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Chawla T, Gopee-Ramanan P, Green CR, Hartery A, Kassam Z, Murray N, Vu KN, Kirkpatrick IDC. CAR/CETARS/CSAR Practice Guideline on Imaging the Adult Patient With Right Lower Quadrant Pain. Can Assoc Radiol J 2024:8465371241266568. [PMID: 39066632 DOI: 10.1177/08465371241266568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2024] Open
Abstract
In 2023, the Canadian Society of Abdominal Radiology (CSAR) and Canadian Emergency, Trauma, and Acute Care Radiology Society (CETARS) received Canadian Association of Radiologists (CAR) member feedback that there was an unmet educational need for guidance in the imaging investigation of right lower quadrant (RLQ) pain. Members requested specific guidance on how to handle controversial scenarios including which test to order when, specifics of imaging protocols, and managing pregnant patients who have RLQ pain-all from a Canadian perspective. After conducting an exhaustive literature review, the working group agreed that a Canadian-specific set of guidelines was warranted. The management recommendations presented in this guideline were discussed as a group to achieve expert consensus. As the workup for RLQ pain can vary considerably in the paediatric population, the scope of this paper was restricted to adults (18 years of age or older). Whenever possible, the best evidence was used to inform the clinical guidance, and where gaps existed, the guidelines reflect consensus among experts in the field. The result is a framework to aid in this process of managing patients with RLQ pain across various clinical scenarios while addressing current questions and controversies, particularly those most relevant to the Canadian healthcare system.
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Affiliation(s)
- Tanya Chawla
- Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
- Mount Sinai Hospital, Toronto, ON, Canada
| | - Prasaanthan Gopee-Ramanan
- Department of Radiology, McMaster University Health Sciences Centre (HSC - 3N26), Hamilton, ON, Canada
- Juravinski Hospital and Cancer Centre, Hamilton Health Sciences, Hamilton, ON, Canada
| | | | - Angus Hartery
- Discipline of Radiology, Faculty of Medicine, Memorial University of Newfoundland, Health Sciences Centre, St John's, NL, Canada
| | - Zahra Kassam
- Department of Medical Imaging, Western University, London, ON, Canada
- St. Joseph's Health Care London, London, ON, Canada
| | - Nicolas Murray
- Emergency and Trauma Radiology, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Kim-Nhien Vu
- Department of Radiology, Radiation Oncology and Nuclear Medicine, Université de Montréal, Montréal, QC, Canada
- Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, QC, Canada
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Kummer J, Koenigbauer J, Peters FSJ, Rickert C, Hellmeyer L. Is Appendectomy During Late Stages of Pregnancy Associated with an Increased Cesarean Delivery Rate? - a Retrospective Analysis of One Center During 10 Years. Geburtshilfe Frauenheilkd 2024; 84:378-386. [PMID: 38618579 PMCID: PMC11006560 DOI: 10.1055/a-2273-2672] [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] [Received: 11/03/2023] [Accepted: 02/20/2024] [Indexed: 04/16/2024] Open
Abstract
Introduction About one in 500 pregnant women requires a surgical intervention that is not pregnancy-related. One of the most common surgical interventions during pregnancy is appendectomy. The primary aim of this study was to assess surgical access of appendectomy during pregnancy and pregnancy outcome. Secondary outcomes were clinical symptoms and diagnostics as well as histopathological analysis. Methods and Material This is a single-center retrospective data analysis conducted at a tertiary perinatal center. A digital search of the hospital record archive was conducted focusing on pregnant women beyond 24 0/7 weeks of pregnancy encoding appendectomy. Descriptive statistical analysis was performed. Results Between January 2013 and January 2023, a total of 20 appendectomies were performed during pregnancy with gestational age beyond 24 0/7 weeks of pregnancy. All of them were performed as lower midline laparotomy. The rate of appendix perforation was 3/20 (15.0%). 19/20 patients (95.0%) delivered via cesarean. In 7/20 patients (35.0%) appendectomy was performed during cesarean delivery due to incidental finding of irritated or abnormal vermiform appendix. In the pathological work-up, only 2/7 (28.6%) of these subjects had inflammation. Conclusion In this small monocentric cohort, only open appendectomies were performed. Our data indicate that it is safe to perform open appendectomy during pregnancy if necessary. In this small patient group, there was an increase in simultaneous cesarean deliveries.
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Affiliation(s)
- Julia Kummer
- Department of Obstetrics and Gynecology, Klinikum im Friedrichshain, Berlin, Germany
| | | | | | - Christian Rickert
- Department of Pathology, Klinikum im Friedrichshain, Berlin, Germany
| | - Lars Hellmeyer
- Department of Obstetrics and Gynecology, Klinikum im Friedrichshain, Berlin, Germany
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Bufman H, Raskin D, Barash Y, Inbar Y, Mashiach R, Tau N. Findings on emergent magnetic resonance imaging in pregnant patients with suspected appendicitis: A single center perspective. PLoS One 2024; 19:e0288156. [PMID: 38329949 PMCID: PMC10852244 DOI: 10.1371/journal.pone.0288156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 06/20/2023] [Indexed: 02/10/2024] Open
Abstract
This study's aim is to describe the imaging findings in pregnant patients undergoing emergent MRI for suspected acute appendicitis, and the various alternative diagnoses seen on those MRI scans. This is a single center retrospective analysis in which we assessed the imaging, clinical and pathological data for all consecutive pregnant patients who underwent emergent MRI for suspected acute appendicitis between April 2013 and June 2021. Out of 167 patients, 35 patients (20.9%) were diagnosed with acute appendicitis on MRI. Thirty patients (18%) were diagnosed with an alternative diagnosis on MRI: 17/30 (56.7%) patients had a gynecological source of abdominal pain (e.g. ectopic pregnancy, red degeneration of a leiomyoma); 8 patients (26.7%) had urological findings such as pyelonephritis; and 6 patients (20%) had gastrointestinal diagnoses (e.g. abdominal wall hernia or inflammatory bowel disease). Our conclusions are that MRI is a good diagnostic tool in the pregnant patient, not only in diagnosing acute appendicitis, but also in providing information on alternative diagnoses to acute abdominal pain. Our findings show the various differential diagnoses on emergent MRI in pregnant patients with suspected acute appendicitis, which may assist clinicians and radiologists is patient assessment and imaging utilization.
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Affiliation(s)
- Hila Bufman
- Department of Diagnostic Imaging, Sheba Medical Center, Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Daniel Raskin
- Department of Diagnostic Imaging, Sheba Medical Center, Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yiftach Barash
- Department of Diagnostic Imaging, Sheba Medical Center, Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yael Inbar
- Department of Diagnostic Imaging, Sheba Medical Center, Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Roy Mashiach
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Obstetrics and Gynecology, Sheba Medical Center, Ramat Gan, Israel
| | - Noam Tau
- Department of Diagnostic Imaging, Sheba Medical Center, Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Thanh Thi Nguyen T, Mai Duy Le H, Thanh Nguyen D, Quang Nguyen H, Hoang Nguyen N, Tan Vo D, Cong Phan C. The Role of Magnetic Resonance Pulse Sequences in the Diagnosis of Acute Appendicitis in Pregnant Women. Cureus 2023; 15:e51312. [PMID: 38288189 PMCID: PMC10823294 DOI: 10.7759/cureus.51312] [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: 12/29/2023] [Indexed: 01/31/2024] Open
Abstract
INTRODUCTION Acute appendicitis (AA) is one of the most common surgical emergencies, with a lifetime risk estimated at 7-8%. Pregnant women with appendicitis can have a difficult diagnosis because many signs and symptoms could overlap with other causes of acute abdominal pain. Although magnetic resonance imaging (MRI) is not contraindicated at all gestational ages for units with a field strength of three Tesla or less, there is still much discussion regarding the best protocol to follow in order to minimize survey time and maximize diagnostic efficiency. The purpose of this study was to assess how well different MR pulse sequences can diagnose AA. METHODS This retrospective study involved 179 pregnant females. All patients treated and admitted to the University Medical Center, Ho Chi Minh City, Vietnam, between January 2016 and October 2023 had their MR scans and medical data examined. MRI results were assessed and compared with surgical and histopathological findings. RESULTS The mean age of the population was 29.7 ± 4.8 years (range, 18-46 years). On T1-weighted (T1W) and T2-weighted (T2W) sequences, the appendix was clearly visualized at rates of 81.8% and 89.9%, respectively. The sensitivity and specificity of the T2W in diagnosing AA were 93.5% and 92.3%, and when combined with T1W and diffusion-weighted (DW) images, the sensitivity and specificity further increased, being 96.8% and 94.9%, respectively. The predictive value of non-AA of the T1 bright appendix sign was 95.6%. CONCLUSION Our study supports the use of MRI as an imaging test to identify appendicitis during pregnancy, as it has been shown to be a useful method for diagnosing the condition in pregnant women. The T2W pulse sequence is a useful tool for diagnosing appendicitis because of its high sensitivity and specificity. When identifying appendicitis from T2W alone proves challenging, T1W with the T1 bright sign and DW to take advantage of the appendix lumen and/or wall's diffusion features can yield additional information and boost diagnostic confidence.
