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Oymaci E, Kahramansoy N, Tan S, Aydogan S, Yildirim M. The diagnostic role of preoperative blood tests in complicated appendicitis: A feasible approach to surgical decision. Niger J Clin Pract 2023; 26:1005-1010. [PMID: 37635587 DOI: 10.4103/njcp.njcp_906_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
Abstract
Background An accurate diagnosis and timely surgical intervention have significant importance in noncomplicated appendicitis (NCA) and complicated appendicitis (CA). Therefore, any factor that helps in the prediction of CA also contributes to suitable treatment options. Aim This retrospective study aimed to identify any relationship between acute appendicitis (AA) and preoperative blood test levels and whether these parameters can differentiate between NCA and CA patients. Patients and Methods A database of 201 appendectomies and 100 control healthy patients was analyzed between 2019 and 2022. Patients were divided into three groups: NCA without peritonitis or phlegmonous appendicitis as group 1; CA with perforated, necrotizing appendicitis with peritonitis as group 2; and the healthy control group (CG) as group 3. White blood cell (WBC), platelet distribution width (PDW), mean platelet volume (MPV), red cell distribution width (RDW), creatine kinase (CK), and bilirubin levels were collected from the patients and compared statistically between the groups. Results Age, WBC, and PDW levels were set as predictive in the differential diagnosis of CA as a result of receiver operating characteristic (ROC) analysis. The multivariate analysis demonstrated that age (OR: 1.023; 95% CI: 1.000-1.045; P = 0.04), male sex (OR: 3.718; 95% CI: 1.501-9.213; P = 0.005), WBC levels (OR: 1.000; 95% CI: 1.000-1.000; P = 0.002), and PDW levels (OR: 2.129; 95% CI: 1.301-3.484; P = 0.003) were independently associated with CA. Conclusion Age, higher WBC count, and PDW levels are valuable in differentiating the diagnosis of CA from NCA, and this could be a feasible approach for surgical decisions.
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Affiliation(s)
- E Oymaci
- Department of General Surgery, Health Sciences University, Izmir Bozyaka Education and Research Hospital, Turkey
| | - N Kahramansoy
- Department of General Surgery, Health Sciences University, Izmir Bozyaka Education and Research Hospital, Turkey
| | - S Tan
- Department of General Surgery, Health Sciences University, Izmir Bozyaka Education and Research Hospital, Turkey
| | - S Aydogan
- Department of General Surgery, Health Sciences University, Izmir Bozyaka Education and Research Hospital, Turkey
| | - M Yildirim
- Department of General Surgery, Health Sciences University, Izmir Bozyaka Education and Research Hospital, Turkey
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Devanathan S, Deshpande SG, Tote D, Shinde S. Efficacy in Predicting Negative Appendectomy Rates in Operated Acute Appendicitis Patients Using the Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) Score Versus Modified Alvarado Score. Cureus 2023; 15:e37873. [PMID: 37223156 PMCID: PMC10202674 DOI: 10.7759/cureus.37873] [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: 01/20/2023] [Accepted: 04/20/2023] [Indexed: 05/25/2023] Open
Abstract
Introduction Acute appendicitis is the commonest abdominal surgical emergency globally. The most accepted management of acute appendicitis is surgical, either open or laparoscopic appendectomy. Overlapping clinical presentations with many genitourinary and gynecological conditions lead to difficulty in accurate diagnosis, making negative appendectomies an unwanted reality. With the advancement in technology, there have been constant efforts to minimize negative appendectomy rates (NAR) using imaging modalities like USG of the abdomen and the gold-standard imaging test, the contrast-enhanced computed tomography of the abdomen. Due to the cost incurred and the lesser availability of such imaging modalities and needed expertise in resource-poor settings, various clinical scoring systems were devised to accurately diagnose acute appendicitis and thereby decrease NAR. We conducted our study to determine the NAR between the Raja Isteri Pengiran Anak Saleha Appendicitis score (RIPASA) and the modified Alvarado (MA) scoring methods. Methods A prospective observational analytical study was conducted, including 50 patients presenting to our hospital with acute appendicitis and who underwent emergency open appendectomy. The need to operate was decided by the treating surgeon. Patients were stratified by both scores; the pre-operative scores were noted and were later compared with the histopathological diagnosis. Results A total of 50 clinically diagnosed patients with acute appendicitis were evaluated utilizing the RIPASA and the MA scores. The NAR was 2% using the RIPASA score vs 10% with the MA score. The sensitivity was 94.11% vs 70.58% (p<0.0001), the specificity was 93.75% vs 68.75% (p<0.0001), the positive predictive value (PPV) of 96.96% vs 82.75% (p<0.001), the negative predictive value (NPV) of 88.23% vs 52.38% (p<0.001), and NAR of 2% vs 10% (p<0.0001) in the RIPASA vs MA scoring method, respectively. Conclusions RIPASA score is highly efficacious and statistically significant in diagnosing acute appendicitis with higher PPV at higher scores and higher NPV with lower scores leading to decreased NAR compared with MA score.
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Affiliation(s)
- Suhas Devanathan
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Swati G Deshpande
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Darshana Tote
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Sandip Shinde
- General Surgery, Chhatrapati Multispeciality Hospital, Hingoli, IND
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Altiner S, Cebeci E, Sucu BB, Col M, Ermiş İ, Senlikci A, Ünal Y, Pekcici MR. Role of immature granulocytes and total bilirubin values in the diagnosis of perforated appendicitis in patients over 65 years. Rev Assoc Med Bras (1992) 2022; 68:1681-1685. [PMID: 36449794 PMCID: PMC9779967 DOI: 10.1590/1806-9282.20220729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 07/22/2022] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE The aim of this study was to investigate the effectiveness of immature granulocyte count, immature granulocyte percentage, and total bilirubin value in predicting complicated and perforated appendicitis in patients aged 65 years and older with a diagnosis of appendicitis. METHODS In this study, 84 patients, aged 65 years and older, who had appendectomy demographic information, preoperative white blood cell count, neutrophil/lymphocyte ratio, immature granulocyte count and immature granulocyte percentage, operation findings, and pathology results were collected retrospectively. They were grouped into 4 categories: complicated, non-complicated, perforated, and non-perforated, according to the data and surgical findings. RESULTS Total bilirubin and immature granulocyte count were found to be statistically significant in predicting complicated and perforated appendicitis in patients aged 65 years and older with a diagnosis of appendicitis. The total bilirubin was found to have the following values in differentiating complicated appendicitis: area under the curve=0.883, sensitivity=78.3%, and specificity=88.5%. Total bilirubin had the highest discrimination power with area under the curve=0.804 in differentiating perforation. CONCLUSION The immature granulocyte percentage and total bilirubin count are the fast, inexpensive, and reliable parameters that can be used to predict complicated and perforated appendicitis in patients aged 65 years and older.
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Affiliation(s)
- Saygın Altiner
- Ankara Training and Research Hospital, Department of General Surgery – Ankara, Turkey
| | - Enes Cebeci
- Ankara Training and Research Hospital, Department of General Surgery – Ankara, Turkey
| | - Bedri Burak Sucu
- Ankara Training and Research Hospital, Department of General Surgery – Ankara, Turkey
| | - Mert Col
- Ankara Training and Research Hospital, Department of General Surgery – Ankara, Turkey
| | - İlker Ermiş
- Kırıkkale Yüksek İhtisas Hastanesi, Department of General Surgery – Kırıkkale, Turkey
| | - Abdullah Senlikci
- Ankara Training and Research Hospital, Department of General Surgery – Ankara, Turkey.,Corresponding author:
| | - Yılmaz Ünal
- Ankara Training and Research Hospital, Department of General Surgery – Ankara, Turkey
| | - Mevlut Recep Pekcici
- Ankara Training and Research Hospital, Department of General Surgery – Ankara, Turkey
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Depetris M, Martínez Chamorro E, Ibáñez Sanz L, Albillos Merino J, Rodríguez Cuellar E, Borruel Nacenta S. The usefulness and positive predictive value of ultrasonography and computed tomography in the diagnosis of acute appendicitis in adults: A retrospective study. RADIOLOGIA 2022; 64:506-515. [PMID: 36402536 DOI: 10.1016/j.rxeng.2020.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 10/13/2020] [Indexed: 10/18/2022]
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Tazeoglu D, Esmer AC, Arslan B, Dag A. Did the COVID-19 Pandemic Affect the Management of Patients With Acute Appendicitis? Cureus 2022; 14:e24631. [PMID: 35664393 PMCID: PMC9152159 DOI: 10.7759/cureus.24631] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2022] [Indexed: 12/02/2022] Open
Abstract
Background The coronavirus disease 2019 (COVID-19) pandemic has changed the lives and habits of people all over the world. In this study, it was planned to investigate the effect of the COVID-19 pandemic on the diagnosis and treatment duration of acute appendicitis (AA), morbidity and mortality. Methods The data of patients who were operated on with the diagnosis of AA in our clinic between March 2019 and March 2021, divided into pre-COVID and post-COVID periods, were analyzed. Patients diagnosed with AA, who had the only appendectomy perioperatively, and who had complete preoperative blood analysis and radiological imaging data were included in the study. Results The time from the onset of symptoms to the time of admission to the hospital was statistically significantly longer than in the post-COVID group (p=0.04). During the COVID-19 pandemic period, the use of ultrasonography was statistically significantly reduced (p<0.01); computed tomography use increased (p<0.001). Laparoscopic appendectomy as a surgical technique decreased statistically significantly during the pandemic period (p=0.02). Postoperative complications and the postoperative complication severity degrees were not statistically significant between periods (p=0.24, p=0.68). The risk for the occurrence of postoperative complications in COVID-19 positive patients was statistically higher (p=0.01) (OR: 9.38 95% CI: 1.96 - 44.88). Conclusion The COVID-19 pandemic had caused delays in the admission and diagnosis of patients who might need surgery due to AA. Postoperative complication frequency and complication severity classification were not affected. COVID-19 positivity was a risk factor for complex AA presenting with periappendicular abscess, gangrenous and perforated appendix.
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Affiliation(s)
- Deniz Tazeoglu
- General Surgery, Faculty of Medicine Mersin University, Mersin, TUR
| | - Ahmet Cem Esmer
- General Surgery, Faculty of Medicine Mersin University, Mersin, TUR
| | - Bilal Arslan
- General Surgery, Faculty of Medicine Mersin University, Mersin, TUR
| | - Ahmet Dag
- General Surgery, Faculty of Medicine Mersin University, Mersin, TUR
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Doolin EC, Doolin EJ. The Impact of Imaging on Negative Appendectomies for Early Appendicitis in Children. Pediatr Emerg Care 2021; 37:e1202-e1203. [PMID: 32097375 DOI: 10.1097/pec.0000000000001965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The rate of negative appendectomy in children is 7%. The value of imaging depends on the institution. In addition, imaging errors can lead to an appendectomy in children who do not have appendicitis. It is the hypothesis that children with short onset of symptoms who undergo negative appendectomy often have erroneous imaging findings. METHODS A retrospective study of patients' records over a 30-month period was carried out. A search by histologic diagnosis in the department of pathology was used to identify the cases of all patients who did not have a diseased appendix with the preoperative diagnosis of appendicitis. In addition, the imaging report was reviewed for the radiologic diagnosis of each patient, and the operative note was reviewed to document the clinical indication for surgery. RESULTS A total of 1377 patients who underwent appendectomy with the preoperative diagnosis of appendicitis were reviewed. Sixty-eight of these children did not have an abnormal pathologic diagnosis; hence, there was a negative appendectomy rate of 4.8%. All 68 had imaging before surgery consistent with appendicitis. Thirty-six of these patients had symptoms less than 3 days. In 30 (84%) of these 36 patients, the note identifies imaging as the indication for surgery. CONCLUSIONS Children who had an appendectomy and found to have a normal appendix shared 2 characteristics. (1) Their symptoms were less than 3 days, and (2) the imaging was considered the indication by the surgical team. In the situation of an unclear diagnosis and a short onset of symptoms, observation or further evaluation should be considered.
