Combined use of modified Alvarado score and USG in decreasing negative appendicectomy rate

Efficacy of modified Alvarado score combined with ultrasound in the diagnosis of acute appendicitis: a prospective analytical study

Background

Appendicitis is the most common surgical emergency encountered in the emergency department, and diagnosis is difficult at times. Imaging and various clinical scoring are present to aid in the diagnosis. Ultrasound is an easily accessible modality and can accomplish more than a computed tomography (CT) scan at times. Modified Alvarado score (MAS) includes parameters that do not pose an extra financial burden to the patient. Combining both the imaging and clinical scoring systems, the authors decided to evaluate the combined MAS for the diagnosis of acute appendicitis.

Methods

This is a prospective analytical study conducted in a tertiary hospital for one and a half years. Fifty-five patients with right lower quadrant pain were enroled, and evaluated along with an ultrasound. MAS and combined MAS were obtained, and the results of the histopathological examination were compared.

Results

Out of 55 clinically diagnosed cases who underwent an emergency appendectomy, 27 were males and 28 were females. Of these, 50 cases had acute appendicitis as per histopathological examination. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of the MAS was 42%, 100%, 100%, 20.8%, 47.27%, respectively. The sensitivity, specificity, PPV, NPV and accuracy of the USG were 84%, 40%, 93.3%, 20%, and 80%, respectively. Combining both the scores, the Combined MAS had the sensitivity, specificity, PPV, NPV, and accuracy of 98.18%, 0%, 90.7%, 0%, and 89.09%, respectively.

Conclusion

As the combination of USG has raised the sensitivity and diagnostic accuracy of the MAS, it can be an alternative to CT/MRI imaging for the diagnosis of acute appendicitis in resource-limited settings. This score requires further studies to validate with a larger sample size.

Combined clinical accuracy of inflammatory markers and ultrasound for the diagnosis of acute appendicitis

Introduction

Acute appendicitis is traditionally a clinical diagnosis where there are a range of diagnostic accuracies reported. The role of ultrasound is to improve specificity and decrease negative appendicectomy rate. It is a simple, non-invasive, easily available technique.The purpose of this study is to determine the diagnostic accuracy of an ultrasound in combination with total leukocyte count, neutrophil percentage and C-reactive protein in diagnosing acute appendicitis.

Methods

This study includes consecutive sampling of suspected patients from January 2021 to February 2022 with the approval of the ethical and research committee. Clinical and personal demographics and characteristics of patients were collected, including age, gender, symptoms and clinical signs. Ultrasonographic findings of fluid-filled appendiceal diameter of more than 6 mm, periappendiceal echogenic mesentry and an appendicolith were primary positive features. Laboratory inflammatory markers of total leukocyte count, neutrophil percentage and C-reactive protein were also included.

Results

A total of 250 patients were included with a mean age of 25 ± 9.79 years. Total leukocyte count showed the highest sensitivity (77.68%), followed by neutrophil percentage (69.96%), C-reactive protein (67.10%) and ultrasound (62.96%). While ultrasound had the best specificity (70.59%), it was followed by C-reactive protein and total leukocyte count (64.71%) and neutrophil percentage (58.82%), respectively. The sensitivity and specificity (99% and 98%) increased significantly when all four tests were combined.

Conclusions

Clinical assessment with laboratory inflammatory markers and ultrasound improves the early diagnosis of appendicitis and decreases the false-positive appendicitis diagnosis, hence saving surgeons' time and relieving patients from unnecessary appendicectomies.

Paediatric negative appendicectomy rates at a regional Western Australian Centre: a five-year cohort study

BACKGROUND

In acute appendicitis, decision-making around operative intervention for paediatric patients differs from adults due to a higher weight placed on clinical assessment and reduced rates of cross-sectional imaging. In regional settings, non-paediatric emergency doctors, general surgeons, and radiologists usually assess and manage this patient group. Differences have been observed in paediatric negative appendicectomy rates between general and paediatric centres.

METHODS

A retrospective cohort study was performed, identifying paediatric patients undergoing emergency appendicectomy at the Southwest Health Campus (Bunbury, Western Australia) from 2017 to 2021. The primary outcome measure was histopathology confirming the absence of transmural inflammation of the appendix. In addition, clinical, biochemical and radiological data were collected to identify predictors of negative appendicectomy (NA). Secondary outcome measures were hospital length-of-stay and post-operative complication rates.

