Repeated Clinical and Laboratory Examinations in Patients with an Equivocal Diagnosis of Appendicitis

Abstract

In-hospital observation with repeated clinical examinations is commonly used in patients with an equivocal diagnosis of appendicitis. It is not known if repeated measurements of temperature and laboratory examinations have any diagnostic importance in this situation. The importance of repeated measurements of the body temperature, white blood cell (WBC) and differential cell counts, C-reactive protein concentration (CRP) and of the surgeon's repeated assessments was prospectively analyzed in 420 patients with an equivocal diagnosis of appendicitis at admission who were reexamined after a median of 6 hours of observation. The final diagnosis was appendicitis in 137 patients. After observation the inflammatory response was increasing among patients with appendicitis and decreasing among patients without appendicitis. The variables discriminating power for appendicitis consequently increased, from an area under the receiver operating characteristic (ROC) curve of 0.56 to 0.77 at admission, to 0.75 to 0.85 after observation. The ROC area of the surgeons' clinical assessment increased from 0.69 to 0.89. The WBC and differential cell counts were the best discriminators at the repeat examination. The change in the variables between the observations had weak discriminating power and had no additional importance in addition to the actual level at the repeat examination. To conclude, the diagnostic information of the temperature and laboratory examinations increased after observation. Repeated controls of the body temperature and laboratory examinations are therefore useful in the management of patients with equivocal signs of appendicitis, but the result of the examinations must be integrated with the clinical assessment.

Usefulness of Modified Alvarado Score in Diagnosis of Acute Appendicitis in Adults

“…In our study many of the parameters are not commonly found, thereby lower scoring of Modified Alvarado score .Lower scoring may be the result of inability of the patient to define the symptoms well for low socioeconomic status. Traditional system of clinical diagnosis of acute appendicitis was highly sensitive (95.5%) in our study which was in concordance with previous studies where accuracy is between 76 and 92% [15][16][17] .…”

The Systemic Inflammatory Response in Patients with Appendicitis: a Progressive Phenomenon

“…Leukocytosis was present in most patients in this study and was more frequent in patients with a diagnostic interval between 25 and 72 h. That was expected because the clinical evolution of appendicitis has its peak between 24 and 48 h after the onset [3,5,6,11]. Most patients in group 1 had leukocytosis which was also expected due to the initial phase of the inflammatory process [3][4][5][6]20]. Only 58 % of patients in group 4 had leukocytosis, and of those with leukocytosis, the value was high.…”

“…Although the absence of leukocytosis does not rule out appendicitis [3,21], its presence supports the clinical diagnosis [2][3][4][5][6][7][8]20]. It is expected that patients with advanced disease have higher WBC count due to increased polymorphonuclear cell count [5,12,20]. However, once the septic process is established, leukopenia may ensue.…”

“…d Progression of Creactive protein levels was steady and consequent with progression of the diagnostic interval, being more marked after 48 h. e SIRS points increased with progression of the diagnostic interval; after 73 h, most patients had three or four points, and this was consequent with the instauration of the septic process WBC Leukocytosis is the most frequent and expected parameter to be present in patients with appendicitis and is considered the best laboratory method to support the diagnosis of uncomplicated appendicitis [4,6,20]. Although the absence of leukocytosis does not rule out appendicitis [3,21], its presence supports the clinical diagnosis [2][3][4][5][6][7][8]20]. It is expected that patients with advanced disease have higher WBC count due to increased polymorphonuclear cell count [5,12,20].…”

The use of ultrasonographic and Alvarado scores in evaluating abdominal pain suggestive of acute appendicitis

“…Several studies have reported diagnostic efficiency using physical exploration and lab studies vs. ultrasound and CT, demonstrating that when abdominal pain in the RLQ is assessed by a surgeon, sensitivity reaches more than 84%. 9,[15][16][17][18] Sonographers use graded compression and the three-step sequential positioning algorithm as a standard protocol. 6 In 12% of patients in this study, it was impossible to visualize the cecal appendix.…”