The use of a pediatric appendicitis pathway in a large integrated health system reduced computed tomography imaging in the ED.

BACKGROUND: Appendicitis is the most common cause of an acute surgical abdomen in children. Diagnosis is often challenging as few pediatric patients present with classic symptoms. Clinicians are thus dependent on imaging to reach an accurate diagnosis. Although computerized tomography (CT) has high sensitivity and specificity, it has the disadvantage of imparting ionizing radiation. Ultrasound (US) is readily available and has comparable accuracy to CT when performed by experienced sonographers. We sought to examine the impact of a system-wide process improvement plan on CT use and other metrics in pediatric patients who presented to the Emergency Department (ED) with suspected appendicitis. METHODS: This is a retrospective study of the impact of a Pediatric Appendicitis Pathway (PAP) within a large integrated hospital system with 12 EDs including 3 designated hub EDs. Patients were placed in an initial risk category utilizing the Pediatric Appendicitis Score (PAS), and received US of the appendix at a hub ED if indicated by the PAS. Patients presenting to community EDs who required US appendix were transferred to hub EDs for imaging. Patients presenting in the 6-month pre-implementation period were compared to patients presenting in a 14-month post-implementation period on CT and US utilization, negative and missed appendectomy rates, and ED length of stay (LOS). RESULTS: 1874 patients (401 pre-PAP and 1473 post-PAP) were included in the study. At the hub EDs the rate of CT imaging for suspected appendicitis was reduced from 31% to 17% with a resultant increase in US utilization from 83% (333/401) to 90% (1331/1473) (p < 0.001). At community general EDs (404 pre-PAP and 449 post-PAP), the rate of CT was decreased from 45% (181/404) to 32%(144/449) (p < 0.001)) There was no significant change in the negative appendectomy rate pre-PAP (1/59 = 1.7%) and post-PAP (4/168 = 2.4%) (p = 0.99) at the hub EDs. There were no missed appendicitis cases after PAP implementation compared to 1 case in the pre-PAP period. Overall LOS was similar pre and post-PAP, however LOS was longer in patients that required transfer from community general EDs to hub EDs (median 264 vs 342 min, p < 0.001). CONCLUSIONS: A PAP that stratified patients into risk groups using the PAS and encouraged the use of US as a first line imaging modality, reduced the number of CT performed in a large integrated health system without significant changes to clinical outcomes. Furthermore, transferring select patients for an US as opposed to obtaining an initial CT in community general EDs was feasible and reduced CT use in the pediatric population.

Effect of Oral Moxifloxacin vs Intravenous Ertapenem Plus Oral Levofloxacin for Treatment of Uncomplicated Acute Appendicitis: The APPAC II Randomized Clinical Trial.

