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Wong YC, Wang LJ, Wu CH, Chang YC, Chen HW, Lin BC, Hsu YP. Using MRI appendicitis scale and DWI for the diagnosis of acute appendicitis in pregnant women. Eur Radiol 2024; 34:1764-1773. [PMID: 37658138 DOI: 10.1007/s00330-023-10162-9] [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: 09/16/2022] [Revised: 08/05/2023] [Accepted: 08/09/2023] [Indexed: 09/03/2023]
Abstract
OBJECTIVES To assess the performance of MRI scale for the diagnosis of acute appendicitis in pregnant women and to determine the added diagnostic value of diffusion-weighted imaging (DWI). METHODS From January 2018 to December 2020, 80 patients were included. All MRI were performed with a 1.5-Tesla scanner with anterior array body coil. This analysis included (1) T2-weighted imaging (T2WI), (2) fat-saturated T2WI, and (3) DWI. Two radiologists blinded to the diagnosis recorded their assessment of four findings: appendiceal diameter, appendiceal wall thickness, luminal mucus, and periappendiceal inflammation. The MRI scale of acute appendicitis which ranged from 0 to 4 was determined from these factors. An additional one point was added to the MRI appendicitis scale in those patients with evidence of appendiceal restricted diffusion on DWI. The diagnostic values and predictive factors were computed. RESULTS Multivariate analysis demonstrated that the calculated MRI appendicitis scale was a significant independent predictor of acute appendicitis with a sensitivity of 96.6%, specificity of 90.2%, and PPV of 84.8%. The odds ratio of appendicitis is increased by 22.3 times for every increase in one point on the MRI appendicitis scale. Therefore, the addition of one point for restricted diffusion in the appendix on DWI imaging can add substantial value, both positive and negative predictive value, towards making an accurate diagnosis of acute appendicitis. CONCLUSIONS MRI appendicitis scale is an objective and significant independent predictive factor for acute appendicitis in pregnant women. Incorporation of diffusion weighted imaging to MRI can improve diagnosis of acute appendicitis. CLINICAL RELEVANCE STATEMENT MRI appendicitis scale is an objective and significant independent predictor of acute appendicitis in pregnant women. Incorporation of DWI/ADC map to MRI examinations can improve diagnosis of acute appendicitis in pregnant women. KEY POINTS • MRI appendicitis scale is an objective and significant independent predictive factor for acute appendicitis in pregnant women. • The odds ratio of appendicitis can be increased by 22.3 times for every increase of one unit in MRI scale. • Incorporation of diffusion-weighted imaging to MRI examinations can add value to the scale (4.2 ± 0.7 vs. 0.7 ± 1.1; p < 0.001) among pregnant women with appendicitis versus pregnant women without appendicitis.
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Affiliation(s)
- Yon-Cheong Wong
- Emergency and Critical Care Radiology, Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan.
| | - Li-Jen Wang
- Emergency and Critical Care Radiology, Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Cheng-Hsien Wu
- Emergency and Critical Care Radiology, Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Yi-Chia Chang
- Emergency and Critical Care Radiology, Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Huan-Wu Chen
- Emergency and Critical Care Radiology, Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Being-Chuan Lin
- Division of Trauma and Emergency Surgery, Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Yu-Pao Hsu
- Division of Trauma and Emergency Surgery, Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
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Zheng X, He X. Analysis of risk factors for complicated appendicitis during pregnancy and evaluation of clinical prediction model: A prospective cohort study. Surgeon 2023; 21:361-368. [PMID: 37210282 DOI: 10.1016/j.surge.2023.05.001] [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: 03/26/2023] [Revised: 04/28/2023] [Accepted: 05/03/2023] [Indexed: 05/22/2023]
Abstract
OBJECTIVE To investigate the risk factors and the value of clinical prediction model for complicated appendicitis (CA) during pregnancy. METHODS Prospective analysis of pregnant patients who underwent appendectomy at a single tertiary care center between February 2020 and February 2023 and who ultimately had pathologically confirmed acute appendicitis (AA). According to intraoperative conditions and postoperative pathology, they were divided into the CA group and the uncomplicated appendicitis (UA) group. The two groups of patients were then compared in terms of demographic characteristics, disease features, ancillary tests and predictive models of acute appendicitis. RESULTS A total of 90 patients with AA in pregnancy were included, 21 of whom had CA in pregnancy and 69 had UA in pregnancy. Multivariate regression analysis showed that gestational week, neutrophil ratio and C-reactive protein (CRP) were independent risk factors for CA during pregnancy. Relative to the first trimester, the third trimesters had an increased risk of complicated appendicitis (OR = 12.48, 95% CI: 1.56-99.57, P = 0.017). Neutrophil ratio ≥85.30% (OR = 24.54, 95% CI: 2.59-232.72, P = 0.005) and CRP ≥34.26 mg/L (OR = 7.86, 95% CI: 2.18-28.38, P = 0.002) had a significantly increased risk of CA. The AIR and AAS score models were statistically different between the two groups, but with a lower sensitivity of 52.38% and 42.86%, respectively. CONCLUSION The third trimesters, neutrophil ratio ≥85.30% and CRP ≥34.26 mg/L may be key predictors of CA in pregnancy. The current scoring model is inadequate to identify complex appendicitis in pregnancy and further research is needed.
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Affiliation(s)
- Xiaosong Zheng
- Department of General Surgery, Maternal and Child Health Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xiaojun He
- Department of General Surgery, Maternal and Child Health Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China.
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Masselli G, Bonito G, Gigli S, Ricci P. Imaging of Acute Abdominopelvic Pain in Pregnancy and Puerperium-Part II: Non-Obstetric Complications. Diagnostics (Basel) 2023; 13:2909. [PMID: 37761275 PMCID: PMC10528125 DOI: 10.3390/diagnostics13182909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 08/28/2023] [Accepted: 09/08/2023] [Indexed: 09/29/2023] Open
Abstract
Emergency imaging in pregnancy and puerperium poses unique challenges both for clinicians and radiologists, requiring timely and accurate diagnosis. Delay in treatment may result in poor outcomes for both the patient and the foetus. Pregnant and puerperal patients may present in the emergency setting with acute abdominopelvic pain for various complications that can be broadly classified into obstetric and non-obstetric related diseases. Ultrasonography (US) is the primary diagnostic imaging test; however, it may be limited due to the patient's body habitus and the overlapping of bowel loops. Computed tomography (CT) carries exposure to ionising radiation to the foetus, but may be necessary in selected cases. Magnetic resonance imaging (MRI) is a valuable complement to US in the determination of the etiology of acute abdominal pain and can be used in most settings, allowing for the identification of a broad spectrum of pathologies with a limited protocol of sequences. In this second section, we review the common non-obstetric causes for acute abdominopelvic pain in pregnancy and post partum, offering a practical approach for diagnosis and pointing out the role of imaging methods (US, MRI, CT) with the respective imaging findings.
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Affiliation(s)
- Gabriele Masselli
- Department of Emergency Radiology-Policlinico Umberto I Hospital, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (G.M.); (P.R.)
| | - Giacomo Bonito
- Department of Emergency Radiology-Policlinico Umberto I Hospital, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (G.M.); (P.R.)
| | - Silvia Gigli
- Department of Diagnostic Imaging, Sandro Pertini Hospital, Via dei Monti Tiburtini 385, 00157 Rome, Italy;
| | - Paolo Ricci
- Department of Emergency Radiology-Policlinico Umberto I Hospital, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (G.M.); (P.R.)
- Department of Radiological, Oncological and Pathological Sciences, Policlinico Umberto I, Sapienza University of Rome, Viale Regina Elena 324, 00161 Rome, Italy
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Zheng X, He X. Development of a nomogram for the prediction of complicated appendicitis during pregnancy. BMC Surg 2023; 23:188. [PMID: 37393302 DOI: 10.1186/s12893-023-02064-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 05/31/2023] [Indexed: 07/03/2023] Open
Abstract
BACKGROUND Complicated appendicitis during pregnancy directly affects the clinical prognosis of both mother and fetus. However, accurate identification of complicated appendicitis in pregnancy is fraught with various challenges. The purpose of this study was to identify the risk factors and to develop a useful nomogram to predict complicated appendicitis during pregnancy. METHODS This retrospective study involved pregnant women who underwent appendectomy at the Maternal and Child Health Hospital of Hubei Provincial from May 2016 to May 2022 and who ultimately had histopathological confirmed acute appendicitis. Univariate and multivariate logistic regression were applied to analyze clinical parameters and imaging features as a way to identify risk factors. Then, nomogram and scoring systems predicting complicated appendicitis in pregnancy were constructed and evaluated. Finally, the potential non-linear association between risk factors and complicated appendicitis was analyzed using restricted cubic splines. RESULTS Three indicators were finally identified for the construction of the nomogram: gestational weeks, C-reactive protein (CRP), and neutrophil percentage (NEUT%). To improve the clinical utility, the gestational weeks were divided into three periods (first trimesters, second trimesters, and third trimesters), while the optimal cut-offs for CRP level and NEUT% were found to be 34.82 mg/L and 85.35%, respectively. Multivariate regression analysis showed that third trimesters (P = 0.013, OR = 16.81), CRP level ≥ 34.82 mg/L (P = 0.007, OR = 6.24) and NEUT% ≥85.35% (P = 0.011, OR = 18.05) were independent risk factors for complicated appendicitis. The area under the ROC curve (AUC) of the nomogram predicting complicated appendicitis in pregnancy was 0.872 (95% CI: 0.803-0.942). In addition, the model was shown to have excellent predictive performance by plotting calibration plots, Decision Curve Analysis (DCA), and clinical impact curves. When the optimal cut-off point of the scoring system was set at 12, the corresponding AUC, sensitivity, specificity, Positive Likelihood Ratio (PLR), Negative Likelihood Ratio (NLR), Positive Predictive Value (PPV), and Negative Predictive Value (NPV) values were AUC: 0.869(95% CI: 0.799-0.939),100%, 58.60%, 2.41, 0, 42%, and 100%, respectively. The restricted cubic splines revealed a linear relationship between these predictors and complicated appendicitis during pregnancy. CONCLUSIONS The nomogram utilizes a minimum number of variables to develop an optimal predictive model. Using this model, the risk of developing complicated appendicitis in individual patients can be determined so that reasonable treatment choices can be made.
