Diagnosis of acute appendicitis in pregnant women: value of sonography

A comparison of the accuracy of Tzanakis and Alvarado Score in the diagnosis of acute appendicitis: A systematic review and meta-analysis

BACKGROUND AND OBJECTIVES

Acute appendicitis is one of the most commonly encountered surgical emergencies on a global level. Due to the requirement of an immediate clinical diagnosis and the presence of limited resources, clinicians and diagnosticians refer to scoring systems to diagnose this condition, among which Alvarado and Tzanakis scoring systems are widely used. This meta-analysis aims to compare the diagnostic accuracy of these two systems.

METHODS

We searched PubMed, Google Scholar, and SCOPUS databases. All studies that reported diagnostic parameters of Alvarado and Tzanakis scores in patients with suspected acute appendicitis were selected. Diagnostic values such as sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy were extracted from the selected studies and statistical analysis was performed with Meta Disc 1.4 software. Quality assessment of the selected studies was performed using the QUADAS-2 and QUADAS-C tools. Fourteen studies were included in our meta-analysis which enrolled 2235 patients.

RESULTS

The overall sensitivity of the Tzanakis score was calculated as 0.86 (95% CI; 0.84-00.87) while the specificity was 0.73 (95% CI; 0.69-0.78). In addition, the area under the curve (AUC) was 0.9261 (SE; 0.0169) and the diagnostic Odds Ratio (OR) was 22.52 (95% CI; 9.47-53.56). The pooled sensitivity of Alvarado score was 0.67 (95% CI; 0.65-0.69) and the specificity was 0.74 (95% CI; 0.69-0.79). Moreover, the area under the curve (AUC) of the Alvarado score was 0.7389 (SE; 0.0489) and the diagnostic Odds Ratio was 4.92 (95% CI; 2.48-9.75).

INTERPRETATION AND CONCLUSION

The Tzanakis scoring system has a higher sensitivity, area under the curve, and diagnostic odds ratio when compared to the Alvarado score. However, the Alvarado score has a marginally better specificity making it more reliable in excluding acute appendicitis.

Accuracy of Point-of-care Ultrasound in Diagnosing Acute Appendicitis During Pregnancy

Introduction: Acute appendicitis is the most common non-obstetrical surgical emergency in pregnancy. Ultrasound is the imaging tool of choice, but its use is complicated due to anatomical changes during pregnancy and depends on the clinician’s expertise. In this study, our aim was to investigate the diagnostic accuracy of point-of-care ultrasound (POCUS) in suspected appendicitis in pregnant women. Methods: We conducted a retrospective analysis of all pregnant women undergoing POCUS for suspected appendicitis between June 2010–June 2020 in a tertiary emergency department. The primary outcome was to establish sensitivity, specificity, and likelihood ratios of POCUS in diagnosing acute appendicitis, overall and for each trimester. We used histology of the appendix as the reference standard in case of surgery. If appendectomy was not performed, the clinical course until childbirth was used to rule out appendicitis. If the patients underwent magnetic resonance imaging (MRI), we compared readings to POCUS. Results: A total of 61 women were included in the study, of whom 34 (55.7%) underwent appendectomy and in 30 (49.2%) an acute appendicitis was histopathologically confirmed. Sensitivity of POCUS was 66.7% (confidence interval [CI] 95% 47.1-82.7), specificity 96.8% (CI 95% 83.3-99.9), and positive likelihood ratio 20.7. Performance of POCUS was comparable in all trimesters, with highest sensitivity in the first trimester (72.7%). The MRI reading showed a sensitivity of 84.6% and a specificity of 100%. In the four negative appendectomies a MRI was not performed. Conclusion: Point-of-care ultrasound showed a high specificity and positive likelihood ratio in diagnosing acute appendicitis in pregnant women in all trimesters with suspected appendicitis. In negative (or inconclusive) cases further imaging as MRI could be helpful to avoid negative appendectomy.

Role of Abdominal Ultrasound and Magnetic Resonance Imaging in Pregnant Women Presenting With Acute Abdominal Pain

Background and Purpose: Abdominal pain during pregnancy is quite common; however, surgical pathology such as acute appendicitis as a cause of such pain is not. Diagnostic tests used in addition to history and physical examination (PE) are ultrasound (US) and magnetic resonance imaging (MRI). We elected to find the role of these tests in pregnant patients who presented to our emergency department with acute abdominal pain.Materials And Methods: Retrospective analysis of 136 pregnant women with acute abdominal pain presented to the emergency department (ED). We reviewed PE, US, MRI, gestational age, comorbid conditions, and length of stay. Statistical analysis was done using student's t-test and chi-square test. Institutional review board approval was obtained.Results: Mean age was 26 (±4.6) and the mean gestational age was 24 (±9.9) weeks. Of those patients, there were 81 patients who had an US and MRI performed. The US was positive in 16 patients, while the MRI was positive in 25 patients. Three patients went for appendectomy. The US sensitivity was 0% and specificity 79%. Positive predictive value for US was 0% and negative predictive value was 95%, which was less than 100%. The MRI likelihood ratios were calculated for each test's clinical application and demonstrated that the US test result was indeterminate for ruling in and for ruling out appendicitis while the MRI allowed for high ability to rule out the disease.Conclusion: In pregnant women with acute abdominal pain and a positive PE highly suggestive of surgical pathology, US had limited value and patients should proceed to MRI.

