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Kryzauskas M, Danys D, Poskus T, Mikalauskas S, Poskus E, Jotautas V, Beisa V, Strupas K. Is acute appendicitis still misdiagnosed? Open Med (Wars) 2016; 11:231-236. [PMID: 28352800 PMCID: PMC5329832 DOI: 10.1515/med-2016-0045] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 04/12/2016] [Indexed: 02/07/2023] Open
Abstract
Objective The optimal diagnostics and treatment of acute appendicitis continues to be a challenge. A false positive diagnosis of appendicitis may lead to an unnecessary operation, which has been appropriately termed negative appendectomy. The aim of our study was to identify the effectiveness of preoperative investigations in preventing negative appendectomy. Methods A retrospective study was performed on adult patients who underwent operation for suspected acute appendicitis from 2008 to 2013 at Vilnius University Hospital Santariskiu Klinikos. Patients were divided into two groups: group A underwent an operation, where appendix was found to be normal (non-inflamed); group B underwent an appendectomy for inflamed appendix. Groups were compared for preoperative data, investigations, treatment results and pathology findings. Results 554 patients were included in the study. Preoperative laboratory tests results of hemoglobin, hematocrit concentrations and white blood cell count were significantly higher in group B (p<0.001). Ultrasonography was performed for 78 % of patients in group A and 74 % in group B and did not provide any statistically significant results. Comparing Alvarado score results, there were more patients with Alvarado score less than 7 in group A than in group B. In our large series we could find only four independent risk factors, and they could only account for 24 % of cases. Conclusions In summary, acute appendicitis is still often misdiagnosed and the ratio of negative appendectomies remains rather high. Additional investigations such as observation and computed tomography should be used to prevent this.
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Affiliation(s)
- Marius Kryzauskas
- Vilnius University Hospital Santariskiu Klinikos, Santariskiu Street 2, LT-08661, Vilnius, Lithuania
| | - Donatas Danys
- Vilnius University Hospital Santariskiu Klinikos, Santariskiu Street 2, LT-08661, Vilnius, Lithuania
| | - Tomas Poskus
- Vilnius University Hospital Santariskiu Klinikos, Santariskiu Street 2, LT-08661, Vilnius, Lithuania
| | - Saulius Mikalauskas
- Vilnius University Hospital Santariskiu Klinikos, Santariskiu Street 2, LT-08661, Vilnius, Lithuania
| | - Eligijus Poskus
- Vilnius University Hospital Santariskiu Klinikos, Santariskiu Street 2, LT-08661, Vilnius, Lithuania
| | - Valdemaras Jotautas
- Vilnius University Hospital Santariskiu Klinikos, Santariskiu Street 2, LT-08661, Vilnius, Lithuania
| | - Virgilijus Beisa
- Vilnius University Hospital Santariskiu Klinikos, Santariskiu Street 2, LT-08661, Vilnius, Lithuania
| | - Kestutis Strupas
- Vilnius University Hospital Santariskiu Klinikos, Santariskiu Street 2, LT-08661, Vilnius, Lithuania
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Di Saverio S, Birindelli A, Kelly MD, Catena F, Weber DG, Sartelli M, Sugrue M, De Moya M, Gomes CA, Bhangu A, Agresta F, Moore EE, Soreide K, Griffiths E, De Castro S, Kashuk J, Kluger Y, Leppaniemi A, Ansaloni L, Andersson M, Coccolini F, Coimbra R, Gurusamy KS, Campanile FC, Biffl W, Chiara O, Moore F, Peitzman AB, Fraga GP, Costa D, Maier RV, Rizoli S, Balogh ZJ, Bendinelli C, Cirocchi R, Tonini V, Piccinini A, Tugnoli G, Jovine E, Persiani R, Biondi A, Scalea T, Stahel P, Ivatury R, Velmahos G, Andersson R. WSES Jerusalem guidelines for diagnosis and treatment of acute appendicitis. World J Emerg Surg 2016; 11:34. [PMID: 27437029 PMCID: PMC4949879 DOI: 10.1186/s13017-016-0090-5] [Citation(s) in RCA: 228] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 07/06/2016] [Indexed: 02/08/2023] Open
Abstract
Acute appendicitis (AA) is among the most common cause of acute abdominal pain. Diagnosis of AA is challenging; a variable combination of clinical signs and symptoms has been used together with laboratory findings in several scoring systems proposed for suggesting the probability of AA and the possible subsequent management pathway. The role of imaging in the diagnosis of AA is still debated, with variable use of US, CT and MRI in different settings worldwide. Up to date, comprehensive clinical guidelines for diagnosis and management of AA have never been issued. In July 2015, during the 3rd World Congress of the WSES, held in Jerusalem (Israel), a panel of experts including an Organizational Committee and Scientific Committee and Scientific Secretariat, participated to a Consensus Conference where eight panelists presented a number of statements developed for each of the eight main questions about diagnosis and management of AA. The statements were then voted, eventually modified and finally approved by the participants to The Consensus Conference and lately by the board of co-authors. The current paper is reporting the definitive Guidelines Statements on each of the following topics: 1) Diagnostic efficiency of clinical scoring systems, 2) Role of Imaging, 3) Non-operative treatment for uncomplicated appendicitis, 4) Timing of appendectomy and in-hospital delay, 5) Surgical treatment 6) Scoring systems for intra-operative grading of appendicitis and their clinical usefulness 7) Non-surgical treatment for complicated appendicitis: abscess or phlegmon 8) Pre-operative and post-operative antibiotics.
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Affiliation(s)
| | - Arianna Birindelli
- S. Orsola Malpighi University Hospital - University of Bologna, Bologna, Italy
| | - Micheal D Kelly
- Locum Surgeon, Acute Surgical Unit, Canberra Hospital, Canberra, ACT Australia
| | - Fausto Catena
- Emergency and Trauma Surgery Department, Maggiore Hospital of Parma, Parma, Italy
| | - Dieter G Weber
- Trauma and General Surgeon Royal Perth Hospital & The University of Western Australia, Perth, Australia
| | | | | | - Mark De Moya
- Harvard Medical School - Massachusetts General Hospital, Boston, USA
| | - Carlos Augusto Gomes
- Department of Surgery Hospital Universitario, Universidade General de Juiz de Fora, Juiz de Fora, Brazil
| | - Aneel Bhangu
- Academic Department of Surgery, University Hospitals Birmingham NHS Foundation Trust, Edgabaston, Birmingham, UK
| | | | - Ernest E Moore
- Denver Health System - Denver Health Medical Center, Denver, USA
| | - Kjetil Soreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Ewen Griffiths
- University Hospitals Birmingham NHS Foundation Trust Queen Elizabeth Hospital, Birmingham, UK
| | | | - Jeffry Kashuk
- Department of Surgery, University of Jerusalem, Jerusalem, Israel
| | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Ari Leppaniemi
- Abdominal Center, University of Helsinki, Helsinki, Finland
| | - Luca Ansaloni
- General Surgery I, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Manne Andersson
- Department of Surgery, Linkoping University, Linkoping, Sweden
| | | | - Raul Coimbra
- UCSD Health System - Hillcrest Campus Department of Surgery Chief Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, San Diego, CA USA
| | | | | | - Walter Biffl
- Queen's Medical Center, University of Hawaii, Honolulu, HI USA
| | | | | | - Andrew B Peitzman
- Department of Surgery, University of Pittsburgh School of Medicine, UPMC-Presbyterian, Pittsburgh, USA
| | - Gustavo P Fraga
- Faculdade de Ciências Médicas (FCM) - Unicamp, Campinas, SP Brazil
| | | | - Ronald V Maier
- Department of Surgery, University of Washington, Harborview Medical Center, Seattle, WA USA
| | | | - Zsolt J Balogh
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW Australia
| | - Cino Bendinelli
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW Australia
| | - Roberto Cirocchi
- Department of Surgery, Terni Hospital, University of Perugia, Terni, Italy
| | - Valeria Tonini
- S. Orsola Malpighi University Hospital - University of Bologna, Bologna, Italy
| | - Alice Piccinini
- Trauma Surgery Unit - Maggiore Hospital AUSL, Bologna, Italy
| | | | - Elio Jovine
- Department of Surgery, Maggiore Hospital AUSL, Bologna, Italy
| | - Roberto Persiani
- Catholic University, A. Gemelli University Hospital, Rome, Italy
| | - Antonio Biondi
- Department of Surgery, University of Catania, Catania, Italy
| | | | - Philip Stahel
- Denver Health System - Denver Health Medical Center, Denver, USA
| | - Rao Ivatury
- Professor Emeritus Virginia Commonwealth University, Richmond, VA USA
| | - George Velmahos
- Harvard Medical School - Chief of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, USA
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Cochon L, Esin J, Baez AA. Bayesian comparative model of CT scan and ultrasonography in the assessment of acute appendicitis: results from the Acute Care Diagnostic Collaboration project. Am J Emerg Med 2016; 34:2070-2073. [PMID: 27480209 DOI: 10.1016/j.ajem.2016.07.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 07/08/2016] [Accepted: 07/09/2016] [Indexed: 12/29/2022] Open
Abstract
The objective of this study was to develop a comparative diagnostic model for computed tomography (CT) and ultrasound (US) in the assessment of acute appendicitis using Alvarado risk score as a predictor of pretest probability and Bayesian statistical model as a tool to calculate posttest probabilities for both diagnostic test. Stratification was made by applying the Alvarado score for the prediction of acute appendicitis. Likelihood ratios were calculated using sensitivity and specificity of both CT and US from a Meta-analysis. Posttest probabilities were obtained after inserting Alvarado score and likelihood ratios into Bayesian nomogram. Absolute and relative gains were calculated. ANOVA was used to assess statistical association. 4341 patients from 31 studies yielded a pooled sensitivity and specificity US of 83% (95% CI, 78%-87%) and 93% (95% CI, 90%-96%) and 94% (95% CI, 92%-95%) and 94% (95% CI, 94%-96%), respectively, for CT studies. Positive likelihood ratios (LR) for US were 12 and negative LR was 0.18; for CT +LR was 16 and -LR 0.06. Bayesian statistical modeling posttest probabilities for +LR and low Alvarado risk results yielded a posttest probability for US of 83.72% and 87.27% for CT, intermediate risk gave 95.88% and 96.88%, high risk 99.37% and 99.53 respectively. No statistical differences were found between Ultrasound and CT. This Bayesian analysis demonstrated slight superiority of CT scan over US low-risk patients, whereas no significant advantage was seen when evaluating intermediate and high risk patients. This study also favored elevated accuracy of the Alvarado score.
