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Bekiaridou K, Kambouri K, Giatromanolaki A, Foutzitzi S, Kouroupi M, Aggelidou M, Deftereos S. Predicting Complicated Appendicitis in Children: Pros and Cons of a New Score Combining Clinical Signs, Laboratory Values, and Ultrasound Images (CLU Score). Diagnostics (Basel) 2023; 13:2275. [PMID: 37443669 DOI: 10.3390/diagnostics13132275] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 06/22/2023] [Accepted: 07/03/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND This retrospective study aimed to combine the clinical signs, laboratory values, and ultrasound images of 199 children with acute appendicitis in order to create a new predictive score for complicated appendicitis in children. METHODS The study included children who had clinical examination of abdominal pain (description of pain, anorexia, body temperature, nausea or vomiting, duration of symptoms), laboratory findings on admission (white blood cell, platelets, neutrophils, C-reactive protein), preoperative abdominal ultrasound, and histopathological report after an operation for appendicitis in their records during the period from January 2016 to February 2022. RESULTS According to the statistical analysis of the values using multivariate logistic regression models, the patients with appendiceal diameter ≥ 8.45 mm, no target sign appearance, appendicolith, abscess, peritonitis, neutrophils ≥ 78.95%, C-reactive protein ≥ 1.99 mg/dL, body temperature ≥ 38 °C, pain migration to right lower quadrant, and duration of symptoms < 24 h were more likely to suffer from complicated appendicitis. The new score was comprised of the 10 variables that were found statistically significant in the multivariate logistic model. Each of these variables was assigned a score of 1 due to the values that were associated with complicated appendicitis. CONCLUSIONS A cutoff value of ≥4 has been a good indicator of the final score. The sensitivity with the usage of this score is 81.1%, the specificity 82.4%, the PPV 73.2%, the NPV approaches 88% and finally the accuracy is 81.9%. Also, the pros and cons of this score are discussed in this study.
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Affiliation(s)
- Konstantina Bekiaridou
- Department of Pediatric Surgery, Democritus University of Thrace, 68100 Alexandroupolis, Greece
| | - Katerina Kambouri
- Department of Pediatric Surgery, Democritus University of Thrace, 68100 Alexandroupolis, Greece
| | | | - Soultana Foutzitzi
- Department of Radiology, Democritus University of Thrace, 68100 Alexandroupolis, Greece
| | - Maria Kouroupi
- Department of Pathology, Democritus University of Thrace, 68100 Alexandroupolis, Greece
| | - Maria Aggelidou
- Department of Pediatric Surgery, Democritus University of Thrace, 68100 Alexandroupolis, Greece
| | - Savas Deftereos
- Department of Pathology, Democritus University of Thrace, 68100 Alexandroupolis, Greece
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Reijntjes MA, de Voogd FAE, Bemelman WA, Hompes R, d'Haens G, Buskens CJ, Gecse KB. Intestinal ultrasound detects an increased diameter and submucosal layer thickness in the appendix of patients with ulcerative colitis compared to healthy controls - a prospective cohort study. Aliment Pharmacol Ther 2023; 57:127-135. [PMID: 36320148 PMCID: PMC10092200 DOI: 10.1111/apt.17267] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 07/05/2022] [Accepted: 10/11/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Increasing evidence suggests that appendicectomy as alternative treatment for ulcerative colitis (UC), especially in patients with histopathological appendiceal inflammation. Intestinal ultrasound (IUS) is a non-invasive diagnostic modality to characterise appendiceal inflammation. AIMS To assess appendiceal IUS characteristics in UC patients and compare findings to healthy controls (HC). METHODS In this prospective study, appendiceal IUS was performed in consecutive UC patients with active (A; n = 35) or quiescent (Q; n = 30) disease and in HC (n = 30). Transverse appendiceal diameter (TAD) and additional IUS parameters (bowel wall thickness, submucosal layer thickness and colour Doppler signal) were assessed. RESULTS The appendix was visualised in 41/65 UC patients (63.1%; A vs. Q: 23/35 vs. 18/30, p = 0.67) and 18/30 (60%) HC. UC patients had a higher TAD (A: 5.5 mm, Q: 5.0 mm, HC: 4.3 mm; A-HC p < 0.01; Q-HC p = 0.01, A-Q p = ns) and submucosal layer thickness (A: 1.0 mm, Q: 1.0 mm, HC: 0.7 mm; A-HC p < 0.01, Q-HC: p = 0.01, A-Q: p = ns) when compared to HC. A TAD ≥6 mm corresponding to an ultrasonographic suspicion of acute appendicitis was mainly reported in A-UC patients (A: 43%; Q: 6%; HC: 0%, p = 0.01) and occurred irrespective of disease extent. However, none of the patients had a clinical suspicion of acute appendicitis. CONCLUSION A TAD ≥6 mm was predominantly seen in A-UC. TAD was higher in UC patients compared to HC irrespective of disease activity and was characterised by an increased submucosal layer thickness. IUS therefore has the potential to identify UC patients with appendiceal inflammation.
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Affiliation(s)
- Maud A Reijntjes
- Department of Surgery, Amsterdam UMC, Amsterdam, the Netherlands.,Amsterdam Gastroenterology Endocrinology Metabolism Research Institute, Amsterdam, the Netherlands
| | - Floris A E de Voogd
- Amsterdam Gastroenterology Endocrinology Metabolism Research Institute, Amsterdam, the Netherlands.,Department of Gastroenterology and Hepatology, Amsterdam UMC, Amsterdam, the Netherlands
| | - Willem A Bemelman
- Department of Surgery, Amsterdam UMC, Amsterdam, the Netherlands.,IBD Unit, Gastroenterology and Endoscopy, IRCCS Ospedale san Raffaele and University Vita-Salute San Raffaele Milano, Milano, Italy
| | - Roel Hompes
- Department of Surgery, Amsterdam UMC, Amsterdam, the Netherlands
| | - Geert d'Haens
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Amsterdam, the Netherlands
| | | | - Krisztina B Gecse
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Amsterdam, the Netherlands
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AL AWAYSHEH MM, ALI SS, AL-AWAYSHEH BM, AL-AWAYSHEH TM. Discovering the true accuracy of ultrasonography in the confirmation of diagnosis of acute appendicitis, a world-wide dilemma. Chirurgia (Bucur) 2022. [DOI: 10.23736/s0394-9508.20.05239-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Kar S, Behera TK, Jena K, Sahoo AK. Hyperbilirubinemia as a Possible Predictor of Appendiceal Perforation in Acute Appendicitis: A Prospective Study. Cureus 2022; 14:e21851. [PMID: 35282512 PMCID: PMC8907080 DOI: 10.7759/cureus.21851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2022] [Indexed: 11/11/2022] Open
Abstract
Introduction: Acute appendicitis, a common abdominal surgical emergency, can mostly be diagnosed clinically by assessing the symptoms and physical findings but confirmation of the diagnosis solely depends upon the histopathological study of the resected appendix specimen, being supplemented by a few laboratory tests and ultrasonography (USG). In spite of all these available investigations, the diagnosis of acute appendicitis, because of its nebulous presentation and the variability of signs, remains a Herculean task for the surgeon. Methods: This is a prospective study conducted on 125 patients diagnosed with acute appendicitis and posted for appendicectomy. Total serum bilirubin (TSB), and total leucocyte count (TLC) were done in all cases. USG of the abdomen was done in all the cases to confirm the diagnosis and to rule out other causes of acute abdomen. TLC more than 11 x 103 cells/µL and TSB more than 1.1 mg/dL were considered positive. They were operated on and their diagnoses were confirmed post-operatively by histopathological examination. Patients were subdivided according to histopathological findings into: normal appendix (n = 11), uncomplicated acute appendicitis (n = 86), gangrenous appendicitis (n = 10) and perforated appendix (n = 18). Laboratory results, operative findings, and histopathological findings were compiled, analyzed, and compared with reference values. Results: Out of 125 patients, 114 (91.2%) were histologically positive for acute appendicitis, while 11 (8.8%) had normal histology. TLC was elevated in 95 (76 %) patients and it was normal in 30 (24%) cases. Among the patients with leucocytosis, only 90 (94.74%) had positive histology for acute appendicitis, while the remaining five (5.26%) had normal histology. Among the 30 patients who had normal TLC, 24 had positive histology for acute appendicitis, while the remaining six had normal histology. The specificity, sensitivity, positive predictive value (PPV), and negative predictive value (NPV) were 78.95%, 54.55%, 94.74%, and 20%respectively. Similarly, 67 patients (53.6%) had elevated TSB, while it was within normal limits in 58 (46.4%) patients. From the patients with hyperbilirubinemia, 65 (97.01%) had positive histology for acute appendicitis, while the remaining two (2.99%) had normal histology. Among 58 patients who had normal TSB, 49 had positive histology for acute appendicitis, while the rest nine had normal histology. The specificity, sensitivity, PPV, and NPV are 57.02%, 81.82%, 97.01%, and 15.52% respectively. However, when both TLC and TSB were compared as markers of appendicular perforation, the sensitivity, specificity, PPV, and NPV of total serum bilirubin were found to be 89.29% against 21.43%; 53.49% vs. 2.33%; 38.46% vs. 6.67% and 93.88% vs. 8.33% of total leukocyte counts respectively. Conclusion: Elevated total serum bilirubin could be used as a better predictor of appendiceal perforation in acute appendicitis.
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Malia L, Sturm JJ, Smith SR, Brown RT, Campbell B, Chicaiza H. Predictors for Acute Appendicitis in Children. Pediatr Emerg Care 2021; 37:e962-e968. [PMID: 31136455 DOI: 10.1097/pec.0000000000001840] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Acute appendicitis in children is the most common condition requiring urgent evaluation and surgery in the emergency department. At times, despite the appendix being seen on ultrasound (US), there can be discrepancy as to whether a patient has clinical appendicitis. Secondary findings suggestive of appendicitis can be helpful in identifying and evaluating these children. OBJECTIVE The aim of this study was to determine if specific US findings and/or laboratory results are predictive of appendicitis in children with a visualized appendix on US. METHODS A prospective study was conducted on children (birth to 18 years) presenting to the pediatric emergency department with suspected appendicitis who underwent right-lower-quadrant US. Ultrasound findings analyzed appendix diameter, compressibility, increased vascularity, presence of appendicolith, inflammatory changes, right-lower-quadrant fluid near the appendix, lower abdominal fluid, tenderness during US, and lymph nodes. Diagnosis was confirmed via surgical pathology. RESULTS There were 1252 patients who enrolled, 60.8 (762) had their appendix visualized, and 39.1 (490) did not. In children where the appendix was seen, 35.2% (268) were diagnosed with appendicitis. Among patients with a visualized appendix, the likelihood of appendicitis was significantly greater if the appendix diameter was 7 mm or greater (odds ratio [OR], 12.4; 95% confidence interval [CI], 4.7-32.7), an appendicolith was present (OR, 3.9; 95% CI, 1.5-10.3), inflammatory changes were seen (OR, 10.2; 95% CI, 3.9-26.1), or the white blood cell (WBC) count was 10,000/μL (OR, 4.8; 95% CI, 2.4-9.7). A duration of abdominal pain of 3 days or more was significantly less likely to be associated with appendicitis (OR, 0.3; 95% CI, 0.08-0.99). The absence of inflammatory changes, WBC count of less than 10,000/μL, and appendix diameter of 7 mm or less had a negative predictive value of 100%. CONCLUSIONS When the appendix is seen on US but diagnosis of appendicitis is questioned, the absence of inflammatory changes, WBC count of less than 10,000/μL, and appendix diameter of 7 mm or less should decrease suspicion for appendicitis.
