Appendicitis and mimicking conditions. A prospective study

Alvarado or RIPASA? Which one do you use to diagnose acute appendicitis?: A cross-sectional study

Background and Aims

Acute appendicitis is one of the most common causes of lower abdominal pain, which is considered a general surgical emergency worldwide. The present study aimed to compare the diagnostic value of Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) and Alvarado score systems in diagnosing acute appendicitis.

Methods

A prospective cross-sectional study was conducted at Shahid Sadoughi and Shahid Rahnemoon Hospitals in Yazd between September 2020 and February 2020. The statistical population consisted of all of the patients referred to the Accident and Emergency department with right iliac fossa (RIF) pain. All patients were scored using Alvarado and RIPASA scoring system. sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were computed by using SPSS statistical software. An receiver operating characteristic curve were plotted.

Results

In present study, one hundred suspected patients with appendicitis who underwent appendectomy were evaluated. The mean age of our study population was 25.2 ± 12.1 years, and the gender distribution was 57% males and 43% females. The sensitivity, specificity, PPV and NPV of RIPASA were 86.6%, 66.7%, 92.2%, and 52.2%, respectively. The sensitivity, specificity, PPV and NPV of Alvarado score were 67.1%, 72.2%, 91.7%, 32.5%, respectively. The diagnostic accuracy was 68% for Alvarado score and 83% for RIPASA. The area under the curve for RIPASA (0.87) was more than that for Alvarado score (0.77).

Conclusion

The RIPASA score system had higher sensitivity, PPV, NPV, and accuracy than the Alvarado one. It is recommended for the physician and surgeon to evaluate patients with RIF pain using the RIPASA score.

Role of circulating fibrocytes in the diagnosis of acute appendicitis

Background

Improved diagnostic biomarkers are required for acute appendicitis. The circulating fibrocyte percentage (CFP) is increased in inflammatory states, but has not been studied in acute appendicitis. This study aimed to determine CFP in acute appendicitis and compare diagnostic accuracy with standard serological biomarkers.

Methods

A prospective cohort study was carried out between June 2015 and February 2016 at University Hospital Limerick. The CFP was determined by dual‐staining peripheral venous samples for CD45 and collagen I using fluorescence‐activated cell sorting, and correlated with histopathological diagnoses. The accuracy of CFP in determining histological acute appendicitis was characterized and compared with the white cell count, C‐reactive protein concentration, neutrophil count, lymphocyte count and neutrophil : lymphocyte ratio.

Results

Of 95 adults recruited, 15 were healthy individuals and 80 had suspected appendicitis at presentation. Forty‐six of these 80 patients had an appendicectomy, of whom 34 had histologically confirmed appendicitis. The CFP was statistically higher in patients with pathologically proven acute appendicitis than in healthy controls (median 6·1 (i.q.r. 1·6–11·6) versus 2·3 (0·9–3·4) per cent respectively; P = 0·008). The diagnostic accuracy of CFP, as determined using the area under the receiver operating characteristic (ROC) curve, was similar to that of standard biomarkers. In multinomial regression analysis, only raised CFP was retained as an independent prognostic determinant of acute appendicitis (odds ratio 1·57, 95 per cent c.i. 1·05 to 2·33; P = 0·027).

Conclusion

The CFP is increased in histologically confirmed acute appendicitis and is as accurate as standard serological biomarkers in terms of diagnosis.

Comparison between the specificity and sensitivity of the RIPASA and Alvarado Scoring systems in the diagnosis of acute appendicitis among patients with complaints of right iliac fossa

Introduction

Acute appendicitis is one of the common prevalent surgical emergencies. Various techniques, such as Alvarado Score are used for diagnosis it. This study was conducted to compare the Alvarado and RIPASA scoring systems in patients referred to Hospital with complaints of right iliac fossa pain.

Methodology

This descriptive-analytic cross-sectional study was conducted in patients over 15 years with abdominal pain referred to emergency room of the Hospital. The data collection form was completed for each patient based on history and examinations and then examined by a surgeon. The pathological specimens were examined and the pathological outcomes of each patient were recorded in the relevant information collection form and finally analyzed.

Results

The results for the Alvarado system showed that 42.1%, 29.2% and 28.80% of the patients had a low probability, moderate probability and high probability of appendicitis, respectively. The findings for RIPASA system showed that 19.3% of patients definitely had appendicitis. The sensitivity and specificity of the Alvarado scoring system were 53.95% and 70.18%, respectively. Positive and negative predictive values of Alvarado were 70.69% and 53.33%, respectively. In contrast, the sensitivity, specificity, and positive and negative predictive values of the RIPASA scoring system were 93.42%, 45.61%, 69.61%, and 83.87%, respectively.

Conclusion

On the basis of the results, the RIPASA scoring system is a better system. Since the best cut-off point is 6 for Alvarado and 7.75 for RIPASA, it is better to use the values as a benchmark for the systems.

Comparative Study of Alvarado Score and its Modifications in the Preoperative Diagnosis of Acute Appendicitis at a Tertiary Center in Sokoto, Nigeria

BACKGROUND

Decision-making in patients suspected of having acute appendicitis has remained a diagnostic challenge worldwide despite the advances in imaging and appendiceal surgery. There have been efforts to improve the diagnosis of appendicitis using clinical scoring systems.

AIM

We evaluated and compared the diagnostic accuracy and role of Alvarado score (AS) and two of its modification (Kalan and Al-Fallouji) in the preoperative diagnosis of acute appendicitis.

MATERIALS AND METHODS

This was a prospective study conducted at the Usmanu Danfodiyo University Teaching Hospital, Sokoto, of all adult patients operated for acute appendicitis from July 2014 to June 2017. The results were analyzed on computer using Statistical Package for the Social Science version 15.

RESULTS

One hundred and eleven patients were studied. Sixty-six (59.5%) patients were males and 45 (40.5%) were females. The male-to-female ratio was 1.5:1. The mean age was 23.89 ± 4.93 years. The AS sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of 90.3%, 83.3%, 96.6%, 62.2%, and 89.2%, respectively, were similar to the findings of Kalan score (90.3%, 83.3%, 96.6%, 62.5%, and 89.2%, respectively) and Al-Fallouji score (96.8%, 66.7%, 93.8%, 80%, and 91.9%, respectively). The receiver operating curve and area under the curve show that Alvarado, Kalan, and Al-Fallouji are accurate scores in the preoperative diagnosis of acute appendicitis with an area under the curve of 0.88, 0.86, and 0.85, respectively.

