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1
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Bonomo RA, Tamma PD, Abrahamian FM, Bessesen M, Chow AW, Dellinger EP, Edwards MS, Goldstein E, Hayden MK, Humphries R, Kaye KS, Potoski BA, Rodríguez-Baño J, Sawyer R, Skalweit M, Snydman DR, Donnelly K, Loveless J. 2024 Clinical Practice Guideline Update by the Infectious Diseases Society of America on Complicated Intra-abdominal Infections: Diagnostic Imaging of Suspected Acute Appendicitis in Adults, Children, and Pregnant People. Clin Infect Dis 2024; 79:S94-S103. [PMID: 38963819 DOI: 10.1093/cid/ciae348] [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: 06/19/2024] [Accepted: 06/27/2024] [Indexed: 07/06/2024] Open
Abstract
This paper is part of a clinical practice guideline update on the risk assessment, diagnostic imaging, and microbiological evaluation of complicated intra-abdominal infections in adults, children, and pregnant people, developed by the Infectious Diseases Society of America (IDSA). In this paper, the panel provides recommendations for diagnostic imaging of suspected acute appendicitis. The panel's recommendations are based on evidence derived from systematic literature reviews and adhere to a standardized methodology for rating the certainty of evidence and strength of recommendation according to the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach.
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Affiliation(s)
- Robert A Bonomo
- Medical Service, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio, USA
- Clinician Scientist Investigator, Research Service, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio, USA
- Departments of Medicine, Pharmacology, Molecular Biology and Microbiology, Biochemistry, and Proteomics and Bioinformatics, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
- CWRU-Cleveland VAMC Center for Antimicrobial Resistance and Epidemiology (Case VA CARES) Cleveland, Ohio, USA
| | - Pranita D Tamma
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Fredrick M Abrahamian
- Department of Emergency Medicine, Olive View-University of California, Los Angeles (UCLA) Medical Center, Sylmar, California, USA
- David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Mary Bessesen
- Department of Medicine, Veterans Affairs Eastern Colorado Health Care, Aurora, Colorado, USA
- Division of Infectious Diseases, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Anthony W Chow
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Morven S Edwards
- Division of Infectious Diseases, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | | | - Mary K Hayden
- Division of Infectious Diseases, Department of Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Romney Humphries
- Division of Laboratory Medicine, Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Keith S Kaye
- Division of Allergy, Immunology and Infectious Diseases, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Brian A Potoski
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, USA
| | - Jesús Rodríguez-Baño
- Division of Infectious Diseases and Microbiology, Department of Medicine, Hospital Universitario Virgen Macarena, University of Seville, Biomedicines Institute of Seville-Consejo Superior de Investigaciones Científicas, Seville, Spain
| | - Robert Sawyer
- Department of Surgery, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, Michigan, USA
| | - Marion Skalweit
- Department of Medicine and Biochemistry, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - David R Snydman
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, Massachusetts, USA
| | - Katelyn Donnelly
- Clinical Affairs and Practice Guidelines, Infectious Diseases Society of America, Arlington, Virginia, USA
| | - Jennifer Loveless
- Clinical Affairs and Practice Guidelines, Infectious Diseases Society of America, Arlington, Virginia, USA
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Luksaite-Lukste R, Gecaite I, Marcinkeviciute K, Dumskis E, Samuilis A, Zvirblis T, Jasiunas E, Bausys A, Drungilas M, Luksta M, Kryzauskas M, Petrulionis M, Beisa A, Uselis S, Valeikaite-Taugininene G, Rackauskas R, Strupas K, Poskus T. Observation Safely Reduces the Use of the Computerized Tomography in Medium-to-Low-Risk Patients with Suspected Acute Appendicitis: Results of a Randomized Controlled Trial. J Clin Med 2024; 13:3363. [PMID: 38929896 PMCID: PMC11203661 DOI: 10.3390/jcm13123363] [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: 04/18/2024] [Revised: 05/28/2024] [Accepted: 06/05/2024] [Indexed: 06/28/2024] Open
Abstract
Objectives-The objective was to compare the effectiveness of observation in standard-of-care computed tomography (CT) in adult patients with suspected acute appendicitis (AA). Methods-Patients with clinically suspected AA and inconclusive diagnosis after primary clinical examination, laboratory examination, and transabdominal ultrasound (TUS) were eligible for the study, and they were randomized (1:1) to parallel groups: observation-group patients were observed for 8-12 h and then, repeated clinical and laboratory examinations and TUS were performed; CT group (control group) patients underwent abdominopelvic CT scan. The study utilized Statistical Analysis System 9.2 for data analysis, including tests, logistic regression, ROC analysis, and significance evaluation. Patients were enrolled in the study at Vilnius University Hospital Santaros Klinikos in Lithuania between December 2018 and June 2021. Results-A total of 160 patients (59 men, 101 women), with a mean age of 33.7 ± 14.71, were included, with 80 patients in each group. Observation resulted in a reduced likelihood of a CT scan compared with the CT group (36.3% vs. 100% p < 0.05). One diagnostic laparoscopy was performed in the observation group; there were no cases of negative appendectomy (NA) in the CT group. Both conditional CT and observation pathways resulted in high sensitivity and specificity (97.7% and 94.6% vs. 96.7% and 95.8%). Conclusions-Observation including the repeated evaluation of laboratory results and TUS significantly reduces the number of CT scans without increasing NA numbers or the number of complicated cases.