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Affiliation(s)
- Xiaosong Zheng
- Department of General Surgery, Maternal and Child Health Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, NO.745 Wuluo Road, Hongshan District, Wuhan City, Hubei Province, 430070, P.R. China
| | - Xiaojun He
- Department of General Surgery, Maternal and Child Health Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, NO.745 Wuluo Road, Hongshan District, Wuhan City, Hubei Province, 430070, P.R. China.
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Kambadakone AR, Santillan CS, Kim DH, Fowler KJ, Birkholz JH, Camacho MA, Cash BD, Dane B, Felker RA, Grossman EJ, Korngold EK, Liu PS, Marin D, McCrary M, Pietryga JA, Weinstein S, Zukotynski K, Carucci LR. ACR Appropriateness Criteria® Right Lower Quadrant Pain: 2022 Update. J Am Coll Radiol 2022; 19:S445-S461. [PMID: 36436969 DOI: 10.1016/j.jacr.2022.09.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 09/01/2022] [Indexed: 11/27/2022]
Abstract
This document focuses on imaging in the adult and pregnant populations with right lower quadrant (RLQ) abdominal pain, including patients with fever and leukocytosis. Appendicitis remains the most common surgical pathology responsible for RLQ abdominal pain in the United States. Other causes of RLQ pain include right colonic diverticulitis, ureteral stone, and infectious enterocolitis. Appropriate imaging in the diagnosis of appendicitis has resulted in decreased negative appendectomy rate from as high as 25% to approximately 1% to 3%. Contrast-enhanced CT remains the primary and most appropriate imaging modality to evaluate this patient population. MRI is approaching CT in sensitivity and specificity as this technology becomes more widely available and utilization increases. Unenhanced MRI and ultrasound remain the diagnostic procedures of choice in the pregnant patient. MRI and ultrasound continue to perform best in the hands of the experts. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
- Avinash R Kambadakone
- Division Chief, Abdominal Imaging, Massachusetts General Hospital, Boston, Massachusetts; Medical Director, Martha's Vineyard Hospital Imaging.
| | - Cynthia S Santillan
- Vice Chair of Clinical Operations, University of California, San Diego, San Diego, California
| | - David H Kim
- Panel Chair; Vice Chair of Education, Department of Radiology, University of Wisconsin Hospital & Clinics, Madison, Wisconsin
| | - Kathryn J Fowler
- Panel Vice-Chair, University of California, San Diego, San Diego, California. ACR LI-RADS; Division Chief, SAR Portfolio Director; RSNA Radiology Senior DE
| | - James H Birkholz
- Divisional Director, Quality and Safety (Abdominal Imaging), Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania. Radiology Representative to the Interdisciplinary Dysmotility (GIMIG) Conference
| | - Marc A Camacho
- The University of South Florida Morsani College of Medicine, Tampa, Florida; Committee on Emergency Radiology-GSER
| | - Brooks D Cash
- Chief of Gastroenterology, Hepatology, and Nutrition Division, University of Texas Health Science Center at Houston and McGovern Medical School, Houston, Texas; American Gastroenterological Association
| | - Bari Dane
- Director of Body CT, Abdominal Imaging; Director of Quality and Safety Outpatient Imaging, NYU Grossman School of Medicine, New York, New York
| | - Robin A Felker
- Associate Clerkship Director for Internal Medicine, Georgetown University; Primary care physician, Medstar Georgetown University Hospital, Washington, District of Columbia
| | - Eric J Grossman
- Medical Director, Multi-Specialty Clinic, Santa Barbara Cottage Hospital, Santa Barbara, California; American College of Surgeons
| | - Elena K Korngold
- Section Chief, Body Imaging, Chair, Department of Radiology Promotion and Tenure Committee, Oregon Health and Science University, Portland, Oregon
| | - Peter S Liu
- Section Head, Abdominal Imaging, Cleveland Clinic, Cleveland, Ohio
| | - Daniele Marin
- Duke University Medical Center, Durham, North Carolina
| | - Marion McCrary
- Associate Director of Duke GME Coaching, Duke Signature Care, Durham, North Carolina; American College of Physicians; Governor-Elect, American College of Physicians North Carolina Chapter
| | | | | | - Katherine Zukotynski
- Co-Associate Chair for Research, Department of Radiology, McMaster University, Hamilton, Ontario, Canada; Commission on Nuclear Medicine and Molecular Imaging
| | - Laura R Carucci
- Specialty Chair; Section Chief Abdominal Imaging, Director of MRI and CT, Virginia Commonwealth University Medical Center, Richmond, Virginia
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Ahmed B, Williams J, Gourash W, Zhang J, Li R, Balasubramani GK, Rangaswamy B. MRI as First Line Imaging for Suspected Acute Appendicitis during Pregnancy: Diagnostic Accuracy and level of Inter-Radiologist Agreement. Curr Probl Diagn Radiol 2022; 51:503-510. [PMID: 34955286 PMCID: PMC9160213 DOI: 10.1067/j.cpradiol.2021.09.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 09/07/2021] [Accepted: 09/19/2021] [Indexed: 09/29/2023]
Abstract
OBJECTIVE Evaluation of acute appendicitis (AA) in pregnancy is supported with diagnostic imaging. Typically, ultrasound (US) is performed first, and then often followed by magnetic resonance imaging (MRI) due to continued diagnostic uncertainty. The purpose of our study was to evaluate the sensitivity, specificity, and accuracy of US as compared to MRI and to evaluate the inter-radiologist agreement amongst body Radiologists with varying levels of expertise. MATERIALS AND METHODS We performed a retrospective study of 364 consecutive pregnant patients with clinical suspicion of AA at a single center over a 6-year period. Sensitivity, Specificity, accuracy, positive and negative predictive values were calculated for US and MRI. Inter Radiologist agreement was determined using Cohen's Kappa analysis between original interpreting Radiologist and retrospective review by expert Radiologist. RESULTS Thirty-one of 364 patients (8.5%) underwent appendectomy based on preoperative diagnosis, with confirmation of acute appendicitis (AA) by pathology in 19. US was able to visualize the appendix in only 6 (1.65%), 5 of whom had appendicitis. 141 patients underwent MRI, and correctly diagnosed appendicitis in 9. No patient with a negative MRI diagnosis had AA. The sensitivity, and negative predictive value for diagnosing AA with MRI was 100%. The MRI inter-reader agreement for appendix visualization and overall accuracy were 87.9 and 98% with Cohen Kappa of 0.7 and 0.56 respectively. CONCLUSIONS Our data suggests that MRI should be considered the first line imaging modality in pregnant patients suspected of having AA. Body Radiologists with varied levels of experience in MRI readouts had substantial agreement.
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Affiliation(s)
- Bestoun Ahmed
- Department of Surgery, Division of Minimally Invasive General and Bariatric Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA.
| | - Jon Williams
- Advanced Laparoscopic and General Surgery of Nevada, Las Vegas, NV
| | - William Gourash
- Department of Surgery, Division of Minimally Invasive General and Bariatric Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | - Runjia Li
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, PA
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D'Souza N, Hicks G, Beable R, Higginson A, Rud B. Magnetic resonance imaging (MRI) for diagnosis of acute appendicitis. Cochrane Database Syst Rev 2021; 12:CD012028. [PMID: 34905621 PMCID: PMC8670723 DOI: 10.1002/14651858.cd012028.pub2] [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: 12/16/2022]
Abstract
BACKGROUND Appendicitis remains a difficult disease to diagnose, and imaging adjuncts are commonly employed. Magnetic resonance imaging (MRI) is an imaging test that can be used to diagnose appendicitis. It is not commonly regarded as a first-line imaging test for appendicitis, but the reported diagnostic accuracy in some studies is equivalent to computed tomography (CT) scans. As it does not expose patients to radiation, it is an attractive imaging modality, particularly in women and children. OBJECTIVES The primary objective was to determine the diagnostic accuracy of MRI for detecting appendicitis in all patients. Secondary objectives: To investigate the accuracy of MRI in subgroups of pregnant women, children, and adults. To investigate the potential influence of MRI scanning variables such as sequences, slice thickness, or field of view. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase until February 2021. We searched the references of included studies and other systematic reviews to identify further studies. We did not exclude studies that were unpublished, published in another language, or retrospective. SELECTION CRITERIA We included studies that compared the outcome of an MRI scan for suspected appendicitis with a reference standard of histology, intraoperative findings, or clinical follow-up. Three study team members independently filtered search results for eligible studies. DATA COLLECTION AND ANALYSIS We independently extracted study data and assessed study quality using the Quality Assessment of Studies of Diagnostic Accuracy - Revised (QUADAS-2) tool. We used the bivariate model to calculate pooled estimates of sensitivity and specificity. MAIN RESULTS We identified 58 studies with sufficient data for meta-analysis including a total of 7462 participants (1980 with and 5482 without acute appendicitis). Estimates of sensitivity ranged from 0.18 to 1.0; estimates of specificity ranged from 0.4 to 1.0. Summary sensitivity was 0.95 (95% confidence interval (CI) 0.94 to 0.97); summary specificity was 0.96 (95% CI 0.95 to 0.97). Sensitivity and specificity remained high on subgroup analysis for pregnant women (sensitivity 0.96 (95% CI 0.88 to 0.99); specificity 0.97 (95% CI 0.95 to 0.98); 21 studies, 2282 women); children (sensitivity 0.96 (95% CI 0.95 to 0.97); specificity 0.96 (95% CI 0.92 to 0.98); 17 studies, 2794 children); and adults (sensitivity 0.96 (95% CI 0.93 to 0.97); specificity 0.93 (95% CI 0.80 to 0.98); 9 studies, 1088 participants), as well as different scanning techniques. In a hypothetical cohort of 1000 patients, there would be 12 false-positive results and 30 false-negative results. Methodological quality of the included studies was poor, and the risk of bias was high or unclear in 53% to 83% of the QUADAS-2 domains. AUTHORS' CONCLUSIONS MRI appears to be highly accurate in confirming and excluding acute appendicitis in adults, children, and pregnant women regardless of protocol. The methodological quality of the included studies was generally low due to incomplete and low standards of follow-up, so summary estimates of sensitivity and specificity may be biased. We could not assess the impact and direction of potential bias given the very low number of high-quality studies. Studies comparing MRI protocols were few, and although we found no influence of MRI protocol variables on the summary estimates of accuracy, our results do not rule out that some MRI protocols are more accurate than others.
