Advances in pelvic ultrasound: endovaginal scanning for ectopic gestation and graded compression sonography for appendicitis

Appendicitis in pregnancy: an ongoing diagnostic dilemma

INTRODUCTION

Appendicitis in pregnancy (AIP) is the most common nonobstetric cause of an acute abdomen requiring surgical intervention. Diagnostic difficulties arising from gestational symptoms compound the risk of foetal loss after negative appendicectomy and exponentially increase the risk to mother and foetus with delay in genuine cases. In this article, we investigate the symptoms and signs of AIP and attempt to identify consistent clinical features and review the role of imaging in diagnosis.

METHOD

MEDLINE and PubMed were searched for case-control studies recording preoperative symptoms/signs suggestive of AIP, as well as appendiceal pathology. Combined likelihood and odds ratios (OR) were created for clinical features across homogenous papers. Papers examining the use of laparoscopy, ultrasound (US), computerized tomography (CT) and magnetic resonance imaging (MRI) were assessed qualitatively.

RESULTS

Seven papers met the inclusion criteria for the analysis of consistent clinical features (450 patients). The only symptoms or signs significantly associated with a diagnosis of appendicitis were nausea (OR: 2.21, 95%CI: 1.34-3.66), vomiting (OR: 0.82-15.6 range) and peritonism (OR: 1.80, 95%CI: 1.06-3.04). US, CT and MRI have all been used to successfully diagnose AIP. Laparoscopic appendicectomy has been safely undertaken in pregnancy.

CONCLUSION

Appendicitis will continue to challenge the diagnostic acumen of surgeons. Whilst useful, consensus regarding the safety of laparoscopy, CT and MRI in pregnancy is yet to be achieved.

Pregnancies complicated by acute appendicitis

Appendicitis is one of the most common acute abdominal conditions that requires operation during pregnancy. The maternal and fetal complications occurring in such situations are well known. However, the diagnostic and therapeutic challenges of acute appendicitis complicating pregnancy persist in current surgical practice. Thirty-eight obstetric cases who had an appendicetomy performed during pregnancy between 1986 and 1993, were reviewed. In 31 cases, acute appendicitis was proven at laparatomy, and by subsequent histopathology. In the confirmed cases, seven occurred in the first trimester, 12 in the second trimester, eight in the third trimester and four in the immediate postpartum period. Two miscarriages occurred in the first trimester group, and two late abortions and two preterm (26 and 28 weeks) deliveries occurred in the second trimester group. In the third trimester/postpartum group, all babies survived, but four patients had Caesarean sections with the appendicetomy and the incidence of perforated/gangrenous appendices was highest. Perinatal outcome was worst, with the highest fetal wastage rate if the acute appendicitis occurred in the second trimester, although maternal morbidity appeared to be the same across different gestational periods.

The surgical management of intra-abdominal inflammatory conditions during pregnancy

The timely diagnosis and treatment of intra-abdominal conditions during pregnancy can challenge the surgical consultant. Familiarity with the anatomic and physiologic changes present in normal pregnancy is essential, as is the knowledge of relative risk by trimester. The general surgeon will be called upon to diagnose and treat appendicitis, biliary tract disease (including pancreatitis), and liver disease. Knowledge of how these conditions become manifest is essential. The surgical consultant should be aware that virtually all complications that occur in the management of these conditions are caused by delay in the detection of the disease process.

Acute appendicitis in children: when does ultrasound help?

Fifty-six patients with possible appendicitis were evaluated clinically and by ultrasound. Ultrasound examination visualized the appendix in 18 of the patients evaluated and showed another pathology in six others. It was useful when the clinical picture was not clear (25 patients) as it showed an inflamed appendix in 10 patients. This was of particular value when there was another critical illness making clinical evaluation difficult (three patients), and for the diagnosis of other unsuspected pathological conditions (six patients). It did not affect the line of management when the clinical picture was clear enough to diagnose or exclude acute appendicitis.

Model curriculum for physician training in emergency ultrasonography

A model curriculum for the implementation and training of physicians in emergency medicine ultrasonography is described. Widespread use of limited bedside ultrasonography by emergency physicians will improve diagnostic accuracy and efficiency, increase the quality of care, and prove to be a cost-effective technique for the practice of emergency medicine.

Clinical application of infrared thermography in the diagnosis of appendicitis

To determine the clinical usefulness of infrared skin temperatures in diagnosing appendicitis, the authors conducted a prospective study of 86 adult and pediatric emergency department (ED) patients presenting during a 4-month study period with acute right lower abdominal pain. Skin temperature readings (FirstTemp digital thermometer, Intelligent Medical Systems, Inc, Carlsbad, CA) were taken from the right lower abdominal quadrant and a corresponding position on the left. An unpaired t test was used to determine if there was a significant difference between the right and left lower quadrants in patients with appendicitis. Discharged patients were followed up by telephone to determine any subsequent morbidity. A total of 23 patients had appendicitis confirmed by surgery; 63 subjects had other medical diagnoses. There was no significant skin temperature differential between the lower abdominal quadrants in either patient group (0.0 degree C vs 0.1 degree C; P > .5). Three patients had a skin temperature on the right that was at least 1 degrees C warmer than on the left; none of these patients had appendicitis. The results suggest that infrared thermography is not a sensitive diagnostic test for acute appendicitis in the ED population.

Ruptured interstitial pregnancy presenting as an intrauterine pregnancy by ultrasound

Interstitial pregnancy is an uncommon subset of ectopic pregnancy in which the conceptum implants in the intrauterine portion of the fallopian tube. These pregnancies tend to progress further before rupture than do other tubal pregnancies and subsequently have greater propensity for massive intra-abdominal bleeding and maternal demise. Abdominal ultrasound can be deceptive in evaluating interstitial ectopic pregnancies. Transvaginal ultrasonography is more sensitive in the diagnosis of early ectopic pregnancy. Knowledge of the application and limitations of both transabdominal and transvaginal ultrasound will assist the emergency physician in the timely evaluation of this potentially lethal condition.