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Affiliation(s)
- Thien Thanh Thi Nguyen
- Department of Diagnostic Imaging, University Medical Center of Ho Chi Minh City, Ho Chi Minh, VNM
| | - Huyen Mai Duy Le
- Department of Diagnostic Imaging, University Medical Center of Ho Chi Minh City, Ho Chi Minh, VNM
| | - Duy Thanh Nguyen
- Department of Diagnostic Imaging, University Medical Center of Ho Chi Minh City, Ho Chi Minh, VNM
| | - Hieu Quang Nguyen
- Department of Diagnostic Imaging, University Medical Center of Ho Chi Minh City, Ho Chi Minh, VNM
| | - Nam Hoang Nguyen
- Department of Diagnostic Imaging, University Medical Center of Ho Chi Minh City, Ho Chi Minh, VNM
| | - Duc Tan Vo
- Department of Diagnostic Imaging, University Medical Center of Ho Chi Minh City, Ho Chi Minh, VNM
| | - Chien Cong Phan
- Department of Diagnostic Imaging, University Medical Center of Ho Chi Minh City, Ho Chi Minh, VNM
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Wang Z, Bao F, Liang W, Wu H, Lin Z, Xu J, Dong F. Appendicitis in pregnant women: A systematic review and meta-analysis of the diagnostic performance of ultrasonography. JOURNAL OF CLINICAL ULTRASOUND : JCU 2023; 51:1492-1501. [PMID: 37747110 DOI: 10.1002/jcu.23566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 08/22/2023] [Accepted: 09/06/2023] [Indexed: 09/26/2023]
Abstract
OBJECTIVES The accuracy of ultrasound in the detection of appendicitis in pregnant women was examined in a meta-analysis. METHODS Pregnant women with suspected acute appendicitis were evaluated using ultrasound in a systematic search of PubMed, EMBASE, and Cochrane Library databases from January 1, 2011 to August 10, 2023. The sensitivity and specificity values and diagnostic odds ratios were obtained using the pooled data. RESULTS A total of 239 patients were studied in four relevant investigations. Ultrasonography has a sensitivity of 56% and a specificity of 88% for the diagnosis of acute appendicitis, with an area under the receiver operating characteristic curve of 0.66%. Ultrasonography had a positive likelihood ratio of 4.65 (95% confidence interval, 1.42-15.23) and a negative likelihood ratio of 0.50 (95% confidence interval, 0.41-0.62). There was no evidence of publication bias (p = 0.93). CONCLUSIONS Ultrasound has moderate sensitivity for identifying appendicitis in pregnant women and may be utilized as an alternative diagnostic method.
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Affiliation(s)
- Zimo Wang
- Department of Ultrasound, Second Clinical College of Jinan University, Shenzhen People's Hospital, First Affiliated Hospital of Southern University of Science and Technology, Shenzhen Medical Ultrasound Engineering Center, Shenzhen, People's Republic of China
| | - Fuxing Bao
- Department of Ultrasound, Second Clinical College of Jinan University, Shenzhen People's Hospital, First Affiliated Hospital of Southern University of Science and Technology, Shenzhen Medical Ultrasound Engineering Center, Shenzhen, People's Republic of China
| | - Weiyu Liang
- Department of Ultrasound, Second Clinical College of Jinan University, Shenzhen People's Hospital, First Affiliated Hospital of Southern University of Science and Technology, Shenzhen Medical Ultrasound Engineering Center, Shenzhen, People's Republic of China
| | - Huaiyu Wu
- Department of Ultrasound, Second Clinical College of Jinan University, Shenzhen People's Hospital, First Affiliated Hospital of Southern University of Science and Technology, Shenzhen Medical Ultrasound Engineering Center, Shenzhen, People's Republic of China
| | - Ziwei Lin
- Department of Ultrasound, Second Clinical College of Jinan University, Shenzhen People's Hospital, First Affiliated Hospital of Southern University of Science and Technology, Shenzhen Medical Ultrasound Engineering Center, Shenzhen, People's Republic of China
| | - Jinfeng Xu
- Department of Ultrasound, Second Clinical College of Jinan University, Shenzhen People's Hospital, First Affiliated Hospital of Southern University of Science and Technology, Shenzhen Medical Ultrasound Engineering Center, Shenzhen, People's Republic of China
| | - Fajin Dong
- Department of Ultrasound, Second Clinical College of Jinan University, Shenzhen People's Hospital, First Affiliated Hospital of Southern University of Science and Technology, Shenzhen Medical Ultrasound Engineering Center, Shenzhen, People's Republic of China
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Masselli G, Bonito G, Gigli S, Ricci P. Imaging of Acute Abdominopelvic Pain in Pregnancy and Puerperium-Part II: Non-Obstetric Complications. Diagnostics (Basel) 2023; 13:2909. [PMID: 37761275 PMCID: PMC10528125 DOI: 10.3390/diagnostics13182909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 08/28/2023] [Accepted: 09/08/2023] [Indexed: 09/29/2023] Open
Abstract
Emergency imaging in pregnancy and puerperium poses unique challenges both for clinicians and radiologists, requiring timely and accurate diagnosis. Delay in treatment may result in poor outcomes for both the patient and the foetus. Pregnant and puerperal patients may present in the emergency setting with acute abdominopelvic pain for various complications that can be broadly classified into obstetric and non-obstetric related diseases. Ultrasonography (US) is the primary diagnostic imaging test; however, it may be limited due to the patient's body habitus and the overlapping of bowel loops. Computed tomography (CT) carries exposure to ionising radiation to the foetus, but may be necessary in selected cases. Magnetic resonance imaging (MRI) is a valuable complement to US in the determination of the etiology of acute abdominal pain and can be used in most settings, allowing for the identification of a broad spectrum of pathologies with a limited protocol of sequences. In this second section, we review the common non-obstetric causes for acute abdominopelvic pain in pregnancy and post partum, offering a practical approach for diagnosis and pointing out the role of imaging methods (US, MRI, CT) with the respective imaging findings.
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Affiliation(s)
- Gabriele Masselli
- Department of Emergency Radiology-Policlinico Umberto I Hospital, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (G.M.); (P.R.)
| | - Giacomo Bonito
- Department of Emergency Radiology-Policlinico Umberto I Hospital, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (G.M.); (P.R.)
| | - Silvia Gigli
- Department of Diagnostic Imaging, Sandro Pertini Hospital, Via dei Monti Tiburtini 385, 00157 Rome, Italy;
| | - Paolo Ricci
- Department of Emergency Radiology-Policlinico Umberto I Hospital, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (G.M.); (P.R.)
- Department of Radiological, Oncological and Pathological Sciences, Policlinico Umberto I, Sapienza University of Rome, Viale Regina Elena 324, 00161 Rome, Italy
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Kambadakone AR, Santillan CS, Kim DH, Fowler KJ, Birkholz JH, Camacho MA, Cash BD, Dane B, Felker RA, Grossman EJ, Korngold EK, Liu PS, Marin D, McCrary M, Pietryga JA, Weinstein S, Zukotynski K, Carucci LR. ACR Appropriateness Criteria® Right Lower Quadrant Pain: 2022 Update. J Am Coll Radiol 2022; 19:S445-S461. [PMID: 36436969 DOI: 10.1016/j.jacr.2022.09.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 09/01/2022] [Indexed: 11/27/2022]
Abstract
This document focuses on imaging in the adult and pregnant populations with right lower quadrant (RLQ) abdominal pain, including patients with fever and leukocytosis. Appendicitis remains the most common surgical pathology responsible for RLQ abdominal pain in the United States. Other causes of RLQ pain include right colonic diverticulitis, ureteral stone, and infectious enterocolitis. Appropriate imaging in the diagnosis of appendicitis has resulted in decreased negative appendectomy rate from as high as 25% to approximately 1% to 3%. Contrast-enhanced CT remains the primary and most appropriate imaging modality to evaluate this patient population. MRI is approaching CT in sensitivity and specificity as this technology becomes more widely available and utilization increases. Unenhanced MRI and ultrasound remain the diagnostic procedures of choice in the pregnant patient. MRI and ultrasound continue to perform best in the hands of the experts. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
- Avinash R Kambadakone
- Division Chief, Abdominal Imaging, Massachusetts General Hospital, Boston, Massachusetts; Medical Director, Martha's Vineyard Hospital Imaging.
