Final Diagnosis Of Appendicitis Research Articles

Study of pediatric appendicitis scores and management strategies: A prospective observational feasibility study.

The objective was to investigate the feasibility of prospectively validating multiple clinical prediction scores (CPSs) for pediatric appendicitis in an Australian pediatric emergency department (ED). A literature search was conducted to identify potential CPSs and a single-center prospective observational feasibility study was performed between November 2022 and May 2023 to evaluate the performance of identified CPSs. Children 5-15 years presenting with acute right-sided or generalized abdominal pain and clinician suspicion of appendicitis were included. CPSs were calculated by the study team from prospectively clinician-collected data and/or review of medical records. Accuracy of CPSs were assessed by area under the receiver operating characteristic curve (AUC) and proportions correctly identifiable as either low-risk or high-risk with the best performing CPS compared to clinician gestalt. Final diagnosis of appendicitis was confirmed on histopathology or by telephone/email follow-up for those discharged directly from ED. Thirty CPSs were identified in the literature search and 481 patients were enrolled in the study. A total of 150 (31.2%) patients underwent appendectomy with three (2.0%) having a normal appendix on histopathology. All identified CPSs were calculable for at least 50% of the patient cohort. The pediatric Appendicitis Risk Calculator for pediatric EDs (pARC-ED; n = 317) was the best performing CPS with AUC 0.90 (95% confidence interval [CI] 0.86-0.94) and specificity 99.0% (95% CI 96.4%-99.7%) in diagnosing high-risk cases and a misclassification rate of 4.5% for low-risk cases. The study identified 30 CPSs that could be validated in a majority of patients to compare their ability to assess risk of pediatric appendicitis. The pARC-ED had the highest predictive accuracy and can potentially assist in risk stratification of children with suspected appendicitis in pediatric EDs. A multicenter study is now under way to evaluate the potential of these CPSs in a broader range of EDs to aid clinical decision making in more varied settings.

Comparison of Clinical and Laboratory Manifestations Between Acute Appendicitis and Mesenteric Lymphadenitis in Children.

Acute appendicitis is a major causeof emergency surgery in children and adolescents. Mesenteric lymphadenitis is also one of the most common differential diagnoses in children with acute appendicitis, and despite its high prevalence, few clinical studies have examined its features. The clinical signs of mesenteric lymphadenitis in children are very similar to those of acute appendicitis. The aim of this study was to determine the clinical manifestations of acute appendicitis and mesenteric lymphadenitis in children. In this cross-sectional study, patients less than 15 years old admitted to the pediatric emergency center of Afzalipour Hospital in Kerman from 2018 to 2021 were studied, and those who had a final diagnosis of appendicitis, mesenteric lymphadenitis, or appendectomy were included in the study by census. Data collection from the records of these patients included age, sex, clinical signs, duration of emergency until diagnosis, fever, number of times of vomiting, leukocytosis, lymphocyte, neutrophil count, neutrophil-to-lymphocyte ratio, sonographic findings, and pathology findings. SPSS software and descriptive and analytical statistics were used to analyze the data. The results showed that unlike sex (p=0.11), there was a significant difference between the two groups in terms of age (p<0.001). Nausea, vomiting, anorexia, pain shift, and leukocytosis were more common in the acute appendicitis group than in the mesenteric lymphadenitis group, with a significant difference between the two groups (p<0.001). There was a significant difference between the two groups in terms of neutrophil percentage and neutrophil-to-lymphocyte ratio (p<0.001). The present study was conducted with the aim of assisting medical professionals due to the possibility of misdiagnosing mesenteric lymphadenitis with acute appendicitis. Differentiation of these two diseases is facilitated by the significant differences in their clinical signs and test results. These results can be a useful guide for physicians to better diagnose the diseases.

Accuracy of point-of-care ultrasound in the diagnosis of acute appendicitis in a pediatric emergency department.

To investigate the accuracy of point-of-care ultrasound (PoCUS) in diagnosing acute appendicitis in children; to evaluate the concordance between PoCUS performed by a pediatric emergency physician (PedEm) and ultrasonography (US) performed by a radiologist; to draw a "learning curve." We prospectively enrolled children aged 0-14 years old led to the Emergency Department of Regina Margherita Children's Hospital, from January 2021 to June 2021, with suspected acute appendicitis. PoCUS was performed by a single trained PedEm, blindly to the radiologist's scan. A "self-assessment score" and the "time of duration of PoCUS" were recorded for each patient. Final diagnosis of appendicitis was made by a pediatric surgeon. We enrolled 62 children (2-14 years). Overall sensitivity of PoCUS was 88%, specificity 90%; PPV 90.6%, and NPV 86.6%. Global concordance between the PedEm and the radiologist was good/excellent (k 0.74). The mean duration of PoCUS significantly decreased during the study period, while the self-assessment score increased. This is a preliminary study that shows the effectiveness of PoCUS in diagnosing acute appendicitis; furthermore, it shows how the PedEm's performance may improve over time. The learning curve showed how the experience of the PedEm affects the accuracy of PoCUS.