Imaging the acute abdomen in pregnancy: a radiological decision-making tool and the role of MRI

Acute abdominal pain in pregnancy poses a significant diagnostic challenge. The differential diagnosis is wide, clinical assessment is difficult, and the use of conventional imaging methods is restricted due to risks to the fetus. This can lead to delay in diagnosis, which increases the risk of maternal and fetal harm. Imaging techniques not involving ionising radiation are preferred. Sonography remains first line, but anatomical visualisation can be limited due to displacement of adjacent structures by the gravid uterus. MRI provides excellent cross-sectional soft-tissue assessment of the abdomen and pelvis, and no study to date has demonstrated significant deleterious effects to the fetus at any gestation; however, there remains a theoretical risk of tissue heating by radiofrequency pulses, and there must be consideration of benefit versus potential risk for any use of magnetic resonance imaging (MRI) in pregnancy. With a limited protocol of sequences, a broad spectrum of pathologies can be evaluated. Computed tomography carries the highest exposure of ionising radiation to the fetus, but may be necessary, particularly in cases of trauma. The patient must be kept informed and any potential risks to the patient and fetus should be clearly explained. We present a radiological decision-making tool to guide choice of imaging and best establish the underlying diagnosis in the acute pregnant abdomen. In addition, using illustrative examples from our practice at a large tertiary centre, we review the advantages and disadvantages of each imaging method, with particular focus on the utility of MRI.

Imaging during pregnancy: What the radiologist needs to know

During the last decades, there has been a growing demand for medical imaging in gravid women. Imaging of the pregnant woman is challenging as it involves both the mother and the fetus and, consequently, several medical, ethical, or legal considerations are likely to be raised. Theoretically, all currently available imaging modalities may be used for the evaluation of the pregnant woman; however, in practice, confusion regarding the safety of the fetus often results in unnecessary avoidance of useful diagnostic tests, especially those involving ionizing radiation. This review article is focused on the current safety guidelines and considerations regarding the use of different imaging modalities in the pregnant population; also presented is an imaging work-up for the most common medical conditions of pregnant women, with emphasis on fetal and maternal safety.

Clinical Outcomes of Acute Appendicitis During Pregnancy: Conservative Management and Appendectomy

PURPOSE

We have described the epidemiology, diagnostic modality, treatment patterns, and outcomes of acute appendicitis during pregnancy.

METHODS

Using a nationwide claim-based database in Japan, we analyzed the data of pregnant patients who were diagnosed with appendicitis between January 2005 and May 2019. Patient characteristics, imaging studies, length of hospital stay, proportion of fetal losses, complications, and type of antibiotics were examined.

RESULTS

The study included 169 patients, of whom 113 patients (67%) underwent conservative management, and appendectomies were performed on 56 patients (open 25% and laparoscopic 8%). The proportion of ultrasonography, computed tomography, and magnetic resonance imaging were 97%, 17%, and 5% (for conservative management); 88%, 39%, and 13% (for appendectomy); 86%, 38%, and 21% (for open appendectomy); and 93%, 43%, and 14% (for laparoscopic appendectomy), respectively. The proportion of complicated appendicitis was 6% in conservative management and 41% in appendectomy (40% in open appendectomy and 43% in laparoscopic appendectomy), respectively. The incidence of fetal loss was 4% in conservative management, 5% in appendectomy (2% in open appendectomy, and 14% in laparoscopic appendectomy). However, there was only one fetal loss (in laparoscopic appendectomy) in the same case of hospitalization. There were no maternal deaths or serious complications after any treatment.

CONCLUSION

All treatments showed acceptable outcomes in appendicitis during pregnancy. Conservative management is considered an acceptable option, especially in uncomplicated cases of appendicitis in pregnant women.

Delaying laparoscopic surgery in pregnant patients with an equivocal acute appendicitis: a step-wise approach does not affect maternal or fetal safety

BACKGROUND

Accurate and timely diagnoses of acute appendicitis (AA) during pregnancy avoids maternal and fetal morbidity and mortality. We present our experience of using an initial transabdominal ultrasound (US) performed at presentation to diagnose AA in pregnant patients as well as the value of a delayed repeat study in those who remain equivocal. We explore the sensitivity and specificity of this algorithm as well as the maternal and fetal safety of this approach.

METHODS

Of the 225 patients identified within the study period who underwent laparoscopic appendectomy, 216 met the inclusion criteria and were retrospectively analyzed. If the US performed on presentation revealed AA, surgery was performed. Patients with a non-diagnostic US were admitted with surgery performed if there was clinical and/or biochemical deterioration. Patients who remained equivocal underwent a repeat delayed study. The results of the initial versus delayed studies were compared. Maternal and fetal complications were recorded and contrasted.