| | - Cynthia S Santillan
- Vice Chair of Clinical Operations, University of California, San Diego, San Diego, California
| | - David H Kim
- Panel Chair; Vice Chair of Education, Department of Radiology, University of Wisconsin Hospital & Clinics, Madison, Wisconsin
| | - Kathryn J Fowler
- Panel Vice-Chair, University of California, San Diego, San Diego, California. ACR LI-RADS; Division Chief, SAR Portfolio Director; RSNA Radiology Senior DE
| | - James H Birkholz
- Divisional Director, Quality and Safety (Abdominal Imaging), Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania. Radiology Representative to the Interdisciplinary Dysmotility (GIMIG) Conference
| | - Marc A Camacho
- The University of South Florida Morsani College of Medicine, Tampa, Florida; Committee on Emergency Radiology-GSER
| | - Brooks D Cash
- Chief of Gastroenterology, Hepatology, and Nutrition Division, University of Texas Health Science Center at Houston and McGovern Medical School, Houston, Texas; American Gastroenterological Association
| | - Bari Dane
- Director of Body CT, Abdominal Imaging; Director of Quality and Safety Outpatient Imaging, NYU Grossman School of Medicine, New York, New York
| | - Robin A Felker
- Associate Clerkship Director for Internal Medicine, Georgetown University; Primary care physician, Medstar Georgetown University Hospital, Washington, District of Columbia
| | - Eric J Grossman
- Medical Director, Multi-Specialty Clinic, Santa Barbara Cottage Hospital, Santa Barbara, California; American College of Surgeons
| | - Elena K Korngold
- Section Chief, Body Imaging, Chair, Department of Radiology Promotion and Tenure Committee, Oregon Health and Science University, Portland, Oregon
| | - Peter S Liu
- Section Head, Abdominal Imaging, Cleveland Clinic, Cleveland, Ohio
| | - Daniele Marin
- Duke University Medical Center, Durham, North Carolina
| | - Marion McCrary
- Associate Director of Duke GME Coaching, Duke Signature Care, Durham, North Carolina; American College of Physicians; Governor-Elect, American College of Physicians North Carolina Chapter
| | | | | | - Katherine Zukotynski
- Co-Associate Chair for Research, Department of Radiology, McMaster University, Hamilton, Ontario, Canada; Commission on Nuclear Medicine and Molecular Imaging
| | - Laura R Carucci
- Specialty Chair; Section Chief Abdominal Imaging, Director of MRI and CT, Virginia Commonwealth University Medical Center, Richmond, Virginia
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Ahmed B, Williams J, Gourash W, Zhang J, Li R, Balasubramani GK, Rangaswamy B. MRI as First Line Imaging for Suspected Acute Appendicitis during Pregnancy: Diagnostic Accuracy and level of Inter-Radiologist Agreement. Curr Probl Diagn Radiol 2022; 51:503-510. [PMID: 34955286 PMCID: PMC9160213 DOI: 10.1067/j.cpradiol.2021.09.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 09/07/2021] [Accepted: 09/19/2021] [Indexed: 09/29/2023]
Abstract
OBJECTIVE Evaluation of acute appendicitis (AA) in pregnancy is supported with diagnostic imaging. Typically, ultrasound (US) is performed first, and then often followed by magnetic resonance imaging (MRI) due to continued diagnostic uncertainty. The purpose of our study was to evaluate the sensitivity, specificity, and accuracy of US as compared to MRI and to evaluate the inter-radiologist agreement amongst body Radiologists with varying levels of expertise. MATERIALS AND METHODS We performed a retrospective study of 364 consecutive pregnant patients with clinical suspicion of AA at a single center over a 6-year period. Sensitivity, Specificity, accuracy, positive and negative predictive values were calculated for US and MRI. Inter Radiologist agreement was determined using Cohen's Kappa analysis between original interpreting Radiologist and retrospective review by expert Radiologist. RESULTS Thirty-one of 364 patients (8.5%) underwent appendectomy based on preoperative diagnosis, with confirmation of acute appendicitis (AA) by pathology in 19. US was able to visualize the appendix in only 6 (1.65%), 5 of whom had appendicitis. 141 patients underwent MRI, and correctly diagnosed appendicitis in 9. No patient with a negative MRI diagnosis had AA. The sensitivity, and negative predictive value for diagnosing AA with MRI was 100%. The MRI inter-reader agreement for appendix visualization and overall accuracy were 87.9 and 98% with Cohen Kappa of 0.7 and 0.56 respectively. CONCLUSIONS Our data suggests that MRI should be considered the first line imaging modality in pregnant patients suspected of having AA. Body Radiologists with varied levels of experience in MRI readouts had substantial agreement.
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Affiliation(s)
- Bestoun Ahmed
- Department of Surgery, Division of Minimally Invasive General and Bariatric Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA.
| | - Jon Williams
- Advanced Laparoscopic and General Surgery of Nevada, Las Vegas, NV
| | - William Gourash
- Department of Surgery, Division of Minimally Invasive General and Bariatric Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | - Runjia Li
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, PA
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D'Souza N, Hicks G, Beable R, Higginson A, Rud B. Magnetic resonance imaging (MRI) for diagnosis of acute appendicitis. Cochrane Database Syst Rev 2021; 12:CD012028. [PMID: 34905621 PMCID: PMC8670723 DOI: 10.1002/14651858.cd012028.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Appendicitis remains a difficult disease to diagnose, and imaging adjuncts are commonly employed. Magnetic resonance imaging (MRI) is an imaging test that can be used to diagnose appendicitis. It is not commonly regarded as a first-line imaging test for appendicitis, but the reported diagnostic accuracy in some studies is equivalent to computed tomography (CT) scans. As it does not expose patients to radiation, it is an attractive imaging modality, particularly in women and children. OBJECTIVES The primary objective was to determine the diagnostic accuracy of MRI for detecting appendicitis in all patients. Secondary objectives: To investigate the accuracy of MRI in subgroups of pregnant women, children, and adults. To investigate the potential influence of MRI scanning variables such as sequences, slice thickness, or field of view. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase until February 2021. We searched the references of included studies and other systematic reviews to identify further studies. We did not exclude studies that were unpublished, published in another language, or retrospective. SELECTION CRITERIA We included studies that compared the outcome of an MRI scan for suspected appendicitis with a reference standard of histology, intraoperative findings, or clinical follow-up. Three study team members independently filtered search results for eligible studies. DATA COLLECTION AND ANALYSIS We independently extracted study data and assessed study quality using the Quality Assessment of Studies of Diagnostic Accuracy - Revised (QUADAS-2) tool. We used the bivariate model to calculate pooled estimates of sensitivity and specificity. MAIN RESULTS We identified 58 studies with sufficient data for meta-analysis including a total of 7462 participants (1980 with and 5482 without acute appendicitis). Estimates of sensitivity ranged from 0.18 to 1.0; estimates of specificity ranged from 0.4 to 1.0. Summary sensitivity was 0.95 (95% confidence interval (CI) 0.94 to 0.97); summary specificity was 0.96 (95% CI 0.95 to 0.97). Sensitivity and specificity remained high on subgroup analysis for pregnant women (sensitivity 0.96 (95% CI 0.88 to 0.99); specificity 0.97 (95% CI 0.95 to 0.98); 21 studies, 2282 women); children (sensitivity 0.96 (95% CI 0.95 to 0.97); specificity 0.96 (95% CI 0.92 to 0.98); 17 studies, 2794 children); and adults (sensitivity 0.96 (95% CI 0.93 to 0.97); specificity 0.93 (95% CI 0.80 to 0.98); 9 studies, 1088 participants), as well as different scanning techniques. In a hypothetical cohort of 1000 patients, there would be 12 false-positive results and 30 false-negative results. Methodological quality of the included studies was poor, and the risk of bias was high or unclear in 53% to 83% of the QUADAS-2 domains. AUTHORS' CONCLUSIONS MRI appears to be highly accurate in confirming and excluding acute appendicitis in adults, children, and pregnant women regardless of protocol. The methodological quality of the included studies was generally low due to incomplete and low standards of follow-up, so summary estimates of sensitivity and specificity may be biased. We could not assess the impact and direction of potential bias given the very low number of high-quality studies. Studies comparing MRI protocols were few, and although we found no influence of MRI protocol variables on the summary estimates of accuracy, our results do not rule out that some MRI protocols are more accurate than others.
