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Altuğ E, Kılavuz H, Çakir A, Şener K, Güven R, Korkut S. Diagnostic value of systemic immune inflammation index in acute appendicitis and complicated appendicitis in pregnant patients. Langenbecks Arch Surg 2024; 409:222. [PMID: 39023796 DOI: 10.1007/s00423-024-03420-x] [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: 04/25/2024] [Accepted: 07/13/2024] [Indexed: 07/20/2024]
Abstract
INTRODUCTION Acute pain in the right lower quadrant during pregnancy is difficult to approach and acute appendicitis must be excluded. The complication rate in pregnant acute appendicitis increases as a result of delayed diagnosis due to physiological and anatomic changes. The systemic immune inflammatory index (SII), which includes several inflammatory tests, is considered to be a good indicator of acute inflammation. The aim of the present study was to investigate the diagnostic value of SII in the diagnosis of acute appendicitis and complicated appendicitis in pregnant women. MATERIAL-METHOD This was designed as a retrospective, single-center case-control study. This study was performed in pregnant women over 12 weeks of gestation who were diagnosed with acute appendicitis as indicated by pathology report and met the inclusion criteria. Vital parameters, demographic characteristics, laboratory values, presence of complicated appendicitis, and pathology reports were taken into analysis. RESULTS The present study was performed with 76 pregnant women, including 38 pregnant women with acute appendicitis and 38 pregnant women with healthy controls. SII had a sensitivity of 82.0% and specificity of 66.7% with a cut-off value of 840.13 in pregnant acute appendicitis cases (AUC: 0.790; 95% CI: 0.686-0.984; p < 0.001) and SII level was significantly higher in complicated appendicitis cases with a sensitivity and specificity of 66.7% and 91.3%, respectively, with a cut-off value of 2301.66 (AUC: 0.812; 95% CI: 0.665-0.958; p = 0.001). CONCLUSION SII is a cost-effective, rapid, easily calculated, and powerful marker that can be used for the diagnosis of both acute and complicated appendicitis in pregnant patients.
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Affiliation(s)
- Ertuğrul Altuğ
- Department of Emergency Medicine, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey.
| | - Hüseyin Kılavuz
- Department of General Surgery, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| | - Adem Çakir
- Department of Emergency Medicine, Ministry of Healthy of Turkey Canakkale Mehmet Akif Ersoy State Hospital, Canakkale, Turkey
| | - Kemal Şener
- Department of Emergency Medicine, Mersin City Hospital, Mersin, Turkey
| | - Ramazan Güven
- Department of Emergency Medicine, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| | - Semih Korkut
- Department of Emergency Medicine, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
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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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3
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Kummer J, Koenigbauer J, Peters FSJ, Rickert C, Hellmeyer L. Is Appendectomy During Late Stages of Pregnancy Associated with an Increased Cesarean Delivery Rate? - a Retrospective Analysis of One Center During 10 Years. Geburtshilfe Frauenheilkd 2024; 84:378-386. [PMID: 38618579 PMCID: PMC11006560 DOI: 10.1055/a-2273-2672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 02/20/2024] [Indexed: 04/16/2024] Open
Abstract
Introduction About one in 500 pregnant women requires a surgical intervention that is not pregnancy-related. One of the most common surgical interventions during pregnancy is appendectomy. The primary aim of this study was to assess surgical access of appendectomy during pregnancy and pregnancy outcome. Secondary outcomes were clinical symptoms and diagnostics as well as histopathological analysis. Methods and Material This is a single-center retrospective data analysis conducted at a tertiary perinatal center. A digital search of the hospital record archive was conducted focusing on pregnant women beyond 24 0/7 weeks of pregnancy encoding appendectomy. Descriptive statistical analysis was performed. Results Between January 2013 and January 2023, a total of 20 appendectomies were performed during pregnancy with gestational age beyond 24 0/7 weeks of pregnancy. All of them were performed as lower midline laparotomy. The rate of appendix perforation was 3/20 (15.0%). 19/20 patients (95.0%) delivered via cesarean. In 7/20 patients (35.0%) appendectomy was performed during cesarean delivery due to incidental finding of irritated or abnormal vermiform appendix. In the pathological work-up, only 2/7 (28.6%) of these subjects had inflammation. Conclusion In this small monocentric cohort, only open appendectomies were performed. Our data indicate that it is safe to perform open appendectomy during pregnancy if necessary. In this small patient group, there was an increase in simultaneous cesarean deliveries.
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Affiliation(s)
- Julia Kummer
- Department of Obstetrics and Gynecology, Klinikum im Friedrichshain, Berlin, Germany
| | | | | | - Christian Rickert
- Department of Pathology, Klinikum im Friedrichshain, Berlin, Germany
| | - Lars Hellmeyer
- Department of Obstetrics and Gynecology, Klinikum im Friedrichshain, Berlin, Germany
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Thanh Thi Nguyen T, Mai Duy Le H, Thanh Nguyen D, Quang Nguyen H, Hoang Nguyen N, Tan Vo D, Cong Phan C. The Role of Magnetic Resonance Pulse Sequences in the Diagnosis of Acute Appendicitis in Pregnant Women. Cureus 2023; 15:e51312. [PMID: 38288189 PMCID: PMC10823294 DOI: 10.7759/cureus.51312] [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: 12/29/2023] [Indexed: 01/31/2024] Open
Abstract
INTRODUCTION Acute appendicitis (AA) is one of the most common surgical emergencies, with a lifetime risk estimated at 7-8%. Pregnant women with appendicitis can have a difficult diagnosis because many signs and symptoms could overlap with other causes of acute abdominal pain. Although magnetic resonance imaging (MRI) is not contraindicated at all gestational ages for units with a field strength of three Tesla or less, there is still much discussion regarding the best protocol to follow in order to minimize survey time and maximize diagnostic efficiency. The purpose of this study was to assess how well different MR pulse sequences can diagnose AA. METHODS This retrospective study involved 179 pregnant females. All patients treated and admitted to the University Medical Center, Ho Chi Minh City, Vietnam, between January 2016 and October 2023 had their MR scans and medical data examined. MRI results were assessed and compared with surgical and histopathological findings. RESULTS The mean age of the population was 29.7 ± 4.8 years (range, 18-46 years). On T1-weighted (T1W) and T2-weighted (T2W) sequences, the appendix was clearly visualized at rates of 81.8% and 89.9%, respectively. The sensitivity and specificity of the T2W in diagnosing AA were 93.5% and 92.3%, and when combined with T1W and diffusion-weighted (DW) images, the sensitivity and specificity further increased, being 96.8% and 94.9%, respectively. The predictive value of non-AA of the T1 bright appendix sign was 95.6%. CONCLUSION Our study supports the use of MRI as an imaging test to identify appendicitis during pregnancy, as it has been shown to be a useful method for diagnosing the condition in pregnant women. The T2W pulse sequence is a useful tool for diagnosing appendicitis because of its high sensitivity and specificity. When identifying appendicitis from T2W alone proves challenging, T1W with the T1 bright sign and DW to take advantage of the appendix lumen and/or wall's diffusion features can yield additional information and boost diagnostic confidence.
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Affiliation(s)
- Thien Thanh Thi Nguyen
- Department of Diagnostic Imaging, University Medical Center of Ho Chi Minh City, Ho Chi Minh, VNM
| | - Huyen Mai Duy Le
- Department of Diagnostic Imaging, University Medical Center of Ho Chi Minh City, Ho Chi Minh, VNM
| | - Duy Thanh Nguyen
- Department of Diagnostic Imaging, University Medical Center of Ho Chi Minh City, Ho Chi Minh, VNM
| | - Hieu Quang Nguyen
- Department of Diagnostic Imaging, University Medical Center of Ho Chi Minh City, Ho Chi Minh, VNM
| | - Nam Hoang Nguyen
- Department of Diagnostic Imaging, University Medical Center of Ho Chi Minh City, Ho Chi Minh, VNM
| | - Duc Tan Vo
- Department of Diagnostic Imaging, University Medical Center of Ho Chi Minh City, Ho Chi Minh, VNM
| | - Chien Cong Phan
- Department of Diagnostic Imaging, University Medical Center of Ho Chi Minh City, Ho Chi Minh, VNM
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5
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Surgical Emergencies in the Pregnant Patient. Curr Probl Surg 2023; 60:101304. [PMID: 37169419 DOI: 10.1016/j.cpsurg.2023.101304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2023]
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Kulali F. Diffusion-weighted imaging versus non-contrast magnetic resonance imaging in the diagnosis of acute appendicitis during pregnancy. REVISTA DA ASSOCIACAO MEDICA BRASILEIRA (1992) 2023; 69:56-60. [PMID: 36629644 PMCID: PMC9937627 DOI: 10.1590/1806-9282.20220578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 09/15/2022] [Indexed: 01/10/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the diagnostic performance of diffusion-weighted imaging compared to non-contrast magnetic resonance imaging in the differential diagnosis of acute appendicitis in pregnant patients. METHODS A total of 72 pregnant patients with the suspicion of acute appendicitis who underwent magnetic resonance imaging combined with diffusion-weighted imaging examinations were enrolled in this retrospective study. Magnetic resonance imaging images (non-contrast and diffusion-weighted imaging sequences) were evaluated. Moreover, apparent diffusion coefficient ratios were estimated. The diagnostic performances of magnetic resonance imaging and diffusion-weighted imaging findings were statistically analyzed on the basis of surgical and follow-up results. RESULTS Of 72 pregnant patients, 10 (14%) had acute appendicitis on magnetic resonance imaging and diffusion-weighted imaging. Among 10 patients with acute appendicitis, three (3/10) had perforation. diffusion-weighted imaging findings had higher sensitivity (90 versus 60%), negative predictive value (98.41 versus 93.94%), and accuracy (98.61 versus 94.44%) ratios compared to non-contrast magnetic resonance imaging in the diagnosis of acute appendicitis. There was one false-negative result on diffusion-weighted imaging. Diffusion restriction facilitated the detection of appendicitis. The apparent diffusion coefficient ratios were lower in acute appendicitis than in the normal appendix (0.70±0.19 versus 0.96±0.16) (p<0.05). CONCLUSION With a shorter scan time and higher diagnostic accuracy, diffusion-weighted imaging can be useful for the early diagnosis of acute appendicitis and for planning appropriate management.
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Affiliation(s)
- Fatma Kulali
- University of Health Sciences, Umraniye Training and Research Hospital, Radiology Department – Istanbul, Turkey.,Corresponding author:
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7
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Ukhanov AP, Zakharov DV, Zhilin SA, Bolshakov SV, Muminov KD, Aselderov YA. [Laparoscopic appendectomy for acute appendicitis in pregnancy]. Khirurgiia (Mosk) 2023:86-94. [PMID: 37707337 DOI: 10.17116/hirurgia202309186] [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] [Indexed: 09/15/2023]
Abstract
The review is devoted to the role of laparoscopic appendectomy in surgical management of acute appendicitis in pregnancy. We analyzed reviews, prospective and retrospective studies in the PubMed, Google, the Springer Link online library, the Cochrane Systematic Review databases. The results of laparoscopic and traditional treatment of acute appendicitis in pregnant women were assessed. We analyzed clinical, epidemiological features in these patients, differential diagnosis of acute appendicitis in pregnant women, indications and contraindications for endoscopic treatment, features of laparoscopic procedures. Comparative assessment of laparoscopic and open surgeries for acute appendicitis in pregnant women was carried out. We also estimated the influence of surgical treatment of acute appendicitis on subsequent course of pregnancy.
