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Evidence-based Clinical Practice Guidelines for

Acute Nontraumatic RLQ Abdominal Pain and Tenderness and

Acute Appendicitis

 

Clinical Issue/Question
 

If paraclinical diagnostic procedure(s) is/are needed, what is/are the most cost-effective ones and how do we interpret the results?

 

Format of Guidelines Development

 

 

 

Clinical Scenario and Issue

 

In a non-immunocompromised patient of any age, any gender, communicative, coherent, with stable vital signs with acute nontraumatic right lower quadrant abdominal pain and tenderness,

With the primary clinical diagnosis being acute appendicitis but uncertain,

 

If paraclinical diagnostic procedure(s) is/are needed, what is/are the most cost-effective ones and how do we interpret the results?

 

 

Statement of Premises:

 

 Objective of Paraclinical Diagnostic Procedure:

 

·        To be more definite on the primary clinical diagnosis of acute appendicitis.

 

·        Why the need to be more definite on the diagnosis?

·        Uncertain clinical diagnosis or degree of certainty is below 90%

·        Management will be altered if diagnosis is not acute appendicitis

                                    Specifically, the concern is that a nonoperative treatment may be

instituted.

 

·        A paraclinical diagnostic procedure is done only if it will significantly increase the pretest probability.

 

Given the following clinical parameters with their corresponding pretest probability,

 

Clinical Parameters

(+)LR

Pretest Probability

RLQ direct tenderness only

 

30%

Direct tenderness with guarding/rebound

~2

46%

Direct tenderness with rigidity

~4

63%

Definite, persistent, and increasing direct tenderness with guarding

 

~21

 

90%

 

a paraclinical diagnostic procedure is needed in the first three situations.

 

 

Goals in paraclinical diagnostic process:

 

·        To select the most cost-effective paraclinical diagnostic procedure.

·        To interprete the results appropriately to come up with a rational and accurate pretreatment diagnosis.

 

 

 

Operational Definition of Terms in the Issue/Question:

 

·        Paraclinical diagnostic procedures – any procedure done after the initial history and physical examination with the objective of being more definite on the primary clinical diagnosis.  It may be a repeat or repeated physical examination (active observation and monitoring), a laboratory examination,  or any diagnostic procedure like a laparoscopy.

 

·        Cost-effective procedure – the best after weighing the benefit-risk-cost-availability factors of paraclinical diagnostic options.

 

·        Interpretation of results – to determine if appendicitis is present or not based on perceived result of the paraclinical diagnostic procedure correlated with the clinical findings or diagnosis.

 

 

Evidence Appraisal Plan:

 

End-points in answering the question:

 

·        In patients with an uncertain clinical diagnosis of acute appendicitis, what is the most cost-effective paraclinical diagnostic procedure that will give a posttest probability of 90% or higher? 

 

Clinical Parameters

Pretest Probability

Paraclinical Diagnostic Options

Posttest Probability

 

RLQ direct tenderness only

30%

???

90% or higher

Direct tenderness with guarding/rebound

46%

???

90% or higher

Direct tenderness with rigidity

63%

???

90% or higher

 

Statistical Formulas

 

LR(+) = sensitivity/ (1-specificity)

LR(-) = (1-sensitivity)/specificity

Prevalence = pretest probability

Pretest odds = prevalence/ (1-prevalence)

Posttest odds = pretest odds x LR

Posttest probability = posttest odds/(posttest odds+1)

 

Comparison of  Various Options of Paraclinical Diagnostic Procedures for Suspected Acute Appendicitis

 

Option

Benefit

Risk

Cost*

Availability

CBC

 

 

 

 

Urinalysis

 

 

 

 

Plain Abdominal X-ray

 

 

 

 

Barium Enema

 

 

 

 

Ultrasound

 

 

 

 

CT Scan

 

 

 

 

Laparoscopy

 

 

 

 

Active Observation and Monitoring

 

 

 

 

*Cost – stat basis (private setting) – most recent

 

Comparison of  Various Options of Paraclinical Diagnostic Procedures for Suspected Acute Appendicitis

