Accuracy of ultrasonography in the diagnosis of acute appendicitis in adult patients: review of the literature

Appendicitis Caused by a Giant Appendicolith

The coproliths of the appendix are accumulations of fecal remnants within its lumen. They are categorized based on their size into coproliths < 1cm, which are the most common, and giant coproliths, with a diameter > 2cm. It's important to note that the pathophysiology of acute appendicitis is characterized by the obstruction of the appendix lumen. This leads to distension due to the inability to expel secretions, ischemia, and ultimately rupture of its wall. This presentation discusses an interesting case of acute appendicitis caused by a giant coprolith. It also covers the clinical approach and information according to international literature. A 38-year-old man presented with sudden-onset right lower quadrant pain. Clinical examination revealed tenderness, a positive McBurney's point, elevated inflammation markers, and a radiopaque finding on an X-ray. A CT scan revealed a 2.5cm coprolith in the appendix. An exploratory laparoscopy revealed appendix wall rupture, followed by subumbilical incision appendicectomy and cleansing of purulent collection. The patient was discharged from the hospital on the fourth postoperative day without any complications, demonstrating a smooth recovery process. The presence of a coprolith predisposes the development of acute appendicitis. This condition is associated with a worse prognosis, as it increases the likelihood of perforation and the formation of intraperitoneal abscesses. This case underscores the clinical significance of giant coproliths as a potential etiology for acute appendicitis. Early recognition and timely surgical intervention are pivotal in achieving favorable patient outcomes.

Comparison of RIPASA and ALVARADO scores for risk assessment of acute appendicitis: A systematic review and meta-analysis

Background

In the last decades, several clinical scores have been developed and currently used to improve the diagnosis and risk management of patients with suspected acute appendicitis (AA). However, some of them exhibited different values of sensitivity and specificity. We conducted a systematic review and metanalysis of epidemiological studies, which compared RIPASA and Alvarado scores for the diagnosis of AA.

Methods

This systematic review was conducted using PubMed and Web of Science databases. Selected studies had to compare RIPASA and Alvarado scores on patients with suspected AA and reported diagnostic parameters. Summary estimates of sensitivity and specificity were calculated by the Hierarchical Summary Receiver Operating Curve (HSROC) using STATA 17 (STATA Corp, College Station, TX) and MetaDiSc (version 1.4) software.

Results

We included a total of 33 articles, reporting data from 35 studies. For the Alvarado score, the Hierarchical Summary Receiver Operating Curve (HSROC) model produced a summary sensitivity of 0.72 (95%CI = 0.66–0.77), and a summary specificity of 0.77 (95%CI = 0.70–0.82). For the RIPASA score, the HSROC model produced a summary sensitivity of 0.95 (95%CI = 0.92–0.97), and a summary specificity of 0.71 (95%CI = 0.60–0.80).

Conclusion

RIPASA score has higher sensitivity, but low specificity compared to Alvarado score. Since these scoring systems showed different sensitivity and specificity parameters, it is still necessary to develop novel scores for the risk assessment of patients with suspected AA.

The role of immature granulocyte in the early prediction of acute perforated and nonperforated appendicitis in children

BACKGROUND

Acute appendicitis (AA) is the most common reason for pediatric abdominal surgery in the world. Despite ad-vances in science and technology, diagnosing AA is still difficult today, and complications are common as a result. The early prediction of complicated appendicitis is of great importance for the surgical planning, further treatments, and predicting the course of disease. The immature granulocyte (IG) is a new and more effective marker in predicting the severity of inflammation than traditional markers. Our aim is to determine the effectiveness of IG% in the diagnosis and severity of AA.

METHODS

Eighty-eight patients diagnosed with AA and a control group of fifty-eight healthy children were included in this prospec-tive study. Patients with pathologically confirmed AA were divided into two subgroups: acute simple appendicitis (ASA) and acute perforated appendicitis (APA). The demographic characteristics, white blood cell (WBC) count, neutrophil-to-lymphocyte ratio (NLR), mean platelet volume (MPV), IG%, and C-reactive protein (CRP) values were analyzed. Receiver operating characteristics (ROC) anal-ysis was used to compare the diagnostic accuracies and predictive performances.

RESULTS

Patients with AA had higher IG%, WBC count, NLR, and MPV value than control group (p=0.28, p=0.22, p<0.001, p=0.001, respectively). Only IG% showed statistically significant difference from other inflammatory markers evaluated in ASA and APA patients (p<0.001). ROC analysis showed that IG% is a good predictor for the presence of APA at an optimal cut-off for IG being 0.2% (sensitivity 81.8%, specificity 85.2%, area under the ROC curve 0.83).

CONCLUSION

In the present study, we demonstrated that AA patients with higher IG levels might be more likely to develop perforation. The IG values combined with a physical examination, imaging studies, and other laboratory tests may help clinicians to identify high-risk AA patients in the pediatric emergency department.

Role of Ultrasonography and Inflammatory Markers in Predicting Complicated Appendicitis

AIM

The aim is to compare the diagnostic accuracy of laboratory investigations and ultrasonography (USG) in distinguishing complicated appendicitis (C-AA) from uncomplicated appendicitis (UC-AA).

MATERIALS AND METHODS

Forty-six children who underwent appendicectomy at our center between November 2018 and July 2020 were included. Based on intraoperative findings, they were divided into two groups - complicated (perforated, gangrenous, or associated with fecal peritonitis; n = 18) and UC-AA (n = 28). USG findings and inflammatory markers were compared in both groups at admission.

RESULTS

At admission, the mean values for total leukocyte count (TLC) (16090.56 vs. 11739.29 per mm³), high sensitivity C-reactive protein (hsCRP) (35.8 vs. 31.62 mg/L), and procalcitonin (PCT) (3.83 vs. 1.41 ng/mL) were significantly higher in C-AA. Visualization of a blind tubular aperistaltic structure was the only sonographic sign showing statistical significance - significantly lower in C-AA (50% vs. 90%). Independent predictors of C-AA were - duration of symptoms >48 h (odds ratio [OR] 6.3), free fluid/loculated collection in right iliac fossa (OR 3.75), TLC >11000/mm³ (OR 3.6), hsCRP >35 mg/L (OR 6.0), PCT >0.6 ng/mL (OR 4.02), and nonvisualization of appendix on USG (OR 8.33). Biochemical factors were sensitive (89%) and specific (55%) in differentiating C-AA from UC-AA but the addition of sonological parameters significantly improved the specificity of predicting complicated AA to 61% (P = 0.0036).

CONCLUSION

Combining laboratory data with sonological findings significantly improves the predictive value for differentiating C-AA from UC-AA and can help decide operative approach and prognosticating.

Variation in imaging outcomes associated with individual sonographers and radiologists in pediatric acute appendicitis: a retrospective cohort of 9271 examinations

OBJECTIVE

To determine if individual sonographers and radiologists impact appendix visualization by ultrasound and utilization of computed tomography (CT) in children with suspected acute appendicitis.

