

A total of 110 consecutive patients presenting to one surgical firm with suspected acute appendicitis underwent peritoneal aspiration cytology. Aspiration was successful in 108 patients and 44 were positive. Patients with a positive result underwent emergency surgery; 42 had histologically proven acute appendicitis and two peritonitis of other causes. Seven patients with a negative result underwent appendicectomy; four had acute appendicitis and three a normal appendix. Peritoneal aspiration cytology had a sensitivity for acute appendicitis of 91 per cent and a specificity of 94 per cent. The positive predictive value of the test was 95 per cent and the negative predictive value 94 per cent. The negative appendicectomy rate was 10 per cent overall and 11 per cent in women of reproductive age. Peritoneal aspiration cytology is a useful diagnostic test in the management of patients with suspected acute appendicitis.

Indications for operation in suspected appendicitis and incidence of perforation

OBJECTIVE

To clarify poorly understood epidemiological features of appendicitis.

DESIGN

Retrospective study of consecutive cases from a defined population and analysis of data from published studies.

SETTING

County of Jönköping, Sweden. 3029 patients who underwent operation in 1984-9 and 4717 patients from the county town who underwent operation in 1970-89, all for suspected appendicitis, plus 48,426 cases from six reported studies.

MAIN OUTCOME MEASURES

Incidences specific for age and sex and temporal trends of perforating and non-perforating appendicitis and removal of a normal appendix. Associations between diagnostic accuracy, rate of perforation, and incidences of removal of a normal appendix and of perforating and non-perforating appendicitis.

RESULTS

The incidence of appendicitis was 116/100,000 inhabitants. Appendicitis was more common in male patients. The incidence of perforating appendicitis was independent of age, stable over time, and uninfluenced by the rate of laparotomy, whereas the incidence of non-perforating appendicitis was age dependent, decreasing over time, and related to the diagnostic accuracy and rate of removal of a normal appendix.

CONCLUSIONS

Perforating and non-perforating appendicitis seem to be separate entities, and appendicitis that resolves spontaneously is common. This may have important implications for managing suspected appendicitis.

The role of ultrasound scanning

Abdominal abscess, if left untreated, has a high mortality rate. Inadequate means of diagnosis and localization was responsible for this high mortality. Ultrasound now provides a simple non-invasive procedure permitting diagnosis with a high degree of sensitivity, although specificity is less commonly achieved. Abscesses do not have absolutely specific features, but given the appropriate clinical context and fine needle aspiration a diagnosis can be made in virtually 100% of cases, i.e. if the lesions can be identified and not obscured by bowel gas and examinations are not rendered difficult by surgical wounds and dressings. Diagnostic aspiration and therapeutic drainage are readily carried out using ultrasound guidance. Ultrasound is also of value in following the progress of lesions.

Impact of adjunctive testing on the diagnosis and clinical course of patients with acute appendicitis

The diagnosis of acute appendicitis is usually made from the history and physical examination. Recently, abdominal ultrasonography (US), laparoscopy, computerized tomography (CT), and barium enema (BE) have been used in the preoperative evaluation of patients with presumed appendicitis in order to improve the diagnostic accuracy. However, the usefulness of these tests in verifying the diagnosis of appendicitis has not been established. We reviewed the medical records of 203 patients who underwent appendectomy. One hundred patients were surgically treated before 1984 (group I) and 103 patients underwent surgery after 1988 (group II). Patients in group II were more likely to have preoperative US, laparoscopy, CT, or BE (24 in group II versus 3 in group I, p < 0.05). When groups I and II were compared, the rates of perforation (27% versus 20%), normal appendectomy (8% versus 11%), and the interval between admission and operation (12.2 hours versus 10.7 hours) and length of hospitalization (5.0 days versus 5.1 days) were not significantly different. We concluded that although adjunctive testing may be beneficial in selected patients, its routine use in patients suspected of having appendicitis cannot be advocated at present.

