Scandinavian Journal of Surgery 94: 201–206, 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. Leppäniemi4, 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 (1–4). 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 (6–12), scoring systems (13–17), ultrasound imaging (18–20), CT Scan, (21–23) scintigraphy (24–27) MRI (28) and laparoscopy (29–36). None of these methods stands alone as they all come in support of, and are secondary to a primary clinical assessment.

otherwise it ranged from 1 to 5. and physical or laboratory findings that were present in each histopathological stage of the disease. we calculated the deviation between the intraoperative and the pathological assessment in each patient by subtracting one from the other. together with the findings of clinical examination and laboratory investigation. Furthermore.05) from the 69. Increased WBC was met in only 47. present and previous medical history.202 V. and again into six categories according to histopathology (Table 1). and elevated PNM absolute number (> 8000/ml). G. e. This differed significantly (p < 0. stage 6 in histopathology corresponds in both stages 5 or 6 in surgical assessment.05) with pain migration to RLQ. in cases of coincidence the subtraction outcome was zero.2 years old).5 % of the whole study population.62 % of the subgroup of 21 patients older than 70 years. 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. Kalliakmanis. Age Males Females <10 12 09 10–20 132 210 20–30 81 96 30–40 48 48 40–50 25 05 50–60 12 03 60–70 9 6 >70 12 09 Total 331 386 717 . We recorded the patient’s sex. signs.e. and laboratory evaluation. The score of the pathological assessment was correlated with the relative frequency of each element of the patient’s history. Karavokyros et al. The two classification scales do not correspond to each other completely. Picoulis. Table 3 summarizes the relative frequencies of the commonest symptoms. 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. All were appendectomized and none was treated conservatively. I. clinical examination. loss of appetite. Among the laboratory values we evaluated elevated White Blood Cell Count (WBC > 1000 ml). Obviously. Special attention was paid on the signs of localized or generalized peritoneal irritation i. periumbilical pain. 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. The symptoms and history of these patients were sought in the standard manner. We assessed each surgeon’s diagnostic accuracy by dividing the total number of patients treated by him with his “deviation score”. however we recorded the physical findings and laboratory values obtained during the surgical assessment and not those of the referring physicians’. The subtraction outcomes of the patients treated by each particular surgeon were summed up and named as “deviation score” for this certain surgeon. we addressed to the relationship between the surgeon’s intraoperative impression of appendiceal inflammation and its severity as assessed in histopathology. E. fever. this error may be overlooked. 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. 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. Histopathological severity correlated significantly (p < 0. Statistical analysis of the male to female ratio between the age groups demonstrated significant difference among the age groups (p < 0. physical examination and plain laboratory tests. 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.g. Right Lower Quadrant (RLQ) tenderness. and muscle rigidity.05). age. Polymorphonuclear cell (PNM) predominance on smear deferential (PNM > 75 %). Statistical comparison of the means of two samples was performed by an F-test for variances and in continuity with t-test. elevated WBC and PMN count and PMN predominance on deferential. Similarly and for comparison reasons. Appendiceal inflammation was classified intraoperatively into six categories as appreciated by the surgeon. TABLE 1 Severity of appendiceal inflammation as assessed intraoperatively by the surgeon and by histopathology. Correlation of variables was evaluated through Spearman’s rank Correlation Coefficient or Pearson’s Correlation in cases of linear association. local rigidity. rebound tenderness. Our aim in this prospective non randomized study was to review the initial diagnostic evaluation of suspected acute appendicitis by history. rebound tenderness. Categorical data were analyzed by Chi-square.