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Affiliation(s)
| | - Edward J Doolin
- Department of General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA
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Chia ML, Justin K, Hong HTC, Vishal GS. Computerized tomography scan in acute appendicitis with eventual negative appendectomy. J Clin Transl Res 2021; 7:326-332. [PMID: 34239992 PMCID: PMC8259608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 04/13/2021] [Accepted: 04/24/2021] [Indexed: 11/29/2022] Open
Abstract
Background and Aim: Acute appendicitis (AA) is traditionally considered a clinical diagnosis and negative appendectomy (NA) rates vary across health-care systems. Computed tomography (CT) scans have been shown to aid in the reduction of NA rates. Our study aimed to determine the pre-operative imaging characteristics in patients undergoing appendectomy with eventual normal histology. Materials and Methods: An audit of all patients with a discharge diagnosis of AA was conducted from January 2011 to December 2015. Histology reports of all patients who underwent appendectomies were reviewed, and medical records of patients with NA were included in the study. To study the impact of CT scan reporting in NA patients, CT scan images of patients with NA were reviewed retrospectively by two blinded radiologists. Results: A total of 2603 patients underwent appendectomy for suspected AA, and NA rate was 3.34% (n=87). The mean age of patients with NA was 30.3 (14.8-69.8) years with no gender difference (51.7% male). Sixty-six (75.9%) patients had laparoscopic appendectomy with 3.5% open conversion rate. CT scans were done in 47 patients. Pre-operative CT scan report was more likely to report dilated appendix (n=26 [55.3%] vs. n=7 [14.9%], P=0.0001). Post-operative blinded radiology review was more like to report other pathology (n=27 [57.4%] vs. n=2 [4.3%], P=0.0001) and normal appendix (n=26 [55.3%] vs. n=5 (10.6%), P=0.0001). Conclusion: The NA rate is low. There needs to be standardized reporting for imaging features of prominent/dilated appendix. Relevance for Patients: Appendectomy must be avoided in patients with a normal CT scan and when another pathological diagnosis is established. Liberal imaging policy assists to reduce NA rates. Imaging features of prominent or dilated appendix can be subjective and international collaboration is needed to define thresholds for imaging diagnosis of AA.
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Affiliation(s)
| | - Kwan Justin
- Department of Radiology, Tan Tock Seng Hospital, Singapore
| | | | - G Shelat Vishal
- Department of General Surgery, Tan Tock Seng Hospital, Singapore
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Depetris MA, Martínez Chamorro E, Ibáñez Sanz L, Albillos Merino JC, Rodríguez Cuellar E, Borruel Nacenta S. The usefulness and positive predictive value of ultrasonography and computed tomography in the diagnosis of acute appendicitis in adults: a retrospective study. RADIOLOGIA 2020; 64:S0033-8338(20)30161-2. [PMID: 33334589 DOI: 10.1016/j.rx.2020.10.007] [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: 05/07/2020] [Revised: 09/10/2020] [Accepted: 10/13/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To analyze the evolution of the use of imaging tests (ultrasonography and computed tomography (CT)) in the diagnosis of acute appendicitis. To determine the positive predictive value of these tests and the percentage of negative and complicated appendectomies. MATERIAL AND METHODS This retrospective study compared adults who underwent appendectomy for suspected acute appendicitis at our tertiary hospital during 2015 versus similar patients at our center during 2007. RESULTS A total of 278 patients were included. The rate of negative appendectomies descended to 5%. The positive predictive value of ultrasonography increased to 97.4% in 2015, and the positive predictive value of CT and combined CT and ultrasonography was 100%. The rate of complicated appendicitis increased (23% in 2015). CONCLUSIONS The use of imaging tests increased, and the rate of "blind" laparotomies decreased. Nevertheless, the rate of complicated appendicitis increased.
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Affiliation(s)
- M A Depetris
- Servicio de Radiodiagnóstico, Hospital Universitario 12 de Octubre, Madrid, España
| | - E Martínez Chamorro
- Servicio de Radiodiagnóstico, Hospital Universitario 12 de Octubre, Madrid, España
| | - L Ibáñez Sanz
- Servicio de Radiodiagnóstico, Hospital Universitario 12 de Octubre, Madrid, España
| | - J C Albillos Merino
- Servicio de Radiodiagnóstico, Hospital Universitario 12 de Octubre, Madrid, España
| | - E Rodríguez Cuellar
- Servicio de Cirugía General, Hospital Universitario 12 de Octubre, Madrid, España
| | - S Borruel Nacenta
- Servicio de Radiodiagnóstico, Hospital Universitario 12 de Octubre, Madrid, España.
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Jabbour P, Sweid A, Tjoumakaris S, Piotin M, Brinjikji W, Bekelis K, Raz E, Sourour N, Nimjee SM, Lopes DK, Hassan AE, Pandey AS, Gonzalez LF, Hanel RA, Siddiqui AH, Hasan D, Lavine SD, Bendok BR. In Reply: May Cooler Heads Prevail During a Pandemic: Stroke in COVID-19 Patients or COVID-19 in Stroke Patients? Neurosurgery 2020; 87:E691-E693. [PMID: 32856706 PMCID: PMC7499717 DOI: 10.1093/neuros/nyaa384] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- Pascal Jabbour
- Department of Neurological Surgery Thomas Jefferson University Hospital Philadelphia, Pennsylvania
| | - Ahmad Sweid
- Department of Neurological Surgery Thomas Jefferson University Hospital Philadelphia, Pennsylvania
| | - Stavropoula Tjoumakaris
- Department of Neurological Surgery Thomas Jefferson University Hospital Philadelphia, Pennsylvania
| | - Michel Piotin
- Department of Interventional Neuroradiology Rothschild Foundation Hospital Paris, France
| | | | - Kimon Bekelis
- Department of Neurosurgery Good Samaritan Hospital Medical Center West Islip, New York
| | - Eytan Raz
- Department of Radiology New York University Langone Medical Center New York, New York
| | - Nader Sourour
- Department of Interventional Neuroradiology Pitié-Salpêtrière Hospital Paris, France
| | - Shahid M Nimjee
- Department of Neurosurgery The Ohio State University Wexner Medical Center Columbus, Ohio
| | | | - Ameer E Hassan
- Department of Neuroscience Valley Baptist Medical Center University of Texas Rio Grande Valley Harlingen, Texas
| | - Aditya S Pandey
- Department of Neurosurgery University of Michigan Ann Arbor, Michigan
| | - L Fernando Gonzalez
- Department of Neurosurgery Duke University Medical Center Durham, North Carolina
| | - Ricardo A Hanel
- Department of Neurosurgery and Toshiba Stroke Research Center School of Medicine and Biomedical Sciences University at Buffalo State University of New York Buffalo, New York
| | - Adnan H Siddiqui
- Department of Neurosurgery and Toshiba Stroke Research Center School of Medicine and Biomedical Sciences University at Buffalo State University of New York Buffalo, New York
| | - David Hasan
- Deparmtent of Neurosurgery University of Iowa Hospital and Clinics Iowa City, Iowa
| | - Sean D Lavine
- Department of Neurosurgery and Radiology Columbia University Medical Center New York, New York
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Park JS, Jeong JH, Lee JI, Lee JH, Park JK, Moon HJ. Accuracies of Diagnostic Methods for Acute Appendicitis. Am Surg 2020. [DOI: 10.1177/000313481307900138] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
The objectives were to evaluate the effectiveness of ultrasonography, computed tomography, and physical examination for diagnosing acute appendicitis with analyzing their accuracies and negative appendectomy rates in a clinical rather than research setting. A total of 2763 subjects were enrolled. Sensitivity, specificity, positive predictive value, and negative predictive value and negative appendectomy rate for ultrasonography, computed tomography, and physical examination were calculated. Confirmed positive acute appendicitis was defined based on pathologic findings, and confirmed negative acute appendicitis was defined by pathologic findings as well as on clinical follow-up. Sensitivity, specificity, positive predictive value, and negative predictive value for ultrasonography were 99.1, 91.7, 96.5, and 97.7 per cent, respectively; for computed tomography, 96.4, 95.4, 95.6, and 96.3 per cent, respectively; and for physical examination, 99.0, 76.1, 88.1, and 97.6 per cent, respectively. The negative appendectomy rate was 5.8 per cent (5.2% in the ultrasonography group, 4.3% in the computed tomography group, and 12.2% in the physical examination group). Ultrasonography/computed tomography should be performed routinely for diagnosis of acute appendicitis. However, in view of its advantages, ultrasonography should be performed first. Also, if the result of a physical examination is negative, imaging studies after physical examination can be unnecessary.
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Affiliation(s)
- Jong Seob Park
- Department of Surgery, Myongji Hospital, Kwandong University, Goyang, Korea
| | - Jin Ho Jeong
- Department of Surgery, Myongji Hospital, Kwandong University, Goyang, Korea
| | - Jong In Lee
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Jong Hoon Lee
- Department of Surgery, Myongji Hospital, Kwandong University, Goyang, Korea
| | - Jea Kun Park
- Department of Surgery, Myongji Hospital, Kwandong University, Goyang, Korea
| | - Hyoun Jong Moon
- Department of Surgery, Myongji Hospital, Kwandong University, Goyang, Korea
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The Accuracy of Low-dose Computed Tomography Protocol in Patients With Suspected Acute Appendicitis: The OPTICAP Study. Ann Surg 2020; 271:332-338. [PMID: 30048324 DOI: 10.1097/sla.0000000000002976] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To compare diagnostic accuracy of contrast enhanced low-dose computed tomography (CT) accomplished in the OPTICAP trial phantom phase to standard CT in patients with suspected acute appendicitis. BACKGROUND Increasing use of CT as the gold standard in diagnosing acute appendicitis has raised concerns regarding radiation exposure. Unenhanced low-dose CT protocols have shown similar diagnostic accuracy with standard CT for diagnosing appendicitis. To our knowledge, there are no other trials in which the same patient with suspected acute appendicitis underwent both standard and low-dose CT allowing interpatient comparison. METHODS OPTICAP is an interpatient protocol sequence randomized noninferiority single-center trial performed at Turku University Hospital between November, 2015 and August, 2016. Sixty patients with suspected acute appendicitis and body mass index <30 kg/m were enrolled to undergo both standard and low-dose contrast enhanced CT scans, which were categorized as normal, uncomplicated or complicated appendicitis by 2 radiologists in blinded manner. All patients with CT confirmed appendicitis underwent appendectomy to obtain histopathology. RESULTS The low-dose protocol was not inferior to standard protocol in terms of diagnostic accuracy; 79% [95% confidence interval (CI) 66%-89%) accurate diagnosis in low-dose and 80% (95% CI 67%-90%) in standard CT by primary radiologist. Accuracy to categorize appendicitis severity was 79% for both protocols. The mean radiation dose of low-dose CT was significantly lower compared with standard CT (3.33 and 4.44 mSv, respectively). CONCLUSION Diagnostic accuracy of contrast enhanced low-dose CT was not inferior to standard CT in diagnosing acute appendicitis or distinguishing between uncomplicated and complicated acute appendicitis in patients with a high likelihood of acute appendicitis. Low-dose CT enabled significant radiation dose reduction.
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12
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Discovery of Urinary Proteomic Signature for Differential Diagnosis of Acute Appendicitis. BIOMED RESEARCH INTERNATIONAL 2020; 2020:3896263. [PMID: 32337245 PMCID: PMC7165319 DOI: 10.1155/2020/3896263] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 12/18/2019] [Indexed: 12/29/2022]
Abstract
Acute appendicitis is one of the most common acute abdomens, but the confident preoperative diagnosis is still a challenge. In order to profile noninvasive urinary biomarkers that could discriminate acute appendicitis from other acute abdomens, we carried out mass spectrometric experiments on urine samples from patients with different acute abdomens and evaluated diagnostic potential of urinary proteins with various machine-learning models. Firstly, outlier protein pools of acute appendicitis and controls were constructed using the discovery dataset (32 acute appendicitis and 41 control acute abdomens) against a reference set of 495 normal urine samples. Ten outlier proteins were then selected by feature selection algorithm and were applied in construction of machine-learning models using naïve Bayes, support vector machine, and random forest algorithms. The models were assessed in the discovery dataset by leave-one-out cross validation and were verified in the validation dataset (16 acute appendicitis and 45 control acute abdomens). Among the three models, random forest model achieved the best performance: the accuracy was 84.9% in the leave-one-out cross validation of discovery dataset and 83.6% (sensitivity: 81.2%, specificity: 84.4%) in the validation dataset. In conclusion, we developed a 10-protein diagnostic panel by the random forest model that was able to distinguish acute appendicitis from confusable acute abdomens with high specificity, which indicated the clinical application potential of noninvasive urinary markers in disease diagnosis.