 

Options

Diagnostic

Parameter

Frequency of Finding Parameter

Sensitivity

Specificity

(+)  LR

CBC

 

 

 

 

 

Urinalysis

 

 

 

 

 

Plain Abdominal

X-ray

 

 

 

 

 

Barium Enema

 

 

 

 

 

Ultrasound

 

 

 

 

 

CT Scan

 

 

 

 

 

Laparoscopy

 

 

 

 

 

Active Observation and Monitoring

 

 

 

 

 

 

Posttest Probability of Various Paraclinical Diagnostic Procedures for Suspected Acute Appendicitis

 

Diagnostic Parameters

Pretest Probability

Posttest Probability

Direct tenderness (DT)

30%

 

DT + leukocytosis

 

 

DT + leukocytosis + left shift

 

 

DT + normal urinalysis

 

 

DT + abnormal urinalysis

 

 

DT + appendicolith on plain abdominal x-ray

 

 

DT + nonfilling of appendix on barium enema

 

 

DT + dilated appendix on ultrasound

 

 

DT + dilated appendix on CT scan

 

 

DT + inflamed appendix on laparoscopy

 

 

DT + persistent DT

 

 

DT + progressive tenderness + guarding/rebound

 

 

DT + progressive tenderness + rigidity

 

 

 

 

Posttest Probability of Various Paraclinical Diagnostic Procedures for Suspected Acute Appendicitis

 

Diagnostic Parameters

Pretest Probability

Posttest Probability

DT + Guarding/Rebound tenderness (DT/G/RT)

46%

 

DT/G/RT + leukocytosis

 

 

DT/G/RT + leukocytosis + left shift

 

 

DT/G/RT + normal urinalysis

 

 

DT/G/RT + abnormal urinalysis

 

 

DT/G/RT + appendicolith on plain abdominal x-ray

 

 

DT/G/RT + nonfilling of appendix on barium enema

 

 

DT/G/RT + dilated appendix on ultrasound

 

 

DT/G/RT + dilated appendix on CT scan

 

 

DT/G/RT + inflamed appendix on laparoscopy

 

 

DT/G/RT +persistence and progression of guarding/rebound

 

 

DT/G/RT with rigidity

 

 

 

 

Posttest Probability of Various Paraclinical Diagnostic Procedures for Suspected Acute Appendicitis

 

Diagnostic Parameters

Pretest Probability

Posttest Probability

DT + Rigidity (DT/R)

63%

 

DT/R + leukocytosis

 

 

DT/R + leukocytosis + left shift

 

 

DT/R + normal urinalysis

 

 

DT/R + abnormal urinalysis

 

 

DT/R + appendicolith on plain abdominal x-ray

 

 

DT/R + nonfilling of appendix on barium enema

 

 

DT/R + dilated appendix on ultrasound

 

 

DT/R + dilated appendix on CT scan

 

 

DT/R + inflamed appendix on laparoscopy

 

 

DT/R+ persistence/progression of rigidity

 

 

 

 

Search Methodology:

 

 Tracking:

            Medline – for international journal publications

            Herdin – for local journal publications

            Internet using various search engines such as AltaVista, Infoseek, Lycos, etc.

 

Retrieval:

 

Retrieval of whole journal article was done through the various libraries of the Metro Manila medical schools, Department of Science and Technology (DOST), and acquaintances.

 

Appraisal (Inclusion Criteria):

 

·        Focus of paper is on paraclinical diagnostic procedures for acute nontraumatic RLQ abdominal pain and acute appendicitis

·        With gold standard (intraoperative findings, histopathological results, follow-up)

·        More than 30 subjects

·        With reliability data (sensitivity and specificity rates; likelihood ratios; odd ratios)

 

 

Search and Tracking Outcome:

 

·        Total no. of papers and abstracts appraised: 500

·        Level of evidences:

All were of Level III Evidence (case series)

 

Tracking and Retrieval Results:

 

Database

Search engine

Search span

Search words

No. of titles

Relevant abstracts/papers

Medline

1966-1999 (August)