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Affiliation(s)
- Raminta Luksaite-Lukste
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania; (M.L.); (M.K.); (M.P.); (A.B.); (S.U.); (G.V.-T.); (R.R.); (K.S.); (T.P.)
- Department of Radiology, Nuclear Medicine and Medical Physics, Institute of Biomedical Sciences, Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania; (I.G.); (E.D.); (A.S.)
| | - Igne Gecaite
- Department of Radiology, Nuclear Medicine and Medical Physics, Institute of Biomedical Sciences, Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania; (I.G.); (E.D.); (A.S.)
| | | | - Eimantas Dumskis
- Department of Radiology, Nuclear Medicine and Medical Physics, Institute of Biomedical Sciences, Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania; (I.G.); (E.D.); (A.S.)
| | - Arturas Samuilis
- Department of Radiology, Nuclear Medicine and Medical Physics, Institute of Biomedical Sciences, Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania; (I.G.); (E.D.); (A.S.)
| | - Tadas Zvirblis
- Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania; (K.M.); (T.Z.); (A.B.)
- Department of Mechanical and Material Engineering, Vilnius Gediminas Technical University, LT-03224 Vilnius, Lithuania
| | - Eugenijus Jasiunas
- Vilnius University Hospital Santaros Klinikos, LT-08406 Vilnius, Lithuania; (E.J.); (M.D.)
| | - Augustinas Bausys
- Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania; (K.M.); (T.Z.); (A.B.)
| | - Mantas Drungilas
- Vilnius University Hospital Santaros Klinikos, LT-08406 Vilnius, Lithuania; (E.J.); (M.D.)
| | - Martynas Luksta
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania; (M.L.); (M.K.); (M.P.); (A.B.); (S.U.); (G.V.-T.); (R.R.); (K.S.); (T.P.)
| | - Marius Kryzauskas
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania; (M.L.); (M.K.); (M.P.); (A.B.); (S.U.); (G.V.-T.); (R.R.); (K.S.); (T.P.)
| | - Marius Petrulionis
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania; (M.L.); (M.K.); (M.P.); (A.B.); (S.U.); (G.V.-T.); (R.R.); (K.S.); (T.P.)
| | - Augustas Beisa
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania; (M.L.); (M.K.); (M.P.); (A.B.); (S.U.); (G.V.-T.); (R.R.); (K.S.); (T.P.)
| | - Simonas Uselis
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania; (M.L.); (M.K.); (M.P.); (A.B.); (S.U.); (G.V.-T.); (R.R.); (K.S.); (T.P.)
| | - Gintare Valeikaite-Taugininene
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania; (M.L.); (M.K.); (M.P.); (A.B.); (S.U.); (G.V.-T.); (R.R.); (K.S.); (T.P.)
| | - Rokas Rackauskas
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania; (M.L.); (M.K.); (M.P.); (A.B.); (S.U.); (G.V.-T.); (R.R.); (K.S.); (T.P.)
| | - Kestutis Strupas
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania; (M.L.); (M.K.); (M.P.); (A.B.); (S.U.); (G.V.-T.); (R.R.); (K.S.); (T.P.)
| | - Tomas Poskus
- Clinic of Gastroenterology, Nephrourology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania; (M.L.); (M.K.); (M.P.); (A.B.); (S.U.); (G.V.-T.); (R.R.); (K.S.); (T.P.)