MATERIALS AND METHODS

Appendix ultrasound examinations performed at Cincinnati Children's Hospital Medical Center on Emergency Department patients ≤ 18 years old were retrospectively identified. Examinations performed/interpreted by sonographers/radiologists with fewer than 100 examinations were excluded. Multivariable logistic regression was used to assess the effect of sonographer, radiologist, clinical variables, and system factors on imaging outcomes, including appendix visualization and subsequent CT utilization.

RESULTS

A total of 9271 ultrasound examinations (mean [SD] patient age, 9.9 [4.2] years; 5392 [58.2%] boys) performed by 31 sonographers (mean number examinations, 299 [139]; range, 115-610) and interpreted by 31 radiologists (mean number examinations, 299 [157]; range, 101-845) were included. The mean frequency of appendix visualization per sonographer was 57.8% [8.7%] (range, 40.9-76.0%) and per radiologist was 59.5% [4.1%] (range, 51.7-66.3%). The mean rate of CT utilization per sonographer was 9.2% [2.0%] (range, 5.9-14.0%) and per radiologist was 9.2% [1.8%] (range, 3.4-12.1%). Predictors of appendix visualization by ultrasound included patient weight (p < 0.0001), sex (p = 0.0003), white blood cell count (p < 0.0001), temperature (p = 0.002), abdominal tenderness (p = 0.004), presence of appendicitis (p < 0.0001), sonographer (p < 0.0001), and radiologist (p = 0.02). Predictors of CT utilization included patient weight (p < 0.0001), white blood cell count (p < 0.0001), abdominal tenderness (p < 0.0001), rebound tenderness (p = 0.0003), and presence of appendicitis (p < 0.0001), but not sonographer or radiologist.

CONCLUSION

Individual sonographers and radiologists were associated with appendix visualization by ultrasound in children with suspected acute appendicitis; neither was associated with CT utilization.

KEY POINTS

• Individual sonographers and radiologists are significantly and independently associated with appendix visualization by ultrasound in children with suspected acute appendicitis. • Frequency of appendix visualization per sonographer demonstrated significant and wide variability across 31 sonographers, ranging from 40.9 to 76.0%. • Fewer than 10% of patients with an ultrasound examination for suspected acute appendicitis underwent CT imaging within the following 24 h. Individual radiologists and sonographers were not predictive of CT utilization within 24 h.

Clinical Prediction Score for Ruptured Appendicitis in ED

Background

Ruptured appendicitis has a high morbidity and mortality and requires immediate surgery. The Alvarado Score is used as a tool to predict the risk of acute appendicitis, but there is no such score for predicting rupture. This study aimed to develop the prediction score to determine the likelihood of ruptured appendicitis in an Asian population.

Methods

This study was a diagnostic, retrospective cross-sectional study in the Emergency Medicine Department of Ramathibodi Hospital between March 2016 and March 2018. The inclusion criteria were age >15 years and an available pathology report after appendectomy. Clinical factors included gender, age>60 years, right lower quadrant pain, migratory pain, nausea and/or vomiting, diarrhea, anorexia, fever>37.3°C, rebound tenderness, guarding, white blood cell count, polymorphonuclear white blood cells (PMN) > 75%, and pain duration before presentation. The predictive model and prediction score for ruptured appendicitis were developed by multivariable logistic regression analysis.

Result

During the study period, 480 patients met the inclusion criteria; of these, 77 (16%) had ruptured appendicitis. Five independent factors were predictive of rupture, age>60 years, fever>37.3°C, guarding, PMN>75%, and duration of pain>24 hours to presentation. A score >6 increased the likelihood ratio of ruptured appendicitis by 3.88 times.

Conclusion

Using the Ramathibodi Welawat Ruptured Appendicitis Score (RAMA WeRA Score) developed in this study, a score of >6 was associated with ruptured appendicitis.

Non-diagnostic sonography may reduce negative appendicectomy rate in women when combined with abbreviated Alvarado score

BACKGROUND

The diagnosis of acute appendicitis (AA) remains a clinical one, with selective use of adjunct imaging. Patients with equivocal clinical presentation often undergo a diagnostic laparoscopy. To help reduce negative appendicectomy rates in women, we aimed to develop a simple scoring system based on the Alvarado score (AS) and ultrasound scan (US), as a diagnostic aid for AA in females.

METHODS

All patients who underwent appendicectomy for AA at The Alfred Hospital Melbourne between 1 July 2012 and 30 June 2017 were included for this case-control study. Logistic regression was used to identify pre-operative parameters predictive of AA. Histopathological identification of AA was interpreted as the gold standard. Statistical analysis was performed using IBM SPSS Statistics V26.

RESULTS

A total of 1194 patients were included, with 26% negative appendicectomy rate in women. Of the 8 parameters in the AS, logistic regression identified migratory pain, leukocytosis and leukocyte left shift as most significant predictors for AA. These three parameters were used in a 3-point test which carried a sensitivity of 92.1% and specificity of 28.7%. In women, a negative or non-diagnostic US improved the negative predictive value of the 3-point test from 57% to 82%.

CONCLUSION

The 3-point abbreviated AS in combination with US may be clinically useful in women to exclude appendicitis without diagnostic laparoscopy. Further large-scale prospective studies are required to validate the utility across different subgroups.

Combination of Common Problem in a Rare Disease: Right Iliac Fossa Pain in a Chronic Myeloid Leukemia Patient

Abdominal symptoms in patients with hematological malignancies can occur due to an array of pathologies. Two diagnoses with similar presentation albeit, generally opposite treatment modalities, are typhlitis (inflammation of cecum) and acute appendicitis. Both diagnoses have to be kept in mind in such a patient presenting with right lower quadrant (RLQ) pain. Sagacious clinical judgment along with the aid of radiological imaging may help in differentiating between the two conditions. We present a case of a young male with chronic myeloid leukemia (CML) on imatinib, diagnosed and started on therapy four years earlier, who presented with symptoms of RLQ pain not typical of acute appendicitis. The accurate diagnosis was made with the assistance of ultrasound (US) imaging and prompt surgical therapy was instituted followed by a smooth postoperative recovery.

Fast acquisition abdominal MRI study for the investigation of suspected acute appendicitis in paediatric patients

Objectives

To assess the diagnostic accuracy of fast acquisition MRI in suspected cases of paediatric appendicitis presenting to a tertiary referral hospital.

Materials and methods

A prospective study was undertaken between May and October 2017 of 52 children who presented with suspected appendicitis and were referred for an abdominal ultrasound. All patients included in this study received both an abdominal ultrasound and five-sequence MRI consisting of axial and coronal gradient echo T2 scans, fat-saturated SSFSE and a diffusion-weighted scan. Participants were randomised into groups of MRI with breath-holds or MRI with free breathing. A patient satisfaction survey was also carried out. Histopathology findings, where available, were used as a gold standard for the purposes of data analysis. Statistical analysis was performed, and p values < 0.05 were considered statistically significant.

