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Abdella Bahta NN, Zeinert P, Rosenberg J, Fonnes S. The Alvarado Score Is the Most Impactful Diagnostic Tool for Appendicitis: A Bibliometric Analysis. J Surg Res 2023; 291:557-566. [PMID: 37540973 DOI: 10.1016/j.jss.2023.06.037] [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: 05/07/2023] [Revised: 06/20/2023] [Accepted: 06/28/2023] [Indexed: 08/06/2023]
Abstract
INTRODUCTION The objective of this bibliometric analysis was to investigate the citation pattern of studies that have developed a diagnostic tool to diagnose appendicitis. METHODS We investigated characteristics of citations, publication frequency, evolution of citations, and fluctuation of previously highly cited studies. We analyzed which studies had been cited in the method section and identified impactful studies in this research field by a network visualization. We analyzed the differences in citations between diagnostic tools requiring a doctor to be present against the diagnostic tools not requiring doctors to be present, English language studies against non-English studies, and identified diagnostic tools targeting children. RESULTS There was an upward trend in publications in this research field, and between 1999-2021 the Alvarado score has been cited the most. In general, there was a high fluctuation, and 40 studies had been cited in the methods sections. There were significant differences in studies regarding diagnostic tools written in English compared to non-English studies, with more citations in the English-language studies. Furthermore, 22 studies had children as the target population. CONCLUSIONS The Alvarado score was the highest cited study since 1999, with 1086 citations, making it the most impactful study in this research field of diagnostic tools to diagnose appendicitis. Due to the diversity of target populations and settings for which diagnostic tools are developed, there is a need to expand research on diagnostic tools for appendicitis.
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Affiliation(s)
- Nadir Noureldin Abdella Bahta
- Department of Surgery, Herlev and Gentofte Hospital, Center for Perioperative Optimization, University of Copenhagen, Herlev, Denmark.
| | | | - Jacob Rosenberg
- Department of Surgery, Herlev and Gentofte Hospital, Center for Perioperative Optimization, University of Copenhagen, Herlev, Denmark
| | - Siv Fonnes
- Department of Surgery, Herlev and Gentofte Hospital, Center for Perioperative Optimization, University of Copenhagen, Herlev, Denmark
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Devanathan S, Deshpande SG, Tote D, Shinde S. Efficacy in Predicting Negative Appendectomy Rates in Operated Acute Appendicitis Patients Using the Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) Score Versus Modified Alvarado Score. Cureus 2023; 15:e37873. [PMID: 37223156 PMCID: PMC10202674 DOI: 10.7759/cureus.37873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 04/20/2023] [Indexed: 05/25/2023] Open
Abstract
Introduction Acute appendicitis is the commonest abdominal surgical emergency globally. The most accepted management of acute appendicitis is surgical, either open or laparoscopic appendectomy. Overlapping clinical presentations with many genitourinary and gynecological conditions lead to difficulty in accurate diagnosis, making negative appendectomies an unwanted reality. With the advancement in technology, there have been constant efforts to minimize negative appendectomy rates (NAR) using imaging modalities like USG of the abdomen and the gold-standard imaging test, the contrast-enhanced computed tomography of the abdomen. Due to the cost incurred and the lesser availability of such imaging modalities and needed expertise in resource-poor settings, various clinical scoring systems were devised to accurately diagnose acute appendicitis and thereby decrease NAR. We conducted our study to determine the NAR between the Raja Isteri Pengiran Anak Saleha Appendicitis score (RIPASA) and the modified Alvarado (MA) scoring methods. Methods A prospective observational analytical study was conducted, including 50 patients presenting to our hospital with acute appendicitis and who underwent emergency open appendectomy. The need to operate was decided by the treating surgeon. Patients were stratified by both scores; the pre-operative scores were noted and were later compared with the histopathological diagnosis. Results A total of 50 clinically diagnosed patients with acute appendicitis were evaluated utilizing the RIPASA and the MA scores. The NAR was 2% using the RIPASA score vs 10% with the MA score. The sensitivity was 94.11% vs 70.58% (p<0.0001), the specificity was 93.75% vs 68.75% (p<0.0001), the positive predictive value (PPV) of 96.96% vs 82.75% (p<0.001), the negative predictive value (NPV) of 88.23% vs 52.38% (p<0.001), and NAR of 2% vs 10% (p<0.0001) in the RIPASA vs MA scoring method, respectively. Conclusions RIPASA score is highly efficacious and statistically significant in diagnosing acute appendicitis with higher PPV at higher scores and higher NPV with lower scores leading to decreased NAR compared with MA score.
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Affiliation(s)
- Suhas Devanathan
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Swati G Deshpande
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Darshana Tote
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Sandip Shinde
- General Surgery, Chhatrapati Multispeciality Hospital, Hingoli, IND
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Many diagnostic tools for appendicitis: a scoping review. Surg Endosc 2023; 37:3419-3429. [PMID: 36735050 DOI: 10.1007/s00464-023-09890-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 01/15/2023] [Indexed: 02/04/2023]
Abstract
BACKGROUND We aimed to provide an overview of all diagnostic tools developed to diagnose appendicitis with their reported accuracy and to further characterize these including their need for diagnostic equipment. METHODS This scoping review followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews and a protocol was registered at Open Science Framework. We performed a systematic literature search in PubMed, Embase, China National Knowledge Infrastructure, Índice Bibliográfico Espanhol de Ciências da Saúde, and Latin American and Caribbean Health Sciences Literature. We included original articles of all languages with the purpose to derive an accessible diagnostic tool. We extracted data regarding study- and diagnostic tool characteristics, and the accuracy of each diagnostic tool. RESULTS The search led to 6419 records, where 74 studies were included, yielding 82 diagnostic tools reported in seven different languages. Among these tools, 35% included patient characteristics, 85% symptoms, 93% physical examinations, 37% vital signs, 78% laboratory values, and 16% imaging. Among the diagnostic tools, 35% relied on a medical doctor/surgeon with access to a laboratory, and six diagnostic tools did not require a bedside medical doctor/surgeon. The median positive predictive value, negative predictive value, sensitivity, and specificity across diagnostic tools were 91%, 94%, 89%, and 86%, respectively. CONCLUSIONS We identified 82 diagnostic tools that most frequently were based on symptoms and physical examinations. Most diagnostic tools relied on a medical doctor/surgeon with access to laboratory values. The accuracy was high across the diagnostic tools.
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Naeem MT, Jamil MA, Anwar MI, Raza H, Asad A, Jamil H, Tahir MJ, Bai J, Ejaz Chauhan TM, Asghar MS. Diagnostic accuracy of Alvarado scoring system relative to histopathological diagnosis for acute appendicitis: A retrospective cohort study. Ann Med Surg (Lond) 2022; 81:104561. [PMID: 36147117 PMCID: PMC9486849 DOI: 10.1016/j.amsu.2022.104561] [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: 06/12/2022] [Revised: 08/28/2022] [Accepted: 08/28/2022] [Indexed: 01/09/2023] Open
Abstract
Background Acute appendicitis (AA) is a surgical emergency that requires prompt diagnosis and suitable management. It may lead to complications resulting in mortality. To evaluate the diagnostic accuracy of the Alvarado scoring system (ASS) for acute appendicitis concerning histopathological data. Methodology About 120 patients were selected for this study consisting of 96 males and 24 females age between 20 and 60. Alvarado scoring system is calculated for each patient after collecting data about demographics, laboratory findings, and clinical examination. Then, we compared it with histopathological diagnosis taking it as a gold standard. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. SPSS version 20 was used for analyzing the data. Results About 120 patients were included in our study. The male to female ratio was 3:1. Sensitivity and specificity were 83.3% and 41% respectively. While PPV and NPV were 85% and 41% respectively. The negative appendectomy rate was 21%. The area under the curve for receiving operating characteristics is 0.628. Conclusion ASS is a useful diagnostic tool regarding sensitivity and positive predictive value, especially in developing countries. It is cheap, reliable, and can be easily applied. We evaluated the diagnostic accuracy of the Alvarado scoring system (ASS) for acute appendicitis. Sensitivity and specificity were 83.3% and 41%. While PPV and NPV were 85% and 41% respectively.