CONCLUSION

Kalan and Al-Fallouji scores have comparably good diagnostic accuracy as the AS among our patients. Any of these scores can be used as an adjunct in the preoperative diagnosis of acute appendicitis.

To Determine Validation of RIPASA Score in Diagnosis of Suspected Acute Appendicitis and Histopathological Correlation with Applicability to Indian Population: a Single Institute Study

Although acute appendicitis is one of the most common surgical emergencies worldwide, timely accurate diagnosis is always difficult for a surgeon even after availability of recent diagnostic tools. Our study is to determine validation of RIPASA score in diagnosis of acute appendicitis and histopathological correlation. A prospective study of 200 patients presented to emergency or surgical opd with right iliac fossa pain and suspected to have acute appendicitis were included in our study. RIPASA score calculated but appendectomy done on the basis of clinical assessment and hospital protocol and histopathological correlation done with a score. A score of 7.5 is cut off threshold, results compared with previous studies. In our study of 200 patients, M:F ratio of 1.56:1. Sensitivity of the RIPASA score was 95.89℅ with specificity 75.92% and diagnostic accuracy of 90.5%, expected and observed rate of negative appendectomy were 8.5 and 12.35%, respectively. So there is net reduction in negative appendectomy rate by 3.85%. Data analysis done with Statistical Package for Social Science (SPSS) version 21.0. RIPASA score at a cutoff value of 7.5 is easier, cheap, and better diagnostic tool in equivocal case of right iliac fossa pain in Indian scenario of limited availability of recent diagnostic tool in remote areas and affordability of these tool in the available set up, simultaneously, it also helps to reduce negative appendectomy rates.

Accuracy and reliability of tablet computer as an imaging console for detection of radiological signs of acute appendicitis using PACS workstation as reference standard

PURPOSE

To ascertain the accuracy and reliability of tablet as an imaging console for detection of radiological signs of acute appendicitis [on focused appendiceal computed tomography (FACT)] using Picture Archiving and Communication System (PACS) workstation as reference standard.

METHODS

From January, 2014 to June, 2015, 225 patients underwent FACT at our institution. These scans were blindly re-interpreted by an independent consultant radiologist, first on PACS workstation and, two weeks later, on tablet. Scans were interpreted for the presence of radiological signs of acute appendicitis. Accuracy of tablet was calculated using PACS as reference standard. Kappa (κ) statistics were calculated as a measure of reliability.

RESULTS

Of 225 patients, 99 had radiological evidence of acute appendicitis on PACS workstation. Tablet was 100% accurate in detecting radiological signs of acute appendicitis. Appendicoliths, free fluid, lymphadenopathy, phlegmon/abscess, and perforation were identified on PACS in 90, 43, 39, 10, and 12 scans, respectively. There was excellent agreement between tablet and PACS for detection of appendicolith (к = 0.924), phlegmon/abscess (к = 0.904), free fluid (к = 0.863), lymphadenopathy (к = 0.879), and perforation (к = 0.904).

CONCLUSIONS

Tablet computer, as an imaging console, was highly reliable and was as accurate as PACS workstation for the radiological diagnosis of acute appendicitis.

Course of acute nonspecific mesenteric lymphadenitis: single-center experience

Available reports dealing with acute nonspecific mesenteric lymphadenitis do not address the total duration of symptoms. However, it is commonly assumed a time for recovery ≤ 4 weeks. The purpose of this report was to investigate the course of acute nonspecific mesenteric lymphadenitis in childhood. A review was made of the patients aged ≤ 16 years in whom the diagnosis of acute nonspecific mesenteric lymphadenitis was established between 2011 and 2015 at the Pediatric Emergency Unit. The records of the Pediatric Emergency Unit, those of the referring family doctors, and the results of a structured telephone interview with each family were used. Forty-four patients (25 girls and 19 boys) aged 2.5 to 16, median 8.2, years were included. A bimodal distribution in duration of symptoms was observed: symptoms persisted for ≤ 2 weeks in 22 patients and 3 to 10 weeks in 22. Clinical and laboratory characteristics were similar in children with symptoms persisting for 2 weeks or less 28 and in those with symptoms persisting for 3-10 weeks.

CONCLUSION

In patients affected with acute nonspecific mesenteric lymphadenitis, it is advantageous to think of the time span for recovery in terms of ≥ 4 weeks. What is Known: • Mesenteric adenitis is a self-limiting inflammatory condition with well-characterized clinical presentation and imaging features. • A total duration of symptoms of ≤ 4 weeks is usually hypothesized. What is New: • Symptoms persist for 3 to 10 weeks in half of the patients. • At presentation, clinical and laboratory characteristics are similar in children with symptoms persisting for 2 weeks or less and in those with 45 symptoms persisting for 3-10 weeks.

Acute Nonspecific Mesenteric Lymphadenitis: More Than "No Need for Surgery"

Acute nonspecific, or primary, mesenteric lymphadenitis is a self-limiting inflammatory condition affecting the mesenteric lymph nodes, whose presentation mimics appendicitis or intussusception. It typically occurs in children, adolescents, and young adults. White blood count and C-reactive protein are of limited usefulness in distinguishing between patients with and without mesenteric lymphadenitis. Ultrasonography, the mainstay of diagnosis, discloses 3 or more mesenteric lymph nodes with a short-axis diameter of 8 mm or more without any identifiable underlying inflammatory process. Once the diagnosis is established, supportive care including hydration and pain medication is advised. Furthermore, it is crucial to reassure patients and families by explaining the condition and stating that affected patients recover completely without residuals within 2-4 weeks.

