Appendicitis In Pregnant Patients Research Articles

Diagnostic value of systemic immune inflammation index in acute appendicitis and complicated appendicitis in pregnant patients.

Acute pain in the right lower quadrant during pregnancy is difficult to approach and acute appendicitis must be excluded. The complication rate in pregnant acute appendicitis increases as a result of delayed diagnosis due to physiological and anatomic changes. The systemic immune inflammatory index (SII), which includes several inflammatory tests, is considered to be a good indicator of acute inflammation. The aim of the present study was to investigate the diagnostic value of SII in the diagnosis of acute appendicitis and complicated appendicitis in pregnant women. This was designed as a retrospective, single-center case-control study. This study was performed in pregnant women over 12 weeks of gestation who were diagnosed with acute appendicitis as indicated by pathology report and met the inclusion criteria. Vital parameters, demographic characteristics, laboratory values, presence of complicated appendicitis, and pathology reports were taken into analysis. The present study was performed with 76 pregnant women, including 38 pregnant women with acute appendicitis and 38 pregnant women with healthy controls. SII had a sensitivity of 82.0% and specificity of 66.7% with a cut-off value of 840.13 in pregnant acute appendicitis cases (AUC: 0.790; 95% CI: 0.686-0.984; p < 0.001) and SII level was significantly higher in complicated appendicitis cases with a sensitivity and specificity of 66.7% and 91.3%, respectively, with a cut-off value of 2301.66 (AUC: 0.812; 95% CI: 0.665-0.958; p = 0.001). SII is a cost-effective, rapid, easily calculated, and powerful marker that can be used for the diagnosis of both acute and complicated appendicitis in pregnant patients.

Acute appendicitis in pregnancy, is there a role for conservative management?

Background: Although rare, acute appendicitis is the most common general surgery problem encountered in pregnancy. A chief concern is timely and accurate diagnosis. Traditionally, delayed diagnosis of appendicitis in pregnant patients can quickly lead to appendiceal rupture associated with miscarriage, premature delivery, or even fetal loss. Hence, appendectomy has been the gold standard. However, emerging evidence suggests conservative management may be more effective than previously thought, after accounting for maternal and fetal characteristics. Methods: This retrospective study included a sample of pregnant women diagnosed with acute appendicitis presenting for treatment to two hospitals in Queens, NY, between Jan 2012 and Dec 2021. The characteristics, presentation, and outcomes of conservatively versus surgically treated patients were compared. Results: The cumulative incidence of acute appendicitis was 0.11% (n=44/28,000). Forty were treated surgically: 78% underwent laparoscopic appendectomy, 15% open appendectomy, and 8% underwent an initial laparoscopy which was converted to an open appendectomy. Four (14%) patients were managed conservatively with IV antibiotics. Eight percent of patients treated surgically had postoperative complications. Neither surgical nor conservatively treated groups reported any instance of mortality or fetal demise. Conclusions: Our study adds to the literature on treatment decisions for pregnant patients with acute appendicitis. Although surgical intervention remains the gold standard, it carries the potential risk of peri- and postoperative complications. These findings suggest conservative management with antibiotics can sometimes be used without a negative impact on maternal or fetal outcomes.

INCIDENCE OF CONVERSION TO OPEN APPENDECTOMY FROM LAPAROSCOPIC APPENDECTOMY IN PREGNANT FEMALES

Acute appendicitis is a common non-obstetric indication for surgery in pregnant women, and the choice between laparoscopic and open appendectomy remains a subject of debate. While the benefits of laparoscopic appendectomy over open surgery are well-established in the non-pregnant population, consensus is lacking in the pregnant cohort. This study aims to contribute insights into the optimal surgical approach for acute appendicitis in pregnant women. The study, conducted from January 2020 to December 2022 at Nishtar Hospital, Multan, focused on 45 pregnant women presenting with abdominal pain and diagnosed with acute appendicitis. Two patients were discharged after magnetic resonance imaging (MRI) revealed a normal appendix. Of the remaining 43 cases, 27 were in the first trimester, 8 in the second trimester, and 8 in the third trimester. All patients underwent successful laparoscopic appendectomy without any conversion to open surgery. The laparoscopic procedure duration ranged from 50 to 80 minutes, with an average postoperative hospital stay of 1.5-3 days. Postoperative wound infection occurred in three patients (6.66%), and two patients (4.44%) experienced preterm labor. Fetal outcomes, assessed through Apgar grading, size, and weight, showed no notable abnormalities after birth. Laparoscopic appendectomy, regardless of gestational age, proves generally safe and suitable for pregnant women with acute appendicitis. The procedure has minimal complications, making it a viable and preferred option during pregnancy. These findings advocate for the continued consideration of laparoscopic appendectomy as a standard approach for managing acute appendicitis in pregnant patients.