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Affiliation(s)
| | | | | | | | - Bo Rud
- Gastrounit, Copenhagen University Hospital Hvidovre , Hvidovre, Denmark
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10
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Baruch Y, Canetti M, Blecher Y, Yogev Y, Grisaru D, Michaan N. The diagnostic accuracy of ultrasound in the diagnosis of acute appendicitis in pregnancy. J Matern Fetal Neonatal Med 2020; 33:3929-3934. [PMID: 30843442 DOI: 10.1080/14767058.2019.1592154] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Objective: Clinically suspected appendicitis is the most common nonobstetric surgical problem encountered in pregnancy. The diagnosis of appendicitis is hampered by equivocal symptoms during pregnancy. Ultrasonography (US) remains, as a rule, the imaging test of choice for the diagnosis of clinically suspected appendicitis during pregnancy and other imaging tools such as computed tomography (CT) or magnetic resonance imaging (MRI) are usually avoided. We evaluated the accuracy of US in the diagnosis of appendicitis during pregnancy.Methods: The clinical and sonographic findings of all pregnant women (n = 90), who underwent appendectomy between January 2005 and December 2017 at our institution, were retrospectively reviewed, analyzed, and compared to the clinical and sonographic findings similarly obtained for a control group of nonpregnant women matched for age and date of surgery (±6 months). The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of ultrasonic findings were calculated and compared between groups as well as within the three pregnancy trimesters.Results: The mean age of the patients was 31.3 ± 0.4. Right lower quadrant pain was present in almost all patients (99%). The sole imaging modality used in our study cohort was US. Among nonpregnant controls, CT scan was primarily used on more occasions (53.3%) compared to US (45.6%). Nonpregnant women underwent significantly more laparoscopies compared to pregnant women (83.3 versus 45.6%, p < .001). The rate of negative appendectomy was higher in pregnant women (31.1 versus 10%, p = .002). Among pregnant women operated there was a higher rate of inconclusive or negative imaging (43.3 versus 11.1%, p < .001). The rate of perforated appendix at surgery was similar in both groups (6.7 and 4.4%, respectively, p = .75).Conclusions: Ultrasonography (US) is of mediocre accuracy for the diagnosis of acute appendicitis in pregnant patients beyond the first trimester of pregnancy. Thirty percent of pregnant women with suspected appendicitis are futilely operated. Given the low yield of US, a second-line imaging should be considered in cases of inconclusive US before surgery.
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Affiliation(s)
- Yoav Baruch
- Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michal Canetti
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yair Blecher
- Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yariv Yogev
- Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dan Grisaru
- Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nadav Michaan
- Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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11
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Hyslop WB. MRI of the Acute Abdomen in Adults. Semin Roentgenol 2020; 55:427-435. [PMID: 33220788 DOI: 10.1053/j.ro.2020.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- W Brian Hyslop
- Department of Radiology, University of North Carolina, Chapel Hill, NC.
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12
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Body mass index as an indicator of the likelihood of ultrasound visualization of the appendix in pregnant women with suspicion of appendicitis. Abdom Radiol (NY) 2020; 45:2637-2646. [PMID: 32514628 DOI: 10.1007/s00261-020-02610-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 05/23/2020] [Accepted: 05/29/2020] [Indexed: 12/26/2022]
Abstract
PURPOSE To determine if clinical characteristics of pregnant women are associated with the likelihood of ultrasound (US) visualization of the appendix in cases where there is a clinical suspicion of appendicitis. MATERIALS AND METHODS A retrospective study of 471 pregnant patients with suspicion of appendicitis from 2009 to 2018 were studied. Patients underwent sonography of the appendix as their initial imaging study. The association of body mass index (BMI) and gestational age with sonographic visualization of the appendix was analyzed using logistic regression. Cut-off values were determined for BMI to predict visualization of the appendix. RESULTS The rate of visualization of the appendix on US was 16% (95% CI 12% to 19%). When stratified by trimester of pregnancy, rebound pain on compression US examination in the 1st trimester and BMI in the 2nd and 3rd trimesters were identified as predictors of US visualization. Applying BMI cut-off values rounded to the nearest whole number, 36, 30, and 26 in the 1st, 2nd, and 3rd trimesters, non-visualization rates would be reduced by 16% (95% CI 10% to 25%), 35% (95% CI 29% to 42%), and 67% (95% CI 58% to 74%). Using BMI index cut-off values would reduce the number of primary US examinations by 35% (95% CI 30% to 39%) and increase the rate of visualization by 6% (95% CI 0.02% to 12%, P = 0.04). CONCLUSION Using BMI cut-off values for determining the efficaciousness of US visualization of the appendix in pregnant women with suspicion of appendicitis could significantly reduce the non-visualization rate.
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13
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Kave M, Parooie F, Salarzaei M. Pregnancy and appendicitis: a systematic review and meta-analysis on the clinical use of MRI in diagnosis of appendicitis in pregnant women. World J Emerg Surg 2019; 14:37. [PMID: 31367227 PMCID: PMC6647167 DOI: 10.1186/s13017-019-0254-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 07/04/2019] [Indexed: 02/07/2023] Open
Abstract
Background The aim of this systematic review and meta-analysis was to evaluate the clinical use of MRI for the evaluation of acute appendicitis during pregnancy. Methods The searches were conducted by two independent researchers (MK, MS) to find the relevant studies published from 1/1/2009 until end of 30/12/2018. We searched for published literature in the English language in MEDLINE via PubMed, EMBASETM via Ovid, The Cochrane Library, and Trip database. For literature published in other languages, we searched national databases (Magiran and SID), KoreaMed, and LILACS. The keywords used in the search strategy are Pregnancy [MeSH], Pregnant [MeSH] OR-Magnetic resonance imaging [MeSH] OR-Appendicitis [MeSH] OR-Ultrasound, [MeSH] OR, imaging, MRI [MeSH] OR"،" and Right lower quadrant pain [MeSH]. The risk of bias of every article was evaluated by using QUADAS-2. On the basis of the results from the 2 × 2 tables, pooled measures for sensitivity, specificity, diagnostic odds ratio (DOR), and area under the curves (AUC) along with their 95% confidence intervals (CIs) were calculated using the DerSimonian Lair methodology. Results As many as 1164 studies were selected. After analyzing the correspondence of the studies with the required criteria, 19 studies were selected for the final review. For appendicitis in pregnancy, the MRI sensitivity was 91.8% at the 95% confidence interval of (95% CI 87.7-94.9%). At the confidence interval of 95%, the specificity was 97.9% (95% CI 0.97.2-100%). The risk of bias in the studies conducted was measured using the QUADAS-2 tool. Conclusion MRI has high sensitivity and specificity (91.8%, 97.9% respectively) for the diagnosis of acute appendicitis in pregnant patients with clinically suspected appendicitis. It is an excellent imaging technique in many instances, which does not expose a fetus, or the mother, to ionizing radiation, making it an excellent option for pregnant patients with suspected acute appendicitis.
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Affiliation(s)
- Mania Kave
- 1Gynecology and Obstetrics Institution, Faculty of Medicine, Zabol University of Medical Sciences, Zabol, Islamic Republic of Iran
| | - Fateme Parooie
- 2Student Research Committee, Faculty of Medicine, Zabol University of Medical Sciences, Zabol, Islamic Republic of Iran
| | - Morteza Salarzaei
- 2Student Research Committee, Faculty of Medicine, Zabol University of Medical Sciences, Zabol, Islamic Republic of Iran
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14
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Garcia EM, Camacho MA, Karolyi DR, Kim DH, Cash BD, Chang KJ, Feig BW, Fowler KJ, Kambadakone AR, Lambert DL, Levy AD, Marin D, Moreno C, Peterson CM, Scheirey CD, Siegel A, Smith MP, Weinstein S, Carucci LR. ACR Appropriateness Criteria ® Right Lower Quadrant Pain-Suspected Appendicitis. J Am Coll Radiol 2019; 15:S373-S387. [PMID: 30392606 DOI: 10.1016/j.jacr.2018.09.033] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 09/07/2018] [Indexed: 02/07/2023]
Abstract
Appendicitis remains the most common surgical pathology responsible for right lower quadrant (RLQ) abdominal pain presenting to emergency departments in the United States, where the incidence continues to increase. Appropriate imaging in the diagnosis of appendicitis has resulted in decreased negative appendectomy rate from as high as 25% to approximately 1% to 3%. Contrast-enhanced CT remains the primary and most appropriate imaging modality to evaluate this patient population. MRI is approaching CT in sensitivity and specificity as this technology becomes more widely available and utilization increases. Unenhanced MRI and ultrasound remain the diagnostic procedures of choice in the pregnant patient. MRI and ultrasound continue to perform best in the hands of experts. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | - Evelyn M Garcia
- Virginia Tech Carilion School of Medicine, Roanoke, Virginia.