Ap +  CBC

30

3

 

 

Ap + Urinalysis

 9

3

 

 

Ap + Observation

91

5

 

 

Ap + Plain Abdominal X-ray

 4

 1

 

 

Ap + Barium Enema

79

 5

 

 

Ap + Ultrasound

121

10

 

 

Ap + CT Scan

 17

  6

 

 

Ap + Laparoscopy

 88

  2

Herdin

 

Appendicitis

 107

 0

AltaVista, Infoseek, Lycos, etc

 

Appendicitis

tntc

 1

 

 

 

 

 

 

Presentation of Primary Evidences:

 

Comparison of  Various Options of Paraclinical Diagnostic Procedures for Suspected Acute Appendicitis

Option

Benefit

Risk

Cost*

Availability

CBC

Indirect evidence

of inflammation

Leukocytosis

Shift to left

Puncture

P 234

Readily

Available (RA)

 

Urinalysis

Indirect evidence

Normal urinalysis

Nil

P 124

RA

Plain Abdominal X-ray

Indirect evidence

Appendicolith

Radiation

P 430

RA

Barium Enema

Indirect evidence

Nonfilling of appendix

Radiation

P 1950

Not

RA (NRA)

Ultrasound

Indirect evidence

Dilated appendix

 

Nil

P 3495 (F)

P 2975 (M)

NRA

CT Scan

Indirect evidence

Dilated appendix

Radiation

P 7000

NRA

Laparoscopy

Direct evidence

Inflamed appendix

Invasive

P 20000

NRA

Active Observation and Monitoring

Indirect evidence

Signs of RLQ peritonitis

No alternative diagnosis

Nil

P 2000-3000

(2 days – MD’s fee with confine-ment cost)

RA

 

*Cost in Philippine Pesos – stat basis (private hospital) [1999]

 

 

 

Presentation of Primary Evidences

 

Comparison of  Various Options of Paraclinical Diagnostic Procedures for Suspected Acute Appendicitis

Options

Diagnostic

Parameter

Frequency of Finding Parameter

Sensitivity

Specificity

(+)  LR

CBC

Leukocytosis

(TLC)

Shift to left

(NP)

66%

(TLC+NP)

65.7

81.4

3.53

(TLC+NP)

Urinalysis

Abnormal urinalysis

All ages =

36-48%

Children =  15-24%

 

 

NO DATA

Plain Abdominal

X-ray

Appendicolith

 

10 - 24%

 ~24

 ~90

 2.4

*

Barium Enema

Nonfilling of the appendix

All ages = 48%

Children = 47%

83

96

20.75

**

Ultrasound

Dilated appendix

 

50-90%

 

55

(13-90)

 83-89

95

(82-100)

 92-96

11

***

24-28

CT Scan

Dilated appendix

 

79-95%

90-100

93-97

14-30

****

Laparos-copy

Inflamed

Appendix

83%

~83

100

~83

*****

Active Observa-tion and Monitoring

Persistent, progressive, RLQ tenderness signifying peritonitis

With no alternative diagnosis

100%

100%

95.33%

21

 

*Plain Abdominal x-ray - No concrete data on likelihood ratio

Calcified appendicoliths have a 90% predictability of acute

appendicitis in a patient with clinical findings suggesting acute appendicitis.

If 24% is used as the sensitivity rate and 90% as the specificity rate, then the positive likelihood ratio is 2.4.

** Barium enema - one study only.

***Ultrasound - multicenter study

            Average (+) likelihood ratio: 20

****CT scan

            Average (+) likelihood ratio: 22

*****No concrete data on laparoscopy:

-          Grossly inflamed appendix is a gold standard for acute

appendicitis.

-          If 83% of appendices can be seen on laparoscopy, if this is considered as the sensitivity rate, with a specificity rate of almost 100%, the positive likelihood ratio would, therefore, be 83.

 

Other notes:

 

-          There are a lot of studies which do not show the frequencies of equivocal results.