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13
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Daldal E, Dagmura H. The Correlation between Complete Blood Count Parameters and Appendix Diameter for the Diagnosis of Acute Appendicitis. Healthcare (Basel) 2020; 8:healthcare8010039. [PMID: 32069909 PMCID: PMC7151080 DOI: 10.3390/healthcare8010039] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 02/05/2020] [Accepted: 02/11/2020] [Indexed: 12/20/2022] Open
Abstract
Acute appendicitis is one of the most common causes of acute abdominal diseases seen between the ages of 10 and 19, mostly seen in males. The lifetime risk of developing acute appendicitis is 8.6% for males and 6.7% for females. We aimed to investigate the efficacy of the complete blood count parameters, C-reactive protein, and Lymphocyte-C-reactive Protein Ratio laboratory tests in the diagnosis of acute appendicitis, as well as their relationship with appendix diameter. We retrospectively examined all patients who underwent appendectomy between 1 January 2012 and 30 June 2019 in the General Surgery Clinic of Gaziosmanpasa University Faculty of Medicine. Laboratory tests, imaging findings, age, and gender were recorded. Lymphoid hyperplasia is considered as normal appendix—in other words, as negative appendicitis. The distribution of Lymphoid hyperplasia and appendicitis rates were statistically different in the groups formed according to appendix diameter (≤6 and >6 mm) (p < 0.001). We found a significant correlation between appendix diameter and WBC (White blood count), Lymphocyte, Neutrophil, RDW(Red blood cell distribution width), NLR(Neutrophil to lymphocyte ratio), and PLT/L (Platelet to lymphocyte ratio), MPV (Mean platelet volume) and RDW were significantly different in patients with an appendix diameter of ≤6 mm (p = 0.007, p = 0.006, respectively). WBC, Neutrophil, PDW, and NLR values were significantly different between appendicitis and hyperplasia groups in patients with an appendix diameter of >6 mm. The sensitivity of the NLR score (cutoff = 2.6057) in the diagnosis of appendicitis was 86.1% and selectivity was 50% in these patients. Complete blood count parameters evaluation with the clinical findings revealed that NLR is an important parameter that may help the diagnosis of acute appendicitis with an appendix diameter of >6 mm. In patients whose pathological results indicated acute appendicitis but who had a diameter of ≤6 mm, we found an elevated MPV and low RDW values.
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Affiliation(s)
- Emin Daldal
- General Surgery, Gaziosmanpasa University, Kaleardı mahallesi, 60250 Tokat, Turkey;
| | - Hasan Dagmura
- General Surgery and Surgical Oncology Department, Gaziosmanpasa University, Kaleardı Mahallesi, 60250 Tokat, Turkey
- Correspondence: ; Tel.: +90-532-162-6615
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Kang HJ, Kang H, Kim B, Chae MS, Ha YR, Oh SB, Ahn JH. Evaluation of the diagnostic performance of a decision tree model in suspected acute appendicitis with equivocal preoperative computed tomography findings compared with Alvarado, Eskelinen, and adult appendicitis scores: A STARD compliant article. Medicine (Baltimore) 2019; 98:e17368. [PMID: 31577737 PMCID: PMC6783186 DOI: 10.1097/md.0000000000017368] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
This study evaluated the diagnostic performance of a new clinical approach based on decision tree (DT) analysis in adult patients with equivocal computed tomography (CT) findings of acute appendicitis (AA) compared with previous scoring systems.This retrospective study of 244 adult patients with equivocal CT findings included appendicitis (AG, n = 80) and non-appendicitis (NAG, n = 164) groups. The chi-squared automatic interaction detection algorithm was for AA prediction. A receiver operating characteristic curve analysis and area under the curve (AUC) were used to compare the DT analysis with Alvarado, Eskelinen score, and adult appendicitis scores (AAS).The following factors were selected for AA prediction: rebound tenderness severity, migration, urinalysis, symptom duration, leukocytosis, neutrophil count, and C-reactive protein levels. The DT comprised 11 final nodes with the following AA probabilities: node 1, 100% (16/16); node 2, 90% (9/10); node 3, 80% (8/10); node 4, 60.9% (14/23); node 5, 50% (3/6); node 6, 43.8% (7/16); node 7, 22.6% (12/53); node 8, 13% (10/77); node 9, 5.6% (1/18); node 10, 0% (0/12); and node 11, 0% (0/3). The AUC of the DT was higher (0.850 [95% confidence interval {CI}; 0.799-0.893]) than the Alvarado score (0.695 [95% CI; 0.633-0.752]), AAS (0.749 [95% CI; 0.690-0.802]), and the Eskelinen score (0.715 [95% CI; 0.654-0.770]). The results were statistically significant when compared with the AUCs of the Alvarado score, Eskelinen score, and AAS (P < .001, P < .001, P = .003, respectively).The DT-based approach facilitated AA diagnosis and determination of clinical status in patients with equivocal preoperative CT findings and ambiguous results.
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Affiliation(s)
- Hyo Jung Kang
- Department of Emergency Medicine, Ajou University School of Medicine
| | - Hyuncheol Kang
- Department of Applied Statistics, Hoseo University, Asan
| | - Bohyun Kim
- Department of Radiology, Ajou University School of Medicine
| | - Min Seok Chae
- Department of Emergency Medicine, Daejin Medical Center, Bundang Jesaeng General Hospital
| | - Young Rock Ha
- Department of Emergency Medicine, Daejin Medical Center, Bundang Jesaeng General Hospital
| | - Seong Beom Oh
- Department of Emergency Medicine, Dangook University School of Medicine
| | - Jung Hwan Ahn
- Department of Emergency Medicine, Ajou University School of Medicine
- Kangwon National University Hospital, Kangwon National University, South Korea
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Early ultrasound in acute appendicitis avoids CT in most patients but delays surgery and increases complicated appendicitis if nondiagnostic - A retrospective study. Am J Surg 2019; 219:683-689. [PMID: 31153584 DOI: 10.1016/j.amjsurg.2019.05.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 05/12/2019] [Accepted: 05/22/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND We determined whether increasing early imaging (in the emergency department) was associated with earlier surgery and a decrease in complicated appendicitis. METHODS Retrospective study; 3013 operations between 12/2006-12/2016. RESULTS Early imaging increased from 13.1% to 74.1%, mostly due to increasing use of ultrasound. Negative appendectomies decreased from 10.7% to 5.1% (p < 0.001). Ultrasound was diagnostic in 80.5%. The false positive rate of ultrasound was 4%. Median time to surgery following positive ultrasound was 7.4 h (IQR 5.8-9.4), shorter compared to no early imaging (13.3 h, IQR 7.2-20.0; p < 0.001). However, median time to surgery following inconclusive and negative ultrasound was 11.5 h (IQR 8.7-16.1) and 17.0 h (IQR 10.3-26.7) respectively. The incidence of complicated appendicitis was 40% and 37.7%, higher than 21.5% in patients with positive US (p < 0.001). CONCLUSIONS Early imaging resulted in earlier surgery but did not reduce the incidence of complicated appendicitis. Ultrasound averted the need for CT in the majority of patients. When ultrasound was negative or inconclusive, time to surgery was delayed and the rate of complicated appendicitis higher.
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16
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Kwon SH, Park SH, Lee HY, Ko EJ, Ban TH, Chung BH, Yang CW. Clinical Characteristics of Acute Appendicitis in Kidney Transplant Recipients. Ann Transplant 2019; 24:168-173. [PMID: 30910996 PMCID: PMC6446653 DOI: 10.12659/aot.914134] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 01/08/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Clinical characteristics of acute appendicitis in kidney transplant recipients may be different from those in the general population due to kidney transplant recipient's immunosuppressive state and position change of appendix caused by graft. MATERIAL AND METHODS Clinical characteristics of 10 cases of acute appendicitis among 2880 cases of kidney transplantation were evaluated, including diagnostic rate, location of appendix and complication in kidney transplant recipients. RESULTS Acute appendicitis was suspected in 9 of 10 patients (90%) with acute appendicitis based on clinical and laboratory findings. Five patients (50%) presented with typical migrating pain and 1 patient (10%) had only periumbilical pain. Leukocytosis (WBC >10 000) was present in 8 patients (80%). Radiologic study revealed various locations of appendix relative to grafted kidney. Computed tomography scan was superior to ultrasonography in diagnosis of acute appendicitis. The complication rate was 50%. Complicated patients showed longer duration from symptoms onset to operation (69±48 hours versus. 25±6 hours, P<0.05) and hospital stay (15.4±15 days versus 5.4±1.8 days, P<0.05) than uncomplicated patients. CONCLUSIONS Clinical suspicion and differential diagnosis are needed for kidney transplantation patients with acute appendicitis. Early diagnosis with radiologic study is essential to reduce complications of acute appendicitis.
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Affiliation(s)
- So Hyun Kwon
- Transplant Research Center, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Sung Hyun Park
- Transplant Research Center, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Hwa Young Lee
- Transplant Research Center, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Eun Jeong Ko
- Transplant Research Center, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Tae Hyun Ban
- Transplant Research Center, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Byung Ha Chung
- Transplant Research Center, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Chul Woo Yang
- Transplant Research Center, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
- Convergent Research Consortium for Immunologic Disease, Seoul St. Mary’s Hospital, The Collage of Medicine, The Catholic University of Korea, Seoul, South Korea
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17
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Lee WH, O'Brien S, Skarin D, Cheek JA, Deitch J, Nataraja R, Craig S, Borland ML. Accuracy of clinician gestalt in diagnosing appendicitis in children presenting to the emergency department. Emerg Med Australas 2019; 31:612-618. [PMID: 30665265 DOI: 10.1111/1742-6723.13220] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Revised: 11/09/2018] [Accepted: 11/29/2018] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Abdominal pain is a common paediatric presentation to the ED. Accurate diagnosis of acute appendicitis is challenging, with the best-performing clinical scoring systems having sensitivities between 72% and 100%. The aim of this study is to assess the diagnostic accuracy of clinician gestalt according to seniority in diagnosing paediatric acute appendicitis in ED. METHODS This is a prospective multi-centre observational study of clinician's prediction of appendicitis in children under the age of 16 years presenting to four EDs with abdominal pain over a 1 month period at each site. Clinician-estimated likelihood of acute appendicitis was compared with the final diagnosis determined by histopathology or operative findings and supplemented by telephone follow up for those without an operation. The primary outcome was diagnostic accuracy of clinician gestalt according to clinician seniority in diagnosing appendicitis. RESULTS There were 381 children enrolled with completed clinician questionnaires, and 224 children had complete follow up or underwent appendicectomy. The median age was 9 years (interquartile range 6-12) and the incidence of appendicitis was 31/224 (13.8%, 95% confidence interval 9.3-18.4). The area under the curve (AUC), sensitivity, specificity, positive predictive value and negative predictive value of clinician gestalt were 0.84 (0.76-0.91), 81% (63-93%), 76% (69-82%), 35% (28-42%) and 96% (92-98%), respectively, giving an overall diagnostic accuracy of 76% (70-82%). AUC stratified by clinician seniority (junior, intermediate and senior) were 0.89 (0.80-0.98), 0.82 (0.69-0.95) and 0.76 (0.56-0.96), respectively. CONCLUSIONS The diagnostic accuracy of ED clinician gestalt in paediatric appendicitis is comparable to current clinical scoring systems irrespective of seniority.
