151
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Atema JJ, van Rossem CC, Leeuwenburgh MM, Stoker J, Boermeester MA. Scoring system to distinguish uncomplicated from complicated acute appendicitis. Br J Surg 2015; 102:979-90. [PMID: 25963411 DOI: 10.1002/bjs.9835] [Citation(s) in RCA: 117] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Revised: 02/04/2015] [Accepted: 03/24/2015] [Indexed: 12/11/2022]
Abstract
Abstract
Background
Non-operative management may be an alternative for uncomplicated appendicitis, but preoperative distinction between uncomplicated and complicated disease is challenging. This study aimed to develop a scoring system based on clinical and imaging features to distinguish uncomplicated from complicated appendicitis.
Methods
Patients with suspected acute appendicitis based on clinical evaluation and imaging were selected from two prospective multicentre diagnostic accuracy studies (OPTIMA and OPTIMAP). Features associated with complicated appendicitis were included in multivariable logistic regression analyses. Separate models were developed for CT and ultrasound imaging, internally validated and transformed into scoring systems.
Results
A total of 395 patients with suspected acute appendicitis based on clinical evaluation and imaging were identified, of whom 110 (27·8 per cent) had complicated appendicitis, 239 (60·5 per cent) had uncomplicated appendicitis and 46 (11·6 per cent) had an alternative disease. CT was positive for appendicitis in 284 patients, and ultrasound imaging in 312. Based on clinical and CT features, a model was created including age, body temperature, duration of symptoms, white blood cell count, C-reactive protein level, and presence of extraluminal free air, periappendiceal fluid and appendicolith. A scoring system was constructed, with a maximum possible score of 22 points. Of the 284 patients, 150 had a score of 6 points or less, of whom eight (5·3 per cent) had complicated appendicitis, giving a negative predictive value (NPV) of 94·7 per cent. The model based on ultrasound imaging included the same predictors except for extraluminal free air. The ultrasound score (maximum 19 points) was calculated for 312 patients; 105 had a score of 5 or less, of whom three (2·9 per cent) had complicated appendicitis, giving a NPV of 97·1 per cent.
Conclusion
With use of novel scoring systems combining clinical and imaging features, 95 per cent of the patients deemed to have uncomplicated appendicitis were correctly identified as such. The score can aid in selection for non-operative management in clinical trials.
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Affiliation(s)
- J J Atema
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - C C van Rossem
- Department of Surgery, Tergooi Hospital, Hilversum, The Netherlands
| | - M M Leeuwenburgh
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - J Stoker
- Department of Radiology, Academic Medical Centre, Amsterdam, The Netherlands
| | - M A Boermeester
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
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152
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Friedman A, Balfour S, Reinus W, Gaughan J. Emergency Department Extremity Radiographs in the Setting of Pain Without Trauma: Are They Worth the Pain? J Emerg Med 2015; 49:152-8. [PMID: 25913167 DOI: 10.1016/j.jemermed.2015.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Revised: 01/08/2015] [Accepted: 01/11/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Few data exist that correlate acute radiographic findings of extremity imaging with patients' complaints in the acute care setting. OBJECTIVE We hypothesize that plain radiographs performed for a complaint of pain in the absence of trauma or signs and symptoms of infection are of low yield. METHODS We retrospectively analyzed the imaging and charts of 1331 patients who presented to our emergency department (ED) and received extremity radiographs with complaints related to limb trauma, infection, and pain alone. Imaging and outcomes of cases interpreted as positive for acute pathology and those interpreted as indeterminate were analyzed using Fisher's exact tests to evaluate the value of extremity radiographs in the setting of isolated limb pain. RESULTS Of the patients analyzed, 935 presented with trauma, 234 presented with nontraumatic pain, and 161 presented with signs or symptoms of infection. The rate of definitively positive cases was 30.6% for trauma, 20.6% for infection, and 1.3% for pain. When indeterminate cases were included in the analysis, the rate of acutely positive cases rose to 33.4% for trauma, 28.0% for infection, and 3.0% for pain. Among the three definitively positive pain cases, all three were fractures, none of which resulted in emergent surgery or orthopedic consults. Among the four indeterminately positive pain cases, three proved to be false positives. CONCLUSIONS Our data suggest that ED imaging of patients presenting with nontraumatic pain is of extremely low yield, resulting in few acute positive findings that require immediate attention in the ED.
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Affiliation(s)
- Andrew Friedman
- Department of Radiology, Albert Einstein School of Medicine, Bronx, New York
| | - Stephen Balfour
- Department of Radiology, Temple University School of Medicine, Philadelphia, Pennsylvania
| | - William Reinus
- Department of Radiology, Temple University School of Medicine, Philadelphia, Pennsylvania
| | - John Gaughan
- Biostatistics Consulting Center, Temple University School of Medicine, Philadelphia, Pennsylvania
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153
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Atema JJ, Gans SL, Van Randen A, Laméris W, van Es HW, van Heesewijk JPM, van Ramshorst B, Bouma WH, Ten Hove W, van Keulen EM, Dijkgraaf MGW, Bossuyt PMM, Stoker J, Boermeester MA. Comparison of Imaging Strategies with Conditional versus Immediate Contrast-Enhanced Computed Tomography in Patients with Clinical Suspicion of Acute Appendicitis. Eur Radiol 2015; 25:2445-52. [PMID: 25903701 PMCID: PMC4495262 DOI: 10.1007/s00330-015-3648-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 12/12/2014] [Accepted: 01/30/2015] [Indexed: 02/07/2023]
Abstract
Objectives To compare the diagnostic accuracy of conditional computed tomography (CT), i.e. CT when initial ultrasound findings are negative or inconclusive, and immediate CT for patients with suspected appendicitis. Methods Data were collected within a prospective diagnostic accuracy study on imaging in adults with acute abdominal pain. All patients underwent ultrasound and CT, read by different observers who were blinded from the other modality. Only patients with clinical suspicion of appendicitis were included. An expert panel assigned a final diagnosis to each patient after 6 months of follow-up (clinical reference standard). Results A total of 422 patients were included with final diagnosis appendicitis in 251 (60 %). For 199 patients (47 %), ultrasound findings were inconclusive or negative. Conditional CT imaging correctly identified 241 of 251 (96 %) appendicitis cases (95 %CI, 92 % to 98 %), versus 238 (95 %) with immediate CT (95 %CI, 91 % to 97 %). The specificity of conditional CT imaging was lower: 77 % (95 %CI, 70 % to 83 %) versus 87 % for immediate CT (95 %CI, 81 % to 91 %). Conclusion A conditional CT strategy correctly identifies as many patients with appendicitis as an immediate CT strategy, and can halve the number of CTs needed. However, conditional CT imaging results in more false positives. Key Points • Conditional CT (CT after negative/inconclusive ultrasound findings) can be used for suspected appendicitis. • Half the number of CT examinations is needed with a conditional strategy. • Conditional CT correctly identifies as many patients with appendicitis as immediate CT. • Conditional imaging results in more false positive appendicitis cases.
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Affiliation(s)
- J J Atema
- Department of Surgery (G4-142), Academic Medical Centre, 1105 AZ, Amsterdam, Netherlands,
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154
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Ingeman ML, Ormstrup TE, Vedsted P. Direct-access to abdominal ultrasonic investigation from general practice—the role in earlier cancer diagnosis. Fam Pract 2015; 32:205-10. [PMID: 25715963 DOI: 10.1093/fampra/cmv004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Abdominal ultrasound (US) is a safe and low-cost diagnostic tool for various abdominal symptoms. Direct-access to US from general practice has been suggested as a feasible option to promote earlier cancer diagnosis because abdominal cancer often presents with non-specific and vague symptoms, and the exact location may be difficult to identify on the basis of symptoms alone. OBJECTIVE To describe patterns of use and cancer prevalence in referred patients when providing Danish GPs with direct-access to hospital-based US. METHODS In an observational study, GPs were given the opportunity to either refer patients directly to US or through a waiting-list at Vejle Regional Hospital in Denmark; 701 patients were included between 1 August 2009 and 31 January 2010. Data were retrieved from the local Radiology Information System, GP referrals and the Danish Cancer Registry. RESULTS GPs referred 60% of all patients to direct-access US. Cancer was diagnosed in 19 (2.7%) of the referred patients within 6 months after the US investigation. US gave rise to the suspicion of cancer in 11 of these patients (57.9%); 10 of these had been referred to direct-access US. At least one non-malignant diagnosis resulted from US in 59.5% of the cases, while 37.8% of the cases had no final diagnosis. CONCLUSION The findings in this study might indicate that GPs refer patients assessed to have a higher risk of cancer through direct-access US. The finding was statistically non-significant, and further research is required to confirm this result.
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Affiliation(s)
- Mads Lind Ingeman
- Research Unit for General Practice, Research Centre for Cancer Diagnosis in Primary Care (CaP) and Section of General Medical Practice, Department of Public Health, Aarhus University, Aarhus and
| | - Tina E Ormstrup
- Vejle Regional Hospital, Lillebaelt Hospital, Vejle, Region of Southern Denmark, Denmark
| | - Peter Vedsted
- Research Unit for General Practice, Research Centre for Cancer Diagnosis in Primary Care (CaP) and
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155
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Gans SL, Atema JJ, Stoker J, Toorenvliet BR, Laurell H, Boermeester MA. C-reactive protein and white blood cell count as triage test between urgent and nonurgent conditions in 2961 patients with acute abdominal pain. Medicine (Baltimore) 2015; 94:e569. [PMID: 25738473 PMCID: PMC4553955 DOI: 10.1097/md.0000000000000569] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The purpose of this article is to assess the diagnostic accuracy of C-reactive protein (CRP) and white blood cell (WBC) count to discriminate between urgent and nonurgent conditions in patients with acute abdominal pain at the emergency department, thereby guiding the selection of patients for immediate diagnostic imaging.Data from 3 large published prospective cohort studies of patients with acute abdominal pain were combined in an individual patient data meta-analysis. CRP levels and WBC counts were compared between patients with urgent and nonurgent final diagnoses. Parameters of diagnostic accuracy were calculated for clinically applicable cutoff values of CRP levels and WBC count, and for combinations.A total of 2961 patients were included of which 1352 patients (45.6%) had an urgent final diagnosis. The median WBC count and CRP levels were significantly higher in the urgent group than in the nonurgent group (12.8 ×10/L; interquartile range [IQR] 9.9-16) versus (9.3 ×10/L; IQR 7.2-12.1) and (46 mg/L; IQR 12-100 versus 10 mg/L; IQR 7-26) (P < 0.001).The highest positive predictive value (PPV) (85.5%) and lowest false positives (14.5%) were reached when cutoff values of CRP level >50 mg/L and WBC count >15 ×10/L were combined; however, 85.3% of urgent cases was missed.A high CRP level (>50 mg/L) combined with a high WBC count (>15 ×10/L) leads to the highest PPV. However, this applies only to a small subgroup of patients (8.7%). Overall, CRP levels and WBC count are insufficient markers to be used as a triage test in the selection for diagnostic imaging, even with a longer duration of complaints (>48 hours).