| | - Marc A Camacho
- The University of South Florida Morsani College of Medicine, Tampa, Florida
| | | | - David H Kim
- Panel Chair, University of Wisconsin Hospital & Clinics, Madison, Wisconsin
| | - Brooks D Cash
- University of Texas Health Science Center at Houston, McGovern Medical School, Houston, Texas; American Gastroenterological Association
| | | | - Barry W Feig
- The University of Texas MD Anderson Cancer Center, Houston, Texas; American College of Surgeons
| | | | | | - Drew L Lambert
- University of Virginia Health System, Charlottesville, Virginia
| | - Angela D Levy
- Medstar Georgetown University Hospital, Washington, District of Columbia
| | - Daniele Marin
- Duke University Medical Center, Durham, North Carolina
| | | | | | | | - Alan Siegel
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Martin P Smith
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | - Laura R Carucci
- Specialty Chair, Virginia Commonwealth University Medical Center, Richmond, Virginia
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15
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Mervak BM, Altun E, McGinty KA, Hyslop WB, Semelka RC, Burke LM. MRI in pregnancy: Indications and practical considerations. J Magn Reson Imaging 2019; 49:621-631. [PMID: 30701610 DOI: 10.1002/jmri.26317] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 07/29/2018] [Accepted: 07/30/2018] [Indexed: 12/12/2022] Open
Abstract
There is a constantly evolving knowledgebase regarding the safety of MRI in pregnant patients, as well as the safety of gadolinium administration, given potential fetal risks. This review provides an overview of national and international recommendations for patient screening and safety by trimester, evaluates the most recent literature regarding administration of gadolinium in pregnant patients, and discusses technical requirements when imaging pregnant patients. A protocol for imaging pregnant patients is provided, and multiple common indications for MRI in pregnancy are discussed. Level of Evidence 5. Technical Efficacy Stage 5. J. Magn. Reson. Imaging 2019;49:621-631.
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Affiliation(s)
- Benjamin M Mervak
- Division of Abdominal Imaging, University of North Carolina Department of Radiology, Chapel Hill, North Carolina, USA
| | - Ersan Altun
- Division of Abdominal Imaging, University of North Carolina Department of Radiology, Chapel Hill, North Carolina, USA
| | - Katrina A McGinty
- Division of Abdominal Imaging, University of North Carolina Department of Radiology, Chapel Hill, North Carolina, USA
| | - W Brian Hyslop
- Division of Abdominal Imaging, University of North Carolina Department of Radiology, Chapel Hill, North Carolina, USA
| | - Richard C Semelka
- Division of Abdominal Imaging, University of North Carolina Department of Radiology, Chapel Hill, North Carolina, USA.,Richard Semelka, MD. Consulting
| | - Lauren M Burke
- Division of Abdominal Imaging, University of North Carolina Department of Radiology, Chapel Hill, North Carolina, USA
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16
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Eng KA, Abadeh A, Ligocki C, Lee YK, Moineddin R, Adams-Webber T, Schuh S, Doria AS. Acute Appendicitis: A Meta-Analysis of the Diagnostic Accuracy of US, CT, and MRI as Second-Line Imaging Tests after an Initial US. Radiology 2018; 288:717-727. [DOI: 10.1148/radiol.2018180318] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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17
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Suspicion of appendicitis in pregnant women: emergency evaluation by sonography and low-dose CT with oral contrast. Eur Radiol 2018; 29:345-352. [PMID: 29948087 DOI: 10.1007/s00330-018-5573-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 05/07/2018] [Accepted: 05/29/2018] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To evaluate non-intravenously enhanced low-dose computed tomography with oral contrast (LDCT) for the assessment of pregnant women with right lower quadrant pain, when magnetic resonance imaging (MRI) is not immediately available. METHODS One hundred and thirty-eight consecutive pregnant women with acute abdominal pain were admitted in our emergency centre. Thirty-seven (27%) of them, with clinical suspicion of acute appendicitis, underwent abdominal ultrasonography (US). No further examination was recommended when US was positive for appendicitis, negative with low clinical suspicion or showed an alternative diagnosis which explained the clinical presentation. All other patients underwent LDCT (<2.5 mSv). Standard intravenously enhanced CT or MRI was performed when LDCT was indeterminate. RESULTS Eight (22%) of 37 US exams were reported normal, 25 (67%) indeterminate, 1 (3%) positive for appendicitis, 3 (8%) positive for an alternative diagnosis. LDCT was obtained in 29 (78%) patients. It was reported positive for appendicitis in 9 (31%), for alternative diagnosis in 2 (7%), normal in 13 (45%) and indeterminate in 5 (17%). Further imaging (standard CT or MRI) showed appendicitis in 2 of these 5 patients, was truly negative in 1, indeterminate in 1 and falsely positive in 1. An appendicitis was confirmed at surgery in 12 (32%) of the 37 patients. The sensitivity and the specificity of the algorithm for appendicitis were 100% (12/12) and 92% (23/25), respectively. CONCLUSIONS The proposed algorithm is very sensitive and specific for detection of acute appendicitis in pregnant women; it reduces the need of standard CTs when MRI is not available as second-line imaging. KEY POINTS • In pregnant women, US is limited by an important number of indeterminate results • Low-dose CT can be used after an inconclusive US for the diagnosis of appendicitis in pregnant women • An algorithm integrating US and low-dose CT is highly sensitive and specific for appendicitis in pregnant women.
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18
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Wood BM, Jia G, Carmichael O, Mcklveen K, Homberger DG. 3D MRI Modeling of Thin and Spatially Complex Soft Tissue Structures without Shrinkage: Lamprey Myosepta as an Example. Anat Rec (Hoboken) 2018; 301:1745-1763. [PMID: 29752863 DOI: 10.1002/ar.23857] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 02/12/2018] [Accepted: 02/23/2018] [Indexed: 11/10/2022]
Abstract
3D imaging techniques enable the nondestructive analysis and modeling of complex structures. Among these, MRI exhibits good soft tissue contrast, but is currently less commonly used for nonclinical research than X-ray CT, even though the latter requires contrast-staining that shrinks and distorts soft tissues. When the objective is the creation of a realistic and complete 3D model of soft tissue structures, MRI data are more demanding to acquire and visualize and require extensive post-processing because they comprise noncubic voxels with dimensions that represent a trade-off between tissue contrast and image resolution. Therefore, thin soft tissue structures with complex spatial configurations are not always visible in a single MRI dataset, so that standard segmentation techniques are not sufficient for their complete visualization. By using the example of the thin and spatially complex connective tissue myosepta in lampreys, we developed a workflow protocol for the selection of the appropriate parameters for the acquisition of MRI data and for the visualization and 3D modeling of soft tissue structures. This protocol includes a novel recursive segmentation technique for supplementing missing data in one dataset with data from another dataset to produce realistic and complete 3D models. Such 3D models are needed for the modeling of dynamic processes, such as the biomechanics of fish locomotion. However, our methodology is applicable to the visualization of any thin soft tissue structures with complex spatial configurations, such as fasciae, aponeuroses, and small blood vessels and nerves, for clinical research and the further exploration of tensegrity. Anat Rec, 301:1745-1763, 2018. © 2018 Wiley Periodicals, Inc.
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Affiliation(s)
- Bradley M Wood
- Department of Biological Sciences, Louisiana State University, Baton Rouge, Louisiana 70803
| | - Guang Jia
- School of Computer Science and Technology, Xidian University, Xi'an, Shaanxi, 710071, China
| | - Owen Carmichael
- Pennington Biomedical Research Center, 6400 Perkins Road, Baton Rouge, Louisiana 70808
| | - Kevin Mcklveen
- Pennington Biomedical Research Center, 6400 Perkins Road, Baton Rouge, Louisiana 70808
| | - Dominique G Homberger
- Department of Biological Sciences, Louisiana State University, Baton Rouge, Louisiana 70803
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19
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Shin I, Chung YE, An C, Lee HS, Kim H, Lim JS, Kim MJ. Optimisation of the MR protocol in pregnant women with suspected acute appendicitis. Eur Radiol 2017; 28:514-521. [PMID: 28894912 DOI: 10.1007/s00330-017-5038-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2017] [Revised: 08/01/2017] [Accepted: 08/16/2017] [Indexed: 11/30/2022]
Abstract
PURPOSE To investigate the optimal magnetic resonance (MR) imaging protocol in pregnant women suspected of having acute appendicitis. MATERIALS AND METHODS One hundred and forty-six pregnant women with suspected appendicitis were included. MR images were reviewed by two radiologists in three separate sessions. In session 1, only axial single-shot turbo spin echo (SSH-TSE) T2-weighted images (WI) were included with other routine sequences. In sessions 2 and 3, coronal and sagittal T2WI were sequentially added. The visibility of the appendix and diagnostic confidence of appendicitis were evaluated in each session using a 5-point grading scale. If diseases other than appendicitis were suspected, specific diagnosis with a 5-point confidence scale was recorded. Diagnostic performance for appendicitis and other diseases were evaluated. RESULTS Twenty-five patients (17.1%) were diagnosed with appendicitis. Among the patients with normal appendix, 28 were diagnosed with other disease. Diagnostic performance including sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and area under the curve values for diagnosing appendicitis and other diseases showed no significant difference among sets for both reviewers (p>0.05). CONCLUSION Diagnostic performance of MR in pregnant patients with suspected appendicitis can be preserved with omission of sagittal or both coronal and sagittal SSH-T2WI. KEY POINTS • Diagnostic performance of appendicitis is preserved with omission of sagittal/coronal T2WIs. • Diagnosis of other disease may be sufficient with axial T2WIs only. • Careful serial omission of sagittal and coronal T2WIs can be considered.
