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Marin JR, Lyons TW, Claudius I, Fallat ME, Aquino M, Ruttan T, Daugherty RJ. Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report. Pediatrics 2024; 154:e2024066855. [PMID: 38932719 DOI: 10.1542/peds.2024-066855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/28/2024] [Indexed: 06/28/2024] Open
Abstract
Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging, are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.
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Affiliation(s)
- Jennifer R Marin
- Departments of Pediatrics, Emergency Medicine, & Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Todd W Lyons
- Division of Emergency Medicine, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
| | - Ilene Claudius
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
| | - Mary E Fallat
- The Hiram C. Polk, Jr Department of Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky
| | - Michael Aquino
- Cleveland Clinic Imaging Institute, and Section of Pediatric Imaging, Cleveland Clinic Lerner College of Medicine of Case Western University, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Timothy Ruttan
- Department of Pediatrics, Dell Medical School, The University of Texas at Austin; US Acute Care Solutions, Canton, Ohio
| | - Reza J Daugherty
- Departments of Radiology and Pediatrics, University of Virginia School of Medicine, UVA Health/UVA Children's, Charlottesville, Virginia
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Marin JR, Lyons TW, Claudius I, Fallat ME, Aquino M, Ruttan T, Daugherty RJ. Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report. J Am Coll Radiol 2024; 21:e37-e69. [PMID: 38944445 DOI: 10.1016/j.jacr.2024.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2024]
Abstract
Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging (MRI), are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.
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Affiliation(s)
- Jennifer R Marin
- Departments of Pediatrics, Emergency Medicine, & Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
| | - Todd W Lyons
- Division of Emergency Medicine, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
| | - Ilene Claudius
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
| | - Mary E Fallat
- The Hiram C. Polk, Jr Department of Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky
| | - Michael Aquino
- Cleveland Clinic Imaging Institute, and Section of Pediatric Imaging, Cleveland Clinic Lerner College of Medicine of Case Western University, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Timothy Ruttan
- Department of Pediatrics, Dell Medical School, The University of Texas at Austin; US Acute Care Solutions, Canton, Ohio
| | - Reza J Daugherty
- Departments of Radiology and Pediatrics, University of Virginia School of Medicine, UVA Health/UVA Children's, Charlottesville, Virginia
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Bendib H. Is non-operative treatment of acute appendicitis possible: A narrative review. Afr J Emerg Med 2024; 14:84-90. [PMID: 38617036 PMCID: PMC11010839 DOI: 10.1016/j.afjem.2024.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 03/19/2024] [Accepted: 03/28/2024] [Indexed: 04/16/2024] Open
Abstract
Introduction Acute appendicitis (AA) represents the most frequent surgical emergency. Perforation was long considered the ultimate outcome of AA, prompting appendectomy; which remains the standard treatment. New data have clarified the role of the appendix, justifying conservative treatment. This narrative review aims to summarize the evidence regarding the non-operative treatment (NOT) of AA in adults. Methods The literature search was performed via the PubMed Medline database. Our criteria-based selection resulted in a total of 48 articles for review. Results Recent trials and meta-analyses have assessed NOT, which support primary antibiotic treatment of uncomplicated AA. Although it has a significant recurrence and failure rate, NOT does not appear to increase the risk of appendicular perforation. Moreover, NOT compared with appendectomy, seems to be associated with less morbidity, lower cost of care and preserved quality of life. Conclusion First-line NOT seems to be a reasonable approach for the treatment of uncomplicated CT-confirmed AA. Careful patient screening would definitely enhance the success rate.
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Affiliation(s)
- Hani Bendib
- Department of General Surgery, EPH Kouba, Algiers, Algeria
- Faculty of Medicine, Algiers 1 University, Algeria
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Taib AG, Kler A, Prayle M, Kanakalingam D, Fani M, Asaad P. Appendicolith appendicitis: should we be operating sooner? A retrospective cohort study. Ann R Coll Surg Engl 2024; 106:237-244. [PMID: 37609681 PMCID: PMC10904264 DOI: 10.1308/rcsann.2023.0055] [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] [Accepted: 06/30/2023] [Indexed: 08/24/2023] Open
Abstract
INTRODUCTION Evidence suggests that delaying an appendicectomy for up to 24 hours does not increase the risk of complicated appendicitis. Appendicoliths are a risk factor for perforation. No study has explored the temporal relationship between appendicolith presence and time to perforation. In this retrospective cohort study, we hypothesise that the presence of an appendicolith confirmed on preoperative computerised tomography scan (pCT) leads to a shorter time to complicated appendicitis. METHODS We undertook a retrospective single-centre study of patients admitted between 2018 and 2020. Inclusion criteria included: age ≥18 years, appendicitis confirmed on histopathology following an operation and a pCT scan. Complicated appendicitis was defined intraoperatively as an appendicular abscess, gangrenous or perforated appendix. RESULTS Some 310 patients were included in the study. Forty-five per cent presented with complicated appendicitis (n = 138). Appendicoliths were present in 79 (25.5%) patients. Multivariate logistic regression identified an appendicolith as a significant risk factor for perforation (odds ratio 3.50, 95% confidence interval [CI] 1.16-10.59; p = 0.027). Within the first 12 hours of admission, patients with an appendicolith accounted for a significantly greater proportion of those with complicated appendicitis intraoperatively compared with those without (56.7% vs 43.3%, respectively; p = 0.003). Within 12 hours of admission, those with an appendicolith were 2.05 times more likely to suffer from complicated appendicitis than those without (95% CI 1.28-3.29). CONCLUSIONS Patients with an appendicolith appendicitis should be considered for an early appendicectomy. Future large-scale multicentre prospective studies are required to explore this further, perhaps informing future guidelines.