The right lower quadrant "revisited"

Appendicitis remains a common and morbid illness in children. The history, epidemiology, pathophysiology, clinical presentation, diagnostic evaluation, and management of acute appendicitis are discussed in this article.

Diagnostic laparoscopy: reducing the number of normal appendectomies

A prospective, controlled study was conducted to determine whether a selective policy of diagnostic laparoscopy could reduce the number of unnecessary normal appendectomies in patients with acute right iliac fossa pain. The cohort consisted of patients admitted with acute right iliac fossa pain by the emergency department. Of 102 patients in the study group, 28 subsequently required a diagnostic laparoscopy when a definite diagnosis could not be reached after 8 to 12 hours of observation. Of these, only 18 had inflamed appendices, which were removed. In the rest of the patients (10), the appendices were normal and unnecessary laparotomies were avoided. In the control group, wherein equivocal cases were laparotomized after a similar period of observation, there was a normal appendectomy rate of 15.7 percent (P < 0.05). There was no significant difference in the incidence of perforation between the control and study groups. Diagnostic laparoscopy in equivocal cases could thus significantly reduce the number of unnecessary appendectomies without compromising on the rate of perforation.

Clinical validity of ultrasound in children with suspected appendicitis

STUDY OBJECTIVE

To determine the accuracy of diagnosing appendicitis in the pediatric population by using graded compression ultrasonography.

DESIGN

Retrospective case review.

SETTING

University-affiliated community hospital with an emergency department census of approximately 19,000 pediatric visits per year.

TYPE OF PARTICIPANTS

Ninety-eight children (age less than 13 years) with clinically suspected appendicitis who had graded compression sonographic studies during the 24-month study period.

INTERVENTIONS

Medical records were reviewed for patient demographics, presenting signs and symptoms, sonographic findings, surgical results, and hospital course. Patients who did not undergo surgery were followed up by telephone for a minimum of two months.

RESULTS

Ninety-eight children (42 boys and 56 girls; age range, 2 to 12 years; mean age, 8.0 years) with clinical signs and symptoms of acute appendicitis were examined sonographically. Of the 26 patients whose appendicitis was verified at surgery, ultrasound was positive in 22, with an overall sensitivity of 85%. Of the 72 patients who did not have appendicitis, ultrasound was negative in 68, with a specificity of 94%. Two patients with false-positive ultrasound went to surgery and were found to have acute ileitis and perforated Meckel's diverticulum. The overall diagnostic accuracy was 91.8% (90 of 98).

CONCLUSION

Use of ultrasound to diagnose acute appendicitis was performed with a sensitivity of 85% and a specificity of 94%. This allows the same accuracy in children as has been reported with adults.

Review of the pathologic diagnoses of 2,216 appendectomy specimens

A retrospective review of 2,216 patients surgically treated for a clinical diagnosis of acute appendicitis was performed. In 80% of cases, histologic acute appendicitis was found; 57% of these patients were male. The rate of normal appendectomy was 16%, and females comprised 68% of that group. The remaining 102 cases (4%) were designated as the alternate diagnosis group. Apart from histologic diagnoses that could be considered variants of normal (57) or acute inflammation (20), the alternate diagnosis group included such entities as neoplasm, parasitic infection, mucocele, and diverticulitis.