 

See References

 

Summary of Paraclinical Diagnostic Procedures with LR of more than 10:

 

Options

Diagnostic Parameter

Frequency of finding parameter

(+) LR

Barium Enema

Nonfilling of the appendix

 47-48%

20

 

Ultrasound

Dilated appendix

50-90%

20

CT Scan

Dilated appendix

79-95%

22

Laparoscopy

Inflamed appendix

83%

~83

Active Observation and Monitoring

Persistent, progressive, RLQ tenderness signifying peritonitis

With no alternative diagnosis

100%

21

 

 

Posttest Probability of Various Paraclinical Diagnostic Procedures for Suspected Acute Appendicitis

 

Diagnostic Parameters

Pretest Probability

Posttest Probability

Direct tenderness (DT)

30%

 

DT + leukocytosis

 

60%

DT + leukocytosis + left shift

 

60%

DT + normal urinalysis

 

30%

DT + abnormal urinalysis

 

30%

DT + appendicolith on plain abdominal x-ray

 

51%

DT + nonfilling of appendix on barium enema

 

90%

DT + dilated appendix on ultrasound

 

90%

DT + dilated appendix on CT scan

 

90%

DT + inflamed appendix on laparoscopy

 

100%

DT + progressive tenderness + guarding/rebound

(+/-) rigidity

 

90%

 

Posttest Probability of Various Paraclinical Diagnostic Procedures for Suspected Acute Appendicitis

 

Diagnostic Parameters

Pretest Probability

Posttest Probability

DT + Guarding/Rebound tenderness (DT/G/RT)

46%

 

DT/G/RT + leukocytosis

 

75%

DT/G/RT + leukocytosis + left shift

 

75%

DT/G/RT + normal urinalysis

 

46%

DT/G/RT + abnormal urinalysis

 

46%

DT/G/RT + appendicolith on plain abdominal x-ray

 

67%

DT/G/RT + nonfilling of appendix on barium enema

 

95%

DT/G/RT + dilated appendix on ultrasound

 

95%

DT/G/RT + dilated appendix on CT scan

 

95%

DT/G/RT + inflamed appendix on laparoscopy

 

100%

DT/G/RT +persistence and progression of guarding/rebound

 

95%

DT/G/RT with rigidity

 

95%

 

Posttest Probability of Various Paraclinical Diagnostic Procedures for Suspected Acute Appendicitis

 

Diagnostic Parameters

Pretest Probability

Posttest Probability

DT + Rigidity (DT/R)

63%

 

DT/R + leukocytosis

 

86%

DT/R + leukocytosis + left shift

 

86%

DT/R + normal urinalysis

 

63%

DT/R + abnormal urinalysis

 

63%

DT/R + appendicolith on plain abdominal x-ray

 

80%

DT/R + nonfilling of appendix on barium enema

 

97%

DT/R + dilated appendix on ultrasound

 

97%

DT/R + dilated appendix on CT scan

 

97%

DT/R + inflamed appendix on laparoscopy

 

100%

DT/R+ persistence/progression of rigidity

 

97%

 

 

 

Distillation of all available evidences to come out with recommendations or answers to the clinical issue/question:

 

In terms of benefit, the best paraclinical diagnostic procedures are those which give direct evidences; with a high frequency of finding the diagnostic parameter; and with a likelihood ratio of more than 10.

 

The paraclinical diagnostic procedure which fulfills these criteria is laparoscopy.  It gives direct evidence (gross evidences of acute appendicitis – presence of purulent exudate, presence of phlegmon, gangrenous and perforated appendix).  The frequency of finding the direct evidences is high (83% in one series which may be higher with other series).  The direct evidences mentioned above constitute the gold standards of acute appendicitis. Thus, the specificity is near 100%.  Putting 83% at the low level of sensitivity, the likelihood ratio will be a high 83.

 

However, with its invasiveness, extremely high cost, and it being not readily available in the Philippines, an alternative option will have to be considered.

 

The other paraclinical diagnostic procedures left after laparoscopy give indirect evidences.

