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Marin JR, Lyons TW, Claudius I, Fallat ME, Aquino M, Ruttan T, Daugherty RJ. Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report. Pediatrics 2024; 154:e2024066855. [PMID: 38932719 DOI: 10.1542/peds.2024-066855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/28/2024] [Indexed: 06/28/2024] Open
Abstract
Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging, are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.
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Affiliation(s)
- Jennifer R Marin
- Departments of Pediatrics, Emergency Medicine, & Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Todd W Lyons
- Division of Emergency Medicine, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
| | - Ilene Claudius
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
| | - Mary E Fallat
- The Hiram C. Polk, Jr Department of Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky
| | - Michael Aquino
- Cleveland Clinic Imaging Institute, and Section of Pediatric Imaging, Cleveland Clinic Lerner College of Medicine of Case Western University, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Timothy Ruttan
- Department of Pediatrics, Dell Medical School, The University of Texas at Austin; US Acute Care Solutions, Canton, Ohio
| | - Reza J Daugherty
- Departments of Radiology and Pediatrics, University of Virginia School of Medicine, UVA Health/UVA Children's, Charlottesville, Virginia
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Marin JR, Lyons TW, Claudius I, Fallat ME, Aquino M, Ruttan T, Daugherty RJ. Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report. J Am Coll Radiol 2024; 21:e37-e69. [PMID: 38944445 DOI: 10.1016/j.jacr.2024.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2024]
Abstract
Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging (MRI), are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.
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Affiliation(s)
- Jennifer R Marin
- Departments of Pediatrics, Emergency Medicine, & Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
| | - Todd W Lyons
- Division of Emergency Medicine, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
| | - Ilene Claudius
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
| | - Mary E Fallat
- The Hiram C. Polk, Jr Department of Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky
| | - Michael Aquino
- Cleveland Clinic Imaging Institute, and Section of Pediatric Imaging, Cleveland Clinic Lerner College of Medicine of Case Western University, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Timothy Ruttan
- Department of Pediatrics, Dell Medical School, The University of Texas at Austin; US Acute Care Solutions, Canton, Ohio
| | - Reza J Daugherty
- Departments of Radiology and Pediatrics, University of Virginia School of Medicine, UVA Health/UVA Children's, Charlottesville, Virginia
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Brook OR, Dadour JR, Robbins JB, Wasnik AP, Akin EA, Borloz MP, Dawkins AA, Feldman MK, Jones LP, Learman LA, Melamud K, Patel-Lippmann KK, Saphier CJ, Shampain K, Uyeda JW, VanBuren W, Kang SK. ACR Appropriateness Criteria® Acute Pelvic Pain in the Reproductive Age Group: 2023 Update. J Am Coll Radiol 2024; 21:S3-S20. [PMID: 38823952 DOI: 10.1016/j.jacr.2024.02.014] [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: 02/20/2024] [Accepted: 02/28/2024] [Indexed: 06/03/2024]
Abstract
This review focuses on the initial imaging in the reproductive age adult population with acute pelvic pain, including patients with positive and negative beta-human chorionic gonadotropin (β-hCG) levels with suspected gynecological and nongynecological etiology. For all patients, a combination of transabdominal and transvaginal pelvic ultrasound with Doppler is usually appropriate as an initial imaging study. If nongynecological etiology in patients with negative β-hCG is suspected, then CT of the abdomen and pelvis with or without contrast is also usually appropriate. In patients with positive β-hCG and suspected nongynecological etiology, CT of the abdomen and pelvis with contrast and MRI of the abdomen and pelvis without contrast may be appropriate. In patients with negative β-hCG and suspected gynecological etiology, CT of the abdomen and pelvis with contrast, MRI of pelvis without contrast, or MRI of pelvis with and without contrast may be appropriate. 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 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 where 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)
- Olga R Brook
- Beth Israel Deaconess Medical Center, Boston, Massachusetts.
| | - Joseph R Dadour
- Research Author, Centre Hospitalier de l'Université de Montréal, Montréal, Montreal, Quebec, Canada
| | | | - Ashish P Wasnik
- Panel Vice Chair, University of Michigan, Ann Arbor, Michigan
| | - Esma A Akin
- The George Washington University Medical Center, Washington, District of Columbia; Commission on Nuclear Medicine and Molecular Imaging
| | - Matthew P Borloz
- Virginia Tech Carilion School of Medicine, Roanoke, Virginia; American College of Emergency Physicians
| | | | | | - Lisa P Jones
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lee A Learman
- Virginia Tech Carilion School of Medicine, Roanoke, Virginia; American College of Obstetricians and Gynecologists
| | - Kira Melamud
- New York University Langone Health, New York, New York
| | | | - Carl J Saphier
- Women's Ultrasound, LLC, Englewood, New Jersey; American College of Obstetricians and Gynecologists
| | | | - Jennifer W Uyeda
- Brigham & Women's Hospital, Boston, Massachusetts; Committee on Emergency Radiology-GSER
| | | | - Stella K Kang
- Specialty Chair, New York University Medical Center, New York, New York
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Lochbühler N, Bölle P, Müller-Abt P. Acute abdomen in pediatric radiology. ROFO-FORTSCHR RONTG 2024; 196:451-462. [PMID: 38134901 DOI: 10.1055/a-2193-0205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2023]
Abstract
BACKGROUND Imaging is a common part of the workup for acute abdomen in childhood and adolescence. Rapid diagnosis is crucial for adequate therapy, especially in young children. METHOD This review is intended to provide an overview of the typical causes of acute abdomen in children and adolescents and is specifically aimed at radiologists who do not regularly work in pediatric radiology. RESULTS AND CONCLUSION Age-specific peculiarities make a division into three age groups useful: Newborns, infants and toddlers, and schoolchildren. Possible causes of acute abdomen in children range from congenital lesions, particularly in newborns, to entities well known in adult radiology, more commonly in school-aged children. Since younger children have a higher sensitivity to radiation and often a limited ability to cooperate, sonography and conventional X-ray are the primary imaging modalities used. Decisive advantages of sonography, especially in younger children, include its widespread availability, the lack of need for sedation, and the possibility of bedside examination. Supplementary cross-sectional imaging, usually MRI, is reserved for special clinical questions. Close interdisciplinary cooperation between attending clinicians and radiologists is essential for efficient diagnostics in this patient group. KEY POINTS · Age-specific features must be observed. · Sonography and radiography are the most important modalities. · Both congenital and acquired pathologies play a role. · Good interdisciplinary cooperation is essential in this patient group. CITATION FORMAT · Lochbühler N, Bölle P, Müller-Abt P. Acute abdomen in pediatric radiology. Fortschr Röntgenstr 2024; 196: 451 - 462.
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Affiliation(s)
- Nina Lochbühler
- Department of Pediatric Radiology Olgahospital, Klinikum Stuttgart Olgahospital Frauenklinik, Stuttgart, Germany
| | - Petra Bölle
- Department of Pediatric Radiology Olgahospital, Klinikum Stuttgart Olgahospital Frauenklinik, Stuttgart, Germany
| | - Peter Müller-Abt
- Department of Pediatric Radiology Olgahospital, Klinikum Stuttgart Olgahospital Frauenklinik, Stuttgart, Germany
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Touati MD, Khefacha F, Ben Othmane MR, Belhadj A, Saidani A, Chebbi F. Fortuitous detection of adult malrotated ectopic kidney during acute appendicitis: A unique case report. Int J Surg Case Rep 2024; 118:109679. [PMID: 38663289 PMCID: PMC11064631 DOI: 10.1016/j.ijscr.2024.109679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 04/15/2024] [Accepted: 04/19/2024] [Indexed: 05/05/2024] Open
Abstract
INTRODUCTION AND IMPORTANCE Renal ectopia, a rare congenital anomaly, can occur in various body regions and may be associated with other abnormalities. It is often asymptomatic, commonly found incidentally, as in our 70-year-old patient during appendicitis exploration. This case highlights the importance of recognizing renal ectopia and associated anomalies, such as vascular abnormalities and renal malrotation, which may predispose patients to potential complications and require vigilant monitoring for urinary tract infections and lithiasis events, as well as potential challenges during laparoscopic surgical procedures, as in our appendectomy case. CASE PRESENTATION A 70-year-old female presented with right iliac fossa pain and elevated inflammatory markers. Abdominopelvic CT scan confirmed uncomplicated appendicitis and revealed a right ectopic and malrotated kidney. Laparoscopic appendectomy was performed without complications. Postoperative recovery was uneventful, and discharge occurred one day post-procedure. A four-week follow-up was scheduled to monitor for urinary infection and stone formation, with initiation of hygienic and dietary measures. CLINICAL DISCUSSION Renal ectopia, a congenital anomaly, frequently positions the kidneys in the pelvic region. Iliac ectopias are often confused with pelvic or abdominal ectopias. Ectopic kidneys can result in complications like vesicoureteral reflux, urinary tract infections, or kidney stones. Despite being typically left-sided, our patient presented with right-sided renal ectopia with malrotation. Despite lacking urinary symptoms, a urological consultation was advised due to the potential risk of infection or kidney stones. Surgical intervention is reserved for complication management. CONCLUSION Renal ectopia, a rare congenital anomaly, can be asymptomatic but often coincides with other renal or vascular issues. Early detection and accurate imaging are essential, emphasizing clinical vigilance and interdisciplinary collaboration for better patient care.
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Affiliation(s)
- Med Dheker Touati
- General Surgery Department, Mahmoud El Matri Hospital, R534+F9H, Rue de la Faculté de Médecine, Tunis, Tunisia; Faculty of Medicine of Tunis, University of Tunis El Manar, R534+F9H, Rue de la Faculté de Médecine, Tunis, Tunisia.
| | - Fahd Khefacha
- General Surgery Department, Mahmoud El Matri Hospital, R534+F9H, Rue de la Faculté de Médecine, Tunis, Tunisia; Faculty of Medicine of Tunis, University of Tunis El Manar, R534+F9H, Rue de la Faculté de Médecine, Tunis, Tunisia
| | - Mohamed Raouf Ben Othmane
- General Surgery Department, Mahmoud El Matri Hospital, R534+F9H, Rue de la Faculté de Médecine, Tunis, Tunisia; Faculty of Medicine of Tunis, University of Tunis El Manar, R534+F9H, Rue de la Faculté de Médecine, Tunis, Tunisia
| | - Anis Belhadj
- General Surgery Department, Mahmoud El Matri Hospital, R534+F9H, Rue de la Faculté de Médecine, Tunis, Tunisia; Faculty of Medicine of Tunis, University of Tunis El Manar, R534+F9H, Rue de la Faculté de Médecine, Tunis, Tunisia
| | - Ahmed Saidani
- General Surgery Department, Mahmoud El Matri Hospital, R534+F9H, Rue de la Faculté de Médecine, Tunis, Tunisia; Faculty of Medicine of Tunis, University of Tunis El Manar, R534+F9H, Rue de la Faculté de Médecine, Tunis, Tunisia
| | - Faouzi Chebbi
- General Surgery Department, Mahmoud El Matri Hospital, R534+F9H, Rue de la Faculté de Médecine, Tunis, Tunisia; Faculty of Medicine of Tunis, University of Tunis El Manar, R534+F9H, Rue de la Faculté de Médecine, Tunis, Tunisia
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Bl YBP, Mehra B, Ghoshal S, Dubhashi SP. Diagnostic Efficacy Study Comparing Tzanakis Scoring System With Alvarado Scoring System in Effective Diagnosis of Acute Appendicitis. Cureus 2024; 16:e58018. [PMID: 38738151 PMCID: PMC11087879 DOI: 10.7759/cureus.58018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/10/2024] [Indexed: 05/14/2024] Open
Abstract
Objective Among the common causes of abdominal emergencies, acute appendicitis ranks at the top, particularly in the young population. While negative appendectomy is not uncommon, the risk of appendicular perforation is substantial if the diagnosis is missed or delayed. This study evaluated the diagnostic efficacy of the Tzanakis scoring system for acute appendicitis, comparing it with the Alvarado scoring system, considering the histopathological finding as the gold standard. Materials and methods This prospective observational study, conducted in the General Surgery department in a tertiary care hospital in India, included clinically diagnosed acute appendicitis cases posted for open or laparoscopic appendicectomy. Results The mean age for the 60 participants included in the study was 30.97±13.44, and the median was 24.5 yrs. The sensitivity of ultrasonography (USG) in diagnosing histopathological positive acute appendicitis was 89%, and the specificity was 50%. The sensitivity, specificity, positive, and negative predictive values of the Tzanakis score were 87%, 50%, 96%, and 22%, respectively, and those of the Alvarado score were 54%, 75%, 96%, and 10%, respectively. Conclusion The receiver operator characteristic (ROC) curve for the Alvarado and Tzanakis scores showed that the area under the curve (AUC) was greater for the Tzanakis scoring system (0.670) than for the Alvarado scoring system (0.598). Differences between the AUCs were not statistically significant. Although the Tzanakis scoring system is more sensitive than the Alvarado scoring system in diagnosing acute appendicitis, studies with larger samples are needed to show the superiority of this scoring system over the Alvarado scoring system.
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Affiliation(s)
| | - Bhupendra Mehra
- General Surgery, All India Institute of Medical Sciences, Nagpur, Nagpur, IND
| | - Soumya Ghoshal
- General Surgery, All India Institute of Medical Sciences, Nagpur, Nagpur, IND
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Rodriguez-Takeuchi S, Sousa-Plata K, Man C, Vidarson L, Rayner T, Mohanta A, Amirabadi A, Schuh S, Doria AS. Characterization and quantification of fluid in the abdomen by ultrasound and magnetic resonance imaging in children with clinical suspicion of appendicitis. Abdom Radiol (NY) 2024; 49:1031-1041. [PMID: 38195800 DOI: 10.1007/s00261-023-04133-3] [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: 04/12/2023] [Revised: 08/18/2023] [Accepted: 08/20/2023] [Indexed: 01/11/2024]
Abstract
PURPOSE While regarded as a secondary sign of pediatric appendicitis, the frequency of physiologic intra-abdominal fluid in children with suspected but absent appendicitis is unknown. Ex vivo: to assess the validity of US/MRI measurements of free fluid. In vivo: in suspected pediatric appendicitis, to assess the amount of abdominal fluid by US and MRI, determine performance characteristics of US in fluid detection and identify fluid volume ranges in confirmed appendicitis. METHODS Ex vivo: criterion validity of US and MRI for fluid volume measurements was tested using tissue-mimicking phantoms filled with different volumes of distilled water. In vivo: all participants from a previous prospective study of suspected appendicitis were evaluated by US; MRI was performed after equivocal USs. Qualitative and quantitative analyses of abdominal fluid and correlation of fluid presence with appendicitis were performed. RESULTS Ex vivo: no difference was found between phantom-fluid amount and measured volume using the formula for volume of an ellipsoid for US (P=0.19) or MRI (P=0.08). In vivo: intra-abdominal fluid was present in 212/591 (35.9%) patients; 75/212 patients with fluid (35.4%) had appendicitis, 60 (28.3%) had alternate diagnoses, and 77 (36.3%) had physiologic fluid. Sensitivity and specificity of US for fluid detection were 84% (95% CI 71-93) and 65% (95% CI 52-77), respectively. In children with versus without appendicitis, the respective ranges of fluid volume were 0.7-1148.8 ml and 0.8-318 ml. CONCLUSION The volume of an ellipsoid formula is a valid method for quantifying intra-abdominal fluid. The sole presence of intra-abdominal fluid on US does not support the diagnosis of pediatric appendicitis.
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Affiliation(s)
- Sara Rodriguez-Takeuchi
- Department of Diagnostic Imaging and Research Institute, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada
- Emergency Department, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada
- Department of Diagnostic Imaging, Fundacion Valle de Lili, Cali, Colombia
| | - Karen Sousa-Plata
- Department of Diagnostic Imaging and Research Institute, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada
- Emergency Department, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada
| | - Carina Man
- Department of Diagnostic Imaging and Research Institute, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada
- Emergency Department, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada
| | - Logi Vidarson
- Department of Diagnostic Imaging and Research Institute, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada
- Emergency Department, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada
| | - Tammy Rayner
- Department of Diagnostic Imaging and Research Institute, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada
- Emergency Department, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada
| | - Arun Mohanta
- Department of Diagnostic Imaging and Research Institute, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada
- Emergency Department, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada
| | - Afsaneh Amirabadi
- Department of Diagnostic Imaging and Research Institute, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada
- Emergency Department, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada
| | - Suzanne Schuh
- Department of Diagnostic Imaging and Research Institute, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada
- Emergency Department, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada
| | - Andrea S Doria
- Department of Diagnostic Imaging and Research Institute, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada.
