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PubMed2005

Acute appendicitis: added diagnostic value of coronal reformations from isotropic voxels at multi-detector row CT.

PURPOSE: To assess retrospectively the added value of coronal reformations from isotropic voxels obtained with 16-section multi-detector row computed tomography (CT) of the abdomen and pelvis in patients with suspected acute appendicitis. MATERIALS AND METHODS: This study was approved by the institutional review board, and informed consent was waived. One hundred consecutive patients (21 men, 79 women; mean age, 38 years) with suspected appendicitis underwent 16-section multi-detector row CT (section thickness, 0.625 mm; pitch, 1.75; table speed, 35 mm/sec [17.5 mm per rotation, two rotations]; and gantry speed, 0.5 second per rotation), with coronal reformations. Twenty-four patients had appendicitis; 76 did not. Protocol included 150 mL oral iopamidol administered at 3 mL/sec. Transverse scans were reconstructed with 5-mm-thick sections at 5-mm intervals and 0.625-mm-thick sections at 0.625-mm intervals. The second data set was reformatted coronally, with 3-mm-thick sections at 5-mm intervals. Three independent blinded readers interpreted transverse scans alone and then coronal scans; confidence in visualization of any portion of appendix, entire appendix, wall thickening, distention, inflammation, fluid, and appendicitis was scored with 1-5 scale. Sensitivity and specificity were determined for each reader and compared by means of signed rank test. Agreement between readers was determined with kappa statistic. Differences in mean confidence ratings for each finding were determined with Wilcoxon signed rank test. RESULTS: Mean sensitivity and specificity for all three readers together were 96% and 95% for transverse reformations alone and 95% and 94% for combined transverse and coronal reformations (not significant), respectively. Visualization rates for portion or all of appendix were higher for combined transverse and coronal reformations than for transverse reformations alone (higher mean confidence scores: 0.23 higher [P < .009] and 0.51 higher [P < .001], respectively). In patients without appendicitis, transverse and coronal reformations together enhanced confidence in exclusion of wall thickening, distention, and fluid (lower confidence scores: 0.21 lower [P < .001], 0.17 lower [P < .01], 1.00 lower [P < .001], respectively). Combined transverse and coronal reformations enhanced confidence in identification of appendix in mean of 57 patients. Combined transverse and coronal scans helped exclude appendicitis in mean of 38 patients and aided diagnosis of it in 15. CONCLUSION: Sixteen-section multi-detector row CT transverse and coronal reformations are equally sensitive and specific for diagnosis of appendicitis. Coronal reformations improve confidence in visualization of appendix (whether diseased or normal) and in diagnosis or exclusion of appendicitis.

Acute Disease↗
PubMed1994

Appendicitis: efficacy of color Doppler sonography.

PURPOSE: To determine whether the addition of color Doppler ultrasonography (US) to gray-scale US can help diagnose appendicitis in children. MATERIALS AND METHODS: One hundred children with suspected appendicitis were evaluated with gray-scale and color Doppler US scanning. Color Doppler US scans were considered positive for appendicitis if increased vascularity was demonstrated in the appendiceal wall and positive for perforation with abscess if a hyperemic right lower quadrant mass was seen. Gray-scale US was positive for appendicitis if a blind-ending, noncompressible appendix larger than 6 mm in diameter, a loculated periappendiceal mass, or both were identified. RESULTS: Thirty-nine patients had acute appendicitis; 26 had uncomplicated appendicitis, and 13 had perforation. Acute appendicitis was identified in 34 of 39 patients (87%) on color Doppler US scans with a sensitivity of 87%, specificity of 97%, and accuracy of 93%. Gray-scale US sensitivity was 87%; specificity, 92%; and accuracy, 90%. CONCLUSION: Blood flow in the appendiceal wall or right lower quadrant mass on color Doppler US scans suggests appendicitis, but absence of flow cannot definitively distinguish a normal from an abnormal appendix.

Appendicitis↗
PubMed1996

Focal appendicitis confined to the tip: diagnosis at US.

