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Moltubak E, Landerholm K, Blomberg M, Andersson RE. Validation of the Appendicitis Inflammatory Response (AIR) score during pregnancy: A nested case-control study. Acad Emerg Med 2024. [PMID: 38597185 DOI: 10.1111/acem.14915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 03/20/2024] [Accepted: 03/21/2024] [Indexed: 04/11/2024]
Abstract
OBJECTIVES Appendicitis poses diagnostic challenges. A correct diagnosis is important during pregnancy to avoid unnecessary surgery on the one hand and delayed surgery on the other hand, as both may negatively affect pregnancy outcomes. Clinical scores for risk-stratified management of suspected appendicitis are well established in adults but have not been validated during pregnancy. This nested case-control study evaluated the diagnostic accuracy of the Appendicitis Inflammatory Response (AIR) score and imaging during pregnancy. METHODS By cross-linking national Swedish health registries from a defined geographical area, we identified a cohort of 154 women who underwent appendectomy for suspected appendicitis during pregnancy and a matched cohort of 232 pregnant women admitted for acute abdominal pain and suspected appendicitis but with a discharge diagnosis of nonspecific abdominal pain (NSAP). All variables were extracted from medical records. The diagnostic value of AIR score and imaging was estimated for patients with a final diagnosis of appendicitis compared with patients with negative appendectomy and NSAP patients. RESULTS The final diagnoses for the operated patients were uncomplicated and complicated appendicitis in 49.4% and 26.6%, respectively, and negative appendectomy in 24.0%. Nearly half of all the patients underwent diagnostic imaging (41%), mainly by ultrasonography. The sensitivity and specificity of diagnostic imaging were 44.9% (95% CI 32.9%-57.4%) and 42.2% (95% CI 31.9%-53.1%), respectively. The area under the receiver operating characteristic curve of AIR score was 0.88 (95% CI 0.84-0.92) for all appendicitis and 0.90 (95% CI 0.84-0.95) for complicated appendicitis. The sensitivity for complicated appendicitis was 100% at a score of ≥4. The specificity for all appendicitis was 97% at a score of ≥9. CONCLUSIONS The results of this study suggest that the AIR score may be a suitable diagnostic tool for risk stratification of pregnant women with abdominal pain and suspected appendicitis but further validation among pregnant women is needed.
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Affiliation(s)
- Elin Moltubak
- Department of Surgery, County Hospital Ryhov, Jönköping, Sweden
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Kalle Landerholm
- Department of Surgery, County Hospital Ryhov, Jönköping, Sweden
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Marie Blomberg
- Department of Surgery, County Hospital Ryhov, Jönköping, Sweden
- Department of Obstetrics and Gynecology, Linköping University Hospital, Linköping, Sweden
| | - Roland E Andersson
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
- Futurum Academy for Health and Care, Jönköping County Council, Jönköping, Sweden
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Shahmoradi L, Safdari R, Mirhosseini MM, Rezayi S, Javaherzadeh M. Development and evaluation of a clinical decision support system for early diagnosis of acute appendicitis. Sci Rep 2023; 13:19703. [PMID: 37951984 PMCID: PMC10640605 DOI: 10.1038/s41598-023-46721-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 11/04/2023] [Indexed: 11/14/2023] Open
Abstract
The most frequent reason for individuals experiencing abdominal discomfort to be referred to emergency departments of hospitals is acute appendicitis, and the most frequent emergency surgery performed is an appendectomy. The purpose of this study was to design and develop an intelligent clinical decision support system for the timely and accurate diagnosis of acute appendicitis. The number of participants which is equal to 181 was chosen as the sample size for developing and evaluating neural networks. The information was gathered from the medical files of patients who underwent appendicectomies at Shahid Modarres Hospital as well as from the findings of their appendix samples' pathological tests. The diagnostic outcomes were then ascertained by the development and comparison of a Multilayer Perceptron network (MLP) and a Support Vector Machine (SVM) system in the MATLAB environment. The SVM algorithm functioned as the central processing unit in the Clinical Decision Support System (CDSS) that was built. The intelligent appendicitis diagnostic system was subsequently developed utilizing the Java programming language. Technical evaluation and system usability testing were both done as part of the software evaluation process. Comparing the output of the optimized artificial neural network of the SVM with the pathology result showed that the network's sensitivity, specificity, and accuracy were 91.7%, 96.2%, and 95%, respectively, in diagnosing acute appendicitis. Based on the existing standards and the opinions of general surgeons, and also comparing the results with the diagnostic accuracy of general surgeons, findings indicated the proper functioning of the network for the diagnosis of acute appendicitis. The use of this system in medical centers is useful for purposes such as timely diagnosis and prevention of negative appendectomy, reducing patient hospital stays and treatment costs, and improving the patient referral system.
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Affiliation(s)
- Leila Shahmoradi
- Health Information Management and Medical Informatics Department, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Safdari
- Health Information Management and Medical Informatics Department, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
| | - Mir Mikail Mirhosseini
- Health Information Management and Medical Informatics Department, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
| | - Sorayya Rezayi
- Health Information Management and Medical Informatics Department, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran.
| | - Mojtaba Javaherzadeh
- General Surgery and Thoracic Surgery, Modarres Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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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.
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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
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Gupta V, Gupta P, Gill CS, Gupta M. Appendicitis Inflammatory Response Score in Acute Appendicitis: A Study at a Tertiary Care Center in North India. Int J Appl Basic Med Res 2022; 12:234-238. [PMID: 36726654 PMCID: PMC9886148 DOI: 10.4103/ijabmr.ijabmr_287_22] [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: 04/25/2022] [Revised: 07/19/2022] [Accepted: 07/28/2022] [Indexed: 12/24/2022] Open
Abstract
Introduction Appendicitis is a common cause of acute abdominal pain. The diagnosis is eminently clinical and the cause is surgically correctable. However, a decision of surgery based on the clinical presentation only has a 15%-30% chance of the removal of a normal appendix. Thus, the diagnosis involves a corroboration of clinical, laboratory, and radiological findings. Appendicitis scoring systems can be considered to expedite the diagnostic and decision-making process. Aim The present study was conducted to study the efficacy of Appendicitis Inflammatory Response (AIR) score in the diagnosis of acute appendicitis and its correlation with the histopathological findings. Materials and Methods A cross-sectional study was conducted at a tertiary care center in North India comprising patients who presented to the surgery department with a provisional diagnosis of acute appendicitis and required appendectomy. Results Appendicitis was histopathologically proven in 54 patients. Patients with an AIR score ≥5 were 2.18 times more likely to have appendicitis. The probability of having appendicitis with AIR score ≥5 was 92.16% (positive predictive value). The diagnostic accuracy of AIR score was 82.81%. Conclusion AIR score has a high sensitivity and positive predictive value in the diagnosis of acute appendicitis. It is a quick and convenient system for clinical evaluation of patients in primary care or peripheral hospitals where advanced facilities such as USG scan or CT scan are not available all the time. The application of this scoring system definitely improves diagnostic accuracy and reduces negative appendectomy rate.
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Affiliation(s)
- Varun Gupta
- Department of Surgery, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Palak Gupta
- Department of Surgery, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Chiranjiv Singh Gill
- Department of Surgery, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Manvi Gupta
- Department of Pathology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
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Zorzetti N, Lauro A, Bellini MI, Vaccari S, Dalla Via B, Cervellera M, Cirocchi R, Sorrenti S, D’Andrea V, Tonini V. Laparoscopic appendectomy, stump closure and endoloops: A meta-analysis. World J Gastrointest Surg 2022; 14:1060-1071. [PMID: 36185568 PMCID: PMC9521468 DOI: 10.4240/wjgs.v14.i9.1060] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 07/22/2022] [Accepted: 08/25/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Acute appendicitis (AA) is one of the main indications for urgent surgery. Laparoscopic appendectomy (LA) has shown advantages in terms of clinical results and cost-effectiveness, even if there is still controversy about different devices to utilize, especially with regards to the endoloop (EL) vs endostapler (ES) when it comes to stump closure.
AIM To compare safety and cost-effectiveness of EL vs ES.
METHODS From a prospectively maintained database, data of 996 consecutive patients treated by LA with a 3 years-follow up in the department of Emergency General Surgery - St Orsola University Hospital, Bologna (Italy) were retrieved. A meta-analysis was performed in terms of surgical complications, in comparison to the international literature published from 1995 to 2021.
RESULTS The meta-analysis showed no evidence regarding wound infections, abdominal abscesses, and total post-operative complications, in terms of superiority of a surgical technique for the stump closure in LA.
CONCLUSION Even when AA is complicated, the routine use of EL is safe in most patients.
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Affiliation(s)
- Noemi Zorzetti
- Department of General Surgery, Ospedale Civile A Costa, Porretta Terme 40046, Italy
- Department of Surgical Sciences, Sapienza University, Rome 00161, Italy
| | - Augusto Lauro
- Department of Surgical Sciences, Sapienza University, Rome 00161, Italy
| | | | - Samuele Vaccari
- Department of Surgical Sciences, Sapienza University, Rome 00161, Italy
- Department of General Surgery, Ospedale di Bentivoglio, Bologna 40010, Italy
| | - Barbara Dalla Via
- Department of Emergency Surgery, St Orsola University Hospital, Bologna 40138, Italy
| | - Maurizio Cervellera
- Department of General Surgery, Ospedale Santissima Annunziata, Taranto 74121, Italy
| | - Roberto Cirocchi
- Department of General Surgery, Ospedale di Terni, Università di Perugia, Terni 05100, Italy
| | | | - Vito D’Andrea
- Department of Surgical Sciences, Sapienza University, Rome 00161, Italy
| | - Valeria Tonini
- Department of Emergency Surgery, St Orsola University Hospital, Bologna 40138, Italy
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Wang WD, Lin JQ, Zheng GW, Fang ZP, Yan YX. Analysis of appendicitis management during COVID-19 pandemic: A study of Chinese adult cohorts. Front Surg 2022; 9:961258. [PMID: 36468079 PMCID: PMC9709813 DOI: 10.3389/fsurg.2022.961258] [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: 06/07/2022] [Accepted: 07/11/2022] [Indexed: 10/03/2023] Open
Abstract
BACKGROUND Healthcare seeking behavior has been widely impacted due to the restricted movements of individuals during the Coronavirus disease-19 (COVID-19) pandemic. This study aims to perform risk stratification in patients requiring timely intervention during the recovery periods. METHODS Operation notes of acute appendicitis (AA) patients within a hospital were analyzed during three six-month periods (23 January-23 July in 2019, 2020, and 2021, respectively). Patient data were collected retrospectively including demographics, pre-emergency status, perioperative information, postoperative outcomes, and follow-up results. RESULTS 321 patients were included in this study, with 111, 86, and 124 patients in 2019, 2020, and 2021 groups, respectively. The median age of patients decreased by 4 years in 2020 as compared to that in 2019. The proportion of pre-hospitalization symptoms duration of more than 48 h in the 2020 group was higher (36.05% in 2020 vs. 22.52% in 2019). Length of hospital stay (LOS) in 2020 was shorter than it was during the same period in 2019 (4.77 vs. 5.64) and LOS in 2021 was shorter than in 2019 (4.13 vs. 5.64). Compared to the lockdown period, the proportion of patients with recurrent AA was higher in the post-lockdown period (15.1% vs. 27.4%). The median age was 34 years (vaccinated) vs. 37 years (unvaccinated). Logistic regression suggests that elevated C-reactive protein (CRP) (OR = 1.018, CI = 1.010-1.028), white cell count (WBC) (OR = 1.207, CI = 1.079-1.350), female (OR = 2.958, CI = 1.286-6.802), recurrent (OR = 3.865, CI = 1.149-12.997), and fecalith (OR = 2.308, CI = 1.007-5.289) were associated with complicated appendicitis (CA). CONCLUSION The lockdown measures during the COVID-19 epidemic are shown to be correlated with a reduction in the proportion of AA patients who underwent surgery, particularly in older adults. Risk factors for CA include elevated CRP, WBC, female, recurrent, and fecalith.