Referrals for Pediatric Appendicitis to a Tertiary Care Children's Hospital.

This study aimed to analyze pediatric referrals for definite or possible appendicitis, to compare clinical predictors and laboratory values between patients with and without a final diagnosis of appendicitis, and to determine the accuracy of prereferral diagnostic interpretations of computed tomography scans, ultrasound, and magnetic resonance imaging modalities. We conducted a retrospective analysis of pediatric patients referred from 2015 to 2019 to a tertiary care children's emergency department with definitive or possible appendicitis. Data abstracted included patient demographics, clinical symptoms, physical examination findings, laboratory results, and diagnostic imaging findings (by the referring center and the pediatric radiologist at the accepting center). An Alvarado and Appendicitis Inflammatory Response (AIR) score was calculated for each patient. Analysis was performed on 381 patients; 226 (59%) had a final diagnosis of appendicitis. Patients with appendicitis were more likely to have symptoms of nausea ( P < 0.0001) and vomiting ( P < 0.0001), have a higher mean temperature ( P = 0.025), right lower quadrant abdominal pain to palpation ( P = <0.0001), rebound tenderness ( P < 0.0001), a higher mean Alvarado score [5.35 vs 3.45 ( P < 0.0001)], and a higher mean AIR score [4.02 vs 2.17 ( P < 0.0001)]. Of the 97 diagnostic images initially interpreted as appendicitis by the referring center, 10 (10.3%) were read as no evidence of appendicitis. Of the 62 diagnostic images initially interpreted as "possible appendicitis" by the referring center, 34 (54.8%) were read as no evidence of appendicitis. Of those diagnostic images initially interpreted as "appendicitis" or "possible appendicitis" by the referring center, 24/89 (27.0%) of computed tomography scans, 17/62 (27.4%) of ultrasounds, and 3/8 (37.5%) of magnetic resonance imaging results were read as no evidence of appendicitis. Usage of established scoring algorithms, such as Alvarado and AIR, may decrease the unnecessary cost of diagnostic imaging and transfer to tertiary care. Virtual radiology consultations may be 1 potential solution to improve the referral process for pediatric appendicitis if initial interpretation is uncertain.

Colonic Diverticulitis Location Affects the Diagnostic Accuracy of Point-of-Care Ultrasound: A Multicenter, 10-Year Study

Point-of-care ultrasound (PoCUS) has high sensitivity and specificity in diagnosing uncomplicated colonic diverticulitis in Western patients. Evidence regarding the accuracy of PoCUS in Asian patients in which diverticulitis frequently occurs in the right-side colon is lacking. This multicenter, 10-y study was aimed at evaluating the diagnostic accuracy of PoCUS in various locations of uncomplicated diverticulitis among Asians. A convenience sample of patients with suspected colonic diverticulitis who had undergone computed tomography (CT) were eligible. Patients undergoing PoCUS before CT were included. The primary outcome was the diagnostic accuracy of PoCUS in the various locations, compared with the final diagnosis made by the expert physicians. The sensitivity, specificity, positive predictive value and negative predictive value were computed. The logistic regression model was used to investigate the possible factors related to the accuracy of PoCUS. A total of 326 patients were included. The overall accuracy of PoCUS was 92% (95% confidence interval [CI]: 89.1%-95.0%) and was lower in the cecum (84.3%, 95% CI: 77.8%-90.8%), compared with other locations (p < 0.0001). Nine of 10 false positives had the final diagnosis of appendicitis: 5 had an outpouching structure whose origin in the cecum could not be traced and 4 had elongated "diverticula." Moreover, body mass index was negatively associated with the accuracy of PoCUS in cecal diverticulitis (odds ratio: 0.79, 95% CI: 0.64-0.97) after adjusting for other covariates. Point-of-care ultrasound exhibits high diagnostic accuracy in diagnosing uncomplicated diverticulitis in the Asian population. However, the accuracy varies according to location, and was relatively low in the cecum.