- Emergency Department, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada.
- Department of Medical Imaging, University of Toronto, Toronto, ON, M5G 1X8, Canada.
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Lastunen KS, Leppäniemi AK, Mentula PJ. Pre-hospital management and patient-related factors affecting access to the surgical care of appendicitis - a survey study. Scand J Prim Health Care 2024:1-9. [PMID: 38497923 DOI: 10.1080/02813432.2024.2329214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 03/06/2024] [Indexed: 03/19/2024] Open
Abstract
BACKGROUND AND AIMS Long pre-hospital delay substantially increases the likelihood of perforated appendicitis. This study aimed to find patient-related factors affecting this delay. METHODS A survey was conducted for patients with acute appendicitis after appendectomy. The participants were asked about their path to the surgical center and socioeconomic status. Variables affecting delays and the rate of complicated appendicitis were analyzed. RESULTS The study included 510 patients; 157 (31%) had complicated appendicitis with a median prehospital delay of 42 h. In patients with uncomplicated appendicitis, the delay was 21 h, p < .001. Forty-six (29%) patients with complicated appendicitis were not referred to the hospital after the first doctor's visit. The multivariate analysis discovered factors associated with long pre-hospital delay: age 40-64 years (OR 1.63 (95% CI 1.06-2.52); compared to age 18-39), age more than 64 years (OR 2.84 (95% CI 1.18-6.80); compared to age 18-39), loss of appetite (OR 2.86 (95% CI 1.64-4.98)), fever (OR 1.66 (95% CI 1.08-2.57)), non-referral by helpline nurse (OR 2.02 (95% CI 1.15-3.53)) and non-referral at first doctors visit (OR 2.16 (95% CI 1.32-3.53)). Age 40-64 years (OR 2.41 (95% CI 1.50-3.88)), age more than 64 years (OR 8.79 (95% CI 2.19-35.36)), fever (OR 1.83 (95% CI 1.15-2.89)) and non-referral at first doctors visit (OR 1.90 (95% CI 1.14-3.14)) were also risk factors for complicated appendicitis. CONCLUSIONS Advanced age, fever and failure to suspect acute appendicitis in primary care are associated with prolonged pre-hospital delay and complicated appendicitis.
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Affiliation(s)
- Kirsi Serenella Lastunen
- Department of Gastrointestinal Surgery, Helsinki University Hospital and the University of Helsinki, Helsinki, Finland
| | - Ari Kalevi Leppäniemi
- Department of Gastrointestinal Surgery, Helsinki University Hospital and the University of Helsinki, Helsinki, Finland
| | - Panu Juhani Mentula
- Department of Gastrointestinal Surgery, Helsinki University Hospital and the University of Helsinki, Helsinki, Finland
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Roberts K, Moore H, Raju M, Gent R, Piotto L, Taranath A, Ee M, Linke R, Goh DW. Diagnostic Ultrasound for Acute Appendicitis: The Gold Standard. J Pediatr Surg 2024; 59:235-239. [PMID: 37985334 DOI: 10.1016/j.jpedsurg.2023.10.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 10/11/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND Acute appendicitis may present a diagnostic dilemma. The aim of this study was to review the accuracy of ultrasound in the diagnosis of paediatric acute appendicitis. METHOD Ultrasound studies performed for investigation of appendicitis during 2015-2021 were retrieved from a tertiary paediatric hospital database and reviewed. Medical records were reviewed to determine operative intervention, further imaging, and final diagnosis. Diagnostic accuracy was assessed by sensitivity, specificity, predictivity, and overall accuracy. All appendicectomy specimens underwent histopathological confirmation. This study was approved by the local Human Research Ethics Committee. RESULTS A total of 8555 consecutive ultrasound examinations were performed during the study period. Mean patient age was 10.8 years ( ± 3.7). Overall diagnostic accuracy was 96.1% (8221/8555) with a visualisation rate of 91.0%. Sensitivity and specificity were 96.2% (CI 95.3-97.0%) and 96.1% (CI 95.6-96.5%), respectively. When limited to positive/negative scans, sensitivity was 99.6% (CI 99.2-99.8%) and specificity 99.0% (CI 98.7-99.3%). Positive and negative predictive values were 96.9% and 99.9%, respectively. Repeat ultrasound following a non-diagnostic scan led to a definitive diagnosis in 76.1%. Negative appendicectomy rate was 5.5% overall in children who had undergone pre-operative ultrasound (107/1938), and 4.4% when other surgical pathologies were excluded. CONCLUSION Ultrasound examination provides gold-standard accuracy in the diagnosis of paediatric appendicitis and reduces rates of negative appendicectomy. Given the disadvantages of computed tomography and magnetic resonance imaging, ultrasound should be considered the first-line investigation of choice in the diagnosis of acute appendicitis in children. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Kiera Roberts
- Department of Paediatric Surgery, Women's and Children's Hospital, Adelaide, SA, Australia.
| | - Hamish Moore
- Department of Paediatric Surgery, Women's and Children's Hospital, Adelaide, SA, Australia
| | - Mahima Raju
- Adelaide Medical School, the University of Adelaide, SA, Australia
| | - Roger Gent
- SA Medical Imaging, Women's and Children's Hospital, SA, Australia
| | - Lino Piotto
- SA Medical Imaging, Women's and Children's Hospital, SA, Australia
| | - Ajay Taranath
- SA Medical Imaging, Women's and Children's Hospital, SA, Australia
| | - Michael Ee
- Department of Paediatric Surgery, Women's and Children's Hospital, Adelaide, SA, Australia; College of Medicine and Public Health, Flinders University, SA, Australia
| | - Rebecca Linke
- SA Medical Imaging, Women's and Children's Hospital, SA, Australia
| | - Day Way Goh
- Department of Paediatric Surgery, Women's and Children's Hospital, Adelaide, SA, Australia; Discipline of Paediatrics, University of Adelaide, SA, Australia
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10
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Gil LA, Deans KJ, Minneci PC. Appendicitis in Children. Adv Pediatr 2023; 70:105-122. [PMID: 37422289 DOI: 10.1016/j.yapd.2023.03.003] [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: 07/10/2023]
Abstract
The management of pediatric appendicitis continues to advance with the development of evidence-based treatment algorithms and a recent shift toward patient-centered treatment approaches. Further research should focus on development of standardized institution-specific diagnostic algorithms to minimize rates of missed diagnosis and appendiceal perforation and refinement of evidence-based clinical treatment pathways that reduce complication rates and minimize health care resource utilization.
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Affiliation(s)
- Lindsay A Gil
- Pediatric Surgery Research Fellow, Nationwide Children's Hospital, The Ohio State University Wexner Medical Center, 700 Children's Drive, Columbus, OH 43206, USA
| | - Katherine J Deans
- Department of Surgery, Nemours Children's Health, Delaware Valley, 1600 Rockland Road, Wilmington, DE 19803, USA
| | - Peter C Minneci
- Division of Pediatric Surgery, Nationwide Children's Hospital, The Ohio State University Wexner Medical Center, 611 East Livingston Avenue, Columbus, OH 43206, USA.
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McNulty E, Greene A, Boehmer SJ, Tsai A, Olympia RP. Referrals for Pediatric Appendicitis to a Tertiary Care Children's Hospital. Pediatr Emerg Care 2023; 39:612-616. [PMID: 37404059 DOI: 10.1097/pec.0000000000003000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/06/2023]
Abstract
OBJECTIVES This study aimed to analyze pediatric referrals for definite or possible appendicitis, to compare clinical predictors and laboratory values between patients with and without a final diagnosis of appendicitis, and to determine the accuracy of prereferral diagnostic interpretations of computed tomography scans, ultrasound, and magnetic resonance imaging modalities. METHODS We conducted a retrospective analysis of pediatric patients referred from 2015 to 2019 to a tertiary care children's emergency department with definitive or possible appendicitis. Data abstracted included patient demographics, clinical symptoms, physical examination findings, laboratory results, and diagnostic imaging findings (by the referring center and the pediatric radiologist at the accepting center). An Alvarado and Appendicitis Inflammatory Response (AIR) score was calculated for each patient. RESULTS Analysis was performed on 381 patients; 226 (59%) had a final diagnosis of appendicitis. Patients with appendicitis were more likely to have symptoms of nausea ( P < 0.0001) and vomiting ( P < 0.0001), have a higher mean temperature ( P = 0.025), right lower quadrant abdominal pain to palpation ( P = <0.0001), rebound tenderness ( P < 0.0001), a higher mean Alvarado score [5.35 vs 3.45 ( P < 0.0001)], and a higher mean AIR score [4.02 vs 2.17 ( P < 0.0001)]. Of the 97 diagnostic images initially interpreted as appendicitis by the referring center, 10 (10.3%) were read as no evidence of appendicitis. Of the 62 diagnostic images initially interpreted as "possible appendicitis" by the referring center, 34 (54.8%) were read as no evidence of appendicitis. Of those diagnostic images initially interpreted as "appendicitis" or "possible appendicitis" by the referring center, 24/89 (27.0%) of computed tomography scans, 17/62 (27.4%) of ultrasounds, and 3/8 (37.5%) of magnetic resonance imaging results were read as no evidence of appendicitis. CONCLUSIONS Usage of established scoring algorithms, such as Alvarado and AIR, may decrease the unnecessary cost of diagnostic imaging and transfer to tertiary care. Virtual radiology consultations may be 1 potential solution to improve the referral process for pediatric appendicitis if initial interpretation is uncertain.
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Affiliation(s)
- Ellie McNulty
- From the Penn State College of Medicine, Hershey, PA
| | - Alicia Greene
- Department of General Surgery, Penn State Milton S. Hershey Medical Center, Hershey, PA
| | - Susan J Boehmer
- Department of Public Health Services, Penn State Milton S. Hershey Medical Center, Hershey, PA
| | - Anthony Tsai
- Department of Pediatric Surgery, Penn State Children's Hospital, Hershey, PA
| | - Robert P Olympia
- Department of Emergency Medicine and Pediatrics, Penn State Milton S. Hershey Medical Center and Penn State Children's Hospital, Hershey, PA
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12
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Cai JH, Zhou H, Liang D, Chen Q, Xiao Y, Li GM. Parsimonious clinical prediction model for the diagnosis of complicated appendicitis. Heliyon 2023; 9:e19067. [PMID: 37636395 PMCID: PMC10457507 DOI: 10.1016/j.heliyon.2023.e19067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 08/03/2023] [Accepted: 08/09/2023] [Indexed: 08/29/2023] Open
Abstract
Objective To develop a logistic regression model that combines clinical and radiological parameters for prediction of complicated appendicitis. Methods 248 patients with histologically proven uncomplicated (n = 214) and complicated (n = 34) acute appendicitis were analyzed retrospectively. All patients had undergone a presurgical abdominal and/or pelvic computed tomography (CT) scan, assessed by two radiologists. A model using univariate and multivariate logistic regression analyses was developed, and the strength of association between independent predictors and complicated acute appendicitis was evaluated by adjusted odds radio. Clinical parameters were gender, age, anorexia, vomiting, duration of symptoms, right lower abdominal quadrant (RLQ) tenderness, rebound tenderness, body temperature, white blood cell (WBC) count, and neutrophil ratio. Radiological parameters were appendix diameter, appendicolith, caecal wall thickening, mesenteric lymphadenopathy, extraluminal air, abscess, fat stranding, and periappendicular fluid. Results Four features (body temperature>37.2 °C, vomiting, appendicolith, and periappendiceal fluid) were included in the logistic regression model, and yielded an area under the curve (AUC) of 0.87 (95% confidence interval (CI), 0.80-0.93), sensitive of 88%, and specificity of 74%. Conclusion The logistic regression model makes an accurate and simple prediction of complicated appendicitis possible.
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Affiliation(s)
- Jia-hui Cai
- Department of Radiology, Guangzhou Hospital of Integrated Traditional and West Medicine, Yingbin Avenue No. 87, Huadu District, Guangzhou, 510800, Guangdong, China
| | - Hui Zhou
- Department of Radiology, Qingyuan People's Hospital, Yinquan Road No. B24, Qingyuan, 511500, Guangdong, China
| | - Dan Liang
- Department of Radiology, Guangzhou First People's Hospital, Panfu Road No.1, Guangzhou, 510000, Guangdong, China
| | - Qiao Chen
- Department of Radiology, Qingyuan People's Hospital, Yinquan Road No. B24, Qingyuan, 511500, Guangdong, China
| | - Yeyu Xiao
- Department of Radiology, Guangzhou Hospital of Integrated Traditional and West Medicine, Yingbin Avenue No. 87, Huadu District, Guangzhou, 510800, Guangdong, China
| | - Guang-ming Li
- Department of Radiology, Qingyuan People's Hospital, Yinquan Road No. B24, Qingyuan, 511500, Guangdong, China
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13
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Steinl G, Grabski D, Fleming M, Levin D, McGahren E, McCullough W, Gander J. Implementation of ultrasound and fast magnetic resonance imaging pathway reduces computed tomography utilization in children with suspected appendicitis. Pediatr Surg Int 2023; 39:238. [PMID: 37486585 DOI: 10.1007/s00383-023-05521-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/12/2023] [Indexed: 07/25/2023]
Abstract
PURPOSE Computed tomography (CT) is still used in the imaging diagnosis of acute appendicitis in children at many hospitals. We implemented an ultrasound (US) and fast magnetic resonance imaging (MRI) pathway for suspected appendicitis at our institution with the goal of reducing radiation exposure in children. METHODS All children (< 18 years old) who underwent appendectomy between January 2011 and July 2021 were reviewed. Data were collected on all imaging studies performed. In December 2015, we initiated an imaging pathway for suspected acute appendicitis. US was the initial imaging study, and a rapid protocol MRI was performed if US was equivocal. Those could not tolerate MRI underwent CT. We evaluated the difference in percentage of patients who underwent CT before and after pathway initiation. RESULTS 554 patients who underwent appendectomy did not have prior imaging studies on presentation to our hospital and were included in analysis. After initiating the pathway, the use of abdominal US increased from 87% (220 of 254) to 97% (291 of 300, p < 0.0001) and the use of MRI increased by 100% (0 MRIs pre-protocol, 90 of 300 patients post-protocol, p < 0.0001). CT utilization decreased significantly from 32% (82 of 254) to 2% (6 of 300, p < 0.0001). CONCLUSION Embracing a new US and rapid MRI pathway to evaluate pediatric patients with suspected acute appendicitis resulted in significant reduction in CT utilization and therefore radiation exposure.
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Affiliation(s)
- Gabrielle Steinl
- Department of Surgery, University of Virginia, Charlottesville, USA
| | - David Grabski
- Department of Surgery, University of Virginia, Charlottesville, USA
| | - Mark Fleming
- Department of Surgery, University of Virginia, Charlottesville, USA
| | - Daniel Levin
- Division of Pediatric Surgery, Department of Surgery, University of Virginia School of Medicine, University of Virginia, 1215 Lee St., Charlottesville, VA, 22904, USA
| | - Eugene McGahren
- Division of Pediatric Surgery, Department of Surgery, University of Virginia School of Medicine, University of Virginia, 1215 Lee St., Charlottesville, VA, 22904, USA
| | - William McCullough
- Department of Radiology, Santa Clara Homestead Medical Center, Santa Clara, CA, USA
| | - Jeffrey Gander
- Division of Pediatric Surgery, Department of Surgery, University of Virginia School of Medicine, University of Virginia, 1215 Lee St., Charlottesville, VA, 22904, USA.