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Affiliation(s)
- Wei Hao Lee
- Emergency Department, Princess Margaret Hospital for Children, Perth, Western Australia, Australia
| | - Sharon O'Brien
- Emergency Department, Princess Margaret Hospital for Children, Perth, Western Australia, Australia
| | - Dmitry Skarin
- Emergency Department, Princess Margaret Hospital for Children, Perth, Western Australia, Australia
| | - John A Cheek
- Emergency Department, Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,The University of Melbourne, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Jessica Deitch
- Department of Medicine, Clinical Sciences at Monash Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Ramesh Nataraja
- Department of Paediatric Surgery, Monash Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, Clinical Sciences at Monash Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Simon Craig
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Medicine, Clinical Sciences at Monash Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia.,Paediatric Emergency Department, Monash Medical Centre, Melbourne, Victoria, Australia
| | - Meredith L Borland
- Emergency Department, Princess Margaret Hospital for Children, Perth, Western Australia, Australia.,Divisions of Emergency Medicine and Paediatrics, School of Medicine, The University of Western Australia, Perth, Western Australia, Australia
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Gómez López JR, Martín Del Olmo JC, Montenegro Martín MA, Concejo Cutoli P, Martín Esteban ML, Toledano Trincado M, López Mestanza IC, Vaquero Puerta C. Laparoscopic Appendectomy in the Setting of Clinical Prediction Rules. J Laparoendosc Adv Surg Tech A 2018; 29:184-191. [PMID: 30585754 DOI: 10.1089/lap.2018.0707] [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: 11/12/2022] Open
Abstract
PURPOSE Acute appendicitis (AA) is the most frequent surgical entity in the emergency department, but its correct diagnosis remains challenging. To improve diagnosis, clinical prediction rules (CPRs) have been created to establish objective scores for the probability of suffering AA. In this study, we establish scores indicating whether laparoscopy would be superior to clinical observation or repeat diagnostic test. METHODS A retrospective observational study was conducted with 433 patients submitted to surgery for suspected AA using a laparoscopic approach. The Alvarado, Raja Isteri Pengiran Anak Saleha Appendicitis, appendicitis inflammatory response, and adult appendicitis score scales were applied in each case to establish a high, medium, or low probability of suffering AA. RESULTS Of the 433 patients analyzed, 381 (88.0%) had AA. Twelve (2.8%) were converted to open surgery, and complications were observed in 54 (12.5%) cases. The CPRs studied showed statistically significant differences between AA and negative appendectomies. However, in patients with intermediate probability scores, the diagnostic accuracy of the CPRs evaluated was not adequate. CONCLUSIONS Laparoscopic surgery can serve as a diagnostic tool for patients with intermediate AA probability scores because of its low associated morbidity and mortality and because it affords a direct diagnosis of the problem, allowing determination of the appropriate treatment.
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19
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The Alvarado score should be used to reduce emergency department length of stay and radiation exposure in select patients with abdominal pain. J Trauma Acute Care Surg 2018. [PMID: 29521805 DOI: 10.1097/ta.0000000000001885] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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20
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Msolli MA, Beltaief K, Bouida W, Jerbi N, Grissa MH, Boubaker H, Boukef R, Nouira S. Value of early change of serum C reactive protein combined to modified Alvarado score in the diagnosis of acute appendicitis. BMC Emerg Med 2018; 18:15. [PMID: 29793425 PMCID: PMC5968536 DOI: 10.1186/s12873-018-0166-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 05/15/2018] [Indexed: 11/12/2022] Open
Abstract
Background The aim of this study is to test the diagnostic value of baseline and early change of C-reactive protein (CRP) concentrations, evaluated separately or in combination with the modified Alvarado score (MAS), in patients with clinically suspected acute appendicitis. Methods This is a prospective observational study including all patients presenting to the emergency department with an equivocal diagnosis of acute appendicitis. After inclusion, clinical and demographic data are recorded and blood samples were taken at baseline and 3 h after for serum CRP measurements (3 h CRP). The MAS is also calculated for all patients. The ultimate diagnosis of appendicitis was based on the histologic findings of the excised appendix in operated patients and clinical follow-up in emergency department discharged patients. Diagnostic accuracy of admission CRP, early change of CRP 3 h CRP minus admission CRP, MAS and the combination of these parameters was expressed by sensitivity, specificity, positive predictive value, negative predictive value and area under receiver operating characteristics curve. Results Five hundred patients were included from January 2010 to December 2013. Overall, 387 patients were operated the negative appendectomy rate was 8,3%. CRP concentrations were higher in patients with acute appendicitis. However, the diagnostic value of admission CRP, delta CRP and MAS was moderate with area under ROC curve respectively equal to 0.63, 0.53 and 0.6. Combining admission CRP and delta CRP values to MAS did not result in a better performance. The area under ROC curve did not exceed 0.7 with the different combinations. Conclusion Early change of CRP has a moderate diagnostic value in patients with clinically suspected acute appendicitis. Combining CRP values to MAS did not improve diagnostic accuracy.
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Affiliation(s)
- Mohamed Amine Msolli
- Emergency Department, FattoumaBourguiba University Hospital Monastir, 5000, Monastir, Tunisia. .,Research Laboratory (LR12SP18), University of Monastir, 5000, Monastir, Tunisia.
| | - Kaouther Beltaief
- Emergency Department, FattoumaBourguiba University Hospital Monastir, 5000, Monastir, Tunisia.,Research Laboratory (LR12SP18), University of Monastir, 5000, Monastir, Tunisia
| | - Wahid Bouida
- Emergency Department, FattoumaBourguiba University Hospital Monastir, 5000, Monastir, Tunisia.,Research Laboratory (LR12SP18), University of Monastir, 5000, Monastir, Tunisia
| | - Nahla Jerbi
- Emergency Department, Mahdia University Hospital, 5100, Mahdia, Tunisia.,Research Laboratory (LR12SP18), University of Monastir, 5000, Monastir, Tunisia
| | - Mohamed Habib Grissa
- Emergency Department, FattoumaBourguiba University Hospital Monastir, 5000, Monastir, Tunisia.,Research Laboratory (LR12SP18), University of Monastir, 5000, Monastir, Tunisia
| | - Hamdi Boubaker
- Emergency Department, FattoumaBourguiba University Hospital Monastir, 5000, Monastir, Tunisia.,Research Laboratory (LR12SP18), University of Monastir, 5000, Monastir, Tunisia
| | - Riadh Boukef
- Emergency Department, Sahloul University Hospital, 4011, Sousse, Tunisia.,Research Laboratory (LR12SP18), University of Monastir, 5000, Monastir, Tunisia
| | - Semir Nouira
- Emergency Department, FattoumaBourguiba University Hospital Monastir, 5000, Monastir, Tunisia.,Research Laboratory (LR12SP18), University of Monastir, 5000, Monastir, Tunisia
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21
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Ambe PC. Negative Appendectomy. It is Really Preventable? J INVEST SURG 2018; 32:474-475. [PMID: 29608342 DOI: 10.1080/08941939.2018.1453566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Peter C Ambe
- a Department of Visceral, Minimally Invasive and Oncologic Surgery, Marien Hospital Düsseldorf , Rochusstr , Düsseldorf.,b Associate Professor of Surgery, Chair of Surgery II, Department of Medicine, Witten / Herdecke University , Germany
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22
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Sensibilidad, especificidad y fiabilidad de la escala RIPASA en el diagnóstico de apendicitis aguda en relación con la escala de Alvarado. Cir Esp 2018; 96:149-154. [DOI: 10.1016/j.ciresp.2017.11.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Revised: 11/10/2017] [Accepted: 11/25/2017] [Indexed: 11/19/2022]
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23
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Naraynsingh V, Teelucksingh SS, Goli S, Islam S, Cawich S, Singh Y, Maharaj R. CT guided appendicectomy incision: A prospective case series. Int J Surg Case Rep 2017; 41:307-310. [PMID: 29128820 PMCID: PMC5684497 DOI: 10.1016/j.ijscr.2017.10.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Revised: 09/15/2017] [Accepted: 10/08/2017] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE Several radiological studies have suggested that the base of the Appendix often does not correspond with Mc Burney's point. The aim of our study is to assess the value of using CT localization of the appendicocaecal junction to guide placement of the appendicectomy incision. DESIGN & METHOD 32 consecutive patients, booked for open appendicectomy were prospectively included in this study. Coronal and axial CT scans with IV contrast were studied to assess site of the appendicocaecal junction. This information was used to guide placement of the incision. RESULTS 28 out of 32 patients studied, the appendicocaecal junctions were accurately identified. It was noted that the final incision sites were cephalad to Mc Burney's point in 8, at the point in 3 and caudal in 17. In 1 patient, it was necessary to extend the incision medially by 2cm to retrieve the distal Appendix which had been detached through the site of rupture. CONCLUSION Mc Burney's point often does not correspond to the base of the appendix. We propose that using CT imaging to guide the appendicectomy incision is safe, facilitates locating the Appendix at surgery, minimizes incision size and decreases the need to extend it.
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Affiliation(s)
- Vijay Naraynsingh
- Department of Clinical surgical Sciences, The University of West Indies, St Augustine, Trinidad and Tobago
| | - Shravan S Teelucksingh
- Department of Clinical surgical Sciences, The University of West Indies, St Augustine, Trinidad and Tobago
| | - Sanjeeva Goli
- Department of Clinical surgical Sciences, The University of West Indies, St Augustine, Trinidad and Tobago
| | - Shariful Islam
- Department of Clinical surgical Sciences, The University of West Indies, St Augustine, Trinidad and Tobago.
| | - Shamir Cawich
- Department of Clinical surgical Sciences, The University of West Indies, St Augustine, Trinidad and Tobago
| | - Yardesh Singh
- Department of Clinical surgical Sciences, The University of West Indies, St Augustine, Trinidad and Tobago
| | - Ravi Maharaj
- Department of Clinical surgical Sciences, The University of West Indies, St Augustine, Trinidad and Tobago
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Chae MS, Hong CK, Ha YR, Chae MK, Kim YS, Shin TY, Ahn JH. Can clinical scoring systems improve the diagnostic accuracy in patients with suspected adult appendicitis and equivocal preoperative computed tomography findings? Clin Exp Emerg Med 2017; 4:214-221. [PMID: 29055962 PMCID: PMC5758620 DOI: 10.15441/ceem.16.168] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2017] [Revised: 08/07/2017] [Accepted: 08/21/2017] [Indexed: 12/29/2022] Open
Abstract
Objective Adult appendicitis (AA) with equivocal computed tomography (CT) findings remains a diagnostic challenge for physicians. Herein we evaluated the diagnostic performance of several clinical scoring systems in adult patients with suspected appendicitis and equivocal CT findings. Methods We retrospectively evaluated 189 adult patients with equivocal CT findings. Alvarado, Eskelinen, appendicitis inflammatory response, Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA), and adult appendicitis score (AAS) scores were evaluated, receiver operating characteristic analysis was conducted, and the optimal, low, and high cut-off values were determined for patient classification into three groups: low, intermediate, or high. Results In total, 61 patients were included in the appendicitis group and 128 in the non-appendicitis group. There were no significant differences between the area under the curve of the clinical scoring systems in the final diagnosis of AA for equivocal appendicitis on CT (Alvarado, 0.698; Eskelinen, 0.710; appendicitis inflammatory response, 0.668; RIPASA, 0.653; AAS, 0.726). A RIPASA score greater than 7.5 had a high positive predictive value (90.9) and an AAS score less than or equal to 5 had a high negative predictive value (91.7) in the diagnosis of AA. Conclusion The accuracy of clinical scoring systems in the diagnosis of AA with equivocal CT findings was moderate. Therefore, a high RIPASA score may assist in the diagnosis of AA in patients with equivocal CT findings, and a low AAS score may be used as a criterion for patient discharge. Most patients presented with intermediate scores. The patients with equivocal CT findings may be considered as a third diagnostic category of AA.