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Affiliation(s)
- Ilah Shin
- Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Yong Eun Chung
- Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
| | - Chansik An
- Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Hye Sun Lee
- Department of Research Affairs, Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Honsoul Kim
- Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Joon Seok Lim
- Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Myeong-Jin Kim
- Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
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20
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Tsai R, Raptis C, Fowler KJ, Owen JW, Mellnick VM. MRI of suspected appendicitis during pregnancy: interradiologist agreement, indeterminate interpretation and the meaning of non-visualization of the appendix. Br J Radiol 2017; 90:20170383. [PMID: 28869395 DOI: 10.1259/bjr.20170383] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To determine the degree of interradiologist agreement between the MRI features of appendicitis during pregnancy, the outcomes associated with an indeterminate interpretation and the negative predictive value of non-visualization of the appendix. METHODS Our study was approved by the institutional review board at the Washington University in St. Louis, Missouri (WUStL) and was HIPAA (Health Insurance Portability and Accountability Act of 1996)-compliant. The informed consent requirement was waived. Cases of suspected appendicitis during pregnancy evaluated using MRI were retrospectively identified using search queries. Scans were re-reviewed by two radiologists (7 and 9 years experience, respectively) to evaluate the interradiologist agreement of different MRI features of appendicitis during pregnancy (visualization of the appendix, appendiceal diameter, appendiceal wall thickening, periappendiceal fat stranding, fluid-filled appendix and periappendiceal fluid). The radiologists were blinded to patient outcome, patient intervention, laboratory data, demographic data and the original MRI reports. Clinical outcomes were documented by surgical pathology or clinical observation. Interradiologist agreement was analysed using Cohen's κ, while patient demographic and clinical data was analysed using Student's t-testing. RESULTS 233 females with suspected appendicitis during pregnancy were evaluated using MRI over a 13-year period (mean age, 28.4 years; range, 17-38 years). There were 14 (6%) positive examinations for appendicitis during pregnancy, including 1 patient whose MRI was interpreted as negative, proven by surgical pathology. The presence of periappendiceal soft-tissue stranding and the final overall impression had the most interradiologist agreement (к = 0.81-1). There were no pregnant patients found to have acute appendicitis who had an indeterminate MR interpretation or when the appendix could not be visualized. CONCLUSION The final impression by the two retrospectively reviewing radiologists of MR examinations performed for suspected appendicitis during pregnancy had near-perfect agreement. In patients where the appendix could not be visualized or in patients that were interpreted as indeterminate, no patients had acute appendicitis. Advances in knowledge: MR impression for suspected appendicitis in the pregnant patient has high interradiologist agreement, and a non-visualized appendix or lack of inflammatory findings at the time of MR, reliably excludes surgical appendicitis.
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Affiliation(s)
- Richard Tsai
- 1 Department of Diagnostic Radiology, Mallinckrodt Institute of Radiology, Washington University, St. Louis, MO, USA
| | - Constantine Raptis
- 1 Department of Diagnostic Radiology, Mallinckrodt Institute of Radiology, Washington University, St. Louis, MO, USA
| | - Kathryn J Fowler
- 1 Department of Diagnostic Radiology, Mallinckrodt Institute of Radiology, Washington University, St. Louis, MO, USA
| | - Joseph W Owen
- 2 Department of Radiology, University of Kentucky, Lexington, KY, USA
| | - Vincent M Mellnick
- 1 Department of Diagnostic Radiology, Mallinckrodt Institute of Radiology, Washington University, St. Louis, MO, USA
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21
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Burns M, Hague CJ, Vos P, Tiwari P, Wiseman SM. Utility of Magnetic Resonance Imaging for the Diagnosis of Appendicitis During Pregnancy: A Canadian Experience. Can Assoc Radiol J 2017; 68:392-400. [PMID: 28728903 DOI: 10.1016/j.carj.2017.02.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 01/09/2017] [Accepted: 02/14/2017] [Indexed: 01/10/2023] Open
Abstract
PURPOSE The objective of the study was to evaluate the performance of magnetic resonance imaging (MRI) for the diagnosis of appendicitis during pregnancy. METHODS We conducted a retrospective review of all MRI scans performed at our institution, between 2006 and 2012, for the evaluation of suspected appendicitis in pregnant women. Details of the MRI scans performed were obtained from the radiology information system as well as details of any ultrasounds carried out for the same indication. Clinical and pathological data were obtained by retrospective chart review. RESULTS The study population comprised 63 patients, and 8 patients underwent a second MRI scan during the same pregnancy. A total of 71 MRI scans were reviewed. The appendix was identified on 40 scans (56.3%). Sensitivity of MRI was 75% and specificity was 100% for the diagnosis of appendicitis in pregnant women. When cases with right lower quadrant inflammatory fat stranding or focal fluid, without appendix visualization, were classified as positive for appendicitis, MRI sensitivity increased to 81.3% but specificity decreased to 96.4%. CONCLUSIONS MRI is sensitive and highly specific for the diagnosis of appendicitis during pregnancy and should be considered as a first line imaging study for this clinical presentation.
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Affiliation(s)
- Michael Burns
- Department of Radiology, St Paul's Hospital & University of British Columbia, Vancouver, British Columbia, Canada.
| | - Cameron J Hague
- Department of Radiology, St Paul's Hospital & University of British Columbia, Vancouver, British Columbia, Canada
| | - Patrick Vos
- Department of Radiology, St Paul's Hospital & University of British Columbia, Vancouver, British Columbia, Canada
| | - Pari Tiwari
- Department of Radiology, St Paul's Hospital & University of British Columbia, Vancouver, British Columbia, Canada
| | - Sam M Wiseman
- Department of Surgery, St Paul's Hospital & University of British Columbia, Vancouver, British Columbia, Canada
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22
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Pearl JP, Price RR, Tonkin AE, Richardson WS, Stefanidis D. SAGES guidelines for the use of laparoscopy during pregnancy. Surg Endosc 2017. [DOI: 10.1007/s00464-017-5637-3] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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23
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Guterman S, Mandelbrot L, Keita H, Bretagnol F, Calabrese D, Msika S. Laparoscopy in the second and third trimesters of pregnancy for abdominal surgical emergencies. J Gynecol Obstet Hum Reprod 2017; 46:417-422. [PMID: 28934085 DOI: 10.1016/j.jogoh.2017.03.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2016] [Revised: 03/16/2017] [Accepted: 03/23/2017] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To assess complications and outcomes of pregnancies following laparoscopic abdominal surgery during the second and third trimesters of pregnancy. MATERIAL AND METHODS Retrospective single-center study of 23 cases of laparoscopic surgery in the second or third trimesters of pregnancy between January 2005 and May 2016. RESULTS The laparoscopies were performed between 15 and 33 weeks of gestation, a mean of 23 weeks+2 days, with 6 cases in the 3rd trimester. The operations were: 11 cholecystectomies, 6 appendectomies, 1 intestinal occlusion (volvulus on a gastric band), 3 adnexal torsions, 1 ovarian cyst and 1 paratubal cyst with torsion. No secondary laparotomy was required. The postoperative courses were favorable in most cases. However, 3 appendectomies were complicated, one by chorioamnionitis and miscarriage at 20½ weeks of gestation and 2 by right iliac fossa abscesses requiring percutaneous radiological drainage, one of these women delivered a healthy term baby and the other had chorioamnionitis and preterm delivery at 34 weeks, followed by neonatal death. CONCLUSION Laparoscopy can be safely performed for surgical indications in the second and third trimesters of pregnancy. In case of abdominal symptoms, a timely diagnosis is required to decide whether or not to operate and imaging should not be withheld particularly in case of suspected appendicitis which has a high risk of complications.
