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Bl YBP, Mehra B, Ghoshal S, Dubhashi SP. Diagnostic Efficacy Study Comparing Tzanakis Scoring System With Alvarado Scoring System in Effective Diagnosis of Acute Appendicitis. Cureus 2024; 16:e58018. [PMID: 38738151 PMCID: PMC11087879 DOI: 10.7759/cureus.58018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/10/2024] [Indexed: 05/14/2024] Open
Abstract
Objective Among the common causes of abdominal emergencies, acute appendicitis ranks at the top, particularly in the young population. While negative appendectomy is not uncommon, the risk of appendicular perforation is substantial if the diagnosis is missed or delayed. This study evaluated the diagnostic efficacy of the Tzanakis scoring system for acute appendicitis, comparing it with the Alvarado scoring system, considering the histopathological finding as the gold standard. Materials and methods This prospective observational study, conducted in the General Surgery department in a tertiary care hospital in India, included clinically diagnosed acute appendicitis cases posted for open or laparoscopic appendicectomy. Results The mean age for the 60 participants included in the study was 30.97±13.44, and the median was 24.5 yrs. The sensitivity of ultrasonography (USG) in diagnosing histopathological positive acute appendicitis was 89%, and the specificity was 50%. The sensitivity, specificity, positive, and negative predictive values of the Tzanakis score were 87%, 50%, 96%, and 22%, respectively, and those of the Alvarado score were 54%, 75%, 96%, and 10%, respectively. Conclusion The receiver operator characteristic (ROC) curve for the Alvarado and Tzanakis scores showed that the area under the curve (AUC) was greater for the Tzanakis scoring system (0.670) than for the Alvarado scoring system (0.598). Differences between the AUCs were not statistically significant. Although the Tzanakis scoring system is more sensitive than the Alvarado scoring system in diagnosing acute appendicitis, studies with larger samples are needed to show the superiority of this scoring system over the Alvarado scoring system.
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Affiliation(s)
| | - Bhupendra Mehra
- General Surgery, All India Institute of Medical Sciences, Nagpur, Nagpur, IND
| | - Soumya Ghoshal
- General Surgery, All India Institute of Medical Sciences, Nagpur, Nagpur, IND
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Abstract
IMPORTANCE Acute appendicitis is the most common abdominal surgical emergency in the world, with an annual incidence of 96.5 to 100 cases per 100 000 adults. OBSERVATIONS The clinical diagnosis of acute appendicitis is based on history and physical, laboratory evaluation, and imaging. Classic symptoms of appendicitis include vague periumbilical pain, anorexia/nausea/intermittent vomiting, migration of pain to the right lower quadrant, and low-grade fever. The diagnosis of acute appendicitis is made in approximately 90% of patients presenting with these symptoms. Laparoscopic appendectomy remains the most common treatment. However, increasing evidence suggests that broad-spectrum antibiotics, such as piperacillin-tazobactam monotherapy or combination therapy with either cephalosporins or fluroquinolones with metronidazole, successfully treats uncomplicated acute appendicitis in approximately 70% of patients. Specific imaging findings on computed tomography (CT), such as appendiceal dilatation (appendiceal diameter ≥7 mm), or presence of appendicoliths, defined as the conglomeration of feces in the appendiceal lumen, identify patients for whom an antibiotics-first management strategy is more likely to fail. CT findings of appendicolith, mass effect, and a dilated appendix greater than 13 mm are associated with higher risk of treatment failure (≈40%) of an antibiotics-first approach. Therefore, surgical management should be recommended in patients with CT findings of appendicolith, mass effect, or a dilated appendix who are fit for surgery, defined as having relatively low risk of adverse outcomes or postoperative mortality and morbidity. In patients without high-risk CT findings, either appendectomy or antibiotics can be considered as first-line therapy. In unfit patients without these high-risk CT findings, the antibiotics-first approach is recommended, and surgery may be considered if antibiotic treatment fails. In unfit patients with high-risk CT findings, perioperative risk assessment as well as patient preferences should be considered. CONCLUSIONS AND RELEVANCE Acute appendicitis affects 96.5 to 100 people per 100 000 adults per year worldwide. Appendectomy remains first-line therapy for acute appendicitis, but treatment with antibiotics rather than surgery is appropriate in selected patients with uncomplicated appendicitis.
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Affiliation(s)
- Dimitrios Moris
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Erik Karl Paulson
- Department of Radiology, Duke University Medical Center, Durham, North Carolina
| | - Theodore N Pappas
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
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Alshebromi MH, Alsaigh SH, Aldhubayb MA. Sensitivity and specificity of computed tomography and ultrasound for the prediction of acute appendicitis at King Fahad Specialist Hospital in Buraidah, Saudi Arabia. Saudi Med J 2019; 40:458-462. [PMID: 31056622 PMCID: PMC6535167 DOI: 10.15537/smj.2019.5.23777] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Objectives: To determine the sensitivity and specificity of computed tomography (CT) and ultrasound (US) in predicting acute appendicitis in relation to histopathology reports at King Fahad Specialist Hospital in Buraidah, Saudi Arabia. Methods: A retrospective cohort study included 500 medical records of patients diagnosed with acute appendicitis upon admission to King Fahad Specialist Hospital, Buraidah, Saudi Arabia, between January 2015 and January 2017. Results: Of the 200 patients, 187 (93.5%) were diagnosed with acute appendicitis by histopathology. Of these 187 patients, 57 (30.5%) underwent CT and 54 (29%) underwent US. Computed tomography correctly identified 86.0% of the patients as having acute appendicitis and incorrectly identified 14% as not having acute appendicitis. Similarly, US correctly identified 37% of the patients as having acute appendicitis, while the remaining 63% were incorrectly identified as not having acute appendicitis. Thirteen patients (6.5%) did not have acute appendicitis (confirmed by histology report). Six (46.15%) of these 13 patients underwent CT. Five of these 6 (83.3%) were incorrectly diagnosed with acute appendicitis by CT, whereas one of the 6 (16.7%) was identified as a true negative. On the other hand, US correctly identified 100% of the 13 patients as true negative. Conclusion: Computed tomography was shown to have sensitivity 86% and a specificity of 16.7% for the diagnosis of acute appendicitis. On the other hand, US had a sensitivity of 37% and a specificity of 100%. Therefore, we conclude that if imaging needed to confirm the diagnosis of appendicitis, CT is the choice. Ultrasound can be used only to exclude gynecological disorders.
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Affiliation(s)
- Mawiah H Alshebromi
- Accident and Emergency Department, College of Medicine, Qassim University, Buraidah, Kingdom of Saudi Arabia. E-mail.
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Abstract
Appendicitis is one of the most common acute abdominal conditions encountered in the Emergency Department. It is a surgical condition that can affect any person of any age and often with varying clinical presentations. In the majority of cases, the diagnosis is straightforward. However in some, the diagnosis requires a heightened clinical suspicion. The application of adjuvant laboratory tests and diagnostic imaging helps to reduce the associated complications, morbidity and mortality of delayed diagnosis.