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Affiliation(s)
- Laurie Malia
- From the Department of Emergency Medicine, Connecticut Children's Medical Center
| | - Jesse J Sturm
- From the Department of Emergency Medicine, Connecticut Children's Medical Center
| | - Sharon R Smith
- From the Department of Emergency Medicine, Connecticut Children's Medical Center
| | | | - Brendan Campbell
- From the Department of Emergency Medicine, Connecticut Children's Medical Center
| | - Henry Chicaiza
- From the Department of Emergency Medicine, Connecticut Children's Medical Center
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Roberts JM, van de Poll T, Hague CJ, Murray N. Ultrasound for Suspected Acute Appendicitis in Adult Women Under Age 40: An Evaluation of On-Call Radiology Resident Scanning. Acad Radiol 2021; 28:1169-1173. [PMID: 32807608 DOI: 10.1016/j.acra.2020.07.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 07/07/2020] [Accepted: 07/16/2020] [Indexed: 11/29/2022]
Abstract
RATIONALE AND OBJECTIVES At our institution, on-call radiology residents perform emergent ultrasounds (US) outside of departmental working hours. The aim of the study was to evaluate radiology resident-performed US for clinically suspected acute appendicitis in women under the age of 40. MATERIALS AND METHODS Retrospective review of 104 consecutive US scans outside of departmental working hours by radiology residents, and 104 consecutive US studies scanned during departmental working hours by sonographers, in women under the age of 40 for clinically suspected appendicitis . RESULTS Appendix visualization rate was 27% for the resident group (sonographer group: 30%, p = 0.759). The sensitivity and specificity of US for appendicitis were 63% (95% confidence interval: 41%-81%) and 98% (95% CI: 91%-100%), respectively for the resident group (sonographer group: 69% [95% CI: 41%-89 %] and 98% [95% CI: 92%-100%], respectively). An alternative cause for right lower quadrant pain was offered in 17% of resident group cases (sonographer group: 21%, p = 0.598). Follow-up CT or MRI was performed in 47% of resident cases (sonographer group: 44%, p = 0.781). Residents performed more focused US (i.e. not imaging the pelvic organs), at 34% (sonographer group: 1%, p < 0.001). When only focused scanning was performed by residents, there was a trend toward increased downstream imaging (CT or MRI), odds ratio = 2.76 (95% CI: 0.99-7.70). CONCLUSIONS Out-of-hours US scans performed by radiology residents had similar performance characteristics compared to departmental sonographers. We discovered an increased rate of downstream imaging in cases in which residents performed limited scans and did not document visualization of the pelvic organs.
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Affiliation(s)
- James M Roberts
- Department of Radiology, University of British Columbia, 11th Floor 2775 Laurel St, Vancouver, BC, V6H 0A5, Canada.
| | | | - Cameron J Hague
- Department of Radiology, University of British Columbia, 11th Floor 2775 Laurel St, Vancouver, BC, V6H 0A5, Canada; Department of Radiology, St Paul's Hospital, Vancouver, BC
| | - Nicolas Murray
- Department of Radiology, University of British Columbia, 11th Floor 2775 Laurel St, Vancouver, BC, V6H 0A5, Canada; Department of Radiology, Vancouver General Hospital, Vancouver, BC
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Fugazzola P, Ceresoli M, Agnoletti V, Agresta F, Amato B, Carcoforo P, Catena F, Chiara O, Chiarugi M, Cobianchi L, Coccolini F, De Troia A, Di Saverio S, Fabbri A, Feo C, Gabrielli F, Gurrado A, Guttadauro A, Leone L, Marrelli D, Petruzzelli L, Portolani N, Prete FP, Puzziello A, Sartelli M, Soliani G, Testini M, Tolone S, Tomasoni M, Tugnoli G, Viale P, Zese M, Ishay OB, Kluger Y, Kirkpatrick A, Ansaloni L. The SIFIPAC/WSES/SICG/SIMEU guidelines for diagnosis and treatment of acute appendicitis in the elderly (2019 edition). World J Emerg Surg 2020; 15:19. [PMID: 32156296 PMCID: PMC7063712 DOI: 10.1186/s13017-020-00298-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 02/25/2020] [Indexed: 12/15/2022] Open
Abstract
The epidemiology and the outcomes of acute appendicitis in elderly patients are very different from the younger population. Elderly patients with acute appendicitis showed higher mortality, higher perforation rate, lower diagnostic accuracy, longer delay from symptoms onset and admission, higher postoperative complication rate and higher risk of colonic and appendiceal cancer. The aim of the present work was to investigate age-related factors that could influence a different approach, compared to the 2016 WSES Jerusalem guidelines on general population, in terms of diagnosis and management of elderly patient with acute appendicitis. During the XXIX National Congress of the Italian Society of Surgical Pathophysiology (SIFIPAC) held in Cesena (Italy) in May 2019, in collaboration with the Italian Society of Geriatric Surgery (SICG), the World Society of Emergency Surgery (WSES) and the Italian Society of Emergency Medicine (SIMEU), a panel of experts participated to a Consensus Conference where eight panelists presented a number of statements, which were developed for each of the four topics about diagnosis and management of acute appendicitis in elderly patients, formulated according to the GRADE system. The statements were then voted, eventually modified and finally approved by the participants to the Consensus Conference. The current paper is reporting the definitive guidelines statements on each of the following topics: diagnosis, non-operative management, operative management and antibiotic therapy.
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Affiliation(s)
- Paola Fugazzola
- General and Emergency Surgery Department, Bufalini Hospital, Viale Ghirotti 286, 47521, Cesena, Italy.
| | - Marco Ceresoli
- General Surgery Department, Milano-Bicocca University, School of Medicine and Surgery, Monza, Italy
| | | | | | - Bruno Amato
- Department of Clinical Medicine and Surgery, University of Naples "Federico II", Naples, Italy
| | - Paolo Carcoforo
- Department of Surgery, S. Anna University Hospital and University of Ferrara, Ferrara, Italy
| | - Fausto Catena
- Emergency and Trauma Surgery, Maggiore Hospital, Parma, Italy
| | - Osvaldo Chiara
- Emergency and Trauma Surgery, Niguarda Hospital, Milan, Italy
| | - Massimo Chiarugi
- Emergency Surgery Unit, State University of Pisa, Cisanello Hospital, Pisa, Italy
| | - Lorenzo Cobianchi
- Department of General Surgery, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Federico Coccolini
- Emergency Surgery Unit, State University of Pisa, Cisanello Hospital, Pisa, Italy
| | - Alessandro De Troia
- Department of Surgery, S. Anna University Hospital and University of Ferrara, Ferrara, Italy
| | - Salomone Di Saverio
- Colorectal Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Andrea Fabbri
- Department of Emergency Medicine, Morgagni-Pierantoni Hospital, Forlì, Italy
| | - Carlo Feo
- Department of Surgery, S. Anna University Hospital and University of Ferrara, Ferrara, Italy
| | - Francesco Gabrielli
- General Surgery Department, Milano-Bicocca University, School of Medicine and Surgery, Monza, Italy
| | - Angela Gurrado
- Department of Biochemical Sciences and Human Oncology, University of Medical School "A. Moro" of Bari, Bari, Italy
| | - Angelo Guttadauro
- General Surgery Department, Milano-Bicocca University, School of Medicine and Surgery, Monza, Italy
| | - Leonardo Leone
- General and Oncological Surgery, Filippo Neri Hospital, Rome, Italy
| | - Daniele Marrelli
- Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Luca Petruzzelli
- Department of Emergency Surgery, Città della Salute e della Scienza University Hospital, Torino, Italy
| | - Nazario Portolani
- Department of Clinical and Experimental Sciences, Surgical Clinic, University of Brescia, Brescia, Italy
| | - Francesco Paolo Prete
- Endocrine, Digestive and Emergency Surgery Department, University of Medical School of Bari, Bari, Italy
| | | | | | - Giorgio Soliani
- Department of Surgery, S. Anna University Hospital and University of Ferrara, Ferrara, Italy
| | - Mario Testini
- Endocrine, Digestive and Emergency Surgery Department, University of Medical School of Bari, Bari, Italy
| | - Salvatore Tolone
- General, Mininvasive and Bariatric Surgery Unit, Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Caserta, Italy
| | - Matteo Tomasoni
- General and Emergency Surgery Department, Bufalini Hospital, Viale Ghirotti 286, 47521, Cesena, Italy
| | - Gregorio Tugnoli
- Trauma Surgery Unit, Maggiore Hospital Regional Emergency Surgery and Trauma Center, Bologna Local Health District, Bologna, Italy
| | - Pierluigi Viale
- Operative Unit of Infectious Diseases, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Monica Zese
- Department of Surgery, S. Anna University Hospital and University of Ferrara, Ferrara, Italy
| | - Offir Ben Ishay
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Andrew Kirkpatrick
- Departments of General Acute Care, Abdominal Wall Reconstruction and Trauma Surgery, Foothills Medical Centre, Calgary, Alberta, Canada
| | - Luca Ansaloni
- General and Emergency Surgery Department, Bufalini Hospital, Viale Ghirotti 286, 47521, Cesena, Italy
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Sams C, Ayyala RS, Swenson DW. Falling through the worm hole: an exploration of the imaging workup of the vermiform appendix in the pediatric population. BJR Open 2019; 1:20190016. [PMID: 33178945 PMCID: PMC7592479 DOI: 10.1259/bjro.20190016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 08/17/2019] [Accepted: 08/21/2019] [Indexed: 12/26/2022] Open
Abstract
Despite the thousands of articles discussing appendicitis in the literature, the dilemma of how to best diagnosis and manage pediatric appendicitis remains unsettled. Over the past decade, evidence has been mounting about the use of antibiotics as the sole therapy in uncomplicated appendicitis in the adult population. This debate has even recently bled over into the lay press. While this change in practice pattern is still in its infancy for the pediatric population, radiologists should be aware of this change in therapy and how it can impact the imaging work-up and relevant findings. This article concisely summarizes the imaging findings and various imaging pathways to arrive at the diagnose of appendicitis with an emphasis of how to best be of use to our surgical colleagues in this evolving paradigm. It also highlights venues for further research, namely increasing accuracy of differentiating complicated from uncomplicated appendicitis.
