Abstract

Objectives: The aim of this retrospective study was to clarify whether plasma markers that are routinely used in the workup of patients suspected for acute appendicitis (AA) can stratify for imaging in both adults and children. Methods: A total of 1388 patients suspected of AA between January 2008 and till 2012 were included. CRP and WBC concentrations were retrospectively abstracted from the electronic health record. Receiver operating characteristic (ROC) curves were used to assess the diagnostic accuracy for the tests and to determine the best cutoff points. Results: In total 432 (22.4%) patients had histopathologically proven AA of whom 45 patients (10.4%) had perforated appendictis. The area under the curve (AUC 95% confidence interval [CI]) was 0.74 (95% CI = 0.70 to 0.77) for CRP and 0.74 (95% Cl = 0.71 to 0.78) for WBC both in adults and children. No cut off points had high enough sensitivity and specificity to accurately diagnose (perforated) AA. However, a high sensitivity of 91% was shown at cut-off 7.5x109/L WBC for AA (both in adults and children). In total 244 (18%) had a cut-off < 7.5×109/L. Those patients could have been sent home. Only 21 (5%) patients would have been missed in the AA group and 1(0.5%) patient in the perforated appendicitis group. Conclusions: None had clinical relevant cutoff points that could accurately discriminate between AA and other pathology, neither perforated appendicitis. However, WBC < 7.5×109/L for AA can identify a subgroup of 245 out of 1388 (18%) patients that could have been sent home without further imaging.

Highlights

  • Acute appendicitis (AA) is the most common abdominal emergency requiring emergency surgery with a lifetime risk of 8.6% in males and 6.7% in females [1]

  • The Dutch College of Surgeons published a new national guideline in 2010 concerning the diagnostic workup of patients suspected for appendicitis, which stated that when the surgeon still suspects appendicitis after clinical and laboratory examination, the patient should proceed to imaging [4,5]

  • The results of the OPTIMA trial showed that ultrasonography (US) and computed tomography (CT) improve diagnostic accuracy in patients with acute abdominal pain [7,8]

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Summary

Introduction

Acute appendicitis (AA) is the most common abdominal emergency requiring emergency surgery with a lifetime risk of 8.6% in males and 6.7% in females [1]. The clinical presentation is often atypical and symptoms often overlap with other conditions, which results in a negative appendectomy rate of 20% [2,3]. This could lead to increased length of hospital stay, costs and higher case fatality rates. The workup of suspected appendicitis is a prime target for improved decision making and a key recommendation of emergency surgical care guidelines. The results of the OPTIMA trial showed that ultrasonography (US) and computed tomography (CT) improve diagnostic accuracy in patients with acute abdominal pain [7,8]

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