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Altuğ E, Şener K, Çakir A, Erdem ZB, Eyüpoğlu G, Güven R. Accuracy of emergency physician bedside ultrasonography compared with private teleradiologist for acute appendicitis diagnosis. Ir J Med Sci 2023; 192:1473-1479. [PMID: 36076151 DOI: 10.1007/s11845-022-03149-w] [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: 06/19/2022] [Accepted: 09/01/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Acute appendicitis (AA) is a common cause of abdominal pain resulting in admission to the emergency room. Imaging methods such as ultrasonography and CT are usually used for diagnosing acute appendicitis. Reports regarding CT scans conducted during night shifts are prepared by private teleradiologists. AIMS The aim of this study was to compare the accuracy of point-of-care ultrasound performed by an emergency medicine specialist and private teleradiologists in the diagnosis of AA. METHODS This study was conducted prospectively and in a single center in the emergency department of a tertiary hospital. Patients who were admitted to the study between 15.09.2020 and 15.09.2021 and were diagnosed with AA who met the study criteria were included. A total of 134 patients diagnosed with AA, who met the inclusion criteria, out of 158 operated patients were included in the study. RESULTS In the study, 77 were male and 57 were female. The mean age of patients with histopathologically positive AA was 31 and 31.5 in negative patients. The sensitivity and specificity of POCUS performed by the emergency physician and private teleradiology for the diagnosis of AA were 78.4% and 59.3% and 58.8% and 53.1%, respectively. CONCLUSIONS POCUS performed by an emergency medicine specialist showed a higher sensitivity for the diagnosis of AA compared with private teleradiology. Hence, POCUS is more successful in diagnosing AA than private teleradiology. In conclusion, we recommend the concurrent use of AS and POCUS in emergency departments rather than private teleradiology for the diagnosis of AA.
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Affiliation(s)
- Ertuğrul Altuğ
- Department of Emergency Medicine, Başakşehir Çam and Sakura City Hospital, Istanbul, Turkey.
| | - Kemal Şener
- Department of Emergency Medicine, Başakşehir Çam and Sakura City Hospital, Istanbul, Turkey
| | - Adem Çakir
- Department of Emergency Medicine, Ministry of Health of Turkey Canakkale Mehmet Akif Ersoy State Hospital, Canakkale, Turkey
| | - Zeynep Betül Erdem
- Department of Medical Pathology, Başakşehir Çam and Sakura City Hospital, Istanbul, Turkey
| | - Gökhan Eyüpoğlu
- Department of Emergency Medicine, Başakşehir Çam and Sakura City Hospital, Istanbul, Turkey
| | - Ramazan Güven
- Department of Emergency Medicine, Başakşehir Çam and Sakura City Hospital, Istanbul, Turkey
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15
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Fowler KJ. Gastrointestinal Imaging: What Has Shaped and What Will Shape Our Field Going Forward. Radiology 2023; 307:e223251. [PMID: 36916893 DOI: 10.1148/radiol.223251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Affiliation(s)
- Kathryn J Fowler
- From the Department of Diagnostic Radiology, Division of Body Imaging, University of California-San Diego, 6206 Lakewood St, San Diego, CA 92122
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16
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Brillantino A, Iacobellis F, Brusciano L, Abu-Omar A, Muto G, Amadu AM, Foroni F, Antropoli M, Antropoli C, Castriconi M, Renzi A, Pirolo L, Giuliani A, Scarano E, Docimo L, Scaglione M, Romano L. Accuracy of computed tomography in staging acute appendicitis and its impact on surgical outcome and strategy: a multi-center retrospective case-control study. LA RADIOLOGIA MEDICA 2023; 128:415-425. [PMID: 36940006 DOI: 10.1007/s11547-023-01619-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 03/07/2023] [Indexed: 03/21/2023]
Abstract
INTRODUCTION The aims of this study were to evaluate the concordance between AAST-CT appendicitis grading criteria, first published in 2014, and surgical findings and to assess the impact of CT staging on the choice of surgical approach. METHODS This was a multi-center retrospective case-control study including 232 consecutive patients undergoing surgery for acute appendicitis and who had undergone preoperative CT evaluation between 1 January 2017 and 1 January 2022. Appendicitis severity was classified in 5 grades. For each degree of severity, the surgical outcome between patients undergoing open and surgical approach was compared. RESULTS An almost perfect agreement (k = 0.96) was found between CT and surgery in staging acute appendicitis. The vast majority of patients with grade 1 and 2 appendicitis underwent laparoscopic surgical approach and showed low morbidity rate. In patients with grade 3 and 4 appendicitis, laparoscopic approach was adopted in 70% of cases and was associated, if compared to open, with a higher prevalence of postoperative abdominal collections (p = 0.05; fisher's exact test) and a significantly lower prevalence of surgical site infections (p = 0.0007; fisher's exact test). All the patients with grade 5 appendicitis were treated by laparotomy. CONCLUSIONS AAST-CT appendicitis grading system seems to show a relevant prognostic value and a potential impact on the choice of surgical strategy, directing toward a laparoscopic approach in patients with grade 1 and 2, an initial laparoscopic approach, replaceable by the open one, for grade 3 and 4 and an open approach in patients with grade 5.
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Affiliation(s)
- Antonio Brillantino
- Department of Surgery, A. Cardarelli Hospital, Via A. Cardarelli 9, 80131, Naples, Italy.
| | - Francesca Iacobellis
- Department of General and Emergency Radiology, A. Cardarelli Hospital, Via A. Cardarelli 9, 80131, Naples, Italy
| | - Luigi Brusciano
- Division of General, Mininvasive and Obesity Surgery, University of Study of Campania Luigi Vanvitelli Naples, Via Luigi Pansini N° 5, 80131, Naples, Italy
| | - Ahmad Abu-Omar
- Department of Radiology, James Cook University Hospital, Marton Road, Middlesbrough, TS4 3BW, UK
| | - Gianluca Muto
- Diagnostic Imaging Department, Hospitaux Universitaires de Genève, Geneva, Switzerland
| | - Antonio Matteo Amadu
- Diagnostic Imaging 1 Unit, University Hospital of Sassari, 07100, Sassari, Italy
| | - Fabrizio Foroni
- Surgery Department, A. Cardarelli Hospital, Via A. Cardarelli 9, 80131, Naples, Italy
| | - Massimo Antropoli
- Surgery Department, A. Cardarelli Hospital, Via A. Cardarelli 9, 80131, Naples, Italy
| | - Carmine Antropoli
- Surgery Department, A. Cardarelli Hospital, Via A. Cardarelli 9, 80131, Naples, Italy
| | - Maurizio Castriconi
- Surgery Department, A. Cardarelli Hospital, Via A. Cardarelli 9, 80131, Naples, Italy
| | - Adolfo Renzi
- Surgery Department, "Buonconsiglio Fatebenefratelli" Hospital, Naples, Italy
| | - Luigi Pirolo
- Radiology Department, "Buonconsiglio Fatebenefratelli" Hospital, Naples, Italy
| | | | - Enrico Scarano
- Radiology Department, "San Carlo" Hospital, Potenza, Italy
| | - Ludovico Docimo
- Division of General, Mininvasive and Obesity Surgery, University of Study of Campania Luigi Vanvitelli Naples, Via Luigi Pansini N° 5, 80131, Naples, Italy
| | - Mariano Scaglione
- Department of Radiology, James Cook University Hospital, Marton Road, Middlesbrough, TS4 3BW, UK.,Department of Medicine, Surgery and Pharmacy, University of Sassari, Viale San Pietro 112, 07199, Sassari, Italy
| | - Luigia Romano
- Radiology Department, A. Cardarelli Hospital, Via A. Cardarelli 9, 80131, Naples, Italy
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17
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Tong L, Nataraja RM, VanHaltren K, Sulaksana TH, Vinycomb TI, Pacilli M. The utility of sonographic signs to diagnose simple and complicated appendicitis in children. Pediatr Surg Int 2023; 39:114. [PMID: 36764977 PMCID: PMC9918567 DOI: 10.1007/s00383-023-05397-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/31/2023] [Indexed: 02/12/2023]
Abstract
BACKGROUND Acute appendicitis is classified into simple (SA) and complicated (CA). Ultrasound scans (USS) can be useful in clinically equivocal cases, by visualising primary and secondary signs. This study explores the utility of sonographic signs to diagnose and differentiate appendicitis in children. METHODS Single-centre retrospective cohort study over a 2-year period. Consecutive USS for suspected appendicitis were included; sonographic signs were extracted from standardised institutional worksheets. USS results were compared with pre-defined intraoperative criteria for SA and CA, confirmed with histological analysis. Data are reported as median [interquartile range], percentages (number), area under the curve (AUC), conventional diagnostic formulae and adjusted odds ratios following multiple logistic regression (p < 0.05 considered significant). RESULTS A total of 934 USS were included, with median age 10.7 [8.0-13.4] years, majority were female (54%). One quarter (n = 226) had SA, 12% (n = 113) had CA, 61% (n = 571) had no appendectomy and 3% (n = 24) had negative appendicectomy. Appendix visualisation rate on USS was 61% (n = 569), with 62% (n = 580) having a conclusive report. Sonographic signs suggesting appendicitis included an appendiceal diameter > 7 mm (AUC 0.92, [95% CI: 0.90-0.94]), an appendicolith (p = 0.003), hyperaemia (p = 0.001), non-compressibility (p = 0.029) and no luminal gas (p = 0.004). Secondary sonographic signs included probe tenderness (p < 0.001) and peri-appendiceal echogenic fat (p < 0.001). Sonographic signs suggesting CA over SA comprised a diameter > 10.1 mm (AUC 0.63, [95% CI: 0.57-0.69]), an appendicolith (p = 0.003) and peri-appendiceal fluid (p = 0.004). CONCLUSION Presence of specific sonographic signs can aid diagnosis and differentiation of simple and complicated appendicitis in children.
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Affiliation(s)
- Lauren Tong
- Department of Paediatrics, School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
| | - Ramesh M Nataraja
- Department of Paediatrics, School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
- Department of Surgery, School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
- Department of Paediatric Surgery, Monash Children's Hospital, Level 5, 246 Clayton Road, Clayton, Melbourne, VIC, 3168, Australia
| | - Keith VanHaltren
- Department of Paediatric Radiology, Monash Children's Hospital, Melbourne, VIC, Australia
| | - Tania H Sulaksana
- Department of Paediatric Surgery, Monash Children's Hospital, Level 5, 246 Clayton Road, Clayton, Melbourne, VIC, 3168, Australia
| | - Toby I Vinycomb
- Department of Paediatric Surgery, Monash Children's Hospital, Level 5, 246 Clayton Road, Clayton, Melbourne, VIC, 3168, Australia
| | - Maurizio Pacilli
- Department of Paediatrics, School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia.
- Department of Surgery, School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia.
- Department of Paediatric Surgery, Monash Children's Hospital, Level 5, 246 Clayton Road, Clayton, Melbourne, VIC, 3168, Australia.
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18
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Klin B, Zlotcavitch L, Lysyy O, Efrati Y, Abu-Kishk I. Complicated appendicitis wrongly diagnosed as nonspecific diarrhea: ways to decrease this continuous threat. Minerva Pediatr (Torino) 2023; 75:14-20. [PMID: 30021409 DOI: 10.23736/s2724-5276.18.04968-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
BACKGROUND The diagnostic assessment of right lower quadrant pain in children and adolescents is still a challenge. The aim of this study was to analyze the cases of complicated appendicitis wrongly diagnosed as nonspecific diarrhea, and based on the information obtained suggest a clear and simple policy in order to decrease misdiagnosis in the future. METHODS Three groups of patients were analyzed: children who underwent appendectomy (group 1); those with gastroenteritis (group 2), and those who underwent appendectomy following hospitalization under the wrong diagnosis of gastroenteritis (group 3). RESULTS Group 3 presented a more prolonged and complicated clinical course, higher fever, diffuse abdominal pain, repeat vomiting, higher C-reactive protein values, longer surgery duration and recovery. CONCLUSIONS When the etiology of right lower quadrant abdominal pain is not immediately evident and associated with atypical diarrhea, high fever, repeat vomiting, and significantly increased CRP values, early surgical consultation is required. If the clinical findings are unclear, an abdominal US should be performed as soon as possible. A limited abdominal computed tomography scan CT should follow those cases not resolved by history, physical examination, blood tests, and abdominal ultrasound.
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Affiliation(s)
- Baruch Klin
- Department of Pediatric Surgery, Assaf Harofeh Medical Center, Zerifin, Israel - .,Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel -
| | | | - Oleg Lysyy
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel.,Department of Diagnostic Imaging, Assaf Harofeh Medical Center, Zerifin, Israel
| | - Yigal Efrati
- Department of Pediatric Surgery, Assaf Harofeh Medical Center, Zerifin, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Ibrahim Abu-Kishk
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel.,Pediatric Intensive Care Unit, Assaf Harofeh Medical Center, Zerifin, Israel
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19
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Stackievicz R, Milner R, Werner M, Arnon S, Steiner Z. Follow-up ultrasonographic findings among children treated conservatively for uncomplicated acute appendicitis. Pediatr Radiol 2023; 53:223-234. [PMID: 36112194 PMCID: PMC9483395 DOI: 10.1007/s00247-022-05497-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 07/29/2022] [Accepted: 08/25/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Ultrasound is an accurate tool for diagnosing acute appendicitis. Conservative treatment for uncomplicated acute appendicitis is feasible and safe in children. However, no sonographic follow-up results from children with nonoperatively managed acute appendicitis have been reported. OBJECTIVE To describe the sonographic appearance of the appendix at follow-up ultrasound and to attempt to identify signs predictive of recurrent acute appendicitis. MATERIALS AND METHODS Children diagnosed with uncomplicated acute appendicitis and treated conservatively in our hospital from 2014 to 2019, and who presented for follow-up ultrasound at 3, 6 and 9 months, were included in our study. Clinical, laboratory and ultrasound data were recorded. RESULTS By the end of follow-up, 29 (14.2%) of 204 children in the cohort had developed recurrent acute appendicitis and 175 had recovered uneventfully. On follow-up ultrasound, appendiceal diameter measured > 6 mm in 56/204 (27.5%) cases at 3 months and in 9/26 (34.5%) at 6 months. After 3 months, 102/204 (50%) children had normal appendiceal diameter on ultrasound. Appendiceal diameter > 6 mm was associated with intraluminal fluid or sludge in the appendiceal lumen at 3- and 6-month follow-up (P < 0.001, P = 0.002, respectively). Comparing cases with and without recurrence, at 3-month follow-up, appendiceal diameter > 6 mm was found in 17/29 (58.6%) cases vs. 39/175 (22.3%), respectively (P < 0.001). Appendiceal diameter returned to normal in 12/19 (63.2%) cases in the nonrecurrent acute appendicitis group compared with 2/7 (28.6%) in the recurrent acute appendicitis group (P = 0.05) at the 6-month follow-up. Intraluminal fluid or sludge was detected more frequently in the recurrent acute appendicitis versus the nonrecurrent acute appendicitis group at 3- (P < 0.001) and 6-month (P = 0.001) follow-up. CONCLUSION Progressive normalization of appendiceal diameter was noted on follow-up ultrasound. The prevalence of both appendiceal diameter > 6 mm and intraluminal fluid or sludge were found to be increased in children who later developed recurrent acute appendicitis. Ultrasound appears to be a useful tool for follow-up in children with conservatively treated uncomplicated acute appendicitis and possibly might help predict recurrence.
