High admission C-reactive protein level and longer in-hospital delay to surgery are associated with increased risk of complicated appendicitis

Pre-hospital management and patient-related factors affecting access to the surgical care of appendicitis - a survey study

BACKGROUND AND AIMS

Long pre-hospital delay substantially increases the likelihood of perforated appendicitis. This study aimed to find patient-related factors affecting this delay.

METHODS

A survey was conducted for patients with acute appendicitis after appendectomy. The participants were asked about their path to the surgical center and socioeconomic status. Variables affecting delays and the rate of complicated appendicitis were analyzed.

RESULTS

The study included 510 patients; 157 (31%) had complicated appendicitis with a median prehospital delay of 42 h. In patients with uncomplicated appendicitis, the delay was 21 h, p < .001. Forty-six (29%) patients with complicated appendicitis were not referred to the hospital after the first doctor's visit. The multivariate analysis discovered factors associated with long pre-hospital delay: age 40-64 years (OR 1.63 (95% CI 1.06-2.52); compared to age 18-39), age more than 64 years (OR 2.84 (95% CI 1.18-6.80); compared to age 18-39), loss of appetite (OR 2.86 (95% CI 1.64-4.98)), fever (OR 1.66 (95% CI 1.08-2.57)), non-referral by helpline nurse (OR 2.02 (95% CI 1.15-3.53)) and non-referral at first doctors visit (OR 2.16 (95% CI 1.32-3.53)). Age 40-64 years (OR 2.41 (95% CI 1.50-3.88)), age more than 64 years (OR 8.79 (95% CI 2.19-35.36)), fever (OR 1.83 (95% CI 1.15-2.89)) and non-referral at first doctors visit (OR 1.90 (95% CI 1.14-3.14)) were also risk factors for complicated appendicitis.

CONCLUSIONS

Advanced age, fever and failure to suspect acute appendicitis in primary care are associated with prolonged pre-hospital delay and complicated appendicitis.

Role of preoperative in-hospital delay on appendiceal perforation while awaiting appendicectomy (PERFECT): a Nordic, pragmatic, open-label, multicentre, non-inferiority, randomised controlled trial

BACKGROUND

Appendicectomy remains the standard treatment for appendicitis. No international consensus exists on the surgical urgency for acute uncomplicated appendicitis, and recommendations vary from surgery without delay to surgery within 24 h. Longer in-hospital delay has been thought to increase the risk of perforation and further morbidity. Therefore, we aimed to compare the rate of appendiceal perforation in patients undergoing appendicectomy scheduled to two different urgencies (<8 h vs <24 h).

METHODS

In this pragmatic, open-label, multicentre, non-inferiority, parallel, randomised controlled trial in two hospitals in Finland and one in Norway, patients (aged ≥18 years) with presumed uncomplicated acute appendicitis were randomly assigned (1:1) to an appendicectomy scheduled within 8 h or within 24 h to determine whether longer in-hospital delay (time between randomisation and surgical incision) is not inferior to shorter delay. Patients were excluded in cases of pregnancy, suspicion of perforated appendicitis (C-reactive protein level of ≥100 mg/L, fever >38·5°C, signs of complicated appendicitis on imaging studies, or clinical generalised peritonitis), or other reasons requiring prompt surgery. The recruiters were on-duty surgeons who decided to proceed with the appendicectomy. The randomisation sequence was generated using block randomisation with randomly varying block sizes and stratified by hospital districts; neither physicians nor patients were masked to group assignment. The primary outcome was perforated appendicitis diagnosed during surgery analysed in all patients who received an appendicectomy by intention to treat. The absolute difference in rates of perforated appendicitis was compared between the groups. Complications and other safety outcomes were analysed in all patients who received an appendicectomy. A margin of 5 percentage points was used to establish non-inferiority. This trial was registered at ClinicalTrials.gov (NCT04378868) and is closed to accrual.

FINDINGS

Between May 18, 2020, and Dec 31, 2022, 2095 patients were assessed for eligibility, of whom 1822 were randomly assigned to appendicectomy scheduled within 8 h (n=914) or 24 h (n=908). After randomisation, 19 (1%) of 1822 patients were excluded due to protocol violation. 1803 patients were included in the intention-to-treat analyses, 985 (55%) of whom were male and 818 (45%) female. Appendiceal perforation rate was similar between groups (77 [8%] of 907 patients assigned to the <8 h group and 81 [9%] of 896 patients assigned to the <24 h group; absolute risk difference 0·6% [95% CI -2·1 to 3·2], p=0·68; risk ratio 1·065, 95% CI 0·790 to 1·435). No significant difference was found between the complication rates within 30 days (66 [7%] of 907 patients in the <8 h group vs 56 [6%] of 896 patients in the <24 h group; difference -1·0% [-3·3 to 1·3]; p=0·39), and no deaths occurred during this follow-up period.

