Abstract
Background
The clinical diagnosis of acute appendicitis in adults remains tricky, but radiological examinations are very helpful to determine the diagnosis even when the adult patient presents atypically. This study was designed to quantify the proportion of patients with a preoperative diagnosis of acute appendicitis that had isolated right lower quadrant pain without biological inflammatory signs and then to determine which imaging examination led to the determination of the diagnosis.
Methods
In this monocentric study based on retrospectively collected data, we analyzed a series of 326 patients with a preoperative diagnosis of acute appendicitis and isolated those who were afebrile and had isolated right lower quadrant pain and normal white blood cell counts and C-reactive protein levels. We determined whether the systematic ultrasonography examination was informative enough or a complementary intravenous contrast media computed tomography scan was necessary to determine the diagnosis, and whether the final pathological diagnosis fit the preoperative one.
Results
A total of 15.6% of the patients with a preoperative diagnosis of acute appendicitis had isolated rebound tenderness in the right lower quadrant, i.e., they were afebrile and their white blood cell counts and C-reactive protein levels were normal. In 96.1% of the cases, the ultrasonography examination, sometimes complemented by an intravenous contrasted computed tomography scan if the ultrasonography result was equivocal, fit the histopathological diagnosis of acute appendicitis.
Conclusions
The diagnosis of acute appendicitis cannot be excluded when an adult patient presents with isolated rebound tenderness in the right lower quadrant even without fever and biological inflammatory signs. In our study, ultrasonography and computed tomography were very helpful when making the final diagnosis.
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References
Crombe A, Weber F, Gruner L et al (2000) L’echographie abdominopelvienne en cas de suspicion d’appendicite aigue: evaluation prospective chez l’adulte. Ann Chir 125:57–61
Tepel J, Sommerfeld A, Klomp HJ et al (2004) Prospective evaluation of diagnostic modalities in suspected acute appendicitis. Langenbecks Arch Surg 389:219–224
Poh AC, Lin M, Teh HS et al (2004) The role of computed tomography in clinically-suspected but equivocal acute appendicitis. Singapore Med J 45:379–384
Johansson EP, Rydh A, Riklund KA (2007) Ultrasound, computed tomography, and laboratory findings in the diagnosis of appendicitis. Acta Radiol 48:267–273
Sauerland S, Agresta F, Bergamaschi R et al (2006) Laparoscopy for abdominal emergencies: evidence-based guidelines of the European Association for Endoscopic Surgery. Surg Endosc 20:14–29
Stromberg C, Johansson G, Adolfsson A (2007) Acute abdominal pain: diagnostic impact of immediate CT scanning. World J Surg 31:2347–2354 discussion 2355-2358
Jones PF (2001) Suspected acute appendicitis: trends in management over 30 years. Br J Surg 88:1570–1577
Jones PF (2001) Ultrasonography in diagnosis of acute appendicitis. Active observation is often sufficient to make diagnosis. BMJ 322:615–616
Arfa N, Gharbi L, Marsaoui L et al (2006) [Value of admission for observation in the management of acute abdominal right iliac fossa pain. Prospective study of 205 cases]. Presse Med 35:393–398
Graffeo CS, Counselman FL (1996) Appendicitis. Emerg Med Clin North Am 14:653–671
Andersson RE, Hugander A, Ravn H et al (2000) Repeated clinical and laboratory examinations in patients with an equivocal diagnosis of appendicitis. World J Surg 24:479–485
Andersson RE, Hugander AP, Ghazi SH et al (2000) Why does the clinical diagnosis fail in suspected appendicitis? Eur J Surg 166:796–802
