1
|
El-Aleem RA, Abd Allah AA, Shehata MR, Seifeldein GS, Hassanein SM. Diagnostic performance of spectral Doppler in acute appendicitis with an equivocal Alvarado score. Emerg Radiol 2024; 31:141-149. [PMID: 38265604 DOI: 10.1007/s10140-024-02205-5] [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: 11/27/2023] [Accepted: 01/12/2024] [Indexed: 01/25/2024]
Abstract
PURPOSE This study aims to evaluate the added value of duplex Doppler examination to the routinely graded compression grayscale ultrasound (US) for patients with suspected acute appendicitis (AA) in correlation with surgical management outcomes. METHODS The study lasted from January 2020 to March 2021. Throughout that period, patients who had suspected appendicitis were included with a visible appendix in the grayscale US. These patients were categorized clinically based on Alvarado's score. They underwent graded compression grayscale US of the appendix and duplex Doppler study. Subsequently, they were assigned for non-contrast multislice computed tomography (MSCT) according to Alvarado's score and underwent either emergency appendicectomy or conservative clinical management afterward. A Student's t-test was used to determine if there were significant differences in the mean values between the groups. The diagnostic performance of spectral Doppler US for the diagnosis of AA was depicted. RESULTS Eighty-four patients with visualized color flow in the appendicular Doppler US were enrolled, with 60 (71.4%) having AA, and 24 (28.6%) not having appendicitis. Spectral Doppler criterion of PSV greater than 8.6 cm/s demonstrated a high sensitivity of 91.67% and specificity of 77.78% for patients with Alvarado score ranging from 4 to 7, and appendiceal MOD ranging from 6 to 8 mm, while a discriminatory criterion of RI greater than 0.51 had a high sensitivity of 100% and a relatively lower specificity of 66.67%. CONCLUSION The patients with AA have significantly higher point PSV and point RI values than those without AA and are especially useful in equivocal patients whose MODs and Alvarado scores are in the diagnostically equivocal ranges of 6-8 mm and 4-7, respectively, with the point PSV and RI demonstrating negative predictive value 87.5% and 100%.
Collapse
Affiliation(s)
- Reham Abd El-Aleem
- Department of Diagnostic Radiology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Abdelrahman A Abd Allah
- Department of Diagnostic Radiology, Faculty of Medicine, New Valley University, Kharga, Egypt
| | | | - Gehan S Seifeldein
- Department of Diagnostic Radiology, Faculty of Medicine, Assiut University, Assiut, Egypt.
| | - Sara M Hassanein
- Department of Diagnostic Radiology, Faculty of Medicine, Assiut University, Assiut, Egypt
| |
Collapse
|
2
|
Li JJ, Boivin Z, Bhalodkar S, Liu R. Point of Care Abdominal Ultrasound. Semin Ultrasound CT MR 2024; 45:11-21. [PMID: 38056783 DOI: 10.1053/j.sult.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/08/2023]
Abstract
Abdominal pain is a common emergency department complaint, and point-of-care ultrasound (POCUS) of the abdomen is increasingly being utilized to evaluate clinical manifestations. It aids in accurate diagnoses and assists in procedures, particularly in emergency and critical care settings. Imaging is often required to confirm the etiology of abdominal pain. POCUS provides the benefit of avoiding radiation exposure and enables quicker diagnosis compared to computed tomography scans. There is growing evidence of the diagnostic accuracy for numerous abdominal POCUS applications, including appendicitis, intussusception, diverticulitis, gastric ultrasound and contrast-enhanced ultrasound.
Collapse
Affiliation(s)
- Jia J Li
- Yale New-Haven Hospital, New Haven, CT.
| | | | | | | |
Collapse
|
3
|
Mán E, Szilágyi A, Simonka Z, Rárosi F, Pető Z, Lázár G. Validation of the modified Alvarado score on patients attending A&E units with suspected appendicitis. BMC Emerg Med 2023; 23:87. [PMID: 37563578 PMCID: PMC10413638 DOI: 10.1186/s12873-023-00846-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 06/20/2023] [Indexed: 08/12/2023] Open
Abstract
INTRODUCTION The aim of our prospective study was to confirm validity and diagnostic accuracy of the modified Alvarado score, which was developed at the Department of Surgery, University of Szeged, on patients presenting with symptoms suggestive of acute appendicitis (right lower quadrant complaints) at the A&E department. PATIENT POPULATION, METHODS 138 patients were included in our study between 01.01.2019 and 01.01.2020. For patients attending A&E, the first medic calculated and recorded the modified Alvarado score before surgical consultation. The consulting surgeon decided on further treatment without knowing the score. Validation of the score was based on the pathology report of the removed appendix (whether the operation was warranted, and if the score also supported indication for surgery), if there was readmission or surgery due to worsening symptoms after discharge from A&E. We also examined if there was any connection between the value of the Alvarado score and the severity of inflammation. Our aim was to prove that using modified Alvarado score at the A&E Units helps to reduce patient's waiting time and avoid unnecessary surgical consultations. Furthermore our study included measuring the diagnostic accuracy of the ultrasound examination (specificity, sensitivity). RESULTS Based on the results, patients presenting at A&E had a mean modified Alvarado score of 6.5. Comparing the score to histological results showed that the specificity of the modified Alvarado score was 100%, and its sensitivity was 80.7%. Based on Spearman's rank correlation (0.796) and ROC analysis (AUC 0.968), the modified Alvarado score has an excellent predictive value in diagnosing acute appendicitis. When comparing the patients' waiting times with the use of modified Alvarado score and without it we found that there was a significant difference in group also in group under 4 points and in group over 7 points when using modified Alvarado score, so the diagnostic and therapeutic algorithm should be much quicker with the help of the score. We found a correlation between the severity of inflammation based on the Fisher's exact test. Rank correlation of the same question also showed a significant connection. All patients had an US examination during their diagnostic course, its sensitivity was 82.6%, specificity was 87%. Based on this, we can conclude that the predictive value of the imaging method is good. CONCLUSIONS We can conclude according to our results that the predictive value of the modified score is excellent, and it can be safely applied by non-surgeons in urgent care in the differential diagnosis of acute appendicitis. The new score incorporates the results of an easily obtainable, ionising radiation free imaging method, the ultrasound, which was not included in previous scores. With the help of the new score, the number of unnecessary surgical referrals and waiting times for patients are reduced, excess examinations will become avoidable.
Collapse
Affiliation(s)
- Eszter Mán
- Department of Surgery, University of Szeged, 6720 Szeged, Semmelweis Street 8, Szeged, Hungary.
| | - András Szilágyi
- Department of Surgery, University of Szeged, 6720 Szeged, Semmelweis Street 8, Szeged, Hungary
| | - Zsolt Simonka
- Department of Surgery, University of Szeged, 6720 Szeged, Semmelweis Street 8, Szeged, Hungary
| | - Ferenc Rárosi
- Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary
| | - Zoltán Pető
- Department of Emergency Medicine, University of Szeged, Szeged, Hungary
| | - György Lázár
- Department of Surgery, University of Szeged, 6720 Szeged, Semmelweis Street 8, Szeged, Hungary
| |
Collapse
|
4
|
Risk factors for periappendiceal adhesions in acute appendicitis: a retrospective comparative study. BMC Surg 2022; 22:134. [PMID: 35392891 PMCID: PMC8991578 DOI: 10.1186/s12893-022-01579-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 03/23/2022] [Indexed: 11/18/2022] Open
Abstract
Purpose Acute appendicitis usually requires immediate surgical treatment, but appendectomies were difficult for some patients with severe periappendiceal adhesions. We investigated risk factors of intraoperative adhesions to help surgeons make better treatment plans for appendicitis. Methods We retrospectively analyzed 186 cases diagnosed with acute appendicitis and underwent surgery in Shandong Provincial Hospital affiliated to Shandong First Medical University between January 2018 and December 2019. According to the degree of intraoperative adhesions, they were divided into mild, moderate and severe groups. Then, we analyzed a number of preoperative factors contributed to adhesions, suppuration and perforation during appendectomy in 186 patients. Results Contrast to the moderate group (MoG) and the mild group (MiG), the severe degree of adhesions group (SG) had a higher intraoperative perforation and suppuration rate, a greater likelihood of conversion to open and more postoperative complications. Multivariable logistic regression analysis showed that recurrent appendicitis and high neutrophil percentage were independently associated with periappendiceal adhesions. The preoperative ultrasonography (US) revealed periappendiceal fluid and high neutrophil percentage were independently associated with appendix suppuration. A high preoperative neutrophil percentage was independently associated with appendix perforation. Conclusions Recurrent appendicitis and preoperative high neutrophil percentage were risk factors of periappendiceal adhesions; preoperative US revealed periappendiceal fluid and high neutrophil percentage were risk factors of appendix suppuration; and a high preoperative neutrophil percentage was a risk factor of appendix perforation.
