Single and Combined Diagnostic Value of Clinical Features and Laboratory Tests in Acute Appendicitis

Abstract

Objectives: The objective was to evaluate the diagnostic accuracy of clinical features and laboratory test results in detecting acute appendicitis.Methods: Clinical features and laboratory test results were prospectively recorded in a consecutive series of 1,101 patients presenting with abdominal pain at the emergency department (ED) in six hospitals. Likelihood ratios (LRs) and the areas under the receiver operating characteristic curve (AUC) were calculated for the individual features. Variants of clinical presentation, based on different combinations of clinical features, were investigated and the accuracies of combinations of clinical features were evaluated.Results: The discriminative power (AUC) of the individual features in patients with suspected appendicitis ranged from 0.50 to 0.65. For five of the 23 predictor sets, the accuracy for appendicitis was more than 85%. This accuracy was only found in male patients. The relative frequency of these predictor sets ranged from 2% to 13% of patients with suspected appendicitis. A combination of the clinical features migration of pain to the right lower quadrant (RLQ), and direct tenderness in the RLQ, was present in only 28% (120 ⁄ 422) of clinically suspected patients, of whom no more than 85 patients had appendicitis (71%). A ''classical'' presentation (combination of migration of pain to the RLQ, tenderness in the RLQ, and rigidity) occurred in only 6% (25 ⁄ 422) of patients with suspected appendicitis and yielded an accuracy of 100% in males but only 46% in females. Conclusions:The discriminative power (AUC) of individual clinical features and laboratory test results for appendicitis was weak in patients with suspected appendicitis. Combinations of clinical features and laboratory tests with high diagnostic accuracy are relatively infrequent in patients with suspected appendicitis.ACADEMIC EMERGENCY MEDICINE 2009; 16:835-842 ª

Negative Appendectomy: an Audit of Resident-Performed Surgery. How Can Its Incidence Be Minimized?

“…Our NAR is comparable to other studies [14][15][16][17]. Various authors have reported that the highest incidence of NAR occurs in females of the reproductive age group (15-49 years) [5,6,13,18]. Although we also recorded a higher incidence in this population, the highest incidence was found in young girls aged 11-20 years.…”

“…These authors suggest that CRP is inexpensive, reduces NAR, and thereby decreases financial burden on the governmental health-care setup [9,20]. The combination of TLC and CRP, however, correlates better than any one of these investigations alone [9,12,13,20]. CRP was not performed in our patients as this facility is not present in our emergency department.…”

“…It goes without saying that every effort should be made for making a correct diagnosis of AA. This may sound simple, but as so many medical and surgical diseases resemble closely the clinical symptoms and signs of AA, it is not infrequent to misdiagnose AA [11][12][13]. Urgent surgical intervention in AA is prudent to avert the complications of an acutely inflamed appendix.…”

A Simple Clinical Decision Rule To Rule Out Appendicitis In Patients With Nondiagnostic Ultrasound Results

“…6 Combinations of clinical features-including pain migration, abdominal rigidity, and elevated inflammatory parameters-have a high predictive value for appendicitis, 7,8 but they are present in only a small proportion of patients suspected of having appendicitis. 9 This makes the clinical diagnosis of appendicitis difficult in the majority of cases and emphasizes the need for imaging in patients suspected of having appendicitis. Several studies have shown that the routine use of imaging has a positive effect on patient outcomes, with two randomized controlled trials reporting substantially lower negative appendectomy rates with routine imaging in all patients, compared to selective use of imaging based on clinical judgment.…”

“…12,19 Development of the CDR. Fourteen clinical variables known to be associated with acute appendicitis based on previous studies 9,21 were evaluated in the development set in patients with inconclusive or negative US. For each variable we estimated the diagnostic odds ratio (OR) for a final diagnosis of acute appendicitis, with corresponding 95% confidence interval (CI), using univariable logistic regression analysis.…”