Scandinavian Journal of Surgery 94: 201206, 2005

ACUTE APPENDICITIS: THE RELIABILITY OF DIAGNOSIS BY CLINICAL ASSESSMENT ALONE

V. Kalliakmanis1, E. Pikoulis2, I. G. Karavokyros2, E. Felekouras2, P. Morfaki3, G. Haralambopoulou3, T. Panogiorgou1, E. Gougoudi2, T. Diamantis2, A. Leppniemi4, C. Tsigris2
1 2 3 4

Department of Surgery, Agrinion General Hospital, Agrinion, Greece First Department of Surgery, Medical School, University of Athens, Athens, Greece Department of Pathology Agrinion General Hospital, Agrinion, Greece Department of Surgery, Meilahti Hospital, University of Helsinki, Finland

ABSTRACT

Background and Aims: This prospective study aimed to review the trustworthiness of the initial clinical assessment in acute appendicitis without employment of imaging modalities, laparoscopy or any other adjunct diagnostic test. Patients and Methods: 717 patients were operated on for appendicitis by six different surgeons. Initial clinical and laboratory examination were evaluated in relation to the intraoperative and the pathological appreciation of the appendiceal inflammation. Results: 598 patients were found to have appendicitis, 34 a different condition, 41 had both appendicitis and an additional condition and 44 no pathology. 6 % of the laparotomies and 11 % of the appendectomies were unnecessary. The severity of the inflammation correlated significantly with periumbilical pain, pain migrating to right lower quadrant, loss of appetite, fever, rebound tenderness, local rigidity, polymorphonuclear predominance on deferential, polymorhonucleosis and leukocytosis. Leukocytosis was less frequent in aged patients. All the six surgeons were found to be equally reliable, although they all underestimated the setting compared to the pathologists. Patients with a long duration of symptoms had milder forms of inflammation and increased percentage of unanticipated abdominal conditions. Conclusions: Appendicitis can be reliably diagnosed clinically without employment of adjunct tests. These can be reserved for equivocal cases.
Key words: Acute appendicitis; acute abdomen; acute appendicitis diagnosis

INTRODUCTION Diagnosing acute appendicitis clinically still remains a common surgical problem (1). Accurate diagnosis can be aided by additional testing or expectant management or both. These might delay laparotomy and
Correspondence: I. G. Karavokyros, M.D. Anastasiou 12, Ampelokipoi 115 24 Athens, Greece Email: iokaravokyros@msn.com

lead to appendiceal perforation with increased morbidity and hospital stay (14). A safe alternative seems to be appendectomy as soon as the condition is suspected, a strategy that increases the number of unnecessary appendectomies (4, 5). A timelier and more accurate diagnosis has been attempted by the employment of additional laboratory tests (612), scoring systems (1317), ultrasound imaging (1820), CT Scan, (2123) scintigraphy (2427) MRI (28) and laparoscopy (2936). None of these methods stands alone as they all come in support of, and are secondary to a primary clinical assessment.

202

V. Kalliakmanis, E. Picoulis, I. G. Karavokyros et al.

Our aim in this prospective non randomized study was to review the initial diagnostic evaluation of suspected acute appendicitis by history, physical examination and plain laboratory tests. Furthermore, we addressed to the relationship between the surgeons intraoperative impression of appendiceal inflammation and its severity as assessed in histopathology. PATIENTS AND METHODS
This study included 717 patients who were admitted and operated upon for acute appendicitis in a period of 48 months (January 2000 to December 2003) by the six surgeons of a rural hospital. All were appendectomized and none was treated conservatively. We recorded the patients sex, age, present and previous medical history, together with the findings of clinical examination and laboratory investigation. For a number of patients (almost half of those reported as delayed presentations) surgical assessment occurred while they were already hospitalized in non surgical departments and under a presumptive treatment for different diagnosis. The symptoms and history of these patients were sought in the standard manner; however we recorded the physical findings and laboratory values obtained during the surgical assessment and not those of the referring physicians. Special attention was paid on the signs of localized or generalized peritoneal irritation i.e. Right Lower Quadrant (RLQ) tenderness, rebound tenderness, and muscle rigidity. Among the laboratory values we evaluated elevated White Blood Cell Count (WBC > 1000 ml), Polymorphonuclear cell (PNM) predominance on smear deferential (PNM > 75 %), and elevated PNM absolute number (> 8000/ml). Appendiceal inflammation was classified intraoperatively into six categories as appreciated by the surgeon; and again into six categories according to histopathology (Table 1). The score of the pathological assessment was correlated with the relative frequency of each element of the patients history, clinical examination, and laboratory evaluation. The two classification scales do not correspond to each other completely, e.g. stage 6 in histopathology corresponds in both stages 5 or 6 in surgical assessment. This can possibly result in a systematic error but as our inten-