Assessing Clinical Acumen in Predicting Acute Appendicitis in Emergency Surgery: A Prospective Study.

Clinical acumen and experience are critical in the diagnosis of the commonest surgical emergency, acute appendicitis. However, there is an increasing focus on haematological and radiological parameters in reaching the diagnosis of appendicitis, which can negate the importance of clinical findings. The aim was to assess the accuracy of each grade of the surgical team in diagnosing acute appendicitis using clinical acuity alone and compare them to each other as well as validated predictive scores. A prospective single-centre study was performed over a six-month period (Dec 2020-May 2021). All patients presenting to the emergency department with right iliac fossa pain were included. A total of 180 patients were included of whom 35% were male. Mean age was 36.2years (range 16-91). 51.1% had a final diagnosis of appendicitis, of which 91.3% were managed surgically and 8.7% were treated conservatively with antibiotics. Consultants were correct in their prediction of appendicitis in 84.6% of cases (females-83.4%, males-86.6%). Registrars accurately predicted appendicitis in 82.2% of patients (females-80.3%, males-85.7%), whilst house officers (SHOs) and interns were right in 73.8% (females-69.2%, males-82.5%) and 72.7% (females-66.6%, males-83.9%) of cases, respectively. In patients with a histological or radiological diagnosis of appendicitis, the mean Acute Inflammatory Response Score and Acute Appendicitis Score were 7.0 (high risk ≥ 9) and 12.5 (high risk ≥ 16), respectively. Clinicians had superior diagnostic accuracy when compared with both the clinical scores used. Seniority was associated with improved diagnostic accuracy in clinically predicting acute appendicitis. This study showed that the clinical judgement of experienced surgeons is more reliable than clinical scores in the diagnosis of appendicitis.

Accuracy of automated identification of delayed diagnosis of pediatric appendicitis and sepsis in the ED

BackgroundDelayed diagnoses of serious emergency conditions can lead to morbidity in children, but are challenging to identify and measure. We developed and piloted an automated tool for identifying delayed diagnosis...

Development of a clinical scoring system for appendicitis in children with presumed appendicitis

Purpose To develop a clinical scoring system for children with presumed appendicitis who visit the emergency department. Methods A registry based-retrospective study was conducted in the pediatric emergency department between September 2015 and December 2016. Patients aged 4 to 17 years who had a > 1 of 5 Likert scale for possibility of appendicitis were included. Multiple logistic regressions based on Akaike information criterion were performed using variables regarding clinical features and inflammatory markers to develop the clinical scoring system. Results A total of 233 patients were included, and 93 (39.9%) had the final diagnosis of appendicitis. The final model with the lowest Akaike information criterion (171.7) consisted of 5 variables, including vomiting (1 point), absence of watery diarrhea (1 point), duration of symptoms ≤ 3 days (1 point), rebound tenderness (1 point), and white blood cell count > 10.0 × 109/L (2 points). If the clinical score was ≥ 4 of 6 points, the area under the receiver operating characteristic curve was 0.78 (95% confidence interval, 0.71-0.86) with a 78.9% sensitivity, 66.7% specificity, positive and negative predictive values of 70.0% and 76.2%, respectively, and positive and negative likelihood ratios of 2.4 and 0.3, respectively. Conclusion The 5-item clinical scoring system shows a fair performance for prediction of pediatric appendicitis. This simple tool could be applied to predict the pediatric appendicitis, and to avoid the use of potentially unnecessary computed tomography. Key Words: Appendicitis; Decision Support Techniques; Emergency Service, Hospital; Leukocytes; Pediatrics

212 3D Volume Ultrasound of the Right Lower Quadrant for Diagnosis of Appendicitis

