Suspected Appendicitis Research Articles

Other Pathologies Were Rarely Reported after Laparoscopic Surgery for Suspected Appendicitis: A Systematic Review and Meta-Analysis

Background: Diagnostic laparoscopy is often used when a patient is suspected of having acute appendicitis. The aim of this study was to assess the rate of other pathologies found during diagnostic laparoscopy for suspected acute appendicitis. Methods: This systematic search included studies with ≥100 patients who received laparoscopy for suspected acute appendicitis and reported on the histopathologic and other intra-abdominal findings. We performed a meta-analysis estimating the rate of other pathologies, and a sensitivity analysis excluding smaller cohorts (≤500 patients). Age groups, sex, specific findings, and geographic regions were investigated. Certainty of evidence was assessed with GRADE. Results: A total of 27 studies were included covering 25,547 patients and of these 793 had an unexpected pathology. The findings were benign pathology in the appendix (34%), malignancy (30%), gynecologic pathology (5%), gastrointestinal pathology (4%), or unspecified (27%). Meta-analysis showed an overall rate of unexpected findings of 3.5% (95% CI 2.7–4.3; moderate certainty), and the sensitivity analysis showed similar results. Malignancy found in the appendix when treating suspected acute appendicitis was 1.0% (95% CI 0.8–1.3%; high certainty). Conclusion: The rate of other histopathological findings in patients with suspected acute appendicitis was low and a malignancy in appendix was found in 1% of patients.

EP-142 Assessing the Diagnostic Sensitivity of CT and Ultrasound in Suspected Appendicitis

Abstract Introduction Acute appendicitis is the most common surgical emergency and accounts for one-third of adult patients presenting to A&E. CT imaging has high positive predictive value for acute appendicitis. Ultrasound, on the other hand, is preferred as a first-line imaging in children and women of child-bearing age. However, it is dependent on operator experience, variation in appendiceal anatomy and patient body habitus. The RCR standards for the CT sensitivity should be >90% and for US it should be >70%. We conducted this study to investigate whether the diagnostic yield of CT and Ultrasound imaging in suspected appendicitis meet that of published research studies. Method All patients who underwent CT or US for suspected appendicitis followed by confirmed diagnosis where included. RCR AuditLive template was used to assess the performance in our local hospital. Results Sixty patients included. Of which eighteen had Ultrasound Abdomen and pelvis, forty-six had contrast CT scan and four patients had US followed by CT. Sensitivity for CT and US was 93% and 40% respectively with negative appendectomy rate of nearly 2%. Conclusion The standards for CT have been met in our hospital, however this is not the case for the US. This could be related to the performing operator, group of patients referred for US or the request itself, weather we request it to confirm the presence of appendicitis or rather excluding other pathologies. In all cases we recommend that we discuss these results in our next joined meeting with the radiologists.

Low-Dose Abdominal CT for Evaluating Suspected Appendicitis: Recommendations for CT Imaging Techniques and Practical Issues

A vast disparity exists between science and practice for CT radiation dose. Despite high-level evidence supporting the use of low-dose CT (LDCT) in diagnosing appendicitis, a recent survey showed that many care providers were still concerned that the low image quality of LDCT may lead to incorrect diagnoses. For successful implementation of LDCT practice, it is important to inform and educate the care providers not only of the scientific discoveries but also of concrete guidelines on how to overcome more practical matters. Here, we discuss CT imaging techniques and other practical issues for implementing LDCT practice.

A Standardized Diagnostic Pathway for Suspected Appendicitis in Children Reduces Unnecessary Imaging.

Introduction:Ultrasound (US) for the diagnosis of acute appendicitis is often nondiagnostic, and additional imaging is required. A standardized approach may reduce unnecessary imaging.Methods:We retrospectively analyzed all patients who had imaging for appendicitis in our emergency department in 2017 and evaluated patient characteristics associated with nondiagnostic US. Using these results, we developed a pediatric appendicitis score (PAS)-based imaging pathway and compared imaging trends prepathway and postpathway implementation.Results:A total of 971 patients received imaging for suspected appendicitis prepathway in 2017. Female sex, obesity, and low/intermediate PAS were significantly associated with nondiagnostic US, but not magnetic resonance imaging (MRI) (P < 0.0001). Nearly one-third of patients received multiple imaging studies (US followed by MRI/computed tomography). As low/intermediate PAS was most strongly associated with a nondiagnostic US on multivariate analysis, we developed a PAS-based imaging stewardship pathway to eliminate imaging in low-PAS patients and reduce the number of patients with an intermediate PAS who received multiple imaging studies by obtaining an MRI as the first-line study. After implementation, only 22 low-PAS patients received imaging (compared with 238 preimplementation), and the proportion of intermediate-PAS patients receiving multiple imaging studies decreased from 31.4% to 13% (P < 0.0001). The cost of imaging per 100 patients increased from $24,255 to $31,082.Conclusion:A PAS-based imaging stewardship pathway reduces unnecessary imaging for suspected appendicitis.

