Computed Tomography and Ultrasonography Do Not Improve and May Delay the Diagnosis and Treatment of Acute Appendicitis ‘Steven L. Lee, MD; Alicia J. Walsh, BS; Hung S. Ho, MD Hypothesis: Computed tomography (CT) and ultra- sonography (US) do not improve the overall diagnostic accuracy for acute appendicitis, Design: Retrospective review. Setting: University tertiary care center. Patients: Seven hundred sixty-six consecutive pa- tients undergoing appendectomy for suspected appen- dicitis from January 1, 1995, to December 31, 1999. Main Outcome Measures: Epidemiology of acute ap- pendicitis and the roles of clinical assessment, CT, US, and laparoscopy. Results: The negative appendectomy rate was 15.7%, and the incidence of perforated appendicitis was 14.6%. his- tory of migratory pain had the highest positive predic- tive value (91%), followed by leukocytosis greater than 12X10". (00.1%), CT (83.8%), and US (81.3%). The false-negative rates were 60% for CT and 76.1% for US. Emergency department evaluation took a meanSD of 5.2454 hours and was prolonged by US or CT (644 74 band 7.84108 h, respectively). The duration of emergency department evaluation did not affect the per- foration rate, but patients with postoperative compli- cations had longer evaluations (meanSD, 8.012.7 b) than did those without (4.843.3 h) (P=.04). Morbidity was 9.19%, 6.4% for nonperforated cases and 19.8% for perforated eases. Seventy-six patients had laparoscopic appendectomy, with a negative appendectomy rate of 42.19%, compared with 15.4% for open appendectomy (P<.001). Laparoscopy, however, had minimal morbid- ity (1.3%) and correctly dentified the abnormality in 91.6% of patients who had a normal-appearing appendix. Conclusions: Migratory pain, physical examination, and initial leukocytosis remain reliable and accurate in diag- nosing acute appendicitis. Neither CT nor US improves the diagnostic accuracy or the negative appendectomy rate; in fact, they may delay surgical consultation and ap- pendectomy. In atypical cases, one should consider the selective use of diagnostic laparoscopy instead. Arch Surg, 2001;136:556-562 LTHOUGH the treatment of acute appendicitis simple and straightforward, its di- agnosis remains a chal- lenge, and the negative ap- improve the diagnostic accuracy for acute appendicitis" On the other hand, there were also concerns about the appropri- ateness and accuracy of these modalities without a surgical evaluation." From the Department of Surgery, University of California Davis School of ‘Medicine, Sacramento, (aepnnreD) ARCTSORGOL Ts NA Ho pendectomy rate in large series ranges from 15% to 33%." Furthermore, in the pa- ents with either atypical history oF equivocal physical examination findings, particularly in women of childbearing age, the negative appendectomy rate has been as high as 45%." With an annual rate of 250000 cases in the US and an incidence of 86 for every 100000 persons world- wide,” acute appendicitis is a common acute abdomen condition in the emer- gency department (ED). During the last decade, studies of white blood cell scan, ultrasonography (US), and computed t0- ‘mographic (CT) scan have suggested that these diagnostic imaging modalities may (©2001 American Med Downloaded From: http:/jamanetwork.com/ on 11/09/2016 ‘Atour institution, history and physi- cal examination, followed by pathologic confirmation after appendectomy, typi- cally diagnose acute appendicitis. During the past 10 years, there has been increas- ing use of imaging modalities before ob- ining surgical consultation in our ED and selective use of diagnostic laparoscopy in the management of acute abdomen. In this, report, we reviewed the current epidemi- ology of acute appendicitis ina tertiary care center and assessed the impacts of US, CT sean, and laparoscopy on ils manage- ‘ment, with the hypothesis that CT sean and US do not improve the overall diagnostic accuracy for acute appendicitis, Association, All rights reserved.PATIENTS AND METHODS We conducted a retrospective review of 766 com: secutive patients undergoing appendectomy forsis- pected acute appendicitis from January 1, 1995, to December 31, 1999, at University of California Davis Medical Center, Scramento, Patients who had inci- dental appendectomy as part of another procedure ‘vere excluded. We aimed to study the epidemiol- ‘ogy ofthe disease, its clinical presentation, and the roleof laboratory tests and imaging stdies in its man ‘agement. The time spent in the ED lor evaluation was defined as the time from admission in the ED until the time when the surgical consultation was ob- tained, The timing of appendectomy, intraoperative