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The Diagnostic Differentiation Challenge in Acute Appendicitis: How to Distinguish between Uncomplicated and Complicated Appendicitis in Adults. Diagnostics (Basel) 2022; 12:diagnostics12071724. [PMID: 35885627 PMCID: PMC9322371 DOI: 10.3390/diagnostics12071724] [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: 05/31/2022] [Revised: 07/07/2022] [Accepted: 07/12/2022] [Indexed: 11/24/2022] Open
Abstract
(1) Background: How to best define, diagnose and differentiate uncomplicated from complicated acute appendicitis remains debated. Hence, the aim of this review was to present an overview of the current knowledge and emerging field of acute appendicitis with a focus on the diagnostic differentiation of severity currently subject to ongoing investigations. (2) Methods: We conducted a PubMed search using the MeSH terms “appendicitis AND severity” and “appendicitis AND classification”, with a focus on studies calling appendicitis as ‘uncomplicated’ or ‘complicated’. An emphasis on the last 5 years was stressed, with further studies selected for their contribution to the theme. Further studies were retrieved from identified full-text articles and included per the authors’ discretion. (3) Results: The assumption that appendicitis invariably will proceed to perforation has been outdated. Both uncomplicated and complicated appendicitis exist with likely different pathophysiology. Hence, this makes it important to differentiate disease severity. Clinicians must diagnose appendicitis, but, in the next step, also differentiate between uncomplicated and complicated appendicitis in order to allow for management decisions. Diagnostic accuracy without supportive imaging is around 75–80% and, based on clinical judgement and blood tests alone, the negative appendectomy rate has been described as high as 36%. More research is needed on available biomarkers, and the routine use of imaging still remains debated. Scoring systems have the potential to improve diagnostic accuracy, but no scoring system has yet been validated for differentiating disease severity. Currently, no universally agreed definition exists on what constitutes a complicated appendicitis. (4) Conclusions: Uncomplicated and complicated appendicitis appear to have different pathophysiology and should be treated differently. The differentiation between uncomplicated and complicated appendicitis remains a diagnostic challenge.
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Wu J, Jiang H, Li S, Wu X, Wang P, Sawyer R, Ren J. Optimising the treatment for uncomplicated acute appendicitis (OPTIMA trial): a protocol for a multicentre, randomised, double-blinded placebo-controlled study. BMJ Open 2022; 12:e057793. [PMID: 35501082 PMCID: PMC9062814 DOI: 10.1136/bmjopen-2021-057793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Emerging evidence has shown that an antibiotic first strategy is a viable treatment option for uncomplicated acute appendicitis (AA). Although there has recently been an interest and increase in the use of antibiotics as the primary strategy for treating uncomplicated AA, there is no consensus regarding the optimum antibiotic regimen. In particular, the long-term outcomes of different antibiotic regimens, such as the recurrence rate, still lack evidence. Given that the flora of the appendix is mainly anaerobic bacteria, we hypothesised that antianaerobe regimens could decrease the recurrence rate compared with those that did not include antianaerobic antibiotics. METHODS AND ANALYSIS The OPTIMA(Optimising the treatment for uncomplicated acute appendicitis) trial is a multicentre, double-blinded placebo-controlled superiority randomised study aimed to evaluate the role of antianaerobic antibiotics in the resolution of uncomplicated AA. Patients (18-65 years) with uncomplicated AA (without gangrenous, perforated appendicitis, appendiceal abscess, or appendiceal fecaliths) are eligible for inclusion. The primary endpoint of this study is the success rate of the treatment, defined as the resolution of AA resulting in discharge from the hospital without surgical intervention and recurrent symptoms within one year. Secondary endpoints include mortality, postintervention complications, recurrent symptoms up to one year after treatment, hospital stay, sick leave, treatment cost, pain symptom scores and quality of life. Data are reported as the number of cases (%), median (range) and relative risk, which will be analysed using the Mann-Whitney U test or χ2 test, as appropriate. P-value<0.05 will be considered significant. ETHICS AND DISSEMINATION The protocol has been approved by the Ethics Committee of Jinling Hospital on 13 November 2018 (2018NZKY-027-01). The trial findings will be published in peer-reviewed journals. TRIAL REGISTRATION NUMBER ChiCTR1800018896.
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Affiliation(s)
- Jie Wu
- Department of General Surgery, The Affiliated BenQ Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Haiyang Jiang
- Department of General Surgery, The Affiliated BenQ Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Shikuan Li
- Department of Emergency Medicine, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xiuwen Wu
- Department of Surgery, Jinling Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Peige Wang
- Department of Emergency Medicine, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Robert Sawyer
- General Surgery Department, Western Michigan University, Kalamazoo, Michigan, USA
| | - Jianan Ren
- Department of Surgery, Jinling Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
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Sensitivity and specificity of the Alvarado Score for the timely differential diagnosis of acute appendicitis for a case series in Samoa. Ann Med Surg (Lond) 2022; 73:103219. [PMID: 35079363 PMCID: PMC8767311 DOI: 10.1016/j.amsu.2021.103219] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 12/23/2021] [Accepted: 12/23/2021] [Indexed: 12/29/2022] Open
Abstract
Background Timely diagnosis of acute appendicitis (AA) is essential for optimal management of abdominal pain emergency presentations. Improved diagnostic procedures should minimise progression to complicated appendicitis, as well as reduce the number of unwanted surgical interventions. The Alvarado Score is an important tool to assist with the management of AA based on clinically predictive values. The aim of the present study was to evaluate the sensitivity and specificity of the Alvarado Score as an instrument for the diagnosis of AA in our low-resourced context of Samoa. Materials and methods The lead investigator performed a retrospective clinical data review design of all patients admitted to the Tupua Tamasese Meaole Hospital Surgical Unit for AA from January 2015 to December 2016. Exclusion criteria were appendiceal abscess and/or mass, and final diagnosis ‘not acute appendicitis’. Age, sex, village, Alvarado Score, Ultrasound Scan Result, surgical management, and histopathology result were the main variables entered into the SPSS statistical software package for analysis. Results Of the 225 patients (2–86 years) admitted for AA, 67.1% (N = 151) underwent appendicectomy, and the remaining 32.9% (N = 74) were treated with antibiotics. An Alvarado Score (≥5) showed 91.7% sensitivity and 50% specificity for AA. There was a significant relationship between the Alvarado Score and the Ultrasound Scan for AA (p < 0.05). Histology results showed complicated AA in 68.6% (N = 94) of cases. The negative appendicectomy rate was 2.6%. Conclusions The Alvarado Score is an effective tool for the timely differential diagnosis of AA in our Samoan context. The high rate of complicated acute appendicitis warrants investigation to further improve the management of AA in the Pacific Island setting. Effective instrument required for the timely diagnosis of appendicitis in low-resource contexts Alvarado Score is an effective tool for the differential diagnosis of acute appendicitis High specificity demonstrated for use of Alvarado Score in the emergency department of Samoa Histology results showed high rate of complicated acute appendicitis in Samoa Surgical outcomes showed low negative appendicectomy rate
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Cullison KM, Franck N. Clinical Decision Rules in the Evaluation and Management of Adult Gastrointestinal Emergencies. Emerg Med Clin North Am 2021; 39:719-732. [PMID: 34600633 DOI: 10.1016/j.emc.2021.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Although abdominal pain is a common chief complaint in the emergency department, only 1 in 6 patients with abdominal pain are diagnosed with a gastrointestinal (GI) emergency. These patients often undergo extensive testing as well as hospitalizations to rule out an acute GI emergency and there is evidence that not all patients benefit from such management. Several clinical decision rules (CDRs) have been developed for the diagnosis and management of patients with suspected acute appendicitis and upper GI bleeding to identify those patients who may safely forgo further testing or hospital admission. Further validation studies demonstrating the superiority of these CDRs over contemporary practice are needed.
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Affiliation(s)
- Kevin M Cullison
- Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, 545 1st Avenue, New York, NY 10016, USA.
| | - Nathan Franck
- Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, 545 1st Avenue, New York, NY 10016, USA
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Harris J, Fleming CA, Stassen PN, Mullen D, Mohan H, Foley J, Heeney A, Nugent E, Schmidt K, Mealy K. A comparison of intra-operative diagnosis to histopathological diagnosis of acute appendicitis in paediatric and adult cohorts: an analysis of over 1000 patients. Ir J Med Sci 2021; 191:1809-1813. [PMID: 34515986 PMCID: PMC9308595 DOI: 10.1007/s11845-021-02770-5] [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: 01/31/2021] [Accepted: 08/28/2021] [Indexed: 10/25/2022]
Abstract
BACKGROUND Appendicitis is a common general surgical emergency. The role of removing a normal appendix is debated. However, this relies on accurate intra-operative diagnosis of a normal appendix by the operating surgeon. This study aimed to compare surgeon's intra-operative assessment to final histological result acute appendicitis in paediatric and adult patients. METHODS All patients who underwent appendicectomy over a 14-year period in a general surgical department were identified using the prospective Lothian Surgical Audit system and pathology reports retrieved to identify final histological diagnosis. Open appendicectomy was selected to examine, as the routine practise at our institution is to remove a normal appendix at open appendicectomy. RESULTS A total of 1035 open appendicectomies were performed for clinically suspected appendicitis. Sensitivity of intra-operative diagnosis of appendicitis with operating surgeon was high at 95.13% with no difference between trainee and consultant surgeon or between adult and paediatric cases. Specificity of intra-operative diagnosis was lower in the paediatric group (32.58%) than in the adult group (40.58%). Women had a higher rate of negative appendicectomy than men. CONCLUSION The results of this study highlight some discordance between histological evidence of acute appendicitis and intra-operative impression. Therefore other clinical variables and not just macroscopic appearance alone should be used when deciding to perform appendicectomy.
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Affiliation(s)
- Johnathon Harris
- Department of General Surgery, Wexford General Hospital, Wexford, Ireland.
| | | | - Paul N Stassen
- Department of General Surgery, Wexford General Hospital, Wexford, Ireland
| | - Daniel Mullen
- Department of General Surgery, Wexford General Hospital, Wexford, Ireland
| | - Helen Mohan
- Department of General Surgery, Wexford General Hospital, Wexford, Ireland
| | - James Foley
- Department of General Surgery, Wexford General Hospital, Wexford, Ireland
| | - Anna Heeney
- Department of General Surgery, Wexford General Hospital, Wexford, Ireland
| | - Emmeline Nugent
- Department of General Surgery, Wexford General Hospital, Wexford, Ireland
| | - Karl Schmidt
- Department of General Surgery, Wexford General Hospital, Wexford, Ireland
| | - Ken Mealy
- Department of General Surgery, Wexford General Hospital, Wexford, Ireland
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Podda M, Pisanu A, Sartelli M, Coccolini F, Damaskos D, Augustin G, Khan M, Pata F, De Simone B, Ansaloni L, Catena F, Di Saverio S. Diagnosis of acute appendicitis based on clinical scores: is it a myth or reality? ACTA BIO-MEDICA : ATENEI PARMENSIS 2021; 92:e2021231. [PMID: 34487066 PMCID: PMC8477120 DOI: 10.23750/abm.v92i4.11666] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 04/26/2021] [Indexed: 12/29/2022]
Affiliation(s)
- Mauro Podda
- Department of Emergency Surgery, Cagliari University Hospital "Duilio Casula", Cagliari (Italy).
| | - Adolfo Pisanu
- Department of Emergency Surgery, Azienda Ospedaliero-Universitaria di Cagliari, University Hospital Policlinico "Duilio Casula", Cagliari, Italy.
| | | | - Federico Coccolini
- General, Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy.
| | - Dimitrios Damaskos
- Department of Upper GI Surgery, Royal Infirmary of Edinburgh, Edinburgh, Scotland, UK.
| | - Goran Augustin
- Department of Surgery, University Hospital Centre of Zagreb, Zagreb, Croatia.
| | - Mansoor Khan
- Department of General and Trauma Surgery, Brighton and Sussex University Hospital NHS Trust, Brighton, United Kingdom.
| | - Francesco Pata
- Department of Surgery, Nicola Giannettasio Hospital, Corigliano-Rossano.
| | - Belinda De Simone
- Department of Visceral Surgery, Centre Hospitalier Intercommunal Poissy/Saint-Germain-en-Laye, Poissy, France.
| | - Luca Ansaloni
- Department of Surgery, "San Matteo" University Hospital, Pavia, Italy.
| | - Fausto Catena
- Emergency and Trauma Surgery Department, Maggiore Hospital of Parma, Parma, Italy.
| | - Salomone Di Saverio
- Department of General Surgery, University of Insubria, University Hospital of Varese, ASST Sette Laghi, Regione Lombardia, Varese, Italy..