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Affiliation(s)
| | | | | | | | - Bo Rud
- Gastrounit, Copenhagen University Hospital Hvidovre , Hvidovre, Denmark
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Badr DA, Selsabil MH, Thill V, Dobos S, Ostrovska A, Jani JC, Cannie MM. Acute appendicitis and pregnancy: diagnostic performance of magnetic resonance imaging. J Matern Fetal Neonatal Med 2021; 35:8107-8110. [PMID: 34365881 DOI: 10.1080/14767058.2021.1961730] [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: 10/20/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the performance of magnetic resonance imaging (MRI) in the diagnosis of acute appendicitis in pregnant women. METHODS The study was conducted in 2 referral centers in Brussels, Belgium, between March 1st 2009 and January 31st 2017. Pregnant women who presented with abdominal pain and underwent MRI were included. Baseline characteristics, clinical, laboratory, and ultrasound test results were extracted retrospectively from the electronic medical charts. MRI exams were prospectively reevaluated by an experienced radiologist blinded to patient outcome and MRI findings. Visualization of the appendix and assessment of gastrointestinal, genitourinary, and vascular systems were recorded. The diagnosis of acute appendicitis was confirmed by pathology exam. RESULTS In total, 85 patients were included. The appendix was identified in all patients on MRI and acute appendicitis was suspected in 7. The diagnosis was confirmed in 6 patients. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of MRI were 100% (95% confidence interval [95% CI]: 54.1%-100%), 98.7% (95% CI: 93.2-99.9%), 85.7% (95% CI: 46.1-97.7%), and 100%, respectively. In contrast, the sensitivity, specificity, PPV, and NPV of the combination of clinical exam, laboratory findings and/or ultrasound were 100% (95% CI: 54.1%-100%), 62% (95% CI: 50.4-72.7%), 16.7% (95% CI: 13.1-20.96%), and 100%, respectively. CONCLUSION MRI is reliable in confirming or excluding acute appendicitis during pregnancy, with a rate of visualization of the appendix approaching 100%. Efforts should be focused on the implementation of MRI as a first-line imaging exam in the workup of suspected acute appendicitis during pregnancy.
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Affiliation(s)
- Dominique A Badr
- Departments of Obstetrics and Gynecology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Mohammed-Hadj Selsabil
- Department of Radiology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Viviane Thill
- Department of Abdominal, Thoracic and Laparoscopic surgery, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Sebastian Dobos
- Department of Abdominal, Thoracic and Laparoscopic surgery, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Adela Ostrovska
- Departments of Obstetrics and Gynecology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Jacques C Jani
- Departments of Obstetrics and Gynecology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Mieke M Cannie
- Department of Radiology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium.,Department of Radiology, UZ Brussel, Vrije Universiteit Brussel, Belgium
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Safety of appendectomy during pregnancy in the totally laparoscopic age. JOURNAL OF MINIMALLY INVASIVE SURGERY 2021; 24:68-75. [PMID: 35600787 PMCID: PMC8965996 DOI: 10.7602/jmis.2021.24.2.68] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 11/17/2020] [Accepted: 11/18/2020] [Indexed: 12/29/2022]
Abstract
Purpose Acute appendicitis is the most common nonobstetric indication for surgical intervention during pregnancy. In the argument of the optimal surgical approach to acute appendicitis in pregnancy, laparoscopy seems to be won with a similar complication rate and shorter postoperative recovery than open. We aimed to compare perioperative outcomes of appendectomy in pregnant and nonpregnant women in the totally laparoscopic age. Methods We retrospectively analyzed 556 nonincidental appendectomies performed in women (aged 18–45 years) between January 2014 and December 2018. To reduce the confounding effects, we used propensity score considering the variables age, American Society of Anesthesiologists physical status classification, and the operative finding; whether the appendicitis was simple or complicated. After propensity score matching, the outcomes of 15 pregnant women were compared with those of the 30 nonpregnant women. Results All the operations were performed with laparoscopy. Most of the pregnant cases were in their first and second trimester. The postoperative morbidity rate was significantly higher in the pregnant group before propensity score matching; however, the significance disappeared after matching. Operative outcomes and the parameters related to the postoperative recovery were not different between the two groups. Two patients in their first trimester decided to terminate the pregnancy after appendectomy. One patient in her second trimester experienced preterm labor which was resolved spontaneously. There was no other obstetric adverse outcome. Conclusion In the laparoscopy age, appendectomy during pregnancy is safe and not associated with a significantly increased risk of postoperative complication.
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Zvi E, Shemer A, Toussia-Cohen S, Zvi D, Bashan Y, Hirschfeld-Dicker L, Oselka N, Amitai MM, Ezra O, Bar-Yosef O, Katorza E. Fetal Exposure to MR Imaging: Long-Term Neurodevelopmental Outcome. AJNR Am J Neuroradiol 2020; 41:1989-1992. [PMID: 32912871 DOI: 10.3174/ajnr.a6771] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 07/14/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND PURPOSE Very few studies have investigated long-term neurodevelopment of children exposed to MR imaging antenatally. Thus, the purpose of our study was to evaluate long-term neurodevelopmental outcomes of children exposed to MR imaging during pregnancy. MATERIALS AND METHODS We conducted a historical prospective cohort study in a single tertiary medical center. Women exposed to 1.5T noncontrast MR imaging for maternal or fetal indications were matched to unexposed controls. Long-term neurodevelopmental outcomes were evaluated of their children, 2.5 to 6 years of age, according to the Vineland-II Adaptive Behavior Scale. The Vineland-II Adaptive Behavior Scale assesses communication, daily living skills, socialization, and motor skills. A composite score summarizes these 4 domains. RESULTS A total of 131 exposed women matched our inclusion criteria and were included in the study group, and 771 unexposed women, in the control group. No difference was identified in the Vineland-II Adaptive Behavior Scale composite score between the children of the study and control groups (mean, 110.79 versus 108.18; P = .098). Differences were also not observed between the children of the 2 groups in 3 of the 4 questionnaire domains: communication (108.84 versus 109.10; P = .888), daily living skills (109.51 versus 108.28; P = .437), and motor skills (105.09 versus 104.42; P = .642). However, the socialization score was favorable for the study group (112.98 versus 106.47; P < .001). CONCLUSIONS Exposure to 1.5T noncontrast MR imaging during pregnancy had no harmful effects on long-term neurodevelopmental outcomes. This study contributes to understanding the safety of MR imaging during pregnancy.
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Affiliation(s)
- E Zvi
- From the Antenatal Diagnostic Unit (E.Z., S.t.-C., O.E., E.K.)
- Sackler School of Medicine (E.Z., A.S., S.t.-C., D.Z., Y.B., L.H.-d., N.O., M.-M.A., O.E., O.B.-Y., E.K.), Tel Aviv University, Tel Aviv, Israel
| | - A Shemer
- Sackler School of Medicine (E.Z., A.S., S.t.-C., D.Z., Y.B., L.H.-d., N.O., M.-M.A., O.E., O.B.-Y., E.K.), Tel Aviv University, Tel Aviv, Israel
| | - S Toussia-Cohen
- From the Antenatal Diagnostic Unit (E.Z., S.t.-C., O.E., E.K.)
- Sackler School of Medicine (E.Z., A.S., S.t.-C., D.Z., Y.B., L.H.-d., N.O., M.-M.A., O.E., O.B.-Y., E.K.), Tel Aviv University, Tel Aviv, Israel
| | - D Zvi
- Sackler School of Medicine (E.Z., A.S., S.t.-C., D.Z., Y.B., L.H.-d., N.O., M.-M.A., O.E., O.B.-Y., E.K.), Tel Aviv University, Tel Aviv, Israel
| | - Y Bashan
- Sackler School of Medicine (E.Z., A.S., S.t.-C., D.Z., Y.B., L.H.-d., N.O., M.-M.A., O.E., O.B.-Y., E.K.), Tel Aviv University, Tel Aviv, Israel
| | - L Hirschfeld-Dicker
- Sackler School of Medicine (E.Z., A.S., S.t.-C., D.Z., Y.B., L.H.-d., N.O., M.-M.A., O.E., O.B.-Y., E.K.), Tel Aviv University, Tel Aviv, Israel
| | - N Oselka
- Sackler School of Medicine (E.Z., A.S., S.t.-C., D.Z., Y.B., L.H.-d., N.O., M.-M.A., O.E., O.B.-Y., E.K.), Tel Aviv University, Tel Aviv, Israel
| | - M-M Amitai
- Sackler School of Medicine (E.Z., A.S., S.t.-C., D.Z., Y.B., L.H.-d., N.O., M.-M.A., O.E., O.B.-Y., E.K.), Tel Aviv University, Tel Aviv, Israel
- Department of Obstetrics and Gynecology, and Department of Diagnostic Radiology (M.-M.A.), Chaim Sheba Medical Center, Tel-Hashomer, Israel
| | - O Ezra
- From the Antenatal Diagnostic Unit (E.Z., S.t.-C., O.E., E.K.)
- Sackler School of Medicine (E.Z., A.S., S.t.-C., D.Z., Y.B., L.H.-d., N.O., M.-M.A., O.E., O.B.-Y., E.K.), Tel Aviv University, Tel Aviv, Israel
| | - O Bar-Yosef
- Sackler School of Medicine (E.Z., A.S., S.t.-C., D.Z., Y.B., L.H.-d., N.O., M.-M.A., O.E., O.B.-Y., E.K.), Tel Aviv University, Tel Aviv, Israel
- Pediatric Neurology Unit (O.B.-Y.), Sheba Medical Center, Ramat-Gan, Israel
| | - E Katorza
- From the Antenatal Diagnostic Unit (E.Z., S.t.-C., O.E., E.K.)
- Sackler School of Medicine (E.Z., A.S., S.t.-C., D.Z., Y.B., L.H.-d., N.O., M.-M.A., O.E., O.B.-Y., E.K.), Tel Aviv University, Tel Aviv, Israel
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11
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Ali A, Beckett K, Flink C. Emergent MRI for acute abdominal pain in pregnancy-review of common pathology and imaging appearance. Emerg Radiol 2020; 27:205-214. [PMID: 31902010 DOI: 10.1007/s10140-019-01747-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 12/20/2019] [Indexed: 12/23/2022]
Abstract
Acute abdominal pain in pregnancy remains a clinically challenging presentation, often requiring imaging. The threat of morbidity and mortality to both mother and fetus necessitates quick and accurate imaging diagnosis, often via ultrasound. However, many of the common causes of acute abdominal pain are not readily diagnosed with sonography, and magnetic resonance imaging (MRI) is increasingly favored in this setting. The purpose of this review is to familiarize the reader with common pathologies which may be encountered in pregnant females presenting with acute abdominal pain requiring emergent MRI.