Gronroos JM (1999) Is there a role for leukocyte and CRP measurements in the diagnosis of acute appendicitis in the elderly? Maturitas 31:255–258
Yang HR, Wang YC, Chung PK et al (2006) Laboratory tests in patients with acute appendicitis. ANZ J Surg 76:71–74
Fox JC, Solley M, Anderson CL et al (2008) Prospective evaluation of emergency physician performed bedside ultrasound to detect acute appendicitis. Eur J Emerg Med 15:80–85
Keyzer C, Zalcman M, De Maertelaer V et al (2005) Comparison of US and unenhanced multi-detector row CT in patients suspected of having acute appendicitis. Radiology 236:527–534
Mun S, Ernst RD, Chen K et al (2006) Rapid CT diagnosis of acute appendicitis with IV contrast material. Emerg Radiol 12:99–102
Wijetunga R, Tan BS, Rouse JC et al (2001) Diagnostic accuracy of focused appendiceal CT in clinically equivocal cases of acute appendicitis. Radiology 221:747–753
Cardall T, Glasser J, Guss DA (2004) Clinical value of the total white blood cell count and temperature in the evaluation of patients with suspected appendicitis. Acad Emerg Med 11:1021–1027
Paajanen H, Mansikka A, Laato M et al (2002) Novel serum inflammatory markers in acute appendicitis. Scand J Clin Lab Invest 62:579–584
Yildirim O, Solak C, Kocer B et al (2006) The role of serum inflammatory markers in acute appendicitis and their success in preventing negative laparotomy. J Invest Surg 19:345–352
Wu HP, Huang CY, Chang YJ et al (2006) Use of changes over time in serum inflammatory parameters in patients with equivocal appendicitis. Surgery 139:789–796
Kessler N, Cyteval C, Gallix B et al (2004) Appendicitis: evaluation of sensitivity, specificity, and predictive values of US, Doppler US, and laboratory findings. Radiology 230:472–478
Khan MN, Davie E, Irshad K (2004) The role of white cell count and C-reactive protein in the diagnosis of acute appendicitis. J Ayub Med Coll Abbottabad 16:17–19
Paajanen H, Mansikka A, Laato M et al (1997) Are serum inflammatory markers age dependent in acute appendicitis? J Am Coll Surg 184:303–308
Fergusson JA, Hitos K, Simpson E (2002) Utility of white cell count and ultrasound in the diagnosis of acute appendicitis. ANZ J Surg 72:781–785
Jones AE, Phillips AW, Jarvis JR et al (2007) The value of routine histopathological examination of appendicectomy specimens. BMC Surg 7:17
Mattei P, Sola JE, Yeo CJ (1994) Chronic and recurrent appendicitis are uncommon entities often misdiagnosed. J Am Coll Surg 178:385–389
Pickuth D, Heywang-Kobrunner SH, Spielmann RP (2000) Suspected acute appendicitis: is ultrasonography or computed tomography the preferred imaging technique? Eur J Surg 166:315–319
Blebea JS, Meilstrup JW, Wise SW (2003) Appendiceal imaging: which test is best? Semin Ultrasound CT MR 24:91–95
van Breda Vriesman AC, Kole BJ, Puylaert JB (2003) Effect of ultrasonography and optional computed tomography on the outcome of appendectomy. Eur Radiol 13:2278–2282
Jang KM, Lee K, Kim MJ et al (2009) What is the complementary role of ultrasound evaluation in the diagnosis of acute appendicitis after CT? Eur J Radiol. doi:10.1016/j.ejrad.2008.11.017
Gronroos JM (2002) [Too many unnecessary appendectomies. Leukocyte count and CRP value for safer diagnosis]. Lakartidningen 99:891–893
Gronroos JM, Gronroos P (1999) Leucocyte count and C-reactive protein in the diagnosis of acute appendicitis. Br J Surg 86:501–504
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Monneuse, O., Abdalla, S., Pilleul, F. et al. Pain as the Only Consistent Sign of Acute Appendicitis: Lack of Inflammatory Signs Does Not Exclude the Diagnosis. World J Surg 34, 210–215 (2010). https://doi.org/10.1007/s00268-009-0349-z
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DOI: https://doi.org/10.1007/s00268-009-0349-z