ª Springer Science+Business Media New York 2016 Abdom Radiol (2016)

Abdominal DOI: 10.1007/s00261-016-0862-0

Radiology

The role of preoperative graded compression

ultrasound in detecting acute appendicitis and
influencing the negative appendectomy rate
Bader Hamza Shirah,1 Hamza Asaad Shirah,2 Wael Awad Alhaidari,3
Mohamed Ali Elraghi,4 Mohammad Azam Chughtai4
1
King Abdullah International Medical Research Center, King Saud bin Abdulaziz University for Health Sciences, P.O.Box 65362,
Jeddah 21556, Saudi Arabia
2
Department of General Surgery, Al Ansar General Hospital, Medina, Saudi Arabia
3
Department of Accidents and Emergency, Al Ansar General Hospital, Medina, Saudi Arabia
4
Department of Radiology, Al Ansar General Hospital, Medina, Saudi Arabia

Abstract ing true positive cases of acute appendicitis, and thus

Purpose: The diagnosis of acute appendicitis is mainly
clinical and is correct in about 80% of patients, but 20–
33% present with atypical findings, which resulted in a
negative appendectomy rate of 20–30%. The graded
compression ultrasound method in the diagnosis of acute
appendicitis was reported with a sensitivity of 89%, and
specificity of 95%. In this study, we aim to evaluate the
graded compression ultrasonography in the diagnosis of
acute appendicitis, its influence on the clinical judgment
to operate, and its role in lowering the negative appen-
dectomy rate.
Methods: 1073 patients treated surgically for acute
appendicitis between January 2005 and December 2014
were reviewed. Ultrasound findings, histopathological
diagnosis, and positive or negative appendectomy rates
were analyzed.
Results: 647 (60.3%) patients were males and 426 (39.7%)
females. The mean age was 26.5 years. Positive ultra-
sound findings were recorded in 892 (83.13%), while
negative findings were recorded in 181 (16.87%). Positive
appendectomy was recorded in 983 (91.6%), while
negative appendectomy was recorded in 90 (8.4%). The
sensitivity was 83%, specificity was 100%, and the rate of
negative appendectomy was 8.39%.
Conclusion: Graded compression technique of ultra-
sound is a useful modality, in addition to the clinical
judgment of the surgeon and clinical findings, in detect-
Correspondence to: Bader Hamza Shirah; email: shirah007@ksau-hs.
edu.sa
reducing the negative appendectomy rate. Values of
100% specificity, and 8.4% negative appendectomy rate,
or better, could be achieved, when an experienced
surgeon and a professional radiologist collaborate in
the diagnosis of acute appendicitis.
Key words: Acute appendicitis—
Ultrasound—Graded compression
technique—Diagnosis—Appendectomy—
Negative appendectomy
Acute appendicitis is the most common emergency acute
surgical abdomen with a lifetime risk of 8.6% in males
and 6.7% in females, and a lifetime risk of appendectomy
of 12% in males and 25% in females. The incidence is
approximately 233/100,000 population, and it manifests
most frequently during the second and third decades of
life with the highest affected age group being between 10
and 19 years of age, but it can occur at any age, with
1.4:1 reported male-to-female ratio [1, 2].
The clinical judgment makes the diagnosis in about
80% of the cases. It depends on a good medical history
(right iliac fossa pain, nausea, and vomiting) and proper
physical examination (right iliac fossa tenderness and
positive rebound tenderness). Nevertheless, in some pa-
tients, it becomes a difficult call to the surgeon causing a
diagnostic dilemma especially in making a decision to
operate or wait. The diagnostic certainty is dependent on
the clinical presentation of the patient, but the picture
could be misleading by the varying positions of the
 B. H. Shirah et al.: Graded compression ultrasound in acute appendicitis
appendix, and it was estimated that about 20–33% of the
patients suspected as acute appendicitis cases could pre-
sent with atypical nonconclusive findings [3].
The clinical outcome of a missed diagnosis of
appendicitis could be catastrophic. Therefore, the safest
surgical practice is to operate on uncertain cases instead
of waiting to reach a certainty of the diagnosis, which led
to an average increase in negative appendectomy rate of
20–30% putting in mind the strategy of open and see
which considers the fact that an unnecessary operation is
safer than a perforation. The cost of negative appen-