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Affiliation(s)
- Arafat Ali
- Department of Radiology, University of Cincinnati Medical Center, 234 Goodman Street, Cincinnati, OH, 45267, USA.
| | - Katrina Beckett
- Department of Radiology, University of California Los Angeles Medical Center, 10833 Le Conte Avenue, Los Angeles, CA, 90095, USA
| | - Carl Flink
- Department of Radiology, University of Cincinnati Medical Center, 234 Goodman Street, Cincinnati, OH, 45267, USA
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12
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Moreno CC, Mittal PK, Miller FH. Nonfetal Imaging During Pregnancy: Acute Abdomen/Pelvis. Radiol Clin North Am 2019; 58:363-380. [PMID: 32044012 DOI: 10.1016/j.rcl.2019.10.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Abdominal pain is a common occurrence in pregnant women and may have a variety of causes, including those that are specific to pregnancy (eg, round ligament pain in the first trimester) and the wide range of causes of abdominal pain that affect men and women who are not pregnant (eg, appendicitis, acute cholecystitis). Noncontrast magnetic resonance (MR) imaging is increasingly performed to evaluate pregnant women with abdominal pain, either as the first-line test or as a second test following ultrasonography. The imaging appearance of causes of abdominal pain in pregnant women are reviewed with an emphasis on noncontrast MR imaging.
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Affiliation(s)
- Courtney C Moreno
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1364-A Clifton Road Northeast Suite AT-627, Atlanta, GA 30327, USA.
| | - Pardeep K Mittal
- Department of Radiology, Medical College of Georgia, 1120 15th Street, BA-1411, Augusta, GA 30912, USA
| | - Frank H Miller
- Body Imaging Section and Fellowship, MRI, Department of Radiology, Northwestern University Feinberg School of Medicine, 676 North Saint Clair, Suite 800, Chicago, IL 60611, USA
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13
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Kave M, Parooie F, Salarzaei M. Pregnancy and appendicitis: a systematic review and meta-analysis on the clinical use of MRI in diagnosis of appendicitis in pregnant women. World J Emerg Surg 2019; 14:37. [PMID: 31367227 PMCID: PMC6647167 DOI: 10.1186/s13017-019-0254-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 07/04/2019] [Indexed: 02/07/2023] Open
Abstract
Background The aim of this systematic review and meta-analysis was to evaluate the clinical use of MRI for the evaluation of acute appendicitis during pregnancy. Methods The searches were conducted by two independent researchers (MK, MS) to find the relevant studies published from 1/1/2009 until end of 30/12/2018. We searched for published literature in the English language in MEDLINE via PubMed, EMBASETM via Ovid, The Cochrane Library, and Trip database. For literature published in other languages, we searched national databases (Magiran and SID), KoreaMed, and LILACS. The keywords used in the search strategy are Pregnancy [MeSH], Pregnant [MeSH] OR-Magnetic resonance imaging [MeSH] OR-Appendicitis [MeSH] OR-Ultrasound, [MeSH] OR, imaging, MRI [MeSH] OR"،" and Right lower quadrant pain [MeSH]. The risk of bias of every article was evaluated by using QUADAS-2. On the basis of the results from the 2 × 2 tables, pooled measures for sensitivity, specificity, diagnostic odds ratio (DOR), and area under the curves (AUC) along with their 95% confidence intervals (CIs) were calculated using the DerSimonian Lair methodology. Results As many as 1164 studies were selected. After analyzing the correspondence of the studies with the required criteria, 19 studies were selected for the final review. For appendicitis in pregnancy, the MRI sensitivity was 91.8% at the 95% confidence interval of (95% CI 87.7-94.9%). At the confidence interval of 95%, the specificity was 97.9% (95% CI 0.97.2-100%). The risk of bias in the studies conducted was measured using the QUADAS-2 tool. Conclusion MRI has high sensitivity and specificity (91.8%, 97.9% respectively) for the diagnosis of acute appendicitis in pregnant patients with clinically suspected appendicitis. It is an excellent imaging technique in many instances, which does not expose a fetus, or the mother, to ionizing radiation, making it an excellent option for pregnant patients with suspected acute appendicitis.
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Affiliation(s)
- Mania Kave
- 1Gynecology and Obstetrics Institution, Faculty of Medicine, Zabol University of Medical Sciences, Zabol, Islamic Republic of Iran
| | - Fateme Parooie
- 2Student Research Committee, Faculty of Medicine, Zabol University of Medical Sciences, Zabol, Islamic Republic of Iran
| | - Morteza Salarzaei
- 2Student Research Committee, Faculty of Medicine, Zabol University of Medical Sciences, Zabol, Islamic Republic of Iran
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14
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Sazhin AV, Kirienko AI, Kurtser MA, Konoplyannikov AG, Panin AV, Son DA, Shulyak GD. [Acute appendicitis during pregnancy]. Khirurgiia (Mosk) 2019:70-77. [PMID: 30789612 DOI: 10.17116/hirurgia201901170] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Acute appendicitis is the most frequent surgical disease complicating pregnancy. Accurate diagnosis is difficult due to atypical and misleading clinical manifestations. Surgeons frequently do not know about advantages and disadvantages of different diagnostic methods applied during pregnancy. Treatment of acute appendicitis in pregnant women remains the real challenge for surgeons. There are enough researches indicating on benefits and risks of both open and laparoscopic operations. The main risk is due to fetal loss after laparoscopic procedure. Safety of diagnostic techniques and laparoscopic procedures, surgical tactics and independent risk factors of pregnancy loss are touched in the article.
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Affiliation(s)
- A V Sazhin
- Pirogov Russian National Research Medical University of Healthcare Ministry of Russia, Moscow, Russia
| | - A I Kirienko
- Pirogov Russian National Research Medical University of Healthcare Ministry of Russia, Moscow, Russia
| | - M A Kurtser
- Pirogov Russian National Research Medical University of Healthcare Ministry of Russia, Moscow, Russia; Clinical Hospital Lapino 'Mother and Child', Moscow region, Russia
| | - A G Konoplyannikov
- Pirogov Russian National Research Medical University of Healthcare Ministry of Russia, Moscow, Russia
| | - A V Panin
- Clinical Hospital Lapino 'Mother and Child', Moscow region, Russia
| | - D A Son
- Pirogov Russian National Research Medical University of Healthcare Ministry of Russia, Moscow, Russia
| | - G D Shulyak
- Pirogov Russian National Research Medical University of Healthcare Ministry of Russia, Moscow, Russia
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15
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Garcia EM, Camacho MA, Karolyi DR, Kim DH, Cash BD, Chang KJ, Feig BW, Fowler KJ, Kambadakone AR, Lambert DL, Levy AD, Marin D, Moreno C, Peterson CM, Scheirey CD, Siegel A, Smith MP, Weinstein S, Carucci LR. ACR Appropriateness Criteria ® Right Lower Quadrant Pain-Suspected Appendicitis. J Am Coll Radiol 2019; 15:S373-S387. [PMID: 30392606 DOI: 10.1016/j.jacr.2018.09.033] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 09/07/2018] [Indexed: 02/07/2023]
Abstract
Appendicitis remains the most common surgical pathology responsible for right lower quadrant (RLQ) abdominal pain presenting to emergency departments in the United States, where the incidence continues to increase. Appropriate imaging in the diagnosis of appendicitis has resulted in decreased negative appendectomy rate from as high as 25% to approximately 1% to 3%. Contrast-enhanced CT remains the primary and most appropriate imaging modality to evaluate this patient population. MRI is approaching CT in sensitivity and specificity as this technology becomes more widely available and utilization increases. Unenhanced MRI and ultrasound remain the diagnostic procedures of choice in the pregnant patient. MRI and ultrasound continue to perform best in the hands of experts. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | - Evelyn M Garcia
- Virginia Tech Carilion School of Medicine, Roanoke, Virginia.
| | - Marc A Camacho
- The University of South Florida Morsani College of Medicine, Tampa, Florida
| | | | - David H Kim
- Panel Chair, University of Wisconsin Hospital & Clinics, Madison, Wisconsin
| | - Brooks D Cash
- University of Texas Health Science Center at Houston, McGovern Medical School, Houston, Texas; American Gastroenterological Association
| | | | - Barry W Feig
- The University of Texas MD Anderson Cancer Center, Houston, Texas; American College of Surgeons
| | | | | | - Drew L Lambert
- University of Virginia Health System, Charlottesville, Virginia
| | - Angela D Levy
- Medstar Georgetown University Hospital, Washington, District of Columbia
| | - Daniele Marin
- Duke University Medical Center, Durham, North Carolina
| | | | | | | | - Alan Siegel
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Martin P Smith
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | - Laura R Carucci
- Specialty Chair, Virginia Commonwealth University Medical Center, Richmond, Virginia
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16
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Eng KA, Abadeh A, Ligocki C, Lee YK, Moineddin R, Adams-Webber T, Schuh S, Doria AS. Acute Appendicitis: A Meta-Analysis of the Diagnostic Accuracy of US, CT, and MRI as Second-Line Imaging Tests after an Initial US. Radiology 2018; 288:717-727. [DOI: 10.1148/radiol.2018180318] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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17
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Clinical utility of magnetic resonance imaging in the evaluation of pregnant females with suspected acute appendicitis. Abdom Radiol (NY) 2018; 43:1446-1455. [PMID: 28849364 DOI: 10.1007/s00261-017-1300-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVES To assess the diagnostic performance of magnetic resonance imaging (MRI) in a large cohort of pregnant females with suspected acute appendicitis and to determine the frequency of non-appendiceal causes of abdominal pain identified by MRI in this population. METHODS This HIPAA compliant, retrospective study was IRB-approved and informed consent was waived. 212 MRI exams were performed consecutively on pregnant women aged 17-47 years old suspected of having acute appendicitis; eight exams were excluded and analyzed separately due to equivocal findings or lack of clinical follow up. Radiology reports for the MRI and any preceding ultrasound exams were reviewed as well as the patients' electronic medical record for surgical, pathological, or clinical follow up. RESULTS Fifteen (7.3%) of 204 MRI scans were determined to be positive for appendicitis, 14 of which were proven on surgical pathology, and one was found to have ileocecal diverticulitis. Out of the remaining 189 scans, none were subsequently shown to have acute appendicitis either surgically or based on clinical follow up. Negative predictive value (NPV) was 100% and positive predictive value was 93.3%. Sensitivity and specificity were 100% and 99.5%, respectively. Non-appendiceal findings which may have accounted for the patient's abdominal pain were seen in 91 (44.2%) of 189 scans. The most common extra-appendiceal causes of abdominal pain identified on MRI include degenerating fibroids (n = 11), significant hydronephrosis (n = 12), cholelithiasis (n = 6), and pyelonephritis (n = 3). CONCLUSION Our large study cohort of pregnant patients confirms MRI to be of high diagnostic value in the workup of acute appendicitis with 100% NPV and sensitivity and 99.5% specificity. Furthermore, an alternative diagnosis for abdominal pain in this patient population can be made in nearly half of MRI exams which are deemed negative for appendicitis.