tion was to compare the surgeons of this study only and the scales were universally applied to them all; this error may be overlooked. Similarly and for comparison reasons, we calculated the deviation between the intraoperative and the pathological assessment in each patient by subtracting one from the other. Obviously, in cases of coincidence the subtraction outcome was zero, otherwise it ranged from 1 to 5. The subtraction outcomes of the patients treated by each particular surgeon were summed up and named as deviation score for this certain surgeon. We assessed each surgeons diagnostic accuracy by dividing the total number of patients treated by him with his deviation score. Statistical comparison of the means of two samples was performed by an F-test for variances and in continuity with t-test. Categorical data were analyzed by Chi-square. Correlation of variables was evaluated through Spearmans rank Correlation Coefficient or Pearsons Correlation in cases of linear association.

RESULTS This study included a population of 717 patients (331 males and 386 females) with an age ranging from 8 to 82 years-old (mean age 25,2 years old). The age and gender distribution are shown in Table 2 where it can readily be seen that the condition concerned females of a younger age compared to males. Statistical analysis of the male to female ratio between the age groups demonstrated significant difference among the age groups (p < 0.05). Table 3 summarizes the relative frequencies of the commonest symptoms, signs, and physical or laboratory findings that were present in each histopathological stage of the disease. Histopathological severity correlated significantly (p < 0.05) with pain migration to RLQ, loss of appetite, periumbilical pain, fever, rebound tenderness, local rigidity, elevated WBC and PMN count and PMN predominance on deferential. Increased WBC was met in only 47.62 % of the subgroup of 21 patients older than 70 years. This differed significantly (p < 0.05) from the 69.5 % of the whole study population.

TABLE 1 Severity of appendiceal inflammation as assessed intraoperatively by the surgeon and by histopathology. Severity 1 2 3 4 5 6 Surgical assessment Normal appendix Catarrhal appendicitis Supurative appendicitis Gangrenous appendicitis Periappendiceal abscess Plastron Generalized peritonitis Histopathological assessment No inflammatory elements PNMs in the appendiceal lumen or in mucosal lacunes Inflamatory infiltration of the mucosa Inflammatory infiltration of the muscularis Periappendiceal infiltration with inflammatory elements Appendiceal gangrene or rupture

TABLE 2 Age and sex distribution of the population of the study. Age Males Females <10 12 09 1020 132 210 2030 81 96 3040 48 48 4050 25 05 5060 12 03 6070 9 6 >70 12 09 Total 331 386 717

Clinical diagnosis of acute appendicitis TABLE 3 Relative frequencies of the symptoms, signs and laboratory findings in acute appendicitis classified according to the histological grading of the inflammation. Histopathological Severity (%) 1 Pain migrating to RLQ * Loss of appetite * Periumbilical pain * Nausea Upper abdominal pain Fever * Vomiting RLQ tenderness Rebound tenderness * Local muscle rigidity * Generalized rigidity WBC > 10000/ml * PMN > 8000/ml * PMN > 75% * 73.1 35.9 53.8 11.5 34.6 26.9 11.5 100 38.5 3.8 3.8 35.9 38.5 34.6 2 73.1 52.7 38.7 12.9 29 41.9 12.9 100 44.1 6.5 0 41.9 32.3 35.5 3 84.2 50.9 55.3 36.8 26.3 36.8 36.8 97.4 44.7 10.5 2.6 55.3 36.8 28.9 4 88.2 53.6 58.3 31.3 39.6 54.2 41.3 100 71.5 22.9 2.1 72.2 58.3 62.5 5 94.2 75 71.2 44.2 34.6 51.9 44.2 98.1 82.7 26.9 0 88.5 80.8 75 6 93.2 71.2 63.6 27.3 45.5 54.5 27.3 97.7 81.8 38.6 9.1 93.2 84.1 70.5 86.2 59.0 58.6 46.9 35.6 33.5 29.7 98.7 64.4 20.5 02.9 69.5 59.4 54.8 618 423 420 213 255 336 240 708 462 147 021 498 426 393 Total (%)

