Accuracy of imaging in discriminating complicated from uncomplicated appendicitis in daily clinical practice

C-Reactive Protein, International Normalized Ratio, and Fibrinogen in Diagnostic Scale of Complicated Acute Appendicitis

Background/Objectives: Differentiating complicated acute appendicitis (CA) and uncomplicated acute appendicitis (UC) is essential to guide clinical management. While CA requires urgent surgical management, UC can be treated with antibiotic therapy in selected cases. However, accurate identification of CA remains a clinical challenge. This study aimed to identify factors associated with CA and to develop a diagnostic severity scale. Methods: In this retrospective study, we included 132 adult patients (>16 years) with a confirmed postsurgical diagnosis of appendicitis, of whom 52 had CA and 80 had UA. Signs, symptoms, comorbidities, laboratory values, and ultrasonographic findings were evaluated to determine predictive factors and construct a diagnostic scale. Results: The factors most significantly associated with CA were elevated plasma concentrations of C-reactive protein (>7.150 mg/dL), fibrinogen (481.5 mg/dL), International Normalized Ratio (INR) (>1.150), and the presence of free fluid periappendicular. The combination of these factors within one scale showed an area under the curve (AUC) of 0.84, with a sensitivity of 78.75% and a specificity of 82.69%. Conclusions: Serum C-reactive protein concentration, fibrinogen, and INR can be employed individually or as part of a scale as important indicators in diagnosing CA.

Ultrasound and computed tomography in differentiating between simple and complicated appendicitis in pediatric patients

OBJECTIVES

This study aims to measure the diagnostic accuracy and reliability of US and CT in diagnosing complicated appendicitis among pediatric patients and to find the performance of the imaging modalities in detecting complication signs.

METHODS

a systematic review and meta-analysis were done on 15 eligible studies from the Medline Database concerning pediatric appendicitis and its complications. Studies either provided an overall estimate of sensitivity and specificity of the imaging modality or addressed signs of complicated appendicitis The reference standard employed was either surgical findings or histopathology reports.

RESULTS

The review included assessments of 4,497 pediatric patients, with 285 undergoing CT and 4,212 undergoing US imaging. CT demonstrated sensitivities of 62% and 68.4%, and specificities of 81% and 92.4%. US showed sensitivities of 33.9% to 51.5% and specificities ranging from 68.8% to 95%. The ultrasound's ability to detect appendiceal wall diameter > 5 mm showed the highest sensitivity (99.4%), while the conglomerate sign indicated the highest specificity (99.9%).

CONCLUSION

The findings suggest that both US and CT exhibit higher specificity than sensitivity in diagnosing complicated appendicitis in pediatric patients. Given its favorable specificity, non-invasiveness, and lack of radiation exposure, US should be the first-line imaging modality in suspected cases of pediatric appendicitis. CT, offering robust specificity, should be reserved for ambiguous cases where US results are inconclusive. These insights underscore the critical role of precise imaging modalities in enhancing diagnostic accuracy, reducing unnecessary surgeries, and improving clinical outcomes in pediatric appendicitis management.

Predictive model for identification of gangrenous or perforated appendicitis in adults: a multicenter retrospective study

BACKGROUND

Gangrene and perforation are severe complications of acute appendicitis, associated with a higher mortality rate compared to uncomplicated appendicitis. Accurate preoperative identification of Gangrenous or perforated appendicitis (GPA) is crucial for timely surgical intervention.

METHODS

This retrospective multicenter study includes 796 patients who underwent appendectomy. Univariate and multivariate logistic regression analyses are used to develop a nomogram model for predicting GPA based on laboratory tests and computed tomography (CT) findings. The model is validated using an external dataset.