Results

Ultrasound had a sensitivity and specificity of 25% and 92.9%, respectively. MRI with breath-hold had a sensitivity and specificity of 81.8% and 66.7%, respectively, whilst MRI with free breathing was superior with sensitivity and specificity of 92.3% and 84.2%, respectively. MRI with free breathing was also more time efficient (p < 0.0001). Group statistics were comparable (p < 0.05).

Conclusions

The use of fast acquisition MRI protocols, particularly free breathing sequences, for patients admitted with suspected appendicitis can result in faster diagnosis, treatment and discharge. It also has a statistically significant diagnostic advantage over ultrasound. Additionally, the higher specificity of MR can reduce the number of negative appendectomies performed in tertiary centres.

Convolutional-neural-network-based diagnosis of appendicitis via CT scans in patients with acute abdominal pain presenting in the emergency department

Acute appendicitis is one of the most common causes of abdominal emergencies. We investigated the feasibility of a neural-network-based diagnosis algorithm of appendicitis by using computed tomography (CT) for patients with acute abdominal pain visiting the emergency room (ER). A neural-network-based diagnostic algorithm of appendicitis was developed and validated using CT data from three institutions who visited the ER with abdominal pain and underwent abdominopelvic CT. For input data, 3D isotropic cubes including the appendix were manually extracted and labeled as appendicitis or a normal appendix. A 3D convolutional neural network (CNN) was trained to binary classification on the input. For model development and testing, 8-fold cross validation was conducted for internal validation and an ensemble model was used for external validation. Diagnostic performance was excellent in both the internal and external validation with an accuracy larger than 90%. The CNN-based diagnosis algorithm may be feasible in diagnosing acute appendicitis using the CT data of patients visiting the ER with acute abdominal pain.

Nongynecologic Causes of Pelvic Pain: Ultrasound First

Ultrasonography (US) is often the first-line imaging study used to evaluate women who present with acute or chronic pelvic pain. Detection of nongynecologic causes of pelvic pain is critical, because delay in diagnosis can cause significant morbidity and mortality. Evaluation of these entities requires a variety of transducers to achieve optimal imaging depth and changes in patient positioning. Specific imaging techniques (such as graded compression) may be required if bowel pathology is suspected. Contrast-enhanced ultrasonography is increasingly used to improve detection of certain entities. The US appearance of common gastrointestinal and urinary tract-related causes of pelvic pain is reviewed.

Value of ultrasonography and the Raja Isteri Pengiran Anak Saleha Appendicitis score in the diagnosis of acute appendicitis

BACKGROUND

The diagnosis of acute appendicitis is a clinical challenge. Clinical scoring systems and radiological examinations are used to assist in diagnosis.

METHODS

We reviewed 106 patients between January 2016 and January 2018 who presented with right iliac fossa pain and underwent appendectomy. Their Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) scores were calculated and abdominopelvic ultrasonography (USG) was performed before they were operated with a prediagnosis of acute appendicitis. RIPASA scores and USG findings were compared to the histopathological results of appendectomy specimens.

RESULTS

The histopathological examinations showed that all of the 100 (94.3%) patients whose RIPASA scores were 7 and more had acute appendicitis and the six (5.7%) patients whose scores were less than 7 had no appendicitis. When the appendectomy specimens of the 70 patients who had been diagnosed with acute appendicitis with USG were examined histopathologically, 69 (98.6%) patients were confirmed to have acute appendicitis. Acute appendicitis was found in 18 (81.8%) of the 22 patients whose appendixes could not be visualized with USG. Acute appendicitis was found in eight (88.9%) of the nine patients who had been reported normal with USG.

CONCLUSION

RIPASA scores should be calculated for all patients who are suspected of having acute appendicitis and for those with a RIPASA score of 7 and more, surgery should be highly recommended without USG.

Accuracy of ultrasound exam performed by emergency medicine versus radiology residents in the diagnosis of acute appendicitis

BACKGROUND

Although the traditional approach to the diagnosis of acute appendicitis (AA) is using clinical methods, experience has shown that strict reliance on clinical data can lead to mismanagement or unnecessary surgery.

OBJECTIVE

The objective of this study was to determine the total agreement of ultrasound (US) results in AA performed by emergency medicine (EM) versus radiology residents in emergency department.

PATIENTS AND METHODS

In this cross-sectional study, 121 patients with AA suspicion underwent an US exam by both trained EM and radiology residents in emergency department. The training course for EM residents consisted of attending an 8-h-workshop and then practicing an US exam on real patients within a 2-month period. The gold standards were either histopathologic or follow-up results. Total agreement of the results in both specialties was compared.

RESULTS

There were 67 men and 54 women, with a mean age of 33.6 ± 16.1 years (18.2-88.7 years). Fifty-four (44.6%) patients underwent surgery with the initial diagnosis of AA and the rest were evaluated by follow-ups. On the basis of our gold standards, the diagnosis was finally confirmed in 46 (38%) cases. There was a high total agreement in AA diagnosis [96% agreement, κ = 0.90; 95% confidence interval (CI) = 0.81-0.99] between the two groups. The specificity and sensitivity of EM and radiology groups were 99% (95% CI = 93-100), 63% (95% CI = 48-77), 97% (95% CI = 91-100), and 72% (95% CI = 57-84), respectively.

CONCLUSION

US has a high diagnostic specificity in patients suspected of having AA and EM residents can perform this modality as accurately as radiologists after training in the emergency setting.

[Sudden chest pain and lower abdominal pain : The usual suspects]

CLINICAL PROBLEM

Sudden chest pain and sudden abdominal pain are among the most common reasons that lead patients to the emergency room. The heterogeneous field of possible, sometimes serious diagnoses requires a structured and rapid interdisciplinary clarification in order to be able to promptly provide patients with an adequate therapy.

STANDARD RADIOLOGICAL PROCEDURES

Knowing the "usual suspects" of sudden chest and abdominal pain enables the radiologist to quickly select the appropriate imaging method that allows a diagnosis to be made without delay. In addition to pain localization and character, age, gender, any previous illnesses and laboratory results are taken into account in the differential diagnosis.

METHODICAL INNOVATION AND EVALUATION

The technical state of computer tomography (CT) now ensures that most diagnoses can be clarified due to its excellent spatial and temporal resolution. In the abdomen, however, ultrasound should continue to be used at least for primary evaluation. Only if there is a further need for abdominal imaging afterwards is CT indicated for clarification. Magnetic resonance imaging is rarely used in the emergency setting of abdominal pain except to avoid radiation exposure in children or pregnant women.

RECOMMENDATION FOR THE PRACTICE

Knowledge of the usual diagnoses that cause sudden chest or abdominal pain, as well as knowledge of the appropriate examination procedures and classic radiological signs are essential to avoid errors and delays in the emergency diagnosis of sudden chest and abdominal pain.