 

Those that give a likelihood ratio of more than 10 are the following:

            Barium enema

            Ultrasound

            CT scan

            Active observation and monitoring

 

Comparing the factors of frequency of finding the diagnostic parameter,   the benefit, risk, cost, and availability, (see table),

 

active observation and monitoring is the most cost-effective paraclinical diagnostic procedure.

 

Next is ultrasound.

 

Comparison of barium enema, ultrasound, CT scan, and active observation and monitoring  in terms of benefit (frequency of finding diagnostic parameter and positive likelihood ratio) risk, cost, and availability

 

 

Options

Frequency

Of

 finding

parameter

(+) LR

Risk

Cost

Availability

Barium Enema

 47-48%

20

 

Radiation

P 1950

NRA

Ultrasound

50-90%

20

Nil

P2975-3495

NRA

CT Scan

79-95%

22

Radiation

P 7000

NRA

Active Observation and Monitoring

100%

21

Nil

P 2000-3000

RA

 

 

 

 

 

 Summary of Answer to Question or Recommendations:

 

In a non-immunocompromised patient of any age, any gender, communicative, coherent, with stable vital signs with acute nontraumatic right lower quadrant abdominal pain and tenderness,

With the primary clinical diagnosis being acute appendicitis,

 

If paraclinical diagnostic procedure(s) is/are needed, what is/are the most cost-effective ones and how do we interpret the results?

 

In patients suspected to have acute appendicitis,     

if  paraclinical diagnostic procedure(s) is/are needed,

 

the most cost-effective is active observation and monitoring.

 

The next most cost-effective is ultrasonography.

 

Diagnostic parameter in active observation and monitoring for acute appendicitis:

 

Definite, persistent, progressive, RLQ tenderness signifying peritonitis

(Direct tenderness with at least guarding or rigidity)

With no alternative diagnosis

 

Ultrasonographic diagnostic parameter for acute appendicitis (not excluding others):

            Dilated appendix, more than 6 mm

 

 

Active Observation and Monitoring Scheme for Acute Appendicitis  (Subject to Validation):

 

1st Evaluation

[Findings]

2nd Evaluation

[30 min after]

Action

3rd Evaluation

[Findings]

Action

*DT

(-) DT

Observe [30 min]

(-)DT

Dx:Not appendicitis

 

DT

Observe [4-6 hrs]

DT

Observe –

Follow DT track*

 

DT+G/RT

Observe [30 min]

DT+G/RT

Dx:Appendicitis

 

DT+RIGID

Observe [30 min]

DT+RIGID

Dx:Appendicitis

 

 

 

 

 

DT+G/RT

(-) DT

Observe [30 min]

(-)DT

Dx:Not appendicitis

 

DT

Observe [30 min]

DT

Observe –

Follow DT track*

 

DT+G/RT

Dx:Appendicitis

 

 

 

DT+RIGID

Dx:Appendicitis

 

 

 

 

 

 

 

DT+

RIGID

(-) DT

Observe [30 min]

(-)DT

Dx:Not appendicitis

 

DT

Observe [30 min]

DT

Observe –

Follow DT track*

 

DT+G/RT

Observe [30 min]

DT+G/RT

Dx:Appendicitis

 

DT+RIGID

Dx:Appendicitis

 

 

 

**During intervals of scheduled evaluation, patient is instructed to

report progression of symptoms so that evaluation can be done earlier.

 

Factors considered in formulating the scheme:

Safety - early vs delayed diagnosis

Reliability of evaluation findings (external and internal variations)

Efficiency

·        Probability of detecting changes over time

·        Utilization of emergency room resources

Experiences on when reliable signs of acute appendicitis usually occur

 

 

Indications for in-hospital observation and monitoring:

 

1.      Strong suspicion for acute appendicitis (direct tenderness + guarding/rebound tenderness or rigidity in the absence of strong cues for an alternative diagnosis)

This is to facilitate treatment.

 

2.      Convenience for the patient 

If it is inconvenient for patient to come back for re-evaluation 4-6 hours after, then he/she may choose to be admitted to the hospital.