Table 7 summarizes all the laparotomy outcomes of the present study with their pathology confirmations.9 32.3 41.7 38.8 36.9 100 44.7 3 17.1 22.5 3 84.2 50.3 36.6 Deviation score Reliability 144 255 192 174 033 153 0. 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% * 73.5 34.6 % (p < 0.7 240. the percentage of different intra-abdominal conditions increased to 43.3 31.1 16. it was not associated with the pathological severity of the inflammation (Spearman’s rho = 0.Clinical diagnosis of acute appendicitis TABLE 3 Relative frequencies of the symptoms.6 26.1 72.3 . 17. In all these appendectomy was combined with the appropriate treatment.7 81.2 71.2 58.3 36.5 86. 09.2 58.2 59.5 0 41.6 5+6 57.6 54.6 6 17.71 1. 639 patients had appendicitis contrasting to 78 ones who had not.2 84.9 4 88. 19.2 75 71.5 22.5 27.5 2. 09.9 69.2 63. as expressed by the number of operations he performed.7 10.9 2.7 12.1 6.9 11. signs and laboratory findings in acute appendicitis classified according to the histological grading of the inflammation.2 15.5 80.9 35.6 240.8 35.3 97.3 62. In conclusion.5 29.0 58.028.001) in the subgroup of 78 patients with no appendicitis.5 54. 34. As it can be seen in Table 6 intraoperative estimation of the appendiceal inflammation differed substantially from the histopathological grading. those with histopathologicaly advanced appendicitis (stages 4 to 6) were in reality in a milder condition.5 16.73 0.1 35.0 14.8 11.1 13.1 160. 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. Histological Grading (%) Surgeon 1 2 3 4 5 6 Patients 105 198 150 123 036 105 1 11.1 33.1 82.2 44. his deviation score and his calculated diagnostic reliability.8 75 6 93.09 0.2 34.1 4 17.6 16.3 36.8 618 423 420 213 255 336 240 708 462 147 021 498 426 393 Total (%) 203 Patients * Correlation is significant at p < 0.4 20. Surgeon Patients 1 2 3 4 5 6 105 198 150 123 036 105 % 14.7 26.7 120.3 35.5 34.9 2 14.6 58.4 74.4 08.6 51.5 3.7 98.9 0 88.8 38.8 3. In 44 out of the 717 appendectomized patients neither exploration nor histology revealed any intraabdominal pathology.3 45.78 0.9 55.8 0 31.5 59. As expected.69 dominal condition responsible for the clinical picture.7 02.4 13.7 34.7 64. 14.8 28.6 33.8 08.5 5 94.6 27.3 39.2 05.1 52.4 54.05 level In Table 4 we can see the number of patients treated by each surgeon.1 70. was not associated significantly with his diagnostic reliability Similarly. In proportion.6 27. Finally.46 %).3 09. and in Table 5 the distribution of the appendices removed by him according to pathology.7 22. 598 patients had only acute appendicitis verified by histology.4 54. As far as this treatment is concerned. p > 0.6 2 73.78 0.7 05.8 26.9 38.6 46.9 53. 56. Unanticipated intra-abdominal conditions were met in 75 out of the 717 patients (10.1 25. two out of the seven Meckel’s diverticula were inflamed and all TABLE 5 Relative percentage of appendices removed by each surgeon according to pathology.9 29 41.6 9.3 5 23.6 55.2 280.8 97.4 44.5 100 38. Statistical analysis showed that the “experience” or “aggressiveness” of each surgeon.2 53.3 100 71. 29.5 02. 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.8 640.7 08.8 120.1 93.9 44.9 12.6 20.05).4 1+2 25.2 41. in 41 patients both appendiceal inflammation and a different intra-abdominal condition were met.6 080.9 17.3 17.2 98.

3 % 69.7 located on the base of the appendix dictating right hemicolectomy. the more the percentage of patients with no (Stage 1) or mild (Stage 2) inflammation increased.84) (43. *** % in the total 717 appendectomized patients TABLE 8 Duration of symptoms and severity of inflammation.95) (1. ** % in the 78 patients with different intra-abdominal conditions met in laparotomy. Crohn’s disease was firstly diagnosed in the “inflamed” appendiceal specimen of 4 patients. Clinical diagnosis was based TABLE 7 Intra-abdominal pathology met during appendectomies AA only Mesenteric lymphadenitis Meckel’s diverticulum Ovarian Cyst Crohn’s 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 (1.4 25.0 15.9 13. * % in the 639 patients with histological proven acute appendicitis. (Table 8).46) NL DC only (%**) 11 2 14 1 2 1 3 34 (14. Stated otherwise.9 1.4 9. Picoulis. Appendiceal carcinoids were met in three cases.10) (2. The condition was treated with suture repair and peritoneal toilet.3 % 41.42) 75 (10.78) (3. Omental torsion was treated with omentectomy.56) (1. Kalliakmanis.55) 3 (0.28) (3.2 % Stages 1+2 % 717 (69.9) .47) (0.2 –16.7 18.6) (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. NL: negative laparotomy. Moreover and as shown on Table 9. except one were removed.1 21. G. E. In no case sophisticated imaging or laboratory tests were employed. while in the third case the disease was more extended and TABLE 6 Difference of inflammation as appreciated by the surgeon and the pathologist.6 % 36.9 20. 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. I. delayed operation was not accompanied with complicated appendicitis but with milder forms or with no-appendicitis. Two aged patients had their ovaries completely destructed necessitating oophorectomy. 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.28) (2. The rest ovarian cysts were treated either with unroofing or with wedge resection. DISCUSSION This study focused on the trustworthiness of clinical assessment in the case of suspected acute appendicitis.44)0 4 (0.21) DC total (%***) 18 (2. significantly different (p < 0.14) 3 (0.8 21.204 V.1) (4.9) (20.4 Difference % 5.51) 7 (0.8 15.42) 1 (0.97) 39 (5.56) (17.001) from that of the whole study population.1)0 (0.91)0 (0.7 –6.45) 44 AA: acute appendicitis with histological verification.6 01. Duration of symptoms < 24 hrs 24–48 hrs 48–72 hrs > 72 hrs Total Patients (%) 1 501 144 33 39 (69.8 18. Stage Surgical estimation Patients 1 2 3 4 5 6 120 132 185 156 112 012 717 % 16. in this subgroup of patients the percentage of incidentally met intra-abdominal conditions rose to 53.9 %.8 5.16) 0 0 41 (6. DC: different intra-abdominal condition.5 cm and located on the appendiceal apex so appendectomy sufficed. The later the patient was operated on.7 Pathological estimation Patients 078 093 114 144 156 132 717 % 10. Karavokyros et al. Two of them were smaller than 1.