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Malia L, Sturm JJ, Smith SR, Brown RT, Campbell B, Chicaiza H. Predictors for Acute Appendicitis in Children. Pediatr Emerg Care 2021; 37:e962-e968. [PMID: 31136455 DOI: 10.1097/pec.0000000000001840] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Acute appendicitis in children is the most common condition requiring urgent evaluation and surgery in the emergency department. At times, despite the appendix being seen on ultrasound (US), there can be discrepancy as to whether a patient has clinical appendicitis. Secondary findings suggestive of appendicitis can be helpful in identifying and evaluating these children. OBJECTIVE The aim of this study was to determine if specific US findings and/or laboratory results are predictive of appendicitis in children with a visualized appendix on US. METHODS A prospective study was conducted on children (birth to 18 years) presenting to the pediatric emergency department with suspected appendicitis who underwent right-lower-quadrant US. Ultrasound findings analyzed appendix diameter, compressibility, increased vascularity, presence of appendicolith, inflammatory changes, right-lower-quadrant fluid near the appendix, lower abdominal fluid, tenderness during US, and lymph nodes. Diagnosis was confirmed via surgical pathology. RESULTS There were 1252 patients who enrolled, 60.8 (762) had their appendix visualized, and 39.1 (490) did not. In children where the appendix was seen, 35.2% (268) were diagnosed with appendicitis. Among patients with a visualized appendix, the likelihood of appendicitis was significantly greater if the appendix diameter was 7 mm or greater (odds ratio [OR], 12.4; 95% confidence interval [CI], 4.7-32.7), an appendicolith was present (OR, 3.9; 95% CI, 1.5-10.3), inflammatory changes were seen (OR, 10.2; 95% CI, 3.9-26.1), or the white blood cell (WBC) count was 10,000/μL (OR, 4.8; 95% CI, 2.4-9.7). A duration of abdominal pain of 3 days or more was significantly less likely to be associated with appendicitis (OR, 0.3; 95% CI, 0.08-0.99). The absence of inflammatory changes, WBC count of less than 10,000/μL, and appendix diameter of 7 mm or less had a negative predictive value of 100%. CONCLUSIONS When the appendix is seen on US but diagnosis of appendicitis is questioned, the absence of inflammatory changes, WBC count of less than 10,000/μL, and appendix diameter of 7 mm or less should decrease suspicion for appendicitis.
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Affiliation(s)
- Laurie Malia
- From the Department of Emergency Medicine, Connecticut Children's Medical Center
| | - Jesse J Sturm
- From the Department of Emergency Medicine, Connecticut Children's Medical Center
| | - Sharon R Smith
- From the Department of Emergency Medicine, Connecticut Children's Medical Center
| | | | - Brendan Campbell
- From the Department of Emergency Medicine, Connecticut Children's Medical Center
| | - Henry Chicaiza
- From the Department of Emergency Medicine, Connecticut Children's Medical Center
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Bhangu A. Evaluation of appendicitis risk prediction models in adults with suspected appendicitis. Br J Surg 2020; 107:73-86. [PMID: 31797357 PMCID: PMC6972511 DOI: 10.1002/bjs.11440] [Citation(s) in RCA: 75] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 10/12/2019] [Accepted: 10/29/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND Appendicitis is the most common general surgical emergency worldwide, but its diagnosis remains challenging. The aim of this study was to determine whether existing risk prediction models can reliably identify patients presenting to hospital in the UK with acute right iliac fossa (RIF) pain who are at low risk of appendicitis. METHODS A systematic search was completed to identify all existing appendicitis risk prediction models. Models were validated using UK data from an international prospective cohort study that captured consecutive patients aged 16-45 years presenting to hospital with acute RIF in March to June 2017. The main outcome was best achievable model specificity (proportion of patients who did not have appendicitis correctly classified as low risk) whilst maintaining a failure rate below 5 per cent (proportion of patients identified as low risk who actually had appendicitis). RESULTS Some 5345 patients across 154 UK hospitals were identified, of which two-thirds (3613 of 5345, 67·6 per cent) were women. Women were more than twice as likely to undergo surgery with removal of a histologically normal appendix (272 of 964, 28·2 per cent) than men (120 of 993, 12·1 per cent) (relative risk 2·33, 95 per cent c.i. 1·92 to 2·84; P < 0·001). Of 15 validated risk prediction models, the Adult Appendicitis Score performed best (cut-off score 8 or less, specificity 63·1 per cent, failure rate 3·7 per cent). The Appendicitis Inflammatory Response Score performed best for men (cut-off score 2 or less, specificity 24·7 per cent, failure rate 2·4 per cent). CONCLUSION Women in the UK had a disproportionate risk of admission without surgical intervention and had high rates of normal appendicectomy. Risk prediction models to support shared decision-making by identifying adults in the UK at low risk of appendicitis were identified.
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Malia L, Sturm JJ, Smith SR, Brown RT, Campbell B, Chicaiza H. Diagnostic accuracy of laboratory and ultrasound findings in patients with a non-visualized appendix. Am J Emerg Med 2018; 37:879-883. [PMID: 30097276 DOI: 10.1016/j.ajem.2018.08.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Revised: 07/28/2018] [Accepted: 08/07/2018] [Indexed: 01/15/2023] Open
Abstract
Ultrasound (US) and laboratory testing are initial diagnostic tests for acute appendicitis. A diagnostic dilemma develops when the appendix is not visualized on US. Objective: To determine if specific US findings and/or laboratory results predict acute appendicitis when the appendix is not visualized. Methods: A prospective study was conducted on children (birth-18 yrs) presenting to the pediatric emergency department with suspected acute appendicitis who underwent right lower quadrant US. Children with previous appendectomy, US at another facility, or eloped were excluded. US findings analyzed: inflammatory changes, right lower quadrant and lower abdominal fluid, tenderness during US exam and lymph nodes. Diagnoses were confirmed via surgical pathology. Results 1252 subjects were enrolled, 60.8% (762) had appendix visualized and 39.1% (490) did not. In children where the appendix was not seen, 6.7% [33] were diagnosed with appendicitis. Among patients with a non-visualized appendix, the likelihood of appendicitis was significantly greater if: inflammatory changes in the RLQ (OR 18.0, 95% CI 4.5-72.1), CRP >0.5 mg/dL (OR 2.64, 95% CI 1.0-6.8), or WBC > 10 (OR 4.36, 95% CI 1.66-11.58). Duration of abdominal pain >3 days was significantly less likely associated with appendicitis in this model (OR 0.34, 95% CI 0.003-0.395). Combined, the absence inflammatory changes, CRP < 0.5 mg/dL, WBC < 10, and pain, ≤3 days had a NPV of 94.0%. Conclusion When the appendix is not visualized on US, predictors for appendicitis include the presence of inflammatory changes in the RLQ, an elevated WBC/CRP and abdominal pain <3 days.
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Affiliation(s)
- Laurie Malia
- Connecticut Children's Medical Center, Hartford, CT 06106, USA.
| | - Jesse J Sturm
- Connecticut Children's Medical Center, Hartford, CT 06106, USA.
| | - Sharon R Smith
- Connecticut Children's Medical Center, Hartford, CT 06106, USA.
| | | | | | - Henry Chicaiza
- Connecticut Children's Medical Center, Hartford, CT 06106, USA.
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Chung KLY, Wong SYS, Liu CSW, Tang PMY, Chao NSY, Liu KKW, Leung MMY. Validity of paediatric appendicitis score in Chinese population: A prospective study. SURGICAL PRACTICE 2016. [DOI: 10.1111/1744-1633.12195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- KLY Chung
- Department of Surgery; Queen Elizabeth Hospital and United Christian Hospital; Hong Kong
| | - SYS Wong
- Department of Surgery; Queen Elizabeth Hospital and United Christian Hospital; Hong Kong
| | - CSW Liu
- Department of Surgery; Queen Elizabeth Hospital and United Christian Hospital; Hong Kong
| | - PMY Tang
- Department of Surgery; Queen Elizabeth Hospital and United Christian Hospital; Hong Kong
| | - NSY Chao
- Department of Surgery; Queen Elizabeth Hospital and United Christian Hospital; Hong Kong
| | - KKW Liu
- Department of Surgery; Queen Elizabeth Hospital and United Christian Hospital; Hong Kong
| | - MMY Leung
- Department of Surgery; Queen Elizabeth Hospital and United Christian Hospital; Hong Kong
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Clinical scores for prediction of acute appendicitis in children in a hospital of Lima, Perú. ANNALS OF PEDIATRIC SURGERY 2014. [DOI: 10.1097/01.xps.0000445129.75228.d8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Toprak H, Kilincaslan H, Ahmad IC, Yildiz S, Bilgin M, Sharifov R, Acar M. Integration of ultrasound findings with Alvarado score in children with suspected appendicitis. Pediatr Int 2014; 56:95-9. [PMID: 23937630 DOI: 10.1111/ped.12197] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Revised: 07/07/2013] [Accepted: 08/05/2013] [Indexed: 12/29/2022]
Abstract
BACKGROUND The aim of this study was to investigate the integration of ultrasound (US) findings with Alvarado score in diagnosing or excluding acute appendicitis. METHODS Data were analyzed in 122 pediatric patients with suspected appendicitis who had undergone US. The US findings were classified into four groups, and the patients were classified into three groups according to Alvarado score. US results and Alvarado score were compared. RESULTS Alvarado score was a good predictor of appendicitis for scores ≥7. CONCLUSION In the case of non-visualization of the appendix without a high Alvarado score, appendicitis can be safely ruled out.