Antibiotic versus surgery in the treatment of acute appendicitis in the pregnant population: A systematic review and meta-analysis.

Introduction: Acute appendicitis is the most common surgical emergency in pregnant women. There has been a wide variance in clinical practice worldwide, with some favoring an antibiotic-only approach while others prefer surgery as the first-line management. Therefore, we designed the current analysis to synthesize the available evidence on the efficacy and safety of antibiotics versus surgery management. Methods: We searched PubMed, Scopus, EuropePMC, and Cochrane Central from March 4, 1904 until November 25, 2022, to look for studies comparing antibiotics and surgery in pregnant patients with acute appendicitis. We only included studies that provided a comparison between the two treatments. We included preterm delivery, fetal loss, maternal death, and complications as outcomes. The results were compared using an odds ratio and 95% confidence interval. We also performed a sensitivity analysis by excluding studies with a serious risk of bias. Results: We included five non-randomized studies for the analysis. We found that patients in the antibiotic group had a lower risk of preterm labor (OR 0.63 [95% CI 0.43-0.92]; p 0.02) but a higher risk of complications (OR 1.79 [95% CI 1.19-2.69]; p 0.005). We did not find any difference in the other outcomes. Conclusion: The increased risk of complications should caution clinicians about using antibiotics as the first-line management. More studies are required to identify patients who would benefit the most before antibiotics could be adopted as a treatment for acute appendicitis in pregnant patients.

Antibiotic versus surgery in the treatment of acute appendicitis in the pregnant population: A systematic review and meta-analysis

Introduction: Acute appendicitis is the most common surgical emergency in pregnant women. There has been a wide variance in clinical practice worldwide, with some favoring an antibiotic-only approach while others prefer surgery as the first-line management. Therefore, we designed the current analysis to synthesize the available evidence on the efficacy and safety of antibiotics versus surgery management. Methods: We searched PubMed, Scopus, EuropePMC, and Cochrane Central from March 4, 1904 until November 25, 2022, to look for studies comparing antibiotics and surgery in pregnant patients with acute appendicitis. We only included studies that provided a comparison between the two treatments. We included preterm delivery, fetal loss, maternal death, and complications as outcomes. The results were compared using an odds ratio and 95% confidence interval. We also performed a sensitivity analysis by excluding studies with a serious risk of bias. Results: We included five non-randomized studies for the analysis. We found that patients in the antibiotic group had a lower risk of preterm labor (OR 0.63 [95% CI 0.43–0.92]; p 0.02) but a higher risk of complications (OR 1.79 [95% CI 1.19–2.69]; p 0.005). We did not find any difference in the other outcomes. Conclusion: The increased risk of complications should caution clinicians about using antibiotics as the first-line management. More studies are required to identify patients who would benefit the most before antibiotics could be adopted as a treatment for acute appendicitis in pregnant patients.

Diffusion-weighted imaging versus non-contrast magnetic resonance imaging in the diagnosis of acute appendicitis during pregnancy