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Affiliation(s)
- LTH Tan
- Hong Kong Baptist Hospital, Department of Radiology, 222 Waterloo Road, Kowloon, Hong Kong
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Eriksson S, Tisell Å, Granström L. Ultrasonographic Findings after Conservative Treatment of Acute Appendicitis and Open Appendicectomy. Acta Radiol 2016. [DOI: 10.1177/028418519503600213] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In a randomized study we investigated the effects of antibiotics as the only treatment in acute appendicitis. Forty patients were examined, 19 after antibiotic treatment (one operated due to perforation) and 21 after surgery. All patients were examined prior to randomization, after 10 days and after 30 days. Of the positive ultrasonographic (US) findings, 18 (86%) of the 21 operated patients had histologically proven acute appendicitis. At the 10th day, 9 patients had a seroma under the scar, which had disappeared a month after surgery in all patients. In the 19 patients conservatively treated with antibiotics, the appendix could be visualized in 8 symptom-free cases on the 10th day. In 5 of the 8 patients the appendix was still visualized after 1 month. Three of these 5 had recurrent appendicitis within a year. It is concluded that US can be used not only in diagnosing acute appendicitis, but also in the evaluation of treatments such as antibiotics.
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Saxena D, Tandon M, Shah Y, Gedam BS. Hyperbilirubinemia as a Diagnostic Tool for the Prediction of Appendicular Perforation: A Prospective Study. Euroasian J Hepatogastroenterol 2016; 5:87-89. [PMID: 29201699 PMCID: PMC5578533 DOI: 10.5005/jp-journals-10018-1141] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Accepted: 04/28/2015] [Indexed: 11/23/2022] Open
Abstract
Background The certainty of diagnosing acute appendicitis in patients presenting with right iliac fossa pain still remains a mystery though acute appendicitis being the commonest surgical procedure done in emergency. In acute appendicitis, serum bilirubin levels are raised due to hepatocellular damage as a result of direct insult caused by Gram-negative bacterial endotoxemia. The need for the study is to conclude whether the serum bilirubin can be considered as a new laboratory marker to aid in the diagnosis of acute appendicitis and if so, does it have the predictive capacity to warn us about appendicular perforation. Materials and methods This is a prospective study carried out at rural tertiary healthcare center and includes 213 patients clinically diagnosed as acute appendicitis. Results Out of 213 patients, raised serum bilirubin ≥1.2 mg/dl was present in 195 (91.5%) patients, out of which 194 (99.4%) patients had histopathologically inflamed appendix and this difference was statistically highly significant with p-value < 0.0001. In this study, 32 patients had perforated appendix. Out of those, 30 patients had bilirubin ≥ 4 mg/dl and 2 patients had bilirubin level between 1.2 and < 4 mg/dl. Raised serum bilirubin (≥4 mg/dl) was present in 35 (17.9%) patients, out of which 30 (87.7%) patients had perforated appendix. How to cite this article Saxena D, Tandon M, Shah Y, Gedam BS. Hyperbilirubinemia as a Diagnostic Tool for the Prediction of Appendicular Perforation: A Prospective Study. Euroasian J Hepato-Gastroenterol 2015;5(2):87-89.
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Affiliation(s)
- Divish Saxena
- Department of Surgery, NKP Salve Institute of Medical Sciences, Digdoh Hills, Nagpur, Maharashtra, India
| | - Mrinal Tandon
- Department of Surgery, NKP Salve Institute of Medical Sciences, Digdoh Hills, Nagpur, Maharashtra, India
| | - Yunus Shah
- Department of Surgery, NKP Salve Institute of Medical Sciences, Digdoh Hills, Nagpur, Maharashtra, India
| | - B S Gedam
- Department of Surgery, NKP Salve Institute of Medical Sciences, Digdoh Hills, Nagpur, Maharashtra, India
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Alvarado A. How to improve the clinical diagnosis of acute appendicitis in resource limited settings. World J Emerg Surg 2016; 11:16. [PMID: 27118990 PMCID: PMC4845369 DOI: 10.1186/s13017-016-0071-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 04/18/2016] [Indexed: 12/29/2022] Open
Abstract
This article is a general review of the diagnostic tools that the clinician can use for the early diagnosis of acute appendicitis with emphasis on the Alvarado Score, and it is aimed principally to the medical practitioners in different parts of the world where the diagnostic facilities and technological resources are limited.
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Affiliation(s)
- Alfredo Alvarado
- />Society of Laparoscopic Surgeons, Miami, FL U.S.A
- />International College of Surgeons, Chicago, IL USA
- />American Medical Association, Chicago, IL USA
- />American College of Emergency Physicians, Irving, TX USA
- />Pennsylvania Medical Society, Harrisburg, PA USA
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Frongia G, Mehrabi A, Ziebell L, Schenk JP, Günther P. Predicting Postoperative Complications After Pediatric Perforated Appendicitis. J INVEST SURG 2016; 29:185-94. [PMID: 26822038 DOI: 10.3109/08941939.2015.1114690] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE Assessment of risk factors for postoperative complications following surgical treatment of pediatric perforated appendicitis (PA) is necessary to identify those patients in need of closer monitoring. In this study, we have investigated the impact of different risk factors on the occurrence of complications after an appendectomy in children with PA. MATERIAL AND METHODS The study was a retrospective, single-centre analysis of all pediatric PA conducted over a 10-year period. Preoperative clinical and laboratory results, intraoperative findings, and postoperative complications were analyzed. Risk factors were defined and a risk score was determined for postoperative complications and reinterventions. RESULTS Surgical treatment for appendicitis was performed in 840 pediatric patients during the observation period. 163 of the included patients were diagnosed with PA (mean age 8.9 ± 3.6 years). 19 (11.7%) patients developed postoperative complications, 17 (10.4%) of which required complication-related intervention. We identified five predictors of postoperative complications: the C-related protein value at admission, purulent peritonitis, open appendectomy (primary, secondary, or converted), placement of an abdominal drain, and administration of antibiotics not compliant to results from the subsequent antibiogram. The determined risk score was significantly higher in the complication group (p < .0001) and reintervention group (p < .001). CONCLUSIONS Postoperative complications following pediatric PA can be predicted using specific preoperative, intraoperative, and postoperative risk factors. In the high-risk group, an active prevention, detection, and intervention of any occurring complication is necessary and we present a new specific pediatric risk score to define patients at risk for complications.
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Affiliation(s)
- G Frongia
- a Division of Pediatric Surgery, Department of General , Visceral and Transplantation Surgery
| | - A Mehrabi
- b Department of General , Visceral and Transplantation Surgery
| | - L Ziebell
- a Division of Pediatric Surgery, Department of General , Visceral and Transplantation Surgery
| | - J P Schenk
- c Division of Pediatric Radiology, Department of Diagnostic and Interventional Radiology , University Hospital of Heidelberg , Heidelberg , Germany
| | - P Günther
- a Division of Pediatric Surgery, Department of General , Visceral and Transplantation Surgery
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Limon O, Oray D, Ertan C, Sahin E, Ugurhan AA. Recognizing Acute Appendicitis Criteria on Abdominal CT: Do Emergency Physicians Need a Preliminary Report? Am J Emerg Med 2015; 33:1002-5. [DOI: 10.1016/j.ajem.2015.04.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Revised: 04/10/2015] [Accepted: 04/10/2015] [Indexed: 12/20/2022] Open
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Affiliation(s)
- Ki Hoon Kim
- Department of Surgery, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
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Shelton JA, Brown JJS, Young JA. Preoperative C-reactive protein predicts the severity and likelihood of complications following appendicectomy. Ann R Coll Surg Engl 2014; 96:369-72. [PMID: 24992421 DOI: 10.1308/003588414x13946184901722] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Diagnostic laparoscopy with appendicectomy (LA) has become the accepted method of investigation and treatment of appendicitis. However, concerns remain in cases of complicated appendicitis when many advocate conversion to an open procedure (LCOA) owing to the risk of complications. The aim of this study was to look for factors that could predict complications occurring in patients undergoing appendicectomy. METHODS Data inclusive of all consecutive appendicectomies over a two-year period were retrieved from the computerised theatre database. Clinical details including admission inflammatory markers, complications, severity (final pathology) and length of stay were collected from the discharge letter. Readmissions were identified as those hospital identifiers had a second set of admission dates and/or a second discharge letter. RESULTS During the 2-year study period, 517 appendicectomies were performed. Of these, 429 patients (83%) had LA and the remaining 88 (17%) had LCOA. The LA group had a mean age of 28 years (range: 2-86 years) and a mean C-reactive protein (CRP) level of 71 mg/l (range: 0-480 mg/l) while the LCOA group had a mean age of 46 years (range: 11-92 years) and a mean CRP level of 162 mg/l (range: 3-404 mg/l). These differences in age and CRP were significant (p<0.001). LA patients were less likely to have complications overall (22% vs 52%, p=0.015). Complications were independently more than twice as common with established inflammation with a CRP level of >150 mg/l (p<0.05). CONCLUSIONS A high preoperative CRP level predicts an increased rate of postoperative complication due to established inflammation and/or infection. This raises the question of whether we should be offering primary open appendicectomies to patients with a CRP level of >150 mg/l.