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Affiliation(s)
- Huseyin Toprak
- Department of Radiology, Bezmialem Vakif University, Istanbul, Turkey
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Mariadason JG, Wang WN, Wallack MK, Belmonte A, Matari H. Negative appendicectomy rate as a quality metric in the management of appendicitis: impact of computed tomography, Alvarado score and the definition of negative appendicectomy. Ann R Coll Surg Engl 2012; 94:395-401. [PMID: 22943328 PMCID: PMC3954319 DOI: 10.1308/003588412x13171221592131] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION The negative appendicectomy rate (NAR) is a quality metric in the management of appendicitis. While computed tomography (CT) has been associated with a low NAR, Alvarado scoring produces an acceptable NAR. The definition of negative appendicectomy may affect the NAR. This study examined the impact of CT, Alvarado score and definition on the NAR. METHODS The charts of 1,306 emergency appendicectomy patients from 1996 to 2010 were reviewed. Three five-year cohorts were created (Cohort A: 1996-2000, Cohort B: 2001-2005, Cohort C: 2006-2010) and the NAR was calculated for each cohort using two definitions of negative appendicectomy: absence of inflammation (NAR-STD) and absence of intramural neutrophils (NAR-STR). NAR-STD was correlated to the CT rate for Cohorts B and C and also to Alvarado score for Cohort C. RESULTS When the definition of negative appendicectomy was changed, the NAR rose from 9.2% to 15.8% (p=0.0097) for Cohort A, from 2.8% to 8.6% (p=0.0180) for Cohort B (CT rate: 80.6%) and from 3.0% to 6.7% (p=0.0255) for Cohort C (CT rate: 92.4%). The introduction of CT lowered NAR-STD from 1996-2000 (9.2%) to 2001-2010 (2.9%) but increasing the CT rate from 2001-2010 had no impact on the NAR. The positive predictive value for Alvarado score (98.60%) and CT (99.03%) were similar. CONCLUSIONS The definition of a negative appendicectomy determines the NAR. CT reduces the NAR regardless of definition but routine CT is unnecessary for male patients with positive Alvarado scores. Early/mild appendicitis may resolve without surgery and CT may contribute to unnecessary surgery. Alvarado scoring allows selective use of CT in suspected appendicitis.
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Affiliation(s)
- J G Mariadason
- Department of Surgery, Metropolitan Hospital, 1,901 First Avenue, New York, NY 10029, USA.
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Nasiri S, Mohebbi F, Sodagari N, Hedayat A. Diagnostic values of ultrasound and the Modified Alvarado Scoring System in acute appendicitis. Int J Emerg Med 2012; 5:26. [PMID: 22673121 PMCID: PMC3410771 DOI: 10.1186/1865-1380-5-26] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2012] [Accepted: 06/06/2012] [Indexed: 11/10/2022] Open
Abstract
Background Making the diagnosis of acute appendicitis is difficult, and is important for preventing perforation of the appendix and negative appendectomy results. Ultrasound and clinical scoring systems are very helpful in making the diagnosis. Ultrasound is non-invasive, available and cost-effective, and can accomplish more than CT scans. However, there is no certainty about its effect on the clinical outcomes of patients, and it is operator dependent. Counting the neutrophils as a parameter of the Alvarado Scale is not routine in many laboratories, so we decided to evaluate the diagnostic value of the Modified Alvarado Scaling System (MASS) by omitting the neutrophil count and ultrasonography. Methods After ethical approval of methodology in Tehran University of Medical Sciences ethical committee, we collected the data. During 9 months, 75 patients with right lower quadrant pain were enrolled in the study, and underwent abdominal ultrasonography and appendectomy, with pathological evaluation of the appendix. The MASS score was calculated for these patients and compared with pathology results. Results Fifty-five male and 20 female patients were assessed. Of these patients 89.3% had acute appendicitis. The sensitivity, specificity, PPV, NPV and accuracy rate of ultrasonography was 71.2%, 83.3%, 97.4%, 25% and 72.4%, respectively. By taking a cutoff point of 7 for the MASS score, a sensitivity of 65.7%, specificity of 37.5%, PPV of 89.8%, NPV of 11.5% and accuracy of 62.7% were calculated. Using the cutoff point of 6, a sensitivity of 85.1%, specificity of 25%, PPV of 90.5%, NPV of 16.7% and accuracy of 78.7% were obtained. Conclusion Ultrasound provides reliable findings for helping to diagnose acute appendicitis in our hospital. A cutoff point of 6 for the MASS score will yield more sensitivity and a better diagnosis of appendicitis, though with an increase in negative appendectomy.
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Affiliation(s)
- Shirzad Nasiri
- Tehran University of Medical Sciences, Shariati Hospital, North Karegar Avenue, Tehran, Iran.
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Asadi M, Mehrabi Bahar M, Sadeghi R, Jangjo A, Dabbagh Kakhki V, Zakavi SR. Value of polyclonal human immunoglobulin tagged with ⁹⁹mTc for detecting acute appendicitis in patients with intermediate probability of appendicitis. World J Surg 2011; 35:1798-802. [PMID: 21553201 DOI: 10.1007/s00268-011-1127-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND The aim of this study was to assess the value of a technetium ((99m)Tc)-polyclonal antibody to detect acute appendicitis in patients with intermediate probability of appendicitis. METHODS A total of 40 patients with mean age of 24.6 ± 6.9 years with intermediate probability of appendicitis according to the Alvarado scoring system (score 5 or 6) were studied. After intravenous injection of 740 MBq of (99m)Tc-immunoglobulin G (IgG), a flow and blood pool image was obtained followed by two planar images and single photon emission tomography (SPECT) scan from the lower abdominal and pelvic regions. The images were subjected to visual and quantitative analysis. Patients were followed clinically, and the surgeon decided to operate on or observe the patient depending on the clinical findings. The pathology results were considered the gold standard if patients underwent an operation. If patients improved without surgery, it was considered negative for appendicitis. RESULTS Altogether, 31 patients were operated on, and 21 patients had acute appendicitis. Nine patients were discharged from hospital and had no symptoms during follow-up. The sensitivity of the planar images for diagnosing appendicitis was 19-24% and specificity was 100%. The sensitivity of SPECT for diagnosis of appendicitis was 62%, the specificity was 68%, and the negative predictive value (NPV) was 62%. Quantitative analysis showed that using a cutoff of >1.2 for the mean right-to-left count per voxel ratio, the sensitivity of the test for detection of appendicitis was 54%, and the specificity was 86%. CONCLUSIONS (99m)Tc-polyclonal IgG scanning has low sensitivity and moderate NPV for detecting appendicitis. Therefore, it is not a suitable tracer for excluding appendicitis.
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Affiliation(s)
- Mehdi Asadi
- Surgical Oncology Research Center, Emam Reza Hospital, Mashhad, Iran
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Abstract
OBJECTIVES The objectives of this study were (1) to validate the Alvarado score and pediatric appendicitis score (PAS) in a prospectively identified pediatric cohort and (2) to assess abdominal ultrasonography (AUS) as a tool to increase the diagnostic reliability of both scores. PATIENTS AND METHODS Prospective study conducted from January 10, 2008, to January 1, 2009. All patients attended at the emergency department with suspected acute appendicitis (AA) who had a blood sample collected were included. Items from both scores were recorded. The performance of an AUS, the decision to admit the patient, and the therapeutics were decided by the physician, disregarding the scores values. Nonadmitted patients were contacted by telephone. RESULTS Ninety-nine patients were included. Mean age was 11 years, and 62.6% were males. Appendectomy was performed in 44.4% patients. The area under the receiver operating characteristic curve for the Alvarado score was 0.96 and that for PAS was 0.97. Not a single patient with an Alvarado score less than 5 or PAS less than 4 had AA. All patients with an Alvarado score greater than 8 or PAS greater than 7 had AA. For both scores, the optimum cutoff point was 6 (sensibility of 90.4% and specificity of 91.2% for the Alvarado score and sensibility of 88.1% and specificity of 98.2% for PAS). Abdominal ultrasonography was performed on 31 patients (sensibility of 84.6% and specificity of 94.4%). We studied the value of scores and AUS together. Assuming an Alvarado score from 1 to 4 and PAS from 1 to 3 as no AA, an Alvarado score from 9 to 10 and PAS from 8 to 9 as AA, and proceeding according to the AUS for intermediate values, a sensibility of 93.3% and 97.2% and a specificity of 100% and 97.6%, respectively, were obtained. CONCLUSIONS Both scores are a useful tool in the evaluation of children with possible AA. For extreme values of scores, the results really ensure their use in the emergency department. The AUS can help on decision making for intermediate values.
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Chattopadhyay S, Rabhi F, Acharya UR, Joshi R, Gajendran R. An approach to model Right Iliac Fossa pain using pain-only-parameters for screening acute appendicitis. J Med Syst 2010; 36:1491-502. [PMID: 20949312 DOI: 10.1007/s10916-010-9610-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2010] [Accepted: 10/06/2010] [Indexed: 02/05/2023]
Abstract
Acute appendicitis (AA) is one of the commonest of multiple possible pathologies at the backdrop of Right Iliac Fossa (RIF) pain. RIF is the most common acute surgical condition of the abdomen. Even though AA is a recognized disease entity since decades, its diagnosis still lacks clinical confidence and mandates laboratory tests. Given the issue, this paper proposes a mathematical model using Pain-Only-Parameters (POP) obtained from available literature to screen AA. Weights have been assigned for each POP to create a training data matrix (N = 51) and used to calculate the cumulative effect or weighted sum, which is termed as the Pain Confidence Score (PCS). Based on PCS, a group of real-world patients (N = 40; AA and NA = 20 each) are classified as cases of AA or non-appendicitis (NA) with satisfactory results (sensitivity 85%, specificity 75%, precision 77%, and accuracy 80%). Most rural health centers (RHC) in developing nations lack specialist services and related infrastructure. Hence, such a tool could be useful in RHC to assist general physicians in screening AA and their timely referral to higher centers.