231 Diagnostic Outcomes in Suspected Appendicitis Before and During the COVID-19 Pandemic

IntroductionRoutine operative treatment of appendicitis was temporarily interrupted during the COVID-19 pandemic. Non-operative management in suspected appendicitis makes a definitive diagnosis difficult. This study investigated diagnostic outcomes of suspected appendicitis patients before and during COVID-19.MethodA retrospective review of patients aged 16–45 undergoing treatment for suspected appendicitis pre-COVID-19 (1st January 2019–1st January 2020) and during the COVID-19 pandemic (1st March 2020 to 31st June 2020) was performed. Patients were followed up for one year (31st June 2021) to explore diagnostic outcomes.ResultsAt one year follow up, 206 patients were identified in the pre-COVID-19 cohort with 100% (n = 206) undergoing an appendicectomy. On histopathological examination 77.2% (n = 159) had appendicitis; 10.7% (n = 22) another pathology; 2.9% (n = 6) neuroendocrine tumour. There were 62 patients in the COVID-19 cohort in which 79% (n = 49) underwent appendicectomy (56% (n = 35) immediate appendicectomy; 23% (n = 13) interval appendicectomy). On histopathological examination 61% (n = 38) had appendicitis; 13% (n = 8) another pathology; 5% (n = 3) neuroendocrine tumour.Of the remaining 13/62 patients, one had undergone a CT scan and colonoscopy for gastrointestinal symptoms demonstrating signs of chronic caecal inflammation treated conservatively. One underwent a CT scan alone for gastrointestinal symptoms finding no pathology. The remaining 11/62 patients had no further reported symptoms or diagnostics.ConclusionsThis study demonstrates that the risk of appendiceal malignancy and chronic inflammation is important in non-operative management of suspected appendicitis and establishing consistent follow up pathways is essential.

Low-Dose Abdominal CT for Evaluating Suspected Appendicitis in Adolescents and Young Adults: Review of Evidence.

Due to its excellent diagnostic performance, CT is the mainstay of diagnostic test in adults with suspected acute appendicitis in many countries. Although debatable, extensive epidemiological studies have suggested that CT radiation is carcinogenic, at least in children and adolescents. Setting aside the debate over the carcinogenic risk of CT radiation, the value of judicious use of CT radiation cannot be overstated for the diagnosis of appendicitis, considering that appendicitis is a very common disease, and that the vast majority of patients with suspected acute appendicitis are adolescents and young adults with average life expectancies. Given the accumulated evidence justifying the use of low-dose CT (LDCT) of only 2 mSv, there is no reasonable basis to insist on using radiation dose of multi-purpose abdominal CT for the diagnosis of appendicitis, particularly in adolescents and young adults. Published data strongly suggest that LDCT is comparable to conventional dose CT in terms of clinical outcomes and diagnostic performance. In this narrative review, we will discuss such evidence for reducing CT radiation in adolescents and young adults with suspected appendicitis.

Length of Laparotomy for Suspected Acute Appendicitis in Relation to Body Mass Index

Length of Laparotomy for Suspected Acute Appendicitis in Relation to Body Mass Index

Racial and Ethnic Disparities in Pain Management of Children With Limb Fractures or Suspected Appendicitis: A Retrospective Cross-Sectional Study.