Appendicitis diagnosis today: clinical and ultrasonic deductions

A total of 111 patients referred with a diagnosis of suspected "appendicitis" were entered into a prospective study. The surgeon and radiologist in charge of ultrasonography made separate diagnoses, and their findings were then combined and discussed as indications for surgery. Clinically, a history of pain migration proved to be reliable (p < 0.0001) as a diagnostic indicator, in contrast to nausea and initial irregularity of bowels. The duration of symptoms was significantly shorter in patients with proved appendicitis than among patients with negative findings (median 24 hours compared with 41 hours, p < 0.04). Among patients with perforated appendicitis, the symptomatic history was prolonged (not significantly) by 3 hours. Peritoneal signs such as pain on percussion, rebound tenderness, guarding, and a leukocytosis of more than 13,000/mm3 were indicative of appendicitis (p = 0.0001 for each sign). Lively bowel sounds excluded the possibility of appendicitis (p = 0.001). Scanty bowel sounds, rectal tenderness, axillorectal temperature difference, and a left shift in leukocytes were of no diagnostic significance. The doctor's "clinical experience" is significant at the level of p < 0.03. On ultrasonography, the following signs were indicative of appendicitis: periappendicular infiltration (p = 0.0003), a visible "cockade," and an appendix larger than 12 mm in diameter (p = 0.04). For 75% of the patients the surgeon was sure of his own clinical diagnosis and did not allow himself to be influenced by the sonographic findings. In 12% of doubtful cases ultrasonographic results decisively favored operation, and in 4.5% (n = 5) it prevented an unnecessary laparotomy in the presence of positive clinical symptoms.(ABSTRACT TRUNCATED AT 250 WORDS)

Perforation associated with barium enema in acute appendicitis

A child with the suspected diagnosis of atypical acute appendicitis underwent a diagnostic barium enema. The study was complicated by perforation with leakage of a large amount of barium into the peritoneal cavity. The complex hospital course that resulted has prompted us to reevaluate the barium enema in the diagnosis of appendicitis and review the literature for contraindications. We conclude that this particular complication is extremely rare and that barium enema still has a part to play in some patients where the clinical diagnosis is uncertain.

Eosinophilic enteritis presenting as acute abdomen: US features of two cases

Eosinophilic enteritis is a rare disease which may mimic acute abdominal emergency. Two sonographically documented cases are presented, which were subsequently proven at operation. Although the sonographic features of severe echolucent bowel wall thickening were not specific, combination with clinical and laboratory data may suggest the correct diagnosis.

Sonography in acute colonic diverticulitis. A prospective study

The clinical value of high-resolution real-time sonography for the diagnosis of acute and complicated colonic diverticulitis was prospectively studied in 130 consecutive patients with abdominal complaints, because of which the disease entered into differential consideration. The results of ultrasound investigation were compared with those of clinical examination on admission. Regarding history and initial clinical evaluation, diverticulitis was graded as "highly suspected" in 19 (36.5 percent) out of a total of 52 patients with later proven colonic diverticulitis (prevalence 40 percent), as "possible but equivocal" in 24 (46.2 percent), and as "very unlikely" in the remaining nine (17.3 percent) patients. Ultrasonography enabled the diagnosis of diverticulitis with an overall accuracy of 97.7 percent, a sensitivity of 98.1 percent, and a specificity of 97.5 percent. The predictive values of positive and negative ultrasound examinations were 96.2 percent and 98.5 percent, respectively. The echomorphologic features of acute diverticulitis include visualization of a colon segment presenting with local tenderness on gradual compression, which showed hypoechogenic thickening of the wall and a targetlike appearance in transverse view due to inflammatory changes and muscular thickening. Sonographic signs of peridiverticulitis (hyperechoic halo) were found in 96 percent of patients, echogenic diverticula in 86 percent. Twelve (92 percent) of 13 abdominal abscesses were detected on initial ultrasound examination and could be treated by percutaneous drainage in seven cases, while six required surgical intervention. These results indicate that high-resolution sonography with graded compression is highly sensitive and specific for the imaging diagnoses of acute colonic diverticulitis and complicating abscess.

Diagnosis and staging of colonic tumors by conventional abdominal sonography as compared with hydrocolonic sonography

BACKGROUND

Ultrasonic examination has become increasingly important in the diagnosis of diseases of the gastrointestinal tract. In neoplastic diseases of the large intestine, however, the diagnostic value of conventional transabdominal sonography is limited. The purpose of this investigation was to determine whether the evaluation and staging of colonic tumors would be improved by the retrograde instillation of water into the colon in a procedure called hydrocolonic sonography.