Findings inal pathologie diagnoses, and postopera tive complications are also recorded. A small sub- {group of our patients was treated with laparoscopic appendectomy, and we aimed to review its impact Dataare reported as meana SD. Statistical snaly- sisforsgnificant differences between groups wasdone lsing a 2sample test for continuots variables and the Fisher exact test for discrete variables. Differ- fences were considered significant al P05, (as From January 1, 1995, to December 31, 1909, 424 men (55.4%) and 342 women (44.6%) had appendectomy for suspected acute appendicitis at University of California Davis Medical Center. The Figure shows the age distri bution, with approximately a quarter of the patients el- ther younger than 10 years (15.7%) or older than 50 years (8.2%). The male to female patient ratio was 1.2:1. The negative appendectomy rate was 15.7%, with a signifi- cantly higher negative rate in women than in men, 24.6% 58.5% (P<001). The negative appendectomy rates were also higher in young adults (20%). Patients younger than 10 years hada negative appendectomy rate of 9.7%, and patients older than 50 years, 14.3% (Table 1), The incidence of perforation was high in the very young and in the older age groups, 20.4% for those younger than 10 years and 28.0% for those older than 50 years (Table 1). Seventeen percent of men (72/424) and 11.4% of women (39/342) had perforated appen- dicitis. The perforation rate was not a function of a delay in evaluation, as the duration from the onset of pain to ED evaluation in perforated appendicitis was 2.943.5 days compared with 2.47.9 days for nonper- forated cases (P=.28). The mean ED evaluation was 5,840.5 hours for perforated appendicitis and 5.043.4 hours for nonperforated appendicitis (P2.38). Perlo- rated appendicitis resulted in a higher complication rate than did nonperforated appendicitis (19.8% vs 6.1%, P=.001) Patients with postoperative complications had longer ED evaluations (8.0412.7 h) than did those without (4.8433 h) P=.04) (aepnnreD) ARCTSORGOL Ts NA Ho (©2001 American Med Downloaded From: http:/jamanetwork.com/ on 11/09/2016 sey Te age alsrbuton of cute appends inthe ate 1880, Table 1. Age, Negative Appendectomy Rate, ‘and Perforation Rate in 766 Patients With Suspected ‘Acute Appendicitis During the Late 1990s" ate Perrates eve ‘Age.y Negative ___appenditts—___Appendcis =10 997) 55/699) 19/204) t020 77104) 273 689), a5(118) sso 42203) 139671), 25128) > 10/143) 401671) 20/288) “Data ate given as number (percentage CLINICAL ASSESSMENT Abdominal pain was the most common presentation of acute appendicitis, reported by 99% of our patients. A history of classic migratory pain (initial periumbilical or epigastric pain localizing to the right lower quadrant) pro- vided the highest positive predictive value (91%) for pa- jents clinically suspected of having acute appendicitis In patients found to have perforated appendicitis, 23.4% presented with diffuse or bilateral lower abdominal pain, compared with only 11.9% of those with nonperforated acute appendicitis (P=.002). Nausea occurred in 81.7% of the patients, anorexia in 72.4%, and emesis in 67.7%. Fever was reported in 44.9% and chills in 27.3% of pa- tients with acute appendicitis, with similar incidence in allstages of appendicitis and in alternative diagnoses, such as mesenteric adenitis, gastroenteritis, pelvic inflam- matory disease, and gynecologic disorders. Leukocyto- sis (>12 X 10°/L) provided the second-best positive pre- dictive value (90.1%). Patients with perforated acute appendicitis had a higher degree of leukocytosis (le.445% 10°/L) than did those with nonperforated acute appendicitis (14.7446 10°/L, P=.002). Many pa- jents with acute appendicitis had no leukocytosis, and 5.3% of these patients had perforation, Conversely, pa- jents with mesenteric adenitis had slightly higher de- agrees of leukocytosis (16.5.6.5 X 10°/L) than did those tients with nonperforated acute appendicitis. Pa- ents with gastroenteritis had degrees of leukocytosis similar to those of patients with acute appendicitis, (14.9464 X 10°/L). In 84.9% of patients, repeated white blood cell counts were lower than the inital values ob- Association, All rights reserved.