Paper reading

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Paper reading

• Topic A Prospective Trial of Computed Tomography
  and Ultrasonography for Diagnosing Appendicitis
  in the Atypical Patient
• Date Sep. 15, 2001
• From the American Journal of Surgery,
• Presented by R2???
• Supervised by VS???

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BACKGROUND

• The diagnosis of appendicitis is made on history,
  physical examination, and WBC.
• In the atypical patient, CT and US have
  demonstrated utility in diagnosis, but have not
  been studied.

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METHOD

• Retrospective review of 500 appendectomy patients
  to develop the algorithm.
• Atypical patients lacking one or more of the
  classic signs (pain lasting less than 48 hours,
  migration pain, anorexia, and WBC gt 10,000).
• Atypical patients was entered into a
  prospective, randomized study of CT or US.

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• Including criteria 18-65 y/o patients with a
  diagnosis of appendicitis but have an atypical
  presentation.
• Between May 1997 and May 1999, 106 patients were
  enrolled into the study.

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• 17 were later excluded due to immediate surgery.
• The remaining 89 patients were then entered into
  image examination.
• 49 patients were assigned to CT and 40 to US.

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• Noncontrast CT with 5-mm cuts from L3 through the
  inferior aspect of the cecum were performed.
• Positive inflamed pericecal fat, an irregular
  semiliquid fluid-filled pericecal lesion with or
  without the presence of a gas bubble, the
  visualization of a fecalith, or a distecded
  appendix (? 7 mm in diameter).

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• Positive findings of US inflamed appendix was
  visualized and the outer-to-outer diameter
  measured 6-7 mm or more.

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RESULTS

• 89 patients were enrolled in the imaging study.
  (41 male, 48 female)
• Average duration of pain 45.9 hrs (3-336)
• Average WBC 12,800 (4700-27,500)
• 60 patients were with anorexia.
• 57 patients were with migration pain.
• 50 patients were with rebound tenderness.

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(No Transcript)
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CONCLUSION

• When should we use the complex diagnostic tests
  in the evaluation of patients with acute
  abdominal pain?
• A simple algorithm could be used to select
  patients.
• Unnecessary examination delayed operation,
  increase cost.
• Uncertainty of diagnosis negative appendectomy
  rate.

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• What kind of patients would benefit from
  diagnostic imaging prior to surgery?
• Which diagnostic imaging modality should there
  patients undergo?

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• A simple algorithm is better to be used in the
  emergency department.
• CT scanning has a greater diagnostic accuracy.
• Advantage of CT scan less dependent on body
  habitus, intestinal gas, technique, less time of
  observation.

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• Other benefit correct diagnosis of other
  surgical situation (Crohns disease and tubal
  abscess in this study).
• Classic presentation immediate operation without
  diagnostic imaging examination.
• Atypical patients CT scan.

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Alvarado score

• Migration of pain
• Anorexia
• Nausea-vomiting
• Tenderness in the right lower quadrant
• Rebound pain
• Elevated temperature
• Leukocytosis,, Shift to the left

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• The high scores in men and children were found to
  be an easy and satisfactory aid in the early
  diagnosis of acute appendicitis, but a high
  false-positive rate for acute appendicitis was
  found in women.

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• Ultrasound is unnecessary when one's degree of
  clinical suspicion is high. However, the
  additional information provided by ultrasound
  does improve diagnostic accuracy in the case of a
  negative or equivocal Alvarado score.

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• An algorithm combining the modified Alvarado
  score with selective laparoscopy is recommended
  for widespread use in the management of suspected
  acute appendicitis.