Importance: Antibiotics are an effective and safe alternative to appendectomy for managing uncomplicated acute appendicitis, but the optimal antibiotic regimen is not known. Objective: To compare oral antibiotics with combined intravenous followed by oral antibiotics in the management of computed tomography-confirmed uncomplicated acute appendicitis. Design, Setting, and Participants: The Appendicitis Acuta (APPAC) II multicenter, open-label, noninferiority randomized clinical trial was conducted from April 2017 until November 2018 in 9 Finnish hospitals. A total of 599 patients aged 18 to 60 years with computed tomography-confirmed uncomplicated acute appendicitis were enrolled in the trial. The last date of follow-up was November 29, 2019. Interventions: Patients randomized to receive oral monotherapy (n = 295) received oral moxifloxacin (400 mg/d) for 7 days. Patients randomized to receive intravenous antibiotics followed by oral antibiotics (n = 288) received intravenous ertapenem (1 g/d) for 2 days followed by oral levofloxacin (500 mg/d) and metronidazole (500 mg 3 times/d) for 5 days. Main Outcomes and Measures: The primary end point was treatment success (≥65%) for both groups, defined as discharge from hospital without surgery and no recurrent appendicitis during 1-year follow-up, and to determine whether oral antibiotics alone were noninferior to intravenous and oral antibiotics, with a margin of 6% for difference. Results: Among 599 patients who were randomized (mean [SD] age, 36 [12] years; 263 [44%] women), 581 (99.7%) were available for the 1-year follow-up. The treatment success rate at 1 year was 70.2% (1-sided 95% CI, 65.8% to ∞) for patients treated with oral antibiotics and 73.8% (1-sided 95% CI, 69.5% to ∞) for patients treated with intravenous followed by oral antibiotics. The difference was -3.6% ([1-sided 95% CI, -9.7% to ∞]; P = .26 for noninferiority), with the confidence limit exceeding the noninferiority margin. Conclusion and Relevance: Among adults with uncomplicated acute appendicitis, treatment with 7 days of oral moxifloxacin compared with 2 days of intravenous ertapenem followed by 5 days of levofloxacin and metronidazole resulted in treatment success rates greater than 65% in both groups, but failed to demonstrate noninferiority for treatment success of oral antibiotics compared with intravenous followed by oral antibiotics. Trial Registration: ClinicalTrials.gov Identifier: NCT03236961; EudraCT Identifier: 2015-003633-10.

Barium-induced appendicitis mimicking accidental ingestion of a dental metal crown in radiological findings.

Barium appendicitis is a rare complication that has only been reported in a small number of case reports in the medical literature. A 57-year-old male presented to the emergency room with a sudden onset of sharp right lower quadrant abdominal pain. He had undergone contrast barium examination of his stomach 2 months previously as part of a periodic examination for gastric cancer. The radiological findings showed that the shape and radiopaque levels were similar to those of a dental metal crown silhouette. The patient was strongly suspected to have a localized intra-abdominal abscess due to ileocaecal perforation with a foreign body such as a dental metal crown. Emergency surgery revealed acute phlegmonous appendicitis. The resected specimen demonstrated a phlegmonous appendix which contained solid coproma. Pathological diagnosis and composition analysis confirmed the onset of appendicitis to be a result of the patient's ingestion of barium sulfate.

Barium appendicitis 1 month after a barium meal.

Because barium sulfate (BaSO(4)) is not harmful to the mucosa, it is widely used for gastrointestinal imaging. Barium appendicitis is a very rare complication of barium meals and barium enema. We report a case of acute appendicitis associated with retained appendiceal barium. A 47-year-old man presented with right lower abdominal pain after upper gastrointestinal imaging was performed using barium 1 month earlier. The abdominal plain roentgenogram showed an area of retained barium in the right lower quadrant. Multiplanar reconstruction of computed tomography scans showed barium retention in the appendix. Emergency appendectomy was performed. A cross section of the specimen revealed the barium mass. Barium-associated appendicitis is a very rare clinical entity but we should be cautious of this uncommon disease when we encounter barium deposits in the appendix after barium examination. This report is significant because barium was identified both macroscopically and microscopically.

Perforated appendicitis and appendicolith in a child presenting as intussusception: a case report.

Simultaneous diagnoses of intussusception and appendicitis in the same patient have rarely been described in the pediatric literature. A case of a 30-month-old boy is presented with an initial diagnosis of intussusception that was successfully reduced by air contrast enema. When the patient's condition deteriorated, a diagnostic search surprisingly revealed a missed perforated appendicitis with an appendicolith that had been part of the intussusception. The patient's hospitalization and surgical course is described along with a discussion of the intermingling of intussusception and appendicitis in a young child. This case illustrates the need to consider alternative diagnoses when a patient's course takes an unexpected and confusing turn.

Does enteral contrast increase the accuracy of appendicitis diagnosis?

