Have the evaluation and treatment of acute appendicitis changed with new technology?

The Use of Inflammatory Markers to Rule Out Acute Appendicitis in Pediatrics

Background Acute appendicitis is the most common abdominal surgical emergency in pediatric patients. The diagnosis of acute appendicitis in pediatrics is challenging and requires an accurate physical examination, laboratory study, and imaging. The aim of this study was to determine the benefits of using three inflammatory markers, white blood count (WBC), neutrophils percent (NE%), and C-reactive protein (CRP), in ruling out appendicitis in pediatric patients. Methods A retrospective study was conducted of 152 pediatric patients aged between 6 months and 14 years presenting to the emergency department between January 2018 and December 2020, with the diagnosis of appendicitis as the primary physician's main diagnosis. Demographic information and clinical data were extracted from the medical file for each patient. Results Out of the 152 patients included, 68 (44.7%) were female and 84 (55.3%) were male, with median age was 8.1 years. Thirty-six (23.7%) had acute appendicitis confirmed by histopathology. Of these 36 patients, only two patients (5.6%) had all inflammatory markers within normal limits. Conclusion  Although raised inflammatory markers may help diagnose acute appendicitis, their role in ruling it out remains limited.

Minimally Invasive Treatment for Appendiceal Mass Formed After Acute Perforated Appendicitis

The optimal treatment for appendiceal mass formed after appendiceal rupture due to acute appendicitis is surrounded with controversy. The treatment strategy ranges from open surgery (emergency or interval appendectomy), laparoscopic appendectomy, and image-guided drainage, to conservative treatment with or without antibiotics. Nonsurgical treatment (including conservative and drainage treatment), followed by interval appendectomy to prevent recurrence, is the traditional management of these patients. The need for interval appendectomy after a successful conservative or/and image-guided drainage treatment, has recently been questioned as the risk of recurrence is relatively small. Several authors consider that even in cases involving only ambulatory follow-up observation, without interval surgery after conservative management, the recurrence rate and risks of missing underlying pathologies were not high. This article evaluates the minimally invasive treatment modalities in the management of appendiceal mass, risk of undetected serious disease, and the need for interval appendectomy to prevent recurrence.

Clinical and Ultrasonographic Diagnosis of Acute Appendicitis

Appendicitis is one of the most common acute abdominal conditions encountered in the Emergency Department. It is a surgical condition that can affect any person of any age and often with varying clinical presentations. In the majority of cases, the diagnosis is straightforward. However in some, the diagnosis requires a heightened clinical suspicion. The application of adjuvant laboratory tests and diagnostic imaging helps to reduce the associated complications, morbidity and mortality of delayed diagnosis.

Acute Appendicitis

Appendicitis is the most common cause of acute abdominal pain requiring surgery. Approximately 250,000 appendectomies are performed annually in the United States. Sonography and computed tomography have both proven to be reliable imaging options for evaluating patients presenting with right lower quadrant pain and possible appendicitis. The authors report a case of acute appendicitis incidentally discovered during routine transvaginal sonography (TVS). Although TVS is not the standard imaging technique for evaluating the acute appendix, it is important for sonographers and sonologists to recognize the pathology when it is encountered and the value of the transvaginal approach.

Surgeon's clinical valuation and accuracy of ultrasound in the diagnosis of acute appendicitis: A comparison with intraoperative evaluation. Five years experience

INTRODUCTION

Acute appendicitis is the most common cause of acute abdomen in adolescents, with an overall incidence of 7%. Two such tools are used to diagnose acute appendicitis: ultrasound and Computer Tomography imaging. End point of this study was to verify the accuracy of ultrasound imaging in the diagnosis of acute appendicitis with respect to intraoperative observations and the respective clinical and laboratory findings in young and in the elderly.

METHODS

We considered all the appendectomies for acute appendicitis performed between 1 January 2010 and 1 January 2015. We evaluated clinical symptoms, laboratory findings, ultrasound findings, intraoperative signs, and anatomical and pathological findings. In the study we compared the ultrasound and intraoperative findings and then compared these with the respective clinical and laboratory data.

RESULTS

In a comparison of diagnostic accuracy, the difference between clinical and ultrasound examinations was not significant. The differences between the diagnostic accuracy of clinical and laboratory findings and between ultrasound and laboratory investigations were statistically significant.

CONCLUSION

We defined white blood cells and C protein levels as non-diagnostic of the type of acute inflammation but rather as indicators of the severity of the inflammatory process. We also agree with the authors who proposed the incorporation of ultrasonography into routine practice in the diagnosis of acute appendicitis, but only and exclusively to support other diagnostic procedures and preferably within emergency departments. A thorough clinical examination of patients with suspected acute appendicitis is still the best diagnostic procedure available to us.

Clinicopathological review of 156 appendicectomies for acute appendicitis in children in Ile-Ife, Nigeria: a retrospective analysis

Background

Acute appendicitis is one of the most common causes of acute abdomen in children. Late surgical intervention is often associated with increase morbidity and sometimes fatal outcome. We sought to determine the pattern of presentation of acute appendicitis, and the effect of late presentation on surgical outcome in children.

Methods

This is a retrospective descriptive study done at the paediatric surgical unit of Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria. The hospital records of all 180 patients (15 years and below) treated for acute appendicitis, between January 1995 and December 2012, were reviewed; only 156 patients had adequate records out of which 139 cases confirmed histologically as having appendicitis were analyzed.