‘Table 2. Comparison Between Clinical Assessment, Table 4. Final Pathologie Diagnoses in 766 Patients, CT Scan, and Ultrasonography inthe Diagnosis With Suspected Acute Appendicltis* of Acute Appendicitis” Ha er sean Ulvasonograpny Diagnosis Seven wae cy Hormal 20157) S248) 36185) Speiioty siya nz cule appndicts aon) 187/547) 282(685) Postvapredcivevaue 66718 fa Gangroous appendicis 47123) 518) 1228), Neguve predictive vale 2570 na Perltaled appendcis, §—114(145) 39114) 72(170) ezurasy me 745. aa Chronic appends 7I0s) 30a) 4109) Subset appends 12) 4a) $112) Data are gen as percentage. CT ndleaes computed omogragh Pappas (18) 928) (12) H&P isiory and physical examination. Cacincdadencarcnoma (10) 42) 409). Ober sits 720) (03) ‘Table 3. Preoperative Care: Time From ED Admission ta Surgical Consultation and Appendectomy* ED Aamision Surgical” €D Admission to consulaton,b_Appendectomy, ip a7s82«1032 144 HAP and abdominal xraylims 49229112308 Utrasoregrphy easte 1312102 Ten Vase 1953313 Patents wih complcaion «801271843287 Patents wihoutcampicaion 4823310803, “Data are gven a mew 2 8D. Dna anergney earn i hs and yea examnaion and Cr, computedfonogrnhe tained in the ED, suggesting that repeated counts may not be clinically useful and may be misleading. Evalua- tion by surgeons correctly diagnosed 536 of 646 pa- tients with acute appendicitis and correctly ruled out the condition in 38 of 120 patients who did not have acute appendicitis. Overall, clinical assessment yielded an ac~ curacy of 74.0% (Table 2) IMAGING STUDIES Abdominal roentgenograms were not helpful in the di- ‘agnosis of acute appendicitis, with 96.3% ofall abdomi- nal lms showing either normal or nonspecific find- ings. lleus and smal-howel obstruction were the 2 most ‘common abnormalities detected, 12 patients had feea- liths, and 1 had free air. Of the 47 patients who had wn- dergone CT imaging, there were 6 false-positive test re sults and 6 false-negative test results, giving CT scan an overall accuracy of 74.5%. Ultrasonography had a false- negative rate of 76.1% (118 of 155 patients), correctly identified 65 of 183 patients with acute appendicitis, and ruled out 37 of 52 patients with normal findings, having fan accuracy of only 43.4%. In patients clinically sus- pected of having acute appendicitis, neither CT scan nor Us improved the diagnostic accuracy compared with cli ‘eal assessment alone (Table 2). PREOPERATIVE CARE Most patients (03.5%) were initially evaluated in the ED. Primary care physicians or outlying hospitals directly referred the rest. Seventy-four patients (0.7%) had been (aepnnreD) ARCTSORGOL Ts NA Ho (©2001 American Med Downloaded From: http:/jamanetwork.com/ on 11/09/2016 “Data ate given as number (percentage previously evaluated and sent home by their ED ot pr mary care physicians. Of these, 11 patients had been seen 1wice and 3 patients, 3 times. Most of these patients returned to the ED within 48 hours of their previous evaluation, 67.6% within 24 hours and 21.6% within 48 hours. Emergency department evaluation took meanaSD of 5.245.4 hours for all patients, It was sig- nificantly longer if either US oF CT scan was obtained (6447-4 h and 7.8410.8 h, respectively). When no Imaging studies were obtained, ED evaluation took only 474! films added minimal ime required for ED evaluation (40429 h, '3). Of the 148 patients who were hospitalized and observed instead of having immediate appendectomy, 30 patients (20.3%) had US, 18 (12.2%) hhad CT scan, and 108 (73%) had repeated laboratory sis. Twenty-one patients (14.2%) eventually had lapa- roscopie appendectomy, and the rest had open appen- 2 hours, The addition of abdominal plain x-ray dectomy. Despite observation and additional diagnostic tests, the negative appendectomy rate in the whole observation group was 25.7%. INTRAOPERATIVE FINDINGS AND FINAL PATHOLOGIC DIAGNOSIS Exploration was carried out through standard right lower quadrant incision in 86.2% ofthe patients, a midline in- cision in 3.8%, and laparoscopy in 10%. Al patients r ceived preoperative antibiotics; however, postoperative antibiotic treatment regimens varied and were based on the attending physician's preference. Table 4 lists the final pathologic conditions, with a 1% incidence of ma- lignancy. THE NORMAL-APPEARING APPENDIX (One hundeed thirty patients had a normal-appearing ap- pendix at the time of exploration. OF these, 10 (7.7%) hhad early appendicitis, 10 (7.7%) had mesenteric adeni- is, and 40 (30.8%) had no other pathologic condition. Twenty women (15.4%) had pelvic inflammatory dis ease, and 19 (14.6%) had other gynecologic disorders. Seve two percent of men and 30% of women with « normal-appearing appendix at the time of exploration had gastroenteritis oF other gastrointestinal disorders. Association, All rights reserved.MORTALITY AND MORBIDITY There was 1 death (0.19%) in our series, a 67-year-old woman who was seen once for abdominal pain and sent home (Rabe 5). When she was reevaluated in the ED, she was admitted and observed for another 4 days be- fore surgical consultation. At exploration, she