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Liese J, Halbinger TM, Ulrich F, Bechstein WO, Strey CW. Appendicitis—the balance between cost effectiveness and safety remains challenging. Langenbecks Arch Surg 2014; 399:493-501. [DOI: 10.1007/s00423-014-1179-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Accepted: 02/21/2014] [Indexed: 01/07/2023]
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Acute appendicitis presenting as acute diarrhea accompanying hypokalemia. Am J Emerg Med 2013; 32:397.e5-6. [PMID: 24332249 DOI: 10.1016/j.ajem.2013.10.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Accepted: 10/29/2013] [Indexed: 11/24/2022] Open
Abstract
Acute appendicitis, characterized as periumbilical pain, migrating to the right iliac fossa, is one of the most common acute surgical conditions. It is usually diagnosed on the basis of clinical signs and symptoms. However, some patients may present atypically and are prone to be misdiagnosed. We report this first case of acute appendicitis who presented initially with complain of diarrhea accompanying hypokalemia. There have been no published data suggesting its existence in any parts of the world.
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Bachar I, Perry ZH, Dukhno L, Mizrahi S, Kirshtein B. Diagnostic Value of Laparoscopy, Abdominal Computed Tomography, and Ultrasonography in Acute Appendicitis. J Laparoendosc Adv Surg Tech A 2013; 23:982-9. [PMID: 24134071 DOI: 10.1089/lap.2013.0035] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Affiliation(s)
- Ira Bachar
- Department of Surgery “A”, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Zvi Howard Perry
- Department of Surgery “A”, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- Department of Epidemiology and Health Services Evaluation, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Larisa Dukhno
- Radiology Institute, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Solly Mizrahi
- Department of Surgery “A”, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Boris Kirshtein
- Department of Surgery “A”, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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Gilmore T, Jordan C, Edelstein E. Right-sided diverticulitis mimics appendicitis. J Emerg Med 2011; 44:e29-32. [PMID: 21996286 DOI: 10.1016/j.jemermed.2011.06.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2010] [Revised: 03/30/2011] [Accepted: 06/05/2011] [Indexed: 12/14/2022]
Abstract
BACKGROUND Right-sided diverticulitis is a rare source of right lower quadrant pain in Western society; however, it is quite common in Asian societies. Right-sided diverticulitis presents very similarly to appendicitis, with right lower quadrant pain, fever, nausea, and laboratory abnormalities, and is often seen in young patients. OBJECTIVES In this report, we present a case of right-sided diverticulitis. We review right-sided diverticulitis' diagnosis and management. It is important to diagnose right-sided diverticulitis because it is a good mimic of appendicitis and ideally should be diagnosed before a patient has unnecessary surgery. CASE REPORT A 26-year-old Asian woman presented for evaluation of right lower quadrant pain and fever. She was initially thought to have appendicitis clinically, but had right-sided diverticulitis diagnosed by computed tomography (CT) scan. She was admitted and received intravenous antibiotics and bowel rest. Her right-sided diverticulitis resolved in 3 days. CONCLUSIONS Severe right lower quadrant pain in young patients of Asian descent can be right-sided diverticulitis. Right-sided diverticulitis is a benign condition managed medically that mimics appendicitis. CT imaging seems to be the best way to avoid unnecessary surgery.
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Affiliation(s)
- Thomas Gilmore
- Department of Emergency Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania 19107, USA
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Kim HC, Yang DM, Lee CM, Jin W, Nam DH, Song JY, Kim JY. Acute appendicitis: relationships between CT-determined severities and serum white blood cell counts and C-reactive protein levels. Br J Radiol 2010; 84:1115-20. [PMID: 21123307 DOI: 10.1259/bjr/47699219] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVES The aim of this study was to evaluate the relationships between the severity of appendicitis as depicted on CT and blood inflammatory markers of serum white blood cell (WBC) count and C-reactive protein (CRP). METHODS CT images in 128 patients (109 surgically proven and 19 with clinically excluded appendicitis) were retrospectively reviewed. Two radiologists by consensus evaluated and scored (using a 0, 1 or 2 point scale) severities based on CT-determined appendiceal diameters, appendiceal wall changes, caecal changes, periappendiceal inflammatory stranding and phlegmon or abscess formation. We investigated whether CT findings were significantly related to elevated WBC counts or CRP levels and performed the correlations of WBC counts and CRP levels with CT severity scores. Patients were also subjectively classified using four grades from normal (Grade I) to perforated appendicitis (Grade IV) on the basis of CT findings to evaluate differences in WBC counts and CRP levels between grades. RESULTS Only appendiceal wall changes and the phlegmon or abscess formation were related to elevated WBC counts and CRP levels, respectively (p<0.05). CT severity scores were found to be more strongly correlated with CRP levels (r = 0.669) than with WBC counts (r = 0.222). On the basis of CT grades, the WBC counts in Grade I were significantly lower than in other grades (p<0.001), whereas CRP levels in Grade IV were significantly higher than in other grades (p<0.001). CONCLUSION CRP levels were found to correlate with CT-determined acute appendicitis severity and could be a useful predictor for perforated appendicitis, whereas WBC counts might be useful to detect early acute appendicitis.
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Affiliation(s)
- H C Kim
- Department of Radiology, East-West Neo Medical Centre, Kyung Hee University, Seoul, Republic of Korea.