BACKGROUND: Several approaches traditionally have helped opacify the bowel when computed tomography (CT) is used to diagnose appendicitis. With the development of multidetector row CT (MDCT), the need for enteral contrast agents is less obvious. Purpose The objective of this study was to evaluate retrospectively the accuracy of MDCT demonstration of appendicitis using enteral contrast agents. METHODS: We reviewed radiologic reports of all 246 adult patients with suspected appendicitis who underwent 16-slice MDCT during 2005-2006 at our department. The use of enteral contrast agents and the route of administration were documented by one investigator. A radiologist evaluated whether the responses in the reports were consistent with diagnosis of appendicitis. The accuracy of the radiologic reports was assessed using the results of surgery, histopathology and 3 to 21 months of follow-up. RESULTS: Of patients studied, 14.6% received no enteral contrast agent, 8.5% received both oral contrast and rectal contrast (enema), 46.7% received oral contrast and 30.1% received rectal contrast enemas. The accuracies for the CT diagnosis of appendicitis with different combinations of agents ranged from 95% to 100%, with no significant difference among groups. CONCLUSION: Our study shows that the accuracy for diagnosis of appendicitis by abdominal 16-slice MDCT is high regardless of enteral contrast use. Therefore, further use of enteral contrast agents for CT diagnosis of appendicitis in adults cannot be recommended.

Can computed tomography scan be performed effectively in the diagnosis of acute appendicitis without the added morbidity of rectal contrast?

The highest degrees of accuracy have been demonstrated for CT scans using rectal contrast in diagnosing appendicitis. However, the administration of rectal contrast is associated with patient discomfort and rarely, rectosigmoid perforation (0.04%). Additionally, the commonly accepted negative appendectomy rate is around 16 per cent. We performed a retrospective review of radiology, operative, and pathology reports of consecutive patients undergoing appendectomy or CT examination for appendicitis during 2006. CT scans were performed without rectal contrast. The accuracy of each type of inpatient CT examination and negative appendectomy rates were determined. Two hundred and thirty-eight patients underwent appendectomy. One hundred and thirty-four appendectomy patients (56%) received a preoperative CT scan. The negative appendectomy rates were 6.3 per cent overall, 8.7 per cent without CT examination and 4.5 per cent with CT (P = 0.3). Two hundred and forty-five inpatient CT scans were performed for suspected appendicitis with a sensitivity of 90 per cent, specificity of 98 per cent, accuracy of 94 per cent, positive predictive value of 98 per cent, and negative predictive value of 91 per cent. CT scanning without rectal contrast is effective for the diagnosis of acute appendicitis making rectal contrast, with its attendant morbidity, unnecessary. The previously acceptable published negative appendectomy rate is higher than that found in current surgical practice likely due to preoperative CT scanning.

The value of contrast-enhanced helical CT scan with rectal contrast enema in the diagnosis of acute appendicitis.

BACKGROUND: The aim of this retrospective study is to assess the accuracy of single slice helical CT scan with intravenous, and rectal contrast (CTRC) in the diagnosis of acute appendicitis (AA) in patients with suspected AA, with particular analysis of the diagnostic signs. PARTICIPANTS AND METHODS: Abdomino-pelvic helical CTRC was performed on 75 consecutive patients with suspicion of AA. Radiologic diagnosis was compared with surgical/pathologic results and clinical follow-up. In addition, the CTRC examinations were retrospectively reviewed independently by two experienced radiologists using predefined diagnostic criteria. The sensitivity, specificity, and frequency of each diagnostic sign were calculated. The interobserver agreement and the statistical significance of the frequency for each diagnostic criterion were assessed using the Kappa and Fisher tests, respectively. RESULTS: The accuracy of helical CTRC in the diagnosis of AA was 94.7%, sensitivity 100%, specificity 90%, PPV 89.7%, and the NPV 100%. Wall enhancement and nonopacification of the appendix recorded the highest sensitivity and specificity (97% and 100%, 94% and 95%, respectively). Appendiceal thickness greater than 6 mm was present in 100% of true-positive cases. However, 26.5% of true-negative cases had also an appendiceal diameter exceeding 6 mm, a value used as a cut-off for normal appendiceal diameter. The highest interobserver agreement was recorded for appendiceal wall enhancement and for nonopacification of the appendix (K=0.97 and 0.88, respectively). CONCLUSIONS: CTRC is an accurate and relatively fast technique for investigation of patients with suspected AA. A negative CTRC can exclude completely the diagnosis of AA. Nonopacification of the appendix and appendiceal wall enhancement are highly sensitive, specific, and reproducible, signs representing major criteria for the diagnosis of AA.