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Affiliation(s)
- Min Seok Chae
- Department of Emergency Medicine, Daejin Medical Center, Bundang Jesaeng General Hospital, Seongnam, Korea
| | - Chong Kun Hong
- Department of Emergency Medicine, Daejin Medical Center, Bundang Jesaeng General Hospital, Seongnam, Korea
| | - Young Rock Ha
- Department of Emergency Medicine, Daejin Medical Center, Bundang Jesaeng General Hospital, Seongnam, Korea
| | - Minjung Kathy Chae
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Young Sik Kim
- Department of Emergency Medicine, Daejin Medical Center, Bundang Jesaeng General Hospital, Seongnam, Korea
| | - Tae Yong Shin
- Department of Emergency Medicine, Daejin Medical Center, Bundang Jesaeng General Hospital, Seongnam, Korea
| | - Jung Hwan Ahn
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon, Korea
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25
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Lietzén E, Salminen P, Rinta-Kiikka I, Paajanen H, Rautio T, Nordström P, Aarnio M, Rantanen T, Sand J, Mecklin JP, Jartti A, Virtanen J, Ohtonen P, Ånäs N, Grönroos JM. The Accuracy of the Computed Tomography Diagnosis of Acute Appendicitis: Does the Experience of the Radiologist Matter? Scand J Surg 2017; 107:43-47. [DOI: 10.1177/1457496917731189] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background and Aims: To assess the accuracy of computed tomography in diagnosing acute appendicitis with a special reference to radiologist experience. Material and Methods: Data were collected prospectively in our randomized controlled trial comparing surgery and antibiotic treatment for uncomplicated acute appendicitis (APPAC trial, NCT01022567). We evaluated 1065 patients who underwent computed tomography for suspected appendicitis. The on-call radiologist preoperatively analyzed these computed tomography images. In this study, the radiologists were divided into experienced (consultants) and inexperienced (residents) ones, and the comparison of interpretations was made between these two radiologist groups. Results: Out of the 1065 patients, 714 had acute appendicitis and 351 had other or no diagnosis on computed tomography. There were 700 true-positive, 327 true-negative, 14 false-positive, and 24 false-negative cases. The sensitivity and the specificity of computed tomography were 96.7% (95% confidence interval, 95.1–97.8) and 95.9% (95% confidence interval, 93.2–97.5), respectively. The rate of false computed tomography diagnosis was 4.2% for experienced consultant radiologists and 2.2% for inexperienced resident radiologists (p = 0.071). Thus, the experience of the radiologist had no effect on the accuracy of computed tomography diagnosis. Conclusion: The accuracy of computed tomography in diagnosing acute appendicitis was high. The experience of the radiologist did not improve the diagnostic accuracy. The results emphasize the role of computed tomography as an accurate modality in daily routine diagnostics for acute appendicitis in all clinical emergency settings.
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Affiliation(s)
- E. Lietzén
- Division of Digestive Surgery and Urology, Department of Acute and Digestive Surgery, Turku University Hospital, Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
| | - P. Salminen
- Division of Digestive Surgery and Urology, Department of Acute and Digestive Surgery, Turku University Hospital, Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
| | - I. Rinta-Kiikka
- Department of Radiology, Tampere University Hospital, Tampere, Finland
| | - H. Paajanen
- Department of Surgery, Kuopio University Hospital, Kuopio, Finland
| | - T. Rautio
- Department of Surgery, Division of Gastroenterology, Oulu University Hospital, Oulu, Finland
- Medical Research Center Oulu, University of Oulu, Oulu, Finland
| | - P. Nordström
- Division of Surgery, Gastroenterology and Oncology, Tampere University Hospital, Tampere, Finland
| | - M. Aarnio
- Department of Surgery, Jyväskylä Central Hospital and University of Eastern Finland, Jyväskylä, Finland
| | - T. Rantanen
- Department of Surgery, Seinäjoki Central Hospital, Seinäjoki, Finland
- Department of Surgery, Kuopio University Hospital, Kuopio, Finland
| | - J. Sand
- Division of Surgery, Gastroenterology and Oncology, Tampere University Hospital, Tampere, Finland
| | - J.-P. Mecklin
- Department of Surgery, Jyväskylä Central Hospital and University of Eastern Finland, Jyväskylä, Finland
| | - A. Jartti
- Department of Radiology, Oulu University Hospital, Oulu, Finland
| | - J. Virtanen
- Department of Radiology, Turku University Hospital, Turku, Finland
| | - P. Ohtonen
- Medical Research Center Oulu, University of Oulu, Oulu, Finland
- Division of Operative Care, Oulu University Hospital, Oulu, Finland
| | - N. Ånäs
- Department of Radiology, Tampere University Hospital, Tampere, Finland
| | - J. M. Grönroos
- Division of Digestive Surgery and Urology, Department of Acute and Digestive Surgery, Turku University Hospital, Turku, Finland
- Department of Surgery, University of Turku, Turku, Finland
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Simianu VV, Shamitoff A, Hippe DS, Godwin BD, Shriki JE, Drake FT, O'Malley RB, Maximin S, Bastawrous S, Moshiri M, Lee JH, Cuevas C, Dighe M, Flum D, Bhargava P. The Reliability of a Standardized Reporting System for the Diagnosis of Appendicitis. Curr Probl Diagn Radiol 2017; 46:267-274. [PMID: 27743632 PMCID: PMC5821469 DOI: 10.1067/j.cpradiol.2016.07.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE Computed tomography (CT) is a fast and ubiquitous tool to evaluate intra-abdominal organs and diagnose appendicitis. However, traditional CT reporting does not necessarily capture the degree of uncertainty and indeterminate findings are still common. The purpose of this study was to evaluate the reproducibility of a standardized CT reporting system for appendicitis across a large population and the system's impact on radiologists' certainty in diagnosing appendicitis. METHODS Using a previously described standardized reporting system, eight radiologists retrospectively evaluated CT scans, blinded to all clinical information, in a stratified random sample of 237 patients from a larger cohort of patients imaged for possible appendicitis (2010-2014). Receiver operating characteristic (ROC) curves and the area under the ROC curve (AUC) were used to evaluate the diagnostic performance of readers for identifying appendicitis. Two-thirds of these scans were randomly selected to be independently read by a second reader, using the original CT reports to balance the number of positive, negative and indeterminate exams across all readers. Inter-reader agreement was evaluated. RESULTS There were 113 patients with appendicitis (mean age 38, 67% male). Using the standardized report, radiologists were highly accurate at identifying appendicitis (AUC=0.968, 95%CI confidence interval: 0.95, 0.99. Inter-reader agreement was >80% for most objective findings, and certainty in diagnosing appendicitis was high and reproducible (AUC=0.955 and AUC=0.936 for the first and second readers, respectively). CONCLUSIONS Using a standardized reporting system resulted in high reproducibility of objective CT findings for appendicitis and achieved high diagnostic accuracy in an at-risk population. Predictive tools based on this reporting system may further improve communication about certainty in diagnosis and guide patient management, especially when CT findings are indeterminate.
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Affiliation(s)
- Vlad V Simianu
- Department of Surgery, University of Washington, Seattle, WA
| | - Anna Shamitoff
- Department of Surgery, University of Washington, Seattle, WA
| | - Daniel S Hippe
- Department of Radiology, University of Washington, Seattle WA
| | | | - Jabi E Shriki
- Department of Radiology, University of Washington, Seattle WA
| | | | - Ryan B O'Malley
- Department of Radiology, University of Washington, Seattle WA
| | - Suresh Maximin
- Department of Radiology, University of Washington, Seattle WA
| | | | - Mariam Moshiri
- Department of Radiology, University of Washington, Seattle WA
| | - Jean H Lee
- Department of Radiology, University of Washington, Seattle WA
| | - Carlos Cuevas
- Department of Radiology, University of Washington, Seattle WA
| | - Manjiri Dighe
- Department of Radiology, University of Washington, Seattle WA
| | - David Flum
- Department of Surgery, University of Washington, Seattle, WA
| | - Puneet Bhargava
- Department of Radiology, University of Washington, Seattle WA.
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Kabir SA, Kabir SI, Sun R, Jafferbhoy S, Karim A. How to diagnose an acutely inflamed appendix; a systematic review of the latest evidence. Int J Surg 2017; 40:155-162. [PMID: 28279749 DOI: 10.1016/j.ijsu.2017.03.013] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 02/11/2017] [Accepted: 03/04/2017] [Indexed: 02/08/2023]
Abstract
Acute appendicitis is the most common condition that presents with an acute abdomen needing emergency surgery. Despite this common presentation, correctly diagnosing appendicitis remains a challenge as clinical signs or positive blood results can be absent in 55% of the patients. The reported proportion of missed diagnoses of appendicitis ranges between 20% and 40%. A delay or mis-diagnosis of appendicitis can result in severe complications such as perforation, abscess formation, sepsis, and intra-abdominal adhesions. Literature has shown that patients who had a negative appendectomy suffer post-op complications and infections secondary to hospital stays; there have even been reported cases of fatality. It is therefore crucial that timely and accurate diagnosis of appendicitis is achieved to avoid complications of both non-operating as well as unnecessary surgical intervention. The aim of this review is to systematically report and analyse the latest evidence on the different approaches used in diagnosing appendicitis. We include discussions of clinical scoring systems, laboratory tests, latest innovative bio-markers and radiological imaging.
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Affiliation(s)
- S A Kabir
- Department of Surgery, Worcester Royal Hospital, UK.
| | - S I Kabir
- Department of Surgery, Oxford University Hospitals NHS Trust, UK
| | - R Sun
- Department of Surgery, Worcester Royal Hospital, UK
| | | | - Ahmed Karim
- Department of Surgery, Worcester Royal Hospital, UK
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The role of 256-slice CT in differentiation between non-perforated and perforated appendicitis. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2017. [DOI: 10.1016/j.ejrnm.2016.12.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Boshnak N, Boshnaq M, Elgohary H. Evaluation of Platelet Indices and Red Cell Distribution Width as New Biomarkers for the Diagnosis of Acute Appendicitis. J INVEST SURG 2017. [PMID: 28635513 DOI: 10.1080/08941939.2017.1284964] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Debate around the value of laboratory tests in establishing the diagnosis of acute appendicitis (AA) still continues. This prospective study aimed to investigate the changes in mean platelet volume (MPV), platelet distribution width (PDW), and red cell distribution width (RDW) with the diagnosis of acute appendicitis. METHOD 200 patients who underwent emergency appendectomy were included. According to postoperative histology, patients were divided into three groups: acute non-complicated, acute complicated appendicitis (positive appendicectomy groups), and negative appendectomy group. White blood cell (WBC), neutrophil, lymphocyte count, neutrophil-to-lymphocyte ratio (NLR), platelets (PLT) count, MPV, PDW, RDW, and C-reactive protein (CRP) were compared among the groups. RESULTS One hundred twenty-five (62.5%) patients had non-complicated acute appendicitis, 20 (10%) had complicated acute appendicitis, while 55 (27.5%) had normal appendix. WBC (p <.001), neutrophil (p <.001), NLR (p <.001), PDW (p =.003), and CRP (p =.001) were higher, while lymphocyte (p <.001) and PLT counts (p =.020) were lower in positive appendectomy compared with negative appendectomy patients. MPV levels were insignificantly different across the groups. RDW level was significantly higher in complicated compared with non-complicated acute appendicitis (p =.006); however, no significant difference was found between positive and negative appendectomy groups. Using receiver operating characteristic analysis, sensitivity, specificity, and diagnostic accuracy respectively were 44.83, 100.0, and 72.415% for WBC count, 72.41, 81.82, and 77.115% for neutrophil count, 48.28, 90.91, and 69.595% for PDW, 89.66, 63.64, and 76.65% for CRP. CONCLUSIONS Increased PDW combined with elevated WBC and neutrophil counts maybe used as diagnostic tests in the cases of acute appendicitis, while MPV and RDW levels were not useful diagnostic markers.
