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Appendicitis

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  • 1. An Evidence Based ApproachAn Evidence Based Approach in the Diagnosis ofin the Diagnosis of Acute AppendicitisAcute Appendicitis Dr. Rashidi Ahmad MD USM, Mmed USM, FADUSM, AM (Mal), Clinical Fellow (Cardiology)
  • 2. The failure to diagnoseThe failure to diagnose appendicitis is routinely listedappendicitis is routinely listed among the top five reasons for aamong the top five reasons for a malpractice suite.malpractice suite. Reigelman R, Minimizing medical mistakes : The Art of Medical Decision Making Fact of lifeFact of life
  • 3. Diagnostic challengesDiagnostic challenges Poor specificity and sensitivity of the historical data, the physical findings, and the laboratory tests currently available. Wagner JM, et al. JAMA 1996;276:1589-94 The American Journal of Emergency Medicine Volume 23, Issue 4 , July 2005, Pages 483-487
  • 4. Diagnostic challengesDiagnostic challenges • Causes of appendicitis – varies in presentation • Position of the appendix • In pediatric and pregnancy • Mimics Goal to diagnose before peritonitis sets inGoal to diagnose before peritonitis sets in
  • 5. Acute appendicitisAcute appendicitis • Disease of civilization • The commonest acute surgical condition. • Approximately 7 – 12% of the population will have appendicitis in their lifetime (1 in 6). • Peak incidence: between the ages of 10 - 30 years. • Misdiagnosis: 15 – 20% . • Rate of “negative” appendicectomy: 20 – 40%. • Removing normal appendix is a an economic burden to patients and health resources Am JAm J EpidemiolEpidemiol 1990;132:9101990;132:910--25.25. Ann R Coll Surg 1994;76:418-9 J Pediatr Surg 2000;35:1320-2
  • 6. •• The incidence of perforated appendicitis in relation toThe incidence of perforated appendicitis in relation to time of abdominal pain till surgerytime of abdominal pain till surgery -- 24 hours:24 hours: 20%20% perforationperforation -- 36 hours:36 hours: 50%50% gangrenous/perforatedgangrenous/perforated -- 48 hours:48 hours: 80%80% perforated with peritonitisperforated with peritonitis •• < 4 years of age: perforation rate< 4 years of age: perforation rate -- 95%95% •• 44 –– 19%19% in non pregnant,in non pregnant, 57%57% in pregnant womanin pregnant woman BrenderBrender, Journal of Pediatrics, August 1985, Journal of Pediatrics, August 1985 AcadAcad EmergEmerg Med.Med. 2000 Nov;7(11):12442000 Nov;7(11):1244--5555 Tracey & Fletcher,2000 Perforated acute appendicitisPerforated acute appendicitis
  • 7. Final diagnosis for 303 subjects with suspected appendicitisFinal diagnosis for 303 subjects with suspected appendicitis Operated patients (n: 161) No. Diagnosis Positive appendectomy 130 (80.8%) SIMPLE 30 SUPPURATIVE 23 ABSCESSED 2 GANGRENOUS 14 PERFORATED Negative appendectomy 31 (19.2%) NSAP 16 ACUTE MESENTERIC ADENITIS 4 ACUTE GYNECOLOGICAL DISEASE 4 DIVERTICULITIS 2 OMENTAL TORSION 2 PGU 2 UTI 1 Tzanakis et al.World J. Surg. Vol. 29, No. 9, September 2005Tzanakis et al.World J. Surg. Vol. 29, No. 9, September 2005 mimicsmimics
  • 8. Common symptomsCommon symptoms Common symptomsCommon symptoms Frequency (%)Frequency (%) Abdominal pain 100 Anorexia 100 Nausea 90 Vomiting 75 Pain migration 50 Classic symptom sequence 50 Graffeo CS, Counselman FL. Appendicitis. Emerg Med Clin North Am 1996;14:653-71
  • 9. Procedure Sensitivity Specificity RLQ 0.81 0.53 Rigidity 0.27 0.83 Migration 0.64 0.82 Pain before vomiting 1.00 0.64 Psoas sign 0.16 0.95 Fever 0.67 0.79 Wagner J,Does this patient have appendicitis? JAMA 1996;276(19):Wagner J,Does this patient have appendicitis? JAMA 1996;276(19):589589--594594