203

Patients

* Correlation is significant at p < 0.05 level

In Table 4 we can see the number of patients treated by each surgeon, his deviation score and his calculated diagnostic reliability, and in Table 5 the distribution of the appendices removed by him according to pathology. Statistical analysis showed that the experience or aggressiveness of each surgeon, as expressed by the number of operations he performed, was not associated significantly with his diagnostic reliability Similarly, it was not associated with the pathological severity of the inflammation (Spearmans rho = 0.028, p > 0.05). As it can be seen in Table 6 intraoperative estimation of the appendiceal inflammation differed substantially from the histopathological grading. It is apparent that patients who according to the surgeon had no (Stage 1) or mild appendicitis (Stage 2) were in fact in a more severe setting than they were thought of. In proportion, those with histopathologicaly advanced appendicitis (stages 4 to 6) were in reality in a milder condition. Table 7 summarizes all the laparotomy outcomes of the present study with their pathology confirmations. In 44 out of the 717 appendectomized patients neither exploration nor histology revealed any intraabdominal pathology. 598 patients had only acute appendicitis verified by histology. In contrast 34 patients without appendicitis had a different intra-ab-

TABLE 4 Relative percentage of patients treated by each surgeon and reliability of surgical diagnosis compared to the pathology. Surgeon Patients 1 2 3 4 5 6 105 198 150 123 036 105 % 14.6 27.6 20.9 17.2 05.0 14.6 Deviation score Reliability 144 255 192 174 033 153 0.73 0.78 0.78 0.71 1.09 0.69

dominal condition responsible for the clinical picture. Finally, in 41 patients both appendiceal inflammation and a different intra-abdominal condition were met. In conclusion, 639 patients had appendicitis contrasting to 78 ones who had not. Unanticipated intra-abdominal conditions were met in 75 out of the 717 patients (10.46 %). As expected, the percentage of different intra-abdominal conditions increased to 43.6 % (p < 0.001) in the subgroup of 78 patients with no appendicitis. In all these appendectomy was combined with the appropriate treatment. As far as this treatment is concerned, two out of the seven Meckels diverticula were inflamed and all

TABLE 5 Relative percentage of appendices removed by each surgeon according to pathology. Histological Grading (%) Surgeon 1 2 3 4 5 6 Patients 105 198 150 123 036 105 1 11.4 13.6 080. 14.6 16.7 02.9 2 14.3 09.1 160. 19.5 16.7 05.7 3 17.1 22.7 120. 09.8 08.3 17.1 4 17.1 13.6 240. 17.1 16.7 34.3 5 23.2 15.2 280. 29.3 41.7 08.6 6 17.1 25.8 120. 09.8 0 31.4 1+2 25.7 22.7 240. 34,1 33,4 08.6 5+6 57.4 54.8 640. 56,2 58,4 74.3

204

V. Kalliakmanis, E. Picoulis, I. G. Karavokyros et al.

except one were removed. The three perforation of the small intestine (1 from a toothpick and 2 from a bone fragment) misguided the clinical diagnosis but exploration clarified the setting. The condition was treated with suture repair and peritoneal toilet. Crohns disease was firstly diagnosed in the inflamed appendiceal specimen of 4 patients. Appendiceal carcinoids were met in three cases. Two of them were smaller than 1.5 cm and located on the appendiceal apex so appendectomy sufficed, while in the third case the disease was more extended and