Results

There were 80 (57.6%) females and 59 (42.4%) males. The age range was 5-15years with mean (SD) age of 11.2 (±2.9) years. Most patients (64.7%) were more than 10 years old. Sixty-four (46%) patients had simple appendicitis while 75 (54%) patients had complicated appendicitis. More children with complicated appendicitis (63, 84.0%) presented after 24 hours of abdominal pain; and they had more vomiting (59, 78.7%), spent longer days on admission (57, 76.0%) and had more post- operative complications (34, 45.3%) compared with uncomplicated appendicitis (25, 39.1%; 29, 45.3%; 7, 10.9%; 1, 1.6% respectively), and this was statistically significant (p < 0.05). No mortality was recorded among these children.

Conclusion

Late presentation was common and was associated with longer duration of hospital stay and high morbidity. No mortality was recorded from the disease.

The normal appendix on CT: does size matter?

PURPOSE

(1) To evaluate the frequency of visualisation and measurements of the normal appendix. (2) To correlate Body Mass Index (BMI) and gender with visualisation of the normal appendix. (3) To correlate age, gender and body length with appendiceal length.

MATERIALS AND METHODS

A retrospective review of 186 patients undergoing abdominal CT without suspicion of acute appendicitis was done. Frequency of visualisation and measurements (including maximal outer diameter, wall thickness, length, content, location of base and tip) of normal appendices were recorded.

RESULTS

Prevalence of appendectomy was 34.4%. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of visualisation of the normal appendix were 76%, 94%, 96%, 67%, and 82% respectively. The mean maximal diameter of the appendix was 8.19 mm±1.6 (SD) (range, 4.2-12.8 mm). The mean length of the appendix was 81.11 mm±28.44 (SD) (range, 7.2-158.8 mm). The mean wall thickness of the appendix was 2.22 mm±0.56 (SD) (range, 1.15-3.85 mm). The most common location of the appendiceal tip was pelvic in 66% appendices. The most common location of the appendiceal base was inferior, medial, and posterior in 37%. The normal appendix contained high-density material in 2.2%. There was a significant correlation between gender and appendiceal length, with men having longer appendices than women.

CONCLUSION

Most normal appendices are seen at multislice CT using i.v. contrast. The maximal outer diameter of the normal appendix overlaps with values currently used to diagnose appendicitis on CT.

The vermiform appendix: a review

New research on the vermiform appendix has shed light on its function. In further understanding the function of the appendix, this information should not negatively impact the clinical judgment in the event of appendicitis. Although the appendix and its pathology have been noted for centuries, it still presents a challenge in the operating room. The most common emergency surgical procedure performed is an appendectomy. Its highly variable position within the abdomen can cause confusion for clinicians. However, improved imaging modalities have heightened the physician's ability to diagnose disease of this organ. This article reviews germane literature regarding the human vermiform appendix.

An analysis of factors influencing accuracy of the diagnosis of acute appendicitis

The aim of the study was to "refresh" the knowledge about the course of acute appendicitis, to confront the classical clinical picture with the practice, analyze its fluctuations and identify factors influencing these.

MATERIAL AND METHODS

All patients admitted to the Department of General Surgery in Grudziądz District Hospital with the suspicion of acute appendicitis, who underwent appendectomy and in whom the appendicitis was confirmed in pathologic examination were included in the study. There were 85 patients, 49 men (58%) and 36 women (42%) in a mean age of 30 years (range 10-75). Symptoms, signs and results of biochemical tests (leukocyte rate and CRP) were considered in the analysis.

RESULTS

The commonest constellation of symptoms and signs, occurring in at least of 3/4 patients consisted of pain and tenderness localized in right lower quadrant (100%), which exacerbates at movements (98%), felling unwell (93%), loss of appetite (88%), and rebound tenderness in right lower quadrant (74%).

CONCLUSIONS

No particular fluctuation of clinical features in relation to gender, age, duration of symptoms, biochemical parameters and morphological severity of the inflammation was observed. Relevant findings included relatively fast development (<12 hrs) of advanced appendicitis in 18% of adult patients and more than a half patients with normal body temperature, regardless true appendicitis.

An approach to model Right Iliac Fossa pain using pain-only-parameters for screening acute appendicitis

Acute appendicitis (AA) is one of the commonest of multiple possible pathologies at the backdrop of Right Iliac Fossa (RIF) pain. RIF is the most common acute surgical condition of the abdomen. Even though AA is a recognized disease entity since decades, its diagnosis still lacks clinical confidence and mandates laboratory tests. Given the issue, this paper proposes a mathematical model using Pain-Only-Parameters (POP) obtained from available literature to screen AA. Weights have been assigned for each POP to create a training data matrix (N = 51) and used to calculate the cumulative effect or weighted sum, which is termed as the Pain Confidence Score (PCS). Based on PCS, a group of real-world patients (N = 40; AA and NA = 20 each) are classified as cases of AA or non-appendicitis (NA) with satisfactory results (sensitivity 85%, specificity 75%, precision 77%, and accuracy 80%). Most rural health centers (RHC) in developing nations lack specialist services and related infrastructure. Hence, such a tool could be useful in RHC to assist general physicians in screening AA and their timely referral to higher centers.

Comparison of clinical characteristics and neutrophil values in omental infarction and acute appendicitis in children

BACKGROUND

Omental infarction is a rare occurrence in children. It is often diagnosed during surgery for suspected appendicitis. This study investigated the use of clinical and laboratory data for distinguishing between omental infarction and acute appendicitis.

METHODS

Seven patients with surgically and pathologically proven omental infarction and 28 age- and sex-matched patients with acute appendicitis were included in this study. The clinical characteristics, imaging study results and laboratory data were analyzed.

RESULTS

All 35 patients had right lower quadrant abdominal pain at presentation. The frequency of nausea and fever were significantly lower in the omental infarction group compared with the acute appendicitis group (p< 0.001 and p= 0.018, respectively). In laboratory studies, the white blood cell count, C-reactive protein value and neutrophil percentage were all higher in the acute appendicitis group compared with the omental infarction group (p= 0.001, p< 0.001, and p= 0.008, respectively). It was possible to separate patients with omental infarction from those with acute appendicitis based on a neutrophil percentage of less than 77% (sensitivity 100%, specificity 100%).