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Affiliation(s)
| | | | - M Prayle
- Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust, UK
| | - D Kanakalingam
- Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust, UK
| | - M Fani
- Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust, UK
| | - P Asaad
- Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust, UK
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Zhao Y, Wang X, Zhang Y, Liu T, Zuo S, Sun L, Zhang J, Wang K, Liu J. Combination of clinical information and radiomics models for the differentiation of acute simple appendicitis and non simple appendicitis on CT images. Sci Rep 2024; 14:1854. [PMID: 38253872 PMCID: PMC10803326 DOI: 10.1038/s41598-024-52390-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 01/18/2024] [Indexed: 01/24/2024] Open
Abstract
To investigate the radiomics models for the differentiation of simple and non-simple acute appendicitis. This study retrospectively included 334 appendectomy cases (76 simple and 258 non-simple cases) for acute appendicitis. These cases were divided into training (n = 106) and test cohorts (n = 228). A radiomics model was developed using the radiomic features of the appendix area on CT images as the input variables. A CT model was developed using the clinical and CT features as the input variables. A combined model was developed by combining the radiomics model and clinical information. These models were tested, and their performance was evaluated by receiver operating characteristic curves and decision curve analysis (DCA). The variables independently associated with non-simple appendicitis in the combined model were body temperature, age, percentage of neutrophils and Rad-score. The AUC of the combined model was significantly higher than that of the CT model (P = 0.041). The AUC of the radiomics model was also higher than that of the CT model but did not reach a level of statistical significance (P = 0.053). DCA showed that all three models had a higher net benefit (NB) than the default strategies, and the combined model presented the highest NB. A nomogram of the combined model was developed as the graphical representation of the final model. It is feasible to use the combined information of clinical and CT radiomics models for the differentiation of simple and non-simple acute appendicitis.
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Affiliation(s)
- Yinming Zhao
- Department of Gastrointestinal Surgery, Peking University First Hospital, Beijing, China
| | - Xin Wang
- Department of Gastrointestinal Surgery, Peking University First Hospital, Beijing, China
| | - Yaofeng Zhang
- Beijing Smart Tree Medical Technology Co. Ltd., Beijing, China
| | - Tao Liu
- Department of Gastrointestinal Surgery, Peking University First Hospital, Beijing, China
| | - Shuai Zuo
- Department of Gastrointestinal Surgery, Peking University First Hospital, Beijing, China
| | - Lie Sun
- Department of Gastrointestinal Surgery, Peking University First Hospital, Beijing, China
| | - Junling Zhang
- Department of Gastrointestinal Surgery, Peking University First Hospital, Beijing, China.
| | - Kexin Wang
- School of Basic Medical Sciences, Capital Medical University Beijing, Beijing, China.
| | - Jing Liu
- Department of Radiology, Peking University First Hospital, Beijing, China.
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Arredondo Montero J, Bueso Asfura OE, Pérez Riveros BP, López Burgos E, Rico Jiménez M. Diagnostic performance of urinary 5-Hydroxyindoleacetic Acid in acute appendicitis: a systematic review and diagnostic test accuracy meta-analysis. Int J Colorectal Dis 2023; 38:269. [PMID: 37982905 DOI: 10.1007/s00384-023-04556-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/26/2023] [Indexed: 11/21/2023]
Abstract
OBJECTIVES This study aimed to analyze the diagnostic performance of urinary 5-Hydroxyindoleacetic Acid (5-HIAA) in acute appendicitis (AA). METHODS This review was registered in PROSPERO (CRD42023399541). We included prospective or retrospective original clinical studies evaluating the diagnostic performance of 5-HIAA in AA. A search was conducted in PubMed, Web of Science, Scopus and OVID. Search terms and keywords were: (appendicitis OR acute appendicitis) AND (5-HIAA OR 5-Hydroxyindoleacetic acid OR serotonin metabolite). Two independent reviewers selected the articles and extracted relevant data. Methodological quality was assessed using the QUADAS2 index. A synthesis of the results, standardization of the metrics, and a random-effect meta-analysis were performed. Additionally, a coupled forest plot and a diagnostic test accuracy meta-analysis (DTA) were performed. RESULTS Twelve studies with data from 1467 participants (724 patients with a confirmed diagnosis of AA and 743 controls) were included in this review. The random-effect meta-analysis of urinary 5-HIAA (AA vs controls) included 7 articles (352 AA and 258 controls) and resulted in a significant mean difference [95% CI] of 23.30 [15.82-30.77] μmol/L (p < 0.001). The DTA meta-analysis of urinary 5-HIAA included 8 articles and resulted in a pooled sensitivity [95% CI] of 68.6 [44.1-85.9]% and a pooled specificity [95% CI] of 82 [54.7-94.5]%. CONCLUSIONS Although the evidence is heterogeneous and limited, urinary 5-HIAA emerges as a potential non-invasive diagnostic tool for AA. Urinary 5-HIAA does not seem to be a useful biomarker to distinguish between NCAA and CAA. Future prospective studies with a large sample size and a rigorous design are necessary to validate these findings. TRIAL REGISTRATION PROSPERO (CRD42023399541).
