How to diagnose acute appendicitis: ultrasound first

Abstract

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.

Preoperative predictive factors for difficult laparoscopic appendectomy

“…11 Ultrasound appendix size more than 1 cm does not predict the difficulty in laparoscopic appendectomy whereas peri appendicular collection significantly predicts the difficulty of laparoscopic appendectomy.…”

Analysis of the predictive value of clinical and sonographic variables in children with suspected acute appendicitis using decision tree algorithms

“…Clinical tests, pathology and diagnostic imaging play a valuable role in stratifying the risk of the condition. Ultrasound is accepted as the first line imaging modality in children, due to the risk from ionising radiation inherent to computed tomography . The value of appendiceal ultrasound to referring clinicians is contingent upon the effect on pre‐test probability.…”

Apendicectomía no terapéutica: Revisión de 1 año en el Centro Hospitalario Pereira Rossell, Montevideo, Uruguay

“…En cuanto a la ecografía, impresiona como poco utilizada para tratarse de pacientes en los cuales, por el resultado anátomo-patológico final, uno supondría que no han de haber sido de fácil diagnóstico por la clínica. Dado que este trabajo no analizó la clínica de estos pacientes ni el tiempo transcurrido entre que el cirujano tomó contacto con el mismo y el momento en que se resolvió la indicación quirúrgica, nos faltan elementos para analizar el hecho, de que gran parte de estos pacientes fue operado a pesar de una ecografía que disminuía en gran medida las probabilidades de estar frente a una apendicitis aguda (20) (21)(22) (23) .…”