CONCLUSIONS

Results of the current study suggest that omental infarction should be considered as a possible diagnosis in patients presenting with right lower quadrant abdominal pain without nausea or fever, and with a neutrophil percentage below 77%.

The value of preoperative diagnostic tests in acute appendicitis, retrospective analysis of 196 patients

BACKGROUND

In this study our aim was to evaluate the diagnostic value of preoperative laboratory and radiological studies for appendicitis.

METHODS

The clinical data of 196 patients who have undergone conventional appendectomy between March 2007 and April 2008 were collected retrospectively. Patients were examined for age, sex, white blood cell count, ultrasonography results, histopathological diagnosis and hospital stay.

RESULTS

Negative appendectomy rate was 17.3% (27% for female, 11.5% for male). White blood cell counts were found to be high in 83% for acute appendicitis group and %61 for negative appendectomy group. There were 66 (34%) patients who had negative USG findings for acute appendicitis. Of these patients, histopathological examination revealed acute appendicitis in 46 patients whereas 20 patients had normal appendix. Hospital stays were 2.79 +/- 1.9 and 2.66 +/- 1.7 days for negative and positive appendicectomies respectively.

CONCLUSIONS

Besides the improvement of diagnostic tests for acute appendicitis, we could not sufficiently reduce the negative appendectomy rate.

CRP in acute appendicitis--is it a necessary investigation?

BACKGROUND

Appendectomy is one of the commonest procedures in surgery. In spite of various investigations used to improve the accuracy of diagnosis, the rate of normal appendices removed is still about 15-30%. Many studies have investigated the role of C-reactive protein (CRP) in acute appendicitis, but with conflicting results.

METHODS

In a prospective, double blind study, blood for the measurement of serum C-reactive protein was collected pre-operatively from 192 children before going to the operating theatre for appendectomy. The histopathology was grouped into positive (acute appendicitis) and negative (normal appendix) and this was correlated with CRP values.

RESULTS

CRP was normal in 14 out of 33 negative explorations (normal appendix on histopathology). The specificity and sensitivity of serum CRP was 42% and 91% respectively. The predictive value of a positive (raised CRP) and negative (normal CRP) test is 88% and 48% respectively.

CONCLUSION

We conclude that neither raised nor normal CRP value is helpful in the diagnosis of acute appendicitis. CRP is not a good tool for helping the surgeon make the diagnosis of appendicitis and it should not be measured in suspected appendicitis.

Inflammatory markers for acute appendicitis in children: are they helpful?

BACKGROUND/PURPOSE

Diagnosis of acute appendicitis in children remains challenging, and the role of blood tests in the decision-making process is still unclear. We prospectively evaluated if routine inflammatory markers could contribute to exclude the presence of acute appendicitis in children.

METHODS

Preoperative white blood cell count (WBCC) and C-reactive protein (CRP) were prospectively tested in children undergoing surgery for suspected appendicitis. Surgery was indicated on the basis of clinical findings and/or ultrasound scan, but WBCC and CRP values were ignored during the decision-making process. Sensitivity of individual markers and their combinations were assessed.

RESULTS

One hundred children (55 males) with a mean age of 9.34 years (SD, 3.54 years) had pathologically confirmed diagnosis of appendicitis. A perforated appendix was found in 23% of cases. Elevated WBCC alone had a sensitivity of 0.6 (confidence interval [CI], 0.506-0.694). Sensitivity of elevated CRP alone was 0.86 (CI, 0.926-0.793). Elevation of either WBCC or CRP or both had a sensitivity of 0.98 (CI, 1.0-0.953).

CONCLUSIONS

White blood cell count or CRP values alone do not appear to provide any useful additional information to the surgeon. However, the sensitivity of the 2 combined tests is extremely high, and normal values of both WBCC and CRP are very unlikely in pathologically confirmed appendicitis.

Classificação laparoscópica da apendicite aguda: correlação entre graus da doença e as variáveis perioperatórias

OBJETIVO: Apresentar a classificação laparoscópica da apendicite aguda e verificar a relação entre os graus da doença com o tempo de sintomas, tempo operatório, permanência hospitalar, complicações infecciosas e uso de antimicrobianos. MÉTODO: Estudo prospectivo, transversal, envolvendo 105 pacientes com diagnóstico de apendicite aguda e submetidos a apendicectomia laparoscópica entre Janeiro de 2000 e Julho de 2001. A doença foi classificada em grau 0 - Normal; 1 - Hiperemia e edema; 2 - Exsudato fibrinoso; 3 - Necrose segmentar; 4A - Abscesso; 4B - Peritonite regional; 4C - Necrose da base do apêndice; 5 - Peritonite difusa. RESULTADOS: A distribuição dos pacientes segundo a classificação foi: grau 0 (10,4%); 1 (40%); 2 (29,5%); 3 (2,9%); 4A (1,9%); 4B (4,8%); 4C (3,8%) e 5 (6,7%). O tempo médio de início de sintomas acima de 40 h correlacionou-se com possibilidade de necrose e peritonite. O tempo operatório variou de 18 a 126 minutos, média de 31,4 minutos. A permanência hospitalar variou de 12 a 192 h, média de 39,5 h. A maior incidência de complicações Infecciosa ocorreu nos graus 4 e 5. O antimicrobiano foi de uso profilático graus 0, 1 e 2 e terapêutico nos demais. A laparotomia foi necessária duas (1,9%) vezes e não houve óbito. CONCLUSÕES: A classificação laparoscópica da apendicite aguda contemplou todas as formas clínicas da doença, possibilitou correlação com os tempos início de sintomas, operatório e de permanência hospitalar. Permitiu ainda, prever complicações infecciosas e racionalizar o uso de antimicrobianos.

