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  • 1. An Evidence Based Approach in the Diagnosis of Acute Appendicitis Dr. Rashidi Ahmad MD USM, Mmed USM, FADUSM, AM (Mal), Clinical Fellow (Cardiology)
  • 2. Fact of life The failure to diagnose appendicitis is routinely listed among the top five reasons for a malpractice suite. Reigelman R, Minimizing medical mistakes : The Art of Medical Decision Making
  • 3. Diagnostic 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 challenges • Causes of appendicitis – varies in presentation • Position of the appendix • In pediatric and pregnancy • Mimics Goal to diagnose before peritonitis sets in
  • 5. Acute 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 J Epidemiol 1990;132:910-25. Ann R Coll Surg 1994;76:418-9 J Pediatr Surg 2000;35:1320-2
  • 6. Perforated acute appendicitis • The incidence of perforated appendicitis in relation to time of abdominal pain till surgery - 24 hours: 20% perforation - 36 hours: 50% gangrenous/perforated - 48 hours: 80% perforated with peritonitis • < 4 years of age: perforation rate - 95% • 4 – 19% in non pregnant, 57% in pregnant woman Brender, Journal of Pediatrics, August 1985 Acad Emerg Med. 2000 Nov;7(11):1244-55 Tracey & Fletcher,2000
  • 7. Final 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 mimics DIVERTICULITIS 2 OMENTAL TORSION 2 PGU 2 UTI 1 Tzanakis et al.World J. Surg. Vol. 29, No. 9, September 2005
  • 8. Common symptoms Common symptoms 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):589-594
  • 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):589-594
  • 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, Acta Paediatr, 1996;85:459-62
  • 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
  • 14. Per Rectal Examination Your opinion…
  • 15. 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% Paajanen H, Acta Paediatr 1995; 85:459-62 *P<.001
  • 16. Role of Leukocyte Count, Neutrophil Percentage, and C-Reactive Protein in the acute appendicitis in elderly. Horng-Ren Yang, et al The American Surgeon; Apr 2005; 71, 4; Health Module pg. 344
  • 17. The American Surgeon; Apr 2005; 71, 4; Health Module pg. 344
  • 18. Tzanakis et al.: Diagnosis of Acute Appendicitis. World J. Surg. Vol. 29, No. 9, September 2005
  • 19. Serial CRP measurement The American Surgeon; Apr 2005; 71, 4; Health Module pg. 344
  • 20. Serial CRP measurement The American Surgeon; Apr 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. No obvious difference P value > 0.05 • These results demonstrated that the increase of 5- HIAA level in urine could be a warning sign of AA. • Require further study. H. Xu et al. / J. Chromatogr. (2006)
  • 23. Scoring system used in HUSM • Alvarado Scoring system SNS: 89.7% SPC: 76.3% PPV: 74.3% NPV: 90.6% Tzanakis et al.: Diagnosis of Acute Appendicitis. World J. Surg. Vol. 29, No. 9, September 2005
  • 24. Application 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 Score Tzanakis et al.: Diagnosis of Acute Appendicitis. World 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. USG Non-compressible, > 6 mm in diameter, fluid, mass, tender with focal compression
  • 30. Appendiceal 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% SNS: 90 – 100% SPS: 95 – 97% Specificity 92% 95 to 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 Scan Distention of appendix, thickened > 5-7 mm walls, target sign
  • 33. Inflamed appendix (A) with Enlarged and inflamed appendix (A) appendicolith (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. USG vs CT • USG • CT • Safe, inexpensive, can • More accurate than USG rule out pelvic disease in • Better identifies phlegmon females, better for and abscess children • Better identifies normal • Operator dependent, appendix technically inadequate • Operator dependent, studies due to gas and ionizing radiation, contrast painful
  • 36. 60 CONSECUTIVE CASES Sensitivity Specificity PPV NPV USG 76 88 90 74 MRI 97 92 94 96 Incesu L, American Journal of Radiology. 168(3):669-74, 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.