Appendicitis is the most common surgical emergency in children and a leading cause of surgery in all patients. Guidelines call for 2-dimensional (2D) ultrasound (US) as the first-line imaging test in pediatric patients with suspected appendicitis, but US is often nondiagnostic, leading to CT. Advantages of CT include its large field of view (FOV) and oriented 3-dimensional (3D) volume imaging, which contribute to diagnostic confidence and the ability to exclude appendicitis or identify complications. 2DUS lacks these advantages due to selective planar sampling from a 3D region. 3DUS volume imaging might improve appendicitis diagnostic accuracy and confidence. We have developed a system for oriented 3DUS volume imaging by augmentation of existing 2DUS machines and transducers. We hypothesized that 3DUS volume imaging of the right lower quadrant (RLQ) would be rapid to perform, visualize a large FOV, and identify appendicitis and complications. Following informed consent, a convenience sample of patients undergoing evaluation for suspected appendicitis in the emergency department (ED) at a tertiary care medical center was enrolled. The study was approved by the institutional review board and registered with ClinicalTrials.gov. Patients undergoing imaging (2DUS, CT) for suspected appendicitis were identified prospectively by the research team. Clinical care proceeded unchanged. Research 3DUS was performed with the experimental system by an emergency physician, who was not explicitly blinded to other clinical imaging results at the time of 3DUS acquisition. B mode 2D source images were obtained using the research device and transformed to 3D volumes using a pixel-based reconstruction algorithm. 3DUS acquisition and reconstruction times were automatically logged by software and compared with times for clinical imaging. 3DUS FOV was quantified by sweep arc and volume for one subject. Final diagnosis was determined by pathology where available and by chart review and follow-up when surgery was not performed. Between October 12, 2015 and March 21, 2017, 20 subjects were enrolled. The mean age was 11.6 years (range 4.6-30.4). A final diagnosis of appendicitis was made in 5 of 20 patients (25%). All imaging diagnoses of appendicitis were confirmed with surgery and pathologic findings. The mean time required for clinical 2DUS was 41 minutes (SD 21; range 7-93). The mean time required for clinical CT was 22 minutes (SD 7; range 15-35). Using a curved array transducer and an imaging depth of 78mm, mean 3DUS acquisition and reconstruction times were 10.3 seconds (SD 2.0, range 6.7-12.7) and 14.5 seconds (SD 1.6, range 12.5-16.8), respectively. Mean 3DUS FOV was 78.8 degrees (SD 13.5, range 53.3-90.5) and mean volume 495ml (SD 83, range 335.7-572.9). 3DUS identified 2 complications of appendicitis, including appendiceal abscess and appendicitis with multiple appendicoliths (figure). 3DUS volume imaging of the right lower quadrant was feasible, rapid to perform, provided a large FOV, and identified appendicitis complications in selected patients. Future studies should study the diagnostic performance in a prospective consecutive patient sample with blinding.

Impact of Family History on Acute Appendicitis – An Iraqi Study at Baghdad Teaching Hospital

Background: Appendicitis is one of the most common causes of the acute abdomen worldwide, but many patients present with atypical signs and symptoms. The study aimed to evaluate the impact of positive family history in the diagnosis of appendicitis in a limited diagnostic setting.&#x0D; Methods: Gender matched case control study of ratio (1:2) was carried out from July 2016 to September 2016 with a sample size of 300 patients. Cases were patients presented in surgical department with acute abdominal pain diagnosed as having appendicitis for whom appendectomy was performed, while controls were hospital based with other abdominal problems. Data was collected using a questionnaire. Primary analysis was a Chi square (χ2) test and the calculation of odds ratio (OR) for the association between final diagnosis of appendicitis and family history.&#x0D; Results: Females were 55% in both groups. Cases were younger than controls (27.05± 12.58 vs. 42.43±17.39 years). Positive family history of appendectomy was higher among cases (66%) than controls (31.5%). The diagnosis of acute appendicitis was 3.8 times higher among those with positive family history of appendectomy and abdominal pain, with a sensitivity of 66% and a specificity of 66.4%. Cases with more than one relative with family history of appendectomy, increased suspicion by 13 times when compared to those without family history.&#x0D; Conclusion: Positive family history of appendectomy in patients with acute abdominal pain and more than one relative with history of appendicitis can be considered as important parameters in the diagnosis of appendicitis in limited diagnostic setting.