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Affiliation(s)
- A P Ukhanov
- Veliky Novgorod City Central Clinical Hospital, Veliky Novgorod, Russia
- Jaroslav the Wise Institute of Medical Education of Novgorod State University, Veliky Novgorod, Russia
| | - D V Zakharov
- Veliky Novgorod City Central Clinical Hospital, Veliky Novgorod, Russia
- Jaroslav the Wise Institute of Medical Education of Novgorod State University, Veliky Novgorod, Russia
| | - S A Zhilin
- Veliky Novgorod City Central Clinical Hospital, Veliky Novgorod, Russia
- Jaroslav the Wise Institute of Medical Education of Novgorod State University, Veliky Novgorod, Russia
| | - S V Bolshakov
- Veliky Novgorod City Central Clinical Hospital, Veliky Novgorod, Russia
| | - K D Muminov
- Veliky Novgorod City Central Clinical Hospital, Veliky Novgorod, Russia
| | - Yu A Aselderov
- Veliky Novgorod City Central Clinical Hospital, Veliky Novgorod, Russia
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8
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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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Marquez A, Wasfie T, Korbitz H, Wong V, Pearson E, Holsinger H, Hella J, Barber K. Role of Abdominal Ultrasound and Magnetic Resonance Imaging in Pregnant Women Presenting With Acute Abdominal Pain. Am Surg 2022; 88:1875-1878. [PMID: 35422127 DOI: 10.1177/00031348221087914] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
Background and Purpose: Abdominal pain during pregnancy is quite common; however, surgical pathology such as acute appendicitis as a cause of such pain is not. Diagnostic tests used in addition to history and physical examination (PE) are ultrasound (US) and magnetic resonance imaging (MRI). We elected to find the role of these tests in pregnant patients who presented to our emergency department with acute abdominal pain.Materials And Methods: Retrospective analysis of 136 pregnant women with acute abdominal pain presented to the emergency department (ED). We reviewed PE, US, MRI, gestational age, comorbid conditions, and length of stay. Statistical analysis was done using student's t-test and chi-square test. Institutional review board approval was obtained.Results: Mean age was 26 (±4.6) and the mean gestational age was 24 (±9.9) weeks. Of those patients, there were 81 patients who had an US and MRI performed. The US was positive in 16 patients, while the MRI was positive in 25 patients. Three patients went for appendectomy. The US sensitivity was 0% and specificity 79%. Positive predictive value for US was 0% and negative predictive value was 95%, which was less than 100%. The MRI likelihood ratios were calculated for each test's clinical application and demonstrated that the US test result was indeterminate for ruling in and for ruling out appendicitis while the MRI allowed for high ability to rule out the disease.Conclusion: In pregnant women with acute abdominal pain and a positive PE highly suggestive of surgical pathology, US had limited value and patients should proceed to MRI.
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Affiliation(s)
- Alexa Marquez
- Department of Gynecology and Obstetrics, 3577Ascension Genesys Hospital, Grand Blanc Township, MI, USA
| | - Tarik Wasfie
- Department of Surgery, 3577Ascension Genesys Hospital, Grand Blanc Township, MI, USA
| | - Holland Korbitz
- Department of Surgery, 3577Ascension Genesys Hospital, Grand Blanc Township, MI, USA
| | - Victor Wong
- College of Osteopathic Medicine, 3078Michigan State University, East Lansing, MI, USA
| | - Eric Pearson
- College of Osteopathic Medicine, 3078Michigan State University, East Lansing, MI, USA
| | - Hunter Holsinger
- College of Osteopathic Medicine, 3078Michigan State University, East Lansing, MI, USA
| | - Jennifer Hella
- Department of Clinical & Academic Research, 3577Ascension Genesys Hospital, Grand Blanc Township, MI, USA
| | - Kimberly Barber
- Department of Clinical & Academic Research, 3577Ascension Genesys Hospital, Grand Blanc Township, MI, USA
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Wolfe C, Halsey-Nichols M, Ritter K, McCoin N. Abdominal Pain in the Emergency Department: How to Select the Correct Imaging for Diagnosis. Open Access Emerg Med 2022; 14:335-345. [PMID: 35899220 PMCID: PMC9309319 DOI: 10.2147/oaem.s342724] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 07/04/2022] [Indexed: 11/23/2022] Open
Abstract
Abdominal pain is a common presenting complaint in the emergency department, and utilization of diagnostic imaging is often a key tool in determining its etiology. Plain radiography has limited utility in this population. Computed tomography (CT) is the imaging modality of choice for undifferentiated abdominal pain. Ultrasound and magnetic resonance imaging may be helpful in specific scenarios, primarily in pediatrics and pregnancy, and offer the benefit of eliminating ionizing radiation risk of CT. Guidance for imaging selection is determined by location of pain, special patient considerations, and specific suspected etiologies. Expert guidance is offered by the American College of Radiology Appropriateness Criteria® which outlines imaging options based on location of pain.
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Affiliation(s)
- Carmen Wolfe
- Department of Emergency Medicine, TriStar Skyline Medical Center, Nashville, TN, USA
| | - Maglin Halsey-Nichols
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Kathryn Ritter
- Department of Emergency Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Nicole McCoin
- Department of Emergency Medicine, Ochsner Medical Center, New Orleans, LA, USA
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11
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Ahmed B, Williams J, Gourash W, Zhang J, Li R, Balasubramani GK, Rangaswamy B. MRI as First Line Imaging for Suspected Acute Appendicitis during Pregnancy: Diagnostic Accuracy and level of Inter-Radiologist Agreement. Curr Probl Diagn Radiol 2022; 51:503-510. [PMID: 34955286 PMCID: PMC9160213 DOI: 10.1067/j.cpradiol.2021.09.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 09/07/2021] [Accepted: 09/19/2021] [Indexed: 09/29/2023]
Abstract
OBJECTIVE Evaluation of acute appendicitis (AA) in pregnancy is supported with diagnostic imaging. Typically, ultrasound (US) is performed first, and then often followed by magnetic resonance imaging (MRI) due to continued diagnostic uncertainty. The purpose of our study was to evaluate the sensitivity, specificity, and accuracy of US as compared to MRI and to evaluate the inter-radiologist agreement amongst body Radiologists with varying levels of expertise. MATERIALS AND METHODS We performed a retrospective study of 364 consecutive pregnant patients with clinical suspicion of AA at a single center over a 6-year period. Sensitivity, Specificity, accuracy, positive and negative predictive values were calculated for US and MRI. Inter Radiologist agreement was determined using Cohen's Kappa analysis between original interpreting Radiologist and retrospective review by expert Radiologist. RESULTS Thirty-one of 364 patients (8.5%) underwent appendectomy based on preoperative diagnosis, with confirmation of acute appendicitis (AA) by pathology in 19. US was able to visualize the appendix in only 6 (1.65%), 5 of whom had appendicitis. 141 patients underwent MRI, and correctly diagnosed appendicitis in 9. No patient with a negative MRI diagnosis had AA. The sensitivity, and negative predictive value for diagnosing AA with MRI was 100%. The MRI inter-reader agreement for appendix visualization and overall accuracy were 87.9 and 98% with Cohen Kappa of 0.7 and 0.56 respectively. CONCLUSIONS Our data suggests that MRI should be considered the first line imaging modality in pregnant patients suspected of having AA. Body Radiologists with varied levels of experience in MRI readouts had substantial agreement.
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Affiliation(s)
- Bestoun Ahmed
- Department of Surgery, Division of Minimally Invasive General and Bariatric Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA.
| | - Jon Williams
- Advanced Laparoscopic and General Surgery of Nevada, Las Vegas, NV
| | - William Gourash
- Department of Surgery, Division of Minimally Invasive General and Bariatric Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | - Runjia Li
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, PA
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D'Souza N, Hicks G, Beable R, Higginson A, Rud B. Magnetic resonance imaging (MRI) for diagnosis of acute appendicitis. Cochrane Database Syst Rev 2021; 12:CD012028. [PMID: 34905621 PMCID: PMC8670723 DOI: 10.1002/14651858.cd012028.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Appendicitis remains a difficult disease to diagnose, and imaging adjuncts are commonly employed. Magnetic resonance imaging (MRI) is an imaging test that can be used to diagnose appendicitis. It is not commonly regarded as a first-line imaging test for appendicitis, but the reported diagnostic accuracy in some studies is equivalent to computed tomography (CT) scans. As it does not expose patients to radiation, it is an attractive imaging modality, particularly in women and children. OBJECTIVES The primary objective was to determine the diagnostic accuracy of MRI for detecting appendicitis in all patients. Secondary objectives: To investigate the accuracy of MRI in subgroups of pregnant women, children, and adults. To investigate the potential influence of MRI scanning variables such as sequences, slice thickness, or field of view. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase until February 2021. We searched the references of included studies and other systematic reviews to identify further studies. We did not exclude studies that were unpublished, published in another language, or retrospective. SELECTION CRITERIA We included studies that compared the outcome of an MRI scan for suspected appendicitis with a reference standard of histology, intraoperative findings, or clinical follow-up. Three study team members independently filtered search results for eligible studies. DATA COLLECTION AND ANALYSIS We independently extracted study data and assessed study quality using the Quality Assessment of Studies of Diagnostic Accuracy - Revised (QUADAS-2) tool. We used the bivariate model to calculate pooled estimates of sensitivity and specificity. MAIN RESULTS We identified 58 studies with sufficient data for meta-analysis including a total of 7462 participants (1980 with and 5482 without acute appendicitis). Estimates of sensitivity ranged from 0.18 to 1.0; estimates of specificity ranged from 0.4 to 1.0. Summary sensitivity was 0.95 (95% confidence interval (CI) 0.94 to 0.97); summary specificity was 0.96 (95% CI 0.95 to 0.97). Sensitivity and specificity remained high on subgroup analysis for pregnant women (sensitivity 0.96 (95% CI 0.88 to 0.99); specificity 0.97 (95% CI 0.95 to 0.98); 21 studies, 2282 women); children (sensitivity 0.96 (95% CI 0.95 to 0.97); specificity 0.96 (95% CI 0.92 to 0.98); 17 studies, 2794 children); and adults (sensitivity 0.96 (95% CI 0.93 to 0.97); specificity 0.93 (95% CI 0.80 to 0.98); 9 studies, 1088 participants), as well as different scanning techniques. In a hypothetical cohort of 1000 patients, there would be 12 false-positive results and 30 false-negative results. Methodological quality of the included studies was poor, and the risk of bias was high or unclear in 53% to 83% of the QUADAS-2 domains. AUTHORS' CONCLUSIONS MRI appears to be highly accurate in confirming and excluding acute appendicitis in adults, children, and pregnant women regardless of protocol. The methodological quality of the included studies was generally low due to incomplete and low standards of follow-up, so summary estimates of sensitivity and specificity may be biased. We could not assess the impact and direction of potential bias given the very low number of high-quality studies. Studies comparing MRI protocols were few, and although we found no influence of MRI protocol variables on the summary estimates of accuracy, our results do not rule out that some MRI protocols are more accurate than others.