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Affiliation(s)
- Noha Boshnak
- a Department of Clinical Pathology, Faculty of Medicine , Ain Shams University , Cairo , Egypt
| | - Mohamed Boshnaq
- b Department of General Surgery , Queen Elizabeth the Queen Mother Hospital , Margate , Kent , UK.,c Department of General Surgery, Faculty of Medicine , Ain Shams University , Cairo , Egypt
| | - Hatem Elgohary
- d Department of General Surgery, Faculty of Medicine , Helwan University , Cairo , Egypt
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Ambe PC, Orth V, Gödde D, Zirngibl H. Improving the Preoperative Diagnostic Accuracy of Acute Appendicitis. Can Fecal Calprotectin Be Helpful? PLoS One 2016; 11:e0168769. [PMID: 28033410 PMCID: PMC5199045 DOI: 10.1371/journal.pone.0168769] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 12/06/2016] [Indexed: 12/13/2022] Open
Abstract
Background Is the patient really suffering from acute appendicitis? Right lower quadrant pain is the most common sign of acute appendicitis. However, many other bowels pathologies might mimic acute appendicitis. Due to fear of the consequences of delayed or missed diagnosis, the indication for emergency appendectomy is liberally made. This has been shown to be associated with high rates of negative appendectomy with risk of potentially serious or lethal complications. Thus there is need for a better preoperative screening of patients with suspected appendicitis. Methods This prospective single center single-blinded pilot study was conducted in the Department of surgery at the HELIOS Universitätsklinikum Wuppertal, Germany. Calprotectin was measured in pre-therapeutic stool samples of patients presenting in the emergency department with pain to the right lower quadrant. Fecal calprotectin (FC) values were analyzed using commercially available ELISA kits. Cut-off values for FC were studied using the receiver-operator characteristic (ROC) curve. The Area under the curve (AUC) was reported for each ROC curve. Results The mean FC value was 51.4 ± 118.8 μg/g in patients with AA, 320.9 ± 416.6 μg/g in patients with infectious enteritis and 24.8 ± 27.4 μg/g in the control group. ROC curve showed a close to 80% specificity and sensitivity of FC for AA at a cut-off value of 51 μg/g, AUC = 0.7. The sensitivity of FC at this cut-off value is zero for enteritis with a specificity of 35%. Conclusion Fecal calprotectin could be helpful in screening patients with pain to the right lower quadrant for the presence of acute appendicitis or infectious enteritis with the aim of facilitating clinical decision-making and reducing the rate of negative appendectomy.
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Affiliation(s)
- Peter C. Ambe
- Department of Surgery HELIOS Universitätsklinikum Wuppertal Witten–Herdecke University Heusnerstr. Wuppertal, Germany
- * E-mail:
| | - Valerie Orth
- Department of Surgery HELIOS Universitätsklinikum Wuppertal Witten–Herdecke University Heusnerstr. Wuppertal, Germany
| | - Daniel Gödde
- Institute of Pathology and Molecular Pathology HELIOS Universitätsklinikum Wuppertal Witten–Herdecke University Heusnerstr. Wuppertal, Germany
| | - Hubert Zirngibl
- Department of Surgery HELIOS Universitätsklinikum Wuppertal Witten–Herdecke University Heusnerstr. Wuppertal, Germany
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Management, treatment and outcomes of acute appendicitis in an elderly population: a single-center experience. Eur J Trauma Emerg Surg 2016; 43:723-727. [PMID: 27807602 DOI: 10.1007/s00068-016-0735-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Accepted: 10/14/2016] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Only 5-10% of cases of acute appendicitis (AA) are diagnosed above the age of 60 years. Complicated AA is more common in the elderly, who also have more comorbidities. The goals of this study were to describe our experience with elderly patients and identify predictors of increased morbidity. MATERIAL AND METHODS Patients ≥65 years who were treated for AA between 2006 and 2013 were selected. The control consisted of patients aged 20-45 years, who were randomly selected from a pool of 900 patients. RESULTS Seventy-four patients ≥65 years, mean age of 74.6 ± 7.4, were included. Time from onset of symptoms to surgery was similar between the groups. CT scan was performed for all patients in the elderly group compared to 55.6% in the younger group (p < 0.001). 77% of the younger patients underwent laparoscopic appendectomy compared to 43.2% of the elderly patients (p < 0.001). Pathological findings of severe appendicitis were significantly more common in the elderly group (39.2 vs. 10.5%, p < 0.001). Sixteen elderly patients (21.6%) developed complications, compared with 4 patients (3.2%) in the younger group (p < 0.001). The length of stay was longer in the elderly group and even longer for patients with complications (p < 0.001). There was no mortality. Cardiac disease was the only independent predictor of peri-operative complications (OR = 4.2). CONCLUSIONS Severe forms of acute appendicitis and post-operative morbidity are higher in the elderly population. Cardiac disease is the only predictor for increased morbidity. Although CT scan was performed universally in the elderly group, it did not appear to increase time from presentation to surgery.
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Biomarkers of acute appendicitis: systematic review and cost-benefit trade-off analysis. Surg Endosc 2016; 31:1022-1031. [PMID: 27495334 PMCID: PMC5315733 DOI: 10.1007/s00464-016-5109-1] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 07/09/2016] [Indexed: 12/12/2022]
Abstract
Background Acute appendicitis is the most common surgical emergency and can represent a challenging diagnosis, with a negative appendectomy rate as high as 20 %. This review aimed to evaluate the clinical utility of individual biomarkers in the diagnosis of appendicitis and appraise the quality of these studies. Methods A systematic review of the literature between January 2000 and September 2015 using of PubMed, OvidMedline, EMBASE and Google Scholar was conducted. Studies in which the diagnostic accuracy, statistical heterogeneity and predictive ability for severity of several biomarkers could be elicited were included. Information regarding costs and process times was retrieved from the regional laboratory. European surgeons blinded to these reviews were independently asked to rank which characteristics of biomarkers were most important in acute appendicitis to inform a cost–benefit trade-off. Sensitivity testing and the QUADAS-2 tool were used to assess the robustness of the analysis and study quality, respectively. Results Sixty-two studies met the inclusion criteria and were assessed. Traditional biomarkers (such as white cell count) were found to have a moderate diagnostic accuracy (0.75) but lower costs in the diagnosis of acute appendicitis. Conversely, novel markers (pro-calcitonin, IL 6 and urinary 5-HIAA) were found to have high process-related costs including analytical times, but improved diagnostic accuracy. QUADAS-2 analysis revealed significant potential biases in the literature. Conclusion When assessing biomarkers, an appreciation of the trade-offs between the costs and benefits of individual biomarkers is needed. Further studies should seek to investigate new biomarkers and address concerns over bias, in order to improve the diagnosis of acute appendicitis. Electronic supplementary material The online version of this article (doi:10.1007/s00464-016-5109-1) contains supplementary material, which is available to authorized users.
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Kryzauskas M, Danys D, Poskus T, Mikalauskas S, Poskus E, Jotautas V, Beisa V, Strupas K. Is acute appendicitis still misdiagnosed? Open Med (Wars) 2016; 11:231-236. [PMID: 28352800 PMCID: PMC5329832 DOI: 10.1515/med-2016-0045] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 04/12/2016] [Indexed: 02/07/2023] Open
Abstract
Objective The optimal diagnostics and treatment of acute appendicitis continues to be a challenge. A false positive diagnosis of appendicitis may lead to an unnecessary operation, which has been appropriately termed negative appendectomy. The aim of our study was to identify the effectiveness of preoperative investigations in preventing negative appendectomy. Methods A retrospective study was performed on adult patients who underwent operation for suspected acute appendicitis from 2008 to 2013 at Vilnius University Hospital Santariskiu Klinikos. Patients were divided into two groups: group A underwent an operation, where appendix was found to be normal (non-inflamed); group B underwent an appendectomy for inflamed appendix. Groups were compared for preoperative data, investigations, treatment results and pathology findings. Results 554 patients were included in the study. Preoperative laboratory tests results of hemoglobin, hematocrit concentrations and white blood cell count were significantly higher in group B (p<0.001). Ultrasonography was performed for 78 % of patients in group A and 74 % in group B and did not provide any statistically significant results. Comparing Alvarado score results, there were more patients with Alvarado score less than 7 in group A than in group B. In our large series we could find only four independent risk factors, and they could only account for 24 % of cases. Conclusions In summary, acute appendicitis is still often misdiagnosed and the ratio of negative appendectomies remains rather high. Additional investigations such as observation and computed tomography should be used to prevent this.
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Affiliation(s)
- Marius Kryzauskas
- Vilnius University Hospital Santariskiu Klinikos, Santariskiu Street 2, LT-08661, Vilnius, Lithuania
| | - Donatas Danys
- Vilnius University Hospital Santariskiu Klinikos, Santariskiu Street 2, LT-08661, Vilnius, Lithuania
| | - Tomas Poskus
- Vilnius University Hospital Santariskiu Klinikos, Santariskiu Street 2, LT-08661, Vilnius, Lithuania
| | - Saulius Mikalauskas
- Vilnius University Hospital Santariskiu Klinikos, Santariskiu Street 2, LT-08661, Vilnius, Lithuania
| | - Eligijus Poskus
- Vilnius University Hospital Santariskiu Klinikos, Santariskiu Street 2, LT-08661, Vilnius, Lithuania
| | - Valdemaras Jotautas
- Vilnius University Hospital Santariskiu Klinikos, Santariskiu Street 2, LT-08661, Vilnius, Lithuania
| | - Virgilijus Beisa
- Vilnius University Hospital Santariskiu Klinikos, Santariskiu Street 2, LT-08661, Vilnius, Lithuania
| | - Kestutis Strupas
- Vilnius University Hospital Santariskiu Klinikos, Santariskiu Street 2, LT-08661, Vilnius, Lithuania
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Ünlüer EE, Urnal R, Eser U, Bilgin S, Hacıyanlı M, Oyar O, Akoğlu H, Karagöz A. Application of scoring systems with point-of-care ultrasonography for bedside diagnosis of appendicitis. World J Emerg Med 2016; 7:124-9. [PMID: 27313807 DOI: 10.5847/wjem.j.1920-8642.2016.02.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Appendicitis is a common disease requiring surgery. Bedside ultrasound (BUS) is a core technique for emergency medicine (EM). The Alvarado score is a well-studied diagnostic tool for appendicitis. This study aimed to investigate the relationship between patients' symptoms, Alvarado score and ultrasound (US) findings, as performed by emergency physicians (EPs) and radiologists, of patients with suspected appendicitis. METHODS Three EM specialists underwent the BUS course and core course for appendicitis assessment. Patients suspected of having appendicitis were selected and their Alvarado and modified (m) Alvarado scores calculated. The specialists performed the BUS. Then, patients were given a formal US and surgery consultation if necessary. Preliminary diagnoses, admission or discharge from the emergency department (ED) and final diagnosis were documented. The patients were also followed up after discharge from the hospital. RESULTS The determined cut-off value was 2 for Alvarado and 3 for mAlvarado scores. The sensitivities of the two scores were 100%. Each score was used to rule out appendicitis. The results of EP-performed BUS were as follows: accuracy 70%, sensitivity 0.733, specificity 0.673, + LR 2.24, and - LR 0.40 (95%CI). Radiologists were better than EPs at diagnosing appendicitis and radiologists and EPs were equally strong at ruling out appendicitis by US. When US was combined with Alvarado and mAlvarado scores, EP US+Alvarado/mAlvarado scores <3 and radiology US+Alvarado/mAlvarado scores <4 perfectly ruled out appendicitis. CONCLUSION BUS performed by EPs is moderately useful in detecting appendicitis. Combined with scoring systems, BUS may be a perfect tool for ruling out decisions in EDs.