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18
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Repplinger MD, Pickhardt PJ, Robbins JB, Kitchin DR, Ziemlewicz TJ, Hetzel SJ, Golden SK, Harringa JB, Reeder SB. Prospective Comparison of the Diagnostic Accuracy of MR Imaging versus CT for Acute Appendicitis. Radiology 2018; 288:467-475. [PMID: 29688158 DOI: 10.1148/radiol.2018171838] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Purpose To compare the accuracy of magnetic resonance (MR) imaging with that of computed tomography (CT) for the diagnosis of acute appendicitis in emergency department (ED) patients. Materials and Methods This was an institutional review board-approved, prospective, observational study of ED patients at an academic medical center (February 2012 to August 2014). Eligible patients were nonpregnant and 12- year-old or older patients in whom a CT study had been ordered for evaluation for appendicitis. After informed consent was obtained, CT and MR imaging (with non-contrast material-enhanced, diffusion-weighted, and intravenous contrast-enhanced sequences) were performed in tandem, and the images were subsequently retrospectively interpreted in random order by three abdominal radiologists who were blinded to the patients' clinical outcomes. Likelihood of appendicitis was rated on a five-point scale for both CT and MR imaging. A composite reference standard of surgical and histopathologic results and clinical follow-up was used, arbitrated by an expert panel of three investigators. Test characteristics were calculated and reported as point estimates with 95% confidence intervals (CIs). Results Analysis included images of 198 patients (114 women [58%]; mean age, 31.6 years ± 14.2 [range, 12-81 years]; prevalence of appendicitis, 32.3%). The sensitivity and specificity were 96.9% (95% CI: 88.2%, 99.5%) and 81.3% (95% CI: 73.5%, 87.3%) for MR imaging and 98.4% (95% CI: 90.5%, 99.9%) and 89.6% (95% CI: 82.8%, 94.0%) for CT, respectively, when a cutoff point of 3 or higher was used. The positive and negative likelihood ratios were 5.2 (95% CI: 3.7, 7.7) and 0.04 (95% CI: 0, 0.11) for MR imaging and 9.4 (95% CI: 5.9, 16.4) and 0.02 (95% CI: 0.00, 0.06) for CT, respectively. Receiver operating characteristic curve analysis demonstrated that the optimal cutoff point to maximize accuracy was 4 or higher, at which point there was no difference between MR imaging and CT. Conclusion The diagnostic accuracy of MR imaging was similar to that of CT for the diagnosis of acute appendicitis.
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Affiliation(s)
- Michael D Repplinger
- From the Departments of Emergency Medicine (M.D.R., S.K.G., J.B.H., S.B.R.), Radiology (M.D.R., P.J.P., J.B.R., D.R.K., T.J.Z., S.B.R.), Biostatistics and Medical Informatics (S.J.H.), Medicine (S.B.R.), Medical Physics (S.B.R.), and Biomedical Engineering (S.B.R.), University of Wisconsin-Madison, 800 University Bay Dr, Suite 310, Mail Code 9123, Madison, WI 53705
| | - Perry J Pickhardt
- From the Departments of Emergency Medicine (M.D.R., S.K.G., J.B.H., S.B.R.), Radiology (M.D.R., P.J.P., J.B.R., D.R.K., T.J.Z., S.B.R.), Biostatistics and Medical Informatics (S.J.H.), Medicine (S.B.R.), Medical Physics (S.B.R.), and Biomedical Engineering (S.B.R.), University of Wisconsin-Madison, 800 University Bay Dr, Suite 310, Mail Code 9123, Madison, WI 53705
| | - Jessica B Robbins
- From the Departments of Emergency Medicine (M.D.R., S.K.G., J.B.H., S.B.R.), Radiology (M.D.R., P.J.P., J.B.R., D.R.K., T.J.Z., S.B.R.), Biostatistics and Medical Informatics (S.J.H.), Medicine (S.B.R.), Medical Physics (S.B.R.), and Biomedical Engineering (S.B.R.), University of Wisconsin-Madison, 800 University Bay Dr, Suite 310, Mail Code 9123, Madison, WI 53705
| | - Douglas R Kitchin
- From the Departments of Emergency Medicine (M.D.R., S.K.G., J.B.H., S.B.R.), Radiology (M.D.R., P.J.P., J.B.R., D.R.K., T.J.Z., S.B.R.), Biostatistics and Medical Informatics (S.J.H.), Medicine (S.B.R.), Medical Physics (S.B.R.), and Biomedical Engineering (S.B.R.), University of Wisconsin-Madison, 800 University Bay Dr, Suite 310, Mail Code 9123, Madison, WI 53705
| | - Tim J Ziemlewicz
- From the Departments of Emergency Medicine (M.D.R., S.K.G., J.B.H., S.B.R.), Radiology (M.D.R., P.J.P., J.B.R., D.R.K., T.J.Z., S.B.R.), Biostatistics and Medical Informatics (S.J.H.), Medicine (S.B.R.), Medical Physics (S.B.R.), and Biomedical Engineering (S.B.R.), University of Wisconsin-Madison, 800 University Bay Dr, Suite 310, Mail Code 9123, Madison, WI 53705
| | - Scott J Hetzel
- From the Departments of Emergency Medicine (M.D.R., S.K.G., J.B.H., S.B.R.), Radiology (M.D.R., P.J.P., J.B.R., D.R.K., T.J.Z., S.B.R.), Biostatistics and Medical Informatics (S.J.H.), Medicine (S.B.R.), Medical Physics (S.B.R.), and Biomedical Engineering (S.B.R.), University of Wisconsin-Madison, 800 University Bay Dr, Suite 310, Mail Code 9123, Madison, WI 53705
| | - Sean K Golden
- From the Departments of Emergency Medicine (M.D.R., S.K.G., J.B.H., S.B.R.), Radiology (M.D.R., P.J.P., J.B.R., D.R.K., T.J.Z., S.B.R.), Biostatistics and Medical Informatics (S.J.H.), Medicine (S.B.R.), Medical Physics (S.B.R.), and Biomedical Engineering (S.B.R.), University of Wisconsin-Madison, 800 University Bay Dr, Suite 310, Mail Code 9123, Madison, WI 53705
| | - John B Harringa
- From the Departments of Emergency Medicine (M.D.R., S.K.G., J.B.H., S.B.R.), Radiology (M.D.R., P.J.P., J.B.R., D.R.K., T.J.Z., S.B.R.), Biostatistics and Medical Informatics (S.J.H.), Medicine (S.B.R.), Medical Physics (S.B.R.), and Biomedical Engineering (S.B.R.), University of Wisconsin-Madison, 800 University Bay Dr, Suite 310, Mail Code 9123, Madison, WI 53705
| | - Scott B Reeder
- From the Departments of Emergency Medicine (M.D.R., S.K.G., J.B.H., S.B.R.), Radiology (M.D.R., P.J.P., J.B.R., D.R.K., T.J.Z., S.B.R.), Biostatistics and Medical Informatics (S.J.H.), Medicine (S.B.R.), Medical Physics (S.B.R.), and Biomedical Engineering (S.B.R.), University of Wisconsin-Madison, 800 University Bay Dr, Suite 310, Mail Code 9123, Madison, WI 53705
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Shin I, Chung YE, An C, Lee HS, Kim H, Lim JS, Kim MJ. Optimisation of the MR protocol in pregnant women with suspected acute appendicitis. Eur Radiol 2017; 28:514-521. [PMID: 28894912 DOI: 10.1007/s00330-017-5038-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2017] [Revised: 08/01/2017] [Accepted: 08/16/2017] [Indexed: 11/30/2022]
Abstract
PURPOSE To investigate the optimal magnetic resonance (MR) imaging protocol in pregnant women suspected of having acute appendicitis. MATERIALS AND METHODS One hundred and forty-six pregnant women with suspected appendicitis were included. MR images were reviewed by two radiologists in three separate sessions. In session 1, only axial single-shot turbo spin echo (SSH-TSE) T2-weighted images (WI) were included with other routine sequences. In sessions 2 and 3, coronal and sagittal T2WI were sequentially added. The visibility of the appendix and diagnostic confidence of appendicitis were evaluated in each session using a 5-point grading scale. If diseases other than appendicitis were suspected, specific diagnosis with a 5-point confidence scale was recorded. Diagnostic performance for appendicitis and other diseases were evaluated. RESULTS Twenty-five patients (17.1%) were diagnosed with appendicitis. Among the patients with normal appendix, 28 were diagnosed with other disease. Diagnostic performance including sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and area under the curve values for diagnosing appendicitis and other diseases showed no significant difference among sets for both reviewers (p>0.05). CONCLUSION Diagnostic performance of MR in pregnant patients with suspected appendicitis can be preserved with omission of sagittal or both coronal and sagittal SSH-T2WI. KEY POINTS • Diagnostic performance of appendicitis is preserved with omission of sagittal/coronal T2WIs. • Diagnosis of other disease may be sufficient with axial T2WIs only. • Careful serial omission of sagittal and coronal T2WIs can be considered.