The aim of this study was to evaluate the diagnostic performance of diffusion-weighted imaging compared to non-contrast magnetic resonance imaging in the differential diagnosis of acute appendicitis in pregnant patients. A total of 72 pregnant patients with the suspicion of acute appendicitis who underwent magnetic resonance imaging combined with diffusion-weighted imaging examinations were enrolled in this retrospective study. Magnetic resonance imaging images (non-contrast and diffusion-weighted imaging sequences) were evaluated. Moreover, apparent diffusion coefficient ratios were estimated. The diagnostic performances of magnetic resonance imaging and diffusion-weighted imaging findings were statistically analyzed on the basis of surgical and follow-up results. Of 72 pregnant patients, 10 (14%) had acute appendicitis on magnetic resonance imaging and diffusion-weighted imaging. Among 10 patients with acute appendicitis, three (3/10) had perforation. diffusion-weighted imaging findings had higher sensitivity (90 versus 60%), negative predictive value (98.41 versus 93.94%), and accuracy (98.61 versus 94.44%) ratios compared to non-contrast magnetic resonance imaging in the diagnosis of acute appendicitis. There was one false-negative result on diffusion-weighted imaging. Diffusion restriction facilitated the detection of appendicitis. The apparent diffusion coefficient ratios were lower in acute appendicitis than in the normal appendix (0.70±0.19 versus 0.96±0.16) (p<0.05). With a shorter scan time and higher diagnostic accuracy, diffusion-weighted imaging can be useful for the early diagnosis of acute appendicitis and for planning appropriate management.

MRI remains highly accurate in the diagnosis of appendicitis in pregnancy when read by radiologists of mixed specialty training and experience.

To audit the accuracy of magnetic resonance imaging (MRI) abdominal studies performed in the diagnosis of appendicitis in pregnant patients when read by radiologists of mixed experience. MRI reports from 45 pregnant women presenting to our emergency department for the investigation of appendicitis between 2009 and 2020 were retrospectively reviewed. Where available, these reports were correlated with surgical and pathology reports as well as follow-up clinical information. Following a review of literature, accuracy targets were set. Statistical analyses including sensitivity, specificity, positive, and negative predictive values were calculated. A total of 18 radiology consultants read 45 MRI abdominal studies in the assessment of appendicitis during pregnancy with 62% (n = 28) of these read by specialist radiologists and the remainder by general radiologists. This yielded an accuracy in diagnosis of 99.8%, sensitivity of 80% (95% CI: 49-94.3%), and specificity of 100% (95% CI: 90-100%). The calculated negative predictive value was 94.6% (95% CI: 82.3-98.5%), and positive predictive value was 100% (95% CI: 90-100%). The appendix was not identified in 19 patients (42%). A statistically significant relationship between the presence of right iliac fossa stranding of the fat OR free fluid was associated with appendicitis (p = 0.01). Alternate diagnoses were identified in 8% (n = 4) of cases. MRI is a highly accurate imaging modality for the assessment of appendicitis in pregnancy. Even with variable reader MRI experience, MRI demonstrates an accuracy of 99.8% and a positive predictive value for acute appendicitis of 100%. Double reading and the possible inclusion of DWI may help further improve accuracy and minimise false-negative rates.

Spontaneous Rupture of Unscarred Uterus in Second Trimester Pregnancy Presented as Acute Appendicitis; An Unusual Obstetric Emergency and the Importance of Imaging in Suspected Acute Appendicitis in Pregnancy

Spontaneous uterine rupture in an unscarred uterus in early trimester is very rare and difficult to diagnose. We reported a case of 28 years old lady at 15th week of gestation with three previous uneventful obstetrical history presented with one-day history of acute right iliac fossa pain and vomiting. She was subjected for an open appendectomy after an assessment by obstetric and surgical team which revealed ruptured of uterine fundal. She recovered well but she lost her pregnancy. Traditional management of acute appendicitis in pregnant patients is an early exploration. However recent studies showed that it was unpractical as the rate of pregnancies loss was two times with negative appendectomy compared to simple appendicitis; and almost as high as complicated appendicitis. All suspected appendicitis cases required ultrasound studies, and when the diagnosis is uncertain, further imaging such as computed tomography (CT) scan or magnetic resonance imaging is needed prior to surgery.