was found tohave perforated appendicitis. Thus, in the group of pa- tients older than 50 years, the adjusted mortality foracute appendicitis was 1.7%. The overall morbidity was 9.19%. Patients with per forated acute appendicitis had a 19.8% morbidity and pa- tients without perforation, 6.4%. Infectious complica- tions accounted for 76.8% of the perioperative morbiclty. The overall wound infection rate was 3.5%, higher in per- forated cases (0%) than in nonperforated cases (2.9%) (P=.006). The incidence of intrs-abdominal abscess was, 2.196, agatn higher in perforated cases (6.39%) than in non- perforated cases (1.7%) (P=.01). There were 12 respi- ratory complications, including 4 patients with pneu- monia and 2 with pulmonary embolism, Two of the patients with pneumonia had a normal-sppearing ap- pendix. Atelectasis that resolved with incentive spirom- ‘etry Was not considered a complication inthis study. There was no case of postoperative myocardial infarction oF con- gestive heart failure, Enterotomies were made in 2 pa- tients; 1 of them had a normal-appearing appendix. Two patients developed postoperative small-bowel abstruc- tion. Two others had prolonged postoperative ileus; both had a normal-appearing appendix, LAPAROSCOPY Laparoscopic appendectomy was performed in 76 pa- tients (10%), 62 women and 14 men. In this subgroup, © (11.8%) had had a CT sean, 41 (53.0%) had had a US, and 21 (27.6%) were clinically observed before laparo- ‘scopic appendectomy. The additional imaging or obser vation led to a significantly longer time from admission to appendectomy (laparoscopic, 10.4148 h; open, 5.7 48.4; P=.008). The negative appendectomy rate was significantly higher in the laparoscopic subgroup (lapa- roscopie, 42.1%: open, 15.4%; P<.001). The use of lapa- roscopy, however, provided valuable additional diagnos- lic information in patients with a normal-appearing appendix, When @ normal-appearing appendix was en- ‘countered, the underlying abnormality was correctly iden- ified in 81.5% of patients undergoing laparoscopic ap- pendectomy: 0, pelvic inflammatory disease; 8, ruptured for hemorrhaged ovarian cysts; 4, adhesion; and 5, mes- centeric adenitis. OF the 6 patients without an intraop- ‘ratively identified pathologic source, 3 were found to have early acute appendicitis. Thus, when a normal- appearing appendix was found during laparoscopy, the underlying abnormality was identified in 91.6% of pa- tients. With respect to open appendectomy, the abnor- malty was correctly identified in only 74% of patients having a normal-appearing appendix. The morbidity of laparoscopic appendectomy was low (1.3%), asingle pa- tient with superficial wound infection, The low morbid- ity may be accounted for by the lower perforation rate (10.3%) in these patients (aepnnreD) ARCTSORGOL Ts NY Ho (©2001 American Med Downloaded From: http:/jamanetwork.com/ on 11/09/2016 Table 5. Mortality and Morbidity in 76 ‘Undergoing Appendectomy* ienaiy 7 Morbi 7183) Wound nection 27 Ineo abcess 4 ter complications 5 (42) Pneumonia 2) Pulmonary emboism (ther espator Atha (her cardi Prolonged ous ‘Smal Borel ebetucon (thr gastinesina Thrombophisits snr Wat nection ‘Anesthasialrug reaction “Data ate given as number (percentage a There has been a slight change in the epidemiology of acute appendicitis during the past 25 years. Inthe 1960s and 1970s, age distribution showed 9.1% ofthe patients with acute appendicitis tobe younger than 10 years and 9.9% to be older than 50 years." At the end of the 20th century, our data showed that approximately a quarter ofthe patients were either younger than 10 years (15.7%) or older than 50 years (8.2%). The disease has also be- come more prevalent in women, with the ratio of male to female patients decreasing from 2:1 a quarter of acen- tury ago to 1.2:1 today The overall negative appendectomy rate in this study was 15.79, which is on the low end of previously r ported rates of 15% to 33%."° Looking at specifie sub- groups, there was no excessively high negative appen- dectomy rate for women aged 20 10 40 years, as was reported 25 years ago (24.4% vs 45%). The low nega- tive appendectomy rate at our institution was not at the expense of higher perforation rate. The perforation rate in our series was 14.6%, which was also lower than the previously reported rates of 17% to 39%." Today, the perforation rate remained higher in patients younger than 10 years (20.41%) oF older than 50 years (28.6%), but it was not because of a delay in presentation or diagnosis, as previously suggested.” Furthermore, in both age groups the perforation rates were significantly lower than those reported