Hospital type predicts computed tomography use for pediatric appendicitis

BackgroundEvidence-based guidelines recommend ultrasound (US) over computed tomography (CT) as the primary imaging modality for suspected pediatric appendicitis. Continued high rates of CT use may result in significant unnecessary radiation exposure in children. The purpose of this study was to evaluate variables associated with preoperative CT use in pediatric appendectomy patients. MethodsA retrospective cohort study of pediatric patients who underwent appendectomy for acute appendicitis in 2015–2016 at National Surgical Quality Improvement Program for Pediatrics (NSQIP-P) hospitals was conducted. Pediatric (<18 years old) patients who underwent appendectomy for acute appendicitis in an NSQIP-P hospital from 2015 to 2016 were included. Patients were excluded if they underwent interval or incidental appendectomy or did not have a final diagnosis of appendicitis. Variables associated with imaging evaluation, including age, body mass index (BMI), race/ethnicity, gender and hospital of presentation (NSQIP-P vs. non-NSQIP-P hospital) were evaluated. The primary outcome was receipt of preoperative CT. Secondary outcomes include reimaging practices and trends over time. Results22,333 children underwent appendectomies, of which almost all were imaged preoperatively (96.5%) and 36% of whom presented initially to a non-NSQIP-P hospital. Overall, US only was the most common imaging modality (52%), followed by CT only (27%), US+CT (16%), no imaging (3%), MRI +/− CT/US (1%) and MRI only (<1%). On regression, older age (>11 years), obesity (BMI >95th percentile for age), and female gender were associated with increased odds of receiving a CT scan. However, initial presentation to a non-NSQIP-P hospital was the strongest predictor of CT use (OR 9.4, 95% CI 8.1–10.8). Reimaging after transfer was common, especially after US and MRI at a non-NSQIP-P hospital. CT use decreased between 2015 and 2016 in non-NSQIP-P hospitals but remained the same (25%) in NSQIP-P facilities. ConclusionsThough patient characteristics were associated with different imaging practices, presentation at a referral, nonchildren's hospital is the strongest predictor of CT use in children with appendicitis. NSQIP-P hospitals frequently reimage transferred patients and have not reduced their CT use. Novel strategies are required for all hospital types in order to sustain reduction in CT use and mitigate unnecessary imaging. Level of EvidenceLevel III. Type of StudyRetrospective comparative study.

A highly sensitive and specific combined clinical and sonographic score to diagnose appendicitis.

Computed tomography (CT) scanning reduces the negative appendectomy rate however it exposes the patient to ionizing radiation. Ultrasound (US) does not carry this risk but may be nondiagnostic. We hypothesized that a clinical-US scoring system would improve diagnostic accuracy. We conducted a retrospective review of all patients (age, >15 years) who presented through the emergency department with suspected appendicitis and underwent initial US. A US score was developed using odds ratios for appendicitis given appendiceal diameter, compressibility, hyperemia, free fluid, and focal or diffuse tenderness. The US score was then combined with the Alvarado score. Final diagnosis of appendicitis was assigned by pathology reports. Three hundred patients who underwent US as initial imaging were identified. Thirty-two patients with evident nonappendiceal pathology on US were excluded. In 114 (38%), the appendix was not visualized and partially visualized in 36 (12%). Fifty-seven (21.3%) had an appendectomy with 1 (1.7%) negative. Six nonvisualized appendicies underwent appendectomy, with no negative cases. Sensitivity and specificity for the sonographic score were 86% and 90%, respectively, at a score of 1.5. The combined score demonstrated 98% sensitivity and 82% specificity at 6.5, and 95% sensitivity, and 87% specificity at a score of 7.5. Sensitivity and specificity were confirmed by bootstrap resampling for validation. Area under receiver operating characteristic (ROC) curves for our new US score were similar to the ROC curve for the Alvarado score (91.9 and 91.1, p = 0.8). The combined US and Alvarado score yielded an area under the ROC curve of 97.1, significantly better than either score alone (p = 0.017 and p < 0.001, respectively). Our scoring system based entirely on US findings was highly sensitive and specific for appendicitis, and it significantly improved when combined with the Alvarado score. After prospective evaluation, the combined US-Alvarado score might replace the need for computed tomography imaging in a majority of patients. Diagnostic Test, Level III.

P066: Outcomes of non-operative versus operative management in pediatric acute uncomplicated appendicitis

Introduction: The purpose of this study was to look at outcomes of pediatric patients with early, acute appendicitis who were treated with non-operative management (NOM) with antibiotics. Primary outcomes were subsequent appendectomy or Emergency Department (ED) visits. Methods: The method used for this study was a retrospective chart review of children under the age of 18, looking at outcomes of those who received non-operative management (NOM) for early acute appendicitis between April 2014-April 2015. The inclusion criteria included: (a) Age 0-17, (b) US or CT suggested acute uncomplicated appendicitis (c) Final diagnosis of appendicitis during April 2014-2015. Outcomes that were investigated were repeat ED visits and need for subsequent appendectomy. Results: Data extracted from the EMR found 209 charts with an ED diagnosis of appendicitis. Two charts (.9%) were excluded as they were duplicates. Sixty-seven patients (32%) were excluded after appendicitis was ruled out. One hundred and forty patients (67%) had a final diagnosis of appendicitis, 124 patients (88.6%) were taken directly to the operating room for appendectomy, 16 patients (11.4%) were treated with antibiotics instead of operative management. Three patients who received non-operative management had complex appendicitis, 13 had acute uncomplicated appendicitis. Six patients out of 13 (46%) were successfully treated with antibiotics with no repeat visits to the ED or Pediatric Surgery for appendectomy, 7 patients (54%) required appendectomy after initial treatment with antibiotics. Two patients who underwent appendectomy after initial NOM had no evidence of clinical appendicitis, one patient was taken to the OR based on parent preference and one patient had an episode of abdominal pain that prompted an interval appendectomy four weeks post the episode of abdominal pain. Conclusion: Treatment of acute uncomplicated appendicitis with NOM remains a management option in the pediatric population. Further studies and long term follow up are required to better identify appropriate patients for non-operative management versus operative management.