Collapse
|
5
|
Bakhshandeh T, Maleknejad A, Sargolzaie N, Mashhadi A, Zadehmir M. The utility of spectral Doppler evaluation of acute appendicitis. Emerg Radiol 2022; 29:371-375. [PMID: 35013851 DOI: 10.1007/s10140-021-02010-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 12/07/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE The use of spectral Doppler, peak systolic velocity (PSV), and resistive index (RI) imaging criteria to improve the accuracy of acute appendicitis diagnosis is hypothesized. METHODS Graded compression ultrasound was performed for suspected patients. The spectral Doppler evaluation was conducted while observing the appendix. A total of 152 patients (82 males and 70 females, ages 4-63 years, mean age of 24.5 years) were examined using the spectral Doppler waveform between 2018 and 2019. RI and PSV values of patients with and without appendicitis were compared to histopathologic findings. SPSS 26 was used to analyze the data, including using descriptive statistics and measures of sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). RESULTS Appendicitis was confirmed in 95 patients (62.5%) and rejected in 57 patients (37.5%). For the diagnosis of appendicitis, the area under the curve (AUC) of receiver operating characteristic (ROC) for RI (0.92 with 95% confidence interval (CI): 0.88, 0.97; P = 0.001) and PSV (0.96, with 95% CI: 0.93, 1.00; P = 0.001) was calculated. The discriminatory RI ≥ 0.49 demonstrated high sensitivity (90.5%) and low specificity (86%), and the discriminatory PSV ≥ 9.6 cm/s had high specificity (94.7%) and sensitivity (94.7%) for appendicitis. CONCLUSION By incorporating spectral Doppler criteria into routine graded compression ultrasound, the diagnostic accuracy of acute appendicitis was increased. In comparison, high PSV and RI values of the appendix with a cut-off point of 9.6 cm/s and 0.49 differ significantly between positive and negative appendectomy patients.
Collapse
Affiliation(s)
- Tahereh Bakhshandeh
- Department of Radiology, Torbat Heydarieh University of Medical Sciences, Torbat Heydarieh, Iran
| | - Abdulbaset Maleknejad
- Department of Surgery, School of Medicine, Zahedan University of Medical Sciences, Zahedan, Iran
| | - Narges Sargolzaie
- Community Medicine Department, Medical School, Zahedan University of Medical Sciences, Zahedan, Iran
| | - Amin Mashhadi
- Department of Radiology, School of Medicine, Zahedan University of Medical Sciences, Zahedan, Iran
| | - Mohadeseh Zadehmir
- Department of Radiology, School of Medicine, Zahedan University of Medical Sciences, Zahedan, Iran.
| |
Collapse
|
6
|
Hoffmann JC, Trimborn CP, Hoffmann M, Schröder R, Förster S, Dirks K, Tannapfel A, Anthuber M, Hollerweger A. Classification of acute appendicitis (CAA): treatment directed new classification based on imaging (ultrasound, computed tomography) and pathology. Int J Colorectal Dis 2021; 36:2347-2360. [PMID: 34143276 DOI: 10.1007/s00384-021-03940-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/21/2021] [Indexed: 02/06/2023]
Abstract
PURPOSE Acute appendicitis (AA) is amongst the most common causes of acute abdominal pain. In spite of progress based on risk stratifications, "negative" appendectomies are performed in up to 30% of patients whilst the appendix perforates in others. Preoperative classification of AA based on imaging is therefore recommended. The aim was to classify AA based on imaging (ultrasound/US, computed tomography/CT), surgical pathology, and/or histopathology in order to differentiate between complicated and uncomplicated AA. A new classification of acute appendicitis (CAA) shall be illustrated by typical US and CT images and be employed in a diagnostic and therapeutic algorithm. METHODS Medline, Embase, and the Cochrane Library were searched. Any study after 1970, which investigated clinical scores, pathology, US, CT, magnetic resonance imaging, and treatment of AA, was included. Typical images were taken from the author's image database. RESULTS Five main types of AA are defined, normal appendix (type 0), nonvisualised appendix (type X), uncomplicated AA (type 1), complicated AA without perforation (type 2), and complicated AA with perforation (type 3). The imaging modality is indicated by an additional letter, e.g., type p3b for free perforation on pathology. Standardised reporting of the appendix evaluation by US and CT is presented, as well as algorithms for AA management. Imaging features indicating imminent perforation, as well as likely recurrence, were both classified as complicated AA. CONCLUSION Imaging is mandatory in suspected AA. The CAA clearly separates uncomplicated from complicated forms of AA allowing nonoperative management in selected patients with uncomplicated forms of AA.
Collapse
Affiliation(s)
- Jörg C Hoffmann
- Medizinische Klinik I mit Schwerpunkt Gastroenterologie, Diabetologie, Rheumatologie und Onkologie, St. Marien- und St. Annastiftskrankenhaus, Salzburger Straße 15, D67067, Ludwigshafen, Germany.
| | - Claus-Peter Trimborn
- Medizinische Klinik I mit Schwerpunkt Gastroenterologie, Diabetologie, Rheumatologie und Onkologie, St. Marien- und St. Annastiftskrankenhaus, Salzburger Straße 15, D67067, Ludwigshafen, Germany
| | - Michael Hoffmann
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Ralf Schröder
- Radiologische Klinik, St. Marien- und St. Annastiftskrankenhaus Ludwigshafen, Ludwigshafen, Germany
| | - Sarah Förster
- Institut für Pathologie der Ruhr-Universität Bochum, Bochum, Germany
| | - Klaus Dirks
- Gastroenterologie, Allgemeine Innere Medizin und Geriatrie, Rems-Murr-Kliniken Winnenden, Winnenden, Germany
| | - Andrea Tannapfel
- Institut für Pathologie der Ruhr-Universität Bochum, Bochum, Germany
| | - Matthias Anthuber
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Alois Hollerweger
- Abteilung für Radiologie und Nuklearmedizin Krankenhaus der Barmherzigen Brüder Salzburg, Salzburg, Austria
| |
Collapse
|
7
|
Kadasne R, Sabih DE, Puri G, Sabih Q. Sonographic diagnosis of appendicitis: A pictorial essay and a new diagnostic maneuver. JOURNAL OF CLINICAL ULTRASOUND : JCU 2021; 49:847-859. [PMID: 34184283 DOI: 10.1002/jcu.23033] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 05/06/2021] [Accepted: 05/28/2021] [Indexed: 06/13/2023]
Abstract
While many cases of appendicitis are easy to diagnose clinically, a significant number need further workup in the form of imaging. Ultrasound and CT are both used extensively to diagnose or exclude appendicitis, or arrive at an alternate diagnosis. Ultrasound has many advantages but can be a difficult modality to use due to, among other reasons, the anatomical variations in appendicial location. The true retrocolic appendix is particularly difficult to diagnose with ultrasound. This pictorial essay examines the ultrasound features of normal and diseased appendix and proposes a new examining station, the prone view, for visualizing true retrocolic appendicitis.
Collapse
Affiliation(s)
- Ravi Kadasne
- Department of Radiology, Emirates International Hospital, Al Ain, UAE
| | - Durr-E- Sabih
- Section of Ultrasound, Multan Ultrasound Service, Multan, Pakistan
| | - Gunjan Puri
- Department of Radiology, Balaji Digital X-Ray and Sonography Clinic, Surat, India
| | - Quratulain Sabih
- Department of Surgery, The Veterans Affairs Medical Centre, Oklahoma City, Oklahoma, USA
| |
Collapse
|
8
|
Penticuff R, Jeffrey RB, Olcott EW. Hyperechoic Periappendiceal Fat: Evaluation of Criteria for Improving Specificity in the Sonographic Diagnosis of Appendicitis in Pediatric Patients. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2021; 40:285-296. [PMID: 32697409 DOI: 10.1002/jum.15399] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 05/28/2020] [Accepted: 06/04/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES To test the hypothesis that abutting and encasing types of hyperechoic periappendiceal fat are specific sonographic indicators of appendicitis in pediatric patients, including individuals with maximum outer diameters (MODs) of 6 to 8 mm in whom diagnosis by the MOD alone is known to be equivocal. METHODS Appendiceal sonograms of 271 consecutive pediatric patients were retrospectively evaluated for hyperechoic periappendiceal fat (globular, ≥1.0 cm; categorized as type 0, none; type 1, "abutting," encompassing <180° of the appendiceal circumference; or type 2, "encasing," encompassing 180° or more of the appendiceal circumference) and the MOD. Histopathologic and medical records constituted reference standards. Statistical methods included the binomial distribution, logistic regression, a receiver operating characteristic analysis, and the exact McNemar test. RESULTS All patients with hyperechoic fat and 105 of 107 patients with appendicitis had MODs of 6 mm or greater. The MOD and fat types 1 and 2 each were significantly associated with appendicitis in the univariable regression. The MOD and fat type 1 were independently associated with appendicitis in multivariable regression (odds ratio, 24.97; P = .034; and odds ratio, 5.35; P < .001, respectively). Specificities of an MOD of 6 to 8 mm and an MOD of 6 mm or greater alone were 89.0% (95% confidence interval, 83.2%-93.4%); these increased to 100.0% each (95% confidence interval, 97.8%-100.0%; P < .001) when combined with fat types 1, 2, and either 1 or 2 as diagnostic criteria, with positive predictive values of 100.0%. CONCLUSIONS Types 1 and 2 periappendiceal fat are specific indicators of appendicitis, and both improve specificity compared to the MOD. Importantly, they add specificity in diagnosing appendicitis in patients with diagnostically equivocal MODs of 6 to 8 mm.