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Affiliation(s)
- Javier Arredondo Montero
- Pediatric Surgery Department, Complejo Asistencial Universitario de León, C/Altos de Nava S/N, 24008, León, Castilla y León, Spain.
- School of Medicine, University of Navarra, Pamplona, Navarra, Spain.
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Kim D, Woodham BL, Chen K, Kuganathan V, Edye MB. Rapid MRI Abdomen for Assessment of Clinically Suspected Acute Appendicitis in the General Adult Population: a Systematic Review. J Gastrointest Surg 2023; 27:1473-1485. [PMID: 37081221 PMCID: PMC10366263 DOI: 10.1007/s11605-023-05626-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 01/27/2023] [Indexed: 04/22/2023]
Abstract
OBJECTIVES To perform a systematic review on the use of magnetic resonance imaging (MRI) of the abdomen to evaluate clinically suspected appendicitis in the general adult population. We examined the diagnostic accuracy, the reported trends of MRI use, and the factors that affect the utility of MRI abdomen, including study duration and cost-benefits. METHODS We conducted a systematic literature search on PubMed, MEDLINE, Embase, Web of Science, and Cochrane Library databases. We enrolled primary studies investigating the use of MRI in diagnosing appendicitis in the general adult population, excluding studies that predominantly reported on populations not representative of typical adult appendicitis presentations, such as those focusing on paediatric or pregnant populations. RESULTS Twenty-seven eligible primary studies and 6 secondary studies were included, totaling 2,044 patients from eight countries. The sensitivity and specificity of MRI for diagnosing appendicitis were 96% (95% CI: 93-97%) and 93% (95% CI: 80-98%), respectively. MRI can identify complicated appendicitis and accurately propose alternative diagnoses. The duration of MRI protocols in each primary study ranged between 2.26 and 30 minutes, and only one study used intravenous contrast agents in addition to the non-contrast sequences. Decision analysis suggests significant benefits for replacing computed tomography (CT) with MRI and a potential for cost reduction. Reported trends in MRI usage showed minimal utilisation in diagnostic settings even when MRI was available. CONCLUSIONS MRI accurately diagnoses appendicitis in the general adult population and improves the identification of complicated appendicitis or alternative diagnoses compared to other modalities using a single, rapid investigation.
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Affiliation(s)
- Dongchan Kim
- School of Medicine, Western Sydney University, Campbelltown, N.S.W. Australia
| | - Benjamin Luke Woodham
- School of Medicine, Western Sydney University, Campbelltown, N.S.W. Australia
- Department of General Surgery, Blacktown and Mount Druitt Hospitals, Blacktown Road, Blacktown, N.S.W. Australia
| | - Kathryn Chen
- School of Medicine, Western Sydney University, Campbelltown, N.S.W. Australia
| | - Vinushan Kuganathan
- School of Medicine, Western Sydney University, Campbelltown, N.S.W. Australia
| | - Michael Benjamin Edye
- School of Medicine, Western Sydney University, Campbelltown, N.S.W. Australia
- Department of General Surgery, Blacktown and Mount Druitt Hospitals, Blacktown Road, Blacktown, N.S.W. Australia
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Babington EA. Complicated appendicitis in an adult patient. ULTRASOUND (LEEDS, ENGLAND) 2022; 30:333-337. [PMID: 36969532 PMCID: PMC10034650 DOI: 10.1177/1742271x221093727] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 03/22/2022] [Indexed: 11/15/2022]
Abstract
Introduction Appendicitis is a common cause for emergency operations in the western part of the world, mostly affecting children and young adults. Ultrasound in well-trained hands is an effective imaging tool in making this diagnosis; however, this does not come without its challenges and potential complications. Case report This is a case of a 19-year-old male with one-day history of severe pain in the right iliac fossa; blood results showed raised inflammatory markers. Ultrasound revealed a large abnormal loop of bowel containing heterogeneously echogenic contents, and two large appendicoliths at the base and fundus, with the presence of free fluid in the right iliac fossa and oedema in the adjacent mesentery. Laparoscopic appendectomy confirmed the presence of severe appendicitis with generalised peritonitis and appendicolith. Histology revealed gangrenous appendicitis with perforation in two places. Discussion This case demonstrates that making a diagnosis of an inflamed appendix alone on ultrasound is not enough, and conducting a detailed assessment of the inflamed appendix and its surrounding anatomy is essential so that all the associated findings can be reported to aid in the patient management, reduce hospital stay and improve overall diagnosis and prognosis.