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Affiliation(s)
- Cassandra Sams
- Department of Diagnostic Imaging, Warren Alpert Medical School of Brown University, Rhode Island Hospital, 593 Eddy St, Providence
| | - Rama S Ayyala
- Department of Diagnostic Imaging, Warren Alpert Medical School of Brown University, Rhode Island Hospital, 593 Eddy St, Providence
| | - David W. Swenson
- Department of Diagnostic Imaging, Warren Alpert Medical School of Brown University, Rhode Island Hospital, 593 Eddy St, Providence
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Tamini N, Santurro L, Chiappetta MF, Gattuso I, Barbieri C, Fattori L, Gianotti L. Morbidity after negative appendectomy: a single-centre experience on 627 cases. Eur J Trauma Emerg Surg 2019; 46:859-864. [PMID: 31041486 DOI: 10.1007/s00068-019-01138-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 04/17/2019] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Acute appendicitis is one of the most common causes of abdominal pain in emergency departments worldwide. Despite the improvement in radiological and clinical investigations, negative appendectomy remains a debated topic as well as the optimal strategy for use in cases demonstrating a nonpathological appendix during a procedure for suspected appendicitis. The aim of the present study was thus to analyse clinical outcomes of histologically NA to better elucidate the burden associated with a potentially avoidable procedure. MATERIALS AND METHODS We retrospectively analysed a prospectively collected database of all patients undergoing appendectomy for suspected appendicitis. Patients who underwent an elective appendectomy or an appendectomy for other causes than suspected appendicitis or even an appendectomy during the course of another procedure were excluded from the analysis. RESULTS Data of 627 patients undergoing an emergency procedure for suspected appendectomy were registered. Of the 627 patients, 533 (85%) were found to have acute appendicitis (378 uncomplicated, 155 severe), while the NA rate was 14.9%. A preoperative CT scan was performed in 148 patients (23.6%), an ultrasound evaluation was conducted in 427 patients (68.1%), and 127 patients (20.3%) underwent no imaging prior to surgical intervention. The large majority of procedures was performed laparoscopically (77.7%) and the median procedure duration was 70 min (range 17-270 min). The cumulative conversion rate (both AA and NA) was 5.7%. Leucocytes were significantly lower in cases of NA, while C-reactive protein (CRP) level was found to be increased fourfold in cases of severe versus uncomplicated appendicitis and NA. An increased use of endoloop in appendiceal stump closure was noted in the NA group (88.3% loop vs. 11.7% stapler), while endostapler usage increased in the severe appendicitis group up to 38.1%. Most patients with NA underwent only preoperative ultrasound (71.3%), with just 8.5% of patients in this group having a CT scan before surgery. Ultrasound sensivity was 0.648 and specificity was 0.438. For CT scan, sensivity was 0.949 and specificity was 0.625. LOS in the NA patient group was comparable to that of patients affected by uncomplicated appendicitis, while patients with severe appendicitis experienced a 2-day-longer median recovery. Complications were significantly higher in the severe appendicitis group but comparable in the other two groups. Surgical site infections were the most frequently reported complications. CONCLUSIONS Young women are particularly at risk for NA. Increasing the use of preoperative CT and incorporating imaging into the overall assessment of a patient seems to be actually the only way to reduce the incidence of NA without increasing the rates of perforation. Considering the relatively high morbidity after an NA procedure, every surgeon must carefully consider the risk-benefit balance prior to performing an appendectomy during diagnostic laparoscopy for suspected acute appendicitis showing a macroscopically noninflamed appendix.
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Affiliation(s)
- Nicolò Tamini
- School of Medicine and Surgery, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy. .,Department of Surgery, San Gerardo Hospital, University of Milano-Bicocca, Via Pergolesi 33, Monza, Italy.
| | - Letizia Santurro
- School of Medicine and Surgery, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy
| | | | - Ilaria Gattuso
- School of Medicine and Surgery, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy
| | - Consuelo Barbieri
- School of Medicine and Surgery, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy
| | - Luca Fattori
- School of Medicine and Surgery, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy
| | - Luca Gianotti
- School of Medicine and Surgery, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy
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10
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Guthrie GJ, Johnston T, Ewing A, Mullen R, Suttie SA, Patil PV. A prospective observational study of the utility of early diagnostic laparoscopy for right lower abdominal pain: a safe and effective diagnostic and therapeutic tool. Scott Med J 2019; 64:49-55. [PMID: 30630393 DOI: 10.1177/0036933016649869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND AIMS Diagnostic laparoscopy is commonly performed for diagnosis of right lower abdominal pain and its use is increasing in the emergency setting. Some studies have reported that diagnostic laparoscopy and laparoscopic appendicectomy have advantages over conventional surgery. Many emergency surgeons now perform diagnostic laparoscopy for both clinically diagnosed appendicitis and when the diagnosis is in doubt. The aim of the present study was to assess whether the use of diagnostic laparoscopy is justified and safe for those admitted with right lower abdominal pain. METHODS AND RESULTS Data were collected prospectively on consecutive patients attending the acute surgical receiving unit with right iliac fossa pain or a suspected diagnosis of acute appendicitis. A total of 284 patients underwent diagnostic laparoscopy. Of them 233 (82%) had a positive finding at laparoscopy, 207 (88%) underwent appendicectomy, the majority of which were carried out laparoscopically. Surgical trainees performed the majority of operations and this did not have a negative impact on operative findings (p 0.856), operation performed (0.642), or operative duration (0.831). No intra-operative complications were sustained. Ultrasound examination was carried out in 49 patients, while CT was carried out in 24. CONCLUSION The results of the present study highlight the utility of early diagnostic laparoscopy as both a diagnostic and therapeutic tool in the acute setting.
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Affiliation(s)
- Graeme Jk Guthrie
- 1 Specialty Registrar General Surgery, Department of General Surgery, Ninewells Hospital, UK
| | - Thomas Johnston
- 2 Foundation Doctor General Surgery, Department of General Surgery, Ninewells Hospital, UK
| | - Anne Ewing
- 3 Foundation Doctor General Surgery, Department of General Surgery, Ninewells Hospital, UK
| | - Russell Mullen
- 4 Specialty Registrar General Surgery, Department of General Surgery, Ninewells Hospital, UK
| | - Stuart A Suttie
- 5 Specialty Registrar General Surgery, Department of General Surgery, Ninewells Hospital, UK
| | - Pradeep V Patil
- 6 Consultant General Surgeon, Department of General Surgery, Ninewells Hospital, UK
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Coccolini F, Fugazzola P, Sartelli M, Cicuttin E, Sibilla MG, Leandro G, De' Angelis GL, Gaiani F, Di Mario F, Tomasoni M, Catena F, Ansaloni L. Conservative treatment of acute appendicitis. ACTA BIO-MEDICA : ATENEI PARMENSIS 2018; 89:119-134. [PMID: 30561405 PMCID: PMC6502196 DOI: 10.23750/abm.v89i9-s.7905] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Indexed: 12/17/2022]
Abstract
Acute appendicitis has been considered by surgeons a progressive disease leading to perforation for more than 100 years. In the last decades the theories about this concept gained attention, especially in adults. However, appendectomy for acute appendicitis remains the most common urgent/emergent surgical procedure. At present, accumulating evidences are showing the changing in clinical practice towards the non-operative management of several cases of acute appendicitis either non-complicated or complicated. The present review aims to show the literature results regarding the non-operative management of acute appendicitis in non-complicated and in complicated cases.
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Affiliation(s)
- Federico Coccolini
- Emergency, General and Trauma Surgery dept., Bufalini hospital, Cesena, Italy.
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12
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Bourcier JE, Gallard E, Redonnet JP, Majourau M, Deshaie D, Bourgeois JM, Garnier D, Geeraerts T. Diagnostic performance of abdominal point of care ultrasound performed by an emergency physician in acute right iliac fossa pain. Crit Ultrasound J 2018; 10:31. [PMID: 30467798 PMCID: PMC6250608 DOI: 10.1186/s13089-018-0112-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 10/17/2018] [Indexed: 12/11/2022] Open
Abstract
Background Right iliac fossa abdominal pain is a common reason for emergency ward admissions, its etiology is difficult to diagnose. It can be facilitated by an imaging examination, such as a Computerized Tomography scan which exposes the patient to ionizing radiation and implies delays. A bedside ultrasound performed by emergency physicians could avoid these issues. The aim of our study was to assess the performance of ultrasound carried out at the patient’s bedside by an emergency physician compared with a clinical-laboratory examination for the diagnosis of a surgical pathology in right iliac fossa pain. Methods This is a single-center prospective cohort study conducted in an Emergency Department receiving 19,000 patients per year. All patients presenting pain in the right iliac fossa were included by four (out of ten) emergency physicians certified in an ultrasound examination. A full grid pattern scan ultrasound of the abdominal cavity with analysis of the right iliac fossa was performed. The primary outcome was to compare the diagnosis performance of bedside ultrasound and clinical-laboratory examination to detect a surgical pathology. Two emergency physicians who did not participate in the study made the final diagnosis (i.e., surgical or non-surgical pathology) by reviewing the entire medical chart of each patient. Results From January 2011 to July 2013, 158 patients with a median age of 17 [13–32] years were analyzed. The diagnosed cases were: appendicitis (53), non-specific abdominal pain (48), lymphadenitis (22), ileitis (11), complicated ovarian cysts (7), neoplasias (5), inflammatory or infectious colitis (5), inguinal herniations (3), bowel obstructions (2), and salpingitis (2). The accuracy of ultrasound diagnoses was 0.89 (95% CI 0.84–0.94) versus 0.70 (95% CI 0.57–0.82) for diagnoses based on clinical-laboratory examination only (p < 0.001). Conclusion Bedsides, ultrasound allows an accurate diagnosis of a surgical pathology in 89% of cases, which is more efficient than the clinical-laboratory examination.
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Affiliation(s)
- Jean-Eudes Bourcier
- Emergency, Anesthesiology and Critical Care Department, Lourdes Hospital, 2 Avenue Alexandre Marqui, 65100, Lourdes, France.
| | - Emeric Gallard
- Emergency, Anesthesiology and Critical Care Department, Lourdes Hospital, 2 Avenue Alexandre Marqui, 65100, Lourdes, France
| | - Jean-Philippe Redonnet
- Emergency, Anesthesiology and Critical Care Department, Lourdes Hospital, 2 Avenue Alexandre Marqui, 65100, Lourdes, France
| | - Magali Majourau
- Emergency, Anesthesiology and Critical Care Department, Lourdes Hospital, 2 Avenue Alexandre Marqui, 65100, Lourdes, France
| | - Dominique Deshaie
- Emergency, Anesthesiology and Critical Care Department, Lourdes Hospital, 2 Avenue Alexandre Marqui, 65100, Lourdes, France
| | | | - Didier Garnier
- Emergency, Anesthesiology and Critical Care Department, Lourdes Hospital, 2 Avenue Alexandre Marqui, 65100, Lourdes, France
| | - Thomas Geeraerts
- Anesthesiology and Critical Care Department, Toulouse University Hospital, University Toulouse III Paul Sabatier, Toulouse, France
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13
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Malia L, Sturm JJ, Smith SR, Brown RT, Campbell B, Chicaiza H. Diagnostic accuracy of laboratory and ultrasound findings in patients with a non-visualized appendix. Am J Emerg Med 2018; 37:879-883. [PMID: 30097276 DOI: 10.1016/j.ajem.2018.08.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Revised: 07/28/2018] [Accepted: 08/07/2018] [Indexed: 01/15/2023] Open
Abstract
Ultrasound (US) and laboratory testing are initial diagnostic tests for acute appendicitis. A diagnostic dilemma develops when the appendix is not visualized on US. Objective: To determine if specific US findings and/or laboratory results predict acute appendicitis when the appendix is not visualized. Methods: A prospective study was conducted on children (birth-18 yrs) presenting to the pediatric emergency department with suspected acute appendicitis who underwent right lower quadrant US. Children with previous appendectomy, US at another facility, or eloped were excluded. US findings analyzed: inflammatory changes, right lower quadrant and lower abdominal fluid, tenderness during US exam and lymph nodes. Diagnoses were confirmed via surgical pathology. Results 1252 subjects were enrolled, 60.8% (762) had appendix visualized and 39.1% (490) did not. In children where the appendix was not seen, 6.7% [33] were diagnosed with appendicitis. Among patients with a non-visualized appendix, the likelihood of appendicitis was significantly greater if: inflammatory changes in the RLQ (OR 18.0, 95% CI 4.5-72.1), CRP >0.5 mg/dL (OR 2.64, 95% CI 1.0-6.8), or WBC > 10 (OR 4.36, 95% CI 1.66-11.58). Duration of abdominal pain >3 days was significantly less likely associated with appendicitis in this model (OR 0.34, 95% CI 0.003-0.395). Combined, the absence inflammatory changes, CRP < 0.5 mg/dL, WBC < 10, and pain, ≤3 days had a NPV of 94.0%. Conclusion When the appendix is not visualized on US, predictors for appendicitis include the presence of inflammatory changes in the RLQ, an elevated WBC/CRP and abdominal pain <3 days.