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Jo YH, Kim K, Rhee JE, Kim TY, Lee JH, Kang SB, Kim DW, Kim YH, Lee KH, Kim SY, Lee CC, Singer AJ. The accuracy of emergency medicine and surgical residents in the diagnosis of acute appendicitis. Am J Emerg Med 2010; 28:766-70. [PMID: 20837252 DOI: 10.1016/j.ajem.2009.03.017] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2009] [Revised: 03/17/2009] [Accepted: 03/19/2009] [Indexed: 10/19/2022] Open
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Nautiyal H, Ahmad S, Keshwani NK, Awasthi DN. Combined use of modified Alvarado score and USG in decreasing negative appendicectomy rate. Indian J Surg 2010; 72:42-8. [PMID: 23133203 PMCID: PMC3452540 DOI: 10.1007/s12262-010-0008-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2008] [Accepted: 07/29/2009] [Indexed: 10/19/2022] Open
Abstract
INTRODUCTION Appendicitis is notorious in its ability to simulate other conditions and in the frequency it can be mimicked by other pathologies. Despite extraordinary advances in modern radiography imaging and diagnostic laboratory investigations the accurate diagnosis of acute appendicitis remains an enigmatic challenge. Of the various commonly used diagnostic aids for appendicitis, no single test can reduce the rate of negative appendicectomy to zero. MATERIALS AND METHODS Fifty admitted cases of suspected appendicitis were subjected to ultrasonography (USG). All the patients were scored out of 9 according to modified Alvarado score. A treatment plan was devised according to which patients with modified Alvarado score ≥7 underwent immediate appendicectomy even if USG was negative for appendicitis and patients with score <7 underwent appendicectomy if USG was positive for appendicitis. RESULT 84.3% of males and 44.4% of females admitted as case of suspected appendicitis had confirmed appendicitis. Due to high sensitivity (97.14%) and accuracy (92%) of our diagnostic approach, 85.71% cases of appendicitis were diagnosed in early stage, with only 8.57% perforation and abscess rate, leading to post appendicectomy complication rate of only 5.14% in our study (one wound infection and one urinary retention). We could achieve low negative appendicectomy rate of 7.14% in males and 11.11% in females and overall 8.11% in our study. CONCLUSION Combined use of modified Alvarado score and high frequency USG not only reduces negative appendicectomy rate but also reduces morbidity and postoperative complications.
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Affiliation(s)
- Hemant Nautiyal
- Department of General Surgery, Motilal Nehru Medical College, Allahabad, Uttar Pradesh India
| | - Shabi Ahmad
- Department of General Surgery, Motilal Nehru Medical College, Allahabad, Uttar Pradesh India
| | - N. K. Keshwani
- Department of General Surgery, Motilal Nehru Medical College, Allahabad, Uttar Pradesh India
| | - D. N. Awasthi
- Department of General Surgery, Motilal Nehru Medical College, Allahabad, Uttar Pradesh India
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Chamisa I. A clinicopathological review of 324 appendices removed for acute appendicitis in Durban, South Africa: a retrospective analysis. Ann R Coll Surg Engl 2010; 91:688-92. [PMID: 19909612 DOI: 10.1308/003588409x12486167521677] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Acute appendicitis remains a common surgical condition and the importance of specific elements in the clinical diagnosis remain controversial. A variety of neoplastic and inflammatory conditions mimic acute appendicitis. The purpose of this study was to determine the presenting pattern of acute appendicitis and to review the pathological diagnosis. PATIENTS AND METHODS This is a retrospective analysis of 324 patients who had appendicectomy for acute appendicitis at Prince Mshiyeni Memorial Hospital (Natal, South Africa) during the period January 2002 to December 2004. Patient demographics, clinical features, white cell count, operative findings, outcome and histology results were recorded on a special patient proforma. RESULTS A total of 371 patients underwent appendicectomy during this period and 324 (M:F, 3.6:1) were available for analysis. The majority of our patients were in the second decade (43.1%) with only 29.3% presenting within 24 h of onset of symptoms. The most common symptoms were abdominal pain (100%), vomiting (57.4%) and anorexia (49.0%). Generalised and localised abdominal tenderness were present in 62.0% and 19.4% of patients, respectively. Pyrexia was noted in 41.0%. Localised and generalised peritonitis were present in 26.4% and 14.0%, respectively. The most common incisions were lower midline laparotomy (47.2%) and gridiron (37.3%). The negative appendicectomy rate was 17.0%. Acute appendiceal inflammation and gangrenous appendicitis was present in 36.1% and 9.6%, respectively. The perforation rate was 34.0% and there was a direct correlation with delayed presentation. There were no patients with carcinoid tumour or adenocarcinoma. Parasites and other associated conditions were seen in 8.6% of cases. Postoperative complications included: wound sepsis (25.3%), prolonged ileus (6.2%), peritonitis (4.6%) and chest infection (3.4%). Four patients died (1.2%) all from the perforated group. CONCLUSIONS Our patients present late with advanced disease and complications. All surgeons should bear in mind the possibility of parasitic infestations mimicking acute appendicitis and the presence of significant unusual histological findings in our setting justifies routine histopathological examination of appendices.
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Affiliation(s)
- I Chamisa
- Department of General Surgery, Prince Mshiyeni Memorial Hospital, University of Kwazulu Natal, Durban, South Africa.
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Prospective evaluation of emergency physician performed bedside ultrasound to detect acute appendicitis. Eur J Emerg Med 2008; 15:80-5. [PMID: 18446069 DOI: 10.1097/mej.0b013e328270361a] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To evaluate the accuracy of emergency physicians using bedside ultrasound to detect appendicitis (BUSA). METHODS Patients presenting to the emergency department with a clinical suspicion of appendicitis were prospectively enrolled and received a 5-min BUSA. Patients received routine work-up for acute appendicitis as deemed appropriate by the attending physician. Radiologists and consulting surgeons were blinded to BUSA results. The criterion standard for the presence or absence of acute appendicitis was the pathology report for patients who received appendectomies, and telephone follow-up for patients discharged home without surgical intervention. RESULTS A total of 132 patients were enrolled. In 44 cases BUSA was positive. Of these, 37 had surgical pathology reports consistent with acute appendicitis, whereas seven did not have appendicitis. In 82 cases, BUSA was negative. Of these, 62 were determined not to have appendicitis, whereas 20 had appendicitis by pathology. Sensitivity for BUSA was 65% [95% confidence interval (CI) 52-76], specificity was 90% (95% CI 81-95), positive predictive value was 84% (95% CI 71-92), and negative predictive value was 76% (95% CI 65-84). The likelihood ratio of a positive BUSA was 6.4 (95% CI 3.1-13.2). Five patients discharged home with a diagnosis other than appendicitis were unable to be reached by telephone, and were excluded from data analysis. CONCLUSION Our study gives insufficient evidence to support the use of bedside ultrasound by emergency physicians to rule out appendicitis. The high specificity in our study, however, suggests that with further training, BUSA may be useful to rule-in appendicitis in some patients.
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Prabhudesai SG, Gould S, Rekhraj S, Tekkis PP, Glazer G, Ziprin P. Artificial neural networks: useful aid in diagnosing acute appendicitis. World J Surg 2008; 32:305-9; discussion 310-1. [PMID: 18043966 DOI: 10.1007/s00268-007-9298-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND [corrected] The purpose of the study was to assess the role of artificial neural networks (ANNs) in the diagnosis of appendicitis in patients presenting with acute right iliac fossa (RIF) pain and comparing its performance with the assessment made by experienced clinicians and the Alvarado score. METHODS After training and testing an ANN, data from 60 patients presenting with suspected appendicitis over a 6-month period to a teaching hospital was collected prospectively. Accuracy of diagnosing appendicitis by the clinician, the Alvarado score, and the ANN was compared. RESULTS The sensitivity, specificity, and positive and negative predictive values of the ANN were 100%, 97.2%, 96.0%, and 100% respectively. The ability of the ANN to exclude accurately the diagnosis of appendicitis in patients without true appendicitis was statistically significant compared to the clinical performance (p=0.031) and Alvarado score of >or=6 (p=0.004) and nearly significant compared to the Alvarado score of >or=7 (p=0.063). CONCLUSIONS ANNs can be an effective tool for accurately diagnosing appendicitis and may reduce unnecessary appendectomies.