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Affiliation(s)
- Rodica Stackievicz
- Department of Radiology, Meir Medical Center, 59 Tchernichovsky St., Kfar Saba, 4428164, Israel. .,Department of Radiology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Rotem Milner
- Department of Radiology, Meir Medical Center, 59 Tchernichovsky St., Kfar Saba, 4428164, Israel
| | - Myriam Werner
- Department of Radiology, Meir Medical Center, 59 Tchernichovsky St., Kfar Saba, 4428164, Israel.,Department of Radiology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shmuel Arnon
- Department of Neonatology, Meir Medical Center, Kfar Saba, Israel.,Department of Pediatrics, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Zvi Steiner
- Department of Pediatric Surgery, Meir Medical Center, Kfar Saba, Israel.,Department of Pediatric Surgery, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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20
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Wright M, Giddings H, Rahman B, Lord RV. Use of oral contrast for CT scanning and time to diagnosis and treatment of acute appendicitis. ANZ J Surg 2023; 93:115-119. [PMID: 36468833 DOI: 10.1111/ans.18194] [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: 07/30/2022] [Revised: 11/14/2022] [Accepted: 11/28/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND The aim of this study was to investigate whether there is a delay in treatment for patients having pre-operative CT imaging with both intravenous and oral contrast (CTIVO) compared to intravenous contrast alone (CTIV). METHODS A retrospective review of patients who underwent emergency appendicectomy at a single hospital during a two-year period (1/1/2019-31/12/2020) was performed. Demographic details, imaging timing/modality; biochemical markers; American Society of Anaesthesiologists (ASA) physical status classification, anaesthetic induction time; operative report findings; histopathology, peri-operative complications, admission/discharge times were recorded. The Sunshine Appendicitis Grading System (SAGS) score was used for severity of appendicitis. RESULTS Pre-operative CT was performed in 294 patients; CTIVO: 159 (54%), CTIV: 135 (46%). Both groups were comparable for age, sex, ASA status and inflammatory markers. The median time from CT request to scanning was longer with CTIVO (CTIVO: 170 min, CTIV: 65 min, P < 0.0001). The median time from CT request to induction of anaesthesia was also longer with CTIVO (CTIVO: 780 minutes, CTIV: 406 min, P < 0.0001). A delay to theatre was not significantly associated with severity of appendicitis (SAGS score). The diagnostic accuracy was not reduced in the CTIV group compared to the CTIVO group. CONCLUSION CTIVO scans significantly delay CT diagnosis and surgical treatment of appendicitis compared to CTIV. Omitting oral contrast does not result in a reduction in diagnostic accuracy for appendicitis.
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Affiliation(s)
- Melissa Wright
- Department of General Surgery, St Vincent's Hospital, Sydney, New South Wales, Australia.,Department of Surgery, School of Medicine, University of Notre Dame Australia, Fremantle, Western Australia, Australia
| | - Hugh Giddings
- Department of General Surgery, St Vincent's Hospital, Sydney, New South Wales, Australia.,Department of Surgery, School of Medicine, University of Notre Dame Australia, Fremantle, Western Australia, Australia
| | - Bayzidur Rahman
- Department of Epidemiology and Biostatistics, School of Medicine, University of Notre Dame Australia, Fremantle, Western Australia, Australia.,Australian Institute of Health and Innovation, Macquarie University, Sydney, New South Wales, Australia.,The Kirby Institute, Faculty of Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia
| | - Reginald V Lord
- Department of General Surgery, St Vincent's Hospital, Sydney, New South Wales, Australia.,Department of Surgery, School of Medicine, University of Notre Dame Australia, Fremantle, Western Australia, Australia
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Heiranizadeh N, Mousavi Beyuki SMH, Kargar S, Abadiyan A, Mohammadi HR. Alvarado or RIPASA? Which one do you use to diagnose acute appendicitis?: A cross-sectional study. Health Sci Rep 2023; 6:e1078. [PMID: 36698708 PMCID: PMC9851161 DOI: 10.1002/hsr2.1078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 11/10/2022] [Accepted: 01/11/2023] [Indexed: 01/20/2023] Open
Abstract
Background and Aims Acute appendicitis is one of the most common causes of lower abdominal pain, which is considered a general surgical emergency worldwide. The present study aimed to compare the diagnostic value of Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) and Alvarado score systems in diagnosing acute appendicitis. Methods A prospective cross-sectional study was conducted at Shahid Sadoughi and Shahid Rahnemoon Hospitals in Yazd between September 2020 and February 2020. The statistical population consisted of all of the patients referred to the Accident and Emergency department with right iliac fossa (RIF) pain. All patients were scored using Alvarado and RIPASA scoring system. sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were computed by using SPSS statistical software. An receiver operating characteristic curve were plotted. Results In present study, one hundred suspected patients with appendicitis who underwent appendectomy were evaluated. The mean age of our study population was 25.2 ± 12.1 years, and the gender distribution was 57% males and 43% females. The sensitivity, specificity, PPV and NPV of RIPASA were 86.6%, 66.7%, 92.2%, and 52.2%, respectively. The sensitivity, specificity, PPV and NPV of Alvarado score were 67.1%, 72.2%, 91.7%, 32.5%, respectively. The diagnostic accuracy was 68% for Alvarado score and 83% for RIPASA. The area under the curve for RIPASA (0.87) was more than that for Alvarado score (0.77). Conclusion The RIPASA score system had higher sensitivity, PPV, NPV, and accuracy than the Alvarado one. It is recommended for the physician and surgeon to evaluate patients with RIF pain using the RIPASA score.
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Affiliation(s)
| | | | - Saeed Kargar
- Department of Surgery Shahid Sadoughi University of Medical Sciences Yazd Iran
| | - Aryana Abadiyan
- Department of Surgery Shahid Sadoughi University of Medical Sciences Yazd Iran
| | - Hamid Reza Mohammadi
- Student Research Committee, Department of Surgery Shahid Sadoughi University of Medical Sciences Yazd Iran
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22
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Delgado-Miguel C, Muñoz-Serrano A, San Basilio M, Miguel-Ferrero M, de Ceano-Vivas M, Martínez L. The role of the neutrophil-to-lymphocyte ratio in avoiding negative appendectomies. An Pediatr (Barc) 2023; 98:12-18. [PMID: 36088243 DOI: 10.1016/j.anpede.2022.08.005] [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: 09/28/2021] [Revised: 11/08/2021] [Accepted: 12/14/2021] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION The neutrophil-to-lymphocyte ratio (NLR) is an inflammatory biomarker that is easily calculated with data from the differential white blood cell count. The aim of our study was to analyse the role of the NLR in the detection of negative appendectomies and to compare its usefulness with other clinical, sonographic and laboratory factors previously described. METHODS We conducted a retrospective study in patients aged less than 16 years who underwent appendectomy in our hospital between 2017 and 2020. We divided patients into 2 groups based on appendiceal histological findings: NA group (negative appendicitis: absence of appendiceal inflammation) and PA group (positive appendicitis: presence of inflammation in any layer of the appendiceal wall). We analysed demographic, clinical, sonographic and laboratory characteristics. RESULTS We included a total of 1269 patients, 1244 in the PA group and 25 in the NA group, with no differences between groups in demographic characteristics. The proportion of patients that presented with nausea and vomiting was significantly smaller in the NA group compared to the PA group (P < .001), and there were no other differences in symptoms. The appendiceal diameter on ultrasound was significantly smaller in the NA group (8.1 ± 2.1 vs. 9.7 ± 2.8 mm; P < .001). The white blood cell and neutrophil counts and the NLR were significantly higher in the PA group (P < .001), as was the level of C-reactive protein (18.6 vs. 2.6; P = .005). The ROC curve analysis revealed that the NLR was the parameter with the highest AUC (0.879) for the diagnosis of negative appendicitis, with a cut-off point of 2.65 for a maximum sensitivity of 84.2% and specificity of 83.8%. CONCLUSION The NLR is the preoperative parameter that best discriminates patients without acute appendicitis. Values of less than 2.65 should make clinicians contemplate diagnoses other than appendicitis.
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Affiliation(s)
| | | | - María San Basilio
- Pediatric Surgery Department, La Paz Children's Hospital, Madrid, Spain
| | | | | | - Leopoldo Martínez
- Pediatric Surgery Department, La Paz Children's Hospital, Madrid, Spain; Institute for Health Research IdiPAZ, Maternal and Child Health and Development Network (SAMID), La Paz University Hospital, Madrid, Spain
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Augustin G, Mikuš M, Bogdanic B, Barcot O, Herman M, Goldštajn MŠ, Tropea A, Vitale SG. A novel Appendicitis TriMOdal prediction Score (ATMOS) for acute appendicitis in pregnancy: a retrospective observational study. Updates Surg 2022; 74:1933-1941. [PMID: 36048362 DOI: 10.1007/s13304-022-01368-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 08/22/2022] [Indexed: 01/20/2023]
Abstract
Several scoring systems exist for the management of acute appendicitis (AA) during pregnancy. However, the systems are based on the nonpregnant adult population. The aim of this study was to create a highly accurate scoring system that can be applied to pregnant women and to compare it to the most commonly used scores in general population and pregnant women. The creation and subsequent implementation of a highly accurate score system could shorten the diagnostic period and minimize the use of (ionizing) diagnostic imaging allowing the selection of the best treatment approach in pregnant patients with acute appendicitis. A single-center, retrospective cohort observational study was conducted at the University Hospital Centre Zagreb, Zagreb, Croatia. Data were extracted from medical records of pregnant patients with suspected AA from January 2010 to December 2020. A total of 59 pregnant patients diagnosed with AA during pregnancy were identified, 41 were treated surgically, and 18 had non-surgical management. The main objective of our study was the detection of predictive factors of AA during pregnancy. Anorexia, pain migration to the right lower quadrant, rebound pain, axillary temperature over 37.3 °C, CRP/platelet ratio > 0.0422, neutrophil/lymphocyte ratio > 7.182, and ultrasonic signs of AA were scored. Scoring in Appendicitis TriMOdal Score (ATMOS) consists of positive clinical parameter, each bringing 1 point and other parameters mentioned above that bring 2 points each. The score ranges from 0 to 10. Our model of ATMOS yields a high area under the receiver-operating characteristic curve of 0.963. The positive likelihood ratio is 9.97 (95% CI 2.64-38.00), and the negative likelihood ratio is 0.1 (95% CI 0.03-0.31), meaning that 94% of cases with ATMOS > 4 have AA, while less than 13% with an ATMOS ≤ 4 have the diagnosis of AA. The potential of ATMOS differentiating AA during pregnancy was demonstrated. Future prospective, randomized trials are needed to evaluate its accuracy and whether it should be used instead of Alvarado or Tzanakis scores in clinical decision-making.Trial registration number ClinicalTrials.gov-NCT05202483. Date of registration: January 21, 2022.
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Affiliation(s)
- Goran Augustin
- Department of Surgery, University Hospital Centre Zagreb, Kišpatićeva 12, Zagreb, Croatia
- School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Mislav Mikuš
- School of Medicine, University of Zagreb, Zagreb, Croatia.
- Department of Obstetrics and Gynecology, University Hospital Centre Zagreb, Petrova 13, 10000, Zagreb, Croatia.
| | - Branko Bogdanic
- Department of Surgery, University Hospital Centre Zagreb, Kišpatićeva 12, Zagreb, Croatia
- School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Ognjen Barcot
- Department of Surgery, University Hospital Split, Spinčićeva 1, Split, Croatia
| | - Mislav Herman
- School of Medicine, University of Zagreb, Zagreb, Croatia
- Department of Obstetrics and Gynecology, University Hospital Centre Zagreb, Petrova 13, 10000, Zagreb, Croatia
| | - Marina Šprem Goldštajn
- School of Medicine, University of Zagreb, Zagreb, Croatia
- Department of Obstetrics and Gynecology, University Hospital Centre Zagreb, Petrova 13, 10000, Zagreb, Croatia
| | - Alessandro Tropea
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies), Via E. Tricomi 1, 90127, Palermo, Italy
| | - Salvatore Giovanni Vitale
- Obstetrics and Gynecology Unit, Department of General Surgery and Medical Surgical Specialties, University of Catania, 95124, Catania, Italy
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Pediatric Appendicitis Score for Identifying Acute Appendicitis in Children Presenting With Acute Abdominal Pain to the Emergency Department. Indian Pediatr 2022. [DOI: 10.1007/s13312-022-2620-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Manglik A, Tomar L, Akash A. Pyelonephritis of an ectopic right kidney pretending as acute appendicitis: An unusual case. Int J Surg Case Rep 2022; 98:107490. [PMID: 35985113 PMCID: PMC9411656 DOI: 10.1016/j.ijscr.2022.107490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 08/04/2022] [Accepted: 08/06/2022] [Indexed: 11/04/2022] Open
Abstract
Introduction Acute appendicitis is a common condition presenting in emergency department. A patient presenting with pain associated with fever, and tenderness in the right iliac fossa will be suspected to have Acute Appendicitis. However a variety of other clinical conditions may have similar features and may be required to be excluded. Acute pyelonephritis in an ectopic right kidney is a rare clinical condition which may mimic Acute Appendicitis. Case presentation We present a middle-age male with complaints of pain in the right lower quadrant of the abdomen with high grade fever for one week. Clinical suspicion and initial ultrasonography (USG) of abdomen supported the diagnosis of acute appendicitis. The patient was initially managed conservatively and later non-contrast computed tomography (NCCT) scan was done that revealed right ectopic kidney with acute pyelonephritis. The appendix was within normal limits on NCCT scan. Discussion Ectopic kidneys result from anomalies of ascend which can result in several complications depending upon its position. Acute appendicitis can also cause pyuria and may mimic urosepsis amounting to its close anatomical proximity to urinary bladder. An un-ascended ectopic kidney with pyelonephritis mimicking acute appendicitis is a rare occurrence. USG and CT scan are important tools in the differential diagnosis but however, USG is greatly operator dependent; CT scan provides excellent diagnostic accuracy. Conclusion This case report signifies importance of NCCT abdomen in accurate diagnosis of conditions featuring as right lower abdominal pain and fever. Also emphasizing significance of NCCT prior to any surgical intervention, if any conflict of diagnosis occurs. Right lower abdomen pain and fever are most commonly attributed to acute appendicitis. Cases are reported in past with co-existing pyelonephritis and appendicitis as well as pyelonephritis mimicking appendicitis. Pyelonephritis in ectopic kidney and appendicitis are very hard to differentiate on basis of history and lab parameters. NCCT abdomen can serve as augmented imaging modality in such cases with diagnostic dilemmas.
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KORKMAZ İ, SEYFETTİN A, ÇELİKKAYA M. Pediatrik Apandisit Olgularında Ultrasonografinin Tanısal Duyarlılığı. MUSTAFA KEMAL ÜNIVERSITESI TIP DERGISI 2022. [DOI: 10.17944/mkutfd.1057560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Amaç: Çalışmamızda pediatrik yaş grubunda ultrasonografinin apandisit tanısındaki duyarlılığının araştırılması amaçlanmıştır.
Gereç Yöntem: Operasyon sonucu apandisit tanısı alan, preoperatif USG tetkiki gerçekleştirilmiş olan ve akut batın nedeni olan ek patolojisi bulunmayan 87 pediatrik olgu çalışmaya dahil edildi. Olguların USG raporları retrospektif olarak incelenerek USG’ nin apandisit tanısındaki duyarlılığı araştırıldı. Ayrıca olguların lökosit sayıları, nötrofil oranları ve CRP değerleri hastane arşivinden ve varsa BT tetkikleri PACS sisteminden incelendi.
Bulgular: Olguların %71’i akut apandisit, %29’u perfore apandisitti. Olguların %74’ünün USG’si apandisit ile uyumlu olup USG’nin tanı duyarlılığı %74’dü, %16 olguda USG’de sekonder apandisit bulguları izlenirken %10 olguda USG tetkiki tamamen normaldi. USG ile tanı konulamayan %26 olgudan %10 olgunun tanısı BT ile konulmuş olup %16 olguda tanıya klinik bulgularla gidilmişti. Olguların %62’sinde lökositoz, %84’ünde nötrofil oranında artış (sola kayma), %86’sında ise CRP yüksekliği bulunmaktaydı ve olguların tamamında bu parametrelerin en az biri yüksekti.
Sonuç: Ultrasonografi her durumda tanı koymak için yeterli olmasa da çalışmamızda ulaşılan yüksek duyarlılık oranı, ultrasonografinin akut apandisit şüphesi bulunan pediatrik hastalarda ilk seçenek tanı aracı olarak kullanılabileceği bilgisini desteklemektedir.