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154
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Meral U, Zor M, Ureyen O, Oren NC, Gungor H. A case of acute appendicitis in a patient with crossed renal ectopia. JOURNAL OF ACUTE DISEASE 2016. [DOI: 10.1016/j.joad.2015.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Lourenco P, Brown J, Leipsic J, Hague C. The current utility of ultrasound in the diagnosis of acute appendicitis. Clin Imaging 2016; 40:944-8. [PMID: 27203288 DOI: 10.1016/j.clinimag.2016.03.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Revised: 03/18/2016] [Accepted: 03/30/2016] [Indexed: 12/29/2022]
Abstract
The purpose of this study is to evaluate the current performance of ultrasound in the diagnosis of acute appendicitis. Retrospectively, patients who presented to a single institution between 2011 and 2012 were included. Diagnostic accuracy was calculated, with surgery considered gold-standard. Our data demonstrates that US relative to surgery-confirmed appendicitis has a sensitivity and specificity of 48.4% and 97.9%, respectively. The diagnostic accuracy was further increased when there was a low pre-test probability, with a NPV of up to 96.6%. Ultrasound has a strong PPV in the diagnosis of acute appendicitis, and in equivocal cases, the NPV is reliable.
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Affiliation(s)
- Pedro Lourenco
- St. Paul's Hospital, Department of Radiology, University of British Columbia, 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
| | - Jacquie Brown
- St. Paul's Hospital, Department of Radiology, University of British Columbia, 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
| | - Jonathan Leipsic
- St. Paul's Hospital, Department of Radiology, University of British Columbia, 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
| | - Cameron Hague
- St. Paul's Hospital, Department of Radiology, University of British Columbia, 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
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156
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How do we approach an adult patient with suspected acute appendicitis? MEDICINA UNIVERSITARIA 2016. [DOI: 10.1016/j.rmu.2016.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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157
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Golden SK, Harringa JB, Pickhardt PJ, Ebinger A, Svenson JE, Zhao YQ, Li Z, Westergaard RP, Ehlenbach WJ, Repplinger MD. Prospective evaluation of the ability of clinical scoring systems and physician-determined likelihood of appendicitis to obviate the need for CT. Emerg Med J 2016; 33:458-64. [PMID: 26935714 DOI: 10.1136/emermed-2015-205301] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 02/10/2016] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To determine whether clinical scoring systems or physician gestalt can obviate the need for computed tomography (CT) in patients with possible appendicitis. METHODS Prospective, observational study of patients with abdominal pain at an academic emergency department (ED) from February 2012 to February 2014. Patients over 11 years old who had a CT ordered for possible appendicitis were eligible. All parameters needed to calculate the scores were recorded on standardised forms prior to CT. Physicians also estimated the likelihood of appendicitis. Test characteristics were calculated using clinical follow-up as the reference standard. Receiver operating characteristic curves were drawn. RESULTS Of the 287 patients (mean age (range), 31 (12-88) years; 60% women), the prevalence of appendicitis was 33%. The Alvarado score had a positive likelihood ratio (LR(+)) (95% CI) of 2.2 (1.7 to 3) and a negative likelihood ratio (LR(-)) of 0.6 (0.4 to 0.7). The modified Alvarado score (MAS) had LR(+) 2.4 (1.6 to 3.4) and LR(-) 0.7 (0.6 to 0.8). The Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) score had LR(+) 1.3 (1.1 to 1.5) and LR(-) 0.5 (0.4 to 0.8). Physician-determined likelihood of appendicitis had LR(+) 1.3 (1.2 to 1.5) and LR(-) 0.3 (0.2 to 0.6). When combined with physician likelihoods, LR(+) and LR(-) was 3.67 and 0.48 (Alvarado), 2.33 and 0.45 (RIPASA), and 3.87 and 0.47 (MAS). The area under the curve was highest for physician-determined likelihood (0.72), but was not statistically significantly different from the clinical scores (RIPASA 0.67, Alvarado 0.72, MAS 0.7). CONCLUSIONS Clinical scoring systems performed equally well as physician gestalt in predicting appendicitis. These scores do not obviate the need for imaging for possible appendicitis when a physician deems it necessary.
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Affiliation(s)
- Sean K Golden
- BerbeeWalsh, Department of Emergency Medicine, University of Wisconsin-Madison, Wisconsin, USA
| | - John B Harringa
- BerbeeWalsh, Department of Emergency Medicine, University of Wisconsin-Madison, Wisconsin, USA
| | - Perry J Pickhardt
- Department of Radiology, University of Wisconsin-Madison, Wisconsin, USA
| | - Alexander Ebinger
- Department of Emergency Medicine, University of Colorado School of Medicine, Denver, Colorado, USA
| | - James E Svenson
- BerbeeWalsh, Department of Emergency Medicine, University of Wisconsin-Madison, Wisconsin, USA
| | - Ying-Qi Zhao
- Department of Biostatistics and Medical Informatics, University of Wisconsin, Madison, Wisconsin, USA
| | - Zhanhai Li
- Department of Biostatistics and Medical Informatics, University of Wisconsin, Madison, Wisconsin, USA
| | - Ryan P Westergaard
- Department of Medicine, University of Wisconsin, Madison, Wisconsin, USA
| | | | - Michael D Repplinger
- BerbeeWalsh, Department of Emergency Medicine, University of Wisconsin-Madison, Wisconsin, USA Department of Radiology, University of Wisconsin-Madison, Wisconsin, USA
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159
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Athans BS, Depinet HE, Towbin AJ, Zhang Y, Zhang B, Trout AT. Use of Clinical Data to Predict Appendicitis in Patients with Equivocal US Findings. Radiology 2016; 280:557-67. [PMID: 26878226 DOI: 10.1148/radiol.2016151412] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Purpose To determine the incremental value of clinical data in patients with ultrasonographic (US) examinations that were interpreted as being equivocal for acute appendicitis. Materials and Methods Institutional review board approval, with a waiver of informed consent, was obtained for this analysis of clinical and imaging data in patients younger than 18 years old who were evaluated for acute appendicitis. Findings from US examinations were reported in a structured fashion, including two possible equivocal impressions. Clinical data were captured as Pediatric Appendicitis (PAS) or Alvarado scores and considered as categoric (high, intermediate, or low likelihood) and continuous variables to simulate stratification of equivocal US examinations to predict appendicitis. Receiver operating characteristic curves were used to define score cutoffs, and logistic regression was used to assess individual clinical variables as predictors of appendicitis. Results The study population was made up of 776 patients (mean age, 11.7 years ± 3.7), with 429 (55.2%) girls. A total of 203 (26%) patients had appendicitis. US had a negative predictive value of 96.2% and a positive predictive value of 93.3% for depicting appendicitis, with 89 of 782 (11.4%) equivocal examinations. Categoric PAS and Alvarado scores were equivocal for 59.5% (53 of 89) and 50.6% (45 of 89) of equivocal US examinations, respectively. Categoric low- and high-likelihood PAS and Alvarado scores correctly predicted the presence of appendicitis in 61.1% (22 of 36) and 77.3% (34 of 44) of equivocal US examinations, respectively. As continuous variables, a PAS or Alvarado score of 5 or lower could be used to exclude appendicitis, with a 80.8% (21 of 26) and 90% (18 of 20) negative predictive value, respectively. Conclusion The study confirms the excellent performance of US for depicting pediatric appendicitis. In the subset of equivocal US examinations, a low clinical score (≤5) may be used to identify patients with a low likelihood of having appendicitis. (©) RSNA, 2016.
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Affiliation(s)
- Brett S Athans
- From the University of Cincinnati College of Medicine, Cincinnati, Ohio (B.S.A.); Division of Emergency Medicine (H.E.D.), Department of Radiology (A.J.T., A.T.T.), and Division of Biostatistics and Epidemiology (B.Z.), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 5031, Cincinnati, OH 45229; and Department of Mathematical Sciences, University of Cincinnati, Cincinnati, Ohio (Y.Z.)
| | - Holly E Depinet
- From the University of Cincinnati College of Medicine, Cincinnati, Ohio (B.S.A.); Division of Emergency Medicine (H.E.D.), Department of Radiology (A.J.T., A.T.T.), and Division of Biostatistics and Epidemiology (B.Z.), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 5031, Cincinnati, OH 45229; and Department of Mathematical Sciences, University of Cincinnati, Cincinnati, Ohio (Y.Z.)
| | - Alexander J Towbin
- From the University of Cincinnati College of Medicine, Cincinnati, Ohio (B.S.A.); Division of Emergency Medicine (H.E.D.), Department of Radiology (A.J.T., A.T.T.), and Division of Biostatistics and Epidemiology (B.Z.), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 5031, Cincinnati, OH 45229; and Department of Mathematical Sciences, University of Cincinnati, Cincinnati, Ohio (Y.Z.)
| | - Yue Zhang
- From the University of Cincinnati College of Medicine, Cincinnati, Ohio (B.S.A.); Division of Emergency Medicine (H.E.D.), Department of Radiology (A.J.T., A.T.T.), and Division of Biostatistics and Epidemiology (B.Z.), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 5031, Cincinnati, OH 45229; and Department of Mathematical Sciences, University of Cincinnati, Cincinnati, Ohio (Y.Z.)
| | - Bin Zhang
- From the University of Cincinnati College of Medicine, Cincinnati, Ohio (B.S.A.); Division of Emergency Medicine (H.E.D.), Department of Radiology (A.J.T., A.T.T.), and Division of Biostatistics and Epidemiology (B.Z.), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 5031, Cincinnati, OH 45229; and Department of Mathematical Sciences, University of Cincinnati, Cincinnati, Ohio (Y.Z.)
| | - Andrew T Trout
- From the University of Cincinnati College of Medicine, Cincinnati, Ohio (B.S.A.); Division of Emergency Medicine (H.E.D.), Department of Radiology (A.J.T., A.T.T.), and Division of Biostatistics and Epidemiology (B.Z.), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 5031, Cincinnati, OH 45229; and Department of Mathematical Sciences, University of Cincinnati, Cincinnati, Ohio (Y.Z.)
