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.