Diagnosis of appendicitis in adults by ultrasonography or computed tomography: a systematic review and meta-analysis

OBJECTIVES

The use of ultrasonography and computed tomography (CT) in the diagnosis of appendicitis in adult patients was compared.

METHODS

Systematic review and meta-analysis of current evidence in two clinical situations: unselected nonpregnant, adult patients with symptoms of appendicitis, and more selective use in only those patients who still have an equivocal diagnosis subsequent to routine clinical investigations.

RESULTS

Meta-analysis of eligible studies shows CT to have better sensitivity and specificity than ultrasound in both clinical situations.

CONCLUSIONS

Application of these findings in clinical practice and/or policy would need to evaluate the better diagnostic performance of CT against its cost and availability. In addition, it is imperative that future studies be conducted in patient populations that are well-defined with respect to prior investigations. Sequelae of false-negative and false-positive diagnoses should also be evaluated.

Cost-effectiveness analysis of weekday and weeknight or weekend shifts for assessment of appendicitis

BACKGROUND

Assessment of appendicitis during a weeknight or weekend shift (after-hours period, AHP) might be more costly and less effective than its assessment on a weekday shift (standard hours period, SHP) because of increased costs (staff premium fees) and perforation risk (longer delays and less experience of fellows).

OBJECTIVES

The objectives were to compare the costs and effectiveness of assessing children with suspected appendicitis who required a laparotomy and had US or CT after-hours with those of assessing children during standard hours, and to evaluate the importance of diagnostic imaging (DI) within the overall costs.

MATERIALS AND METHODS

We retrospectively microcosted resource use within six areas of a tertiary hospital (emergency [ED], diagnostic imaging (DI), surgery, wards, transport, and pathology) in a tertiary hospital. About 41 children (1.8-17 years) in the AHP and 35 (2.9-16 years) in the SHP were evaluated. Work shift effectiveness was measured with a histological score that assessed the severity of appendicitis (non-perforated appendicitis: scores 1-3; perforated appendicitis: score 4).

RESULTS

The SHP was less costly and more effective regardless of whether the calculation included US or CT costs only. For a salary-based fee schedule, 733 US dollars were saved per case of perforated appendicitis averted in the SHP. For a fee-for-service payment schedule, 847 dollars were saved. Within the overall budget, the highest costs were those incurred on the ward for both shifts. The average cost per patient in DI ranged from 2 to 5% of the total costs in both shifts. Most perforation cases were found in the AHP (31.7%, AHP vs. 17.1%, SHP), which resulted in higher ward costs for patients in the AHP.

CONCLUSION

A higher proportion of severe cases was seen in the AHP, which led to its higher costs. As a result, the SHP dominated the AHP, being less costly and more effective regardless of the fee schedule applied. The DI costs contributed little to the overall cost of the assessment of appendicitis.

Current surgical opinion of computed tomography for acute appendicitis

BACKGROUND

Appendiceal computed tomography (CTA) for the diagnosis of acute appendicitis (AA) has become popular, with a growing body of literature reporting excellent rates of sensitivity, specificity, and accuracy (S/S/A). However, several studies indicate that the true S/S/A of CTA is lower than the best results reported, especially if the white blood count is normal, the reader is inexperienced, or the study is obtained in the absence of surgical consultation. Thus, it is possible that skepticism of the value of CTA to diagnose AA may exist. Our objective was to determine the current knowledge of and attitudes regarding CTA among practicing surgeons.

METHODS

Two thousand questionnaires were sent randomly to general surgeon Fellows of the American College of Surgeons. Questions detailed the surgeon's practice, experience, hospital characteristics, and opinion regarding the utility and use of CTA. The existence of a formal CTA protocol, its characteristics, and radiologist availability for CT interpretation were determined. Data were analyzed by x(2) with Fisher exact test, multiple-group x(2), and univariate ANOVA as appropriate. Results are reported as mean +/- SEM with significance accepted at p < 0.05.

RESULTS

The response rate was 27%. Mean age was 51 +/- 1 years, 60% of respondents were general surgeons, and 9% were laparoscopic surgeons. Seventy-four percent of respondents believe the accuracy rate of CTA is less than the originally reported 98%; those who disbelieve are less likely to utilize CTA (p < 0.0001). Sixty-two percent of respondents believe CTA is over-utilized; 43% obtain CTA in </=25% of patients, and 62% obtain CTA in fewer than 50% of patients. Only 36% of respondents had access to CTA by protocol; those surgeons were more likely to know protocol details (p < 0.0001). Emergency medicine physicians order CTA most often (63%), and studies are most often interpreted by an attending radiologist (69%).

CONCLUSIONS

Practicing surgeons are skeptical of the role of CTA for diagnosis of AA. Incorporation of CTA into practice is not widespread, perhaps because CTA by protocol is unavailable to most surgeons and because it is often obtained in the absence of surgical consultation.

Are negative appendectomies still acceptable?

BACKGROUND

The goal was to ascertain if there was a significant change in the negative appendectomy (NA) rate in our community hospital with the increased use of computed tomography (CT).

METHODS

This was a retrospective chart review of all appendectomies for acute disease performed at our institution from January 2000 to December 2002. There is no established protocol; therefore, CT scans were performed at the discretion of the involved physicians. The results of the physical exams, CT scans and pathology were recorded.

RESULTS

Three hundred eighty-nine appendectomies were performed for appendicitis. There was a progressive increase in the use of CT: 52% in 2000, 74% in 2001, and 86% in 2002. There was also a decrease in the NA rate over the 3 years: 17% in 2000, 9% in 2001 and 2% in 2002. The perforated appendicitis rate decreased from 25% in 2000 to 9% in 2002.