INTERPRETATION

In patients with presumed uncomplicated acute appendicitis, scheduling appendicectomy within 24 h does not increase the risk of appendiceal perforation compared with scheduling appendicectomy within 8 h. The results can be used to allocate operating room resources, for example postponing night-time appendicectomy to daytime.

FUNDING

The Finnish Medical Foundation, Mary and Georg Ehrnrooth's Foundation, Biomedicum Helsinki Foundation, and the Finnish Government.

Individual biomarkers in the blood are not yet applicable in diagnosing complicated appendicitis: A scoping review

BACKGROUND

Appendicitis is one of the most common surgical emergencies globally and it can both be difficult to diagnose but also to differentiate complicated from uncomplicated appendicitis preoperatively. The objective of this scoping review was to develop an overview of biomarkers in blood discriminating complicated from uncomplicated appendicitis and characterize their applicability in an acute setting including time, cost, and analysis technique required as well as their individual precision.

METHOD

This scoping review was reported in accordance with PRISMA-ScR. The included studies had to report on biomarkers measured in the blood for at least ten patients with suspected appendicitis. A systematic literature search was conducted on August 28, 2022, in PubMed and Embase but restricted to articles published in January 2000 and onwards. A protocol was uploaded to Open Science Framework prior to data extraction.

RESULTS

A total of 65 biomarkers were included from 52 studies, covering 14,312 patients. There was 60% routine- and 40% novel biomarkers based on the reported analysis technique. The most frequently investigated biomarkers within each group were white blood cell count and procalcitonin. The routine biomarkers were of low financial cost but poor diagnostic accuracy with sensitivity ranging between 15 and 100% and specificity between 27 and 100%. Novel markers were costly ranging from 275 to 800$, and their diagnostic accuracy was based on limited population sizes (median 34 patients) and reported for only 5% of the novel markers.

CONCLUSION

Routine biomarkers were applicable in an acute setting but had poor diagnostic accuracy. Novel biomarkers are being investigated for potential, but the concept is still premature due to lack of diagnostic accuracy studies reporting cost-benefit for individual markers and whether they can be applied in an acute setting.

Complicated appendicitis increases the hospital length of stay

Background

There are insufficient data from Saudi Arabia regarding appendectomy outcomes and hospital length of stay. Further, there is a need to compare the length of stay of Saudi patients and the literature. The purpose is to evaluate the surgical outcomes and hospital length of stay for complicated appendicitis and simple appendicitis.

Method

This is a single-center retrospective review of patients who had undergone an appendectomy between 2016 and 2018. The patients were divided into 2 groups: complicated appendicitis versus simple appendicitis.

Results

Of 449 patients who underwent appendectomy, 60 (13.4%) had complicated appendicitis. The complicated appendicitis was significantly associated with increased age, pain duration, neutrophilia, high C-reactive protein, fecalith presence, and free fluid. The incidence rate of surgical site infection was 5.8% (identified in 26 patients). Compared to simple appendicitis, complicated appendicitis was associated more with wound infection (1.8% vs 10%, respectively, P = .001), postoperative collection (1.2% vs 11.6%, respectively, P = .001), and readmission within 30 days (2.3% vs 13.4%, respectively, P = .001). By multivariate analysis, factors associated more with increased hospitalization were pain duration (hazard ratio = 2.37, 95% confidence interval = 1.09–5.16, P = .029), operative time (hazard ratio = 2.09, 95% confidence interval = 1.04–4.21, P = .038), and complicated appendicitis (hazard ratio = 6.61, 95% confidence interval = 2.67–14.21, P = .001).

Conclusion

Complicated appendicitis correlates with significant morbidity, readmission rate, and 6 times more hospital LOS than simple appendicitis. This review might help in appreciating the burden of complicated appendicitis on hospital length of stay, which needs allocating patients and planning the discharge day for hospitals with limited beds.

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Practically one fifth of acute appendicitis will be complicated.