Collapse
Affiliation(s)
- Ryan Penticuff
- Department of Radiology, Stanford University School of Medicine, Stanford, California, USA
| | - R Brooke Jeffrey
- Department of Radiology, Stanford University School of Medicine, Stanford, California, USA
| | - Eric W Olcott
- Department of Radiology, Stanford University School of Medicine, Stanford, California, USA
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| |
Collapse
|
9
|
Atwood R, Blair S, Fisk M, Bradley M, Coleman C, Rodriguez C. NSQIP Based Predictors of False Negative and Indeterminate Ultrasounds in Adults With Appendicitis. J Surg Res 2021; 261:326-333. [PMID: 33486414 DOI: 10.1016/j.jss.2020.10.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 08/11/2020] [Accepted: 10/31/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND It has been well established that ultrasound (US) is the initial screening tool for children with suspected acute appendicitis. However, computed tomography (CT) has become the standard screening modality for adults presenting with abdominal pain. A recent review of National Surgical Quality Improvement Program (NSQIP) data revealed US is being utilized as a screening modality in adults. We aimed to assess the diagnostic performance of US in evaluating adults with acute appendicitis. STUDY DESIGN The American College of Surgeons NSQIP and NSQIP Procedure Targeted Data Files were accessed and examined for all patients in 2016 and 2017 who received an US and underwent an appendectomy. The US results were then correlated to the pathology in order to determine the diagnostic performance. Additionally, we identified predictors for indeterminate and false negative US results. RESULTS Our study included 3607 appendectomy patients of which 1135 (30%) had an indeterminate US, 683 (18%) had an US not consistent with appendicitis, and 1789 (49%) had an US consistent with appendicitis. Sensitivity and Specificity were 74.3% and 53.0%, respectively. Positive Predictive Value (PPV) and Negative Predictive Value (NPV) were 95.9% and 12.2%, respectively. On regression analysis, clinically relevant predictors for false negative and indeterminate studies included age, sex, and BMI. CONCLUSIONS Ultrasound is an effective initial imaging modality for acute appendicitis in the adult population. Females, age >30 y, and elevated BMI were more likely to have indeterminate or false negative results. These patients may benefit from CT as their initial screening test.
Collapse
Affiliation(s)
- Rex Atwood
- Department of Surgery, Walter Reed National Military Medical Center and The Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Somer Blair
- Office of Clinical Research, John Peter Smith Health Network, Fort Worth, Texas
| | - Mandy Fisk
- Office of Clinical Research, John Peter Smith Health Network, Fort Worth, Texas
| | - Matthew Bradley
- Department of Surgery, Walter Reed National Military Medical Center and The Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Cathryn Coleman
- Department of Surgery, John Peter Smith Health Network, Fort Worth, Texas
| | - Carlos Rodriguez
- Department of Surgery, John Peter Smith Health Network, Fort Worth, Texas.
| |
Collapse
|
10
|
The Borderline-Size Appendix: Grayscale, Color Doppler, and Spectral Doppler Findings That Improve Specificity for the Sonographic Diagnosis of Acute Appendicitis. Ultrasound Q 2020; 36:314-320. [PMID: 33136933 DOI: 10.1097/ruq.0000000000000536] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Diagnostic criteria for acute appendicitis using graded compression sonography have been well established based on the maximum outer diameter (MOD) of the appendix, with MOD values of <6 mm nearly always indicating normal appendices and MOD values of >8 mm nearly always indicating appendicitis. However, the "borderline-size" appendix, meaning one whose MOD lies between these ranges (ie, an appendix with MOD of 6-8 mm), presents a diagnostic dilemma because appendices in this size range are neither clearly normal nor abnormal when diagnosis is based on the MOD alone; accordingly, such borderline MOD values are diagnostically equivocal, and sonographic diagnosis must rely on sonographic findings other than the MOD. The goal of this review was to examine the additional sonographic findings that can add specificity and help enable an accurate diagnosis to be made in patients with borderline-size appendices.
Collapse
|
11
|
Andric M, Kalff JC, Schwenk W, Farkas S, Hartwig W, Türler A, Croner R. [Recommendations on treatment of acute appendicitis : Recommendations of an expert group based on the current literature]. Chirurg 2020; 91:700-711. [PMID: 32747976 DOI: 10.1007/s00104-020-01237-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The paradigm shift in the treatment concept for acute appendicitis is currently the subject of intensive discussions. The diagnosis and differentiation of an uncomplicated from a complicated appendicitis as well as the selection of an adequate treatment is very challenging, especially since nonoperative treatment models have been published. The laparoscopic appendectomy is still the standard for most cases. Guidelines for the treatment of acute appendicitis do not exist in Germany. Therefore, a group of experts elaborated 21 recommendations on the treatment of acute appendicitis after 3 meetings. After initial definition of population, intervention, comparison and outcome (PICO) questions, recommendations have been finalized through the Delphi voting system. The results were evaluated according to the current literature. The aim of this initiative was to define a basic support for decision making in the clinical routine for treatment of acute appendicitis.
Collapse
Affiliation(s)
- M Andric
- Klinik für Allgemein‑, Viszeral‑, Gefäß- und Transplantationschirurgie, Universitätsklinikum Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Deutschland.
| | - J C Kalff
- Klinik und Poliklinik für Allgemein‑, Viszeral‑, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn, Bonn, Deutschland
| | - W Schwenk
- Allgemein‑, Viszeral- und Gefäßchirurgie, Städtisches Klinikum Solingen, Solingen, Deutschland
| | - S Farkas
- Allgemein- und Viszeralchirurgie, St. Josefs-Hospital Wiesbaden, Wiesbaden, Deutschland
| | - W Hartwig
- Klinik für Allgemein‑, Viszeral- und Onkologische Chirurgie, Evangelisches Krankenhaus Düsseldorf, Düsseldorf, Deutschland
| | - A Türler
- Allgemein- und Viszeralchirurgie, Johanniter Kliniken Bonn, Bonn, Deutschland
| | - R Croner
- Klinik für Allgemein‑, Viszeral‑, Gefäß- und Transplantationschirurgie, Universitätsklinikum Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Deutschland
| |
Collapse
|
12
|
Perrone G, Sartelli M, Mario G, Chichom-Mefire A, Labricciosa FM, Abu-Zidan FM, Ansaloni L, Biffl WL, Ceresoli M, Coccolini F, Coimbra R, Demetrashvili Z, Di Saverio S, Fraga GP, Khokha V, Kirkpatrick AW, Kluger Y, Leppaniemi A, Maier RV, Moore EE, Negoi I, Ordonez CA, Sakakushev B, Lohse HAS, Velmahos GC, Wani I, Weber DG, Bonati E, Catena F. Management of intra-abdominal-infections: 2017 World Society of Emergency Surgery guidelines summary focused on remote areas and low-income nations. Int J Infect Dis 2020; 99:140-148. [PMID: 32739433 DOI: 10.1016/j.ijid.2020.07.046] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 07/23/2020] [Accepted: 07/26/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Most remote areas have restricted access to healthcare services and are too small and remote to sustain specialist services. In 2017, the World Society of Emergency Surgery (WSES) published guidelines for the management of intra-abdominal infections. Many hospitals, especially those in remote areas, continue to face logistical barriers, leading to an overall poorer adherence to international guidelines. METHODS The aim of this paper is to report and amend the 2017 WSES guidelines for the management of intra-abdominal infections, extending these recommendations for remote areas and low-income countries. A literature search of the PubMed/MEDLINE databases was conducted covering the period up until June 2020. RESULTS The critical shortages of healthcare workers and material resources in remote areas require the use of a robust triage system. A combination of abdominal signs and symptoms with early warning signs may be used to screen patients needing immediate acute care surgery. A tailored diagnostic step-up approach based on the hospital's resources is recommended. Ultrasound and plain X-ray may be useful diagnostic tools in remote areas. The source of infection should be totally controlled as soon as possible. CONCLUSIONS The cornerstones of effective treatment for intra-abdominal infections in remote areas include early diagnosis, prompt resuscitation, early source control, and appropriate antimicrobial therapy. Standardization in applying the guidelines is mandatory to adequately manage intra-abdominal infections.
Collapse
Affiliation(s)
- Gennaro Perrone
- Department of Emergency Surgery, Maggiore Hospital, Parma, Italy
| | | | - Giuffrida Mario
- Department of General Surgery, Maggiore Hospital, Parma, Italy.
| | - Alain Chichom-Mefire
- Department of Surgery and Obstetrics/Gynaecology, Regional Hospital, Limbe, Cameroon
| | - Francesco Maria Labricciosa
- Department of Biomedical Sciences and Public Health, Unit of Hygiene, Preventive Medicine and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Luca Ansaloni
- General Surgery Department, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Walter L Biffl
- Acute Care Surgery at The Queen's Medical Center, John A. Burns School of Medicine, University of Hawai'i, Honolulu, USA
| | - Marco Ceresoli
- General Surgery Department, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy
| | - Raul Coimbra
- Department of Surgery, UC San Diego Medical Center, San Diego, CA, USA
| | - Zaza Demetrashvili
- Department of Surgery, Tbilisi State Medical University, Kipshidze Central University Hospital, Tbilisi, Georgia
| | - Salomone Di Saverio
- Department of General Surgery, University Hospital of Varese, University of Insubria, Varese, Italy
| | - Gustavo Pereira Fraga
- Division of Trauma Surgery, Department of Surgery, School of Medical Sciences, University of Campinas (Unicamp), Campinas, SP, Brazil
| | - Vladimir Khokha
- Department of Emergency Surgery, Mozyr City Hospital, Mozyr, Belarus
| | - Andrew W Kirkpatrick
- Departments of Surgery, Critical Care Medicine, and the Regional Trauma Service, Foothills Medical Centre, Calgary, Alberta, Canada
| | - Yoram Kluger
- Department of General Surgery, Division of Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Ari Leppaniemi
- Abdominal Center, University Hospital Meilahti, Helsinki, Finland
| | - Ronald V Maier
- Department of Surgery, University of Washington, Seattle, WA, USA
| | - Ernest Eugene Moore
- Department of Surgery, University of Colorado, Denver Health Medical Center, Denver, CO, USA
| | - Ionut Negoi
- Department of Surgery, Emergency Hospital of Bucharest, Bucharest, Romania
| | - Carlos A Ordonez
- Department of Surgery and Critical Care, Universidad del Valle, Fundación Valle del Lili, Cali, Colombia
| | - Boris Sakakushev
- General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | - Helmut A Segovia Lohse
- II Cátedra de Clínica Quirúrgica, Hospital de Clínicas, Facultad de Ciencias Medicas, Universidad Nacional de Asuncion, Asuncion, Paraguay
| | - George C Velmahos
- Trauma, Emergency Surgery, and Surgical Critical Care Harvard Medical School, Massachusetts General Hospital, Boston, USA
| | - Imtaz Wani
- Department of Surgery, Sheri-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Dieter G Weber
- Department of Trauma Surgery, Royal Perth Hospital, Perth, Australia
| | - Elena Bonati
- Department of General Surgery, Maggiore Hospital, Parma, Italy
| | - Fausto Catena
- Department of Emergency Surgery, Maggiore Hospital, Parma, Italy
| |
Collapse
|
13
|
Monsonis B, Mandoul C, Millet I, Taourel P. Imaging of appendicitis: Tips and tricks. Eur J Radiol 2020; 130:109165. [PMID: 32663765 DOI: 10.1016/j.ejrad.2020.109165] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 06/25/2020] [Accepted: 06/30/2020] [Indexed: 12/29/2022]
Abstract
Acute appendicitis is one of the most common surgical emergencies worldwide. Over the past 30 years, imaging has become central to the diagnosis of appendicitis, reducing both negative appendicectomy rate and healthcare expenses. Appendicitis can be challenging in many ways for radiologists with various clinical presentations, complications and differential diagnoses. The aim of this review is to present a step-by-step reasoning with key findings, tips and tricks leading to the diagnosis of appendicitis and its complications. The first steps are with the use of the appropriate imaging modality (US, CT and MRI) to locate the appendix in abdominal cavity and to identify the features of appendicitis and its complications through specific imaging signs. The next steps are to eliminate an unusual morphology of the appendix that may simulate acute appendicitis and to recognize an unusual imaging presentation of appendicitis. Then, to corroborate the diagnosis of appendicitis, the last step is to rule out any differential diagnoses mainly from the genitourinary and gastrointestinal tracts. Following these steps can help to accurately diagnose appendicitis and its complications.