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Prognostic capabilities and agreement of three different scores in diagnosing appendicitis in children from a developing setting. ANNALS OF PEDIATRIC SURGERY 2016. [DOI: 10.1097/01.xps.0000476033.40918.0f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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161
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Bhangu A, Søreide K, Di Saverio S, Assarsson JH, Drake FT. Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management. Lancet 2015; 386:1278-1287. [PMID: 26460662 DOI: 10.1016/s0140-6736(15)00275-5] [Citation(s) in RCA: 582] [Impact Index Per Article: 64.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Acute appendicitis is one of the most common abdominal emergencies worldwide. The cause remains poorly understood, with few advances in the past few decades. To obtain a confident preoperative diagnosis is still a challenge, since the possibility of appendicitis must be entertained in any patient presenting with an acute abdomen. Although biomarkers and imaging are valuable adjuncts to history and examination, their limitations mean that clinical assessment is still the mainstay of diagnosis. A clinical classification is used to stratify management based on simple (non-perforated) and complex (gangrenous or perforated) inflammation, although many patients remain with an equivocal diagnosis, which is one of the most challenging dilemmas. An observed divide in disease course suggests that some cases of simple appendicitis might be self-limiting or respond to antibiotics alone, whereas another type often seems to perforate before the patient reaches hospital. Although the mortality rate is low, postoperative complications are common in complex disease. We discuss existing knowledge in pathogenesis, modern diagnosis, and evolving strategies in management that are leading to stratified care for patients.
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Affiliation(s)
- Aneel Bhangu
- Academic Department of Surgery, Queen Elizabeth Hospital, Edgbaston, Birmingham UK; College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Kjetil Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Salomone Di Saverio
- Emergency and General Surgery Department, CA Pizzardi Maggiore Hospital, Bologna, Italy
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Factors Associated with Perforated Appendicitis in Elderly Patients in a Tertiary Care Hospital. Surg Res Pract 2015; 2015:847681. [PMID: 26380377 PMCID: PMC4561309 DOI: 10.1155/2015/847681] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Revised: 08/03/2015] [Accepted: 08/10/2015] [Indexed: 12/15/2022] Open
Abstract
Background. The incidence of perforated appendicitis in elderly patients is high and carries increased morbidity and mortality rates. The aim of this study was to identify risk factors of perforation in elderly patients who presented with clinical of acute appendicitis. Methods. This was a retrospective study, reviewing medical records of patients over the age of 60 years who had a confirmed diagnosis of acute appendicitis. Patients were classified into two groups: those with perforated appendicitis and those with nonperforated appendicitis. Demographic data, clinical presentations, and laboratory analysis were compared. Results. Of the 206 acute appendicitis patients over the age of 60 years, perforated appendicitis was found in 106 (50%) patients. The four factors which predicted appendiceal rupture were as follows: male; duration of pain in preadmission period; fever (>38°C); and anorexia. The overall complication rate was 34% in the perforation group and 12.6% in the nonperforation group. Conclusions. The incidence of perforated appendicitis in elderly patients was higher in males and those who had certain clinical features such as fever and anorexia. Duration of pain in the preadmission period was also an important factor in appendiceal rupture. Early diagnosis may decrease the incidence of perforated appendicitis in elderly patients.
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163
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Kollár D, McCartan DP, Bourke M, Cross KS, Dowdall J. Predicting acute appendicitis? A comparison of the Alvarado score, the Appendicitis Inflammatory Response Score and clinical assessment. World J Surg 2015; 39:104-9. [PMID: 25245432 DOI: 10.1007/s00268-014-2794-6] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Patients presenting with suspected appendicitis pose a diagnostic challenge. The appendicitis inflammatory response (AIR) score has outperformed the Alvarado score in two retrospective studies. The aim of this study was to evaluate the AIR Score and compare its performance in predicting risk of appendicitis to both the Alvarado score and the clinical impression of a senior surgeon. METHODS All parameters included in the AIR and Alvarado scores as well as the initial clinical impression of a senior surgeon were prospectively recorded on patients referred to the surgical on call team with acute right iliac fossa pain over a 6-month period. Predictions were correlated with the final diagnosis of appendicitis. RESULTS Appendicitis was the final diagnosis in 67 of 182 patients (37 %). The three methods of assessment stratified similar proportions (~40 %) of patients to a low probability of appendicitis (p = 0.233) with a false negative rate of <8 % that did not differ between the AIR score, Alvarado score or clinical assessment. The AIR score assigned a smaller proportion of patients to the high probability zone than the Alvarado score (14 vs. 45 %) but it did so with a substantially higher specificity (97 %) and positive predictive value (88 %) than the Alvarado score (76 and 65 %, respectively). CONCLUSIONS The AIR score is accurate at excluding appendicitis in those deemed low risk and more accurate at predicting appendicitis than the Alvarado score in those deemed high risk. Its use as the basis for selective CT imaging in those deemed medium risk should be considered.
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Affiliation(s)
- D Kollár
- Department of Surgery, Waterford Regional Hospital, Dunmore Road, Waterford, Republic of Ireland
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Walczak DA, Pawełczak D, Żółtaszek A, Jaguścik R, Fałek W, Czerwińska M, Ptasińska K, Trzeciak PW, Pasieka Z. The Value of Scoring Systems for the Diagnosis of Acute Appendicitis. POLISH JOURNAL OF SURGERY 2015; 87:65-70. [PMID: 26146097 DOI: 10.1515/pjs-2015-0021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
UNLABELLED Accurate diagnosis of acute appendicitis (AA) is still a problem and is not always easy, even for experienced surgeons. Studies have shown that 20 to 30% of the appendices removedwere normal. Therefore, various scoring systems have been developed to aid in the diagnosis of doubtful cases and reduce the number of unnecessary appendectomies. The aim of this study was to assess the diagnostic value of different scoring systems in acute appendicitis. MATERIAL AND METHODS The study involved 94 patients who underwent laparotomy due to suspected acute appendicitis. Medical examination at hospital admission was performed by a resident and a general surgery specialist. The probability of AA was evaluated using six different scoring systems: Alvarado, Fenyo, Eskelinen, Ohman, Tzankis, and RIPASA. The resident calculated the results in individual systems. The decision to perform the operation was taken by a specialist surgeon who did not know the results. RESULTS Normal appendix was removed in 26% of cases. Eskelinen, RIPASA and Alvarado systems showed highest sensitivity (99%, 88% and 85%, respectively). Tzankis and Fenyo systems showed highest specificity (62% and 50%, respectively). CONCLUSIONS Our study has shown limited value of scoring systems for the diagnosis of acute appendicitis. The systems may improve diagnostic accuracy as they require obtaining a more detailed medical history, and making a more thorough and organized data analysis. However, the scoring systems should be treated only as an aid to diagnosis.
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Corrigan D, McDonnell R, Zarabzadeh A, Fahey T. A Multistep Maturity Model for the Implementation of Electronic and Computable Diagnostic Clinical Prediction Rules (eCPRs). EGEMS 2015; 3:1153. [PMID: 26290890 PMCID: PMC4537149 DOI: 10.13063/2327-9214.1153] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Introduction: The use of Clinical Prediction Rules (CPRs) has been advocated as one way of implementing actionable evidence-based rules in clinical practice. The current highly manual nature of deriving CPRs makes them difficult to use and maintain. Addressing the known limitations of CPRs requires implementing more flexible and dynamic models of CPR development. We describe the application of Information and Communication Technology (ICT) to provide a platform for the derivation and dissemination of CPRs derived through analysis and continual learning from electronic patient data. Model Components: We propose a multistep maturity model for constructing electronic and computable CPRs (eCPRs). The model has six levels – from the lowest level of CPR maturity (literaturebased CPRs) to a fully electronic and computable service-oriented model of CPRs that are sensitive to specific demographic patient populations. We describe examples of implementations of the core model components – focusing on CPR representation, interoperability, electronic dissemination, CPR learning, and user interface requirements. Conclusion: The traditional focus on derivation and narrow validation of CPRs has severely limited their wider acceptance. The evolution and maturity model described here outlines a progression toward eCPRs consistent with the vision of a learning health system (LHS) – using central repositories of CPR knowledge, accessible open standards, and generalizable models to avoid repetition of previous work. This is useful for developing more ambitious strategies to address limitations of the traditional CPR development life cycle. The model described here is a starting point for promoting discussion about what a more dynamic CPR development process should look like.