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Wang Z, Bao F, Liang W, Wu H, Lin Z, Xu J, Dong F. Appendicitis in pregnant women: A systematic review and meta-analysis of the diagnostic performance of ultrasonography. JOURNAL OF CLINICAL ULTRASOUND : JCU 2023; 51:1492-1501. [PMID: 37747110 DOI: 10.1002/jcu.23566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 08/22/2023] [Accepted: 09/06/2023] [Indexed: 09/26/2023]
Abstract
OBJECTIVES The accuracy of ultrasound in the detection of appendicitis in pregnant women was examined in a meta-analysis. METHODS Pregnant women with suspected acute appendicitis were evaluated using ultrasound in a systematic search of PubMed, EMBASE, and Cochrane Library databases from January 1, 2011 to August 10, 2023. The sensitivity and specificity values and diagnostic odds ratios were obtained using the pooled data. RESULTS A total of 239 patients were studied in four relevant investigations. Ultrasonography has a sensitivity of 56% and a specificity of 88% for the diagnosis of acute appendicitis, with an area under the receiver operating characteristic curve of 0.66%. Ultrasonography had a positive likelihood ratio of 4.65 (95% confidence interval, 1.42-15.23) and a negative likelihood ratio of 0.50 (95% confidence interval, 0.41-0.62). There was no evidence of publication bias (p = 0.93). CONCLUSIONS Ultrasound has moderate sensitivity for identifying appendicitis in pregnant women and may be utilized as an alternative diagnostic method.
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Affiliation(s)
- Zimo Wang
- Department of Ultrasound, Second Clinical College of Jinan University, Shenzhen People's Hospital, First Affiliated Hospital of Southern University of Science and Technology, Shenzhen Medical Ultrasound Engineering Center, Shenzhen, People's Republic of China
| | - Fuxing Bao
- Department of Ultrasound, Second Clinical College of Jinan University, Shenzhen People's Hospital, First Affiliated Hospital of Southern University of Science and Technology, Shenzhen Medical Ultrasound Engineering Center, Shenzhen, People's Republic of China
| | - Weiyu Liang
- Department of Ultrasound, Second Clinical College of Jinan University, Shenzhen People's Hospital, First Affiliated Hospital of Southern University of Science and Technology, Shenzhen Medical Ultrasound Engineering Center, Shenzhen, People's Republic of China
| | - Huaiyu Wu
- Department of Ultrasound, Second Clinical College of Jinan University, Shenzhen People's Hospital, First Affiliated Hospital of Southern University of Science and Technology, Shenzhen Medical Ultrasound Engineering Center, Shenzhen, People's Republic of China
| | - Ziwei Lin
- Department of Ultrasound, Second Clinical College of Jinan University, Shenzhen People's Hospital, First Affiliated Hospital of Southern University of Science and Technology, Shenzhen Medical Ultrasound Engineering Center, Shenzhen, People's Republic of China
| | - Jinfeng Xu
- Department of Ultrasound, Second Clinical College of Jinan University, Shenzhen People's Hospital, First Affiliated Hospital of Southern University of Science and Technology, Shenzhen Medical Ultrasound Engineering Center, Shenzhen, People's Republic of China
| | - Fajin Dong
- Department of Ultrasound, Second Clinical College of Jinan University, Shenzhen People's Hospital, First Affiliated Hospital of Southern University of Science and Technology, Shenzhen Medical Ultrasound Engineering Center, Shenzhen, People's Republic of China
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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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Motavaselian M, Bayati F, Amani-Beni R, Khalaji A, Haghverdi S, Abdollahi Z, Sarrafzadeh A, Rafie Manzelat AM, Rigi A, Arabzadeh Bahri R, Nakhaee Z, Fadaei M, Ghasemi Falaverjani H, Malekpour-Dehkordi S, Hoseinpour M, Bidares M, Zandkarimi S, Ahmadi R, Beheshtiparvar D, Ahadiat SA, Farshi M, Farrokhi M. Diagnostic Performance of Magnetic Resonance Imaging for Detection of Acute Appendicitis in Pregnant Women; a Systematic Review and Meta-Analysis. ARCHIVES OF ACADEMIC EMERGENCY MEDICINE 2022; 10:e81. [PMID: 36426165 PMCID: PMC9676701 DOI: 10.22037/aaem.v10i1.1727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