during the last several decades, which ranged from 17% to 59% for the very young and from 37% to 69% for older persons." History of migratory pain, right lower quadrant ten- derness, and leukocytosis remain reliable and accurate diagnostic clues in the patients suspected of having acute appendicitis. History of migratory pain and leukocyto- sis (12 10°71) had positive predictive values higher than 90%, and nearly all patients with acute appendici- tishad localized right lower quadrant tenderness. When Association, All rights reserved.acute appendicitis presents in this classic form, itis eas- ily diagnosed and should be treated without the aid of further imaging modalities, In prospective studies, US has hhad an excellent performance, with a mean sensitivity of ‘80% and a median specificity of 96% in diagnosing ap- pendicitis.'° However, US has the limitation of variable reliability and its well-known operator dependency. Al- though US is noninvasive, the test adds expense and may delay surgical consultation. In our experience, ED evall- lion was significantly longer when an abdominal or pel- Vie US was oblained. Furthermore, US missed the dis- ‘ease in 118 patients who eventually were found to have acute appendicitis despite normal US findings, yielding a false-negative rate of 76.1%. Thus, it appears that US may be most useful in excluding potential pelvic abnor- ality in equivocal cases, but there are little data avail- able to unequivocally support the benefit of US in the pa- tients with classic clinical signs and symptoms of acute appendicitis. Routine contrast-enhanced CT scan has also been de- scribed as an accurate diagnostic imaging modality for pa- Uients with suspected acute appendicitis and equivocal find- ings. In clinical ils, CT scan has been superior to US in terms of diagnostic accuracy and reliability in atypical pre- sentation of appendicitis, and it can be specific and senst- liven diagnosing classic acute appendicitis" However, most authors do not enthusiastically endorse the use of CT im= ‘agingalone, but instead recommend that related with clinical findings." In our study, the positive predictive value for CT scan in patients with clinical find- Ings consistent with acute appendicitis was only 83.89%, a rate that ean be achieved solely with good history taking and physical examination. Our data suggest that the next step in managing the patients with suspected acule appen- dicitis who have a history of migratory pain or leukocyto- sis iso oblain surgical consultation for appendectomy. Fur- ther imaging studies in such patients do not help, and they muy significantly prolong ED evaluation and delay the even- tually needed appendectomy 1n reality, the classic migratory pain occurred in only fone half of the patients with acute appendicitis in our study, 396 patients (51.7%). Thus, accurate and timely diagnosis of acute appendicitis remains challenging, and cule appendicitis sll is one of the most commonly mis- diagnosed conditions in the ED.” Although immediate appendectomy is indicated in the patients with a classic presentation of acute appendicitis, those with an atypi- cal presentation should be hospitalized for observation, serial examination, and additional laboratory or radio“ ‘graphic studies, Although the risk of perforation during this observation is small, an accurate preoperative diag- nosis is often not accomplished. We observed and re- evaluated 148 patients with suspected acute appendict- Uis before appendectomy, with additional CT scan or US performed in 49 patients and subsequent laboratory data in 108 patients, but the negative appendectomy rate remained high at 25.7%. In fact, successive white blood cell counts offered litle diagnostic value and should be avoided. In such patients, diagnostic laparoscopy may have a role. In our series, 10% of the patients underwent laparoscopic appendectomy. Although a high negative appendectomy rate (42.1%) was encountered, the patho- resultsbe cor- (aepnnreD) ARCTSORGOL Ts NA To (©2001 American Med Downloaded From: http:/jamanetwork.com/ on 11/09/2016 logic source of the patient’s symptoms was identified and effectively treated in 01.6% of patients undergoing, this diagnostic and treatment modality. A possible factor allecting the high negative appendectomy rate is that laparoscopy was often used in patients in whom diag- nostic dilemmas remained despite additional imaging studies, laboratory data, and clinical observation. Given tts excellent diagnostic yield, zero mortality, low mor- bidity (1.3%), and easy availability, one should consider the early use of diagnostic laparescopy instead of CT scan, US, or