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Affiliation(s)
- Laurie Malia
- Connecticut Children's Medical Center, Hartford, CT 06106, USA.
| | - Jesse J Sturm
- Connecticut Children's Medical Center, Hartford, CT 06106, USA.
| | - Sharon R Smith
- Connecticut Children's Medical Center, Hartford, CT 06106, USA.
| | | | | | - Henry Chicaiza
- Connecticut Children's Medical Center, Hartford, CT 06106, USA.
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Kim J, Kim K, Kim J, Yoo J, Jeong W, Cho S, Joo K, Cho Y, Lee J, Ryu S, Yoo Y. The learning curve in diagnosing acute appendicitis with emergency sonography among novice emergency medicine residents. JOURNAL OF CLINICAL ULTRASOUND : JCU 2018; 46:305-310. [PMID: 29315613 DOI: 10.1002/jcu.22577] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2017] [Revised: 11/25/2017] [Accepted: 12/21/2017] [Indexed: 06/07/2023]
Abstract
PURPOSE Ultrasonography (US) has good accuracy for diagnosing appendicitis when it is performed by emergency physicians. This study aimed to determine the amount of experience that is required to achieve competency in this field. METHODS Three novice emergency medicine residents completed a 1-day training course regarding the US diagnosis of appendicitis. Then, they performed appendix US in the emergency department on patients complaining of right lower quadrant pain. All included patients also underwent computed tomography or US performed by a board-certified radiologist, to confirm the emergency US diagnosis. The agreement between the diagnoses of novices and experts was evaluated. RESULTS A total of 266 patients were included, and the overall Cohen's kappa coefficient was 0.77 (95% confidence interval [CI]: 0.69-0.84). The kappa value of first 20 cases was 0.49 (95% CI: 0.27-0.71). It increased rapidly during evaluation of the first 20 cases. After the first 20 cases, the kappa coefficient was 0.84 (95% CI: 0.77-0.92). The sensitivity and specificity values for the first 20 cases were 64.3% (95% CI: 77.6%-90.7%) and 84.4% (95% CI: 85.4%-95.4%), respectively. After the first 20 cases, the sensitivity and specificity values increased to 90.9% (95% CI: 83.4%-95.8%) and 93.5% (95% CI: 87.0%-97.3%), respectively. CONCLUSIONS A minimum of 20 cases are needed to achieve competency in emergency US diagnosis of acute appendicitis.
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Affiliation(s)
- Jeehyun Kim
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, South Korea
| | - Kipum Kim
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, South Korea
| | - Jungwan Kim
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, South Korea
| | - Jungwoo Yoo
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, South Korea
| | - Wonjoon Jeong
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, South Korea
| | - Sunguk Cho
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, South Korea
| | - Kihyuk Joo
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, South Korea
| | - Yongchul Cho
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, South Korea
| | - Jinwoong Lee
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, South Korea
| | - Seung Ryu
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, South Korea
| | - Yeonho Yoo
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, South Korea
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15
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Ultrasound Guidelines: Emergency, Point-of-Care and Clinical Ultrasound Guidelines in Medicine. Ann Emerg Med 2017; 69:e27-e54. [PMID: 28442101 DOI: 10.1016/j.annemergmed.2016.08.457] [Citation(s) in RCA: 393] [Impact Index Per Article: 56.1] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Indexed: 02/06/2023]
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16
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Abstract
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.
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Affiliation(s)
- LTH Tan
- Hong Kong Baptist Hospital, Department of Radiology, 222 Waterloo Road, Kowloon, Hong Kong
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17
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Matthew Fields J, Davis J, Alsup C, Bates A, Au A, Adhikari S, Farrell I. Accuracy of Point-of-care Ultrasonography for Diagnosing Acute Appendicitis: A Systematic Review and Meta-analysis. Acad Emerg Med 2017; 24:1124-1136. [PMID: 28464459 DOI: 10.1111/acem.13212] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 03/31/2017] [Accepted: 04/07/2017] [Indexed: 01/07/2023]
Abstract
BACKGROUND The use of ultrasonography (US) to diagnose appendicitis is well established. More recently, point-of-care ultrasonography (POCUS) has also been studied for the diagnosis of appendicitis, which may also prove a valuable diagnostic tool. The purpose of this study was through systematic review and meta-analysis to identify the test characteristics of POCUS, specifically US performed by a nonradiologist physician, in accurately diagnosing acute appendicitis in patients of any age. METHODS We conducted a thorough and systematic literature search of English language articles published on point-of-care, physician-performed transabdominal US used for the diagnosis of acute appendicitis from 1980 to May, 2015 using OVID MEDLINE In-Process & Other Non-indexed Citations and Scopus. Studies were selected and subsequently independently abstracted by two trained reviewers. A random-effects pooled analysis was used to construct a hierarchical summary receiver operator characteristic curve, and a meta-regression was performed. Quality of studies was assessed using the QUADAS-2 tool. RESULTS Our search yielded 5,792 unique studies and we included 21 of these in our final review. Prevalence of disease in this study was 29.8%, (range = 6.4%-75.4%). The sensitivity and specificity for POCUS in diagnosing appendicitis were 91% (95% confidence interval [CI] = 83%-96%) and 97% (95% CI = 91%-99%), respectively. The positive and negative predictive values were 91 and 94%, respectively. Studies performed by emergency physicians had slightly lower test characteristics (sensitivity = 80%, specificity = 92%). There was significant heterogeneity between studies (I2 = 99%, 95% CI = 99%-100%) and the quality of the reported studies was moderate, mostly due to unclear reporting of blinding of physicians and timing of scanning and patient enrollment. Several of the studies were performed by a single operator, and the education and training of the operators were variably reported. CONCLUSION Point-of-care US has relatively high sensitivity and specificity for diagnosing acute appendicitis, although the data presented are limited by the quality of the original studies and large CIs. In the hands of an experienced operator, POCUS is an appropriate initial imaging modality for diagnosing appendicitis. Based on our results, it is premature to utilize POCUS as a stand-alone test or to rule out appendicitis.
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Affiliation(s)
- J. Matthew Fields
- Department of Emergency Medicine; Thomas Jefferson University; Philadelphia PA
| | - Joshua Davis
- Department of Emergency Medicine; Penn State Milton S. Hershey Medical Center; Hershey PA
| | - Carl Alsup
- Department of Emergency Medicine; Thomas Jefferson University; Philadelphia PA
| | | | - Arthur Au
- Department of Emergency Medicine; Thomas Jefferson University; Philadelphia PA
| | | | - Isaac Farrell
- The University of Arizona College of Medicine; Tucson AZ
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The role of 256-slice CT in differentiation between non-perforated and perforated appendicitis. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2017. [DOI: 10.1016/j.ejrnm.2016.12.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Abstract
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.
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20
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Eriksson S, Tisell Å, Granström L. Ultrasonographic Findings after Conservative Treatment of Acute Appendicitis and Open Appendicectomy. Acta Radiol 2016. [DOI: 10.1177/028418519503600213] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In a randomized study we investigated the effects of antibiotics as the only treatment in acute appendicitis. Forty patients were examined, 19 after antibiotic treatment (one operated due to perforation) and 21 after surgery. All patients were examined prior to randomization, after 10 days and after 30 days. Of the positive ultrasonographic (US) findings, 18 (86%) of the 21 operated patients had histologically proven acute appendicitis. At the 10th day, 9 patients had a seroma under the scar, which had disappeared a month after surgery in all patients. In the 19 patients conservatively treated with antibiotics, the appendix could be visualized in 8 symptom-free cases on the 10th day. In 5 of the 8 patients the appendix was still visualized after 1 month. Three of these 5 had recurrent appendicitis within a year. It is concluded that US can be used not only in diagnosing acute appendicitis, but also in the evaluation of treatments such as antibiotics.
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21
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Scott T, Swan H, Jurriaans E, Voss M. Sonographic Detection of the Normal Appendix. JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY 2016. [DOI: 10.1177/8756479304267641] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The purpose of this study was to determine if the application of tissue harmonic imaging (THI) and real-time spatial compounding (RTSC) would result in a significant difference in the rate of detection and quality of visualization of the normal appendix. Subjects were scanned using the experimental method (the combination of THI and RTSC) and the conventional method (without THI and RTSC). The rate of detection was 85% with the experimental method and 66% with the conventional method. The quality of visualization was measured across three scales—visualized length, walls, and lumen—with a total score equal to the sum of the three scales. The experimental method demonstrated a significant difference in visualized length and total score. The mean score for length using the conventional method was 2.18 compared with 2.56 for the experimental method. The mean score for all three scales for the conventional method was 7.97 compared with 8.67 for the experimental method.
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Affiliation(s)
- Ted Scott
- Institute for Applied Health Sciences, Mohawk College, Hamilton, Ontario, Canada,
| | - Hans Swan
- School of Clinical Sciences, Charles Sturt University, Wagga Wagga, Australia
| | | | - M. Voss
- St. Joseph’s Healthcare, Hamilton, Ontario, Canada
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Tseng P, Berdahl C, Kearl YL, Behar S, Cooper J, Dollbaum R, Hardasmalani M, Hardiman K, Rose E, Santillanes G, Lam C, Claudius I. Does Right Lower Quadrant Abdominal Ultrasound Accurately Identify Perforation in Pediatric Acute Appendicitis? J Emerg Med 2016; 50:638-42. [DOI: 10.1016/j.jemermed.2015.10.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Revised: 09/11/2015] [Accepted: 10/05/2015] [Indexed: 11/25/2022]
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Debnath J, George RA, Ravikumar R. Imaging in acute appendicitis: What, when, and why? Med J Armed Forces India 2016; 73:74-79. [PMID: 28123249 DOI: 10.1016/j.mjafi.2016.02.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Accepted: 02/18/2016] [Indexed: 02/07/2023] Open
Abstract
Acute appendicitis (AA) is the commonest cause of pain abdomen requiring surgical intervention. Diagnosis as well as management of acute appendicitis is mired in controversies and contradictions even today. Clinicians often face the dilemma of balancing negative appendectomy rate and perforation rate if the diagnosis is based on clinical scoring alone. Laboratory results are often non-specific. Imaging has an important role not only in diagnosing appendicitis and its complication but also suggesting alternate diagnosis in appropriate cases. However, there is no universally accepted diagnostic imaging algorithm for appendicitis. Imaging of acute appendicitis needs to be streamlined keeping pros and cons of the available investigative modalities. Radiography has practically no role today in the diagnosis and management of acute appendicitis. Ultrasonography (USG) should be the first line imaging modality for all ages, particularly for children and non-obese young adults including women of reproductive age group. If USG findings are unequivocal and correlate with clinical assessment, no further imaging is needed. In case of equivocal USG findings or clinico-radiological dissociation, follow-up/further imaging (computed tomography (CT) scan/magnetic resonance imaging (MRI)) is recommended. In pediatric and pregnant patients with inconclusive initial USG, MRI is the next option. Routine use of CT scan for diagnosis of AA needs to be discouraged. Our proposed version of a practical imaging algorithm, with USG first and always has been incorporated in the article.