Collapse
Affiliation(s)
- Benjamin Monsonis
- Radiology Department, CHU Lapeyronie, 371 Avenue du doyen Gaston Giraud, 34295 Montpellier, France
| | - Caroline Mandoul
- Radiology Department, CHU Lapeyronie, 371 Avenue du doyen Gaston Giraud, 34295 Montpellier, France
| | - Ingrid Millet
- Radiology Department, CHU Lapeyronie, 371 Avenue du doyen Gaston Giraud, 34295 Montpellier, France
| | - Patrice Taourel
- Radiology Department, CHU Lapeyronie, 371 Avenue du doyen Gaston Giraud, 34295 Montpellier, France.
| |
Collapse
|
14
|
Di Saverio S, Podda M, De Simone B, Ceresoli M, Augustin G, Gori A, Boermeester M, Sartelli M, Coccolini F, Tarasconi A, De' Angelis N, Weber DG, Tolonen M, Birindelli A, Biffl W, Moore EE, Kelly M, Soreide K, Kashuk J, Ten Broek R, Gomes CA, Sugrue M, Davies RJ, Damaskos D, Leppäniemi A, Kirkpatrick A, Peitzman AB, Fraga GP, Maier RV, Coimbra R, Chiarugi M, Sganga G, Pisanu A, De' Angelis GL, Tan E, Van Goor H, Pata F, Di Carlo I, Chiara O, Litvin A, Campanile FC, Sakakushev B, Tomadze G, Demetrashvili Z, Latifi R, Abu-Zidan F, Romeo O, Segovia-Lohse H, Baiocchi G, Costa D, Rizoli S, Balogh ZJ, Bendinelli C, Scalea T, Ivatury R, Velmahos G, Andersson R, Kluger Y, Ansaloni L, Catena F. Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines. World J Emerg Surg 2020; 15:27. [PMID: 32295644 PMCID: PMC7386163 DOI: 10.1186/s13017-020-00306-3] [Citation(s) in RCA: 430] [Impact Index Per Article: 107.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 03/30/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND AIMS Acute appendicitis (AA) is among the most common causes of acute abdominal pain. Diagnosis of AA is still challenging and some controversies on its management are still present among different settings and practice patterns worldwide. In July 2015, the World Society of Emergency Surgery (WSES) organized in Jerusalem the first consensus conference on the diagnosis and treatment of AA in adult patients with the intention of producing evidence-based guidelines. An updated consensus conference took place in Nijemegen in June 2019 and the guidelines have now been updated in order to provide evidence-based statements and recommendations in keeping with varying clinical practice: use of clinical scores and imaging in diagnosing AA, indications and timing for surgery, use of non-operative management and antibiotics, laparoscopy and surgical techniques, intra-operative scoring, and peri-operative antibiotic therapy. METHODS This executive manuscript summarizes the WSES guidelines for the diagnosis and treatment of AA. Literature search has been updated up to 2019 and statements and recommendations have been developed according to the GRADE methodology. The statements were voted, eventually modified, and finally approved by the participants to the consensus conference and by the board of co-authors, using a Delphi methodology for voting whenever there was controversy on a statement or a recommendation. Several tables highlighting the research topics and questions, search syntaxes, and the statements and the WSES evidence-based recommendations are provided. Finally, two different practical clinical algorithms are provided in the form of a flow chart for both adults and pediatric (< 16 years old) patients. CONCLUSIONS The 2020 WSES guidelines on AA aim to provide updated evidence-based statements and recommendations on each of the following topics: (1) diagnosis, (2) non-operative management for uncomplicated AA, (3) timing of appendectomy and in-hospital delay, (4) surgical treatment, (5) intra-operative grading of AA, (6) ,management of perforated AA with phlegmon or abscess, and (7) peri-operative antibiotic therapy.
Collapse
Affiliation(s)
- Salomone Di Saverio
- Cambridge Colorectal Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge Biomedical Campus, Hills Road, Cambridge, CB2 0QQ, UK.
- Department of General Surgery, University of Insubria, University Hospital of Varese, ASST Sette Laghi, Regione Lombardia, Varese, Italy.
| | - Mauro Podda
- Department of General and Emergency Surgery, Cagliari University Hospital, Cagliari, Italy
| | - Belinda De Simone
- Emergency and Trauma Surgery Department, Maggiore Hospital of Parma, Parma, Italy
| | - Marco Ceresoli
- Emergency and General Surgery Department, University of Milan-Bicocca, Milan, Italy
| | - Goran Augustin
- Department of Surgery, University Hospital Centre of Zagreb, Zagreb, Croatia
| | - Alice Gori
- Maggiore Hospital Regional Emergency Surgery and Trauma Center, Bologna Local Health District, Bologna, Italy
| | - Marja Boermeester
- Department of Surgery, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Federico Coccolini
- General, Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy
| | - Antonio Tarasconi
- Emergency and Trauma Surgery Department, Maggiore Hospital of Parma, Parma, Italy
| | - Nicola De' Angelis
- Department of Digestive, Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Henri Mondor University Hospital, Paris, France
| | - Dieter G Weber
- Trauma and General Surgeon Royal Perth Hospital & The University of Western Australia, Perth, Australia
| | - Matti Tolonen
- Department of Abdominal Surgery, Abdominal Center, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
| | - Arianna Birindelli
- Department of General Surgery, Azienda Socio Sanitaria Territoriale, di Valle Camonica, Italy
| | - Walter Biffl
- Queen's Medical Center, University of Hawaii, Honolulu, HI, USA
| | - Ernest E Moore
- Denver Health System - Denver Health Medical Center, Denver, USA
| | - Michael Kelly
- Acute Surgical Unit, Canberra Hospital, ACT, Canberra, Australia
| | - Kjetil Soreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Jeffry Kashuk
- Department of Surgery, University of Jerusalem, Jerusalem, Israel
| | - Richard Ten Broek
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Carlos Augusto Gomes
- Department of Surgery Hospital Universitario, Universidade General de Juiz de Fora, Juiz de Fora, Brazil
| | | | - Richard Justin Davies
- Cambridge Colorectal Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge Biomedical Campus, Hills Road, Cambridge, CB2 0QQ, UK
| | - Dimitrios Damaskos
- Department of Upper GI Surgery, Royal Infirmary of Edinburgh, Edinburgh, Scotland, UK
| | - Ari Leppäniemi
- Department of Abdominal Surgery, Abdominal Center, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
| | - Andrew Kirkpatrick
- General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, Alberta, Canada
| | - Andrew B Peitzman
- Department of Surgery, University of Pittsburgh School of Medicine, UPMC-Presbyterian, Pittsburgh, USA
| | - Gustavo P Fraga
- Faculdade de Ciências Médicas (FCM) - Unicamp, Campinas, SP, Brazil
| | - Ronald V Maier
- Department of Surgery, University of Washington, Harborview Medical Center, Seattle, WA, USA
| | - Raul Coimbra
- UCSD Health System - Hillcrest Campus Department of Surgery Chief Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, San Diego, CA, USA
| | - Massimo Chiarugi
- General, Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy
| | - Gabriele Sganga
- Department of Emergency Surgery, "A. Gemelli Hospital", Catholic University of Rome, Rome, Italy
| | - Adolfo Pisanu
- Department of General and Emergency Surgery, Cagliari University Hospital, Cagliari, Italy
| | - Gian Luigi De' Angelis
- Gastroenterology and Endoscopy Unit, University Hospital of Parma, University of Parma, Parma, Italy
| | - Edward Tan
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Harry Van Goor
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Francesco Pata
- Department of Surgery, Nicola Giannettasio Hospital, Corigliano-Rossano, and La Sapienza University of Rome, Rome, Italy
| | - Isidoro Di Carlo
- Department of Surgical Sciences and Advanced Technologies "GF Ingrassia", Cannizzaro Hospital, University of Catania, Catania, Italy
| | | | - Andrey Litvin
- Department of Surgery, Immanuel Kant Baltic Federal University, Kaliningrad, Russia
| | - Fabio C Campanile
- Department of Surgery, San Giovanni Decollato Andosilla Hospital, Viterbo, Italy
| | - Boris Sakakushev
- General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | - Gia Tomadze
- Department of Surgery, Tbilisi State Medical University, TSMU, Tbilisi, Georgia
| | - Zaza Demetrashvili
- Department of Surgery, Tbilisi State Medical University, TSMU, Tbilisi, Georgia
| | - Rifat Latifi
- Section of Acute Care Surgery, Westchester Medical Center, Department of Surgery, New York Medical College, Valhalla, NY, USA
| | - Fakri Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | | | | | - Gianluca Baiocchi
- Surgical Clinic, Department of Experimental and Clinical Sciences, University of Brescia, Brescia, Italy
| | - David Costa
- Hospital universitario de Alicante, departamento de Cirugia General, Alicante, Spain
| | - Sandro Rizoli
- Department of Surgery, St. Michael Hospital, University of Toronto, Toronto, Canada
| | - Zsolt J Balogh
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW, Australia
| | - Cino Bendinelli
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW, Australia
| | | | - Rao Ivatury
- Professor Emeritus Virginia Commonwealth University, Richmond, VA, USA
| | - George Velmahos
- Harvard Medical School, Massachusetts General Hospital, Boston, USA
| | | | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Luca Ansaloni
- Department of General Surgery and Trauma, Bufalini Hospital, Cesena, Italy
| | - Fausto Catena
- Emergency and Trauma Surgery Department, Maggiore Hospital of Parma, Parma, Italy
| |
Collapse
|
15
|