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Affiliation(s)
- Sarah L Gans
- From the Department of Surgery (SLG, JJA, MAB); Department of Radiology(JS), Academic Medical Centre, Amsterdam; Department of Surgery (BRT), Ikazia Hospital, Rotterdam, the Netherlands; and Department of Surgery (HL), Mora Hospital, Mora, Sweden
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156
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Gans SL, Pols MA, Stoker J, Boermeester MA. Guideline for the diagnostic pathway in patients with acute abdominal pain. Dig Surg 2015; 32:23-31. [PMID: 25659265 DOI: 10.1159/000371583] [Citation(s) in RCA: 110] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Accepted: 12/15/2014] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Diagnostic practice for acute abdominal pain at the Emergency Department varies widely and is mostly based on doctor's preferences. We aimed at developing an evidence-based guideline for the diagnostic pathway of patients with abdominal pain of non-traumatic origin. METHODS All available international literature on patients with acute abdominal pain was identified and graded according to their methodological quality by members of the multidisciplinary steering group. A guideline was synthetized, providing evidence-based recommendations together with considerations based on expertise of group members, patient preferences, costs, availability of facilities, and organizational aspects. DEFINITION Uniform terminology is needed in patients with acute abdominal pain to avoid difficulty in interpretation and ease comparison of findings between studies. We propose the use of the following definition for acute abdominal pain: pain of nontraumatic origin with a maximum duration of 5 days. Clinical diagnosis: Clinical evaluation is advised to differentiate between urgent and nonurgent causes. The diagnostic accuracy of clinical assessment is insufficient to identify the correct diagnosis but can discriminate between urgent and nonurgent causes. Patients suspected of nonurgent diagnoses can safely be reevaluated the next day. Based on current literature, no conclusions can be drawn on the differences in accuracy between residents and specialists. No conclusions can be drawn on the influence of a gynecological consultation. In patients suspected of an urgent condition, additional imaging is justified. CRP and WBC count alone are insufficient to discriminate urgent from nonurgent diagnoses. Diagnostic imaging: There is no place for conventional radiography in the work-up of patients with acute abdominal pain due to the lack of added value on top of clinical assessment. Computed tomography leads to the highest sensitivity and specificity in patients with acute abdominal pain. Positive predictive value of ultrasound is comparable with CT and therefore preferred as the first imaging modality due to the downsides of computed tomography; negative or inconclusive ultrasound is followed by CT. Based on current literature, no conclusions can be drawn on the added value of a diagnostic laparoscopy in the work-up of patients with acute abdominal pain. Antibiotic treatment should be started within the first hour after recognition of sepsis. Administration of opioids (analgesics) decreases the intensity of the pain and does not affect the accuracy of physical examination.
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Affiliation(s)
- Sarah L Gans
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
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157
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Bugiantella W, Rondelli F, Longaroni M, Mariani E, Sanguinetti A, Avenia N. Left colon acute diverticulitis: an update on diagnosis, treatment and prevention. Int J Surg 2014; 13:157-164. [PMID: 25497007 DOI: 10.1016/j.ijsu.2014.12.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Revised: 11/19/2014] [Accepted: 12/03/2014] [Indexed: 02/06/2023]
Abstract
Diverticulosis of the colon is a common disease with an increasing incidence in Western Countries. It represents a significant burden for National Health Systems in terms of costs. Most people with diverticulosis remain asymptomatic, about one quarter of them will develop an episode of symptomatic diverticular disease and up to 5% an episode of acute diverticulitis (AD). AD shows an increasing prevalence. Recently, progresses have been reached about the etiology, pathogenesis, natural course of diverticular disease and its complications; improvements about the diagnosis and treatment of AD have been achieved. However, the treatment options are not well defined because of a lack of solid evidence: there are few systematic reviews and well conducted trials to guide decision-making in the treatment of AD and in the prevention of its recurrences. This review describes the recent evidence about diagnosis, treatment and prevention of AD.
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Affiliation(s)
- Walter Bugiantella
- General Surgery, "San Giovanni Battista" Hospital, AUSL Umbria 2, Via M. Arcamone, 06034, Foligno, Perugia, Italy; University of Perugia, PhD School in Biotechnologies, Italy.
| | - Fabio Rondelli
- General Surgery, "San Giovanni Battista" Hospital, AUSL Umbria 2, Via M. Arcamone, 06034, Foligno, Perugia, Italy; University of Perugia, Department of Surgical and Biomedical Sciences, Via G. Dottori, 06100 Perugia, Italy.
| | - Maurizio Longaroni
- General Surgery, "San Giovanni Battista" Hospital, AUSL Umbria 2, Via M. Arcamone, 06034, Foligno, Perugia, Italy.
| | - Enrico Mariani
- General Surgery, "San Giovanni Battista" Hospital, AUSL Umbria 2, Via M. Arcamone, 06034, Foligno, Perugia, Italy.
| | - Alessandro Sanguinetti
- General and Specialized Surgery, "Santa Maria" Hospital, Via T. Di Joannuccio, 05100 Terni, Italy.
| | - Nicola Avenia
- General and Specialized Surgery, "Santa Maria" Hospital, Via T. Di Joannuccio, 05100 Terni, Italy.
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158
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Murata A, Okamoto K, Mayumi T, Maramatsu K, Matsuda S. Age-related differences in outcomes and etiologies of acute abdominal pain based on a national administrative database. TOHOKU J EXP MED 2014; 233:9-15. [PMID: 24739505 DOI: 10.1620/tjem.233.9] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Acute abdominal pain is one of the most frequent causes of admission to emergency departments. However, there is a shortage of detail information showing the difference of outcomes or etiology of acute abdominal pain according to age. We therefore conducted an epidemiological analysis to reveal the difference between age on outcomes and etiology of acute abdominal pain using an administrative database associated with the Diagnosis Procedure Combination (DPC) system. We obtained discharge data relating to 12,209 patients with acute abdominal pain from 931 DPC participation hospitals between 2009 and 2011 in Japan. We compared length of hospital stay (LOS), in-hospital mortality, and etiology of acute abdominal pain between age categories. Patients were divided into five age groups as follows: < 20 (n = 1,106), 20-39 (n = 3,353), 40-59 (n = 2,925), 60-79 (n = 3,144), and ≥ 80 years (n = 1,681). Longer LOS and higher in-hospital mortality were observed in patients aged ≥ 80 years (p < 0.001). Regarding etiologies of acute abdominal pain, intestinal infection or acute appendicitis were more frequent in patients aged < 20 or 20-39 years, while ileus or cholelithiasis were more frequent in patients aged 60-79 or ≥ 80 years in both male and female patients (p < 0.001). This study demonstrated the significant differences between age with regard to the patient outcomes and etiology of acute abdominal pain. The current findings highlight the importance of improving the quality of medical care for patients with acute abdominal pain.
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Affiliation(s)
- Atsuhiko Murata
- Department of Preventive Medicine and Community Health, School of Medicine, University of Occupational and Environmental Health
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159
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Pate A, Baltazar G, Chasin C, Chendrasekhar A. Have Plain Abdominal Radiographs Outlived Their Usefulness? Am Surg 2014. [DOI: 10.1177/000313481408001111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Amy Pate
- Wyckoff Heights Medical Center Brooklyn, New York
| | | | - Cara Chasin
- Wyckoff Heights Medical Center Brooklyn, New York
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160
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Cuomo R, Barbara G, Pace F, Annese V, Bassotti G, Binda GA, Casetti T, Colecchia A, Festi D, Fiocca R, Laghi A, Maconi G, Nascimbeni R, Scarpignato C, Villanacci V, Annibale B. Italian consensus conference for colonic diverticulosis and diverticular disease. United European Gastroenterol J 2014; 2:413-42. [PMID: 25360320 PMCID: PMC4212498 DOI: 10.1177/2050640614547068] [Citation(s) in RCA: 93] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Accepted: 07/18/2014] [Indexed: 02/05/2023] Open
Abstract
The statements produced by the Consensus Conference on Diverticular Disease promoted by GRIMAD (Gruppo Italiano Malattia Diverticolare, Italian Group on Diverticular Diseases) are reported. Topics such as epidemiology, risk factors, diagnosis, medical and surgical treatment of diverticular disease (DD) in patients with uncomplicated and complicated DD were reviewed by a scientific board of experts who proposed 55 statements graded according to level of evidence and strength of recommendation, and approved by an independent jury. Each topic was explored focusing on the more relevant clinical questions. Comparison and discussion of expert opinions, pertinent statements and replies to specific questions, were presented and approved based on a systematic literature search of the available evidence. Comments were added explaining the basis for grading the evidence, particularly for controversial areas.