INTRODUCTION The diagnosis of acute appendicitis (AA) in pregnant women is commonly challenging owing to the normal results of laboratory tests, organ displacement, and normal physiological inflammatory alterations. This meta-analysis aimed to investigate the accuracy of magnetic resonance imaging (MRI) in diagnosis of AA in pregnant women. METHODS Two investigators independently performed a comprehensive systematic literature search of electronic databases including MEDLINE, Cochrane Central, EMBASE, Web of Science, Scopus, and Google Scholar to identify studies that reported accuracy of MRI for diagnosis of AA in pregnant women from inception to April 1, 2022. RESULTS Our systematic search identified a total of 525 published papers. Finally, a total of 26 papers were included in the meta-analysis. The pooled sensitivity and specificity of MRI in diagnosis of AA in pregnant women were 0.92 (95% CI: 0.88-0.95) and 0.98 (95% CI 0.97-0.98), respectively. The pooled positive likelihood ratio and negative likelihood ratio were 29.52 (95% CI: 21.90-39.81) and 0.10 (95% CI: 0.04-0.25), respectively. The area under hierarchical summary receiver operating characteristic (HSROC) curve indicated that the accuracy of MRI for diagnosis of AA in pregnant women is 99%. CONCLUSION This meta-analysis showed that MRI has high sensitivity, specificity, and accuracy for diagnosis of AA in pregnant women and can be used as a first-line imaging modality for suspected cases of AA during pregnancy. Furthermore, it should be noted that when the result of ultrasonography is inconclusive, the use of MRI can reduce unnecessary appendectomy in pregnant patients.
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Affiliation(s)
- Mohsen Motavaselian
- School of Medicine, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Fateme Bayati
- USERN Office, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Reza Amani-Beni
- School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Amirreza Khalaji
- Liver and Gastrointestinal Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Sara Haghverdi
- Kermanshah University of Medical Sciences, Kermanshah, Iran
| | | | - Arash Sarrafzadeh
- School of Dentistry, Arak University of Medical Sciences, Arak, Iran
| | | | - Amir Rigi
- Islamic Azad University, Zahedan Branch, Zahedan, Iran
| | | | | | - Mahta Fadaei
- School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hajar Ghasemi Falaverjani
- Department of Internal Medicine, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | | | - Matin Bidares
- Islamic Azad University of Najafabad, Najafabad, Iran
| | - Sarvenaz Zandkarimi
- Faculty of Pharmacy, Islamic Azad University of Tehran Medical Sciences, Tehran, Iran
| | - Rasha Ahmadi
- Shariati Hospital, Tehran University of Medical Science, Tehran, Iran
| | | | - Seyed-Amirabbas Ahadiat
- Research Center of Biochemistry and Nutrition in Metabolic Disorder, Kashan University of Medical science. Kashan, Iran
| | - Mohsen Farshi
- School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mehrdad Farrokhi
- Men’s Health and Reproductive Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Corresponding author: Mehrdad Farrokhi; Men’s Health and Reproductive Health Research Center, Shohadaye Tajrish Hospital, Tehran, Iran. , Phone number: +989384226664
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Abstract
Acute appendicitis is the most common surgical pathology during pregnancy. It occurs in about 1 in 500 to 1 in 635 pregnancies per year,[1] and appendectomy is the gold standard in the treatment approach.[2] However, its diagnosis represents a challenge to both surgeons and obstetrician-gynecologists. In addition, the role of laparoscopy remains controversial. This study discusses the diagnostic approach and reviews the appropriate surgical approach while evaluating the part of laparoscopy. This is a retrospective descriptive analysis reviewing 36 patients who underwent surgery for acute appendicitis during pregnancy at the "Surgery Department of Jendouba Hospital from January 1, 2005 to December 31, 2019. Data include age, comorbidities, previous abdominal surgery, symptoms, physical examination findings, complementary exams results, operative treatment details, the emergency status of the procedure, associated medical treatment, antibiotics and tocolysis, the pathology reports, and follow-up. The mean age of patients was 27 years. Twenty-one patients (58, 33%) were in the second trimester of pregnancy, 6 patients (16, 66 %) were in the first trimester, and 9 (25%) in the third one. The physical examination reported a right iliac fossa tenderness in 27 patients (75%). The abdominal ultrasound was performed in all cases and guided the diagnosis in 24 cases (66, 66%). 18 patients (50%) underwent laparoscopy, 12 patients (33, 33%) underwent laparotomy. The remaining 6 patients (16, 66%) required a conversion from laparoscopic to open surgery. The clinical presentation of appendicitis in pregnancy is often misguiding. Therefore, an abdominal ultrasound should be performed for all pregnant patients having abdominal pain. The difficulty of operating under laparoscopy increases with the pregnancy term, leading to a higher risk of conversion, which increases the operating time and the doses of anesthetics, causing a maternal and fetal risk.