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Affiliation(s)
- Ilah Shin
- Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Yong Eun Chung
- Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
| | - Chansik An
- Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Hye Sun Lee
- Department of Research Affairs, Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Honsoul Kim
- Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Joon Seok Lim
- Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Myeong-Jin Kim
- Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
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Tsai R, Raptis C, Fowler KJ, Owen JW, Mellnick VM. MRI of suspected appendicitis during pregnancy: interradiologist agreement, indeterminate interpretation and the meaning of non-visualization of the appendix. Br J Radiol 2017; 90:20170383. [PMID: 28869395 DOI: 10.1259/bjr.20170383] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To determine the degree of interradiologist agreement between the MRI features of appendicitis during pregnancy, the outcomes associated with an indeterminate interpretation and the negative predictive value of non-visualization of the appendix. METHODS Our study was approved by the institutional review board at the Washington University in St. Louis, Missouri (WUStL) and was HIPAA (Health Insurance Portability and Accountability Act of 1996)-compliant. The informed consent requirement was waived. Cases of suspected appendicitis during pregnancy evaluated using MRI were retrospectively identified using search queries. Scans were re-reviewed by two radiologists (7 and 9 years experience, respectively) to evaluate the interradiologist agreement of different MRI features of appendicitis during pregnancy (visualization of the appendix, appendiceal diameter, appendiceal wall thickening, periappendiceal fat stranding, fluid-filled appendix and periappendiceal fluid). The radiologists were blinded to patient outcome, patient intervention, laboratory data, demographic data and the original MRI reports. Clinical outcomes were documented by surgical pathology or clinical observation. Interradiologist agreement was analysed using Cohen's κ, while patient demographic and clinical data was analysed using Student's t-testing. RESULTS 233 females with suspected appendicitis during pregnancy were evaluated using MRI over a 13-year period (mean age, 28.4 years; range, 17-38 years). There were 14 (6%) positive examinations for appendicitis during pregnancy, including 1 patient whose MRI was interpreted as negative, proven by surgical pathology. The presence of periappendiceal soft-tissue stranding and the final overall impression had the most interradiologist agreement (к = 0.81-1). There were no pregnant patients found to have acute appendicitis who had an indeterminate MR interpretation or when the appendix could not be visualized. CONCLUSION The final impression by the two retrospectively reviewing radiologists of MR examinations performed for suspected appendicitis during pregnancy had near-perfect agreement. In patients where the appendix could not be visualized or in patients that were interpreted as indeterminate, no patients had acute appendicitis. Advances in knowledge: MR impression for suspected appendicitis in the pregnant patient has high interradiologist agreement, and a non-visualized appendix or lack of inflammatory findings at the time of MR, reliably excludes surgical appendicitis.
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Affiliation(s)
- Richard Tsai
- 1 Department of Diagnostic Radiology, Mallinckrodt Institute of Radiology, Washington University, St. Louis, MO, USA
| | - Constantine Raptis
- 1 Department of Diagnostic Radiology, Mallinckrodt Institute of Radiology, Washington University, St. Louis, MO, USA
| | - Kathryn J Fowler
- 1 Department of Diagnostic Radiology, Mallinckrodt Institute of Radiology, Washington University, St. Louis, MO, USA
| | - Joseph W Owen
- 2 Department of Radiology, University of Kentucky, Lexington, KY, USA
| | - Vincent M Mellnick
- 1 Department of Diagnostic Radiology, Mallinckrodt Institute of Radiology, Washington University, St. Louis, MO, USA
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Burns M, Hague CJ, Vos P, Tiwari P, Wiseman SM. Utility of Magnetic Resonance Imaging for the Diagnosis of Appendicitis During Pregnancy: A Canadian Experience. Can Assoc Radiol J 2017; 68:392-400. [PMID: 28728903 DOI: 10.1016/j.carj.2017.02.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 01/09/2017] [Accepted: 02/14/2017] [Indexed: 01/10/2023] Open
Abstract
PURPOSE The objective of the study was to evaluate the performance of magnetic resonance imaging (MRI) for the diagnosis of appendicitis during pregnancy. METHODS We conducted a retrospective review of all MRI scans performed at our institution, between 2006 and 2012, for the evaluation of suspected appendicitis in pregnant women. Details of the MRI scans performed were obtained from the radiology information system as well as details of any ultrasounds carried out for the same indication. Clinical and pathological data were obtained by retrospective chart review. RESULTS The study population comprised 63 patients, and 8 patients underwent a second MRI scan during the same pregnancy. A total of 71 MRI scans were reviewed. The appendix was identified on 40 scans (56.3%). Sensitivity of MRI was 75% and specificity was 100% for the diagnosis of appendicitis in pregnant women. When cases with right lower quadrant inflammatory fat stranding or focal fluid, without appendix visualization, were classified as positive for appendicitis, MRI sensitivity increased to 81.3% but specificity decreased to 96.4%. CONCLUSIONS MRI is sensitive and highly specific for the diagnosis of appendicitis during pregnancy and should be considered as a first line imaging study for this clinical presentation.
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Affiliation(s)
- Michael Burns
- Department of Radiology, St Paul's Hospital & University of British Columbia, Vancouver, British Columbia, Canada.
| | - Cameron J Hague
- Department of Radiology, St Paul's Hospital & University of British Columbia, Vancouver, British Columbia, Canada
| | - Patrick Vos
- Department of Radiology, St Paul's Hospital & University of British Columbia, Vancouver, British Columbia, Canada
| | - Pari Tiwari
- Department of Radiology, St Paul's Hospital & University of British Columbia, Vancouver, British Columbia, Canada
| | - Sam M Wiseman
- Department of Surgery, St Paul's Hospital & University of British Columbia, Vancouver, British Columbia, Canada
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Patel D, Fingard J, Winters S, Low G. Clinical use of MRI for the evaluation of acute appendicitis during pregnancy. Abdom Radiol (NY) 2017; 42:1857-1863. [PMID: 28194513 DOI: 10.1007/s00261-017-1078-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE The purpose of this study was to determine the diagnostic accuracy of MRI for detecting acute appendicitis in pregnancy in a multi-institution study involving general body MR readers with no specific expertise in MR imaging of the pregnant patient. METHODS Retrospective review of MRI examinations on PACS in 42 pregnant patients was evaluated for acute right lower quadrant pain. Three fellowship-trained general body radiologists analyzed the MRI examinations in consensus and attempted to localize the appendix, assess for features of appendicitis, and exclude alternative etiologies for the right lower quadrant pain. RESULTS Of the 42 MRI examinations, the readers noted 6 cases of acute appendicitis, 16 cases of a normal appendix, and 20 cases involving non-visualization of the appendix but where there were no secondary features of acute appendicitis. Based on the surgical data and clinical follow-up, there were 3 true-positive cases, 3 false-positive cases, 34 true-negative cases, and 2 false-negative cases of acute appendicitis on MRI. This yielded an accuracy of 88.1%, sensitivity of 60%, specificity of 91.9%, positive predictive value of 50%, and negative predictive value of 94.4% for the detection of acute appendicitis in the pregnant patient on MRI. Alternative etiologies for the right lower quadrant pain on MRI included torsion of an ovarian dermoid in 1 case and pyelonephritis in 1 case. CONCLUSION MRI is an excellent modality for excluding acute appendicitis in pregnant patients presenting with right lower quadrant pain.
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Affiliation(s)
- Darshan Patel
- Department of Radiology & Diagnostic Imaging, University of Alberta Hospital, 2A2.41 WMC, 8440 - 112 Street, Edmonton, AB, T6G 2B7, Canada.
| | - Jordan Fingard
- Department of Radiology & Diagnostic Imaging, University of Alberta Hospital, 2A2.41 WMC, 8440 - 112 Street, Edmonton, AB, T6G 2B7, Canada
| | - Sean Winters
- Department of Radiology & Diagnostic Imaging, University of Alberta Hospital, 2A2.41 WMC, 8440 - 112 Street, Edmonton, AB, T6G 2B7, Canada
| | - Gavin Low
- Department of Radiology & Diagnostic Imaging, University of Alberta Hospital, 2A2.41 WMC, 8440 - 112 Street, Edmonton, AB, T6G 2B7, Canada
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Pearl JP, Price RR, Tonkin AE, Richardson WS, Stefanidis D. SAGES guidelines for the use of laparoscopy during pregnancy. Surg Endosc 2017. [DOI: 10.1007/s00464-017-5637-3] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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T1 bright appendix sign to exclude acute appendicitis in pregnant women. Eur Radiol 2017; 27:3310-3316. [PMID: 28097379 DOI: 10.1007/s00330-016-4727-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 12/05/2016] [Accepted: 12/22/2016] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To evaluate the diagnostic value of the T1 bright appendix sign for the diagnosis of acute appendicitis in pregnant women. MATERIAL AND METHODS This retrospective study included 125 pregnant women with suspected appendicitis who underwent magnetic resonance (MR) imaging. The T1 bright appendix sign was defined as a high intensity signal filling more than half length of the appendix on T1-weighted imaging. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of the T1 bright appendix sign for normal appendix identification were calculated in all patients and in those with borderline-sized appendices (6-7 mm). RESULTS The T1 bright appendix sign was seen in 51% of patients with normal appendices, but only in 4.5% of patients with acute appendicitis. The overall sensitivity, specificity, PPV, and NPV of the T1 bright appendix sign for normal appendix diagnosis were 44.9%, 95.5%, 97.6%, and 30.0%, respectively. All four patients with borderline sized appendix with appendicitis showed negative T1 bright appendix sign. CONCLUSION The T1 bright appendix sign is a specific finding for the diagnosis of a normal appendix in pregnant women with suspected acute appendicitis. KEY POINTS • Magnetic resonance imaging is increasingly used in emergency settings. • Acute appendicitis is the most common cause of acute abdomen. • Magnetic resonance imaging is widely used in pregnant population. • T1 bright appendix sign can be a specific sign representing normal appendix.