Acute appendicitis in pregnancy

Acute appendicitis is the most frequent non-obstetrical surgical emergency encountered in pregnancy with negative maternal and fetal outcomes, mostly attributed to appendicular perforation. The purpose of this article is to discuss the characteristics in diagnosing appendicitis in pregnancy, recommendations of management, as well as maternal and fetal outcomes. It is significantly challenging to diagnose appendicitis in pregnancy due to the anatomic displacement of the appendix caused by the enlargement of the uterus (which may cause uncommon symptomatology), the physiologic leukocytosis of pregnancy, the raised prevalence of abdominal discomfort along with the inability to perform computed tomography because of the radiation exposure of the fetus. These particularities may delay an accurate and timely diagnosis which is of utmost importance in order to avoid the significant complications associated with peritonitis. Rapid surgical intervention (especially laparoscopy) is recommended, nevertheless, the key in managing appendicitis in pregnant patients is finding a balance between the risk of delaying the diagnosis and consequent perforation against the risk associated with a negative appendectomy.

The diagnostic role of hemogram parameters in pregnant appendicitis.

Acute appendicitis is the most frequently encountered non-obstetric disease requiring surgical intervention during pregnancy. Early diagnosis reduces maternal and fetal morbidity / mortality rates. This study aims to investigate hemogram parameters in the diagnosis of acute appendicitis in pregnant women. A retrospective case-controlled study was conducted in three groups. Thirty-nine pregnant patients with acute appendicitis (Group A), 39 fertile nonpregnant patients with acute appendicitis (Group B), and 39 healthy pregnant women (Group C) were included in the study. WBC, neutrophil count, lymphocyte count, NLR, PLR, MPV and RDW values were compared. The mean NLR values in group A, group B and group C were 7.39 (1.58-46.6), 5.66 (1-20) and 4.23 (1.54-10.77) respectively, and there was a significant difference in NLR values between the groups (P= 0.002). The mean PLR values in group A, group B and group C were 159.09 (69.1-574), 134.28 (21.5-360) and 120 (68.7-334) and difference was statistically significant (P= 0.019). Cutoff points for WBC count was 14155 106/μL (51,3% sensitivity, 82,1% specificity), for neutrophil count is 10955 106/μL (53,8% sensitivity, 84,6% specificity), for NLR is 9.23 (46,2% sensitivity, 92,3% specificity) and PLR is 157,6 (51,3% sensitivity and 82,1% specificity) NLR had largest area under the curve with 0.667 NLR. Neutrophil count, WBC and PLR were found to be the most valuable inflammatory parameters however, RDW, Lymphocyte count, and MPV levels are not found valuable markers in terms of sensitivity and specificity in the diagnosis of acute appendicitis in pregnant patients by this study.

Acute Appendicitis During Pregnancy: A Case Series of 42 Pregnant Women.

IntroductionIt is difficult to diagnose the symptoms of acute appendicitis in pregnant women due to its similarities with pregnancy physiology. In this study, we examined the diagnostic value of laboratory parameters in the diagnosis of acute appendicitis in pregnant women.Material and methodsForty-two patients who underwent appendectomy during pregnancy were evaluated. The demographic characteristics, laboratory parameters and imaging methods of the patients were examined. According to the pathology results, the patients were evaluated in two groups as normal appendix and acute appendicitis. In addition, a non-pregnant control group was formed to compare the results between the pregnant and control groups.ResultsThe mean age of the 42 patients was 30±6 years, and the pathology results were evaluated as normal in 16 (38.1%) of the patients. As imaging methods, ultrasonography was undertaken in all patients, with MRI being additionally performed in two patients. When the normal appendix and acute appendicitis groups were compared, no significant difference was observed in terms of laboratory parameters (neutrophil, lymphocyte, white blood cell and platelet counts, neutrophil-lymphocyte ratio, platelet-lymphocyte ratio, mean thrombocyte volume, red cell distribution width, and pregnancy trimesters (P>0.05). The group that had undergone appendectomy had a significantly higher rate of negative appendectomy compared to the control group (P=0.001).ConclusionLaboratory parameters alone cannot be sufficient for the diagnosis of acute appendicitis in pregnant patients. If clinical examination, laboratory parameters and USG are not sufficient for diagnosis, MRI is the imaging method that should be considered to reduce negative appendectomy rate.