Characteristics of mesenteric lymphadenitis in comparison with those of acute appendicitis in children

Mesenteric lymphadenitis (ML) is considered as one of the most common alternative diagnosis in a child with suspected acute appendicitis (AA). In this retrospective study, patients diagnosed with ML (n = 99) were compared in terms of demographic, clinical, and laboratory findings to patients diagnosed with AA (n = 102). This comparison was applied for both lymph nodes smaller and larger than 10 mm. When compared to patients with AA, patients with ML had significantly longer duration of symptoms prior to emergency department (ED) presentation (2.4 ± 2.6 vs 1.4 ± 1.4 days, P = 0.002) and multiple ED presentations (1.3 ± 0.7 vs 1.05 ± 0.3, P < 0.001) and had longer duration of stay in the ED (9.2 ± 5.9 vs 5.2 ± 4 h, P < 0.001), respectively. They also had significantly lower WBC (10.16 ± 4.7 × 10³/dl vs 15.8 ± 4.4 × 10³/dl, P < 0.001) with lymphocyte predominance (24.6 ± 14 vs 13 ± 8.7%, P < 0.001) and lower CRP levels (0.48 vs 1.6 mg/dl). Migration of pain (28 vs 7%), vomiting (62 vs 34%), and classic abdominal findings of AA (72 vs 20%) were all significantly more common for children with AA. When comparing lymph node size, no significant difference was found between those presenting with small and large nodes.

CONCLUSION

This study highlights multiple clinical and laboratory findings that differentiate ML and AA. Moreover, the absence of any difference with regard to the lymph nodes size might suggest that lymph nodes enlargement is a non-specific finding. What is Known : • Mesenteric lymphadenitis is a very common diagnosis in children with suspected acute appendicitis. • Despite its prevalence, only few studies addressed the clinical characteristics of this clinical entity and their comparison with acute appendicitis. What is New: • Mesenteric lymphadenitis and acute appendicitis could be differentiated by multiple clinical and laboratory parameters. • No significant difference was found between those presenting with small and large lymph nodes.

Evaluation of modified Alvarado scoring system and RIPASA scoring system as diagnostic tools of acute appendicitis

BACKGROUND

Acute appendicitis is the most common surgical condition presented in emergency departments worldwide. Clinical scoring systems, such as the Alvarado and modified Alvarado scoring systems, were developed with the goal of reducing the negative appendectomy rate to 5%-10%. The Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) scoring system was established in 2008 specifically for Asian populations. The aim of this study was to compare the modified Alvarado with the RIPASA scoring system in Kuwait population.

METHODS

This study included 180 patients who underwent appendectomies and were documented as having "acute appendicitis" or "abdominal pain" in the operating theatre logbook (unit B) from November 2014 to March 2016. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), diagnostic accuracy, predicted negative appendectomy and receiver operating characteristic (ROC) curve of the modified Alvarado and RIPASA scoring systems were derived using SPSS statistical software.

RESULTS

A total of 136 patients were included in this study according to our criteria. The cut-off threshold point of the modified Alvarado score was set at 7.0, which yielded a sensitivity of 82.8% and a specificity of 56%. The PPV was 89.3% and the NPV was 42.4%. The cut-off threshold point of the RIPASA score was set at 7.5, which yielded a 94.5% sensitivity and an 88% specificity. The PPV was 97.2% and the NPV was 78.5%. The predicted negative appendectomy rates were 10.7% and 2.2% for the modified Alvarado and RIPASA scoring systems, respectively. The negative appendectomy rate decreased significantly, from 18.4% to 10.7% for the modified Alvarado, and to 2.2% for the RIPASA scoring system, which was a significant difference (P<0.001) for both scoring systems.

CONCLUSION

Based on the results of this study, the RIPASA score is a simple scoring system with better sensitivity and specificity than the modified Alvarado scoring system in Asian populations. It consists of 14 clinical parameters that can be obtained from a good patient history, clinical examination and laboratory investigations. The RIPASA scoring system is more accurate and specific than the modified Alvarado scoring system for Kuwait population.

A Comparative Study of RIPASA Score and ALVARADO Score in the Diagnosis of Acute Appendicitis

BACKGROUND

Acute appendicitis is one of the most common surgical emergencies. Different techniques have been devised to assist in equivocal cases in attempts to decrease negative appendicectomy rates. A number of scoring systems have been used for aiding in early diagnosis of acute appendicitis and its prompt management of which Alvarado score is the most popular. The accuracy of Alvarado score in the diagnosis of acute appendicitis is disappointingly low in Asian population and RIPASA scoring has been designed for the diagnosis of acute appendicitis in the Asian population. So we prospectively applied and compared Alvarado and RIPASA score in the diagnosis of acute appendicitis in Indian population.

MATERIALS AND METHODS

We compared prospectively RIPASA and Alvarado scoring system by applying them to 206 patients. Both scores were calculated for patients who presented with right iliac fossa pain during the study period. Depending on clinical judgment appendicectomy was done. Post operative histopathology report was correlated with the scores. A score of 7.5 is the optimal cut off threshold for RIPASA and 7 for Alvarado scoring system. Sensitivity, specificity, positive predictive value (PPV) and negative predictive (NPV) for RIPASA & Alvarado system was done.

RESULTS

The sensitivity and specificity of RIPASA score were 96.2% and 90.5% respectively. The sensitivity and specificity of Alvarado score were 58.9% and 85.7% respectively. RIPASA score correctly classified 96 percent of all patients confirmed with histological acute appendicitis to the high probability group (RIPASA score greater than 7.5) compared with 58.9% with Alvarado score (Alvarado score greater than 7.0; p-value less than 0.001).

CONCLUSION

RIPASA scoring system is more convenient, accurate, and specific scoring system for Indian population than Alvarado scoring system.

Transabdominal ultrasound for bowel evaluation

This article considers the case for a strategic place for ultrasound (US) bowel evaluation focusing on three common clinical contexts. These include imaging for suspected acute appendicitis and acute diverticulitis, as well as the role of US in a multimodality approach for the diagnosis and management of inflammatory bowel disease and associated complications.

Modified Alvarado Scoring System as a diagnostic tool for acute appendicitis at Bugando Medical Centre, Mwanza, Tanzania

Background

Decision-making in patients with acute appendicitis poses a diagnostic challenge worldwide, despite much advancement in abdominal surgery. The Modified Alvarado Scoring System (MASS) has been reported to be a cheap and quick diagnostic tool in patients with acute appendicitis. However, differences in diagnostic accuracy have been observed if the scores were applied to various populations and clinical settings. The purpose of this study was to evaluate the diagnostic value of Modified Alvarado Scoring System in patients with acute appendicitis in our setting.

Methods

A cross-sectional study involving all patients suspected to have acute appendicitis at Bugando Medical Centre over a six-month period between November 2008 and April 2009 was conducted. All patients who met the inclusion criteria were consecutively enrolled in the study. They were evaluated on admission using the MASS to determine whether they had acute appendicitis or not. All patients underwent appendicectomy according to the hospital protocol. The decision to operate was the prerogative of the surgeon or surgical resident based on overall clinical judgment and not the MASS. The diagnosis was confirmed by histopathological examination. Data was collected using a pre-tested coded questionnaire and analyzed using SPSS statistical computer software.