 

Note: For patients to be re-evaluated after 4-6 hours, they can be sent home with properly documented advices on what to monitor at home and when to come back.

 

 

End-points of observation and monitoring:

 

1.      Until abdominal pain disappears.

2.      Until diagnosis of acute appendicitis is quite certain.

3.      Until a definite diagnosis other than acute appendicitis is obtained.

 

 

 

 

 

Future Research Issues/Questions Arising from Attempts to Answer Issue:

 

Validation of the active observation and monitoring scheme in terms

 

Cost-effectiveness

Length of stay in the emergency room

Whether patients can be observed at home

Negative appendectomy rate

Perforating appendectomy rate

 

 

 

References:

 

 CBC as a Paraclinical Diagnostic Option

 

Lau WY, Ho YC, Chu W, Yeung C. Leukocyte count and neutrophil percentage in appendicectomy for suspected appendicitis.  Aust N.Z. J. Surg 1989, 59, 395-398.

 

Title

Laboratory aid and ultrasonography in the diagnosis of appendicitis in children.

Author

Ko YS; Lin LH; Chen DF

Address

Department of Pediatrics, Cathay General Hospital, Taipei, Taiwan, R.O.C.

Source

Chung Hua Min Kuo Hsiao Erh Ko I Hsueh Hui Tsa Chih, 1995 Nov, 36:6, 415-9

Title

White blood cell count is a poor predictor of severity of disease in the diagnosis of appendicitis.

Author

Coleman C; Thompson JE Jr; Bennion RS; Schmit PJ

Address

Olive View-University of California at Los Angeles Medical Center, Sylmar 91342, USA.

Source

Am Surg, 1998 Oct, 64:10, 983-5

 

Title

Urinalysis, ultrasound analysis, and renal dynamic scintigraphy in acute appendicitis.

Author

Puskar D; Bedalov G; Fridrih S; Vuckovic I; Banek T; Pasini J

Address

Department of Urology, New Hospital, Zagreb, Croatia.

Source

Urology, 1995 Jan, 45:1, 108-12

 

Abnormal urinalysis in appendicitis.

Author

Scott JH 3d; Amin M; Harty JI

Address

Source

J Urol, 1983 May, 129:5, 1015

Plain Abdominal X-ray as a Paraclinical Diagnostic Option

 

·        10% of finding abnormality (appendicolith) on plain abdominal x-ray

 

Craig S. Acute appendicitis. Online

http://www.emedicine.com/emerg/topic41.htm

 

·        14% of finding abnormality (appendicolith) on plain abdominal x-ray

 

Baker SR, Elkin M. Plain film approach to abdominal calcifications. Philadelphia, 1983, WB Saunders.

 

 

·        Mollitt DL, Mitchum D, Tepas JJ III.  Pediatric appendicitis: efficacy of laboratory and radiologic evaluation. South Med J 1988;81:1477-9.

 

(24% abnormal x-ray films of the abdomen)

 

·        Calcified appendicoliths have a 90% predictability of acute appendicitis in a patient with clinical findings suggesting acute appendicitis.

 

Copeland EM, Long JM.  Elective appendectomy for appendiceal calculus.  Surg Gynecol Obstet 1970;130:439-442.

 

Barium Enema as a Paraclinical Diagnostic Option

 

Frequency of finding non-filling appendix

·        Hatch EI Jr., Naffis D, Chandler NW.  Pitfalls in the use of barium enema in early appendicitis in children.  J Pediatr Surg 1981;16:3,309-12.                     

            66 patients – 31/66

 

·        Wild RE, Rutledge R, Herbst CA, Jr. The use of barium enema in the evaluation of patients with possible appendicitis.  Am Surg 1985; 51:8, 474-6.

            33 patients (all ages) – 16/33

 

Title

Barium enema in the diagnosis of acute appendicitis.

Author

el Ferzli G; Ozuner G; Davidson PG; Isenberg JS; Redmond P; Worth MH Jr

Address

Department of Surgery, Staten Island Hospital, New York 10305.

