Related discussion and paper reading

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Related discussion and paper reading

• 2003.1.14
• ????? ??
• ????? ??

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PE terminology

• MacBurneys point
• Guarding voluntary
• Rigidity involuntary
• Rebound tenderness
• Late finding
• Gradually pressing 5-10 sec, then withdrawing the
  hand just above skin level.
• Rovsings sign
• Obturator sign
• Psoas sign

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Special group

• Children
• Often misdiagnosed
• Prone to rupture due to thinness of the
  appendiceal wall
• Diffuse peritonitis due to immature omentum

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Special group

• Women
• 25 with signs of appendicitis ultimately have
  gynecologic disease
• Cervical motion tenderness doesnt differentiate
  women with/without app.
• US, CT, laparoscopy can be helpful.
• Pregnant women
• Nasea, vomiting and leukocytosis non-specific
• Perforation rate 2-3x (due to delayed Dx)
• If appendix is perforated, fetal abortion 20

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Special group (2)

• Elderly patients
• 3x perforated appendix rate
• Weak appendiceal wall
• Delay seeking medical care
• Inability to leave home
• Difficulties in communication
• Atypical presentations
• Minimally abnormal lab tests

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Lab tests

• WBC 80-90 gt 10000/mm3
• CRP Sen 62, Spe 66
• U/A WBC gt 20/hpf suggest UTI

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Other studies

• Diagnostic scores
• Not performed consistently well
• KUB not useful in Dx
• US
• Sen 75-90, Spe 85-95
• Operator dependent
• Difficult Obesity, strictures, retrocecal
  appendix, perforated appencix
• Negative study is not helpful.

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Other studies (2)

• Computed tomography
• Diameter gt 6mm, pericecal inflammation,
  appedicolith.
• High negative predictive value
• Differentiate appendiceal/pelvic lesion.
• MRI
• T2W very sensitive
• Entire appendix visualized

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Other studies (3)

• Laparoscopy
• Suits female pts of childbearing age
• Minilaparoscopy (at bed side)
• Not promising due to inadequately visualize the
  appendix
• Most promising and readily
• CT and Ultrasound

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Management

• Parental antiemetics
• Short-acting opiates initially
• Longer-actiing opiates after consultation.
• IV 2nd-Generation cephalosporin
• Perforated
• Ampicilline gentamycin clindamycin
• Surgical resection

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Disposition

• Low suspicion
• MBD
• Kept on a liquid diet for next 6-8 hours
• Understand the sign/symptoms of appendicitis
• Document the discussion in the chart.
• Diagnose of gastroenteritis
• Only in patients with nausea, vomiting and
  diarrhea!!!

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Question 1

• ??????????????????Helical CT?

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Effect of computed tomography of the appendix on
treatment of patients and use of hospital
resources.

• Rao P, Rhea J, Novelline R, Mostafavi A, McCabe
  C. Effect of computed tomography of the appendix
  on treatment of patients and the use of hospital
  resources. N Engl J Med 1998338141-6.
• The results of CT led to changes in the treatment
  of 59/100 patients.
• Conclusions improves patient care and reduces
  the use of hospital resources.
• Sen 98, Spe 98
• Laparotomy 130932 NT
• Hospital admission per day 14580 NT
• CT 8208 NT
• Comments May still suit in Taiwan.

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Question 2

• ??????????CT?

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The use of helical computed tomography in
pregnancy for the diagnosis of acute
appendicitis.

• Ames Castro M - Am J Obstet Gynecol -
  01-Apr-2001 184(5) 954-7
• report for the first time the use of helical CT
  for a series of pregnant patients with suspected
  acute appendicitis
• All patients received colon contrast medium, 700
  to 1000 mL of a 3 meglumine diatrizote solution
  (Gastrografin Bristol-Myers Squib, Wallingford,
  Conn), through a rectal catheter immediately
  before scanning
• oral contrast medium, up to 750 mL as tolerated,
  of a 2.1 barium sulfate suspension (SCAN-C LPI
  Diagnostics, Anaheim, Calif) 30 minutes before
  scanning
• Total 7 patients, symptoms to presenting lt 12
  hrs. GA 20-38.

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• Advantages of helical CT
• Rapid examination time of approximately 15
  minutes.
• rectal contrast alone
• reliable in the diagnosis of appendicitis
• reduces the risk of systemic reactions of IV
  contrast
• use of a specific smaller incision rather than a
  large vertical incision during OP
• radiation exposure is approximately 300 mrad
• below the accepted safe level of fetal exposure
  (5 rad)
• chest radiography is 0.02 to 0.07 mrad and from
  CT pelvimetry is 250 mrad.

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Question 3, 4

• ?????????rectal contrast?
• ??????
• CT???????
• ????perforation
• ??????pelvis CT???Helical mode??
• ??,??????????routine??
• ??8mm??miss
• Appendix???????