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Jose T, Rajesh PS. Appendicitis Inflammatory Response Score in Comparison to Alvarado Score in Acute Appendicitis. Surg J (N Y) 2021; 7:e127-e131. [PMID: 34295969 PMCID: PMC8289675 DOI: 10.1055/s-0041-1731446] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 05/17/2021] [Indexed: 12/29/2022] Open
Abstract
Appendicitis is a common differential diagnosis of right lower quadrant pain. Clinical evaluation alone results in high negative appendicectomy rates. Alvarado scoring is the most commonly used clinical prediction rule. The study aimed to compare the recently developed appendicitis inflammatory response (AIR) score with the Alvarado score. This cross-sectional observational study included patients who underwent appendicectomy for clinical suspicion of appendicitis. The clinical and laboratory parameters required for obtaining Alvarado score and AIRS were gathered. Area under ROC curve was calculated for both Alvarado score and AIRS. The study included 130 patients (77 males and 53 females). The negative appendicectomy rate was 10.7%. The perforation rate was 10.3%. The area under ROC for Alvarado score was 0.821 and for AIR score was 0.901. The Alvarado score had a sensitivity of 72% and a specificity of 79% at score ≥6. The appendicitis inflammatory response score had a sensitivity of 98% for scores ≥5 and a specificity of 97% for score ≥6. The C-reactive protein (CRP) value was the best performing individual parameter with an area under ROC of 0.789, followed by WBC count with an area under ROC of 0.762. Appendicitis inflammatory response score is a recently developed score that outperforms the Alvarado score. AIR score has a higher specificity. The sound construction, gradation of parameters, the inclusion of CRP, and avoidance of subjective parameters make the AIR score an attractive clinical prediction rule which can decrease the rate of negative appendicectomy.
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Affiliation(s)
- Toney Jose
- Department of Surgical Gastroenterology, Bangalore Medical College and Research Institute, Bangalore, India
| | - P S Rajesh
- Department of General Surgery, Government Medical College, Kottayam, Kerala, India
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Abstract
INTRODUCTION The rate of misdiagnosis of appendicitis in children is a challenge and clinical prediction scores could be part of the solution. However, the pediatric appendicitis score (PAS) and the Alvarado score have shown disappointing diagnostic accuracy in pediatric validation studies, while the appendicitis inflammatory response (AIR) score and the novel pediatric appendicitis risk calculator (pARC) have not yet been validated thoroughly. Therefore, the aim of the present study was to evaluate these four prediction scores prospectively in children with suspected appendicitis. MATERIALS AND METHODS A prospective study was conducted over a 2-year period. All patients <15 years with suspected appendicitis were eligible for inclusion. The four prediction scores were compared regarding predictive values, receiver operating characteristics (ROC) curves, decision curve analysis, and clinical outcome. RESULTS Of the 318 patients included, 151 (47 %) patients had appendicitis. The AIR score and the pARC had substantially higher specificity and positive predictive value, and lower rate of false positives (7% and 2%), than the PAS and Alvarado score (36 and 28%, p < 0.001). Across the different gender and age groups, the AIR score and the pARC generally had fewer false positives than the PAS and Alvarado score. There were no significant differences in sensitivity, negative predictive values, rates of missed appendicitis, or ROC curve analysis. In decision curve analysis, the AIR score and the pARC outperformed the PAS and Alvarado score at most threshold probabilities. CONCLUSION The AIR score and the pARC are superior to the PAS and Alvarado score in diagnosing children with suspected appendicitis.
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Podda M, Andersson R, Boermeester M, Coccolini F, Sartelli M, Moore EE, Sugrue M, Abu-Zidan F, Tolonen M, Damaskos D, Kluger Y, Soreide K, Pisanu A, Augustin G, Latifi R, Kelly M, Leppaniemi A, Fraga GP, Ten Broek R, Tan E, Van Goor H, Chiara O, Maier RV, Pata F, De Simone B, Ordoñez CA, Ansaloni L, Catena F, Di Saverio S. Do young patients with high clinical suspicion of appendicitis really need cross-sectional imaging? Proceedings from a highly controversial debate among the experts' panel of 2020 WSES Jerusalem guidelines. J Trauma Acute Care Surg 2021; 90:e101-e107. [PMID: 33496553 DOI: 10.1097/ta.0000000000003097] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Mauro Podda
- From the Department of Emergency Surgery (M.P., A.P.), Azienda Ospedaliero-Universitaria di Cagliari, University Hospital Policlinico Duilio Casula, Cagliari, Italy; Department of Surgery (R.A.), Linkoping University, Linkoping, Sweden; Department of Surgery (M.B.), University of Amsterdam, Amsterdam, The Netherlands; General, Emergency and Trauma Surgery (F.C.), Pisa University Hospital, Pisa, Italy; Department of Surgery (M.S.), Macerata Hospital, Macerata, Italy; Denver Health System-Denver Health Medical Center (E.E.M.), Denver, Colorado; Department of Surgery (M.S.), Letterkenny Hospital, Donegal, Ireland; Department of Surgery (F.A.-Z.), College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates; Department of Abdominal Surgery (M.T., A.L.), Abdominal Center, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland; Department of Upper GI Surgery (D.D.), Royal Infirmary of Edinburgh, Edinburgh, Scotland, United Kingdom; Division of General Surgery (Y.K.), Rambam Health Care Campus, Haifa, Israel; Department of Gastrointestinal Surgery (K.S.), Stavanger University Hospital, Stavanger, Norway; Department of Surgery (G.A.), University Hospital Centre of Zagreb, Zagreb, Croatia; Section of Acute Care Surgery, Westchester Medical Center, Department of Surgery (R.L.), New York Medical College, Valhalla, New York; Acute Surgical Unit (M.K.), Canberra Hospital, ACT, Canberra, Australia; Faculdade de Ciências Médicas (FCM)-Unicamp, Campinas (G.P.F.), SP, Brazil; Department of Surgery (R.T.B., E.T., H.V.G.), Radboud University Medical Center, Nijmegen, The Netherlands; Niguarda Hospital Trauma Center (O.C.), Milan, Italy; Department of Surgery (R.V.M.), University of Washington, Harborview Medical Center, Seattle, Washington; Department of Surgery (F.P.), Nicola Giannettasio Hospital, Corigliano-Rossano, and La Sapienza University o Rome, Rome, Italy; Department of Visceral Surgery (B.D.S.), Centre Hospitalier Intercommunal Poissy/Saint-Germain-en-Laye, Poissy, France; Division of Trauma and Acute Care Surgery, Department of General Surgery (C.A.O.), Fundación Valle del Lili, Cali, Colombia; Department of General Surgery and Trauma (L.A.), Bufalini Hospital, Cesena, Italy; Emergency and Trauma Surgery Department (F.C.), Maggiore Hospital of Parma, Parma, Italy; and Department of General Surgery (S.D.S.), University of Insubria, University Hospital of Varese, ASST Sette Laghi, Regione Lombardia, Varese, Italy
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Validity of Appendicitis Inflammatory Response Score in Distinguishing Perforated from Non-Perforated Appendicitis in Children. CHILDREN-BASEL 2021; 8:children8040309. [PMID: 33921577 PMCID: PMC8073718 DOI: 10.3390/children8040309] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 03/28/2021] [Accepted: 04/13/2021] [Indexed: 12/29/2022]
Abstract
Background: This prospective observational study aimed to evaluate the validity of appendicitis inflammatory response (AIR) score in differentiating advanced (perforated) from simple (non-perforated) appendicitis in pediatric patients. Methods: A single-center prospective cross-sectional study was conducted between 1 January 2019 until 1 May 2020 including 184 pediatric patients who underwent appendectomy. Based on the intraoperative finding of advanced (n = 38) or simple (n = 146) appendicitis the patients were divided into two groups. Recipient-operator curve (ROC), with calculation of sensitivity and specificity of best cutoff and the area under the curve (AUC), were used to measure the diagnostic value and the potential for risk stratification of the AIR score, among the patients with simple or advanced acute appendicitis. Results: The median value of the AIR score in the perforated and non-perforated groups was 10 (interquartile range, IQR 9, 11), and was 7 (IQR 6, 9), respectively (p < 0.001). Based on the calculated value of AIR score, the patients were classified with a high precision into low, indeterminate and high risk groups for acute appendicitis (p < 0.001). A cutoff value of ≥9 was demonstrated to serve as a reliable indicator of perforated appendicitis with a sensitivity and a specificity of 89.5% and 71.9%, respectively (AUC = 0.80; 95% CI: 0.719–0.871; p < 0.001). Conclusions: Acute appendicitis can be detected with a high level of sensitivity and specificity using the AIR score. Also, the AIR score may differentiate perforated from non-perforated appendicitis in pediatric patients with a high level of accuracy.
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Vaziri M, Nafissi N, Jahangiri F, Nasiri M. Comparison of the appendicitis inflammatory response and Alvarado scoring systems in the diagnosis of acute appendicitis in children. J Med Life 2021; 14:75-80. [PMID: 33767789 PMCID: PMC7982267 DOI: 10.25122/jml-2020-0031] [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] [Indexed: 12/01/2022] Open
Abstract
Our objective was to compare the diagnostic accuracy of Alvarado and appendicitis inflammatory response (AIR) scoring systems among children suspected of acute appendicitis concerning their postoperative outcomes. During a two-year period, a prospective multicentric study was carried in the selected hospitals of Iran. All children who were admitted with the diagnosis of acute appendicitis were enrolled in the study. However, patients suffering from generalized peritonitis or those who had a history of abdominal surgery were excluded. Before decision-making, each patient’s score according to two appendicitis scoring systems was calculated. The clinical outcomes and diagnosis of patients were then compared to the results of each scoring system. For those patients who were a candidate for surgery, the final diagnosis of acute appendicitis was made by histopathology. Patients were divided into a high- and low-risk group according to scoring systems outcomes. Among the patients with a low score for appendicitis, the AIR scoring system had a sensitivity and specificity of 95% and 74%, respectively, which was more promising in comparison to that of the Alvarado system (90% and 70%, respectively). Regarding the patients at higher risk of acute appendicitis, none of the scoring systems provided reliable results since both systems showed sensitivity and specificity of less than 50%, which was not sufficient to distinguish patients who are a candidate for surgery. AIR and Alvarado scoring systems are not accurate models to predict the risk of acute appendicitis among children; however, the AIR system could be used as a reliable material to rule out the acute appendicitis diagnosis.
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Affiliation(s)
- Mohammad Vaziri
- Department of Surgery, Hazrat-e Rasoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Nahid Nafissi
- Department of Breast Surgery, Hazrat-e Rasoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Fariba Jahangiri
- Department of Pediatric Surgery, Ali-Asghar children Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Nasiri
- Department of Surgery, Hazrat-e Rasoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
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Andersson M, Kolodziej B, Andersson RE. Validation of the Appendicitis Inflammatory Response (AIR) Score. World J Surg 2021; 45:2081-2091. [PMID: 33825049 PMCID: PMC8154764 DOI: 10.1007/s00268-021-06042-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2021] [Indexed: 02/07/2023]
Abstract
Background Patients with suspicion of appendicitis present with a wide range of severity. Score-based risk stratification can optimise the management of these patients. This prospective study validates the Appendicitis Inflammatory Response (AIR) score in patients with suspicion of appendicitis. Method Consecutive patients over the age of five with suspicion of appendicitis presenting at 25 Swedish hospital’s emergency departments were prospectively included. The diagnostic properties of the AIR score are estimated. Results Some 3878 patients were included, 821 with uncomplicated and 724 with complicated appendicitis, 1986 with non-specific abdominal pain and 347 with other diagnoses. The score performed better in detecting complicated appendicitis (ROC area 0.89 (95% confidence interval (CI) 0.88–0.90) versus 0.83 (CI 0.82–0.84) for any appendicitis, p < 0.001), in patients below age 15 years and in patients with >47 h duration of symptoms (ROC area 0.93, CI 0.90–0.95 for complicated and 0.87, CI 0.84–0.90 for any appendicitis in both categories). Complicated appendicitis is unlikely at AIR score <4 points (Negative Predictive Value 99%, CI 98–100%). Appendicitis is likely at AIR score >8 points, especially in young patients (positive predictive value (PPV) 96%, CI 90–100%) and men (PPV 89%, CI 84–93%). Conclusions The AIR score has high sensitivity for complicated appendicitis and identifies subgroups with low probability of complicated appendicitis or high probability of appendicitis. The discriminating capacity is high in children and patients with long duration of symptoms. It performs equally well in both sexes. This verifies the AIR score as a valid decision support. Trial registration number https://clinicaltrials.gov/ct2/show/NCT00971438
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Affiliation(s)
- Manne Andersson
- Department of Biomedical and Clinical Sciences, Faculty of Health Sciences, Linköping University, Linköping, Sweden
- Department of Surgery, County Hospital Ryhov, 551 85, Jönköping, Sweden
| | - Blanka Kolodziej
- Department of Pathology, County Hospital Ryhov, County Council of Jönköping, Jönköping, Sweden
| | - Roland E Andersson
- Department of Biomedical and Clinical Sciences, Faculty of Health Sciences, Linköping University, Linköping, Sweden.
- Department of Surgery, County Hospital Ryhov, 551 85, Jönköping, Sweden.