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Affiliation(s)
- Subhagata Chattopadhyay
- School of Computer Studies, National Institute of Science and Technology, Berhampur, Orissa, India
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Clinically monitored delay-A valid option in cases with doubtful diagnosis of acute appendicitis. Indian J Surg 2010; 72:215-9. [PMID: 23133250 DOI: 10.1007/s12262-010-0049-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2009] [Accepted: 01/31/2010] [Indexed: 10/19/2022] Open
Abstract
AIM To evaluate the effect of delayed surgery after a period of observation in patients with doubtful diagnosis of acute appendicitis in the form of improvement in negative appendectomy rates and the incidence of complications. MATERIALS AND METHODS One hundred twelve patients operated with the diagnosis of acute appendicitis between May 2008 to June 2009 were included in this retrospective study. They were divided into two groups based on timing of surgery after admission. These two groups were studied in respect to age, sex, Alvarado score at presentation, ultrasound findings, operative findings, histopathology and postoperative complications. Proportions of negative appendectomies, and complicated appendicitis were analysed statistically. RESULTS Group wise age and sex distribution was comparable. The mean Alvarado score in the group 1 was 7.9 (range, 6-10) where as in those operated later than 12 hours (group 2), it was 4.5 (range, 3-8). Normal appendectomies were significantly (p < 0.05) less in group 2 (1 out of 40) as compared to group 1 (4 out of 72). The number of complicated appendicitis were higher in group 1 (14/72) as compared to group 2 (4/40) but not significantly (p > 0.06). The number of postoperative complications was also high in group 1 (11 vs 2 in group 2). CONCLUSION It is better to wait in cases with doubtful initial diagnosis of appendicitis on admission in order to decrease negative appendectomy rates. These patients need to be continuously monitored clinically to prevent complications.
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Ting HW, Wu JT, Chan CL, Lin SL, Chen MH. Decision model for acute appendicitis treatment with decision tree technology--a modification of the Alvarado scoring system. J Chin Med Assoc 2010; 73:401-6. [PMID: 20728850 DOI: 10.1016/s1726-4901(10)70087-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2009] [Accepted: 06/29/2010] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND How to decide the proper time to do laparotomies for acute appendicitis patients is sometimes very difficult, especially in areas with no imaging diagnostic tools. The Alvarado scoring system (ASS) is a convenient and inexpensive decision making tool; however, its accuracy needs to be improved. The decision tree is the most frequently used data mining technology for diagnostic model building. This study used a decision tree to modify the ASS and to prioritize the variables. METHODS We collected 532 patients who underwent appendectomy. Patients who had undergone incidental appendectomy were excluded from the study. The decision tree algorithm was constructed with the data mining workbench Clementine version 8.1. It is a top-down algorithm designed to generate a decision tree model with entropy. The algorithm chooses the best decision node with which to separate different classes from empirical data. The Wilcoxon signed rank test, Student t test and chi(2) test were used for statistical analysis. RESULTS Among the 532 patients recruited into the study, 420 had acute appendicitis and 112 had normal appendix. Women with acute appendicitis were older than their male counterparts (p < 0.001). All patients had right lower quadrant tenderness. The new model was constructed with decision tree technology, and the accuracy of the diagnostic rate was better than that of ASS (p < 0.001). The sensitivity and specificity of the new model were 0.945 and 0.805, respectively. CONCLUSION The new model is more convenient and accurate than ASS. Right lower quadrant tenderness is an inclusion criterion for acute appendicitis diagnosis. Migrating pain and neutrophil count > 75% were significant factors for acute appendicitis diagnosis if ASS score < 6. Although the criteria of nausea/vomiting and white blood cell count > 10,000/dL were significantly different between acute appendicitis and normal appendix, there was no significant contribution of entropy change below the "neutrophil count > 75%" nodes in the model. So they were erased from the decision tree model. Further studies need to be conducted to investigate why older women are at higher risk for acute appendicitis.
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Affiliation(s)
- Hsien-Wei Ting
- Department of Neurosurgery, Taipei Hospital, Department of Health, Taipei, Taiwan, R.O.C
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The use of the Alvarado score in the management of right lower quadrant abdominal pain in the adult. J Visc Surg 2010; 147:e40-4. [DOI: 10.1016/j.jviscsurg.2010.05.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Nautiyal H, Ahmad S, Keshwani NK, Awasthi DN. Combined use of modified Alvarado score and USG in decreasing negative appendicectomy rate. Indian J Surg 2010; 72:42-8. [PMID: 23133203 PMCID: PMC3452540 DOI: 10.1007/s12262-010-0008-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2008] [Accepted: 07/29/2009] [Indexed: 10/19/2022] Open
Abstract
INTRODUCTION Appendicitis is notorious in its ability to simulate other conditions and in the frequency it can be mimicked by other pathologies. Despite extraordinary advances in modern radiography imaging and diagnostic laboratory investigations the accurate diagnosis of acute appendicitis remains an enigmatic challenge. Of the various commonly used diagnostic aids for appendicitis, no single test can reduce the rate of negative appendicectomy to zero. MATERIALS AND METHODS Fifty admitted cases of suspected appendicitis were subjected to ultrasonography (USG). All the patients were scored out of 9 according to modified Alvarado score. A treatment plan was devised according to which patients with modified Alvarado score ≥7 underwent immediate appendicectomy even if USG was negative for appendicitis and patients with score <7 underwent appendicectomy if USG was positive for appendicitis. RESULT 84.3% of males and 44.4% of females admitted as case of suspected appendicitis had confirmed appendicitis. Due to high sensitivity (97.14%) and accuracy (92%) of our diagnostic approach, 85.71% cases of appendicitis were diagnosed in early stage, with only 8.57% perforation and abscess rate, leading to post appendicectomy complication rate of only 5.14% in our study (one wound infection and one urinary retention). We could achieve low negative appendicectomy rate of 7.14% in males and 11.11% in females and overall 8.11% in our study. CONCLUSION Combined use of modified Alvarado score and high frequency USG not only reduces negative appendicectomy rate but also reduces morbidity and postoperative complications.
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Affiliation(s)
- Hemant Nautiyal
- Department of General Surgery, Motilal Nehru Medical College, Allahabad, Uttar Pradesh India
| | - Shabi Ahmad
- Department of General Surgery, Motilal Nehru Medical College, Allahabad, Uttar Pradesh India
| | - N. K. Keshwani
- Department of General Surgery, Motilal Nehru Medical College, Allahabad, Uttar Pradesh India
| | - D. N. Awasthi
- Department of General Surgery, Motilal Nehru Medical College, Allahabad, Uttar Pradesh India
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Kim BS, Ryu DH, Kim TH, Jeong IU, Song JH, Cho SI, Kim JK, Jeong YS, Lee SJ. Diagnosis of Acute Appendicitis Using Scoring System: Compared with the Alvarado Score. JOURNAL OF THE KOREAN SURGICAL SOCIETY 2010. [DOI: 10.4174/jkss.2010.79.3.207] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Bin Soo Kim
- Department of Surgery, Hana Hospital, Cheongju, Korea
| | - Dong Hee Ryu
- Department of Surgery, Chungbuk National University Hospital, Cheongju, Korea
| | - Tae Hwa Kim
- Department of Surgery, Hana Hospital, Cheongju, Korea
| | - Il Ung Jeong
- Department of Surgery, Cheongju Medical Center, Cheongju, Korea
| | - Jun Ho Song
- Department of Surgery, Cheongju St. Mary's Hospital, Cheongju, Korea
| | - Sung Il Cho
- Department of Surgery, Cheongju St. Mary's Hospital, Cheongju, Korea
| | - Jin Kweon Kim
- Department of Surgery, Hyosung Hospital, Cheongju, Korea
| | - Yong Sik Jeong
- Department of Surgery, Hyosung Hospital, Cheongju, Korea
| | - Sang Jeon Lee
- Department of Surgery, Chungbuk National University Hospital, Cheongju, Korea
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Brigand C, Steinmetz JP, Rohr S. [The usefulness of scores in the diagnosis of appendicitis]. ACTA ACUST UNITED AC 2009; 146 Spec No 1:2-7. [PMID: 19846100 DOI: 10.1016/j.jchir.2009.08.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The diagnosis of acute appendicitis relies largely on clinical experience; the performance of complementary tests is oftentimes unnecessary. We have created a score based on clinical and laboratory findings which can reliably categorize three zones of diagnostic probability : probable, doubtful, or improbable. Only the intermediate category requires complementary imaging. Alvarado first developed a scoring system based on operative findings and this has been modified and improved by others. In our experience, the scoring system of François has been most useful. This score is based on simple clinical data and findings such as age, sex, duration of symptoms, leucocytosis, palpable mass on rectal exam, and urinary symptoms. We have validated this score in a cohort of 202 patients presenting with right lower quadrant abdominal pain and found a sensitivity of 94.7% and a negative predictive value of 97.4% for patients falling into the probable and improbable categories. Management of patients with either very high or very low scores can proceed more expeditiously and with less expense. Diagnostic imaging can be reserved for those patients with intermediate scores where the diagnosis is in doubt. We have established a clinical pathway in our emergency department based on this scoring system.