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Affiliation(s)
- Jyotindu Debnath
- Professor, Department of Radiodiagnosis, Armed Forces Medical College, Pune 411040, India
| | - R A George
- Senior Adviser (Radiodiagnosis), Command Hospital (Air Force), Bengaluru, India
| | - R Ravikumar
- Professor & Head, Department of Radiodiagnosis, Armed Forces Medical College, Pune 411040, India
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Barber-Millet S, Bueno Lledó J, Granero Castro P, Gómez Gavara I, Ballester Pla N, García Domínguez R. Update on the management of non-obstetric acute abdomen in pregnant patients. Cir Esp 2016; 94:257-65. [PMID: 26875476 DOI: 10.1016/j.ciresp.2015.11.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Revised: 11/03/2015] [Accepted: 11/10/2015] [Indexed: 12/29/2022]
Abstract
Acute abdomen is a rare entity in the pregnant patient, with an incidence of one in 500-635 patients. Its appearance requires a quick response and an early diagnosis to treat the underlying disease and prevent maternal and fetal morbidity. Imaging tests are essential, due to clinical and laboratory masking in this subgroup. Appendicitis and complicated biliary pathology are the most frequent causes of non-obstetric acute abdomen in the pregnant patient. The decision to operate, the timing, and the surgical approach are essential for a correct management of this pathology. The aim of this paper is to perform a review and update on the diagnosis and treatment of non-obstetric acute abdomen in pregnancy.
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Affiliation(s)
| | - José Bueno Lledó
- Servicio de Cirugía, Hospital Universitari i Politècnic La Fe, Valencia, España
| | | | | | - Neus Ballester Pla
- Servicio de Cirugía, Hospital Universitari i Politècnic La Fe, Valencia, España
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Gangadhar K, Kielar A, Dighe MK, O’Malley R, Wang C, Gross JA, Itani M, Lalwani N. Multimodality approach for imaging of non-traumatic acute abdominal emergencies. Abdom Radiol (NY) 2016; 41:136-48. [PMID: 26830620 DOI: 10.1007/s00261-015-0586-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
"Acute abdomen" includes spectrum of medical and surgical conditions ranging from a less severe to life-threatening conditions in a patient presenting with severe abdominal pain that develops over a period of hours. Accurate and rapid diagnosis of these conditions helps in reducing related complications. Clinical assessment is often difficult due to availability of over-the-counter analgesics, leading to less specific physical findings. The key clinical decision is to determine whether surgical intervention is required. Laboratory and conventional radiographic findings are often non-specific. Thus, cross-sectional imaging plays a pivotal role for helping direct management of acute abdomen. Computed tomography is the primary imaging modality used for these cases due to fast image acquisition, although US is more specific for conditions such as acute cholecystitis. Magnetic resonance imaging or ultrasound is very helpful in patients who are particularly sensitive to radiation exposure, such as pregnant women and pediatric patients. In addition, MRI is an excellent problem-solving modality in certain conditions such as assessment for choledocholithiasis in patients with right upper quadrant pain. In this review, we discuss a multimodality approach for the usual causes of non-traumatic acute abdomen including acute appendicitis, diverticulitis, cholecystitis, and small bowel obstruction. A brief review of other relatively less frequent but important causes of acute abdomen, such as perforated viscus and bowel ischemia, is also included.
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The challenging ultrasound diagnosis of perforated appendicitis in children: constellations of sonographic findings improve specificity. Pediatr Radiol 2015; 45:820-30. [PMID: 25471754 DOI: 10.1007/s00247-014-3232-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Revised: 08/22/2014] [Accepted: 11/04/2014] [Indexed: 01/07/2023]
Abstract
BACKGROUND Rapid and accurate diagnosis of appendicitis, particularly with respect to the presence or absence of perforation, is essential in guiding appropriate management. Although many studies have explored sonographic findings associated with acute appendicitis, few investigations discuss specific signs that can reliably differentiate perforated appendicitis from acute appendicitis prior to abscess formation. OBJECTIVE The purpose of our study was to identify sonographic findings that improve the specificity of US in the diagnosis of perforated appendicitis. Our assessment of hepatic periportal echogenicity, detailed analysis of intraperitoneal fluid, and formulation of select constellations of sonographic findings expands upon the literature addressing this important diagnostic challenge. MATERIALS AND METHODS We retrospectively reviewed 116 abdominal US examinations for evaluation of abdominal pain in children ages 2 to 18 years from January 2008 to September 2011 at a university hospital pediatric radiology department. The study group consisted of surgical and pathology proven acute appendicitis (n = 51) and perforated appendicitis (n = 22) US exams. US exams without a sonographic diagnosis of appendicitis (n = 43) confirmed by follow-up verbal communication were included in the study population as the control group. After de-identification, the US exams were independently reviewed on a PACS workstation by four pediatric radiologists blinded to diagnosis and all clinical information. We recorded the presence of normal or abnormal appendix, appendicolith, appendiceal wall vascularity, thick-walled bowel, dilated bowel, right lower quadrant (RLQ) echogenic fat, increased hepatic periportal echogenicity, bladder debris and abscess or loculated fluid. We also recorded the characteristics of intraperitoneal fluid, indicating the relative quantity (number of abdominal regions) and quality of the fluid (simple fluid or complex fluid). We used logistic regression for correlated data to evaluate the association of diagnosis with the presence versus absence of each US finding. We conducted multivariable analysis to identify constellations of sonographic findings that were predictive of perforated appendicitis. RESULTS The individual US findings of abscess/loculated fluid, appendicolith, dilated bowel and increased hepatic periportal echogenicity were significantly associated with perforated appendicitis when compared with acute appendicitis (P < 0.01). The sonographic observation of increased hepatic periportal echogenicity demonstrated a statistically significant association with perforated appendicitis compared with acute appendicitis (P < 0.01). The presence of complex fluid yielded a specificity of 87.7% for perforated appendicitis compared with the acute appendicitis group. The US findings of ≥2 regions or ≥3 regions with fluid had specificity of 87.3% and 99.0%, respectively, for perforated appendicitis compared with the acute appendicitis group. Select combinations of sonographic findings yielded high specificity in the diagnosis of perforated appendicitis compared with acute appendicitis. These constellations yielded higher specificity than that of each individual finding in isolation. The constellation of dilated bowel, RLQ echogenic fat, and complex fluid had the highest specificity (99.5%) for perforated appendicitis (P < 0.01). CONCLUSION Our study demonstrates that identification of select constellations of findings using abdominal sonography, in addition to focused US examination of the right lower quadrant, can improve sonographic diagnosis of perforated appendicitis in the pediatric population.
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Journal Club: the Alvarado score as a method for reducing the number of CT studies when appendiceal ultrasound fails to visualize the appendix in adults. AJR Am J Roentgenol 2015; 204:519-26. [PMID: 25714280 DOI: 10.2214/ajr.14.12864] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE. The purpose of this article is to evaluate the hypothesis that Alvarado scores of 3 or lower identify adult patients who are unlikely to benefit from CT after appendiceal ultrasound fails to show the appendix and is otherwise normal. MATERIALS AND METHODS. We identified 119 consecutive adults for whom the appendix was not seen on otherwise normal appendiceal sonography performed as the first imaging study for suspected appendicitis, who subsequently underwent CT within 48 hours, and whose data permitted retrospective calculation of admission Alvarado scores. Specific benefits of CT were defined as diagnoses of appendicitis or significant alternative findings, and specific benefits were compared between patients with Alvarado scores of 3 or less and 4 or higher. Significant alternative findings on CT were findings other than appendicitis that were treated with medical or surgical therapy during the admission or that were to be addressed during follow-up care. Diagnostic reference standards were discharge diagnoses, pathologic examinations, and clinical follow-up. RESULTS. No patients (0.0%, 0/49) with Alvarado scores 3 or lower had appendicitis, compared with 17.1% (12/70) of patients with Alvarado scores 4 or higher (p = 0.001), and CT showed neither appendicitis nor significant alternative findings in 85.7% (42/49) versus 58.6% (41/70) of these patients, respectively (p = 0.002). The rates of perforated appendicitis, as well as significant alternative CT findings, did not differ significantly. CONCLUSION. Adults with Alvarado scores 3 or lower who have nonvisualized appendixes and otherwise normal appendiceal sonography are at very low risk for appendicitis or significant alternative findings and therefore are not likely to benefit from CT.
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Schuh S, Chan K, Langer JC, Kulik D, Preto-Zamperlini M, Aswad NA, Man C, Mohanta A, Stephens D, Doria AS. Properties of serial ultrasound clinical diagnostic pathway in suspected appendicitis and related computed tomography use. Acad Emerg Med 2015; 22:406-14. [PMID: 25808065 DOI: 10.1111/acem.12631] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 07/24/2014] [Accepted: 11/26/2014] [Indexed: 12/16/2022]
Abstract
OBJECTIVES The primary objective was to determine the diagnostic accuracy of a serial ultrasound (US) clinical diagnostic pathway to detect appendicitis in children presenting to the emergency department (ED). The secondary objective was to examine the diagnostic performance of the initial and interval US and to compare the accuracy of the pathway to that of the initial US. METHODS This was a prospective cohort study of 294 previously healthy children 4 to 17 years old with suspected appendicitis and baseline pediatric appendicitis scores of ≥2, who were managed with the serial US clinical diagnostic pathway. This pathway consisted of an initial US followed by a clinical reassessment in each patient and an interval US and surgical consultation in patients with equivocal initial US and persistent concern about appendicitis. The USs were interpreted by published criteria as positive, negative, or equivocal for appendicitis. Children in whom this pathway did not rule in or rule out appendicitis underwent computed tomography (CT). Cases with missed appendicitis, negative operations, and CTs after the pathway were considered inaccurate. The primary outcome was the diagnostic accuracy of the serial US clinical diagnostic pathway. The secondary outcomes included the test performance of the initial and interval US imaging studies. RESULTS Of the 294 study children, 111 (38%) had appendicitis. Using the serial US clinical diagnostic pathway, 274 of 294 children (93%, 95% confidence interval [CI] = 90% to 96%) had diagnostically accurate results: 108 of the 111 (97%) appendicitis cases were successfully identified by the pathway without CT scans (two missed and one CT), and 166 of the 183 (91%) negative cases were ruled out without CT scans (14 negative operations and three CTs). The sensitivity of this pathway was 108 of 111 (97%, 95% CI = 94% to 100%), specificity 166 of 183 (91%, 95% CI = 87% to 95%), positive predictive value 108 of 125 (86%; 95% CI = 79% to 92%), and negative predictive value 166 of 169 (98%, 95% CI = 96% to 100%). The diagnostic accuracy of the pathway was higher than that of the initial US alone (274 of 294 vs. 160 of 294; p < 0.0001). Of 123 patients with equivocal initial US, concern about appendicitis subsided on clinical reassessment in 73 (no surgery and no missed appendicitis). Of 50 children with persistent symptoms, 40 underwent interval US and 10 had surgical consultation alone. The interval US confirmed or ruled out appendicitis in 22 of 40 children (55.0%) with equivocal initial US, with one false-positive interval US. CONCLUSIONS The serial US clinical diagnostic pathway in suspected appendicitis has an acceptable diagnostic accuracy that is significantly higher than that of the initial US and results in few CT scans. This approach appears most useful in children with equivocal initial US, in whom the majority of negative cases were identified at clinical reassessment and appendicitis was diagnosed by interval US or surgical consultation in most study patients.