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Affiliation(s)
- S Guterman
- Service de gynécologie-obstétrique, hôpital Louis-Mourier, hôpitaux universitaires Paris-Nord Val de Seine, Assistance publique-Hôpitaux de Paris, 178, rue des Renouillers, 92700 Colombes, France; Université Paris Diderot, université Sorbonne Paris-Cité, 75018 Paris, France; Département hospitalier universitaire risques et grossesse, 75018 Paris, France
| | - L Mandelbrot
- Service de gynécologie-obstétrique, hôpital Louis-Mourier, hôpitaux universitaires Paris-Nord Val de Seine, Assistance publique-Hôpitaux de Paris, 178, rue des Renouillers, 92700 Colombes, France; Université Paris Diderot, université Sorbonne Paris-Cité, 75018 Paris, France; Département hospitalier universitaire risques et grossesse, 75018 Paris, France.
| | - H Keita
- Université Paris Diderot, université Sorbonne Paris-Cité, 75018 Paris, France; Service d'anesthésie-réanimation, hôpital Louis-Mourier, hôpitaux universitaires Paris-Nord Val de Seine, Assistance publique-Hôpitaux de Paris, 92700 Colombes, France
| | - F Bretagnol
- Université Paris Diderot, université Sorbonne Paris-Cité, 75018 Paris, France; Service de chirurgie digestive, hôpital Louis-Mourier, hôpitaux universitaires Paris-Nord Val de Seine, Assistance publique-Hôpitaux de Paris, 92700 Colombes, France
| | - D Calabrese
- Université Paris Diderot, université Sorbonne Paris-Cité, 75018 Paris, France; Service de chirurgie digestive, hôpital Louis-Mourier, hôpitaux universitaires Paris-Nord Val de Seine, Assistance publique-Hôpitaux de Paris, 92700 Colombes, France
| | - S Msika
- Université Paris Diderot, université Sorbonne Paris-Cité, 75018 Paris, France; Service de chirurgie digestive, hôpital Louis-Mourier, hôpitaux universitaires Paris-Nord Val de Seine, Assistance publique-Hôpitaux de Paris, 92700 Colombes, France
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Shirah BH, Shirah HA, Alhaidari WA, Elraghi MA, Chughtai MA. The role of preoperative graded compression ultrasound in detecting acute appendicitis and influencing the negative appendectomy rate. Abdom Radiol (NY) 2017; 42:109-114. [PMID: 27503383 DOI: 10.1007/s00261-016-0862-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
PURPOSE The diagnosis of acute appendicitis is mainly clinical and is correct in about 80% of patients, but 20-33% present with atypical findings, which resulted in a negative appendectomy rate of 20-30%. The graded compression ultrasound method in the diagnosis of acute appendicitis was reported with a sensitivity of 89%, and specificity of 95%. In this study, we aim to evaluate the graded compression ultrasonography in the diagnosis of acute appendicitis, its influence on the clinical judgment to operate, and its role in lowering the negative appendectomy rate. METHODS 1073 patients treated surgically for acute appendicitis between January 2005 and December 2014 were reviewed. Ultrasound findings, histopathological diagnosis, and positive or negative appendectomy rates were analyzed. RESULTS 647 (60.3%) patients were males and 426 (39.7%) females. The mean age was 26.5 years. Positive ultrasound findings were recorded in 892 (83.13%), while negative findings were recorded in 181 (16.87%). Positive appendectomy was recorded in 983 (91.6%), while negative appendectomy was recorded in 90 (8.4%). The sensitivity was 83%, specificity was 100%, and the rate of negative appendectomy was 8.39%. CONCLUSION Graded compression technique of ultrasound is a useful modality, in addition to the clinical judgment of the surgeon and clinical findings, in detecting true positive cases of acute appendicitis, and thus reducing the negative appendectomy rate. Values of 100% specificity, and 8.4% negative appendectomy rate, or better, could be achieved, when an experienced surgeon and a professional radiologist collaborate in the diagnosis of acute appendicitis.
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Affiliation(s)
- Bader Hamza Shirah
- King Abdullah International Medical Research Center, King Saud bin Abdulaziz University for Health Sciences, P.O.Box 65362, Jeddah, 21556, Saudi Arabia.
| | - Hamza Asaad Shirah
- Department of General Surgery, Al Ansar General Hospital, Medina, Saudi Arabia
| | - Wael Awad Alhaidari
- Department of Accidents and Emergency, Al Ansar General Hospital, Medina, Saudi Arabia
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Imaging trends in suspected appendicitis-a Canadian perspective. Emerg Radiol 2016; 24:249-254. [PMID: 27933409 DOI: 10.1007/s10140-016-1472-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 11/25/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE The purpose of our study was to assess trends in the imaging of suspected appendicitis in adult patients in emergency departments of academic centers in Canada. METHODS A questionnaire was sent to all 17 academic centers in Canada to be completed by a radiologist who works in emergency radiology. The questionnaires were sent and collected over a period of 4 months from October 2015 to February 2016. RESULTS Sixteen centers (94%) responded to the questionnaire. Eleven respondents (73%) use IV contrast-enhanced computed tomography (CT) as the imaging modality of choice for all patients with suspected appendicitis. Thirteen respondents (81%) use ultrasound as the first modality of choice in imaging pregnant patients with suspected appendicitis. Eleven respondents (69%) use ultrasound (US) as the first modality of choice in patients younger than 40 years of age. Ten respondents (67%) use ultrasound as the first imaging modality in female patients younger than 40 years of age. When CT is used, 81% use non-focused CT of the abdomen and pelvis, and 44% of centers use oral contrast. Thirteen centers (81%) have ultrasound available 24 h a day/7 days a week. At 12 centers (75%), ultrasound is performed by ultrasound technologists. Four centers (40%) perform magnetic resonance imaging (MRI) in suspected appendicitis in adult patients at the discretion of the attending radiologist. Eleven centers (69%) have MRI available 24/7. All 16 centers (100%) use unenhanced MRI. CONCLUSIONS Various imaging modalities are available for the work-up of suspected appendicitis. Although there are North American societal guidelines and recommendations regarding the appropriateness of the multiple imaging modalities, significant heterogeneity in the first-line modalities exist, which vary depending on the patient demographics and resource availability. Imaging trends in the use of the first-line modalities should be considered in order to plan for the availability of the imaging examinations and to consider plans for an imaging algorithm to permit standardization across multiple centers. While this study examined the imaging trends specifically in Canada, there are implications to other countries seeking to streamline imaging protocols and determining appropriateness of the first-line imaging modalities.
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Abstract
Pregnant women with an acute abdomen present a critical issue due to the necessity for an immediate diagnosis and treatment; in fact, a diagnostic delay could worsen the outcome for both the mother and the fetus. There is evidence that emergencies during pregnancy are subject to mismanagement; however, the percentage of errors in the diagnosis of emergencies in pregnancy has not been studied in depth. The purpose of this article is to review the most common imaging error emergencies. The topics covered are divided into gynecological and non-gynecological entities and, for each pathology, possible errors have been dealt with in the diagnostic pathway, the possible technical errors in the exam execution, and finally the possible errors in the interpretation of the images. These last two entities are often connected owing to a substandard examination, which can cause errors in the interpretation. Consequently, the systemization of errors reduces the possibility of reoccurrences in the future by providing a valid approach in helping to learn from these errors.
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27
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A Systematic Review and Meta-Analysis of Diagnostic Performance of MRI for Evaluation of Acute Appendicitis. AJR Am J Roentgenol 2016; 206:508-17. [PMID: 26901006 DOI: 10.2214/ajr.15.14544] [Citation(s) in RCA: 91] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE A meta-analysis was performed to determine the accuracy of MRI in the diagnosis of acute appendicitis in the general population and in subsets of pregnant patients and children. MATERIALS AND METHODS A systematic search of the PubMed and EMBASE databases for articles published through the end of October 2014 was performed to identify studies that used MRI to evaluate patients suspected of having acute appendicitis. Pooled data for sensitivity, specificity, and positive and negative predictive values were calculated. RESULTS A total of 30 studies that comprised 2665 patients were reviewed. The sensitivity and specificity of MRI for the diagnosis of acute appendicitis are 96% (95% CI, 95-97%) and 96% (95% CI, 95-97%), respectively. In a subgroup of studies that focused solely on pregnant patients, the sensitivity and specificity of MRI were 94% (95% CI, 87-98%) and 97% (95% CI, 96-98%), respectively, whereas in studies that focused on children, sensitivity and specificity were found to be 96% (95% CI, 95-97%) and 96% (95% CI, 94-98%), respectively. CONCLUSION MRI has a high accuracy for the diagnosis of acute appendicitis, for a wide range of patients, and may be acceptable for use as a first-line diagnostic test.