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Naya I, Adachi K, Takeuchi K, Ariyama Y, Hosaka A, Imamura K, Morita Y, Matsubara S, Lefor AK, Horie H. Clinical predictors of gangrenous appendicitis: elevated total bilirubin level and computed tomography scan findings. Acute Med Surg 2021; 8:e620. [PMID: 33815809 PMCID: PMC8013822 DOI: 10.1002/ams2.620] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 11/30/2020] [Accepted: 12/02/2020] [Indexed: 12/29/2022] Open
Abstract
Aim Patients with gangrenous appendicitis usually require emergency surgery. Preoperative diagnosis of gangrenous appendicitis is clinically important but not always straightforward. We undertook this study to identify preoperative predictors of gangrenous appendicitis. Methods This was a single‐center case–control study. We identified 162 patients who underwent appendectomy between September 2011 and August 2014 after the diagnosis of acute appendicitis was established. We identified laboratory parameters and computed tomography (CT) scan findings predictive of histologically or surgically diagnosed gangrenous appendicitis by univariable and multivariable analyses. Results Of 146 study patients, gangrenous appendicitis was confirmed in 102. Univariable analysis showed that two laboratory factors (C‐reactive protein []and total bilirubin [T‐Bil]) and three CT scan findings were significant predictors for gangrenous appendicitis. Multivariable analysis showed that T‐Bil and two CT scan findings (appendicolith and fat stranding around the appendix) were independent predictors. The combination of “T‐Bil ≥ 1.0 mg/dL or appendicolith” was able to predict gangrenous appendicitis with a sensitivity of 90.5%, positive predictive value of 80.4%, and accuracy of 77.8%. The combination of “T‐Bil ≥ 1.0 mg/dL or fat stranding around the appendix” was able to predict gangrenous appendicitis with a sensitivity of 98.9%, positive predictive value of 76.4%, and accuracy of 71.9%. Conclusion These combinations of laboratory and CT scan findings could be valuable as predictors of gangrenous appendicitis.
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Affiliation(s)
- Itsuki Naya
- Department of Surgery Tokyo Metropolitan Tama Medical Center Tokyo Japan
| | - Kensuke Adachi
- Department of Surgery Tokyo Metropolitan Tama Medical Center Tokyo Japan.,Department of Surgery Tokyo Metropolitan Bokutoh Hospital Bokutoh Hospital Tokyo Japan
| | - Koichi Takeuchi
- Department of Welfare and Medical Intelligence Chiba University Hospital Chiba Japan
| | - Yuno Ariyama
- Department of Surgery Tokyo Metropolitan Tama Medical Center Tokyo Japan
| | - Akihiro Hosaka
- Department of Surgery Tokyo Metropolitan Tama Medical Center Tokyo Japan
| | - Kazuhiro Imamura
- Department of Surgery Tokyo Metropolitan Tama Medical Center Tokyo Japan
| | - Yasuhiro Morita
- Department of Surgery Tokyo Metropolitan Tama Medical Center Tokyo Japan
| | - Shigeki Matsubara
- Department of Obstetrics and Gynecology Jichi Medial University Tochigi Japan
| | | | - Hisanaga Horie
- Department of Surgery Jichi Medial University Tochigi Japan
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Fransvea P, Fico V, Cozza V, Costa G, Lepre L, Mercantini P, La Greca A, Sganga G. Clinical-pathological features and treatment of acute appendicitis in the very elderly: an interim analysis of the FRAILESEL Italian multicentre prospective study. Eur J Trauma Emerg Surg 2021; 48:1177-1188. [PMID: 33738537 DOI: 10.1007/s00068-021-01645-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 03/08/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Emergency abdominal surgery in the elderly represents a global issue. Diagnosis of AA in old patients is often more difficult. Appendectomy remains the gold standard of treatment and, even though it is performed almost exclusively with a minimally invasive technique, it can still represent a great risk for the elderly patient, especially above 80 years of age. A careful selection of elderly patients to be directed to surgery is, therefore, fundamental. The primary aim was to critically appraise and compare the clinical-pathological characteristics and the outcomes between oldest old (≥ 80 years) and elderly (65-79 years) patients with Acute Appendicitis (AA). METHODS The FRAILESEL is a large, nationwide, multicentre, prospective study investigating the perioperative outcomes of patients aged ≥ 65 years who underwent emergency abdominal surgery. Particular focus has been directed to the clinical and biochemical presentation as well as to the need for operative procedures, type of surgical approach, morbidity and mortality, and in-hospital length of stay. Two multivariate logistic regression analyses were performed to assess perioperative risk factors for morbidity and mortality. RESULTS 182 patients fulfilled the inclusion criteria. Mean age, ileocecal resection, OAD and ASA score ≥ 3 were related with both overall and major complication. The multivariate analysis showed that MPI and complicated appendicitis were independent factors associated with overall complications. OAD and ASA scores ≥ 3 were independent factors for both overall and major complications. CONCLUSIONS Age ≥ 80 years is not an independent risk factor for morbidities. POCUS is safe and effective for the diagnosis; however, a CECT is often needed. Having the oldest old a smaller functional organ reserve, an earlier intervention should be considered especially because they often show a delay in presentation and frequently exhibit a complicated appendicitis.
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Affiliation(s)
- Pietro Fransvea
- Emergency Surgery and Trauma-Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Catholic University of Sacred Heart, Largo A. Gemelli 8, 00168, Rome, Italy.
| | - Valeria Fico
- Emergency Surgery and Trauma-Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Catholic University of Sacred Heart, Largo A. Gemelli 8, 00168, Rome, Italy
| | - Valerio Cozza
- Emergency Surgery and Trauma-Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Catholic University of Sacred Heart, Largo A. Gemelli 8, 00168, Rome, Italy
| | - Gianluca Costa
- Surgery Center, Campus Bio-Medico University Hospital, University Campus Bio-Medico of Rome, Rome, Italy
- Surgical and Medical Department of Translational Medicine, Sant'Andrea Teaching Hospital, Sapienza University of Roma, Rome, Italy
| | - Luca Lepre
- General Surgery Unit, Santo Spirito in Sassia Hospital, ASL Roma 1, Rome, Italy
| | - Paolo Mercantini
- Surgical and Medical Department of Translational Medicine, Sant'Andrea Teaching Hospital, Sapienza University of Roma, Rome, Italy
| | - Antonio La Greca
- Emergency Surgery and Trauma-Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Catholic University of Sacred Heart, Largo A. Gemelli 8, 00168, Rome, Italy
| | - Gabriele Sganga
- Emergency Surgery and Trauma-Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Catholic University of Sacred Heart, Largo A. Gemelli 8, 00168, Rome, Italy
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Davoodabadi A, Zandi H, Moravveji A, Azadchehr MJ. Acute inflammatory response and Alvarado scoring systems in the diagnosis of acute appendicitis: which one is more accurate? Chirurgia (Bucur) 2021. [DOI: 10.23736/s0394-9508.20.05089-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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22
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Simon LE, Kene MV, Warton EM, Rauchwerger AS, Vinson DR, Reed ME, Chettipally UK, Mark DG, Sax DR, McLachlan DI, Cotton DM, Lin JS, Vazquez-Benitez G, Kharbanda AB, Kharbanda EO, Ballard DW. Diagnostic Performance of Emergency Physician Gestalt for Predicting Acute Appendicitis in Patients Age 5 to 20 Years. Acad Emerg Med 2020; 27:821-831. [PMID: 32239713 PMCID: PMC8310728 DOI: 10.1111/acem.13931] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 01/31/2020] [Accepted: 02/01/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Pediatric appendicitis remains a challenging diagnosis in the emergency department (ED). Available risk prediction algorithms may contribute to excessive ED imaging studies. Incorporation of physician gestalt assessment could help refine predictive tools and improve diagnostic imaging decisions. METHODS This study was a subanalysis of a parent study that prospectively enrolled patients ages 5 to 20.9 years with a chief complaint of abdominal pain presenting to 11 community EDs within an integrated delivery system between October 1, 2016, and September 30, 2018. Prior to diagnostic imaging, attending emergency physicians enrolled patients with ≤5 days of right-sided or diffuse abdominal pain using a Web-based application embedded in the electronic health record. Predicted risk (gestalt) of acute appendicitis was prospectively entered using a sliding scale from 1% to 100%. As a planned secondary analysis, we assessed the performance of gestalt via c-statistics of receiver operating characteristic (ROC) curves; tested associations between gestalt performance and patient, physician, and facility characteristics; and examined clinical characteristics affecting gestalt estimates. RESULTS Of 3,426 patients, 334 (9.8%) had confirmed appendicitis. Physician gestalt had excellent ROC curve characteristics (c-statistic = 0.83, 95% confidence interval = 0.81 to 0.85), performing particularly well in the low-risk strata (appendicitis rate = 1.1% in gestalt 1%-10% range, negative predictive value of 98.9% for appendicitis diagnosis). Physicians with ≥5 years since medical school graduation demonstrated improved gestalt performance over those with less experience (p = 0.007). All clinical characteristics tested, except pain <24 hours, were significantly associated with physician gestalt value (p < 0.05). CONCLUSION Physician gestalt for acute appendicitis diagnosis performed well, especially in low-risk patients and when employed by experienced physicians.
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Affiliation(s)
- Laura E. Simon
- Division of Research, Kaiser Permanente, Oakland, CA
- University of California San Diego School of Medicine, La Jolla, CA
| | - Mamata V. Kene
- The Permanente Medical Group, Kaiser Permanente San Leandro Medical Center, San Leandro, CA
| | | | | | - David R. Vinson
- Division of Research, Kaiser Permanente, Oakland, CA
- The Permanente Medical Group, Kaiser Permanente Roseville Medical Center, Roseville, CA
| | - Mary E. Reed
- Division of Research, Kaiser Permanente, Oakland, CA
| | - Uli K. Chettipally
- The Permanente Medical Group, Kaiser Permanente San Francisco Medical Center, San Francisco, CA
| | - Dustin G. Mark
- Division of Research, Kaiser Permanente, Oakland, CA
- The Permanente Medical Group, Kaiser Permanente Oakland Medical Center, Oakland, CA
| | - Dana R. Sax
- The Permanente Medical Group, Kaiser Permanente Oakland Medical Center, Oakland, CA
| | - D. Ian McLachlan
- The Permanente Medical Group, Kaiser Permanente San Francisco Medical Center, San Francisco, CA
| | - Dale M. Cotton
- The Permanente Medical Group, Kaiser Permanente South Sacramento Medical Center, Sacramento, CA
| | - James S. Lin
- The Permanente Medical Group, Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA
| | | | | | | | - Dustin W. Ballard
- Division of Research, Kaiser Permanente, Oakland, CA
- The Permanente Medical Group, Kaiser Permanente San Rafael Medical Center, San Rafael, CA
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A systematic review on the cost evaluation of two different laparoscopic surgical techniques among 996 appendectomies from a single center. Updates Surg 2020; 72:1167-1174. [PMID: 32474801 DOI: 10.1007/s13304-020-00817-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 05/20/2020] [Indexed: 02/08/2023]
Abstract
Acute appendicitis is one of the main indications for urgent surgery representing a high-volume procedure worldwide. The current spending review in Italy (and not only in this country) affects the health service and warrants care regarding the use of different surgical devices. The aim of our study is to perform a cost evaluation, comparing the use of endoloops and staplers in complicated acute appendicitis (phlegmonous and gangrenous), taking into consideration the cost of the device in relation to the management of any associated postoperative complications. We retrospectively evaluated 996 laparoscopic appendectomies of adult patients performed in the Emergency General Surgery-St. Orsola University Hospital in Bologna (Italy). Surgical procedures together with the related choice of using endoloops or staplers were performed by attending surgeons or resident surgeons supervised by a tutor. A systematic review was performed to compare our outcomes with those reported in the literature. In our experience, the routine use of endoloop leads to a real estimated saving of 375€ for each performed laparoscopic appendectomy, even considering post-operative complications. Comparing endoloop and stapler groups, the total number of complications is significantly lower in the endoloop group. Our systematic review confirmed these findings even if the superiority of one technique has not been proved yet. Our analysis shows that the routine use of endoloop is safe in most patients affected by acute appendicitis, even when complicated, and it is a cost-effective device even when taking into consideration extra costs for potential post-operative complications.