38). Leonidas JC. 37) on the value of rebound tenderness and RLQ rigidity because their frequency correlated significantly with the severity of the inflammation. Karakas SP. Hallan S. Most patients of those with delayed operation have already been “pre-treated” with antibiotics. sophisticated and costly testing. Pediatrics 1979. Rasmussen OO: Aids in the diagnosis of acute appendicitis. Asfar S. 43). 23. Scan J Clin Lab Invest 1997. Guelfguat M. Savrin RA.63:36–43 03. Our results support literature (13–15.25 10. 39.150: 535–538 04. Khourseed M. if he proceeds into delayed laparotomy and meets evidence of resolving inflammation. Bartlett MJ. although minimally invasive. The prevailing sign of acute appendicitis in our study was RLQ tenderness. it remains an operation.12 23. All the surgeons enrolled underestimated the severely inflamed appendices. Surg Gynecol Obstet 1980.Clinical diagnosis of acute appendicitis 205 TABLE 9 solely on history. East African Med J 2004. Similarly. Campbell TJ: Acute appendicitis in children: Factors affecting morbidity.57:373–80 10.81:40–41 07. Hoffmann J.147:605–610 02. Safar H. physical signs and plain laboratory evaluation will lead to reliable diagnosis in nine out of ten conditions. Taha AS. 79:130–133 . The various diagnostic adjuncts and especially laparoscopy decrease misdiagnosis. 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. underestimation of appendiceal inflammation by the surgeon is well known (41) and supports our data. Careful consideration of the patient’s history. Turhan T. Patients Intestinal perforation by foreign body Meckel’s diverticulum Ovarian Cyst Crohn’s disease Mesenteric lymphadenitis Carcinoid Total 1 2 9 4 4 1 210 % in 39 2.25 2. Goodwin AT. Chadwick SJ: Can serum interleukin-6 levels predict the outcome of patients with right iliac fossa pain? Ann R Coll Surg Engl 1997. Unforeseen conditions were met in one out of ten patients. Oruc MT. however these should not become routine. Clatworthy HW Jr: Appendiceal rupture: a continuing diagnostic problem. and verified the lack of specificity of leukocytosis in older patients (1. The observed overestimation of the mildly or non-inflamed ones is the outcome of proportion maintenance. Equivocal cases may deserve special diagnostic tests in order to avoid or to modify the surgical approach. Negative appendectomies amounted up to approximately 11 %. Singh SP: Acute appendicitis in children: comparison of clinical diagnosis with ultrasound and CT imaging. Moreover all the participating surgeons appeared to be equally accurate in their pre-operative diagnosis and intraoperative assessment. 30:94–98 05. Ozozan O. Kulah B. Asberg A: The accuracy of C-reactive protein in diagnosing acute appendicitis – a meta analysis. again mostly in fertile females (29–33).79:159–163 08.07 10. Pediatr Radiol 2000. Am J Surg 1984. 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.84 probably intraoperatively – even ten days after the onset of the setting (43). appendectomy must follow as the recurrence rate remains high (42. Grant V. Fernando BS. 40) our results indicate that adjunct testing should not become routine and be reserved for special occasions. 22. unnecessary laparotomies approached 6 %. Kulacoglu. Postgrad Med J 2003. al.56 53. 40) and peaks to 18–38 % in the subpopulation of fertile females (29–33). Coskun F: The value of 5-hydroxyl indole acetic acid measurement in spot urine in diagnosis of acute appendicitis. Scher KS. 18. 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. Dashti H. 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A further decrease of negative explorations perhaps could have been achieved by imaging or adjunct testing. A negative laparoscopy would spare the patient an appendectomy but not an operation. and in good agreement with others (16. Coil JA: The continuing challenge of perforating appendicitis. This can partially explain the diversity between the surgeon’s and the pathologist’s appreciation.56 5.Bader A: Would measurement of C-reactive protein reduce the rate of negative exploration for acute appendicitis? JRColl Surg Edinb 2000. Campbell JR. 76: 774–779 06. The two classification scales for the staging of appendiceal inflammation employed in this study do not correspond to each other precisely. polymorphonucleosis and PMN predominance on smear deferential (8–11). 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). 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