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Complicated appendicitis increases conversion to open, surgical site infection, hospital length of stay, and 30-day readmission rate.

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Prolonged operation time and complicated appendicitis are independent risk factors to increase hospitalization.

Role of delay and antibiotics on PERForation rate while waiting appendicECTomy (PERFECT): a protocol for a randomized non-inferiority trial

Background

Longer duration from symptom onset is associated with increased risk of perforation in appendicitis. In previous studies, in-hospital delay to surgery has had conflicting effects on perforation rates. Although preoperative antibiotics have been shown to reduce postoperative infections, there are no data showing that administration of antibiotics while waiting for surgery has any benefits. The aims of this study are to evaluate the role of both in-hospital delay to surgery and antibiotic treatment while waiting for surgery on the rate of appendiceal perforation.

Methods

This prospective, open-label, randomized, controlled non-inferiority trial compares the in-hospital delay to surgery of less than 8 hours versus less than 24 hours in adult patients with predicted uncomplicated acute appendicitis. Additionally, participants are randomized either to receive or not to receive antibiotics while waiting for surgery. The primary study endpoint is the rate of perforated appendicitis discovered during appendicectomy. The aim is to randomize 1800 patients, that is estimated to give a power of 90 per cent (χ²) for the non-inferiority margin of 5 percentage points for both layers (urgency and preoperative antibiotic). Secondary endpoints include length of hospital stay, 30-day complications graded using Clavien–Dindo classification, preoperative pain, conversion rate, histopathological diagnosis and Sunshine Appendicitis Grading System classification.

Discussion

There are no previous randomized controlled studies for either in-hospital delay or preoperative antibiotic treatment. The trial will yield new level 1 evidence.

EU Clinical Trials Register, EudraCT Number: 2019–002348-26; registration number: NCT04378868 (http://www.clinicaltrials.gov)

Perforation rate after a diagnosis of uncomplicated appendicitis on CT

Background

Appendicectomy is a common emergency operation. The aim of this analysis was to study the effect of preoperative delay on disease progression, and whether a novel scoring system (Atema score) could be useful in predicting complicated appendicitis.

Methods

Patients with uncomplicated acute appendicitis on CT and who underwent appendicectomy in 2014–2015 were analysed for patient characteristics, preoperative delay and outcomes.

Results

Of 837 patients with uncomplicated appendicitis on CT, 187 (22.3 per cent) were found to have complicated appendicitis at surgery. The median time estimate for perforation was 25.4 h after CT, with an hourly rate of perforation of 2 per cent. Patients with an Atema score of 6 or less and those with no appendicolith on CT and a C-reactive protein level below 51 mg/l were the slowest to develop perforation, reaching a perforation rate of 5 per cent in 7.1 and 7.6 h respectively.

Conclusion

A substantial proportion of patients with uncomplicated acute appendicitis on CT have complicated appendicitis at surgery. However, in patients with no risk factors, surgery can be postponed safely for up to 7 h.

Inflammatory Markers and Duration of Symptoms Have a Close Connection With Diagnosis and Staging of Acute Appendicitis in Children

Background: For children with acute appendicitis (AA), a clear diagnosis is a challenge. The purpose of this study is to explore whether inflammatory markers in the blood combined with symptom duration are helpful in the diagnosis of acute appendicitis and in predicting the severity of acute appendicitis. Methods: All the selected patients underwent appendectomy between November 10, 2011 and November 15, 2019, in whom preoperative WBCC, CRP, and NE% had been measured in a short time. All patients were divided into two groups: uncomplicated AA and complicated AA, postoperatively. Results: For our standards, 813 patients were selected, 442 of them had complicated AA. The mean [standard deviation (SD)] age for the uncomplicated AA group was 9.78 ± 2.02 years and for the complicated AA group was 9.69 ± 2.16 years (P = 0.55). Elevated WBCC, CRP, and NE% had a higher relatively sensitivity in complicated AA than uncomplicated AA especially when WBCC, CRP, and NE% were at normal levels, which had a sensitivity of 100% in uncomplicated AA, but this only applied to nine patients. CRP values were significantly different in three time groups, whether uncomplicated or complicated AA. Conclusion: The combination of WBCC, CRP, and NE% values is very sensitive for the diagnosis of acute appendicitis, and when we predict complicated AA using the CRP value, we also need to consider the time of symptom onset.