Using Online Survey Software to Enhance Radiology Learning

Online educational modules can augment radiology learning by creating opportunities to interact with images in more dynamic ways than with static presentation of images in lectures or journal articles. Building these modules on an online survey platform allows for quantitative assessment and learner feedback, without requiring programming knowledge or need for new website creation. Interactive online tutorials were built on a web-based survey platform (Qualtrics, Provo, Utah) accessible by computer or mobile device to teach radiology imaging findings of selected high-morbidity diagnoses. Topics included congenital-type internal hernias (module 1), acute appendicitis in the pregnant patient (module 2), and unintentionally retained surgical instruments (RSI; module 3). Modules consisted of pretest, educational module, and post-test components. For modules 1 and 2, graphics interchange formats were utilized to show CT and MRI image stacks for the diagnosis of congenital-type internal hernias and acute appendicitis in pregnant patients, respectively. For module 3, the "Heat Map" format was chosen to showcase intraoperative radiograph cases, which allowed participants to click on the potential RSI in the image. Pre- and post-test scores were evaluated. To determine statistical significance, an alpha level of 0.05 was utilized. Module 1 (Internal Hernia): Twenty-one radiology trainees completed the module. The mean pretest score was 3.66 (±1.13) points out of a total 6 possible points (61%), compared to 4.52 (±1.03) points on the post-test (75%). This was a statistically significant increase on the post-test of 0.87 points (95% CI [confidence interval] 0.36, 1.38), t(20) = 3.53, p= 0.002. Module 2 (MR Appendicitis): Seventeen radiology trainees completed the module. The mean pretest score was 3.18 (±1.42) points out of a total 6 possible points (53%), compared to 5.12 (±0.86) points on the post-test (85%). This was a statistically significant increase on the post-test of 1.94 points (95% CI 1.12, 2.76), t(16) = 5.00, p< 0.001. Module 3 (RSI): One hundred seven participants completed the module. The mean pretest score was 3.60 (±1.53) points out of a total 6 possible points (60%), compared to 4.54 (±1.36) points on the post-test (76%). This was a statistically significant increase on the post-test of 0.94 points (95% CI 0.67, 1.21), t(106) = 6.84, p< 0.001. An online survey platform can be used to build interactive education modules. Post-test scores significantly improved from pretest scores with these educational modules.

The value of inflammatory markers in diagnosing acute appendicitis in pregnant patients.

Acute appendicitis (AA) is the most common extra-obstetric condition requiring surgery during pregnancy. AA diagnosis is made by laboratory tests along with anamnesis and physical examination findings. Due to the physiological and anatomical changes during the pregnancy, AA diagnosis is more challenging in pregnant women compared to non-pregnant patients. The present study evaluated the significance of white blood cell counts (WBC), neutrophil-to-lymphocyte ratio (NLR), C-reactive protein/albumin ratio (CAR) and lymphocyte-to-C-reactive protein ratio (LCR) to diagnose acute appendicitis during pregnancy. Pregnant patients admitted to General Surgery Inpatient Clinic with AA pre-diagnosis in September 2015-December 2019 period were screened using International Statistical Classification of Diseases and Related Health Problems-10 (ICD-10) diagnosis code (K35= acute appendicitis, Z33= pregnancy), and AA patients were identified retrospectively. The patients were divided into two groups. The Group I included the patients who had appendectomy due to AA and had a suppurative appendicitis diagnosis based on the pathological evaluation. On the other hand, Group II had the patients admitted as an inpatient with AA pre-diagnosis, but discharged from the hospital with full recovery without operation. Group III, i.e., the control group, on the other hand, was constituted by 32 randomly and prospectively recruited healthy pregnant women who were willing to participate in the study and who had matching study criteria among the patients followed in Obstetrics and Gynecology outpatient clinic of our hospital. This study included 96 pregnant women with an average age of 29.20±4.47 years (32 healthy pregnant women, 32 pregnant women followed for acute abdominal observation and 32 pregnant women who underwent appendectomy). Of these patients, three cases who turned out not to have suppurative appendicitis (negative appendectomy) and two cases found to have perforated appendicitis based on intraoperative and histopathological evaluations were excluded from this study. The results showed that Group I patients had significantly higher WBC (p=0.001), CAR (p=0.001) and NLR (p=0.001), but significantly lower LCR values (p=0.001) compared to the Groups II and III. Besides, based on logistic regression analysis, it was revealed that higher WBC, CAR and NLR values and lower LCR values were independent variables that could be used for the diagnosis of AA in pregnant women. Considering WBC, NLR, CAR and LCR parameters in addition to medical history, physical examination and imaging techniques could help clinicians diagnose acute appendicitis in pregnant women.

