Luminal obstruction in uncomplicated appendicitis: Detection with sonography and potential clinical implications

Abstract

Purpose: To determine the frequency of luminal obstruction on appendiceal graded compression sonography (US) in patients with uncomplicated appendicitis and test the hypothesis that this frequency is similar to the failure rates of primary antibiotic therapy for uncomplicated appendicitis when treatment selection is based on CT findings.Methods: Sonograms of 150 consecutive patients with appendicitis diagnosed on ultrasound (US) and proven histopathologically were retrospectively evaluated; 114 (76.0%) had uncomplicated appendicitis, that is, appendicitis without gangrene or perforation, and were evaluated for appendicolithiasis and lymphoid hyperplasia using previously published sonographic criteria, and for luminal obstruction. Results: Of the 114 patients with uncomplicated appendicitis, US demonstrated no luminal obstruction in 74 (64.9%) and luminal obstruction in 40 (35.1%, P = .018), the latter including 16 (40.0%) with lymphoid hyperplasia and 24 (60.0%, P = .074) with appendicolithiasis. Conclusions: US demonstrated luminal obstruction in 35.1% of patients with uncomplicated appendicitis, similar to the published failure rates of antibiotic therapy when treatment selection is based on CT. This confirms the hypothesis, supporting the possibility that undiagnosed luminal obstruction may account for treatment failures when patients are selected by CT for primary antibiotic therapy, and suggests a role for US in selecting patients without luminal obstruction for antibiotic therapy. K E Y W O R D S appendectomy, appendicitis, appendix, diagnostic imaging, gastrointestinal ultrasound, sonography

Hyperechoic Periappendiceal Fat

“…A searchable electronic database was used to identify 271 consecutive pediatric patients (age < 19 years) whose appendixes were visualized on appendiceal sonography performed for suspected appendicitis between January 2016 and November 2017; 247 others had nonvisualized appendixes and were not included. Among those included were 22 patients reported in a prior study addressing antibiotic treatment failure and luminal obstruction in appendicitis 9 . Sonography is the preferred first‐line imaging modality for the evaluation of patients with suspected appendicitis at our institution.…”

“…Among those included were 22 patients reported in a prior study addressing antibiotic treatment failure and luminal obstruction in appendicitis. 9 Sonography is the preferred first-line imaging modality for the evaluation of patients with suspected appendicitis at our institution. By long-term agreements with our Departments of Surgery and Emergency Medicine, patients with body mass indices exceeding 30 kg/m 2 , or clinical signs of peritonitis or appendiceal perforation, are triaged to computed tomography rather than sonography.…”

Commentary on the article “Luminal obstruction in uncomplicated appendicitis: detection with sonography and potential clinical implications”

“…In this very interesting retrospective study, the authors try to support the theory that failure of antibiotic therapy in uncomplicated appendicitis may be associated with luminal obstruction . They speculate that the two main causes of obstruction are appendicolithiasis and lymphoid hyperplasia.…”

Reply by Authors

“…We are grateful for the thoughtful consideration inspired by our article, particularly as clinical interest in primary antibiotic therapy for acute appendicitis continues to grow.…”