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Affiliation(s)
- Atef Mejri
- Tunis El Manar University, Tunisia
- Department of General Surgery, Jendouba Hospital, Tunisia
| | - Khaoula Arfaoui
- Tunis El Manar University, Tunisia
- Department of General Surgery, Jendouba Hospital, Tunisia
- *Correspondence: Khaoula, Arfaoui, (e-mail: )
| | - Emna Trigui
- Tunis El Manar University, Tunisia
- Department of Obstetrics and Gynecology, Jendouba Hospital, Tunisia
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Lie G, Eleti S, Chan D, Roshen M, Cross S, Qureshi M. Imaging the acute abdomen in pregnancy: a radiological decision-making tool and the role of MRI. Clin Radiol 2022; 77:639-649. [PMID: 35760752 DOI: 10.1016/j.crad.2022.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 05/18/2022] [Accepted: 05/23/2022] [Indexed: 11/03/2022]
Abstract
Acute abdominal pain in pregnancy poses a significant diagnostic challenge. The differential diagnosis is wide, clinical assessment is difficult, and the use of conventional imaging methods is restricted due to risks to the fetus. This can lead to delay in diagnosis, which increases the risk of maternal and fetal harm. Imaging techniques not involving ionising radiation are preferred. Sonography remains first line, but anatomical visualisation can be limited due to displacement of adjacent structures by the gravid uterus. MRI provides excellent cross-sectional soft-tissue assessment of the abdomen and pelvis, and no study to date has demonstrated significant deleterious effects to the fetus at any gestation; however, there remains a theoretical risk of tissue heating by radiofrequency pulses, and there must be consideration of benefit versus potential risk for any use of magnetic resonance imaging (MRI) in pregnancy. With a limited protocol of sequences, a broad spectrum of pathologies can be evaluated. Computed tomography carries the highest exposure of ionising radiation to the fetus, but may be necessary, particularly in cases of trauma. The patient must be kept informed and any potential risks to the patient and fetus should be clearly explained. We present a radiological decision-making tool to guide choice of imaging and best establish the underlying diagnosis in the acute pregnant abdomen. In addition, using illustrative examples from our practice at a large tertiary centre, we review the advantages and disadvantages of each imaging method, with particular focus on the utility of MRI.
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Affiliation(s)
- G Lie
- Department of Radiology, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London, E1 1FR, UK
| | - S Eleti
- Department of Radiology, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London, E1 1FR, UK.