CONCLUSION

The appropriate utilization of CT scan as an aid in the diagnosis of acute appendicitis should decrease the NA rate to 2%.

Alvarado score: an admission criterion in patients with right iliac fossa pain

Appendicitis is an important differential diagnosis in patients with right iliac fossa pain. The diagnosis in patients with equivocal signs can be difficult. Many patients with suspected appendicitis are admitted for observation. We studied the Alvarado scores of 175 patients who presented to the emergency department with right iliac fossa pain and found that patients with scores of 4 or less did not have appendicitis. We also present an algorithm incorporating the Alvarado score for patients with suspected appendicitis.

What have we learned over the past 20 years about appendicitis in the elderly?

BACKGROUND

This study evaluates appendicitis in the elderly, comparing our findings to those previously published a decade earlier.

METHODS

Comparison of appendicitis in the elderly (aged 60 years and older) from 1978 to 1988 with the following 10 years, 1988 to 1998.

RESULTS

Overall (1978-1998) 26% of patients presented typically, one third delayed seeking care, with only half diagnosed correctly on admission. Computed tomography (CT) use increased (44% versus rarely in the previous decade). Perforation rates declined (72% first group versus 51% second group) with a concomitant drop in complications from 32% to 21% respectively. Overall, three fourths of complications occurred in patients with perforated appendicitis. Mortality rates remained constant.

CONCLUSIONS

Appendicitis in the elderly is a difficult problem with delays in medical care, non-typical presentation resulting in incorrect diagnosis, relatively high rates of perforation often with associated postoperative complications and mortality. A higher index of suspicion with liberal early utilization of CT in uncertain cases may result in more appropriate management.

The contribution of transvaginal ultrasound in the diagnosis of acute appendicitis: an observational study

OBJECTIVE

To assess the contribution of transvaginal and transabdominal sonography in the diagnosis of acute appendicitis.

METHODS

The study group included female patients in whom acute appendicitis was diagnosed preoperatively by ultrasound and confirmed by histology. Each patient was examined by transabdominal (TAS) and transvaginal (TVS) sonography. The contribution of both approaches to the diagnosis of acute appendicitis was assessed.

RESULTS

Acute appendicitis was diagnosed sonographically in 38 women. In all of them the diagnosis was confirmed histologically. All patients had both TAS and TVS. In 16 (42%) patients the inflamed appendix was detected by both approaches, in 13 (34%) only by the transabdominal route and in nine (24%) only transvaginally. Thus, TAS detected only 76% of the cases and TVS added 24%.

CONCLUSION

The use of TVS in conjunction with TAS seems to improve the detection rate of acute appendicitis.

US as a primary diagnostic tool in relation to negative appendectomy: six years experience

PURPOSE

To evaluate the effect of ultrasonography (US) on the rate of appendectomy after false-positive diagnosis of acute appendicitis (negative appendectomy).

MATERIALS AND METHODS

Data were analyzed in 736 pediatric patients (mean age, 13.2 years) who had undergone appendectomy between 1995 and 2000. Histologic data were compared in patients who underwent US with those who did not undergo imaging prior to surgery. US was performed by a radiologist or a pediatric surgeon or both.

RESULTS

A total of 643 (87.4%) of the 736 pediatric patients underwent preoperative US, and 93 (12.6%) of the 736 did not undergo preoperative US. Of the 736 patients, 97 (13.2%) underwent negative appendectomy. Thirty-four (36.6%) of the 93 patients who underwent appendectomy with no preoperative US and 63 (9.8%) of the 643 patients who underwent preoperative US underwent negative appendectomy. There was a significant association between US and positive appendectomy (P <.001).

CONCLUSION

US in pediatric patients suspected of having appendicitis can significantly lower the negative appendectomy rate.

Appendiceal enlargement as a criterion for clinical diagnosis of acute appendicitis: is it reliable and valid?

The purpose of this study was to evaluate appendiceal enlargement as a radiographic criterion for the diagnosis of acute appendicitis. We examined medical records and specimens of 190 adults and children who presented to a teaching hospital in New York City with right-lower-quadrant pain and who underwent surgery. Computed tomography (CT), clinical evaluation (based on Alvarado's predictive model) and pathologic data of these 190 cases revealed that appendiceal enlargement might in some cases represent a normal anatomic variant of a vermiform appendix and that the lack of a dilated lumen and thickened wall did not necessarily establish the absence of inflammation. Yet, radiologic evidence of appendix size often influences the diagnosis and management of patients with acute abdominal pain, including the decision to operate. This tendency to equate an enlarged appendix with appendicitis is shown to lead to an inappropriate diagnosis and jeopardize optimal care of patients with acute abdominal pain.

Unenhanced helical CT scanning of the abdomen and pelvis changes disposition of patients presenting to the emergency department with possible acute appendicitis

This study sought to determine if obtaining an unenhanced abdominopelvic computed tomography (UHCT) scan alters the disposition of patients presenting to the Emergency Department (ED) with signs and symptoms of acute appendicitis. A convenience sample of 101 patients presenting with a clinical picture suggestive of appendicitis were prospectively enrolled. Emergency physicians (EPs) and general surgeons independently recorded their anticipated disposition of each patient as: discharge, admit for observation, or admit for appendectomy. A UHCT scan was then obtained and the patient's ultimate disposition recorded. EPs altered their dispositions after UHCT scanning in 35 patients (34.7%, 95% CI 25.4% to 44.0%), and general surgeons altered their dispositions in 27 patients (26.7%, 95% CI 18.1% to 35.3%). More patients underwent operative intervention than were originally selected by EPs [14 additional patients, (13.9%, 95% CI 7.1% to 20.6%)] or by surgeons [20 additional patients, (19.8%, 95% CI 12.0% to 27.6%)]. CT scan revealed alternative diagnoses in 20 patients (19.8%). UHCT scanning significantly alters patient disposition, and significantly increases the number of operative interventions performed in patients with suspected appendicitis. UHCT scanning may also identify alternate pathology that clinically mimics appendicitis.