Correlating Abdominal Wall Thickness and Body Mass Index to Predict Usefulness of Right Lower Quadrant Ultrasound for Evaluation of Pediatric Appendicitis. Pediatr Emerg Care 2020; 36:e156-e159. [PMID: 29112539 DOI: 10.1097/pec.0000000000001313] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To inform selective and efficient use of appendix ultrasound (US) beyond adult parameters of body mass index (BMI) of less than 25 kg/m, we correlate abdominal wall thickness (AWT) with age and BMI to generate parameters for male and female children. Information presented in chart format can aid in the decision to utilize US for the evaluation of appendicitis. METHODS In this observational study, 1600 pediatric computed tomography scans of the abdomen and pelvis were analyzed to obtain measurements of AWT in the right lower quadrant. Measurements were correlated by patient age, BMI, and sex. Results and consensus-based recommendations were presented in chart format with color-coded groupings to allow for convenient referencing in the clinical setting. RESULTS One thousand four hundred eighty-eight computed tomography scans and AWT measurements were included. All age groups with BMI of less than 25 kg/m and all male and female groups younger than 6 years regardless of BMI had median AWT of less than 4 cm resulting in strong recommendation for US. Males older than 6 years and all female age groups with BMI of greater than 30 kg/m and female older than 15 years and BMI of greater than 25 kg/m had AWT of more than 5 cm resulting in low recommendation for US. CONCLUSIONS While the BMI cutoff standard of less than 25 kg/m for usefulness of appendix US holds in the adult population, our data expand the acceptable range in children younger than 9 years regardless of BMI and male children with BMI up to 30 kg/m. Female children younger than 15 years with a BMI up to 30 kg/m may also be amenable to right lower quadrant US based on AWT. These parameters inform selective and efficient use of US for appendix evaluation.
Collapse
|
16
|
Mimery A, Pereira R, Tsao SCH. Left-sided tubo-ovarian abscess mimicking appendicitis: a diagnostic dilemma. ANZ J Surg 2020; 90:2092-2093. [PMID: 32077572 DOI: 10.1111/ans.15770] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 01/07/2020] [Accepted: 02/03/2020] [Indexed: 12/29/2022]
Affiliation(s)
- Alexander Mimery
- Department of Surgery, Gladstone Hospital, Gladstone, Queensland, Australia
| | - Ryan Pereira
- Department of Surgery, Gladstone Hospital, Gladstone, Queensland, Australia
| | | |
Collapse
|
17
|
Revzin MV, Moshiri M, Bokhari J, Pellerito JS, Menias C. Sonographic assessment of infectious diseases of the gastrointestinal tract: from scanning to diagnosis. Abdom Radiol (NY) 2020; 45:261-292. [PMID: 31960117 DOI: 10.1007/s00261-019-02358-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Sonography of the gastrointestinal (GI) tract is a practical, safe, inexpensive, and reproducible diagnostic tool for the evaluation, diagnosis, and follow-up of infectious bowel disease. The modality is rapidly gaining prominence among clinicians on a global scale. In the United States, however, ultrasound of the bowel remains underutilized primarily due to insufficient experience among radiologists and sonographers in performing sonographic bowel assessment. This lack of experience and knowledge results in misinterpretations, missed diagnoses, and underutilization of this modality in patients with acute abdomen, with the majority of GI pathology on sonography discovered incidentally. OBJECTIVES This article aims to demonstrate the characteristic sonographic findings associated with GI infectious processes as well as provide dedicated ultrasound protocols for evaluation of the GI tract. CONCLUSION This article serves a twofold purpose, raising awareness of the utility of this imaging modality within the radiology community and also providing practical teaching points for sonographic evaluation of infectious disorders of the GI tract.
Collapse
Affiliation(s)
- Margarita V Revzin
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, 333 Cedar Street, PO Box 208042, Room TE-2, New Haven, CT, 06520, USA.
| | - Mariam Moshiri
- Department of Radiology, University of Washington Medical Center, Seattle, WA, USA
| | - Jamal Bokhari
- Department of Diagnostic Radiology, Yale University School of Medicine, 333 Cedar Street, PO Box 208042, Room TE-2, New Haven, CT, 06520, USA
| | - John S Pellerito
- Department of Radiology, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, 300 Community Drive, Manhasset, NY, 11030, USA
| | - Christine Menias
- Radiology, Mayo Clinic Arizona, 5777 East Mayo Blvd, Phoenix, AZ, 85054, USA
| |
Collapse
|
18
|
Chakraborty AK, Olcott EW, Jeffrey BR. Hyperechoic Abdominal Fat: A Sentinel Sign of Inflammation. Ultrasound Q 2020; 35:186-194. [PMID: 30300322 DOI: 10.1097/ruq.0000000000000387] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
One of the most useful sonographic signs of acute abdominal inflammation is the identification of increased echogenicity of the surrounding fat. Hyperechoic fat results from vasodilation and edema extending from an adjacent source of infection or inflammation. These changes are mediated by such factors such as bradykinin, histamine, and various cytokines. The recognition of hyperechoic fat on sonography may be an important indicator of the primary source of pathology. In addition, it often reflects a more advanced degree of transmural pathology, such as "walled-off" perforation of a hollow viscus. This pictorial essay will present a variety of examples of hyperechoic inflamed fat involving different abdominal organs and will illustrate the diagnostic value of this finding.
Collapse
Affiliation(s)
- Amit K Chakraborty
- Department of Radiology, Stanford University School of Medicine, Stanford, CA
| | | | - Brooke R Jeffrey
- Department of Radiology, Stanford University School of Medicine, Stanford, CA
| |
Collapse
|
19
|
Aydin S, Tek C, Ergun E, Kazci O, Kosar PN. Acute Appendicitis or Lymphoid Hyperplasia: How to Distinguish More Safely? Can Assoc Radiol J 2019; 70:354-360. [PMID: 31500858 DOI: 10.1016/j.carj.2018.09.006] [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: 02/05/2018] [Revised: 07/05/2018] [Accepted: 09/20/2018] [Indexed: 12/20/2022] Open
Abstract
PURPOSE Lymphoid hyperplasia can be an important mimicker of acute appendicitis by creating a non-compressible appendix more than 6 mm in diameter. The aim of this study was to evaluate methods of distinguishing lymphoid hyperplasia and appendicitis on the basis of sonography, lamina propria thickness, and Alvarado scoring. METHODS This retrospective study included 259 patients (142 appendicitis, 117 lymphoid hyperplasia). The US (ultrasound) reports of the patients were reviewed and the maximum diameter of the appendix, the presence or absence of increased echogenicity of the surrounding pericaecal fat, local fluid collection, the presence of reactive lymph nodes in the periappendiceal area, and mural hyperemia within the appendix were recorded. RESULTS The use of additional sonographic criteria, lamina propria thickness (≤1 mm is indicative for appendicitis), or Alvarado scoring (>6 mm is indicative for appendicitis) provided a true-positive diagnosis for acute appendicitis. CONCLUSION The presence of local fluid collection in the periappendiceal area and a lamina propria thickness ≤ 1 mm are the most successful parameters for distinguishing appendicitis from lymphoid hyperplasia.
Collapse
Affiliation(s)
- Sonay Aydin
- Ankara Training and Research Hospital, Department of Radiology, Ankara, Turkey.
| | - Cihat Tek
- Ankara Training and Research Hospital, Department of Radiology, Ankara, Turkey
| | - Elif Ergun
- Ankara Training and Research Hospital, Department of Radiology, Ankara, Turkey
| | - Omer Kazci
- Ankara Training and Research Hospital, Department of Radiology, Ankara, Turkey
| | - Pinar Nercis Kosar
- Ankara Training and Research Hospital, Department of Radiology, Ankara, Turkey
| |
Collapse
|
20
|
Early ultrasound in acute appendicitis avoids CT in most patients but delays surgery and increases complicated appendicitis if nondiagnostic - A retrospective study. Am J Surg 2019; 219:683-689. [PMID: 31153584 DOI: 10.1016/j.amjsurg.2019.05.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 05/12/2019] [Accepted: 05/22/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND We determined whether increasing early imaging (in the emergency department) was associated with earlier surgery and a decrease in complicated appendicitis. METHODS Retrospective study; 3013 operations between 12/2006-12/2016. RESULTS Early imaging increased from 13.1% to 74.1%, mostly due to increasing use of ultrasound. Negative appendectomies decreased from 10.7% to 5.1% (p < 0.001). Ultrasound was diagnostic in 80.5%. The false positive rate of ultrasound was 4%. Median time to surgery following positive ultrasound was 7.4 h (IQR 5.8-9.4), shorter compared to no early imaging (13.3 h, IQR 7.2-20.0; p < 0.001). However, median time to surgery following inconclusive and negative ultrasound was 11.5 h (IQR 8.7-16.1) and 17.0 h (IQR 10.3-26.7) respectively. The incidence of complicated appendicitis was 40% and 37.7%, higher than 21.5% in patients with positive US (p < 0.001). CONCLUSIONS Early imaging resulted in earlier surgery but did not reduce the incidence of complicated appendicitis. Ultrasound averted the need for CT in the majority of patients. When ultrasound was negative or inconclusive, time to surgery was delayed and the rate of complicated appendicitis higher.
