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

Leeuwenburgh, Marjolein M. N.; Stockmann, H. B. A. C.; Bouma, Wim H.; Houdijk, Alexander P. J.; Verhagen, Matthijs F.; Vrouenraets, B. C.; Cobben, Lodewijk P. J.; Bossuyt, Patrick M.; Stoker, Jaap; Boermeester, Marja A.

doi:10.1111/acem.12374

Cited by 36 publications

(15 citation statements)

References 35 publications

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“…Another study reported on a set of clinical features that can rule out appendicitis in patients with suspected AA and non-diagnostic US results [ 37 ]. Patients were discharged after inconclusive US if less than two predictors were present: male sex, migration of pain to right lower quadrant, vomiting and leucocyte count >12.0 x 10 9 /l and re-evaluated the next day.…”

Section: When To Use Imagingmentioning

confidence: 99%

How to diagnose acute appendicitis: ultrasound first

et al. 2016

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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.

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Section: When To Use Imagingmentioning

confidence: 99%

How to diagnose acute appendicitis: ultrasound first

et al. 2016

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“…Given the high NPV of US, active clinical observation and patient education may be options that do not increase negative outcomes. 10,11 At the same time, it is important to note that in 21% of patients, an alternate cause of pain was identified. This finding should encourage technologists and others performing USs to search for a cause of pain, even when the appendix is not identified.…”

Section: Discussionmentioning

confidence: 99%

When the Appendix Is Not Seen on Ultrasound for Right Lower Quadrant Pain

Ly¹,

Khalili²,

Gray³

et al. 2016

Ultrasound Quarterly

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A survey was administered to 166 academic emergency department (ED) physicians to determine their interpretation and practice after receiving an ultrasound (US) report with nonvisualization of the appendix (NVA). Annual incidence of reported NVA from 2 academic hospitals was calculated for 2002-2013. A retrospective review of the same hospitals revealed that 291 (17.4%) of 1672 USs performed for appendicitis in 2012 indicated NVA. These cases underwent a chart review to determine the negative predictive value of reported NVA and utility of secondary findings. Univariate analysis was performed to determine significant predictors of secondary signs of appendicitis on computed tomography. Ninety eight (59%) of 166 ED physicians completed the survey. Forty nine (52%) of 94 respondents agreed that in the setting of reported NVA with no other acute findings, appendicitis has not been excluded and requires further imaging. There was a significant rise in the incidence rate of reported NVA for appendicitis, 22.5% (2002) up to 41.2% (2013, P < 0.0001). Negative predictive value for reported NVA was 216 (94.3%) of 229; in 9 (69%) of 13 patients, secondary signs of appendicitis were noted. Inflammatory changes in right lower quadrant (P = 0.01) and focal tenderness (P = 0.02) noted on US were significant predictors of a positive computed tomography scan. Current perceptions and practice of some ED physicians equate NVA on US as an inadequate study to exclude appendicitis. However, reported NVA is itself a highly predictive sign (94.3%) of absence of appendicitis even when an alternate cause of pain is not seen.

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“…It is relevant to incorporate in clinical practice tests such as scores that aid in the diagnosis of AA 16 . There are numerous risk classifications whose objective is to identify low, medium and high-risk patients for AA, allowing later investigations to be stratified according to the same 17 . Among these tests, the Alvarado score was designed with the intention of reducing the number of requested imaging tests 18 .…”

Section: Associação Entre O Escore De Alvarado Achados Cirúrgicos E mentioning

confidence: 99%

Associação entre o escore de Alvarado, achados cirúrgicos e aspecto histopatológico da apendicite aguda.

Nascimento

Souza

Alexandre

et al. 2018

Rev. Col. Bras. Cir.

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RESUMO Objetivo: comparar o resultado do escore de Alvarado com os achados cirúrgicos e com os resultados do exame histopatológico do apêndice de pacientes operados por apendicite aguda. Métodos: estudo observacional com delineamento transversal de 101 pacientes com 14 anos de idade ou mais, submetidos à apendicectomia de urgência. A avaliação continha o escore de Alvarado, pontuação no escore, sexo, idade, etnia dos pacientes e tempo de evolução. Foi obtido o aspecto cirúrgico do apêndice, dados a respeito das complicações pós-operatórias e o resultado do exame histopatológico. O intervalo de confiança pré-estabelecido foi de 95%. Foram calculadas sensibilidade, especificidade, valor preditivo positivo e negativo do escore, e realizada uma análise através da curva ROC. Resultados: a associação entre o escore de Alvarado e a confirmação diagnóstica utilizando como ponto de corte uma pontuação maior ou igual a seis encontrou-se significância estatística (P=0,002), com sensibilidade de 72% e especificidade de 87,5%. A pontuação maior ou igual a seis mostrou maior tendência a apresentar fases mais avançadas da apendicite aguda tanto no aspecto cirúrgico quanto histopatológico, quando comparado a uma pontuação menor que seis. O sexo masculino apresentou maiores chances de complicações quando comparado ao sexo feminino (P=0,003). Conclusão: o escore de Alvarado se mostrou um bom método para triagem diagnóstica na apendicite aguda, já que pontuações maiores ou iguais a seis estão associadas a uma probabilidade maior de confirmação diagnóstica e de quadros mais avançados da doença aguda.

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

Cited by 36 publications

References 35 publications

How to diagnose acute appendicitis: ultrasound first

How to diagnose acute appendicitis: ultrasound first

When the Appendix Is Not Seen on Ultrasound for Right Lower Quadrant Pain

Associação entre o escore de Alvarado, achados cirúrgicos e aspecto histopatológico da apendicite aguda.

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