23
views
0
recommends
+1 Recommend
0 collections
    0
    shares
      • Record: found
      • Abstract: found
      • Article: found
      Is Open Access

      Diagnosing Appendicitis: Evidence-Based Review of the Diagnostic Approach in 2014

      review-article

      Read this article at

      Bookmark
          There is no author summary for this article yet. Authors can add summaries to their articles on ScienceOpen to make them more accessible to a non-specialist audience.

          Abstract

          Introduction

          Acute appendicitis is the most common abdominal emergency requiring emergency surgery. However, the diagnosis is often challenging and the decision to operate, observe or further work-up a patient is often unclear. The utility of clinical scoring systems (namely the Alvarado score), laboratory markers, and the development of novel markers in the diagnosis of appendicitis remains controversial. This article presents an update on the diagnostic approach to appendicitis through an evidence-based review.

          Methods

          We performed a broad Medline search of radiological imaging, the Alvarado score, common laboratory markers, and novel markers in patients with suspected appendicitis.

          Results

          Computed tomography (CT) is the most accurate mode of imaging for suspected cases of appendicitis, but the associated increase in radiation exposure is problematic. The Alvarado score is a clinical scoring system that is used to predict the likelihood of appendicitis based on signs, symptoms and laboratory data. It can help risk stratify patients with suspected appendicitis and potentially decrease the use of CT imaging in patients with certain Alvarado scores. White blood cell (WBC), C-reactive protein (CRP), granulocyte count and proportion of polymorphonuclear (PMN) cells are frequently elevated in patients with appendicitis, but are insufficient on their own as a diagnostic modality. When multiple markers are used in combination their diagnostic utility is greatly increased. Several novel markers have been proposed to aid in the diagnosis of appendicitis; however, while promising, most are only in the preliminary stages of being studied.

          Conclusion

          While CT is the most accurate mode of imaging in suspected appendicitis, the accompanying radiation is a concern. Ultrasound may help in the diagnosis while decreasing the need for CT in certain circumstances. The Alvarado Score has good diagnostic utility at specific cutoff points. Laboratory markers have very limited diagnostic utility on their own but show promise when used in combination. Further studies are warranted for laboratory markers in combination and to validate potential novel markers.

          Related collections

          Most cited references 64

          • Record: found
          • Abstract: found
          • Article: not found

          A practical score for the early diagnosis of acute appendicitis.

          We conducted a retrospective study of 305 patients hospitalized with abdominal pain suggestive of acute appendicitis. Signs, symptoms, and laboratory findings were analyzed for specificity, sensitivity, predictive value, and joint probability. The total joint probability, the sum of a true-positive and a true-negative result, was chosen as a diagnostic weight indicative of the accuracy of the test. Eight predictive factors were found to be useful in making the diagnosis of acute appendicitis. Their importance, according to their diagnostic weight, was determined as follows: localized tenderness in the right lower quadrant, leukocytosis, migration of pain, shift to the left, temperature elevation, nausea-vomiting, anorexia-acetone, and direct rebound pain. Based on this weight, we devised a practical diagnostic score that may help in interpreting the confusing picture of acute appendicitis.
            Bookmark
            • Record: found
            • Abstract: found
            • Article: not found

            Meta-analysis of the clinical and laboratory diagnosis of appendicitis.

             R Andersson (2003)
            The importance of specific elements in the clinical diagnosis of appendicitis is controversial. This review analyses the diagnostic value of elements of disease history, clinical findings and laboratory test results in suspected appendicitis. A systematic Medline search was made of all published studies on the clinical and laboratory diagnosis of appendicitis in patients admitted to hospital with suspected disease. Meta-analyses of receiver-operator characteristic (ROC) areas, and positive and negative likelihood ratios, of 28 diagnostic variables described in 24 studies are presented. Inflammatory response variables (granulocyte count, proportion of polymorphonuclear blood cells, white blood cell count and C-reactive protein concentration), descriptors of peritoneal irritation (rebound and percussion tenderness, guarding and rigidity) and migration of pain were the strongest discriminators, with ROC areas of 0.78 to 0.68. The discriminatory power of the inflammatory variables was particularly strong for perforated appendicitis, with ROC areas of 0.85 to 0.87. Appendicitis was likely when two or more inflammatory variables were increased and unlikely when all were normal. Although all clinical and laboratory variables are weak discriminators individually, they achieve a high discriminatory power when combined. Laboratory examination of the inflammatory response, clinical descriptors of peritoneal irritation, and a history of migration of pain yield the most important diagnostic information and should be included in any diagnostic assessment. Copyright 2004 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
              Bookmark
              • Record: found
              • Abstract: found
              • Article: not found

              US or CT for Diagnosis of Appendicitis in Children and Adults? A Meta-Analysis.

              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. (c) RSNA, 2006.
                Bookmark

                Author and article information

                Journal
                West J Emerg Med
                West J Emerg Med
                WestJEM
                Western Journal of Emergency Medicine
                Department of Emergency Medicine, University of California, Irvine School of Medicine
                1936-900X
                1936-9018
                November 2014
                07 October 2014
                : 15
                : 7
                : 859-871
                Affiliations
                [* ]Duke University, Division of Emergency Medicine, Duke University, Durham, North Carolina
                []Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, Massachusetts
                []Beth Israel Deaconess Medical Center, Department of Surgery, Boston, Massachusetts
                [§ ]Beth Israel Deaconess Medical Center, Department of Emergency Medicine and Center for Vascular Biology, Boston, Massachusetts
                Author notes
                Address for Correspondence: Daniel Shogilev, MD, 4130 Garrett Rd. Apt. 1014, Durham, North Carolina, 27707. E-mail: dshogilev@ 123456gmail.com .
                Article
                wjem-15-859
                10.5811/westjem.2014.9.21568
                4251237
                25493136
                c9ac3736-e6b4-4617-8d00-5a6bbee7555e
                Copyright © 2014 the authors.

                This is an Open Access article distributed under the terms of the Creative Commons Non-Commercial Attribution License, which permits its use in any digital medium, provided the original work is properly cited and not altered. For details, please refer to http://creativecommons.org/licenses/by-nc-nd/3.0/. Authors grant Western Journal of Emergency Medicine a nonexclusive license to publish the manuscript.

                Categories
                Diagnostic Acumen
                Review Article

                Emergency medicine & Trauma

                Comments

                Comment on this article