Routine Ultrasound and Limited Computed Tomography for the Diagnosis of Acute Appendicitis

Abstract

BackgroundAcute appendicitis continues to be a challenging diagnosis. Preoperative radiological imaging using ultrasound (US) or computed tomography (CT) has gained popularity as it may offer a more accurate diagnosis than classic clinical evaluation. The optimal implementation of these diagnostic modalities has yet to be established. The aim of the present study was to investigate a diagnostic pathway that uses routine US, limited CT, and clinical re-evaluation for patients with acute appendicitis.MethodsA prospective analysis was performed of all patients presenting with acute abdominal pain at the emergency department from June 2005 until July 2006 using a structured diagnosis and management flowchart. Daily practice was mimicked, while ensuring a valid assessment of clinical and radiological diagnostic accuracies and the effect they had on patient management.ResultsA total of 802 patients were included in this analysis. Additional radiological imaging was performed in 96.3% of patients with suspected appendicitis (n = 164). Use of CT was kept to a minimum (17.9%), with a US:CT ratio of approximately 6:1. Positive and negative predictive values for the clinical diagnosis of appendicitis were 63 and 98%, respectively; for US 94 and 97%, respectively; and for CT 100 and 100%, respectively. The negative appendicitis rate was 3.3%, the perforation rate was 23.5%, and the missed perforated appendicitis rate was 3.4%. No (diagnostic) laparoscopies were performed.ConclusionsA diagnostic pathway using routine US, limited CT, and clinical re-evaluation for patients with acute abdominal pain can provide excellent results for the diagnosis and treatment of appendicitis.

On the Role of Ultrasonography and CT Scan in the Diagnosis of Acute Appendicitis

“…Whether a patient of suspected AA should undergo CT scan or not is decided by the attending radiologist based on the USG findings and overall merit of the case. Many institutions follow this principle of USG first followed by CT scan if indicated especially in pediatric cases [15,16]. Third, another school of thought is that WBC count and serum biomarkers such as CRP help in the diagnosis of AA [17,18].…”

Comparison of appendicectomy outcomes: acute surgical versus traditional pathway

“…Since then, several randomized control trials and meta-analyses have shown advantages to laparoscopic appendicectomy with less postoperative pain and wound infections and shorter recovery times, 13,14 resulting in a worldwide trend towards an increase in the popularity of laparoscopic appendicectomy, 15,16 similar to that seen in our study and the study by Gandy et al 1 The role of preoperative imaging in appendicitis is still debated. There are studies that show a decrease in the rate of perforation and negative appendicectomy 17,18 and others studies that show no significant differences in outcome and increase in the TTT [19][20][21][22] as a result of preoperative scanning. In addition to confirming the increase in the preoperative LOS for those patients who have preoperative imaging, our study shows that the rate of detection of the appendix on preoperative scans (68.6%) was lower than the clinical operative diagnostic accuracy (78.0%, n = 1448).…”

Effect of surgeon’s judgement on the diagnosis of acute appendicitis

“…Diagnosis of AA based only on clinical and laboratory data results in high negative appendectomy rates and missed diagnoses with increased morbidity (1)(2)(3)(4). Imaging tests such as graded compression ultrasound (US) with or without color Doppler evaluation and computed tomography (CT) have been used to improve diagnostic performance for the last several decades (1,(5)(6)(7)(8).…”