CT scans do not reliably identify appendicoliths in acute appendicitis

Mariadason, James G.; Bhattarai, Prabhat; Shah, Seema; Mitaszka, Katie; Belmonte, A.; Matari, Hussein; Chiechi, M.; Mk, Wallack

doi:10.1016/j.sipas.2022.100113

Cited by 3 publications

(4 citation statements)

References 29 publications

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“… 9 , 21 The reported sensitivity and specificity of modern pCT imaging in detecting an appendicolith is 66% and 82%, respectively. 28 This may be falsely low because appendicoliths seen on pCT may be removed from histopathology specimens by handling of the appendix intraoperatively. 6 With significant evidence suggesting that an appendicolith appendicitis is a risk factor for failure of nonoperative management, 7 , 29 along with the increasing trend of preoperative diagnostic imaging providing additional radiological data to our clinical practice, 9 , 21 we advocate that the presence of an appendicolith should be considered in the management of acute appendicitis patients despite its low sensitivity when pCT is utilised.…”

Section: Discussionmentioning

confidence: 99%

Appendicolith appendicitis: should we be operating sooner? A retrospective cohort study

Taib,

Kler,

Prayle

et al. 2024

annals

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Introduction Evidence suggests that delaying an appendicectomy for up to 24 hours does not increase the risk of complicated appendicitis. Appendicoliths are a risk factor for perforation. No study has explored the temporal relationship between appendicolith presence and time to perforation. In this retrospective cohort study, we hypothesise that the presence of an appendicolith confirmed on preoperative computerised tomography scan (pCT) leads to a shorter time to complicated appendicitis. Methods We undertook a retrospective single-centre study of patients admitted between 2018 and 2020. Inclusion criteria included: age ≥18 years, appendicitis confirmed on histopathology following an operation and a pCT scan. Complicated appendicitis was defined intraoperatively as an appendicular abscess, gangrenous or perforated appendix. Results Some 310 patients were included in the study. Forty-five per cent presented with complicated appendicitis (n = 138). Appendicoliths were present in 79 (25.5%) patients. Multivariate logistic regression identified an appendicolith as a significant risk factor for perforation (odds ratio 3.50, 95% confidence interval [CI] 1.16–10.59; p = 0.027). Within the first 12 hours of admission, patients with an appendicolith accounted for a significantly greater proportion of those with complicated appendicitis intraoperatively compared with those without (56.7% vs 43.3%, respectively; p = 0.003). Within 12 hours of admission, those with an appendicolith were 2.05 times more likely to suffer from complicated appendicitis than those without (95% CI 1.28–3.29). Conclusions Patients with an appendicolith appendicitis should be considered for an early appendicectomy. Future large-scale multicentre prospective studies are required to explore this further, perhaps informing future guidelines.

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Section: Discussionmentioning

confidence: 99%

Appendicolith appendicitis: should we be operating sooner? A retrospective cohort study

Taib,

Kler,

Prayle

et al. 2024

annals

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“…The negative appendectomy rates in western countries also vary with the rate being 19% to 33% in the United Kingdom [14,15].…”

Section: Negative Appendectomy Defini-tion and Ratementioning

confidence: 99%

Negative Appendectomy Rates -Current Prospective- A Review

Kumar

Soma

2023

AJMAH

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The negative appendectomy rate is generally accepted in the diagnosis of acute appendicitis to prevent complications like perforation. This rate varies according to countries in western and eastern regions of the world. Clinical scoring systems, inflammatory markers and imaging have been used to reduce the negative appendectomy rate. The introduction of computerized tomography has improved the diagnostic accuracy of acute appendicitis. As this rate has been progressively decreasing over the past few years, a review article was done to look at the role of scoring systems, inflammatory markers, and imaging in diagnosing acute appendicitis and hence reduce the negative appendectomy rate.