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The Diagnostic Differentiation Challenge in Acute Appendicitis: How to Distinguish between Uncomplicated and Complicated Appendicitis in Adults. Diagnostics (Basel) 2022; 12:diagnostics12071724. [PMID: 35885627 PMCID: PMC9322371 DOI: 10.3390/diagnostics12071724] [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] [Received: 05/31/2022] [Revised: 07/07/2022] [Accepted: 07/12/2022] [Indexed: 11/24/2022] Open
Abstract
(1) Background: How to best define, diagnose and differentiate uncomplicated from complicated acute appendicitis remains debated. Hence, the aim of this review was to present an overview of the current knowledge and emerging field of acute appendicitis with a focus on the diagnostic differentiation of severity currently subject to ongoing investigations. (2) Methods: We conducted a PubMed search using the MeSH terms “appendicitis AND severity” and “appendicitis AND classification”, with a focus on studies calling appendicitis as ‘uncomplicated’ or ‘complicated’. An emphasis on the last 5 years was stressed, with further studies selected for their contribution to the theme. Further studies were retrieved from identified full-text articles and included per the authors’ discretion. (3) Results: The assumption that appendicitis invariably will proceed to perforation has been outdated. Both uncomplicated and complicated appendicitis exist with likely different pathophysiology. Hence, this makes it important to differentiate disease severity. Clinicians must diagnose appendicitis, but, in the next step, also differentiate between uncomplicated and complicated appendicitis in order to allow for management decisions. Diagnostic accuracy without supportive imaging is around 75–80% and, based on clinical judgement and blood tests alone, the negative appendectomy rate has been described as high as 36%. More research is needed on available biomarkers, and the routine use of imaging still remains debated. Scoring systems have the potential to improve diagnostic accuracy, but no scoring system has yet been validated for differentiating disease severity. Currently, no universally agreed definition exists on what constitutes a complicated appendicitis. (4) Conclusions: Uncomplicated and complicated appendicitis appear to have different pathophysiology and should be treated differently. The differentiation between uncomplicated and complicated appendicitis remains a diagnostic challenge.
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Herrod PJJ, Kwok AT, Lobo DN. Randomized clinical trials comparing antibiotic therapy with appendicectomy for uncomplicated acute appendicitis: meta-analysis. BJS Open 2022; 6:6667669. [PMID: 35971796 PMCID: PMC9379374 DOI: 10.1093/bjsopen/zrac100] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 07/01/2022] [Accepted: 07/08/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND This aim of this study was to provide an updated meta-analysis comparing antibiotic therapy with appendicectomy in adults (16 years or older) with uncomplicated acute appendicitis. METHODS A search for randomized clinical trials comparing antibiotic therapy with appendicectomy in adults with uncomplicated acute appendicitis from inception to 3 October 2021 in MEDLINE, Embase and CENTRAL with no language constraints was performed. Studies were excluded if they included paediatric participants or those with complicated appendicitis. Data on complications of treatment, treatment efficacy (defined in the antibiotic group as not undergoing appendicectomy within 1 year of enrolment, versus surgery without complications or no negative histology in the appendicectomy group), readmissions, and length of stay (LOS) were presented. RESULTS Eight RCTs involving 3203 participants (1613 antibiotics/1590 appendicectomy; 2041 males/1162 females) were included. There was no significant benefit of antibiotic treatment on complication rates (risk ratio (RR) 0.66, 95 per cent c.i. 0.41 to 1.04). Antibiotics had a reduced treatment efficacy compared with appendicectomy (RR 0.75, 95 per cent c.i. 0.63 to 0.89). Antibiotic treatment at 1 year was successful in 1016 of 1613 (62.9 per cent) participants. There was a six-fold increase in hospital readmissions within 1 year of enrolment in participants receiving antibiotic treatment (RR 6.28, 95 per cent c.i. 2.87 to 13.74). There was no difference in index admission LOS (mean difference 0.15 days (95 per cent c.i. -0.05 to 0.35)). CONCLUSIONS Earlier optimism regarding the benefits of antibiotic therapy for uncomplicated acute appendicitis does not persist at the same level now that further, large trials have been included. If antibiotic treatment is to be offered routinely as first-line therapy, patients should be counselled appropriately.