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Affiliation(s)
- C Brigand
- Pôle des pathologies digestives, hépatiques et de la transplantation, hôpital de Hautepierre, 1, avenue Molière, 67098 Strasbourg cedex 2, France.
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Goldman RD, Carter S, Stephens D, Antoon R, Mounstephen W, Langer JC. Prospective validation of the pediatric appendicitis score. J Pediatr 2008; 153:278-82. [PMID: 18534219 DOI: 10.1016/j.jpeds.2008.01.033] [Citation(s) in RCA: 112] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2005] [Revised: 10/05/2007] [Accepted: 01/24/2008] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To prospectively validate the Pediatric Appendicitis Score (PAS), developed on a cohort of children with abdominal pain suggestive of appendicitis, in unselected children with abdominal pain who present to the emergency department. STUDY DESIGN Over a 19-month period, we prospectively recruited children 1 to 17 years old who came to our tertiary pediatric emergency department, with a chief complaint of abdominal pain of duration less than 7 days. PAS components included fever >38 degrees C, anorexia, nausea/vomiting, cough/percussion/hopping tenderness (2 points), right-lower-quadrant tenderness (2 points), migration of pain, leukocytosis >10 000 cells/mm(3), and polymorphonuclear neutrophilia > 7500 cells/mm(3). A follow-up call was made to verify final outcome. Sensitivity, specificity, and the receiver operating characteristic curve of the PAS with respect to diagnosis of appendicitis were calculated. RESULTS We collected data on 849 children. 123 (14.5%) had pathologic study-proven appendicitis. Mean (median, range) score for children with appendicitis and without appendicitis was 7.0 (7, 2-10) and 1.9 (1, 0-9), respectively. If a cutoff PAS of <or=2 was used to discharge patients without further investigation, only 3 (2.4%) with appendicitis would be sent home. If a PAS of >or=7 was used to take children to the operating room without further investigation, only 29 (4%) would not have appendicitis. For the PAS the area under the receiver operator curve was 0.95. CONCLUSIONS The PAS is useful, because a value <or=2 (found in 73% of children without appendicitis) has high validity for ruling out appendicitis, and a score >or=7 (found in 61% of children with appendicitis) has a high validity for predicting the presence of appendicitis. Children with PAS of 3 to 6 (37% with appendicitis and 23% without appendicitis in this study) should undergo further investigation such as observation, ultrasonography, or computed tomography.
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Affiliation(s)
- Ran D Goldman
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Pediatric Research in Emergency Therapeutics Program, BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada.
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Lin EJ, Purcell TB, McPheeters RA. Adaptation of Predictive Models to PDA Hand-Held Devices. West J Emerg Med 2008; 9:13-9. [PMID: 19561697 PMCID: PMC2672238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2007] [Accepted: 11/08/2007] [Indexed: 12/01/2022] Open
Abstract
Prediction models using multiple logistic regression are appearing with increasing frequency in the medical literature. Problems associated with these models include the complexity of computations when applied in their pure form, and lack of availability at the bedside. Personal digital assistant (PDA) hand-held devices equipped with spreadsheet software offer the clinician a readily available and easily applied means of applying predictive models at the bedside. The purposes of this article are to briefly review regression as a means of creating predictive models and to describe a method of choosing and adapting logistic regression models to emergency department (ED) clinical practice.
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Affiliation(s)
- Edward J. Lin
- Address for correspondence: Edward J. Lin, M.D., M.P.H., Dept. of Emergency Medicine, Kern Medical Center, 1830 Flower Street, Bakersfield, CA 93305,
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Rabinowitz CB, Egglin TK, Beland MD, Mayo-Smith WW. Outcomes in 74 patients with an appendicolith who did not undergo surgery: is follow-up imaging necessary? Emerg Radiol 2007; 14:161-5. [PMID: 17457624 DOI: 10.1007/s10140-007-0613-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2007] [Revised: 03/19/2007] [Accepted: 04/02/2007] [Indexed: 01/07/2023]
Abstract
The objective of this study was to report the clinical outcome of patients with an appendicolith on computed tomography (CT) who did not undergo appendectomy on initial presentation. Reports from 45,901 abdominal CT examinations performed between March 2000-March 2004 containing the words "appendicolith" or "fecalith" were identified. Patients with appendicoliths not initially undergoing appendectomy were followed to assess re-presentation with abdominal pain ultimately requiring appendectomy. Seventy-four patients had an appendicolith on CT report, were discharged without surgery, and had clinical follow-up. Fifty-two of 74 (70%) patients had no appendiceal symptoms, were given an alternate diagnosis, and did not return with appendicitis. Twenty-two of 74 (30%) patients were discharged without acute appendicitis but with possible appendiceal symptoms. Five of these 22 (23%) patients returned with pathologically proven acute appendicitis, and all had possible appendiceal symptoms at initial presentation. An appendicolith may be a marker of increased risk for appendicitis but is not an indication for appendectomy.
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Affiliation(s)
- Chad B Rabinowitz
- Department of Diagnostic Imaging, Brown Medical School, Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903, USA
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Birchley D. Patients with clinical acute appendicitis should have pre-operative full blood count and C-reactive protein assays. Ann R Coll Surg Engl 2006; 88:27-32. [PMID: 16460636 PMCID: PMC1963644 DOI: 10.1308/003588406x83041] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION The role of inflammatory markers in the diagnosis of acute appendicitis has not been clearly defined. The aims of this prospective audit were to define the role of the serum markers of inflammation total white cell count, neutrophil count and C-reactive protein in the diagnosis of acute appendicitis with particular reference to the discrimination between uncomplicated and complicated appendicitis, and the prediction of abscess. PATIENTS AND METHODS The author compiled a prospective database over a 13-month period of all appendicectomies performed. After five exclusions (three having no notes for review and two having confounding second morbidity in the presence of a normal appendix), the data relating to 75 patients were analysed. RESULTS In patients judged on clinical grounds to require laparotomy for suspected acute appendicitis, white cell count and neutrophil count distinguish acute appendicitis from normal appendices when used as categorical variables, though they do not reflect the presence of abscess. C-reactive protein neither distinguishes appendicitis from normal, nor predicts abscess when used as a categorical variable, though higher levels suggest abscess. CONCLUSIONS Laboratory tests of the white cell count, neutrophil count and C-reactive protein are more effective in supporting a clinical diagnosis of acute appendicitis in patients with typical clinical features than in excluding the diagnosis.
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Affiliation(s)
- D Birchley
- Department of Vascular Surgery, Torbay Hospital, Torquay, UK.
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Tzanakis NE, Efstathiou SP, Danulidis K, Rallis GE, Tsioulos DI, Chatzivasiliou A, Peros G, Nikiteas NI. A new approach to accurate diagnosis of acute appendicitis. World J Surg 2005; 29:1151-6, discussion 1157. [PMID: 16088420 DOI: 10.1007/s00268-005-7853-6] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
This study aimed (1) to develop a simple scoring system incorporating ultrasound (US) examination and clinical or laboratory predictors for increasing diagnostic accuracy in acute appendicitis (AA), and (2) to evaluate the performance of the scoring system as compared to that of previous models. Fifteen variables including US assessment for patients admitted with suspected AA were considered in multivariate analysis using the finding of AA at operation as the end point (internal study). The new score, together with 11 previous ones, was applied to a prospective independent population of subjects with suspected AA, and the respective performances were compared (external validation study). Among 303 patients (170 males, mean age 28.3 +/- 13.3 years) of the internal study, 161 went on to surgery, and 130 had AA at operation. Four independent correlates of AA were identified and used for the derivation of the following integer-based scoring system: number of points = 6 for US demonstrating AA + 4 for tenderness in the right lower quadrant + 3 for rebound tenderness + 2 for leukocyte count >12,000/microl. In the external study (201 subjects, 105 males, mean age 28.7 +/- 11.9 years, 109 operated, 87 with AA), when the cut-off of >/or = 8 points for AA was used, sensitivity, specificity, accuracy, and area under the curve of the proposed score were 95.4%, 97.4%, 96.5%, and 93%, respectively, exceeding noticeably the previous models. The proposed scoring system introduces a quantitative combination of the clinical evaluation with US imaging and a marker of inflammatory response, which may enhance the diagnostic accuracy for subjects with suspected AA especially in geographical areas where CT scanning is not readily available on a 24-hour basis.