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Affiliation(s)
- İnan KORKMAZ
- HATAY MUSTAFA KEMAL ÜNİVERSİTESİ, TAYFUR ATA SÖKMEN TIP FAKÜLTESİ, DAHİLİ TIP BİLİMLERİ BÖLÜMÜ, RADYOLOJİ ANABİLİM DALI
| | | | - Mehmet ÇELİKKAYA
- HATAY MUSTAFA KEMAL ÜNİVERSİTESİ, TAYFUR ATA SÖKMEN TIP FAKÜLTESİ, CERRAHİ TIP BİLİMLERİ BÖLÜMÜ, ÇOCUK CERRAHİSİ ANABİLİM DALI
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Utilidad del índice neutrófilo-linfocito en la detección de apendicectomías negativas. An Pediatr (Barc) 2022. [DOI: 10.1016/j.anpedi.2021.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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28
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Time to source control and outcome in community-acquired intra-abdominal infections: The multicentre observational PERICOM study. Ugeskr Laeger 2022; 39:540-548. [PMID: 35608877 DOI: 10.1097/eja.0000000000001683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Optimal management of community-acquired intra-abdominal infections (IAI) requires timely surgical source control and adequate anti-infective treatment. OBJECTIVE To describe the initial management of community-acquired IAI admitted to the emergency department and assess the association between the length of time to either diagnosis or therapeutic procedures and patient outcomes. DESIGN A prospective, multicentre, observational study. SETTING Thirteen teaching hospitals in France between April 2018 and February 2019. PATIENTS Two hundred and five patients aged at least 18 years diagnosed with community-acquired IAI. MAIN OUTCOME MEASURES The primary outcome was hospital length of stay. The secondary outcome was hospital mortality. RESULTS Patients had a mean age of 56 (± 21) years and a median [interquartile] SAPS II of 26 [17 to 34]. Among the study cohort, 18% were postoperatively transferred to intensive care unit and 7% had died by day 28. Median [IQR] time to imaging, antibiotic therapy and surgery were 4 [2 to 6], 7.5 [4 to 12.5] and 9 [5.5 to 17] hours, respectively. The length of time to surgical source control [0.99, 95% confidence interval (CI), 0.98 to 0.99], SOFA greater than 2 [0.36 (95% CI, 0.26 to 0.651)], age greater than 60 years [0.65 (95% CI, 0.45 to 0.94)], generalized peritonitis [0.7 (95% CI, 0.56 to 0.89)] and laparotomy surgery [0.657 (95% CI, 0.42 to 0.78)] were associated with longer hospital length of stay. The duration of time to surgical source control [1.02 (95% CI, 1.01 to 1.04)], generalized peritonitis [2.41 (95% CI, 1.27 to 4.61)], and SOFA score greater than 2 [6.14 (95% CI, 1.40 to 26.88)] were identified as independent risk factors for 28-day mortality. CONCLUSION This multicentre observational study revealed that the time to surgical source control, patient severity and generalized peritonitis were identified as independent risk factors for increased hospital LOS and mortality in community-acquired IAI. Organisational strategies to reduce the time to surgical management of intra-abdominal infections should be further evaluated. STUDY REGISTRATION ClinicalTrials.gov on 1 April 2018, NCT03544203.
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Lehmann B, Koeferli U, Sauter TC, Exadaktylos A, Hautz WE. Diagnostic accuracy of a pragmatic, ultrasound-based approach to adult patients with suspected acute appendicitis in the ED. Emerg Med J 2022; 39:931-936. [PMID: 35301219 DOI: 10.1136/emermed-2019-208643] [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: 04/06/2019] [Accepted: 02/22/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Systematic imaging reduces the rate of missed appendicitis and negative appendectomies in patients with suspected acute appendicitis (AA). Little is known about the utility of ultrasound as a first diagnostic measure in patients with suspected AA. The aim of this retrospective study is to determine whether ultrasound, performed by emergency physicians or radiologists, can be used as first diagnostic measure in suspected cases to rule out AA and to avoid unnecessary CT. METHODS We performed a retrospective analysis at the ED of the University Hospital Bern, Switzerland, from 2012 to 2014. Our standard protocol is that all adult patients suspected of appendicitis receive an ultrasound as their first imaging test, either by an emergency physician or a radiologist. The test characteristics of conclusive and inconclusive ultrasound exams were compared with a pragmatic gold standard. RESULTS The study included 508 patients with suspected AA. 308 patients (60.4%) had a conclusive ultrasound. Among these, sensitivity for appendicitis was 89.6% (95% CI 82.1% to 94.3%), specificity 93.8% (89.1% to 96.6%), the positive predictive value was 87.98 (80.84 to 92.71) and the negative predictive value was 94.65 (91.18 to 96.80). The remaining 200 (39.4%) patients had an inconclusive ultrasound exam. 29% (59/200) of these patients ultimately had appendicitis. Less experienced emergency physician sonographers came to a definitive conclusion in 48.1% (95% CI 36.9% to 59.5%), experienced emergency physician sonographers in 76.0% (68.4% to 82.5%) and radiologists in 52.4% (44.5% to 60.2%). CONCLUSION A conclusive ultrasound of the appendix performed by either emergency physicians or radiologists is a sensitive and specific exam to diagnose or exclude AA in patients with suspected AA. Because of 6% false negative exams, clinical follow-up is mandatory for patients with negative ultrasound. An inconclusive ultrasound warrants further imaging or a follow-up visit, since 29% of patients with inconclusive ultrasound had an AA.
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Affiliation(s)
- Beat Lehmann
- Department of Emergency Medicine, Inselspital University Hospital Bern, Bern, Switzerland
| | - Ursina Koeferli
- Department of Emergency Medicine, Inselspital University Hospital Bern, Bern, Switzerland
| | - Thomas C Sauter
- Department of Emergency Medicine, Inselspital University Hospital Bern, Bern, Switzerland
| | | | - Wolf E Hautz
- Department of Emergency Medicine, Inselspital University Hospital Bern, Bern, Switzerland
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Park KB, Hong J, Moon JY, Jung J, Seo HS. Relationship Between Appendectomy Incidence and Computed Tomography Scans Based on Korean Nationwide Data, 2003-2017. J Korean Med Sci 2022; 37:e27. [PMID: 35075826 PMCID: PMC8787806 DOI: 10.3346/jkms.2022.37.e27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 12/05/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Advances in medicine and changes in the medical environment can affect the diagnosis and treatment of diseases. The main purpose of the present study was to investigate whether the difference in accessibility to diagnosis and treatment facilities influenced the occurrence of appendectomy in Korea. METHODS We collected data on 183,531 appendectomy patients between 2003 and 2017 using the National Health Insurance Services claims. Retrospective analysis of relationship between the age-standardized rate (ASR) of appendectomy and clinical variables affecting medical accessibility was performed. Pearson's correlation analyses were used. RESULTS The incidence of appendectomy decreased from 30,164 cases in 2003 to 7,355 cases in 2017. The rate of computerized tomography (CT) scans for diagnosis of appendicitis increased from 4.73% in 2003 to 86.96% in 2017. The ASR of appendectomy in uncomplicated and complicated appendicitis decreased from 48.71 in 2005 to 13.40 in 2010 and 8.37 in 2005 to 2.96 in 2009, respectively. The ASR of appendectomy was higher in the high-income group. The proportion and ASR of appendectomy in older age group increased steadily with years. The total admission days continued to decrease from 6.02 days in 2003 to 4.96 days in 2017. CONCLUSION The incidence of appendectomy was seemingly associated with the rate of CT scan. In particular, the incidence of appendectomy in uncomplicated appendicitis was markedly reduced. Through enhanced accessibility to CT scans, accurate diagnosis and treatment of appendicitis can be facilitated.
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Affiliation(s)
- Ki Bum Park
- Department of Surgery, St. Vincent's Hospital, College of Medicine, the Catholic University of Korea, Seoul, Korea
| | - Jinwook Hong
- Artificial Intelligence and Big-Data Convergence Center, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Jong Youn Moon
- Artificial Intelligence and Big-Data Convergence Center, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
- Center for Public Healthcare, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
- Departement of Preventive Medicine, Gachon University College of Medicine, Incheon, Korea
| | - Jaehun Jung
- Artificial Intelligence and Big-Data Convergence Center, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
- Departement of Preventive Medicine, Gachon University College of Medicine, Incheon, Korea.
| | - Ho Seok Seo
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, the Catholic University of Korea, Seoul, Korea.
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Xu Q, Liu M, Wu Q, Ling W, Guo S. Retrospective Analysis of the Accuracy of High-Frequency Ultrasound for Pancreaticobiliary Maljunction in Pediatrics at a Single Center. Front Pediatr 2022; 10:775378. [PMID: 35498787 PMCID: PMC9047754 DOI: 10.3389/fped.2022.775378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 02/08/2022] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To determine the clinical value of high-frequency ultrasonography (US) in the evaluation and diagnosis of pancreaticobiliary maljunction (PBM) among children. METHODS The clinical subjects consisted of 31 pediatric patients who were diagnosed with PBM from January 2015 to May 2021 in Fujian Provincial Maternity and Children's Hospital. The primary outcomes included diagnosis accuracy, imaging characteristics of each type of PBM based on JSPBM, time length of operation, and cost of service. Secondary outcomes were the serum amylase and bilirubin levels. RESULTS The diagnostic accuracy of US was 90.3% and comparable to the other imaging methods-MRCP (82.6%), IOC (79.2%), and ERCP (100%), respectively. The time length of operation and direct cost were significantly lower than other imaging pathways. Stenotic type (A) is associated with a high internal diameter of CBD, and dilated channel type (C) presents increased internal diameter and length of CC as well as internal diameter of PD. There were higher levels of the serum bilirubin seen in type A and of serum amylase in type C compared with others. CONCLUSION High-frequency US is a safe, cost-effective, and non-invasive imaging tool for the diagnosis and evaluation of PBM in pediatrics.
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Affiliation(s)
- Qiuchen Xu
- Department of Medical Ultrasonics, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Min Liu
- Department of Medical Ultrasonics, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Qiumei Wu
- Department of Medical Ultrasonics, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Wen Ling
- Department of Medical Ultrasonics, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Shan Guo
- Department of Medical Ultrasonics, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
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Cho J, Kim Y, Lee S, Min HD, Ko Y, Chee CG, Kim HY, Park JH, Lee KH. Appendiceal Visualization on 2-mSv CT vs. Conventional-Dose CT in Adolescents and Young Adults with Suspected Appendicitis: An Analysis of Large Pragmatic Randomized Trial Data. Korean J Radiol 2022; 23:413-425. [PMID: 35289144 PMCID: PMC8961010 DOI: 10.3348/kjr.2021.0504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 09/29/2021] [Accepted: 11/10/2021] [Indexed: 11/15/2022] Open
Affiliation(s)
- Jungheum Cho
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Youngjune Kim
- Aerospace Medical Group, Air Force Education and Training Command, Jinju, Korea
| | - Seungjae Lee
- Department of Applied Bioengineering, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, Korea
| | - Hooney Daniel Min
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Yousun Ko
- Biomedical Research Center, Asan Institute for Life Sciences, Asan Medical Center, Seoul, Korea
| | | | - Hae Young Kim
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Ji Hoon Park
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Applied Bioengineering, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, Korea
- Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Kyoung Ho Lee
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
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Coleman B, Ramakrishnan K. Surgical Problems of the Digestive System. Fam Med 2022. [DOI: 10.1007/978-3-030-54441-6_100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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James NC, Ahmadian R, Mckee JQ, Sarangarm D, Bussmann SC, Williamson S, Upham BD. Magnetic Resonance Imaging Availability Reduces Computed Tomography Use for Pediatric Appendicitis Diagnosis. Pediatr Emerg Care 2022; 38:e219-e224. [PMID: 32898123 DOI: 10.1097/pec.0000000000002222] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To determine if introducing magnetic resonance imaging (MRI) as an imaging option for children with suspected appendicitis and an inconclusive ultrasound reduces computed tomography (CT) use. METHODS This is a retrospective cohort study of patients aged 5 to 18 years who presented to a pediatric emergency department (ED) with suspected appendicitis. Rates of CT use 1 year before and 1 year after MRI availability are compared. Secondary outcomes include missed and negative appendectomies, imaging charges, time to antibiotics and surgery, time to radiology read, ED length of stay, and test characteristics of MRI and CT. RESULTS Of the 981 patients screened, 499 patients met inclusion criteria. There was an absolute reduction of CT use of 25% from 38% in year 1 to 13% in year 2 (95% confidence interval, 18% to 33%). Advanced imaging charges were $371 higher in year 2 (MRI) than year 1 (CT), and median time to radiologist reads was longer in MRIs than CTs (129 versus 62 minutes; difference 53 minutes, 95% confidence interval, 23 to 74 minutes). All other secondary outcomes, including ED length of stay and test characteristics, were statistically similar. CONCLUSIONS Introducing MRI for as an imaging option for children with suspected appendicitis and an inconclusive ultrasound markedly reduced CT use, but did result in a small increase in imaging charges and time to preliminary radiology read.
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Affiliation(s)
- Natasha C James
- From the Division of Pediatric Emergency Medicine, Department of Emergency Medicine, University of New Mexico
| | | | - Jason Q Mckee
- Division of Pediatric Surgery, Department of Surgery
| | | | | | - Susan Williamson
- Department of Radiology, University of New Mexico, Albuquerque, NM
| | - Bryan D Upham
- From the Division of Pediatric Emergency Medicine, Department of Emergency Medicine, University of New Mexico
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Ashjaei B, Mehdizadeh M, Alizadeh H, Najm N, Moghtaderi M. Evaluating the value of different sonographic findings in diagnosis of acute appendicitis in children. Afr J Paediatr Surg 2022; 19:13-17. [PMID: 34916345 PMCID: PMC8759413 DOI: 10.4103/ajps.ajps_124_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Appendicitis is one of the most common paediatric surgical emergencies occurring in about 7% of healthy children. To make a definitive diagnosis preferably avoiding unnecessary X-ray radiation exposure, ultrasound is the ideal modality. The aim of this study is to evaluate the diagnostic value of sonographic findings in children with acute appendicitis and comparing them with surgical findings to demonstrate the safety, simplicity and accuracy of this procedure in emergency departments as the first diagnostic procedure. MATERIALS AND METHODS One hundred and eight children aged 1-15 years suspected of acute appendicitis in our tertiary hospital emergency department enrolled the study. Patients presenting as acute abdomen suspected as having acute appendicitis underwent abdominal ultrasonography (US) at first. Sonographic findings were compared to surgical and pathologic results, and sensitivity and specificity of each sonographic parameter in paediatric appendicitis were evaluated. RESULTS The analysis of sonographic results showed that 67.6% of patients had acute appendicitis, 13.9% had perforated appendicitis and 18.5% had normal appendix. On the other hand, there were acute appendicitis in 63.9% of patients, perforated appendicitis in 12% and normal appendix in 8.3% in surgical reports. Sensitivity of uncompressible appendicitis, appendicitis, maximal outer diameter (MOD) above 6 mm, maximal mural thickness (MMT) above 3 mm, round appendix was 98.68%, 28.04%, 94.74%, 61.84% and 68.42%, respectively. Specificity of incompressible appendicitis, appendicitis, MOD above 6 mm, MMT above 3 mm, round appendix was 64.71%, 96.15%, 64.71%, 82.35% and 94.12%, respectively. Overall sensitivity and specificity of US in appendicitis were 97.56% and 69.23%, respectively. CONCLUSION According to the findings of this study, sensitivity of US in diagnosing appendicitis is higher than other studies, but its specificity was lower. Ultrasonographic accuracy and efficacy to diagnose acute appendicitis in children are high enough to allow clinicians to do it as an imaging modality of first choice, and also, in problematic cases to assist correct clinical diagnosis avoiding unnecessary X-ray exposure, decreasing negative appendectomies, decreasing perforation rate and lowering the cost of patients. Furthermore, negative US do not justify immediate computed tomography because clinical re-evaluation and a second US can help greatly the clinicians in the correct diagnosis.