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Affiliation(s)
- Erden Erol Ünlüer
- Department of Emergency Medicine, Atatürk Training and Research Hospital, İzmir Katip Çelebi University, Karabağlar, İzmir 35150, Turkey
| | - Rıfat Urnal
- Department of Emergency Medicine, Atatürk Training and Research Hospital, İzmir Katip Çelebi University, Karabağlar, İzmir 35150, Turkey
| | - Utku Eser
- Department of Emergency Medicine, Atatürk Training and Research Hospital, İzmir Katip Çelebi University, Karabağlar, İzmir 35150, Turkey
| | - Serkan Bilgin
- Department of Emergency Medicine, Atatürk Training and Research Hospital, İzmir Katip Çelebi University, Karabağlar, İzmir 35150, Turkey
| | - Mehmet Hacıyanlı
- Department of General Surgery, Atatürk Training and Research Hospital, İzmir Katip Çelebi University, Karabağlar, İzmir 35150, Turkey
| | - Orhan Oyar
- Department of Radiology, Atatürk Training and Research Hospital, İzmir Katip Çelebi University, Karabağlar, İzmir 35150, Turkey
| | - Haldun Akoğlu
- Department of Emergency Medicine, Faculty of Medicine, Marmara University, İstanbul, İstanbul 34890, Turkey
| | - Arif Karagöz
- Department of Emergency Medicine, Karşıyaka State Hospital, Karşıyaka, İzmir 35520, Turkey
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Ambe PC, Gödde D, Bönicke L, Papadakis M, Störkel S, Zirngibl H. Calprotectin could be a potential biomarker for acute appendicitis. J Transl Med 2016; 14:107. [PMID: 27118309 PMCID: PMC4847263 DOI: 10.1186/s12967-016-0863-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 04/12/2016] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Acute appendicitis is a common cause for a visit to the emergency department and appendectomy represents the most common emergency procedure in surgery. The rate of negative appendectomy however has remained high despite modern diagnostic apparatus. Therefore, there is need for a better preoperative screening of patients with suspected appendicitis. Calprotectin represents a predominant protein in the cytosol of neutrophil granulocytes and has been extensively investigated with regard to bowel pathologies. This study investigates the expression of calprotectin in the lumen of the vermiform appendix of patients undergoing appendectomy for suspected appendicitis. METHODS Appendix specimens from patients undergoing emergency appendectomy for suspected acute appendicitis were examined. Acute appendicitis was confirmed on histopathology. The qualitative expression of calprotectin in the vermiform appendix specimens was analyzed using specific calprotectin antibodies. RESULTS Vermiform appendix specimens from 52 patients (22 female and 30 male) including 11 with uncomplicated and 41 with complicated appendicitis were analyzed. Strong immunostainings were achieved with calprotectin antibody in the lumen of all specimens irrespective of the extent of appendicitis. Immunostaining was negative in the uninflamed appendix. CONCLUSIONS High calprotectin activity could be demonstrated within the lumen of vermiform appendix specimens following appendectomy for acute appendicitis. The high luminal accumulation of calprotectin-carrying cells could be interpreted as an invitation to study the expression of calprotectin in stool as a new diagnostic aid in patients with suspected appendicitis.
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Affiliation(s)
- Peter C Ambe
- Department of Surgery, HELIOS Universitätsklinikum Wuppertal, Witten-Herdecke University, Heusnerstr. 40, 42283, Wuppertal, Germany.
| | - Daniel Gödde
- Institute of Pathology and Molecular Pathology, HELIOS Universitätsklinikum Wuppertal, Witten-Herdecke University, Heusnerstr. 40, 42283, Wuppertal, Germany
| | - Lars Bönicke
- Department of Surgery, HELIOS Universitätsklinikum Wuppertal, Witten-Herdecke University, Heusnerstr. 40, 42283, Wuppertal, Germany
| | - Marios Papadakis
- Department of Surgery, HELIOS Universitätsklinikum Wuppertal, Witten-Herdecke University, Heusnerstr. 40, 42283, Wuppertal, Germany
| | - Stephan Störkel
- Institute of Pathology and Molecular Pathology, HELIOS Universitätsklinikum Wuppertal, Witten-Herdecke University, Heusnerstr. 40, 42283, Wuppertal, Germany
| | - Hubert Zirngibl
- Department of Surgery, HELIOS Universitätsklinikum Wuppertal, Witten-Herdecke University, Heusnerstr. 40, 42283, Wuppertal, Germany
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Alvarado score: can it reduce unnecessary CT scans for evaluation of acute appendicitis? Am J Emerg Med 2015; 33:266-70. [PMID: 25542452 DOI: 10.1016/j.ajem.2014.11.056] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Revised: 11/29/2014] [Accepted: 11/29/2014] [Indexed: 12/29/2022] Open
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Prospective Comparison of the Alvarado Score and CT Scan in the Evaluation of Suspected Appendicitis: A Proposed Algorithm to Guide CT Use. J Am Coll Surg 2015; 220:218-24. [DOI: 10.1016/j.jamcollsurg.2014.10.010] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Revised: 10/17/2014] [Accepted: 10/21/2014] [Indexed: 12/29/2022]
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Canders CP, Brown AJ, Chiem AT. False positive appendicitis on bedside ultrasound. West J Emerg Med 2014; 15:832-3. [PMID: 25493128 PMCID: PMC4251229 DOI: 10.5811/westjem.2014.9.23550] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2014] [Revised: 08/21/2014] [Accepted: 09/23/2014] [Indexed: 11/11/2022] Open
Affiliation(s)
- Caleb P Canders
- University of California at Los Angeles Medical Center, Department of Emergency Medicine, Los Angeles, California
| | - Angela J Brown
- University of California at Los Angeles Medical Center, Department of Emergency Medicine, Los Angeles, California
| | - Alan T Chiem
- Olive View - University of California at Los Angeles Medical Center, Department of Emergency Medicine, Sylmar, California
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Fedko M, Bellamkonda VR, Bellolio MF, Hess EP, Lohse CM, Laack TA, Laughlin MJ, Campbell RL. Ultrasound evaluation of appendicitis: importance of the 3 × 2 table for outcome reporting. Am J Emerg Med 2014; 32:346-8. [DOI: 10.1016/j.ajem.2013.12.052] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Accepted: 12/28/2013] [Indexed: 10/25/2022] Open
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Teo ATK, Lefter LP, Zarrouk AJM, Merrett ND. Institutional review of patients presenting with suspected appendicitis. ANZ J Surg 2014; 85:420-4. [PMID: 24640953 DOI: 10.1111/ans.12531] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/26/2013] [Indexed: 12/29/2022]
Abstract
BACKGROUND Appendicitis is a common gastrointestinal surgical emergency. Treatment balances the risks of negative appendicectomy (NA) against potential complicated appendicitis in determining clinical priority. This study reviewed the population characteristics, results of the diagnostic modalities and Alvarado score (AlvS) of patients with suspected appendicitis. METHODS A clinical audit of emergency appendicectomies was performed. Generalized linear models with a binomial distribution were used to evaluate the association between the age groups, gender, white cell count (WCC), neutrophil count (NC) and C-reactive protein (CRP) levels versus NAs and the different types of appendicitis. The utilization and accuracy of preoperative ultrasound and computed tomography (CT) and a preliminary analysis of AlvS were also evaluated. RESULTS Patients 17 to 24 years old had significantly higher odds of NA but lower odds of complicated appendicitis compared with patients above 40 years. Adult women and men had significantly higher odds of NA and suppurative appendicitis (SA), respectively. Only adults with SA and acute appendicitis had significantly higher odds of raised WCC, NC and CRP. The sensitivity of CT for adult females was high (100%). Patients who had CT and an AlvS of more than 7 did not have NAs. CONCLUSION Elevated WCC, NC and CRP were all associated with acute appendicitis and SA in adults only. CT is useful for refining the diagnosis in adult females. A combination of inflammatory markers, ultrasound and AlvS may be used selectively to complement or maximize the advantages of CT.
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Affiliation(s)
- Andrew Teck Kwee Teo
- Department of Surgery, Campbelltown Hospital, Sydney, New South Wales, Australia
| | - Liviu Paul Lefter
- Department of Surgery, Campbelltown Hospital, Sydney, New South Wales, Australia
| | | | - Neil Donald Merrett
- Department of Surgery, Campbelltown Hospital, Sydney, New South Wales, Australia.,Department of Surgery, University of Western Sydney, Sydney, New South Wales, Australia
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Abstract
Our attempts to systematically improve accuracy in the evaluation of patients with suspected appendicitis are, in some ways, hindered by the fact that the condition is so frequently straightforward to diagnose. Careful history-taking and physical examination are reliable in most patients. However, establishing the diagnosis with these skills alone remains vulnerable to conditions that masquerade as acute appendicitis. A substantial body of clinical research over the last quarter-century has shown that improved accuracy is possible. Strategies for improvement include the use of diagnostic scoring systems, laboratory makers such as CRP, diagnostic laparoscopy, and advanced imaging modalities such as CT, MRI, and US. How clinicians use these strategies depends on many factors related to practice setting, the population served, and clinical goals. In children, for instance, the desire to limit exposure to ionizing radiation competes with the greater anatomic detail that a CT scan can provide; at the same time, many hospitals that treat children do not have the resources to maintain the sort of full-time, highly sophisticated abdominal US programs that achieve the highest rates of diagnostic accuracy in clinical studies. Trade-offs have to be made, but improvement is possible in almost all groups of patients: the clinical community should no longer settle for a 15% NA rate when 5% is clearly possible without adverse consequences. Many clinicians will be faced with the task of evaluating patients suspected of having acute appendicitis. A deliberate, proactive, and, ideally, benchmarked strategy for improving diagnosis should be the standard to which we hold ourselves and the promise we deliver to our patients.
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Suen K, Hayes IP, Thomson BNJ, Shedda S. Effect of the introduction of an emergency general surgery service on outcomes from appendicectomy. Br J Surg 2013; 101:e141-6. [DOI: 10.1002/bjs.9320] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2013] [Indexed: 12/16/2022]
Abstract
Abstract
Background
Appendicectomy is a common general surgical emergency procedure and may be used as a surrogate marker to evaluate quality in surgical management. The aim of this study was to assess the outcomes of appendicectomy before and after the introduction of a consultant-led emergency general surgery (EGS) service at a large metropolitan tertiary referral centre.
Methods
A retrospective historical control study was performed that included all adult patients undergoing appendicectomy during two 18-month periods, before and after the introduction of the EGS service. Data collected included patient demographics, use of radiological investigations, time to surgery, length of hospital stay and histopathology findings. Outcome measures were time to surgery, hospital length of stay, use of radiological investigations, negative appendicectomy rate and perforation rate.
Results
A total of 675 patients were identified of whom 276 had an appendicectomy before the EGS service was introduced (2008–2009) and 399 after its introduction (2011–2012). The EGS service resulted in an increase in time to surgery (15 versus 18 h; P < 0·001) with no increase in length of hospital stay (3 days for both periods; P = 0·424). An increase in the rate of appendicectomies performed within office hours was seen (54·3 versus 64·4 per cent; P < 0·001), with no significant increase in negative appendicectomy (13·0 versus 15·8 per cent; P = 0·322) or perforation (8·3 versus 5·5 per cent; P = 0·149) rates. The use of preoperative computed tomography reduced from 38·4 to 26·6 per cent (P = 0·001).
Conclusion
The introduction of a consultant-led EGS service resulted in a decrease in the use of computed tomography and a greater proportion of appendicectomies performed within office hours, with no increase in length of stay. Overall negative appendicectomy and perforation rates did not change.
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Affiliation(s)
- K Suen
- Department of Specialist General Surgery, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - I P Hayes
- Department of Specialist General Surgery, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - B N J Thomson
- Department of Specialist General Surgery, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - S Shedda
- Department of Specialist General Surgery, Royal Melbourne Hospital, Melbourne, Victoria, Australia
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43
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Affiliation(s)
- Phil Truskett
- Department of Surgery; Prince of Wales Clinical School; Sydney New South Wales Australia
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44
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Brockman SF, Scott S, Guest GD, Stupart DA, Ryan S, Watters DAK. Does an Acute Surgical Model increase the rate of negative appendicectomy or perforated appendicitis? ANZ J Surg 2013; 83:744-7. [PMID: 23692520 DOI: 10.1111/ans.12211] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2013] [Indexed: 12/29/2022]
Abstract
INTRODUCTION The clinical outcomes from suspected appendicitis depend on balancing the rate of negative appendicectomy (NA) with perforated appendicitis (PA). An Acute Surgical Model (ASM) was introduced at Geelong Hospital (GH) in 2011 involving a dedicated emergency general surgery theatre list every business day giving greater access to theatre for general surgeons. The aim of this study was to evaluate the effect of the ASM at GH on the management of appendicitis, in particular the NA and PA rates. METHODS Data for 357 patients undergoing emergency appendicectomy was collected prospectively over 1 year (2011) and compared with a historical control group of 351 patients (2010). The data was analysed for patient demographics, preoperative diagnostic radiology and outcomes including NA and PA rates and complications. The negative appendicectomy rates were compared with contemporary studies. RESULTS There was no difference between the two groups in rates of negative appendicectomy 21% (ASM; 73/357) versus 21% (Control; 73/351) P = 0.98, or perforated appendicitis 17% (ASM; 61/357) versus 13% (Control; 47/351) P = 0.18. The introduction of the ASM corresponded to a significantly lower proportion of emergency appendicectomies overnight (4% [16/357] versus 12% [44/351] P = 0.005). There was no significant difference in the use of preoperative diagnostic radiology or complications. Matched contemporary studies had a NA rate of 26%. CONCLUSION The introduction of the ASM at GH has not significantly altered the rate of NA or PA. The NA rate at GH is comparable to other published UK and Australian series.
