Clinical Policy: Critical Issues in the Evaluation and Management of Emergency Department Patients With Suspected Appendicitis

Howell, John M.; Eddy, Orin L.; Lukens, Thomas W.; Thiessen, Molly E.W.; Weingart, Scott D.; Decker, Wyatt W.

doi:10.1016/j.annemergmed.2009.10.004

Cited by 168 publications

(133 citation statements)

References 65 publications

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“…Worldwide, CT scans are being increasingly performed as the primary imaging modality over USG in suspected patients of AA, especially for adults apparently for the sake of higher accuracy but with a relative disregard for the associated radiation burden. Literature is abundant with publications documenting higher accuracy of CT scan as compared to USG for diagnosing AA [4,6,9]. Clinical policy (2010) from the American College of Emergency Physicians on the evaluation and management of emergency department patients with suspected appendicitis discusses various aspects of CT scan; however, it does not even mention the role of USG in the diagnosis of appendicitis in adults although it does mention about the possible role of both CT and USG in pediatric cases [9].…”

Section: Discussionmentioning

confidence: 99%

“…Literature is abundant with publications documenting higher accuracy of CT scan as compared to USG for diagnosing AA [4,6,9]. Clinical policy (2010) from the American College of Emergency Physicians on the evaluation and management of emergency department patients with suspected appendicitis discusses various aspects of CT scan; however, it does not even mention the role of USG in the diagnosis of appendicitis in adults although it does mention about the possible role of both CT and USG in pediatric cases [9]. As far as utility of USG in the diagnosis of AA is concerned, the situation is not completely gloomy either.…”

Section: Discussionmentioning

confidence: 99%

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

Debnath

Kumar²,

Mathur

et al. 2012

Indian J Surg

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The purposes of this study were to revisit the utility of ultrasonography (USG) as a primary imaging modality in acute appendicitis (AA) and to establish the role of CT scan as a second-line/problem-solving modality. All cases of suspected AA were referred for urgent USG. USG was done with standard protocol for appendicitis. Limited computed tomographic (CT) scan [NCCT ± CECT (IV contrast only)] was done for the lower abdomen and pelvis where sonographic findings were equivocal. One hundred and twenty-one patients were referred for USG for suspected appendicitis. Eight-four patients underwent surgery for AA based on clinical as well as imaging findings, of whom 76 had appendicitis confirmed at histopathology. Three patients were misdiagnosed (3.6 %) on USG as appendicitis. Of 76 patients of appendicitis confirmed histopathologically, 63 (82.8 %) had features of appendicitis on USG and did not require any additional imaging modality. Of 121 patients, 12 (10 %) needed CT scan because of atypical features on USG. Of these 12 patients, seven had retrocecal appendicitis, and three high-up paracolic appendicitis. USG alone had sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of 81, 88, 92.6, 71.6, and 83 %, respectively. When combined with CT scan in select cases, the sensitivity, specificity, PPV, NPV, and accuracy of combined USG + CT scan were 96 % (P 00.0014), 89 %, 93 %, 93.5 % (P00.0001), and 93 % (P00.0484), respectively. Twentyeight (23 %) patients were given alternative diagnosis on USG. Dedicated appendiceal USG should be used as a primary imaging modality in diagnosing or excluding AA. Appendiceal CT can serve as a problem-solving modality.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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

Debnath

Kumar²,

Mathur

et al. 2012

Indian J Surg

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“…Few biochemical investigations like raised TLC and C-reactive protein (CRP) have been found to be associated with AA; however, raised TLC was found in only 59.3 % of our patients. It is known that TLC may be normal in AA and when used alone is not a consistent predictor of appendicitis [9,19]. Some studies have found a strong correlation between raised CRP and AA.…”

Section: Discussionmentioning

confidence: 99%

“…Some studies have found a strong correlation between raised CRP and AA. 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].…”

Section: Discussionmentioning

confidence: 99%

“…Various scoring systems, biochemical markers, and imaging modalities have been introduced to substantiate the diagnosis of AA and thereby decrease NAR. However, there is continuing controversy regarding their availability, cost, validity, and routine use [1,9,10]. A number of studies have been conducted in the West to audit and decrease NAR, but there is paucity of similar studies from the developing world.…”

Section: Introductionmentioning

confidence: 99%

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

Joshi

Alam

et al. 2014

Indian J Surg

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Negative appendectomy remains a concern in current surgical practice. Data from the developing world is scarce. Data of appendectomies during the last 5 years were analyzed. Interval and incidental appendectomies were excluded. The demographic details, presenting complaints, clinical signs, and investigations performed were recorded in a predesigned proforma. The data were critically analyzed. Six hundred eighty-five appendectomies were performed during the period. One hundred eighty-five patients with a normal appendix were identified on histopathology. Sixty-seven patients with incidental or interval appendectomies were excluded. Thus, 118 patients had appendectomies performed erroneously. All these patients with presumed diagnosis of acute appendicitis were operated on by resident surgeons. Records of 17 patients could not be retrieved. The most common symptom was abdominal pain (100 %), and the commonest sign was right iliac fossa tenderness (93 %). Most of the patients underwent USG to supplement the diagnosis. CT scan and diagnostic laparoscopy were not performed. The negative appendectomy rate was 17.2 % (12.4 % in males; 33.3 % in females). The highest incidence of negative appendectomy was in females aged 11-20 years (66.7 %). The rate of negative appendectomy at our institute is comparable with the world statistics. More diligence is required in making the clinical diagnosis of acute appendicitis, especially in young females. The use of C-reactive protein and CT scan may decrease the negative appendectomy rate.

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Effect of Reduction in the Use of Computed Tomography on Clinical Outcomes of Appendicitis

et al. 2015

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IMPORTANCE Advanced diagnostic imaging is commonly used in the evaluation of suspected appendicitis in children. Despite its inferior diagnostic performance, ultrasonography (US) is now preferred to computed tomography (CT) owing to concerns about ionizing radiation exposure. With changes in imaging modalities, the influence on outcomes should be assessed.OBJECTIVES To review trends in the use of US and CT for children with appendicitis and to investigate simultaneous changes in the proportions of negative appendectomy, appendiceal perforation, and emergency department (ED) revisits.

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Clinical Policy: Critical Issues in the Evaluation and Management of Emergency Department Patients With Suspected Appendicitis

Cited by 168 publications

References 65 publications

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

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

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

Effect of Reduction in the Use of Computed Tomography on Clinical Outcomes of Appendicitis

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