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Affiliation(s)
- Bahar Ashjaei
- Children Medical Center Hospital, Departments of Pediatric Surgery, Tehran University of Medical Sciences, Tehran, Iran
| | - Mehrzad Mehdizadeh
- Children Medical Center Hospital, Departments of Pediatric Radiology, Tehran University of Medical Sciences, Tehran, Iran
| | - Houman Alizadeh
- Children Medical Center Hospital, Departments of Pediatric Radiology, Tehran University of Medical Sciences, Tehran, Iran
| | - Nooshin Najm
- Children Medical Center Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mastaneh Moghtaderi
- Children Medical Center Hospital, Pediatric Chronic Kidney Disease Research Center, Tehran University of Medical Sciences, Tehran, Iran
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Wongwaisayawa S, Prapruttam D, Klawandee S, Tangkittithaworn P. Effect of Alvarado Score on the Negative Predictive Value of Nondiagnostic Ultrasound for Acute Appendicitis. J Med Ultrasound 2022; 30:125-129. [PMID: 35832371 PMCID: PMC9272718 DOI: 10.4103/jmu.jmu_139_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 07/22/2021] [Accepted: 08/03/2021] [Indexed: 11/12/2022] Open
Abstract
Background: The purposes of this study were to calculate the negative predictive value (NPV) of nondiagnostic ultrasound (US) in patients with suspected appendicitis and to identify the clinical factors that were associated with the nondiagnostic US. Methods: We conducted a retrospective review of 412 patients who had graded-compression appendiceal US performed during January 2017 and December 2017. The NPV of the nondiagnostic US in combination with clinical parameters was calculated. Multivariate regression analysis was used to determine the independent predictors for the nondiagnostic US. Results: The US exam was nondiagnostic in 64.8% of the patients, giving an NPV of 70.8%. The NPV of nondiagnostic US increased to 96.2% in patients who had an Alvarado score of <5. The patients who did not have migratory pain, did not have leukocytosis, and had a pain score of <7 were more likely to have a nondiagnostic US study (P < 0.001). Conclusion: Alvarado score had an inverse effect on the NPV of nondiagnostic appendiceal US. Patients who had nondiagnostic US and Alvarado score of <5 were very unlikely to have appendicitis. Active clinical observation or re-evaluation rather than immediate computed tomography may be a safe alternative approach in these low-risk patients. However, the Alvarado score itself was not a predictive factor of nondiagnostic US. The absence of migratory pain, absence of leukocytosis, and low pain score were the independent predictors of nondiagnostic appendiceal US.
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Park JH, Salminen P, Tannaphai P, Lee KH. Low-Dose Abdominal CT for Evaluating Suspected Appendicitis in Adolescents and Young Adults: Review of Evidence. Korean J Radiol 2022; 23:517-528. [PMID: 35289145 PMCID: PMC9081692 DOI: 10.3348/kjr.2021.0596] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 10/18/2021] [Accepted: 11/21/2021] [Indexed: 11/15/2022] Open
Abstract
Due to its excellent diagnostic performance, CT is the mainstay of diagnostic test in adults with suspected acute appendicitis in many countries. Although debatable, extensive epidemiological studies have suggested that CT radiation is carcinogenic, at least in children and adolescents. Setting aside the debate over the carcinogenic risk of CT radiation, the value of judicious use of CT radiation cannot be overstated for the diagnosis of appendicitis, considering that appendicitis is a very common disease, and that the vast majority of patients with suspected acute appendicitis are adolescents and young adults with average life expectancies. Given the accumulated evidence justifying the use of low-dose CT (LDCT) of only 2 mSv, there is no reasonable basis to insist on using radiation dose of multi-purpose abdominal CT for the diagnosis of appendicitis, particularly in adolescents and young adults. Published data strongly suggest that LDCT is comparable to conventional dose CT in terms of clinical outcomes and diagnostic performance. In this narrative review, we will discuss such evidence for reducing CT radiation in adolescents and young adults with suspected appendicitis.
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Affiliation(s)
- Ji Hoon Park
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Applied Bioengineering, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, Korea
- Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Paulina Salminen
- Department of Surgery, University of Turku, Turku, Finland, Thailand
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland, Thailand
| | - Penampai Tannaphai
- Department of Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Kyoung Ho Lee
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Applied Bioengineering, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, Korea
- Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Interdisciplinary Program in Bioengineering, Seoul National University, Seoul, Korea
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Malia L, Sturm JJ, Smith SR, Brown RT, Campbell B, Chicaiza H. Predictors for Acute Appendicitis in Children. Pediatr Emerg Care 2021; 37:e962-e968. [PMID: 31136455 DOI: 10.1097/pec.0000000000001840] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Acute appendicitis in children is the most common condition requiring urgent evaluation and surgery in the emergency department. At times, despite the appendix being seen on ultrasound (US), there can be discrepancy as to whether a patient has clinical appendicitis. Secondary findings suggestive of appendicitis can be helpful in identifying and evaluating these children. OBJECTIVE The aim of this study was to determine if specific US findings and/or laboratory results are predictive of appendicitis in children with a visualized appendix on US. METHODS A prospective study was conducted on children (birth to 18 years) presenting to the pediatric emergency department with suspected appendicitis who underwent right-lower-quadrant US. Ultrasound findings analyzed appendix diameter, compressibility, increased vascularity, presence of appendicolith, inflammatory changes, right-lower-quadrant fluid near the appendix, lower abdominal fluid, tenderness during US, and lymph nodes. Diagnosis was confirmed via surgical pathology. RESULTS There were 1252 patients who enrolled, 60.8 (762) had their appendix visualized, and 39.1 (490) did not. In children where the appendix was seen, 35.2% (268) were diagnosed with appendicitis. Among patients with a visualized appendix, the likelihood of appendicitis was significantly greater if the appendix diameter was 7 mm or greater (odds ratio [OR], 12.4; 95% confidence interval [CI], 4.7-32.7), an appendicolith was present (OR, 3.9; 95% CI, 1.5-10.3), inflammatory changes were seen (OR, 10.2; 95% CI, 3.9-26.1), or the white blood cell (WBC) count was 10,000/μL (OR, 4.8; 95% CI, 2.4-9.7). A duration of abdominal pain of 3 days or more was significantly less likely to be associated with appendicitis (OR, 0.3; 95% CI, 0.08-0.99). The absence of inflammatory changes, WBC count of less than 10,000/μL, and appendix diameter of 7 mm or less had a negative predictive value of 100%. CONCLUSIONS When the appendix is seen on US but diagnosis of appendicitis is questioned, the absence of inflammatory changes, WBC count of less than 10,000/μL, and appendix diameter of 7 mm or less should decrease suspicion for appendicitis.
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Affiliation(s)
- Laurie Malia
- From the Department of Emergency Medicine, Connecticut Children's Medical Center
| | - Jesse J Sturm
- From the Department of Emergency Medicine, Connecticut Children's Medical Center
| | - Sharon R Smith
- From the Department of Emergency Medicine, Connecticut Children's Medical Center
| | | | - Brendan Campbell
- From the Department of Emergency Medicine, Connecticut Children's Medical Center
| | - Henry Chicaiza
- From the Department of Emergency Medicine, Connecticut Children's Medical Center
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Ahmad T, Khdair Ahmad F, Manson D. Diagnostic Performance of a Staged Pathway for Imaging Acute Appendicitis in Children. Pediatr Emerg Care 2021; 37:e1197-e1201. [PMID: 31913249 DOI: 10.1097/pec.0000000000001964] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION The objective of this work is to assess the performance of our staged diagnostic pathway in the evaluation of suspected appendicitis cases in children. The pathway consisted of clinical assessment by the emergency physician, performing initial ultrasound (US), consultation, and clinical reevaluation by the surgery team followed by a repeat focused US scan in inconclusive cases. Computed tomography (CT) was limited to cases where the repeat US remained inconclusive and the clinical reassessment indicated persistent concerns for appendicitis. METHOD Retrospective review of the electronic medical records of 206 consecutive children who presented to our emergency department with acute abdominal pain and underwent US examination for suspected appendicitis. The imaging findings, management plan, and surgical outcome (in those who underwent surgery) were reviewed. The diagnostic performance of the initial US, repeat US, and the full imaging protocol were evaluated including the negative appendectomy rate (NAR) and the number of CT scans performed. RESULTS Of the 206 cases, 73 (35.4%) had appendicitis. Computed tomography was performed in 9 (4.3%) of 206 cases. The US/CT ratio was 23:1. Our approach showed a diagnostic accuracy of 95.6% (197/206), sensitivity of 97.3% (73/75), specificity of 93.7% (124/133), positive predictive value of 89.0% (73/82), and negative predictive value of 98.7% (82/95). The NAR was 2.7% (2/72). The accuracy of the protocol is higher than that of the initial US alone (61.2%; 126/206) and that of the repeat US (84.2%; 16/19). CONCLUSION The strategy of repeating limited focused US followed by CT scan in cases that remain inconclusive has good diagnostic accuracy and reasonable NAR and decreases the number of CT scans.
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Affiliation(s)
- Tahani Ahmad
- From the Department of Radiology, Dalhousie University, Department of Diagnostic Imaging, IWK Health Centre, Halifax, Nova Scotia, Canada
| | - Fareed Khdair Ahmad
- Section of Pediatric Gastroenterology, Department of Pediatrics, The University of Jordan, Amman, Jordan
| | - David Manson
- Department of Medical Imaging, University of Toronto, Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada
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Whitehead A, Fullerton K, Miller HC. Minimizing Ionizing Radiation in Evaluating Suspected Appendicitis in Children Before and After the Release of the ACEP Clinical Policy. Pediatr Emerg Care 2021; 37:e1434-e1438. [PMID: 32097377 DOI: 10.1097/pec.0000000000002068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
STUDY OBJECTIVE The aim of this study was to examine the impact of the ACEP (American College of Emergency Physicians) clinical policy regarding diagnosis of suspected appendicitis on changing practice in the pediatric emergency department (ED) in the absence of a formal departmental protocol. METHODS This was a retrospective chart review in a pediatric ED in which patients aged 2 to 18 years were evaluated for appendicitis via ultrasound, computed tomography (CT), or both, over a 7-year study period. We compared rates of CT utilization in the period before the release of the ACEP clinical policy regarding diagnosis and treatment of appendicitis (2008-2009) and the period after (2010-2014). Other metrics of interest were ultrasound results and physician response to results, as well as surrogate markers for quality of care. RESULTS Seven hundred pediatric ED visits were included, with 200 prepolicy release and 500 postrelease. Computed tomography utilization decreased significantly postpolicy release from 43.5% (95% confidence interval [CI], 36.6%-50.3%) to 22.2% (95% CI, 18.5%-25.8%). The proportion of ultrasounds with indeterminate results also decreased, with 71.5% (95% CI, 65.1%-77.9%) and 55.1% (95% CI, 50.7%-59.5%) in the pre and post groups, respectively. Physicians ordered fewer CTs after indeterminate ultrasounds, decreasing from 63.7% (95% CI, 56.9%-70.5%) to 48.3%% (95% CI, 43.9%-52.7%). CONCLUSIONS After the release of the clinical policy, CT utilization decreased significantly suggesting possible effectiveness of the policy in bringing about change in practice. Subsequently, there was an increase in the definitiveness in the ultrasound results. Physicians also evolved in their response to indeterminate ultrasound results, with fewer CTs ordered reflexively after indeterminate results.
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Affiliation(s)
| | - Katherine Fullerton
- Department of Pediatrics, Inova Fairfax Hospital for Children, Falls Church, VA
| | - Helen C Miller
- George Washington University School of Medicine and Health Sciences, Washington, DC
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Akgül F, Er A, Ulusoy E, Çağlar A, Çitlenbik H, Keskinoğlu P, Şişman AR, Karakuş OZ, Özer E, Duman M, Yılmaz D. Integration of Physical Examination, Old and New Biomarkers, and Ultrasonography by Using Neural Networks for Pediatric Appendicitis. Pediatr Emerg Care 2021; 37:e1075-e1081. [PMID: 31503129 DOI: 10.1097/pec.0000000000001904] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of this study was to evaluate physical examinations, imaging, and laboratory analyses individually and combined using innovative statistical analysis methods for the accurate diagnosis of pediatric appendicitis. METHODS Patients admitted to hospital with symptoms of abdominal pain whose pediatric appendicitis scores greater than 3 were included in the study. Clinical, radiologic, and laboratory findings and as a new biomarker calprotectin (CPT) concentrations were evaluated individually and combined using artificial neural networks (ANNs), which revealed latent relationships for a definitive diagnosis. RESULTS Three hundred twenty patients were evaluated (190 appendicitis [43 perforated] vs 130 no appendicitis). The mean ± SD age was 11.3 ± 3.6 years and 63% were male. Pediatric appendicitis scores, white blood cell (WBC) count, absolute neutrophil count (ANC), C-reactive protein (CRP) level, procalcitonin (PCT) and CPT concentrations were higher in the appendicitis group; however, only WBC and ANC were higher in first 24 hours of pain. White blood cells and CRP were diagnostic markers in patients whose appendix could not be visualized using ultrasonography (US). On classic receiver operating characteristic (ROC) analysis, the areas under the curve (AUCs) were not strong enough for differential diagnosis (WBC, 0.73; ANC, 0.72; CRP, 0.65; PCT and CPT, 0.61). However, when the physical examination, US, and laboratory findings were analyzed in a multivariate model and the ROC analysis obtained from the variables with ANN, an ROC curve could be obtained with 0.91 AUC, 89.8% sensitivity, and 81.2% specificity. C-reactive protein and PCT were diagnostic for perforated appendicitis with 0.83 and 0.75 AUC on ROC. CONCLUSIONS Although none of the biomarkers were sufficient for an accurate diagnosis of appendicitis individually, a combination of physical examination and laboratory and US was a good diagnostic tool for pediatric appendicitis.
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Affiliation(s)
- Fatma Akgül
- From the Department of Pediatric Emergency Care
| | - Anıl Er
- From the Department of Pediatric Emergency Care
| | - Emel Ulusoy
- From the Department of Pediatric Emergency Care
| | | | | | | | | | | | - Erdener Özer
- Department of Pathology, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Murat Duman
- From the Department of Pediatric Emergency Care
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Hull NC, Kim HHR, Phillips GS, Lee EY. Neonatal and Pediatric Bowel Obstruction: Imaging Guidelines and Recommendations. Radiol Clin North Am 2021; 60:131-148. [PMID: 34836560 DOI: 10.1016/j.rcl.2021.08.006] [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: 10/19/2022]
Abstract
Pediatric bowel obstructions are one of the most common surgical emergencies in children, and imaging plays a vital role in the evaluation and diagnosis. An evidence-based and practical imaging approach to diagnosing and localizing pediatric bowel obstructions is essential for optimal pediatric patient care. This article discusses an up-to-date practical diagnostic imaging algorithm for pediatric bowel obstructions and presents the imaging spectrum of pediatric bowel obstructions and their underlying causes.