METHODS

Three hundred patients were examined in a prospective study in which both conventional transabdominal sonography and transabdominal hydrocolonic sonography were performed before the diagnosis was verified by colonoscopy. The indication for the examinations was abdominal pain, diarrhea, weight loss, or the presence of occult blood in a stool specimen.

RESULTS

With the instillation of water into the colon, it was possible to display the colon sonographically from the rectosigmoid transition to the cecum in 97 percent of the patients examined. In addition to permitting the evaluation of the colonic lumen, the procedure allowed the five layers of the colonic wall and the connective tissue surrounding the colon to be examined in detail. Only 9 of 29 carcinomas were diagnosed by conventional abdominal sonography (31 percent), whereas hydrocolonic sonography permitted the diagnosis of 28 (97 percent). No polyps could be detected by conventional abdominal sonography, whereas hydrocolonic sonography permitted the diagnosis of 38 of 42 polyps greater than or equal to 7 mm (91 percent) and 3 of 12 polyps less than 7 mm (25 percent). In addition, detailed evaluation of the structure of the bowel wall with hydrocolonic sonography permitted a more precise staging of colonic tumors.

CONCLUSIONS

Hydrocolonic sonography, a new diagnostic procedure, can facilitate the diagnosis and staging of colonic tumors.

Strategies for reducing inappropriate laparotomy rate in the acute abdomen

Images

Ultrasonography in the acute abdomen

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.

Use of portable ultrasound to assist urine collection by suprapubic aspiration

STUDY OBJECTIVE

To determine whether portable ultrasound can improve the success rate of suprapubic aspiration (SPA).

DESIGN

Patients were randomly assigned to either ultrasound or no ultrasound groups. In the ultrasound group, patients underwent SPA if ultrasound revealed urine in the bladder: if no urine was present, patients underwent catheterization instead of SPA. In the no-ultrasound group, SPA was attempted without ultrasound. All unsuccessful SPAs were followed by catheterization and measurement of urine volume.

SETTING

Children's hospital-based pediatric emergency department.

PARTICIPANTS

Children less than 2 years old who required SPA.

INTERVENTIONS

Ultrasound versus no ultrasound.

RESULTS

Thirty-five patients were randomized to the ultrasound group, and 31 were randomized to the no-ultrasound group. SPA was successful in 79% of attempts in the ultrasound group compared with 52% in the no-ultrasound group (P = .04). The sensitivity and specificity of ultrasound were 90% and 86%, respectively.

CONCLUSION

Portable ultrasound can significantly improve the success rate of SPA and limit nonproductive attempts at SPA.

Ultrasonography in the diagnosis of gynecologic disorders

Ultrasonographic examination is being used with progressively greater frequency as an aid in diagnosis of gynecologic disorders but too often without consideration of whether information other than that obtained from clinical examination is needed and whether ultrasonography can supply it. The size, number, and position of pelvic masses and, in some instances, the type of tumor can be identified, but it is not often necessary when operation is clearly indicated. Ultrasonographic screening for diseases of the reproductive organs has been proposed, but its use for this purpose is limited and it is not cost-effective. It should be used as an adjunct to clinical diagnosis, not as a primary diagnostic procedure.

Ultrasonography in the diagnosis of acute appendicitis

Ultrasonography with graded compression was performed in 525 patients with clinical signs of acute appendicitis. Of 207 patients with surgically proven appendicitis the inflamed appendix (diameter greater than or equal to 6 mm) had been visualized sonographically in 177 (86 per cent). The score for non-perforated appendicitis (91 per cent) was higher than for perforated appendicitis (55 per cent). Twenty-four patients in whom an inflamed appendix was seen on ultrasonography did not undergo surgery because of rapidly subsiding symptoms ('abortive appendicitis'). Four of these 24 developed recurrent appendicitis warranting surgery. Two underwent elective appendectomy and 18 have remained symptom-free. Of 155 patients with a subsequently confirmed alternative condition, ultrasonography made the correct diagnosis in 140: bacterial ileocaecitis (69), mesenteric lymphadenitis (eight), gynaecological conditions (34), urological conditions (eight), caecal diverticulitis (six), perforated peptic ulcer (six), Crohn's disease (two) and miscellaneous conditions (seven). Of 139 patients in whom no definite diagnosis was made ultrasonography showed no abnormalities in 138. In four patients a false positive sonographic diagnosis of appendicitis was made and in two patients with appendicitis an alternative condition was incorrectly diagnosed. During the last 3 years of the study the negative appendicectomy rate was 7 per cent and delay beyond 6 h after admission occurred in only 2 per cent of patients with surgically proven appendicitis. When used to complement the clinical diagnosis ultrasonography improves the diagnostic accuracy and patient management in those suspected of having acute appendicitis.