RESULTS

Of the 216 patients included, 164 (75.9%) had AA, 14 (6.5%) had complicated AA and 38 (17.6%) had a normal appendix. Initial US was diagnostic for 125/216 (57.9%) of patients and 19/34 (55.8%) of patients who underwent a delayed repeat study. The remaining patients underwent empirical surgery. The pooled sensitivity and specificity of US for the cohort was 79.2% and 92.1%, respectively. There was no difference in proxies of maternal or fetal safety between the groups.

CONCLUSION

US is a useful tool for diagnosing AA in pregnancy. In this cohort, performing a delayed repeat US during a period of observation in those patients who remained otherwise equivocal increased the diagnostic yield of the US. Delaying surgery in this specific group of patients does not affect maternal or fetal safety.

Latest Considerations in Diagnosis and Treatment of Appendicitis During Pregnancy

Pregnancy can obscure signs and symptoms of acute appendicitis, making diagnosis challenging. Furthermore, avoiding radiation-based imaging due to fetal risk limits the diagnostic options clinicians have. Once appendicitis has been diagnosed, performing appendectomies has been the more commonly accepted course of action, but conservative, nonsurgical approaches are now being considered. This report describes the latest recommendations from different fields and organizations for the diagnosis and treatment of appendicitis during pregnancy.

The Alvarado Score is accurate in pregnancy: a retrospective case-control study

BACKGROUND

Acute appendicitis is the most frequent abdominal condition that requires non-obstetric surgical intervention during pregnancy. This study aims to scan pregnant patients operated on for acute appendicitis to evaluate the efficiency of using the Alvarado Score (AS) for diagnosis.

METHODS

Our study included 48 pregnant patients who were pre-diagnosed with acute appendicitis and operated on at our department of general surgery from January 2010 to July 2016 and whose files were accessed. Fifty-three non-pregnant female patients of reproductive age who were operated on for appendicitis during the same period were included in the study as the control group. The patients in both groups were divided into two groups based on their AS total score being 7 and ≥ 7.

RESULTS

The mean age of the 48 pregnant patients was 28 (19-42) years, while the mean age of the 53 control patients was 31 (18-45) years. Among pregnant and non-pregnant women, about a third of patients had an AS < 7 (16 of 48 versus 18 of 53). There was no significant difference when the AS scores of both groups were compared (p = 0.947). Using pathology results as reference test, the sensitivity and specificity of the AS in pregnant women was 79 and 80%.

CONCLUSIONS

As a result, when the data collected by our study are evaluated, we see that pregnancy does not have a negative effect on the efficacy of AS. Therefore, the AS system can be an easy, non-invasive auxiliary diagnostic tool with high diagnosis accuracy rates that can be used in pregnant patients suspected of having acute appendicitis.

Utility of Magnetic Resonance Imaging for the Diagnosis of Appendicitis During Pregnancy: A Canadian Experience

PURPOSE

The objective of the study was to evaluate the performance of magnetic resonance imaging (MRI) for the diagnosis of appendicitis during pregnancy.

METHODS

We conducted a retrospective review of all MRI scans performed at our institution, between 2006 and 2012, for the evaluation of suspected appendicitis in pregnant women. Details of the MRI scans performed were obtained from the radiology information system as well as details of any ultrasounds carried out for the same indication. Clinical and pathological data were obtained by retrospective chart review.

RESULTS

The study population comprised 63 patients, and 8 patients underwent a second MRI scan during the same pregnancy. A total of 71 MRI scans were reviewed. The appendix was identified on 40 scans (56.3%). Sensitivity of MRI was 75% and specificity was 100% for the diagnosis of appendicitis in pregnant women. When cases with right lower quadrant inflammatory fat stranding or focal fluid, without appendix visualization, were classified as positive for appendicitis, MRI sensitivity increased to 81.3% but specificity decreased to 96.4%.

CONCLUSIONS

MRI is sensitive and highly specific for the diagnosis of appendicitis during pregnancy and should be considered as a first line imaging study for this clinical presentation.

The diagnostic performance of ultrasound for acute appendicitis in pregnant and young nonpregnant women: A case-control study

BACKGROUND

Ultrasonography is frequently used to diagnose acute appendicitis in women of reproductive age, but its diagnostic value in pregnant patients remains unclear. This study sought to compare the diagnostic performance of ultrasound in pregnant and young nonpregnant women with suspected acute appendicitis.

METHODS

The database of a single tertiary medical center was reviewed for all women of reproductive age who underwent appendectomy either during pregnancy (2000-2014) or in the nonpregnant state (2004-2007) following ultrasound evaluation. The performance of ultrasound in terms of predicting the final pathologic diagnosis was compared between the pregnant and non pregnant groups using receiver operating characteristic curve analysis.

RESULTS

Of 586 young women treated for appendicitis during the study periods (92 pregnant, 494 non-pregnant), 200 underwent preoperative ultrasound [67 pregnant, and 133 nonpregnant young women]. The pregnant and nonpregnant groups were comparable in age and presenting symptoms. There was no significant difference in the predictive performance of ultrasound between the two groups (AUC 0.76 and 0.73 respectively, p = 0.78) or within the pregnant group, by trimester [first (n = 23), AUC 0.73; second (n = 32), AUC 0.67; third (n = 12), AUC 0.86; p = 0.4]. Ultrasound had a positive predictive value of 0.94 in the pregnant group and 0.91 in the nonpregnant group; corresponding negative predictive values were 0.40 and 0.43.