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Affiliation(s)
- Nikolaos E Tzanakis
- Fourth Surgical Clinic, Athens University, Medical School, General State Hospital of Nikea, 3 D. Mantouvalou Str., Piraeus 18454, Greece
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Lintula H, Pesonen E, Kokki H, Vanamo K, Eskelinen M. A diagnostic score for children with suspected appendicitis. Langenbecks Arch Surg 2005; 390:164-70. [PMID: 15723233 DOI: 10.1007/s00423-005-0545-8] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2004] [Accepted: 01/19/2005] [Indexed: 12/13/2022]
Abstract
BACKGROUND/PURPOSE Appendicectomy is an operation that is often performed without certainty of diagnosis. This study aimed to construct and to validate a prognostic score for the diagnosis of acute appendicitis in children. METHODS Data for 35 symptoms and signs were prospectively recorded for 131 consecutive children with suspected appendicitis. Logistic regression analysis of the variables yielded a diagnostic score: gender (male 2 points, female 0) + intensity of abdominal pain (severe 2, mild or moderate 0) + relocation of pain (yes 4, no 0) + vomiting (yes 2, no 0) + pain in the right lower abdominal quadrant (yes 4, no 0) + fever (yes 3, no 0) + guarding (yes 4, no 0) + bowel sounds (abnormal 4, normal 0) + rebound tenderness (yes 7, no 0). The cut-off level for recommendation of appendicectomy was > or =21, and the cut-off level for non-appendicitis was < or =15. The score was prospectively validated on 109 children. RESULTS In the validation sample, based on clinical judgment, unnecessary appendicectomy was performed in ten (27%) children, and one (4%) child was misdiagnosed as not having appendicitis. By application of the score, unnecessary appendicectomies would have been reduced to four (13%), and three children (11%) with appendicitis would have been discharged. CONCLUSION The use of a predictive mathematical model may facilitate the diagnosis of appendicitis to avoid unnecessary operations.
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Affiliation(s)
- Hannu Lintula
- Department of Pediatric Surgery, Kuopio University Hospital, PO Box 1777, 70211 Kuopio, Finland.
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Sakellaris G, Tilemis S, Charissis G. Acute appendicitis in preschool-age children. Eur J Pediatr 2005; 164:80-3. [PMID: 15703977 DOI: 10.1007/s00431-004-1568-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2004] [Accepted: 09/30/2004] [Indexed: 10/26/2022]
Abstract
UNLABELLED During the last 11 years, 122 children aged less than 5 years underwent appendectomy with a preoperative diagnosis of acute appendicitis. At surgery, 29 children (24%) presented with acute suppurative appendicitis, 64 children (52%) perforated appendices and 26 children (21%) with appendiceal abscess. In three cases (2%) there was no acute intra-abdominal process. In this study the following data were analysed: age, gender, symptoms, duration of symptoms, whether seen by a physician prior to admission and surgery, physical findings, stage of the disease at operation, histology, postoperative complications and mortality. CONCLUSION The accurate diagnosis in early childhood appendicitis is still a difficult matter. The responsibility of the paediatric surgeon is mainly the clinical examination with all his clinical skills and facilities and if serious doubt still exists, to proceed with a laparotomy in order to reach a definite diagnosis.
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Affiliation(s)
- George Sakellaris
- Department of Paediatric Surgery, School of Medicine, University of Crete, Heraklion, Greece.
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Agaba EA, Goon P, Pushdary K, Wong LS. Perforated Appendicitis in the Elderly Masquerading as Acute Coronary Syndrome. Surg Infect (Larchmt) 2004; 5:195-9. [PMID: 15353117 DOI: 10.1089/sur.2004.5.195] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Evaluation of acute appendicitis in the elderly presents a diagnostic challenge to the surgeon. The diagnosis is often difficult to establish on account of general poverty of history and clinical signs, comorbidity and the unreliability of diagnostic procedures. Due to this, morbidity and mortality statistics in this group of patients is unacceptably higher than the general population. METHODS Individual case report and literature review. RESULTS We present an unusual case of perforated appendicitis masquerading as acute coronary syndrome. CONCLUSIONS Patient's education, high index of suspicion, and an aggressive surgical approach is needed if the outcome among the elderly population is to be improved.
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Tepel J, Sommerfeld A, Klomp HJ, Kapischke M, Eggert A, Kremer B. Prospective evaluation of diagnostic modalities in suspected acute appendicitis. Langenbecks Arch Surg 2003; 389:219-24. [PMID: 14634825 DOI: 10.1007/s00423-003-0439-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2003] [Accepted: 10/10/2003] [Indexed: 01/07/2023]
Abstract
BACKGROUND The aim of this prospective study was to evaluate different diagnostic modalities routinely employed in a district hospital. METHOD Four hundred subsequent patients presenting with acute abdominal pain were included over a period of 18 months. Patient characteristics, diagnostic work-up, intraoperative findings, histology and clinical outcome were documented. Rectal temperature, white cell count (WCC), C-reactive protein (CRP), ultrasonography (US) and Ohmann score were analysed with relation to diagnostic value. RESULTS Negative appendicectomy rate and negative laparotomy rate on the day of admission were 22% and 21%, respectively. Sensitivity was highest for WCC and CRP (0.82 and 0.85) but US showed highest values for specificity (0.92), accuracy (0.85) and odds ratio (13.06). No patient with an Ohmann score below 6.5 suffered from acute appendicitis. With regard to different levels of training in US, experienced surgeons and radiologists had best values for specificity (1.00 and 0.98) and accuracy (0.90 and 0.94). Surprisingly, less-experienced sonographers also achieved good results with regard to specificity (up to 0.96) and positive predictive value (up to 0.89). CONCLUSION Diagnostic accuracy of acute appendicitis remains insufficient, with an unacceptable high rate of unnecessary operations. Only the promotion of routine ultrasonography might contribute to an improvement in the near future.
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Affiliation(s)
- Juergen Tepel
- Department of General Surgery and Thoracic Surgery, University-Hospital of Schleswig-Holstein, Campus Kiel, Arnold Heller Strasse 7, 24105 Kiel, Germany.
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Sitter H, Hoffmann S, Hassan I, Zielke A. Diagnostic score in appendicitis. Validation of a diagnostic score (Eskelinen score) in patients in whom acute appendicitis is suspected. Langenbecks Arch Surg 2003; 389:213-8. [PMID: 14624293 DOI: 10.1007/s00423-003-0436-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2003] [Accepted: 09/25/2003] [Indexed: 12/01/2022]
Abstract
BACKGROUND AND AIM At times, the diagnosis of acute appendicitis may be difficult. However, for minimum morbidity to be obtained, early and accurate diagnosis is essential. This study aimed to validate a scoring system proposed by Eskelinen et al. as an aid in making the diagnosis of appendicitis. PATIENTS AND METHODS The prospectively documented data of a consecutive series of 2,359 patients admitted for suspicion of appendicitis were used for validation. Accuracy and positive predictive value were defined as the main overall performance parameters, as was the rate of unnecessary operations to assess changes of patient management. Overall performance was assessed by receiver-operator characteristics (ROC) analysis. RESULTS Of 2,359 patients, 662 were proven to have acute appendicitis (prevalence of 28%). The overall sensitivity, specificity, positive and negative predictive value, and accuracy of the score were 0.79, 0.85, 0.68, 0.91 and 0.835 at a cut-off value of 55. Calibration of the score's cut-off value to 57 yielded more favourable results (0.72, 0.91, 0.76, 0.9 and 0.86), and the rate of unnecessary operations declined from 26.6% to 15.4% ( P<0.05, chi2). ROC analysis revealed an area index of 0.91. CONCLUSION The Eskelinen score delivered acceptable clinical results only after calibration to a cut-off value of 57. The data from this study suggest the investigation of whether a calibrated score might be particularly instrumental in the pre-admission evaluation of the patient in whom appendicitis is suspected.
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Affiliation(s)
- H Sitter
- Institute of Theoretical Surgery, Philipps University of Marburg, Baldingerstrasse, 35033 Marburg, Germany.
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DeArmond GM, Dent DL, Myers JG, Chopra S, Mumbower AL, Kumar A, Stewart RM. Appendicitis: selective use of abdominal CT reduces negative appendectomy rate. Surg Infect (Larchmt) 2003; 4:213-8. [PMID: 12906722 DOI: 10.1089/109629603766957013] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Recent literature supports the use of CT for all patients with right lower quadrant pain to improve diagnostic accuracy and reduce hospital cost. Our current practice at a large teaching hospital is to use CT only for patients whose diagnosis remains in question after a thorough history, physical examination, and focused laboratory assessment. In consideration of a more liberal use of CT for right lower quadrant pain, we reviewed our experience with selective CT and the effect this has had on our practice, paying particular attention to perforation rate and negative appendectomy rate. MATERIALS AND METHODS A retrospective chart review was performed for all patients who underwent appendectomy in 1995 and 1998. These two patient populations were evaluated for patient demographics, use of CT scan, perforation rate, and incidence of negative appendectomy. RESULTS Three hundred ninety-four patients underwent appendectomy in 1995 versus 372 in 1998. Gender (64% male in 1995 vs. 60% in 1998), age (mean 24.9 vs. 25.5) and perforation rate (31% in 1995 vs. 29% in 1998) did not change. The use of CT increased in 1998 (12% vs. 34%, p < 0.001) and overall nontherapeutic appendectomy decreased (14% vs. 7%, p < 0.005). This decrease was seen in patients who were operated without CT (13% vs. 7%, p < 0.03) and after CT (19% vs. 6%, p < 0.02). CONCLUSION Selective use of CT scan in patients presenting with right lower quadrant pain is helpful in reducing the incidence of nontherapeutic appendectomy.