Results

A total number of 127 patients were studied. Their ages ranged from eight to 76 years (mean 29.64 ± 12.97). There were 37 (29.1%) males and 90 (70.9%) females (M: F = 1:2.4). All patients in this study underwent appendicectomy. The perforation rate was 9.4%. Histopathological examination confirmed appendicitis in 85 patients (66.9%) and the remaining 42 patients had normal appendix giving a negative appendicectomy rate of 33.1% (26.8% for males and 38.3% for females). The sensitivity and specificity of MASS in this study were 94.1% (males 95.8% and females 88.3%) and 90.4% (males 92.9% and females 89.7%) respectively. The Positive Predictive Value and Negative Predictive Value were 95.2% (males 95.5% and females 90.6%) and 88.4% (males 89.3% and females 80.1%) respectively. The accuracy of MASS was 92.9% (males 91.5% and females 87.6%).

Conclusion

The study shows that use of MASS in patients suspected to have acute appendicitis provides a high degree of diagnostic accuracy and can be employed at Bugando Medical Centre to improve the diagnostic accuracy of acute appendicitis and subsequently reduces negative appendicectomy and complication rates. However, additional investigations may be required to confirm the diagnosis in case of atypical presentation.

Evidence-based appendicitis: the initial work-up

In this article we provide an evidence-based review of appendicitis, which is one of the most challenging conditions to diagnose in patients presenting with abdominal pain. Almost all clinicians are faced with the diagnostic work-up of these patients, and missing the diagnosis can result in patient decompensation. We review the literature from the initial description of McBurney's point to the clinical presentation, as well as the most appropriate imaging testing. Additionally, we review the usefulness of specific diagnostic laboratory tests. The use of computed tomography scans has reduced negative appendectomy rates when combined with a physical examination, and assists in ruling out appendicitis. Computed tomography scans with no contrast or just rectal contrast are becoming the standard in many institutions. It is essential that when the diagnosis of abdominal pain of unclear etiology is suspected, the clinician's discussion with the patient is well documented on the patient's chart.

Clinical prediction rule to distinguish pelvic inflammatory disease from acute appendicitis in women of childbearing age

OBJECTIVE

We aimed to develop a clinical prediction rule to distinguish pelvic inflammatory disease (PID) from acute appendicitis in women of childbearing age.

METHODS

We reviewed medical records over a 4-year period of female patients of childbearing age who had presented with abdominal pain at an urban emergency department and had either appendicitis (n = 109) or PID (n = 72). A prediction rule was developed by use of recursive partitioning based on significant factors for the discrimination.

RESULTS

The significant factors to favor PID over appendicitis were (1) no migration of pain (odds ratio [OR], 4.2; 95% confidence interval [CI], 1.5-11.5), (2) bilateral abdominal tenderness (OR, 16.7; 95% CI, 5.3-50.0), and (3) absence of nausea and vomiting (OR, 8.4; 95% CI, 2.8-24.8). The prediction rule could rule out appendicitis from PID with sensitivity of 99% (95% CI, 94-100%) when classified as a low-risk group by the following factors: (1) no migration of pain, (2) bilateral abdominal tenderness, and (3) no nausea and vomiting.

CONCLUSION

We developed a prediction rule for childbearing-aged women presenting with acute abdominal pain to distinguish acute appendicitis from PID based on 3 simple, clinical features: migration of pain, bilateral abdominal tenderness, and nausea and vomiting. Prospective validation is needed in other settings.

Clinical criteria for diagnosing perforated appendix in pediatric patients

OBJECTIVE

To determine predictive variables associated with a perforated appendix in pediatric patients with acute appendicitis.

METHODS

This is a retrospective, cross-sectional, observational study from a medical center with more than 2000 beds (230 beds in Department of Pediatrics and Pediatric Surgery), with a mean admission of more than 12000 cases and 2200 surgeries per year. The outcome variable was perforated appendix, and the predictive variables included demographic and clinical factors.

RESULTS

During a 6-year period, appendectomies were performed on 274 patients ranging in age from 1 to 18 years. Perforated appendix was found in 100 children (36.5%). Predictive factors significantly associated with perforated appendix were age younger than 9 years, abdominal pain of more than 2 days' duration, temperature of more than 37.9 degrees C, peritoneal signs, and erythrocyte sedimentation rate of more than 25 mm/h. Abdominal ultrasound was performed in 89 patients (32%). For perforated appendix, the ultrasound had a sensitivity of 35%, specificity of 98%, positive predictive value of 95%, and negative predictive value of 55%. Indications for an abdominal ultrasound were determined from a scoring system using the predictive variables significantly associated with perforated appendix.

CONCLUSION

The use of our proposed scoring system to determine the indications to perform an abdominal ultrasound may prove to assist in deciding treatment (medical vs surgical) for children with perforated appendix. Initial antibiotic treatment followed by interval appendectomy would become a more likely treatment option if our study results can be validated in a prospective study.

On-table Diagnostic Accuracy and the Clinical Significance of Routine Exploration in Open Appendectomies

INTRODUCTION

The current practice of further exploration for other intra-abdominal pathology only when a normal appendix is found may leave other organic causes of acute abdomen undetected if the surgeon's on-table diagnostic accuracy is low.

METHODS

In this retrospective study in 518 patients who underwent surgery for acute appendicitis, the on-table operative diagnosis of surgeons was correlated with the histological diagnosis of pathologists.

RESULTS

Surgeons were unable to make an accurate on-table diagnosis in 14.3% of cases. The sensitivity for diagnosing normal appendices was also low at 51.3%, suggesting that almost half of normal appendices were misdiagnosed as acute appendicitis and there was no further exploration for other pathology. It was also found that surgeon's experience, patient gender and patient age had no significant effect on diagnostic accuracy.

CONCLUSION

Based on these results, it seems that the on-table diagnostic accuracy in open appendectomies is low and surgeons' on-table diagnosis should not be the determining factor for whether further exploration is necessary. Exploration for other intra-abdominal pathology should be routine irrespective of the on-table diagnosis, the surgeon's experience and patient gender and age. An alternative is minimal-access surgery in which inspection of other intra-abdominal organs can be performed more easily.