The rational use of computed tomography scans in the diagnosis of appendicitis

BACKGROUND

Recently, limited abdominal computed tomography (CT) scans have been reported (Rao, New England Journal of Medicine, 1998) to have accuracy as high as 98%. We compare our hospital's CT accuracy ordered by emergency room (ER) physicians with that of experienced surgeons provided only with the ER history and physical examination in the evaluation of appendicitis.

METHODS

All charts of patients 16 years or older with limited CT scans ordered by ER from January 1, 1996, through February 28, 1998, were reviewed. CT scans ordered when appendicitis was not in the differential were excluded from analysis. Pathology and clinical follow-up were criterion standards. Four surgeons reviewed ER history and physical and placed them into one of three categories: appendectomy, observe to rule out appendicitis, or discharge with follow-up (included admitting to another service or treating for another disorder).

RESULTS

A total of 526 charts were reviewed; 129 met the criteria for the study. The accuracy of CT scans as used by our ER was not as high as reported in the literature. In addition, surgeon accuracy approached that of the CT scan even without the ability to evaluate the patients in person. Noncontrast CTs were ordered before surgical evaluation in contrast to the Rao protocol, likely reducing their accuracy.

CONCLUSIONS

Ordering CT scans to evaluate for appendicitis prior to surgical evaluation is of limited value.

Factors associated with conversion to laparotomy in patients undergoing laparoscopic appendectomy

BACKGROUND

Laparoscopic appendectomy (LA) has been increasingly adopted for its advantages over the open technique, but there is a possibility of conversion to open appendectomy (OA) if complications occur or the extent of inflammation prohibits successful dissection. This study aimed to identify the preoperative predictors for conversion from laparoscopic to open appendectomy.

STUDY DESIGN

Medical records of 705 consecutive patients who underwent surgery for suspected appendicitis were reviewed retrospectively. LA was attempted in 595 patients by 25 different surgeons. Factors evaluated were age, gender, body mass index, previous abdominal surgery, previous appendicitis attack, pain, nausea, vomiting, fever, duration of symptoms, local or diffuse tenderness, leukocyte count and surgeon's experience in LA.

RESULTS

Conversion to OA occurred in 58 patients (9.7%). The most common reason for conversion was dense adhesions due to inflammation, followed by localized perforation and diffuse peritonitis. Based on 261 patients evaluated by CT scan preoperatively, significant factors in the final multivariate analysis associated with conversion to OA were age > or = 65 [Odds ratio (OR) = 3.78, 95% CI:1.11-12.84], diffuse tenderness on physical examination (OR = 11.32, 95% CI: 1.32-96.62), and a surgeon with less experience in LA (< or = 10 operations, OR = 3.38, 95% CI:1.02-11.17). The presence of significant fat stranding associated with fluid accumulation, inflammatory mass or localized abscess in CT scan also significantly increased the possibility of conversion (OR = 5.60, 95% CI:2.48-12.65).

CONCLUSIONS

Identifying the potential factors for conversion preoperatively may assist the surgeons in making decisions concerning the management of patients with appendicitis and in the judicious use of LA.

99m Tc anti-CD 15 monoclonal antibody (LeuTech) imaging improves diagnostic accuracy and clinical management in patients with equivocal presentation of appendicitis

BACKGROUND

Appendicitis frequently presents in an atypical fashion leading to misdiagnosis or a delay in diagnosis. This is particularly true in early cases where the patient may be erroneously discharged from an emergency department and will invariably return with perforated appendicitis. The standard of care is hospital admission for observation or early operation. Adjunctive imaging tests have been used with mixed results in this equivocal patient population. The authors studied a promising new monoclonal antibody, 99mTc-labeled anti-CD 15 (LeuTech; Palatin Technologies, Inc., Princeton, NJ), which specifically targets neutrophils and may be used for imaging appendicitis. This prospective, multicenter, open-label study evaluated the diagnostic efficacy and clinical impact of LeuTech scintigraphy for detecting appendicitis in patients with an equivocal presentation.

METHODS

A total of 200 patients (121 females, 79 males; age range 5-86 years; mean age 30.5 +/- 16.5 years) completed the study. Management plan was formulated before and reassessed following LeuTech imaging to determine impact on management. Following intravenous injection of LeuTech, the abdomen was imaged with a standard gamma camera for 30 to 90 minutes.

RESULTS

Fifty-nine patients had a histopathologic diagnosis of acute appendicitis. LeuTech identified 53 of 59 patients with appendicitis (90% sensitivity) and was negative in 122 of 141 patients without appendicitis (87% specificity). Accuracy, positive predictive value, and negative predictive value were 88%, 74%, and 95%, respectively. Diagnostic efficacy was unchanged in a subgroup of 48 pediatric patients (5-17 years). Diagnostic images for appendicitis were achieved within 8 minutes postinjection in 50% of patients and within 47 minutes in 90% of patients. Significant shifts in patient management decisions were evident following LeuTech results. LeuTech was well tolerated with no serious adverse events reported.

CONCLUSION

LeuTech is a convenient, safe, rapid, and sensitive imaging test for diagnosis of appendicitis and favorably impacts patient management in adult and pediatric patients with equivocal signs and symptoms.