dectomies to the patient and the health care system is
rather large, and a complication rate after removal of
normal appendices was reported to be up to 6.1% [4–6].
In 1986, Puylaert introduced the ultrasound graded
compression technique in the diagnosis of acute appen-
dicitis. It implies that when a steady pressure is applied in
the right iliac fossa by the ultrasound transducer, the
normal or gas-filled intestinal loops will be moved away
from the field of vision or become compressed between
the anterior and posterior abdominal walls. On the other
hand, the inflamed appendix, which is incompressible,
will be clearly visualized as a blind-ended tubular struc-
ture that has a laminated wall which arises from the base
of the caecum, incompressible, a peristaltic, and having a
diameter of more than 6 mm with possible appearance of
faecolith as a bright echogenic focus having a distal
acoustic shadow, and an increased periappendiceal fat
echogenicity. The tenderness elicited by the ultrasound
probe can lead the patient to localize the most tender
point and the site of the inflamed appendix. Puylaert
reported a sensitivity of 89% and specificity of 100% [7,
8].
In 1996, Lim and Quillin outlined the usefulness of
color Doppler in detecting the inflamed appendix, in
which the inflamed thick walled, incompressible appen-
dix that is fixed in position by the compressing trans-
ducer will show circumferential color in contrast to the
healthy gut which appears thin walled and compliant
with frequent peristalsis transmitting no or minimum
signals [9]. The graded compression ultrasound technique
could decrease the rate of the healthily removed appen-
dices, particularly in ovulating females where about 40%
of appendectomy specimens show no pathologic proof of
inflammation [10–12].
Khairy [13] reported negative appendectomy of 9.2%
in 852 patients and concluded that despite the advances
in the diagnostic and imaging techniques, the rates of the
findings of negative appendectomy have not decreased
much. In another study, Al Thoubaity [14] reported that
the prevalence of advanced appendicitis was about
13.7%, and the negative appendectomy rate was about
27.2%. The accuracy rate of appendicitis with Alvarado
scale was 67.7%, with the ultrasound was 57.9%, and
with computed tomography (CT) scan was 66.7%. A
randomized study by Wade [15] stated that the overall
accuracy of ultrasound in the diagnosis of acute appen-
dicitis was statistically found to be superior compared to
that of the surgeon’s clinical judgment (P < .0001).
While 24% of the patients with normal ultrasound find-
ings were found to have appendicitis at operation,
showing that ultrasound cannot be considered a reliable
tool to the exclusion of the surgeon’s careful and re-
peated evaluation.
In this study, we aim to analyze and evaluate the role
of graded compression ultrasound used as a diagnostic
tool preoperatively, its influence on the clinical judgment
to operate, and whether it has any role in decreasing the
negative appendectomy rate.
Materials and methods
A retrospective database analysis of the treatment out-
come of 1073 patients treated surgically for acute
appendicitis between January 2005 and December 2014
in a public health referral general hospital of 200 bed
capacity serving a population of 2.4 millions was done.
The study inclusion criteria included adult patients
(12 year old and above as per national health policy),
diagnosed clinically in the emergency department as
acute appendicitis, had graded compression ultrasound
done in the emergency department and operated as a case
of urgency within 6 h of admission. The exclusion crite-
ria included all patients admitted for observation and
treated conservatively, all cases diagnosed by the ultra-
sound as a perforated appendix, appendicular mass, and
gynecological cases (pregnancy, ovarian cyst, and ectopic
pregnancy). The collected data included age, sex, pre-
senting symptoms, physical examination findings, fever,
leukocytosis, graded compression ultrasound findings,
intraoperative findings, histopathological findings, and
positive or negative appendectomy. Data were recorded
on a database-computerized file for analysis.
The ultrasound method used was unified to all radi-
ologists by a clinical pathway protocol guidelines. All the
patients had the same ultrasound examination performed