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Affiliation(s)
| | | | | | | | - Bo Rud
- Gastrounit, Copenhagen University Hospital Hvidovre , Hvidovre, Denmark
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Somuncu E, Bozdag E, sarici I, Ozcan A, Ozkan C, Basaran C. The diagnostic role of hemogram parameters in pregnant appendicitis. POLISH JOURNAL OF SURGERY 2021; 94:48-53. [DOI: 10.5604/01.3001.0015.3961] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background: Acute appendicitis is the most frequently encountered non-obstetric disease requiring surgical intervention during pregnancy. Early diagnosis reduces maternal and fetal morbidity / mortality rates.
Aim: This study aims to investigate hemogram parameters in the diagnosis of acute appendicitis in pregnant women.
Material and Methods: A retrospective case-controlled study was conducted in three groups. Thirty-nine pregnant patients with acute appendicitis (Group A), 39 fertile nonpregnant patients with acute appendicitis (Group B), and 39 healthy pregnant women (Group C) were included in the study. WBC, neutrophil count, lymphocyte count, NLR, PLR, MPV and RDW values were compared.
Results: The mean NLR values in group A, group B and group C were 7.39 (1.58–46.6), 5.66 (1–20) and 4.23 (1.54–10.77) respectively, and there was a significant difference in NLR values between the groups (P= 0.002). The mean PLR values in group A, group B and group C were 159.09 (69.1–574), 134.28 (21.5-360) and 120 (68.7–334) and difference was statistically significant (P= 0.019). Cutoff points for WBC count was 14155 106/μL (51,3% sensitivity, 82,1% specificity), for neutrophil count is 10955 106/μL (53,8% sensitivity, 84,6% specificity), for NLR is 9.23 (46,2% sensitivity, 92,3% specificity) and PLR is 157,6 (51,3% sensitivity and 82,1% specificity) NLR had largest area under the curve with 0.667 NLR.
Conclusion: Neutrophil count, WBC and PLR were found to be the most valuable inflammatory parameters however, RDW, Lymphocyte count, and MPV levels are not found valuable markers in terms of sensitivity and specificity in the diagnosis of acute appendicitis in pregnant patients by this study.
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Affiliation(s)
- Erkan Somuncu
- Department of General Surgery, University of Health Sciences, Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey
| | - Emre Bozdag
- Department of General Surgery, University of Health Sciences, Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey
| | - inanc sarici
- Department of General Surgery, University of Health Sciences, Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey
| | - Adem Ozcan
- Department of General Surgery, University of Health Sciences, Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey
| | - Cenk Ozkan
- Department of General Surgery, University of Health Sciences, Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey
| | - Ceren Basaran
- Department of General Surgery, University of Health Sciences, Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey
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Akın T, Birben B, Akkurt G, Karaca O, Dönmez M, Er S, Tez M. Acute Appendicitis During Pregnancy: A Case Series of 42 Pregnant Women. Cureus 2021; 13:e17627. [PMID: 34646676 PMCID: PMC8484999 DOI: 10.7759/cureus.17627] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2021] [Indexed: 12/14/2022] Open
Abstract
Introduction It is difficult to diagnose the symptoms of acute appendicitis in pregnant women due to its similarities with pregnancy physiology. In this study, we examined the diagnostic value of laboratory parameters in the diagnosis of acute appendicitis in pregnant women. Material and methods Forty-two patients who underwent appendectomy during pregnancy were evaluated. The demographic characteristics, laboratory parameters and imaging methods of the patients were examined. According to the pathology results, the patients were evaluated in two groups as normal appendix and acute appendicitis. In addition, a non-pregnant control group was formed to compare the results between the pregnant and control groups. Results The mean age of the 42 patients was 30±6 years, and the pathology results were evaluated as normal in 16 (38.1%) of the patients. As imaging methods, ultrasonography was undertaken in all patients, with MRI being additionally performed in two patients. When the normal appendix and acute appendicitis groups were compared, no significant difference was observed in terms of laboratory parameters (neutrophil, lymphocyte, white blood cell and platelet counts, neutrophil-lymphocyte ratio, platelet-lymphocyte ratio, mean thrombocyte volume, red cell distribution width, and pregnancy trimesters (P>0.05). The group that had undergone appendectomy had a significantly higher rate of negative appendectomy compared to the control group (P=0.001). Conclusion Laboratory parameters alone cannot be sufficient for the diagnosis of acute appendicitis in pregnant patients. If clinical examination, laboratory parameters and USG are not sufficient for diagnosis, MRI is the imaging method that should be considered to reduce negative appendectomy rate.
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Affiliation(s)
- Tezcan Akın
- General Surgery, Ankara Bilkent City Hospital, Ankara, TUR
| | - Birkan Birben
- General Surgery, Ankara Bilkent City Hospital, Ankara, TUR
| | - Gökhan Akkurt
- General Surgery, Ankara Bilkent City Hospital, Ankara, TUR
| | - Onur Karaca
- General Surgery, Ankara Bilkent City Hospital, Ankara, TUR
| | - Mustafa Dönmez
- General Surgery, Yildirim Beyazit University Hospital, Ankara, TUR
| | - Sadettin Er
- General Surgery, Ankara Bilkent City Hospital, Ankara, TUR
| | - Mesut Tez
- General Surgery, Ankara Bilkent City Hospital, Ankara, TUR
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Çomçalı B, Kocaoz S, Altun Özdemir B, Canlıkarakaya F, Korukluoğlu B. What is the effectiveness of the Tzanakis scoring system modified by the Delta Neutrophil Index in the diagnosis of acute appendicitis in pregnant women? Eur J Obstet Gynecol Reprod Biol 2021; 264:219-223. [PMID: 34375821 DOI: 10.1016/j.ejogrb.2021.06.038] [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: 02/06/2021] [Revised: 06/16/2021] [Accepted: 06/23/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Acute appendicitis is the most common cause of abdominal pain that is unrelated to pregnancy in pregnant women. The aim of this study was to evaluate the performance of the Alvarado, Ohmann, and Tzanakis scores in the prediction of acute appendicitis in pregnant women and compare the hematological parameters. PATIENTS AND METHODS Herein, 1542 patients, aged 18-49 years, who were admitted to the emergency department with abdominal pain and underwent appendectomy were evaluated retrospectively. Of these, 140 female patients, including 35 who were pregnant and had been diagnosed with acute appendicitis, were included in the study. The obtained data were used to calculate the Alvarado, Tzanakis, and Ohmann scores. Histopathological evaluation reports were examined, and the diagnosis of acute appendicitis was confirmed. Those with different histopathological diagnoses were recorded as negative appendectomy. RESULTS In the pregnant and non-pregnant women, the Tzanakis scoring system showed the best predictive performance in terms of the sensitivity and accuracy percentage from the Alvarado and Ohmann scoring systems (84.85%, 85.71% vs. 92.93%, and 92.38%, respectively). When the parameters showing infection were compared, the Delta Neutrophil Index (DNI) was significantly higher in the pregnant appendicitis patients (P = 0.012). When the Tzanakis scoring system was modified with the DNI, the sensitivity, accuracy, and negative predictive values were significantly increased (93.94%, 94.29%, 50% vs. 94.95%, 94.29%, and 50%, respectively). CONCLUSION The Tzanakis scoring system appeared to be more effective than the other scoring systems in the diagnosis of acute appendicitis. Modification of the Tzanakis scoring system with the DNI was more successful in predicting appendicitis in pregnant women.
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Affiliation(s)
- Bülent Çomçalı
- Department of General Surgery, Ankara City Hospital, Çankaya, Ankara, Turkey.
| | - Servet Kocaoz
- Department of General Surgery, Ankara City Hospital, Çankaya, Ankara, Turkey
| | - Buket Altun Özdemir
- Department of General Surgery, Ankara City Hospital, Çankaya, Ankara, Turkey
| | - Fırat Canlıkarakaya
- Department of General Surgery, Ankara City Hospital, Çankaya, Ankara, Turkey
| | - Birol Korukluoğlu
- Department of General Surgery, Faculty of Medicine, University of Health Sciences, Çankaya, Ankara, Turkey
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Safety of appendectomy during pregnancy in the totally laparoscopic age. JOURNAL OF MINIMALLY INVASIVE SURGERY 2021; 24:68-75. [PMID: 35600787 PMCID: PMC8965996 DOI: 10.7602/jmis.2021.24.2.68] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 11/17/2020] [Accepted: 11/18/2020] [Indexed: 12/29/2022]
Abstract
Purpose Acute appendicitis is the most common nonobstetric indication for surgical intervention during pregnancy. In the argument of the optimal surgical approach to acute appendicitis in pregnancy, laparoscopy seems to be won with a similar complication rate and shorter postoperative recovery than open. We aimed to compare perioperative outcomes of appendectomy in pregnant and nonpregnant women in the totally laparoscopic age. Methods We retrospectively analyzed 556 nonincidental appendectomies performed in women (aged 18–45 years) between January 2014 and December 2018. To reduce the confounding effects, we used propensity score considering the variables age, American Society of Anesthesiologists physical status classification, and the operative finding; whether the appendicitis was simple or complicated. After propensity score matching, the outcomes of 15 pregnant women were compared with those of the 30 nonpregnant women. Results All the operations were performed with laparoscopy. Most of the pregnant cases were in their first and second trimester. The postoperative morbidity rate was significantly higher in the pregnant group before propensity score matching; however, the significance disappeared after matching. Operative outcomes and the parameters related to the postoperative recovery were not different between the two groups. Two patients in their first trimester decided to terminate the pregnancy after appendectomy. One patient in her second trimester experienced preterm labor which was resolved spontaneously. There was no other obstetric adverse outcome. Conclusion In the laparoscopy age, appendectomy during pregnancy is safe and not associated with a significantly increased risk of postoperative complication.
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Appendicitis in the Pregnant Patient: Risk, Diagnosis, Management, and Outcomes. CURRENT SURGERY REPORTS 2021. [DOI: 10.1007/s40137-020-00278-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Reasons for Undesirable Pregnancy Outcomes among Women with Appendicitis: The Experience of a Tertiary Center. Emerg Med Int 2020; 2020:6039862. [PMID: 33014470 PMCID: PMC7512082 DOI: 10.1155/2020/6039862] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 07/18/2020] [Accepted: 09/05/2020] [Indexed: 12/29/2022] Open
Abstract
Background Although laparoscopic appendectomy increases its popularity today, the answer to the question of whether to perform open or laparoscopic appendectomy during pregnancy is appropriate in many studies, and the choice of surgery depends on the surgeon. Herein, we aimed to evaluate the variables that affect undesirable pregnancy outcomes that occur as a result of appendicitis during pregnancy. Methods Seventy-eight pregnant patients with acute appendicitis who underwent laparoscopic or open technique intervention enrolled in this retrospective study. In addition to the demographic structure of the patients, surgical technique, the number of pregnancies, multiple pregnancy status, surgical pathologies, laboratory values, radiological imaging methods, and length of hospital stay were evaluated. The severity of appendicitis was classified according to the pathology results. The patients were divided into two groups according to the outcomes of their pregnancy. Preterm delivery and abortion involved in the study as a single complication section. Results The mean age of the pregnant patients was 28.6 ± 5. Of the 78 pregnant women with appendicitis, 47.4% had their first pregnancy, 37.2% had their second pregnancy, and 15.4% had 3 or more pregnancies. The preterm delivery and abortus were 19.5% in the open appendectomy (OA) group and 16.2% in the laparoscopic appendectomy (LA) group. No statistically significant difference was detected in this group in terms of appendicitis pathology triggering preterm delivery or abortion (p 0.075). When white blood count (WBC) and C-reactive protein (CRP) were evaluated by laboratory findings, CRP was found to be statistically significantly higher in patients with preterm birth (p 0.042). Conclusion Consequently, acute appendicitis may cause serious intra-abdominal infection and inflammation in addition to the complexity of the diagnosis due to the nature of pregnancy, as well as undesired pregnancy outcomes with the surgical technique, or independently with other variables.