  • 10. Procedure Sensitivity Specificity Rebound 0.63 0.69 Guarding 0.74 0.57 No similar pain 0.81 0.41 Rectal tenderness 0.41 0.77 Anorexia 0.68 0.36 Nausea 0.58 0.37 Vomiting 0.51 0.45 Cough test 0.78 0.79 Wagner J,Does this patient have appendicitis? JAMA 1996;276(19):Wagner J,Does this patient have appendicitis? JAMA 1996;276(19):589589--594594
  • 11. Appendicitis Perforated Normal Duration 1.3 ± 0.7 3.1 ± 1.9 1.9 ± 2.2 Vomiting 60% 69% 31% Diarrhea 0% 25% 10% Fever 80% 88% 71% RLQ T 88% 100% 82% Diffuse P 12% 44% 0% Temp 38.4 ± 0.9 38.4 ± 0.64 37.9 ± .8 Paajanen H,Paajanen H, ActaActa PaediatrPaediatr, 1996;85:459, 1996;85:459--6262
  • 12. Madan samuel. J Pediatr Surg. Vol 37, No 6 (June) 2002:877-881..
  • 13. • Alternative method for rebound tenderness detection LTC Bruce. Southern Medical Journal, Jan 2006, Jan 2006
  • 14. Per Rectal ExaminationPer Rectal Examination Your opinionYour opinion……
  • 15. Paajanen H, Acta Paediatr 1995; 85:459-62 *P<.001 Test Appendicitis Perforated Normal WBC 16 ± 4.6 16 ± 6.9 16 ± 5.1 CRP* 37 ± 36 92 ± 50 35 ± 44 Urinalysis WBC >3 32% 19% 10% RBC >3 0% 13% 10% Bacteria 0% 6% 0%
  • 16. Role of Leukocyte Count,Role of Leukocyte Count, NeutrophilNeutrophil Percentage, and CPercentage, and C--Reactive Protein in the acuteReactive Protein in the acute appendicitis in elderly.appendicitis in elderly. HorngHorng--RenRen Yang, et alYang, et al The American Surgeon;The American Surgeon; Apr 2005; 71, 4;Apr 2005; 71, 4; Health Module pg. 344Health Module pg. 344
  • 17. The American Surgeon;The American Surgeon; Apr 2005; 71, 4; Health Module pg. 344Apr 2005; 71, 4; Health Module pg. 344
  • 18. Tzanakis et al.: Diagnosis of Acute Appendicitis.Tzanakis et al.: Diagnosis of Acute Appendicitis. World J.World J. SurgSurg. Vol. 29, No. 9, September 2005. Vol. 29, No. 9, September 2005
  • 19. Serial CRP measurementSerial CRP measurement The American Surgeon;The American Surgeon; Apr 2005; 71, 4; Health Module pg. 344Apr 2005; 71, 4; Health Module pg. 344
  • 20. Serial CRP measurementSerial CRP measurement The American Surgeon;The American Surgeon; Apr 2005; 71, 4; Health Module pg. 344Apr 2005; 71, 4; Health Module pg. 344
  • 21. Urine 5-hydroxyindoleacetic acid and 5-hydroxytryptamine • Ongoing inflammatory process of the appendix - elevated blood serotonin level. • Upon release, 5-hydroxytryptamine (5-HT) is rapidly metabolized in the liver by the monoamine oxidase (MAO) system to 5-hydroxyindoleacetic acid (5- HIAA) and, thereafter, is secreted in the urine
  • 22. • These results demonstrated that the increase of 5- HIAA level in urine could be a warning sign of AA. • Require further study. No obvious differenceNo obvious difference P value > 0.05P value > 0.05 H. Xu et al. / J. Chromatogr. (2006)
  • 23. Scoring system used in HUSMScoring system used in HUSM • Alvarado Scoring system SNS: 89.7%SNS: 89.7% SPC: 76.3%SPC: 76.3% PPV: 74.3%PPV: 74.3% NPV: 90.6%NPV: 90.6% Tzanakis et al.: Diagnosis of Acute Appendicitis.Tzanakis et al.: Diagnosis of Acute Appendicitis. World J.World J. SurgSurg. Vol. 29, No. 9, September 2005. Vol. 29, No. 9, September 2005
  • 24. Application of Alvarado ScoreApplication of Alvarado Score • Aggregate score 7-10: emergency appendicectomy. • Aggregate score 5-6: kept under observation for 24 hours with frequent re-evaluation of the clinical data and reapplication of the score. • Aggregate score 1-4: discharged with symptomatic treatment and proper instructions.