observation in the selected patients sus- pected of having acute appendicitis but with atypical presentation, Mortality was 0.196 in this study, consistent with low. mortalities of 0% to 1.4% reported during the 1960s and 1070s." Unlike the morbidities of 21°% in the 1960s and 23% in the 19703," the total complication rate in ur series was only 9.196. Infectious complications con- Uinued to account for most postoperative morbidity fol- lowing appendectomy, with wound infection account- ing for 3.5% and intra-abdominal abscess, 2.1%. Although the overall complication rate has decreased, perforated appendicitis continues to be associated with a signifi cantly higher complication rate than that associated with nonperforated appendicitis." In conclusion, the demographics of acute appendi- citis in the late 1990s include an increased ineidence of patients younger than 10 years and older than 50 years. These 2 age groups continue to have asignificantly higher perforation rate and an increased morbidity, Clinical acu- ‘men remains the most reliable diagnostic asset for evalu- ating a patient with suspected acute appendicitis in the ED. In such patients, a history of migratory pain or leu- kocytosis greater than 12 10°/L provides high positive predictive values above 00%. These patients should hay immediate appendectomy: imaging modalities stich as C scan of US do not improve the overall accuracy, but may delay surgical consultation and the eventually needed ap- pendectomy. The lack of prospective data in our study prevents ts from concluding that the early use of diag- nostic laparoscopy isa more cost-effective, accurate, and rapid method of diagnosing atypical cases of acute ap- pendicitis. However, its low morbidity and high yield of alternative diagnoses merit prospective, randomized clini cal tials of the selective use of laparoscopic appendec- tomy in the management of alypical acute appendicitis. Such an approach may reduce further the perforation rate and subsequently the mortality and morbidity, espe- cially in women of childbearing age or in the older age group. resented at the 108th Scientific Session ofthe Western Sur~ ‘geal Association, Dana Point, Calif, November 14, 2000. Corresponding author and reprints: Hung S. Ho, MD, Department of Surgery, University of California Davis Medi cal Center, 2221 Stockton Blvd, 3rd Floor, Sacramento, CA 95817 (e-mail: hsho@uedavis.edu. Es} 1. Matauri 8 Nora. Cret fuente trent of ae spend: ‘nara o 100 carseat Surge. 1EESDSTIATS Association, All rights reserved.Spite, Auteapoents: an aas oS appndetoies in aus: 1988 168. SJ Sig 196072817 Faria PC Aut appends in uivsy stufets: 20 fu stay f 1028 ee JAm Col Aen esos 19722027 20, 4 Lani F,Holct J, Sy J Ouphy E Append cite rave od anes and esmartin 100 cates, Mc Surg 1975105768, 5. Paper, Kae Nasman Aue copes: ci tty of 1018 cass emergency appendetony. Acts Oh Sand 86218 51-82 6. Ae D6 Sater Fowl 88, Tani RY. Thespaemolagy of pendn| the Unie Sie. An J nde 080; 12.810 05, Karner, Sandee, Serie J eine of et ranted and peoaed appends: agespace ard sex species Word J Sug far2raieai7 Apis E8, Ears OG Hivichs Wel e-90m-HMPAO webbed cal ean ‘or dagoss of zl appends in patents wih equvoe li pee tne Am Sug. 18972085885, Harton ID, Courter SF, Ference MG a A pospsive ial computed graphy and ulvasonography or dagrosing appends in the atypical alent: A J Surg 200,178. 979-81 10, Fame Bobet H, Yang Oe al Ultasaragrapy for agnosis a azte spent ests oa prospective mullet, Word Sug. 19825: wei. 11, Went, Eacbonpt SR, Mau WA, tl. Intpreain of compte to ography does acolo ibrar ar paoeg ings in sugialy antes seat pense Sugary 2000728 15152 12, Kenran KE, Rose, Meshemer WL Darang maaan inereng motiy rom ae append. Am J Su 170 101-85, 12, Stone, Sander SL, Marin JO Parra pnd in chisn, Sry. sarees. "4. Hutol 5, Baron WK, Solomon 0. Append ined peel. Surg Ge ol Gate 6110290 202 15, Ber, Gln He ea Adin pian ana 1, 000con sein aun spl emerganc room. Am JS. 187510 ‘Wayne Ht, Schwesinger, MD, San ABtono, Tex: The results tha hve been projcedover years ar enclln: one death sla morbidiy ate offs than 10%, il, he 15 rae of nega tie appendectomics deserves petal tcalon. seems tbc the premise ofthis paper that we can do beter, and I tendo gre that weshould not accept the same els that have been iexstence forth last 30 years. fal, technology taal able to sugges tht we ean do beter Usforumatel this et rospective study ound that very technology. CTseans and US, Wa ching in major respect The fst at neler study Mas very accurate The seconds hat both tues delayed su ual nervention, The authors conclodd rom these data that Alagnosi laparoscopy, in