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Affiliation(s)
- Rosario Cuomo
- Department of Clinical Medicine and Surgery, Federico II University, Napoli, Italy
- Rosario Cuomo, Department of Clinical Medicine and Surgery, Federico II University Hospital School of Medicine via S. Pansini 5, 80131 Napoli, Italy.
| | - Giovanni Barbara
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Fabio Pace
- Department of Biochemical and Clinical Sciences, University of Milan, Milan, Italy
| | - Vito Annese
- Department of Gastroenterology, AOU Careggi, Florence, Italy
| | - Gabrio Bassotti
- Gastroenterology and Hepatology Section, University of Perugia School of Medicine, Perugia, Italy
| | | | | | - Antonio Colecchia
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Davide Festi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Roberto Fiocca
- Pathology Unit, IRCCS San Martino-IST University Hospital, Genoa, Italy
| | - Andrea Laghi
- Department of Radiological Sciences, Oncology and Pathology, La ‘Sapienza' University, Rome, Italy
| | - Giovanni Maconi
- Gastroenterology Unit, L. Sacco University Hospital, Milan, Italy
| | - Riccardo Nascimbeni
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Carmelo Scarpignato
- Clinical Pharmacology & Digestive Pathophysiology Unit, University of Parma, Parma, Italy
| | | | - Bruno Annibale
- Medical-Surgical and Translational Medicine Department, La Sapienza University, Rome, Italy
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161
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Andeweg CS, Wegdam JA, Groenewoud J, van der Wilt GJ, van Goor H, Bleichrodt RP. Toward an evidence-based step-up approach in diagnosing diverticulitis. Scand J Gastroenterol 2014; 49:775-84. [PMID: 24874087 DOI: 10.3109/00365521.2014.908475] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The lack of pathognomonic findings and the chance of complicated disease have resulted in the widespread use of additional imaging to diagnose acute colonic diverticulitis (ACD). The added value of additional imaging in the diagnostic workup of patients suspected of ACD is not well defined. AIMS The aim of this study was to systematically review the literature of the accuracy of the clinical evaluation and diagnostic modalities for patients with suspected ACD, to come to an evidence-based approach to diagnose ACD. METHODS A systematic review and meta-analysis of studies that reported diagnostic accuracy of the clinical diagnosis and diagnostic modalities in patients with suspected diverticulitis were performed. Study quality was assessed with the STARD checklist. True-positive, true-negative, false-positive, and false-negative findings were extracted and pooled estimates of sensitivity and specificity per diagnostic test were calculated, if applicable. RESULTS The overall quality of the studies reporting the diagnostic accuracy of the clinical diagnosis, contrast enema and magnetic resonance imaging (MRI) were moderate to poor and not suitable for meta-analysis. Sensitivity of the clinical diagnosis varied between 64% and 68%. Ultrasound (US) and computed tomography (CT) studies were eligible for meta-analysis. Summary sensitivity estimates for US were 90% (95% CI: 76-98%) versus 95% (95% CI: 91-97%) for CT (p = 0.86). Summary specificity estimates for US were 90% (95% CI: 86-94%) versus 96% (95% CI: 90-100%) for CT (p = 0.04). Sensitivity for MRI was 98% and specificity varied between 70% and 78%. Sensitivity of contrast enema studies varied between 80% and 83%. CONCLUSION In two-thirds of the patients, the diagnosis of ACD can be made based on clinical evaluation alone. In one-third of the patients, additional imaging is a necessity to establish the diagnosis. US and CT are comparable in diagnosing diverticulitis and superior to other modalities. CT has the advantage of higher specificity and the ability to identify alternative diagnoses. The role of MRI is not yet clear in diagnosing ACD. Contrast enema is considered an obsolete imaging technique to diagnose ACD based on lower sensitivity and specificity than US and CT. A step-up approach with CT performed after an inconclusive or negative US, seems a logical and safe approach for patients suspected of ACD.
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Affiliation(s)
- Caroline S Andeweg
- Department of Surgery, Radboud University Nijmegen Medical Centre , Nijmegen , The Netherlands
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162
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Plain abdominal radiography in acute abdominal pain—is it really necessary? Emerg Radiol 2014; 21:597-603. [DOI: 10.1007/s10140-014-1244-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Accepted: 05/26/2014] [Indexed: 10/25/2022]
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163
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Steward MJ, Taylor SA, Halligan S. Abdominal computed tomography, colonography and radiation exposure: what the surgeon needs to know. Colorectal Dis 2014; 16:347-52. [PMID: 24119259 DOI: 10.1111/codi.12451] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Accepted: 08/14/2013] [Indexed: 02/08/2023]
Abstract
AIM Abdominal computed tomography (CT) improves the accuracy of clinical diagnosis and facilitates patient management. Radiation exposure must be considered by requesting clinicians and is especially relevant owing to the increasing use of CT colonography for diagnosis and screening of colorectal disorders. This review describes the radiation dose of abdominopelvic CT and colonography and attempts to quantify the risk for the clinician. METHOD Articles were searched in the PubMed and Medline databases using combinations of the MeSH terms 'radiation', 'abdominal computed tomography' and 'colonography'. Electronic English language abstracts were read by two reviewers and the full article was retrieved if relevant to the review. RESULTS Abdominopelvic CT and CT colonography convey significant radiation dose to the patient but also have considerable diagnostic potential. In the right clinical context, the radiation risk should not be overestimated. Techniques to reduce the dose should be used. Repeated imaging in certain patients is a concern and should be monitored. CONCLUSION Radiation risk can be quantified and presented simply in a manner that both patients and doctors can comprehend and evaluate. This approach will diminish misconceptions and allow a rational choice of diagnostic test.
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Affiliation(s)
- M J Steward
- Department of Radiology, Whittington Hospital, London, UK
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164
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Leeuwenburgh MMN, Stockmann HBAC, Bouma WH, Houdijk APJ, Verhagen MF, Vrouenraets B, Cobben LPJ, Bossuyt PMM, Stoker J, Boermeester MA. A simple clinical decision rule to rule out appendicitis in patients with nondiagnostic ultrasound results. Acad Emerg Med 2014; 21:488-96. [PMID: 24842498 DOI: 10.1111/acem.12374] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2013] [Revised: 12/19/2013] [Accepted: 12/20/2013] [Indexed: 01/14/2023]
Abstract
OBJECTIVES The objective was to identify a set of clinical features that can rule out appendicitis in patients with suspected acute appendicitis and nondiagnostic ultrasound (US) results, allowing safe discharge and next-day reevaluation without initial computed tomography (CT) or magnetic resonance imaging (MRI). METHODS Data on clinical and US evaluation, including a number of prespecified variables potentially associated with acute appendicitis, were prospectively collected in two diagnostic accuracy studies of imaging. These studies included patients with suspected appendicitis seen in the emergency department (ED). For development and validation of the clinical decision rule (CDR), only patients with inconclusive or negative US results were included. There were 199 (of 422) patients in the development cohorts and 120 (of 211) patients in the validation cohort. Logistic regression analysis was used for data from patients with inconclusive or negative US results, and profiles were created of all possible combinations of predictors retained in the multivariable model. A final diagnosis was assigned by an expert panel based on perioperative data, histopathology, and clinical follow-up of at least 3 months. RESULTS The CDR selected patients after negative or inconclusive US for discharge and next-day reevaluation without initial CT or MRI if fewer than two of the following predictors were present: male sex, migration of pain to the right lower quadrant, vomiting, and white blood cell (WBC) count higher than 12.0 × 10(9) /L. Applying the CDR in the development set selected 126 of 199 (63%) patients with negative or inconclusive US results for discharge without further imaging. This rule reduced the probability of appendicitis from 26% (51 of 199) in the total group of patients with negative or inconclusive US results to 12% (15 of 126) in the group that would be discharged based on the rule (p = 0.001). In the validation set (n = 120), the decision rule selected 72 (60%) patients for discharge and next-day reevaluation and reduced the probability of appendicitis from 20% (24 of 120) in the total group to 6% (4 of 72) in the patients selected on the rule (p = 0.001). The negative predictive value of the decision rule in the validation set was 94% (95% confidence interval [CI] = 87% to 98%). In comparison, the negative predictive value of CT in the same group was 99% (95% CI = 93% to 100%, p = 0.14), and that of MRI was 99% (95% CI = 94% to 100%, p = 0.12). Alternative decision rules based on combinations of the present decision rule with C-reactive protein (CRP) results did not improve selection. CONCLUSIONS This newly developed CDR significantly reduces the probability of appendicitis in a large subgroup of patients with negative or inconclusive US results. These patients can be safely discharged for outpatient reevaluation without further initial imaging if proper follow-up is available. This could assist in lowering the number of ED imaging investigations in patients with suspected appendicitis.
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Affiliation(s)
- Marjolein M. N. Leeuwenburgh
- The Department of Radiology; Academic Medical Center; University of Amsterdam; Amsterdam
- The Department of Surgery; Academic Medical Center; University of Amsterdam; Amsterdam
| | | | - Wim H. Bouma
- The Department of Surgery; Gelre Hospitals; Apeldoorn
| | | | | | - Bart Vrouenraets
- The Department of Surgery; Sint Lucas Andreas Hospital; Amsterdam
| | - Lodewijk P. J. Cobben
- The Department of Radiology; Haaglanden Medical Center; Leidschendam the Netherlands
| | - Patrick M. M. Bossuyt
- The Department of Clinical Epidemiology; Academic Medical Center; University of Amsterdam; Amsterdam
| | - Jaap Stoker
- The Department of Radiology; Academic Medical Center; University of Amsterdam; Amsterdam
| | - Marja A. Boermeester
- The Department of Surgery; Academic Medical Center; University of Amsterdam; Amsterdam
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Kiewiet JJS, Andeweg CS, Laurell H, Daniels L, Laméris W, Reitsma JB, Hendriks JCM, Bleichrodt RP, van Goor H, Boermeester MA. External validation of two tools for the clinical diagnosis of acute diverticulitis without imaging. Dig Liver Dis 2014; 46:119-24. [PMID: 24252579 DOI: 10.1016/j.dld.2013.09.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2013] [Revised: 08/13/2013] [Accepted: 09/17/2013] [Indexed: 12/11/2022]
Abstract
AIM External validation and comparison of the diagnostic accuracy of two predictive tools, the emergency department triad and the clinical scoring tool in diagnosing acute diverticulitis. METHODS Two derivation datasets were used crosswise for external validation. In addition, both tools were validated in a third independent cohort. Predictive values were reassessed and the Area Under the Curve expressed discriminatory capacity. Performance was compared by calculating positive predictive values of the emergency department triad in the validation cohorts and with a cut-off analysis for the clinical scoring tool at a positive predictive value of 90%. RESULTS Predictive value of the emergency department triad was comparable to the clinical scoring tool. The positive predictive value of the emergency department triad (97%) decreased in the clinical scoring tool cohort (81%) and was excellent in the independent cohort (100%), identifying 24%, 20% and 14% of the patients. A smaller proportion of patients with diverticulitis could be identified with the clinical scoring tool (6%, 19% and 9%). CONCLUSION The emergency department triad as well as the clinical scoring tool have significant predictive value in external cohorts of patients suspected of diverticulitis. These tools can be used to select patients in whom additional imaging to diagnose acute diverticulitis may be omitted.