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Affiliation(s)
- S G Prabhudesai
- Department of Biosurgery and Surgical Technology, Faculty of Medicine, Imperial College London, St. Mary's Hospital Campus, Room 1029, 10th floor QEQM Building, Praed Street, London, W2 1NY, UK.
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23
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Mohebbi HA, Mehrvarz S, Kashani MT, Kabir A, Moharamzad Y. Predicting negative appendectomy by using demographic, clinical, and laboratory parameters: A cross-sectional study. Int J Surg 2008; 6:115-8. [DOI: 10.1016/j.ijsu.2008.01.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2007] [Accepted: 01/08/2008] [Indexed: 12/29/2022]
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Kim K, Lee CC, Song KJ, Kim W, Suh G, Singer AJ. The Impact of Helical Computed Tomography on the Negative Appendectomy Rate: A Multi-Center Comparison. J Emerg Med 2008; 34:3-6. [DOI: 10.1016/j.jemermed.2007.05.042] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2006] [Revised: 05/05/2007] [Accepted: 05/19/2007] [Indexed: 01/07/2023]
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Petrosyan M, Estrada J, Chan S, Somers S, Yacoub WN, Kelso RL, Mason RJ. CT scan in patients with suspected appendicitis: clinical implications for the acute care surgeon. Eur Surg Res 2007; 40:211-9. [PMID: 17998781 DOI: 10.1159/000110863] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2007] [Accepted: 08/22/2007] [Indexed: 01/29/2023]
Abstract
OBJECTIVE To determine the influence of computed tomography (CT) scans on diagnosis and management of patients with suspected appendicitis. METHODS Retrospective 2-year review of 1,630 patients with suspected appendicitis, categorized into three groups based on the likelihood (Alvarado scores) of having appendicitis. Group 1: low likelihood (Alvarado score < or =4); group 2: intermediate likelihood (Alvarado scores 5-7), and group 3: high likelihood (Alvarado score > or = 8). CT scan utilization, hospital course, and final pathology were retrospectively reviewed. RESULTS More patients received a CT scan in 2006 as compared with 2005 (60 vs. 52%; p = 0.001). The overall appendectomy rate was similar between the 2 years (57% in 2005 vs. 57% in 2006; p = 0.995). The overall appendectomy rate in patients with a CT was significantly higher as compared with those without (60 vs. 53%; p = 0.002). The appendectomy rate in patients with Alvarado scores < or =4 and no CT scan was significantly lower than in those with a CT scan (12 vs. 48%; p < 0.0001). The overall negative appendectomy rate in patients with a CT scan was similar to that in those without: 31/546 (6%) vs. 23/383 (6%). CONCLUSIONS CT scan utilization increased the appendectomy rate only in patients with a low clinical suspicion for appendicitis. Preoperative CT scans did not decrease the negative appendectomy rate.
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Affiliation(s)
- M Petrosyan
- Division of Emergency Surgery, Department of Surgery, Keck School of Medicine of University of Southern California and Los Angeles County + USC Medical Center, Los Angeles, Calif., USA
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26
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Evaluación de escalas diagnósticas en pacientes con dolor abdominal sugestivo de apendicitis. BIOMEDICA 2007. [DOI: 10.7705/biomedica.v27i3.204] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Ganguli S, Raptopoulos V, Komlos F, Siewert B, Kruskal JB. Right Lower Quadrant Pain: Value of the Nonvisualized Appendix in Patients at Multidetector CT. Radiology 2006; 241:175-80. [PMID: 16928971 DOI: 10.1148/radiol.2411050191] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To retrospectively determine the value of the nonvisualized appendix at multidetector computed tomography (CT) in patients with acute right lower quadrant pain in whom appendicitis was a consideration. MATERIALS AND METHODS Institutional review board approval was obtained for this HIPAA-compliant study, with waiver of informed consent. Records were retrospectively reviewed in patients who presented to the emergency department between April 29 and October 31, 2003, with right lower quadrant pain. Scanning was performed with the same eight-detector row CT scanner by using oral and (unless contraindicated) intravenous contrast agents, and transverse and coronal reformations were obtained. Two radiologists prospectively evaluated all scans at the time of the examination and rendered a consensus opinion. Clinical follow-up of at least 3 months' duration was performed retrospectively for patients whose appendix was not visualized to determine whether appendicitis had developed. Statistical analysis and calculation of percentages with confidence intervals (CIs) were performed. RESULTS Of the 400 consecutive patients who underwent multidetector CT, 132 (33.0%) were male and 268 (67.0%) were female. Eighty patients (20.0%) had acute appendicitis and 79 (19.8%) had another cause for abdominal pain. A normal appendix with no other cause for pain was seen in 182 patients (45.5%). In 59 patients (14.8%), the appendix was not visualized. Of these 59 patients, 50 had adequate follow-up. Clinical follow-up was uneventful in 49 of these 50 patients. Thus, on otherwise normal multidetector CT scans in patients suspected of having acute appendicitis, nonvisualization of the appendix was negative for appendicitis in 98% (95% CI: 71%, 100%) of cases. Conversely, when the appendix was seen at multidetector CT and was abnormal, appendicitis was present in 95% (95% CI: 72%, 100%) of cases. CONCLUSION In patients with right lower quadrant pain, a nonvisualized appendix at multidetector CT reliably excludes acute appendicitis.
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Affiliation(s)
- Suvranu Ganguli
- Department of Radiology, Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Ave, Boston, MA 02215, USA
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Birkhahn RH, Briggs M, Datillo PA, Van Deusen SK, Gaeta TJ. Classifying patients suspected of appendicitis with regard to likelihood. Am J Surg 2006; 191:497-502. [PMID: 16531143 DOI: 10.1016/j.amjsurg.2005.08.031] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2005] [Revised: 05/30/2005] [Accepted: 08/15/2005] [Indexed: 01/07/2023]
Abstract
BACKGROUND We sought to develop a clinical predictive model for acute appendicitis and contrast it with current clinical practice. METHODS A prospective observational study of patients presenting with signs or symptoms consistent with acute appendicitis. Random-partition modeling was used to develop an appendicitis likelihood model (ALM). RESULTS Four hundred thirty-nine patients were enrolled, 101 with appendicitis, and 338 with other diagnoses. The ALM classified patients as "low likelihood" if they had a white blood cell count <9,500 and either no right lower-quadrant tenderness or a neutrophil count <54%. Patients were classified as "high likelihood" if they had a white blood cell count >13,000 with rebound tenderness or both voluntary guarding and neutrophil count >82%. The ALM outperformed actual clinical practice with regard to "missed" appendicitis, negative laparotomies, and total number of imaging studies. CONCLUSION The ALM may permit more judicious use of advanced radiographic imaging with lower nontherapeutic laparotomy rates.
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Affiliation(s)
- Robert H Birkhahn
- Department of Emergency Medicine, New York Methodist Hospital, Brooklyn, NY 11215, USA.