fac, may be the preferable study The dat thatthe provide clearly document the limita vons of US and Ct scan thei clinkel environment wih furacis of 494 for Us and 5% fr CT sean were tinted But would eto paraphrase one of oursll waling atonal presidential candidat: we shouldnt rush to Judge. The Indictment ofthese 2 technologies may be soinewhat prema ture, sy that for ont specie reason The technology is cone Unsingt improve The perspetve ends mc toseveal ques tions that perhaps will add some light to thi sue ist ppeats that there no radiologist included inthe authorship at ths paper, Conan, {don mean ths sarc, but Ales race an ese, an tha show active or involved are your Tallis In ths parclar ea? Do they empl to opt ize the studies that you have Wdentiied? Second, and morespecialy, hor standardized ithe CT seanthat you are deserling? Ther arc oumerousruhors pow Aro are suggesting that, wi he use of thirsecion CT sar hing isolated tothe right lower quadrant, that i, with 3mm Collation, one can achieve very high evel of accuracy inthe diagnosis of ppendiciie In snather regard, who wa actualy pevlorming ie Usstudies? ithe adllogiaradlogy ec (aepnnreD) ARCTSORGOL Ts NV Tr (©2001 American Medical Ass Downloaded From: http:/jamanetwork.com/ on 11/09/2016 ciao somcone inthe emergency center, and is graded com- pression used? Inthe case of women who are at rik for gyne- Cologic diseases, sendovaginal US also available? Finally, in relation to the delays that seem to impact on how fst patients can get to the operating room, can You not control or minimize delays by using clinical pathway that de fines when you are called o see the patient? “This manuscript raises an appropriate caution about the use of technology anditciects uo reexamine what the proper tole of radiologic imaging is vs laparoscopy. Say. Groseld, MD, Indianapolis, nd: 1 couldnt judge fromthe abstract whether the patients who underwent laa roscopy were mainly tenage gis. Can he authors streamline their comment regtrding abdominal pain evaluation inten age gil group in whom the negative ppendectomy tale ra- fiona fins been the highest? Would hey recommend more liberal ust of laparoscopy prior to considering somecf the othe studies 1, US, C1)? tml, would like the authors to fur ther define what they called the "very young” For instance, peiiatrie surgeons refer to the very young with appendicitis a= Pallets less than 3 to 4 years of age. The perforation rae in this subst of children may be a high as 73%. This ea much higher rate than noted in older children, What would the au thors do fora patient who ts evaluated fr abdominal pina tera tay illness who has amass in the right lower quadrant? Would you promprly operate on that patient? Would you a quire a CT san ts? Would you consider draining an appen- diceal abscess percutaneously with US or CT guidance’ We didn't hear much about wheiRer US or CT stades are of value in patients with adelay in dlagnosis. “oe Kuhn, MD, Dallas, Tex: The auhorsare tying say wwhai many of us fel when the presentation typical and un equivocal In these cases, additional confirmative tests may, fat delay dhe riptosurgery My question dese ith he wor kp of patients with atypical presentations Our awn recently pub- lished experience st Bajlor in Dallas involving over 100 pa Lents with uncertain or equivocal findings of appendicitis showed that there was clear benefit in CT sean, witha result ant 8% negative appendectomy rate. In your experience, since CT sean was used in 47 patents, or about Sa was CT scan Fesricted to patients with atypical presenations? Do you feel thatthe delay inthe ED in patients with CT scans was du to thelr atypical presentations? Then, nally do you feel that CT sarin jour aperene may beberle Gal presentations? Keith W. Milikan, MD, Chicago: 1 wold like to dis gee with he authors forthe reason bln that | think we are lookingat the wrong denominator. The denominator a they sid ic that the patients gt thelr CT scan and US for abdominal pain Tongbeforethe surgeon sconsled So, when we areal bout tow good we ae with appendectomies the patients who have been diagnosed with gynecologic dea or sigmoid dverticul tein the elderly by geting» CT scan fist ae making us look better because our ED physicians have ordered the et and ex: cluded the patents with other dignoces The denominator inthis study shoul be the patents wh come in with abdominal pain and how have these stsbrought the surgeon fewer number of Patients to evaluate for appendicitis Edward T. Peter, MD, Redbluff, Calif ¥ got interested in appendicitis when was in Fresno. This was prompted bya study by Dr Blsdell and his colleagues