RESULTS

Four hundred and twenty-one patients were identified, of which 44.9% had a negative appendicectomy. Statistically significant associations between female gender, white cell count less than 10 × 109 , neutrophil ratio less than 75%, low CRP and NA were observed. NA was not associated with a lower risk of re-admission or complications compared with appendicectomy for appendicitis.

CONCLUSIONS

Our centre's NA rate is higher than that observed in the literature at both non-paediatric and paediatric surgical centres. NA has similar morbidity risk to appendicectomy for uncomplicated appendicitis and offers a timely reminder that diagnostic laparoscopy in children is not benign.

A systematic review and meta-regression for validation of the Alvarado score as a tool for predicting acute appendicitis

The Alvarado score (AS) has not been widely used for diagnosing acute appendicitis although it has shown to be a good predictor for diagnosing appendicitis. The aim was to perform a systematic review of the available literature and synthesize the evidence.

Methods

A systematic review was performed as per the PRISMA guidelines using search engines like Ovid, PubMed, and Google Scholar with predefined, strict inclusion and exclusion criteria. The quality assessment of included studies was performed using the QUADAS 2 tool. Summary statistics were performed for all variables. A linear regression model was performed between dependent and independent variables using STATA software. Heterogeneity testing showed significant heterogeneity within the included studies; hence, a forest plot with pooled estimates could not be constructed, and therefore a meta-regression was performed.

Results

Seventeen full-text articles met inclusion and exclusion criteria. Ten of which were identified as low-risk studies. Five studies were included in final data pooling with total patients being 2239 and mean age of 31.9 years. (1) Linear regression demonstrated an association between 'histological appendicitis' and 'AS 7-0' with patients receiving intervention, with a significant P value of less than 0.005. (2) Meta-regression demonstrated a positive coefficient (0.298), a positive Z score of 2.20 with a significant P value of 0.028 for patients with 'high AS' who received interventions that were significantly proven to be 'histologically appendicitis', indicating a cause-and-effect relationship.

Conclusion

High AS (7 and above) is a significant predictor of acute appendicitis. The authors recommend further prospective randomized clinical trials to establish a cause-and-effect relationship.

Appendicitis Inflammatory Response Score in Comparison to Alvarado Score in Acute Appendicitis

Appendicitis is a common differential diagnosis of right lower quadrant pain. Clinical evaluation alone results in high negative appendicectomy rates. Alvarado scoring is the most commonly used clinical prediction rule. The study aimed to compare the recently developed appendicitis inflammatory response (AIR) score with the Alvarado score. This cross-sectional observational study included patients who underwent appendicectomy for clinical suspicion of appendicitis. The clinical and laboratory parameters required for obtaining Alvarado score and AIRS were gathered. Area under ROC curve was calculated for both Alvarado score and AIRS. The study included 130 patients (77 males and 53 females). The negative appendicectomy rate was 10.7%. The perforation rate was 10.3%. The area under ROC for Alvarado score was 0.821 and for AIR score was 0.901. The Alvarado score had a sensitivity of 72% and a specificity of 79% at score ≥6. The appendicitis inflammatory response score had a sensitivity of 98% for scores ≥5 and a specificity of 97% for score ≥6. The C-reactive protein (CRP) value was the best performing individual parameter with an area under ROC of 0.789, followed by WBC count with an area under ROC of 0.762. Appendicitis inflammatory response score is a recently developed score that outperforms the Alvarado score. AIR score has a higher specificity. The sound construction, gradation of parameters, the inclusion of CRP, and avoidance of subjective parameters make the AIR score an attractive clinical prediction rule which can decrease the rate of negative appendicectomy.

Value of ultrasonography and the Raja Isteri Pengiran Anak Saleha Appendicitis score in the diagnosis of acute appendicitis

BACKGROUND

The diagnosis of acute appendicitis is a clinical challenge. Clinical scoring systems and radiological examinations are used to assist in diagnosis.