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Arfa N, Gharbi L, Marsaoui L, Ben Rhouma S, Farhati S, Bougamra S, Mannai S, Ghariani B, Mestiri H, Khalfallah MT. Douleurs aiguës de la fosse iliaque droite: intérêt de la surveillance clinique hospitalière. Presse Med 2006; 35:393-8. [PMID: 16550128 DOI: 10.1016/s0755-4982(06)74602-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
INTRODUCTION Because of the potential severity of acute appendicitis, many authors recommend the broad use of appendectomy. In this case, 15 to 20% of appendectomies are ultimately found to have been unnecessary. Hospital observation with repeated clinical and laboratory exams can be useful for patients with atypical clinical presentation. This paper assesses our approach, in which some patients with pain in the right iliac fossa (RIF) are admitted for observation before a decision about appendectomy. PATIENTS AND METHODS All patients (205 cases) admitted from March 2002 through February 2003 for acute abdominal pain of the RIF were included in this prospective study. The 120 women and 85 men (sex ratio=0.7) had a mean age of 27 years. We classified the patients into 3 groups: those who had an emergency appendectomy, those who had surgery after an observation period, and those discharged without appendectomy after observation. RESULTS The first group included 110 patients: 63% had a (rectal) temperature greater than 38 degrees C; 44% had guarding of the RIF and 87% elevated white blood cell counts (>10000/mm3). At surgery, appendicitis was diagnosed in 92%. After a mean delay of 36 hours of observation, 50 of the patients in the second group underwent surgery: 44% with (rectal) temperature > 38 degrees C, RIF guarding in 8%, and elevated white blood cell count (>10000/mm3) in 74%. In this group, 94% were diagnosed with appendicitis during surgery. Forty-five patients were discharged without surgery after 36 hours of observation. COMMENTARY In this study, pain and RIF guarding, associated with temperature greater than 38 degrees C and elevated white blood cell counts, were predictive of appendicitis in 96% of cases. Admission for observation of patients with atypical presentation avoided 45 unnecessary appendectomies (22%).
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Affiliation(s)
- Nafaa Arfa
- Service de Chirurgie Générale, Hôpital Mongi Slim, La Marsa, Tunisie.
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Weston AR, Jackson TJ, Blamey S. Diagnosis of appendicitis in adults by ultrasonography or computed tomography: a systematic review and meta-analysis. Int J Technol Assess Health Care 2006; 21:368-79. [PMID: 16110717 DOI: 10.1017/s0266462305050488] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVES The use of ultrasonography and computed tomography (CT) in the diagnosis of appendicitis in adult patients was compared. METHODS Systematic review and meta-analysis of current evidence in two clinical situations: unselected nonpregnant, adult patients with symptoms of appendicitis, and more selective use in only those patients who still have an equivocal diagnosis subsequent to routine clinical investigations. RESULTS Meta-analysis of eligible studies shows CT to have better sensitivity and specificity than ultrasound in both clinical situations. CONCLUSIONS Application of these findings in clinical practice and/or policy would need to evaluate the better diagnostic performance of CT against its cost and availability. In addition, it is imperative that future studies be conducted in patient populations that are well-defined with respect to prior investigations. Sequelae of false-negative and false-positive diagnoses should also be evaluated.
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Affiliation(s)
- Adèle R Weston
- Health Technology Analysts Pty Ltd., Balmain, New South Wales, Australia.
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31
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Chan I, Bicknell SG, Graham M. Utility and diagnostic accuracy of sonography in detecting appendicitis in a community hospital. AJR Am J Roentgenol 2005; 184:1809-12. [PMID: 15908535 DOI: 10.2214/ajr.184.6.01841809] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this study was to determine the utility and accuracy of sonography in diagnosing acute appendicitis in patients with suspected acute appendicitis in a general community hospital. MATERIALS AND METHODS All reports relating to appendicitis were retrospectively obtained from archived transcription reports of nine radiologists from a geographically constrained hospital between December 1999 and December 2003 by a search on the keyword "appendicitis." These files were correlated with the histopathology reports from surgical appendectomy or findings from clinical follow-up during the same period. A survey eliciting the views of five local surgeons on the utility of sonography for the detection of acute appendicitis was also collected. RESULTS Sonography reports for 667 patients (mean age, 34 years; range, 6-93 years) were obtained. Of these, a total of 174 had pathologically proven appendicitis and 145 had positive findings for appendicitis on sonography. The accuracy was 92%; sensitivity, 83%; and specificity, 95%. The positive predictive value was 86%, and the negative predictive value was 94%. Three of the five surveyed surgeons indicated they used sonography less than 25% of the time, with none using it more than 75%. CONCLUSION The sensitivity, specificity, accuracy, and positive and negative predicative values of sonography performed by general radiologists in a community hospital are comparable to statistics quoted in the literature for academic institutions. The most common error was the tendency to misclassify appendixes under 6 mm. Most surgeons surveyed stated their use of sonography would increase if sonography yielded a sensitivity and specificity of 85% or greater.
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Affiliation(s)
- Ida Chan
- University of British Columbia, Vancouver, BC, Canada
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Abstract
BACKGROUND The importance of specific elements in the clinical diagnosis of appendicitis is controversial. This review analyses the diagnostic value of elements of disease history, clinical findings and laboratory test results in suspected appendicitis. METHODS A systematic Medline search was made of all published studies on the clinical and laboratory diagnosis of appendicitis in patients admitted to hospital with suspected disease. Meta-analyses of receiver-operator characteristic (ROC) areas, and positive and negative likelihood ratios, of 28 diagnostic variables described in 24 studies are presented. RESULTS Inflammatory response variables (granulocyte count, proportion of polymorphonuclear blood cells, white blood cell count and C-reactive protein concentration), descriptors of peritoneal irritation (rebound and percussion tenderness, guarding and rigidity) and migration of pain were the strongest discriminators, with ROC areas of 0.78 to 0.68. The discriminatory power of the inflammatory variables was particularly strong for perforated appendicitis, with ROC areas of 0.85 to 0.87. Appendicitis was likely when two or more inflammatory variables were increased and unlikely when all were normal. CONCLUSION Although all clinical and laboratory variables are weak discriminators individually, they achieve a high discriminatory power when combined. Laboratory examination of the inflammatory response, clinical descriptors of peritoneal irritation, and a history of migration of pain yield the most important diagnostic information and should be included in any diagnostic assessment.
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Affiliation(s)
- R E B Andersson
- Department of Surgery, County Hospital Ryhov, SE-551 85 Jönköping, Sweden.
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Abstract
Appendicitis remains a common disease with over 250,000 cases in the United States per year. Surgical intervention has been the primary treatment for over a century, and clinical evaluation has been the mainstay for diagnosis of acute appendicitis for decades. Appendiceal imaging modalities have become increasingly popular to assist with the diagnosis of appendicitis, and the surgeon is no longer the sole diagnostician for this disease. Radiologists and emergency medical physicians have entered the arena. This review examines the surgical and radiological literature to evaluate the current atmosphere of how surgeons, radiologists, and emergency physicians interact in the diagnosis of appendicitis.
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Affiliation(s)
- Erik B Wilson
- University of Texas Health Science Center at Houston, Houston, TX 77030, USA.
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Affiliation(s)
- Erik K Paulson
- Department of Radiology, Duke University Medical Center, Durham, NC 27710, USA.
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Abstract
Enumeration of band neutrophils has a long clinical tradition as a diagnostic test for bacterial infection. Yet, the band count is a nonspecific, inaccurate, and imprecise laboratory test. Review of the literature provides little support for the clinical utility of the band count in patients greater than 3 months of age. The white blood cell count and the automated absolute neutrophil count are better diagnostic tests for adults and most children. Absolute numbers of bands are required for the Rochester criteria, a diagnostic algorithm for acutely ill, febrile children less than 3 months of age. No studies, however, assess the independent contribution of bands to the performance of the algorithm, or the use of the automated total neutrophil count as a replacement for the band count. Band counts also are required to calculate an immature to total neutrophil ratio (I:T ratio), an index widely used to aid in the diagnosis of neonatal sepsis. Studies, however, show a wide range of sensitivity and specificity for the I:T ratio, indicating variable performance. In the near future, rapid analysis of inflammatory factors, adhesion molecules, cytokines, neutrophil surface antigens, or even bacterial DNA may be superior alternative tests for the early diagnosis of sepsis.