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Segev L, Segev Y, Rayman S, Nissan A, Sadot E. The diagnostic performance of ultrasound for acute appendicitis in pregnant and young nonpregnant women: A case-control study. Int J Surg 2016; 34:81-85. [PMID: 27554180 DOI: 10.1016/j.ijsu.2016.08.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Revised: 07/23/2016] [Accepted: 08/11/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Ultrasonography is frequently used to diagnose acute appendicitis in women of reproductive age, but its diagnostic value in pregnant patients remains unclear. This study sought to compare the diagnostic performance of ultrasound in pregnant and young nonpregnant women with suspected acute appendicitis. METHODS The database of a single tertiary medical center was reviewed for all women of reproductive age who underwent appendectomy either during pregnancy (2000-2014) or in the nonpregnant state (2004-2007) following ultrasound evaluation. The performance of ultrasound in terms of predicting the final pathologic diagnosis was compared between the pregnant and non pregnant groups using receiver operating characteristic curve analysis. RESULTS Of 586 young women treated for appendicitis during the study periods (92 pregnant, 494 non-pregnant), 200 underwent preoperative ultrasound [67 pregnant, and 133 nonpregnant young women]. The pregnant and nonpregnant groups were comparable in age and presenting symptoms. There was no significant difference in the predictive performance of ultrasound between the two groups (AUC 0.76 and 0.73 respectively, p = 0.78) or within the pregnant group, by trimester [first (n = 23), AUC 0.73; second (n = 32), AUC 0.67; third (n = 12), AUC 0.86; p = 0.4]. Ultrasound had a positive predictive value of 0.94 in the pregnant group and 0.91 in the nonpregnant group; corresponding negative predictive values were 0.40 and 0.43. CONCLUSIONS There appears to be no difference in the ability of ultrasound to predict the diagnosis of acute appendicitis between pregnant women and nonpregnant women of reproductive age. Therefore, similar preoperative imaging algorithms may be used in both patient populations.
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Affiliation(s)
- Lior Segev
- Department of General Surgery and Oncological Surgery - Surgery C, Sheba Medical Center, Tel Hashomer, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Yakir Segev
- Department of Obstetrics and Gynecology, Carmel Medical Center, Haifa, Israel; Bruce Rappaport Faculty of Medicine, Israel Institute of Technology, Haifa, Israel
| | - Shlomi Rayman
- Department of General Surgery and Oncological Surgery - Surgery C, Sheba Medical Center, Tel Hashomer, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Aviram Nissan
- Department of General Surgery and Oncological Surgery - Surgery C, Sheba Medical Center, Tel Hashomer, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eran Sadot
- Department of Surgery, Rabin Medical Center, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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A Systematic Review and Meta-Analysis of Diagnostic Performance of MRI for Evaluation of Acute Appendicitis. AJR Am J Roentgenol 2016; 206:508-17. [PMID: 26901006 DOI: 10.2214/ajr.15.14544] [Citation(s) in RCA: 91] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE A meta-analysis was performed to determine the accuracy of MRI in the diagnosis of acute appendicitis in the general population and in subsets of pregnant patients and children. MATERIALS AND METHODS A systematic search of the PubMed and EMBASE databases for articles published through the end of October 2014 was performed to identify studies that used MRI to evaluate patients suspected of having acute appendicitis. Pooled data for sensitivity, specificity, and positive and negative predictive values were calculated. RESULTS A total of 30 studies that comprised 2665 patients were reviewed. The sensitivity and specificity of MRI for the diagnosis of acute appendicitis are 96% (95% CI, 95-97%) and 96% (95% CI, 95-97%), respectively. In a subgroup of studies that focused solely on pregnant patients, the sensitivity and specificity of MRI were 94% (95% CI, 87-98%) and 97% (95% CI, 96-98%), respectively, whereas in studies that focused on children, sensitivity and specificity were found to be 96% (95% CI, 95-97%) and 96% (95% CI, 94-98%), respectively. CONCLUSION MRI has a high accuracy for the diagnosis of acute appendicitis, for a wide range of patients, and may be acceptable for use as a first-line diagnostic test.
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Petkovska I, Martin DR, Covington MF, Urbina S, Duke E, Daye ZJ, Stolz LA, Keim SM, Costello JR, Chundru S, Arif-Tiwari H, Gilbertson-Dahdal D, Gries L, Kalb B. Accuracy of Unenhanced MR Imaging in the Detection of Acute Appendicitis: Single-Institution Clinical Performance Review. Radiology 2016; 279:451-60. [DOI: 10.1148/radiol.2015150468] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Abstract
OBJECTIVE The purpose of this article is to describe our approach to contrast-enhanced abdominal MRI in patients with nontraumatic abdominal pain and suspected appendicitis. We aim to share our experience on the advantages, pearls, and pitfalls of MRI in this clinical setting, in comparison with CT and ultrasound. CONCLUSION We present some typical cases of appendicitis and alternative diagnoses in patients presenting with acute nontraumatic abdominal pain.
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Repplinger MD, Weber AC, Pickhardt PJ, Rajamanickam VP, Svenson JE, Ehlenbach WJ, Westergaard RP, Reeder SB, Jacobs EA. Trends in the Use of Medical Imaging to Diagnose Appendicitis at an Academic Medical Center. J Am Coll Radiol 2016; 13:1050-6. [PMID: 27053160 DOI: 10.1016/j.jacr.2016.02.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 02/11/2016] [Accepted: 02/19/2016] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To quantify the trends in imaging use for the diagnosis of appendicitis. METHODS A retrospective study covering a 22-year period was conducted at an academic medical center. Patients were identified by International Classification of Diseases-9 diagnosis code for appendicitis. Medical record data extraction of these patients included imaging test used (ultrasound, CT, or MRI), gender, age, and body mass index (BMI). The proportion of patients undergoing each scan was calculated by year. Regression analysis was performed to determine whether age, gender, or BMI affected imaging choice. RESULTS The study included a total of 2,108 patients, including 967 (43.5%) females and 599 (27%) children (<18 years old). CT use increased over time for the entire cohort (2.9% to 82.4%, P < .0001), and each subgroup (males, females, adults, children; P < .0001 for each). CT use increased more in females and adults than in males and children, but differences in trends were not statistically significant (male versus female, P = .8; adult versus child, P = .1). The percentage of patients who had no imaging used for the diagnosis of appendicitis decreased over time (P < .0001 overall and for each subgroup), and no difference was found in trends between complementary subgroups (male versus female, P = .53; adult versus child, P = .66). No statistically significant changes were found in use of ultrasound or MRI over the study period. With increasing BMI, CT was more frequently used. CONCLUSIONS Of those diagnosed with appendicitis at an academic medical center, CT use increased more than 20-fold. However, no statistically significant trend was found for increased use of ultrasound or MRI.
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Affiliation(s)
- Michael D Repplinger
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, Madison, Wisconsin; Department of Radiology, University of Wisconsin-Madison, Madison, Wisconsin.
| | - Andrew C Weber
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, Madison, Wisconsin
| | - Perry J Pickhardt
- Department of Radiology, University of Wisconsin-Madison, Madison, Wisconsin
| | - Victoria P Rajamanickam
- Department of Biostatistics & Medical Informatics, University of Wisconsin-Madison, Madison, Wisconsin
| | - James E Svenson
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, Madison, Wisconsin
| | | | - Ryan P Westergaard
- Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin
| | - Scott B Reeder
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, Madison, Wisconsin; Department of Radiology, University of Wisconsin-Madison, Madison, Wisconsin; Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin; Department of Medical Physics, University of Wisconsin-Madison, Madison, Wisconsin; Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, Wisconsin
| | - Elizabeth A Jacobs
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, Madison, Wisconsin; Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin
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Reply. Am J Obstet Gynecol 2016; 214:136-7. [PMID: 26383998 DOI: 10.1016/j.ajog.2015.09.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Accepted: 09/08/2015] [Indexed: 11/23/2022]
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Burke LM, Bashir MR, Miller FH, Siegelman ES, Brown M, Alobaidy M, Jaffe TA, Hussain SM, Palmer SL, Garon BL, Oto A, Reinhold C, Ascher SM, Demulder DK, Thomas S, Best S, Borer J, Zhao K, Pinel-Giroux F, De Oliveira I, Resende D, Semelka RC. Magnetic resonance imaging of acute appendicitis in pregnancy: a 5-year multiinstitutional study. Am J Obstet Gynecol 2015. [PMID: 26215327 DOI: 10.1016/j.ajog.2015.07.026] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE The purpose of this study was to determine the diagnostic performance of magnetic resonance imaging (MRI) in the diagnosis of acute appendicitis during pregnancy in a multiinstitutional study. STUDY DESIGN In this multicenter retrospective study, the cases of pregnant women who underwent MRI evaluation of abdominal or pelvic pain and who had clinical suspicion of acute appendicitis between June 1, 2009, and July 31, 2014, were reviewed. All MRI examinations with positive findings for acute appendicitis were confirmed with surgical pathologic information. Sensitivity, specificity, negative predictive values, and positive predictive values were calculated. Receiver operating characteristic curves were generated, and area under the curve analysis was performed for each participating institution. RESULTS Of the cases that were evaluated, 9.3% (66/709) had MRI findings of acute appendicitis. Sensitivity, specificity, accuracy, positive predictive value, and negative predictive values were 96.8%, 99.2%, 99.0%, 92.4%, and 99.7%, respectively. There was no statistically significant difference between centers that were included in the study (pair-wise probability values ranged from 0.12-0.99). CONCLUSION MRI is useful and reproducible in the diagnosis of suspected acute appendicitis during pregnancy.
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Strizek B, Jani JC, Mucyo E, De Keyzer F, Pauwels I, Ziane S, Mansbach AL, Deltenre P, Cos T, Cannie MM. Safety of MR Imaging at 1.5 T in Fetuses: A Retrospective Case-Control Study of Birth Weights and the Effects of Acoustic Noise. Radiology 2015; 275:530-7. [DOI: 10.1148/radiol.14141382] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abstract
Evaluation of acute abdominal and pelvic pain in pregnancy presents a diagnostic challenge for clinicians and radiologists alike. The differential diagnosis includes obstetric and nonobstetric conditions unique to pregnancy, in addition to causes of acute abdominal and pelvic pain unrelated to the pregnancy. The clinical presentation and course of disease may be altered in pregnancy, and several pathologies are exacerbated by pregnancy. Discriminating clinical features in the diagnosis of abdominal and pelvic pain are often confounded by expected anatomic and physiologic changes in pregnancy. Moreover, while diagnostic pathways may be altered in pregnancy, the necessity for a timely and accurate diagnosis must be underscored, as delay in treatment may result in an undesirable increase in morbidity and/or mortality for both the patient and fetus. Advances in magnetic resonance imaging (MRI) through faster acquisition and motion-insensitive techniques, coupled with increased awareness and education regarding the value of MRI in diagnosing a wide range of pathology, have established MRI as a valuable strategy in the investigation of acute abdominal and pelvic pain in the pregnant patient. This review presents a practical approach to common obstetric and nonobstetric causes of acute abdominal and pelvic pain during pregnancy, as well as safety considerations for performing MRI in this patient population.