PURPOSE: To evaluate the diagnostic value of graded-compression ultrasonography (US) for the diagnosis of focal appendicitis confined to the tip. MATERIALS AND METHODS: During a 4-year period, US was performed in 1,450 patients with clinically suspected acute appendicitis. Of these patients, 443 had appendicitis at pathologic examination, 20 of whom had focal appendicitis confined to the tip. Focal appendicitis confined to the tip was defined as occurring when the resected specimen had inflammation only at the distal third of the appendix. RESULTS: Of 20 patients with focal appendicitis confirmed at pathologic examination, 17 patients (85%) had focal appendicitis that was correctly diagnosed at US. The remaining three patients' appendices were diagnosed at US as normal (false-negative cases). Five patients had perforation at the tip, and one patient had an appendicolith. CONCLUSION: Although US appears to be fairly accurate in the diagnosis of focal appendicitis confined to the tip, the entire length of the appendix should be evaluated in order to avoid a false-negative diagnosis.

Acute Disease↗
PubMed1997

Distal appendicitis: CT appearance and diagnosis.

PURPOSE: To determine the appearance of appendicitis in the distal part of the organ (distal appendicitis) on computed tomographic (CT) scans and to evaluate the accuracy of diagnosis based on CT findings. MATERIALS AND METHODS: CT scans and medical records in 180 consecutive patients with proved appendicitis were reviewed. Fourteen had distal appendicitis with at least a 3-cm length of normal proximal appendix. Appendiceal CT scans and initial reports were reviewed retrospectively. RESULTS: The proximal appendix was collapsed (n = 6) or was filled with contrast material (n = 6) or air (n = 2). Inflamed distal appendices averaged 13.2 mm in diameter and were associated with periappendiceal fat stranding (n = 14), adenopathy (n = 6), appendolith(s) (n = 4), or fluid (n = 2). Transition points consisted of a progressively narrowed appendiceal lumen and thickened wall (n = 5) or appendiceal diameter enlargement (n = 9). No cecal apical changes were seen. Scans in all 14 patients were prospectively interpreted as indicative of appendicitis, including 12 (86%) interpreted as indicative of distal appendicitis. CONCLUSION: CT findings are useful for the accurate diagnosis of distal appendicitis. Visualization of the proximal appendix alone is insufficient to exclude distal appendicitis.

Appendicitis↗
PubMed2000

Presence or absence of gas in the appendix: additional criteria to rule out or confirm acute appendicitis--evaluation with US.

PURPOSE: To investigate whether the presence or absence of gas in the appendix may be considered as additional ultrasonographic (US) criteria to rule out or confirm acute appendicitis. MATERIALS AND METHODS: The appendices in 239 control subjects, 138 patients with lower right quadrant pain without acute appendicitis, and 80 patients with acute appendicitis were prospectively evaluated for intraluminal gas with US. RESULTS: The appendices in 206 (86%) control subjects showed gas at US, and those in 33 (14%) did not. The appendices in 109 (79%) symptomatic patients without acute appendicitis showed gas, and those in 29 (21%) did not. The appendices in 12 (15%) patients with acutely inflamed appendices showed gas, and those in 68 (85%) did not. The absence of gas as a criterion for acute appendicitis had a sensitivity of 85%; specificity, 79%; positive and negative predictive values, 57% and 94%, respectively; and accuracy, 81%. Gas was useful to exclude acute appendicitis in 64 (46%) symptomatic patients because the established criteria were misleading. In 19 (24%) patients, the absence of gas was useful for diagnosis of acute appendicitis because the other criteria were not convincing. CONCLUSION: US-based detection of gas in the appendiceal lumen helps to rule out acute appendicitis, whereas the absence of gas further confirms its presence, especially in cases where established US criteria are either insufficiently present or misleading.

Acute Disease↗
PubMed2004

Clinical value of the total white blood cell count and temperature in the evaluation of patients with suspected appendicitis.