Collapse
|
21
|
Kuhn KJ, Brooke Jeffrey R, Olcott EW. Luminal obstruction in uncomplicated appendicitis: Detection with sonography and potential clinical implications. JOURNAL OF CLINICAL ULTRASOUND : JCU 2019; 47:113-119. [PMID: 30350372 DOI: 10.1002/jcu.22655] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 08/29/2018] [Accepted: 09/27/2018] [Indexed: 06/08/2023]
Abstract
PURPOSE To determine the frequency of luminal obstruction on appendiceal graded compression sonography (US) in patients with uncomplicated appendicitis and test the hypothesis that this frequency is similar to the failure rates of primary antibiotic therapy for uncomplicated appendicitis when treatment selection is based on CT findings. METHODS Sonograms of 150 consecutive patients with appendicitis diagnosed on ultrasound (US) and proven histopathologically were retrospectively evaluated; 114 (76.0%) had uncomplicated appendicitis, that is, appendicitis without gangrene or perforation, and were evaluated for appendicolithiasis and lymphoid hyperplasia using previously published sonographic criteria, and for luminal obstruction. RESULTS Of the 114 patients with uncomplicated appendicitis, US demonstrated no luminal obstruction in 74 (64.9%) and luminal obstruction in 40 (35.1%, P = .018), the latter including 16 (40.0%) with lymphoid hyperplasia and 24 (60.0%, P = .074) with appendicolithiasis. CONCLUSIONS US demonstrated luminal obstruction in 35.1% of patients with uncomplicated appendicitis, similar to the published failure rates of antibiotic therapy when treatment selection is based on CT. This confirms the hypothesis, supporting the possibility that undiagnosed luminal obstruction may account for treatment failures when patients are selected by CT for primary antibiotic therapy, and suggests a role for US in selecting patients without luminal obstruction for antibiotic therapy.
Collapse
Affiliation(s)
- Karin J Kuhn
- Department of Radiology, Stanford University School of Medicine, Stanford, California
| | - R Brooke Jeffrey
- Department of Radiology, Stanford University School of Medicine, Stanford, California
| | - Eric W Olcott
- Department of Radiology, Stanford University School of Medicine, Stanford, California
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| |
Collapse
|
22
|
Sonography of the Cecum: Gateway to the Right Lower Quadrant. Ultrasound Q 2018; 34:133-140. [PMID: 29346264 DOI: 10.1097/ruq.0000000000000332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Sonography of the cecum has come of age largely as a consequence of the successful evolution of appendiceal sonography as a useful tool in the evaluation of patients with right lower-quadrant pain. At some medical centers, graded-compression sonography (GCS) has become the initial imaging study of choice in the assessment of these individuals. The cecum serves as a helpful anatomic landmark for localization of the appendix in these examinations-providing a sonographic starting point in the search for the appendix. During GCS, primary pathology within the cecum itself can become evident, including a variety of processes, such as infectious, inflammatory, or neoplastic disorders, whose presentations commonly mimic that of appendicitis. The accurate diagnosis of cecal abnormalities and their differentiation from acute appendicitis play valuable roles in the management of affected patients because the options for further workup and subsequent treatment vary greatly according to the diagnosis at hand. Additionally, the compressed cecum often becomes an acoustic window into the right lower quadrant, revealing pathology apart from the appendix within the right iliac fossa. The purpose of this pictorial essay is to highlight the importance and value of performing a careful evaluation of the cecum during GCS of patients with suspected appendicitis and to review the differential diagnosis and imaging findings of primary cecal abnormalities whose clinical presentations can mimic that of acute appendicitis.
Collapse
|
23
|
Anatomic Reasons for Failure to Visualize the Appendix With Graded Compression Sonography: Insights From Contemporaneous CT. AJR Am J Roentgenol 2017; 209:W128-W138. [PMID: 28829172 DOI: 10.2214/ajr.17.18059] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this study is to identify the anatomic locations of appendixes on CT when graded compression sonography fails to visualize the appendix. MATERIALS AND METHODS The study included 197 patients with suspected appendicitis whose appendixes were not visualized on graded compression sonography performed with typically used transducers of at least 10 MHz, who underwent CT within 48 hours following graded compression sonography, and who had available either pathologic examination following surgery or 6-week follow-up if surgery was not performed. Appendixes were retrospectively localized using four transverse quadrants (including the posteromedial quadrant) centered on the ileocecal valve and projected vertically, the craniocaudal level relative to the iliac crests, and the depth of the appendix as measured from the surface of the skin. Data were assessed using the Fisher exact test, t test, multinomial test, binomial distribution, ANOVA, and linear regression. RESULTS Appendixes were most frequently located in the posteromedial quadrant (123 of 197 patients [62.4%]; 95% CI, 55.3-69.2%) at a statistically significantly greater frequency than that expected by chance (p < 0.00001). Appendixes were located above the iliac crests in 19.8% of patients (39/197; 95% CI, 14.5-26.1%) and at depths exceeding the penetration of typical transducers of at least 10 MHz in 19.3% of patients (38/197; 95% CI, 14.0-25.5%). All appendixes (95% CI, 98.1-100.0%) were located within the range of 6-MHz transducers. CONCLUSION Appendixes that are not visualized on graded compression sonography are most frequently located in the posteromedial quadrant and are often located above the iliac crests or at depths too great for visualization with typically used transducers of at least 10 MHz. Accordingly, when the appendix is not visualized on graded compression sonography, targeted scanning of the posteromedial quadrant and the region above the iliac crests, and scanning with 6-MHz transducers, may enable visualization of the appendix and are recommended additions to scanning protocols.
Collapse
|
24
|
Abstract
Pelvic pain is a common complaint in female patients who present to the emergency department. Although encountered frequently, the path to a definitive diagnosis is not always a straightforward one, and imaging offers a valuable tool to aid in this diagnostic challenge. Radiologists must be familiar with the most common etiologies of female pelvic pain in the emergency setting, their imaging characteristics, and the best way to further evaluate challenging clinical presentations. This allows the radiologist to serve as a valuable asset to the treating physician, aiding in accurate diagnosis, and in guiding the course of treatment, all while ensuring the "Image Wisely" principle. A sonographic approach to female patients presenting to the emergency setting with pelvic pain has been presented in this article and some example entities along with their imaging findings have also been reviewed.
Collapse
Affiliation(s)
- Daniel P Thut
- Department of Radiology, Baystate Medical Center, University of Massachusetts Medical School, Springfield, MA.
| | - Michael S Morrow
- Department of Radiology, Baystate Medical Center, University of Massachusetts Medical School, Springfield, MA
| | - Christopher C Moore
- Department of Radiology, Baystate Medical Center, University of Massachusetts Medical School, Springfield, MA
| |
Collapse
|
25
|
Shin LK, Jeffrey RB, Berry GJ, Olcott EW. Spectral Doppler Waveforms for Diagnosis of Appendicitis: Potential Utility of Point Peak Systolic Velocity and Resistive Index Values. Radiology 2017; 285:990-998. [PMID: 28582634 DOI: 10.1148/radiol.2017162251] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Purpose To test the hypothesis that appendiceal spectral Doppler waveforms can distinguish patients with and patients without appendicitis. Materials and Methods In this retrospective study, Doppler waveforms were obtained from intramural appendiceal arteries identified with color Doppler imaging in 60% (93 of 155) of consecutive patients whose appendices were visualized at graded compression ultrasonography (US) performed for suspected appendicitis (53 male and 40 female; age, 1-56 years; mean, 14.5 years) over the 5-month period from November 2015 through March 2016. Point, non-angle-corrected peak systolic velocity (PSV) and resistive index (RI) values were compared between patients with and patients without appendicitis by utilizing histopathologically proven appendicitis and 6-week clinical follow-up as diagnostic reference standards. Data were assessed by using the Student t test, exact binomial distribution, two-sample test of proportions, and receiver operating characteristic analysis. Results Among the 93 patients, 36 (38.7%) had proven appendicitis (mean PSV, 19.7 cm/sec; mean RI, 0.69) and 57 patients (61.2%) did not (mean PSV, 7.1 cm/sec, P < .0001; mean RI, 0.50, P < .0001). The area under the receiver operating characteristic curve for the diagnosis of appendicitis was 0.97 (95% confidence interval [CI]: 0.95, 1.00) for PSV and 0.86 (95% CI: 0.78, 0.95; P = .011) for RI. Chosen discriminatory criteria of PSV greater than 10 cm/sec and RI greater than 0.65 yielded specificity for appendicitis of 94.7% and 96.5% with sensitivity of 88.9% and 63.9% (P = .013) and negative predictive value of 93.1% and 80.9% (P = .045), respectively. Original clinical graded compression US interpretations based on established US findings demonstrated specificity of 96.2% and sensitivity of 100.0%. Considering the subset of 20 patients whose maximum outer diameter measured 6-8 mm, the discriminatory criteria of PSV greater than 10 cm/sec and RI greater than 0.65 yielded specificity for appendicitis of 88.9% each, with sensitivity of 100.0% and 63.6% and negative predictive value of 100.0% and 66.6%, respectively. Conclusion In patients with visualized appendices at US, those with appendicitis exhibit significantly higher point PSV and point RI values than do patients without appendicitis and are distinguishable with high specificity by using a PSV greater than 10 cm/sec and an RI greater than 0.65 as diagnostic criteria. © RSNA, 2017.