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Affiliation(s)
- Jordy J S Kiewiet
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands.
| | - Caroline S Andeweg
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | | | - Lidewine Daniels
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - Wytze Laméris
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - Johannes B Reitsma
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Centre, Amsterdam, The Netherlands
| | - Jan C M Hendriks
- Department of Epidemiology, Biostatistics and HTA, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Robert P Bleichrodt
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Harry van Goor
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
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Journal club: Acute abdominal pain in elderly patients: effect of radiologist awareness of clinicobiologic information on CT accuracy. AJR Am J Roentgenol 2014; 201:1171-8; quiz 1179. [PMID: 24261352 DOI: 10.2214/ajr.12.10287] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVE The purpose of this study was to assess whether the availability of clinicobiologic findings would affect the diagnostic performance of CT of elderly emergency department patients with nontraumatic acute abdominal pain. MATERIALS AND METHODS The cases of 333 consecutively registered patients 75 years old or older presenting to the emergency department with acute abdominal pain and who underwent CT were retrospectively reviewed by two radiologists blinded or not to the patient's clinicobiologic results. Diagnostic accuracy was calculated according to the level of correctly classified cases in both the entire cohort and a surgical subgroup and was compared between readings performed with and without knowledge of the clinicobiologic findings. Agreement between each reading and the reference diagnosis and interobserver agreement were assessed with kappa statistics. RESULTS In both the entire cohort (87.4% vs 85.3%, p = 0.07) and the surgical group (94% vs 91%, p = 0.15), there was no significant difference in CT accuracy between diagnoses made when the radiologist was aware and those made when the radiologist was not aware of the clinicobiologic findings. Agreement between the CT diagnosis and the final diagnosis was excellent whether or not the radiologist was aware of the clinicobiologic findings. CONCLUSION In the care of elderly patients, CT is accurate for diagnosing the cause of acute abdominal pain, particularly when it is of surgical origin, regardless of the availability of clinical and biologic findings. Thus CT interpretation should not be delayed until complete clinicobiologic data are available, and the images should be quickly transmitted to the emergency physician so that appropriate therapy can be begun.
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Leeuwenburgh MM, Wiarda BM, Jensch S, van Es HW, Stockmann HB, Gratama JWC, Cobben LP, Bossuyt PM, Boermeester MA, Stoker J. Accuracy and interobserver agreement between MR-non-expert radiologists and MR-experts in reading MRI for suspected appendicitis. Eur J Radiol 2014; 83:103-10. [DOI: 10.1016/j.ejrad.2013.09.022] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Revised: 08/20/2013] [Accepted: 09/23/2013] [Indexed: 12/01/2022]
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Leeuwenburgh MMN, Wiezer MJ, Wiarda BM, Bouma WH, Phoa SSKS, Stockmann HBAC, Jensch S, Bossuyt PMM, Boermeester MA, Stoker J. Accuracy of MRI compared with ultrasound imaging and selective use of CT to discriminate simple from perforated appendicitis. Br J Surg 2013; 101:e147-55. [PMID: 24272981 DOI: 10.1002/bjs.9350] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2013] [Indexed: 01/05/2023]
Abstract
BACKGROUND Discrimination between simple and perforated appendicitis in patients with suspected appendicitis may help to determine the therapy, timing of surgery and risk of complications. The aim of this study was to estimate the accuracy of magnetic resonance imaging (MRI) in distinguishing between simple and perforated appendicitis, and to compare MRI against ultrasound imaging with selected additional (conditional) use of computed tomography (CT). METHODS Patients with clinically suspected appendicitis were identified prospectively at the emergency department of six hospitals. Consenting patients underwent MRI, but were managed based on findings at ultrasonography and conditional CT. Radiologists who evaluated the MRI were blinded to the results of ultrasound imaging and CT. The presence of perforated appendicitis was recorded after each evaluation. The final diagnosis was assigned by an expert panel based on perioperative data, histopathology and clinical follow-up after 3 months. RESULTS MRI was performed in 223 of 230 included patients. Acute appendicitis was the final diagnosis in 118 of 230 patients, of whom 87 had simple and 31 perforated appendicitis. MRI correctly identified 17 of 30 patients with perforated appendicitis (sensitivity 57 (95 per cent confidence interval 39 to 73) per cent), whereas ultrasound imaging with conditional CT identified 15 of 31 (sensitivity 48 (32 to 65) per cent) (P = 0.517). All missed diagnoses of perforated appendicitis were identified as simple acute appendicitis with both imaging protocols. None of the MRI features for perforated appendicitis had a positive predictive value higher than 53 per cent. CONCLUSION MRI is comparable to ultrasonography with conditional use of CT in identifying perforated appendicitis. However, both strategies incorrectly classify up to half of all patients with perforated appendicitis as having simple appendicitis. Triage of appendicitis based on imaging for conservative treatment is inaccurate and may be considered unsafe for decision-making. Presented to a scientific meeting of the Association of Surgeons of the Netherlands, Veldhoven, The Netherlands, May 2012; published in abstract form as Br J Surg 2012; 99(Suppl 7): S6.
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Affiliation(s)
- M M N Leeuwenburgh
- Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands; Department of Radiology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
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Oudheusden TRV, Aerts BAC, Hingh IHJTD, Luyer MDP. Challenges in diagnosing adhesive small bowel obstruction. World J Gastroenterol 2013; 19:7489-7493. [PMID: 24616565 PMCID: PMC3837247 DOI: 10.3748/wjg.v19.i43.7489] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Revised: 09/11/2013] [Accepted: 09/17/2013] [Indexed: 02/06/2023] Open
Abstract
Adhesive small bowel obstruction (ASBO) is the most frequently encountered surgical disorder of the small intestine. Up to 80% of ASBO cases resolve spontaneously and do not require invasive treatment. It is important to identify such patients that will benefit from conservative treatment in order to prevent unnecessarily exposing them to the risks associated with surgical intervention, such as morbidity and further adhesion formation. For the remaining ASBO patients, timely surgical intervention is necessary to prevent small bowel strangulation, which may cause intestinal ischemia and bowel necrosis. While early identification of these patients is key to decreasing ASBO-related morbidity and mortality, the non-specific signs and laboratory findings upon clinic presentation limit timely diagnosis and implementation of appropriate clinical management. Combining the clinical presentation findings with those from other diagnostic imaging modalities, such as abdominal X-ray, computed tomography-scan and water-soluble contrast studies, will improve diagnosis of ASBO and help clinicians to better evaluate the potential of conservative management as a safe strategy for a particular patient. Nonetheless, patients who present with moderate findings by all these approaches continue to represent a challenge. A new diagnostic strategy is urgently needed to further improve our ability to identify early signs of strangulated bowel, and this diagnostic modality should be able to indicate when surgical management is required. A number of potential serum markers have been proposed for this purpose, including intestinal fatty acid binding protein and α-glutathione S transferase. On-going research is attempting to clearly define their diagnostic utility and to optimize their potential role in determining which patients should be managed surgically.
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170
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Andeweg CS, Mulder IM, Felt-Bersma RJF, Verbon A, van der Wilt GJ, van Goor H, Lange JF, Stoker J, Boermeester MA, Bleichrodt RP. Guidelines of diagnostics and treatment of acute left-sided colonic diverticulitis. Dig Surg 2013; 30:278-92. [PMID: 23969324 DOI: 10.1159/000354035] [Citation(s) in RCA: 125] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Accepted: 06/25/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND The incidence of acute left-sided colonic diverticulitis (ACD) is increasing in the Western world. To improve the quality of patient care, a guideline for diagnosis and treatment of diverticulitis is needed. METHODS A multidisciplinary working group, representing experts of relevant specialties, was involved in the guideline development. A systematic literature search was conducted to collect scientific evidence on epidemiology, classification, diagnostics and treatment of diverticulitis. Literature was assessed using the classification system according to an evidence-based guideline development method, and levels of evidence of the conclusions were assigned to each topic. Final recommendations were given, taking into account the level of evidence of the conclusions and other relevant considerations such as patient preferences, costs and availability of facilities. RESULTS The natural history of diverticulitis is usually mild and treatment is mostly conservative. Although younger patients have a higher risk of recurrent disease, a higher risk of complications compared to older patients was not found. In general, the clinical diagnosis of ACD is not accurate enough and therefore imaging is indicated. The triad of pain in the lower left abdomen on physical examination, the absence of vomiting and a C-reactive protein >50 mg/l has a high predictive value to diagnose ACD. If this triad is present and there are no signs of complicated disease, patients may be withheld from further imaging. If imaging is indicated, conditional computed tomography, only after a negative or inconclusive ultrasound, gives the best results. There is no indication for routine endoscopic examination after an episode of diverticulitis. There is no evidence for the routine administration of antibiotics in patients with clinically mild uncomplicated diverticulitis. Treatment of pericolic or pelvic abscesses can initially be treated with antibiotic therapy or combined with percutaneous drainage. If this treatment fails, surgical drainage is required. Patients with a perforated ACD resulting in peritonitis should undergo an emergency operation. There is an ongoing debate about the optimal surgical strategy. CONCLUSION Scientific evidence is scarce for some aspects of ACD treatment (e.g. natural history of ACD, ACD in special patient groups, prevention of ACD, treatment of uncomplicated ACD and medical treatment of recurrent ACD), leading to treatment being guided by the surgeon's personal preference. Other aspects of the management of patients with ACD have been more thoroughly researched (e.g. imaging techniques, treatment of complicated ACD and elective surgery of ACD). This guideline of the diagnostics and treatment of ACD can be used as a reference for clinicians who treat patients with ACD.
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Panes J, Bouhnik Y, Reinisch W, Stoker J, Taylor SA, Baumgart DC, Danese S, Halligan S, Marincek B, Matos C, Peyrin-Biroulet L, Rimola J, Rogler G, van Assche G, Ardizzone S, Ba-Ssalamah A, Bali MA, Bellini D, Biancone L, Castiglione F, Ehehalt R, Grassi R, Kucharzik T, Maccioni F, Maconi G, Magro F, Martín-Comín J, Morana G, Pendsé D, Sebastian S, Signore A, Tolan D, Tielbeek JA, Weishaupt D, Wiarda B, Laghi A. Imaging techniques for assessment of inflammatory bowel disease: joint ECCO and ESGAR evidence-based consensus guidelines. J Crohns Colitis 2013; 7:556-85. [PMID: 23583097 DOI: 10.1016/j.crohns.2013.02.020] [Citation(s) in RCA: 441] [Impact Index Per Article: 40.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Accepted: 02/20/2013] [Indexed: 12/12/2022]
Abstract
The management of patients with IBD requires evaluation with objective tools, both at the time of diagnosis and throughout the course of the disease, to determine the location, extension, activity and severity of inflammatory lesions, as well as, the potential existence of complications. Whereas endoscopy is a well-established and uniformly performed diagnostic examination, the implementation of radiologic techniques for assessment of IBD is still heterogeneous; variations in technical aspects and the degrees of experience and preferences exist across countries in Europe. ECCO and ESGAR scientific societies jointly elaborated a consensus to establish standards for imaging in IBD using magnetic resonance imaging, computed tomography, ultrasonography, and including also other radiologic procedures such as conventional radiology or nuclear medicine examinations for different clinical situations that include general principles, upper GI tract, colon and rectum, perineum, liver and biliary tract, emergency situation, and the postoperative setting. The statements and general recommendations of this consensus are based on the highest level of evidence available, but significant gaps remain in certain areas such as the comparison of diagnostic accuracy between different techniques, the value for therapeutic monitoring, and the prognostic implications of particular findings.