RESULTS

Seven independent predictors were included in the nomogram: white blood cell count, lymphocyte count, D-dimer, serum glucose, albumin, maximum outer diameter of the appendix, and presence of appendiceal fecalith. The nomogram achieved good discrimination and calibration in both the training and testing sets. In the training set, the AUC was 0.806 (95%CI: 0.763-0.849), and the sensitivity and specificity were 82.1% and 66.9%, respectively. The Hosmer-Lemeshow test showed good calibration (P = 0.7378). In the testing set, the AUC was 0.799 (95%CI: 0.741-0.856), and the sensitivity and specificity were 70.5% and 75.3%, respectively. Decision curve analysis (DCA) confirmed the clinical utility of the nomogram.

CONCLUSION

The laboratory test-CT nomogram model can effectively identify GPA patients, aiding in surgical decision-making and improving patient outcomes.

Is non-operative treatment of acute appendicitis possible: A narrative review

Introduction

Acute appendicitis (AA) represents the most frequent surgical emergency. Perforation was long considered the ultimate outcome of AA, prompting appendectomy; which remains the standard treatment. New data have clarified the role of the appendix, justifying conservative treatment. This narrative review aims to summarize the evidence regarding the non-operative treatment (NOT) of AA in adults.

Methods

The literature search was performed via the PubMed Medline database. Our criteria-based selection resulted in a total of 48 articles for review.

Results

Recent trials and meta-analyses have assessed NOT, which support primary antibiotic treatment of uncomplicated AA. Although it has a significant recurrence and failure rate, NOT does not appear to increase the risk of appendicular perforation. Moreover, NOT compared with appendectomy, seems to be associated with less morbidity, lower cost of care and preserved quality of life.

Conclusion

First-line NOT seems to be a reasonable approach for the treatment of uncomplicated CT-confirmed AA. Careful patient screening would definitely enhance the success rate.

The Diagnostic Accuracy of Hyperbilirubinemia in Predicting Appendicitis and Appendiceal Perforation

Background Every diagnostic tool that may assist in the identification of appendicitis is of great importance to emergency general surgeons. While recent research has indicated that hyperbilirubinemia can serve as a valuable predictor of appendiceal perforation, these studies have not specifically examined the role of bilirubin as an indicator for acute appendicitis. This study aimed to assess the role of hyperbilirubinemia as a diagnostic factor in detecting appendicitis and appendiceal perforation. Methodology This single-center retrospective study involved 333 patients with acute appendicitis who underwent an emergency appendectomy at a model three hospital between January 2021 and December 2022. Statistical analysis was performed using STATA/SE 18.0 for Windows (StataCorp., College Station, TX, USA) to compare bilirubin levels, white blood cell count (WCC), and C-reactive protein (CRP) among normal appendices, non-perforated appendicitis, and perforated appendicitis. Results Among 333 patients, 60.66% were male, and 39.34% were female, with a male-to-female ratio of 1.54:1. The average hospital stay was 3.27 ± 3.02 days. Hyperbilirubinemia was observed in 25.53% (85 individuals). Among the 51 cases of perforated appendicitis, 70.59% had elevated bilirubin levels of above 20 μmol/L. Significantly more patients with appendiceal perforation had hyperbilirubinemia than non-perforated appendicitis (70.59% vs. 19.03%, p < 0.001). Bilirubin had higher specificity (94.29%) for detecting non-perforated appendicitis than normal appendices (odds ratio = 3.88), while WCC and CRP showed higher sensitivities. WCC had a sensitivity of 73.28% and a specificity of 42.86%, and CRP had a sensitivity of 76.53% and a specificity of 60.00%. When comparing perforated appendicitis with non-perforated appendicitis, bilirubin showed a specificity of 80.97% and an odds ratio of 10.21. The likelihood of a patient with hyperbilirubinemia having perforated appendicitis was more than 10 times higher than those without appendiceal perforation, suggesting it to be a potential indicator for appendiceal perforation. WCC showed a specificity of 26.72% and an odds ratio of 4.28, while CRP had a specificity of 23.48% and an odds ratio of 4.91. Conclusions The significant association between bilirubin levels and appendicitis highlights its potential as a valuable marker for predicting appendicitis and appendiceal perforation. The simplicity, cost-effectiveness, and diagnostic value of bilirubin assessment support its routine use in suspected cases of acute appendicitis.