Collapse
Affiliation(s)
- Lewis K Shin
- From the Departments of Radiology (L.K.S., R.B.J., E.W.O.) and Pathology (G.J.B.), Stanford University School of Medicine, 300 Pasteur Dr, Room H1307, Stanford, CA 94305-5105; and Department of Radiology, Veterans Affairs Palo Alto Health Care System, Palo Alto, Calif (L.K.S., E.W.O.)
| | - R Brooke Jeffrey
- From the Departments of Radiology (L.K.S., R.B.J., E.W.O.) and Pathology (G.J.B.), Stanford University School of Medicine, 300 Pasteur Dr, Room H1307, Stanford, CA 94305-5105; and Department of Radiology, Veterans Affairs Palo Alto Health Care System, Palo Alto, Calif (L.K.S., E.W.O.)
| | - Gerald J Berry
- From the Departments of Radiology (L.K.S., R.B.J., E.W.O.) and Pathology (G.J.B.), Stanford University School of Medicine, 300 Pasteur Dr, Room H1307, Stanford, CA 94305-5105; and Department of Radiology, Veterans Affairs Palo Alto Health Care System, Palo Alto, Calif (L.K.S., E.W.O.)
| | - Eric W Olcott
- From the Departments of Radiology (L.K.S., R.B.J., E.W.O.) and Pathology (G.J.B.), Stanford University School of Medicine, 300 Pasteur Dr, Room H1307, Stanford, CA 94305-5105; and Department of Radiology, Veterans Affairs Palo Alto Health Care System, Palo Alto, Calif (L.K.S., E.W.O.)
| |
Collapse
|
26
|
Sammalkorpi HE, Mentula P, Savolainen H, Leppäniemi A. The Introduction of Adult Appendicitis Score Reduced Negative Appendectomy Rate. Scand J Surg 2017; 106:196-201. [PMID: 28737110 DOI: 10.1177/1457496916683099] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND AIMS Implementation of a clinical risk score into diagnostics of acute appendicitis may provide accurate diagnosis with selective use of imaging studies. The aim of this study was to prospectively validate recently described diagnostic scoring system, Adult Appendicitis Score, and evaluate its effects on negative appendectomy rate. MATERIAL AND METHODS Adult Appendicitis Score stratifies patients into three groups: high, intermediate, and low risk of appendicitis. The score was implemented in diagnostics of adult patients suspected of acute appendicitis in two university hospitals. We analyzed the effects of Adult Appendicitis Score on diagnostic accuracy, imaging studies, and treatment. The study population was compared with a reference population of 829 patients suspected of acute appendicitis originally enrolled for the study of construction of the Adult Appendicitis Score. RESULTS This study enrolled 908 patients of whom 432 (48%) had appendicitis. The score stratified 49% of all appendicitis patients into high-risk group with specificity of 93.3%. In the low-risk group, prevalence of appendicitis was 7%. The histologically confirmed negative appendectomy rate decreased from 18.2% to 8.7%, p<0.001, compared to the original dataset. CONCLUSION Adult Appendicitis Score is a reliable tool for stratification of patients into selective imaging, which results in low negative appendectomy rate.
Collapse
Affiliation(s)
- H E Sammalkorpi
- 1 Department of Gastrointestinal Surgery, Helsinki University Central Hospital, Helsinki, Finland.,2 Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - P Mentula
- 1 Department of Gastrointestinal Surgery, Helsinki University Central Hospital, Helsinki, Finland
| | - H Savolainen
- 3 Department of Surgery, Kuopio University Hospital, Kuopio, Finland
| | - A Leppäniemi
- 1 Department of Gastrointestinal Surgery, Helsinki University Central Hospital, Helsinki, Finland
| |
Collapse
|
27
|
Xu Y, Jeffrey RB, Chang ST, DiMaio MA, Olcott EW. Sonographic Differentiation of Complicated From Uncomplicated Appendicitis: Implications for Antibiotics-First Therapy. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2017; 36:269-277. [PMID: 28039865 DOI: 10.7863/ultra.16.03109] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 05/09/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVES To evaluate sonographic findings as indicators of complicated versus uncomplicated appendicitis in the setting of known appendicitis, a necessary distinction in deciding whether to proceed with antibiotic therapy or with appendectomy. METHODS With Institutional Review Board approval and Health Insurance Portability and Accountability Act compliance, appendiceal sonograms of 119 patients with histopathologically proven appendicitis were retrospectively blindly reviewed to determine the presence or absence of the normally echogenic submucosal layer, the presence of mural hyperemia, periappendiceal fluid, appendicoliths, and hyperechoic periappendiceal fat and to determine the maximum outside diameter. Results were compared with the presence of complicated versus uncomplicated appendicitis on histopathologic examination and assessed by both univariate and mulitvariate logistic regression; confidence intervals (CIs) of proportions were assessed by the exact binomial test. RESULTS Thirty-two (26.9%) of the 119 patients had complicated appendicitis, including 11 with gangrenous appendicitis without perforation and 21 with gangrenous appendicitis and perforation. Loss of the submucosal layer was the only independent significant indicator of complicated appendicitis in multivariate regression (P < .001) and provided sensitivity and specificity values of 100.0% (95% CI, 89.1%-100.0%) and 92.0% (95% CI, 84.1%-96.7%), respectively. CONCLUSIONS Loss of the normally echogenic submucosal layer was the most useful sonographic finding for discriminating complicated from uncomplicated appendicitis, being the only finding independently and significantly associated with complicated appendicitis and, additionally, providing both high sensitivity and high specificity. This information may help a physician decide whether to proceed with antibiotic therapy or with appendectomy when treating a patient with appendicitis.
Collapse
Affiliation(s)
- Yingding Xu
- Department of Radiology, Stanford University School of Medicine, Stanford, California, USA
| | - R Brooke Jeffrey
- Department of Radiology, Stanford University School of Medicine, Stanford, California, USA
| | - Stephanie T Chang
- Department of Radiology, Stanford University School of Medicine, Stanford, California, USA
| | - Michael A DiMaio
- Department of Pathology, Stanford University School of Medicine, Stanford, California, USA
| | - Eric W Olcott
- Department of Radiology, Stanford University School of Medicine, Stanford, California, USA
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| |
Collapse
|
28
|
Xu Y, Jeffrey RB, Shin LK, DiMaio MA, Olcott EW. Color Doppler Imaging of the Appendix: Criteria to Improve Specificity for Appendicitis in the Borderline-Size Appendix. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2016; 35:2129-2138. [PMID: 27562977 DOI: 10.7863/ultra.15.11064] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Accepted: 01/11/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVES To test the hypothesis that continuous intramural vascular signal measuring at least 3 mm on color Doppler imaging is highly specific for appendicitis in patients with diagnostically borderline-size appendices. METHODS Two blinded observers independently reviewed color Doppler images of the appendix in 94 consecutive patients who had undergone sonography for suspected appendicitis and whose appendices were of diagnostically borderline size (6-8 mm maximum outer diameter). Intramural vascular flow on color Doppler images was classified as absent, type 1 (only punctate and dispersed signal), or type 2 (continuous linear or curvilinear signal measuring at least 3.0 mm in long- or short-axis views). Histopathologic examination and clinical follow-up served as reference standards. Proportions were assessed by the exact binomial test. RESULTS Of the 94 patients, 33 (35.1%) had type 1 flow (of whom 5 [15.2%] had appendicitis); 23 (24.5%) had type 2 flow (of whom 20 [87.0%] had appendicitis); and 38 (40.4%) had absent flow (of whom 10 [26.3%] had appendicitis). The sensitivity, specificity, and odds ratio of type 2 flow as an indicator of appendicitis were 57.1%, 94.9%, and 24.9 (P< .001), respectively; the corresponding values for type 1 flow as an indicator of normal appendices were and 47.5%, 85.7%, and 5.4 (P = .002). CONCLUSIONS Continuous intramural linear or curvilinear signal measuring at least 3 mm on color Doppler imaging is a highly specific, although relatively insensitive, sign of acute appendicitis in noncompressible appendices of diagnostically borderline size (6-8 mm).