OBJECTIVES: The total white blood cell (WBC) count and temperature are often expected to be elevated in patients with appendicitis. Clinicians often use the results of these parameters in making a judgment about the presence or absence of disease. The objective of this study was to assess the discriminatory value of the total WBC count and presenting body temperature in patients presenting to the emergency department (ED) with signs and symptoms suggestive of appendicitis. METHODS: This was a prospective consecutive case series in a university ED with an annual census of 38,000. All patients presenting to the ED in whom the diagnosis of appendicitis was the attending physician's primary consideration were enrolled. Measures included age, gender, symptoms, physical findings, patient temperature as taken in the ED, initial total WBC count, and discharge diagnosis. Admitted patients were followed up until surgical or clinical outcomes, and discharged patients were followed up by telephone two weeks after the initial visit. All statistical analysis was performed using StatsDirect version 1.9.8. RESULTS: A total of 293 patients were enrolled over a two-year study period. The total WBC count was measured in 274 cases, and the temperature was measured in 293 cases. There were 130 male patients and 163 female patients. The mean age of the patients was 30.8 years (range, 7-75 years). Appendicitis was confirmed in 92 patients. In this study group of patients, a total WBC count >10,000 cells/mm(3) had a sensitivity of 76% (95% confidence interval [95% CI] = 65% to 84%) and a specificity of 52% (95% CI = 45% to 60%). The positive predictive value (PPV) was 42% (95% CI = 35% to 51%), and the negative predictive value (NPV) was 82% (95% CI = 74% to 89%). The positive likelihood ratio (LR) was 1.59 (95% CI = 1.31 to 1.93), and the negative LR was 0.46 (95% CI = 0.31 to 0.67). A temperature >99.0 degrees F had a sensitivity of 47% (95% CI = 36% to 57%) and a specificity of 64% (95% CI = 57% to 71%). The PPV was 37% (95% CI = 29% to 46%), and the NPV was 72% (95% CI = 65% to 79%). The positive LR was 1.3 (95% CI = 0.97 to 1.72), and the negative LR was 0.82 (95% CI = 0.65 to 1.01). The areas under the curve for the receiver-operating characteristic (ROC) curve were 0.72 (95% CI = 0.65 to 0.79) and 0.59 (95% CI = 0.52 to 0.66) for an elevated total WBC count and an elevated temperature, respectively. CONCLUSIONS: An elevated total WBC count >10,000 cells/mm(3), while statistically associated with the presence of appendicitis, had very poor sensitivity and specificity and almost no clinical utility. There was minimal statistical association between a temperature of >99 degrees F and the presence of appendicitis. The ROC curve suggests there is no value of total WBC count or temperature that has sufficient sensitivity and specificity to be of clinical value in the diagnosis of appendicitis. Clinicians should be wary of reliance on either elevated temperature or total WBC count as an indicator of the presence of appendicitis.

Adolescent↗
PubMed2002

Effect of an imaging protocol on clinical outcomes among pediatric patients with appendicitis.

OBJECTIVE: In 1998, we implemented a clinical imaging protocol in which children with suspected appendicitis underwent ultrasonography (US) followed by computed tomography (CT). We sought to determine the impact of the US-CT protocol on changes in perforation and negative appendectomy rates. METHODS: Children with unequivocal presentations for appendicitis went to the operating room without entering the imaging protocol. Using a modified time series design, we analyzed a prospective and retrospective cohort of consecutive patients who were admitted from the emergency department for suspected appendicitis. The perforation and negative appendectomy rates were computed for the periods before and after implementation of the imaging protocol and adjustment for time trends was made. RESULTS: A total of 1338 children were identified. Eight hundred ten (60.5%) children had equivocal clinical findings. A total of 920 patients were admitted for suspected appendicitis before the protocol was implemented; 526 (57.2%) of the 920 children had appendicitis, and 186 (35.4%) of them had perforation. A total of 91 (14.7%) of 617 had negative appendectomies. After the protocol was implemented, 418 patients were admitted for suspected appendicitis; 328 (78.5%) had appendicitis with 51 (15.5%) perforated. There were 14 (4.1%) of 342 cases of negative appendectomies. After implementation of the imaging protocol, the perforation rate decreased from 35.4% to 15.5%, and the negative appendectomy rate decreased from 14.7% to 4.1%. After secular time trends were adjusted for, the imaging protocol continued to have a strong association with a reduction in perforation rate and negative appendectomy rate. CONCLUSION: The implementation of an imaging protocol using US and CT resulted in a marked decrease in the perforation and negative appendectomy rates in children with suspected appendicitis.