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Barışık CC, Bener A. Predictors risk factors for acute complex appendicitis pain in patients: Are there gender differences? J Family Med Prim Care 2020; 9:2688-2692. [PMID: 32984108 PMCID: PMC7491777 DOI: 10.4103/jfmpc.jfmpc_140_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 03/13/2020] [Accepted: 04/08/2020] [Indexed: 12/29/2022] Open
Abstract
Objective: The purpose of this study is to determine the predictive risk factors for appendicitis and the cost-effectiveness of using abdominal helical computed tomography (CT) in comparison to abdominal ultrasonography (US) for the diagnosis of acute appendicitis in patients. Subjects and Methods: The typical case was a patient with abdominal pain in the right lower quadrant and suspicion of appendicitis. A total of 643 patients who were consequently treated with appendectomy upon diagnosis of acute appendicitis between January 2015 and December 2018 were included in the study. The four diagnostic alternatives chosen were US, CT, biochemistry parameters, and physical examination in the hospital. Results: There were statistically significant differences between male and female patients with regards to age, BMI, cigarette smoking, sheesha smoking, family history of diabetes, hypertension and family history of gastrointestinal discomfort (GI), anxiety (P < 0.001), red eye (P = 0.006), dizziness (P = 0.021), headache (P < 0.001), muscular symptoms, weakness and cramps (P < 0.001), bloating or swollen stomach (P < 0.001), UTI (P < 0.001), chest pain (P < 0.001), guarding (P < 0.001), loss of appetite (P = 0.004), nausea (P < 0.001) vomiting (P = 0.042), anorexia (P = 0.009), and constipation (P = 0.002). Moreover, there were statistically significant differences between male and female patients for pain (P < 0.001), pain right belly (P = 0.027), severe crumps (P = 0.007), high temperature and fever (P < 0.001), irritable bowel syndrome (P < 0.001), right iliac fossa (RIF) pain (P = 0.008), rebound tenderness (P = 0.024), positive bowel sounds (P = 0.029), and pointing tenderness (P < 0.001). Multivariate stepwise logistic regression showed nausea (P < 0.001), C-reactive protein (CRP) (P < 0.001), dizziness (P = 0.016), vomiting (P < 0.001), muscular symptoms (P = 0.007), irritable bowel syndrome (P = 0.034), guarding (P = 0.040), and loss appetite (P = 0.046) were considered at higher risk as predictors for appendicitis patients. Conclusions: CT is more cost-effective than the US and clinical examination for determining appendicitis. The current study suggested that nausea, C-reactive protein, dizziness, vomiting, muscular symptoms, irritable bowel syndrome, guarding, and loss appetite were considered as higher risk predictors for appendicitis patients.
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Affiliation(s)
- Cem Cahit Barışık
- Department of Radiology, Medipol School of Medicine, Istanbul Medipol University, Istanbul, Turkey
| | - Abdulbari Bener
- Department of Biostatistics and Medical Informatics, Cerrahpaşa Faculty of Medicine, Istanbul University Cerrahpaşa, Istanbul, Turkey.,Department of Evidence for Population Health Unit, School of Epidemiology and Health Sciences, The University of Manchester, Manchester, UK.,Department of Public Health, Medipol School of Medicine, Istanbul Medipol University, Istanbul, Turkey
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Mantoglu B, Gonullu E, Akdeniz Y, Yigit M, Firat N, Akin E, Altintoprak F, Erkorkmaz U. Which appendicitis scoring system is most suitable for pregnant patients? A comparison of nine different systems. World J Emerg Surg 2020; 15:34. [PMID: 32423408 PMCID: PMC7236497 DOI: 10.1186/s13017-020-00310-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 04/21/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Acute appendicitis is the most common non-gynecological emergency during pregnancy. The diagnosis of appendicitis during pregnancy is challenging due to changes in both physiological and laboratory variables. Guidelines suggest patients with suspected acute appendicitis should be stratified based on clinical scoring systems, to optimize the use of diagnostic imaging and prevent unnecessary surgery. Surgeons require additional information beyond that provided by imaging studies before deciding upon exploratory laparoscopy in patients with a high suspicion of appendicitis. Various scoring methods have been evaluated for the diagnosis of acute appendicitis. However, there is no consensus on a method to use during pregnancy, and a detailed comparison of existing scoring methods for this purpose has not yet been conducted. The purpose of this study was to evaluate the efficacy of the most popular scoring systems applied to diagnose acute appendicitis during pregnancy. METHODS This single-center retrospective study included 79 pregnant patients who were admitted to the emergency department with abdominal pain between May 2014 and May 2019. The patients were diagnosed with acute appendicitis and underwent an appendectomy. As a control group, the study also included 79 non-pregnant patients who underwent appendectomy within the last 1.5 years. To ensure that the groups were similar, women in the case group were stratified according to age, and the proportions of women in the strata were determined. The women in the control group were similarly stratified. Women were randomly selected from the strata to prevent bias. Both laboratory and examination findings required for each scoring method were obtained and assessed separately for each patient. Negative appendectomy rates were evaluated according to pathology results. Categorical variables were compared using the chi-square test. A p value < 0.05 was considered to indicate significance. Receiver operator characteristic curve analysis was used to identify the best threshold value and to assess the performance of the test scores in terms of diagnosing appendicitis. RESULTS Among all scoring systems, the Tzanakis score was most efficacious at predicting appendicitis in non-pregnant women. The positive predictive value (PPV) of the Tzanakis score was 90.6%, whereas the negative predictive value (NPV) was 46.7%. The RIPASA score performed the best among the scoring systems in pregnant women. It was associated with a PPV of 94.40%, NPV of 44%, and sensitivity and specificity of 78.46% and 78.57%, respectively. CONCLUSION Although the RIPASA score can be used to efficaciously diagnose acute appendicitis in pregnant women, a specific scoring system is needed for diagnosis during the gestation period.
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Affiliation(s)
- Baris Mantoglu
- Department of General Surgery, Sakarya University Educating and Research Hospital, Sakarya, Turkey.
| | - Emre Gonullu
- Department of General Surgery, Sakarya University Educating and Research Hospital, Sakarya, Turkey
| | - Yesim Akdeniz
- Department of General Surgery, Sakarya University Educating and Research Hospital, Sakarya, Turkey
| | - Merve Yigit
- Department of General Surgery, Sakarya University Educating and Research Hospital, Sakarya, Turkey
| | - Necattin Firat
- Faculty of Medicine, Department of General Surgery, Sakarya University, Sakarya, Turkey
| | - Emrah Akin
- Department of General Surgery, Sakarya University Educating and Research Hospital, Sakarya, Turkey
| | - Fatih Altintoprak
- Faculty of Medicine, Department of General Surgery, Sakarya University, Sakarya, Turkey
| | - Unal Erkorkmaz
- Faculty of Medicine, Department of Biostatistics, Sakarya University, Sakarya, Turkey
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Kim K, Ko M, Sim HC, Kim CL, Jung YJ, Kim TO. [Intussusception Caused by Colon Cancer in Pregnancy]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2019; 73:355-359. [PMID: 31234626 DOI: 10.4166/kjg.2019.73.6.355] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 04/06/2019] [Accepted: 04/18/2019] [Indexed: 01/06/2023]
Abstract
Intussusception is a common in pediatric age group. But it is rare in adults. And intussusception caused by tumor account for 1% of bowel obstructions in adult. Intussusception is an extremely rare cause of abdominal pain in pregnancy. In particular, cases of Intussusception due to colorectal cancer during pregnancy have never been reported in Korea. Our patient is a 34 years old woman who presented at 14 weeks of her second pregnancy. She presented with right lower abdominal discomfort and intermittent palpable mass which was usually spontaneously resolved. In the MRI study, pathologic asymmetric wall thickening was still noted and ileocolic intussusception was noted, and in colonoscopy, there was ulcerofungating mass around ileocecal valve which may be a leading point of intussusception. Biopsy was done. Pathologic finding was poorly differentiated adenocarcinoma. Under the patient agreement, we performed dilatation and curettage and laparoscopic right hemicolectomy and lymph node dissection. Now she is receiving a FOLFOX chemotherapy.
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Affiliation(s)
- Kyungjoong Kim
- Division of Gastroenterology, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Busan, Korea
| | - Myungkwan Ko
- Division of Gastroenterology, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Busan, Korea
| | - Ho Chan Sim
- Division of Gastroenterology, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Busan, Korea
| | - Chang Lae Kim
- Division of Gastroenterology, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Busan, Korea
| | - Yeo Jin Jung
- Division of Gastroenterology, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Busan, Korea
| | - Tae Oh Kim
- Division of Gastroenterology, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Busan, Korea
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Somberg Gunther M, Kanmaniraja D, Kobi M, Chernyak V. MRI of Acute Gynecologic Conditions. J Magn Reson Imaging 2019; 51:1291-1309. [PMID: 31833165 DOI: 10.1002/jmri.27002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 10/30/2019] [Accepted: 10/31/2019] [Indexed: 11/08/2022] Open
Abstract
Although usually not a first-line imaging modality in the setting of acute pelvic pain, magnetic resonance imaging (MRI) is able to depict and characterize a wide range gynecologic diagnoses with high accuracy. Lack of ionizing radiation renders MRI particularly useful for assessment of pregnant women and children. Furthermore, inherent high soft-tissue resolution of MRI allows accurate diagnosis without intravenous contrast use, which is advantageous for patients with renal insufficiency and pregnant patients. Familiarity with the typical MRI appearance of various acute gynecologic conditions helps establish the correct diagnosis. This article reviews the common MRI findings of acute gynecologic processes, in both pregnant and nonpregnant patients. Level of Evidence: 3 Technical Efficacy Stage: 3 J. Magn. Reson. Imaging 2020;51:1291-1309.