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“…The accurate noninvasive detection of appendicoliths in adults with appendicitis becomes important for determining whether NOM is a feasible option in an otherwise uncomplicated case. The diagnostic performance of contrast-enhanced CT in the detection of appendicoliths had been explored in detail in a few investigations that used surgical specimens and histopathology as a reference standard [30,33]. These investigations identified a wide range of sensitivity (21-81%; overall 56%), specificity (78-96%; overall 86%), and radiologists' agreement (kappa; 0.48-0.83) [33].…”

Section: Diagnostic Performance Of Portovenous-phase Ct In the Detect...mentioning

confidence: 99%

“…The diagnostic performance of contrast-enhanced CT in the detection of appendicoliths had been explored in detail in a few investigations that used surgical specimens and histopathology as a reference standard [30,33]. These investigations identified a wide range of sensitivity (21-81%; overall 56%), specificity (78-96%; overall 86%), and radiologists' agreement (kappa; 0.48-0.83) [33]. However, we believe that the poor CT performance in the detection of appendicolith in these reports stemmed from the radiologic definition of appendicoliths as a "calcific" deposit [9,10], which categorically excludes noncalcific intraluminal contents within an appendix from being classified as appendicolith.…”

Section: Diagnostic Performance Of Portovenous-phase Ct In the Detect...mentioning

confidence: 99%

CT of appendicoliths in adult appendicitis: clinical significance and characteristics of overlooked cases

Kaewlai,

Wongveerasin,

Lekanamongkol

et al. 2023

Eur Radiol

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Objectives Accurate computed tomography (CT) identification of appendicoliths in adults with acute appendicitis is crucial as it may preclude nonoperative management due to high risk of failure and complications. This investigation aimed to identify the significance of appendicoliths in acute appendicitis and to evaluate the performance of portovenous-phase (PVP) CT and the consequences of overlooked appendicoliths. Methods CT examinations of 324 consecutive patients (mean age 51.9 years, 112 men) with pathologically confirmed acute appendicitis were retrospectively included. Two radiologists independently reviewed the images, and disagreement was resolved by a consensus. Results Appendicoliths were identified in 134/324 patients, of which 75 had complicated appendicitis. Among 190 patients without appendicoliths, 52 had complicated appendicitis. An appendicolith was independently associated with complicated appendicitis (adjusted odds ratio 2.289; 95% CI: 1.343–3.902; p = 0.002). The larger minimum diameter was significantly associated with complication. The 4.5-/6.0-mm cutoffs for minimum and maximum diameters of appendicoliths demonstrated 82.7%/85.3% sensitivity and 35.6%/33.9% specificity in predicting complications. The PVP alone had 82.1–88.1% sensitivity, respectively per patient and per appendicolith, and a 100% specificity in the detection of appendicoliths, as compared with combined noncontrast and PVP. PVP overlooked 28/237 appendicoliths (11.8%) corresponding to 24/134 patients (17.9%). Of the 24 patients with overlooked appendicoliths, 16 had complicated appendicitis but 14 were correctly categorized by findings other than appendicoliths. In total, 2/127 patients (1.6%) with complicated appendicitis were misdiagnosed as having uncomplicated appendicitis. Conclusions Appendicoliths in acute appendicitis were strongly associated with complications. While PVP overlooked some appendicoliths, only 1.6% of complicated appendicitis were misclassified when considering other CT findings. Clinical relevance statement This study found a strong association between appendicoliths and complications. Its presence may preclude conservative management. Although portovenous-phase CT overlooked some appendicoliths, the combination with other CT findings allowed correct classification in a vast majority of cases. Key Points • Accurate identification of appendicoliths is crucial for nonoperative management decisions in adult acute appendicitis. • Appendicoliths are strongly associated with complications in adult acute appendicitis. • Portovenous-phase CT overlooked some appendicoliths, but only a small percentage of patients with complicated appendicitis were misclassified when considering other CT findings.

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CT scans do not reliably identify appendicoliths in acute appendicitis

Cited by 3 publications

References 29 publications

Appendicolith appendicitis: should we be operating sooner? A retrospective cohort study

Appendicolith appendicitis: should we be operating sooner? A retrospective cohort study

Negative Appendectomy Rates -Current Prospective- A Review

CT of appendicoliths in adult appendicitis: clinical significance and characteristics of overlooked cases

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