Adolescent↗
PubMed1989

1989 ARRS President's Award. The validity and utility of sonography in the diagnosis of appendicitis in the community setting.

Two hundred six patients with suspected appendicitis were examined with sonography over a 6-month period in three community teaching hospitals. Of 41 patients in whom the surgeons judged the clinical findings severe enough to warrant immediate surgery (group A), 34 (83%) had appendicitis, and sonography had a sensitivity of 0.76, a specificity of 0.71, and an accuracy of 0.76. Of 165 patients in whom the surgeons judged the clinical findings severe enough to warrant hospitalization for observation but not immediate surgery (group B), 51 (31%) had appendicitis at subsequent surgery. Sonography had a sensitivity of 0.96, a specificity of 0.94, and an accuracy of 0.95. Of 49 surgeons surveyed, the mean testing threshold (i.e., the probability of appendicitis below which they would send the patient home without further tests or observation) was 0.11, and the mean treatment threshold (i.e., the probability of appendicitis above which they would operate immediately) was 0.82. The posttest probability of appendicitis with findings indicating appendicitis present on sonography was 0.93 in group A and 0.88 in group B, and with findings absent on sonography it was 0.62 in group A and 0.02 in group B. We conclude that in group A patients, the use of sonography remains controversial in the diagnosis of appendicitis, but in group B patients it is both valid and useful.

Appendicitis↗
PubMed1998

MR imaging in children with nonperforated acute appendicitis: value of unenhanced MR imaging in sonographically selected cases.

OBJECTIVE: The aim of this study was to describe the MR appearance of acute appendicitis and to determine the value of MR imaging for diagnosis of acute appendicitis. SUBJECTS AND METHODS: Forty-five children (28 girls, 17 boys), 7-16 years old (mean age, 13 years old), with clinically diagnosed acute appendicitis underwent independently graded compression sonography by two radiologists. MR imaging was performed when sonography revealed acute appendicitis (observer 1, 16 [36%] patients; observer 2, 18 [40%] patients), was inconclusive (observer 1, two [4%] patients; observer 2, one [2%] patient), and was interpreted as normal (observer 1, two [4%] patients; observer 2, one [2%] patient) (n = 20). Axial T1-weighted turbo spin-echo sequences, T2-weighted turbo spin-echo sequences in the axial and coronal planes, and fat-suppressed short inversion time inversion recovery turbo spin-echo sequences in the axial plane (4-mm slice thickness) were obtained and evaluated independently by two radiologists. The ability to see acute appendicitis with MR imaging was evaluated, the appearance and morphologic changes were described, and the most accurate sequence was determined. All children in whom MR imaging was performed underwent surgery. RESULTS: MR imaging revealed acute appendicitis in all cases (100%) by both observers. On T2-weighted ultra turbo spin-echo images, acute appendicitis appeared with a markedly hyperintense center, a slightly hyperintense thickened wall, and markedly hyperintense periappendiceal tissue. Unenhanced axial T2-weighted spin-echo imaging was the most sensitive sequence. CONCLUSION: In this study group, MR imaging was a valuable technique for depiction of acute appendicitis.

Acute Disease↗
PubMed2005

Incidence of acute appendicitis in patients with equivocal CT findings.

OBJECTIVE: The purpose of our study was to determine the incidence of acute appendicitis in patients for whom the CT interpretation is deemed equivocal. MATERIALS AND METHODS: Of 1,344 patients referred for CT with suspected appendicitis between January 1998 and December 2002, 172 patients were identified in whom the radiographic findings were equivocal. Two radiologists reviewed the equivocal CT cases, reassessing appendiceal size and the presence of right lower quadrant stranding, fluid, or an appendicolith. The reviewers' findings were correlated with surgical pathology reports and clinical follow-up. RESULTS: Fifty-three (31%) of 172 patients with indeterminate findings on CT scans were subsequently diagnosed with appendicitis. For reviewers 1 and 2, respectively, appendicitis was present in five (14%) of 36 and six (13%) of 47 patients who had isolated appendiceal diameter less than 9 mm, and in 11 (52%) of 21 and in 10 (50%) of 20 patients who had isolated appendiceal dilatation equal to or greater than 9 mm. If a normal diameter appendix (< 6 mm) was visualized in a patient who had right lower quadrant stranding or fluid, appendicitis was present in only one (17%) of six and in four (27%) of 15 patients for reviewers 1 and 2, respectively. If the appendix could not be identified but there was right lower quadrant stranding or fluid, appendicitis was present in seven (37%) of 19 and in eight (53%) of 15 patients. CONCLUSION: Appendicitis is encountered in about 30% of patients with equivocal findings on CT, and the diagnosis should be considered in most of these patients if they are appropriately symptomatic. However, when the appendix measures less than 9 mm alone, the likelihood of appendicitis is much smaller.