Diagnostic Accuracy of Abdominal Ultrasonography in Pediatric Acute Appendicitis

OBJECTIVE

To evaluate the diagnostic accuracy of ultrasonography in pediatric acute appendicitis.

METHODS

In this cross-sectional study, 230 children aged 5-15 years with the diagnosis of acute appendicitis were studied. This study included the evaluation of demographic indices, ultrasound findings at diagnosis, and then comparing the results with the description of the patient's procedure and the pathology report of these patients. Patients who did not undergo ultrasound before surgery or their ultrasound did not include the evaluation of appendicitis or their pathologic report was not available were excluded.

RESULTS

Overall, we have included a total number of 230 children with clinical diagnosis of acute appendicitis among whom there were 121 (52.6%) girls and 109 (47.4%) boys with mean age of 11.44 ± 2.90 years. Preoperative ultrasound report showed that 51.3% were normal and 48.7% had acute appendicitis. 34.8% had normal appendix and 65.2% had a pathological diagnosis of acute appendicitis. The sensitivity and specificity of ultrasound in these children were 58% and 68%, respectively. Positive and negative predictive values ​​were 77% and 46%, respectively. The area under curve (AUC) was 0.853 (CI 95% 0.788-0.917) indicating a test with moderate accuracy.

CONCLUSION

According to the obtained results, abdominal ultrasonography is of acceptable diagnostic accuracy in pediatric patients with acute appendicitis. The use of auxiliary techniques in ultrasound would increase the sensitivity and specificity in the diagnosis of acute appendicitis in children.

Diagnostic performance of abdominal point of care ultrasound performed by an emergency physician in acute right iliac fossa pain

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.

[Point-of-care ultrasonography of the abdomen in emergency and intensive care medicine]

Point-of-care ultrasound is a fundamental part of diagnostic and therapeutic management in emergency and intensive care medicine. The availability of high-resolution mobile ultrasound systems allows high-quality imaging at the bedside of the patient. Point-of-care ultrasound is not a comprehensive differential diagnostic abdominal ultrasound examination. Rather, the aim of the method is to integrate easily detectable sonographic findings into the clinical context. From this, the necessary diagnostic or therapeutic procedures are derived. This article shows opportunities and limitations of this method. The structure of the article is given by the leading clinical symptoms. The focus is on the ultrasound examination and the characteristic sonographic findings with illustrative ultrasound images. This is followed by a short differential diagnostic interpretation. Further diagnostic or therapeutic management is also briefly addressed.

Investigating Diagnostic Value of Ultrasonography in Acute Appendicitis

Background:

Acute appendicitis is one of the most commonly diagnosed surgical diseases that its accurate diagnosis is still a problem, and there is no certainty. Ultrasound is recommended for diagnosis of appendicitis as an easy and noninvasive method. Therefore, due to the spread of disease and the urgent need to accurately diagnose in all educational centers, we decided to determine the diagnostic value of this inclusive method in identifying acute appendicitis.

Materials and Methods:

This is a descriptive cross-sectional research that was conducted on 540 patients referring to Educational Center of Ayatollah Kashani Hospital. All individuals suspected to appendicitis, and undergone ultrasound was included in the study, and then the result of ultrasound was compared to the obvious pathological results. Data were entered into statistical software of SPSS 20 and were analyzed.

Results:

According to the ultrasound findings, appendicitis was diagnosed as negative in 351 ones and positive in 189 ones. Ultrasound sensitivity in the diagnosis of appendicitis was 37.1%, while its specificity was 87.2%. The positive predictive value was 96.8% and the negative predictive value was only 11.7%.

Conclusion:

Considering very low-negative predictive value in educational centers, it is suggested that ultrasound is done for diagnosis of appendicitis only in complicated cases of appendicitis and differential diagnose (kidney stones, and ovarian cysts). In addition, it is recommended that routine ultrasound be avoided for all patients.

Ultrasound for the Diagnosis of Acute Calculous Cholecystitis, and the Impact of Analgesics: A Retrospective Cohort Study

Collapse

The learning curve in diagnosing acute appendicitis with emergency sonography among novice emergency medicine residents

PURPOSE

Ultrasonography (US) has good accuracy for diagnosing appendicitis when it is performed by emergency physicians. This study aimed to determine the amount of experience that is required to achieve competency in this field.

METHODS

Three novice emergency medicine residents completed a 1-day training course regarding the US diagnosis of appendicitis. Then, they performed appendix US in the emergency department on patients complaining of right lower quadrant pain. All included patients also underwent computed tomography or US performed by a board-certified radiologist, to confirm the emergency US diagnosis. The agreement between the diagnoses of novices and experts was evaluated.

RESULTS

A total of 266 patients were included, and the overall Cohen's kappa coefficient was 0.77 (95% confidence interval [CI]: 0.69-0.84). The kappa value of first 20 cases was 0.49 (95% CI: 0.27-0.71). It increased rapidly during evaluation of the first 20 cases. After the first 20 cases, the kappa coefficient was 0.84 (95% CI: 0.77-0.92). The sensitivity and specificity values for the first 20 cases were 64.3% (95% CI: 77.6%-90.7%) and 84.4% (95% CI: 85.4%-95.4%), respectively. After the first 20 cases, the sensitivity and specificity values increased to 90.9% (95% CI: 83.4%-95.8%) and 93.5% (95% CI: 87.0%-97.3%), respectively.

CONCLUSIONS

A minimum of 20 cases are needed to achieve competency in emergency US diagnosis of acute appendicitis.

The Diagnostic Accuracy of Sonography, With Graded Compression to Image Acute Appendicitis Compared to Histopathologic Results

Acute appendicitis is the most common surgical abdominal emergency. Its clinical diagnosis remains a challenge to surgeons, so different imaging options were introduced to improve diagnostic accuracy. Among these imaging modality choices, diagnostic medical sonography (DMS) is a simple, easily available, and cost effective clinical tool. The purpose of this study was to assess the accuracy of DMS, in the diagnosis of acute appendicitis compared to the histopathology report, as a gold standard. Between May 2015 and May 2016, 215 patients with suspected appendicitis were examined with DMS. The DMS findings were recorded as positive and negative for acute appendicitis and compared with the histopathological results, as a gold standard. In all, 173 patients were correctly diagnosed as having acute appendicitis by DMS out of 200 cases, with a final histopathologic result. Similarly, DMS revealed 13 normal appendices out of 15 nonappendicitis patients. This demonstrated that DMS has a sensitivity of 86.5%, specificity of 86.6%, positive predictive value of 99.8%, negative predictive value of 32.5%, and overall accuracy of 86.5%. These results suggest that DMS may be an accurate, sensitive, and specific tool for diagnosing acute appendicitis and reducing unnecessary appendectomies. DMS should be considered as a credible imaging modality for diagnosing acute appendicitis.