Risk of Perforation in the Era of Nonemergent Management for Acute Appendicitis

Prompt appendectomy has long been the standard of care for acute appendicitis because of the risk of progression to perforation. Recently, studies have suggested nonemergent management of acute appendicitis. Our study aimed to determine changes in risk of rupture and complications in patients with appendicitis, with increasing time from symptom onset to treatment. Retrospective study of patients aged ≥18 years presenting to the University of North Carolina Hospitals with signs and symptoms of acute appendicitis who subsequently underwent appendectomy from 2011 to 2015 was performed. Demographic, clinical, laboratory, and pathologic data were reviewed. Bivariate analysis was performed to assess variables associated with increased risk of perforation. Poisson regression modeling was completed to evaluate the risk of perforation and postoperative abscess based on time from symptoms to treatment. Within our database of 1007 patients, the mean time from onset of symptoms to operative intervention was 3.24 ± 2.2 days. Modified Poisson regression modeling demonstrated the relative risk for perforation increases by 9% (RR 1.09, P < 0.001) for each day delay. Age (RR 1.03), male gender (RR 1.50), temperature on admission (RR 1.32), and the presence of fecalith (RR 1.89) statistically significantly increased the risk of perforation. Furthermore, for each day delay, there is an 8% increased risk of postoperative abscess (RR 1.08, P = 0.027). The relative risk for appendiceal perforation is 9 per cent per day delay with a resultant 8 per cent increased risk of postoperative abscess. Thus, appendectomy for acute appendicitis should remain an emergent procedure, given that delays in operative management lead to complications and increases in cost of care.

[Can Uncomplicated Adult Appendicitis Also Be Treated Conservatively?]

Can Uncomplicated Adult Appendicitis Also Be Treated Conservatively? Abstract. For more than a century, appendectomy has been the first-line treatment for acute appendicitis. Despite modern imaging, it is not an easy disease to diagnose and is one of the most common emergency procedures worldwide. Conservative therapy for uncomplicated adult appendicitis is increasingly becoming the focus of discussion. Due to current data, a recommendation for conservative therapy of uncomplicated adult appendicitis can not be given. For the time being it should be reserved for a selected patient group.

Meta-analysis of in-hospital delay before surgery as a risk factor for complications in patients with acute appendicitis

Background

The traditional fear that every case of acute appendicitis will eventually perforate has led to the generally accepted emergency appendicectomy with minimized delay. However, emergency and thereby sometimes night‐time surgery is associated with several drawbacks, whereas the consequences of surgery after limited delay are unclear. This systematic review aimed to assess in‐hospital delay before surgery as risk factor for complicated appendicitis and postoperative morbidity in patients with acute appendicitis.

Methods

PubMed and EMBASE were searched from 1990 to 2016 for studies including patients who underwent appendicectomy for acute appendicitis, reported in two or more predefined time intervals. The primary outcome measure was complicated appendicitis after surgery (perforated or gangrenous appendicitis); other outcomes were postoperative surgical‐site infection and morbidity. Adjusted odds ratios (ORs) were pooled using forest plots if possible. Unadjusted data were pooled using generalized linear mixed models.

Results

Forty‐five studies with 152 314 patients were included. Pooled adjusted ORs revealed no significantly higher risk for complicated appendicitis when appendicectomy was delayed for 7–12 or 13–24 h (OR 1·07, 95 per cent c.i. 0·98 to 1·17, and OR 1·09, 0·95 to 1·24, respectively). Meta‐analysis of unadjusted data supported these findings by yielding no increased risk for complicated appendicitis or postoperative complications with a delay of 24–48 h.

Conclusion

This meta‐analysis demonstrates that delaying appendicectomy for presumed uncomplicated appendicitis for up to 24 h after admission does not appear to be a risk factor for complicated appendicitis, postoperative surgical‐site infection or morbidity. Delaying appendicectomy for up to 24 h may be an acceptable alternative for patients with no preoperative signs of complicated appendicitis.

Delay is safe

Effect of Delay to Operation on Outcomes in Patients with Acute Appendicitis: a Systematic Review and Meta-analysis

BACKGROUND

Many studies have investigated the association between time interval and incidence of complicated appendicitis and post-operative surgical site infection (SSI), but the results are controversial.

METHODS

A systematic search of the electronic databases identified studies that investigated the association of appendectomy delay with complicated appendicitis and SSI among patients with acute appendicitis. Qualitative and quantitative meta-analysis of the results was conducted.