by the two sonographic radiologists involved in our
study (authors 4 and 5) using a Philips HD11 XE
Ultrasound System. The protocol consisted of using a
high-frequency linear and curvilinear probes transducers,
variable or short focal zone, and a frequency of 3–
9 MHz. The horizontal scan technique of the abdomen
started at the lower edge of the liver and going down to
the right iliac fossa, identification of the ascending colon,
proceeding down until reaching the tip of the caecum
where the patients were instructed to localize the point of
maximum tenderness. A slow uniform compression was
conducted to squeeze the bowel loops. The appendix
looked as a blind-ended, a peristaltic, tubular structure,
arising from the tip of the caecum. It was carefully
examined and scanned through all access and
length, measuring the anteroposterior dimension of the
B. H. Shirah et al.: Graded compression ultrasound in acute appendicitis
appendix. A color Doppler ultrasound was also per-
formed to all the patients to detect the blood flow signal
using an L12–3 Broadband Linear-Array Transducer,
12–3 MHz extended frequency range, 35 mm effective
aperture length, 10° of trapezoidal imaging, and steerable
pulsed wave.
The ultrasound findings were recorded in a database-
structured file and saved on an external hard drive for
analysis, classified as positive or negative for acute
appendicitis. The features of a positive test included a
proven visualization of an incompressible tubular, blind-
ended, a peristaltic structure, with a diameter of 6 mm or
more in the right iliac fossa. The presence of appendic-
ular faecolith, probe tenderness, increased echogenicity
of the periappendiceal fat, free intraperitoneal fluid
particularly in the right iliac fossa or pelvis, and cir-
cumferential color on Doppler ultrasound were addi-
tional criteria of positivity. The features of a negative test
included no visualization of the appendix, visualization
of a normal appendix, and the presence of alternative
diagnosis (Figs. 1, 2).
The operative findings were recorded in a database-
structured file and saved on an external hard drive for
analysis, classified as positive and negative. Positive
appendectomy was defined as an appendix showing acute
inflammatory changes intraoperatively and on
histopathology. Negative appendectomy was defined as
the absence of acute inflammation on histopathology.
The collected data were subjected to statistical analysis to
determine the accuracy of graded compression ultra-
sound technique calculating the sensitivity, the speci-
ficity, the false negative and positive values, and the
predictive values. The rate of negative appendectomy
Fig. 1. Features of acute appendicitis in graded compression ultrasound.
was calculated as the percentage of operated cases with a
normal appendix by histopathology. The statistical
analysis was performed using the Statistical Package for
Social Science (SPSS) software program (Release 22).
Results
1073 Saudi Arabian patients treated surgically for acute
appendicitis between January 2005 and December 2014
were included. 647 (60.3%) patients were males, and 426
(39.7%) patients were females. The male-to-female ratio
in our study was 1.32:1. The mean age was 26.5 years in
the range of 13–37. Right lower abdominal pain and
right iliac fossa tenderness in all patients (100%), fever in
821 (76.5%), and leukocytosis in 937 (87.3%) were re-
corded (Fig. 3).
Positive ultrasound findings were recorded in 892
(83.13%), while negative results were reported in 181
(16.87%). Positive appendectomy has been recorded in
983 (91.6%), while negative appendectomy has been
documented in 90 (8.4%) (Fig. 4).
The true positive was defined as patients with a
positive disease and positive ultrasound results (892
patients). The true negative was defined as patients
with a negative disease and negative ultrasound results
(90 patients). The false negative was defined as patients
with a positive disease and negative ultrasound results
(91 patients). The false positive was defined as indi-
viduals with a negative disease and positive ultrasound
results (0 patient) (Table 1).
The sensitivity was 83%, and the specificity was 100%.
The false negative rate was 93%, and the false positive
rate was 0. The positive predictive value was 90%, and
 B. H. Shirah et al.: Graded compression ultrasound in acute appendicitis