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Affiliation(s)
- Suzanne Schuh
- Division of Pediatric Emergency Medicine; University of Toronto; Toronto Ontario Canada
- Department of Pediatrics; University of Toronto; Toronto Ontario Canada
- Research Institute; University of Toronto; Toronto Ontario Canada
| | - Kevin Chan
- Division of Pediatric Emergency Medicine; University of Toronto; Toronto Ontario Canada
| | - Jacob C. Langer
- Department of Surgery; University of Toronto; Toronto Ontario Canada
| | - Dina Kulik
- Division of Pediatric Emergency Medicine; University of Toronto; Toronto Ontario Canada
| | | | - Nadine Al Aswad
- Division of Diagnostic Imaging; The Hospital for Sick Children; University of Toronto; Toronto Ontario Canada
| | - Carina Man
- Division of Diagnostic Imaging; The Hospital for Sick Children; University of Toronto; Toronto Ontario Canada
| | - Arun Mohanta
- Division of Diagnostic Imaging; The Hospital for Sick Children; University of Toronto; Toronto Ontario Canada
| | - Derek Stephens
- Research Institute; University of Toronto; Toronto Ontario Canada
| | - Andrea S. Doria
- Division of Diagnostic Imaging; The Hospital for Sick Children; University of Toronto; Toronto Ontario Canada
- Research Institute; University of Toronto; Toronto Ontario Canada
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Piyarom P, Kaewlai R. False-negative appendicitis at ultrasound: nature and association. ULTRASOUND IN MEDICINE & BIOLOGY 2014; 40:1483-1489. [PMID: 24768483 DOI: 10.1016/j.ultrasmedbio.2014.02.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Revised: 02/05/2014] [Accepted: 02/08/2014] [Indexed: 06/03/2023]
Abstract
The objective was to describe nature and factors associated with false-negative ultrasound (US) for adult appendicitis. Patients with pathologically proven appendicitis and pre-operative US from January 2011 to May 2013 were included in this retrospective case-control study. They were divided into true-positive and false-negative groups, matched by age and gender. There were 112 patients (40 men, mean age = 40 y, 56 true positives) included. Two factors were found differ significantly: abdominal wall thickness and pain score. Greater abdominal wall thickness (18.6 mm vs. 14.9 mm, p = 0.001) and lower pain score (6.6 vs. 7.5, p = 0.018) were statistically associated with false negativity. The two groups did not differ significantly in terms of weight, height, body mass index, symptom duration, Alvarado score, US examination time, appendix position/size, perforation rate and operator. In conclusion, lower pain score and increased abdominal wall thickness are associated with false negativity in US examinations.
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Affiliation(s)
- Patwadee Piyarom
- Department of Radiology, Ramathibodi Hospital and Mahidol University, 270 Rama VI Rd, Ratchatewi, Bangkok 10400, Thailand
| | - Rathachai Kaewlai
- Department of Radiology, Ramathibodi Hospital and Mahidol University, 270 Rama VI Rd, Ratchatewi, Bangkok 10400, Thailand.
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Leeuwenburgh MMN, Stockmann HBAC, Bouma WH, Houdijk APJ, Verhagen MF, Vrouenraets B, Cobben LPJ, Bossuyt PMM, Stoker J, Boermeester MA. A simple clinical decision rule to rule out appendicitis in patients with nondiagnostic ultrasound results. Acad Emerg Med 2014; 21:488-96. [PMID: 24842498 DOI: 10.1111/acem.12374] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2013] [Revised: 12/19/2013] [Accepted: 12/20/2013] [Indexed: 01/14/2023]
Abstract
OBJECTIVES The objective was to identify a set of clinical features that can rule out appendicitis in patients with suspected acute appendicitis and nondiagnostic ultrasound (US) results, allowing safe discharge and next-day reevaluation without initial computed tomography (CT) or magnetic resonance imaging (MRI). METHODS Data on clinical and US evaluation, including a number of prespecified variables potentially associated with acute appendicitis, were prospectively collected in two diagnostic accuracy studies of imaging. These studies included patients with suspected appendicitis seen in the emergency department (ED). For development and validation of the clinical decision rule (CDR), only patients with inconclusive or negative US results were included. There were 199 (of 422) patients in the development cohorts and 120 (of 211) patients in the validation cohort. Logistic regression analysis was used for data from patients with inconclusive or negative US results, and profiles were created of all possible combinations of predictors retained in the multivariable model. A final diagnosis was assigned by an expert panel based on perioperative data, histopathology, and clinical follow-up of at least 3 months. RESULTS The CDR selected patients after negative or inconclusive US for discharge and next-day reevaluation without initial CT or MRI if fewer than two of the following predictors were present: male sex, migration of pain to the right lower quadrant, vomiting, and white blood cell (WBC) count higher than 12.0 × 10(9) /L. Applying the CDR in the development set selected 126 of 199 (63%) patients with negative or inconclusive US results for discharge without further imaging. This rule reduced the probability of appendicitis from 26% (51 of 199) in the total group of patients with negative or inconclusive US results to 12% (15 of 126) in the group that would be discharged based on the rule (p = 0.001). In the validation set (n = 120), the decision rule selected 72 (60%) patients for discharge and next-day reevaluation and reduced the probability of appendicitis from 20% (24 of 120) in the total group to 6% (4 of 72) in the patients selected on the rule (p = 0.001). The negative predictive value of the decision rule in the validation set was 94% (95% confidence interval [CI] = 87% to 98%). In comparison, the negative predictive value of CT in the same group was 99% (95% CI = 93% to 100%, p = 0.14), and that of MRI was 99% (95% CI = 94% to 100%, p = 0.12). Alternative decision rules based on combinations of the present decision rule with C-reactive protein (CRP) results did not improve selection. CONCLUSIONS This newly developed CDR significantly reduces the probability of appendicitis in a large subgroup of patients with negative or inconclusive US results. These patients can be safely discharged for outpatient reevaluation without further initial imaging if proper follow-up is available. This could assist in lowering the number of ED imaging investigations in patients with suspected appendicitis.
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Affiliation(s)
- Marjolein M. N. Leeuwenburgh
- The Department of Radiology; Academic Medical Center; University of Amsterdam; Amsterdam
- The Department of Surgery; Academic Medical Center; University of Amsterdam; Amsterdam
| | | | - Wim H. Bouma
- The Department of Surgery; Gelre Hospitals; Apeldoorn
| | | | | | - Bart Vrouenraets
- The Department of Surgery; Sint Lucas Andreas Hospital; Amsterdam
| | - Lodewijk P. J. Cobben
- The Department of Radiology; Haaglanden Medical Center; Leidschendam the Netherlands
| | - Patrick M. M. Bossuyt
- The Department of Clinical Epidemiology; Academic Medical Center; University of Amsterdam; Amsterdam
| | - Jaap Stoker
- The Department of Radiology; Academic Medical Center; University of Amsterdam; Amsterdam
| | - Marja A. Boermeester
- The Department of Surgery; Academic Medical Center; University of Amsterdam; Amsterdam
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Toprak H, Kilincaslan H, Ahmad IC, Yildiz S, Bilgin M, Sharifov R, Acar M. Integration of ultrasound findings with Alvarado score in children with suspected appendicitis. Pediatr Int 2014; 56:95-9. [PMID: 23937630 DOI: 10.1111/ped.12197] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Revised: 07/07/2013] [Accepted: 08/05/2013] [Indexed: 12/29/2022]
Abstract
BACKGROUND The aim of this study was to investigate the integration of ultrasound (US) findings with Alvarado score in diagnosing or excluding acute appendicitis. METHODS Data were analyzed in 122 pediatric patients with suspected appendicitis who had undergone US. The US findings were classified into four groups, and the patients were classified into three groups according to Alvarado score. US results and Alvarado score were compared. RESULTS Alvarado score was a good predictor of appendicitis for scores ≥7. CONCLUSION In the case of non-visualization of the appendix without a high Alvarado score, appendicitis can be safely ruled out.
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Affiliation(s)
- Huseyin Toprak
- Department of Radiology, Bezmialem Vakif University, Istanbul, Turkey
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Elikashvili I, Tay ET, Tsung JW. The effect of point-of-care ultrasonography on emergency department length of stay and computed tomography utilization in children with suspected appendicitis. Acad Emerg Med 2014; 21:163-70. [PMID: 24673672 DOI: 10.1111/acem.12319] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Revised: 07/29/2013] [Accepted: 09/11/2013] [Indexed: 01/21/2023]
Abstract
OBJECTIVES The role of clinician-performed ultrasonography (US) for suspected appendicitis is unclear. Published data conclude that US has high specificity to rule in the diagnosis of appendicitis, with variable sensitivity to rule it out. Newer data suggest that point-of-care (POC) US may have similar test characteristics. Our objective was to evaluate the effect of POC US in children with suspected appendicitis and its effect on emergency department (ED) length of stay (LOS) and computed tomography (CT) utilization. METHODS This was a prospective observational convenience sample of children with suspected appendicitis requiring imaging evaluation that adhered to the Standards for the Reporting of Diagnostic accuracy studies (STARD) criteria. Outcomes were determined by operative or pathology report in those who had appendicitis, and 3-week phone follow-up in those patients who were nonoperative. Differences in ED LOS were analyzed by one-way analysis of variance (ANOVA) between patients who received dispositions after POC US, radiology US, or CT. Test performance characteristics were calculated for all imaging modalities. RESULTS Among 150 enrolled patients, 50 had appendicitis (33.3%). There were no missed cases of appendicitis in discharged patients at 3-week phone follow-up, nor negative laparotomies in those who went to the operating room. Those who had dispositions after POC US (n = 25) had a significantly decreased mean ED LOS (154 minutes, 95% confidence interval [CI] = 115 to 193 minutes) compared with those requiring radiology US (288 minutes, 95% CI = 257 to 319 minutes) or CT scan (487 minutes; 95% CI = 434 to 540 minutes). Baseline CT rate was 44.2% (95% CI = 30.7% to 57.7%) prior to study start and decreased to 27.3% (95% CI = 20.17% to 34.43%) during the study. CTs were avoided in four patients with conclusive POC US results and inconclusive radiology US results. The sensitivity, specificity, positive likelihood ratio (LR+), and negative likelihood ratio (LR-) for POC US were 60% (95% CI = 46% to 72%), 94% (95% CI = 88% to 97%), 10 (95% CI = 4 to 23), and 0.4 (95% CI = 0.3 to 0.6). For radiology US they were 63% (95% CI = 48% to 75%), 99% (95% CI = 94% to 99%), 94 (95% CI = 6 to 1,500), and 0.4 (95% CI = 0.3 to 0.6); and for CT they were 83% (95% CI = 58% to 95%), 98% (95% CI = 85% to 99%), 45 (95% CI = 3 to 707), and 0.2 (95% CI = 0.05 to 0.5). CONCLUSIONS It may be feasible to reduce ED LOS and avoid CT scan when using POC US to evaluate children with suspected appendicitis. Test characteristics for POC US have high specificity to rule in appendicitis, similar to radiology US. Addition of POC US prior to sequential radiology imaging was safe, without missed cases of appendicitis or negative laparotomies.