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Affiliation(s)
- Nathan C Hull
- Department of Radiology, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
| | - Helen H R Kim
- Department of Radiology, Seattle Children's Hospital and University of Washington, 4800 Sand Point Way Northeast, Seattle, WA 98105, USA
| | - Grace S Phillips
- Department of Radiology, Seattle Children's Hospital and University of Washington, 4800 Sand Point Way Northeast, Seattle, WA 98105, USA
| | - Edward Y Lee
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, 330 Longwood Avenue, Boston, MA 02115, USA
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Hajibandeh S, Hajibandeh S, Marshall MJ, Smart NJ, Winyard PG, Hyde C, Shaw AM, Daniels IR. Biomarkers for diagnosis of acute appendicitis in adults. Hippokratia 2021. [DOI: 10.1002/14651858.cd011592.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Shahab Hajibandeh
- General Surgery; Wales Deanery, Health Education and Improvement Wales; Nantgarw UK
| | - Shahin Hajibandeh
- Department of General Surgery; Sandwell and West Birmingham NHS Trust; West Bromwich UK
| | - Morwena J Marshall
- Exeter Health Services Research Unit; Royal Devon & Exeter NHS Foundation Trust; Exeter UK
| | - Neil J Smart
- Colorectal Surgery; Royal Devon & Exeter NHS Foundation Trust; Exeter UK
| | | | - Chris Hyde
- Exeter Test Group; College of Medicine and Health, University of Exeter Medical School, University of Exeter; Exeter UK
| | - Andrew M Shaw
- Biosciences, College of Life and Environmental Sciences; University of Exeter; Exeter UK
| | - Ian R Daniels
- Colorectal Surgery; Royal Devon & Exeter NHS Foundation Trust; Exeter UK
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Khashoggi AA, Hakami NA, Alghamdi MA, Ayed HY, Alqarni AD, Alshahrani TJ, Alshamrani AM, Alayyaf AS, Almansour RA, Alolyan SA, Alotaibi AA, Alabdulltif SK, Obaidi EA, Akkasi HA, Alshammari M. Hematocolpos: An Unusual Cause of Right Iliac Fossa Pain. Cureus 2021; 13:e18835. [PMID: 34804690 PMCID: PMC8593911 DOI: 10.7759/cureus.18835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2021] [Indexed: 11/05/2022] Open
Abstract
Acute appendicitis is the most frequent indication for emergency abdominal surgery in childhood. Despite being a common condition, the diagnosis of acute appendicitis can be challenging. Ultrasound examination remains the imaging tool of choice for the diagnosis of acute appendicitis. We report the case of a nine-year-old girl who presented with acute abdominal pain in the right lower quadrant accompanied by nausea and vomiting. Physical examination revealed right iliac fossa rebound tenderness. Ultrasound examination showed a dilated blind-ended structure in the right iliac fossa conferring the diagnosis of acute appendicitis. The patient underwent a CT scan which made the diagnosis of imperforate hymen with hematocolpos. The patient underwent hymenotomy and her symptoms showed complete resolution. Imperforate hymen with hematocolpos is a rare congenital genital tract anomaly. The case highlights the importance of appropriate genital examination in pediatric patients. In the present case, the patient might have undergone an unnecessary abdominal surgery if the correct diagnosis was not established.
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Affiliation(s)
- Alya A Khashoggi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | | | | | - Hussam Y Ayed
- College of Medicine, King Khalid University, Abha, SAU
| | - Ali D Alqarni
- College of Medicine, Ibn Sina National College for Medical Studies, Jeddah, SAU
| | - Talal J Alshahrani
- College of Medicine, Ibn Sina National College for Medical Studies, Jeddah, SAU
| | | | - Abdallah S Alayyaf
- College of Medicine, Prince Sattam Bin Abdulaziz University, Al-Kharj, SAU
| | - Raghad A Almansour
- College of Medicine, Imam Mohammad Ibn Saud Islamic University, Riyadh, SAU
| | | | | | | | | | - Hatim A Akkasi
- College of Medicine, Majmaah University, Al Majmaah, SAU
| | - Malak Alshammari
- College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, SAU
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A QI Partnership to Decrease CT Use for Pediatric Appendicitis in the Community Hospital Setting. Pediatr Qual Saf 2021; 6:e479. [PMID: 34589653 PMCID: PMC8476057 DOI: 10.1097/pq9.0000000000000479] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 06/09/2021] [Indexed: 10/29/2022] Open
Abstract
The primary aim of this quality improvement initiative was to decrease the use of computerized tomography (CT) in the evaluation of pediatric appendicitis in a community general emergency department (GED) system by 50% (from 32% to 16%) in 1 year. Methods Colleagues within a State Emergency Medical Service for Children (EMSC) community of practice formed the quality improvement team, representing multiple stakeholders across 3 independent institutions. The team generated project aims by reviewing baseline practice trends and implemented changes using the Model for Improvement. Ultrasound (US) use and nondiagnostic US rates served as process measures. Transfer and "over-transfer" rates served as balancing measures. Interventions included a GED pediatric appendicitis clinical pathway, US report templates, and case audit and feedback. Statistical process control tracked the main outcomes. Additionally, frontline GED providers shared perceptions of knowledge gains, practice changes, and teamwork. Results The 12-month baseline revealed a GED CT scan rate of 32%, a US rate of 63%, a nondiagnostic US rate of 77%, a transfer to a children's hospital rate of 23.5%, and an "over-transfer" rate of 0%. Project interventions achieved and sustained the primary aim by decreasing the CT scan rate to 4.5%. Frontline GED providers reported positive perceptions of knowledge gains and standardization of practice. Conclusions Engaging regional colleagues in a pediatric-specific quality improvement initiative significantly decreased CT scan use in children cared for in a community GED system. The emphasis on the community of practice facilitated by Emergency Medical Service for Children may guide future improvement work in the state and beyond.
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Sartelli M, Coccolini F, Kluger Y, Agastra E, Abu-Zidan FM, Abbas AES, Ansaloni L, Adesunkanmi AK, Atanasov B, Augustin G, Bala M, Baraket O, Baral S, Biffl WL, Boermeester MA, Ceresoli M, Cerutti E, Chiara O, Cicuttin E, Chiarugi M, Coimbra R, Colak E, Corsi D, Cortese F, Cui Y, Damaskos D, de’ Angelis N, Delibegovic S, Demetrashvili Z, De Simone B, de Jonge SW, Dhingra S, Di Bella S, Di Marzo F, Di Saverio S, Dogjani A, Duane TM, Enani MA, Fugazzola P, Galante JM, Gachabayov M, Ghnnam W, Gkiokas G, Gomes CA, Griffiths EA, Hardcastle TC, Hecker A, Herzog T, Kabir SMU, Karamarkovic A, Khokha V, Kim PK, Kim JI, Kirkpatrick AW, Kong V, Koshy RM, Kryvoruchko IA, Inaba K, Isik A, Iskandar K, Ivatury R, Labricciosa FM, Lee YY, Leppäniemi A, Litvin A, Luppi D, Machain GM, Maier RV, Marinis A, Marmorale C, Marwah S, Mesina C, Moore EE, Moore FA, Negoi I, Olaoye I, Ordoñez CA, Ouadii M, Peitzman AB, Perrone G, Pikoulis M, Pintar T, Pipitone G, Podda M, Raşa K, Ribeiro J, Rodrigues G, Rubio-Perez I, Sall I, Sato N, Sawyer RG, Segovia Lohse H, Sganga G, Shelat VG, Stephens I, Sugrue M, Tarasconi A, Tochie JN, Tolonen M, Tomadze G, Ulrych J, Vereczkei A, Viaggi B, Gurioli C, Casella C, Pagani L, Baiocchi GL, Catena F. WSES/GAIS/SIS-E/WSIS/AAST global clinical pathways for patients with intra-abdominal infections. World J Emerg Surg 2021; 16:49. [PMID: 34563232 PMCID: PMC8467193 DOI: 10.1186/s13017-021-00387-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 08/05/2021] [Indexed: 02/08/2023] Open
Abstract
Intra-abdominal infections (IAIs) are common surgical emergencies and have been reported as major contributors to non-trauma deaths in hospitals worldwide. The cornerstones of effective treatment of IAIs include early recognition, adequate source control, appropriate antimicrobial therapy, and prompt physiologic stabilization using a critical care environment, combined with an optimal surgical approach. Together, the World Society of Emergency Surgery (WSES), the Global Alliance for Infections in Surgery (GAIS), the Surgical Infection Society-Europe (SIS-E), the World Surgical Infection Society (WSIS), and the American Association for the Surgery of Trauma (AAST) have jointly completed an international multi-society document in order to facilitate clinical management of patients with IAIs worldwide building evidence-based clinical pathways for the most common IAIs. An extensive non-systematic review was conducted using the PubMed and MEDLINE databases, limited to the English language. The resulting information was shared by an international task force from 46 countries with different clinical backgrounds. The aim of the document is to promote global standards of care in IAIs providing guidance to clinicians by describing reasonable approaches to the management of IAIs.
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Affiliation(s)
- Massimo Sartelli
- Department of Surgery Department of Surgery, Macerata Hospital, Macerata, Italy
| | - Federico Coccolini
- grid.144189.10000 0004 1756 8209Department of General, Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy
| | - Yoram Kluger
- grid.413731.30000 0000 9950 8111Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Ervis Agastra
- General Surgery Department, Regional Hospital of Durres, Durres, Albania
| | - Fikri M. Abu-Zidan
- grid.43519.3a0000 0001 2193 6666Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Ashraf El Sayed Abbas
- grid.469958.fDepartment of General and Emergency Surgery Faculty of Medicine, Mansoura University Hospital, Mansoura, Egypt
| | - Luca Ansaloni
- grid.8982.b0000 0004 1762 5736Department of Surgery, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Abdulrashid Kayode Adesunkanmi
- grid.10824.3f0000 0001 2183 9444Department of Surgery, Faculty of Clinical Sciences, College of Health Sciences, Obafemi Awolowo University, Osun State, Ile-Ife, Nigeria
| | - Boyko Atanasov
- grid.35371.330000 0001 0726 0380Department of General Surgery, Medical University of Plovdiv, UMHAT Eurohospital, Plovdiv, Bulgaria
| | - Goran Augustin
- grid.412688.10000 0004 0397 9648Department of Surgery, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Miklosh Bala
- grid.17788.310000 0001 2221 2926Trauma and Acute Care Surgery Unit, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Oussama Baraket
- grid.12574.350000000122959819Department of general surgery Bizerte hospital, Faculty of Medicine of Tunis, University Tunis El Manar, Tunis, Tunisia
| | - Suman Baral
- Department of Surgery, Lumbini Medical College and Teaching Hospital Ltd., Palpa, Tansen, Nepal
| | - Walter L. Biffl
- grid.415401.5Division of Trauma/Acute Care Surgery, Scripps Clinic Medical Group, La Jolla, CA USA
| | - Marja A. Boermeester
- grid.509540.d0000 0004 6880 3010Department of Surgery, Amsterdam University Medical Centers, location AMC, Amsterdam Gastroenterology Endocrinology Metabolism Research Institute, Amsterdam, The Netherlands
| | - Marco Ceresoli
- grid.7563.70000 0001 2174 1754Emergency and General Surgery Department, University of Milan-Bicocca, Milan, Italy
| | - Elisabetta Cerutti
- grid.415845.9Anesthesia and Transplant Surgical Intensive Care Unit, Ospedali Riuniti, Ancona, Italy
| | - Osvaldo Chiara
- grid.416200.1Emergency Department, Niguarda Ca’Granda Hospital, Milan, Italy
| | - Enrico Cicuttin
- grid.144189.10000 0004 1756 8209Department of General, Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy
| | - Massimo Chiarugi
- grid.144189.10000 0004 1756 8209Department of General, Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy
| | - Raul Coimbra
- grid.43582.380000 0000 9852 649XRiverside University Health System, CECORC Research Center, Loma Linda University, Loma Linda, USA
| | - Elif Colak
- Department of General Surgery, Health Sciences University, Samsun Training and Research Hospital, Samsun, Turkey
| | - Daniela Corsi
- General Direction, Area Vasta 3, ASUR Marche, Macerata, Italy
| | | | - Yunfeng Cui
- grid.265021.20000 0000 9792 1228Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China
| | - Dimitris Damaskos
- grid.418716.d0000 0001 0709 1919Department of Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Nicola de’ Angelis
- Minimally Invasive and Robotic Digestive Surgery Unit, Regional General Hospital F. Miulli, Bari, Italy
- grid.410511.00000 0001 2149 7878Université Paris Est, UPEC, Creteil, France
| | - Samir Delibegovic
- grid.412410.20000 0001 0682 9061Department of Surgery, University Clinical Center of Tuzla, Tuzla, Bosnia and Herzegovina
| | - Zaza Demetrashvili
- Department General Surgery, Kipshidze Central University Hospital, Tbilisi, Georgia
| | - Belinda De Simone
- grid.418056.e0000 0004 1765 2558Department of general, Digestive and Metabolic Minimally Invasive Surgery, Centre Hospitalier Intercommunal De Poissy/St Germain en Laye, Poissy, France
| | - Stijn W. de Jonge
- grid.415401.5Division of Trauma/Acute Care Surgery, Scripps Clinic Medical Group, La Jolla, CA USA
| | - Sameer Dhingra
- grid.464629.b0000 0004 1775 2698Department of Pharmacy Practice, National Institute of Pharmaceutical Education and Research (NIPER), Hajipur, Bihar India
| | - Stefano Di Bella
- grid.5133.40000 0001 1941 4308Clinical Department of Medical, Surgical and Health sciences, Trieste University, Trieste, Italy
| | | | - Salomone Di Saverio
- grid.412972.bDepartment of General Surgery, University of Insubria, University Hospital of Varese, ASST Sette Laghi, Regione Lombardia, Varese, Italy
| | - Agron Dogjani
- Department of Surgery, University Hospital of Trauma, Tirana, Albania
| | - Therese M. Duane
- grid.429044.f0000 0004 0402 1407Department of Surgery, Texas Health Resources, Fort Worth, TX USA
| | - Mushira Abdulaziz Enani
- grid.415277.20000 0004 0593 1832Department of Medicine, Infectious Disease Division, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Paola Fugazzola
- grid.8982.b0000 0004 1762 5736Department of Surgery, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Joseph M. Galante
- grid.27860.3b0000 0004 1936 9684Division of Trauma and Acute Care Surgery, Department of Surgery, University of California Davis, Sacramento, CA USA
| | - Mahir Gachabayov
- Department of Abdominal Surgery, Vladimir City Clinical Hospital of Emergency Medicine, Vladimir, Russia
| | - Wagih Ghnnam
- grid.10251.370000000103426662Department of General Surgery, Mansoura Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - George Gkiokas
- grid.5216.00000 0001 2155 0800Second Department of Surgery, Aretaieion University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Carlos Augusto Gomes
- Department of Surgery, Hospital Universitário Terezinha de Jesus, Faculdade de Ciências Médicas e da Saúde de Juiz de Fora, Juiz de Fora, Brazil
| | - Ewen A. Griffiths
- grid.412563.70000 0004 0376 6589Department of Upper GI Surgery, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Timothy C. Hardcastle
- Trauma Service, Inkosi Albert Luthuli Central Hospital and Department of Surgery, Nelson R Mandela School of Clinical Medicine, Durban, South Africa
| | - Andreas Hecker
- grid.411067.50000 0000 8584 9230Department of General and Thoracic Surgery, University Hospital Giessen, Giessen, Germany
| | - Torsten Herzog
- grid.5570.70000 0004 0490 981XDepartment of Surgery, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Syed Mohammad Umar Kabir
- grid.415900.90000 0004 0617 6488Donegal Clinical Research Academy Emergency Surgery Outcome Project, Letterkenny University Hospital, Donegal, Ireland
| | - Aleksandar Karamarkovic
- grid.7149.b0000 0001 2166 9385Surgical Clinic “Nikola Spasic”, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Vladimir Khokha
- Department of Emergency Surgery, City Hospital, Mozyr, Belarus
| | - Peter K. Kim
- grid.251993.50000000121791997Department of Surgery, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY USA
| | - Jae Il Kim
- grid.411612.10000 0004 0470 5112Department of Surgery, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Republic of Korea
| | - Andrew W. Kirkpatrick
- grid.414959.40000 0004 0469 2139General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, AB Canada
| | - Victor Kong
- grid.414386.c0000 0004 0576 7753Department of Surgery, Edendale Hospital, Pietermaritzburg, South Africa
| | - Renol M. Koshy
- grid.412570.50000 0004 0400 5079Department of General Surgery, University Hospital of Coventry & Warwickshire, Coventry, UK
| | - Igor A. Kryvoruchko
- grid.412081.eDepartment of Surgery #2, National Medical University, Kharkiv, Ukraine
| | - Kenji Inaba
- grid.42505.360000 0001 2156 6853Division of Trauma and Surgical Critical Care, Department of Surgery, University of Southern California, Los Angeles, CA USA
| | - Arda Isik
- grid.411776.20000 0004 0454 921XDepartment of General Surgery, School of Medicine, Istanbul Medeniyet University, Istanbul, Turkey
| | - Katia Iskandar