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Affiliation(s)
| | | | - Mariya Kobi
- Department of Radiology, Montefiore Medical Center, Bronx, New York, USA
| | - Victoria Chernyak
- Department of Radiology, Montefiore Medical Center, Bronx, New York, USA
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Saillant NN, Kilcoyne A, Fagenholz PJ, Lui R, Krystel-Whittemore M. Case 25-2019: A 41-Year-Old Pregnant Woman with Abdominal Pain. N Engl J Med 2019; 381:656-664. [PMID: 31412181 DOI: 10.1056/nejmcpc1900596] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Noelle N Saillant
- From the Departments of Surgery (N.N.S., P.J.F.), Radiology (A.K.), Obstetrics and Gynecology (R.L.), and Pathology (M.K.-W.), Massachusetts General Hospital, and the Departments of Surgery (N.N.S., P.J.F.), Radiology (A.K.), Obstetrics and Gynecology (R.L.), and Pathology (M.K.-W.), Harvard Medical School - both in Boston
| | - Aoife Kilcoyne
- From the Departments of Surgery (N.N.S., P.J.F.), Radiology (A.K.), Obstetrics and Gynecology (R.L.), and Pathology (M.K.-W.), Massachusetts General Hospital, and the Departments of Surgery (N.N.S., P.J.F.), Radiology (A.K.), Obstetrics and Gynecology (R.L.), and Pathology (M.K.-W.), Harvard Medical School - both in Boston
| | - Peter J Fagenholz
- From the Departments of Surgery (N.N.S., P.J.F.), Radiology (A.K.), Obstetrics and Gynecology (R.L.), and Pathology (M.K.-W.), Massachusetts General Hospital, and the Departments of Surgery (N.N.S., P.J.F.), Radiology (A.K.), Obstetrics and Gynecology (R.L.), and Pathology (M.K.-W.), Harvard Medical School - both in Boston
| | - Raymond Lui
- From the Departments of Surgery (N.N.S., P.J.F.), Radiology (A.K.), Obstetrics and Gynecology (R.L.), and Pathology (M.K.-W.), Massachusetts General Hospital, and the Departments of Surgery (N.N.S., P.J.F.), Radiology (A.K.), Obstetrics and Gynecology (R.L.), and Pathology (M.K.-W.), Harvard Medical School - both in Boston
| | - Melissa Krystel-Whittemore
- From the Departments of Surgery (N.N.S., P.J.F.), Radiology (A.K.), Obstetrics and Gynecology (R.L.), and Pathology (M.K.-W.), Massachusetts General Hospital, and the Departments of Surgery (N.N.S., P.J.F.), Radiology (A.K.), Obstetrics and Gynecology (R.L.), and Pathology (M.K.-W.), Harvard Medical School - both in Boston
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Kave M, Parooie F, Salarzaei M. Pregnancy and appendicitis: a systematic review and meta-analysis on the clinical use of MRI in diagnosis of appendicitis in pregnant women. World J Emerg Surg 2019; 14:37. [PMID: 31367227 PMCID: PMC6647167 DOI: 10.1186/s13017-019-0254-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 07/04/2019] [Indexed: 02/07/2023] Open
Abstract
Background The aim of this systematic review and meta-analysis was to evaluate the clinical use of MRI for the evaluation of acute appendicitis during pregnancy. Methods The searches were conducted by two independent researchers (MK, MS) to find the relevant studies published from 1/1/2009 until end of 30/12/2018. We searched for published literature in the English language in MEDLINE via PubMed, EMBASETM via Ovid, The Cochrane Library, and Trip database. For literature published in other languages, we searched national databases (Magiran and SID), KoreaMed, and LILACS. The keywords used in the search strategy are Pregnancy [MeSH], Pregnant [MeSH] OR-Magnetic resonance imaging [MeSH] OR-Appendicitis [MeSH] OR-Ultrasound, [MeSH] OR, imaging, MRI [MeSH] OR"،" and Right lower quadrant pain [MeSH]. The risk of bias of every article was evaluated by using QUADAS-2. On the basis of the results from the 2 × 2 tables, pooled measures for sensitivity, specificity, diagnostic odds ratio (DOR), and area under the curves (AUC) along with their 95% confidence intervals (CIs) were calculated using the DerSimonian Lair methodology. Results As many as 1164 studies were selected. After analyzing the correspondence of the studies with the required criteria, 19 studies were selected for the final review. For appendicitis in pregnancy, the MRI sensitivity was 91.8% at the 95% confidence interval of (95% CI 87.7-94.9%). At the confidence interval of 95%, the specificity was 97.9% (95% CI 0.97.2-100%). The risk of bias in the studies conducted was measured using the QUADAS-2 tool. Conclusion MRI has high sensitivity and specificity (91.8%, 97.9% respectively) for the diagnosis of acute appendicitis in pregnant patients with clinically suspected appendicitis. It is an excellent imaging technique in many instances, which does not expose a fetus, or the mother, to ionizing radiation, making it an excellent option for pregnant patients with suspected acute appendicitis.
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Affiliation(s)
- Mania Kave
- 1Gynecology and Obstetrics Institution, Faculty of Medicine, Zabol University of Medical Sciences, Zabol, Islamic Republic of Iran
| | - Fateme Parooie
- 2Student Research Committee, Faculty of Medicine, Zabol University of Medical Sciences, Zabol, Islamic Republic of Iran
| | - Morteza Salarzaei
- 2Student Research Committee, Faculty of Medicine, Zabol University of Medical Sciences, Zabol, Islamic Republic of Iran
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Mukherjee R, Samanta S. Surgical emergencies in pregnancy in the era of modern diagnostics and treatment. Taiwan J Obstet Gynecol 2019; 58:177-182. [PMID: 30910134 DOI: 10.1016/j.tjog.2019.01.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2018] [Indexed: 12/30/2022] Open
Abstract
Pregnancy can be complicated with different surgical emergencies which may potentially endanger the mother as well as foetus. In the modern era of advanced diagnostics and treatments, neither of them in response to a surgical emergency in a pregnant woman should be delayed. Appropriate early intervention is essential to decrease the morbidity and mortality. Following article encompasses common surgical emergencies that can arise in a pregnant woman and tries to suggest the approach that may be taken to reduce the burden of morbidity and mortality.
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Kamishima Y. [5. Magnetic Resonance Imaging of Pregnancy and Fetus 5-2. Diagnostic Imaging of the Pregnancy and Fetus]. Nihon Hoshasen Gijutsu Gakkai Zasshi 2019; 74:1480-1488. [PMID: 30568100 DOI: 10.6009/jjrt.2018_jsrt_74.12.1480] [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)
- Yuki Kamishima
- Nagoya City West Medical Center Department of Radiology, Department of Radiology, Nagoya City University Graduate School of Medical Sciences
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Wi SA, Kim DJ, Cho ES, Kim KA. Diagnostic performance of MRI for pregnant patients with clinically suspected appendicitis. Abdom Radiol (NY) 2018; 43:3456-3461. [PMID: 29869102 DOI: 10.1007/s00261-018-1654-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE To evaluate the accuracy of magnetic resonance imaging (MRI) in the diagnosis of acute appendicitis in pregnant patients and the value of additional diffusion-weighted MRI (DWI). METHODS A total of 125 pregnant patients with clinically suspected appendicitis who underwent 1.5 T MRI were enrolled between May 2011 and January 2016. During this period, two radiologists prospectively predicted acute appendicitis on MRI during daily interpretation. We retrospectively reviewed clinical records, and radiological results were correlated with surgical pathology and clinical outcomes. We calculated the sensitivity, specificity, and accuracy of MRI for diagnosing acute appendicitis. We performed additional DWI between August 2014 and January 2016, and we calculated sensitivity, specificity, and accuracy of MRI with or without DWI. RESULTS The sensitivity, specificity, and accuracy of MRI for acute appendicitis were 100%, 95%, and 96%, respectively. The sensitivity, specificity, and accuracy of MRI without DWI (n = 72) vs. with DWI (n = 53) were 100%, 94.7%, and 95.8% versus 100%, 95%, and 96%, respectively. CONCLUSIONS MRI has high accuracy for the diagnosis of acute appendicitis in pregnant patients. Therefore, MRI is recommended for use as a first-line diagnostic test for pregnant patients with clinically suspected appendicitis.
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Affiliation(s)
- Sung Ah Wi
- Department of Radiology, CHA Bundang Medical Center, CHA University, 351 Yatap-dong, Bundang-gu, Seongnam-si, Gyeonggi-do, 463-712, Korea
| | - Dae Jung Kim
- Department of Radiology, CHA Bundang Medical Center, CHA University, 351 Yatap-dong, Bundang-gu, Seongnam-si, Gyeonggi-do, 463-712, Korea.
| | - Eun-Suk Cho
- Department of Radiology, Yonsei University College of Medicine, Gangnam Severance Hospital, Seoul, Korea
| | - Kyoung Ah Kim
- Department of Radiology, CHA Bundang Medical Center, CHA University, 351 Yatap-dong, Bundang-gu, Seongnam-si, Gyeonggi-do, 463-712, Korea
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Logrado A, Constantino J, Pereira J, Casimiro C. Laparostomy during pregnancy: A case report. Int J Surg Case Rep 2018; 51:120-124. [PMID: 30149329 PMCID: PMC6110995 DOI: 10.1016/j.ijscr.2018.08.029] [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: 07/06/2018] [Revised: 08/12/2018] [Accepted: 08/15/2018] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Acute appendicitis is the main indication for surgery during pregnancy. Physiologic changes during pregnancy and fear of using ionising radiation exams are some of the reasons to delayed diagnosis and consequently to higher morbidity and mortality rates for mother and fetus. PRESENTATION OF CASE We present the case of a 38-year-old woman that resorted to the emergency room on the 13th week of pregnancy with abdominal discomfort, nausea and vomiting that lasted for 7 days. She had been in the Obstetric Emergency Department 6 days prior with the same complaints. She had no fever and she was discharged home following normal obstetric ultrasound. On this second visit, after surgical consultation, septic shock with abdominal source was recognised and patient was taken for emergency exploratory laparotomy. Intraoperatively we found generalised purulent peritonitis secondary to perforated acute appendicitis. Appendectomy, thorough abdominal washing and laparostomy were performed. Patient was admitted on the Intensive Care Unit with septic shock, need for vasopressor therapy and dialysis. Four days after the first intervention the abdominal cavity was closed. She was discharged home on the 14th post-operative day and maintained obstetric follow-up for the remaining uncomplicated pregnancy. DISCUSSION In the presented clinical case, diagnostic delay evolves to abdominal sepsis that demanded a damage control approach. Laparostomy constitutes a damage control gesture, limiting abdominal contamination, preventing abdominal compartment syndrome and allowing subsequent surgical revisions. CONCLUSION Acute abdominal approach using laparostomy allowed for a good outcome, maintaining ongoing pregnancy and with incisional hernia as the only observed morbidity.
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Affiliation(s)
- Ana Logrado
- Serviço de Cirurgia Geral do Centro Hospitalar Tondela-Viseu, Avenida Rei D. Duarte, 3504-509, Viseu, Portugal.
| | - Júlio Constantino
- Serviço de Cirurgia Geral do Centro Hospitalar Tondela-Viseu, Avenida Rei D. Duarte, 3504-509, Viseu, Portugal.
| | - Jorge Pereira
- Serviço de Cirurgia Geral do Centro Hospitalar Tondela-Viseu, Avenida Rei D. Duarte, 3504-509, Viseu, Portugal.
| | - Carlos Casimiro
- Serviço de Cirurgia Geral do Centro Hospitalar Tondela-Viseu, Avenida Rei D. Duarte, 3504-509, Viseu, Portugal.