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Affiliation(s)
- Inna Elikashvili
- Departments of Emergency Medicine and Pediatrics; Divisions of Pediatric Emergency Medicine; Mount Sinai School of Medicine; New York NY
| | - Ee Tein Tay
- Departments of Emergency Medicine and Pediatrics; Divisions of Pediatric Emergency Medicine; Mount Sinai School of Medicine; New York NY
- Emergency Ultrasound; Mount Sinai School of Medicine; New York NY
| | - James W. Tsung
- Departments of Emergency Medicine and Pediatrics; Divisions of Pediatric Emergency Medicine; Mount Sinai School of Medicine; New York NY
- Emergency Ultrasound; Mount Sinai School of Medicine; New York NY
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Huang TH, Huang YC, Tu CW. Acute appendicitis or not: Facts and suggestions to reduce valueless surgery. J Acute Med 2013. [DOI: 10.1016/j.jacme.2013.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Leeuwenburgh MMN, Wiezer MJ, Wiarda BM, Bouma WH, Phoa SSKS, Stockmann HBAC, Jensch S, Bossuyt PMM, Boermeester MA, Stoker J. Accuracy of MRI compared with ultrasound imaging and selective use of CT to discriminate simple from perforated appendicitis. Br J Surg 2013; 101:e147-55. [PMID: 24272981 DOI: 10.1002/bjs.9350] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2013] [Indexed: 01/05/2023]
Abstract
BACKGROUND Discrimination between simple and perforated appendicitis in patients with suspected appendicitis may help to determine the therapy, timing of surgery and risk of complications. The aim of this study was to estimate the accuracy of magnetic resonance imaging (MRI) in distinguishing between simple and perforated appendicitis, and to compare MRI against ultrasound imaging with selected additional (conditional) use of computed tomography (CT). METHODS Patients with clinically suspected appendicitis were identified prospectively at the emergency department of six hospitals. Consenting patients underwent MRI, but were managed based on findings at ultrasonography and conditional CT. Radiologists who evaluated the MRI were blinded to the results of ultrasound imaging and CT. The presence of perforated appendicitis was recorded after each evaluation. The final diagnosis was assigned by an expert panel based on perioperative data, histopathology and clinical follow-up after 3 months. RESULTS MRI was performed in 223 of 230 included patients. Acute appendicitis was the final diagnosis in 118 of 230 patients, of whom 87 had simple and 31 perforated appendicitis. MRI correctly identified 17 of 30 patients with perforated appendicitis (sensitivity 57 (95 per cent confidence interval 39 to 73) per cent), whereas ultrasound imaging with conditional CT identified 15 of 31 (sensitivity 48 (32 to 65) per cent) (P = 0.517). All missed diagnoses of perforated appendicitis were identified as simple acute appendicitis with both imaging protocols. None of the MRI features for perforated appendicitis had a positive predictive value higher than 53 per cent. CONCLUSION MRI is comparable to ultrasonography with conditional use of CT in identifying perforated appendicitis. However, both strategies incorrectly classify up to half of all patients with perforated appendicitis as having simple appendicitis. Triage of appendicitis based on imaging for conservative treatment is inaccurate and may be considered unsafe for decision-making. Presented to a scientific meeting of the Association of Surgeons of the Netherlands, Veldhoven, The Netherlands, May 2012; published in abstract form as Br J Surg 2012; 99(Suppl 7): S6.
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Affiliation(s)
- M M N Leeuwenburgh
- Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands; Department of Radiology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
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Calabrese E, Zorzi F, Visconti E, De Angelis G, Cerretti R, Del Vecchio Blanco G, Picardi A, Cudillo L, Postorino M, Franceschini L, Biancone L, Arcese W, Pallone F. Bowel ultrasonography as an aid for diagnosis of intestinal acute graft-versus-host-disease after allogeneic haematopoietic stem cell transplantation. Dig Liver Dis 2013; 45:899-904. [PMID: 23680035 DOI: 10.1016/j.dld.2013.04.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2012] [Revised: 04/01/2013] [Accepted: 04/10/2013] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Aim of our prospective study was to investigate accuracy of bowel ultrasonography in detecting gastrointestinal acute graft versus host disease (GVHD), when using clinical assessment as gold standard. In a subgroup of patients, bowel ultrasonography was compared with colonoscopy and histology in diagnosing of gastrointestinal acute GVHD. METHODS Fifty-two patients underwent allogeneic hematopoietic stem cell transplantation and developed gastrointestinal symptoms. RESULTS Clinical assessment lead to a diagnosis of gastrointestinal acute GVHD in 17/52 patients, no gastrointestinal acute GVHD was detected in 20/52 patients, while 15 patients were not able to complete the study. Bowel ultrasonography detected either bowel wall thickness of the ileum and the colon or dilation in 16/17 patients and showed 94% sensitivity (95% CI 0.69-0.99), 95% specificity (95% CI 0.73-0.99), and 94.5% accuracy. Colonoscopy was performed in 13/52 patients, showing gastrointestinal acute GVHD in 11/13. In these 11 patients, histology confirmed the diagnosis of gastrointestinal acute GVHD, and bowel ultrasonography detected findings compatible with gastrointestinal acute GVHD in all 11 patients, and was negative in the 2 patients with no gastrointestinal acute GVHD. CONCLUSION Bowel ultrasonography can be considered a valuable tool to add to clinical assessment for patients with suspected gastrointestinal acute GVHD for addressing a prompt and appropriate treatment.
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Affiliation(s)
- Emma Calabrese
- Gastroenterology Unit, Department of Systems Medicine, University of Rome "Tor Vergata", Italy.
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Helou N, Abdalkader M, Abu-Rustum RS. Sonography: first-line modality in the diagnosis of acute colonic diverticulitis? JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2013; 32:1689-1694. [PMID: 24065248 DOI: 10.7863/ultra.32.10.1689] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Affiliation(s)
- Nabil Helou
- Center for Advanced Fetal Care, Najah Center, First Floor, Aasheer Al Dayeh Street, Tripoli, Lebanon.,
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Mazzei MA, Guerrini S, Cioffi Squitieri N, Cagini L, Macarini L, Coppolino F, Giganti M, Volterrani L. The role of US examination in the management of acute abdomen. Crit Ultrasound J 2013; 5 Suppl 1:S6. [PMID: 23902801 PMCID: PMC3711740 DOI: 10.1186/2036-7902-5-s1-s6] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Acute abdomen is a medical emergency, in which there is sudden and severe pain in abdomen of recent onset with accompanying signs and symptoms that focus on an abdominal involvement. It can represent a wide spectrum of conditions, ranging from a benign and self-limiting disease to a surgical emergency. Nevertheless, only one quarter of patients who have previously been classified with an acute abdomen actually receive surgical treatment, so the clinical dilemma is if the patients need surgical treatment or not and, furthermore, in which cases the surgical option needs to be urgently adopted. Due to this reason a thorough and logical approach to the diagnosis of abdominal pain is necessary. Some Authors assert that the location of pain is a useful starting point and will guide a further evaluation. However some causes are more frequent in the paediatric population (like appendicitis or adenomesenteritis) or are strictly related to the gender (i.e. gynaechologic causes). It is also important to consider special populations such as the elderly or oncologic patients, who may present with atypical symptoms of a disease. These considerations also reflect a different diagnostic approach. Today, surely the integrated imaging, and in particular the use of multidetector Computed Tomography (MDCT) has revolutionised the clinical approach to this condition, simplyfing the diagnosis but burdening the radiologists with the problems related to the clinical management. However although CT emerging as a modality of choice for evaluation of the acute abdomen, ultrasonography (US) remains the primary imaging technique in the majority of cases, especially in young and female patients, when the limitation of the radiation exposure should be mandatory, limiting the use of CT in cases of nondiagnostic US and in all cases where there is a discrepancy between the clinical symptoms and negative imaging at US.
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Affiliation(s)
- Maria Antonietta Mazzei
- Department of Medical, Surgical and Neuro Sciences, Section of Radiological Sciences, Siena, Italy.
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Sibileau E, Boulay-Coletta I, Jullès MC, Benadjaoud S, Oberlin O, Zins M. Appendicitis and diverticulitis of the colon: Misleading forms. Diagn Interv Imaging 2013; 94:771-92. [PMID: 23759294 DOI: 10.1016/j.diii.2013.03.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Roccarina D, Garcovich M, Ainora ME, Caracciolo G, Ponziani F, Gasbarrini A, Zocco MA. Diagnosis of bowel diseases: The role of imaging and ultrasonography. World J Gastroenterol 2013; 19:2144-2153. [PMID: 23599640 PMCID: PMC3627878 DOI: 10.3748/wjg.v19.i14.2144] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Revised: 11/28/2012] [Accepted: 12/25/2012] [Indexed: 02/06/2023] Open
Abstract
Examinations with a visualisation of the anatomy and pathology of the gastrointestinal (GI) tract are often necessary for the diagnosis of GI diseases. Traditional radiology played a crucial role for many years. Endoscopy, despite some limitations, remains the main technique in the differential diagnosis and treatment of GI diseases. In the last decades, the introduction of, and advances in, non-invasive cross-sectional imaging modalities, including ultrasound (US), computed tomography (CT), positron-emission tomography (PET), and magnetic resonance imaging, as well as improvements in the resolution of imaging data, the acquisition of 3D images, and the introduction of contrast-enhancement, have modified the approach to the examination of the GI tract. Moreover, additional co-registration techniques, such as PET-CT and PET-MRI, allow multimodal data acquisition with better sensitivity and specificity in the study of tissue pathology. US has had a growing role in the development and application of the techniques for diagnosis and management of GI diseases because it is inexpensive, non-invasive, and more comfortable for the patient, and it has sufficient diagnostic accuracy to provide the clinician with image data of high temporal and spatial resolution. Moreover, Doppler and contrast-enhanced ultrasound (CEUS) add important information about blood flow. This article provides a general review of the current literature regarding imaging modalities used for the evaluation of bowel diseases, highlighting the role of US and recent developments in CEUS.
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Rapp EJ, Naim F, Kadivar K, Davarpanah A, Cornfeld D. Integrating MR imaging into the clinical workup of pregnant patients suspected of having appendicitis is associated with a lower negative laparotomy rate: single-institution study. Radiology 2013; 267:137-144. [PMID: 23360736 DOI: 10.1148/radiol.12121027] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
PURPOSE To determine if integrating magnetic resonance (MR) imaging into the workup of right lower quadrant pain in pregnant patients was associated with improved outcomes as measured by the negative laparotomy rate (NLR) and the perforation rate (PR). MATERIALS AND METHODS Institutional review board approval was obtained for this retrospective review of medical records. Two hundred sixty-seven pregnant patients who underwent either surgery (n = 82) or an MR imaging examination (n = 217) because of suspicion of appendicitis between January 1, 1996, and August 31, 2011, were identified. Relevant ultrasonographic and MR imaging reports were classified as showing true-positive, false-positive, true-negative, false-negative, or equivocal findings. MR imaging utilization was analyzed to define pre- and post-MR imaging cohorts. NLR and PR were calculated for both cohorts and were compared by using a Fisher exact probability test. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for MR imaging were calculated. RESULTS MR imaging was introduced into the clinical workup in 2004. From 1996 to 2003, the NLR for pregnant patients was 55% (17 of 31), and the PR was 21% (three of 14). From 2004 to 2011, the NLR was 29% (15 of 51), and the PR was 26% (nine of 35). The 47% decline in the NLR ([55%-29%]/55%) was statistically significant (P = .02). The change in PR was not significant (P > .99). The sensitivity, specificity, PPV, and NPV of MR imaging in the diagnosis of appendicitis were 89% (17 of 19), 97% (187 of 193), 74% (17 of 23), and 99% (187 of 189), respectively. CONCLUSION The routine incorporation of MR imaging into the clinical workup for suspicion of appendicitis in pregnant patients at this institution was associated with a decrease in the NLR of 47% without a significant change in the PR. SUPPLEMENTAL MATERIAL http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.12121027/-/DC1.
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Affiliation(s)
- Elliot J Rapp
- Department of Internal Medicine, Cambridge Hospital, Cambridge, Mass, USA
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Jin Ong S, Whitley S, Safar-Aly H, Borgstein R. Imaging the patient with suspected appendicitis. Br J Hosp Med (Lond) 2013; 73:C178-82. [PMID: 23519064 DOI: 10.12968/hmed.2012.73.sup12.c178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Shao Jin Ong
- Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
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Stewart JK, Olcott EW, Jeffrey RB. Sonography for appendicitis: nonvisualization of the appendix is an indication for active clinical observation rather than direct referral for computed tomography. JOURNAL OF CLINICAL ULTRASOUND : JCU 2012; 40:455-461. [PMID: 22638942 DOI: 10.1002/jcu.21928] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2011] [Accepted: 03/16/2012] [Indexed: 06/01/2023]
Abstract
PURPOSE To determine the prevalence of perforated and nonperforated appendicitis in patients with nonvisualization of the appendix on ultrasound (US) performed for suspected appendicitis, and to evaluate the value of CT in these patients. METHODS We analyzed 400 consecutive patients undergoing US for suspected appendicitis. Of these patients, 260 had nonvisualization of the appendix, but otherwise normal scans. We analyzed the clinical outcome in these patients to determine the prevalence of appendicitis, referrals for CT, and the contribution of CT in these patients. RESULTS Of the 400 patients, 140 (35%) had either a normal (80 patients, 25%) or an abnormal appendix (60 patients, 15%); 260 (65%) had nonvisualization of the appendix. Overall 75 patients had appendicitis (18.8%) and 17 (4.3%) had appendicitis with perforation. Of the 260 patients with nonvisualization of the appendix, 14 patients (5.4%) had appendicitis and 2 were perforated (0.8%). The prevalence of perforated and nonperforated appendicitis in this group was significantly lower than the overall group (p < 0.001 and p < 0.01, respectively). Of these 260 patients, 101 patients (38.8%) had CT within 48 hours and 79 (78.2%) had normal scans. CONCLUSIONS Patients with nonvisualization of the appendix on US, but otherwise normal scans, are at significantly lower risk for appendicitis, either perforated or nonperforated. Active clinical observation should be considered in these patients, rather than direct referral for CT.