Pregnancy and appendicitis: a systematic review and meta-analysis on the clinical use of MRI in diagnosis of appendicitis in pregnant women

BackgroundThe aim of this systematic review and meta-analysis was to evaluate the clinical use of MRI for the evaluation of acute appendicitis during pregnancy.MethodsThe searches were conducted by two independent researchers (MK, MS) to find the relevant studies published from 1/1/2009 until end of 30/12/2018. We searched for published literature in the English language in MEDLINE via PubMed, EMBASETM via Ovid, The Cochrane Library, and Trip database. For literature published in other languages, we searched national databases (Magiran and SID), KoreaMed, and LILACS. The keywords used in the search strategy are Pregnancy [MeSH], Pregnant [MeSH] OR—Magnetic resonance imaging [MeSH] OR—Appendicitis [MeSH] OR—Ultrasound, [MeSH] OR, imaging, MRI [MeSH] OR"،" and Right lower quadrant pain [MeSH]. The risk of bias of every article was evaluated by using QUADAS-2. On the basis of the results from the 2 × 2 tables, pooled measures for sensitivity, specificity, diagnostic odds ratio (DOR), and area under the curves (AUC) along with their 95% confidence intervals (CIs) were calculated using the DerSimonian Lair methodology.ResultsAs many as 1164 studies were selected. After analyzing the correspondence of the studies with the required criteria, 19 studies were selected for the final review. For appendicitis in pregnancy, the MRI sensitivity was 91.8% at the 95% confidence interval of (95% CI 87.7–94.9%). At the confidence interval of 95%, the specificity was 97.9% (95% CI 0.97.2–100%). The risk of bias in the studies conducted was measured using the QUADAS-2 tool.ConclusionMRI has high sensitivity and specificity (91.8%, 97.9% respectively) for the diagnosis of acute appendicitis in pregnant patients with clinically suspected appendicitis. It is an excellent imaging technique in many instances, which does not expose a fetus, or the mother, to ionizing radiation, making it an excellent option for pregnant patients with suspected acute appendicitis.

The diagnostic accuracy of ultrasound in the diagnosis of acute appendicitis in pregnancy

Objective: Clinically suspected appendicitis is the most common nonobstetric surgical problem encountered in pregnancy. The diagnosis of appendicitis is hampered by equivocal symptoms during pregnancy. Ultrasonography (US) remains, as a rule, the imaging test of choice for the diagnosis of clinically suspected appendicitis during pregnancy and other imaging tools such as computed tomography (CT) or magnetic resonance imaging (MRI) are usually avoided. We evaluated the accuracy of US in the diagnosis of appendicitis during pregnancy.Methods: The clinical and sonographic findings of all pregnant women (n = 90), who underwent appendectomy between January 2005 and December 2017 at our institution, were retrospectively reviewed, analyzed, and compared to the clinical and sonographic findings similarly obtained for a control group of nonpregnant women matched for age and date of surgery (±6 months). The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of ultrasonic findings were calculated and compared between groups as well as within the three pregnancy trimesters.Results: The mean age of the patients was 31.3 ± 0.4. Right lower quadrant pain was present in almost all patients (99%). The sole imaging modality used in our study cohort was US. Among nonpregnant controls, CT scan was primarily used on more occasions (53.3%) compared to US (45.6%). Nonpregnant women underwent significantly more laparoscopies compared to pregnant women (83.3 versus 45.6%, p < .001). The rate of negative appendectomy was higher in pregnant women (31.1 versus 10%, p = .002). Among pregnant women operated there was a higher rate of inconclusive or negative imaging (43.3 versus 11.1%, p < .001). The rate of perforated appendix at surgery was similar in both groups (6.7 and 4.4%, respectively, p = .75).Conclusions: Ultrasonography (US) is of mediocre accuracy for the diagnosis of acute appendicitis in pregnant patients beyond the first trimester of pregnancy. Thirty percent of pregnant women with suspected appendicitis are futilely operated. Given the low yield of US, a second-line imaging should be considered in cases of inconclusive US before surgery.

