To CT or not to CT? The influence of computed tomography on the diagnosis of appendicitis in obese pediatric patients

Obesity is not associated with increased resource utilization or morbidity in patients undergoing appendectomy

BACKGROUND

Obesity is a growing public health concern that places patients at risk of morbidity and mortality following surgery. We sought to determine whether obesity influences our resource utilization and postoperative outcomes for patients who present with appendicitis.

METHODS

Charts were reviewed for patients age 1-18 years identified from a prospective registry who presented with a diagnosis of appendicitis from 2017 to 2020. Patients who underwent appendectomy were eligible. Charts were reviewed for demographics, imaging studies, laboratory studies, length of stay, operative times and thirty-day postoperative adverse events defined as return to the emergency room, re-admission, postoperative abscess or return to the operating room. A multivariate logistic regression analysis was performed to identify differences in resource utilization and outcome.

RESULTS

A total of 451 patients were identified. There were 126 obese patients (27.9%). Obese patients were not more likely to present with perforated appendicitis and were not more likely to undergo computed tomography scans. All patients underwent laparoscopic appendectomy. Although intraoperative times were significantly longer for Black patients and older patients, BMI did not influence length of surgery. Length of stay was significantly higher for younger patients (p = 0.019). Adverse events were seen in 38 patients (8.4%). There was no association between BMI and adverse events.

CONCLUSIONS

Within our standardized management pathway, obesity does not influence management or patient outcomes for the treatment of appendicitis. Furthermore, obese patients did not require additional resource utilization.

LEVEL OF EVIDENCE

III.

Prospective validation of neutrophil-to-lymphocyte ratio as a diagnostic and management adjunct in acute appendicitis

BACKGROUND

No optimal biomarker exists that accurately diagnoses appendicitis or predicts severity, estimates post-operative complications or total length of hospital stay (LOS).

AIM

To prospectively validate the utility of neutrophil-to-lymphocyte (NLR) ratio in predicting the severity of appendicitis, LOS, and 30-day complication rates.

METHODS

Patients who were admitted with a provisional diagnosis of acute appendicitis over a period of 18 months (Oct 2014-April 2016) were included. Patient demographics and blood results were prospectively collected. Details of imaging, operative intervention, severity of appendicitis, length of stay, and 30-days post admission complications were recorded. Recommended cut-off values of NLR and C-reactive protein for severity of appendicitis were determined using receiver operating characteristic analysis (ROC). These cut-off values were compared with C-reactive protein levels. Mann-Whitney test was performed to assess the correlations between LOS and 30-day complications to NLR.

RESULTS

Four hundred fifty-three patients were included in the study; 55.2% (n = 245) were female with mean patient age of 23 years. Two-thirds (n = 281, 62.03%) underwent operative management. Histologically, appendicitis was confirmed in 214 (76%) patients. A NLR of >6.36 or CRP of >28 were statistically associated with complicated acute appendicitis, with a median of one extra hospital day (p < 0.0001). Mean NLR was statistically higher in patients with post-operative complications (14.42 vs. 7.29 for simple appendicitis group, p < 0.001).

CONCLUSION

This confirms previous reports that NLR is a simple, readily available adjunct in predicting severity of appendicitis. Additionally, it can aid delineating severe appendicitis that should proceed to surgery without substantial delay.

The clinical value of pathology tests and imaging study in the diagnosis of acute appendicitis

OBJECTIVE

To explore the diagnostic accuracy of acute appendicitis among different patient groups and evaluate the statistical diagnostic values of common pathology and imaging tests for the diagnosis of acute appendicitis.

MAIN MEASURES

Proportions of histology-proven appendicitis in different patient groups. Statistical parameters including sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (+LR), negative likelihood ratio (-LR) and diagnostic odds ratio (DOR) between the histology-proven appendicitis and abnormal results of U/S, CT, WCC, CRP, bilirubin, pancreatic, and combined test results of WCC and CRP.

RESULTS

Our data showed that up to 25.7% of patients underwent appendectomy has normal appendix. Appendicitis is often accurately diagnosed among male patients, up to 90.3% of the time, while misdiagnosis of appendicitis among young females (<40 years old) is significantly high, up to 30.9%. CT has high diagnostic performance index for appendicitis, sensitivity > 90%, and no individual pathology test out of those examined can rival the sensitivity of CT. Nevertheless, by examining the combined results of WCC and CRP, we found that abnormal results in one or both these yields sensitivity similar to CT scans in detecting acute appendicitis, up to 95%.

CONCLUSION

Young female patients have highest risk of being falsely diagnosed with acute appendicitis and hence unnecessary surgery. Bilirubin and lipase exhibit no correlations with acute appendicitis. Combined interpretation of WCC or CRP abnormal results yields competitive sensitivity as CT. Hencewe would suggest that, under the appropriate clinical context, one can use both WCC and CRP as a simple tool to support the diagnosis of appendicitis. If both tests show normal results, we would highly recommend considering alternative diagnosis.

Low vs. standard dose computed tomography in suspected acute appendicitis: Is it time for a change?

BACKGROUND

Clinical diagnosis is accurate in only 80% of patients with suspected appendicitis with negative appendectomy rates of up to 21%. In the UK the use of standard-dose CT (SDCT) is conservative due to concerns over radiation exposure and resource implications. The use of low dose computer tomography (LDCT) instead of standard dose computer tomography (SDCT) may partially address these concerns.

AIM

To compare LDCT and SDCT in the diagnosis of appendicitis.

METHODS

A literature search of the EMBASE and MEDLINE databases in July 2015 was conducted using the keywords 'low dose CT' and 'appendicitis'. Data were analysed and p values calculated using the Chi-square test. P values less than 0.05 were considered to be significant.

RESULTS

LDCT (1.2-5.3 mSv) was not inferior to SDCT (5.2-10.2 mSv) in the diagnosis of acute appendicitis and proposing alternative diagnoses. SDCT was superior to LDCT in the negative predictive value of diagnosis of appendiceal perforation. There was no significant difference between LDCT and SDCT in negative appendectomy rate, appendiceal perforation rate and the need for additional imaging.

CONCLUSION

LDCT is not inferior to SDCT in the diagnosis of acute appendicitis and proposing alternative diagnoses. Further studies are recommended to further assess the potential role of LDCT & its cost effectiveness. Its use may improve the current management of patients with suspected acute appendicitis.