Mesenteric lymphadenopathy as a cause of abdominal pain in children with lobar or segmental pneumonia

We investigated whether mesenteric lymphadenopathy could be a cause of abdominal pain in children with lobar or segmental pneumonia. The study population consisted of 1)119 consecutive children with lobar pneumonia, older than 4 years of age, and 2) 31 healthy controls. Demographic, clinical, inflammatory, and radiographic data were recorded in all patients. All study subjects underwent abdominal ultrasound, focusing on the identification of mesenteric lymphadenopathy. One month later, a follow-up ultrasound was performed in patients with enlarged mesenteric lymph nodes at the initial examination. Forty patients complaining of abdominal pain were included in group 1, while the remaining 79 were in group 2. The two groups of patients did not significantly differ regarding their demographic, clinical (other than abdominal pain), and radiographic indices. In contrast, enlarged mesenteric lymph nodes with a sagittal diameter of at least 10 mm were identified significantly more commonly in the children of group 1 (P = 0.001). The association of enlarged lymph nodes with the presence of abdominal pain remained significant when the data were analyzed through multiple regression analysis (odds raio, 1.47; 95% confidence interval, 3-44). Enlarged mesenteric lymph nodes were found in a significantly lower ratio of healthy controls (3/31) compared to that observed in group 1 (P = 0.003). In all patients who were followed up, mesenteric lymph nodes had either decreased or were not detectable. Our findings indicate that mesenteric lymphadenopathy might be considered as a mechanism responsible for the development of abdominal pain in a relatively high percentage of children with pneumonia.

Sonography of acute right side colonic diverticulitis

BACKGROUND

To describe the prevalence and sonographic findings and ultrasound diagnostic accuracy of the right side colonic diverticulitis in patients having right lower abdominal pain with indeterminate nature.

METHODS

A total of 934 patients with acute right lower abdominal pain of clinically indeterminate nature were referred for ultrasound examination (US). US studies were performed with 3.5 to 7.0 (or occasionally 10) MHz transducers using graded compression method. Twenty-three patients were finally diagnosed to have an uncomplicated acute diverticulitis of the right colon. The gray-scale sonographic images were reviewed. A retrospective study was undertaken to evaluate diagnostic contribution of US.

RESULTS

The prevalence of acute right side colonic diverticulitis was 2.5% in patients with clinically indeterminate acute right lower abdominal pain. Locations of the inflamed diverticula include cecum in 6 patients, proximal ascending colon in 15 patients, and distal ascending colon in only 2 patients. Sonography detected 21 inflamed diverticula with 1 false positive and 2 false negative results. The most typical sonographic feature of an inflamed diverticulum of right side colon was a rounded or oval-shaped hypoechoic or nearly anechoic structure (52%) protruding out from the segmentally thickened colonic wall. Some of them might contain strong echoes representing gas or feces (43%), or stone in the lumen (5%). Regional pericolic or peridiverticular fat thickening was noted in 57% of patients, and segmental colon wall thickening in 38%. US examination yielded a sensitivity of 91.3%, a specificity of 99.8%, an overall accuracy of 99.5%, a positive predictive value of 95.5%, and a negative predictive value of 99.7%. A positive sonogram made the likelihood of acute right side diverticulitis 456.5 times greater compared with the pretest clinical impression. US differentiated acute right side colonic diverticulitis from acute appendicitis with a 100% accuracy.

CONCLUSIONS

Ultrasound can be extremely useful in diagnosing acute right side colonic diverticulitis. Careful ultrasound evaluation of the right colon and the cecum may facilitate a correct diagnosis and help differentiate from acute appendicitis, and steer the surgeon to a more effective management.

Imaging of acute right lower abdominal quadrant pain

This article reviews the clinical diagnosis of appendicitis, indications and options for appendiceal imaging, compares appendiceal CT techniques, and describes the imaging findings with appendicitis and alternative conditions that can clinically mimic appendicitis.

Traumatic and nontraumatic perforation of hollow viscera

Hollow viscus injuries are usually managed with few complications. However, if their diagnosis is delayed, or if reparative suture closure should fail, the patient is placed at risk of multiple organ failure. This article presents diagnostic approaches, emphasizing imaging modalities, and therapeutic strategies for three clinical scenarios of hollow viscus perforation: 1) acute appendicitis, 2) gastroduodenal peptic ulcer disease, and 3) trauma.

Appendicitis

A complete understanding of the anatomy, pathophysiology, and presenting signs and symptoms of appendicitis, combined with a thorough history and physical examination, will be the most important factors in allowing the practicing emergency physician to make the correct diagnosis of acute appendicitis. For patients in which the diagnosis is less clear or for patients in high-risk groups (extremes of age, pregnant women, and immunocompromised patients) additional diagnostic testing, usually US or CT, and early surgical consultation are recommended.

Tc-99m HMPAO-labeled WBC scans to detect appendicitis in women

Fifty female patients with acute abdomen and suspected appendicitis but atypical findings were included in this study. After intravenous injection of Tc-99m HMPAO-labeled WBCs, serial anterior abdominal/pelvic images at 30, 60, 120, and 240 minutes were obtained by a gamma camera. Any abnormal localization of WBC accumulation in the right lower quadrant of the abdomen with equal to or greater than bone marrow activity was considered as a positive scan. Thirty patients had positive WBC scans and underwent laparotomy, 28 had proven appendicitis, and 2 were not related to appendicitis. Twenty patients had negative WBC scans, 2 patients underwent laparotomy and were proved to have appendicitis. The remaining 18 patients did not undergo surgery and revealed no evidence of appendicitis after follow-up. The overall sensitivity, specificity, accuracy, and positive and negative predictive values for WBC scans to diagnose appendicitis is 93.3%, 90.0%, 92.0%, 93.3%, and 90.0%, respectively. In conclusion, Tc-99m HMPAO-labeled WBC imaging provides a rapid and highly accurate method for diagnosis of appendicitis in female patients with equivocal clinical examinations.

99mTechnetium labelled leucocyte scanning in acute lower abdominal pain: can it reduce the negative appendectomy rate?