RESULTS

Twenty-one studies were included in the final analysis. Meta-analysis showed no significant difference in complicated appendicitis incidence between patients in the 6-12 h, > 12 and < 6 h groups (OR 1.07, 95% CI 0.89-1.30, p = 0.47; OR 1.04, 95% CI 0.88-1.22, p = 0.64). Comparison of the 6-12 h category with the < 6 h category of in-hospital delay revealed significant associations between longer in-hospital delay and increased risk of post-operative SSI (OR 1.40, 95% CI 1.11-1.77, p = 0.004). Patients in the 24-48 h category had 1.99- and 1.84-fold (p < 0.05) higher odds of developing complicated appendicitis compared to patients in the < 24 h category for pre-hospital delay and total delay, respectively (OR 1.99, 95% CI 1.35-2.94, p = 0.0006; OR 1.84, 95% CI 1.05-3.21, p = 0.03). When pre-hospital and total delay time extended to more than 48 h, the odds of risk increased 4.62- and 7.57-fold, respectively (OR 4.62, 95% CI 2.99-7.13, p < 0.00001; OR 7.57, 95% CI 6.14-9.35, p = < 0.00001).

CONCLUSION

Complicated appendicitis incidence was associated with overall elapsed time from symptom onset to admission or operation; short appendectomy in-hospital delay did not increase the risk of complicated appendicitis but was associated with a slightly increased risk of SSI. Prompt surgical intervention is warranted to avoid additional morbidity, enabling quicker recovery in this population.

[Management of acute appendicitis : Evidence for prompt surgical treatment?]

BACKGROUND

Acute appendicitis is a common disease which requires immediate surgical treatment of the focus of inflammation. So far there are no reliable data on how much time can pass between hospitalization, indications for surgery and initiating surgery without an increased risk of morbidity and mortality for the patient.

OBJECTIVE

The aim of this study was to investigate how much time can lapse between admission and initiation of surgery for acute appendicitis while still providing patient safety and no increase in complication rates.

MATERIAL AND METHODS

This retrospective analysis investigated the management of all patients who underwent appendectomy under the suspicion of acute appendicitis. Besides the time span between hospital admittance and beginning of the operation (admission to incision time, AIT), anamnestic, diagnostic, technical and perioperative data were assessed and statistically analyzed (mean ± SD).

RESULTS

From January 2008 to April 2013 a total of 655 patients underwent appendectomy. The mean AIT was 7 h and the rate of negative appendectomy was 9.8 %. The mean hospitalization period was 5.9 ± 8.7 days with a postoperative stay of 5.2 ± 7.1 days. A comparison of the subgroups stratified by increasing AIT showed that there was no increased probability for perforation or postoperative complications with an AIT of up to 8 h.

DISCUSSION

This retrospective cohort study showed that appendectomy should be performed within the first 8 h after hospitalization of the patient.

DIAGNOSTIC VALUE OF C-REACTIVE PROTEIN AND THE INFLUENCE OF VISCERAL FAT IN PATIENTS WITH OBESITY AND ACUTE APPENDICITIS

BACKGROUND

The C reactive protein (CRP) is one of the most accurate inflammatory markers in acute appendicitis (AA). Obesity leads to a pro-inflammatory state with increased CRP, which may interfere with the interpretation of this laboratory test in AA.

AIM

To assess sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of CRP in patients with AA and their correlation to body mass index (BMI) and body fat composition.

METHOD

This is a retrospective study based on clinical records and imaging studies of 191 subjects with histopathologically confirmed AA compared to 249 controls who underwent abdominal computed tomography (CT). Clinical and epidemiological data, BMI, and CRP values were extracted from medical records. CT scans were assessed for AA findings and body composition measurements.

RESULTS

CRP values increased according to patients' BMI, with varying sensitivity from 79.78% in subjects with normal or lean BMI, 87.87% in overweight, and 93.5% in individuals with obesity. A similar pattern was observed for NPV: an increase with increasing BMI, 69.3% in individuals with normal or lean BMI, 84.3% in overweight, and 91.3% in individuals with obesity. There was a positive correlation between CRP and visceral fat area in patients with AA.

CONCLUSIONS

Variations exist for sensitivity, specificity, PPV, and NPV values of CRP in patients with AA, stratified by BMI. An increase in visceral fat area is associated with elevated CRP across the BMI spectrum.