Computed tomography evaluation of diverticulitis.

Acute diverticulitis is a frequent and important diagnosis in gastrointestinal disease, most commonly involving the colon. It is estimated that approximately 15% to 30% of patients with diverticulosis develop symptomatic diverticulitis at some point in the natural history of the condition, often requiring medical and/or surgical therapy. The clinical diagnosis is often difficult to make, and several radiological studies have been used over the past decades to assist in the diagnosis of acute diverticulitis. These include barium enema, ultrasound, and computed tomography (CT). A number of studies over the past decade have shown CT to be the preferable initial examination because of its ability to demonstrate not only the extent of intramural inflammation but also the degree of pericolic disease, including intraperitoneal inflammation, perforation, and abscess formation. Additional benefits of CT imaging include guiding therapeutic interventions in complicated forms of diverticular disease and providing an alternative diagnosis in patients without diverticulitis. The accuracy, techniques, criteria for diagnosis, and staging and applications of CT imaging in acute diverticulitis are discussed.

McBurney's point: are we missing it?

A prospective study of 100 post-evacuation barium enemas was done. Films were centered at McBurney's point, with an opaque skin marker at that point. Analysis of these revealed that in only one case (1%) was the base of the appendix at McBurney's point. In 67% it was cephalic and in 32% it was caudal to this point. The limitations of McBurney's point as an anatomical landmark should be recognized. This needs to be highlighted in teaching anatomy, especially to surgical trainees. Planning and choice of surgical incisions should be based on an understanding of these anatomical variations since McBurney's original description was clinical rather than anatomical.

Apendicitis crónica en apéndice invaginado / Chronic appendicitis and complete appendiceal invagination. UC, CT and MRI findings

La invaginación apendicular es una rara entidad, y cuando se diagnostica generalmente se encuentra alguna causa predisponente asociada. (ej. tumores, mucoceles, etc.). Se presenta el caso de una paciente de sexo femenino, de 61 años de edad, que fue estudiada por presentar dolor abdominal recurrente, localizado en la fosa ilíaca derecha. Se realizaron varios estudios, colon por enema, colonscopía, tránsito de intestino delgado, ecografía, tomografía computada y resonancia magnética. Posteriormente la cirugía, y finalmente la anatomía patológica, confirmaron el diagnóstico de una invaginación apendicular, complicada con un proceso inflamatorio crónico. No se encontró causa apendicular que predisponga a la invaginación. La invaginación apendicular y la apendicitis crónica son infrecuentes, y más aún, su asociación. Además, en esta paciente no se halló ninguna lesión predisponente. Por estos motivos, creemos que se trata de una forma de presentación inusual de la invaginación apendicular, no comunicada hasta el momento actual (AU)

Improved sonographic visualization of the appendix with a saline enema in children with suspected appendicitis.

OBJECTIVE: To determine whether abdominal sonography after a saline enema can identify the appendix that is not visualized at graded compression sonography in children with suspected appendicitis. METHODS: High-frequency compression sonography was prospectively performed in 120 consecutive children with suspected appendicitis; the appendix was not identified in 27 of these patients. Among the 27 patients with a nonvisualized appendix, abdominal sonography after a saline enema was performed in 12 to identify the appendix. RESULTS: Abdominal sonography after the saline enema revealed the appendix in all 12 children in whom the appendix was not visualized at graded compression sonography. A normal appendix was found in 11 children, and acute appendicitis confined to the appendiceal tip was found in 1. The appendix was located in the pelvis (n = 5), posterior to the cecum (n = 4), posterior to the ileum (n = 2), and anterior to the ileum (n = 1). The appendix could be identified by using a window of the saline-filled sigmoid colon (n = 5), saline-filled cecum (n = 4), and saline-filled terminal ileum (n = 2). CONCLUSIONS: Abdominal sonography after a saline enema is a helpful technique for depiction of the appendix that is not visible at graded compression sonography in children with suspected appendicitis. Key words: appendix, sonography; appendicitis; children, gastrointestinal tract.