TABLE 6 Difference of inflammation as appreciated by the surgeon and the pathologist. Stage Surgical estimation Patients 1 2 3 4 5 6 120 132 185 156 112 012 717 % 16.7 18.4 25.8 21.8 15.6 01.7 Pathological estimation Patients 078 093 114 144 156 132 717 % 10.9 13.0 15.9 20.1 21.8 18.4 Difference % 5.8 5.4 9.9 1.7 6.2 16.7

located on the base of the appendix dictating right hemicolectomy. Omental torsion was treated with omentectomy. Two aged patients had their ovaries completely destructed necessitating oophorectomy. The rest ovarian cysts were treated either with unroofing or with wedge resection. To examine the impact of delayed laparotomy on the severity of appendiceal inflammation we correlated the symptoms duration till laparotomy with the severity of the histological alterations. The later the patient was operated on, the more the percentage of patients with no (Stage 1) or mild (Stage 2) inflammation increased. (Table 8). Stated otherwise, delayed operation was not accompanied with complicated appendicitis but with milder forms or with no-appendicitis. Moreover and as shown on Table 9, in this subgroup of patients the percentage of incidentally met intra-abdominal conditions rose to 53,9 %, significantly different (p < 0.001) from that of the whole study population. DISCUSSION This study focused on the trustworthiness of clinical assessment in the case of suspected acute appendicitis. In no case sophisticated imaging or laboratory tests were employed. Clinical diagnosis was based

TABLE 7 Intra-abdominal pathology met during appendectomies AA only Mesenteric lymphadenitis Meckels diverticulum Ovarian Cyst Crohns disease Foreign body intestinal perforation Omental torsion Carcinoid Total Total AA Total non-AA Total Patients 717 AA plus DC (%*) 7 5 25 3 1 598 639 78 (1.1)0 (0.78) (3.91)0 (0.47) (0.16) 0 0 41 (6.46) NL DC only (%**) 11 2 14 1 2 1 3 34 (14.10) (2.56) (17.95) (1.28) (2.56) (1.28) (3.84) (43.21) DC total (%***) 18 (2.51) 7 (0.97) 39 (5.44)0 4 (0.55) 3 (0.42) 1 (0.14) 3 (0.42) 75 (10.45)

44

AA: acute appendicitis with histological verification; NL: negative laparotomy; DC: different intra-abdominal condition; * % in the 639 patients with histological proven acute appendicitis; ** % in the 78 patients with different intra-abdominal conditions met in laparotomy; *** % in the total 717 appendectomized patients

TABLE 8 Duration of symptoms and severity of inflammation. Duration of symptoms < 24 hrs 2448 hrs 4872 hrs > 72 hrs Total Patients (%) 1 501 144 33 39 (69.9) (20.1) (4.6) (5.4) 48 23 01 06 2 24 36 11 21 Pathological staging 3 60 43 10 03 4 1200 14 06 03 5 145 006 003 003 6 1040 22 03 03 14.3 % 41.6 % 36.3 % 69.2 % Stages 1+2 %

717 (69.9)