CONCLUSIONS

There appears to be no difference in the ability of ultrasound to predict the diagnosis of acute appendicitis between pregnant women and nonpregnant women of reproductive age. Therefore, similar preoperative imaging algorithms may be used in both patient populations.

Magnetic Resonance Imaging of Abdominal and Pelvic Pain in the Pregnant Patient

The utility of MR imaging in evaluating abdominal and pelvic pain in the pregnant patient is discussed. Details regarding the indications, technical aspects, and imaging findings of various common abdominal and pelvic abnormalities in pregnancy are reviewed.

ACR Appropriateness Criteria® Right Lower Quadrant Pain--Suspected Appendicitis

The most common cause of acute right lower quadrant (RLQ) pain requiring surgery is acute appendicitis (AA). This narrative's focus is on imaging procedures in the diagnosis of AA, with consideration of other diseases causing RLQ pain. In general, Computed Tomography (CT) is the most accurate imaging study for evaluating suspected AA and alternative etiologies of RLQ pain. Data favor intravenous contrast use for CT, but the need for enteric contrast when intravenous contrast is used is not strongly favored. Radiation exposure concerns from CT have led to increased investigation in minimizing CT radiation dose while maintaining diagnostic accuracy and in using algorithms with ultrasound as a first imaging examination followed by CT in inconclusive cases. In children, ultrasound is the preferred initial examination, as it is nearly as accurate as CT for the diagnosis of AA in this population and without ionizing radiation exposure. In pregnant women, ultrasound is preferred initially with MRI as a second imaging examination in inconclusive cases, which is the majority.The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every three years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Acute appendicitis in pregnancy: literature review

INTRODUCTION

suspected appendicitis is the most common indication for surgery in non-obstetric conditions during pregnancy and occurs in about one in 500 to one in 635 pregnancies per year. This occurs more often in the second trimester of pregnancy. Acute appendicitis is the most common general surgical problem encountered during pregnancy.

METHODS

a literature review on research of scientific articles, under the terms "acute appendicitis" and "pregnancy", in PubMed, Lilacs/SciELO, Scopus, Cochrane Library and Uptodate databases.

RESULTS

the clinical manifestations of appendicitis are similar to non-pregnant women, however, without a classic presentation, which often occurs, diagnosis is difficult and must be supported by imaging.

DISCUSSION

clinical diagnosis should be strongly suspected in pregnant women with classic findings such as abdominal pain that migrates to the right lower quadrant. The main purpose of imaging is to reduce delays in surgical intervention due to diagnostic uncertainty. A secondary objective is to reduce, but not eliminate, the negative appendectomy rate. Differential diagnosis of suspected acute appendicitis usually includes pathologies considered in non-pregnant people.

CONCLUSION

the imaging study of choice is ultrasound, MRI may be used when the former is not conclusive and, as a last resort, a CT scan can be performed. The treatment remains appendectomy by laparotomy, since the feasibility of video- assisted surgery in these cases remains controversial.

Appendicitis during pregnancy with a normal MRI

Abdominal pain frequently represents a diagnostic challenge in the acute setting. In pregnant patients, the gravid abdomen and concern for ionizing radiation exposure further limit evaluation. If undiagnosed, appendicitis may cause disastrous consequences for the mother and fetus. We present the case of a pregnant female who was admitted for right lower quadrant abdominal pain. Advanced imaging of the abdomen and pelvis was interpreted to be either indeterminate or normal and a diagnosis of acute appendicitis was made on purely clinical grounds. This patient’s management and a literature review of diagnostic techniques for acute appendicitis during pregnancy are discussed.

Magnetic resonance imaging of acute abdominal and pelvic pain in pregnancy

Evaluation of acute abdominal and pelvic pain in pregnancy presents a diagnostic challenge for clinicians and radiologists alike. The differential diagnosis includes obstetric and nonobstetric conditions unique to pregnancy, in addition to causes of acute abdominal and pelvic pain unrelated to the pregnancy. The clinical presentation and course of disease may be altered in pregnancy, and several pathologies are exacerbated by pregnancy. Discriminating clinical features in the diagnosis of abdominal and pelvic pain are often confounded by expected anatomic and physiologic changes in pregnancy. Moreover, while diagnostic pathways may be altered in pregnancy, the necessity for a timely and accurate diagnosis must be underscored, as delay in treatment may result in an undesirable increase in morbidity and/or mortality for both the patient and fetus. Advances in magnetic resonance imaging (MRI) through faster acquisition and motion-insensitive techniques, coupled with increased awareness and education regarding the value of MRI in diagnosing a wide range of pathology, have established MRI as a valuable strategy in the investigation of acute abdominal and pelvic pain in the pregnant patient. This review presents a practical approach to common obstetric and nonobstetric causes of acute abdominal and pelvic pain during pregnancy, as well as safety considerations for performing MRI in this patient population.