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Question 5

• Conventional CT?Helical CT??????
• Conventional CT, entire abdomen and pelvis, oral
  and IV contrast
• accurate (93 to 94), sensitivity (96 to 98)
• 2-hour delay
• Conventional CT, L3-pubic symphysis , without
  contrast
• accurate (94), relatively insensitive (87)
• Helical CT, T12-pubic symphysis, without contrast
• accurate (94) and moderately sensitive (90)
• Helical CT, abdominopelvic junction, oral and
  colon contrast
• highly accurate (98) and sensitive (100)
• 30-minute delay (??oral contrast?????ileum)
• Helical CT, abdominopelvic junction after,
  contrast through the colon only
• highly accurate (98) and sensitive (98)
• performed almost immediately

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Question 6

• Appendiceal CT??????
• Patient is moved onto a CT table
• Right-side-down decubitus position
• 1000 mL of a 3 meglumine diatrizoate solution
  (Gastrografin, Bristol-Meyers Squibb,
  Wallingford, CT) is infused through the colon
• Using gravity-drip through IV tubing and a soft
  rubber rectal catheter, without use of a balloon.
• The patient is then placed supine, and a digital
  abdominal radiograph is obtained to localize
  cecal position and confirm cecal opacification
  if contrast material has not reached the cecum,
  more is administered.
• A helical CT series covering approximately 15 cm
  of the abdominopelvic junction is performed with
  5-mm collimation 7.5 mm/s table speed (1.5
  pitch) and 5-mm image spacing. The scan is
  centered about 3 cm above the cecal tip.

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Question 7

• Appendiceal CT???appdendix?????
• periappendiceal inflammation
• cecal apical changes
• measures greater than 6 mm in diameter
• fails to fill completely with contrast material
• may contain one or more intraluminal appendoliths
• appendiceal wall thickening
• appendiceal wall enhancement

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Question 8

• ?colon?contrast?????
• The RLQ anatomy is optimally depicted
• The ascending colon, ileocecal valve, and
  inferior cecal tip are readily identified,
  allowing for confident localization of the
  anatomic cecal apex (appendiceal origin) and the
  appendix itself.
• The normal appendix fills more often
• This improves appendix identification and
  definitively excludes obstructive appendicitis.
• The cecal apical changes of appendicitis are more
  likely to be identified with good cecal
  distention
• Both oral and IV contrast material can be avoided
  with no loss in diagnostic accuracy. This avoids
  the time delay

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Normal appendix

• Normal appendix. CT scan shows a patent lumen
  appendix (arrow) filled with air and contrast
  material

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Appendicitis

• CT scan shows a distended appendix (A) with
  adjacent inflammation behind a redundant sigmoid
  colon (S).

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Appendicitis

• Appendicitis. CT scan reveals a distended
  appendix with multiple layering appendoliths
  (arrow).

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Appendicitis

• phlegmon (P), arrowhead sign of appendicitis
  (arrow).

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Appendicitis

• CT scan shows a multiloculated abscess (arrows)
  containing an appendolith

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Appendicitis

• Normal appendix, ectopic location. CT scan shows
  a mobile cecum with a collapsed lumen appendix
  (arrow) in the left pelvis.

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Appendicitis

• Value of colon contrast material. CT scan shows a
  borderline abnormal, 7-mm appendix (A) with
  subtle focal cecal apical thickening (arrows).
  Focal cecal apical thickening is seen optimally
  when the cecum is distended, as with colonic
  contrast material administration.

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Appendicitis

• Distal appendicitis. CT scan shows a portion of a
  normal proximal appendix (arrow) and an inflamed
  distal appendix (curved arrow).

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Mesenteric adenitis-ileitis complex

• A, CT scan shows clumped, enlarged mesenteric
  lymph nodes (N) in the common mesentery for the
  terminal ileum, appendix, and cecum. B, Lower CT
  scan shows that the terminal ileal (T) wall is
  thickened. A portion of the normal appendix
  (arrow) is identified.

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Cecal diverticulitis

• CT scan shows multiple diverticula (arrow), and
  cecal (C) inflammatory wall thickening is
  identified. The normal appendix was noted at a
  lower level (not shown).

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Right-sided ovarian torsion

• At CT, a 6-cm ovarian cyst (O) is identified. In
  patients with suspected appendicitis, this should
  raise the suspicion for ovarian torsion.

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Right ureteral stone

• CT scan showing a mid-ureteral stone (arrow),
  with proximal ureteral obstruction (not shown).
  The normal appendix was at a lower level (not
  shown).

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Reference

• Question 5-8 and CT images
• Helical CT of appendicitis and diverticulitis.
• Rao PM - Radiol Clin North Am - 01-Sep-1999
  37(5) 895-910

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Thank you for comments and patience