METHODS

We reviewed 106 patients between January 2016 and January 2018 who presented with right iliac fossa pain and underwent appendectomy. Their Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) scores were calculated and abdominopelvic ultrasonography (USG) was performed before they were operated with a prediagnosis of acute appendicitis. RIPASA scores and USG findings were compared to the histopathological results of appendectomy specimens.

RESULTS

The histopathological examinations showed that all of the 100 (94.3%) patients whose RIPASA scores were 7 and more had acute appendicitis and the six (5.7%) patients whose scores were less than 7 had no appendicitis. When the appendectomy specimens of the 70 patients who had been diagnosed with acute appendicitis with USG were examined histopathologically, 69 (98.6%) patients were confirmed to have acute appendicitis. Acute appendicitis was found in 18 (81.8%) of the 22 patients whose appendixes could not be visualized with USG. Acute appendicitis was found in eight (88.9%) of the nine patients who had been reported normal with USG.

CONCLUSION

RIPASA scores should be calculated for all patients who are suspected of having acute appendicitis and for those with a RIPASA score of 7 and more, surgery should be highly recommended without USG.

Integration of radiology and clinical score in pediatric appendicitis

BACKGROUND

The efficacy of ultrasonography (US) and abdominal X-ray in combination with Pediatric Appendicitis Score (PAS) is complicated in the diagnosis of acute appendicitis. Abdominal X-ray is as useful as US with clinical assessment when evaluated by experienced pediatric radiologist in acute appendicitis. The aim of this study was to determine the value of US and abdominal X-ray for appendicitis in children when combined with clinical assessment based on PAS, and to establish a practical pathway for acute appendicitis in childhood.

METHODS

A prospective, observational cohort study was conducted at an urban, academic pediatric emergency department. Patients were classified at low (PAS 1-4), intermediate (PAS 5-7), or high (PAS 8-10) risk for appendicitis. Low-risk patients were discharged with telephone follow-up in ≤10 days; those at intermediate risk underwent X-ray and US. High-risk patients received immediate surgical consultation. Patients were grouped on histopathology as having either proven acute appendicitis or no appendicitis.

RESULTS

A total of 288 children were analyzed. Surgery was performed in 134 patients (46.5%), and 128 (95.5%) had positive histopathology. Mean PAS in the patients with and without appendicitis was 7.09 ± 1.42 and 4.97 ± 2.29, respectively (P = 0.00). The rate of missed cases was 6/288 (2%), and the negative appendectomy rate was 6/134 (4.4%). When the score cut-off was set at 6, the sensitivity and specificity of PAS was 86.7% and 63.1%, respectively. The diagnostic performance of daytime US had a sensitivity of 91.1% and specificity of 71.1%. Also, positive US or PAS >6 or both, had sensitivity and specificity 96.7% and 59.9%, respectively.

CONCLUSION

US or abdominal X-ray in children with possible appendicitis should be integrated with PAS to determine the next steps in management. In the case of discordance between the clinical findings and radiology, prolonged observation or further imaging are recommended.

Accuracy of Ultrasonography in Diagnosing Acute Appendicitis

OBJECTIVES

To evaluate the accuracy of sonography in diagnosing acute appendicitis in patients with Alvarado score 4-7.

METHODS

This is a retrospective cross-sectional study being performed in Namazee hospital affiliated with Shiraz University of Medical sciences during a one year period from 9/2007 to 9/2008. We evaluated all patients with Alvarado score 4-7 and divided them in two groups: those with Ultrasound study prior to surgery and those without any imaging modalities for diagnosis of AA. The demographic information, histopathology, physical examination, laboratory data, sonography report and histopathological reports of patients were gathered.

RESULTS

A total of 238 patients had Alvarado scores 4-7 including 160 males and 78 females. 110 patients did not have any imaging and 128 had undergone sonography before operation. Ultrasound had overall sensitivity of 75 %, specificity 69.2 %, PPV 88 %, NPV 46.1% and accuracy of 73.6 %. Negative appendectomy rate was 20.9 % and 23.4 % in those without sonography and inpatients with sonography respectively, with a higher rate in females.

CONCLUSION

Ultrasound is more useful when the patient is female and the result of sonography is positive; however, it is not reliable when the result is negative and maybe other diagnostic modalities such as CT scan can help us in better diagnosis of Acute Appendicitis.