- grid.444421.30000 0004 0417 6142Department of Pharmacy, Lebanese International University, Beirut, Lebanon
| | - Rao Ivatury
- grid.224260.00000 0004 0458 8737Department of Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA USA
| | | | - Yeong Yeh Lee
- grid.11875.3a0000 0001 2294 3534School of Medical Sciences, Universitiy Sains Malaysia, Kota Bharu, Kelantan Malaysia
| | - Ari Leppäniemi
- grid.15485.3d0000 0000 9950 5666Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Andrey Litvin
- grid.410686.d0000 0001 1018 9204Department of Surgical Disciplines, Immanuel Kant Baltic Federal University, Regional Clinical Hospital, Kaliningrad, Russia
| | - Davide Luppi
- Department of General and Emergency Surgery, ASMN, Reggio Emilia, Italy
| | - Gustavo M. Machain
- grid.412213.70000 0001 2289 5077Department of Surgery, Universidad Nacional de Asuncion, Asuncion, Paraguay
| | - Ronald V. Maier
- grid.34477.330000000122986657Department of Surgery, University of Washington, Seattle, WA USA
| | - Athanasios Marinis
- grid.417374.2First Department of Surgery, Tzaneion General Hospital, Piraeus, Greece
| | - Cristina Marmorale
- grid.7010.60000 0001 1017 3210Department of Surgery, Università Politecnica delle Marche, Ancona, Italy
| | - Sanjay Marwah
- grid.412572.70000 0004 1771 1642Department of Surgery, Post-Graduate Institute of Medical Sciences, Rohtak, India
| | - Cristian Mesina
- Second Surgical Clinic, Emergency Hospital of Craiova, Craiova, Romania
| | - Ernest E. Moore
- grid.239638.50000 0001 0369 638XErnest E Moore Shock Trauma Center at Denver Health, Denver, USA
| | - Frederick A. Moore
- grid.15276.370000 0004 1936 8091Department of Surgery, Division of Acute Care Surgery, and Center for Sepsis and Critical Illness Research, University of Florida College of Medicine, Gainesville, FL USA
| | - Ionut Negoi
- Department of Surgery, Emergency Hospital of Bucharest, Bucharest, Romania
| | - Iyiade Olaoye
- grid.412975.c0000 0000 8878 5287Department of Surgery, University of Ilorin Teaching Hospital, Ilorin, Nigeria
| | - Carlos A. Ordoñez
- grid.477264.4Division of Trauma and Acute Care Surgery, Fundacion Valle del Lili, Cali, Colombia
- grid.8271.c0000 0001 2295 7397Department of Surgery, Universidad del Valle, Cali, Colombia
| | - Mouaqit Ouadii
- grid.412817.9Department of Surgery, Hassan II University Hospital, Medical School of Fez, Sidi Mohamed Benabdellah University, Fez, Morocco
| | - Andrew B. Peitzman
- grid.21925.3d0000 0004 1936 9000Department of Surgery, University of Pittsburgh School of Medicine, UPMC-Presbyterian, Pittsburgh, USA
| | - Gennaro Perrone
- Department of Emergency Surgery, Parma Maggiore Hospital, Parma, Italy
| | - Manos Pikoulis
- grid.5216.00000 0001 2155 08003rd Department of Surgery, Attiko Hospital, MSc “Global Health-Disaster Medicine”, National and Kapodistrian University of Athens (NKUA), Athens, Greece
| | - Tadeja Pintar
- grid.29524.380000 0004 0571 7705Department of Surgery, UMC Ljubljana, Ljubljana, Slovenia
| | - Giuseppe Pipitone
- National Institute for Infectious Diseases - INMI - Lazzaro Spallanzani IRCCS, Rome, Italy
| | - Mauro Podda
- grid.7763.50000 0004 1755 3242Department of General and Emergency Surgery, Cagliari University Hospital, Cagliari, Italy
| | - Kemal Raşa
- Department of Surgery, Anadolu Medical Center, Kocaeli, Turkey
| | - Julival Ribeiro
- grid.414433.5Infection Control, Hospital de Base, Brasília, DF Brazil
| | - Gabriel Rodrigues
- grid.411639.80000 0001 0571 5193Department of General Surgery, Kasturba Medical College & Hospital, Manipal Academy of Higher Education, Manipal, India
| | - Ines Rubio-Perez
- grid.81821.320000 0000 8970 9163General Surgery Department, Colorectal Surgery Unit, La Paz University Hospital, Madrid, Spain
| | - Ibrahima Sall
- General Surgery Department, Military Teaching Hospital, Dakar, Senegal
| | - Norio Sato
- grid.255464.40000 0001 1011 3808Department of Aeromedical Services for Emergency and Trauma Care, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Robert G. Sawyer
- grid.268187.20000 0001 0672 1122Department of Surgery, Western Michigan University School of Medicine, Kalamazoo, MI USA
| | - Helmut Segovia Lohse
- grid.412213.70000 0001 2289 5077Department of Surgery, Universidad Nacional de Asuncion, Asuncion, Paraguay
| | - Gabriele Sganga
- grid.414603.4Department of Medical and Surgical Sciences, Emergency Surgery & Trauma, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Vishal G. Shelat
- grid.240988.fDepartment of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Ian Stephens
- grid.415900.90000 0004 0617 6488Donegal Clinical Research Academy Emergency Surgery Outcome Project, Letterkenny University Hospital, Donegal, Ireland
| | - Michael Sugrue
- grid.415900.90000 0004 0617 6488Donegal Clinical Research Academy Emergency Surgery Outcome Project, Letterkenny University Hospital, Donegal, Ireland
| | - Antonio Tarasconi
- Department of Emergency Surgery, Parma Maggiore Hospital, Parma, Italy
| | - Joel Noutakdie Tochie
- grid.412661.60000 0001 2173 8504Department of Emergency medicine, Anesthesiology and critical care, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
| | - Matti Tolonen
- grid.15485.3d0000 0000 9950 5666Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Gia Tomadze
- grid.412274.60000 0004 0428 8304Surgery Department, Tbilisi State Medical University, Tbilisi, Georgia
| | - Jan Ulrych
- grid.411798.20000 0000 9100 9940First Department of Surgery, Department of Abdominal, Thoracic Surgery and Traumatology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Andras Vereczkei
- grid.9679.10000 0001 0663 9479Department of Surgery, Clinical Center University of Pecs, Pecs, Hungary
| | - Bruno Viaggi
- grid.24704.350000 0004 1759 9494Department of Anesthesiology, Neuro Intensive Care Unit, Florence Careggi University Hospital, Florence, Italy
| | - Chiara Gurioli
- Department of Surgery, Camerino Hospital, Macerata, Italy
| | - Claudio Casella
- grid.7637.50000000417571846Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Leonardo Pagani
- Department of Infectious Diseases, Bolzano Hospital, Bolzano, Italy
| | - Gian Luca Baiocchi
- Department of Surgery, AAST Cremona, Cremona, Italy
- grid.7637.50000000417571846Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Fausto Catena
- Department of Emergency Surgery, Parma Maggiore Hospital, Parma, Italy
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Tung EL, Baird GL, Ayyala RS, Sams C, Herliczek TW, Swenson DW. Comparison of MRI appendix biometrics in children with and without acute appendicitis. Eur Radiol 2021; 32:1024-1033. [PMID: 34383146 DOI: 10.1007/s00330-021-08120-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 03/24/2021] [Accepted: 06/02/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVES The goal of this study is to improve MRI-specific diagnostic criteria for pediatric appendicitis through comparison of normal and abnormal appendix-related imaging features. METHODS A retrospective multireader-multicase design was used, including non-contrast MRI performed for suspected pediatric appendicitis following non-diagnostic US from January 2014 to December 2017. Positive diagnosis was defined by surgical pathology or symptom resolution after antibiotics. Four pediatric radiologists independently graded study biometrics while blinded to clinical data. Balanced complete block design was used to determine performance characteristics. RESULTS Global diagnosis of appendicitis (208 studies) had sensitivity 90.6% and specificity 97.7%. Median appendix diameter was 10.4 mm among positive cases and 5.8 mm among negative cases (p < 0.001) with an optimal diagnostic cutoff of 7.5 mm (sensitivity 89.4%, specificity 86.5%). Median appendix wall thickness was 2.6 mm among positive cases and 1.7 mm among negative cases (p < 0.001) with an optimal diagnostic cutoff of 2.3 mm (sensitivity 63.1%, specificity 82.9%). Performance characteristics for qualitative appendix features included distinguishable appendix luminal signal (sensitivity 89.6%, specificity 83.7%), intraluminal fluid-signal intensity (sensitivity 63.6%; specificity 52.3%), intraluminal signal intermediate between fluid and bowel wall (sensitivity 91.0%; specificity 37.1%), appendicolith (sensitivity 34.9%; specificity 100.0%), intraluminal layering (sensitivity 25.9%; specificity 100.0%), hyperintense appendix wall signal (sensitivity 31.7%; specificity 100.0%), periappendiceal fluid (sensitivity 66.8%; specificity 72.5%), periappendiceal fatty edema (sensitivity 91.3%; specificity 94.5%), and free pelvic fluid (sensitivity 88.5%; specificity 26.0). CONCLUSIONS This study provides MRI-specific performance of pediatric appendicitis quantitative and qualitative biometrics with peri-appendiceal fatty edema, appendix diameter > 7.5 mm, and distinguishable appendix luminal signal demonstrating the highest overall accuracy. KEY POINTS • This retrospective multireader-multicase study characterized magnetic resonance imaging-specific diagnostic accuracy of quantitative and qualitative biometrics for pediatric appendicitis. • The optimal quantitative diagnostic thresholds for an abnormal pediatric appendix at MRI included diameter and wall thickness of 7.5 mm and 2.3 mm, respectively. • Qualitative imaging biometrics with high specificity for pediatric appendicitis on MRI included the presence of distinguishable appendix lumen signal from wall signal, appendicolith, intraluminal fluid-fluid layer, appendix wall hyperintensity, and peri-appendiceal fatty edema.
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Affiliation(s)
- Eric L Tung
- , Cambridge, USA. .,Department of Radiology, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA.
| | - Grayson L Baird
- Lifespan Biostatistics Core, Rhode Island Hospital, 593 Eddy Street, Providence, RI, 02903, USA
| | - Rama S Ayyala
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA.,Department of Radiology, University of Cincinnati College of Medicine, 3320 Eden Ave, Cincinnati, OH, 45267, USA
| | - Cassandra Sams
- Department of Diagnostic Imaging, Rhode Island Hospital - Hasbro Children's Hospital, Warren Alpert Medical School of Brown University, 593 Eddy St, Providence, RI, 02903, USA
| | - Thaddeus W Herliczek
- Department of Diagnostic Imaging, Rhode Island Hospital - Hasbro Children's Hospital, Warren Alpert Medical School of Brown University, 593 Eddy St, Providence, RI, 02903, USA
| | - David W Swenson
- Department of Diagnostic Imaging, Rhode Island Hospital - Hasbro Children's Hospital, Warren Alpert Medical School of Brown University, 593 Eddy St, Providence, RI, 02903, USA
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Walid A, Muhammad A, Hussain Z. Value of Periappendiceal Fat Sign on Ultrasound in Acute Appendicitis. Cureus 2021; 13:e16321. [PMID: 34395109 PMCID: PMC8357021 DOI: 10.7759/cureus.16321] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2021] [Indexed: 11/11/2022] Open
Abstract
Introduction Acute right lower quadrant abdominal pain is one of the most common surgical presentations to the emergency department with acute appendicitis being the topmost differential diagnosis. Although computed tomography (CT) is the gold standard in diagnosing appendicitis, in our setup ultrasound is often the initial imaging modality available in urgent care settings especially for children and pregnant females. On ultrasound, an inflamed appendix has a diameter of 6 mm or more and is non-compressible. Increased periappendiceal fat echogenicity is an important ancillary sign of acute appendicitis that supports the sonographic diagnosis of acute appendicitis. To determine the association of periappendiceal fat echo sign (PFES) on ultrasound in surgically proven cases of acute appendicitis. Methods This cross-sectional study was held at the Department of Radiology at the Aga Khan University Hospital in Karachi, Pakistan. Periappendiceal fat echogenicity was assessed and prospectively graded in 59 patients. These patients had sonographic features of acute appendicitis which was later confirmed by surgery. Data were collected on a proforma and later analyzed. Frequency of increased periappendiceal fat echogenicity in acute appendicitis was calculated. Association of PFES with gender and ascites was evaluated with Fischer's exact test and with patient's age and appendiceal diameter was assessed using analysis of variance (ANOVA). Results Increased periappendiceal fat echogenicity was seen in 89.8% of patients with acute appendicitis. 10.2% of patients had acute appendicitis with normal surrounding fat. Mean appendiceal diameter in patients with grade 3 PFES was significantly more than those with grade 2 or grade 1 PFES. PFES had no association with age and gender of the patient or with ascites. Conclusion Increased periappendiceal fat echogenicity is an important ancillary sign of acute appendicitis that helps support its sonographic diagnosis.
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Affiliation(s)
- Ayesha Walid
- Radiology, Dow University of Health Sciences, Civil Hospital Karachi, Karachi, PAK
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49
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Fu J, Zhou X, Chen L, Lu S. Abdominal Ultrasound and Its Diagnostic Accuracy in Diagnosing Acute Appendicitis: A Meta-Analysis. Front Surg 2021; 8:707160. [PMID: 34262936 PMCID: PMC8273278 DOI: 10.3389/fsurg.2021.707160] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 05/31/2021] [Indexed: 12/31/2022] Open
Abstract
Background: Acute appendicitis (AA) is a common cause of abdominal pain encountering unnecessary surgeries in emergency departments. The present meta-analysis aims to assess the accuracy of abdominal ultrasound in suspected acute appendicitis cases in terms of sensitivity, specificity, and post-test odds for positive and negative results. Materials and Methods: An extensive and systematic search was conducted in Medline (via PubMed), Cinahl (via Ebsco), Scopus, and Web of Sciences from 2010 till the end of March 2021. Two authors analyzed studies for inclusion, collected results, and conducted analyses separately. Examination of the histopathological tissue collected during appendectomy served as a gold standard for determining the final diagnosis of appendicitis. The accuracy was determined by evaluating sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), diagnostic odds ratio. Results: Out of 3,193 references, a total of 18 studies were selected. Overall sensitivity of 77.2% (95% CI – 75.4–78.9%) and specificity of 60% (95% CI – 58–62%) were observed. The diagnostic odds ratio of 6.88(95% CI 1.99–23.82) was obtained. Conclusion: Abdominal ultrasound shows significant accuracy of diagnosis in patients with suspected acute appendicitis.
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Affiliation(s)
- Jian Fu
- Department of Ultrasound, Affiliated Haian Hospital of Nantong University, Nantong, China
| | - Xu Zhou
- Department of Ultrasound, Affiliated Haian Hospital of Nantong University, Nantong, China
| | - Liang Chen
- Department of Ultrasound, Affiliated Haian Hospital of Nantong University, Nantong, China
| | - Sheng Lu
- Department of Ultrasound, Affiliated Haian Hospital of Nantong University, Nantong, China
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Usefulness of computed tomography for hospitalized adult patients with fever to investigate cause of fever: single-center, retrospective cohort study. Jpn J Radiol 2021; 39:802-810. [PMID: 33932188 PMCID: PMC8088207 DOI: 10.1007/s11604-021-01117-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 04/05/2021] [Indexed: 11/09/2022]
Abstract
Purpose To verify that physicians’ presumptive diagnosis is the most significant factor for finding any signs related to the cause of fever on computed tomography (CT) images. Materials and methods This single-center retrospective cohort study included patients (age ≥ 16 years) who underwent CT to investigate the cause of fever between January 1, 2014, and August 31, 2016. Patients who underwent surgical procedures were excluded. The primary outcome was the presence of suspicious CT findings related to the cause of fever. We performed univariate and multivariate logistic regression analyses, adjusted for CT contrast agent use, quick sequential organ failure assessment score > 1, and C-reactive protein level. Results We enrolled 171 patients, of which 57 had CT findings, and 114 did not. Multivariate logistic regression analyses demonstrated a significant difference for the presence of a presumptive diagnosis by the attending physician (odds ratio, 4.99; 95% confidence interval 2.31–10.76; p < 0.01), but not for other covariates, including C-reactive protein. Conclusions In hospitalized patients with fever, an attending physicians’ presumptive diagnosis is associated with the presence of fever-related CT findings. Improving the quality of the diagnostic assessment before the CT scan may lead to more appropriate CT imaging use. Supplementary Information The online version contains supplementary material available at 10.1007/s11604-021-01117-5.
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