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Bord S, El Khuri C. High-Risk Chief Complaints III. Emerg Med Clin North Am 2020; 38:499-522. [DOI: 10.1016/j.emc.2020.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Ko Y, Lee WJ, Park JH, Kim HY, Sim JY, Tannaphai P, Lee KH. Diagnostic sensitivity and specificity of 2-mSv CT vs. conventional-dose CT in adolescents and young adults with suspected appendicitis: post hoc subgroup analysis of the LOCAT data. Eur Radiol 2020; 30:4573-4585. [PMID: 32240354 DOI: 10.1007/s00330-020-06811-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 03/02/2020] [Accepted: 03/13/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To test whether the difference in sensitivity or specificity between 2-mSv CT and conventional-dose CT (CDCT) for the diagnosis of appendicitis differs across subgroups of adolescents and young adults with suspected appendicitis. MATERIALS AND METHODS We used the per-protocol analysis data of a trial conducted between Dec 2013 and Aug 2016, including 2773 patients (median age [interquartile range], 28 [21-35] years) and 160 radiologists from 20 hospitals. We defined subgroups by sex, body size, clinical risk scores for appendicitis, time of CT examination (i.e., working vs. after hours), CT machines, radiologists' experience, previous site experience in 2-mSv CT, and site practice volume. We drew forest plots and tested for additive or multiplicative interaction between radiation dose and subgroup attributes. If any subgroup had fewer than 200 patients, we considered the results from that subgroup not meaningful. RESULTS For most subgroups, the 95% CIs for the differences in sensitivity and specificity were 4.0 percentage points or narrower and contained the minute overall between-group differences. There was no significant interaction on sensitivity or specificity. A few subgroups, including those of extreme body sizes, high appendicitis inflammatory response scores, and hospitals with small appendectomy volume, were regarded to have insufficient numbers of patients. CONCLUSIONS There was no notable subgroup heterogeneity, which implies that 2-mSv CT can replace CDCT in diverse populations. Further studies are needed for the subgroups for which we had only small data. KEY POINTS • The minute difference in sensitivity or specificity between the 2-mSv CT and conventional-dose CT (typically 7 mSv) groups were consistent across various patient or hospital characteristics. • These results indicate that 2-mSv CT can replace conventional-dose CT in diverse populations. • Further studies are needed to confirm whether 2-mSv CT can replace conventional-dose CT in patients of extreme body sizes, high appendicitis inflammatory response scores, or hospitals with small appendectomy volume, as those subgroups in our data included limited numbers of patients.
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Affiliation(s)
- Yousun Ko
- Program in Biomedical Radiation Sciences, Department of Transdisciplinary Studies, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, South Korea.,Biomedical Research Center, Asan Institute for Life Sciences, Asan Medical Center, Seoul, South Korea
| | - Woo Joo Lee
- Department of Statistics, Inha University, Incheon, South Korea
| | - Ji Hoon Park
- Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
| | - Hae Young Kim
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
| | - Ji Ye Sim
- Department of Radiology, Hanil General Hospital, Seoul, South Korea
| | - Penampai Tannaphai
- Department of Radiology, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Kyoung Ho Lee
- Program in Biomedical Radiation Sciences, Department of Transdisciplinary Studies, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, South Korea. .,Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea. .,Interdisciplinary Program in Bioengineering, Seoul National University, Seoul, South Korea.
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Guaitoli E, Gallo G, Cardone E, Conti L, Famularo S, Formisano G, Galli F, Giuliani G, Martino A, Pasculli A, Patini R, Soriero D, Pappalardo V, Casoni Pattacini G, Sparavigna M, Meniconi R, Mazzari A, Barra F, Orsenigo E, Pertile D. Consensus Statement of the Italian Polispecialistic Society of Young Surgeons (SPIGC): Diagnosis and Treatment of Acute Appendicitis. J INVEST SURG 2020; 34:1089-1103. [PMID: 32167385 DOI: 10.1080/08941939.2020.1740360] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background: Acute appendicitis (AA) is one of the most common causes of abdominal pain requiring surgical intervention. Approximately 20% of AA cases are characterized by complications such as gangrene, abscesses, perforation, or diffuse peritonitis, which increase patients' morbidity and mortality. Diagnosis of AA can be difficult, and evaluation of clinical signs, laboratory index and imaging should be part of the management of patients with suspicion of AA.Methods: This consensus statement was written in relation to the most recent evidence for diagnosis and treatment of AA, performing a literature review on the most largely adopted scientific sources. The members of the SPIGC (Italian Polispecialistic Society of Young Surgeons) worked jointly to draft it. The recommendations were defined and graded based on the current levels of evidence and in accordance with the criteria adopted by the American College of Chest Physicians (CHEST) for the strength of the recommendations.Results: Fever and migratory pain tend to be present in patients with suspicion of AA. Laboratory and radiological examinations are commonly employed in the clinical practice, but today also scoring systems based on clinical signs and laboratory data have slowly been adopted for diagnostic purpose. The clinical presentation of AA in children, pregnant and elderly patients can be unusual, leading to more difficult and delayed diagnosis. Surgery is the best option in case of complicated AA, whereas it is not mandatory in case of uncomplicated AA. Laparoscopic surgical treatment is feasible and recommended. Postoperative antibiotic treatment is recommended only in patients with complicated AA.
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Affiliation(s)
| | - Gaetano Gallo
- Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
| | - Eleonora Cardone
- Department of Surgery, Santa Maria del Popolo degli Incurabili Hospital, Napoli, Italy
| | - Luigi Conti
- Department of Surgery, G. Da Saliceto Hospital, Piacenza, Italy
| | - Simone Famularo
- Department of Medicine and Surgery University of Milan Bicocca HPB Unit, San Gerardo Hospital, Monza, Italy
| | - Giampaolo Formisano
- Department of General and Minimally Invasive Surgery, Misericordia Hospital, Grosseto, Italy
| | | | - Giuseppe Giuliani
- Department of General and Minimally Invasive Surgery, Misericordia Hospital, Grosseto, Italy
| | - Antonio Martino
- Department of General Surgery, University of Genoa, Genova, Italy
| | | | - Romeo Patini
- Odontostomatology and Oral Surgery, Sacro Cuore Hospital, Rome, Italy
| | - Domenico Soriero
- Department of General Surgery, University of Genoa, Genova, Italy
| | | | | | - Marco Sparavigna
- Department of General Surgery, University of Genoa, Genova, Italy
| | - Roberto Meniconi
- Department of General Surgeon and Transplantations, San Camillo-Forlanini Hospital, Rome, Italy
| | - Andrea Mazzari
- Mini Invasive and General Surgery, Cristo Re Hospital, Rome, Italy
| | - Fabio Barra
- Academic Unit of Obstetrics and Gynaecology, IRCCS Ospedale Policlinico San Martino, Genova, Italy.,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genova, Genova, Italy
| | - Elena Orsenigo
- Department of General and Emergency Surgery, San Raffaele Scientific Institute, Milano, Italy
| | - Davide Pertile
- Department of General Surgery, University of Genoa, Genova, Italy
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Daldal E, Dagmura H. The Correlation between Complete Blood Count Parameters and Appendix Diameter for the Diagnosis of Acute Appendicitis. Healthcare (Basel) 2020; 8:healthcare8010039. [PMID: 32069909 PMCID: PMC7151080 DOI: 10.3390/healthcare8010039] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 02/05/2020] [Accepted: 02/11/2020] [Indexed: 12/20/2022] Open
Abstract
Acute appendicitis is one of the most common causes of acute abdominal diseases seen between the ages of 10 and 19, mostly seen in males. The lifetime risk of developing acute appendicitis is 8.6% for males and 6.7% for females. We aimed to investigate the efficacy of the complete blood count parameters, C-reactive protein, and Lymphocyte-C-reactive Protein Ratio laboratory tests in the diagnosis of acute appendicitis, as well as their relationship with appendix diameter. We retrospectively examined all patients who underwent appendectomy between 1 January 2012 and 30 June 2019 in the General Surgery Clinic of Gaziosmanpasa University Faculty of Medicine. Laboratory tests, imaging findings, age, and gender were recorded. Lymphoid hyperplasia is considered as normal appendix—in other words, as negative appendicitis. The distribution of Lymphoid hyperplasia and appendicitis rates were statistically different in the groups formed according to appendix diameter (≤6 and >6 mm) (p < 0.001). We found a significant correlation between appendix diameter and WBC (White blood count), Lymphocyte, Neutrophil, RDW(Red blood cell distribution width), NLR(Neutrophil to lymphocyte ratio), and PLT/L (Platelet to lymphocyte ratio), MPV (Mean platelet volume) and RDW were significantly different in patients with an appendix diameter of ≤6 mm (p = 0.007, p = 0.006, respectively). WBC, Neutrophil, PDW, and NLR values were significantly different between appendicitis and hyperplasia groups in patients with an appendix diameter of >6 mm. The sensitivity of the NLR score (cutoff = 2.6057) in the diagnosis of appendicitis was 86.1% and selectivity was 50% in these patients. Complete blood count parameters evaluation with the clinical findings revealed that NLR is an important parameter that may help the diagnosis of acute appendicitis with an appendix diameter of >6 mm. In patients whose pathological results indicated acute appendicitis but who had a diameter of ≤6 mm, we found an elevated MPV and low RDW values.
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Affiliation(s)
- Emin Daldal
- General Surgery, Gaziosmanpasa University, Kaleardı mahallesi, 60250 Tokat, Turkey;
| | - Hasan Dagmura
- General Surgery and Surgical Oncology Department, Gaziosmanpasa University, Kaleardı Mahallesi, 60250 Tokat, Turkey
- Correspondence: ; Tel.: +90-532-162-6615
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Lin W, Han W, Wen K, Huang S, Tang Y, Lin Z, Han M. The Alterations of Copper and Zinc Homeostasis in Acute Appendicitis and the Clinical Significance. Biol Trace Elem Res 2019; 192:116-122. [PMID: 30771140 DOI: 10.1007/s12011-019-01661-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 02/04/2019] [Indexed: 02/05/2023]
Abstract
Copper (Cu) and zinc (Zn) are involved in inflammatory process. This study was to investigate the clinical significance of Cu and Zn homeostasis alterations in acute appendicitis (AA). One hundred twenty-two AA patients and 102 healthy controls were enrolled in this study. Of which, 85 patients' appendixes were collected after appendectomy. Another six appendixes from colon cancer patients were collected as tissue controls. The contents of Cu and Zn in serum or appendix were detected, and the Cu to Zn ratio (CZr) was calculated. The concentrations of serum ceruloplasmin (CP), Cu/Zn superoxide dismutase (SOD1), interleukin-6 (IL-6), and interleukin-22 in serum were measured, as well as the activity of CP and SOD1. The serum Zn concentration and SOD1 activity, appendix contents of Cu and Zn significantly decreased in AA patients, compared with those of controls, while serum CZr, concentrations of CP, SOD1, and IL-6, as well as CP activity increased significantly in AA patients. Additionally, serum concentrations of Zn, CP, CZr, or SOD1 activity varied in different pathological types of AA. Indicators such as serum SOD1 activity might serve as predictors for pathological classification before surgery. The serum Zn and CZr may be helpful for diagnosis of pure AA. The Cu and Zn homeostasis was altered in AA patients, which might contribute to inflammatory process of AA.
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Affiliation(s)
- Wenhao Lin
- Emergency Department of Second Affiliated Hospital, Shantou University Medical College, Shantou, China
| | - Wei Han
- Emergency Department of Shenzhen University General Hospital, Shenzhen, China
| | - Ke Wen
- Department of Microsurgery, Taihe Hospital, Shiyan, China
| | - Sunhua Huang
- Emergency Department of Second Affiliated Hospital, Shantou University Medical College, Shantou, China
| | - Yao Tang
- Emergency Department of Second Affiliated Hospital, Shantou University Medical College, Shantou, China
| | - Zhexuan Lin
- Bio-analytical Laboratory, Shantou University Medical College, Shantou, China.
| | - Ming Han
- Emergency Department of Shenzhen University General Hospital, Shenzhen, China.
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Abstract
Acute appendicitis is one of the most common abdominal emergencies. An accurate preoperative diagnosis is still a challenge in many cases. Patient history and clinical examination are the mainstay of diagnostics but other tools are also needed in order to reduce the number of misdiagnoses. Laboratory parameters and radiological imaging procedures are widely used and scoring systems can help in the risk stratification of patients with suspected appendicitis. In the USA most patients undergo preoperative computed tomography (CT) as the first-line examination, which can reduce the number of negative appendectomies to less than 5%; however, this practice results in substantial radiation exposure and is less accepted in Europe due to concerns about radiation-induced cancer in the often younger patients. Ultrasound is a valuable first-line imaging procedure and in experienced hands can achieve very good results. In patients with an equivocal diagnosis inpatient surveillance with close control of clinical and laboratory parameter represents a suitable method to reduce the number of negative explorations without resulting in an increase in the rate of perforation or morbidity.