Three-step sequential positioning algorithm during sonographic evaluation for appendicitis increases appendiceal visualization rate and reduces CT use

OBJECTIVE

The purpose of this article is to examine the rates of appendiceal visualization by sonography, imaging-based diagnoses of appendicitis, and CT use after appendiceal sonography, before and after the introduction of a sonographic algorithm involving sequential changes in patient positioning.

MATERIALS AND METHODS

We used a search engine to retrospectively identify patients who underwent graded-compression sonography for suspected appendicitis during 6-month periods before (period 1; 419 patients) and after (period 2; 486 patients) implementation of a new three-step positional sonographic algorithm. The new algorithm included initial conventional supine scanning and, as long as the appendix remained nonvisualized, left posterior oblique scanning and then "second-look" supine scanning. Abdominal CT within 7 days after sonography was recorded.

RESULTS

Between periods 1 and 2, appendiceal visualization on sonography increased from 31.0% to 52.5% (p < 0.001), postsonography CT use decreased from 31.3% to 17.7% (p < 0.001), and the proportion of imaging-based diagnoses of appendicitis made by sonography increased from 63.8% to 85.7% (p = 0.002). The incidence of appendicitis diagnosed by imaging (either sonography or CT) remained similar at 16.5% and 17.3%, respectively (p = 0.790). Sensitivity and overall accuracy were 57.8% (95% CI, 44.8-70.1%) and 93.0% (95% CI, 90.1-95.3%), respectively, in period 1 and 76.5% (95% CI, 65.8-85.2%) and 95.4% (95% CI, 93.1-97.1%), respectively, in period 2. Similar findings were observed for adults and children.

CONCLUSION

Implementation of an ultrasound algorithm with sequential positioning significantly improved the appendiceal visualization rate and the proportion of imaging-based diagnoses of appendicitis made by ultrasound, enabling a concomitant decrease in abdominal CT use in both children and adults.

Management of pregnant patients undergoing general surgical procedures

Pregnant patients have a 0.2% to 0.75% chance of developing a medical condition that requires a general surgical intervention during pregnancy. To safely and appropriately care for patients, surgeons must be cognizant of the maternal physiologic changes in pregnancy as well as of the unique risk to both mothers and fetuses of diagnostic modalities, anesthetic care, operative intervention, and postoperative management. Surgeons can be assured that, if these risks are understood and considered, operating during pregnancy, even in the abdomen, can be safely undertaken.

Ultrasound imaging in the management of bleeding and pain in early pregnancy

Bleeding and pain are experienced by 20% of women during the first trimester of pregnancy. Although most pregnancies complicated by pain and bleeding tend to progress normally, these symptoms are distressing for woman, and they are also associated with an increased risk of miscarriage and ectopic pregnancy. Ultrasound is the first and often the only diagnostic modality that is used to determine location of early pregnancy and to assess its health. Ultrasound is an accurate, safe, painless and relatively inexpensive diagnostic tool, which all contributed to its widespread use in early pregnancy. Pain and bleeding in early pregnancy are sometimes caused by concomitant gynaecological, gastrointestinal, and urological problems, which could also be detected on ultrasound scan. In women with suspected intra-abdominal bleeding, ultrasound scan can be used to detect the presence of blood and provide information about the extent of bleeding. In this chapter, we comprehensively review the use of ultrasound in the diagnosis and management of early pregnancy complications. We include information about the diagnosis of gynaecological and other pelvic abnormalities, which could cause pain or bleeding in pregnancy. We also provide a summary of the current views on the safety of ultrasound in early pregnancy.

A case of Hickam's dictum: concurrent appendicitis and ectopic pregnancy

BACKGROUND

Both ectopic pregnancy and appendicitis are surgical emergencies that should be considered in female patients who present with right lower-quadrant pain. Deciding on the appropriate imaging modality in the pregnant patient can be difficult. The challenge of diagnosis is compounded when one considers that both pathologies may be present simultaneously.

OBJECTIVES

We present a case demonstrating co-occurrence of ectopic pregnancy and appendicitis and suggest an algorithm for evaluation and management of cases with this presentation.

CASE REPORT

A 25-year-old woman presented to the Emergency Department complaining of 3 days of abdominal pain and a positive urine pregnancy test. After consultation with Obstetrics/Gynecology (OB/GYN) and General Surgery, a nondiagnostic pelvic ultrasound (US), and a magnetic resonance imaging (MRI) study consistent with appendiceal inflammation, the patient was taken to the operating room for a laparoscopic appendectomy. While removing the inflamed appendix, the general surgeon noted the right fallopian tube was enlarged, suggestive of an ectopic pregnancy. OB/GYN was consulted again intraoperatively and noted a right ectopic pregnancy. The surgical intervention was completed with a right salpingectomy.

CONCLUSION

In a pregnant patient with right lower-quadrant pain, the differential diagnosis includes ectopic pregnancy, acute appendicitis, or in rare cases, both.