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Affiliation(s)
- Derek Corrigan
- HRB Centre for Primary Care Research, RCSI Medical School, Dublin
| | - Ronan McDonnell
- HRB Centre for Primary Care Research, RCSI Medical School, Dublin
| | - Atieh Zarabzadeh
- HRB Centre for Primary Care Research, RCSI Medical School, Dublin
| | - Tom Fahey
- HRB Centre for Primary Care Research, RCSI Medical School, Dublin
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Öztürk A, Yananlı Z, Atalay T, Akıncı ÖF. The comparison of the effectiveness of tomography and Alvarado scoring system in patients who underwent surgery with the diagnosis of appendicitis. ULUSAL CERRAHI DERGISI 2015; 32:111-4. [PMID: 27436935 DOI: 10.5152/ucd.2015.2813] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Accepted: 11/16/2014] [Indexed: 12/29/2022]
Abstract
OBJECTIVE The aim of this study is to compare the effectiveness of computed tomography and Alvarado scoring system in the diagnosis of acute appendicitis in patients who underwent appendectomy with the preliminary diagnosis of acute appendicitis. MATERIAL AND METHODS One hundred and one patients who underwent appendectomy with the diagnosis of acute appendicitis between January and December 2011 were included in the study. Alvarado scores were calculated, and abdominal tomography scans were obtained for each patient before surgery. Patients with Alvarado score ≥7 were considered to have appendicitis while patients with a score <7 were considered not to have appendicitis. Patients were classified into two groups based on the presence of appendicitis findings on abdominal tomography. Histopathological examination of the appendices was performed following appendectomy. All patients were classified into groups according to pathology results, Alvarado score and tomography findings. The effectiveness of Alvarado score and tomography were compared using the McNemar test. RESULTS Sixty patients (59.4%) were male and 41 (40.6%) were female, with a mean age of 32 years (5-85 years). The rate of negative appendectomy was 3.9%. In 78 patients (77.3%) the Alvarado score was ≥7, while 23 patients (22.7%) had Alvarado scores <7. The presence of appendicitis was determined by histopathology in 22 out of 23 patients whose Alvarado score was <7. Tomography indicated appendicitis in 97 patients (95.9%) whereas four patients (4.1%) exhibited no signs of appendicitis by tomography. However, histopathological evaluation indicated the presence of appendicitis in those four patients as well. CONCLUSION The study results imply that tomography is a more effective means of diagnosing acute appendicitis as compared to the Alvarado scoring system.
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Affiliation(s)
- Alaattin Öztürk
- Department of General Surgery, Fatih University School of Medicine, İstanbul, Turkey
| | - Zuhal Yananlı
- Department of General Surgery, Fatih University School of Medicine, İstanbul, Turkey
| | - Talha Atalay
- Department of General Surgery, Fatih University School of Medicine, İstanbul, Turkey
| | - Ömer Faruk Akıncı
- Department of General Surgery, Fatih University School of Medicine, İstanbul, Turkey
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Sandell E, Berg M, Sandblom G, Sundman J, Fränneby U, Boström L, Andrén-Sandberg Å. Surgical decision-making in acute appendicitis. BMC Surg 2015; 15:69. [PMID: 26032861 PMCID: PMC4450839 DOI: 10.1186/s12893-015-0053-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Accepted: 05/13/2015] [Indexed: 12/29/2022] Open
Abstract
Background Acute appendicitis is one of the most common acute abdominal conditions. Among other parameters, the decision to perform surgical exploration in suspected appendicitis involves diagnostic accuracy, patient age and co-morbidity, patient’s own wishes, the surgeon’s core medical values, expected natural course of non-operative treatment and priority considerations regarding the use of limited resources. Do objective clinical findings, such as radiology and laboratory results, have greater impact on decision-making than “soft” clinical variables? In this study we investigate the parameters that surgeons consider significant in decision-making in cases of suspected appendicitis; specifically we describe the process leading to surgical intervention in real settings. The purpose of the study was to explore the process behind the decision to undertake surgery on a patient with suspected appendicitis as a model for decision-making in surgery. Methods All appendectomy procedures (n = 201) at the Department of Surgery at Karolinska University Hospital performed in 2009 were retrospectively evaluated. Every two consecutive patients seeking for abdominal pain after each case undergoing surgery were included as controls. Signs and symptoms documented in the medical records were registered according to a standardized protocol. The outcome of this retrospective review formed the basis of a prospective registration of patients undergoing appendectomy. During a three- month period in 2011, the surgeons who made the decision to perform acute appendectomy on 117 consecutive appendectomized patients at the Karolinska University Hospital, Huddinge, and Södersjukhuset, were asked to answer a questionnaire about symptoms, signs and diagnostic measures considered in their treatment decision. They were also asked which three symptoms, signs and diagnostic measures had the greatest impact on their decision to perform appendectomy. Results In the retrospective review, tenderness in the right fossa had the greatest impact (OR 76) on treatment decision. In the prospective registration, the most frequent symptom present at treatment decision was pain in the right fossa (94 %). Tenderness in the right fossa (69 %) was also most important for the decision to perform surgery. Apart from local status, image diagnostics and blood sample results had the greatest impact. Conclusion Local tenderness in the right fossa, lab results and the results of radiological investigations had the greatest impact on treatment decision.
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Affiliation(s)
- Eva Sandell
- The department of Gastroenterology, Karolinska University Hospital, Stockholm, Sweden.
| | - Maria Berg
- Vårby General Practice, Stockholm, Sweden
| | - Gabriel Sandblom
- The department of Gastrointestinal Surgery, Karolinska University Hospital, Stockholm, Sweden.,Karolinska Institute, CLINTEC, Stockholm, Sweden
| | - Joar Sundman
- The department of Otorhinolaryngology, Karolinska University Hospital, Stockholm, Sweden
| | - Ulf Fränneby
- The department of Gastrointestinal Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Lennart Boström
- The department of Surgery, Södersjukhuset, Stockholm, Sweden
| | - Åke Andrén-Sandberg
- The department of Gastroenterology, Karolinska University Hospital, Stockholm, Sweden.,Karolinska Institute, CLINTEC, Stockholm, Sweden
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Al-Abed YA, Alobaid N, Myint F. Diagnostic markers in acute appendicitis. Am J Surg 2015; 209:1043-7. [DOI: 10.1016/j.amjsurg.2014.05.024] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2014] [Revised: 05/20/2014] [Accepted: 05/27/2014] [Indexed: 12/29/2022]
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Journal Club: the Alvarado score as a method for reducing the number of CT studies when appendiceal ultrasound fails to visualize the appendix in adults. AJR Am J Roentgenol 2015; 204:519-26. [PMID: 25714280 DOI: 10.2214/ajr.14.12864] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE. The purpose of this article is to evaluate the hypothesis that Alvarado scores of 3 or lower identify adult patients who are unlikely to benefit from CT after appendiceal ultrasound fails to show the appendix and is otherwise normal. MATERIALS AND METHODS. We identified 119 consecutive adults for whom the appendix was not seen on otherwise normal appendiceal sonography performed as the first imaging study for suspected appendicitis, who subsequently underwent CT within 48 hours, and whose data permitted retrospective calculation of admission Alvarado scores. Specific benefits of CT were defined as diagnoses of appendicitis or significant alternative findings, and specific benefits were compared between patients with Alvarado scores of 3 or less and 4 or higher. Significant alternative findings on CT were findings other than appendicitis that were treated with medical or surgical therapy during the admission or that were to be addressed during follow-up care. Diagnostic reference standards were discharge diagnoses, pathologic examinations, and clinical follow-up. RESULTS. No patients (0.0%, 0/49) with Alvarado scores 3 or lower had appendicitis, compared with 17.1% (12/70) of patients with Alvarado scores 4 or higher (p = 0.001), and CT showed neither appendicitis nor significant alternative findings in 85.7% (42/49) versus 58.6% (41/70) of these patients, respectively (p = 0.002). The rates of perforated appendicitis, as well as significant alternative CT findings, did not differ significantly. CONCLUSION. Adults with Alvarado scores 3 or lower who have nonvisualized appendixes and otherwise normal appendiceal sonography are at very low risk for appendicitis or significant alternative findings and therefore are not likely to benefit from CT.
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171
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Liu W, Wei Qiang J, Xun Sun R. Comparison of multislice computed tomography and clinical scores for diagnosing acute appendicitis. J Int Med Res 2015; 43:341-9. [PMID: 25762518 DOI: 10.1177/0300060514564475] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Accepted: 11/14/2014] [Indexed: 12/11/2022] Open
Abstract
Objective To compare Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) and Alvarado scores with multislice computed tomography (MSCT) for diagnosing acute appendicitis (AA). Methods This retrospective study included patients with abdominal pain who had undergone MSCT, and whose medical notes included RIPASA and Alvarado score parameters. MSCT was compared with RIPASA and Alvarado scores for diagnosing AA. Results Of 297 patients included, sensitivity, specificity and accuracy for diagnosing AA were 95.2%, 73.6% and 87.2% for RIPASA score (cutoff value 7.5) and 63.1%, 80.9% and 69.7% for Alvarado score (cutoff value 7). Sensitivity, specificity and accuracy of MSCT for diagnosing AA were 98.9%, 96.4% and 98.0%, respectively. In terms of accuracy, statistically significant differences were observed between RIPASA and Alvarado scores, and between MSCT and RIPASA scores. The mean RIPASA score was significantly different in the simple AA group (9.7 ± 2.2) compared with other AA groups (10.5 ± 1.7). No statistically significant difference was observed in RIPASA score between nonperforated and perforated AA. MSCT sensitivity, specificity and accuracy for diagnosing simple AA were 94.1%, 96.4% and 95.8%, respectively; for differentiating perforated and nonperforated AA, scores were 90.2%, 95.2% and 94.1%, respectively. Conclusion MSCT is the optimum diagnostic tool for AA, followed by RIPASA score and Alvarado score, particularly in diagnosing simple and perforated AA.