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Affiliation(s)
- M Hoffmann
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Klinikum Augsburg, Stenglinstr. 2, 86156, Augsburg, Deutschland.
| | - M Anthuber
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Klinikum Augsburg, Stenglinstr. 2, 86156, Augsburg, Deutschland
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Chen Y, Wang M, Chen H, Zhao L, Liu L, Wang X, Huang J, Fan Z. WITHDRAWN: Endoscopic intervention for acute appendicitis: retrospective study of 101 cases. Gastrointest Endosc 2019:S0016-5107(19)31957-1. [PMID: 31228430 DOI: 10.1016/j.gie.2019.06.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 06/07/2019] [Indexed: 02/08/2023]
Abstract
This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.
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Affiliation(s)
- Yingtong Chen
- Digestive Endoscopy Department, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China; Department of General Surgery, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Min Wang
- Digestive Endoscopy Department, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - He Chen
- Digestive Endoscopy Department, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Lili Zhao
- Digestive Endoscopy Department, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Li Liu
- Digestive Endoscopy Department, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Xiang Wang
- Digestive Endoscopy Department, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Jin Huang
- Department of Gastroenterology, Changzhou No. 2 People's Hospital, Changzhou, China
| | - Zhining Fan
- Digestive Endoscopy Department, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China; Department of General Surgery, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
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Musbahi A, Rudd D, Dordea M, Gopinath B, Kurup V. Comparison of the use of Alvarado and AIR scores as an adjunct to the clinical diagnosis of acute appendicitis in the pediatric population. WORLD JOURNAL OF PEDIATRIC SURGERY 2019. [DOI: 10.1136/wjps-2019-000040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BackgroundAcute appendicitis is one of the most common causes of acute abdominal pain with an incidence of 1.17 per 1000 and lifetime risk of approximately 7%. It remains the most common indication for emergency abdominal surgery in childhood. Diagnosis of acute appendicitis is particularly difficult in young women and the pediatric population. In the USA, CT imaging is used to avert diagnostic dilemma, however the procedure is associated with radiation risk in this vulnerable population. Additionally, the procedure has high cost and variable availability.MethodsA retrospective study involving all suspected pediatric cases of appendicitis between the ages of 5 and 17 who were operated on between 2012 and 2015 was carried out. Data were collated from clinical notes on age, sex, ultrasound findings; postoperative complications, white cell count, neutrophils, C-reactive protein, histology result, and number of days to theater. All patients in the time period were retrospectively scored on the Alvarado and Appendicitis Inflammatory Response (AIR) scores.ResultsA total of 239 patients between 11 and 17 (mean 13.6±SE) years of age were included in the study. Of these, 79 had preoperative ultrasound, of which 52 were negative, and only one patient had CT scan. 213 of the patients had an appendicectomy and 26 had diagnostic laparoscopy with no appendicectomy. Of the 213 appendixes removed, 71 were histopathologically normal, giving a negative appendectomy rate of 33.3%. 28 appendixes were perforated. The average number of days from admission to theater was 1.0 SE in males and 1.424 in females (p=0.0498). The average number of days from admission to theater in those who had ultrasound was 2.03 days compared with 0.75 in those who did not have ultrasound (p<0.0001). AIR scoring that was high and medium risk showed slightly lower negative appendicectomy rates but not significantly different.ConclusionsOur study has found no significant difference between the AIR scores and Alvarado. There is a role for scoring systems to be used to aid in the decision to undergo imaging and as an adjunct to clinical diagnosis.
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Jiménez HC, Martínez-Montalvo CM, Maduro DA, González JC, Suaza C. "Apendicitis aguda perforada secundaria a cuerpo
extraño: reporte de caso". REVISTA COLOMBIANA DE CIRUGÍA 2019. [DOI: 10.30944/20117582.115] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
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Bax T, Macha M, Mayberry J. The utility of CT scan for the diagnostic evaluation of acute abdominal pain. Am J Surg 2019; 217:959-966. [DOI: 10.1016/j.amjsurg.2019.02.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 01/16/2019] [Accepted: 02/06/2019] [Indexed: 02/08/2023]
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Gómez López JR, Martín Del Olmo JC, Montenegro Martín MA, Concejo Cutoli P, Martín Esteban ML, Toledano Trincado M, López Mestanza IC, Vaquero Puerta C. Laparoscopic Appendectomy in the Setting of Clinical Prediction Rules. J Laparoendosc Adv Surg Tech A 2018; 29:184-191. [PMID: 30585754 DOI: 10.1089/lap.2018.0707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE Acute appendicitis (AA) is the most frequent surgical entity in the emergency department, but its correct diagnosis remains challenging. To improve diagnosis, clinical prediction rules (CPRs) have been created to establish objective scores for the probability of suffering AA. In this study, we establish scores indicating whether laparoscopy would be superior to clinical observation or repeat diagnostic test. METHODS A retrospective observational study was conducted with 433 patients submitted to surgery for suspected AA using a laparoscopic approach. The Alvarado, Raja Isteri Pengiran Anak Saleha Appendicitis, appendicitis inflammatory response, and adult appendicitis score scales were applied in each case to establish a high, medium, or low probability of suffering AA. RESULTS Of the 433 patients analyzed, 381 (88.0%) had AA. Twelve (2.8%) were converted to open surgery, and complications were observed in 54 (12.5%) cases. The CPRs studied showed statistically significant differences between AA and negative appendectomies. However, in patients with intermediate probability scores, the diagnostic accuracy of the CPRs evaluated was not adequate. CONCLUSIONS Laparoscopic surgery can serve as a diagnostic tool for patients with intermediate AA probability scores because of its low associated morbidity and mortality and because it affords a direct diagnosis of the problem, allowing determination of the appropriate treatment.
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Bourcier JE, Gallard E, Redonnet JP, Majourau M, Deshaie D, Bourgeois JM, Garnier D, Geeraerts T. Diagnostic performance of abdominal point of care ultrasound performed by an emergency physician in acute right iliac fossa pain. Crit Ultrasound J 2018; 10:31. [PMID: 30467798 PMCID: PMC6250608 DOI: 10.1186/s13089-018-0112-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 10/17/2018] [Indexed: 12/11/2022] Open
Abstract
Background Right iliac fossa abdominal pain is a common reason for emergency ward admissions, its etiology is difficult to diagnose. It can be facilitated by an imaging examination, such as a Computerized Tomography scan which exposes the patient to ionizing radiation and implies delays. A bedside ultrasound performed by emergency physicians could avoid these issues. The aim of our study was to assess the performance of ultrasound carried out at the patient’s bedside by an emergency physician compared with a clinical-laboratory examination for the diagnosis of a surgical pathology in right iliac fossa pain. Methods This is a single-center prospective cohort study conducted in an Emergency Department receiving 19,000 patients per year. All patients presenting pain in the right iliac fossa were included by four (out of ten) emergency physicians certified in an ultrasound examination. A full grid pattern scan ultrasound of the abdominal cavity with analysis of the right iliac fossa was performed. The primary outcome was to compare the diagnosis performance of bedside ultrasound and clinical-laboratory examination to detect a surgical pathology. Two emergency physicians who did not participate in the study made the final diagnosis (i.e., surgical or non-surgical pathology) by reviewing the entire medical chart of each patient. Results From January 2011 to July 2013, 158 patients with a median age of 17 [13–32] years were analyzed. The diagnosed cases were: appendicitis (53), non-specific abdominal pain (48), lymphadenitis (22), ileitis (11), complicated ovarian cysts (7), neoplasias (5), inflammatory or infectious colitis (5), inguinal herniations (3), bowel obstructions (2), and salpingitis (2). The accuracy of ultrasound diagnoses was 0.89 (95% CI 0.84–0.94) versus 0.70 (95% CI 0.57–0.82) for diagnoses based on clinical-laboratory examination only (p < 0.001). Conclusion Bedsides, ultrasound allows an accurate diagnosis of a surgical pathology in 89% of cases, which is more efficient than the clinical-laboratory examination.
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Affiliation(s)
- Jean-Eudes Bourcier
- Emergency, Anesthesiology and Critical Care Department, Lourdes Hospital, 2 Avenue Alexandre Marqui, 65100, Lourdes, France.
| | - Emeric Gallard
- Emergency, Anesthesiology and Critical Care Department, Lourdes Hospital, 2 Avenue Alexandre Marqui, 65100, Lourdes, France
| | - Jean-Philippe Redonnet
- Emergency, Anesthesiology and Critical Care Department, Lourdes Hospital, 2 Avenue Alexandre Marqui, 65100, Lourdes, France
| | - Magali Majourau
- Emergency, Anesthesiology and Critical Care Department, Lourdes Hospital, 2 Avenue Alexandre Marqui, 65100, Lourdes, France
| | - Dominique Deshaie
- Emergency, Anesthesiology and Critical Care Department, Lourdes Hospital, 2 Avenue Alexandre Marqui, 65100, Lourdes, France
| | | | - Didier Garnier
- Emergency, Anesthesiology and Critical Care Department, Lourdes Hospital, 2 Avenue Alexandre Marqui, 65100, Lourdes, France
| | - Thomas Geeraerts
- Anesthesiology and Critical Care Department, Toulouse University Hospital, University Toulouse III Paul Sabatier, Toulouse, France
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Wagner M, Tubre DJ, Asensio JA. Evolution and Current Trends in the Management of Acute Appendicitis. Surg Clin North Am 2018; 98:1005-1023. [DOI: 10.1016/j.suc.2018.05.006] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Allaway MGR, Eslick GD, Cox MR. The Unacceptable Morbidity of Negative Laparoscopic Appendicectomy. World J Surg 2018; 43:405-414. [PMID: 30209573 DOI: 10.1007/s00268-018-4784-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Augustin G, Čižmešija Z, Žedelj J, Petrović I, Ivković V, Antabak A, Mijatović D, Škegro M. LAPAROSCOPIC APPENDECTOMY DOES NOT INCREASE THE RATE OF NEGATIVE APPENDECTOMY along with a lower rate of perforated appendicitis - RESULTS IN 1899 PATIENTS at Zagreb UHC. Acta Clin Croat 2018; 57:503-509. [PMID: 31168184 PMCID: PMC6536279 DOI: 10.20471/acc.2018.57.03.14] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
SUMMARY – Laparoscopic appendectomy is the method of choice of many professional societies owing to its many advantages. The question arises whether surgeons urge more easily to laparoscopic exploration due to its less invasiveness, faster recovery and adequate exploration of the entire abdominal cavity than to observation in unequivocal cases. This retrospective analysis (2009-2016) included 1899 patients undergoing laparoscopic (lap) or gridiron intra-abdominal approach treated at Zagreb University Hospital Centre. The analysis included total negative appendectomy, negative-negative appendectomy (normal appendix and no other pathology found), and negative-positive appendectomy (normal appendix but another pathology found) in children (≤16 years) and adults. There was no statistically significant difference in the rates of negative appendectomy (children) – lap vs. open (p=0.24); negative appendectomy (adults) – lap vs. open (p=0.15); negative-negative appendectomy (children) – lap vs. open (p=0.36); negative-negative appendectomy (adults) – lap vs. open (p=0.21); negative-positive appendectomy (children) – lap vs. open (p=0.53); negative-positive appendectomy (adults) – lap vs. open (p=0.56); and laparoscopy group negative appendectomy in children vs. adults (p=0.56). There was a statistically significantly higher perforation rate with the open approach in total (p<0.0001), in children (p<0.0001) and in adults (p=0.02). There was no statistically significant difference between adults and children in the perforation rate with laparoscopic approach (p=0.24) and perforation rate with open approach (p=0.29). Results confirmed that there was no statistically significant difference in the rate of negative appendectomy in all subgroups. It is concluded that laparoscopic appendectomy should be offered as the method of choice in any patient population with suspicion of acute appendicitis.