| | - D Chan
- Department of Radiology, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London, E1 1FR, UK
| | - M Roshen
- Department of Radiology, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London, E1 1FR, UK
| | - S Cross
- Department of Radiology, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London, E1 1FR, UK
| | - M Qureshi
- Department of Radiology, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London, E1 1FR, UK
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Petrauskas V, Poskus E, Luksaite – Lukste R, Kryzauskas M, Petrulionis M, Strupas K, Poskus T. Suspected and Confirmed Acute Appendicitis During the COVID-19 Pandemic: First and Second Quarantines-a Prospective Study. Front Surg 2022; 9:896206. [PMID: 35800113 PMCID: PMC9253423 DOI: 10.3389/fsurg.2022.896206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 05/26/2022] [Indexed: 01/08/2023] Open
Abstract
Purpose COVID-19 posed an unprecedented modern global healthcare crisis affecting both elective and urgent surgeries. The aim of this study is to evaluate the difference in the presentation of acute appendicitis (AA) before and during the COVID-19 era, the first and second quarantines. Methods We performed a prospective study from December 2018 to May 2021. Two cohorts were analysed, one with patients who presented to the emergency department (ED) with suspected AA and the second with confirmed AA. Both cohorts were divided into four groups: before COVID-19, during the first quarantine, between the first and second quarantine, and during the second quarantine. Data such as demographics, the time to first contact with the healthcare provider and time to operation, laboratory tests, clinical stage of AA, length of stay, and COVID-19 status were collected. A total of 469 patients were enrolled. Results A total of 209 patients were male (45%) and 260 were female (55%), with the median age being 33 years (24-45). In the first cohort of suspected AA, there was no difference in sex; however, more older patients presented to the ED during the first quarantine (41 years) compared with other groups (28.5, 36, and 32.5 years), p < 0.000. Before the pandemic, there was a shorter duration of symptoms to first contact with the healthcare provider (13 h) compared with other groups, p = 0.001. In the second cohort of confirmed AA, there was a shorter period of time to operation from first symptoms before the pandemic (22 h) compared with other groups (30, 35, 30.5 h), p < 0.000. There were more complicated gangrenous, perforated appendicitis or periappendicular abscess in Group 2 and 3 (26, 22 and 10%, and 26, 22 and 2%, respectively) compared with Group 1 (20, 4 and 3%) and Group 4 (22, 12, and 2%), p = 0.009. Hospital stay was longer during the first quarantine (3 days) compared with other groups (2 days), p = 0.009. Six patients were COVID-19 positive: one from Group 3 and five from Group 4 (p > 0.05). Conclusions Our study suggests that during the first quarantine of the COVID-19 pandemic, there was delayed presentation to the ED with suspected AA and there was a greater proportion of complicated appendicitis and longer hospitalization in confirmed cases as well.
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Affiliation(s)
- Vidas Petrauskas
- Clinic of Gastroenterology, Nephro-Urology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Eligijus Poskus
- Clinic of Gastroenterology, Nephro-Urology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Raminta Luksaite – Lukste
- Department of Radiology, Nuclear Medicine and Medical Physics, Institute of Biomedical Sciences, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Marius Kryzauskas
- Clinic of Gastroenterology, Nephro-Urology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Marius Petrulionis
- Clinic of Gastroenterology, Nephro-Urology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Kestutis Strupas
- Clinic of Gastroenterology, Nephro-Urology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Tomas Poskus
- Clinic of Gastroenterology, Nephro-Urology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
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The Dynamics of Inflammatory Markers in Patients with Suspected Acute Appendicitis. Medicina (B Aires) 2021; 57:medicina57121384. [PMID: 34946329 PMCID: PMC8709480 DOI: 10.3390/medicina57121384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 12/12/2021] [Accepted: 12/15/2021] [Indexed: 12/03/2022] Open
Abstract
Background: Laboratory tests of inflammatory mediators are routinely used in the diagnosis of acute appendicitis (AA). The aim of this study was to evaluate the differences of dynamics of inflammatory markers of the blood in patients with suspected acute appendicitis between complicated AA (CAA), non-complicated AA (NAA), and when AA was excluded (No-AA). Methods: This was a retrospective analysis of prospectively collected data of patients presented to the Emergency Department (ER) of a tertiary hospital center during a three-year period. All patients suspected of acute appendicitis were prospectively registered from 1 January 2016 to 31 December 2018. The dynamics of inflammatory markers of the blood between different types of AA (No-AA, NAA or CAA) during different periods of time are presented. Results: A total of 453 patients were included in the study, with 297 patients in the No-AA group, 99 in the NAA group, and 57 in the CAA group. White blood cell (WBC) count in the No-AA decreased with time, with a statistically significant difference between the <8 h and 25–72 h group. The neutrophils (NEU) percentage decreased in the No-AA group and was statistically significantly different between the <8 h and 25–72 h and <8 h and >72 h groups. C-reactive protein (CRP) increased significantly in the No-AA group throughout all time intervals, and from the first 24 h to the 25–72 h in the NAA and CAA groups. There was a statistically significant difference between the WBC count between No-AA, NAA, and No-AA and CAA groups during the first 24 and 24–48 h. There was a statistically significant difference between NEU percentage and LYMP percentage and in the NEU/LYMP ratio between No-AA and CAA groups through all time periods. CRP was significantly higher in the first 24 h in the CAA than in the No-AA group, and in the 24–48 h in the CAA group than in the No-AA and NAA groups. The linear logistic regression model, involving inflammatory mediators and clinical characteristics, showed mediocre diagnostic accuracy for diagnosing AA with an AUC of 0.737 (0.671–0.802). Conclusions: Increasing concentrations of inflammatory markers are more characteristic in CAA patients than in No-AA during the first 48 h after onset of the disease. A combination of laboratory tests with clinical signs and symptoms has a mediocre diagnostic accuracy in suspecting AA.