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Affiliation(s)
- Philip J J Herrod
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen’s Medical Centre, Nottingham, UK
| | - Alex T Kwok
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen’s Medical Centre, Nottingham, UK
| | - Dileep N Lobo
- Correspondence to: Dileep N. Lobo, Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen’s Medical Centre, Nottingham NG7 2UH, UK (e-mail: )
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Choi YS, Yi JW, Chung CTY, Shin WY, Choi SK, Heo YS. Clinical Experience of Emergency Appendectomy under the COVID-19 Pandemic in a Single Institution in South Korea. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58060783. [PMID: 35744046 PMCID: PMC9230818 DOI: 10.3390/medicina58060783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 06/06/2022] [Accepted: 06/08/2022] [Indexed: 11/16/2022]
Abstract
Background and Objectives: The COVID-19 pandemic has brought serious changes in healthcare systems worldwide, some of which have affected patients who need emergency surgery. Acute appendicitis is the most common surgical disease requiring emergency surgery. This study was performed to determine how the COVID-19 pandemic has changed the treatment of patients with acute appendicitis in South Korea. Materials and Methods: We retrospectively reviewed a medical database that included patients who underwent surgery for acute appendicitis in our hospital from January 2019 to May 2021. We classified the patients into two groups according to whether they were treated before or after the COVID pandemic and 10 March 2020 was used as the cutoff date, which is when the World Health Organization declared the COVID pandemic. Results: A total of 444 patients were included in the “Pre-COVID-19” group and 393 patients were included in the “COVID-19” group. In the “COVID-19” group, the proportion of patients with severe morbidity was significantly lower. The time that the patients spent in the emergency room before surgery was significantly longer in the ”COVID-19” group (519.11 ± 486.57 min vs. 705.27 ± 512.59 min; p-value < 0.001). There was no difference observed in the severity of appendicitis or in the extent of surgery between the two groups. Conclusions: During the COVID-19 pandemic, a statistically significant time delay (186.16 min) was needed to confirm COVID-19 infection status. However, there was no clinical difference in the severity of appendicitis or in the extent of surgery. To ensure the safety of patients and medical staff, a COVID-19 PCR test should be performed.
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Bom WJ, Scheijmans JCG, Ubels S, van Geloven AAW, Gans SL, Tytgat KMAJ, van Rossem CC, Koens L, Stoker J, Bemelman WA, Dijkgraaf MGW, Boermeester MA. Optimising diagnostics to discriminate complicated from uncomplicated appendicitis: a prospective cohort study protocol. BMJ Open 2022; 12:e054304. [PMID: 35365522 PMCID: PMC8977816 DOI: 10.1136/bmjopen-2021-054304] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Growing evidence is showing that complicated and uncomplicated appendicitis are two different entities that may be treated differently. A correct diagnosis of the type of appendicitis is therefore essential. The Scoring system of Appendicitis Severity (SAS) combines clinical, laboratory and imaging findings. The SAS rules out complicated appendicitis in 95% (negative predictive value, NPV) and detects 95% (sensitivity) of patients with complicated appendicitis in adults suspected of acute appendicitis. However, this scoring system has not yet been validated externally. In this study, we aim to provide a prospective external validation of the SAS in a new cohort of patients with clinical suspicion of appendicitis. We will optimise the score when necessary. METHODS AND ANALYSIS The SAS will be validated in 795 consecutive adult patients diagnosed with acute appendicitis confirmed by imaging. Data will be collected prospectively in multiple centres. The predicted diagnosis based on the SAS score will be compared with the combined surgical and histological diagnosis. Diagnostic accuracy for ruling out complicated appendicitis will be calculated. If the SAS does not reach a sensitivity and NPV of 95% in its present form, the score will be optimised. After optimisation, a second external validation will be performed in a new group of 328 patients. Furthermore, the diagnostic accuracy of the clinical perspective of the treating physician for differentiation between uncomplicated and complicated appendicitis and the patient's preferences for different treatment options will be assessed. ETHICS AND DISSEMINATION Ethical approval was granted by the Amsterdam UMC Medical Ethics Committee (reference W19_416 # 19.483). Because of the observational nature of this study, the study does not fall under the scope of the Medical Research Involving Human Subjects Act. Results will be presented in peer-reviewed journals. This protocol is submitted for publication before analysis of the results.