Objective: To evaluate whether racial/ethnical differences in analgesia administration existed in two different cohorts of children with painful conditions: children with either limb fracture or suspected appendicitis.Methods: Retrospective cross-sectional analysis of children visiting a pediatric emergency department (Boston Children Hospital) for limb fracture or suspected appendicitis from 2011 to 2015. We computed the proportion of children that received any analgesic treatment and any opioid analgesia. We performed multivariable logistic regressions to investigate race/ethnicity differences in analgesic and opioid administration, after adjusting for pain score, demographics and visit covariates.Results: Among the 8,347 children with a limb fracture and the 4,780 with suspected appendicitis, 65.0 and 60.9% received any analgesic treatment, and 35.9 and 33.4% an opioid analgesia, respectively. Compared to White non-Hispanic Children, Black non-Hispanic children and Hispanic children were less likely to receive opioid analgesia in both the limb fracture cohort [Black: aOR = 0.61 (95% CI, 0.50–0.75); Hispanic aOR = 0.66 (95% CI, 0.55–0.80)] and in the suspected appendicitis cohort [Black: aOR = 0.75 (95% CI, 0.58–0.96); Hispanic aOR = 0.78 (95% CI, 0.63–0.96)]. In the limb fracture cohort, Black non-Hispanic children and Hispanic children were more likely to receive any analgesic treatment (non-opioid or opioid) than White non-Hispanic children [Black: aOR = 1.63 (95% CI, 1.33–2.01); Hispanic aOR = 1.43 (95% CI, 1.19–1.72)].Conclusion: Racial and ethnic disparities exist in the pain management of two different painful conditions, which suggests true inequities in health care delivery. To provide equitable analgesic care, emergency departments should monitor variation in analgesic management and develop appropriate universal interventions.

Diagnostic Imaging Examinations for Suspected Appendicitis

The vermiform appendix is a unique organ, especially when considering its role in human physiology, which has been speculated and debated for centuries. Recent findings and correlations indicate that the vermiform appendix has some homeostatic function in gut health and plays a critical role in the microbial makeup of the large intestine. Diagnostic Imaging to rule out an inflamed appendix is a routine procedure in health emergencies. Yet the associated risks with appendicitis and appendectomy elicit continued research on the topic. The lifetime risk of appendicitis was found to be 8.6% for males and 6.7% for females, with the highest incidence rate in individuals aged 10 to 19 years (23.3 cases per 10,000 people annually). A family history of appendicitis has also been shown to increase the risk for appendicitis in adulthood. Acute appendicitis is the most common cause of emergency abdominal surgery in children. The concern for radiation dose, especially for pregnant and pediatric populations, makes appendiceal imaging a balancing act between various patient populations and image modality tradeoffs. While computed tomography remains the imaging modality of choice for nonpregnant adult populations, the implementation of ultrasound is an invaluable imaging modality without the concern for ionizing radiation.

Diagnostic Accuracy of Suspected Appendicitis: A Comparative Analysis of Misdiagnosed Appendicitis in Children.

When evaluating suspected appendicitis, limited data support quality benchmarks for negative appendectomy (NA); none exist for delayed diagnosis of appendicitis (DDA). The objectives of this study are the following: (1) to provide preliminary evidence supporting a quality benchmark for DDA and 2) to compare presenting features and diagnostic evaluations of children with NA and DDA with those with pathology-confirmed appendicitis (PCA) diagnosed during initial emergency department (ED) encounter. Secondary analysis of data from a QI project designed to reduce the use computed tomography when evaluating suspected appendicitis using a case-control design. Patients undergoing appendectomy in an academic tertiary care children's hospital system between January 1, 2015, and December 31, 2016 (n = 1,189) were eligible for inclusion in this case-control study. Negative appendectomy was defined as no pathologic change or findings consistent with a different diagnosis. Delayed diagnosis of appendicitis was defined as patients undergoing appendectomy within 7 days of a prior ED visit for a related complaint. Controls of PCA (n = 150) were randomly selected from all cases undergoing appendectomy. There were 42 NA (3.5%) and 31 DDA (2.6%). Cases of PCA and NA exhibited similar histories, examination findings, and underwent comparable diagnostic evaluations. Cases of PCA more frequently demonstrated a white blood cell count greater than 10 × 103/μL (85% vs 67%; P = 0.01), a left-shift (77% vs 45%; P < 0.001), and an ultrasound interpretation with high probability for appendicitis (73% vs 54%; P = 0.03). Numerous significant differences in history, examination findings, and diagnostic tests performed existed between cases of PCA and DDA. Children with PCA and NA present similarly and undergo comparable evaluations resulting in appendectomy. A 3% to 4% NA rate may be unavoidable given these similarities. Presenting features in DDA significantly differ from those of PCA. An irreducible proportion of appendicitis diagnoses may be delayed.

Suspected appendicitis and COVID-19, a change in investigation and management-a multicentre cohort study.