The Accuracy of Emergency Physicians in Ultrasonographic Screening of Acute Appendicitis; a Cross Sectional Study.

Diagnostic values reported for ultrasonographic screening of acute appendicitis vary widely and are dependent on the operator's skill, patient's gender, weight, etc. The present study aimed to evaluate the effect of operator skill on the diagnostic accuracy of ultrasonography in detection of appendicitis by comparing the results of ultrasonography done by radiologists and emergency physicians. This prospective diagnostic accuracy was carried out on patients suspected to acute appendicitis presenting to EDs of 2 hospitals. After the initial clinical examinations, all the patients underwent ultrasonography for appendicitis by emergency physician and radiologist, respectively. The final diagnosis of appendicitis was based on either pathology report or 48-hour follow-up. Screening performance characteristics of appendix ultrasonography by emergency physician and radiologist were compared using STATA 11.0 software. 108 patients with the mean age of 23.91 ± 7.46 years were studied (61.1% male). Appendicitis was confirmed for 37 (34.26%) cases. Cohen's kappa coefficient between ultrasonography by the radiologist and emergency physician in diagnosis of acute appendicitis was 0.51 (95% CI: 0.35 - 0.76). Area under the ROC curve of ultrasonography in appendicitis diagnosis was 0.78 (95% CI: 0.69 - 0.86) for emergency physician and 0.88 (95% CI: 0.81 - 0.94) for radiologist (p = 0.052). Sensitivity and specificity of ultrasonography by radiologist and emergency physician in appendicitis diagnosis were 83.87% (95% CI: 67.32 - 93.23), 91.5% (95% CI: 81.89 - 96.52), 72.97% (95% CI: 55.61 - 85.63), and 83.10% (95% CI: 71.94 - 90.59), respectively. Findings of the present study showed that the diagnostic accuracy of ultrasonography carried out by radiologist (89%) is a little better compared to that of emergency physician (80%) in diagnosis of appendicitis, but none are excellent.

A simple clinical decision rule to rule out appendicitis in patients with nondiagnostic ultrasound results.

The objective was to identify a set of clinical features that can rule out appendicitis in patients with suspected acute appendicitis and nondiagnostic ultrasound (US) results, allowing safe discharge and next-day reevaluation without initial computed tomography (CT) or magnetic resonance imaging (MRI). Data on clinical and US evaluation, including a number of prespecified variables potentially associated with acute appendicitis, were prospectively collected in two diagnostic accuracy studies of imaging. These studies included patients with suspected appendicitis seen in the emergency department (ED). For development and validation of the clinical decision rule (CDR), only patients with inconclusive or negative US results were included. There were 199 (of 422) patients in the development cohorts and 120 (of 211) patients in the validation cohort. Logistic regression analysis was used for data from patients with inconclusive or negative US results, and profiles were created of all possible combinations of predictors retained in the multivariable model. A final diagnosis was assigned by an expert panel based on perioperative data, histopathology, and clinical follow-up of at least 3 months. The CDR selected patients after negative or inconclusive US for discharge and next-day reevaluation without initial CT or MRI if fewer than two of the following predictors were present: male sex, migration of pain to the right lower quadrant, vomiting, and white blood cell (WBC) count higher than 12.0 × 10(9) /L. Applying the CDR in the development set selected 126 of 199 (63%) patients with negative or inconclusive US results for discharge without further imaging. This rule reduced the probability of appendicitis from 26% (51 of 199) in the total group of patients with negative or inconclusive US results to 12% (15 of 126) in the group that would be discharged based on the rule (p = 0.001). In the validation set (n = 120), the decision rule selected 72 (60%) patients for discharge and next-day reevaluation and reduced the probability of appendicitis from 20% (24 of 120) in the total group to 6% (4 of 72) in the patients selected on the rule (p = 0.001). The negative predictive value of the decision rule in the validation set was 94% (95% confidence interval [CI] = 87% to 98%). In comparison, the negative predictive value of CT in the same group was 99% (95% CI = 93% to 100%, p = 0.14), and that of MRI was 99% (95% CI = 94% to 100%, p = 0.12). Alternative decision rules based on combinations of the present decision rule with C-reactive protein (CRP) results did not improve selection. This newly developed CDR significantly reduces the probability of appendicitis in a large subgroup of patients with negative or inconclusive US results. These patients can be safely discharged for outpatient reevaluation without further initial imaging if proper follow-up is available. This could assist in lowering the number of ED imaging investigations in patients with suspected appendicitis.