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Douglas CD, Macpherson NE, Davidson PM, Gani JS. Randomised controlled trial of ultrasonography in diagnosis of acute appendicitis, incorporating the Alvarado score. BMJ (CLINICAL RESEARCH ED.) 2000; 321:919-22. [PMID: 11030676 PMCID: PMC27498 DOI: 10.1136/bmj.321.7266.919] [Citation(s) in RCA: 139] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To determine whether diagnosis by graded compression ultrasonography improves clinical outcomes for patients with suspected appendicitis. DESIGN A randomised controlled trial comparing clinical diagnosis (control) with a diagnostic protocol incorporating ultrasonography and the Alvarado score (intervention group). SETTING Single tertiary referral centre. PARTICIPANTS 302 patients (age 5-82 years) referred to the surgical service with suspected appendicitis. 160 patients were randomised to the intervention group, of whom 129 underwent ultrasonography. Ultrasonography was omitted for patients with extreme Alvarado scores (1-3, 9, or 10) unless requested by the admitting surgical team. MAIN OUTCOME MEASURES Time to operation, duration of hospital stay, and adverse outcomes, including non-therapeutic operations and delayed treatment in association with perforation. RESULTS Sensitivity and specificity of ultrasonography were measured at 94. 7% and 88.9%, respectively. Patients in the intervention group who underwent therapeutic operation had a significantly shorter mean time to operation than patients in the control group (7.0 v 10.2 hours, P=0.016). There were no differences between groups in mean duration of hospital stay (53.4 v 54.5 hours, P=0.84), proportion of patients undergoing a non-therapeutic operation (9% v 11%, P=0.59) or delayed treatment in association with perforation (3% v 1%, P=0.45). CONCLUSION Graded compression ultrasonography is an accurate procedure that leads to the prompt diagnosis and early treatment of many cases of appendicitis, although it does not prevent adverse outcomes or reduce length of hospital stay.
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Affiliation(s)
- C D Douglas
- Department of Surgery, John Hunter Hospital, NSW 2310, Australia.
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Dado G, Anania G, Baccarani U, Marcotti E, Donini A, Risaliti A, Pasqualucci A, Bresadola F. Application of a clinical score for the diagnosis of acute appendicitis in childhood: a retrospective analysis of 197 patients. J Pediatr Surg 2000; 35:1320-2. [PMID: 10999688 DOI: 10.1053/jpsu.2000.9316] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE The aim of this study was to validate a clinical scoring system for the diagnosis of acute appendicitis in childhood. METHODS The authors retrospectively applied a clinical scoring system on 197 consecutive pediatric patients operated on for acute appendicitis. They therefore looked for a correlation between the management suggested by the scoring system and pathologic diagnosis on surgical specimens. RESULTS Based on final pathologic specimen, surgery has been performed unnecessarily in 23% of cases. The proposed scoring system could have reduced unnecessary surgery to 2%. Only 8% of patients with acute appendicitis would have been discharged home. Sensitivity and specificity of the scoring system used in this study was 87% and 86%, respectively. CONCLUSION The clinical scoring system proposed in this study could be of help in early clinical diagnosis of appendicitis to reduce the rate of unnecessary emergency surgery.
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Affiliation(s)
- G Dado
- Department of Surgery, University of Udine School of Medicine, Italy
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L'échographie abdominopelvienne en cas de suspicion d'appendicite aiguë : évaluation prospective chez l'adulte. ACTA ACUST UNITED AC 2000. [DOI: 10.1016/s0001-4001(00)00111-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Reynolds SL. Diagnosing pediatric appendicitis. CLINICAL PEDIATRIC EMERGENCY MEDICINE 1999. [DOI: 10.1016/s1522-8401(99)90005-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Affiliation(s)
- S J Scholer
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, USA
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Abstract
Ultrasonography, CT scanning, and prolonged observation may improve diagnostic accuracy of appendicitis in children with atypical presentations. This article describes diagnostic pitfalls, including early presentation and abnormal appendiceal location.
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Affiliation(s)
- M D Joffe
- Emergency Department, Children's Hospital of Philadelphia, PA 19104, USA
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39
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Galindo Gallego M, Fadrique B, Nieto MA, Calleja S, Fernández-Aceñero MJ, Ais G, González J, Manzanares JJ. Evaluation of ultrasonography and clinical diagnostic scoring in suspected appendicitis. Br J Surg 1998; 85:37-40. [PMID: 9462380 DOI: 10.1046/j.1365-2168.1998.00543.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Several diagnostic aids have been developed to improve diagnosis in suspected appendicitis including ultrasonography and clinical diagnostic scoring. The aim of this study was to elaborate a new scoring system and to measure its accuracy in the preoperative diagnosis of appendicitis, comparing it with the available scoring systems. METHODS The clinical, radiological and ultrasonographic data of 192 patients with suspected appendicitis were collected prospectively. RESULTS Only six of the 12 variables analysed were shown to have prognostic significance. Using Bayesian methodology, a weight was given to each criterion and two overall scores were calculated (ultrasonographic and classical scores). A cut-off point was identified to separate patients who needed surgery and those for observation. The ultrasonographic score showed an 81 per cent sensitivity and a 96 per cent specificity, compared with 60 and 73 per cent respectively for the classical score. CONCLUSION Ultrasonography increases the diagnostic accuracy in patients with suspected acute appendicitis.
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Abstract
Hollow viscus injuries are usually managed with few complications. However, if their diagnosis is delayed, or if reparative suture closure should fail, the patient is placed at risk of multiple organ failure. This article presents diagnostic approaches, emphasizing imaging modalities, and therapeutic strategies for three clinical scenarios of hollow viscus perforation: 1) acute appendicitis, 2) gastroduodenal peptic ulcer disease, and 3) trauma.
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Affiliation(s)
- R Espinoza
- Department of Surgery, Pontificia Catholic University of Chile, Santiago, Chile
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Varoğlu E, Polat KY, Taştekin G, Akçay F, Polat C. Diagnostic value of Tc-99m HIG scintigraphy in the detection of acute appendicitis. Clin Nucl Med 1996; 21:645-7. [PMID: 8853921 DOI: 10.1097/00003072-199608000-00013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- E Varoğlu
- Department of Nuclear Medicine, Atatürk University, Medical School, Erzurum, Turkey
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Abstract
A radiographically demonstrated fecalith is widely considered a virtually pathognomonic sign of acute appendicitis. This case report describes a patient with a clinical presentation suggestive of appendicitis and a well-defined right lower quadrant fecalith who was found to have a normal appendix at surgery. This case calls into question the venerable dogma surrounding the fecalith and highlights the necessity for the physician to continue to rely on clinical judgment in making the diagnosis of appendicitis.
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Affiliation(s)
- R L Maenza
- University of Pittsburgh Affiliated Residency in Emergency Medicine, Pennsylvania, USA
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Golledge J, Toms AP, Franklin IJ, Scriven MW, Galland RB. Assessment of peritonism in appendicitis. Ann R Coll Surg Engl 1996; 78:11-4. [PMID: 8659965 PMCID: PMC2502643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
The aim of this study was to evaluate the accuracy of different methods of demonstrating right iliac fossa peritonism in appendicitis. The methods used were cat's eye symptom (pain on going over a bump in the road), cough sign, right iliac fossa tenderness, percussion tenderness, rebound tenderness and guarding. A series of 100 consecutive patients with a median age of 25 years (range 4-81 years), presenting with right iliac fossa pain were studied prospectively; the male:female ratio was 39:61. In all, 58 patients underwent operation, 44 had appendicitis confirmed on histology. Fourteen patients had a normal appendix removed; 11 were women aged between 16 and 45 years. Cat's eye symptom and cough sign were sensitive indicators of appendicitis (sensitivity 0.80 and 0.82, respectively), but were not specific (specificity 0.52 and 0.50, respectively) and therefore inaccurate (accuracy 64%). Percussion tenderness was less sensitive (sensitivity 0.57) but more specific (specificity 0.86). Rebound tenderness proved to be sensitive (sensitivity 0.82), specific (specificity 0.89) and accurate (accuracy 86%). Thus, rebound tenderness had a positive predictive value of 86% compared with 56% and 57% for cough sign and cat's eye symptom, respectively. In the difficult diagnostic group of young women, the positive predictive value of rebound tenderness was 88% compared with 58% and 56% for cat's eye symptom and cough sign. Appendicitis remains a difficult diagnosis, particularly in young women. Rebound tenderness still has an important role to play in clinical assessment.