PurposeThe COVID-19 pandemic has reformed global healthcare delivery. On 25 March 2020, Intercollegiate guidelines were published in the UK to promote safe surgical provision during the COVID-19 outbreak advocating non-operative management or avoidance of laparoscopy when surgery is essential. The effects of this on the investigation and management of appendicitis remain unknown.MethodsWe performed a multicentre, prospective, observational study from the start of the new guidelines to the 6th of May 2020. We included all patients referred to surgical teams with suspected appendicitis. A recent historical cohort was identified for comparison. The primary outcome was the impact of the COVID-19 pandemic on the use of non-operative management in appendicitis. Secondary outcomes included imaging, negative appendicectomy rate (NAR), length of stay (LOS) and 30-day complications.ResultsA total of 63/164 (38%) patients compared to 79/191 (41%) were diagnosed with appendicitis before and after the guidelines were introduced (p = 0.589). CT scanning increased (71/164 vs 105/191; p = 0.033) while ultrasound scanning decreased (71/164 vs 62/191; p = 0.037). Appendicitis was more likely to be managed non-operatively (11/63 vs 51/79; p < 0.001) and, of those managed surgically, with an open approach (3/52 vs 26/28 p < 0.001). The NAR also reduced (5/52 vs 0/28; p = 0.157). LOS was shorter in non-operatively managed patients (1 day vs 3 days; p < 0.001) without a difference in complications (10/51 vs 4/28; p = 0.760).ConclusionIntroduction of the guidelines was associated with changes in practice. Despite these changes, short-term complications did not increase and LOS decreased. Questions remain on the longer-term complication rates in non-operatively managed patients.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00423-020-02023-6.

An Administrative Data-based Surrogate Definition Identifies Children Evaluated Beyond Physical Examination for Suspected Appendicitis.

Introduction:Previous studies have reported on the evaluation of patients diagnosed with appendicitis. Very little is known about all patients evaluated for suspected appendicitis. Patients evaluated beyond physical examination with laboratory and imaging testing, then found not to have appendicitis, are more difficult to identify. Data readily available in administrative databases may be used to identify these patients.Methods:A multidisciplinary team developed a surrogate definition for evaluating suspected appendicitis in children based on available administrative data. Appendicitis was “suspected” if the patient underwent ultrasonography of the appendix or had a chief complaint of abdominal pain with both complete blood count performed and the word “appendicitis” in the ED provider note. Performance characteristics described the surrogate definition’s ability to retrospectively identify patients evaluated for suspected appendicitis through comparison to a population identified via chart review.Results:Compared with manual chart review of 498 patients from June 2014, the surrogate definition identified patients evaluated beyond physical examination for suspected appendicitis with a sensitivity of 79.8%, a specificity of 96.3%, a positive predictive value of 83.3%, and a negative predictive value of 95.3%. Of the 94 patients evaluated beyond physical examination for suspected appendicitis, 37 (39%) underwent appendectomy.Conclusions:Health systems can retrospectively identify children evaluated beyond physical examination for appendicitis using discrete administrative data and a word search of clinical notes. This surrogate definition for evaluation of suspected appendicitis enables research in quality improvement efforts and health care resource utilization.

Chronological Changes in Appendiceal Pathology Among Patients Who Underwent Appendectomy for Suspected Acute Appendicitis.

Given recent advances in imaging and the development of diagnostic parameters, the rate of unnecessary appendectomy (i.e., negative appendectomy) has been decreasing. However, the incidence of acute appendicitis (AA) in elderly patients is rising due to the aging of society. We aimed to identify chronological changes in demographics and appendiceal pathology among patients who underwent appendectomy for suspected AA. Data from 881 patients who underwent appendectomy for suspected AA between January 2006 and December 2017 were analyzed. The final diagnosis was based on intraoperative findings, pathological reports, and clinical course. Negative appendectomy was defined as the absence of appendiceal diseases including inflammation, fibrosis, and neoplasm. We compared demographics and appendiceal pathology between early (2006-2011) and late study phases (2012-2017). The mean age of patients with pathologically proven AA (n = 761) was significantly greater in the late phase than in the early phase (38.6 ± 19.8years vs. 44.0 ± 20.3years, p = 0.0002), and the ratio of patients with AA aged ≧75years was also increased (from 5.6 to 8.6%, p = 0.1120). The incidences of complicated appendicitis (defined as perforated or gangrenous appendicitis) and appendiceal diverticulitis (AD) were increased in the late phase compared to those in the early phase (61.3% vs. 77.2% and 3.7% vs. 6.6%, respectively). The negative appendectomy rate was significantly reduced in the late phase compared to that in the early phase (10.0% vs. 2.5%, p < 0.0001). During a 12-year period, the mean age of patients with AA and the incidences of complicated appendicitis and AD increased, whereas the negative appendectomy rate decreased.