Predicting complicated appendicitis is possible without the use of sectional imaging-presenting the NoCtApp score

PURPOSE

Appendicitis is among the most common acute conditions treated by general surgery. While uncomplicated appendicitis (UA) can be treated delayed or even non-operatively, complicated appendicitis (CA) is a serious condition with possible long-term morbidity that should be managed with urgent appendectomy. Distinguishing both conditions is usually done with computed tomography. The goal of this study was to develop a model to reliably predict CA with widespread available clinical and laboratory parameters and without the use of sectional imaging.

METHODS

Data from 1132 consecutive patients treated for appendicitis between 2014 and 2021 at a tertiary care hospital were used for analyses. Based on year of treatment, the data was divided into training (n = 696) and validation (n = 436) samples. Using the development sample, candidate predictors for CA-patient age, gender, body mass index (BMI), American Society of Anesthesiologist (ASA) score, duration of symptoms, white blood count (WBC), total bilirubin and C-reactive protein (CRP) on admission and free fluid on ultrasound-were first investigated using univariate logistic regression models and then included in a multivariate model. The final development model was tested on the validation sample.

RESULTS

In the univariate analysis age, BMI, ASA score, symptom duration, WBC, bilirubin, CRP, and free fluid each were statistically significant predictors of CA (each p < 0.001) while gender was not (p = 0.199). In the multivariate analysis BMI and bilirubin were not predictive and therefore not included in the final development model which was built from 696 patients. The final development model was significant (x2 = 304.075, p < 0.001) with a sensitivity of 61.7% and a specificity of 92.1%. The positive predictive value (PPV) was 80.4% with a negative predictive value (NPV) of 82.0%. The receiver operator characteristic of the final model had an area under the curve of 0.861 (95% confidence interval 0.830-0.891, p < 0.001. We simplified this model to create the NoCtApp score. Patients with a point value of ≤ 2 had a NPV 95.8% for correctly ruling out CA.

CONCLUSIONS

Correctly identifying CA is helpful for optimizing patient treatment when they are diagnosed with appendicitis. Our logistic regression model can aid in correctly distinguishing UA and CA even without utilizing computed tomography.

The Prognostic Value of Ultrasound Findings in Preoperatively Distinguishing between Uncomplicated and Complicated Types of Pediatric Acute Appendicitis Based on Correlation with Intraoperative and Histopathological Findings

OBJECTIVE

This study compares the preoperative ultrasound findings of all children with a clinical picture of acute appendicitis on the basis of intraoperative and histopathological findings to assess the feasibility of this approach in preoperatively distinguishing between uncomplicated and complicated cases.

METHODS

This retrospective study includes 224 pediatric patients who underwent ultrasound prior to appendectomy at our institution between January 2016 and February 2022. Logistic regression analysis was used to investigate the association between sonographic and intraoperative histopathological findings.

RESULTS

Of the 224 participants, 61.1% were intraoperatively diagnosed with uncomplicated appendicitis (59.8% male). Multivariate logistic regression analysis revealed that patients with a higher appendiceal diameter, presence of appendicolith, and peritonitis were more likely to suffer from complicated appendicitis. Finally, the common anatomical position of the appendix and an appendiceal diameter greater than 6 mm had the highest sensitivity (94.6% and 94.5%, respectively) for predicting complicated appendicitis, with the most specific (99.3%) sonographic finding being the existence of an abscess.

CONCLUSIONS

Preoperative abdominal ultrasound in children with a clinical diagnosis of acute appendicitis can distinguish between uncomplicated and complicated appendicitis in most cases of pediatric appendicitis. A higher appendiceal diameter, the presence of appendicolith, and peritonitis are parameters noted by ultrasound that strongly predict complicated appendicitis.