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Affiliation(s)
- J Panes
- Gastroenterology Department, Hospital Clinic Barcelona, CIBERehd, IDIBAPS, Barcelona, Spain.
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Schellekens DHSM, Hulsewé KWE, van Acker BAC, van Bijnen AA, de Jaegere TMH, Sastrowijoto SH, Buurman WA, Derikx JPM. Evaluation of the diagnostic accuracy of plasma markers for early diagnosis in patients suspected for acute appendicitis. Acad Emerg Med 2013; 20:703-10. [PMID: 23859584 DOI: 10.1111/acem.12160] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Revised: 02/13/2013] [Accepted: 02/21/2013] [Indexed: 12/29/2022]
Abstract
OBJECTIVES The main objective of this study was to evaluate the diagnostic accuracy of two novel biomarkers, calprotectin (CP) and serum amyloid A (SAA), along with the more traditional inflammatory markers C-reactive protein (CRP) and white blood cell count (WBC), in patients suspected of having acute appendicitis (AA). The secondary objective was to compare diagnostic accuracy of these biomarkers with a clinical scoring system and radiologic imaging. METHODS A total of 233 patients with suspected AA, presenting to the emergency department (ED) between January 2010 and September 2010, and 52 healthy individuals serving as controls, were included in the study. Blood was drawn and CP and SAA-1 concentrations were measured using enzyme-linked immunosorbent assay (ELISA). CRP and WBC concentrations were routinely measured and retrospectively abstracted from the electronic health record, together with physical examination findings and radiologic reports. The Alvarado score was calculated as a clinical scoring system for AA. Final diagnosis of AA was based on histopathologic examination. The Mann-Whitney U-test was used for between-group comparisons. Receiver operating characteristic (ROC) curves were used to measure the diagnostic accuracy for the tests and to determine the best cutoff points. RESULTS Seventy-seven of 233 patients (33%) had proven AA. Median plasma levels for CP and SAA-1 were significantly higher in patients with AA than in those with another final diagnosis (CP, 320.9 ng/mL vs. 212.9 ng/mL; SAA-1, 30 mg/mL vs. 0.6 mg/mL; p < 0.001). CRP and WBC were significantly higher in patients with AA as well. The Alvarado score was helpful at the extremes (<3 or >7). Ultrasound (US) had a sensitivity of 84% and a specificity of 94%. Computed tomography (CT) had a sensitivity of 100% and a specificity of 91%. The area under the ROC (95% confidence interval [CI]) was 0.67 (95% CI = 0.60 to 0.74) for CP, 0.76 (95% CI = 0.70 to 0.82) for SAA, 0.71 (95% CI = 0.64 to 0.78) for CRP, and 0.79 (95% CI = 0.73 to 0.85) for WBC. No cutoff points had high enough sensitivity and specificity to accurately diagnose AA. However, a high sensitivity of 97% was shown at 7.5 × 10(9) /L for WBC and 0.375 mg/mL for SAA. CONCLUSIONS CP, SAA-1, CRP, and WBC were significantly elevated in patients with AA. None had cutoff points that could accurately discriminate between AA and other pathology in patients with suspected AA. A WBC < 7.5 × 10(9) /L, with a low level of clinical suspicion for AA, can identify a subgroup of patients who may be sent home without further evaluation, but who should have available next-day follow-up.
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Affiliation(s)
| | | | | | - Annemarie A. van Bijnen
- Department of Surgery; Maastricht University Medical Center and Nutrition and Toxicology Research Institute Maastricht; Maastricht; the Netherlands
| | | | | | - Wim A. Buurman
- Department of Surgery; Maastricht University Medical Center and Nutrition and Toxicology Research Institute Maastricht; Maastricht; the Netherlands
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Asch E, Shah S, Kang T, Levine D. Use of pelvic computed tomography and sonography in women of reproductive age in the emergency department. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2013; 32:1181-1187. [PMID: 23804340 DOI: 10.7863/ultra.32.7.1181] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
OBJECTIVES The purpose of this study was to review use of pelvic computed tomography (CT) and sonography in the emergency department for women of reproductive age and to identify cases in which sonography might have been adequate. METHODS Computed tomographic and sonographic examinations of the pelvis performed on women up to 55 years of age in our emergency department during a 6-month period were reviewed. Repeated CT and CT with indications for which sonography would not be the first-line imaging modality (eg, diverticulitis and trauma) were excluded. For the sonographic-only assessment, repeated sonography and sonography with indications for which CT would not be the first-line imaging modality (eg, vaginal bleeding) were excluded. Patient referral indications, imaging diagnoses, and discharge diagnoses were compared for the groups with CT only, CT first, sonography first, and sonography only. RESULTS Of 509 women who underwent CT, 407 (80%) underwent CT only; 54 (11%) underwent CT first; and 48 (9%) underwent pelvic sonography first. The percentages with negative CT findings were 42%,17%, and 50%, respectively. Overall, 63 (CT only), 38 (CT first), and 12 (sonography first) patients had CT diagnoses of pelvic conditions only (113 of 509 women [22%]). Of the patients with CT and discharge diagnoses of pelvic conditions, 36 of 44 (82%) had CT only or CT first; 58 of 110 (53%) of cases with sonography only showed acute pelvic conditions. CONCLUSIONS Twenty-two percent of pelvic CT examinations performed in women of reproductive age in our emergency department showed only pelvic conditions, suggesting that sonography would have been a reasonable primary imaging test for these patients.
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Affiliation(s)
- Elizabeth Asch
- Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215, USA
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Priola AM, Priola SM, Volpicelli G, Giraudo MT, Martino V, Fava C, Veltri A. Accuracy of 64-row multidetector CT in the diagnosis of surgically treated acute abdomen. Clin Imaging 2013; 37:902-7. [PMID: 23764231 DOI: 10.1016/j.clinimag.2013.02.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2013] [Accepted: 02/22/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To assess the accuracy of 64-row computed tomography (CT) in the differential diagnosis of acute abdomen in the emergency department. MATERIALS AND METHODS Prospective analysis of 181 patients with surgically treated acute abdomen. RESULTS In 158/181 cases, CT was totally concordant with surgical repertoire. Partial concordance was found in 15 cases. Overall sensitivity was 87.3% when only cases of complete concordance were considered, 95.6% if also partial concordance cases were included. CONCLUSION CT showed high reliability in the differential diagnosis of acute abdomen surgically treated, although associated conditions can sometimes be missed.
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Affiliation(s)
- Adriano Massimiliano Priola
- Department of Diagnostic and Interventional Radiology, University of Turin, San Luigi Gonzaga University Hospital, Regione Gonzole 10, 10043, Orbassano (Torino), Italy.
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Lehtimäki T, Juvonen P, Valtonen H, Miettinen P, Paajanen H, Vanninen R. Impact of routine contrast-enhanced CT on costs and use of hospital resources in patients with acute abdomen. Results of a randomised clinical trial. Eur Radiol 2013; 23:2538-45. [DOI: 10.1007/s00330-013-2848-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Accepted: 03/10/2013] [Indexed: 10/26/2022]
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Berdahl CT, Vermeulen MJ, Larson DB, Schull MJ. Emergency department computed tomography utilization in the United States and Canada. Ann Emerg Med 2013; 62:486-494.e3. [PMID: 23683773 DOI: 10.1016/j.annemergmed.2013.02.018] [Citation(s) in RCA: 107] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2012] [Revised: 02/03/2013] [Accepted: 02/18/2013] [Indexed: 10/26/2022]
Abstract
STUDY OBJECTIVE We compare secular trends in computed tomography (CT) utilization in emergency departments (EDs) in the United States and Ontario, Canada. METHODS Using a systematic survey in the US (The National Hospital Ambulatory Medical Care Survey) and administrative databases in Ontario, we performed a retrospective study of ED visits from 2003 to 2008. We calculated utilization overall, by visit characteristics, and for 5 clinical conditions in which CT is commonly indicated: abdominal pain, complex abdominal pain (abdominal pain, age ≥65 years, urgent to most urgent triage), admitted complex abdominal pain (abdominal pain, age ≥65 years, urgent to most urgent triage, and admitted to hospital), headache, and chest pain/shortness of breath. US data were weighted to produce national estimates. RESULTS On-site CT was available for 97% (95% confidence interval [CI] 95% to 99%) of visits in the United States compared with 80% (95% CI 80% to 80%) in Ontario. Visits were more frequently triaged as higher acuity in the United States than in Ontario, with 15.1% (95% CI 13.9% to 16.4%) of US visits categorized as most urgent versus 11.8% (95% CI 11.8% to 11.8%) in Ontario. The proportion of all ED visits in which CT was performed was 11.4% (95% CI 10.8% to 12.0%) in the United States versus 5.9% (95% CI 5.9% to 5.9%) in Ontario. The proportion for children was 4.7% (95% CI 4.3% to 5.1%) in the United States versus 1.4% (95% CI 1.4% to 1.4%) in Ontario. The rate of visits involving CT per year increased faster from 2003 to 2008 in the United States (odds ratio 2.00; 95% CI 1.81 to 2.21) than Ontario (odds ratio 1.69; 95% CI 1.68 to 1.70). Over time, all subgroups experienced increases in CT rate except Ontario children younger than 10 years, who experienced a significant decrease. United States-Ontario differences in CT proportions were significant among patients presenting with headache, abdominal pain, chest pain/shortness of breath, and complex abdominal pain. Proportions for visits involving admitted complex abdominal pain in the two jurisdictions were indistinguishable: 45.8% in the United States (95% CI 39.9% to 51.7%) versus 44.7% (95% CI 44.4% to 45.0%) in Ontario. CONCLUSION CT was more readily available in US EDs, and US clinicians used the technology more frequently than their colleagues in Ontario for nearly every category of patients, including children. CT utilization increased over time in both jurisdictions, but faster in the United States. Different demographic features between the two jurisdictions, including triage severity, frequency of hospitalization, and availability of CT scanners, likely account for at least some of the differences in CT utilization. Investigation of both clinical and nonclinical reasons for the differences in CT utilization between the United States and Canada would be a fruitful area for further research.