While the incidence of 'negative' appendectomy has long been justified as a necessary evil in the management of acute appendicitis, attempts to improve diagnostic accuracy have met with mixed results. In a prospective study of 34 selected patients who presented with acute lower abdominal pain the potential role of 99mTechnetium labelled leucocyte scanning in the diagnosis of acute appendicitis has been evaluated. Patient management was not based on the result of the nuclear scan. The clinical outcome was correlated with the scan diagnosis. There was one false positive and one false negative scan result with respect to the clinical diagnosis of appendicitis yielding a sensitivity of 90% and a specificity of 96%. 99mTechnetium labelled leucocyte scanning may have an important role in the assessment of selected patients presenting with acute lower abdominal pain.

Differentiating acute appendicitis from pelvic inflammatory disease in women of childbearing age

A retrospective study was performed to evaluate the usefulness of various historical, clinical, and laboratory findings in differentiating acute appendicitis from pelvic inflammatory disease (PID) in women of childbearing age. The records of all female patients presenting to the emergency department with abdominal pain who were found to have histologically proven appendicitis (n = 80) or PID confirmed on endocervical culture (n = 71) were reviewed. Clinically useful indicators favoring appendicitis included the presence of anorexia and the onset of pain later than day 14 of the menstrual cycle. Indicators favoring PID included a history of vaginal discharge, urinary symptoms, prior PID, tenderness outside the right lower quadrant, cervical motion tenderness, vaginal discharge on pelvic examination, and positive urinalysis. Despite these indicators, differentiating acute appendicitis from PID remains difficult.

Psychological factors in patients with non-specific abdominal pain acutely admitted to a general surgical ward

Non-specific abdominal pain is the commonest reason for acute admission to a general surgical ward. The present study assessed the importance of specific symptom patterns, psychological and behavioural factors in a group of acute admissions and compared patients with appendicitis with those with no specific diagnosis. Psychiatric symptoms were no more prominent than in subjects with appendicitis as measured by psychological rating scales. Patients with non-specific abdominal pain had a poor symptomatic prognosis with continuing use of medical services. NSAP is best seen as a behavioural syndrome with repeated consultation over a long period before and after the index admission for both abdominal and other non specific symptoms.

Role of sequential leucocyte counts and C-reactive protein measurements in acute appendicitis

The accurate clinical diagnosis of acute appendicitis is difficult, and many techniques have been suggested to improve diagnostic accuracy such as laparoscopy, ultrasonography and barium enema examination. In this study serial total leucocyte counts and serial C-reactive protein (CRP) concentrations in acute appendicitis were measured. The sensitivity and specificity of serial leucocyte counts in acute appendicitis were 92 and 100 per cent, and for CRP concentrations 69 and 75 per cent, respectively. The sensitivity and specificity of serial total leucocyte counts fulfilled the criteria for a diagnostic test. It is suggested that in patients with equivocal clinical findings, clinical observation combined with serial leucocyte counts may improve decision making.

[The value of clinical, laboratory and sonographic findings in acute appendicitis--effect of surgical experience and bacteriologic diagnosis on the rate of wound healing disorders]

A total of 361 patients were admitted to the Department of Surgery of the University of Heidelberg between January 1989 and April 1990 for acute appendicitis. Neither the physical examination nor laboratory results were unequivocally diagnostic in a third of the patients. The ultrasonographic visualization of the inflamed appendix could confirm the diagnosis in 50% of the clinically doubtful cases (predictive value: 84%). Further diagnostic procedures were rarely necessary. The perforation rate was independent of the duration of the preoperative hospitalization due to the rapid surgical treatment. Contrary to previous reports, the likelihood of an intraoperatively innocent appendix increased with delayed surgery. Wound infection rates were similar after appendectomies by surgeons in training and by fully qualified surgeons although perforated appendices were typically removed by the latter ones. Antibiotic therapy was usually administered for severely inflamed appendices depending on the intraoperative findings and for perforated appendices and reduced the rate of wound infections if more than two bacteria had been cultured from a routine intraoperative swab. The documentation used in Baden-Württemberg for quality control should include the result of an intraoperative appendiceal swab.

The acute abdomen: the role of laparoscopy

The ability to improve surgical decision-making in the acute abdomen using selective laparoscopy is now established. When the decision to operate is uncertain laparoscopy not only identifies those patients who do not require laparotomy, but also reveals those who need surgery which might otherwise have been delayed. Furthermore, the high error rates in diagnosing acute appendicitis in young women provides overwhelming support to the current view that all women with suspected appendicitis should undergo laparoscopy before appendicectomy, irrespective of clinical 'certainty'. Improvements in the management of the acute abdomen can also be achieved by other techniques such as computer-assisted diagnosis (McAdam et al, 1990) and peritoneal cytology (Stewart et al, 1988), and a combination of these with selective laparotomy would be appropriate. Initial patient assessment using a structured proforma would appear to be one of the most significant factors in the improvement of diagnostic accuracy associated with the use of computers (Gunn, 1976), and their combination with a policy of selective laparoscopy has been shown to be beneficial (Paterson-Brown et al, 1989). The ability to detect which patients are likely to benefit from laparoscopy by performing peritoneal cytology first (Vipond et al, 1990) has been shown to be helpful in reducing the number of patients who undergo a 'negative laparoscopy' (Baigrie et al, 1990). It is now time for laparoscopy to return to the bosom of general surgery from where it was conceived almost a century ago. When it does, as the developments in laparoscopic cholecystectomy would predict it will, so surgeons in training must take the earliest opportunity to become as familiar and proficient with the technique as their gynaecological colleagues have done, even if this means attending the gynaecological operating lists to do so. It is only then that the undoubted benefits of laparoscopy will be spread more widely in general surgery and particularly for the patient with acute abdominal pain.

Ultrasonography in the diagnosis of acute appendicitis

Ultrasonography with graded compression was performed in 525 patients with clinical signs of acute appendicitis. Of 207 patients with surgically proven appendicitis the inflamed appendix (diameter greater than or equal to 6 mm) had been visualized sonographically in 177 (86 per cent). The score for non-perforated appendicitis (91 per cent) was higher than for perforated appendicitis (55 per cent). Twenty-four patients in whom an inflamed appendix was seen on ultrasonography did not undergo surgery because of rapidly subsiding symptoms ('abortive appendicitis'). Four of these 24 developed recurrent appendicitis warranting surgery. Two underwent elective appendectomy and 18 have remained symptom-free. Of 155 patients with a subsequently confirmed alternative condition, ultrasonography made the correct diagnosis in 140: bacterial ileocaecitis (69), mesenteric lymphadenitis (eight), gynaecological conditions (34), urological conditions (eight), caecal diverticulitis (six), perforated peptic ulcer (six), Crohn's disease (two) and miscellaneous conditions (seven). Of 139 patients in whom no definite diagnosis was made ultrasonography showed no abnormalities in 138. In four patients a false positive sonographic diagnosis of appendicitis was made and in two patients with appendicitis an alternative condition was incorrectly diagnosed. During the last 3 years of the study the negative appendicectomy rate was 7 per cent and delay beyond 6 h after admission occurred in only 2 per cent of patients with surgically proven appendicitis. When used to complement the clinical diagnosis ultrasonography improves the diagnostic accuracy and patient management in those suspected of having acute appendicitis.