[Radiology and pregnancy : Part 2: clinical recommendations]

In spite of a growing number of radiological scans in pregnant women there is still a high level of uncertainty concerning radiation exposure to the fetus. At the same time, the risk of fetal radiation injury is frequently overestimated. This entails an avoidable fear in the pregnant patient and may delay urgently required imaging and thus lead to an increased risk for maternal and fetal health. As a consequence, radiological scans in pregnant patients do not only require a thorough medical check but also a careful estimate of the specific radiation exposure to the fetus. The previous first part of the article described the legal requirements in Germany, the technical exposure and pharmacological risks for the pregnant woman and the fetus. The current second article focuses on the risk analysis for examinations with ionizing radiation and will provide recommendations for typical indications for maternal and fetal imaging.

Appendicitis: changing perspectives

Neoplasms are an uncommon finding after appendectomy, with malignant tumors occurring in less than 1% of the surgical specimens, and carcinoid being the most frequent malignancy. A negative or inconclusive ultrasound is not adequate to rule out appendicitis and should be followed by CT scan. For pregnant patients, MRI is a reasonable alternative to CT scan. Nonoperative treatment with antibiotics is safe as an initial treatment of uncomplicated appendicitis, with a significant decrease in complications but a high failure rate. Open and laparoscopic appendectomies for appendicitis provide similar results overall, although the laparoscopic technique may be advantageous for obese and elderly patients but may be associated with a higher incidence of intraabdominal abscess. Preoperative diagnostic accuracy is of utmost importance during pregnancy because a negative appendectomy is associated with a significant incidence of fetal loss. The increased morbidity associated with appendectomy delay suggests that prompt surgical intervention remains the safest approach. Routine incidental appendectomy should not be performed except in selected cases. Interval appendectomy is not indicated because of considerable risks of complications and lack of any clinical benefit. Patients older than 40 years with an appendiceal mass or abscess treated nonoperatively should routinely have a colonoscopy as part of their follow-up to rule out cancer or alternative diagnosis.

APPENDICITIS IN PREGNANCY

Acute appendicitis is the most common non-obstetric indication for surgical intervention in pregnancy, complicating 1/500 to 1/2000 deliveries. Due to the anatomical and physiological changes associated with pregnancy, appendicitis may present a diagnostic dilemma, leading to management delays and thus increasing the risk of appendiceal perforation. Many of the common presenting symptoms of appendicitis are common features of normal pregnancy including lower abdominal pain, nausea, vomiting and leukocytosis. Furthermore, the enlarging gravid uterus may displace the appendix to varying degrees thus altering the classic symptom pattern of appendicitis. The often nonspecific presentation in pregnancy may necessitate the utilization of diagnostic imaging to aid in accurate diagnosis. However, the perforated appendix is the most common surgical cause of fetal loss and the time required for any diagnostic aid must be weighed against the increasing risk of perforation caused by delay in surgical intervention.

Appendicitis during Pregnancy: The Clinical Experience of a Secondary Hospital

PURPOSE

Appendicitis is the most common condition leading to an intra-abdominal operation for a non-obstetric problem in pregnancy. The aim of this study was to examine our experience and to analyze the clinical characteristics and the pregnancy outcomes for appendicitis during pregnancy that was reported in Korea.

METHODS

We reported 25 cases of appendicitis during pregnancy that were treated at Good Moonhwa Hospital from January 2004 to March 2010. We also analyzed appendicitis during pregnancy reported in Korea between 1970 and 2008 by a review of journals.

RESULTS

The incidence of acute appendicitis during pregnancy was one per 568 deliveries. The mean age was 27.92 years old, the gestational stage at the onset of symptoms was the first trimester in 10 patients (40%), the second trimester in 14 patients (56%), and the third trimester in 1 patient (4%). Among the 25 cases, 21 were treated with an open appendectomy and 4 with laparoscopic appendectomies. The postoperative complications were 2 wound infections and 1 spontaneous abortion.

CONCLUSION

Our experience demonstrated that appendectomies on pregnant patients can be successfully performed at secondary hospitals.

Imaging of pregnant and lactating patients: part 2, evidence-based review and recommendations

OBJECTIVE

The objectives of this article are to discuss the current evidence-based recommendations regarding the use of diagnostic imaging in the evaluation of pulmonary embolism, appendicitis, urolithiasis, and cholelithiasis during pregnancy.

CONCLUSION

Diagnostic imaging should be performed during pregnancy only with an understanding of the maternal and fetal risks and benefits, the comparative advantages of different modalities, and the unique anatomic and physiologic issues associated with pregnancy.

