Abstract
Introduction This manuscript aims to investigate the amount of intraluminal gas in acute, nonperforated appendicitis identified on computed tomography (CT) in diagnosing gangrenous appendicitis. Methods This is a retrospective observational, case-control study with consecutive data collected at a tertiary institution over a two-year period, of patients with CT-diagnosed acute appendicitis who subsequently went on for surgery within 48 hours. Patients who were less than 16 years old, who had an interval between CT and surgery of more than 48 hours, or with CT evidence of appendiceal perforation were excluded. Images were independently assessed by 3 radiologists for intraluminal gas, and the results were then correlated with reference standards obtained from surgical and histopathology reports for the diagnosis of nongangrenous versus gangrenous appendicitis. The sensitivity, specificity, and predictive values of CT intraluminal gas in gangrenous appendicitis were calculated. Results Our study identified 93 patients with nonperforated acute appendicitis who underwent surgery within the stated timeframe. Intraluminal gas in the appendix was identified in 26 patients (28%), of which 54% had macroscopic and/or microscopic evidence of gangrenous appendicitis. This is in contrast to the subgroup of patients who did not have intraluminal gas (72%), of which only 33% had gangrenous appendicitis. The specificity of intraluminal gas for gangrenous appendicitis is 79%, with a negative predictive value of 86% and likelihood ratio of 1.85. Conclusion In cases of established acute appendicitis, the presence of intraluminal gas is a moderately specific sign for gangrenous complication. This is worth reporting as it can help prognosticate and triage patients accordingly, for a timelier surgical management and a better outcome.
Highlights
Acute appendicitis is an important cause of acute abdominal pain, with appendectomies being the most common emergency procedure performed in Australia [1]
Gangrenous appendicitis is associated with higher rates of complications such as perforation, abscess, and faeculent peritonitis. ese have significant implications in patients, as they are associated with increased length of hospital stay, higher morbidity and mortality, and higher rates of open incision surgery and hospital readmission [1]
Due to the wide variation of clinical findings on examination in cases of acute appendicitis, computed tomography (CT) has been a useful imaging modality to decrease the rate of negative appendicectomies and identify complicated cases such as perforation [13, 14]. ere are many studies researching CT markers to differentiate perforated versus nonperforated appendicitis
Summary
Acute appendicitis is an important cause of acute abdominal pain, with appendectomies being the most common emergency procedure performed in Australia [1]. Whilst acute appendicitis is a clinical diagnosis, CT scanning has become an important imaging tool to reduce the rate of negative or unnecessary surgeries by identifying other causes of abdominal pain which can mimic appendicitis. Appendicitis can have different clinical presentations, with overlapping clinical features between acute uncomplicated and complicated appendicitis such as perforation and abscess collection [2], and imaging plays an important role in differentiating between the simple and complicated cases [3]. Gangrenous appendicitis is estimated to occur in 17% of cases of acute appendicitis [5] and is associated with increased rates of complications such as intra-abdominal abscesses and appendiceal perforation [1] if surgical management is delayed. As the inflammation progresses towards gangrenous complication, intraluminal air develops in a similar pathophysiology as in the development of pneumatosis intestinalis
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