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Affiliation(s)
- Wen Liu
- Department of Radiology, Jinshan Hospital, Fudan University, Shanghai, China
| | - Jin Wei Qiang
- Department of Radiology, Jinshan Hospital, Fudan University, Shanghai, China
| | - Rong Xun Sun
- Department of General Surgery, Jinshan Hospital, Fudan University, Shanghai, China
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172
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A comparison of univariate and bivariate models in meta-analysis of diagnostic accuracy studies. INT J EVID-BASED HEA 2015; 13:28-34. [PMID: 25734862 DOI: 10.1097/xeb.0000000000000037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
AIM : An implicit diagnostic threshold has been thought to be the cause of between-study variation in meta-analyses of diagnostic accuracy studies. Bivariate models have been used to account for implicit diagnostic thresholds. However, little difference in estimates of test performance has been reported between univariate and bivariate models. This study aims to undertake another comparison of these two models in order to determine if spectrum effects could better explain the variation across studies. METHODS Studies were selected from those provided in Ohle et al.'s meta-analysis and quality scored using QUADAS 2. Univariate analyses of sensitivity and specificity were computed using two models: one bias-adjusted and the other not. The univariate sensitivity and specificity results were compared with the bivariate logit-normal summary ROC method. RESULTS Similar results were obtained when using summary ROC and univariate pooling methods for sensitivity and specificity. Differences in study characteristics were found for outlier studies in univariate analyses, suggesting spectrum effects. CONCLUSION Univariate pooling methods provide an estimate of test performance for an average disease spectrum which is possibly why results concur with the bivariate models. A better appreciation of such spectrum effects can be demonstrated through univariate analyses, especially when the forest plots are examined in either bias-adjusted or non-bias-adjusted univariate models.
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Prospective Comparison of the Alvarado Score and CT Scan in the Evaluation of Suspected Appendicitis: A Proposed Algorithm to Guide CT Use. J Am Coll Surg 2015; 220:218-24. [DOI: 10.1016/j.jamcollsurg.2014.10.010] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Revised: 10/17/2014] [Accepted: 10/21/2014] [Indexed: 12/29/2022]
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Dumlu EG, Tokaç M, Bozkurt B, Yildirim MB, Ergin M, Yalçin A, Kiliç M. Correlation between the serum and tissue levels of oxidative stress markers and the extent of inflammation in acute appendicitis. Clinics (Sao Paulo) 2014; 69:677-82. [PMID: 25518019 PMCID: PMC4221314 DOI: 10.6061/clinics/2014(10)05] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 06/27/2014] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES To determine the serum and tissue levels of markers of impaired oxidative metabolism and correlate these levels with the histopathology and Alvarado score of acute appendicitis patients. METHOD Sixty-five acute appendicitis patients (mean age, 31.4±12.06 years; male/female, 30/35) and 30 healthy control subjects were studied. The Alvarado score was recorded. Serum samples were obtained before surgery and 12 hours postoperatively to examine the total antioxidant status, total oxidant status, paraoxonase, stimulated paraoxonase, arylesterase, catalase, myeloperoxidase, ceruloplasmin, oxidative stress markers (advanced oxidized protein products and total thiol level) and ischemia-modified albumin. Surgical specimens were also evaluated. RESULTS The diagnoses were acute appendicitis (n = 37), perforated appendicitis (n = 8), phlegmonous appendicitis (n = 12), perforated+phlegmonous appendicitis (n = 4), or no appendicitis (n = 4). The Alvarado score of the acute appendicitis group was significantly lower than that of the perforated+phlegmonous appendicitis group (p = 0.004). The serum total antioxidant status, total thiol level, advanced oxidized protein products, total oxidant status, catalase, arylesterase, and ischemia-modified albumin levels were significantly different between the acute appendicitis and control groups. There was no correlation between the pathological extent of acute appendicitis and the tissue levels of the markers; additionally, there was no correlation between the tissue and serum levels of any of the parameters. CONCLUSIONS The imbalance of oxidant/antioxidant systems plays a role in the pathogenesis acute appendicitis. The Alvarado score can successfully predict the presence and extent of acute appendicitis.
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Affiliation(s)
- Ersin Gürkan Dumlu
- Department of General Surgery, Atatürk Training and Research Hospital, Ankara, Turkey
| | - Mehmet Tokaç
- Department of General Surgery, Atatürk Training and Research Hospital, Ankara, Turkey
| | - Birkan Bozkurt
- Department of General Surgery, Atatürk Training and Research Hospital, Ankara, Turkey
| | - Murat Baki Yildirim
- Department of General Surgery, Atatürk Training and Research Hospital, Ankara, Turkey
| | - Merve Ergin
- Department of Biochemistry, Atatürk Training and Research Hospital, Ankara, Turkey
| | - Abdussamed Yalçin
- Department of General Surgery, Yildirim Beyazit University Faculty of Medicine, Bilkent, Ankara, Turkey
| | - Mehmet Kiliç
- Department of General Surgery, Yildirim Beyazit University Faculty of Medicine, Bilkent, Ankara, Turkey
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The Challenge of Clinical Diagnosis of Appendicitis and Nonoperative Management of Patients With Right Lower Abdominal Pain. Ann Surg 2014; 263:e22-3. [PMID: 25371133 DOI: 10.1097/sla.0000000000001025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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176
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Acute Abdomen due to Primary Omental Torsion and Infarction. Case Rep Surg 2014; 2014:208382. [PMID: 25431726 PMCID: PMC4241260 DOI: 10.1155/2014/208382] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Accepted: 10/08/2014] [Indexed: 12/29/2022] Open
Abstract
Background. Torsion of greater omentum is a quite uncommon cause of acute abdomen. It can be primary or secondary but in both cases omentum twists upon itself and causes omental segmentary or diffuse necrosis. Symptoms are unspecific and preoperative diagnosis is difficult. The widespread and increasing use of computer tomography (CT) in differential diagnosis of acute abdomen can be useful for making a specific diagnosis. Objectives. This work aims to describe primary omental torsion in order to help avoid misdiagnosis, especially with acute appendicitis, which is eventually based solely on a physical examination. Case Report. We present a case of primary omental torsion in a young man and discuss contemporary methods in diagnosis and management of the condition. Conclusions. When a right diagnosis has been posed, possible treatments for omental torsion and necrosis are two: conservative or surgical. Conservative treatment had been rarely carried out because of frequent and important sequelae just like abdominal abscesses. Nowadays, surgical treatment, laparoscopic or laparotomic, is preferred because it is a safe method in diagnosis and management of this condition.
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Shogilev DJ, Duus N, Odom SR, Shapiro NI. Diagnosing appendicitis: evidence-based review of the diagnostic approach in 2014. West J Emerg Med 2014; 15:859-71. [PMID: 25493136 PMCID: PMC4251237 DOI: 10.5811/westjem.2014.9.21568] [Citation(s) in RCA: 128] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Revised: 07/29/2014] [Accepted: 09/02/2014] [Indexed: 12/29/2022] Open
Abstract
Introduction Acute appendicitis is the most common abdominal emergency requiring emergency surgery. However, the diagnosis is often challenging and the decision to operate, observe or further work-up a patient is often unclear. The utility of clinical scoring systems (namely the Alvarado score), laboratory markers, and the development of novel markers in the diagnosis of appendicitis remains controversial. This article presents an update on the diagnostic approach to appendicitis through an evidence-based review. Methods We performed a broad Medline search of radiological imaging, the Alvarado score, common laboratory markers, and novel markers in patients with suspected appendicitis. Results Computed tomography (CT) is the most accurate mode of imaging for suspected cases of appendicitis, but the associated increase in radiation exposure is problematic. The Alvarado score is a clinical scoring system that is used to predict the likelihood of appendicitis based on signs, symptoms and laboratory data. It can help risk stratify patients with suspected appendicitis and potentially decrease the use of CT imaging in patients with certain Alvarado scores. White blood cell (WBC), C-reactive protein (CRP), granulocyte count and proportion of polymorphonuclear (PMN) cells are frequently elevated in patients with appendicitis, but are insufficient on their own as a diagnostic modality. When multiple markers are used in combination their diagnostic utility is greatly increased. Several novel markers have been proposed to aid in the diagnosis of appendicitis; however, while promising, most are only in the preliminary stages of being studied. Conclusion While CT is the most accurate mode of imaging in suspected appendicitis, the accompanying radiation is a concern. Ultrasound may help in the diagnosis while decreasing the need for CT in certain circumstances. The Alvarado Score has good diagnostic utility at specific cutoff points. Laboratory markers have very limited diagnostic utility on their own but show promise when used in combination. Further studies are warranted for laboratory markers in combination and to validate potential novel markers.
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Affiliation(s)
- Daniel J Shogilev
- Duke University, Division of Emergency Medicine, Duke University, Durham, North Carolina
| | - Nicolaj Duus
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, Massachusetts
| | - Stephen R Odom
- Beth Israel Deaconess Medical Center, Department of Surgery, Boston, Massachusetts
| | - Nathan I Shapiro
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine and Center for Vascular Biology, Boston, Massachusetts
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Sousa-Rodrigues CFD, Rocha ACD, Rodrigues AKB, Barbosa FT, Ramos FWDS, Valões SHC. Correlation between the Alvarado Scale and the macroscopic aspect of the appendix in patients with appendicitis. Rev Col Bras Cir 2014; 41:336-9. [DOI: 10.1590/0100-69912014005007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2013] [Accepted: 01/30/2014] [Indexed: 12/14/2022] Open
Abstract
Objective: To evaluate the possible association between the scale of Alvarado (EA) and macroscopic appearance (MA) of the appendix in patients with acute appendicitis.Methods: after receiving the diagnosis of acute appendicitis, EA data were collected. During appendectomy, MA data were collected. Data from patients without appendicitis were excluded. The Spearman correlation test was used to compare EA with Appendix MA (p < 0.05). Other variables were represented by simple frequency. The confidence interval (CI) of 95% was calculated for the correlation test.Results: Data were collected from 67 consecutive patients. The mean age was 37.1 ± 12.5 years and 77.6% of patients were male. The Spearman correlation test used for EA and MA was + 0.77 (95% CI 0.65-0.85, p < 0.0001).Conclusion: although correlation was not perfect, our data indicate that a high score on the scale of Alvarado in patients with appendicitis is correlated with advanced stages of the inflammatory process of acute appendicitis.