Preoperative factors associated with technical difficulties of laparoscopic cholecystectomy in acute cholecystitis

OBJECTIVE

To identify preoperative factors associated with surgical time and conversion of the laparoscopic cholecystectomy (LC) to open surgery in subjects with acute cholecystitis (AC).

METHOD

We developed a cross-sectional study that included 99 subjects older than 17 years with definitive diagnosis of AC who had undergone to LC. Preoperative variables such as clinical data, laboratory markers and ultrasound findings as wall thickness, the size of the major calculus and the presence of: perivesicular fluid, multiple cholelithiasis, biliary mud or microlithiasis were registered. We consider indirect measures of technical difficulties of LC the total surgical time and the need for conversion to open surgery. We used the square chi and Mann-Whitney U test to stablish the correlation between preoperative variables and the technical difficulties of LC. We build ROC curves of the variables with significant statistical association (p ≤0.05 and 95% confidence interval [95%CI]) to determine the cut-off points of better sensitivity and specificity to predict conversion of LC to open surgery.

RESULTS

A gallbladder wall thickness ≥6mm detected by ultrasound has a sensitivity of 87.5% and a specificity of 62.6% with OR 11.71 (95%CI: 1.38-99; p = 0.008) for predict conversion to open surgery. There was no relationship between surgical time and the preoperative evaluated variables.

CONCLUSION

The gallbladder wall thickness detected by the ultrasound is associated with the need of conversion of LC to open surgery in subjects with AC, furthermore this finding could warn the surgeon on the complexity with a particular patient.

A highly sensitive and specific combined clinical and sonographic score to diagnose appendicitis

BACKGROUND

Computed tomography (CT) scanning reduces the negative appendectomy rate however it exposes the patient to ionizing radiation. Ultrasound (US) does not carry this risk but may be nondiagnostic. We hypothesized that a clinical-US scoring system would improve diagnostic accuracy.

METHODS

We conducted a retrospective review of all patients (age, >15 years) who presented through the emergency department with suspected appendicitis and underwent initial US. A US score was developed using odds ratios for appendicitis given appendiceal diameter, compressibility, hyperemia, free fluid, and focal or diffuse tenderness. The US score was then combined with the Alvarado score. Final diagnosis of appendicitis was assigned by pathology reports.

RESULTS

Three hundred patients who underwent US as initial imaging were identified. Thirty-two patients with evident nonappendiceal pathology on US were excluded. In 114 (38%), the appendix was not visualized and partially visualized in 36 (12%). Fifty-seven (21.3%) had an appendectomy with 1 (1.7%) negative. Six nonvisualized appendicies underwent appendectomy, with no negative cases. Sensitivity and specificity for the sonographic score were 86% and 90%, respectively, at a score of 1.5. The combined score demonstrated 98% sensitivity and 82% specificity at 6.5, and 95% sensitivity, and 87% specificity at a score of 7.5. Sensitivity and specificity were confirmed by bootstrap resampling for validation. Area under receiver operating characteristic (ROC) curves for our new US score were similar to the ROC curve for the Alvarado score (91.9 and 91.1, p = 0.8). The combined US and Alvarado score yielded an area under the ROC curve of 97.1, significantly better than either score alone (p = 0.017 and p < 0.001, respectively).

CONCLUSION

Our scoring system based entirely on US findings was highly sensitive and specific for appendicitis, and it significantly improved when combined with the Alvarado score. After prospective evaluation, the combined US-Alvarado score might replace the need for computed tomography imaging in a majority of patients.

LEVEL OF EVIDENCE

Diagnostic Test, Level III.

Can common serum biomarkers predict complicated appendicitis in children?

PURPOSE

As appendicitis in children can be managed differently according to the severity of the disease, we investigated whether commonly used serum biomarkers on admission could distinguish between simple and complicated appendicitis.

METHODS

Admission white blood cell (WBC), neutrophil (NEU), and C-reactive protein (CRP) levels were analysed by ROC curve, and Kruskal-Wallis and contingency tests. Patients were divided according to age and histology [normal appendix (NA), simple appendicitis (SA), complicated appendicitis (CA)].

RESULTS

Of 1197 children (NA = 186, SA = 685, CA = 326), 7% were <5 years, 55% 5-12, 38% 13-17. CA patients had higher CRP and WBC levels than NA and SA (p < 0.0001). NEU levels were lower in NA compared to SA or CA (p < 0.0001), but were similar between SA and CA (p = 0.6). CA patients had higher CRP and WBC levels than SA patients in 5-12- (p < 0.0001) and 13-17-year groups (p = 0.0075, p = 0.005), but not in <5-year group (p = 0.72, p = 0.81). We found CRP >40 mg/L in 58% CA and 37% SA (p < 0.0001), and WBC >15 × 10⁹/L in 58% CA and 43% SA (p < 0.0001).

CONCLUSIONS

Admission CRP and WBC levels may help the clinician predict complicated appendicitis in children older than 5 years of age. Early distinction of appendicitis severity using these tests may guide caregivers in the preoperative decision-making process.

Diagnostic Value and Effect of Bedside Ultrasound in Acute Appendicitis in the Emergency Department

OBJECTIVE

Early and accurate diagnosis of acute appendicitis (AA) with ultrasound (US) can minimize the morbidity and mortality of the patients. In this regard, US can help emergency physicians (EPs) in the diagnosing process and clinical decision making for AA. Therefore, we primarily aimed to evaluate the effectiveness of point-of-care US (POCUS) in clinical decision making of EPs for the diagnostic evaluation for AA in the emergency department (ED).

METHODS

The study sample consisted of patients aged > 18 years who presented to the ED with abdominal pain and underwent diagnostic evaluation for AA. All patients were examined initially with POCUS by EPs and then with radiology-performed US (RADUS) by radiologists. Pre- and post-POCUS median diagnostic certainty values (MDCVs) for AA were determined with visual analog scale (VAS) scores (0 = not present, 100 = certainly present) by POCUS performers. Definitive diagnoses were determined by surgery, pathologic evaluation of appendectomy specimens, or clinical follow-up results. The sensitivity, specificity, positive likelihood ratio (PLR), and negative likelihood ratio (NLR) for POCUS and RADUS together with pre- and post-POCUS VAS scores for MDCVs were compared.

RESULTS

A total of 264 patients were included into the final analysis and 169 (64%) had a diagnosis of AA. The sensitivity, specificity, PLR, and NLR of US examinations were 92.3% (95% confidence interval [CI] = 87.2%-95.8%), 95.8% (89.5%-98.8%), 21.9 (8.4-57.2), and 0.08 (0.05-0.1) for POCUS and 76.9% (69.8-83%), 97.8% (84.9-99.7%), 36.4 (9.25-144.3), and 0.24 (0.18-0.31) for RADUS, respectively. Pre-POCUS and post-POCUS VAS scores for MDCVs were 60 (interquartile range [IQR] = 50-65) and 95 (IQR = 20-98), respectively (p = 0.000).