Diagnostic performance of MRI for pregnant patients with clinically suspected appendicitis.

To evaluate the accuracy of magnetic resonance imaging (MRI) in the diagnosis of acute appendicitis in pregnant patients and the value of additional diffusion-weighted MRI (DWI). A total of 125 pregnant patients with clinically suspected appendicitis who underwent 1.5T MRI were enrolled between May 2011 and January 2016. During this period, two radiologists prospectively predicted acute appendicitis on MRI during daily interpretation. We retrospectively reviewed clinical records, and radiological results were correlated with surgical pathology and clinical outcomes. We calculated the sensitivity, specificity, and accuracy of MRI for diagnosing acute appendicitis. We performed additional DWI between August 2014 and January 2016, and we calculated sensitivity, specificity, and accuracy of MRI with or without DWI. The sensitivity, specificity, and accuracy of MRI for acute appendicitis were 100%, 95%, and 96%, respectively. The sensitivity, specificity, and accuracy of MRI without DWI (n = 72) vs. with DWI (n = 53) were 100%, 94.7%, and 95.8% versus 100%, 95%, and 96%, respectively. MRI has high accuracy for the diagnosis of acute appendicitis in pregnant patients. Therefore, MRI is recommended for use as a first-line diagnostic test for pregnant patients with clinically suspected appendicitis.

Differential diagnoses of magnetic resonance imaging for suspected acute appendicitis in pregnant patients.

Accurate and timely diagnosis of acute surgical disease in pregnant patient is challenging. Although magnetic resonance imaging (MRI) is the most accurate modality to diagnose acute appendicitis in pregnant patients, it is often used as a last resort because of high cost and long scan time. We performed this study to analyze differential diagnoses of appendix MRI and to investigate if there are any blood tests that can predict surgical condition in pregnant patients. A retrospective, cross-sectional study was conducted on 46 pregnant patients who underwent non-enhanced appendix MRI in suspicion of acute appendicitis from 2010 to 2016. Differential diagnoses of appendix MRI were analyzed and blood tests were compared between those who had surgical and non-surgical disease. Appendix MRI differentiated two surgical disease; acute appendicitis and ovarian torsion; and various non-surgical conditions such as uterine myoma, hydronephrosis, ureterolithiasis and diverticulitis among clinically suspected acute appendicitis in pregnancy. The diagnostic accuracy of MRI for acute appendicitis in this study was 93.5%. Patients who had surgical disease showed significantly higher WBC count (≥11,000/mm3), proportion of neutrophils in the WBC (≥79.9%), neutrophil-to-lymphocyte ratio (NLR≥6.4), levels of C-reactive protein (CRP≥1.82 mg/dL) and bilirubin (≥0.66 mg/dL) than those who had non-surgical disease. MRI can reliably differentiate surgical conditions and several blood tests (WBC, proportion of neutrophils in the WBC, NLR, CRP, bilirubin) can help anticipate acute surgical condition among pregnant patients suspected to have acute appendicitis.

Clinical use of MRI for the evaluation of acute appendicitis during pregnancy.

The purpose of this study was to determine the diagnostic accuracy of MRI for detecting acute appendicitis in pregnancy in a multi-institution study involving general body MR readers with no specific expertise in MR imaging of the pregnant patient. Retrospective review of MRI examinations on PACS in 42 pregnant patients was evaluated for acute right lower quadrant pain. Three fellowship-trained general body radiologists analyzed the MRI examinations in consensus and attempted to localize the appendix, assess for features of appendicitis, and exclude alternative etiologies for the right lower quadrant pain. Of the 42 MRI examinations, the readers noted 6 cases of acute appendicitis, 16 cases of a normal appendix, and 20 cases involving non-visualization of the appendix but where there were no secondary features of acute appendicitis. Based on the surgical data and clinical follow-up, there were 3 true-positive cases, 3 false-positive cases, 34 true-negative cases, and 2 false-negative cases of acute appendicitis on MRI. This yielded an accuracy of 88.1%, sensitivity of 60%, specificity of 91.9%, positive predictive value of 50%, and negative predictive value of 94.4% for the detection of acute appendicitis in the pregnant patient on MRI. Alternative etiologies for the right lower quadrant pain on MRI included torsion of an ovarian dermoid in 1 case and pyelonephritis in 1 case. MRI is an excellent modality for excluding acute appendicitis in pregnant patients presenting with right lower quadrant pain.