Sonographic features of acute colonic diverticulitis: the "dome sign".

PURPOSE: This study was performed to clarify the sonographic features of acute colonic diverticulitis to enable its differentiation from appendicitis. METHODS: Of 119 patients who were referred to our hospitals for lower abdominal pain between June 1997 and December 1998 and underwent sonography, 12 patients had a definitive diagnosis of acute colonic diverticulitis and 4 patients a tentative diagnosis. Seventy-eight patients were diagnosed as having acute appendicitis, confirmed by appendectomy. In the 16 patients with diagnoses of diverticulitis, the sonographic and clinical features of acute colonic diverticulitis were studied. RESULTS: Among the 12 patients with definitive diagnoses of acute colonic diverticulitis, sonographic findings included localized thickening of the colonic wall (100%) and a hemispheric mass (the "dome sign") protruding at the thickened colonic wall (100%) and consisting of a hypoechoic wall (100%) and a central echogenic area (66%). The presence of diverticula was confirmed by barium-enema x-ray study in all 12 patients. The 4 patients with tentative diagnoses of acute colonic diverticulitis all had colonic wall thickening but no dome sign. Colonoscopy revealed colitis in 3 of these patients. All 16 patients recovered with conservative treatment, without laparotomy. CONCLUSIONS: Sonography was useful for differentiating acute colonic diverticulitis from appendicitis. The sonographic finding of the dome sign seems to be specific for acute colonic diverticulitis.

Tc-99m-HMPAO white blood cell scan for diagnosis of acute appendicitis in patients with equivocal clinical presentation.

OBJECTIVE: The authors' goal was to evaluate the accuracy of Technetium 99m-HMPAO-labeled leukocyte imaging for screening patients with atypically presenting appendicitis and to determine how availability of this test affected practice patterns of surgeons at the authors' medical center. SUMMARY BACKGROUND DATA: Appendicitis can be difficult to diagnose and in equivocal cases usually requires inpatient observation. The delay may increase morbidity and costs. A test that rules out acute appendicitis could be cost effective if it allowed early discharge from the emergency department. Previously, there have been no simple, rapid, accurate noninvasive methods for improving diagnostic accuracy in patients with equivocal presentations of appendicitis. METHODS: Patients referred to rule out appendicitis were analyzed. Patients were imaged up to 3 hours after injection of 10-mCi 99mTc-HMPAO-labeled autologous leukocytes (Tc-WBC), and when the scans became positive, imaging was terminated and the requesting physician notified of the results. Diagnostic accuracy was established by surgical and histopathologic findings or by absence of symptoms after 1 month clinical follow-up. The source of referral, hospital length of stay, disposition of patients, and ancillary tests (ultrasound, computed tomographic scan, and barium enema) were analyzed. RESULTS: One hundred twenty-four patients were studied from November 1991 through December 1995. Fifty-eight percent of positive scans showed uptake within 1 hour of injection and 73% by 2 hours. The Tc-WBC scan correctly identified an inflammatory source of abdominal pain in 65 of 66 cases (sensitivity = 98%) and was correctly negative in 55 of 58 cases (specificity = 95%). The scan correctly diagnosed appendicitis in 50 of 51 cases (sensitivity = 98%) and correctly excluded appendicitis in 62 of 73 cases (specificity = 85%). Outpatient referrals increased from 38% to 87%. In those patients with negativescans, inpatient observation, number of adjunctive tests, and length of stay decreased significantly. CONCLUSIONS: The high sensitivity and negative predictive value of Tc-WBC imaging may permit patients to be screened and discharged from the emergency department. Focally positive scans often indicate disease requiring operation but not in all cases. The Tc-WBC imaging reduced the negative laparotomy rate to 3.9% while reducing admission rates and hospital length of stay.