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Affiliation(s)
- Stephen F Brockman
- Department of Surgery, Geelong Hospital and Deakin University, Geelong, Victoria, Australia
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Tan WJ, Pek W, Kabir T, Goh YC, Chan WH, Wong WK, Ong HS. Alvarado score: a guide to computed tomography utilization in appendicitis. ANZ J Surg 2013; 83:748-52. [PMID: 23351046 DOI: 10.1111/ans.12076] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2013] [Indexed: 12/29/2022]
Abstract
BACKGROUND Although useful in evaluation of suspected appendicitis, not all patients require computed tomography (CT) evaluation. Clinical stratification of patients who benefit from CT evaluation is essential. We utilize the Alvarado score (AS) to stratify patients with suspected appendicitis into subgroups who benefit from CT evaluation and propose an objective algorithm with AS guiding CT utilization. METHODS This study is a retrospective review of medical records of all patients admitted for suspected appendicitis over a 6-month duration. Relevant data were recorded. The AS for each patient was determined retrospectively and correlated with histological and CT findings. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were determined for various ASs and for CT. RESULTS Three hundred fifty-eight patients were studied, with 167 males (46.6%) and 191 females (53.4%). Prevalence of appendicitis was 50% (179 patients). Two hundred fourteen patients (59.8%) had CT performed. Surgery was performed for 206 patients (57.5%). Overall negative appendicectomy rate was 13.1%. Patients who underwent CT evaluation had a negative appendicectomy rate of 5.7% compared to 17.9% in those without CT evaluation (P = 0.009). CT scan had a sensitivity and specificity of 92.6% and 96.9%, respectively. An AS greater than 3 had a sensitivity superior to CT (95.5%), while an AS of 9 or greater had a specificity superior to CT (100%). CONCLUSIONS In suspected appendicitis, patients who benefit from CT evaluation are those with the AS ranging from 4 to 8. We propose a management algorithm with the AS guiding the necessity for CT evaluation.
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Progress in the diagnosis of appendicitis: a report from Washington State's Surgical Care and Outcomes Assessment Program. Ann Surg 2012; 256:586-94. [PMID: 22964731 DOI: 10.1097/sla.0b013e31826a9602] [Citation(s) in RCA: 101] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND AND OBJECTIVES Studies suggest that computed tomography and ultrasonography can effectively diagnose and rule out appendicitis, safely reducing negative appendectomies (NAs); however, some within the surgical community remain reluctant to add imaging to clinical evaluation of patients with suspected appendicitis. The Surgical Care and Outcomes Assessment Program (SCOAP) is a physician-led quality initiative that monitors performance by benchmarking processes of care and outcomes. Since 2006, accurate diagnosis of appendicitis has been a priority for SCOAP. The objective of this study was to evaluate the association between imaging and NA in the general community. METHODS Data were collected prospectively for consecutive appendectomy patients (age > 15 years) at nearly 60 hospitals. SCOAP data are obtained directly from clinical records, including radiological, operative, and pathological reports. Multivariate logistic regression models were used to examine the association between imaging and NA. Tests for trends over time were also conducted. RESULTS Among 19,327 patients (47.9% female) who underwent appendectomy, 5.4% had NA. Among patients who were imaged, frequency of NA was 4.5%, whereas among those who were not imaged, it was 15.4% (P < 0.001). This association was consistent for men (3% vs 10%, P < 0.001) and for women of reproductive age (6.9% vs 24.7%, P < 0.001). In a multivariate model adjusted for age, sex, and white blood cell count, odds of NA for patients not imaged were 3.7 times the odds for those who received imaging (95% CI: 3.0-4.4). Among SCOAP hospitals, use of imaging increased and NA decreased significantly over time; frequency of perforation was unchanged. CONCLUSIONS Patients who were not imaged during workup for suspected appendicitis had more than 3 times the odds of NA as those who were imaged. Routine imaging in the evaluation of patients suspected to have appendicitis can safely reduce unnecessary operations. Programs such as SCOAP improve care through peer-led, benchmarked practice change.
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Correlation of serum C-reactive protein, white blood count and neutrophil percentage with histopathology findings in acute appendicitis. World J Emerg Surg 2012; 7:27. [PMID: 22866907 PMCID: PMC3469372 DOI: 10.1186/1749-7922-7-27] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2012] [Accepted: 07/31/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Acute appendicitis is one of the most common surgical emergencies. Accurate diagnosis of acute appendicitis is based on careful history, physical examination, laboratory and imaging investigation. The aim of the study is to analyze the role of C-reactive protein (CRP), white blood count (WBC) and Neutrophil percentage (NP) in improving the accuracy of diagnosis of acute appendicitis and to compare it with the intraoperative assessment and histopathology findings. MATERIALS AND METHODS This investigation was a prospective double blinded clinical study. The study was done on 173 patients surgically treated for acute appendicitis. The WBC, NP, and measurement of CRP were randomly collected pre-operatively from all involved patients. Macroscopic assessment was made from the operation. Appendectomy and a histopathology examination were performed on all patients. Gross description was compared with histopathology results and then correlated with CRP, WBC, and NP. RESULTS The observational accuracy was 87,3%, as compared to histopathological accuracy which was 85.5% with a total of 173 patients that were operated on. The histopathology showed 25 (14.5%) patients had normal appendices, and 148 (85.5%) patients had acutely inflamed, gangrenous, or perforated appendicitis. 52% were male and 48% were female, with the age ranging from 5 to 59 with a median of 19.7. The gangrenous type was the most frequent (52.6%). The WBC was altered in 77.5% of the cases, NP in 72.3%, and C-reactive protein in 76.9% cases. In those with positive appendicitis, the CRP and WBC values were elevated in 126 patients (72.8%), whereas NP was higher than 75% in 117 patients (67.6%). Out of 106 patients with triple positive tests, 101 (95.2%) had appendicitis. The sensitivity, specificity, and positive predictive values of the 3 tests in combination were 95.3%, 72.2%, and 95.3%, respectively. CONCLUSION The raised value of the CRP was directly related to the severity of inflammation (p-value <0.05). CRP monitoring enhances the diagnostic accuracy of acute appendicitis. The diagnostic accuracy of CRP is not significantly greater than WBC and NP. A combination of these three tests significantly increases the accuracy. We found that elevated serum CRP levels support the surgeon's clinical diagnosis.
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The negative appendectomy rate: who benefits from preoperative CT? AJR Am J Roentgenol 2011; 197:861-6. [PMID: 21940573 DOI: 10.2214/ajr.10.5369] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVE The purpose of this article is to determine the negative appendectomy rates of patients who did and did not undergo preoperative CT and to determine, more specifically, whether men benefit from preoperative CT. MATERIALS AND METHODS We identified 512 patients who had a nonincidental appendectomy between July 1, 2002, and June 30, 2007. Pathology records were compared with a radiology records search to determine which patients underwent preoperative CT. Proportions of patients were compared between groups using the Fisher exact test. RESULTS Of 512 patients who had a nonincidental appendectomy, 465 (91%) underwent preoperative CT, and 47 (9%) underwent appendectomy only on the basis of clinical findings. Overall, 22 of 465 patients (4.7%) who underwent preoperative CT had a negative appendectomy compared with six of 47 patients who did not undergo preoperative imaging (negative appendectomy rate, 12.7%; p = 0.03). Among men, six of 237 (2.5%) with preoperative CT had a negative appendectomy, versus five of 42 without imaging (negative appendectomy rate, 11.9%; p = 0.01). CONCLUSION The negative appendectomy rate was decreased for adult patients who underwent preoperative CT compared with patients who did not undergo preoperative imaging. Although most prior studies have suggested that CT is efficacious only in decreasing the negative appendectomy rate among women, we found that men benefit from CT as well.
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Krajewski S, Brown J, Phang PT, Raval M, Brown CJ. Impact of computed tomography of the abdomen on clinical outcomes in patients with acute right lower quadrant pain: a meta-analysis. Can J Surg 2011; 54:43-53. [PMID: 21251432 DOI: 10.1503/cjs.023509] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Clinical evaluation alone is still considered adequate by many clinicians who treat patients with appendicitis. The impact of computed tomography (CT) on clinical outcomes remains unclear, and there is no consensus regarding the appropriate use of CT in these patients. We sought to evaluate the impact of abdominal CT on the clinical outcomes of patients presenting with suspected appendicitis. METHODS We conducted a systematic review of the literature to identify studies that examined clinical outcomes related to the use of abdominal CT in the diagnosis of acute appendicitis. Inclusion criteria were studies of adult patients with suspected appendicitis that evaluated the impact of abdominal CT on negative appendectomy rates, perforation rates or time to surgery. Two independent investigators reviewed all titles and abstracts and extracted data from 28 full-text articles. Statistical analysis was conducted using Review Manager 5.0.10 software. RESULTS The negative appendectomy rate was 8.7% when using CT compared with 16.7% when using clinical evaluation alone (p < 0.001). There was also a significantly lower negative appendectomy rate during the CT era compared with the pre-CT era (10.0% v. 21.5%, p < 0.001). Time to surgery was evaluated in 10 of the 28 studies, 5 of which demonstrated a significant increase in the time to surgery with the use of CT. Appendiceal perforation rates were unchanged by the use of CT (23.4% in the CT group v. 16.7% in the clinical evaluation group, p = 0.15). Similarly, the perforation rate during the CT era was not significantly different than that during the pre-CT era (20.0% v. 19.6%, p = 0.74). CONCLUSION This meta-analysis supports the hypothesis that the use of preoperative abdominal CT is associated with lower negative appendectomy rates. The use of CT in the absence of an expedited imaging protocol may delay surgery, but this delay is not associated with increased appendiceal perforation rates. Routine CT in all patients presenting with suspected appendicitis could reduce the rate of unnecessary surgery without increasing morbidity.
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Affiliation(s)
- Susan Krajewski
- Department of Surgery, University of British Columbia, Vancouver, BC
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Güller U, Rosella L, McCall J, Brügger LE, Candinas D. Negative appendicectomy and perforation rates in patients undergoing laparoscopic surgery for suspected appendicitis. Br J Surg 2011; 98:589-95. [PMID: 21259233 DOI: 10.1002/bjs.7395] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2010] [Indexed: 12/24/2022]
Abstract
BACKGROUND Despite widespread use of imaging technologies including ultrasonography and computed tomography, rates of negative appendicectomy and perforated appendicitis remain high. This trend analysis examined whether rates of negative appendicectomy and perforated appendicitis have decreased over time, and sought to evaluate clinical predictors associated with negative appendicectomy and perforated appendicitis. METHODS This analysis was based on the prospective database of the Swiss Association of Laparoscopic and Thoracoscopic Surgery (SALTS). All patients aged 12 years and over undergoing emergency laparoscopic appendicectomy between 1995 and 2006 were included. Unadjusted and risk-adjusted logistic regression analyses were performed. RESULTS A total of 7964 patients underwent laparoscopic appendicectomy, of whom 7452 (93.6 per cent) had acute appendicitis and 512 (6.4 per cent) had a macroscopically normal appendix. Perforation occurred in 1230 (16.5 per cent) of those with appendicitis. In multivariable analysis, younger age (12-18 years), female sex, absence of local or generalized peritonitis and an early point during the study period were significant predictors of negative appendicectomy. For perforated appendicitis, significant predictors included age over 36 years, presence of localized or generalized peritonitis, and high American Society of Anesthesiologists grade. The rate of negative appendicectomy decreased from 12.7 per cent in 1995 to 2.8 per cent in 2006, there being a significant reduction in both unadjusted and risk-adjusted analyses (P < 0.001 for trend). In adjusted analyses, the rate of perforated appendicitis did not increase significantly over time. CONCLUSION The rate of negative appendicectomy decreased over time, without an accompanying increase in perforated appendicitis. The risk of having a negative appendicectomy was highest in girls aged 12-18 years without local or generalized peritonitis during the early study period, whereas perforation was associated with age over 36 years, presence of localized or generalized peritonitis, and greater co-morbidity. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
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Affiliation(s)
- U Güller
- Department of Surgery, Division of Visceral Surgery and Transplantation, University of Berne, Berne, Switzerland.
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