Developing and evaluating an automated appendicitis risk stratification algorithm for pediatric patients in the emergency department

ObjectiveTo evaluate a proposed natural language processing (NLP) and machine-learning based automated method to risk stratify abdominal pain patients by analyzing the content of the electronic health record (EHR).MethodsWe analyzed the EHRs of a random sample of 2100 pediatric emergency department (ED) patients with abdominal pain, including all with a final diagnosis of appendicitis. We developed an automated system to extract relevant elements from ED physician notes and lab values and to automatically assign a risk category for acute appendicitis (high, equivocal, or low), based on the Pediatric Appendicitis Score. We evaluated the performance of the system against a manually created gold standard (chart reviews by ED physicians) for recall, specificity, and precision.ResultsThe system achieved an average F-measure of 0.867 (0.869 recall and 0.863 precision) for risk classification, which was comparable to physician experts. Recall/precision were 0.897/0.952 in the low-risk category, 0.855/0.886 in the high-risk category, and 0.854/0.766 in the equivocal-risk category. The information that the system required as input to achieve high F-measure was available within the first 4 h of the ED visit.ConclusionsAutomated appendicitis risk categorization based on EHR content, including information from clinical notes, shows comparable performance to physician chart reviewers as measured by their inter-annotator agreement and represents a promising new approach for computerized decision support to promote application of evidence-based medicine at the point of care.

Performance of Ultrasound in the Diagnosis of Appendicitis in Children in a Multicenter Cohort

The objectives were to assess the test characteristics of ultrasound (US) in diagnosing appendicitis in children and to evaluate site-related variations based on the frequency of its use. Additionally, the authors assessed the test characteristics of US when the appendix was clearly visualized. This was a secondary analysis of a prospective, 10-center observational study. Children aged 3 to 18 years with acute abdominal pain concerning for appendicitis were enrolled. US was performed at the discretion of the treating physician. Of 2,625 patients enrolled, 965 (36.8%) underwent abdominal US. US had an overall sensitivity of 72.5% (95% confidence interval [CI] = 58.8% to 86.3%) and specificity 97.0% (95% CI = 96.2% to 97.9%) in diagnosing appendicitis. US sensitivity was 77.7% at the three sites (combined) that used it in 90% of cases, 51.6% at a site that used it in 50% of cases, and 35% at the four remaining sites (combined) that used it in 9% of cases. US retained a high specificity of 96% to 99% at all sites. Of the 469 (48.6%) cases across sites where the appendix was clearly visualized on US, its sensitivity was 97.9% (95% CI = 95.2% to 99.9%), with a specificity of 91.7% (95% CI = 86.7% to 96.7%). Ultrasound sensitivity and the rate of visualization of the appendix on US varied across sites and appeared to improve with more frequent use. US had universally high sensitivity and specificity when the appendix was clearly identified. Other diagnostic modalities should be considered when the appendix is not definitively visualized by US.

Poor Sensitivity of a Modified Alvarado Score in Adults With Suspected Appendicitis