Clinical features of misdiagnosed appendicitis in children

STUDY OBJECTIVE

To compare clinical features of children with misdiagnosed appendicitis with those of children with appendicitis initially diagnosed correctly.

DESIGN

Retrospective review of hospital, emergency department, and clinic records.

SETTING

University medical center with annual ED census of 40,000 patients.

PARTICIPANTS

Children less than 13 years old admitted between May 1, 1979, and April 30, 1989, with a discharge diagnosis of appendicitis.

MEASUREMENTS

Records were reviewed for historical, physical examination, laboratory, and pathologic features for all patients on their initial presentation to a physician and on final presentation during which the correct diagnosis was made. Using chi 2 analysis and Student's test, clinical features of misdiagnosed patients and patients diagnosed correctly were compared.

RESULTS

One hundred eighty-one cases were identified with 50 initially misdiagnosed. On initial presentation, misdiagnosed patients were younger and more likely to have vomiting before pain onset, constipation, diarrhea, dysuria, and signs and symptoms of upper respiratory infections. Misdiagnosed cases were less likely to have right lower quadrant tenderness and documentation of bowel sounds, peritoneal signs, and rectal examinations. On final presentation, misdiagnosed patients were more likely to have pain duration of more than two days, temperature of more than 38.3 C, and to appear lethargic and irritable (P less than .05 for all measurements).

CONCLUSION

Clinical features of children with misdiagnosed appendicitis differ from those of children with appendicitis initially diagnosed correctly.

Ultrasonography in patients with suspected acute appendicitis: a prospective study

The diagnostic accuracy of high-resolution real-time ultrasonography was prospectively studied in 240 patients admitted to the hospital with suspected acute appendicitis. The criteria for ultrasound diagnosis of appendicitis included a sausage-shaped, aperistaltic, hypoechoic structure when imaged along its longitudinal axis, with a target-like appearance on transverse section. The ultrasonographic findings were correlated with surgical-pathological outcome in 82 cases with proven appendicitis, with laparotomy findings in another 21 patients and with clinical follow-up in the remainder. The overall sensitivity, specificity and accuracy of ultrasonography in the diagnosis of acute appendicitis were 78%, 92% and 87%, respectively. The positive predictive value was 84% and the negative predictive value was 88%. Ultrasonography may significantly improve the diagnostic accuracy in patients with suspected acute appendicitis and should be performed in all patients in whom the clinical diagnosis is equivocal. The ultrasonographic findings must be interpreted in light of the clinical findings.

Evaluation of women with possible appendicitis using technetium-99m leukocyte scan

The authors evaluated the use of technetium-99m albumin colloid white blood cell (TAC-WBC) scan in women with possible appendicitis. One hundred and nine women underwent 110 TAC-WBC scans. One woman had a second scan on a separate admission and was considered two individual patients in the analysis. Twenty-six women had appendicitis, 10 of whom had a perforated appendix at surgery. The TAC-WBC scan was indeterminate (abnormal but nondiagnostic for appendicitis) in 52 women (47%), nine of whom had appendicitis. Fifty-eight scans were read as positive or negative for appendiceal pathology. There were 16 true positives, 5 false positives, 36 true negatives, and 1 false negative. The predictive value of a positive scan was 76%, and the predictive value of a negative scan was 97%. The TAC-WBC scan was positive in 62% of patients with appendicitis and negative in 43% of the patients without appendicitis resulting in an overall accuracy of 47% in the 109 women. The main value of TAC-WBC scan in women with possible appendicitis is its high negative predictive value and the main problem with the TAC-WBC scan is its high indeterminate rate.