Source

Surg Gynecol Obstet, 1990 Jul, 171:1, 40-2

 

Ultrasound as a Paraclinical Diagnostic Option

 

Frequency of finding abnormality on ultrasound:

 

Ooms HWA, Koumans RKJ, Ho Kang You PJ, Puylaert JBCM. Ultrasonography in the diagnosis of acute appendicitis.  Br J Surg 1991; 78:315-319.

Rioux M. Sonographic detection of the normal and abnormal appendix.  AJR 1992;158:773-779.

Balthazar EJ, Birnbaum BA, Yee J, Megibow AJ, Roshkow J, Gray C.  Acute appendicitis: CT and US correlation in 100 patients.  Radiology 1994;190:31-5.

 

Title

Ultrasonography for diagnosis of acute appendicitis: results of a prospective multicenter trial.Acute Abdominal Pain Study Group.

Author

Franke C; Böhner H; Yang Q; Ohmann C; Röher HD

Address

Department of General and Trauma Surgery, Heinrich-Heine-Universit at, Moorenstrasse 5, 40225 Düsseldorf, Germany.

Source

World J Surg, 1999 Feb, 23:2, 141-6

Title

Influence of ultrasound on clinical decision making in acute appendicitis: a prospective study.

Author: Zielke A; Hasse C; Sitter H; Rothmund M

Address: Department of Surgery, Phillips-University of Marburg, Germany. Zielke@mailer.uni-marburg.de

Source: Eur J Surg, 1998 Mar, 164:3, 201-9

Title

Sonography of acute appendicitis in children: 7 years experience.

Author

Hahn HB; Hoepner FU; Kalle T; Macdonald EB; Prantl F; Spitzer IM; Faerber DR

Address

Department of Paediatric Radiology, Kinderklinik, Technischen UniversitÂat, Mâunchen, Germany.

Source

Pediatr Radiol, 1998 Mar, 28:3, 147-51

Title

“Surgical” ultrasound in suspected acute appendicitis.

Author

Zielke A; Hasse C; Sitter H; Kisker O; Rothmund M

Address

Department of General Surgery, Philipps-University of Marburg, Baldinger Strasse, PO-Box 100, 35043 Marburg, Germany.

Source

Surg Endosc, 1997 Apr, 11:4, 362-5

Title

Ultrasonography in suspected acute appendicitis in childhood-report of 1285 cases.

Author

Schulte B; Beyer D; Kaiser C; Horsch S; Wiater A

Address

Department of Diagnostic and Interventional Radiology, Academic Teaching Hospital Cologne-Porz, University of Cologne Medical School, Urbacher Weg 19, Krankenhaus Porz am Rhein, D-51149, Kâoln, Germany.

Source

Eur J Ultrasound, 1998 Dec, 8:3, 177-82

Title

Ultrasonography in patients with suspected acute appendicitis: a prospective study.

Author

Skaane P; Amland PF; Nordshus T; Solheim K

Address

Department of Radiology, Ullevaal University Hospital, Oslo, Norway.

Source

Br J Radiol, 1990 Oct, 63:754, 787-93

 

Title

Clinical validity of ultrasound in children with suspected appendicitis.

Author

Crady SK; Jones JS; Wyn T; Luttenton CR

Address

Emergency Medicine Residency Program, Butterworth Hospital, Grand Rapids.

Source

Ann Emerg Med, 1993 Jul, 22:7, 1125-9

 

Title

Ultrasonography in the diagnosis of acute appendicitis: a prospective study.

Author

Schwerk WB; Wichtrup B; Rothmund M; Rüschoff J

Address

Department of Internal Medicine, Philipps-University of Marburg, Federal Republic of Germany.

Source

Gastroenterology, 1989 Sep, 97:3, 630-9

 

Title

Ultrasonography as an adjunct in the diagnosis of acute appendicitis: a 4-year experience.

Author: Ramachandran P; Sivit CJ; Newman KD; Schwartz MZ

Address: Department of Surgery, Children’s National Medical Center, Washington, D.C. 20010, USA.