CONCLUSION

Point-of-care ultrasonography, when performed in ED for the diagnosis of AA, has high sensitivity and specificity and had a positive impact on the clinical decision making of EPs.

Comparison of Antibiotic Therapy and Appendectomy for Acute Uncomplicated Appendicitis in Children: A Meta-analysis

IMPORTANCE

Antibiotic therapy for acute uncomplicated appendicitis is effective in adult patients, but its application in pediatric patients remains controversial.

OBJECTIVE

To compare the safety and efficacy of antibiotic treatment vs appendectomy as the primary therapy for acute uncomplicated appendicitis in pediatric patients.

DATA SOURCES

The PubMed, MEDLINE, EMBASE, and Cochrane Library databases and the Cochrane Controlled Trials Register for randomized clinical trials were searched through April 17, 2016. The search was limited to studies published in English. Search terms included appendicitis, antibiotics, appendectomy, randomized controlled trial, controlled clinical trial, randomized, placebo, drug therapy, randomly, and trial.

STUDY SELECTION

Randomized clinical trials and prospective clinical controlled trials comparing antibiotic therapy with appendectomy for acute uncomplicated appendicitis in pediatric patients (aged 5-18 years) were included in the meta-analysis. The outcomes included at least 2 of the following terms: success rate of antibiotic treatment and appendectomy, complications, readmissions, length of stay, total cost, and disability days.

DATA EXTRACTION AND SYNTHESIS

Data were independently extracted by 2 reviewers. The quality of the included studies was examined in accordance with the Cochrane guidelines and the Newcastle-Ottawa criteria. Data were pooled using a logistic fixed-effects model, and the subgroup pooled risk ratio with or without appendicolith was estimated.

MAIN OUTCOMES AND MEASURES

The primary outcome was the success rate of treatment. The hypothesis was formulated before data collection.

RESULTS

A total of 527 articles were screened. In 5 unique studies, 404 unique patients with uncomplicated appendicitis (aged 5-15 years) were enrolled. Nonoperative treatment was successful in 152 of 168 patients (90.5%), with a Mantel-Haenszel fixed-effects risk ratio of 8.92 (95% CI, 2.67-29.79; heterogeneity, P = .99; I2 = 0%). Subgroup analysis showed that the risk for treatment failure in patients with appendicolith increased, with a Mantel-Haenszel fixed-effects risk ratio of 10.43 (95% CI, 1.46-74.26; heterogeneity, P = .91; I2 = 0%).

CONCLUSIONS AND RELEVANCE

This meta-analysis shows that antibiotics as the initial treatment for pediatric patients with uncomplicated appendicitis may be feasible and effective without increasing the risk for complications. However, the failure rate, mainly caused by the presence of appendicolith, is higher than for appendectomy. Surgery is preferably suggested for uncomplicated appendicitis with appendicolith.

Performance of imaging studies in patients with suspected appendicitis after stratification with adult appendicitis score

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.

The Accuracy of Emergency Physicians in Ultrasonographic Screening of Acute Appendicitis; a Cross Sectional Study

INTRODUCTION

Diagnostic values reported for ultrasonographic screening of acute appendicitis vary widely and are dependent on the operator's skill, patient's gender, weight, etc. The present study aimed to evaluate the effect of operator skill on the diagnostic accuracy of ultrasonography in detection of appendicitis by comparing the results of ultrasonography done by radiologists and emergency physicians.

METHODS

This prospective diagnostic accuracy was carried out on patients suspected to acute appendicitis presenting to EDs of 2 hospitals. After the initial clinical examinations, all the patients underwent ultrasonography for appendicitis by emergency physician and radiologist, respectively. The final diagnosis of appendicitis was based on either pathology report or 48-hour follow-up. Screening performance characteristics of appendix ultrasonography by emergency physician and radiologist were compared using STATA 11.0 software.

RESULTS

108 patients with the mean age of 23.91 ± 7.46 years were studied (61.1% male). Appendicitis was confirmed for 37 (34.26%) cases. Cohen's kappa coefficient between ultrasonography by the radiologist and emergency physician in diagnosis of acute appendicitis was 0.51 (95% CI: 0.35 - 0.76). Area under the ROC curve of ultrasonography in appendicitis diagnosis was 0.78 (95% CI: 0.69 - 0.86) for emergency physician and 0.88 (95% CI: 0.81 - 0.94) for radiologist (p = 0.052). Sensitivity and specificity of ultrasonography by radiologist and emergency physician in appendicitis diagnosis were 83.87% (95% CI: 67.32 - 93.23), 91.5% (95% CI: 81.89 - 96.52), 72.97% (95% CI: 55.61 - 85.63), and 83.10% (95% CI: 71.94 - 90.59), respectively.

CONCLUSION

Findings of the present study showed that the diagnostic accuracy of ultrasonography carried out by radiologist (89%) is a little better compared to that of emergency physician (80%) in diagnosis of appendicitis, but none are excellent.

Imaging trends in suspected appendicitis-a Canadian perspective

PURPOSE

The purpose of our study was to assess trends in the imaging of suspected appendicitis in adult patients in emergency departments of academic centers in Canada.

METHODS

A questionnaire was sent to all 17 academic centers in Canada to be completed by a radiologist who works in emergency radiology. The questionnaires were sent and collected over a period of 4 months from October 2015 to February 2016.

RESULTS

Sixteen centers (94%) responded to the questionnaire. Eleven respondents (73%) use IV contrast-enhanced computed tomography (CT) as the imaging modality of choice for all patients with suspected appendicitis. Thirteen respondents (81%) use ultrasound as the first modality of choice in imaging pregnant patients with suspected appendicitis. Eleven respondents (69%) use ultrasound (US) as the first modality of choice in patients younger than 40 years of age. Ten respondents (67%) use ultrasound as the first imaging modality in female patients younger than 40 years of age. When CT is used, 81% use non-focused CT of the abdomen and pelvis, and 44% of centers use oral contrast. Thirteen centers (81%) have ultrasound available 24 h a day/7 days a week. At 12 centers (75%), ultrasound is performed by ultrasound technologists. Four centers (40%) perform magnetic resonance imaging (MRI) in suspected appendicitis in adult patients at the discretion of the attending radiologist. Eleven centers (69%) have MRI available 24/7. All 16 centers (100%) use unenhanced MRI.

CONCLUSIONS

Various imaging modalities are available for the work-up of suspected appendicitis. Although there are North American societal guidelines and recommendations regarding the appropriateness of the multiple imaging modalities, significant heterogeneity in the first-line modalities exist, which vary depending on the patient demographics and resource availability. Imaging trends in the use of the first-line modalities should be considered in order to plan for the availability of the imaging examinations and to consider plans for an imaging algorithm to permit standardization across multiple centers. While this study examined the imaging trends specifically in Canada, there are implications to other countries seeking to streamline imaging protocols and determining appropriateness of the first-line imaging modalities.