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Theilen LH, Mellnick VM, Longman RE, Tuuli MG, Odibo AO, Macones GA, Cahill AG. Utility of magnetic resonance imaging for suspected appendicitis in pregnant women. Am J Obstet Gynecol 2015; 212:345.e1-6. [PMID: 25291255 DOI: 10.1016/j.ajog.2014.10.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Revised: 08/26/2014] [Accepted: 10/02/2014] [Indexed: 12/29/2022]
Abstract
OBJECTIVE The purpose of this study was to estimate the rate and risk of appendix nonvisualization and alternative diagnoses made with magnetic resonance imaging (MRI) for suspected appendicitis in pregnant women. STUDY DESIGN We performed a retrospective cohort study of consecutive pregnant women who underwent MRI for suspected appendicitis at a single center from 2007-2012. Data on clinical presentation, imaging, and surgical pathologic evidence were extracted from electronic medical records. Odds ratios estimated risk factors for nondiagnosis. Radiologic diagnoses were identified, and rates of diagnoses were calculated. Subgroup analysis was performed among women who underwent initial imaging with ultrasound scanning. RESULTS Over the 5-year period, 171 pregnant women underwent MRI for suspected appendicitis. The rate of nonvisualization was 30.9% (n = 53). Of the remaining 118 women with a visualized appendix, 18 women had imaging findings that were consistent with appendicitis and underwent appendectomy. Twelve cases of appendicitis were confirmed on pathologic evaluation (66.7%). Women with nonvisualization of the appendix on MRI were more likely to be beyond the first trimester (odds ratio, 2.1; 95% confidence interval, 1.0-4.5). Seventy-four women had disease diagnosed on MRI (43.3%). In the group of 43 women who had a nondiagnostic ultrasound scanning before the MRI, the rate of subsequent diagnostic MRI was 65% (n = 28). CONCLUSION MRI yields a high diagnostic rate and accuracy in pregnant women with suspected appendicitis and provides alternative diagnoses to guide further management. Given the high rate of appendix nonvisualization on ultrasound scanning that has been reported in the literature, we recommend MRI as the imaging modality of choice for this population in settings in which MRI is readily available.
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Aggenbach L, Zeeman GG, Cantineau AEP, Gordijn SJ, Hofker HS. Impact of appendicitis during pregnancy: no delay in accurate diagnosis and treatment. Int J Surg 2015; 15:84-9. [PMID: 25638737 DOI: 10.1016/j.ijsu.2015.01.025] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Revised: 01/10/2015] [Accepted: 01/26/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND Acute appendicitis during pregnancy may be associated with serious maternal and/or fetal complications. To date, the optimal clinical approach to the management of pregnant women suspected of having acute appendicitis is subject to debate. The purpose of this retrospective study was to provide recommendations for prospective clinical management of pregnant patients with suspected appendicitis. METHOD Case records of all pregnant patients suspected of having appendicitis whom underwent appendectomy at our hospital between 1990 and 2010 were reviewed. RESULTS Appendicitis was histologically verified in fifteen of twenty-one pregnant women, of whom six were diagnosed with perforated appendicitis. Maternal morbidity was seen in two cases. Premature delivery occurred in two out of six cases with perforated appendicitis cases and two out of six cases following a negative appendectomy. Perinatal mortality did not occur. CONCLUSION Both (perforated) appendicitis and negative appendectomy during pregnancy are associated with a high risk of premature delivery. Clinical presentation and imaging remains vital in deciding whether surgical intervention is indicated. We recommend to cautiously weigh the risks of delay until correct diagnosis with associated increased risk of appendiceal perforation and the risk of unnecessary surgical intervention. Based upon current literature, we recommend clinicians to consider an MRI following an inconclusive or negative abdominal ultrasound aiming to improve diagnostic accuracy to reduce the rate of negative appendectomies. Accurate and prompt diagnosis of acute appendicitis should be strived for to avoid unnecessary exploration and to aim for timely surgical intervention in pregnant women suspected of having appendicitis.
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Affiliation(s)
- L Aggenbach
- Department of Surgery, University Medical Center Groningen (UMCG), Hanzeplein 1, 9700 RB Groningen, The Netherlands.
| | - G G Zeeman
- Department of Gynaecology and Obstetrics, University Medical Center Groningen (UMCG), Hanzeplein 1, 9700 RB Groningen, The Netherlands
| | - A E P Cantineau
- Department of Gynaecology and Obstetrics, University Medical Center Groningen (UMCG), Hanzeplein 1, 9700 RB Groningen, The Netherlands
| | - S J Gordijn
- Department of Gynaecology and Obstetrics, University Medical Center Groningen (UMCG), Hanzeplein 1, 9700 RB Groningen, The Netherlands
| | - H S Hofker
- Department of Surgery, University Medical Center Groningen (UMCG), Hanzeplein 1, 9700 RB Groningen, The Netherlands
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Abstract
During the past century, imaging of the pregnant patient has been performed with radiography, scintigraphy, computed tomography, magnetic resonance imaging, and ultrasonography (US). US imaging has emerged as the primary imaging modality, because it provides real-time images at relatively low cost without the use of ionizing radiation. This review begins with a discussion of the history and current status of imaging modalities other than US for the pregnant patient. The discussion then turns to an in-depth description of how US technology advanced to become such a valuable diagnostic tool in the obstetric patient. Finally, the broad range of diagnostic uses of US in these patients is presented, including its uses for distinguishing an intrauterine pregnancy from a failed or ectopic pregnancy in the first trimester; assigning gestational age and assessing fetal weight; evaluating the fetus for anomalies and aneuploidy; examining the uterus, cervix, placenta, and amniotic fluid; and guiding obstetric interventional procedures.
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Affiliation(s)
- Carol B Benson
- From the Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115
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Drake FT, Kotagal M, Simmons LE, Parr Z, Dighe MK, Flum DR. Single institution and statewide performance of ultrasound in diagnosing appendicitis in pregnancy. J Matern Fetal Neonatal Med 2014; 28:727-33. [PMID: 24913357 DOI: 10.3109/14767058.2014.932344] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Assess the performance of ultrasound (US) in pregnant patients presenting with acute abdominal pain concerning for appendicitis. METHODS Descriptive analysis of pregnant patients who underwent an US for acute abdominal pain over a 6-year period using data from a statewide quality improvement collaborative and a single center. RESULTS Statewide, 131 pregnant patients underwent an appendectomy and 85% had an US. In our single-center case series, 49 pregnant patients underwent an US for acute abdominal pain and four patients had appendicitis (8%). Of those, three were definitively diagnosed with US. The appendix was visualized by US in five patients (3 appendicitis/2 normal). Mean gestational age was 11 weeks for visualization of the appendix versus 20 weeks for non-visualization (p < 0.001). Concordance between US and pathology was similar statewide and at our institution (43%). CONCLUSIONS US appears to play a central role in the evaluation of appendicitis in pregnant women, especially in the first trimester, and often contributes to definitive disposition. US performed less well in excluding appendicitis; however, in certain clinical settings, providers appeared to trust US findings. From these results, we developed a multidisciplinary imaging pathway for pregnant patients who present with acute abdominal pain concerning for appendicitis.
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Affiliation(s)
- Frederick T Drake
- Department of Surgery, University of Washington Medical Center , Seattle, WA , USA
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Magnetic resonance imaging of the gut: a primer for the luminal gastroenterologist. Am J Gastroenterol 2014; 109:497-509; quiz 510. [PMID: 24394750 DOI: 10.1038/ajg.2013.452] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2013] [Accepted: 11/24/2013] [Indexed: 12/11/2022]
Abstract
Magnetic resonance imaging (MRI) is well established for imaging the solid organs of the abdomen and pelvis. In recent years it has been having an increasingly important role in the evaluation of the gastrointestinal (GI) tract. Fluoroscopy and abdominal computed tomography, the traditional mainstays of bowel imaging, remain valuable; however, the contemporary emphasis on decreasing patient radiation exposure is driving practice toward non-ionizing modalities such as MRI. The inherent dynamic properties of MRI, its superior tissue contrast, and cross-sectional capabilities offer additional advantages. Here we review, from esophagus to anus, techniques and indications for MRI of the GI lumen with an emphasis on the normal MRI appearance of the GI tract and commonly encountered pathology.
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Leeuwenburgh MMN, Jensch S, Gratama JWC, Spilt A, Wiarda BM, Van Es HW, Cobben LPJ, Bossuyt PMM, Boermeester MA, Stoker J. MRI features associated with acute appendicitis. Eur Radiol 2013; 24:214-22. [PMID: 24013847 DOI: 10.1007/s00330-013-3001-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Revised: 07/25/2013] [Accepted: 08/07/2013] [Indexed: 12/28/2022]
Abstract
OBJECTIVES To identify MRI features associated with appendicitis. METHODS Features expected to be associated with appendicitis were recorded in consensus by two expert radiologists on 223 abdominal MRIs in patients with suspected appendicitis. Nine MRI features were studied: appendix diameter >7 mm, appendicolith, peri-appendiceal fat infiltration, peri-appendiceal fluid, absence of gas in the appendix, appendiceal wall destruction, restricted diffusion of the appendiceal wall, lumen or focal fluid collections. Appendicitis was assigned as the final diagnosis in 117/223 patients. Associations between imaging features and appendicitis were evaluated with logistic regression analysis. RESULTS All investigated features were significantly associated with appendicitis in univariate analysis. Combinations of two and three features were associated with a probability of appendicitis of 88 % and 92 %, respectively. In patients without any of the nine features, appendicitis was present in 2 % of cases. After multivariate analysis, only an appendix diameter >7 mm, peri-appendiceal fat infiltration and restricted diffusion of the appendiceal wall were significantly associated with appendicitis. The probability of appendicitis was 96 % in their presence and 2 % in their absence. CONCLUSIONS An appendix diameter >7 mm, peri-appendiceal fat infiltration and restricted diffusion of the appendiceal wall have the strongest association with appendicitis on MRI. KEY POINTS • An enlarged appendix, fat infiltration and restricted diffusion are associated with appendicitis. • One such feature on MRI gives an 88 % probability of appendicitis. • Two features in combination give a probability of appendicitis of 94 %. • Combinations of three features give a probability of appendicitis of 96 %. • The absence of these features almost rules out appendicitis (2 %).
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