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Affiliation(s)
- Carl T Berdahl
- Department of Emergency Medicine, Los Angeles County and University of Southern California Medical Center, Los Angeles, CA.
| | - Marian J Vermeulen
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada; Department of Health Policy, Management and Evaluation, Toronto, ON, Canada
| | - David B Larson
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Michael J Schull
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada; Department of Health Policy, Management and Evaluation, Toronto, ON, Canada; Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, ON, Canada
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177
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Nojkov B, Duffy MC, Cappell MS. Utility of repeated abdominal CT scans after prior negative CT scans in patients presenting to ER with nontraumatic abdominal pain. Dig Dis Sci 2013. [PMID: 23179149 DOI: 10.1007/s10620-012-2473-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
PURPOSE The purpose of this study was to analyze diagnostic yield of repeat computed tomography (CT) after negative initial CT versus yield of initial CT in patients presenting repeatedly to emergency room (ER) for nontraumatic abdominal pain. Medical costs and radiation exposure from repeat CT could be reduced if repeat CT after negative initial CT has a low diagnostic yield. METHODS Patients included consecutive adults presenting to William Beaumont Hospital, from 2007 to 2010, undergoing abdominal CT for nontraumatic abdominal pain retrospectively identified by medical diagnostic and CT procedural codes. Exclusion criteria were prior abdominal trauma, recent abdominal surgery, and known chronic gastrointestinal disease. The CT was labeled "positive" if findings explained patient's abdominal pain or was clinically significant. Positivity rate was compared for repeat versus initial CT. RESULTS Among 200 consecutive patients undergoing (659) multiple CTs (mean age = 45.7 years, 74 % female), positivity rate for initial CT (22.5 %) was significantly higher than positivity rates for CT#2 (8.4 %, p = 0.002), for CT#3 (4.9 %, p = 0.005), and for CT ≥ #4 (5.9 %, p = 0.006). Generally, CT positivity rate declined with increasing number of prior negative CTs. CT positivity rate was significantly higher in 100 patients undergoing single CT versus 155 patients undergoing repeat CTs (46.5 vs. 6.5 %, p = 0.0001). Positive repeat CT findings included intestinal mural thickening/mass (7), colitis (5), appendicitis (4), and other (14). Among 15 analyzed clinical parameters, two significantly predicted repeat CT positivity, namely, leukocytosis (p = 0.03) and APACHE-II-score >5 (p = 0.01). Repeat CTs constituted 47 % of all CTs. CONCLUSIONS Repeat abdominal CT after initially negative CT(s) performed for nontraumatic abdominal pain has a low diagnostic yield. Leukocytosis and APACHE-II score might help predict CT scan positivity. Data suggest restricted abdominal CT utilization in ER patients with multiple prior negative CTs. Findings warrant confirmation in prospective studies.
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Affiliation(s)
- Borko Nojkov
- Division of Gastroenterology and Hepatology, Department of Medicine, William Beaumont Hospital, Oakland University William Beaumont School of Medicine, 3535 West 13 Mile Rd, Royal Oak, MI 48073, USA
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178
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Westwood DA, Roberts RH. Management of Primary Group A Streptococcal Peritonitis: A Systematic Review. Surg Infect (Larchmt) 2013; 14:171-6. [DOI: 10.1089/sur.2012.038] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- David A. Westwood
- Department of Surgery, Christchurch Hospital, Canterbury, New Zealand
| | - Ross H. Roberts
- Department of Surgery, Christchurch Hospital, Canterbury, New Zealand
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179
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Leeuwenburgh MMN, Wiarda BM, Wiezer MJ, Vrouenraets BC, Gratama JWC, Spilt A, Richir MC, Bossuyt PMM, Stoker J, Boermeester MA. Comparison of imaging strategies with conditional contrast-enhanced CT and unenhanced MR imaging in patients suspected of having appendicitis: a multicenter diagnostic performance study. Radiology 2013; 268:135-43. [PMID: 23481162 DOI: 10.1148/radiol.13121753] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE To compare the diagnostic performance of imaging strategies with magnetic resonance (MR) imaging and computed tomographic (CT) imaging in adult patients suspected of having appendicitis. MATERIALS AND METHODS Institutional review board approval was obtained prior to study initiation, and patients gave written informed consent. In a multicenter diagnostic performance study, adults suspected of having appendicitis were prospectively identified in the emergency department. Consenting patients underwent ultrasonography (US) and subsequent contrast-enhanced CT if US imaging yielded negative or inconclusive results. Additionally, all patients underwent unenhanced MR imaging, with the reader blinded to other findings. An expert panel assigned final diagnosis after 3 months. Diagnostic performance of three imaging strategies was evaluated: conditional CT after US, conditional MR imaging after US, and immediate MR imaging. Sensitivity and specificity were calculated by comparing findings with final diagnosis. RESULTS Between March and September 2010, 229 US, 115 CT, and 223 MR examinations were performed in 230 patients (median age, 35 years; 40% men). Appendicitis was the final diagnosis in 118 cases. Conditional and immediate MR imaging had sensitivity and specificity comparable to that of conditional CT, which resulted in 3% (three of 118; 95% confidence interval [CI]: 1%, 7%) missed appendicitis, and 8% (10 of 125; 95% CI: 4%, 14%) false-positives. Conditional MR missed appendicitis in 2% (two of 118; 95% CI: 0%, 6%) and generated 10% (13 of 129; 95% CI: 6%, 16%) false-positives. Immediate MR missed 3% (four of 117; 95% CI: 1%, 8%) appendicitis with 6% (seven of 120; 95% CI: 3%, 12%) false-positives. Conditional strategies resulted in more false-positives in women than in men (conditional CT, 17% vs 0%; P = .03; conditional MR, 19% vs 1%; P = .04), wherease immediate MR imaging did not. CONCLUSION The accuracy of conditional or immediate MR imaging was similar to that of conditional CT in patients suspected of having appendicitis, which implied that strategies with MR imaging may replace conditional CT for appendicitis detection.
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Affiliation(s)
- Marjolein M N Leeuwenburgh
- Department of Radiology, Surgery, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands.
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Added value of ultrasound re-evaluation for patients with equivocal CT findings of acute appendicitis: a preliminary study. Eur Radiol 2013; 23:1882-90. [DOI: 10.1007/s00330-013-2769-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2012] [Revised: 12/08/2012] [Accepted: 12/12/2012] [Indexed: 12/11/2022]
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181
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[Unclear abdominal pain in central emergency admissions. An algorithm]. Med Klin Intensivmed Notfmed 2013; 108:33-40. [PMID: 23370893 DOI: 10.1007/s00063-012-0172-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Accepted: 01/07/2013] [Indexed: 01/08/2023]
Abstract
One of the chief complaints in the emergency department is abdominal pain which is associated with a large spectrum of possible underlying diagnoses. Life-threatening diseases have to be identified urgently to treat them rapidly either conservatively or by surgical intervention. The algorithm presented in this article starts with the triage in the emergency department. After triage the first step in the algorithm is an interdisciplinary communication to start the standardized diagnostic process which includes medical history, clinical examination, laboratory analyses, ultrasound and electrocardiogram. Further diagnostic escalation should be done in unspecific and urgent cases of abdominal pain after consulting a specialist. In approximately 30 % of patients with abdominal pain on admittance to an emergency department the cause remains unclear after undergoing the diagnostic process. In these cases it can be useful for risk stratification to transfer the patient to a ward related to the emergency department for observation und further diagnostics.
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182
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Evaluation of the appendicitis inflammatory response score for patients with acute appendicitis. World J Surg 2012; 36:1540-5. [PMID: 22447205 PMCID: PMC3368113 DOI: 10.1007/s00268-012-1521-4] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Acute appendicitis is still a difficult diagnosis. Scoring systems are designed to aid in the clinical assessment of patients with acute appendicitis. The Alvarado score is the most well known and best performing in validation studies. The purpose of the present study was to externally validate a recently developed appendicitis inflammatory response (AIR) score and compare it to the Alvarado score. METHODS The present study selected consecutive patients who presented with suspicion of acute appendicitis between 2006 and 2009. Variables necessary to evaluate the scoring systems were registered. The diagnostic performance of the two scores was compared. RESULTS The present study included 941 consecutive patients with suspicion of acute appendicitis. There were 410 male patients (44%) and 531 female patients (56%). The area under the receiver operating characteristic curve of the AIR score was 0.96 and significantly better than the area under the curve of 0.82 of the Alvarado score (p < 0.05). The AIR score also outperformed the Alvarado score when analyzing the more difficult patients, including women, children, and the elderly. CONCLUSIONS This study externally validates the AIR Score for patients with acute appendicitis. The scoring system has a high discriminating power and outperforms the Alvarado score.
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183
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Kiewiet JJS, Leeuwenburgh MMN, Bipat S, Bossuyt PMM, Stoker J, Boermeester MA. A systematic review and meta-analysis of diagnostic performance of imaging in acute cholecystitis. Radiology 2012; 264:708-20. [PMID: 22798223 DOI: 10.1148/radiol.12111561] [Citation(s) in RCA: 170] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE To update previously summarized estimates of diagnostic accuracy for acute cholecystitis and to obtain summary estimates for more recently introduced modalities. MATERIALS AND METHODS A systematic search was performed in MEDLINE, EMBASE, Cochrane Library, and CINAHL databases up to March 2011 to identify studies about evaluation of imaging modalities in patients who were suspected of having acute cholecystitis. Inclusion criteria were explicit criteria for a positive test result, surgery and/or follow-up as the reference standard, and sufficient data to construct a 2 × 2 table. Studies about evaluation of predominantly acalculous cholecystitis in intensive care unit patients were excluded. Bivariate random-effects modeling was used to obtain summary estimates of sensitivity and specificity. RESULTS Fifty-seven studies were included, with evaluation of 5859 patients. Sensitivity of cholescintigraphy (96%; 95% confidence interval [CI]: 94%, 97%) was significantly higher than sensitivity of ultrasonography (US) (81%; 95% CI: 75%, 87%) and magnetic resonance (MR) imaging (85%; 95% CI: 66%, 95%). There were no significant differences in specificity among cholescintigraphy (90%; 95% CI: 86%, 93%), US (83%; 95% CI: 74%, 89%) and MR imaging (81%; 95% CI: 69%, 90%). Only one study about evaluation of computed tomography (CT) met the inclusion criteria; the reported sensitivity was 94% (95% CI: 73%, 99%) at a specificity of 59% (95% CI: 42%, 74%). CONCLUSION Cholescintigraphy has the highest diagnostic accuracy of all imaging modalities in detection of acute cholecystitis. The diagnostic accuracy of US has a substantial margin of error, comparable to that of MR imaging, while CT is still underevaluated.