Acute Disease↗
PubMed2005

CT evaluation of appendicitis and its complications: imaging techniques and key diagnostic findings.

OBJECTIVE: This article reviews various CT protocols for appendicitis, identifies key CT findings for diagnosing appendicitis, discusses unusual manifestations such as chronic and recurrent appendicitis, and profiles imaging features that differentiate appendicitis from other inflammatory and neoplastic ileocecal conditions. Patients were studied with helical CT. CONCLUSION: CT is a highly accurate, noninvasive test for appendicitis, but the optimal CT technique is controversial. Major complications of appendicitis (perforation, abscess formation, peritonitis, bowel obstruction, septic seeding of mesenteric vessels, gangrenous appendicitis) and their management are discussed. Abdominal CT is a well-established technique in the study of acute abdominal pain and has shown high sensitivity and specificity for diagnosing and differentiating appendicitis, providing an accurate diagnosis in the early stages of disease.

Appendicitis↗
PubMed2006

[Application of a diagnostic score for appendicitis by health-related non-physician professionals].

BACKGROUND: Diagnostic scores have been developed as simple, user-friendly, cost-effective instruments to improve the early diagnosis of acute appendicitis. AIM: To assess the yield of a diagnostic score for acute appendicitis, measured by trained health-related non-physician professional. PATIENTS AND METHODS: A prospective, double blind, non-randomized trial. Emergency room nurses applied a previously validated diagnostic score for appendicitis to patients aged more than 15 years with abdominal pain and tachycardia or fever. The main outcome was the percentage of patients operated for acute appendicitis that had a positive score for appendicitis and a pathologically demonstrated appendicitis. RESULTS: The mean scores for patients operated or not operated for appendicitis were 8.64 and 3.31, respectively. The figures for sensitivity, specificity and diagnostic accuracy of the score were 0.83, 0.98 and 0.94, respectively. CONCLUSIONS: An appendicitis score measured by health-related non-physician professionals has a similar diagnostic yield than clinical judgment.

Acute Disease↗
PubMed2001

Acute appendicitis in a Kenyan rural hospital.

OBJECTIVES: The literature on appendicitis in Africa is almost all derived from urban teaching hospitals. As most of Africa's people are from rural areas, we sought to review our experience from a rural hospital in Kenya. DESIGN: Retrospective chart review. SETTING: A rural Kenyan church hospital. SUBJECTS: One hundred and twelve cases of acute appendicitis presenting at Kijabe Hospital over a five year period were reviewed. INTERVENTION: Appendicectomy. MAIN OUTCOME MEASURES: Sex, age, pre-hospital delay, operative findings, wound infection, post-operative length of stay. RESULTS: The male to female ratio was 1.8:1. The median age was 29 (4-71 years). Median prehospital delays were one day (normal appendix), one and a half days (simple appendicitis), three days (perforated appendix) and six and a half days (appendical abscess). Operative findings were 14% normal appendix, 42% simple appendicitis, 22% perforated, 21% abscess. Overall wound infection rate was 22%; ranging from 11% for simple appendicitis to 46% for an appendiceal abscess. The mean post-operative length of stay was nine and a half days. CONCLUSIONS: Acute appendicitis in rural Kenya is similar to patterns reported in urban African centres. The main difference from western data is the high complicated appendicitis rate which is most likely related to prolonged pre-hospital delay.

Acute Disease↗
PubMed1992

Sonography of acute appendicitis in childhood: perforation versus nonperforation.