How to improve the clinical diagnosis of acute appendicitis in resource limited settings

This article is a general review of the diagnostic tools that the clinician can use for the early diagnosis of acute appendicitis with emphasis on the Alvarado Score, and it is aimed principally to the medical practitioners in different parts of the world where the diagnostic facilities and technological resources are limited.

Risk of Gastrointestinal Cancers among Patients with Appendectomy: A Large-Scale Swedish Register-Based Cohort Study during 1970-2009

BACKGROUND

Removal of the appendix might induce physiological changes in the gastrointestinal tract, and subsequently play a role in carcinogenesis. Therefore, we conducted a nationwide register-based cohort study in Sweden to investigate whether appendectomy is associated with altered risks of gastrointestinal cancers.

METHODS

A population-based cohort study was conducted using the Swedish national registries, including 480,382 eligible patients followed during the period of 1970-2009 for the occurrence of site-specific gastrointestinal cancer (esophageal/gastric/colon/rectal cancer). Outcome and censoring information was collected by linkage to health and demography registers. We examined the incidence of appendectomy in Sweden using data from 1987-2009. We also calculated standardized incidence ratios (SIRs) with 95% confidence intervals (CIs) to estimate the relative gastrointestinal cancer risk through comparison to the general population.

RESULTS

We noted an overall decrease in the age-standardized incidence of appendectomy among the entire Swedish population from 189.3 to 105.6 per 100,000 individuals between 1987 and 2009. Grouped by different discharge diagnosis, acute appendicitis, incidental appendectomy, and entirely negative appendectomy continuously decreased over the study period, while the perforation ratio (18%-23%) stayed relatively constant. Compared to the general population, no excess cancer risk was observed for gastrointestinal cancers under study with the exception of a marginally elevated risk for esophageal adenocarcinoma (SIR 1.32, 95% CI 1.09-1.58).

CONCLUSIONS

In Sweden, the incidence of appendectomy and acute appendicitis has decreased during 1987-2009. No excess gastrointestinal cancer risks were observed among these appendectomized patients, with the possible exception of esophageal adenocarcinoma.

Mean Platelet Volume is Reduced in Acute Appendicitis

Objectives

Acute appendicitis (AA) is the most common indication for emergency abdominal surgery, although it remains difficult to diagnose. In this study, we investigated the the clinical utility of mean platelet volume in the diagnosis of acute appendicitis.

Methods

The medical records of 241 patients who had undergone appendectomy between June 2013 and March 2014 were investigated retrospectively. Sixty patients who had undergone at least one complete blood count during preoperative hospital admission and who had no other active inflammatory conditions at the time the sample was taken were included in the study. Mean platelet volume and leukocyte count values were determined in each patient at hospital admission and during active acute appendicitis. Age, sex, mean platelet volume and leukocyte counts were recorded for each patient.

Results

The mean age of patients was 33.15±10.94 years and the male to female ratio was 1.5:1. The mean leukocyte count prior to acute appendicitis was 7.42±2.12×10³/mm³. Mean leukocyte count was significantly higher (13.14±2.99×10³/mm³) in acute appendicitis. The optimal leukocyte count cutoff point for the diagnosis of acute appendicitis was 10.10×10³/mm³, with sensitivity of 94% and a specificity of 75%. The mean platelet volume prior to acute appendicitis was 7.58±1.11 fL. Mean platelet volume was significantly lower (7.03±0.8 fL) in acute appendicitis. The optimal mean platelet volume cutoff point for the diagnosis of AA was 6.10 fL, with a sensitivity of 83% and a specificity of 42%. Area under the curve for leukocyte count diagnosis was 0.67 and 0.69 for the diagnosis of AA by mean platelet volume.

Conclusions

Mean platelet volume was significantly decreased in acute appendicitis. Mean platelet volume can be used as a supportive diagnostic parameter in the diagnosis of acute appendicitis.

How to diagnose acute appendicitis: ultrasound first

Acute appendicitis (AA) is a common abdominal emergency with a lifetime prevalence of about 7 %. As the clinical diagnosis of AA remains a challenge to emergency physicians and surgeons, imaging modalities have gained major importance in the diagnostic work-up of patients with suspected AA in order to keep both the negative appendectomy rate and the perforation rate low. Introduced in 1986, graded-compression ultrasound (US) has well-established direct and indirect signs for diagnosing AA. In our opinion, US should be the first-line imaging modality, as graded-compression US has excellent specificity both in the paediatric and adult patient populations. As US sensitivity is limited, and non-diagnostic US examinations with non-visualization of the appendix are more a rule than an exception, diagnostic strategies and algorithms after non-diagnostic US should focus on clinical reassessment and complementary imaging with MRI/CT if indicated. Accordingly, both ionizing radiation to our patients and cost of pre-therapeutic diagnosis of AA will be low, with low negative appendectomy and perforation rates.

Main Messages

• Ultrasound (US) should be the first imaging modality for diagnosing acute appendicitis (AA).

• Primary US for AA diagnosis will decrease ionizing radiation and cost.

• Sensitivity of US to diagnose AA is lower than of CT/MRI.

• Non-visualization of the appendix should lead to clinical reassessment.

• Complementary MRI or CT may be performed if diagnosis remains unclear.

The utility of acoustic radiation force impulse imaging in diagnosing acute appendicitis and staging its severity

PURPOSE

The aim of this study was to investigate the feasibility of using acoustic radiation force impulse (ARFI) imaging to diagnose acute appendicitis.

METHODS

Abdominal ultrasonography (US) and ARFI imaging were performed in 53 patients that presented with right lower quadrant pain, and the results were compared with those obtained in 52 healthy subjects. Qualitative evaluation of the patients was conducted by Virtual Touch™ tissue imaging (VTI), while quantitative evaluation was performed by Virtual Touch™ tissue quantification (VTQ) measuring the shear wave velocity (SWV). The severity of appendix inflammation was observed and rated using ARFI imaging in patients diagnosed with acute appendicitis. Alvarado scores were determined for all patients presenting with right lower quadrant pain. All patients diagnosed with appendicitis received appendectomies. The sensitivity and specificity of ARFI imaging relative to US was determined upon confirming the diagnosis of acute appendicitis via histopathological analysis.

RESULTS

The Alvarado score had a sensitivity and specificity of 70.8% and 20%, respectively, in detecting acute appendicitis. Abdominal US had 83.3% sensitivity and 80% specificity, while ARFI imaging had 100% sensitivity and 98% specificity, in diagnosing acute appendicitis. The median SWV value was 1.11 m/s (range, 0.6-1.56 m/s) for healthy appendix and 3.07 m/s (range, 1.37-4.78 m/s) for acute appendicitis.

CONCLUSION

ARFI imaging may be useful in guiding the clinical management of acute appendicitis, by helping its diagnosis and determining the severity of appendix inflammation.

C-reactive protein has a better discriminative power than white cell count in the diagnosis of acute cholecystitis

BACKGROUND

The diagnosis of acute cholecystitis (AC) is challenging and may result in a delay in surgery, hospital discharge, and increased mortality. To improve its diagnosis, C-reactive protein (CRP) has been proposed as a benchmark. The aim of this study was to evaluate discriminative power of CRP against white cell count (WCC) in AC.