Fig. 2. Features of acute

appendicitis in color
Doppler.

Presenng symptoms, signs, fever, and leukocytosis Paents %

1200
100
1000
90
80
800 70
60
Paents

600
%

50
40
400
30
200
20
10
0 0
Right lower Right iliac
abdominal fossa Rebound Posive Negave Posive Negave
Nausea Voming Fever tenderness leukocytosis
pain tenderness ultrasound ultrasound appendicectomy appendicectomy
Paents No. 1073 849 472 821 1073 904 937 Paents % 83.13 16.87 91.6 8.4

Fig. 3. Presenting symptoms, signs, fever, and leucocytosis. Fig. 4. Positive and negative ultrasound and appendicitis.

interval before the study period (i.e., from January 1995

the negative predictive value was 49%. The rate of neg-
ative appendectomy was 8.39%. The prevalence of acute
appendicitis among the study population was 91.6%
(Table 2).
The graded compression technique was adopted in
our hospital by a quality care protocol and clinical
pathway starting from January 2005. Since then, it has
been the standard method. As a result, we compared the
result of our study with the result documented in the data
system of our quality care program for the 10 years
to December 2004). In our study, the rate of negative
appendectomy was 8.39% compared to 16.4% in the
previous 10 years. Positive ultrasound findings were re-
corded in our study in 83.13% compared to 62.8% in the
last 10 years (Fig. 5).
Discussion
In our study, the specificity is significantly high being
100%. It is reflected in low false positive rate and
B. H. Shirah et al.: Graded compression ultrasound in acute appendicitis

Table 1. True and negative values

Value Acute appendicitis+ (D+) Acute appendicitis- (D-) Total

USG diagnosis+ (T+) 892 (TP) 0 (FP) 892 (all test positive)
USG diagnosis- (T-) 91 (FN) 90 (TN) 181 (all test negative)
Total 983 (all diseased) 90 (all disease free) 1073 (grand total)

USG ultrasonography, T+ positive test, T- negative test, D+ positive diagnosis, D- negative diagnosis, TP true positive, FP false positive, FN false
negative, TN true negative