Integrating MR Imaging into the Clinical Workup of Pregnant Patients Suspected of Having Appendicitis Is Associated with a Lower Negative Laparotomy Rate: Single-Institution Study

To determine if integrating magnetic resonance (MR) imaging into the workup of right lower quadrant pain in pregnant patients was associated with improved outcomes as measured by the negative laparotomy rate (NLR) and the perforation rate (PR). Institutional review board approval was obtained for this retrospective review of medical records. Two hundred sixty-seven pregnant patients who underwent either surgery (n = 82) or an MR imaging examination (n = 217) because of suspicion of appendicitis between January 1, 1996, and August 31, 2011, were identified. Relevant ultrasonographic and MR imaging reports were classified as showing true-positive, false-positive, true-negative, false-negative, or equivocal findings. MR imaging utilization was analyzed to define pre- and post-MR imaging cohorts. NLR and PR were calculated for both cohorts and were compared by using a Fisher exact probability test. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for MR imaging were calculated. MR imaging was introduced into the clinical workup in 2004. From 1996 to 2003, the NLR for pregnant patients was 55% (17 of 31), and the PR was 21% (three of 14). From 2004 to 2011, the NLR was 29% (15 of 51), and the PR was 26% (nine of 35). The 47% decline in the NLR ([55%-29%]/55%) was statistically significant (P = .02). The change in PR was not significant (P > .99). The sensitivity, specificity, PPV, and NPV of MR imaging in the diagnosis of appendicitis were 89% (17 of 19), 97% (187 of 193), 74% (17 of 23), and 99% (187 of 189), respectively. The routine incorporation of MR imaging into the clinical workup for suspicion of appendicitis in pregnant patients at this institution was associated with a decrease in the NLR of 47% without a significant change in the PR. http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.12121027/-/DC1.

The value of 3D T1-weighted gradient-echo MR imaging for evaluation of the appendix during pregnancy: preliminary results

The use of oral contrast has been essential for the identification of a normal appendix on MR imaging during pregnancy. However, stool could be used as a positive oral contrast as it is characterized by a relatively high signal on T1-weighted imaging, and 3D T1-weighted gradient-echo (T1W-GRE) MR imaging has been used to evaluate 3 mm diameter intestines in fetuses. To evaluate the added value of 3D T1W-GRE MR imaging in combination with T2-weighted imaging (T2WI) compared to T2WI alone for evaluating the appendix during pregnancy. Eighteen consecutive pregnant patients who were clinically suspected of having acute appendicitis underwent appendix MR imaging which included T2WI with or without spectral presaturation attenuated inversion-recovery (SPAIR) fat suppression, and 3D T1W-GRE with SPAIR fat suppression. Two radiologists reviewed the two image sets (the T2WI set and the combined set of T2WI and 3D T1W-GRE images). Pathologic and clinical results served as the reference standard. The differences in the degree of visibility of the appendix and confidence scale for diagnosing acute appendicitis between two image sets were compared by using the paired Wilcoxon signed rank test. For both reviewers, the degree of visibility of the appendix using the combined T2WI and 3D T1W-GRE images was significantly higher than using T2WI alone (P < 0.01), and the confidence levels for acute appendicitis using combined T2WI and 3D T1W-GRE images were significantly different from those using T2WI alone (P < 0.01). In the 13 patients with a normal appendix, both reviewers showed improved confidence levels for appendicitis using combined T2WI and 3D T1W-GRE images than T2WI alone. Adding 3D T1W-GRE images to T2WI is helpful for identification of the appendix, as compared to T2WI alone in pregnant women without ingestion of oral contrast material. This may improve diagnostic confidence for acute appendicitis in pregnant patients.