ACR Appropriateness Criteria® right lower quadrant pain--suspected appendicitis

The diagnostic imaging of patients presenting with right lower quadrant pain and suspected appendicitis may be organized according to age and gender and to the presence or absence of "classic" signs and symptoms of acute appendicitis. Among adult patients presenting with clinical signs of acute appendicitis, the sensitivity and specificity of CT are greater than those of ultrasound, with improved performance when CT is performed with intravenous contrast. The use of rectal contrast has been associated with decreased time in the emergency department. Computed tomography has also been shown to reduce cost and negative appendectomy rates. Both CT and ultrasound are also effective in the identification of causes of right lower quadrant pain unrelated to appendicitis. Among pediatric patients, the sensitivity and specificity of graded-compression ultrasound can approach those of CT, without the use of ionizing radiation. Performing MRI after inconclusive ultrasound in pregnant patients has been associated with sensitivity and specificity of 80% to 86% and 97% to 99%, respectively. The ACR Appropriateness Criteria(®) are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Utility of ultrasound for evaluating the appendix during the second and third trimester of pregnancy

This study aims to retrospectively evaluate the right lower quadrant ultrasounds in women presenting during the second or third trimester of pregnancy for the frequency of appendix visualization and accuracy in diagnosing appendicitis. Institutional Review Board approval was obtained for this Health Insurance Portability and Accountability Act-compliant study. We reviewed imaging records from 99 consecutive pregnant women from 2001 to 2011 who presented during the second (≥14 weeks gestation) or third trimester for right lower quadrant ultrasound to evaluate the appendix. Visualization of the appendix as well as the size and compressibility, if identified, were recorded. The medical records and labs related to the initial patient presentation, subsequent management, and follow-up were reviewed for surgical and clinical outcomes. Pathology records were reviewed to determine if appendicitis was present when appendectomy was performed. Patients who underwent appendectomy were considered to have appendicitis based on pathology results, and patients managed non-operatively with symptom improvement and those with a normal appendix at pathology were considered to not have appendicitis. During the study period, 99 women meeting inclusion criteria presented to our institution for right lower quadrant ultrasound to evaluate the appendix during the second or third trimester of pregnancy. The mean gestational age at presentation was 23 weeks (±7 weeks). The mean maternal age was 28 years (±6.6 years). The appendix was not visualized in 97% (96/99) of right lower quadrant ultrasound examinations. Of the three studies in which the appendix was visualized, two were considered positive for appendicitis and one was considered negative. Eight patients in this group ultimately underwent appendectomy, including the two patients with positive right lower quadrant ultrasounds, and appendicitis confirmed at pathology in seven of these cases (87.5%). Right lower quadrant ultrasound successfully demonstrated an abnormal appendix in 28.7% (two of seven) of surgically confirmed cases; however, this technique did not detect appendicitis in 71% (five of seven) of patients with surgically proven disease due to nonvisualization of the appendix. Retrospective review of right lower quadrant ultrasounds performed during the second and third trimester of pregnancy suggests that this modality has limited utility for diagnosing appendicitis due to infrequent visualization of the appendix.

Nontraumatic abdominal pain in pregnancy: imaging considerations for a multiorgan system problem

Nontraumatic abdominal pain in the pregnant patient can present a clinician with a variety of diagnostic possibilities. The overlap between signs and symptoms expected in normal pregnancy and these many pathologic possibilities does little to help focus the clinician's diagnostic efforts. Fear of ionizing radiation's effects on the fetus has driven efforts to refine medical imaging algorithms in such a way as to attempt to eliminate its use at all cost. In today's world, we are nearly there. In this review the differential diagnosis of nontraumatic abdominal pain in the pregnant patient will be explored. Of note is the recurring theme that much of what can be done today with regard to diagnostic imaging, both in general and with regard to this specific subset of patients, centers on the use of the non-ionizing modalities of ultrasound and magnetic resonance imaging.

Suspicion of acute appendicitis in the third trimester of pregnancy: pros and cons of a laparoscopic procedure

This review suggests that diagnostic laparoscopy during the third trimester of pregnancy is a logical strategy to minimize maternal and fetal risk when acute appendicitis is suspected.

The presentation of acute appendicitis during pregnancy may cause diagnostic and therapeutic difficulty. Delay in diagnosis may lead to increased maternal and fetal risk. Therefore, an aggressive surgical approach is mandatory, even though this may result in an increased number of appendectomies for normal appendices. Diagnostic laparoscopy, followed by laparoscopic appendectomy in case of inflammation, seems a logical strategy. We present the case of a 36-week pregnant woman who presented with suspicion of acute appendicitis. The pro and cons of a laparoscopic approach in the third trimester of pregnancy are discussed as is its safety by reviewing the literature.

Laparoscopic management of fallopian tube torsion at 35 weeks of gestation: case report

Isolated fallopian tube torsion requiring surgical intervention in pregnancy is rare. Herein is reported a case of fallopian tube torsion that was managed laparoscopically at 35 weeks of gestation.

The value of 3D T1-weighted gradient-echo MR imaging for evaluation of the appendix during pregnancy: preliminary results

BACKGROUND

The use of oral contrast has been essential for the identification of a normal appendix on MR imaging during pregnancy. However, stool could be used as a positive oral contrast as it is characterized by a relatively high signal on T1-weighted imaging, and 3D T1-weighted gradient-echo (T1W-GRE) MR imaging has been used to evaluate 3 mm diameter intestines in fetuses.

PURPOSE

To evaluate the added value of 3D T1W-GRE MR imaging in combination with T2-weighted imaging (T2WI) compared to T2WI alone for evaluating the appendix during pregnancy.