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Affiliation(s)
- Wouter J Bom
- Department of Surgery, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Surgery, Tergooi Hospitals, Hilversum, The Netherlands
| | - Jochem C G Scheijmans
- Department of Surgery, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Sander Ubels
- Departement of Surgery, Universitair Medisch Centrum Sint Radboud, Nijmegen, The Netherlands
| | | | - Sarah L Gans
- Department of Surgery, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Kristien M A J Tytgat
- Gastroenterology and Hepatology, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | | | - Lianne Koens
- Pathology, Amsterdam Universitair Medische Centra, Amsterdam, The Netherlands
| | - Jaap Stoker
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - Willem A Bemelman
- Department of Surgery, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marcel G W Dijkgraaf
- Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam UMC - Locatie AMC, Amsterdam, The Netherlands
| | - Marja A Boermeester
- Department of Surgery, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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KUBAT M, SAHİN S. Validation and Efficiency of a Scoring System Used in the Differentiation of Uncomplicated Appendicitis. ACTA MEDICA ALANYA 2022. [DOI: 10.30565/medalanya.995148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Can The ‘Speed Bump Sign’ Be a Diagnostic Tool for Acute Appendicitis? Evidence-Based Appraisal by Meta-Analysis and GRADE. Life (Basel) 2022; 12:life12020138. [PMID: 35207428 PMCID: PMC8875208 DOI: 10.3390/life12020138] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 12/30/2021] [Accepted: 01/14/2022] [Indexed: 12/29/2022] Open
Abstract
Objectives: The ‘speed bump sign’ is a clinical symptom characterised by aggravated abdominal pain while driving over speed bumps. This study aimed to perform a diagnostic meta-analysis, rate the certainty of evidence (CoE) and analyse the applicability of the speed bump sign in the diagnosis of acute appendicitis. Materials and Methods: Four databanks and websites were systemically searched, and the Quality Assessment of Diagnostic Accuracy Studies 2 was used to evaluate the risk of bias. Meta-analysis was assessed by MIDAS commands in Stata 15. Grading of Recommendations, Assessment, Development and Evaluation methodology was applied to examine the CoE. Results: Four studies with 343 participants were included. The pooled sensitivity and specificity were 0.94 (95% CI (confidence interval) = 0.83–0.98; I2 = 79%) and 0.49 (95% CI = 0.33–0.66; I2 = 67%), respectively. The area under the summary receiver operating characteristic curve was 0.78 (95% CI = 0.74–0.81). The diagnostic odds ratio was 14.1 (95% CI = 3.6–55.7). The pooled positive and negative likelihood ratios (LR (+) and LR (−)) were 1.84 (95% CI = 1.30–2.61) and 0.13 (95% CI = 0.04–0.41), respectively. According to Fagan’s nomogram plot, when the pretest probabilities were 25%, 50% and 75%, the related posttest probabilities increased to 38%, 65% and 85% calculated through LR (+), respectively, and the posttest probabilities were 4%, 12% and 28% calculated through LR (−), respectively. The overall CoEs were low and very low in sensitivity and specificity, respectively. Conclusion: Current evidence shows that the speed bump sign is a useful ‘rule-out’ test for diagnosing acute appendicitis. With good accessibility, the speed bump sign may be added as a routine part of taking the history of patients with abdominal pain.
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Park JH, Salminen P, Tannaphai P, Lee KH. Low-Dose Abdominal CT for Evaluating Suspected Appendicitis in Adolescents and Young Adults: Review of Evidence. Korean J Radiol 2022; 23:517-528. [PMID: 35289145 PMCID: PMC9081692 DOI: 10.3348/kjr.2021.0596] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 10/18/2021] [Accepted: 11/21/2021] [Indexed: 11/15/2022] Open
Abstract
Due to its excellent diagnostic performance, CT is the mainstay of diagnostic test in adults with suspected acute appendicitis in many countries. Although debatable, extensive epidemiological studies have suggested that CT radiation is carcinogenic, at least in children and adolescents. Setting aside the debate over the carcinogenic risk of CT radiation, the value of judicious use of CT radiation cannot be overstated for the diagnosis of appendicitis, considering that appendicitis is a very common disease, and that the vast majority of patients with suspected acute appendicitis are adolescents and young adults with average life expectancies. Given the accumulated evidence justifying the use of low-dose CT (LDCT) of only 2 mSv, there is no reasonable basis to insist on using radiation dose of multi-purpose abdominal CT for the diagnosis of appendicitis, particularly in adolescents and young adults. Published data strongly suggest that LDCT is comparable to conventional dose CT in terms of clinical outcomes and diagnostic performance. In this narrative review, we will discuss such evidence for reducing CT radiation in adolescents and young adults with suspected appendicitis.