Appendicitis: use of arrowhead sign for diagnosis at CT.

PURPOSE: To determine the frequency of collection of a contrast medium in the upper portion of the cecum, which the authors call the arrowhead sign, on computed tomographic (CT) scans of the lower abdomen and to assess the sensitivity and specificity of this sign for appendicitis. MATERIALS AND METHODS: One hundred consecutive patients clinically suspected of having appendicitis prospectively underwent helical CT limited to the lower abdomen. Contrast media were administered orally and by means of an enema. Each scan was reviewed for the arrowhead sign, and the findings were correlated with surgical and pathologic results or clinical follow-up findings. RESULTS: The arrowhead sign was present in 17 of 56 cases (30%) of appendicitis and in no case of excluded appendicitis. It allowed the unequivocal diagnosis of appendicitis in four cases (7%) of otherwise non-specific right lower-quadrant inflammation and in one case (2%) of subtle appendicitis seen at CT. CONCLUSION: The arrowhead sign is an often present, highly specific sign of appendicitis that can add specificity to the diagnosis of right lower-quadrant inflammatory processes at CT.

Appendicitis: usefulness of color Doppler US.

PURPOSE: To assess whether color Doppler ultrasonography (US) can help diagnose early acute appendicitis in appendices of equivocal size at gray-scale US. MATERIALS AND METHODS: In a retrospective study, color Doppler US findings were evaluated in 20 individuals with proved normal appendix at barium enema examination and in 50 patients in whom pathologic findings confirmed acute appendicitis. In a prospective study, the diagnostic value of hyperemia in the wall of the appendix in differentiating a normal from an inflamed appendix was evaluated in 26 patients with appendices of equivocal size (5-7 mm in maximal outer diameter) at grayscale US. RESULTS: In the retrospective study, 44 of the 50 patients had hyperemia at color Doppler US. The remaining six patients had no hyperemia, and pathologic findings confirmed gangrenous appendices. The 20 patients with proved normal appendix at barium enema examination had no detectable blood flow in the wall. In the prospective study, 10 of 26 patients had hyperemia at color Doppler US, and pathologic findings confirmed early acute appendicitis. Results of barium enema examination (n = 12) or clinical follow-up (n = 4) confirmed no appendicitis in the remaining 16 patients. CONCLUSION: Hyperemia in the wall of the appendix at color Doppler US is a sensitive indicator for inflammation. A simple additional color Doppler US examination may be helpful in the diagnosis of early acute appendicitis when an appendix is well depicted and is equivocal in size at gray-scale US.

Intussusception: ability of fluoroscopic images obtained during air enemas to depict lead points and other abnormalities.

PURPOSE: To evaluate the ability of fluoroscopic images obtained during air enemas to depict or exclude lead points of intussusceptions and other abnormalities that require surgical treatment in the absence of intussusception. MATERIALS AND METHODS: The clinical, radiologic, surgical, and pathologic findings were reviewed in 14 patients with lead points or other lesions. RESULTS: Fluoroscopic images failed to depict a lead point in 10 patients. The air enema easily reduced intussusceptions with benign lead points in seven patients. Fluoroscopic images depicted pathologic lead points in two patients and were normal in two patients with intussusception. Fluoroscopic images failed to depict an abnormality that required surgery in the absence of intussusception in two patients. CONCLUSION: Successful reduction of an intussusception does not always rule out a lead point. Other imaging studies, the patient's condition, and laparotomy may also be necessary to diagnose and treat lead points and other lesions.