Source: J Pediatr Surg, 1996 Jan, 31:1, 164-7; discussion 167-9

 

CT Scan as a Paraclinical Diagnostic Option

 

Author

N

Sensitivity

Specificity

(+) LR

Lane, 1997

109

90

97

30

Rao, 1997

100

100

93

14.29

Balthazar, 1994

100

96

89

8.72

 

 

 

 

Ave: 17.67

 

Balthazar EJ, Birnbaum BA, Yee J, Megibow AJ, Roshkow J, Gray C.  Acute appendicitis: CT and US correlation in 100 patients.  Radiology 1994;190:31-5.

 

Frequency of finding the parameter: 79 – 95%

 

Balthazar EJ, Megibow AJ, Hulnick D, Gordon RB, Naidich DP, Beranbaum ER. CT of Appendicitis.  AJR 1986:147:705-710.

 

79% yield

 

Rao PM, Rhea JT, Novelline RA, Mostafavi AA, McCabe CJ. Effect of computed tomography of the appendix on treatment of patients and use of hospital resources.  N Eng J Med 1998;338:141-146.

 

                        95% yield

 

 

Title

Unenhanced helical CT for suspected acute appendicitis.

Author

Lane MJ; Katz DS; Ross BA; Clautice Engle TL; Mindelzun RE; Jeffrey RB Jr

Address

Department of Radiology, Stanford University, School of Medicine, CA 94305-5105, USA.

Source

AJR Am J Roentgenol, 1997 Feb, 168:2, 405-9

 

Title

Helical CT technique for the diagnosis of appendicitis: prospective evaluation of a focused appendix CT examination [see comments]

Author

Rao PM; Rhea JT; Novelline RA; McCabe CJ; Lawrason JN; Berger DL; Sacknoff R

Address

Department of Radiology, Massachusetts General Hospital, Boston 02114, USA.

Source

Radiology, 1997 Jan, 202:1, 139-44

 

Laparoscopy as a Paraclinical Diagnostic Option

 

Olsen JB, Myren CJ, Haahr PE. Randomized study of the value of laparoscopy before appendicectomy.  Br J Surg 1993; 80:922-923.

 

                        Yield: 83%

 

 

Title

Does laparoscopy reduce the incidence of unnecessary appendicectomies?

Author

Barrat C; Catheline JM; Rizk N; Champault GG

Address

UniversitÆe Paris XIII, EFR de MÆedecine de Bobigny, HÈopital Jean-Verdier, Bondy, France.

Source

Surg Laparosc Endosc, 1999 Jan, 9:1, 27-31

 

Observation as a Paraclinical Diagnostic Option

 

Author

N

Sensitivity (%)

Specificity (%)

(+) LR

Joson, 1990

505

100

95.33

21.38

Senbanjo, 1997

312

96

93

13.7

 

Title

Management of patients with equivocal signs of appendicitis.

Author

Senbanjo RO

Address

Department of Surgery, General Hospital, Sarat Abeidah, Kingdom of Saudi Arabia.

Source

J R Coll Surg Edinb, 1997 Apr, 42:2, 85-8

Abstract

 

Title

Probability of appendicitis before and after observation.

Author

Graff L; Radford MJ; Werne C

Address

Department of Medicine, University of Connecticut Health Center, Farmington.

Source

Ann Emerg Med, 1991 May, 20:5, 503-7

 

 

·        Joson RO. Active observation in the evaluation of patients with possible acute appendicitis. Phil J Surg Special 1990; 45:3, 108-111

 

 

 

Quick Reference Guide or Algorithm:

 

In a non-immunocompromised patient of any age, any gender, communicative, coherent, with stable vital signs with acute nontraumatic right lower quadrant abdominal pain and tenderness,

With the primary clinical diagnosis being acute appendicitis but uncertain,

 

If paraclinical diagnostic procedure(s) is/are needed, what is/are the most cost-effective ones and how do we interpret the results?

 

 

In patients suspected to have acute appendicitis,          

if  paraclinical diagnostic procedure(s) is/are needed,

 

the most cost-effective is active observation and monitoring.