We evaluated the sonographic findings in 133 consecutive children referred for suspected appendicitis. Fifty-eight of these patients (44%) ultimately underwent surgery, with 54 of these proved to have acute appendicitis. Thirty-one (58%) of the 54 had nonperforated appendicitis, and 23 (43%) had evidence of perforation. Previously described sonographic findings that have been employed in the diagnosis of appendicitis were evaluated, with the presence or absence of these findings being compared in patients with non-perforated and perforated appendicitis. In those patients who did not undergo surgery, the following findings were documented and compared to the findings in patients with proved appendicitis: (1) an identifiable appendix and its sonographic characteristics, (2) fluid localized to the right peritoneal reflection or periappendiceal region, or both, (3) free pelvic fluid, and (4) right lower quadrant adenopathy. Our results suggest that high-resolution, real-time sonography, using graded compression, is very sensitive in the identification of acute nonperforated appendicitis. Perforated appendicitis, however, can be a more difficult diagnosis because the appendix frequently decompresses with perforation and yet may not "wall off" or form a well-defined abscess. As a result, the appendix can be very difficult to identify.

Acute Disease↗
PubMed1998

Appendicitis: a continuing challenge.

Acute appendicitis is a common surgical emergency in urban setting, of a developing country. The computerised hospital patient database at Aga Khan University Hospital, Karachi, was utilised to obtain records of all adults with a histologically proven diagnosis of acute appendicitis. A review of patients treated over a 18 month period was undertaken. One hundred and three appendicectomies were performed for acute appendicitis during this period. The diagnosis was clinical in all cases. Investigations like leucocyte count and lower abdominal ultrasound scan were used to improve diagnostic accuracy without a clear advantage. A number of routine investigations like, haemoglobin estimation and urea, creatinine, electrolyte measurements, did not provide additional information. The duration of antibiotic treatment in acute simple appendicitis was empiric and could be reduced to a single preoperative dose. Peritoneal fluid culture studies had a poor yield (26%) and results were not found to effect management in acute simple appendicitis. The routine use of Ampicillin in all cases of bacterial peritonitis needs re-evaluation, as a high incidence (73%) of resistance was seen. Studies to define the role and duration of treatment, with a single antibiotic, in acute simple appendicitis should be undertaken. Acute appendicitis is probably the most frequently considered surgical differential diagnosis at any hospital dealing with acute surgical conditions. The established treatment continues to be surgical removal of the inflamed organ. The diagnosis and decision to operate both are accepted to be based on clinical judgement, though a number of investigative manoeuvres have been described to reduce the negative appendicectomy rate. Other areas of debate are the number and length of antibiotic treatment and use of bacterial culture studies in cases of simple acute appendicitis. To analyse present practice and identify areas for study and change, a retrospective study was undertaken at Aga Khan University Hospital (AKUH), Karachi.

Acute Disease↗
PubMed1999

The role of radiolabeled leukocyte imaging in the management of patients with acute appendicitis.

Acute appendicitis is a clinically challenging surgical disease particularly difficult to diagnosis in women and children. An atypical presentation of acute appendicitis is a major factor leading to delay in diagnosis and unnecessary surgery. Delay in diagnosis is associated with morbidity from perforation, abscess and prolonged hospitalization. The routine use of adjunctive imaging studies has not improved the diagnostic accuracy for acute appendicitis nor has impacted clinical outcome. 99mTc HMPAO-labeled leukocyte imaging is one diagnostic imaging test that has the potential of altering the clinical management of acute appendicitis. 99mTc HMPAO-labeled leukocyte imaging is highly sensitive for detecting even small inflammatory processes in the abdomen because of high target to background and early rapid uptake at sites of inflammation. We studied the use of 99mTc HMPAO-labeled leukocytes for diagnosis and management of suspected acute appendicitis in 124 patients with an atypical clinical presentation. Emergent imaging was performed immediately following injection of labeled leukocytes and continued until positive or through 2 hours if negative. The scan correctly and rapidly detected acute appendicitis in 50 of 51 patients with surgical confirmation for a sensitivity of 98%. The specificity was 82% leading to an overall accuracy of 90%. The high negative predicted value of 98% allowed early discharge from the emergency department and avoided costly observation in the hospital and potentially unnecessary surgery in these patients with negative scans. The negative exploratory laparotomy rate was 4% in this patient population compared to 9% in a similar population of patients who were not scanned. These data have been confirmed now in over 600 patients scanned in our department. The main drawbacks of 99mTc HMPAO-labeled leukocyte imaging are the requirement of blood handling and a delay in diagnosis because of the 2-hours preparation time prior to imaging. There are new radiopharmaceuticals on the horizon which have the potential of replacing 99mTc HMPAO-labeled leukocyte imaging and offer advantages of a shorter preparation time and no blood handling. These include 99mTc labeled monoclonal antibodies and chemotactic peptides. The 99mTc anti-SSEA-1 IgM antibody (LeuTech) is currently under investigation for use in acute appendicitis. In summary, nuclear medicine can play a key role in the diagnosis of acute appendicitis in patients with an atypical presentation. This technique is cost effective and appears to impact favorably on clinical outcome.