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Affiliation(s)
- Ji Hoon Park
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Applied Bioengineering, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, Korea
- Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Paulina Salminen
- Department of Surgery, University of Turku, Turku, Finland, Thailand
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland, Thailand
| | - Penampai Tannaphai
- Department of Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Kyoung Ho Lee
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Applied Bioengineering, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, Korea
- Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Interdisciplinary Program in Bioengineering, Seoul National University, Seoul, Korea
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El Nakeeb A, Emile SH, AbdelMawla A, Attia M, Alzahrani M, ElGamdi A, Nouh AE, Alshahrani A, AlAreef R, Kayed T, Hamza HM, AlMalki A, Rayzah F, Alsharif M, Alsharif F, Mohammed MM. Presentation and outcomes of acute appendicitis during COVID-19 pandemic: lessons learned from the Middle East-a multicentre prospective cohort study. Int J Colorectal Dis 2022; 37:777-789. [PMID: 35152340 PMCID: PMC8853311 DOI: 10.1007/s00384-022-04108-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/03/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND The coronavirus disease 2019 (COVID-19) pandemic had a striking impact on healthcare services in the world. The present study aimed to investigate the impact of the COVID-19 pandemic on the presentation management and outcomes of acute appendicitis (AA) in different centers in the Middle East. METHODS This multicenter cohort study compared the presentation and outcomes of patients with AA who presented during the COVID-19 pandemic in comparison to patients who presented before the onset of the pandemic. Demographic data, clinical presentation, management strategy, and outcomes were prospectively collected and compared. RESULTS Seven hundred seventy-one patients presented with AA during the COVID pandemic versus 1174 in the pre-COVID period. Delayed and complex presentation of AA was significantly more observed during the pandemic period. Seventy-six percent of patients underwent CT scanning to confirm the diagnosis of AA during the pandemic period, compared to 62.7% in the pre-COVID period. Non-operative management (NOM) was more frequently employed in the pandemic period. Postoperative complications were higher amid the pandemic as compared to before its onset. Reoperation and readmission rates were significantly higher in the COVID period, whereas the negative appendicectomy rate was significantly lower in the pandemic period (p = 0.0001). CONCLUSION During the COVID-19 pandemic, a remarkable decrease in the number of patients with AA was seen along with a higher incidence of complex AA, greater use of CT scanning, and more application of NOM. The rates of postoperative complications, reoperation, and readmission were significantly higher during the COVID period.
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Affiliation(s)
| | | | | | | | - Mohamed Alzahrani
- Khamis Mushait General Hospital, Aseer region, Khamis Mushait, Kingdom of Saudi Arabia
| | - Ayman ElGamdi
- Khamis Mushait General Hospital, Aseer region, Khamis Mushait, Kingdom of Saudi Arabia
| | - Abd elwahab Nouh
- Khamis Mushait General Hospital, Aseer region, Khamis Mushait, Kingdom of Saudi Arabia
| | - Abdulaziz Alshahrani
- Khamis Mushait General Hospital, Aseer region, Khamis Mushait, Kingdom of Saudi Arabia
| | - Riyadh AlAreef
- Khamis Mushait General Hospital, Aseer region, Khamis Mushait, Kingdom of Saudi Arabia
| | | | | | - Ahmad AlMalki
- Aseer Central Hospital, Aseer region, Abha, Kingdom of Saudi Arabia
| | - Fares Rayzah
- Aseer Central Hospital, Aseer region, Abha, Kingdom of Saudi Arabia
| | - Motaz Alsharif
- Aseer Central Hospital, Aseer region, Abha, Kingdom of Saudi Arabia
| | - Fares Alsharif
- Aseer Central Hospital, Aseer region, Abha, Kingdom of Saudi Arabia
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Waki Y, Hotchi M, Utsunomiya D, Inoue T, Obatake M. Preoperative predictors of extended resection in patients with complicated acute appendicitis undergoing surgery. THE JOURNAL OF MEDICAL INVESTIGATION 2021; 68:334-341. [PMID: 34759155 DOI: 10.2152/jmi.68.334] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Background : Appendectomy can be challenging and occasionally converted to extensive resection for complicated appendicitis. However, optimal treatment strategies can be developed using preoperative risk assessment. Thus, we aimed to investigate the preoperative predictors of extensive resection in complicated appendicitis patients undergoing surgery. Materials and methods : In total, 173 complicated appendicitis patients undergoing surgery between 2014 and 2019 were classified into the appendectomy (n = 153) or extensive resection (n = 20) groups. Clinicopathological factors and surgical outcomes were compared between groups. Results : Extensive resection was performed in 20 of 173 complicated appendicitis patients (11.5%). The rates of having defects in the wall structure at the appendix root on computed tomography images were significantly higher, and the duration from onset to surgery was significantly longer in the extensive resection group. Significant differences were found in operative duration, blood loss and postoperative hospitalization, but none in the incidence of postoperative complications between groups. Multivariate analyses showed that defects in the wall structure at the appendix root and five days or longer from onset were identified as independent predictors of extensive resection. Conclusions : Defects in the wall structure at the appendix root and five days or longer from onset predict extensive resection performance in complicated appendicitis patients. J. Med. Invest. 68 : 334-341, August, 2021.