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Affiliation(s)
- Jordy J S Kiewiet
- Department of Surgery, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, G4-129, 1105 AZ Amsterdam, the Netherlands.
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Gans SL, Stoker J, Boermeester MA. Plain abdominal radiography in acute abdominal pain; past, present, and future. Int J Gen Med 2012; 5:525-33. [PMID: 22807640 PMCID: PMC3396109 DOI: 10.2147/ijgm.s17410] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Several studies have demonstrated that a diagnosis based solely on a patient’s medical history, physical examination, and laboratory tests is not reliable enough, despite the fact that these aspects are essential parts of the workup of a patient presenting with acute abdominal pain. Traditionally, imaging workup starts with abdominal radiography. However, numerous studies have demonstrated low sensitivity and accuracy for plain abdominal radiography in the evaluation of acute abdominal pain as well as various specific diseases such as perforated viscus, bowel obstruction, ingested foreign body, and ureteral stones. Computed tomography, and in particular computed tomography after negative ultrasonography, provides a better workup than plain abdominal radiography alone. The benefits of computed tomography lie in decision-making for management, planning of a surgical strategy, and possibly even avoidance of negative laparotomies. Based on abundant available evidence, major advances in diagnostic imaging, and changes in the management of certain diseases, we can conclude that there is no place for plain abdominal radiography in the workup of adult patients with acute abdominal pain presenting in the emergency department in current practice.
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Affiliation(s)
- Sarah L Gans
- Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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185
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Hematuria: A Problem-Based Imaging Algorithm Illustrating the Recent Dutch Guidelines on Hematuria. AJR Am J Roentgenol 2012; 198:1256-65. [DOI: 10.2214/ajr.11.8255] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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187
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Abstract
BACKGROUND A recurrent episode of diverticulitis is a new distinct episode of acute inflammation after a period of complete remission of symptoms. Outdated literature suggested a high recurrence rate (>40%) and a worse clinical presentation with less chance of conservative treatment. More recent studies showed a more benign course with no need toward an aggressive policy of treatment. METHODS We report data from revised literature and from our study: a 4-year multicenter retrospective and prospective database analysis of 743 patients hospitalized for acute diverticulitis (AD) treated medically or surgically and then followed for a minimum of 9 years. RESULTS The literature showed a recurrence rate of 25-35% at 5 years of follow-up, with a reduced risk of severe complications (i.e. perforations), a risk of subsequent emergency surgery of 2-14% and a risk of stoma and related death of 0-2.7%. Several risk factors of recurrence have been advocated: family history, abscess, severe CT stage, comorbidities (renal failure, collagen vascular disease) and nonsteroidal anti-inflammatory drugs. Young age is still a matter of debate. These studies have different limitations: retrospective, lack of definition of AD, small number of patients, long recruiting time, short follow-up, study population or hospital-system based. In our study of 320 followed-up, medically treated patients, 61% were asymptomatic and 22% complained of chronic symptoms: the 12-year actuarial risk of recurrence, emergency surgery, stoma and death was 21.2, 8.3, 1 and 0%, respectively. Recurrence was related to very young age (<40 years) and more than 3 previous episodes of AD. CONCLUSION This study confirms the benign course of diverticulitis treated conservatively, with a low long-term risk of serious complications and death, and does not support an aggressive surgical policy to prevent them.
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Weir-McCall J, Shaw A, Arya A, Knight A, Howlett DC. The use of pre-operative computed tomography in the assessment of the acute abdomen. Ann R Coll Surg Engl 2012; 94:102-7. [PMID: 22391377 PMCID: PMC3954130 DOI: 10.1308/003588412x13171221501663] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2011] [Indexed: 01/11/2023] Open
Abstract
INTRODUCTION While there are a lot of data on the accuracy of computed tomography (CT) in diagnosing specific causes of an acute abdomen, there is very little information on the accuracy of CT in the acute general surgical admissions workload. We look at the diagnostic accuracy of CT in patients presenting with an acute abdomen who ultimately required a laparotomy. METHODS Patients who underwent an emergency laparotomy between 2008 and 2010 at Eastbourne District General Hospital with pre-operative CT on the same admission were included in the study. The CT report was compared with the laparotomy and histology findings and, where a discrepancy existed, the original imaging was reviewed by a senior consultant blinded to the original report and laparotomy findings. RESULTS A total of 196 emergency laparotomies were performed over the 2-year period, with 112 patients undergoing preoperative CT. Fifteen patients were excluded from the study due to missing notes. In the remaining 97 patients, 80 CT reports correlated with the final operative diagnosis, giving a diagnostic accuracy of 82%. Of these, the on-call registrar was the initial reporter in 37 scans, with a diagnostic accuracy of 78%. On review of the CT by a second consultant, this increased to 90 correlations, yielding an accuracy of 93%. Delay between CT and the operation did not significantly alter diagnostic accuracy, nor was there any statistically significant reduction in accuracy in reports issued by on-call registrars. CONCLUSIONS On first reporting, CT misses 18% of diagnoses that ultimately require operative intervention. Reducing the threshold for obtaining a second consultant radiologist review significantly improves the diagnostic accuracy to 93%.
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Podbregar M, Kralj E, Čičak R, Pavlinjek A. A triad algorithm for analysing individual ante- and post-mortem findings to improve the quality of intensive care. Anaesth Intensive Care 2012; 39:1086-92. [PMID: 22165363 DOI: 10.1177/0310057x1103900617] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Autopsy is an important source of data for education and quality control. The aim of this study was comparison of ante- to post-mortem findings to detect weak points of intensive care unit (ICU) care. Patients who died in our 14-bed university medical ICU care and underwent an autopsy examination over 20 months (September 2007 to May 2009) were included. Modified Goldman's criteria were used to categorise discrepancies between diagnoses and post-mortem findings. A triad algorithm was constructed to analyse individual ante- to post-mortem findings. One hundred and seventy post-mortem examinations were conducted (45.6% autopsy rate). Major diagnostic discrepancies were detected in 20 patients (11.8%); four class I (2.4%) and 16 class II (9.4%). Massive pulmonary embolism with cardiac arrest was the most common class I discrepancy (75%). Triad analysis of major class I discrepancies showed that all patients had a history of chronic disease; the majority (75%) had a short ICU length of stay. In 75% adequate tests were used to detect disorders. There were interpretation problems of bedside data in complex emergency clinical conditions, especially with less experienced ICU physicians. Inappropriate or incorrectly interpreted diagnostic procedures were performed in more than half of cases with class II discrepancies (9/16, 56%). Abdominal ultrasonography was misleading in 31% (5/16) cases with class II discrepancies. In conclusion, triad algorithm analysis revealed problematic interpretation of bedside diagnostics in emergency cases by inexperienced physicians in class I major discrepancies detected at autopsy. No correct test and wrong interpretation of abdominal ultrasonography were major causes of class II discrepancies.
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Affiliation(s)
- M Podbregar
- Medical Intensive Care Unit, University Medical Center, University of Ljubljana, Ljubljana, Slovenia.
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190
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Helwig U. Möglichkeiten und Grenzen der ambulanten Therapie der Divertikelkrankheit. VISZERALMEDIZIN 2012. [DOI: 10.1159/000339393] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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191
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Wong CS, Al-Ajami AK, Boshahri M, Naqvi SA. Diagnosis of acute surgical abdomen – The best diagnostic tool to reach a final diagnosiscin. JOURNAL OF ACUTE DISEASE 2012. [DOI: 10.1016/s2221-6189(13)60005-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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de Korte N, Klarenbeek BR, Kuyvenhoven JP, Roumen RMH, Cuesta MA, Stockmann HBAC. Management of diverticulitis: results of a survey among gastroenterologists and surgeons. Colorectal Dis 2011; 13:e411-7. [PMID: 21819518 DOI: 10.1111/j.1463-1318.2011.02744.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
AIM The study aimed to investigate current management strategies for left-sided diverticulitis and compare them with current international guidelines. Differences between surgeons and gastroenterologists and between gastrointestinal and nongastrointestinal surgeons were assessed. METHOD A web-based survey of treatment options for uncomplicated and complicated diverticulitis was carried out among surgeons and gastroenterologists in the Netherlands. Only surgeons were asked about surgical strategy. RESULTS A total of 292 surgeons and 87 gastroenterologists responded, representing 92% of all surgical and 46% of all gastroenterology departments. Ninety per cent of respondents treated mild diverticulitis without antibiotics. About one-fifth (18% gastroenterologists; 19% surgeons) regarded a CT scan as mandatory in the initial assessment. Most surgeons and gastroenterologists used some form of bowel rest, would consider outpatient treatment and would perform a colonoscopy on follow up. For Hinchey Stage 3, 78% of surgeons would consider resection and primary anastomosis and laparoscopic lavage was viewed as a valid alternative by 30% of gastrointestinal and 2% of nongastrointestinal surgeons. For Hinchey stage 4, 46% of gastrointestinal and 72% of nongastrointestinal surgeons would always perform Hartmann's procedure. CONCLUSION The treatment of diverticulitis in the Netherlands shows major differences when compared with guidelines for all stages of disease.
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Affiliation(s)
- N de Korte
- Department of Surgery, Kennemer Gasthuis, Haarlem, The Netherlands.
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193
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Binda GA, Arezzo A, Serventi A, Bonelli L, Facchini M, Prandi M, Carraro PS, Reitano MC, Clerico G, Garibotto L, Aloesio R, Sganzaroli A, Zanoni M, Zanandrea G, Pellegrini F, Mancini S, Amato A, Barisone P, Bottini C, Altomare DF, Milito G. Multicentre observational study of the natural history of left-sided acute diverticulitis. Br J Surg 2011; 99:276-85. [PMID: 22105809 DOI: 10.1002/bjs.7723] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2011] [Indexed: 12/16/2022]
Abstract
BACKGROUND The natural history of acute diverticulitis (AD) is still unclear. This study investigated the recurrence rate, and the risks of emergency surgery, associated stoma and death following initial medical or surgical treatment of AD. METHODS The Italian Study Group on Complicated Diverticulosis conducted a 4-year multicentre retrospective and prospective database analysis of patients admitted to hospital for medical or surgical treatment of AD and then followed for a minimum of 9 years. The persistence of symptoms, recurrent episodes of AD, new hospital admissions, medical or surgical treatment, and their outcome were recorded during follow-up. RESULTS Of 1046 patients enrolled at 17 centres, 743 were eligible for the study (407 recruited retrospectively and 336 prospectively); 242 patients (32·6 per cent) underwent emergency surgery at accrual. After a mean follow-up of 10·7 years, rates of recurrence (17·2 versus 5·8 per cent; P < 0·001) and emergency surgery (6·9 versus 1·3 per cent; P = 0·021) were higher for medically treated patients than for those treated surgically. Among patients who had initial medical treatment, age less than 40 years and a history of at least three episodes of AD were associated with an increased risk of AD recurrence. There was no association between any of the investigated parameters and subsequent emergency surgery. The risk of stoma formation was below 1 per cent and disease-related mortality was zero in this group. The disease-related mortality rate was 0·6 per cent among patients who had surgical treatment. CONCLUSION Long-term risks of recurrent AD or emergency surgery were limited and colectomy did not fully protect against recurrence.