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Suspicion of appendicitis in pregnant women: emergency evaluation by sonography and low-dose CT with oral contrast. Eur Radiol 2018; 29:345-352. [PMID: 29948087 DOI: 10.1007/s00330-018-5573-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 05/07/2018] [Accepted: 05/29/2018] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To evaluate non-intravenously enhanced low-dose computed tomography with oral contrast (LDCT) for the assessment of pregnant women with right lower quadrant pain, when magnetic resonance imaging (MRI) is not immediately available. METHODS One hundred and thirty-eight consecutive pregnant women with acute abdominal pain were admitted in our emergency centre. Thirty-seven (27%) of them, with clinical suspicion of acute appendicitis, underwent abdominal ultrasonography (US). No further examination was recommended when US was positive for appendicitis, negative with low clinical suspicion or showed an alternative diagnosis which explained the clinical presentation. All other patients underwent LDCT (<2.5 mSv). Standard intravenously enhanced CT or MRI was performed when LDCT was indeterminate. RESULTS Eight (22%) of 37 US exams were reported normal, 25 (67%) indeterminate, 1 (3%) positive for appendicitis, 3 (8%) positive for an alternative diagnosis. LDCT was obtained in 29 (78%) patients. It was reported positive for appendicitis in 9 (31%), for alternative diagnosis in 2 (7%), normal in 13 (45%) and indeterminate in 5 (17%). Further imaging (standard CT or MRI) showed appendicitis in 2 of these 5 patients, was truly negative in 1, indeterminate in 1 and falsely positive in 1. An appendicitis was confirmed at surgery in 12 (32%) of the 37 patients. The sensitivity and the specificity of the algorithm for appendicitis were 100% (12/12) and 92% (23/25), respectively. CONCLUSIONS The proposed algorithm is very sensitive and specific for detection of acute appendicitis in pregnant women; it reduces the need of standard CTs when MRI is not available as second-line imaging. KEY POINTS • In pregnant women, US is limited by an important number of indeterminate results • Low-dose CT can be used after an inconclusive US for the diagnosis of appendicitis in pregnant women • An algorithm integrating US and low-dose CT is highly sensitive and specific for appendicitis in pregnant women.
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Clinical utility of magnetic resonance imaging in the evaluation of pregnant females with suspected acute appendicitis. Abdom Radiol (NY) 2018; 43:1446-1455. [PMID: 28849364 DOI: 10.1007/s00261-017-1300-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVES To assess the diagnostic performance of magnetic resonance imaging (MRI) in a large cohort of pregnant females with suspected acute appendicitis and to determine the frequency of non-appendiceal causes of abdominal pain identified by MRI in this population. METHODS This HIPAA compliant, retrospective study was IRB-approved and informed consent was waived. 212 MRI exams were performed consecutively on pregnant women aged 17-47 years old suspected of having acute appendicitis; eight exams were excluded and analyzed separately due to equivocal findings or lack of clinical follow up. Radiology reports for the MRI and any preceding ultrasound exams were reviewed as well as the patients' electronic medical record for surgical, pathological, or clinical follow up. RESULTS Fifteen (7.3%) of 204 MRI scans were determined to be positive for appendicitis, 14 of which were proven on surgical pathology, and one was found to have ileocecal diverticulitis. Out of the remaining 189 scans, none were subsequently shown to have acute appendicitis either surgically or based on clinical follow up. Negative predictive value (NPV) was 100% and positive predictive value was 93.3%. Sensitivity and specificity were 100% and 99.5%, respectively. Non-appendiceal findings which may have accounted for the patient's abdominal pain were seen in 91 (44.2%) of 189 scans. The most common extra-appendiceal causes of abdominal pain identified on MRI include degenerating fibroids (n = 11), significant hydronephrosis (n = 12), cholelithiasis (n = 6), and pyelonephritis (n = 3). CONCLUSION Our large study cohort of pregnant patients confirms MRI to be of high diagnostic value in the workup of acute appendicitis with 100% NPV and sensitivity and 99.5% specificity. Furthermore, an alternative diagnosis for abdominal pain in this patient population can be made in nearly half of MRI exams which are deemed negative for appendicitis.
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Identifying and Disseminating More Best Practices. AJR Am J Roentgenol 2018; 210:1179-1180. [PMID: 29787317 DOI: 10.2214/ajr.18.19997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Morton A, Teasdale S. Review article: Investigations and the pregnant woman in the emergency department - part 2: Point-of-care ultrasound, electrocardiography, respiratory function tests and radiology. Emerg Med Australas 2018; 30:749-753. [PMID: 29577627 DOI: 10.1111/1742-6723.12956] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 02/07/2018] [Indexed: 12/13/2022]
Abstract
Accurate assessment of the pregnant patient in the ED depends on knowledge of physiological changes in pregnancy, and how these changes may impact on pathology tests, appearance on point-of-care ultrasound, electrocardiography and respiratory function tests. In addition, the emergency physician needs to be cognisant of disorders that are unique to or more common during pregnancy. Part 2 of this review addresses the role of point-of-care ultrasound in pregnancy, physiological changes that may affect interpretation of point-of-care ultrasound, changes in electrocardiography and respiratory function tests, and the safety of radiological procedures in the pregnant patient. Part 1 addressed potential deviations in laboratory investigation reference intervals resulting from physiological alterations in pregnancy and the important causes of abnormal laboratory results in pregnancy.
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Affiliation(s)
- Adam Morton
- Mater Health and The University of Queensland, Brisbane, Queensland, Australia
| | - Stephanie Teasdale
- Mater Health and The University of Queensland, Brisbane, Queensland, Australia
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The Role of Conventional Ultrasonography in the Evaluation of Antrum Wall Thickness in Obese Patients. Obes Surg 2017; 26:2995-3000. [PMID: 27334646 DOI: 10.1007/s11695-016-2221-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND The objective of this study is to evaluate the utility of conventional ultrasonography (USG) in the evaluation of the stomach antrum and distal corpus lesions. METHODS A prospective evaluation was made of 69 patients who underwent sleeve gastrectomy. Preoperative USG was applied to the patients and measurements were taken and recorded of the stomach antrum full layer wall thickness (USGFT) and of mucosal thickness (USGMT). Postoperatively, same parameters were again measured histopathologically and the pathological full thickness (PFT) and pathological mucosal thickness (PMT) values were compared. RESULTS When evaluation was made in respect of USG and pathological measurements, the USGFT was 8.51 ± 3.07 (range 4.5-15.8) and USGMT was 5.80 ± 2.15 (range 2.36-10.5). The PFT was determined as 8.13 ± 2.24 (range 4-14) and PMT as 5.53 ± 1.86 (range 2-10.5). In the histopathological examination, gastritis was seen in 53 (76.8 %) patients and Helicobacter pylori (HP) positivity was determined in 32 (46.4 %) patients. When the patients were grouped as obese (BMI ≤ 49.9 kg/m2) (group 1, n = 50) and super obese (BMI ≥ 50 kg/m2) (group 2, n = 19), no difference was determined between the groups ultrasonographically or histopathologically (p > 0.05). The antrum wall thickness was seen to be significantly greater in the patients with gastritis and HP positivity compared to the patients who were negative. In ROC analysis, cutoff values were calculated for USGFT (5.86 mm) and USGMT (4.49 mm). In gastritis diagnosis, the USGFT cutoff value was found to have 796 % sensitivity and 68.7 % specificity. CONCLUSION USG was seen to be an extremely effective method in visualising the antrum wall and gastritis diagnosis can be made comfortably from the wall thickness measurement.
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Skubic JJ, Salim A. Emergency general surgery in pregnancy. Trauma Surg Acute Care Open 2017; 2:e000125. [PMID: 29766116 PMCID: PMC5887777 DOI: 10.1136/tsaco-2017-000125] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 08/20/2017] [Accepted: 08/28/2017] [Indexed: 01/07/2023] Open
Abstract
It is often that the acute care surgeon will be called on to evaluate the pregnant patient with abdominal pain. Most of the diagnostic and management decisions regarding pregnant patients will follow the usual tenets of surgery; however, there are important differences in the pregnant patient to be aware of to avoid pitfalls which can lead to complications for both mother and fetus. This review hopes to describe the most common emergencies facing the surgeon caring for the pregnant patient and the latest management options.
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Affiliation(s)
- Jeffrey J Skubic
- Division of Trauma, Burn and Surgical Critical Care, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Ali Salim
- Division of Trauma, Burn and Surgical Critical Care, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Abstract
Acute appendicitis is a common nonobstetric indication for surgical intervention during pregnancy with serious potential complications for the mother and fetus. The aim of this study was to evaluate the presentation, management practices, outcomes, and costs of appendectomy during pregnancy. We did a retrospective analysis of 62,118 nonincidental appendectomies performed in women (age 15–45 years) identified from the California State Inpatient Database (2005–2011). Primary outcomes included diagnosis or type of appendicitis, use of laparoscopy, morbidity, length of stay, and cost. Pregnant women were less likely to undergo laparoscopy (OR = 0.51, P < 0.01). Pregnancy had no effect on perforation rates, but was associated with higher rates of negative appendectomy (OR = 9.29, P < 0.01). Pregnancy was not associated with nonpregnancy-related complications after appendectomy. Pregnant women had longer length of stay (RR = 1.07, P < 0.01) but similar costs. Appendectomy did increase risk of preterm delivery at the time of surgical admission (19.5 vs 8.8%, P < 0.01). However, once discharged, there was no difference in rates of preterm delivery (9.1 vs 8.9%, P = 0.23). Pregnant women had higher rates of negative appendectomy with lower rates of laparoscopy. Despite these differences, there was no difference in nonpregnancy-related morbidity and cost. Appendectomy did increase risk of preterm birth, but the increased risk normalized over time.
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Affiliation(s)
- Roy P. Won
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, California
- Los Angeles Biomedical Research Institute, Torrance, California
| | | | - Steven L. Lee
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, California
- Los Angeles Biomedical Research Institute, Torrance, California
- Department of Pediatrics, Harbor-UCLA Medical Center, Torrance, California
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Tsai R, Raptis C, Fowler KJ, Owen JW, Mellnick VM. MRI of suspected appendicitis during pregnancy: interradiologist agreement, indeterminate interpretation and the meaning of non-visualization of the appendix. Br J Radiol 2017; 90:20170383. [PMID: 28869395 DOI: 10.1259/bjr.20170383] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To determine the degree of interradiologist agreement between the MRI features of appendicitis during pregnancy, the outcomes associated with an indeterminate interpretation and the negative predictive value of non-visualization of the appendix. METHODS Our study was approved by the institutional review board at the Washington University in St. Louis, Missouri (WUStL) and was HIPAA (Health Insurance Portability and Accountability Act of 1996)-compliant. The informed consent requirement was waived. Cases of suspected appendicitis during pregnancy evaluated using MRI were retrospectively identified using search queries. Scans were re-reviewed by two radiologists (7 and 9 years experience, respectively) to evaluate the interradiologist agreement of different MRI features of appendicitis during pregnancy (visualization of the appendix, appendiceal diameter, appendiceal wall thickening, periappendiceal fat stranding, fluid-filled appendix and periappendiceal fluid). The radiologists were blinded to patient outcome, patient intervention, laboratory data, demographic data and the original MRI reports. Clinical outcomes were documented by surgical pathology or clinical observation. Interradiologist agreement was analysed using Cohen's κ, while patient demographic and clinical data was analysed using Student's t-testing. RESULTS 233 females with suspected appendicitis during pregnancy were evaluated using MRI over a 13-year period (mean age, 28.4 years; range, 17-38 years). There were 14 (6%) positive examinations for appendicitis during pregnancy, including 1 patient whose MRI was interpreted as negative, proven by surgical pathology. The presence of periappendiceal soft-tissue stranding and the final overall impression had the most interradiologist agreement (к = 0.81-1). There were no pregnant patients found to have acute appendicitis who had an indeterminate MR interpretation or when the appendix could not be visualized. CONCLUSION The final impression by the two retrospectively reviewing radiologists of MR examinations performed for suspected appendicitis during pregnancy had near-perfect agreement. In patients where the appendix could not be visualized or in patients that were interpreted as indeterminate, no patients had acute appendicitis. Advances in knowledge: MR impression for suspected appendicitis in the pregnant patient has high interradiologist agreement, and a non-visualized appendix or lack of inflammatory findings at the time of MR, reliably excludes surgical appendicitis.