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Affiliation(s)
- Yuhei Waki
- Division of Digestive Surgery, Ehime Prefectural Central Hospital, Ehime, Japan
| | - Masanori Hotchi
- Division of Digestive Surgery, Ehime Prefectural Central Hospital, Ehime, Japan
| | - Daichi Utsunomiya
- Division of General Surgery, Ehime Prefectural Imabari Hospital, Ehime, Japan
| | - Takeshi Inoue
- Division of Radiology, Ehime Prefectural Central Hospital, Ehime, Japan
| | - Masayoshi Obatake
- Division of Digestive Surgery, Ehime Prefectural Central Hospital, Ehime, Japan
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Basta Nikolic M, Spasic A, Hadnadjev Simonji D, Stojanović S, Nikolic O, Nikolic D. Imaging of acute pelvic pain. Br J Radiol 2021; 94:20210281. [PMID: 34491817 DOI: 10.1259/bjr.20210281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Acute pelvic pain (APP) requires urgent medical evaluation and treatment. Differential diagnosis of APP is broad, including a variety of gynecologic and non-gynecologic/ urinary, gastrointestinal, vascular and other entities. Close anatomical and physiological relations of pelvic structures, together with similar clinical presentation of different disorders and overlapping of symptoms, especially in the emergency background, make the proper diagnosis of APP challenging. Imaging plays a crucial role in the fast and precise diagnosis of APP. Ultrasonography is the first-line imaging modality, often accompanied by CT, while MRI is utilized in specific cases, using short, tailored protocols. Recognizing the cause of APP in females is a challenging task, due to the wide spectrum of possible origin and overlap of their imaging features. Therefore, the radiologist has to be familiar with the possible causes of APP, and, relying on clinical presentation, together with laboratory findings, choose the best imaging strategy in order to establish a fast and accurate diagnosis.
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Affiliation(s)
- Marijana Basta Nikolic
- Centre of Radiology, Clinical Centre of Vojvodina, Faculty of Medicine, University of Novi Sad, Vojvodina, Serbia
| | - Aleksandar Spasic
- Centre of Radiology, Clinical Centre of Vojvodina, Faculty of Medicine, University of Novi Sad, Vojvodina, Serbia
| | - Darka Hadnadjev Simonji
- Centre of Radiology, Clinical Centre of Vojvodina, Faculty of Medicine, University of Novi Sad, Vojvodina, Serbia
| | - Sanja Stojanović
- Centre of Radiology, Clinical Centre of Vojvodina, Faculty of Medicine, University of Novi Sad, Vojvodina, Serbia
| | - Olivera Nikolic
- Centre of Radiology, Clinical Centre of Vojvodina, Faculty of Medicine, University of Novi Sad, Vojvodina, Serbia
| | - Dragan Nikolic
- Clinic for Vascular and Endovascular Surgery, Clinical Centre of Vojvodina, Faculty of Medicine, University of Novi Sad, Vojvodina, Serbia
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Bom WJ, Scheijmans JCG, Salminen P, Boermeester MA. Diagnosis of Uncomplicated and Complicated Appendicitis in Adults. Scand J Surg 2021; 110:170-179. [PMID: 33851877 PMCID: PMC8258714 DOI: 10.1177/14574969211008330] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background: Diagnostic work-up of acute appendicitis remains challenging. While some guidelines advise to use a risk stratification based on clinical parameters, others use standard imaging in all patients. As non-operative management of uncomplicated appendicitis has been identified as feasible and safe, differentiation between uncomplicated and complicated appendicitis is of paramount importance. We reviewed the literature to describe the optimal strategy for diagnosis of acute appendicitis. Methods: A narrative review about the diagnosis of acute appendicitis in adult patients was conducted. Both diagnostic strategies and goals were analyzed. Results: For diagnosing acute appendicitis, both ruling in and ruling out the disease are important. Clinical and laboratory findings individually do not suffice, but when combined in a diagnostic score, a better risk prediction can be made for having acute appendicitis. However, for accurate diagnosis imaging seems obligatory in patients suspected for acute appendicitis. Scoring systems combining clinical and imaging features may differentiate between uncomplicated and complicated appendicitis and may enable ruling out complicated appendicitis. Within conservatively treated patients with uncomplicated appendicitis, predictive factors for non-responsiveness to antibiotics and recurrence of appendicitis need to be defined in order to optimize treatment outcomes. Conclusion: Standard imaging increases the diagnostic power for both ruling in and ruling out acute appendicitis. Incorporating imaging features in clinical scoring models may provide better differentiation between uncomplicated and complicated appendicitis. Optimizing patient selection for antibiotic treatment of appendicitis may minimize recurrence rates, resulting in better treatment outcomes.
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Affiliation(s)
- W J Bom
- Department of Surgery, Amsterdam UMC, location AMC, Amsterdam Gastroenterology Endocrinology Metabolism, University of Amsterdam, Amsterdam, The Netherlands
| | - J C G Scheijmans
- Department of Surgery, Amsterdam UMC, location AMC, Amsterdam Gastroenterology Endocrinology Metabolism, University of Amsterdam, Amsterdam, The Netherlands
| | - P Salminen
- Department of Surgery, University of Turku, Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
| | - M A Boermeester
- Department of Surgery, Amsterdam UMC, location AMC, Amsterdam Gastroenterology Endocrinology Metabolism, University of Amsterdam, Amsterdam, The Netherlands
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