Abstract
Study Objective
Appendicitis is part of the differential of an acute abdomen and can be a difficult
diagnosis to make. Strategies to suggest which patients presenting to the emergency
department (ED) should undergo computed tomography (CT) scan to confirm appendicitis
have not been addressed. We develop guidelines for CT scanning based on Alvarado clinical
scores for patients with suspected and confirmed cases of appendicitis.
Methods
A retrospective review of 150 charts of patients aged 7 and older who presented with
abdominal pain to the ED of a 392-bed acute care facility over a 6-month period were
evaluated by ED physicians and underwent CT to rule out appendicitis. Patient demographics,
presenting signs, and symptoms were documented. Using the scoring system for appendicitis,
developed by Alvarado, each chart was retrospectively scored. The Alvarado scores
were correlated with positive pathology findings, as well as Alvarado scores with
a negative CT scan. Equivocal scores, having neither high sensitivity nor specificity
for appendicitis were calculated.
Results
Computed tomography scans with Alvarado scores of 3 or lower were performed in 37%
(55/150) of patients to rule out appendicitis. The sensitivity of Alvarado scores
3 or lower for not having appendicitis was 96.2% (53/55), and the specificity 67%
(2/3). Patients with Alvarado scores 7 or higher had an incidence of acute appendicitis
of 77.7% (28/36). The sensitivity of Alvarado scores 7 or higher for appendicitis
was 77% (28/36), and the specificity 100% (8/8). The sensitivity of equivocal Alvarado
scores, defined as scores of 4 to 6, for acute appendicitis was 35.6% (21/59), and
the specificity 94% (36/38). The sensitivity and specificity of CT scans in patients
with equivocal Alvarado scores remained high, at 90.4% and 95%, respectively.
Conclusions
In the equivocal clinical presentation of appendicitis as defined by Alvarado scores
of 4 to 6, adjunctive CT is recommended to confirm the diagnosis in the ED setting.
If clinical presentation suggests acute appendicitis by an Alvarado score of 7 or
higher, surgical consultation is recommended. Computed tomography is not indicated
in patients with Alvarado scores of 3 or lower to diagnose acute appendicitis.
To read this article in full you will need to make a payment
One-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D; use, select 'Corporate R&D; Professionals'
Subscribe:
Subscribe to The American Journal of Emergency MedicineAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- A practical score for the early diagnosis of acute appendicitis.Ann Emerg Med. 1986; 15: 557-564
- Diagnostic scores for acute appendicitis. Abdominal Pain Study Group.Eur J Surg. 1995; 161: 273-281
- Scoring and diagnostic laparoscopy for suspected appendicitis.Eur J Surg. 2002; 168: 349-354
- Diagnostic decision support in suspected acute appendicitis: validation of a simplified scoring system.Eur J Surg. 1997; 163: 831-838
- A simple scoring system to reduce the negative appendicectomy rate.Ann R Coll Surg Engl. 1992; 74: 281-285
- A prospective randomized study of clinical assessment versus computed tomography for the diagnosis of acute appendicitis.Surg Infect. 2003; 4: 231-239
- Diagnosis of acute appendicitis in children using a clinical practice guideline.J Pediatr Surg. 2004; 39: 458-463
- The status of appendiceal CT in an urban medical center 5 years after its introduction: experience with 753 patients.Am J Roentgenol. 2005; 184: 1802-1808
- Are negative appendectomies still acceptable?.Am J Surg. 2004; 188: 748-754
- Incidence of acute appendicitis in patients with equivocal CT findings.Am J Roentgenol. 2005; 184: 1813-1820
- CT is useful for identifying patients with complicated appendicitis.Dig Liver Dis. 2004; 36: 195-198
- Diagnostic pathways and delays on route to operative intervention in acute appendicitis.Am Surg. 2004; 70: 1010-1013
- Computed tomography and ultrasonography do not improve and may delay the diagnosis and treatment of acute appendicitis.Arch Surg. 2001; 136: 556-562
- Risk of cancer from diagnostic x-rays: estimates for the UK and 14 other countries.Lancet. 2004; 363: 345-351
- Is appendiceal CT scan overused for evaluating patients with right lower quadrant pain?.Am J Emerg Med. 2001; 19: 199-203
- Ultrasonography and computed tomography in suspected acute appendicitis.Semin Ultrasound CT MR. 2003; 24: 69-73
- A prospective evaluation of the use of emergency department computed tomography for suspected acute appendicitis.Surg Infect. 2001; 2: 205-214
- Is there a role for abdominal computed tomographic scans in appendicitis?.Arch Surg. 1998; 133: 373-377
- Effectiveness of imaging studies in acute appendicitis: a simplified decision model.Eur J Emerg Med. 2000; 7: 25-30
- The CT diagnosis of acute appendicitis.Semin Ultrasound CT MR. 2003; 24: 101-106
- Practical score to aid decision making in doubtful cases of appendicitis.Br J Surg. 1994; 81: 680-683
- The Fenyo-Lindberg scoring system for appendicitis increases positive predictive value in fertile women—a prospective study in 455 patients randomized to either laparoscopic or open appendectomy.Surg Endosc. 2004; 18: 1509-1513
- Helical computed tomography in differentiating appendicitis and acute gynecologic conditions.Obstet Gynecol. 1999; 93: 417-421
- Imaging for suspected appendicitis: negative appendectomy and perforation rates.Radiology. 2002; 225: 131-136
- The role of selective computed tomography in the diagnosis and management of suspected acute appendicitis.Am Surg. 2002; 68: 1003-1007
- Histologic severity of appendicitis can be predicted by computed tomography.Arch Surg. 2004; 139: 1304-1308
Article Info
Publication History
Accepted:
August 13,
2006
Received:
July 24,
2006
Footnotes
☆The article did not receive any financial support and has no conflict of interest.
Identification
Copyright
© 2007 Elsevier Inc. Published by Elsevier Inc. All rights reserved.