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Affiliation(s)
- Richard Tsai
- 1 Department of Diagnostic Radiology, Mallinckrodt Institute of Radiology, Washington University, St. Louis, MO, USA
| | - Constantine Raptis
- 1 Department of Diagnostic Radiology, Mallinckrodt Institute of Radiology, Washington University, St. Louis, MO, USA
| | - Kathryn J Fowler
- 1 Department of Diagnostic Radiology, Mallinckrodt Institute of Radiology, Washington University, St. Louis, MO, USA
| | - Joseph W Owen
- 2 Department of Radiology, University of Kentucky, Lexington, KY, USA
| | - Vincent M Mellnick
- 1 Department of Diagnostic Radiology, Mallinckrodt Institute of Radiology, Washington University, St. Louis, MO, USA
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Burns M, Hague CJ, Vos P, Tiwari P, Wiseman SM. Utility of Magnetic Resonance Imaging for the Diagnosis of Appendicitis During Pregnancy: A Canadian Experience. Can Assoc Radiol J 2017; 68:392-400. [PMID: 28728903 DOI: 10.1016/j.carj.2017.02.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 01/09/2017] [Accepted: 02/14/2017] [Indexed: 01/10/2023] Open
Abstract
PURPOSE The objective of the study was to evaluate the performance of magnetic resonance imaging (MRI) for the diagnosis of appendicitis during pregnancy. METHODS We conducted a retrospective review of all MRI scans performed at our institution, between 2006 and 2012, for the evaluation of suspected appendicitis in pregnant women. Details of the MRI scans performed were obtained from the radiology information system as well as details of any ultrasounds carried out for the same indication. Clinical and pathological data were obtained by retrospective chart review. RESULTS The study population comprised 63 patients, and 8 patients underwent a second MRI scan during the same pregnancy. A total of 71 MRI scans were reviewed. The appendix was identified on 40 scans (56.3%). Sensitivity of MRI was 75% and specificity was 100% for the diagnosis of appendicitis in pregnant women. When cases with right lower quadrant inflammatory fat stranding or focal fluid, without appendix visualization, were classified as positive for appendicitis, MRI sensitivity increased to 81.3% but specificity decreased to 96.4%. CONCLUSIONS MRI is sensitive and highly specific for the diagnosis of appendicitis during pregnancy and should be considered as a first line imaging study for this clinical presentation.
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Affiliation(s)
- Michael Burns
- Department of Radiology, St Paul's Hospital & University of British Columbia, Vancouver, British Columbia, Canada.
| | - Cameron J Hague
- Department of Radiology, St Paul's Hospital & University of British Columbia, Vancouver, British Columbia, Canada
| | - Patrick Vos
- Department of Radiology, St Paul's Hospital & University of British Columbia, Vancouver, British Columbia, Canada
| | - Pari Tiwari
- Department of Radiology, St Paul's Hospital & University of British Columbia, Vancouver, British Columbia, Canada
| | - Sam M Wiseman
- Department of Surgery, St Paul's Hospital & University of British Columbia, Vancouver, British Columbia, Canada
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Patel D, Fingard J, Winters S, Low G. Clinical use of MRI for the evaluation of acute appendicitis during pregnancy. Abdom Radiol (NY) 2017; 42:1857-1863. [PMID: 28194513 DOI: 10.1007/s00261-017-1078-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE The purpose of this study was to determine the diagnostic accuracy of MRI for detecting acute appendicitis in pregnancy in a multi-institution study involving general body MR readers with no specific expertise in MR imaging of the pregnant patient. METHODS Retrospective review of MRI examinations on PACS in 42 pregnant patients was evaluated for acute right lower quadrant pain. Three fellowship-trained general body radiologists analyzed the MRI examinations in consensus and attempted to localize the appendix, assess for features of appendicitis, and exclude alternative etiologies for the right lower quadrant pain. RESULTS Of the 42 MRI examinations, the readers noted 6 cases of acute appendicitis, 16 cases of a normal appendix, and 20 cases involving non-visualization of the appendix but where there were no secondary features of acute appendicitis. Based on the surgical data and clinical follow-up, there were 3 true-positive cases, 3 false-positive cases, 34 true-negative cases, and 2 false-negative cases of acute appendicitis on MRI. This yielded an accuracy of 88.1%, sensitivity of 60%, specificity of 91.9%, positive predictive value of 50%, and negative predictive value of 94.4% for the detection of acute appendicitis in the pregnant patient on MRI. Alternative etiologies for the right lower quadrant pain on MRI included torsion of an ovarian dermoid in 1 case and pyelonephritis in 1 case. CONCLUSION MRI is an excellent modality for excluding acute appendicitis in pregnant patients presenting with right lower quadrant pain.
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Affiliation(s)
- Darshan Patel
- Department of Radiology & Diagnostic Imaging, University of Alberta Hospital, 2A2.41 WMC, 8440 - 112 Street, Edmonton, AB, T6G 2B7, Canada.
| | - Jordan Fingard
- Department of Radiology & Diagnostic Imaging, University of Alberta Hospital, 2A2.41 WMC, 8440 - 112 Street, Edmonton, AB, T6G 2B7, Canada
| | - Sean Winters
- Department of Radiology & Diagnostic Imaging, University of Alberta Hospital, 2A2.41 WMC, 8440 - 112 Street, Edmonton, AB, T6G 2B7, Canada
| | - Gavin Low
- Department of Radiology & Diagnostic Imaging, University of Alberta Hospital, 2A2.41 WMC, 8440 - 112 Street, Edmonton, AB, T6G 2B7, Canada
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Baheti AD, Nicola R, Bennett GL, Bordia R, Moshiri M, Katz DS, Bhargava P. Magnetic Resonance Imaging of Abdominal and Pelvic Pain in the Pregnant Patient. Magn Reson Imaging Clin N Am 2016; 24:403-17. [PMID: 27150326 DOI: 10.1016/j.mric.2015.11.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The utility of MR imaging in evaluating abdominal and pelvic pain in the pregnant patient is discussed. Details regarding the indications, technical aspects, and imaging findings of various common abdominal and pelvic abnormalities in pregnancy are reviewed.
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Affiliation(s)
- Akshay D Baheti
- Department of Radiology, University of Washington, 1959 NE Pacific Street, Room BB308, Box 357115, Seattle, WA 98195, USA.
| | - Refky Nicola
- Department of Radiology, University of Rochester Medical Center, 601 Elmwood Avenue, Box 648, Rochester, NY 14642, USA
| | - Genevieve L Bennett
- Department of Radiology, New York University School of Medicine, 660 First Avenue, New York, NY 10016, USA
| | - Ritu Bordia
- Section of Neuroradiology, Department of Radiology, Winthrop-University Hospital, 259 First Street, Mineola, NY 11501, USA
| | - Mariam Moshiri
- Department of Radiology, University of Washington, 1959 NE Pacific Street, Room BB308, Box 357115, Seattle, WA 98195, USA
| | - Douglas S Katz
- Section of Neuroradiology, Department of Radiology, Winthrop-University Hospital, 259 First Street, Mineola, NY 11501, USA
| | - Puneet Bhargava
- Department of Radiology, University of Washington, 1959 NE Pacific Street, Room BB308, Box 357115, Seattle, WA 98195, USA
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Franca Neto AHD, Amorim MMRD, Nóbrega BMSV. Acute appendicitis in pregnancy: literature review. Rev Assoc Med Bras (1992) 2016; 61:170-7. [PMID: 26107368 DOI: 10.1590/1806-9282.61.02.170] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 07/03/2014] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION suspected appendicitis is the most common indication for surgery in non-obstetric conditions during pregnancy and occurs in about one in 500 to one in 635 pregnancies per year. This occurs more often in the second trimester of pregnancy. Acute appendicitis is the most common general surgical problem encountered during pregnancy. METHODS a literature review on research of scientific articles, under the terms "acute appendicitis" and "pregnancy", in PubMed, Lilacs/SciELO, Scopus, Cochrane Library and Uptodate databases. RESULTS the clinical manifestations of appendicitis are similar to non-pregnant women, however, without a classic presentation, which often occurs, diagnosis is difficult and must be supported by imaging. DISCUSSION clinical diagnosis should be strongly suspected in pregnant women with classic findings such as abdominal pain that migrates to the right lower quadrant. The main purpose of imaging is to reduce delays in surgical intervention due to diagnostic uncertainty. A secondary objective is to reduce, but not eliminate, the negative appendectomy rate. Differential diagnosis of suspected acute appendicitis usually includes pathologies considered in non-pregnant people. CONCLUSION the imaging study of choice is ultrasound, MRI may be used when the former is not conclusive and, as a last resort, a CT scan can be performed. The treatment remains appendectomy by laparotomy, since the feasibility of video- assisted surgery in these cases remains controversial.
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Dick EA, Varma D, Kashef E, Curtis J. Use of advanced imaging techniques during visits to emergency departments--implications, costs, patient benefits/risks. Br J Radiol 2016; 89:20150819. [PMID: 26693970 PMCID: PMC4985454 DOI: 10.1259/bjr.20150819] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Revised: 12/18/2015] [Accepted: 12/21/2015] [Indexed: 11/05/2022] Open
Abstract
25 years ago, on a Friday evening at 9 pm, the emergency department (ED) was full of patients with a wide range of clinical problems. Their investigations included plain radiographs, but no other imaging was included until the next working day. At present, many patients are receiving advanced imaging such as ultrasound, CT and MRI, often delivered out of hours--an obvious advance for patients or sometimes an unnecessary development? In this article, we will consider how to assess patient benefits and whether increased use of advanced imaging is an overall advance for patients. We will address the general implications for healthcare services which come with greater use of advanced imaging. We will then address the effect of advanced imaging on individual fictional ED patients with a variety of complaints.
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Affiliation(s)
- Elizabeth A Dick
- St Mary's Hospital, Imperial College Healthcare Trust, London, UK
| | | | - Elika Kashef
- St Mary's Hospital, Imperial College Healthcare Trust, London, UK
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Yazar FM, Bakacak M, Emre A, Urfalıoglu A, Serin S, Cengiz E, Bülbüloglu E. Predictive role of neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios for diagnosis of acute appendicitis during pregnancy. Kaohsiung J Med Sci 2015; 31:591-6. [PMID: 26678940 DOI: 10.1016/j.kjms.2015.10.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 09/18/2015] [Accepted: 09/29/2015] [Indexed: 10/22/2022] Open
Abstract
Acute appendicitis (AA) is not uncommon during pregnancy but can be difficult to diagnose. This study evaluated the neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) in addition to conventional diagnostic indicators of the disease to diagnose AA during pregnancy. Age, gestational age, white blood cell (WBC) count, Alvarado scores, C-reactive protein (CRP), lymphocyte count, NLR and PLR were compared among 28 pregnant women who underwent surgery for AA, 35 pregnant women wrongly suspected as having AA, 29 healthy pregnant women, and 30 nonpregnant healthy women. Mean WBC counts and CRP levels were higher in women with proven AA than in those of control groups (all p < 0.05). Among all the groups, the median NLR and PLR were significantly different in women with proven AA (all p < 0.05). Receiver operating characteristic analysis was used to determine cut-off values for WBC count, CRP, lymphocyte count, NLR and PLR, and multiple logistic regression analysis showed that NLR and PLR used with routine methods could diagnose AA with 90.5% accuracy. Used in addition to routine diagnostic methods, NLR and PLR increased the accuracy of the diagnosis of AA in pregnant women.