Clinical diagnosis of acute appendicitis

205 TABLE 9

solely on history, physical examination and simple laboratory tests and as our results indicate this triple modality is effective and efficient in ordinary daily practice. The prevailing sign of acute appendicitis in our study was RLQ tenderness; however it was of limited help as this sign is necessary for the diagnosis. Our results support literature (1315, 37) on the value of rebound tenderness and RLQ rigidity because their frequency correlated significantly with the severity of the inflammation. Similarly, we validated the usefulness of leukocytosis, polymorphonucleosis and PMN predominance on smear deferential (811); and verified the lack of specificity of leukocytosis in older patients (1, 38). Resection of normal appendices in the general population after simple clinical assessment occurs in approximately 1020 % of open appendectomies (8, 18, 22, 39, 40) and peaks to 1838 % in the subpopulation of fertile females (2933). The various diagnostic adjuncts and especially laparoscopy decrease misdiagnosis, again mostly in fertile females (2933). The present study did not employ any adjunct diagnostic modality and was conducted on the general population with fertile females being approximately half of the population included. Moreover all the participating surgeons appeared to be equally accurate in their pre-operative diagnosis and intraoperative assessment. No difference existed in the percentage of mildly or severely inflamed appendices removed by each surgeon. Negative appendectomies amounted up to approximately 11 %, ranging well within the literature when appendicitis is diagnosed clinically. Considering the various unanticipated intra-abdominal conditions necessitating therapeutic laparotomy, unnecessary laparotomies approached 6 %. A further decrease of negative explorations perhaps could have been achieved by imaging or adjunct testing. However, and in good agreement with others (16, 23, 40) our results indicate that adjunct testing should not become routine and be reserved for special occasions. Exploratory laparoscopy in particular, although minimally invasive, it remains an operation. A negative laparoscopy would spare the patient an appendectomy but not an operation. The two classification scales for the staging of appendiceal inflammation employed in this study do not correspond to each other precisely. This can partially explain the diversity between the surgeons and the pathologists appreciation. On the other hand, underestimation of appendiceal inflammation by the surgeon is well known (41) and supports our data. All the surgeons enrolled underestimated the severely inflamed appendices. The observed overestimation of the mildly or non-inflamed ones is the outcome of proportion maintenance. Unforeseen conditions were met in one out of ten patients. They have been responsible for the clinical picture in 43 % of the patients without acute appendicitis and in more than half of those operated late. Most patients of those with delayed operation have already been pre-treated with antibiotics. This could have down-staged inflammation (42) but a dilated appendix can be detected sonographically and

Various intra-abdominal situations met during appendectomy in cases with delayed presentation (>72 hrs). Patients Intestinal perforation by foreign body Meckels diverticulum Ovarian Cyst Crohns disease Mesenteric lymphadenitis Carcinoid Total 1 2 9 4 4 1 210 % in 39 2.56 5.12 23.07 10.25 10.25 2.56 53.84

probably intraoperatively even ten days after the onset of the setting (43). It seems therefore prudent for the surgeon to exclude all possible different conditions when the intraoperative findings are not impressive or when the patient reports a long history and antibiotic treatment. On the other hand, if he proceeds into delayed laparotomy and meets evidence of resolving inflammation, appendectomy must follow as the recurrence rate remains high (42, 43). In conclusion clinical diagnosis of acute appendicitis can be safely reached in most cases without adjunct, sophisticated and costly testing. Careful consideration of the patients history, physical signs and plain laboratory evaluation will lead to reliable diagnosis in nine out of ten conditions. Equivocal cases may deserve special diagnostic tests in order to avoid or to modify the surgical approach, however these should not become routine.

REFERENCES
01. Harrison MW, Lindner DJ, Campbell JR, Campbell TJ: Acute appendicitis in children: Factors affecting morbidity. Am J Surg 1984;147:605610 02. Savrin RA, Clatworthy HW Jr: Appendiceal rupture: a continuing diagnostic problem. Pediatrics 1979;63:3643 03. Scher KS, Coil JA: The continuing challenge of perforating appendicitis. Surg Gynecol Obstet 1980;150: 535538 04. Karakas SP, Guelfguat M, Leonidas JC, Springer S, Singh SP: Acute appendicitis in children: comparison of clinical diagnosis with ultrasound and CT imaging. Pediatr Radiol 2000; 30:9498 05. Hoffmann J, Rasmussen OO: Aids in the diagnosis of acute appendicitis. Br J Surg 1989; 76: 774779 06. Oruc MT, Kulah B, Ozozan O, Ozer V, Kulacoglu, Turhan T, Coskun F: The value of 5-hydroxyl indole acetic acid measurement in spot urine in diagnosis of acute appendicitis. East African Med J 2004;81:4041 07. Taha AS, Grant V, Kelly RW: Urine analysis for interleukin-8 in the non invasive diagnosis of acute and chronic inflammatory diseases. Postgrad Med J 2003;79:159163 08. Asfar S, Safar H, Khourseed M, Dashti H, al- Bader A: Would measurement of C-reactive protein reduce the rate of negative exploration for acute appendicitis? JRColl Surg Edinb 2000;45:2124 09. Hallan S, Asberg A: The accuracy of C-reactive protein in diagnosing acute appendicitis a meta analysis. Scan J Clin Lab Invest 1997;57:37380 10. Goodwin AT, Swift RI, Bartlett MJ, Fernando BS, Chadwick SJ: Can serum interleukin-6 levels predict the outcome of patients with right iliac fossa pain? Ann R Coll Surg Engl 1997; 79:130133