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Affiliation(s)
- J Golledge
- Cardiff Vascular Unit, University Hospital of Wales
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Bouillot JL, Salah S, Fernandez F, al-Hajj G, Dehni N, Dhote J, Badawy A, Alexandre JH. Laparoscopic procedure for suspected appendicitis. A prospective study in 283 consecutive patients. Surg Endosc 1995; 9:957-60. [PMID: 7482212 DOI: 10.1007/bf00188450] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Between September 1990 and December 1993, 283 consecutive patients were admitted with clinical symptoms of acute appendicitis. These patients underwent primary laparoscopic approach so that an appendicectomy could be performed by this method. In 49 cases (17.3%), primary laparoscopic examination corrected the preoperative diagnosis and the appendix was left in situ. Appendicectomy was performed in 234 cases (149 women, 85 men) with a mean age of 30 years. Requirement for open surgery occurred in 29 cases. The main cause of unsuccessful procedures was inflammation due to local or generalized peritonitis. Median operative time for a successful procedure was 60 min (range, 25-160). Four postoperative complications (one related to laparoscopic procedure), one case of wound infection, and no mortality resulted. After laparoscopic appendicectomy, the median hospital stay was 3 days (range, 1-16). These results suggest that a laparoscopic approach for suspected appendicitis is reliable, allowing abdominal exploration and safe appendicectomy.
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Affiliation(s)
- J L Bouillot
- Department of General Surgery, University Paris VI, Hospital Broussais, France
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Eskelinen M, Ikonen J, Lipponen P. The value of history-taking, physical examination, and computer assistance in the diagnosis of acute appendicitis in patients more than 50 years old. Scand J Gastroenterol 1995; 30:349-55. [PMID: 7610351 DOI: 10.3109/00365529509093289] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The accuracy of the clinical diagnosis of acute appendicitis in patients more than 50 years old was studied in connection with the Research Committee of the World Organization of Gastroenterology (OMGE) survey of acute abdominal pain. Criteria for inclusion and the diagnostic criteria in this prospective study were those set out by the OMGE Research Committee. METHODS The clinical findings in each patient were recorded in detail, using a predefined structured data collection sheet, and the collected data were compared with the final diagnosis of the patients. Twenty-three preoperative clinical history variables, 14 clinical signs, and 3 tests were evaluated in a single variable and multivariate analysis. RESULTS In multivariate logistic regression analysis the most significant predictors of acute appendicitis in patients more than 50 years old were tenderness (relative risk (RR) = 39.4), rigidity (RR = 18.8), and pain at diagnosis (RR = 11.0). The sensitivity of the preoperative clinical decision is detecting acute appendicitis in the aged was 0.87, with a specificity of 0.92, an efficiency of 0.91 and a usefulness index (UI) of 0.69. The computer-aided diagnostic score (DS) reached a sensitivity of 0.92 in detecting acute appendicitis, with a specificity of 0.90 and an efficiency of 0.90. When the patients with a DS value between -0.47 and 0.07 were considered nondefined (n = 43, follow-up required before the decision to operate), the efficiency of the computer-aided diagnosis in detecting acute appendicitis in the aged improved to 0.97. In patients more than 50 years old whose body temperature was available (n = 374), tenderness, rigidity, location of pain at diagnosis, and body temperature predicted significantly acute appendicitis. At a cut-off level of -1.49 the diagnostic score reached a sensitivity of 0.94 in detecting acute appendicitis, with a specificity of 0.91, an efficiency of 0.92 and a UI of 0.80. When the patients with a DS value between -1.49 and 0.46 were considered nondefined (n = 43, follow-up required before the decision to operate), the sensitivity of the computer-aided diagnosis in detecting acute appendicitis in the aged was 0.92, with a specificity of 0.99 and an efficiency of 0.98, and the UI improved to 0.84. CONCLUSION Acute abdominal pain at the right lower quadrant, with tenderness, rigidity, and increased body temperature (> or = 37.1 degrees C), is indicative of acute appendicitis in patients more than 50 years old. The diagnostic scoring system did perform well, increasing the sensitivity, specificity, efficiency, and usefulness index of the diagnosis of acute appendicitis in the aged.
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Affiliation(s)
- M Eskelinen
- Dept. of Surgery, University Hospital, Kuopio, Finland
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Puskar D, Bedalov G, Fridrih S, Vucković I, Banek T, Pasini J. Urinalysis, ultrasound analysis, and renal dynamic scintigraphy in acute appendicitis. Urology 1995; 45:108-12. [PMID: 7817461 DOI: 10.1016/s0090-4295(95)97134-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVES The influence of acute appendicitis (AA) on the right kidney and urinalysis was investigated. Permanent damage of the urinary tract and abnormal urinalysis have been previously reported in AA. METHODS Appendectomy was performed in 84 patients with no previous urogenital, retroperitoneal, or pelvic disease, trauma, or operation. AA was confirmed in 66 of them. Control groups were the remaining 18 patients and 40 patients with varicocele repair. Renal sonography and urinalyses were done prior to operation, on days 1, 3, and 6 postoperatively. Pentetic acid renal scintigraphy was done on postoperative day 1 in patients with abnormal urinalysis. An obstructive radiographic curve indicated furosemide renography. RESULTS Abnormal urinalysis was found in 48% of patients with AA before appendectomy and in 12% on day 6 postoperatively. Sonography showed pyelocaliceal dilation of the right kidney in 38% of patients with AA prior to appendectomy and in none on day 6 postoperatively. Patients with AA had pyelocaliceal dilation of the right kidney more frequently than those in the control groups (P < 0.001). It was more frequent in patients having abnormal urinalysis (P < 0.01). Scintigraphy confirmed pyelocaliceal dilation of the right kidney in 38% of patients with abnormal urinalysis. Furosemide renography excluded an obstruction in all of them. CONCLUSIONS Inflammation is the major cause of abnormal urinalysis and transitory pyelocaliceal dilation in some patients with AA. Erythrocyturia, pyuria, proteinuria, and pyelocaliceal dilation detected by sonography or scintigraphy can frequently be found in patients with AA, but should not mislead the surgeon in the diagnosis of AA.
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Affiliation(s)
- D Puskar
- Department of Urology, New Hospital, Zagreb, Croatia
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Eskelinen M, Ikonen J, Lipponen P. Contributions of history-taking, physical examination, and computer assistance to diagnosis of acute small-bowel obstruction. A prospective study of 1333 patients with acute abdominal pain. Scand J Gastroenterol 1994; 29:715-21. [PMID: 7973431 DOI: 10.3109/00365529409092499] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The accuracy of clinical diagnosis of acute small-bowel studied in connection with the survey of acute abdominal pain by the Research Committee of the World Organization of Gastroenterology (OMGE). Criteria for inclusion and the diagnostic criteria of this prospective study were those set out by the OMGE Research Committee. METHODS The clinical findings in each patient were recorded in detail on a pre-defined structured data collection sheet, and the collected data were compared with the final diagnosis of patients. RESULTS The most efficient symptoms in the diagnosis of acute small-bowel obstruction were previous abdominal surgery (relative risk (RR) = 12.1) and type of pain (colic/intermittent versus steady) (RR = 2.4). The most efficient clinical tests were abdominal distension (yes versus no) (RR = 13.1) and bowel sounds (abnormal versus normal) (RR = 9.0). The sensitivity of the clinical decision was 0.75, with a specificity of 0.99 and an efficiency of 0.98. The computer-based diagnostic score reached a sensitivity of 0.87 with a specificity of 0.95 and an efficiency of 0.95. CONCLUSIONS Acute abdominal pain with distension, abnormal bowel sounds, and previous abdominal surgery are indicative of a small-bowel obstruction. A computer-based diagnostic score increases the sensitivity and usefulness index of the diagnosis of acute small-bowel obstruction in comparison with clinical decision alone.
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Affiliation(s)
- M Eskelinen
- Dept. of Surgery, University of Kuopio, Finland
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Rusnak RA, Borer JM, Fastow JS. Misdiagnosis of acute appendicitis: common features discovered in cases after litigation. Am J Emerg Med 1994; 12:397-402. [PMID: 8031420 DOI: 10.1016/0735-6757(94)90047-7] [Citation(s) in RCA: 75] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
To identify differences between correctly diagnosed appendicitis and misdiagnosed cases that resulted in litigation between 1982 and 1989 retrospective review of malpractice claims was conducted. A total of emergency department (ED) charts at the time of the initial ED visit were reviewed and compared with 66 concurrent controls. Missed cases appeared less acutely ill, had fewer complaints of right lower quadrant pain, received fewer rectal examinations, received intramuscular (IM) narcotic pain medication for undiagnosed abdominal pain or symptoms, and more often received an ED discharge diagnosis of gastroenteritis. Misdiagnosed patients had a 91% incidence of ruptured appendix, more extensive surgical procedures, and more postoperative complications. Data were analyzed using the Pearson's chi 2 Test, Mann-Whitney U Test, and stepwise discriminant analysis. Significance was defined as P < or = .05. Misdiagnosis of acute appendicitis is more likely to occur with patients who present atypically, are not thoroughly examined (as indexed by documentation of a rectal examination), are given IM narcotic pain medication and then discharged from the ED, are diagnosed as having gastroenteritis (despite the absence of the typical diagnostic criteria), and with patients who do not receive appropriate discharge or follow-up instructions.
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Affiliation(s)
- R A Rusnak
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis MN 55415
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