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Diagnostic Value and Effect of Bedside Ultrasound in Acute Appendicitis in the Emergency Department
Abstract
In their introduction, Gungor et al described ultrasound as a technique for evaluation of patients with low prior probability of acute appendicitis. This testing protocol for appendicitis is being proposed to challenge and perhaps replace the current standard of care for imaging, CT scanning. Specificity of CT scanning is reported in the range of 92-98% and CT is generally felt to be more accurate than ultrasonography The finding of 95.8% specificity for their method appears competitive and may be arithmetically correct but is seriously flawed. This article is protected by copyright. All rights reserved.
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To perform a meta-analysis to evaluate the diagnostic performance of ultrasonography (US) and computed tomography (CT) for the diagnosis of appendicitis in pediatric and adult populations.
Medical literature (from 1986 to 2004) was searched for articles on studies that used US, CT, or both as diagnostic tests for appendicitis in children (26 studies, 9356 patients) or adults (31 studies, 4341 patients). Prospective and retrospective studies were included if they separately reported the rate of true-positive, true-negative, false-positive, and false-negative diagnoses of appendicitis from US and CT findings compared with the positive and negative rates of appendicitis at surgery or follow-up. Clinical variables, technical factors, and test performance were extracted. Three readers assessed the quality of studies.
Pooled sensitivity and specificity for diagnosis of appendicitis in children were 88% (95% confidence interval [CI]: 86%, 90%) and 94% (95% CI: 92%, 95%), respectively, for US studies and 94% (95% CI: 92%, 97%) and 95% (95% CI: 94%, 97%), respectively, for CT studies. Pooled sensitivity and specificity for diagnosis in adults were 83% (95% CI: 78%, 87%) and 93% (95% CI: 90%, 96%), respectively, for US studies and 94% (95% CI: 92%, 95%) and 94% (95% CI: 94%, 96%), respectively, for CT studies.
From the diagnostic performance perspective, CT had a significantly higher sensitivity than did US in studies of children and adults; from the safety perspective, however, one should consider the radiation associated with CT, especially in children.
Objective:
A meta-analysis was performed to compare low-dose CT and standard-dose CT in the diagnosis of acute appendicitis with an emphasis on diagnostic value.
Materials and methods:
A systematic literature search for articles published through June 2016 was performed to identify studies that compared low-dose CT with standard-dose CT for the evaluation of patients suspected of having acute appendicitis. Summary estimates of sensitivity and specificity with 95% CIs were calculated using a bivariate random-effects model. Meta-regression was used to perform statistical comparisons of low-dose CT and standard-dose CT.
Results:
Of 154 studies, nine studies investigating a total of 2957 patients were included in this meta-analysis. The pooled sensitivity and specificity of low-dose CT were 96.25% (95% CI, 91.88-98.31%) and 93.22% (95% CI, 88.75-96.00%), respectively. The pooled sensitivity and specificity of standard-dose CT were 96.40% (95% CI, 93.55-98.02%) and 92.17% (95% CI, 88.24-94.86%), respectively. In a joint model estimation of meta-regression, lowand standard-dose CT did not show a statistically significant difference (p = 0.71). Both lowand standard-dose CT seem to be characterized by high positive and negative predictive values across a broad spectrum of pretest probabilities for acute appendicitis.
Conclusion:
Low-dose CT is highly effective for the diagnosis of suspected appendicitis and can be considered a valid alternative first-line imaging test that reduces the potential risk of exposure to ionizing radiation.
Objective:
Early and accurate diagnosis of acute appendicitis (AA) with ultrasound can minimize the morbidity and mortality of the patients. In this regard, ultrasound can help to the emergency physicians (EPs) in the diagnosing process and clinical decision making for AA. Therefore, we primarily aimed to evaluate the effectiveness of point of care ultrasound (POCUS) in clinical decision making of EPs for the diagnostic evaluation for AA in the emergency department (ED).
Methods:
The study sample consisted of patients aged >18 years that presented to the ED with an abdominal pain and underwent diagnostic evaluation for AA. All patients were examined initially with POCUS by EPs and then with radiology-performed ultrasound (RADUS) by radiologists. Pre- and post-POCUS median diagnostic certainty values (MDCVs) for AA were determined with visual analogue scale (VAS) scores (0 not present, 100 certainly present) by POCUS performers. Definitive diagnoses were determined by surgery, pathologic evaluation of appendectomy specimens, or clinical follow results. The sensitivity, specificity, positive likelihood ratio (PLR), and negative likelihood ratio (NLR) for POCUS and RADUS together with pre- and post-POCUS VAS scores for MDCVs were compared.
Results:
A total of 264 patients were included into the final analysis and 169 (64%) had a diagnosis of AA. The sensitivity, specificity, PLR, and NLR of ultrasound examinations were 92.3% (95% CI; 87.2-95.8%), 95.8% (89.5-98.8%), 21.9 (8.4-57.2) and 0.08 (0.05-0.1) for POCUS, and 76.9% (69.8-83%), 97.8% (84.9-99.7%), 36.4 (9.25-144.3) and 0.24 (0.18-0.31) for RADUS, respectively. Pre-POCUS and post-POCUS VAS scores for MDCVs were 60 (IQR: 50-65) and 95 (IQR: 20-98), respectively (p=0.000).
Conclusion:
POCUS, when performed in ED for the diagnosis of AA, has high sensitivity and specificity, and had a positive impact on the clinical decision making of EPs. This article is protected by copyright. All rights reserved.
Appendicitis is the most common abdominal emergency. While the clinical diagnosis may be straightforward in patients who present with classic signs and symptoms, atypical presentations may result in diagnostic confusion and delay in treatment. Abdominal pain is the primary presenting complaint of patients with acute appendicitis. Nausea, vomiting, and anorexia occur in varying degrees. Abdominal examination reveals localised tenderness and muscular rigidity after localisation of the pain to the right iliac fossa. Laboratory data upon presentation usually reveal an elevated leukocytosis with a left shift. Measurement of C-reactive protein is most likely to be elevated. The advances in imaginology trend to diminish the false positive or negative diagnosis. Radiographic image of faecal loading image in the caecum has a sensitivity of 97% and a negative predictive value that is 98%. In experienced hands, ultrasound may have a sensitivity of 90% and specificity higher than 90%. Helical CT has reported a sensitivity that may reach 95% and specificity higher than 95%. Despite all medical advances, the diagnosis of acute appendicitis continues to be a medical challenge.
Graded compression sonography is an established imaging modality in the clinical setting of acute right lower quadrant pain or to diagnose acute appendicitis because of its easy assessability, noninvasiveness, real-time imaging. However, the ability to accurately diagnose appendicitis can be affected by several factors including operator dependence, deeper-located appendix, and obesity or muscularity of the patient. However, adjuvant techniques utilizing advanced equipment and accumulated operator's experience to conventional graded compression sonography will yield more frequent detection of the vermiform appendix and more accurate results of acute appendicitis on sonography. This article introduces adjuvant techniques and various know-how of real field in the detection of the vermiform appendix and diagnosis of acute appendicitis.