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Kong VY, van der Linde S, Aldous C, Handley JJ, Clarke DL. The accuracy of the Alvarado score in predicting acute appendicitis in the black South African population needs to be validated. Can J Surg 2014; 57:E121-5. [PMID: 25078937 DOI: 10.1503/cjs.023013] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The Alvarado score is the most widely used clinical prediction tool to facilitate decision-making in patients with acute appendicitis, but it has not been validated in the black South African population, which has much wider differential diagnosis than developed world populations. We investigated the applicability of this score to our local population and sought to introduce a checklist for rural doctors to facilitate early referral. METHODS We analyzed patients with proven appendicitis for the period January 2008 to December 2012. Alvarado scores were retrospectively assigned based on patients' admission charts. We generated a clinical probability score (1-4 = low, 5-6 = intermediate, 7-10 = high). RESULTS We studied 1000 patients (54% male, median age 21 yr). Forty percent had inflamed, nonperforated appendices and 60% had perforated appendices. Alvarado scores were 1-4 in 20.9%, 5-6 in 35.7% and 7-10 in 43.4%, indicating low, intermediate and high clincial probability, respectively. In our subgroup analysis of 510 patients without generalized peritonitis, Alvarado scores were 1-4 in 5.5%, 5-6 in 18.1% and 7-10 in 76.4%, indicating low, intermediate and high clinical probability, respectively. CONCLUSION The widespread use of the Alvarado score has its merits, but its applicability in the black South African population is unclear, with a significant proportion of patients with the disease being potentially missed. Further prospective validation of the Alvarado score and possible modification is needed to increase its relevance in our setting.
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Affiliation(s)
- Victor Y Kong
- The Department of Surgery, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Stefan van der Linde
- The Department of Surgery, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Colleen Aldous
- The Department of Surgery, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Jonathan J Handley
- The Department of Anaesthetics and Critical Care, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Damian L Clarke
- The Department of Surgery, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
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Lam SHF, Grippo A, Kerwin C, Konicki PJ, Goodwine D, Lambert MJ. Bedside ultrasonography as an adjunct to routine evaluation of acute appendicitis in the emergency department. West J Emerg Med 2014; 15:808-15. [PMID: 25493122 PMCID: PMC4251223 DOI: 10.5811/westjem.2014.9.21491] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2014] [Revised: 06/09/2014] [Accepted: 09/02/2014] [Indexed: 12/14/2022] Open
Abstract
Introduction Appendicitis is a common condition presenting to the emergency department (ED). Increasingly emergency physicians (EP) are using bedside ultrasound (BUS) as an adjunct diagnostic tool. Our objective is to investigate the test characteristics of BUS for the diagnosis of appendicitis and identify components of routine ED workup and BUS associated with the presence of appendicitis. Methods Patients four years of age and older presenting to the ED with suspected appendicitis were eligible for enrollment. After informed consent was obtained, BUS was performed on the subjects by trained EPs who had undergone a minimum of one-hour didactic training on the use of BUS to diagnose appendicitis. They then recorded elements of clinical history, physical examination, white blood cell count (WBC) with polymophonuclear percentage (PMN), and BUS findings on a data form. We ascertained subject outcomes by a combination of medical record review and telephone follow-up. Results A total of 125 subjects consented for the study, and 116 had adequate image data for final analysis. Prevalence of appendicitis was 40%. Mean age of the subjects was 20.2 years, and 51% were male. BUS was 100% sensitive (95% CI 87–100%) and 32% specific (95% CI 14–57%) for detection of appendicitis, with a positive predictive value of 72% (95% CI 56–84%), and a negative predictive value of 100% (95% CI 52–100%). Assuming all non-diagnostic studies were negative would yield a sensitivity of 72% and specificity of 81%. Subjects with appendicitis had a significantly higher occurrence of anorexia, nausea, vomiting, and a higher WBC and PMN count when compared to those without appendicitis. Their BUS studies were significantly more likely to result in visualization of the appendix, appendix diameter >6mm, appendix wall thickness >2mm, periappendiceal fluid, visualization of the appendix tip, and sonographic Mcburney’s sign (p<0.05). In subjects with diagnostic BUS studies, WBC, PMN, visualization of appendix, appendix diameter >6mm, appendix wall thickness >2mm, periappendiceal fluid were found to be predictors of appendicitis on logistic regression. Conclusion BUS is moderately useful for appendicitis diagnosis. We also identified several components in routine ED workup and BUS that are associated with appendicitis generating hypothesis for future studies.
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Affiliation(s)
- Samuel H F Lam
- Advocate Christ Medical Center, Department of Emergency Medicine, Oak Lawn, Illinois
| | - Anthony Grippo
- Advocate Christ Medical Center, Department of Emergency Medicine, Oak Lawn, Illinois
| | - Chistopher Kerwin
- Advocate Christ Medical Center, Department of Emergency Medicine, Oak Lawn, Illinois
| | - P John Konicki
- Advocate Christ Medical Center, Department of Emergency Medicine, Oak Lawn, Illinois
| | - Diana Goodwine
- Advocate Christ Medical Center, Department of Emergency Medicine, Oak Lawn, Illinois
| | - Michael J Lambert
- Advocate Christ Medical Center, Department of Emergency Medicine, Oak Lawn, Illinois
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181
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Clinical Evaluation of Acute Appendicitis. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2014. [DOI: 10.1016/j.cpem.2014.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Shah BR, Stewart J, Jeffrey RB, Olcott EW. Value of short-interval computed tomography when sonography fails to visualize the appendix and shows otherwise normal findings. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2014; 33:1589-1595. [PMID: 25154940 DOI: 10.7863/ultra.33.9.1589] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVES The purpose of this study was to evaluate the type and incidence of disorders revealed by short-interval computed tomography (CT) in patients with suspected appendicitis after graded compression sonography fails to reveal the appendix and shows otherwise normal findings. METHODS Computed tomographic findings and clinical courses were assessed retrospectively for 318 patients identified consecutively in a searchable database who met inclusion criteria specifying that sonography was the initial imaging examination for suspected appendicitis; sonography revealed nonvisualization of the appendix and otherwise normal results; and abdominopelvic CT was performed within 48 hours after sonography. RESULTS Of the 318 patients, short-interval CT revealed normal findings in 250 (78.6%). Appendicitis was revealed in 52 (16.4%) others, of whom 7 had perforation and all of whom had pathologic results confirming these CT findings. Important alternative diagnoses other than appendicitis were revealed in 16 (5.0%) others, including 2 (0.6%) who required urgent surgery and 14 (4.4%) who did not. No significant differences were observed between adult patients (>18 years) and pediatric patients. CONCLUSIONS Most short-interval CT scans in this clinical setting reveal normal findings, and relatively few disclose appendicitis or disorders that require urgent surgery. In view of concerns regarding radiation exposure associated with CT, these observations argue for the development of clinical triage methods that differentiate patients who are likely to benefit from short-interval postsonography CT from those who are not.
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Affiliation(s)
- Bhavya R Shah
- Department of Radiology, Stanford University School of Medicine, Stanford, California USA (B.R.S., J.S., R.B.J., E.W.O.); and Radiology Service, VA Palo Alto Health Care System, Palo Alto, California USA (E.W.O.)
| | - Jessica Stewart
- Department of Radiology, Stanford University School of Medicine, Stanford, California USA (B.R.S., J.S., R.B.J., E.W.O.); and Radiology Service, VA Palo Alto Health Care System, Palo Alto, California USA (E.W.O.)
| | - R Brooke Jeffrey
- Department of Radiology, Stanford University School of Medicine, Stanford, California USA (B.R.S., J.S., R.B.J., E.W.O.); and Radiology Service, VA Palo Alto Health Care System, Palo Alto, California USA (E.W.O.)
| | - Eric W Olcott
- Department of Radiology, Stanford University School of Medicine, Stanford, California USA (B.R.S., J.S., R.B.J., E.W.O.); and Radiology Service, VA Palo Alto Health Care System, Palo Alto, California USA (E.W.O.).
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The NOTA Study (Non Operative Treatment for Acute Appendicitis): prospective study on the efficacy and safety of antibiotics (amoxicillin and clavulanic acid) for treating patients with right lower quadrant abdominal pain and long-term follow-up of conservatively treated suspected appendicitis. Ann Surg 2014; 260:109-17. [PMID: 24646528 DOI: 10.1097/sla.0000000000000560] [Citation(s) in RCA: 179] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To assess the safety and efficacy of antibiotics treatment for suspected acute uncomplicated appendicitis and to monitor the long term follow-up of non-operated patients. BACKGROUND Right lower quadrant abdominal pain is a common cause of emergency department admission. The natural history of acute appendicitis nonoperatively treated with antibiotics remains unclear. METHODS In 2010, a total of 159 patients [mean AIR (Appendicitis Inflammatory Response) score = 4.9 and mean Alvarado score = 5.2] with suspected appendicitis were enrolled and underwent nonoperative management (NOM) with amoxicillin/clavulanate. The follow-up period was 2 years. RESULTS Short-term (7 days) NOM failure rate was 11.9%. All patients with initial failures were operated within 7 days. At 15 days, no recurrences were recorded. After 2 years, the overall recurrence rate was 13.8% (22/159); 14 of 22 patients were successfully treated with further cycle of amoxicillin/clavulanate. No major side effects occurred. Abdominal pain assessed by the Numeric Rating Scale and the visual analog scale; median Numeric Rating Scale score was 3 at 5 days and 2 after 7 days. Mean length of stay of nonoperatively managed patients was 0.4 days, and mean sick leave period was 5.8 days. Long-term efficacy of NOM treatment was 83% (118 patients recurrence free and 14 patients with recurrence nonoperatively managed). None of the single factors forming the Alvarado or AIR score were independent predictors of failure of NOM or long-term recurrence. Alvarado and AIR scores were the only independent predictive factors of NOM failure after multivariate analysis, but both did not correlate with recurrences. Overall costs of NOM and antibiotics were &OV0556;316.20 per patient. CONCLUSIONS Antibiotics for suspected acute appendicitis are safe and effective and may avoid unnecessary appendectomy, reducing operation rate, surgical risks, and overall costs. After 2 years of follow-up, recurrences of nonoperatively treated right lower quadrant abdominal pain are less than 14% and may be safely and effectively treated with further antibiotics.