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Petkovska I, Martin DR, Covington MF, Urbina S, Duke E, Daye ZJ, Stolz LA, Keim SM, Costello JR, Chundru S, Arif-Tiwari H, Gilbertson-Dahdal D, Gries L, Kalb B. Accuracy of Unenhanced MR Imaging in the Detection of Acute Appendicitis: Single-Institution Clinical Performance Review. Radiology 2016; 279:451-60. [DOI: 10.1148/radiol.2015150468] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Abstract
OBJECTIVE The purpose of this article is to describe our approach to contrast-enhanced abdominal MRI in patients with nontraumatic abdominal pain and suspected appendicitis. We aim to share our experience on the advantages, pearls, and pitfalls of MRI in this clinical setting, in comparison with CT and ultrasound. CONCLUSION We present some typical cases of appendicitis and alternative diagnoses in patients presenting with acute nontraumatic abdominal pain.
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31
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Kearl YL, Claudius I, Behar S, Cooper J, Dollbaum R, Hardasmalani M, Hardiman K, Rose E, Santillanes G, Berdahl C. Accuracy of Magnetic Resonance Imaging and Ultrasound for Appendicitis in Diagnostic and Nondiagnostic Studies. Acad Emerg Med 2016; 23:179-85. [PMID: 26765503 DOI: 10.1111/acem.12873] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 08/24/2015] [Accepted: 09/22/2015] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Suggestive radiographic studies with nonvisualization of the appendix can present a challenge to clinicians in the evaluation of pediatric abdominal pain. The primary objective of this study was to quantify the accuracy of magnetic resonance imaging (MRI) and of ultrasound (US) in the setting of nonvisualization of the appendix. Secondary objectives reported include sensitivity of MRI and US overall and correlation between MRI and US for diagnosis of appendicitis. METHODS Records of pediatric emergency department patients aged 3 to 21 years undergoing MRI and/or US for the evaluation of appendicitis were retrospectively reviewed. Radiographs were categorized as a normal appendix, neither demonstrating the appendix nor demonstrating abnormalities consistent with appendicitis; equivocal, not demonstrating the appendix but showing evidence of appendicitis; demonstrating an abnormal appendix consistent with appendicitis; or demonstrating an alternate pathology. The reading was compared with the final diagnosis for accuracy. RESULTS Of the 589 patients included, 146 had appendicitis. Diagnostic accuracy for studies with a nonvisualized appendix without secondary signs of appendicitis was 100% for MRI and 91.4% (95% CI = 87.3% to 94.2%) for US. Diagnostic accuracy for studies with a nonvisualized appendix with secondary signs of appendicitis was 50% (95% CI = 2.5% to 97.5%) for MRI and 38.9% (95% CI = 18.2% to 64.5%) for US. Appendicitis was ultimately diagnosed in 8.6% of patients with an otherwise negative right lower quadrant (RLQ) US that failed to directly identify the appendix. There was a moderate correlation between US and MRI (ρ = 0.573, p = 0.0001) when all studies were considered. CONCLUSIONS Magnetic resonance imaging without secondary signs of appendicitis is effective in excluding appendicitis regardless of whether the appendix is directly visualized, while otherwise negative RLQ US that fail to identify the appendix are less useful. Secondary signs of appendicitis without visualization of the appendix were not helpful regardless of radiographic modality. Results of MRI and US correlated moderately well.
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Affiliation(s)
- Y. Liza Kearl
- Department of Emergency Medicine; University of Southern California; Keck School of Medicine; Los Angeles CA
| | - Ilene Claudius
- Department of Emergency Medicine; University of Southern California; Keck School of Medicine; Los Angeles CA
| | - Sol Behar
- Department of Emergency Medicine; University of Southern California; Keck School of Medicine; Los Angeles CA
| | - John Cooper
- Department of Pediatrics; Los Angeles County and University of Southern California Hospital; Los Angeles CA
| | - Ryan Dollbaum
- University of Southern California; Keck School of Medicine; Los Angeles CA
| | - Madhu Hardasmalani
- Department of Emergency Medicine; University of Southern California; Keck School of Medicine; Los Angeles CA
| | - Kevin Hardiman
- Department of Emergency Medicine; Los Angeles County and University of Southern California Hospital; Los Angeles CA
| | - Emily Rose
- Department of Emergency Medicine; University of Southern California; Keck School of Medicine; Los Angeles CA
| | - Genevieve Santillanes
- Department of Emergency Medicine; University of Southern California; Keck School of Medicine; Los Angeles CA
| | - Carl Berdahl
- Department of Emergency Medicine; Los Angeles County and University of Southern California Hospital; Los Angeles CA
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Repplinger MD, Levy JF, Peethumnongsin E, Gussick ME, Svenson JE, Golden SK, Ehlenbach WJ, Westergaard RP, Reeder SB, Vanness DJ. Systematic review and meta-analysis of the accuracy of MRI to diagnose appendicitis in the general population. J Magn Reson Imaging 2015; 43:1346-54. [PMID: 26691590 DOI: 10.1002/jmri.25115] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 11/24/2015] [Indexed: 12/22/2022] Open
Abstract
PURPOSE To perform a systematic review and meta-analysis of all published studies since 2005 that evaluate the accuracy of magnetic resonance imaging (MRI) for the diagnosis of acute appendicitis in the general population presenting to emergency departments. MATERIALS AND METHODS All retrospective and prospective studies evaluating the accuracy of MRI to diagnose appendicitis published in English and listed in PubMed, Web of Science, Cinahl Plus, and the Cochrane Library since 2005 were included. Excluded studies were those without an explicitly stated reference standard, with insufficient data to calculate the study outcomes, or if the population enrolled was limited to pregnant women or children. Data were abstracted by one investigator and confirmed by another. Data included the number of true positives, true negatives, false positives, false negatives, number of equivocal cases, type of MRI scanner, type of MRI sequence, and demographic data including study setting and gender distribution. Summary test characteristics were calculated. Forest plots and a summary receiver operator characteristic plot were generated. RESULTS Ten studies met eligibility criteria, representing patients from seven countries. Nine were prospective and two were multicenter studies. A total of 838 subjects were enrolled; 406 (48%) were women. All studies routinely used unenhanced MR images, although two used intravenous contrast-enhancement and three used diffusion-weighted imaging. Using a bivariate random-effects model the summary sensitivity was 96.6% (95% confidence interval [CI]: 92.3%-98.5%) and summary specificity was 95.9% (95% CI: 89.4%-98.4%). CONCLUSION MRI has a high sensitivity and specificity for the diagnosis of appendicitis, similar to that reported previously for computed tomography. J. Magn. Reson. Imaging 2016;43:1346-1354.
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Affiliation(s)
- Michael D Repplinger
- Department of Emergency Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA.,Department of Radiology, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Joseph F Levy
- Department of Population Health Sciences, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Erica Peethumnongsin
- Department of Emergency Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Megan E Gussick
- Department of Emergency Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - James E Svenson
- Department of Emergency Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Sean K Golden
- Department of Emergency Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - William J Ehlenbach
- Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Ryan P Westergaard
- Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Scott B Reeder
- Department of Emergency Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA.,Department of Radiology, University of Wisconsin-Madison, Madison, Wisconsin, USA.,Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA.,Department of Medical Physics, University of Wisconsin-Madison, Madison, Wisconsin, USA.,Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - David J Vanness
- Department of Population Health Sciences, University of Wisconsin-Madison, Madison, Wisconsin, USA
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Burke LM, Bashir MR, Miller FH, Siegelman ES, Brown M, Alobaidy M, Jaffe TA, Hussain SM, Palmer SL, Garon BL, Oto A, Reinhold C, Ascher SM, Demulder DK, Thomas S, Best S, Borer J, Zhao K, Pinel-Giroux F, De Oliveira I, Resende D, Semelka RC. Magnetic resonance imaging of acute appendicitis in pregnancy: a 5-year multiinstitutional study. Am J Obstet Gynecol 2015. [PMID: 26215327 DOI: 10.1016/j.ajog.2015.07.026] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE The purpose of this study was to determine the diagnostic performance of magnetic resonance imaging (MRI) in the diagnosis of acute appendicitis during pregnancy in a multiinstitutional study. STUDY DESIGN In this multicenter retrospective study, the cases of pregnant women who underwent MRI evaluation of abdominal or pelvic pain and who had clinical suspicion of acute appendicitis between June 1, 2009, and July 31, 2014, were reviewed. All MRI examinations with positive findings for acute appendicitis were confirmed with surgical pathologic information. Sensitivity, specificity, negative predictive values, and positive predictive values were calculated. Receiver operating characteristic curves were generated, and area under the curve analysis was performed for each participating institution. RESULTS Of the cases that were evaluated, 9.3% (66/709) had MRI findings of acute appendicitis. Sensitivity, specificity, accuracy, positive predictive value, and negative predictive values were 96.8%, 99.2%, 99.0%, 92.4%, and 99.7%, respectively. There was no statistically significant difference between centers that were included in the study (pair-wise probability values ranged from 0.12-0.99). CONCLUSION MRI is useful and reproducible in the diagnosis of suspected acute appendicitis during pregnancy.
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