Use of the MANTRELS score in childhood appendicitis: a prospective study of 187 children with abdominal pain

We report an evaluation of the MANTRELS clinical score in predicting appendicitis in a prospectively studied pediatric population presenting with abdominal pain. One hundred eighty-nine independent episodes from 187 children 2 to 17 years old were studied. For the groups as a whole and for the individual groups less than 16 years old, the score failed to satisfactorily discriminate those with appendicitis from those without. Had the MANTRELS score been used to determine observation and laparotomy in our patients, 21 additional patients would have been unnecessarily hospitalized, and 16 would have been subjected to unnecessary laparotomies. One patient would have received appropriate intervention earlier. In the 40 children 16 and 17 years old, the MANTRELS score adequately distinguished the two groups. A seven-variable discriminant function, derived from stepwise discriminant analysis, performed slightly better but showed essentially the same findings as the MANTRELS score. We believe the MANTRELS score failed to predict appendicitis in younger children because it does not contain variables that allow for separation of appendicitis from the numerous other conditions mimicking it in the pediatric population. The clinician remains the best judge of the acute abdomen in the pediatric age group.

Ultrasonography in the management of possible appendicitis in childhood

One hundred thirty-four children referred to the pediatric surgical service with the diagnosis of possible acute appendicitis underwent abdominal ultrasonography within 24 hours of admission. A final diagnosis of appendicitis was made in 45, and of gynecological disease in 11 children. One child had pancreatitis, another jejunal perforation, and a third gross mesenteric lymphadenopathy. In 75 children the clinical picture completely resolved without a definitive diagnosis being made. Clinical diagnosis of gynecological disease showed two false-negatives, and three false-positives, whereas the ultrasonographic diagnosis was accurate in all patients. The sensitivity of the pediatric surgical diagnosis at the time of admission for acute appendicitis was 49% (23 false-negatives) and the specificity was 95% (three false-positives). Ultrasonographic diagnosis of appendicitis had a sensitivity of 89% (five false-negatives) and a specificity of 92% (five false-positives). There was a negative laparotomy rate of 0.7% (one patient) using both clinical evaluation and ultrasonography. These data suggest that abdominal ultrasonography in the child with possible appendicitis is an important diagnostic adjunct.

Acute and perforated appendicitis: current experience with ultrasound-aided diagnosis

The clinical value of high-resolution real-time sonography for the diagnosis of acute and complicated appendicitis was prospectively investigated in 857 patients admitted with suspected appendicitis. The ultrasound findings were correlated with history and physical examination on admission. Sonography was able to make the diagnosis of appendicitis with a sensitivity of 89.7%, a specificity of 98.2%, an overall accuracy of 96.3%, and a positive and negative predictive value of 93.6% and 97%, respectively. Routine use of ultrasound before making therapeutic decisions has reduced the rate of unnecessary laparotomies from 20.3% to 11.3%. In 48 (24.7%) of 194 patients with proven appendicitis, the disease had progressed to perforation at laparotomy. History and clinical findings on admission classified 30 (62.5%) of these patients as "highly suspect;" however, 9 (18.8%) were classified as "equivocal" and 9 (18.8%) as "very unlikely." Only half (48%) of the patients with appendiceal rupture had white blood cell counts higher than 13,000/mm3 or fever above 38 degrees C (50%). Sonography enabled the visualization of the inflamed appendix and/or appendicular abscess in 44 (91.7%) patients with perforation. In 47 of 48 patients with appendiceal rupture, the ultrasound-aided diagnosis was made on hospital admission. Thus, the incidence of complicated appendicitis (24.7%) in our study population must be attributed to disease progression before admission and preclinical diagnostic delay.