Role of fine catheter peritoneal cytology and laparoscopy in the management of acute abdominal pain

Laparoscopy and fine catheter peritoneal cytology (FCPC) have been advocated as aids in the assessment of acute abdominal pain. In all, 411 patients admitted to a district general hospital during a 10-month period were managed using a standard protocol incorporating these techniques. After initial assessment by a surgical registrar, 151 patients were excluded from further progress through the protocol (age less than 16 years, definite diagnosis made or contraindication to FCPC. The remaining 260 patients were placed in one of four management groups: (A) urgent operation (23 patients); (B) 'look and see' (40 patients); (C) 'wait and see' (59 patients); (D) urgent operation not indicated (138 patients). Eighty-eight of 99 patients (88 per cent) in groups B and C, where the need for operation was uncertain, underwent successful FCPC and 39 patients (39 per cent) underwent laparoscopy. In these patients the initial registrar management decision proved to be incorrect in 33 cases (33 per cent), but by following the protocol the number of management errors actually made was reduced to 13 (13 per cent, P less than 0.001). This would have been reduced to 8 per cent if the protocol had not been violated in five patients. This study demonstrates the effectiveness of a protocol using FCPC and laparoscopy to improve the management of patients with acute abdominal pain.

Evaluation of women with possible appendicitis using technetium-99m leukocyte scan

The authors evaluated the use of technetium-99m albumin colloid white blood cell (TAC-WBC) scan in women with possible appendicitis. One hundred and nine women underwent 110 TAC-WBC scans. One woman had a second scan on a separate admission and was considered two individual patients in the analysis. Twenty-six women had appendicitis, 10 of whom had a perforated appendix at surgery. The TAC-WBC scan was indeterminate (abnormal but nondiagnostic for appendicitis) in 52 women (47%), nine of whom had appendicitis. Fifty-eight scans were read as positive or negative for appendiceal pathology. There were 16 true positives, 5 false positives, 36 true negatives, and 1 false negative. The predictive value of a positive scan was 76%, and the predictive value of a negative scan was 97%. The TAC-WBC scan was positive in 62% of patients with appendicitis and negative in 43% of the patients without appendicitis resulting in an overall accuracy of 47% in the 109 women. The main value of TAC-WBC scan in women with possible appendicitis is its high negative predictive value and the main problem with the TAC-WBC scan is its high indeterminate rate.

Use of the MANTRELS score in childhood appendicitis: a prospective study of 187 children with abdominal pain

We report an evaluation of the MANTRELS clinical score in predicting appendicitis in a prospectively studied pediatric population presenting with abdominal pain. One hundred eighty-nine independent episodes from 187 children 2 to 17 years old were studied. For the groups as a whole and for the individual groups less than 16 years old, the score failed to satisfactorily discriminate those with appendicitis from those without. Had the MANTRELS score been used to determine observation and laparotomy in our patients, 21 additional patients would have been unnecessarily hospitalized, and 16 would have been subjected to unnecessary laparotomies. One patient would have received appropriate intervention earlier. In the 40 children 16 and 17 years old, the MANTRELS score adequately distinguished the two groups. A seven-variable discriminant function, derived from stepwise discriminant analysis, performed slightly better but showed essentially the same findings as the MANTRELS score. We believe the MANTRELS score failed to predict appendicitis in younger children because it does not contain variables that allow for separation of appendicitis from the numerous other conditions mimicking it in the pediatric population. The clinician remains the best judge of the acute abdomen in the pediatric age group.

Acute and perforated appendicitis: current experience with ultrasound-aided diagnosis

The clinical value of high-resolution real-time sonography for the diagnosis of acute and complicated appendicitis was prospectively investigated in 857 patients admitted with suspected appendicitis. The ultrasound findings were correlated with history and physical examination on admission. Sonography was able to make the diagnosis of appendicitis with a sensitivity of 89.7%, a specificity of 98.2%, an overall accuracy of 96.3%, and a positive and negative predictive value of 93.6% and 97%, respectively. Routine use of ultrasound before making therapeutic decisions has reduced the rate of unnecessary laparotomies from 20.3% to 11.3%. In 48 (24.7%) of 194 patients with proven appendicitis, the disease had progressed to perforation at laparotomy. History and clinical findings on admission classified 30 (62.5%) of these patients as "highly suspect;" however, 9 (18.8%) were classified as "equivocal" and 9 (18.8%) as "very unlikely." Only half (48%) of the patients with appendiceal rupture had white blood cell counts higher than 13,000/mm3 or fever above 38 degrees C (50%). Sonography enabled the visualization of the inflamed appendix and/or appendicular abscess in 44 (91.7%) patients with perforation. In 47 of 48 patients with appendiceal rupture, the ultrasound-aided diagnosis was made on hospital admission. Thus, the incidence of complicated appendicitis (24.7%) in our study population must be attributed to disease progression before admission and preclinical diagnostic delay.

Ultrasonography in the diagnosis of acute appendicitis: a prospective study

The diagnostic accuracy and practical impact of high-resolution sonography were prospectively studied in 523 consecutive patients admitted to the hospital with suspected appendicitis. The criteria for ultrasound diagnosis of acute appendicitis included visualization of a noncompressible aperistaltic appendix, with a targetlike appearance in transverse view and a diameter greater than or equal to 7 mm. In 115 of 130 patients with proven appendicitis the inflamed appendix or appendiceal abscess could be visualized, giving a sensitivity of 88.5%. The mean diameter of ultrasonically visible appendices was 11.4 +/- 3.2 mm. The overall accuracy and specificity of sonography in the diagnosis of acute appendicitis were 95.7% and 98%, respectively. The predictive value of a positive test was 94.5% and that of a negative result 96.3%. In a separate analysis of the results in 121 women of childbearing age, who have a high risk of preoperative misdiagnosis, the overall accuracy was found to be 96.7%, with 82.6% sensitivity and 100% specificity. Twenty-four (89%) of the 27 patients with appendiceal rupture (incidence 20.8%) were correctly diagnosed with ultrasound. The other 3 cases (11%) were missed. Routine use of ultrasonography has significantly improved the diagnostic accuracy in patients with suspected appendicitis and has reduced the negative laparotomy rate from 22.9% to 13.2%.