when he was at San Francisco General, where they studied almost 1000 patients We reviewed a 5-year period of patients with appends in cluding approximately 700 patents, mostly performed by house stall, Werhad a negative rate of approximately 5%, Ihave been appalled at these high negative tves, 15% to 20%, persisting through the years. In my personal experience, for 8 years have not had negative appendectomy. You might say that missed lation, All rights reserved.some cases of appendicitis, but lam in a small town and there isonly one cmergenc room, lam cen would sce them again “Theretore, Veal believe have not been missing cases of a pendiciis Asfaras the CT sean, lthink ican be helpl when Sou use selectively 1s most helpful in the female patient ‘who has arezocecal appendicitis rH With eg othe caution of not rushing to judg- tment, isnot the surgeon who rushes to judgment i's our ED Colleagues who might. They decided thal they shoul do these Alagnostic procedures betore geting our opinion on the pa- tient oth acute appendicitis dificult for me to under stand the concep thats advocated by some to replace the str- fens gress oan wha apent oh "prSchiwesinger also brings up te issue of whether or not the CT scan or Us was read bythe radiologist. tam very much sre tht it wa read by the radiologist, perhaps after the fac. ‘We probably did the appendectomy by then. That brings up another point You dom expect to have dedkated CT scan rt ATologist inthe ED atthe te that you wll examine the pa- tient So even i radiologists read the CT scan, they all come foul with 75% accuracy: therefore, you might aswel go with our clinical impression and operate on the patient YON Secon, who did the US? That is the main problem with US. Its ttllyoperstor dependent and, worse yet, itis nol performed! by a physician, 9, the question i do you trust $rgeon or do you trust the technician in the ED tha night? | certainly have my bis ‘Las, as far a clinical pathways re concemmed, thats ab- solutelyan excellent des, nd the purpose of the paper was tale some caulion about rushing to judgment on using CT scan or Uswithouta clemly defined clinical pathway. Dr Groseld mentioned the aiypical group of patients with laparoscopic appendectomy. specifically the teenage girs, We didnot look specially at those subgroups the way you sug- es, but thats absolutely one ofthe indications for using Aidgnontic laparoscopy. There are many’ studies shout laparor scopic appendectomy vs open appendectomy, and ustaly (aepnnreD) ARCTSORGOL Ts NA TT (©2001 American Med Downloaded From: http:/jamanetwork.com/ on 11/09/2016 most ofthe authors miss the main point, which is if you use laparoscopic appendectomy selectively, you wll ce the most benelt out ofthat procedure. The resto the alent, most of the patients, probably should have an open appendectomy and have the problem solved at that time, AC UC Davis, we would consider laparoscopic appendectomy, or diagnostic Taparescopy for that mater, the patient happened to bein the childbearing age group. We do hot lok specially athe ‘ge group younger Un 3 years, but the data can certainly be analyzed Dr Kuhn also asked about atypical findings tn the atypi- cal goup of patients, CT scan docs havea role. According to our data ic probably best thatthe patients have a surglcl Consultation to decide which ones need the CT scan, With that fpproach, you not only save ime but ls redice cost, and you improve thew of CT scan whch men te ap “Another way todo this sto use diagnostic laparoscopy, but that requires a prospective randomized study comparing CT sean ws laparostopy in atypical cases before we can have any recommendation, ” ‘DrMillikan disagreed with us on the wrong denominator of our analysis, The poi tha we wanted to ring up is that if you use CT scans fa all abdominal pain inthe ED and then Call he surgeon, wheress you know forse that itis epic of acute appendicis, not only are you wasting your time you ae wasting the health ere resources, though such pracice tight make «surgeon lok better because they preseleted the tonstrgicaleace for us, what about the patent they selected out incorrectly and has « missed acute appendiciis? Forthe last question from Dr Peter, leongratulate you for a very good negative appendectomy rate, bu do you have the dataon the perforation ae? Ione has ever seen apaient who died or sullered from perforated sppendiis one wil change sor her mind the next time nthe ED. Ina small tov, (agree with you thatthe patient wil come back o you because yours ithe only emergency room. Ina large urban area, when you send them out you may not se them agin Association, All rights reserved.