When William of Ockham meets Thomas Bayes: finding a few diagnoses among a great many symptoms

Bayes' formula is a means to estimate disease probability based on the presence of symptoms and the outcome of clinical tests. The probability helps to decide among competing diagnostic options. If, however, several diseases present with similar symptoms, they may appear equally probable, and Bayes' formula will fail as an aid to reach a diagnostic decision. The aim of this study is to show how a merger of Bayes' principle with that of Ockham can help to decide in favour of one diagnosis among multiple, seemingly equally probable diagnostic hypotheses. The hypotheses are compared to each other with respect to those tests and symptoms which they fail to explain. The unexplained tests and symptoms are used to estimate the probabilities for a set of secondary diagnoses that match each one of the primary diagnoses. The more likely a secondary diagnosis appears, the less likely its corresponding primary diagnosis will remain as the sole diagnosis to explain all the clinical findings. Even without a detailed calculation, the proposed concept of using unexplained tests and symptoms to rate competing differential diagnoses could help the clinician to select the most probable diagnosis.

The diagnosis of acute appendicitis: clinical assessment versus computed tomography evaluation

The goal of this study was to validate Alvarado's predictive model as a diagnostic test and to assess the effectiveness of computed tomography (CT) scan as a supplemental tool in the evaluation of acute appendicitis. Clinical and radiologic data of 215 patients with acute abdominal pain were evaluated. Clinical assessment was based on positive findings of migration of pain, anorexia, nausea and vomiting, tenderness of the lower right quadrant, rebound tenderness, fever, and leukocytosis with a left shift. Evaluation by CT scan had a sensitivity of 90.1% and a specificity of 94.1%. Clinical assessment based on the MANTRELS criteria had a sensitivity of 91.6% and a specificity of 84.7%. With the assistance of CT scan, sensitivity and specificity increased to 98.3% and 95.8%, respectively.

Appendicectomy in Western Australia: profile and trends, 1981-1997

OBJECTIVE

To measure and describe changes in the incidence of appendicectomy in the population of Western Australia (WA) for 1981-1997.

DESIGN

Population-based incidence study using hospital discharge data.

SETTING

All hospitals in WA (1981-1997).

PATIENTS

All patients who underwent an appendicectomy in WA hospitals.

MAIN OUTCOME MEASURES

Changes in the incidence of appendicectomy procedures over time; age-standardised rates and age-sex profiles of four appendicectomy subgroups: (1) acute emergency admission, (2) other emergency admission, (3) incidental appendicectomy and (4) other appendicectomy.

RESULTS

From 1981 to 1997, there were 59,749 appendicectomies in WA hospitals. The age-standardised rate of appendicectomy declined by 63% in metropolitan females, by 44% in non-metropolitan females, by 41% in metropolitan males and by 21% in non-metropolitan males. The rate of decline was significantly greater in females and in metropolitan patients. From 1988 to 1997, acute emergency admission for appendicectomy was the most common admission status and was more common in males than females (122 v 103 per 100,000 person-years) and in non-metropolitan areas. The rate of incidental appendicectomy was higher among females than males (20 v 7 per 100,000 person-years). From 1988 to 1997, recorded diagnosis coding for appendicitis became more specific, with a marked reduction in the use of the "unspecified" appendicitis code.

CONCLUSIONS

The overall incidence of appendicectomy has declined markedly in WA and includes a decline in the practice of incidental appendicectomy. The trend was greatest in the metropolitan hospitals.

Effect of cross-sectional imaging on negative appendectomy and perforation rates in children

PURPOSE

To compare negative appendectomy and perforation rates in children who underwent ultrasonography (US), computed tomography (CT), or no imaging before urgent appendectomy.

MATERIALS AND METHODS

All children who underwent urgent appendectomy during a 4(1/2)-year period were identified in a surgical billing database. Pathology reports were coded as negative or as showing acute inflammation or perforation. Imaging up to 14 days before appendectomy or abscess drainage was noted, and imaging-based diagnoses were compared with pathologic findings. Patient age and sex were recorded.

RESULTS

Two hundred ninety-nine children, 176 (59%) male and 123 (41%) female (mean age, 10.4 years; age range, 1--21 years), underwent urgent appendectomy. One hundred twenty-six (42%) underwent no imaging, 121 (41%) underwent US with or without CT, and 52 (17%) underwent CT only; 44 (15%) underwent both US and CT. There were significantly higher rates of appendectomy with normal pathologic findings ("negative appendectomy") in patients who underwent no imaging (14% [18 of 126]) or US (17% [20 of 121]) versus the rates in those who underwent CT only (2% [one of 52]) (P =.02 and P =.007, respectively). The negative appendectomy rate was 7% in 96 patients who underwent CT with or without prior US. The perforation rates were not significantly different.

CONCLUSION

As compared with children who underwent no preoperative imaging and those who underwent US, children who underwent CT had a significantly lower negative appendectomy rate, without a significantly higher perforation rate.

[Suspected acute appendicitis. Role of enhanced helical computed tomography. Prospective study of 100 patients]

AIM OF STUDY

To assess the diagnosis accuracy of helical computed tomography (CT) in patients with suspected appendicitis.

PATIENTS AND METHODS

This prospective study included 100 consecutive patients hospitalized for suspected appendicitis. There were 57 men and 43 women with a median age of 30 years (range: 17-91). An enhanced helical CT was performed at admission, without digestive opacification. Four criteria were interpreted as positive signs for appendicitis: appendix enlarged > or = 7 mm, right lower quadrant inflammation, stercorolith, and peri-appendicular collection. The patient was managed by the surgeon without knowing the result of CT. The final diagnosis was made pathologically.

RESULTS

Eighty-one patients were operated on laparoscopically for suspected appendicitis. Intraoperative diagnosis was corrected in three cases and 78 appendectomies were performed (73 histological appendicitis, six normal appendix). Final diagnosis was a medical disease in 19 patients. The findings of 67 CT were interpreted as positive (63 true positive and four false positive) and the findings of 33 CT were interpreted as negative (24 true negative, nine false negative). Sensitivity was 87%, specificity was 86%, positive predictive value was 94%, and negative predictive value was 73%. If the nine false negative cases with minimal lesions at pathological examination were considered as true negative, the rates would be 100%, 89%, 94%, 100%, respectively.