Aids in the diagnosis of acute appendicitis

Methods used to improve the accuracy of diagnosis of acute appendicitis are reviewed. Laparoscopy, barium enema, ultrasonography and computer assistance have all been shown to improve accuracy, but no one method is of proven superiority. Such diagnostic aids or intensive in-hospital observation must be used to reduce the 15-30 per cent negative laparotomy rate when acute appendicitis is suspected, without increasing the incidence of appendiceal perforation.

Leucocyte count and neutrophil percentage in appendicectomy for suspected appendicitis

The total leucocyte count (TLC) and neutrophil percentage (NP) were studied prospectively in 1032 patients who underwent appendicectomy for suspected acute appendicitis. On histopathological study of the resected appendices, 97 patients had normal appendices, and 935 patients had acutely inflamed, gangrenous or perforated appendicitis. Statistically more patients with appendicitis had either raised TLC or raised NP compared with patients with normal appendices (P less than 0.001), and also compared with 357 patients who were admitted with right lower quadrant abdominal pain but were not subjected to operation (P less than 0.001). The sensitivity and specificity of raised TLC in diagnosing appendicitis for patients who underwent appendicectomy were 81.4% and 77.3%, respectively. Sensitivity increased when either raised TLC or raised NP were used, but specificity decreased. In contrast, sensitivity decreased when both raised TLC and raised NP were used together, but specificity increased. Raised TLC, preferably combined with raised NP, is a useful diagnostic aid in acute appendicitis. The TLC and NP, however, should only be interpreted in the light of physical findings in patients with suspected appendicitis because these blood tests have false positive and false negative results.

The influence of gender and use of barium enema on morbidity in acute appendicitis

The records of 166 patients with appendicitis were analyzed by sex for time from presentation in the emergency department to surgery. Additionally, the effects of barium enema examinations on these times were noted. Our findings indicate that there was no significant delay in surgery based on gender (P = .42). However, those patients who had barium enema as part of their workup had significantly longer delays from presentation to surgery (P = .00005). These results support the notion that the most appropriate treatment for acute appendicitis is early diagnosis, a short preoperative resuscitation, and early surgical intervention. Barium enema is indicated only when the diagnosis is highly suspect and only if it can be carried out in a timely manner.

Peritoneoscopy for the diagnosis of acute appendicitis in females of reproductive age

The diagnosis of acute appendicitis in women of reproductive age can be a difficult clinical problem. A retrospective audit found our incidence of normal appendix removal in this patient population to be 42%. This study was undertaken to determine if the selective use of peritoneoscopy would improve the accuracy of diagnosis and thereby reduce the need for celiotomy in these patients. Peritoneoscopy was performed on 21 patients, and acute appendicitis was confirmed in 12 cases. Tubo-ovarian pathology was found in 5 patients, no pathology was found in 4 patients, and an unnecessary celiotomy was avoided in 8 patients. The incidence of normal appendix removal was reduced to 15%. There were no serious complications associated with peritoneoscopy. Diagnostic peritoneoscopy should be liberally employed in women of reproductive age with suspected appendicitis.

A prospective study of ultrasonography in the diagnosis of appendicitis

The diagnosis of appendicitis is frequently difficult. We studied prospectively the diagnostic accuracy and clinical impact of abdominal ultrasonography in 111 consecutive patients thought to have appendicitis. Ultrasonography was performed with small high-resolution, linear-array transducers, with the abdomen compressed to displace or compress bowel and fat. Among 52 patients later shown in surgery to have appendicitis, ultrasonography was unequivocally positive in 39 (sensitivity, 75 percent). Of 31 patients in whom appendicitis was definitely excluded, none had a positive ultrasound examination (specificity, 100 percent). The sensitivity in those with a perforated appendix (28.5 percent) was much lower than in those with acute nonperforating appendicitis (80.5 percent) or appendiceal mass (89 percent), but the low sensitivity did not influence clinical management, since the need for surgery in patients with a perforated appendix was clinically obvious. Ultrasonography resulted in changes in the proposed management in 29 of the 111 patients (26 percent). It also led to the correct diagnosis in the 16 patients who were found to have a disease other than appendicitis. We conclude that ultrasonography is a useful aid in the diagnosis of appendicitis.

Laparoscopy--a diagnostic aid in cases of suspected appendicitis. Its use in women of reproductive age

In women of reproductive age the usefulness of laparoscopy in diagnosing acute appendicitis was evaluated. Eighty-six women underwent diagnostic laparoscopy. There was complete visualization of the appendix in 93% of the patients. Twenty-two patients were spared laparotomy. In the nonpregnant patients, salpingitis was the disease most often confused with appendicitis. Eighty-five percent of the patients with salpingitis had the onset of symptoms within 14 days of the last menstrual period, whereas acute appendicitis was found in 86% of the patients with the onset of symptoms greater than 14 days after the last menstrual period. The onset of symptoms relative to the first day of the last menstrual period differed in these two groups of patients (p less than 0.01). Patients who were spared unnecessary laparotomy had significantly diminished hospital stays (p less than 0.001). Laparoscopy was found to be a safe and effective way to diagnose acute appendicitis in women of reproductive age, and its liberal use is recommended.

Active observation in acute abdominal pain

Only a minority of patients admitted with acute abdominal pain require urgent operation, but the identification of those who need an operation may be difficult. Many surgeons adopt a radical approach and operate when the diagnosis is doubtful, which often leads to 20 percent rate of negative findings on laparotomy. In this study, 220 patients of all ages admitted with acute abdominal pain were studied prospectively, and when the diagnosis on admission was uncertain, a policy of active observation was employed. In all, 39 percent of the patients underwent operation and only 5 percent had negative findings on laparotomy. No patient suffered as a result of this policy, which is recommended as a safe and effective approach to the management of acute abdominal pain.