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Affiliation(s)
| | - Zrinka Čižmešija
- 1Department of Surgery, Zagreb University Hospital Centre and School of Medicine, University of Zagreb, Zagreb, Croatia; 2School of Medicine, University of Zagreb (cand. med.), Zagreb, Croatia; 3Department of Internal Medicine, Zagreb University Hospital Centre, Zagreb, Croatia
| | - Jurica Žedelj
- 1Department of Surgery, Zagreb University Hospital Centre and School of Medicine, University of Zagreb, Zagreb, Croatia; 2School of Medicine, University of Zagreb (cand. med.), Zagreb, Croatia; 3Department of Internal Medicine, Zagreb University Hospital Centre, Zagreb, Croatia
| | - Igor Petrović
- 1Department of Surgery, Zagreb University Hospital Centre and School of Medicine, University of Zagreb, Zagreb, Croatia; 2School of Medicine, University of Zagreb (cand. med.), Zagreb, Croatia; 3Department of Internal Medicine, Zagreb University Hospital Centre, Zagreb, Croatia
| | - Vanja Ivković
- 1Department of Surgery, Zagreb University Hospital Centre and School of Medicine, University of Zagreb, Zagreb, Croatia; 2School of Medicine, University of Zagreb (cand. med.), Zagreb, Croatia; 3Department of Internal Medicine, Zagreb University Hospital Centre, Zagreb, Croatia
| | - Anko Antabak
- 1Department of Surgery, Zagreb University Hospital Centre and School of Medicine, University of Zagreb, Zagreb, Croatia; 2School of Medicine, University of Zagreb (cand. med.), Zagreb, Croatia; 3Department of Internal Medicine, Zagreb University Hospital Centre, Zagreb, Croatia
| | - Davor Mijatović
- 1Department of Surgery, Zagreb University Hospital Centre and School of Medicine, University of Zagreb, Zagreb, Croatia; 2School of Medicine, University of Zagreb (cand. med.), Zagreb, Croatia; 3Department of Internal Medicine, Zagreb University Hospital Centre, Zagreb, Croatia
| | - Mate Škegro
- 1Department of Surgery, Zagreb University Hospital Centre and School of Medicine, University of Zagreb, Zagreb, Croatia; 2School of Medicine, University of Zagreb (cand. med.), Zagreb, Croatia; 3Department of Internal Medicine, Zagreb University Hospital Centre, Zagreb, Croatia
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Bazdar S, Dehghankhalili M, Yaghmaei S, Azadegan M, Pourdavood A, Niakan MH, Bananzadeh AM. Acute Appendicitis during Pregnancy; Results of a Cohort Study in a Single Iranian Center. Bull Emerg Trauma 2018; 6:122-127. [PMID: 29719842 DOI: 10.29252/beat-060206] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Objective To determine the effects of pregnancy on the presentation, management, surgical and obstetrics outcome of patients with acute appendicitis. Methods This prospective cohort study was conducted during a 2-year period from 2014 to 2016 in Shahid Faghihi hospital of Shiraz University of Medical Sciences. We enrolled all the pregnant individuals with acute appendicitis who required surgical appendectomy. We also enrolled age-matched controls of non-pregnant women undergoing open appendectomy during the study period. The presentation, clinical and laboratory characteristics, surgical and obstetrics outcomes were determined in both study groups and were further compared between them. In order to determine the determinants of outcome, we also ran a multivariate logistic regression model. Results Overall we included a total number of 584 patients with presumed appendicitis among whom there were 58 (9.94%) and 526 (90.06%) non-pregnant individuals. The pregnant patients had significantly longer duration of symptoms (p=0.038), lower temperature (p=0.026), longer duration of hospital stay (p=0.026) and higher rate of hospital admission longer than 2 days (p=0.031). The complications of the surgical procedure were comparable between the two study groups except for the pneumonia which was significantly higher in pregnant patient (p=0.041). After adjusting for confounders such as age and ethnicity, pregnancy remained significantly associated with lower temperature (p=0.018), longer symptom duration (p=0.042) and higher rate of pneumonia (p=0.049). Conclusion Acute appendicitis during the pregnancy was associated with longer duration of symptoms, lower body temperature and higher rate of pneumonia. The pregnancy and neonatal outcomes were comparable to the previously reported data.
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Affiliation(s)
- Somaye Bazdar
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Maryam Dehghankhalili
- Student Research Committee, Department of General Surgery, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Shekoofeh Yaghmaei
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Maryam Azadegan
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
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Kularatna M, Lauti M, Haran C, MacFater W, Sheikh L, Huang Y, McCall J, MacCormick AD. Clinical Prediction Rules for Appendicitis in Adults: Which Is Best? World J Surg 2018; 41:1769-1781. [PMID: 28258458 DOI: 10.1007/s00268-017-3926-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Clinical prediction rules (CPRs) provide an objective method of assessment in the diagnosis of acute appendicitis. There are a number of available CPRs for the diagnosis of appendicitis, but it is unknown which performs best. AIM The aim of this study was to identify what CPRs are available and how they perform when diagnosing appendicitis in adults. METHOD A systematic review was performed in accordance with the PRISMA guidelines. Studies that derived or validated a CPR were included. Their performance was assessed on sensitivity, specificity and area under curve (AUC) values. RESULTS Thirty-four articles were included in this review. Of these 12 derived a CPR and 22 validated these CPRs. A narrative analysis was performed as meta-analysis was precluded due to study heterogeneity and quality of included studies. The results from validation studies showed that the overall best performer in terms of sensitivity (92%), specificity (63%) and AUC values (0.84-0.97) was the AIR score but only a limited number of studies investigated at this score. Although the Alvarado and Modified Alvarado scores were the most commonly validated, results from these studies were variable. The Alvarado score outperformed the modified Alvarado score in terms of sensitivity, specificity and AUC values. CONCLUSION There are 12 CPRs available for diagnosis of appendicitis in adults. The AIR score appeared to be the best performer and most pragmatic CPR.
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Affiliation(s)
- Malsha Kularatna
- Department of Surgery, Middlemore Hospital, Counties Manukau Health, Auckland, New Zealand.
| | - Melanie Lauti
- Department of Surgery, South Auckland Clinical Campus, University of Auckland, Auckland, New Zealand
| | - Cheyaanthan Haran
- Department of Surgery, South Auckland Clinical Campus, University of Auckland, Auckland, New Zealand
| | - Wiremu MacFater
- Department of Surgery, South Auckland Clinical Campus, University of Auckland, Auckland, New Zealand
| | - Laila Sheikh
- Department of Surgery, Middlemore Hospital, Counties Manukau Health, Auckland, New Zealand
| | - Ying Huang
- Section of Epidemiology and Biostatistics, School of Population Health, University of Auckland, Auckland, New Zealand
| | - John McCall
- Department of Surgery, University of Otago, Dunedin, New Zealand
| | - Andrew D MacCormick
- Department of Surgery, Middlemore Hospital, Counties Manukau Health, Auckland, New Zealand. .,Department of Surgery, South Auckland Clinical Campus, University of Auckland, Auckland, New Zealand.
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41
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Karami MY, Niakan H, Zadebagheri N, Mardani P, Shayan Z, Deilami I. Which One is Better? Comparison of the Acute Inflammatory Response, Raja Isteri Pengiran Anak Saleha Appendicitis and Alvarado Scoring Systems. Ann Coloproctol 2017; 33:227-231. [PMID: 29354605 PMCID: PMC5768477 DOI: 10.3393/ac.2017.33.6.227] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2017] [Accepted: 07/12/2017] [Indexed: 12/13/2022] Open
Abstract
Purpose Acute appendicitis (AA) is one of the most common causes of an acute abdomen. The accuracies of the Alvarado and the acute inflammatory response (AIR) scores in the diagnosis of appendicitis is very low in Asian populations, so a new scoring system, the Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) system, was designed recently. We applied and compared the Alvarado, AIR, and RIPASA scores in the diagnoses of appendicitis in the Iranian population. Methods We prospectively compared the RIPASA, Alvarado, and AIR systems by applying them to 100 patients. All the scores were calculated for patients who presented with right quadrant pain. Appendectomies were performed; then, the postoperative pathology reports were correlated with the scores. Scores of 8, 7, and 5 or more are optimal cutoffs for the RIPASA, Alvarado, and AIR scoring systems, respectively. The sensitivities, specificities, positive predictive values, negative predictive values (NPVs), positive and negative likelihood ratios (LRs) for the 3 systems were determined. Results The sensitivity and the specificity of the RIPASA score were 93.18% and 91.67%, respectively. The sensitivities of the Alvarado and the AIR scores were both 78.41%. The specificities of the Alvarado and the AIR scores were 100% and 91.67%, respectively. The RIPASA score correctly classified 93% of all patients confirmed with histological AA compared with 78.41% for the Alvarado and the AIR scores. Conclusion The RIPASA scoring system had more sensitivity, better NPV, a positive LR, and a less negative LR for the Iranian population whereas the Alvarado scoring system was more specific.
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Affiliation(s)
- Mohammad Yasin Karami
- Student Research Committee, Faculty of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hadi Niakan
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Fars Province, Shiraz, Iran
| | - Navid Zadebagheri
- Student Research Committee, Faculty of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Parviz Mardani
- Department of Surgery, Faculty of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Zahra Shayan
- Trauma Research Center, Department of Community Medicine, The Medical School, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Iman Deilami
- Student Research Committee, Faculty of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
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42
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Kamer E, Acar T. Editorial comment on: 'Evaluation of the Alvarado scoring system in the management of acute appendicitis'. Turk J Surg 2017; 33:320-321. [PMID: 29260147 DOI: 10.5152/turkjsurg.2017.4002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2017] [Accepted: 10/25/2017] [Indexed: 11/22/2022]
Affiliation(s)
- Erdinç Kamer
- Department of General Surgery, İzmir Katip Çelebi University Atatürk Training and Research Hospital, İzmir, Turkey
| | - Turan Acar
- Department of General Surgery, İzmir Katip Çelebi University Atatürk Training and Research Hospital, İzmir, Turkey
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43
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Andersson M, Kolodziej B, Andersson RE, Andersson M, Eriksson T, Ramsing A, Westman L, Björkman J, Håkansson HO, Lundström T, Björkman H, Johansson P, Hjert O, Edin R, Ekström A, Wenander C, Wallon C, Andersson P, Frisk J, Arvidsson B, Lantz R, Wallin G, Wickberg Å, Stenberg E, Erixon C, Schmidt W, Räntfors J, Göthberg G, Styrud J, Elias K, Boström L, Kretschmar G, Jonsson M, Brav C, Nilsson I, Kamran F, Hammarqvist F, Rutqvist J, Almström M, Hedberg M, Lindh V, Rosemar A, Wangberg H, Gustafsson J, Neovius G, Juhlin C, Christofferson R, Månsson C, Zittel T, Fagerström N. Randomized clinical trial of Appendicitis Inflammatory Response score-based management of patients with suspected appendicitis. Br J Surg 2017; 104:1451-1461. [PMID: 28730753 DOI: 10.1002/bjs.10637] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 05/23/2017] [Accepted: 05/31/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND The role of imaging in the diagnosis of appendicitis is controversial. This prospective interventional study and nested randomized trial analysed the impact of implementing a risk stratification algorithm based on the Appendicitis Inflammatory Response (AIR) score, and compared routine imaging with selective imaging after clinical reassessment. METHOD Patients presenting with suspicion of appendicitis between September 2009 and January 2012 from age 10 years were included at 21 emergency surgical centres and from age 5 years at three university paediatric centres. Registration of clinical characteristics, treatments and outcomes started during the baseline period. The AIR score-based algorithm was implemented during the intervention period. Intermediate-risk patients were randomized to routine imaging or selective imaging after clinical reassessment. RESULTS The baseline period included 1152 patients, and the intervention period 2639, of whom 1068 intermediate-risk patients were randomized. In low-risk patients, use of the AIR score-based algorithm resulted in less imaging (19·2 versus 34·5 per cent; P < 0·001), fewer admissions (29·5 versus 42·8 per cent; P < 0·001), and fewer negative explorations (1·6 versus 3·2 per cent; P = 0·030) and operations for non-perforated appendicitis (6·8 versus 9·7 per cent; P = 0·034). Intermediate-risk patients randomized to the imaging and observation groups had the same proportion of negative appendicectomies (6·4 versus 6·7 per cent respectively; P = 0·884), number of admissions, number of perforations and length of hospital stay, but routine imaging was associated with an increased proportion of patients treated for appendicitis (53·4 versus 46·3 per cent; P = 0·020). CONCLUSION AIR score-based risk classification can safely reduce the use of diagnostic imaging and hospital admissions in patients with suspicion of appendicitis. Registration number: NCT00971438 ( http://www.clinicaltrials.gov).