  • 25. Proposed ScoreProposed Score Tzanakis et al.: Diagnosis of Acute Appendicitis.Tzanakis et al.: Diagnosis of Acute Appendicitis. World J. Surg. Vol. 29, No. 9, September 2005World J. Surg. Vol. 29, No. 9, September 2005
  • 26. 6 points: appendiceal ultrasonogram is positive 4 points: RLQ tenderness 3 points: rebound tenderness 2 points: WBC count greater than 12,000
  • 27. •1-year Observational study •Small sample size •PAR helped clinicians diagnosis AA in < 10% in which mostly in those with perforations. CURRENT SURGERY • Volume 60/Number 3 • May/June 2003
  • 28. • Meta-analysis, 17 studies, 3,358 patient • Overall sensitivity 84.7% (81.0 to 87.8%) • Overall specificity 92.1% (88.0 to 95.2%) • PPV 87.3%, NPV 89.9% • Most useful in equivocal group ** limitation: negative USG and yet acute appendicitis, Academic emergency medicine, 2(7):644-50, 1995
  • 29. USGUSG Non-compressible, > 6 mm in diameter, fluid, mass, tender with focal compression
  • 30. Appendiceal CTAppendiceal CT • … is a focused, helical, appendiceal CT after a Gastrografin-saline enema (with or without oral contrast) • If appendiceal CT is not available, standard abdominal/pelvic CT with contrast remains highly useful and may be more accurate than ultrasonography. Gupta H, Dupuy DE. Advances in imaging of the acute abdomen. Surg Clin North Am 1997;77: 1245-63
  • 31. IV contrast-enhanced helical CT without oral contrast Sensitivity 85% 90 to 100% Specificity 92% 95 to 97% SNS: 90SNS: 90 –– 100%100% SPS: 95SPS: 95 –– 97%97% Rao PM, et al. Helical CT technique for the diagnosis of appendicitis: prospective evaluation of a focused appendix CT examination. Radiology 1997;202:139-44
  • 32. CT ScanCT Scan Distention of appendix, thickened > 5-7 mm walls, target sign
  • 33. Inflamed appendix (A) with appendicolith (a). Enlarged and inflamed appendix (A) extending from the cecum (C).
  • 34. Sensitivity Specificity PPV NPV USG 76 91 95 76 CT 96 89 96 95 Balthazan E, Radiology 1994;190:31-35
  • 35. USGUSG vsvs CTCT • USG • Safe, inexpensive, can rule out pelvic disease in females, better for children • Operator dependent, technically inadequate studies due to gas and painful • CT • More accurate than USG • Better identifies phlegmon and abscess • Better identifies normal appendix • Operator dependent, ionizing radiation, contrast
  • 36. 60 CONSECUTIVE CASES Sensitivity Specificity PPV NPV USG 76 88 90 74 MRI 97 92 94 96 IncesuIncesu L, American Journal of Radiology. 168(3):669L, American Journal of Radiology. 168(3):669--74, 199774, 1997
  • 37. • Very careful history and physical exam especially in high risk patients. • High sensitivity (history): pain before vomiting • High specificity (PE): cough & hoping tenderness in children • Serial CRP as objective measurement is valuable – high specificity and conclusive (+ ve LR > 10)
  • 38. • Alvarado scoring system is easy, cheap and reliable • Proposed score is a new challenge for EP • Appendiceal CT – high accuracy but costly • High index of suspicious, close observation, appropriate follow up are also as good as surgeon’s hand.