A clinical decision rule that identifies patients at low risk for appendicitis may reduce the reliance on computed tomography (CT) for diagnosis. We seek to prospectively evaluate the accuracy of a low modified Alvarado score in emergency department (ED) patients with suspected appendicitis and compare the score to clinical judgment. We hypothesize that a low modified Alvarado score will have a sufficiently high sensitivity to rule out acute appendicitis. We performed a prospective observational study of adult patients with suspected appendicitis at 2 academic urban EDs. A low modified Alvarado score was defined as less than 4. The sensitivity and specificity were calculated with 95% confidence interval (CI) for a low modified Alvarado score, and a final diagnosis of appendicitis was confirmed by CT, laparotomy, or 7-day follow-up. Two hundred sixty-one patients were included for analysis (mean age 35 years [range 18 to 89 years], 68% female patients, 52% white). Fifty-three patients (20%) had acute appendicitis. The modified Alvarado score test characteristics demonstrated a sensitivity and specificity of 72% (95% CI 58% to 84%) and 54% (95% CI 47% to 61%), respectively. Unstructured clinical judgment that appendicitis was either the most likely or second most likely diagnosis demonstrated a sensitivity and specificity of 93% (95% CI 82% to 98%) and 33% (95% CI 27% to 40%), respectively. With a sensitivity of 72%, a low modified Alvarado score is less sensitive than clinical judgment in excluding acute appendicitis.

Diagnostic Value of Ultrasonography in Patients Suspected Acute Appendicitis

Introduction: Appendectomy is one of the most frequently performed abdominal operations in surgical practice. Preoperative imaging has been demonstrated to improve diagnostic accuracy in appendicitis. Abdominal ultrasonography (US) is the most commonly and first-line imaging modality used for diagnosing acute appendicitis (AA).The aim of this study was to demonstrate the diagnostic value of abdominal ultrasonography for diagnosing acute appendicitis. Methods: In a retrospective study, we analyzed 200 consecutive patients with abdominal pain that undergoing appendectomy, from June 2009 to April 2012. Patient characteristics, preoperative ultrasonography (US) and laboratory assessment including WBC were collected. Final diagnosis of appendicitis was confirmed by histopathological examination. Results were compared with US. Results: Two hundred patients were admitted to this study that undergoing appendectomy. Mean age was 24 years (range: 1 to 91 years), and 57% were females. Patient White blood cell counts were found to be high in 78% while it was 86% for AA group and 64% for NA group (p &lt; 0.05). One hundred sixty-six of these patients (83%) were diagnosed as acute appendicitis on pathology, and 34 (17%) were diagnosed differently. 157 of patients underwent US, eighty two of this patients diagnosed as acute appendicitis on US examinations and in 78 of them were also reported as acute appendicitis on histopathological examination. The sensitivity and specificity of abdominal US for diagnosing appendicitis were 70% and 90.2% respectively. Positive predictive value (PPV) was 93% and negative predictive value (NPV) was reported 62%. Conclusion: Ultrasonography has a high PPV and specificity, so as a diagnostic tool, positive US strongly suggests the diagnosis of AA. A low negative predictive value recommends that negative US is not sufficient to exclude the diagnosis of AA and patients could not be managed on an outpatient basis following a negative scan. Nepalese Journal of Radiology; Vol. 2; Issue 2; July-Dec. 2012; 13-19 DOI: http://dx.doi.org/10.3126/njr.v2i2.7680

Use of computed tomography in diagnosing appendicitis: redundant, expensive, toxic, and potentially unnecessary.

Computed tomography is routinely used for the diagnosis of appendicitis despite its high cost and its radiation exposure to patients. To examine the usefulness and clinical relevance of computed tomography to diagnose appendicitis at a community-based academic medical center. A retrospective review of medical records of patients who received a final diagnosis of appendicitis (according to International Classification of Diseases, Ninth Revision) from April 26, 2009, to July 27, 2009, was conducted. Emergency department and admission history, physical examination reports, ultrasonography and computed tomography reports, and operative and pathology reports were included in the review. A modified version of the pediatric appendicitis score (mPAS) was used to determine the utility of imaging vs physical and laboratory examinations. Charts from 36 patients, aged 8 to 22 years, were included. All patients had pathologic evidence of appendicitis. Imaging was mentioned in 20 of 36 operative reports, but no operative report mentioned imaging as a crucial factor in surgical decisions. Two of 5 patients with the elevated mPAS of 6 had undergone no imaging; operative decisions were based on history, physical examination, and laboratory results. Among the 35 patients who had mPAS values, 23 (65.7%) had an mPAS of 5 or greater. The average mPAS for all patients was 4.5. Thirty-one of 36 patients (86.1%) had typical physical examination indications for appendicitis. Computed tomography was used as an initial part of the diagnostic workup in most patients, rather than as a tool for only atypical cases. A tiered approach-consisting of routine clinical evaluation with mPAS, followed by imaging in only atypical cases-would likely result in diagnostic accuracy similar to that obtained with early, routine imaging. Such an approach would also decrease expense and radiation exposure to young, developing bodies.