206

V. Kalliakmanis, E. Picoulis, I. G. Karavokyros et al. 27. Wong DW, Vasinrapee P, Spieth ME, Cook RE, Ansari AN, Jones M Jr, Mandal A: Rapid detection of acute appendicitis with Tc-99m-labeled intact polyvalent human immune globulin. J Am Coll Surg 1997;185:534543 28. Incesu L, Coskun A, Selcuk MB, Akan H, Sozubir S, Bernay F Acute appendicitis: MR imaging and sonographic correlation. AJR Am J Roentgenol 1997;168:316318 29. Larsson PG, Henriksson G, Olsson M, Boris J, Stroberg P, Tronstad SE, Skullman S: Laparoscopy reduces unnecessary appendicectomies and improves diagnosis in fertile women. A randomized study. Surg Endosc 2001;15:200202 30. Lamparelli MJ, Hoque HM, Pogson CJ, Ball AB: A prospective evaluation of the combined use of the modified Alvarado score with selective laparoscopy in adult females in the management of suspected appendicitis. Ann R Coll Surg Engl 2000;82:192195 31. Bruwer F, Coetzer M, Warren BL: Laparoscopic versus open surgical exploration in premenopausal women with suspected acute appendicitis Afr J Surg 2003;41:8285 32. Navarra G, Ascanelli S, Turini A, Carcoforo P, Tonini G, Pozza E: Laparoscopic appendectomy versus open appendectomy in suspected acute appendicitis in female patients Ann Ital Chir 2002;73:5963 33. Borgstein PJ, Gordijn RV, Eijsbouts QA, Cuesta MA: Acute appendicitis a clear-cut case in men, a guessing game in young women. A prospective study on the role of laparoscopy. Surg Endosc. 1997;11:923927 34. Laine S, Rantala A, Gullichsen R, Ovaska J: Laparoscopic appendectomy-is it worthwhile? A prospective, randomized study in young women. Surg Endosc 1997;11:9597 35. Zaninotto G, Rossi M, Anselmino M, Costantini M, Pianalto S, Baldan N, Pizzato D, Ancona E: Laparoscopic versus conventional surgery for suspected appendicitis in women. Surg Endosc 1995;9:337340 36. Olsen JB, Myren CJ, Haahr PE: Randomized trial on the value of diagnostic laparoscopy before appendectomy. Ugeskr Laeger 1995;157:584585 37. Alshehri MY, Ibrahim A, Abuaisha N, Malatani T, Abu-Eshy S, Khairulla S, Bahamdan K: Value of rebound tenderness in acute appendicitis. East Afr Med J 1995;72:504506 38. Lau WY, Fan ST, Yiu TF, Chu KW, Lee JMH: Acute appendicitis in the elderly. Surg Gynecol Obstet 1985;161:157160 39. Martin LC, Puente I, Sosa JL, Bassin A, Breslaw R, McKenney MG, Ginzburg E, Sleeman D: Open versus laparoscopic appendectomy. A prospective randomized comparison. Ann Surg 1995;222:256262 40. Browder W, Smith JW, Vivoda LM, Nichols RL: Nonperforative appendicitis: a continuing surgical dilemma. J Infect Dis 1989;159:10881094 41. Sarfati MR, Hunter GC, Witzke DB, Bebb GG, Smythe SH, Boyan S, Rappaport WD: Impact of adjunctive testing on the diagnosis and clinical course of patients with acute appendicitis. Am J Surg 1993;166:660665 42. Eriksson S, Granstrom L: Randomized controlled trial of appendicectomy versus antibiotic therapy for acute appendicitis. Br J Surg 1995;82:166169 43. Eriksson S, Tisell A, Granstrom L: Ultrasonographic findings after conservative treatment of acute appendicitis and open appendicectomy. Acta Radiol 1995;36:173177