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Koumarelas K, Theodoropoulos GE, Spyropoulos BG, Bramis K, Manouras A, Zografos G. A prospective longitudinal evaluation and affecting factors of health related quality of life after appendectomy. Int J Surg 2014; 12:848-57. [DOI: 10.1016/j.ijsu.2014.06.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Revised: 04/29/2014] [Accepted: 06/22/2014] [Indexed: 12/11/2022]
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Validation of the diagnostic score for acute lower abdominal pain in women of reproductive age. Emerg Med Int 2014; 2014:320926. [PMID: 24971177 PMCID: PMC4058215 DOI: 10.1155/2014/320926] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2014] [Revised: 04/27/2014] [Accepted: 05/13/2014] [Indexed: 12/29/2022] Open
Abstract
Background. The differential diagnoses of acute appendicitis obstetrics, and gynecological conditions (OB-GYNc) or nonspecific abdominal pain in young adult females with lower abdominal pain are clinically challenging. The present study aimed to validate the recently developed clinical score for the diagnosis of acute lower abdominal pain in female of reproductive age. Method. Medical records of reproductive age women (15-50 years) who were admitted for acute lower abdominal pain were collected. Validation data were obtained from patients admitted during a different period from the development data. Result. There were 302 patients in the validation cohort. For appendicitis, the score had a sensitivity of 91.9%, a specificity of 79.0%, and a positive likelihood ratio of 4.39. The sensitivity, specificity, and positive likelihood ratio in diagnosis of OB-GYNc were 73.0%, 91.6%, and 8.73, respectively. The areas under the receiver operating curves (ROC), the positive likelihood ratios, for appendicitis and OB-GYNc in the validation data were not significantly different from the development data, implying similar performances. Conclusion. The clinical score developed for the diagnosis of acute lower abdominal pain in female of reproductive age may be applied to guide differential diagnoses in these patients.
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Ebell MH, Shinholser J. What are the most clinically useful cutoffs for the Alvarado and Pediatric Appendicitis Scores? A systematic review. Ann Emerg Med 2014; 64:365-372.e2. [PMID: 24731432 DOI: 10.1016/j.annemergmed.2014.02.025] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2013] [Revised: 01/25/2014] [Accepted: 02/28/2014] [Indexed: 12/13/2022]
Abstract
STUDY OBJECTIVE The objective of this study is to systematically review the accuracy of the Alvarado score and Pediatric Appendicitis Score and to identify optimal cutoffs for low- and high-risk populations. METHODS We performed a systematic review of the literature and identified 26 studies of the accuracy of the Alvarado score and Pediatric Appendicitis Score. Data were abstracted in parallel, and only prospective, cohort studies that avoided verification bias were included. We calculated summary likelihood ratios for low-, moderate-, and high-risk groups, using all possible cutoffs based on available data, even if not reported in the original study. RESULTS The pretest probability of appendicitis was approximately 33% in studies of children and approximately 66% in studies of adults. Likelihood ratios at different cutoffs for the Alvarado score in adults were as follows: 0.03 (<4 points), 0.42 (4 to 6 points), and 3.4 (≥ 7 points); and 0.01 (<5 points), 0.98 (5 to 8 points), and 6.7 (≥ 9 points). Likelihood ratios for the Alvarado score in children were as follows: 0.02 (<4 points), 0.27 (4 to 6 points), and 4.2 (≥ 7 points); and 0.04 (<5 points), 1.2 (5 to 8 points), and 8.5 (≥ 9 points). For the Pediatric Appendicitis Score, likelihood ratios were 0.13 (<4 points), 0.70 (4 to 7 points), and 8.1 (≥ 8 points). CONCLUSION For children with a pretest probability of acute appendicitis of 60% or less, an Alvarado score below 4 rules out the diagnosis; this is also true for a score less than 5 if the pretest probability is up to approximately 40%. In adults with a pretest probability greater than or equal to 60%, an Alvarado score of 8 or higher rules in the diagnosis, whereas one of 9 or higher rules in the diagnosis at pretest probabilities greater than or equal to 40%. The Pediatric Appendicitis Score did not identify clinically useful low- or high-risk groups at typical pretest probabilities.
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Affiliation(s)
- Mark H Ebell
- Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA.
| | - JoAnna Shinholser
- Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA
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Mán E, Simonka Z, Varga Á, Rárosi F, Lázár G. Impact of the alvarado score on the diagnosis of acute appendicitis: comparing clinical judgment, alvarado score, and a new modified score in suspected appendicitis: a prospective, randomized clinical trial. Surg Endosc 2014; 28:2398-405. [DOI: 10.1007/s00464-014-3488-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Accepted: 02/14/2014] [Indexed: 12/29/2022]
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Improving the Application of Imaging Clinical Decision Support Tools: Making the Complex Simple. J Am Coll Radiol 2014; 11:257-61. [DOI: 10.1016/j.jacr.2013.10.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2013] [Accepted: 10/09/2013] [Indexed: 12/26/2022]
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Teo ATK, Lefter LP, Zarrouk AJM, Merrett ND. Institutional review of patients presenting with suspected appendicitis. ANZ J Surg 2014; 85:420-4. [PMID: 24640953 DOI: 10.1111/ans.12531] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/26/2013] [Indexed: 12/29/2022]
Abstract
BACKGROUND Appendicitis is a common gastrointestinal surgical emergency. Treatment balances the risks of negative appendicectomy (NA) against potential complicated appendicitis in determining clinical priority. This study reviewed the population characteristics, results of the diagnostic modalities and Alvarado score (AlvS) of patients with suspected appendicitis. METHODS A clinical audit of emergency appendicectomies was performed. Generalized linear models with a binomial distribution were used to evaluate the association between the age groups, gender, white cell count (WCC), neutrophil count (NC) and C-reactive protein (CRP) levels versus NAs and the different types of appendicitis. The utilization and accuracy of preoperative ultrasound and computed tomography (CT) and a preliminary analysis of AlvS were also evaluated. RESULTS Patients 17 to 24 years old had significantly higher odds of NA but lower odds of complicated appendicitis compared with patients above 40 years. Adult women and men had significantly higher odds of NA and suppurative appendicitis (SA), respectively. Only adults with SA and acute appendicitis had significantly higher odds of raised WCC, NC and CRP. The sensitivity of CT for adult females was high (100%). Patients who had CT and an AlvS of more than 7 did not have NAs. CONCLUSION Elevated WCC, NC and CRP were all associated with acute appendicitis and SA in adults only. CT is useful for refining the diagnosis in adult females. A combination of inflammatory markers, ultrasound and AlvS may be used selectively to complement or maximize the advantages of CT.
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Affiliation(s)
- Andrew Teck Kwee Teo
- Department of Surgery, Campbelltown Hospital, Sydney, New South Wales, Australia
| | - Liviu Paul Lefter
- Department of Surgery, Campbelltown Hospital, Sydney, New South Wales, Australia
| | | | - Neil Donald Merrett
- Department of Surgery, Campbelltown Hospital, Sydney, New South Wales, Australia.,Department of Surgery, University of Western Sydney, Sydney, New South Wales, Australia
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Bates MF, Khander A, Steigman SA, Tracy TF, Luks FI. Use of white blood cell count and negative appendectomy rate. Pediatrics 2014; 133:e39-44. [PMID: 24379236 DOI: 10.1542/peds.2013-2418] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Despite increased utilization of laboratory, radiologic imaging, and scoring systems, negative appendectomy (NA) rates in children remain above 3% nationwide. We reviewed the clinical data of patients undergoing appendectomy to further reduce our NA rate. METHODS A retrospective review was conducted of all appendectomies performed for suspected appendicitis at a tertiary children's hospital during a 42-month period. Preoperative clinical, laboratory, and radiographic data were collected. Variables absent or normal in more than half of NAs were further analyzed. Receiver operating characteristic curves were constructed for continuous variables by using appropriate cutoff points to determine sensitivity and false-positive rates. The results were validated by analyzing the 12 months immediately after the establishment of these rules. RESULTS Of 847 appendectomies performed, 22 (2.6%) had a pathologically normal appendix. The only variables found to be normal in more than half of NAs were white blood cell (WBC) count (89%) and neutrophil count (79%). A receiver operating characteristic curve indicates that using WBC cutoffs of 9000 and 8000 per µL yielded sensitivities of 92% and 95%, respectively, and reduction in NA rates by 77% and 36%, respectively. Results observed in the subsequent 12 months confirmed these expected sensitivities and specificities. CONCLUSIONS Absence of an elevated WBC count is a risk factor for NA. Withholding appendectomy for WBC counts <9000 and 8000 per µL reduces the NA rate to 0.6% and 1.2%, respectively. Missed true appendicitis in patients with normal WBC counts can be mitigated by a trial of observation in those presenting with early symptom onset.
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Affiliation(s)
- Maria F Bates
- Division of Pediatric Surgery, 2 Dudley St, Suite 190, Providence, RI 02905.