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Affiliation(s)
- P Joanne Cornbleet
- Department of Pathology, Stanford University Medical Center, Stanford, California, USA.
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L'échographie abdominopelvienne en cas de suspicion d'appendicite aiguë : évaluation prospective chez l'adulte. ACTA ACUST UNITED AC 2000. [DOI: 10.1016/s0001-4001(00)00111-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Vermeulen B, Morabia A, Unger PF, Goehring C, Grangier C, Skljarov I, Terrier F. Acute appendicitis: influence of early pain relief on the accuracy of clinical and US findings in the decision to operate--a randomized trial. Radiology 1999; 210:639-43. [PMID: 10207461 DOI: 10.1148/radiology.210.3.r99fe54639] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To determine the influence of early pain relief on the diagnostic performance of ultrasonography (US) and on the appropriateness of the surgical decision. MATERIALS AND METHODS A prospective randomized, double-blind placebo-controlled trial with morphine was conducted. A visual analog scale was used to evaluate pain in 340 patients aged 16 years or older. US was performed with a standardized protocol. Diagnosis was confirmed at histologic analysis or, in the patients released without surgery, at follow-up. RESULTS One hundred seventy-five patients were injected with morphine, and 165 were injected with the placebo. Pain relief was stronger in the morphine group. In the morphine group, US had lower (71.1%) sensitivity (difference, -9.5%; 95% CI, -18.5%, -0.5%) and higher (65.2%) specificity (difference, 11.4%; 95% CI, 1.0%, 21.8%). This group had also a higher positive predictive value (64.6%) and a lower negative predictive value (71.4%), but the differences between this group and the placebo group were not statistically significant. Among female patients, the decision to operate was appropriate more often in the morphine group (75.8%), but the difference between this group and the placebo group was not statistically significant (5.1%; 95% CI, -7.4%, 17.6%). In male patients and overall, opiate analgesia did not influence the appropriateness of the decision. The appropriateness to discharge patients without surgery was 100% in all groups. CONCLUSION Morphine does not improve US-based diagnosis of appendicitis.
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Affiliation(s)
- B Vermeulen
- Emergency Department, Hôpitaux Universitaires de Genève, Switzerland
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Warner BW, Kulick RM, Stoops MM, Mehta S, Stephan M, Kotagal UR. An evidenced-based clinical pathway for acute appendicitis decreases hospital duration and cost. J Pediatr Surg 1998; 33:1371-5. [PMID: 9766356 DOI: 10.1016/s0022-3468(98)90010-0] [Citation(s) in RCA: 97] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
BACKGROUND/PURPOSE In the pediatric population, appendicitis remains the most common surgical emergency encountered. The purpose of this study was to determine the impact of an evidence-based clinical pathway for acute appendicitis on patient care as well as hospital and home care costs at the authors' pediatric institution. METHODS A prospective evaluation was conducted of an appendicitis clinical pathway (June 1996 through November 1996) compared with historical control patients (June 1994 through November 1994) not cared for by the pathway. RESULTS Data (average +/- SD) for 120 pathway (P) patients were compared with 122 control (C) patients. Age (11.5 +/- 3.6 years for C v 11.2 +/- 3.9 years for P), rates of negative appendectomy (12.3% for C v 9.2% for P) and perforation (26.2% for C v 18.3% for P) were similar. Pathway patients with nonperforated appendicitis were more often discharged from the hospital within 24 hours (48% for C v 67% for P; P = .014) with lower hospital costs ($4,095 +/- $1,280 for C v $3,638 +/- $1,633 for P; P = .001). Pathway patients with perforated appendicitis had shorter hospitalization (185.2 +/- 59 hours for C v 113 +/- 44 hours for P; P = .0001) and lower hospital costs ($11,175 +/- $3,893 for C v $7,823 +/- $2,366 for P; P = .0001). CONCLUSION An evidence-based appendicitis pathway decreased duration of hospitalization and cost without adversely affecting diagnosis or therapy. Clinical pathways for surgical diagnoses may prove useful as a means to minimize costs without compromising patient care.
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Affiliation(s)
- B W Warner
- Division of Pediatric Surgery, Children's Hospital Medical Center, University of Cincinnati College of Medicine, OH 45229, USA
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Galindo Gallego M, Fadrique B, Nieto MA, Calleja S, Fernández-Aceñero MJ, Ais G, González J, Manzanares JJ. Evaluation of ultrasonography and clinical diagnostic scoring in suspected appendicitis. Br J Surg 1998; 85:37-40. [PMID: 9462380 DOI: 10.1046/j.1365-2168.1998.00543.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Several diagnostic aids have been developed to improve diagnosis in suspected appendicitis including ultrasonography and clinical diagnostic scoring. The aim of this study was to elaborate a new scoring system and to measure its accuracy in the preoperative diagnosis of appendicitis, comparing it with the available scoring systems. METHODS The clinical, radiological and ultrasonographic data of 192 patients with suspected appendicitis were collected prospectively. RESULTS Only six of the 12 variables analysed were shown to have prognostic significance. Using Bayesian methodology, a weight was given to each criterion and two overall scores were calculated (ultrasonographic and classical scores). A cut-off point was identified to separate patients who needed surgery and those for observation. The ultrasonographic score showed an 81 per cent sensitivity and a 96 per cent specificity, compared with 60 and 73 per cent respectively for the classical score. CONCLUSION Ultrasonography increases the diagnostic accuracy in patients with suspected acute appendicitis.
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Wilcox RT, Traverso LW. Have the evaluation and treatment of acute appendicitis changed with new technology? Surg Clin North Am 1997; 77:1355-70. [PMID: 9431344 DOI: 10.1016/s0039-6109(05)70622-8] [Citation(s) in RCA: 72] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The evaluation and treatment of acute appendicitis remain essentially unchanged for the majority of individuals who present with this disease. Although advancements have been made in laboratory analysis as well as imaging via ultrasonography and CT, nothing can replace careful evaluation by an experienced surgeon. Appendicitis remains a diagnosis based primarily on history and physical examination, with further studies being useful adjuncts in atypical cases--more likely to occur in the very young or very old and most cost effective when ordered by the surgical consultant. Improvement in outcomes has not been demonstrated with routine use of "new technology." The treatment of acute appendicitis continues to be early surgical intervention. Although laparoscopic appendectomy may offer advantages in women of childbearing age and in obese individuals, its routine use is not indicated based upon current reports in the literature. Debate continues regarding the optimal treatment of the periappendiceal mass. Further clinical research regarding early operation compared with intravenous antibiotics with or without drainage, as well as comparison of outcomes with or without interval appendectomy, needs to be performed. With continued research and definition of populations likely to benefit from advances in technology, a more focused application will be possible. This will lead to improved outcomes and decreased overall cost. The issue of delay in treatment, a major determinant of morbidity associated with appendicitis, warrants further evaluation and should be addressed on a population-specific basis. Emphasis should remain on the early clinical diagnosis of acute appendicitis with its associated low morbidity and mortality.