Minimizing Ionizing Radiation in Evaluating Suspected Appendicitis in Children Before and After the Release of the ACEP Clinical Policy.

The aim of this study was to examine the impact of the ACEP (American College of Emergency Physicians) clinical policy regarding diagnosis of suspected appendicitis on changing practice in the pediatric emergency department (ED) in the absence of a formal departmental protocol. This was a retrospective chart review in a pediatric ED in which patients aged 2 to 18 years were evaluated for appendicitis via ultrasound, computed tomography (CT), or both, over a 7-year study period. We compared rates of CT utilization in the period before the release of the ACEP clinical policy regarding diagnosis and treatment of appendicitis (2008-2009) and the period after (2010-2014). Other metrics of interest were ultrasound results and physician response to results, as well as surrogate markers for quality of care. Seven hundred pediatric ED visits were included, with 200 prepolicy release and 500 postrelease. Computed tomography utilization decreased significantly postpolicy release from 43.5% (95% confidence interval [CI], 36.6%-50.3%) to 22.2% (95% CI, 18.5%-25.8%). The proportion of ultrasounds with indeterminate results also decreased, with 71.5% (95% CI, 65.1%-77.9%) and 55.1% (95% CI, 50.7%-59.5%) in the pre and post groups, respectively. Physicians ordered fewer CTs after indeterminate ultrasounds, decreasing from 63.7% (95% CI, 56.9%-70.5%) to 48.3%% (95% CI, 43.9%-52.7%). After the release of the clinical policy, CT utilization decreased significantly suggesting possible effectiveness of the policy in bringing about change in practice. Subsequently, there was an increase in the definitiveness in the ultrasound results. Physicians also evolved in their response to indeterminate ultrasound results, with fewer CTs ordered reflexively after indeterminate results.

Cost-effectiveness of Imaging Protocols for Suspected Appendicitis.

Inaccurate diagnosis of appendicitis leads to increased costs and morbidity. Ultrasound costs less than computed tomography (CT) or MRI but has lower sensitivity and may not visualize the appendix. We conducted a cost-effectiveness analysis using a decision-analytic model of 10 imaging strategies for suspected appendicitis in a hypothetical cohort of patients: no imaging with discharge or surgery; CT only; MRI only; or staged approach with CT or MRI after 1) negative ultrasound result or ultrasound without appendix visualization, 2) ultrasound without appendix visualization, or 3) ultrasound without appendix visualization but with secondary signs of inflammation. Inputs were derived from published literature and secondary data (quality-of-life and cost data). Sensitivity analyses varied risk of appendicitis and proportion of visualized ultrasound. Outcomes were effectiveness (quality-adjusted life-years [QALYs]), total direct medical costs, and cost-effectiveness (cost per QALY gained). The most cost-effective strategy for patients at moderate risk for appendicitis is initial ultrasound, followed by CT if the appendix is not visualized but secondary signs are present (cost of $4815.03; effectiveness of 0.99694 QALYs). Other strategies were well above standard willingness-to-pay thresholds or were more costly and less effective. Cost-effectiveness was sensitive to patients' risk of appendicitis but not the proportion of visualized appendices. Tailored approaches to imaging based on patients' risk of appendicitis are the most cost-effective. Imaging is not cost-effective in patients with a probability <16% or >95%. For moderate-risk patients, ultrasound without secondary signs of inflammation is sufficient even without appendix visualization.

Quality Assurance and Performance Improvement Project for Suspected Appendicitis.