MATERIAL AND METHODS

Eighteen consecutive pregnant patients who were clinically suspected of having acute appendicitis underwent appendix MR imaging which included T2WI with or without spectral presaturation attenuated inversion-recovery (SPAIR) fat suppression, and 3D T1W-GRE with SPAIR fat suppression. Two radiologists reviewed the two image sets (the T2WI set and the combined set of T2WI and 3D T1W-GRE images). Pathologic and clinical results served as the reference standard. The differences in the degree of visibility of the appendix and confidence scale for diagnosing acute appendicitis between two image sets were compared by using the paired Wilcoxon signed rank test.

RESULTS

For both reviewers, the degree of visibility of the appendix using the combined T2WI and 3D T1W-GRE images was significantly higher than using T2WI alone (P < 0.01), and the confidence levels for acute appendicitis using combined T2WI and 3D T1W-GRE images were significantly different from those using T2WI alone (P < 0.01). In the 13 patients with a normal appendix, both reviewers showed improved confidence levels for appendicitis using combined T2WI and 3D T1W-GRE images than T2WI alone.

CONCLUSION

Adding 3D T1W-GRE images to T2WI is helpful for identification of the appendix, as compared to T2WI alone in pregnant women without ingestion of oral contrast material. This may improve diagnostic confidence for acute appendicitis in pregnant patients.

Appendicitis During Pregnancy

Acute appendicitis is the most common extra-uterine surgical emergency requiring immediate surgical intervention during pregnancy [1]. Six young female patients presented with appendicitis during May 1996 to May 2001 in different service hospitals. Five patients underwent emergency appendectomy successfully. Gestational age at presentation included first trimester in 4 patients, second trimester in 2 patients and none in third trimester. 84% had pathologically proven acute appendicitis. One patient presented with appendicular lump in first trimester, proved on ultra sonography examination, which was treated by Oshner Sherren regime and subsequently interval appendectomy was done in second trimester. No long term adverse maternal morbidity or mortality was reported. One patient had premature onset of labour and delivered. Natural history of acute appendicitis is not changed during pregnancy while gestational physiological changes obscure the accurate diagnosis of acute appendicitis.

Safety and outcome of general surgical open and laparoscopic procedures during pregnancy

BACKGROUND

Surgical procedures during pregnancy carry the risk of adverse fetal outcome. We analyzed outcomes of open and laparoscopic approaches in patients treated for symptomatic cholelithiasis and suspected appendicitis. We reviewed the literature for evidence on the safety of both procedures.

METHODS

We retrospectively reviewed the data of all patients who underwent surgery for symptomatic cholelithiasis and suspicion of appendicitis during pregnancy between January 2004 and March 2009. Fetal loss, preterm delivery, maternal outcome, and surgical complications were assessed.

RESULTS

Twenty patients were operated on during pregnancy: 5 of 652 (0.8%) patients with symptomatic cholelithiasis and 15 (4.5%) of 331 for suspected appendicitis. All cholecystectomies were performed by laparoscopic procedure; no premature deliveries or fetal death occurred. In patients with suspicion of appendicitis, three appendices sana were diagnosed laparoscopically, and nine laparoscopic appendectomies and three open appendectomies were performed. The outcome was two preterm deliveries and one fetal death.

CONCLUSION

Reviewing our results and the available literature, we believe that the outcome of surgery during pregnancy is not dictated by the type of procedure but by the type of disease. The gain for fetal outcome in the future most likely lies in the diagnostic pathway rather than the type of surgery.

Diagnostic performance of magnetic resonance imaging in the detection of appendicitis in adults: a meta-analysis

RATIONALE AND OBJECTIVES

Perform a meta-analysis evaluating the diagnostic performance of magnetic resonance imaging (MRI) for the diagnosis of acute appendicitis.

MATERIALS AND METHODS

MEDLINE and EMBASE were queried between January 1995 and December 2009. Prospective and retrospective studies were included if they: used MRI as a diagnostic test for appendicitis, used pathology or clinical follow-up as the reference standard, and reported absolute number of true-positive, true-negative, false-positive, and false-negative results, or stated sufficient data to derive these values. Summary sensitivity, summary specificity, positive and negative likelihood ratios (LR+) and (LR-), and diagnostic odds ratio were calculated. Heterogeneity of the results was assessed using Forest plots and the value of inconsistency index (I(2)).

RESULTS

The inclusion criteria were fulfilled by eight articles with a total of 363 patients (mean age 26.9 ± 7.2 years; 86.2 % female). The appendix was not found in eight patients, with one article not reporting such data. The summary sensitivity was 97% (92%-99% at 95% confidence interval [CI]) and summary specificity was 95% (CI: 94%-99%), with a LR+ of 16.3 (CI: 9.1-29.1) and a LR- of 0.09 (CI: 0.04-0.197). Diagnostic odds ratio was 299.85 (CI: 97.5-921.61). No heterogeneity was found in the sensitivity (I(2) = 0.0, P = .4589). Minimal heterogeneity was found in the specificity (I(2) = 21.9%, P = .2553).

CONCLUSION

MRI appears promising in the evaluation of acute appendicitis, although larger future studies are warranted to confirm the results.