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191
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Huang TH, Huang YC, Tu CW. Acute appendicitis or not: Facts and suggestions to reduce valueless surgery. J Acute Med 2013. [DOI: 10.1016/j.jacme.2013.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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192
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Raines A, Garwe T, Wicks R, Palmer M, Wood F, Adeseye A, Tuggle D. Pediatric appendicitis: the prevalence of systemic inflammatory response syndrome upon presentation and its association with clinical outcomes. J Pediatr Surg 2013; 48:2442-5. [PMID: 24314184 DOI: 10.1016/j.jpedsurg.2013.08.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Accepted: 08/26/2013] [Indexed: 12/29/2022]
Abstract
INTRODUCTION To our knowledge, the prevalence of Systemic Inflammatory Response Syndrome (SIRS) in pediatric patients with appendicitis has not been previously investigated. Our specific aim was to determine the prevalence of SIRS at the time of presentation of pediatric patients with appendicitis. Additionally, we sought to determine if the presence of SIRS had any value in predicting their clinical outcomes. METHODS This retrospective cohort study included pediatric patients (age <17 years) presenting to a single hospital and being diagnosed with appendicitis between July 1, 2011, and June 30, 2012. The primary exposure variable of interest was SIRS, dichotomously defined as positive or negative. The primary outcome of interest was the presence/development of an intraabdominal abscess. The secondary outcome of interest was length of hospital stay (LOS). Chi-squared and t-tests were used to evaluate the association between presence of SIRS and development of abscess and LOS. RESULTS This study consisted of 212 patients. The definition of SIRS was met in 66 patients (31.1%). Thirty of the 66 (45.6%) patients with SIRS had/developed an abscess versus 28 (19.2%) of those without SIRS (P<0.001). Patients with SIRS had a mean LOS of 4 days (+/-2.7), while those without SIRS stayed a mean of 2.5 days (+/-2.3) [p<0.0001]). Adjusting for age did not alter these associations. CONCLUSION Our study found a 31.1% prevalence of SIRS in pediatric patients presenting with appendicitis. Our results suggest these patients with SIRS have a significantly higher risk of having/developing an intraabdominal abscess (RR, 2.4; 95% CI: 1.6-3.6) and significantly longer LOS.
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Affiliation(s)
- Alexander Raines
- Oklahoma University Health Sciences Center, Oklahoma City, OK, USA.
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Thirumallai S, Wijesuriya SR, Mitchell A, Delriviere L. Predictive value of C-reactive protein with Alvarado score in acute appendicitis. ANZ J Surg 2013; 84:335-6. [DOI: 10.1111/ans.12408] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2013] [Indexed: 12/29/2022]
Affiliation(s)
- Siva Thirumallai
- General Surgery; Sir Charles Gairdner Hospital; Perth Western Australia Australia
| | | | - Andrew Mitchell
- General Surgery; Sir Charles Gairdner Hospital; Perth Western Australia Australia
| | - Luc Delriviere
- General Surgery; Sir Charles Gairdner Hospital; Perth Western Australia Australia
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Poor Sensitivity of a Modified Alvarado Score in Adults With Suspected Appendicitis. Ann Emerg Med 2013; 62:126-31. [DOI: 10.1016/j.annemergmed.2013.01.021] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2012] [Revised: 01/17/2013] [Accepted: 01/28/2013] [Indexed: 12/29/2022]
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195
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Kruis W, Morgenstern J, Schanz S. Appendicitis/diverticulitis: diagnostics and conservative treatment. Dig Dis 2013; 31:69-75. [PMID: 23797126 DOI: 10.1159/000347185] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Appendicitis and diverticulitis are very common entities that show some similarities in diagnosis and course of disease. Both are widely believed to be simple clinical diagnoses, which is in contrast to scientific evidence. An accurate diagnosis has to describe not only the initial detection, but particularly the severity of the disease. It is based mainly on cross-sectional imaging by ultrasound (US) and computed tomography (CT). Appendectomy is the standard treatment for acute appendicitis and is mandatory in complicated cases. Antibiotic therapy is similarly effective in uncomplicated appendicitis, but long-term results are not sufficiently known. Treatment of diverticulitis is related to the disease status. Complications such as perforation and bleeding require intervention. Uncomplicated diverticulitis as graded by US or CT are subject to conservative management, in the form of outpatient or hospital care. It is an unresolved debate as to whether antibiotic treatment offers benefits. Mesalazine seems at least to improve pain. The real challenge is treatment of recurrent diverticulitis. Lifestyle measures such as nutritional habits and physical activity are found to influence diverticular disease. Besides immunosuppression, obesity is a significant risk factor for complicated diverticulitis. Whether any medication such as chronic antibiotics, probiotics or mesalazine offers benefits is unclear. The indication for sigmoid resection has changed; it is no longer given by the number of attacks, but rather by structural changes as depicted by cross-sectional imaging.
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Affiliation(s)
- Wolfgang Kruis
- Innere Abteilung, Evangelisches Krankenhaus Kalk, Universität zu Köln, Köln, Germany.
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196
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A preclustering-based ensemble learning technique for acute appendicitis diagnoses. Artif Intell Med 2013; 58:115-24. [DOI: 10.1016/j.artmed.2013.03.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2011] [Revised: 03/03/2013] [Accepted: 03/17/2013] [Indexed: 12/29/2022]
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197
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Roosinovich E, Reay-Jones N. Use of blood tests in the diagnosis of acute appendicitis. Br J Hosp Med (Lond) 2013; 73:C183-5. [PMID: 23519065 DOI: 10.12968/hmed.2012.73.sup12.c183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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198
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Tan WJ, Pek W, Kabir T, Goh YC, Chan WH, Wong WK, Ong HS. Alvarado score: a guide to computed tomography utilization in appendicitis. ANZ J Surg 2013; 83:748-52. [PMID: 23351046 DOI: 10.1111/ans.12076] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2013] [Indexed: 12/29/2022]
Abstract
BACKGROUND Although useful in evaluation of suspected appendicitis, not all patients require computed tomography (CT) evaluation. Clinical stratification of patients who benefit from CT evaluation is essential. We utilize the Alvarado score (AS) to stratify patients with suspected appendicitis into subgroups who benefit from CT evaluation and propose an objective algorithm with AS guiding CT utilization. METHODS This study is a retrospective review of medical records of all patients admitted for suspected appendicitis over a 6-month duration. Relevant data were recorded. The AS for each patient was determined retrospectively and correlated with histological and CT findings. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were determined for various ASs and for CT. RESULTS Three hundred fifty-eight patients were studied, with 167 males (46.6%) and 191 females (53.4%). Prevalence of appendicitis was 50% (179 patients). Two hundred fourteen patients (59.8%) had CT performed. Surgery was performed for 206 patients (57.5%). Overall negative appendicectomy rate was 13.1%. Patients who underwent CT evaluation had a negative appendicectomy rate of 5.7% compared to 17.9% in those without CT evaluation (P = 0.009). CT scan had a sensitivity and specificity of 92.6% and 96.9%, respectively. An AS greater than 3 had a sensitivity superior to CT (95.5%), while an AS of 9 or greater had a specificity superior to CT (100%). CONCLUSIONS In suspected appendicitis, patients who benefit from CT evaluation are those with the AS ranging from 4 to 8. We propose a management algorithm with the AS guiding the necessity for CT evaluation.
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Abstract
Neoplasms are an uncommon finding after appendectomy, with malignant tumors occurring in less than 1% of the surgical specimens, and carcinoid being the most frequent malignancy. A negative or inconclusive ultrasound is not adequate to rule out appendicitis and should be followed by CT scan. For pregnant patients, MRI is a reasonable alternative to CT scan. Nonoperative treatment with antibiotics is safe as an initial treatment of uncomplicated appendicitis, with a significant decrease in complications but a high failure rate. Open and laparoscopic appendectomies for appendicitis provide similar results overall, although the laparoscopic technique may be advantageous for obese and elderly patients but may be associated with a higher incidence of intraabdominal abscess. Preoperative diagnostic accuracy is of utmost importance during pregnancy because a negative appendectomy is associated with a significant incidence of fetal loss. The increased morbidity associated with appendectomy delay suggests that prompt surgical intervention remains the safest approach. Routine incidental appendectomy should not be performed except in selected cases. Interval appendectomy is not indicated because of considerable risks of complications and lack of any clinical benefit. Patients older than 40 years with an appendiceal mass or abscess treated nonoperatively should routinely have a colonoscopy as part of their follow-up to rule out cancer or alternative diagnosis.
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Affiliation(s)
- Pedro G R Teixeira
- Division of Trauma and Acute Care Surgery, LAC and USC Medical Center, University of Southern California, 2051 Marengo Street, IPT, Room C5L 100, Los Angeles, CA 90033-4525, USA
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Hong YR, Chung CW, Kim JW, Kwon CI, Ahn DH, Kwon SW, Kim SK. Hyperbilirubinemia is a significant indicator for the severity of acute appendicitis. JOURNAL OF THE KOREAN SOCIETY OF COLOPROCTOLOGY 2012. [PMID: 23185704 PMCID: PMC3499425 DOI: 10.3393/jksc.2012.28.5.247] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Purpose This study aims to reveal more effective clinical or laboratory markers for the diagnosis of acute appendicitis and to score the severity based on a sufficiently large number of patients with acute appendicitis. Methods We identified 1,195 patients with acute appendicitis after excluding those with other causes of hyperbilirubinemia among the 1,271 patients that underwent a laparoscopic or an open appendectomy between 2009 and 2010. A retrospective chart review of the medical records, including laboratory and histologic results, was conducted. We then analyzed the data using univariate and multivariate analyses. Results Among the 1,195 patients, a laparoscopic appendectomy was performed in 685 cases (57.32%), and an open appendectomy was performed in 510 cases (42.68%). The univariate analysis demonstrated significant differences for white blood cell count (P < 0.0001), segmented neutrophils (P = 0.0035), total bilirubin (P < 0.0001), and systemic inflammatory response syndrome (SIRS) score between groups (P < 0.0001). The multivariate analysis demonstrated that total bilirubin (odds ratio, 1.772; 95% confidence interval, 1.320 to 2.379; P = 0.0001) and SIRS score (odds ratio, 1.583; 95% confidence interval, 1.313 to 1.908; P < 0.0001) have statistically significant diagnostic value for perforated appendicitis. Conclusion Hyperbilirubinemia is a statistically significant diagnostic marker for acute appendicitis and the likelihood of perforation.
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Affiliation(s)
- Young Ran Hong
- Department of Surgery, Bundang CHA Hospital, CHA University College of Medicine, Seongnam, Korea
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