CONCLUSION

Enhanced helical CT is a good imaging diagnostic tool for suspected appendicitis. It may reduce the number of patients admitted for observation and decrease the rate of negative appendectomy.

Is appendiceal CT scan overused for evaluating patients with right lower quadrant pain?

Reports citing excellent sensitivity, specificity, and predictive accuracy of focused appendiceal computed tomography (CT) and showing an overall reduction in resource use and nontherapeutic laparotomies have led to increasing use of that imaging modality. Diagnostic algorithms have begun to incorporate appendiceal CT for patients presenting to the emergency department with right lower quadrant pain. We present a series of 4 cases in which use of appendiceal CT ultimately led to increased cost, resource use, and complexity in patient care. The results of these cases support an argument against unbridled use of appendiceal CT scanning and reinforce the need for clinical evaluation by the operating surgeon before routine performance of appendiceal CT scan.

Is There a Role for Interval Appendectomy in the Management of Acute Appendicitis?

Interval appendectomy (IA) remains a controversial subject in surgery. To determine its effectiveness we reviewed our results with this approach. From January 1990 through December 1998 a total of 73 patients underwent appendectomy, five (7%) of which were interval in nature. These IA patients had a palpable abdominal mass or delayed presentation that led to CT scan. The decision to delay surgery was determined by two factors: 1) a CT scan that showed advanced inflammatory changes (phlegmon or abscess) associated with acute appendicitis and 2) a rapid response to conservative management. All patients received antibiotics—first intravenous and then oral. Repeat CT scans were performed before surgery and showed a virtual resolution of the inflammatory process. Appendectomy was delayed from 35 to 66 days from the time of diagnosis (average 51 days). There were no preoperative complications, the operations were uneventful, and there were no significant postoperative sequelae. IA appears to convert an unfavorable surgical situation potentially fraught with complications (fistula, abscess, wound infection) to one that is essentially elective in nature. It should be considered for the patient who is found to have an extensive periappendiceal inflammatory process, is clinically stable, and responds favorably to initial nonoperative management.

Costs and effectiveness of ultrasonography and limited computed tomography for diagnosing appendicitis in children

BACKGROUND

A protocol of ultrasonography (US) followed by computed tomography with rectal contrast (CTRC) has been shown to be 94% accurate in the diagnosis of acute appendicitis in children.

OBJECTIVE

To evaluate the changes in patient management and costs of a protocol using US and CTRC in the evaluation of appendicitis in children.

DESIGN, SETTING, AND SUBJECTS

Prospective cohort study of 139 children between 3 and 21 years of age who had equivocal clinical findings for acute appendicitis seen in the emergency department of a large, urban pediatric teaching hospital between July 1998 and December 1998.

PROTOCOL

Children with equivocal clinical presentations for acute appendicitis were prospectively evaluated with US. Patients with positive findings for acute appendicitis went directly to the operating room. Patients with negative or equivocal findings on US underwent CTRC. Surgical management plans were recorded before imaging, after US, and after CTRC.

MAIN OUTCOME MEASURES

Surgical management plans before and after the imaging protocol as well as total hospital direct and indirect costs incurred or saved by each change in management were determined. Costs were obtained through the hospital's cost database and by ratios of costs to charges.

RESULTS

Of the 139 children, the protocol resulted in a beneficial change in management in 86 children (61.9%), no change in management in 50 children (36.0%) and an incorrect change in management in 3 children (2.1%). US alone resulted in a beneficial change in management decision in 12/31 children (38.7%), while US followed by CTRC resulted in a beneficial change in management in 74/108 children (68.5%). The protocol resulted in a total cost savings of $78 503.99 or $565/patient.

CONCLUSION

A protocol of US followed by CTRC in children with negative or equivocal US examinations results in a high rate of beneficial change in management as well as in total cost savings in children with equivocal clinical presentations for suspected appendicitis.

Scintigraphic Determination of Equivocal Appendicitis

We evaluated Tc-99m-labeled anti-CD15 immunoglobulin M monoclonal antibody (LeuTech)™ for scintigraphic detection of acute appendicitis in patients with an equivocal clinical presentation. LeuTech™ avidly binds to circulating and sequestered human polymorphonuclear neutrophils in vivo eliminating the need for in vitro cell labeling and the risks of blood handling. We studied 99 patients to evaluate the safety and efficacy of LeuTech™ imaging. Serial dynamic and static planar images were acquired for up to 3 hours after the intravenous administration of 10 to 20 mCi of Tc-99m LeuTech™. Scans were read as positive or negative for acute appendicitis or other intra-abdominal infection. The institutional diagnosis was established by surgery and histopathology of the appendix, results of other diagnostic studies, or 2-week clinical follow-up. Scans were positive for appendicitis in 39 of 40 patients with appendicitis at surgery (sensitivity 98%) and negative for appendicitis in 49 of 58 patients without appendicitis (specificity 84%). One was lost to follow-up. Accuracy, positive predictive value, and negative predictive value were 90, 81, and 98 per cent respectively. In patients with appendicitis and positive scans more than 50 per cent of the images were positive at 4 minutes, and all were positive by 1 hour. Mean time of first positive image was 15 minutes. There were no serious adverse reactions. We conclude that LeuTech™ imaging is a highly sensitive test for detection of appendicitis in equivocal cases. There are advantages of this agent over the other currently used radiotracers in terms of convenience and time to diagnosis particularly the rapidity with which acute appendicitis will be seen on the images.