Introduction:Considerable variability exists in the diagnosis and management of acute appendicitis, affecting both quality and costs of care. This prospective cohort study aimed to decrease unnecessary radiological investigations, standardize radiological imaging, avoid unnecessary hospital admissions, and decrease our institution rate of negative appendectomy.Methods:A multidisciplinary appendicitis care pathway was implemented. This pathway involved the use of the Pediatric Appendicitis Score, standardization of ultrasound reporting, and risk stratification to determine patient disposition. Patients were prospectively enrolled in the pathway and compared a preimplementation retrospective cohort.Results:We included 235 patients in this study that took place between February 2017 and January 2018. An 88.5% pathway adherence rate for appropriate referral for ultrasounds, an 84% compliance rate for correct risk stratification, and the need for a surgical consult were achieved. After implementation, standardization of ultrasound (U/S) reporting increased from 0% to 78%. The rate of computed tomography utilization decreased from 7.3% to 4.7%. An appendectomy was completed in 68 (29%) of patients. There was only 1 (1.5%) negative appendectomy, compared to the prepathway institutional negative appendectomy rate of 4%.Conclusion:The implementation of a standardized, evidence-based, appendicitis care pathway has the potential to improve quality of care by reducing negative appendectomies, unnecessary computed tomography scans, and unnecessary hospital admissions. The participation of the emergency and diagnostic imaging departments is critical to the successful implementation of this quality improvement measure. This simple, effective model can be easily implemented at other centers to improve the care of children.

Sensitivity of Alvarado Score among the Suspected Appendicitis Patients at a Tertiary Level Teaching Hospital

Introduction: The aim of this study was to screening the Sensitivity of Alvarado score among the hospitalized suspected appendicitis patients at Dhaka National Medical College Hospital for determine the diagnostic accuracy.&#x0D; Materials and Methods: It was an observational type of descriptive study, conducted in the Dhaka National Medical College Hospital, Dhaka, during the study period of July 2015 to December 2015. The study was approved by the institutional ethical committee.&#x0D; Results: Most of the appendicitis patients belonged to the between 21-30 years which was 64 (32%). Male appendicitis patients (52%) are more than the female patients (48%). Majority of the patients (69%) complains pain occurs in the Right iliac fossa. The sensitivity of Alvarado scores was 81.60%, specificity 74.58%, accuracy 79.35%, positive and negative predictive values were 87.18% and 65.67% respectively.&#x0D; Conclusion: Alvarado score has more specificity.&#x0D; Medicine Today 2020 Vol.32(1): 45-47

Alvarado Scores Predict Additive Value of Magnetic Resonance Imaging in Workup of Suspected Appendicitis in Children

BackgroundThe presentation of appendicitis in pediatrics is variable, and diagnostic imaging is often used. Magnetic resonance imaging (MRI) is replacing computed tomography in some centers, particularly after a nondiagnostic ultrasound (NDUS). Nonetheless, MRI is not widely used in this setting because of cost, procedure time, institutional capacity, and high rates of negative scans. We hypothesized that the Alvarado Score (AS) could be used to determine the additive diagnostic value of MRI after an NDUS. Materials and methodsRetrospective review of patients aged ≤18 y at a single tertiary care children's hospital who received an ultrasound for suspected appendicitis during 10 consecutive months in 2017. NDUS were defined as nonvisualization of the appendix or secondary signs without radiologic diagnosis. AS were retrospectively calculated from the electronic medical record. Primary outcomes were pathology-confirmed appendicitis, appendectomy, and perforation. ResultsAS was determined for 352 patients out of 463 who met inclusion criteria (76%). Sixty-two percent had an NDUS, and 45% of these patients received MRI. Patients with high-risk AS were significantly more likely to have MRI diagnostic of appendicitis (P = 0.0015), and low-risk AS patients were more likely to have a negative or equivocal MRI (P = 0.0169). Twenty-one MRI scans were required per each additional diagnosis of appendicitis in patients with low AS after NDUS versus 4.2 in intermediate-risk AS patients and 2.1 in high-risk AS patients. ConclusionsRisk stratification with AS can help assess the additive diagnostic utility of MRI after NDUS. MRI may be overutilized for diagnosing acute appendicitis in pediatric patients with low-risk AS.

The Accur¬acy of Pre-Operative Radiological Assessment with Histopathological Correlation in Suspected Acute Appendicitis: Research in Saudi Arabia and Recommended Diagnostic Routine Approach

The Accur¬acy of Pre-Operative Radiological Assessment with Histopathological Correlation in Suspected Acute Appendicitis: Research in Saudi Arabia and Recommended Diagnostic Routine Approach

A Study of Efficacy of Alvarado Score vs Ultrasonography in Evaluation of Suspected Appendicitis

A Study of Efficacy of Alvarado Score vs Ultrasonography in Evaluation of Suspected Appendicitis