METHODS

This was a retrospective cohort study. Over a 5-y period, 1959 patients were identified from the audit of cholecystectomies. The exclusion criteria were coexisting acute surgical conditions, absence of blood tests within 3 d before hospital admission for elective surgery, and private patients.

RESULTS

The eligibility criteria were met by 1843 patients. Comparison of the area under receiver operating characteristic (AUC) curve of CRP and WCC in acute on chronic, edematous, necrotic, suppurative, and gangrenous AC showed a better discriminative power of CRP. Both tests performed equally well in patients with pericholecystic abscess and gallbladder perforation. CRP was superior than WCC in mild AC, AUC = 0.93 (95% confidence interval [CI], 0.9-0.95) and 0.79 (95% CI, 0.74-0.84), P < 0.00005, in moderate and severe AC, AUC = 0.99 (95% CI, 0.97-1.0) and 0.92 (95% CI, 0.88-0.97), P = 0.009, and in all forms of AC combined, AUC = 0.94; (95% CI, 0.92-0.97) and 0.83 (95% CI, 0.79-0.87), respectively, P < 0.00005.

CONCLUSIONS

CRP has a better discriminative power than WCC in most forms of AC and is a useful diagnostic marker of AC.

Diagnostic accuracy of emergency physician performed graded compression ultrasound study in acute appendicitis: a prospective study

PURPOSE

Accurate early diagnosis of appendicitis can decrease its complications and minimize the mortality, morbidity and costs. This prospective study evaluates the accuracy of bedside emergency physician performed ultrasound study diagnosis in acute appendicitis.

METHODS

Patients who were suspicious to have appendicitis based on their clinical findings were included and underwent emergency physician performed ultrasound study. Then they were followed up until the recognition of final diagnosis based on pathology report or identification of an alternative diagnosis. Ultrasound studies were done by post-graduate year three emergency medicine residents or emergency medicine attending physicians who were attended in a 4 h didactic and practical course and with 7.5 MHz linear probe both in longitudinal and axial axes.

RESULTS

Ninety-seven patients were included and analyzed. 27 (27.8 %) of patients had appendicitis according to the results of emergency physicians performed ultrasound studies. 19 (70.37 %) of them had appendicitis according to their pathologic reports too. Forty-three (44.3 %) of patients had appendicitis according to pathology reports. Only 19 (44.18 %) of them were diagnosed by emergency physicians. Emergency physician performed ultrasound study had a sensitivity of 44.18 %, specificity of 85.18 %, positive predictive value of 70.37 %, negative predictive value of 65.71 % and overall accuracy of 67.01 % in diagnosing appendicitis in patients clinically suspicious to have acute appendicitis.

CONCLUSION

Emergency physician performed bedside ultrasound has an acceptable overall accuracy but its sensitivity is low thus it can help emergency physicians to diagnose the acute appendicitis when used in conjunction with other clinical and para-clinical evaluations but not per se.

False-negative appendicitis at ultrasound: nature and association

The objective was to describe nature and factors associated with false-negative ultrasound (US) for adult appendicitis. Patients with pathologically proven appendicitis and pre-operative US from January 2011 to May 2013 were included in this retrospective case-control study. They were divided into true-positive and false-negative groups, matched by age and gender. There were 112 patients (40 men, mean age = 40 y, 56 true positives) included. Two factors were found differ significantly: abdominal wall thickness and pain score. Greater abdominal wall thickness (18.6 mm vs. 14.9 mm, p = 0.001) and lower pain score (6.6 vs. 7.5, p = 0.018) were statistically associated with false negativity. The two groups did not differ significantly in terms of weight, height, body mass index, symptom duration, Alvarado score, US examination time, appendix position/size, perforation rate and operator. In conclusion, lower pain score and increased abdominal wall thickness are associated with false negativity in US examinations.

Feasibility of a nonoperative management strategy for uncomplicated acute appendicitis in children

BACKGROUND

For decades, urgent operation has been considered the only appropriate management of acute appendicitis in children. The purpose of this study was to investigate the feasibility of nonoperative management of uncomplicated acute appendicitis in children.

STUDY DESIGN

A prospective nonrandomized clinical trial of children with uncomplicated acute appendicitis comparing nonoperative management with urgent appendectomy was performed. The primary result was 30-day success rate of nonoperative management. Secondary outcomes included comparisons of disability days, missed school days, hospital length of stay, and measures of quality of life and health care satisfaction.

RESULTS

Seventy-seven patients were enrolled during October 2012 to October 2013; 30 chose nonoperative management and 47 chose surgery. There were no significant differences in demographic or clinical characteristics. The immediate and 30-day success rates of nonoperative management were 93% (28 of 30) and 90% (27 of 30). There was no evidence of progression of appendicitis to rupture at the time of surgery in the 3 patients for whom nonoperative management failed. Compared with the surgery group, the nonoperative group had fewer disability days (3 vs 17 days; p < 0.0001), returned to school more quickly (3 vs 5 days; p = 0.008), and exhibited higher quality of life scores in both the child (93 vs 88; p = 0.01) and the parent (96 vs 90; p = 0.03), but incurred a longer length of stay (38 vs 20 hours; p < 0.0001).

CONCLUSIONS

Nonoperative management of uncomplicated acute appendicitis in children is feasible, with a high 30-day success rate and short-term benefits that include quicker recovery and improved quality of life scores. Additional follow-up will allow for determination of longer-term success rate, safety, and cost effectiveness.

Accuracy of Ultrasonography in Diagnosing Acute Appendicitis

OBJECTIVES

To evaluate the accuracy of sonography in diagnosing acute appendicitis in patients with Alvarado score 4-7.

METHODS

This is a retrospective cross-sectional study being performed in Namazee hospital affiliated with Shiraz University of Medical sciences during a one year period from 9/2007 to 9/2008. We evaluated all patients with Alvarado score 4-7 and divided them in two groups: those with Ultrasound study prior to surgery and those without any imaging modalities for diagnosis of AA. The demographic information, histopathology, physical examination, laboratory data, sonography report and histopathological reports of patients were gathered.

RESULTS

A total of 238 patients had Alvarado scores 4-7 including 160 males and 78 females. 110 patients did not have any imaging and 128 had undergone sonography before operation. Ultrasound had overall sensitivity of 75 %, specificity 69.2 %, PPV 88 %, NPV 46.1% and accuracy of 73.6 %. Negative appendectomy rate was 20.9 % and 23.4 % in those without sonography and inpatients with sonography respectively, with a higher rate in females.

CONCLUSION

Ultrasound is more useful when the patient is female and the result of sonography is positive; however, it is not reliable when the result is negative and maybe other diagnostic modalities such as CT scan can help us in better diagnosis of Acute Appendicitis.