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Luksaite-Lukste R, Kliokyte R, Samuilis A, Jasiunas E, Luksta M, Strupas K, Poskus T. Conditional CT Strategy-An Effective Tool to Reduce Negative Appendectomy Rate and the Overuse of the CT. J Clin Med 2021; 10:jcm10112456. [PMID: 34206008 PMCID: PMC8198775 DOI: 10.3390/jcm10112456] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 05/11/2021] [Accepted: 05/25/2021] [Indexed: 12/29/2022] Open
Abstract
(1) Background: Diagnosis of acute appendicitis (AA) remains challenging; either computed tomography (CT) is universally used or negative appendectomy rates of up to 30% are reported. Transabdominal ultrasound (TUS) as the first-choice imaging modality might be useful in adult patients to reduce the need for CT scans while maintaining low negative appendectomy (NA) rates. The aim of this study was to report the results of the conditional CT strategy for the diagnosis of acute appendicitis. (2) Methods: All patients suspected of acute appendicitis were prospectively registered from 1 January 2016 to 31 December 2018. Data on their clinical, radiological and surgical outcomes are presented. (3) Results: A total of 1855 patients were enrolled in our study: 1206 (65.0%) were women, 649 (35.0%) were men, and the median age was 34 years (IQR, 24.5–51). TUS was performed in 1851 (99.8%) patients, and CT in 463 (25.0%) patients. Appendices were not visualized on TUS in 1320 patients (71.3%). Furthermore, 172 (37.1%) of 463 CTs were diagnosed with AA, 42 (9.1%) CTs revealed alternative emergency diagnosis and 249 (53.8%) CTs were normal. Overall, 519 (28.0%) patients were diagnosed with AA: 464 appendectomies and 27 diagnostic laparoscopies were performed. The NA rate was 4.2%. The sensitivity and specificity for TUS and CT are as follows: 71.4% and 96.2%; 93.8% and 93.6%. (4) Conclusion: A conditional CT strategy is effective in reducing NA rates and avoids unnecessary CT in a large proportion of patients. Observation and repeated TUS might be useful in unclear cases.
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Affiliation(s)
- Raminta Luksaite-Lukste
- Clinic of Gastroenterology, Nephrourology and Surgery, Faculty of Medicine, Institute of Clinical Medicine, Vilnius University, LT-08661 Vilnius, Lithuania; (M.L.); (K.S.); (T.P.)
- Correspondence: ; Tel.: +37-068-9606-11
| | - Ruta Kliokyte
- Department of Radiology, Nuclear Medicine and Medical Physics, Faculty of Medicine, Institute of Biomedical Sciences, Vilnius University, LT-08661 Vilnius, Lithuania; (R.K.); (A.S.)
| | - Arturas Samuilis
- Department of Radiology, Nuclear Medicine and Medical Physics, Faculty of Medicine, Institute of Biomedical Sciences, Vilnius University, LT-08661 Vilnius, Lithuania; (R.K.); (A.S.)
| | - Eugenijus Jasiunas
- Centre of Informatics and Development, Vilnius University Hospital, Santara Clinics, LT-08661 Vilnius, Lithuania;
| | - Martynas Luksta
- Clinic of Gastroenterology, Nephrourology and Surgery, Faculty of Medicine, Institute of Clinical Medicine, Vilnius University, LT-08661 Vilnius, Lithuania; (M.L.); (K.S.); (T.P.)
| | - Kestutis Strupas
- Clinic of Gastroenterology, Nephrourology and Surgery, Faculty of Medicine, Institute of Clinical Medicine, Vilnius University, LT-08661 Vilnius, Lithuania; (M.L.); (K.S.); (T.P.)
| | - Tomas Poskus
- Clinic of Gastroenterology, Nephrourology and Surgery, Faculty of Medicine, Institute of Clinical Medicine, Vilnius University, LT-08661 Vilnius, Lithuania; (M.L.); (K.S.); (T.P.)
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