Doppler ultrasound accurately screens patients with appendicitis

Ultrasound (US) has been reported as a useful aid to increase the sensitivity and specificity of the diagnosis of appendicitis. To determine the accuracy of US, we performed a prospective study of patients evaluated in the emergency department for acute appendicitis. US results of 125 consecutive patients over an 11-month period were correlated with operative and pathologic findings and clinical follow-up. The appendix was visualized as a noncompressible structure in 19 patients, and 18 had appendicitis (95%). Ten of the 12 patients with abnormal Doppler activity in the appendix had appendicitis (83%). Conversely, the appendix could not be visualized in 102 patients, and 100 did not have appendicitis (98%). One hundred five of the 113 patients (93%) with absent abnormal Doppler activity did not have appendicitis. Ninety-four of the 125 patients had neither visualization of the appendix nor abnormal activity, and 2 had appendicitis. The sensitivity of US for appendicitis was 90 per cent, and the specificity was 94 per cent. Visualization of the noncompressible appendix or abnormal Doppler activity strongly suggests appendicitis. More importantly, the absence of both of these ultrasonographic findings defines a patient subset that may be safely discharged from the emergency department without admission.

The use of technetium-labeled erythrocyte scintigraphy in the evaluation and treatment of lower gastrointestinal hemorrhage

The percentage of incorrect operations performed as a result of technetium-labeled erythrocyte scintigraphy has been reported as high as 42 per cent. Recent studies have found scintigraphy to be superior to angiography and propose that it be used as the primary diagnostic test in patients with lower gastrointestinal (GI) bleeding. A retrospective analysis was conducted of 105 patients with the symptoms of lower GI hemorrhage to determine the effect of erythrocyte scintigraphy on surgical management. Operative and pathology results were analyzed to determine the accuracy of the scintigraphy for localization of the bleeding source. In addition to tagged erythrocyte scans, 95 of 105 patients had additional diagnostic procedures: colonoscopy (78), upper endoscopy (47), and angiography (9). Scintigraphy localized a site of bleeding in 42 patients (colon, 29; jejunum/ileum, 10; duodenum, 2; esophagus, 1). Surgical intervention was required in 25 patients, and the site of bleeding was correctly determined by scintigraphy in 22 of these patients (88%). The scans were negative in two patients, and the bleeding site was incorrectly reported in another. The patients who had operations were significantly more likely to have positive scintigraphy than the nonoperative group (P < 0.05). Preoperative localization of GI hemorrhage is possible in most patients with technetium-labeled erythrocyte scans (88% of operative patients). When combined with other tests to exclude upper GI bleeding, scintigraphy is a reliable means of guiding surgical intervention.

Oxyphilic (Hürthle cell) adenoma arising in a black thyroid gland

We report this case to further document in the literature morphologic changes encountered in a black thyroid gland. It is only through an expanding data base that future conclusions may be reached regarding the role, if any, of minocycline in some of these alterations.

Aggressive management of cholecystitis during pregnancy

Nonoperative management of symptomatic cholelithiasis has generally been recommended for pregnant patients. However, a review of our experience with 44 patients at the Los Angeles County-University of Southern California Medical Center indicates that conservative management is associated with recurrent episodes of biliary tract symptoms, often requiring multiple hospitalizations, as well as a significant rate of fetal loss; whereas operation performed during the second trimester was associated with little maternal morbidity, no fetal loss, and a substantial reduction in total hospital days.