Time to appendectomy for acute appendicitis: A systematic review

OBJECTIVE

The goal of this systematic review by the American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee was to develop recommendations regarding time to appendectomy for acute appendicitis in children within the context of preventing adverse events, reducing cost, and optimizing patient/parent satisfaction.

METHODS

The committee selected three questions that were addressed by searching MEDLINE, Embase, and the Cochrane Library databases for English language articles published between January 1, 1970 and November 3, 2016. Consensus recommendations for each question were made based on the best available evidence for both children and adults.

RESULTS

Based on level 3-4 evidence, appendectomy performed within 24h of admission in patients with acute appendicitis does not appear to be associated with increased perforation rates or other adverse events. Based on level 4 evidence, time from admission to appendectomy within 24h does not increase hospital cost or length of stay (LOS). Data are currently limited to determine an association between the timing of appendectomy and parent/patient satisfaction.

CONCLUSIONS

There is a paucity of high-quality evidence in the literature regarding timing of appendectomy for patients with acute appendicitis and its association with adverse events or resource utilization. Based on available evidence, appendectomy performed within the first 24h from presentation is not associated with an increased risk of perforation or adverse outcomes.

TYPE OF STUDY

Systematic Review of Level 1-4 studies.

Can common serum biomarkers predict complicated appendicitis in children?

PURPOSE

As appendicitis in children can be managed differently according to the severity of the disease, we investigated whether commonly used serum biomarkers on admission could distinguish between simple and complicated appendicitis.

METHODS

Admission white blood cell (WBC), neutrophil (NEU), and C-reactive protein (CRP) levels were analysed by ROC curve, and Kruskal-Wallis and contingency tests. Patients were divided according to age and histology [normal appendix (NA), simple appendicitis (SA), complicated appendicitis (CA)].

RESULTS

Of 1197 children (NA = 186, SA = 685, CA = 326), 7% were <5 years, 55% 5-12, 38% 13-17. CA patients had higher CRP and WBC levels than NA and SA (p < 0.0001). NEU levels were lower in NA compared to SA or CA (p < 0.0001), but were similar between SA and CA (p = 0.6). CA patients had higher CRP and WBC levels than SA patients in 5-12- (p < 0.0001) and 13-17-year groups (p = 0.0075, p = 0.005), but not in <5-year group (p = 0.72, p = 0.81). We found CRP >40 mg/L in 58% CA and 37% SA (p < 0.0001), and WBC >15 × 10⁹/L in 58% CA and 43% SA (p < 0.0001).

CONCLUSIONS

Admission CRP and WBC levels may help the clinician predict complicated appendicitis in children older than 5 years of age. Early distinction of appendicitis severity using these tests may guide caregivers in the preoperative decision-making process.

Current Approach to the Diagnosis and Emergency Department Management of Appendicitis in Children

Concerns about radiation exposure have led to a decrease in the use of computed tomography in suspected appendicitis, with increased reliance on ultrasound. Children with suspected appendicitis should be risk stratified using a combination of clinical signs and symptoms, white blood cell count, and ultrasound in order to guide further evaluation and management. Magnetic resonance imaging is a promising imaging modality but remains costly. Ongoing research is evaluating the role of nonoperative management in children with confirmed appendicitis.

Performance of imaging studies in patients with suspected appendicitis after stratification with adult appendicitis score

Background

Diagnostic scoring is used to stratify patients with suspected appendicitis into three groups: high, intermediate, and low probability of appendicitis. The stratification can be used for selective imaging to avoid the harms of radiation without compromising diagnostic accuracy.

The aim was to study how stratification by Adult Appendicitis Score affects diagnostic performance of imaging studies.

Methods

Analysis of 822 patients who underwent diagnostic imaging for suspected appendicitis was made. Adult Appendicitis Score was used to stratify patients into groups of high, intermediate, and low probability of appendicitis. Diagnostic performance of computed tomography (CT) and ultrasound (US) was compared between these patient groups.

Results

After scoring, pre-test probability of appendicitis ranged from 9-16% in low probability group to 75-79% in high probability group in patients who underwent US or CT. Post-test probability of appendicitis after positive CT was 99, 91, and 75% in high probability, intermediate probability and low probability groups, respectively, p < 0.001. After positive US the respective probabilities were 95, 91 and 42%, p < 0.001.

Conclusion

Diagnostic imaging has limited value in patients with low probability of appendicitis according to Adult Appendicitis Score.