Table 2. Sensitivity, specificity, and statistical analysis results difficult to scan adequately with a poorly penetrating,
Sensitivity 83% linear array, small-parts transducer. We believe that the
Specificity 100% crucial factor is a transducer with a variable or short
False negative rate 9.3%
False positive rate 0%
focal zone and with a frequency between 5 and 9 MHz.
Positive predictive value 90% The mean age of our study population was 26.5 years
Negative predictive value 49% in the range of 13–37, which is the average age distri-
Rate of negative appendectomy 8.39%
bution for appendicitis in our local community. In fact,
we only encountered two cases of appendicitis in patients
above 40 years of age in the last 20 years.
90 The most widely studied diagnostic modalities are CT
80 scan, ultrasonography, and laparoscopy [8–10]. In our
70 study, we have selected the graded compression ultra-
60 sound, because it is the standard diagnostic modality in
50 our emergency department and thus, it is available all the
40 time, and all our radiologists are well trained in per-
30 forming the technique, as it is simple and non-invasive.
January 2005 to
December 2014 20 Usefulness of graded compression ultrasound in the
January 1995 to 10 diagnosis of acute appendicitis is now established. When
December 2004 0 Puylaert first introduced his graded compression method,
he reported a sensitivity of 89% and specificity of 100%
Negave Posive
appendectomy ultrasound [8]. Many other studies, later on, reproduced the same
rate findings findings [9, 10, 12, 15]. The graded compression ultra-
sound technique is an inexpensive, fast and noninvasive
Fig. 5. Comparison between our study results and data from method with an accuracy rate of 71–90% for the diag-
the previous 10 years. nosis of acute appendicitis (sensitivity 75–90% and
specificity 86–100%) with positive and negative predic-
consequently low negative appendectomy rate. Predictive tive values of 91–94 and 89–97%, respectively. However,
values, both positive (90%) and negative (49%) were on there is no certainty regarding the effect of ultrasonog-
the high side, an observation which reflects the usefulness raphy on the clinical outcomes of patients. Also, the
of graded compression ultrasound based on statistical clinical judgment should not be abandoned because of
analysis. The improved performance parameters were the lack of ultrasound findings in patients with a high
translated into better clinical outcome as negative probability of acute appendicitis [16].
appendectomy rate was low (8.39%). Exclusion criteria Incorporation of graded compression ultrasound led
for a perforated appendix and other conditions may have to a decrease in the negative appendectomy rate, which is
had contributed to the result of very high specificity, in accordance with many other reports where preopera-
taking into consideration that all the cases of right lower tive ultrasound improved the clinical outcome [17].
quadrant abdominal pain (suspected appendicitis) are Many authors had reported increased diagnostic accu-
scheduled for ultrasound examination as a standard racy when ultrasound was added to the clinical workup
policy in our hospital. of these patients. Puig et al. [18] in 2003 have reported
In our protocol, we used both the high-frequency 36.6% negative appendectomy rate without ultrasound
linear probes and curvilinear probes. We have found that and 13.2% after an ultrasound.
curvilinear probes give equal results to the linear probes Ultrasound has been reported more helpful in clini-
in many patients but provide a slightly larger field of cally equivocal cases because of false positive and false
view and greater penetration, which was of considerable negative results. It has been observed that the policy of
benefit in some of the obese patient with whom it was selective usage of diagnostic adjuncts only in equivocal
 B. H. Shirah et al.: Graded compression ultrasound in acute appendicitis
cases of appendicitis does not significantly reduce the
negative appendectomy rate. Ultrasound should not be
allowed to override the clinical acumen in extremes of the
wide clinical spectrum of acute appendicitis [19]. Some
authors recommend routine use of ultrasonography or
CT scan for diagnosis of acute appendicitis [20]. Corso
[21] demonstrated that 22% of apparently healthy
appendices at laparoscopy were, in fact, acutely inflamed
on histopathology. Naked eye assessment of the appen-
dix alone could be misleading as was observed by Gru-
newald [22], who misdiagnosed 11 out of 43 cases (26%).
In our study, we noted that out of 90 patients with a
negative appendectomy, 67 (6.2%) patients were females,
and 23 (2.2%) were males. The overall negative appen-
dectomy rate was 8.4% in which it was higher in females
(2.2% in males and 6.2% in females). Many studies have
reported significantly fewer negative appendectomy in
males compared with females [23]. Women of child-
bearing age have the highest negative appendectomy rate
of 35–45% because of gynecological conditions simulat-
ing appendicitis [24, 25].
Given our results, the graded compression ultrasound
technique has enhanced our diagnostic accuracy for
acute appendicitis by increasing the positive detection
rate and improved the outcome of appendectomy by
lowering the negative appendectomy rate.
Conclusion
We conclude that the graded compression technique of
ultrasound is a useful modality, in addition to the clinical
judgment of the surgeon and clinical findings, in detect-
ing true positive cases of acute appendicitis, and thus,
reducing the negative appendectomy rate. Values of
100% specificity, and 8.4% negative appendectomy rate,
or better, could be achieved when an experienced sur-
geon and a professional radiologist collaborate in the
diagnosis of acute appendicitis.
Authors contribution All authors have substantially contributed to the
paper. HAS and WAA conducted the clinical part of the study. MAE
and MAC participated in the radiological part of the study. BHS wrote,
edited the manuscript, and analyzed the clinical data. All authors read
and approved the final manuscript.
Compliance with ethical standards
Conflict of Interest The authors declare that they have no conflict of
interest.
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