Collapse
Affiliation(s)
- Yingding Xu
- Department of Radiology, Stanford University School of Medicine, Stanford, California USA
| | - R Brooke Jeffrey
- Department of Radiology, Stanford University School of Medicine, Stanford, California USA
| | - Lewis K Shin
- Department of Radiology, Stanford University School of Medicine, Stanford, California USA, Department of Radiology, Veterans Affairs Palo Alto Health Care System, Palo Alto, California USA
| | - Michael A DiMaio
- Department of Pathology, Stanford University School of Medicine, Stanford, California USA
| | - Eric W Olcott
- Department of Radiology, Stanford University School of Medicine, Stanford, California USA, Department of Radiology, Veterans Affairs Palo Alto Health Care System, Palo Alto, California USA
| |
Collapse
|
29
|
Di Saverio S, Birindelli A, Kelly MD, Catena F, Weber DG, Sartelli M, Sugrue M, De Moya M, Gomes CA, Bhangu A, Agresta F, Moore EE, Soreide K, Griffiths E, De Castro S, Kashuk J, Kluger Y, Leppaniemi A, Ansaloni L, Andersson M, Coccolini F, Coimbra R, Gurusamy KS, Campanile FC, Biffl W, Chiara O, Moore F, Peitzman AB, Fraga GP, Costa D, Maier RV, Rizoli S, Balogh ZJ, Bendinelli C, Cirocchi R, Tonini V, Piccinini A, Tugnoli G, Jovine E, Persiani R, Biondi A, Scalea T, Stahel P, Ivatury R, Velmahos G, Andersson R. WSES Jerusalem guidelines for diagnosis and treatment of acute appendicitis. World J Emerg Surg 2016; 11:34. [PMID: 27437029 PMCID: PMC4949879 DOI: 10.1186/s13017-016-0090-5] [Citation(s) in RCA: 228] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 07/06/2016] [Indexed: 02/08/2023] Open
Abstract
Acute appendicitis (AA) is among the most common cause of acute abdominal pain. Diagnosis of AA is challenging; a variable combination of clinical signs and symptoms has been used together with laboratory findings in several scoring systems proposed for suggesting the probability of AA and the possible subsequent management pathway. The role of imaging in the diagnosis of AA is still debated, with variable use of US, CT and MRI in different settings worldwide. Up to date, comprehensive clinical guidelines for diagnosis and management of AA have never been issued. In July 2015, during the 3rd World Congress of the WSES, held in Jerusalem (Israel), a panel of experts including an Organizational Committee and Scientific Committee and Scientific Secretariat, participated to a Consensus Conference where eight panelists presented a number of statements developed for each of the eight main questions about diagnosis and management of AA. The statements were then voted, eventually modified and finally approved by the participants to The Consensus Conference and lately by the board of co-authors. The current paper is reporting the definitive Guidelines Statements on each of the following topics: 1) Diagnostic efficiency of clinical scoring systems, 2) Role of Imaging, 3) Non-operative treatment for uncomplicated appendicitis, 4) Timing of appendectomy and in-hospital delay, 5) Surgical treatment 6) Scoring systems for intra-operative grading of appendicitis and their clinical usefulness 7) Non-surgical treatment for complicated appendicitis: abscess or phlegmon 8) Pre-operative and post-operative antibiotics.
Collapse
Affiliation(s)
| | - Arianna Birindelli
- S. Orsola Malpighi University Hospital - University of Bologna, Bologna, Italy
| | - Micheal D Kelly
- Locum Surgeon, Acute Surgical Unit, Canberra Hospital, Canberra, ACT Australia
| | - Fausto Catena
- Emergency and Trauma Surgery Department, Maggiore Hospital of Parma, Parma, Italy
| | - Dieter G Weber
- Trauma and General Surgeon Royal Perth Hospital & The University of Western Australia, Perth, Australia
| | | | | | - Mark De Moya
- Harvard Medical School - Massachusetts General Hospital, Boston, USA
| | - Carlos Augusto Gomes
- Department of Surgery Hospital Universitario, Universidade General de Juiz de Fora, Juiz de Fora, Brazil
| | - Aneel Bhangu
- Academic Department of Surgery, University Hospitals Birmingham NHS Foundation Trust, Edgabaston, Birmingham, UK
| | | | - Ernest E Moore
- Denver Health System - Denver Health Medical Center, Denver, USA
| | - Kjetil Soreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Ewen Griffiths
- University Hospitals Birmingham NHS Foundation Trust Queen Elizabeth Hospital, Birmingham, UK
| | | | - Jeffry Kashuk
- Department of Surgery, University of Jerusalem, Jerusalem, Israel
| | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Ari Leppaniemi
- Abdominal Center, University of Helsinki, Helsinki, Finland
| | - Luca Ansaloni
- General Surgery I, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Manne Andersson
- Department of Surgery, Linkoping University, Linkoping, Sweden
| | | | - Raul Coimbra
- UCSD Health System - Hillcrest Campus Department of Surgery Chief Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, San Diego, CA USA
| | | | | | - Walter Biffl
- Queen's Medical Center, University of Hawaii, Honolulu, HI USA
| | | | | | - Andrew B Peitzman
- Department of Surgery, University of Pittsburgh School of Medicine, UPMC-Presbyterian, Pittsburgh, USA
| | - Gustavo P Fraga
- Faculdade de Ciências Médicas (FCM) - Unicamp, Campinas, SP Brazil
| | | | - Ronald V Maier
- Department of Surgery, University of Washington, Harborview Medical Center, Seattle, WA USA
| | | | - Zsolt J Balogh
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW Australia
| | - Cino Bendinelli
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW Australia
| | - Roberto Cirocchi
- Department of Surgery, Terni Hospital, University of Perugia, Terni, Italy
| | - Valeria Tonini
- S. Orsola Malpighi University Hospital - University of Bologna, Bologna, Italy
| | - Alice Piccinini
- Trauma Surgery Unit - Maggiore Hospital AUSL, Bologna, Italy
| | | | - Elio Jovine
- Department of Surgery, Maggiore Hospital AUSL, Bologna, Italy
| | - Roberto Persiani
- Catholic University, A. Gemelli University Hospital, Rome, Italy
| | - Antonio Biondi
- Department of Surgery, University of Catania, Catania, Italy
| | | | - Philip Stahel
- Denver Health System - Denver Health Medical Center, Denver, USA
| | - Rao Ivatury
- Professor Emeritus Virginia Commonwealth University, Richmond, VA USA
| | - George Velmahos
- Harvard Medical School - Chief of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, USA
| | | |
Collapse
|
30
|
Reddan T, Corness J, Mengersen K, Harden F. Sonographic diagnosis of acute appendicitis in children: a 3-year retrospective. SONOGRAPHY 2016. [DOI: 10.1002/sono.12068] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Tristan Reddan
- Medical Imaging and Nuclear Medicine; Lady Cilento Children's Hospital; South Brisbane Queensland Australia
- Science and Engineering Faculty; Queensland University of Technology; Brisbane Queensland Australia
| | - Jonathan Corness
- Medical Imaging and Nuclear Medicine; Lady Cilento Children's Hospital; South Brisbane Queensland Australia
| | - Kerrie Mengersen
- Science and Engineering Faculty; Queensland University of Technology; Brisbane Queensland Australia
| | - Fiona Harden
- Science and Engineering Faculty; Queensland University of Technology; Brisbane Queensland Australia
| |
Collapse
|
31
|
Lymphoid Hyperplasia of the Appendix: A Potential Pitfall in the Sonographic Diagnosis of Appendicitis. AJR Am J Roentgenol 2016; 206:189-94. [DOI: 10.2214/ajr.15.14846] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
|
32
|
Binkovitz LA, Unsdorfer KML, Thapa P, Kolbe AB, Hull NC, Zingula SN, Thomas KB, Homme JL. Appendiceal ultrasound: the importance of determinacy. Pediatr Radiol 2015; 45:1932-3. [PMID: 26280636 DOI: 10.1007/s00247-015-3429-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 07/02/2015] [Indexed: 11/25/2022]
Affiliation(s)
- Larry A Binkovitz
- Department of Diagnostic Radiology, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905, USA.
| | | | - Prabin Thapa
- Department of Biostatistics, Mayo Clinic, Rochester, MN, USA
| | - Amy B Kolbe
- Department of Diagnostic Radiology, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905, USA
| | - Nathan C Hull
- Department of Diagnostic Radiology, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905, USA
| | - Shannon N Zingula
- Department of Diagnostic Radiology, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905, USA
| | - Kristen B Thomas
- Department of Diagnostic Radiology, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905, USA
| | - James L Homme
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
33
|
Pediatric appendiceal ultrasound: accuracy, determinacy and clinical outcomes. Pediatr Radiol 2015; 45:1934-44. [PMID: 26280637 DOI: 10.1007/s00247-015-3432-7] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2015] [Revised: 05/08/2015] [Accepted: 07/07/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Ultrasonography is considered the most appropriate initial imaging study in the evaluation of acute appendicitis in children but has recently come under criticism with reports of low specificity and high indeterminate study rates, particularly when used in obese patients and patients early in the course of their disease, or when performed by sonographers with limited experience. OBJECTIVE To (1) assess the impact of patient factors (gender, age, body mass index, and symptom duration) and system factors (call status or year of exam) on pediatric appendiceal US accuracy and indeterminate study rate, (2) assess the impact of indeterminate study results on follow-up CT and negative laparotomy rates and (3) present strategies to reduce the rate of indeterminate US studies and improve accuracy. MATERIALS AND METHODS We retrospectively reviewed all US reports performed for the assessment of acute appendicitis in children <18 years old at Mayo Clinic Rochester from January 2010 to June 2014. RESULTS A total of 790 US examinations were performed in 452 girls (57%) and 338 boys (43%). The prevalence of appendicitis was 18.5% (146/790). There were 109 true-positive, 440 true-negative, 17 false-positive, 6 false-negative, 218 equivocal and 41 technically inadequate US studies. A definitive interpretation was made in 72% of the studies, with an accuracy, sensitivity and specificity of 0.960, 0.948 and 0.963, respectively. No patient or system factors significantly affected US accuracy. Indeterminate studies (28%) had significantly higher CT utilization (46% vs. 11%) and normal appendectomy rates (6.9% vs. 3.5%). CONCLUSION US should be the initial imaging study of choice for pediatric appendicitis. When a definitive interpretation was given, the accuracy was 96%, was independent of patient and system factors and resulted in reduced follow-up CTs and negative laparotomies. Accuracy can be increased by requiring the presence of periappendiceal inflammatory changes prior to interpreting a mildly distended appendix as positive for acute appendicitis. The indeterminate study rate can be reduced by not requiring visualization of the normal appendix for the exclusion of acute appendicitis.
Collapse
|