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Affiliation(s)
- Jessica K Stewart
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
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Varadhan KK, Neal KR, Lobo DN. Safety and efficacy of antibiotics compared with appendicectomy for treatment of uncomplicated acute appendicitis: meta-analysis of randomised controlled trials. BMJ 2012; 344:e2156. [PMID: 22491789 PMCID: PMC3320713 DOI: 10.1136/bmj.e2156] [Citation(s) in RCA: 250] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/23/2012] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To compare the safety and efficacy of antibiotic treatment versus appendicectomy for the primary treatment of uncomplicated acute appendicitis. DESIGN Meta-analysis of randomised controlled trials. POPULATION Randomised controlled trials of adult patients presenting with uncomplicated acute appendicitis, diagnosed by haematological and radiological investigations. INTERVENTIONS Antibiotic treatment versus appendicectomy. OUTCOME MEASURES The primary outcome measure was complications. The secondary outcome measures were efficacy of treatment, length of stay, and incidence of complicated appendicitis and readmissions. RESULTS Four randomised controlled trials with a total of 900 patients (470 antibiotic treatment, 430 appendicectomy) met the inclusion criteria. Antibiotic treatment was associated with a 63% (277/438) success rate at one year. Meta-analysis of complications showed a relative risk reduction of 31% for antibiotic treatment compared with appendicectomy (risk ratio (Mantel-Haenszel, fixed) 0.69 (95% confidence interval 0.54 to 0.89); I(2)=0%; P=0.004). A secondary analysis, excluding the study with crossover of patients between the two interventions after randomisation, showed a significant relative risk reduction of 39% for antibiotic therapy (risk ratio 0.61 (0.40 to 0.92); I(2)=0%; P=0.02). Of the 65 (20%) patients who had appendicectomy after readmission, nine had perforated appendicitis and four had gangrenous appendicitis. No significant differences were seen for treatment efficacy, length of stay, or risk of developing complicated appendicitis. CONCLUSION Antibiotics are both effective and safe as primary treatment for patients with uncomplicated acute appendicitis. Initial antibiotic treatment merits consideration as a primary treatment option for early uncomplicated appendicitis.
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Affiliation(s)
- Krishna K Varadhan
- Division of Gastrointestinal Surgery, Nottingham Digestive Diseases Centre NIHR Biomedical Research Unit, Nottingham University Hospitals, Queen's Medical Centre, Nottingham NG7 2UH, UK
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Lehnert BE, Gross JA, Linnau KF, Moshiri M. Utility of ultrasound for evaluating the appendix during the second and third trimester of pregnancy. Emerg Radiol 2012; 19:293-9. [PMID: 22370694 DOI: 10.1007/s10140-012-1029-0] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2012] [Accepted: 02/14/2012] [Indexed: 11/30/2022]
Abstract
This study aims to retrospectively evaluate the right lower quadrant ultrasounds in women presenting during the second or third trimester of pregnancy for the frequency of appendix visualization and accuracy in diagnosing appendicitis. Institutional Review Board approval was obtained for this Health Insurance Portability and Accountability Act-compliant study. We reviewed imaging records from 99 consecutive pregnant women from 2001 to 2011 who presented during the second (≥14 weeks gestation) or third trimester for right lower quadrant ultrasound to evaluate the appendix. Visualization of the appendix as well as the size and compressibility, if identified, were recorded. The medical records and labs related to the initial patient presentation, subsequent management, and follow-up were reviewed for surgical and clinical outcomes. Pathology records were reviewed to determine if appendicitis was present when appendectomy was performed. Patients who underwent appendectomy were considered to have appendicitis based on pathology results, and patients managed non-operatively with symptom improvement and those with a normal appendix at pathology were considered to not have appendicitis. During the study period, 99 women meeting inclusion criteria presented to our institution for right lower quadrant ultrasound to evaluate the appendix during the second or third trimester of pregnancy. The mean gestational age at presentation was 23 weeks (±7 weeks). The mean maternal age was 28 years (±6.6 years). The appendix was not visualized in 97% (96/99) of right lower quadrant ultrasound examinations. Of the three studies in which the appendix was visualized, two were considered positive for appendicitis and one was considered negative. Eight patients in this group ultimately underwent appendectomy, including the two patients with positive right lower quadrant ultrasounds, and appendicitis confirmed at pathology in seven of these cases (87.5%). Right lower quadrant ultrasound successfully demonstrated an abnormal appendix in 28.7% (two of seven) of surgically confirmed cases; however, this technique did not detect appendicitis in 71% (five of seven) of patients with surgically proven disease due to nonvisualization of the appendix. Retrospective review of right lower quadrant ultrasounds performed during the second and third trimester of pregnancy suggests that this modality has limited utility for diagnosing appendicitis due to infrequent visualization of the appendix.
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Affiliation(s)
- Bruce E Lehnert
- Department of Radiology, Harborview Medical Center, University of Washington, Box 359728, 325-9th Avenue, Room 1CT-119, Seattle, WA 98104-2499, USA.
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Jones GE, Kreckler S, Shah A, Stechman MJ, Handa A. Increased use of laparoscopy in acute right iliac fossa pain - is it good for patients? Colorectal Dis 2012; 14:237-42. [PMID: 21689285 DOI: 10.1111/j.1463-1318.2011.02576.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
AIM The use of laparoscopy, with or without appendicectomy, is becoming more common in the management of acute right iliac fossa (RIF) pain, but little is known of the 'unintended' consequences of this change. This study aimed to evaluate the impact of increased use of laparoscopy on the number and type of patients treated surgically and on the rate of negative appendicectomy. METHOD A prospective audit was carried out of admissions to a teaching hospital over two, 3-month periods during 2007 and 2008. The management, investigations and outcome of patients presenting with RIF pain were studied. RESULTS Admissions were stable over the two time-periods. There was a significant increase in the number of laparoscopic operations performed, from 22.5% (14/62) in 2007 to 85.7% (72/84) in 2008 (P < 0.0001), and the percentage of patients undergoing surgery rose from 55.4% (n = 62) in 2007 to 71.2% (n = 84) in 2008 (P < 0.01). In 2008, female patients were more likely to have surgery, an increase from 37.1% to 66.2% (P < 0.001), and were more likely to have a laparoscopic procedure, an increase from 50% to 98% (P < 0.0001). The rate of histologically confirmed appendicitis did not increase significantly (50/122 vs 57/118; P = 0.25), but the number of patients with a normal appendix either left in situ because it was macroscopically normal or found to be histologically normal following excision, increased significantly, from 9.01% in 2007 to 21.2% in 2008 (P < 0.01). The diagnostic value of pelvic ultrasound decreased from 75.6% of examinations in 2007 to 54.5% in 2008 (P = 0.039). CONCLUSION An increase in laparoscopic procedures has resulted in more operations in women, an associated higher negative appendicectomy rate and decreased usefulness of pelvic ultrasound. Increased use of laparoscopy needs to be balanced against the diagnostic benefits of 'negative' laparoscopy.
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Affiliation(s)
- G E Jones
- Department of Surgery, John Radcliffe Hospital, Oxford, UK.
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Danse E, Dragean A. Affections du côlon en situation d’urgence et en réanimation chez le patient adulte : qu’attendre du radiologue ? MEDECINE INTENSIVE REANIMATION 2012. [DOI: 10.1007/s13546-011-0340-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Liu K, Fogg L. Use of antibiotics alone for treatment of uncomplicated acute appendicitis: a systematic review and meta-analysis. Surgery 2011; 150:673-83. [PMID: 22000179 DOI: 10.1016/j.surg.2011.08.018] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2011] [Accepted: 08/18/2011] [Indexed: 12/17/2022]
Abstract
BACKGROUND The use of antibiotics alone in the treatment of uncomplicated acute appendicitis has been controversial. The present report is based on a systematic review and meta-analysis of existing studies that compared antibiotics treatment to appendectomy in patients with uncomplicated acute appendicitis. METHODS A Medline search was performed for studies published between 1970 and 2009. Studies were selected based on specific inclusion and exclusion criteria. Six reports comprised of 1,201 patients were analyzed. RESULTS In patients treated with antibiotics alone, 6.9 ± 4.4% failed to respond and required appendectomy, and acute appendicitis recurred in 14.2 ± 10.6%. One appendectomy patient had a recurrence. A normal appendix was found in 7.3 ± 5.1% of patients at appendectomy. Complications were considerably less likely to occur with antibiotic treatment than with appendectomy. Major surgical complications included enterocutaneous fistula and reoperation. CONCLUSION In some cases, antibiotic treatment may fail, and there is a risk of recurrence. However, surgically treated patients, including those with the potential for spontaneous resolution and those with a normal appendix, are subjected to the risks of operative morbidity and mortality. Antibiotic therapy incurs significantly fewer complications. Prospective randomized studies are urgently needed to conclusively define the roles of appendectomy and antibiotic treatment in the management of uncomplicated acute appendicitis.
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Affiliation(s)
- Katherine Liu
- Department of General Surgery, Rush University Medical Center, Chicago, IL 60612, USA.
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Yiğiter M, Kantarci M, Yalçin O, Yalçin A, Salman AB. Does obesity limit the sonographic diagnosis of appendicitis in children? JOURNAL OF CLINICAL ULTRASOUND : JCU 2011; 39:187-190. [PMID: 21480284 DOI: 10.1002/jcu.20782] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2010] [Accepted: 10/15/2010] [Indexed: 05/30/2023]
Abstract
PURPOSE The purpose of this study is to evaluate whether obesity has a negative impact on the ultrasound (US) visualization of the appendix in children clinically diagnosed with appendicitis. METHODS The medical records and US examinations of 122 children who underwent surgery due to acute or perforated appendicitis between February 2007 and January 2010 were reviewed. The body mass index (BMI) of each child was calculated and children were placed in one of three categories: group 1, underweight (BMI <10th percentile); group 2, normal weight (BMI between 10th and 85th percentiles); and group 3, overweight (BMI >85th percentile). US findings were classified as nonvisualized, normal, or inflamed appendix. The visualization rates of the appendix were compared between the three groups and the diagnostic accuracy of the US examination was calculated based on the histopathological results for each group. RESULTS There was no statistical difference between the three groups with regard to the visualization of the appendix by US. Diagnostic accuracy of US was 90.4%, 80.5%, and 80% in group 1, group 2, and group 3, respectively. CONCLUSION The findings of our study, in contrast to the findings of other reported studies, demonstrate that obesity does not affect the success rate of US in the visualization of the inflamed appendix in children.
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Affiliation(s)
- Murat Yiğiter
- Department of Pediatric Surgery, Ataturk University Faculty of Medicine, Erzurum 25240, Turkey
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