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Affiliation(s)
- Fatih Mehmet Yazar
- Department of General Surgery, Kahramanmaras Sutcu Imam University, School of Medicine, Kahramanmaraş, Turkey
| | - Murat Bakacak
- Department of Obstetrics and Gynecology, Kahramanmaras Sutcu Imam University, School of Medicine, Kahramanmaraş, Turkey.
| | - Arif Emre
- Department of General Surgery, Kahramanmaras Sutcu Imam University, School of Medicine, Kahramanmaraş, Turkey
| | - Aykut Urfalıoglu
- Department of Anesthesia and Reanimation, Kahramanmaras Sutcu Imam University, School of Medicine, Kahramanmaraş, Turkey
| | - Salih Serin
- Department of Obstetrics and Gynecology, Kahramanmaras Sutcu Imam University, School of Medicine, Kahramanmaraş, Turkey
| | - Emrah Cengiz
- Department of General Surgery, Kahramanmaras Sutcu Imam University, School of Medicine, Kahramanmaraş, Turkey
| | - Ertan Bülbüloglu
- Department of General Surgery, Kahramanmaras Sutcu Imam University, School of Medicine, Kahramanmaraş, Turkey
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Burke LM, Bashir MR, Miller FH, Siegelman ES, Brown M, Alobaidy M, Jaffe TA, Hussain SM, Palmer SL, Garon BL, Oto A, Reinhold C, Ascher SM, Demulder DK, Thomas S, Best S, Borer J, Zhao K, Pinel-Giroux F, De Oliveira I, Resende D, Semelka RC. Magnetic resonance imaging of acute appendicitis in pregnancy: a 5-year multiinstitutional study. Am J Obstet Gynecol 2015. [PMID: 26215327 DOI: 10.1016/j.ajog.2015.07.026] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE The purpose of this study was to determine the diagnostic performance of magnetic resonance imaging (MRI) in the diagnosis of acute appendicitis during pregnancy in a multiinstitutional study. STUDY DESIGN In this multicenter retrospective study, the cases of pregnant women who underwent MRI evaluation of abdominal or pelvic pain and who had clinical suspicion of acute appendicitis between June 1, 2009, and July 31, 2014, were reviewed. All MRI examinations with positive findings for acute appendicitis were confirmed with surgical pathologic information. Sensitivity, specificity, negative predictive values, and positive predictive values were calculated. Receiver operating characteristic curves were generated, and area under the curve analysis was performed for each participating institution. RESULTS Of the cases that were evaluated, 9.3% (66/709) had MRI findings of acute appendicitis. Sensitivity, specificity, accuracy, positive predictive value, and negative predictive values were 96.8%, 99.2%, 99.0%, 92.4%, and 99.7%, respectively. There was no statistically significant difference between centers that were included in the study (pair-wise probability values ranged from 0.12-0.99). CONCLUSION MRI is useful and reproducible in the diagnosis of suspected acute appendicitis during pregnancy.
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Thompson MM, Kudla AU, Chisholm CB. Appendicitis during pregnancy with a normal MRI. West J Emerg Med 2015; 15:652-4. [PMID: 25247035 PMCID: PMC4162721 DOI: 10.5811/westjem.2014.7.22988] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Accepted: 07/03/2014] [Indexed: 11/11/2022] Open
Abstract
Abdominal pain frequently represents a diagnostic challenge in the acute setting. In pregnant patients, the gravid abdomen and concern for ionizing radiation exposure further limit evaluation. If undiagnosed, appendicitis may cause disastrous consequences for the mother and fetus. We present the case of a pregnant female who was admitted for right lower quadrant abdominal pain. Advanced imaging of the abdomen and pelvis was interpreted to be either indeterminate or normal and a diagnosis of acute appendicitis was made on purely clinical grounds. This patient’s management and a literature review of diagnostic techniques for acute appendicitis during pregnancy are discussed.
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Affiliation(s)
| | - Alexei U Kudla
- Naval Medical Center, Emergency Department, San Diego, California
| | - Chris B Chisholm
- Naval Medical Center, Emergency Department, San Diego, California
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de Moya MA, Sideris AC, Choy G, Chang Y, Landman WB, Cropano CM, Cohn SM. Appendectomy and Pregnancy: Gestational Age Does Not Affect the Position of the Incision. Am Surg 2015. [DOI: 10.1177/000313481508100331] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The position of the base of the appendix during advancing gestational age is based on inadequate data. Therefore, the proper location for an appendectomy incision during pregnancy is highly unclear. This study investigated the location of the appendix during pregnancy to determine the optimal location for an incision in pregnant patients with appendicitis relative to McBurney's point. Magnetic resonance images (MRIs) were reviewed independently by two fellowship-trained abdominal MRI radiologists blinded to the imaging report. The distance of the appendix from anatomic landmarks was measured in a total of 114 pregnant women with an abdominal or pelvic MRI who were admitted between 2001 and 2011 at a Level I trauma center. Patients with a history of appendectomy were excluded. The distance from the base of the appendix to McBurney's point changed over the course of the gestation by only 1.2 cm and which did not amount to a clinically or statistically significant change in position. Our data provide evidence that there is minimal upward or lateral displacement of the appendix during pregnancy, and therefore its distance from the McBurney's point remains essentially unchanged. These findings justify the use of the McBurney's incision for appendectomy during pregnancy regardless of the trimester.
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Affiliation(s)
| | | | | | | | - Wendy B. Landman
- Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts; and the
| | | | - Stephen M. Cohn
- Department of Surgery, University of Texas Health Science Center, San Antonio, Texas
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Theilen LH, Mellnick VM, Longman RE, Tuuli MG, Odibo AO, Macones GA, Cahill AG. Utility of magnetic resonance imaging for suspected appendicitis in pregnant women. Am J Obstet Gynecol 2015; 212:345.e1-6. [PMID: 25291255 DOI: 10.1016/j.ajog.2014.10.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Revised: 08/26/2014] [Accepted: 10/02/2014] [Indexed: 12/29/2022]
Abstract
OBJECTIVE The purpose of this study was to estimate the rate and risk of appendix nonvisualization and alternative diagnoses made with magnetic resonance imaging (MRI) for suspected appendicitis in pregnant women. STUDY DESIGN We performed a retrospective cohort study of consecutive pregnant women who underwent MRI for suspected appendicitis at a single center from 2007-2012. Data on clinical presentation, imaging, and surgical pathologic evidence were extracted from electronic medical records. Odds ratios estimated risk factors for nondiagnosis. Radiologic diagnoses were identified, and rates of diagnoses were calculated. Subgroup analysis was performed among women who underwent initial imaging with ultrasound scanning. RESULTS Over the 5-year period, 171 pregnant women underwent MRI for suspected appendicitis. The rate of nonvisualization was 30.9% (n = 53). Of the remaining 118 women with a visualized appendix, 18 women had imaging findings that were consistent with appendicitis and underwent appendectomy. Twelve cases of appendicitis were confirmed on pathologic evaluation (66.7%). Women with nonvisualization of the appendix on MRI were more likely to be beyond the first trimester (odds ratio, 2.1; 95% confidence interval, 1.0-4.5). Seventy-four women had disease diagnosed on MRI (43.3%). In the group of 43 women who had a nondiagnostic ultrasound scanning before the MRI, the rate of subsequent diagnostic MRI was 65% (n = 28). CONCLUSION MRI yields a high diagnostic rate and accuracy in pregnant women with suspected appendicitis and provides alternative diagnoses to guide further management. Given the high rate of appendix nonvisualization on ultrasound scanning that has been reported in the literature, we recommend MRI as the imaging modality of choice for this population in settings in which MRI is readily available.
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Aggenbach L, Zeeman GG, Cantineau AEP, Gordijn SJ, Hofker HS. Impact of appendicitis during pregnancy: no delay in accurate diagnosis and treatment. Int J Surg 2015; 15:84-9. [PMID: 25638737 DOI: 10.1016/j.ijsu.2015.01.025] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Revised: 01/10/2015] [Accepted: 01/26/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND Acute appendicitis during pregnancy may be associated with serious maternal and/or fetal complications. To date, the optimal clinical approach to the management of pregnant women suspected of having acute appendicitis is subject to debate. The purpose of this retrospective study was to provide recommendations for prospective clinical management of pregnant patients with suspected appendicitis. METHOD Case records of all pregnant patients suspected of having appendicitis whom underwent appendectomy at our hospital between 1990 and 2010 were reviewed. RESULTS Appendicitis was histologically verified in fifteen of twenty-one pregnant women, of whom six were diagnosed with perforated appendicitis. Maternal morbidity was seen in two cases. Premature delivery occurred in two out of six cases with perforated appendicitis cases and two out of six cases following a negative appendectomy. Perinatal mortality did not occur. CONCLUSION Both (perforated) appendicitis and negative appendectomy during pregnancy are associated with a high risk of premature delivery. Clinical presentation and imaging remains vital in deciding whether surgical intervention is indicated. We recommend to cautiously weigh the risks of delay until correct diagnosis with associated increased risk of appendiceal perforation and the risk of unnecessary surgical intervention. Based upon current literature, we recommend clinicians to consider an MRI following an inconclusive or negative abdominal ultrasound aiming to improve diagnostic accuracy to reduce the rate of negative appendectomies. Accurate and prompt diagnosis of acute appendicitis should be strived for to avoid unnecessary exploration and to aim for timely surgical intervention in pregnant women suspected of having appendicitis.
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Affiliation(s)
- L Aggenbach
- Department of Surgery, University Medical Center Groningen (UMCG), Hanzeplein 1, 9700 RB Groningen, The Netherlands.
| | - G G Zeeman
- Department of Gynaecology and Obstetrics, University Medical Center Groningen (UMCG), Hanzeplein 1, 9700 RB Groningen, The Netherlands
| | - A E P Cantineau
- Department of Gynaecology and Obstetrics, University Medical Center Groningen (UMCG), Hanzeplein 1, 9700 RB Groningen, The Netherlands
| | - S J Gordijn
- Department of Gynaecology and Obstetrics, University Medical Center Groningen (UMCG), Hanzeplein 1, 9700 RB Groningen, The Netherlands
| | - H S Hofker
- Department of Surgery, University Medical Center Groningen (UMCG), Hanzeplein 1, 9700 RB Groningen, The Netherlands
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Ramalingam V, LeBedis C, Kelly JR, Uyeda J, Soto JA, Anderson SW. Evaluation of a sequential multi-modality imaging algorithm for the diagnosis of acute appendicitis in the pregnant female. Emerg Radiol 2014; 22:125-32. [DOI: 10.1007/s10140-014-1260-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Accepted: 07/28/2014] [Indexed: 01/28/2023]
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