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Affiliation(s)
- M Andersson
- Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Linköping, Sweden.,Department of Surgery, Ryhov County Hospital, County Council of Jönköping, Jönköping, Sweden
| | - B Kolodziej
- Department Pathology, Ryhov County Hospital, County Council of Jönköping, Jönköping, Sweden
| | - R E Andersson
- Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Linköping, Sweden.,Department of Surgery, Ryhov County Hospital, County Council of Jönköping, Jönköping, Sweden
| | | | | | | | | | | | | | | | | | | | | | | | - R Edin
- Varbergs Sjukhus, Varberg
| | | | | | - C Wallon
- Universitetssjukhuset, Linköping
| | | | - J Frisk
- Norrköpings Lasarett, Norrköping
| | | | - R Lantz
- Västerviks Sjukhus, Västervik
| | - G Wallin
- Universitetssjukhuset Örebro, Örebro
| | | | | | | | | | - J Räntfors
- Drottning Silvias barn- och ungdomssjukhus, Göteborg
| | - G Göthberg
- Drottning Silvias barn- och ungdomssjukhus, Göteborg
| | | | | | | | | | | | - C Brav
- Södersjukhuset, Stockholm
| | | | - F Kamran
- Capio St Göans Sjukhus, Stockholm
| | | | - J Rutqvist
- Astrid Lindgrens Barnsjukhuset, Karolinska Universitetssjukhuset, Stockholm
| | - M Almström
- Astrid Lindgrens Barnsjukhuset, Karolinska Universitetssjukhuset, Stockholm
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Simianu VV, Shamitoff A, Hippe DS, Godwin BD, Shriki JE, Drake FT, O'Malley RB, Maximin S, Bastawrous S, Moshiri M, Lee JH, Cuevas C, Dighe M, Flum D, Bhargava P. The Reliability of a Standardized Reporting System for the Diagnosis of Appendicitis. Curr Probl Diagn Radiol 2017; 46:267-274. [PMID: 27743632 PMCID: PMC5821469 DOI: 10.1067/j.cpradiol.2016.07.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE Computed tomography (CT) is a fast and ubiquitous tool to evaluate intra-abdominal organs and diagnose appendicitis. However, traditional CT reporting does not necessarily capture the degree of uncertainty and indeterminate findings are still common. The purpose of this study was to evaluate the reproducibility of a standardized CT reporting system for appendicitis across a large population and the system's impact on radiologists' certainty in diagnosing appendicitis. METHODS Using a previously described standardized reporting system, eight radiologists retrospectively evaluated CT scans, blinded to all clinical information, in a stratified random sample of 237 patients from a larger cohort of patients imaged for possible appendicitis (2010-2014). Receiver operating characteristic (ROC) curves and the area under the ROC curve (AUC) were used to evaluate the diagnostic performance of readers for identifying appendicitis. Two-thirds of these scans were randomly selected to be independently read by a second reader, using the original CT reports to balance the number of positive, negative and indeterminate exams across all readers. Inter-reader agreement was evaluated. RESULTS There were 113 patients with appendicitis (mean age 38, 67% male). Using the standardized report, radiologists were highly accurate at identifying appendicitis (AUC=0.968, 95%CI confidence interval: 0.95, 0.99. Inter-reader agreement was >80% for most objective findings, and certainty in diagnosing appendicitis was high and reproducible (AUC=0.955 and AUC=0.936 for the first and second readers, respectively). CONCLUSIONS Using a standardized reporting system resulted in high reproducibility of objective CT findings for appendicitis and achieved high diagnostic accuracy in an at-risk population. Predictive tools based on this reporting system may further improve communication about certainty in diagnosis and guide patient management, especially when CT findings are indeterminate.
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Affiliation(s)
- Vlad V Simianu
- Department of Surgery, University of Washington, Seattle, WA
| | - Anna Shamitoff
- Department of Surgery, University of Washington, Seattle, WA
| | - Daniel S Hippe
- Department of Radiology, University of Washington, Seattle WA
| | | | - Jabi E Shriki
- Department of Radiology, University of Washington, Seattle WA
| | | | - Ryan B O'Malley
- Department of Radiology, University of Washington, Seattle WA
| | - Suresh Maximin
- Department of Radiology, University of Washington, Seattle WA
| | | | - Mariam Moshiri
- Department of Radiology, University of Washington, Seattle WA
| | - Jean H Lee
- Department of Radiology, University of Washington, Seattle WA
| | - Carlos Cuevas
- Department of Radiology, University of Washington, Seattle WA
| | - Manjiri Dighe
- Department of Radiology, University of Washington, Seattle WA
| | - David Flum
- Department of Surgery, University of Washington, Seattle, WA
| | - Puneet Bhargava
- Department of Radiology, University of Washington, Seattle WA.
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45
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Neutrophil-to-lymphocyte count ratio is associated with perforated appendicitis in elderly patients of emergency department. Aging Clin Exp Res 2017; 29:529-536. [PMID: 27216860 DOI: 10.1007/s40520-016-0584-8] [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] [Received: 12/17/2015] [Accepted: 04/29/2016] [Indexed: 12/17/2022]
Abstract
PURPOSE The diagnostic value of the neutrophil-to-lymphocyte count ratio (NLR) and the Appendicitis Inflammatory Response (AIR) score for identifying acute appendicitis (AA) perforation in elderly patients in the emergency department (ED) were evaluated. METHODS A total of 103 patients who were admitted for appendectomy for AA via the ED between January 2012 and December 2014 were reviewed retrospectively. Patients aged 65 and over were included. Patient age, sex, comorbidities, body temperature, clinical findings and initial laboratory results including white blood cell (WBC) count, NLR, serum levels of CRP and total bilirubin (TB) in the ED were assessed, and the AIR score was calculated. RESULTS Perforation due to AA was identified in 58 (56.3 %) elderly patients. Median WBC count, neutrophil count, CRP and TB were significantly higher in the perforated group compared to the non-perforated group (p = 0.005, p = 0.001, p = 0.004 and p = 0.012) in the ED. The NLR was significantly different in the two groups (perforated vs non-perforated group, 9.5 vs 5.1, p < 0.001). The area under the curve value of NLR was 0.755 (95 % CI 0.660-0.834), and the cutoff value was 5.6 (sensitivity 78.0 % and specificity 65.9 %). In multivariate logistic analysis, NLR > 5.6 [odds ratio (OR) 6.794, p = 0.001] was significant independent factor for AA perforation in elderly patients. The AIR score risk probability did not differ between the two groups of elderly patients (p = 0.094). Twenty-five (42.4 %) patients in the perforated group and five (11.4 %) patients in the non-perforated group were classified as high probability by the modified AIR score including the NLR value (p = 0.001). CONCLUSION We suggest that the initial NLR in the elderly patient is the most powerful predictive factor for the diagnosis of AA perforation in the ED.
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46
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How much Reliable Is Alvarado Scoring System in Reducing Negative Appendectomy? Indian J Surg 2017; 79:106-110. [PMID: 28442835 DOI: 10.1007/s12262-015-1433-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Accepted: 12/23/2015] [Indexed: 12/29/2022] Open
Abstract
There is still an ongoing debate, especially regarding early diagnosis of acute appendicitis. Early surgery leads to inadequate evaluation of acute abdominal pain and negative appendectomy, whereas delayed surgery leads to appendicitis perforation complications. The diagnosis of this condition is considerably difficult, especially due to subtle early symptoms and clinical condition. The aim of the present study was to identify whether the Alvarado scoring system could reduce the incidence of negative appendectomy in patients who will undergo surgery for acute appendicitis. Patients who underwent surgery with acute appendicitis prediagnosis were retrospectively classified as negative appendectomies (group A) and positive appendectomies (group B) according to histological diagnosis. All groups were evaluated for age, gender, Alvarado scores, and parameters. Two hundred eighty-one patients were included in the study. Group A contained 71 (25.3 %) patients, and group B contained 210 (74.7 %) patients. There was a significant difference in WBC, left shift, rebound, and change of pain localization between the groups (p = 0.002, p < 0.001, p < 0.001, and p = 0.023, respectively). Alvarado scores were significantly different between the groups (p < 0.001). In logistic model examination, the major factor was the Alvarado score (7 or above) and the minor factor was spreading pain. The Alvarado scoring system can be used to reduce negative appendectomy in patients who will undergo surgery with acute appendicitis.
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Malik MU, Connelly TM, Awan F, Pretorius F, Fiuza-Castineira C, El Faedy O, Balfe P. The RIPASA score is sensitive and specific for the diagnosis of acute appendicitis in a western population. Int J Colorectal Dis 2017; 32:491-497. [PMID: 27981378 DOI: 10.1007/s00384-016-2713-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/18/2016] [Indexed: 02/04/2023]
Abstract
AIM The definitive diagnosis of acute appendicitis (AA) requires histopathological examination. Various clinical diagnostic scoring systems attempt to reduce negative appendectomy rates. The most commonly used in Western Europe and the USA is the Alvarado score. The Raja Isteri Pengiran Anak Saleha appendicitis (RIPASA) score achieves better sensitivity and specificity in Asian and Middle Eastern populations. We aimed to determine the diagnostic accuracy of the RIPASA score in Irish patients with AA. METHODS All patients who presented to our institution with right iliac fossa pain and clinically suspected AA between January 1 and December 31, 2015, were indentified from our hospital inpatient enquiry database and retrospectively studied. Operating theatre records and histology reports confirmed those who underwent a non-elective operative procedure and the presence or absence of AA. SPSS version 22 was used for statistical analysis. Standard deviation is provided where appropriate. RESULTS Two hundred eight patients were included in the study (106/51% male, mean age 22.7 ± 9.2 years). One hundred thirty-five (64.9%) had histologically confirmed AA (mean symptom duration = 36.19 ± 15.90 h). At a score ≥7.5, the previously determined score most likely associated with AA in Eastern populations, the RIPASA scoring system demonstrated a sensitivity of 85.39%, specificity of 69.86%, positive predictive value of 84.06%, negative predictive value of 72.86% and diagnostic accuracy of 80% in our cohort. CONCLUSION The RIPASA score is a useful tool to aid in the diagnosis of acute appendicitis in the Irish population. A score of ≥7.5 provides sensitivity and specificity exceeding that previously documented for the Alvarado score in Western populations. WHAT DOES THIS PAPER ADD TO THE LITERATURE?: This is the first study evaluating the utility of the RIPASA score in predicting acute appendicitis in a Western population. At a value of 7.5, a cut-off score suggestive of appendicitis in the Eastern population, RIPASA demonstrated a high-sensitivity, specificity, positive predictive value and diagnostic accuracy in our cohort and was more accurate than the commonly used Alvarado score.
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Affiliation(s)
| | - Tara M Connelly
- Department of Surgery, University Hospital Waterford, Waterford, Ireland.
| | - Faisal Awan
- Department of Surgery, St. Luke's Hospital, Kilkenny, Ireland
| | | | | | - Osama El Faedy
- Department of Surgery, St. Luke's Hospital, Kilkenny, Ireland
| | - Paul Balfe
- Department of Surgery, St. Luke's Hospital, Kilkenny, Ireland
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48
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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.
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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
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49
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Sammalkorpi HE, Leppäniemi A, Lantto E, Mentula P. Performance of imaging studies in patients with suspected appendicitis after stratification with adult appendicitis score. World J Emerg Surg 2017; 12:6. [PMID: 28163774 PMCID: PMC5282904 DOI: 10.1186/s13017-017-0119-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 01/25/2017] [Indexed: 12/29/2022] Open
Abstract
Background Diagnostic scoring is used to stratify patients with suspected appendicitis into three groups: high, intermediate, and low probability of appendicitis. The stratification can be used for selective imaging to avoid the harms of radiation without compromising diagnostic accuracy. The aim was to study how stratification by Adult Appendicitis Score affects diagnostic performance of imaging studies. Methods Analysis of 822 patients who underwent diagnostic imaging for suspected appendicitis was made. Adult Appendicitis Score was used to stratify patients into groups of high, intermediate, and low probability of appendicitis. Diagnostic performance of computed tomography (CT) and ultrasound (US) was compared between these patient groups. Results After scoring, pre-test probability of appendicitis ranged from 9-16% in low probability group to 75-79% in high probability group in patients who underwent US or CT. Post-test probability of appendicitis after positive CT was 99, 91, and 75% in high probability, intermediate probability and low probability groups, respectively, p < 0.001. After positive US the respective probabilities were 95, 91 and 42%, p < 0.001. Conclusion Diagnostic imaging has limited value in patients with low probability of appendicitis according to Adult Appendicitis Score.
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Affiliation(s)
- Henna E Sammalkorpi
- Department of Gastrointestinal Surgery, Helsinki University Central Hospital, Helsinki, Finland.,University of Helsinki, Medical Faculty, Helsinki, Finland
| | - Ari Leppäniemi
- Department of Gastrointestinal Surgery, Helsinki University Central Hospital, Helsinki, Finland
| | - Eila Lantto
- Department of Radiology, Helsinki University Central Hospital, Helsinki, Finland
| | - Panu Mentula
- Department of Gastrointestinal Surgery, Helsinki University Central Hospital, Helsinki, Finland
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Sallinen V, Tikkinen KAO. Antibiotics or Appendectomy for Acute Non-Perforated Appendicitis--How to Interpret the Evidence? Scand J Surg 2016; 105:3-4. [PMID: 26976819 DOI: 10.1177/1457496916632188] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Ville Sallinen
- Departments of Abdominal, Liver and Transplantation Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Kari A O Tikkinen
- Departments of Urology and Public Health, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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