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Affiliation(s)
- R T Wilcox
- Department of General Surgery, Virginia Mason Medical Center, Seattle, Washington, USA
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Abstract
Hollow viscus injuries are usually managed with few complications. However, if their diagnosis is delayed, or if reparative suture closure should fail, the patient is placed at risk of multiple organ failure. This article presents diagnostic approaches, emphasizing imaging modalities, and therapeutic strategies for three clinical scenarios of hollow viscus perforation: 1) acute appendicitis, 2) gastroduodenal peptic ulcer disease, and 3) trauma.
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Affiliation(s)
- R Espinoza
- Department of Surgery, Pontificia Catholic University of Chile, Santiago, Chile
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Paajanen H, Tainio H, Laato M. A chance of misdiagnosis between acute appendicitis and renal colic. SCANDINAVIAN JOURNAL OF UROLOGY AND NEPHROLOGY 1996; 30:363-6. [PMID: 8936624 DOI: 10.3109/00365599609181311] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The symptoms of right-sided renal colic mimic sometimes acute appendicitis. A prospective comparative study of 188 patients with ureteral stone and 188 patients with acute appendicitis was performed to evaluate the features of differential diagnosis. Appendicitis caused more often nausea (81 vs 11%), fever and localized pain in the McBurney (97 vs 59%) than renal colic. The patients with ureteral stone had tenderness in 16% in the right lower quadrant. The mean values of C-reactive protein (41 mg/l) and blood leukocytes (14 x 10(9)/l) were elevated in appendicitis, but not in renal colic (14 mg/l and 10 x 10(9)/ l). Urinanalysis revealed red cells in 92% of ureteral stones compared with 26% in appendicitis. Only one of 188 patients with appendicitis was first misdiagnosed to have renal colic. A mistake of appendicitis for ureteral stone is clinically rare occurring only once or twice per year in the hospital where 700-800 emergency appendectomies are annually performed.
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Affiliation(s)
- H Paajanen
- Department of Surgery, Kuopio University Hospital, Finland
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Wagner M, Aronsky D, Tschudi J, Metzger A, Klaiber C. Laparoscopic stapler appendectomy. A prospective study of 267 consecutive cases. Surg Endosc 1996; 10:895-9. [PMID: 8703146 DOI: 10.1007/s004649900192] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The value of laparoscopic appendectomy remains controversial. Therefore, we investigated the accuracy of diagnostic laparoscopy in detecting acute appendicitis and tested the applicability and safety of stapling appendectomy as a routine procedure. METHODS Data from 267 consecutive patients with suspicion of acute appendicitis were recorded prospectively. RESULTS Histopathological examination revealed nonperforated and perforated appendicitis in 63.3% and 13.1%, respectively, and no inflammation in 10.8%. Other pathological findings were observed in 12.7%. Diagnostic laparoscopy detected appendicitis with a sensitivity and specificity of 95.6% and 96.6%, respectively; the positive and negative predictive value were 99.5% and 74.3%, respectively. Morbidity was 10.2% in total and 40% for perforated appendicitis. Planned laparoscopic reexploration reduced morbidity by 23.4% in patients with perforated appendicitis and substantial peritonitis. Mortality was 0.4%. CONCLUSIONS Laparoscopy improves diagnostic accuracy for acute appendicitis and laparoscopic stapling appendectomy is a safe and efficient procedure for all forms of appendicitis.
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Affiliation(s)
- M Wagner
- Surgical Department, Spital Aarberg, Switzerland
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Gurleyik E, Gurleyik G, Unalmişer S. Accuracy of serum C-reactive protein measurements in diagnosis of acute appendicitis compared with surgeon's clinical impression. Dis Colon Rectum 1995; 38:1270-4. [PMID: 7497838 DOI: 10.1007/bf02049151] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
UNLABELLED Diagnosis of acute appendicitis is established generally by the surgeon's clinical impression. Today, negative laparotomy rate because of clinical diagnosis is still 15 to 25 percent. PURPOSE This study was designed to determine the accuracy of C-reactive protein (CRP) measurements in the diagnosis of acute appendicitis and to compare it with the surgeon's clinical diagnosis. METHODS One hundred eight consecutive patients were studied prospectively. Depending on results of the examination by a surgeon, patients underwent surgery for acute appendicitis. Serum CRP measurements were performed before the operations but were not taken into account for the decision of laparotomy to compare it with the surgeon's clinical diagnosis. RESULTS Histopathologic findings confirmed acute appendicitis in 90 patients. Normal appendixes were removed in the remaining 18 patients. Mean serum CRP value was 5 (range, 0-12.6) mg/l in patients with normal appendix, 33.8 (range, 5-85.1) mg/l in patients with nonperforated appendicitis, and 128.5 (range, 79.2-230) mg/l in patients with perforated appendixes. These differences were highly significant (P < 10(-6)). Serum CRP levels were normal in three patients with acute appendicitis. Thus, the false-negative rate of CRP was 3 percent. Of 18 patients with normal appendectomy serum CRP levels were slightly elevated in two patients. We determined, therefore, a false-positive rate of CRP as 11 percent. CRP levels were false-negative in three patients and false-positive in two patients. Thus, CRP levels were true (positive or negative) in the remaining 103 patients. On the other hand, the diagnosis depending on surgeon's clinical impression was true in 90 patients and false in 18 patients. This difference was statistically significant (P = 0.0035). In the present study the sensitivity, specificity, and accuracy of serum CRP measurements were calculated as 93.5, 80, and 91 percent, respectively. CONCLUSION We found that elevated serum CRP levels support surgeon's clinical diagnosis. We recommend CRP measurement as a routine laboratory test in patients with suspected diagnosis of acute appendicitis.
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Affiliation(s)
- E Gurleyik
- Department of Surgery, Haydarpasa Numune Hospital, Istanbul, Turkey
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Orr RK, Porter D, Hartman D. Ultrasonography to evaluate adults for appendicitis: decision making based on meta-analysis and probabilistic reasoning. Acad Emerg Med 1995; 2:644-50. [PMID: 8521213 DOI: 10.1111/j.1553-2712.1995.tb03606.x] [Citation(s) in RCA: 76] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVES To review ultrasonography (US) test performance and to develop recommendations for the use of US to aid in the evaluation of potential appendicitis. METHODS A meta-analysis was conducted using all English-language articles published since 1986 (17 studies; 3,358 patients) to ascertain sensitivity and specificity of US for diagnosing appendicitis in adults and teenagers. Calculation of the predictive value of US was performed for three groups of patients: group I--usually operated on (prevalence of appendicitis = 80%); group II--usually observed in hospital (prevalence = 40%); and group III--usually released home (prevalence 2%). RESULTS Overall sensitivity was 84.7% (95% CI: 81.0-87.8%), and specificity 92.1% (88.0-95.2). The accuracy and usefulness of US were related to the likelihood of appendicitis. In group I, a positive test was accurate [positive predictive value (PPV) = 97.6%], but a negative study could not rule out appendicitis [negative predictive value (NPV) = 59.5%]. The converse was true for group III patients (PPV = 19.5%, NPV = 99.7%). Test performance accuracy was balanced only for group II patients (PPV = 87.3%, NPV = 89.9%). CONCLUSIONS 1) US should not be used to exclude appendicitis for patients who have "classic" signs/symptoms, due to the underlying high false-negative rate. 2) US is most useful for patients who have an indeterminate probability of disease after the initial evaluation--if US is positive, the patient should have an operation; otherwise, he or she should be observed. 3) US is not recommended for screening patients who have a low probability of appendicitis, due to the low prevalence of disease and high false-positive rate in this group.
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Affiliation(s)
- R K Orr
- Department of Surgery, Fallon Health Care System, Worcester, MA 01605, USA
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