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Affiliation(s)
- G A Binda
- Department of General Surgery, Galliera Hospital, Genoa, Italy.
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Berger M, de Wit N, Vogelenzang R, Wetzels R, Kortenhof NVRV, Opstelten W. NHG-Standaard Diverticulitis. ACTA ACUST UNITED AC 2011. [DOI: 10.1007/s12445-011-0238-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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195
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Albrecht DA, Schuler A, Kratzer W, Vogt JL, Haenle MM, Mason RA, Lorenz R, Klaus J. Benefit of early abdominal ultrasonography in non-surgical patients admitted to the emergency department: a pilot study. J Med Ultrason (2001) 2011; 38:203. [PMID: 27278585 DOI: 10.1007/s10396-011-0315-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2011] [Accepted: 05/20/2011] [Indexed: 11/27/2022]
Abstract
PURPOSE Ultrasonography plays a decisive role in emergency patients. The primary aim of this study is to assess whether early emergency ultrasonography alters the length of stay. METHODS In a prospective study, patients admitted to the emergency department were divided into two groups. The first group underwent early abdominal ultrasonography (within 24 h after admission), and the second group underwent ultrasonography after more than 24 h. The two groups were compared in terms of length of stay, age, admission diagnosis, and number of further imaging techniques used. A subgroup analysis was carried out for admission diagnosis. One hundred and forty-five patients were included in the study. RESULTS In terms of length of stay, no difference was seen between the first group (11.7 ± 11.4 days) and the second group (13.6 ± 11.0 days) (p = 0.1196). In the subgroups "abdominal pain" (p = 0.0333) and "cardiopulmonary disorders" (p = 0.0207), a shorter length of stay was associated with early ultrasonography, while in the subgroup "infectious disease/fever," the early ultrasonography group was associated with a prolonged length of stay (p = 0.0211). CONCLUSION Early ultrasonography in our setting of emergency patients with a variety of different admission diagnoses did not shorten the length of stay, but the subgroups of patients with "abdominal pain" and "cardiopulmonary disorders" might have benefited from early ultrasonography.
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Affiliation(s)
- David Arkadij Albrecht
- Department of Internal Medicine I, Center for Internal Medicine, University Hospital Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Andreas Schuler
- Helfensteinklinik Geislingen, Medical Clinic, Eybstr. 16, 73312, Geislingen, Germany
| | - Wolfgang Kratzer
- Department of Internal Medicine I, Center for Internal Medicine, University Hospital Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany.
| | - Jovana Louisa Vogt
- Department of Internal Medicine I, Center for Internal Medicine, University Hospital Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Mark Martin Haenle
- Department of Internal Medicine I, Center for Internal Medicine, University Hospital Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Richard Andrew Mason
- Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Brecksville Division, Brecksville, OH, 44141, USA
| | - Richard Lorenz
- Department of Internal Medicine I, Center for Internal Medicine, University Hospital Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Jochen Klaus
- Department of Internal Medicine I, Center for Internal Medicine, University Hospital Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany
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La tomografía computarizada multidetector en el abdomen agudo. RADIOLOGIA 2011; 53 Suppl 1:60-9. [PMID: 21742357 DOI: 10.1016/j.rx.2011.03.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2010] [Revised: 03/17/2011] [Accepted: 03/26/2011] [Indexed: 11/21/2022]
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197
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Simoni F, Vitturi N, Tagliente M, Soattin M, Realdi G. US in the evaluation of abdominal pain in a department of internal medicine. J Ultrasound 2011; 14:142-6. [DOI: 10.1016/j.jus.2011.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Poletti PA, Platon A, De Perrot T, Sarasin F, Andereggen E, Rutschmann O, Dupuis-Lozeron E, Perneger T, Gervaz P, Becker CD. Acute appendicitis: prospective evaluation of a diagnostic algorithm integrating ultrasound and low-dose CT to reduce the need of standard CT. Eur Radiol 2011; 21:2558-66. [PMID: 21805194 DOI: 10.1007/s00330-011-2212-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2011] [Revised: 05/25/2011] [Accepted: 06/13/2011] [Indexed: 10/17/2022]
Abstract
OBJECTIVES To evaluate an algorithm integrating ultrasound and low-dose unenhanced CT with oral contrast medium (LDCT) in the assessment of acute appendicitis, to reduce the need of conventional CT. METHODS Ultrasound was performed upon admission in 183 consecutive adult patients (111 women, 72 men, mean age 32) with suspicion of acute appendicitis and a BMI between 18.5 and 30 (step 1). No further examination was recommended when ultrasound was positive for appendicitis, negative with low clinical suspicion, or demonstrated an alternative diagnosis. All other patients underwent LDCT (30 mAs) (step 2). Standard intravenously enhanced CT (180 mAs) was performed after indeterminate LDCT (step 3). RESULTS No further imaging was recommended after ultrasound in 84 (46%) patients; LDCT was obtained in 99 (54%). LDCT was positive or negative for appendicitis in 81 (82%) of these 99 patients, indeterminate in 18 (18%) who underwent standard CT. Eighty-six (47%) of the 183 patients had a surgically proven appendicitis. The sensitivity and specificity of the algorithm were 98.8% and 96.9%. CONCLUSIONS The proposed algorithm achieved high sensitivity and specificity for detection of acute appendicitis, while reducing the need for standard CT and thus limiting exposition to radiation and to intravenous contrast media.
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Affiliation(s)
- Pierre-Alexandre Poletti
- Department of Radiology, University Hospital of Geneva, 4 rue Gabrielle Perret-Gentil, 1211, Genève-14, Switzerland.
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van Randen A, Laméris W, van Es HW, van Heesewijk HPM, van Ramshorst B, Ten Hove W, Bouma WH, van Leeuwen MS, van Keulen EM, Bossuyt PM, Stoker J, Boermeester MA. A comparison of the accuracy of ultrasound and computed tomography in common diagnoses causing acute abdominal pain. Eur Radiol 2011; 21:1535-45. [PMID: 21365197 PMCID: PMC3101356 DOI: 10.1007/s00330-011-2087-5] [Citation(s) in RCA: 142] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2010] [Revised: 12/06/2010] [Accepted: 12/15/2010] [Indexed: 12/23/2022]
Abstract
Objectives Head-to-head comparison of ultrasound and CT accuracy in common diagnoses causing acute abdominal pain. Materials and methods Consecutive patients with abdominal pain for >2 h and <5 days referred for imaging underwent both US and CT by different radiologists/radiological residents. An expert panel assigned a final diagnosis. Ultrasound and CT sensitivity and predictive values were calculated for frequent final diagnoses. Effect of patient characteristics and observer experience on ultrasound sensitivity was studied. Results Frequent final diagnoses in the 1,021 patients (mean age 47; 55% female) were appendicitis (284; 28%), diverticulitis (118; 12%) and cholecystitis (52; 5%). The sensitivity of CT in detecting appendicitis and diverticulitis was significantly higher than that of ultrasound: 94% versus 76% (p < 0.01) and 81% versus 61% (p = 0.048), respectively. For cholecystitis, the sensitivity of both was 73% (p = 1.00). Positive predictive values did not differ significantly between ultrasound and CT for these conditions. Ultrasound sensitivity in detecting appendicitis and diverticulitis was not significantly negatively affected by patient characteristics or reader experience. Conclusion CT misses fewer cases than ultrasound, but both ultrasound and CT can reliably detect common diagnoses causing acute abdominal pain. Ultrasound sensitivity was largely not influenced by patient characteristics and reader experience.
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Affiliation(s)
- Adrienne van Randen
- Department of Radiology (Suite G1-227), Academic Medical Centre, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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Toorenvliet BR, Wiersma F, Bakker RFR, Merkus JWS, Breslau PJ, Hamming JF. Routine ultrasound and limited computed tomography for the diagnosis of acute appendicitis. World J Surg 2011; 34:2278-85. [PMID: 20582544 PMCID: PMC2936677 DOI: 10.1007/s00268-010-0694-y] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Background Acute appendicitis continues to be a challenging diagnosis. Preoperative radiological imaging using ultrasound (US) or computed tomography (CT) has gained popularity as it may offer a more accurate diagnosis than classic clinical evaluation. The optimal implementation of these diagnostic modalities has yet to be established. The aim of the present study was to investigate a diagnostic pathway that uses routine US, limited CT, and clinical re-evaluation for patients with acute appendicitis. Methods A prospective analysis was performed of all patients presenting with acute abdominal pain at the emergency department from June 2005 until July 2006 using a structured diagnosis and management flowchart. Daily practice was mimicked, while ensuring a valid assessment of clinical and radiological diagnostic accuracies and the effect they had on patient management. Results A total of 802 patients were included in this analysis. Additional radiological imaging was performed in 96.3% of patients with suspected appendicitis (n = 164). Use of CT was kept to a minimum (17.9%), with a US:CT ratio of approximately 6:1. Positive and negative predictive values for the clinical diagnosis of appendicitis were 63 and 98%, respectively; for US 94 and 97%, respectively; and for CT 100 and 100%, respectively. The negative appendicitis rate was 3.3%, the perforation rate was 23.5%, and the missed perforated appendicitis rate was 3.4%. No (diagnostic) laparoscopies were performed. Conclusions A diagnostic pathway using routine US, limited CT, and clinical re-evaluation for patients with acute abdominal pain can provide excellent results for the diagnosis and treatment of appendicitis.
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Affiliation(s)
- Boudewijn R Toorenvliet
- Department of Surgery, Leiden University Medical Centre, P.O. Box 9600, 2300 RC, Leiden, The Netherlands.
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