11. Vermeulen B, Morabia A, Unger PF: Influence of white cell count on surgical decision making in patients with abdominal pain in the right lower quadrant. Eur J Surg 1995;161:483 486. 12. Albu E , Miller BM, Choi Y, Lakhanpal S, Murthy RN, Gerst PH: Diagnostic value of C-reactive protein in acute appendicitis. Dis Colon Rectum 1994;37:4951 13. Christian F, Christian GP: A simple scoring system to reduce the negative appendicectomy rate. Ann R Coll Surg Engl. 1992; 74:281285 14. Eskelinen M, Ikonen J, Lipponen P: The value of history-taking, physical examination, and computer assistance in the diagnosis of acute appendicitis in patients more than 50 years old. Scand J Gastroenterol 1995;30:349355 15. Alvarado A: A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med 1986;15;557564 16. Ohmann C, Franke C, Yang Q: Clinical benefit of a diagnostic score for appendicitis: results of a prospective interventional study. German Study Group of Acute Abdominal Pain. Arch Surg 1999;134:993996 17. Zielke A, Sitter H, Rampp T, Schafer E, Mobius E, Lorenz W, Rothmund M: Can diagnostic scoring systems help decision making in primary care of patients with suspected acute appendicitis? Zielke Dtsch Med Wochenschr. 1999;124:545550 18. Douglas CD, Macpherson NE, Davidson PM, Gani JS: Randomised controlled trial of ultrasonography in diagnosis of acute appendicitis, incorporating the Alvarado score. BMJ 2000;321:919922 19. Rettenbacher T, Hollerweger A, Gritzmann N, Gotwald T, Schwamberger K, Ulmer H, Nedden DZ: Appendicitis: should diagnostic imaging be performed if the clinical presentation is highly suggestive of the disease? Gastroenterology 2002; 123:992998 20. Zielke A, Hasse C, Sitter H, Rothmund M: Influence of ultrasound on clinical decision making in acute appendicitis: a prospective study. Eur J Surg 1998;164:201209 21. Lane MJ, Liu DM, Huynh MD, Jeffrey RB Jr, Mindelzun RE, Katz DS: Suspected acute appendicitis: nonenhanced helical CT in 300 consecutive patients. Radiology. 1999;213:341346 22. Walker S, Haun W, Clark J, McMillin K, Zeren F, Gilliland T: The value of limited computed tomography with rectal contrast in the diagnosis of acute appendicitis. Am J Surg 2000; 180:450455 23. Hong JJ, Cohn SM, Ekeh AP, Newman M, Salama M, Leblang SD; Miami Appendicitis Group: A prospective randomized study of clinical assessment versus computed tomography for the diagnosis of acute appendicitis. Surg Infect (Larchmt) 2003;4:231239. 24. Rypins EB, Evans DG, Hinrichs W, Kipper SL: Tc-99m-HMPAO white blood cell scan for diagnosis of acute appendicitis in patients with equivocal clinical presentation. Ann Surg 1997;226:5865 25. Barron B, Hanna C, Passalaqua AM, Lamki L, Wegener WA, Goldenberg DM: Rapid diagnostic imaging of acute, nonclassic appendicitis by leukoscintigraphy with sulesomab, a technetium 99m-labeled antigranulocyte antibody Fab fragment. LeukoScan Appendicitis Clinical Trial Group. Surgery. 1999; 125:288296 26. Colak T, Gungor F, Ozugur S, Bozan H, Yildiz A, Boz A, Karayalcin B, Akaydin M, Melikoglu M: The value of 99mTcHMPAO labelled white blood cell scintigraphy in acute appendicitis patients with an equivocal clinical presentation. Eur J Nucl Med 2001;28:575580

Received: January 10, 2005 Accepted: April 6, 2005