Acute Disease↗
PubMed2000

Neutrophil-specific 99mTc-labeled anti-CD15 monoclonal antibody imaging for diagnosis of equivocal appendicitis.

UNLABELLED: We evaluated 99mTc-labeled anti-CD15 immunoglobulin M monoclonal antibody (LeuTech) for diagnosing acute appendicitis in patients with an equivocal clinical presentation. LeuTech avidly binds to circulating and sequestered human polymorphonuclear neutrophils in vivo, eliminating in vitro cell labeling and blood handling. METHODS: We studied 49 patients to evaluate the safety and efficacy of LeuTech imaging. 99mTc-labeled LeuTech was prepared on site using a lyophilized kit, 99mTc-labeled pertechnetate, and 2 different incubation techniques, 1 at room temperature and the other at 37 degrees C. The abdomen was serially imaged for up to 3 h after the intravenous administration of 370-740 MBq 99mTc-labeled LeuTech. Scans were read as positive or negative for acute appendicitis or other intraabdominal infection. The institutional diagnosis was established by surgery, other diagnostic studies, or 1-mo clinical follow-up. RESULTS: Scans were positive for appendicitis in all 26 patients with appendicitis, for a sensitivity of 100%, and negative for appendicitis in 19 of 23 patients without appendicitis, for a specificity of 83%. Accuracy, positive predictive value, and negative predictive value were 92%, 87%, and 100%, respectively. Results were not different between the LeuTech preparations. The rate of laparotomies with negative findings in patients who underwent surgery was 10%. The average time from injection to LeuTech visualization in the appendix for cases positive for appendicitis was 9 min. No serious adverse reactions occurred. CONCLUSION: LeuTech imaging is safe, rapid, and sensitive for diagnosis of appendicitis in equivocal cases. The potential advantages of LeuTech over currently available radiopharmaceuticals for infection imaging are ease of preparation, absence of blood handling, excellent image quality, no requirement for SPECT, and rapid diagnostic uptake.

Acute Disease↗
PubMed2000

Appendicitis: why so complicated? Analysis of 5755 consecutive appendectomies.

A perceived high rate of complicated (gangrenous or perforated) appendicitis, despite advances in laboratory and radiographic diagnostic modalities, prompted a review of our experience with appendicitis followed by a prospective analysis that examined the time course from presentation to definitive treatment in 218 consecutive patients. In 5755 appendectomies, our overall rate of complicated appendicitis was 32 per cent; higher in males, in the young, and in the elderly; and relatively stable over each year reviewed. Prospectively, we determined that of the various time intervals, the time from the onset of symptoms to first seeking medical attention is the only significant predictor of complicated appendicitis (39.8 vs 16.5 hours for acute appendicitis). On the other hand, the time from surgical evaluation to operative intervention was significantly shorter for complicated appendicitis (3.8 vs 4.7 hours for acute appendicitis). The high rate of complicated appendicitis with its subsequent sequelae of increased morbidity and resource expenditure is primarily the direct result of patient delay in seeking medical attention and not the result of diagnostic dilemma or surgical delay. Public education, specifically targeting those groups at risk, may provide a substantial and significant solution to the complicated appendix.

Adolescent↗