redbeans

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I just diagnosed my first appendicitis by telephone tonight in a family member, who went to the ER and it was confirmed by CT. However, I had just been scolded by an attending who didn't think US or CT was necessary if the clinical presentation was classic and straightforward. I'm on a pedi surg rotation right now so appys are all the rage. Our hospital seems to use US more than CT, though probably because they're trying to limit CT exposure in children.

Just curious to see what other people have been taught is sufficient to take to the OR? Obviously there's a drive to catch appendicitis before perforation, so there's some acceptable range of negative appendectomies, but what are some strategies you've learned to keep that number low? And what do you say to the negative appy patients (like that woman who was suing, which was discussed in a previous thread)?
 

dynx

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I just diagnosed my first appendicitis by telephone tonight in a family member, who went to the ER and it was confirmed by CT. However, I had just been scolded by an attending who didn't think US or CT was necessary if the clinical presentation was classic and straightforward. I'm on a pedi surg rotation right now so appys are all the rage. Our hospital seems to use US more than CT, though probably because they're trying to limit CT exposure in children.

Just curious to see what other people have been taught is sufficient to take to the OR? Obviously there's a drive to catch appendicitis before perforation, so there's some acceptable range of negative appendectomies, but what are some strategies you've learned to keep that number low? And what do you say to the negative appy patients (like that woman who was suing, which was discussed in a previous thread)?

Physical exam is enough in men in most cases, if its a chick always get the U/s

You say: "remember I told you before hand that sometimes we get in there and the appendix doesn't seem to be the problem"
Unless of course you didn't say that before the operation, in which case you look at the ground and say sorry.
 

Kubed

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Digging deep here, but I thought the number of false positive appys is something crazy high like 20%. I take this to mean that if you're sure, cut. If you're not sure, get imaging, then cut. If you're sure there's no way in hell, why did you order the imaging? Now you've got to cut
 

SocialistMD

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1. U/S is not all that helpful in most adults due mostly to body habitus.
2. Many surgeons go the imaging route simply for medico-legal reasons. To have a complication after a negative appy opens you to stupid lawsuits that some people don't want to entertain.
 

ExtraCrispy

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My rule of thumb:

1) Young guy (<30) with classic presentation: straight to the OR
2) Girl < reproductive age with classic presentation: straight to the OR

Everyone else, I get a CT. Even in the cases above, the patient can have mesenteric adenitis, and you take out a white appendix.
 

XoQo

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Digging deep here, but I thought the number of false positive appys is something crazy high like 20%. I take this to mean that if you're sure, cut. If you're not sure, get imaging, then cut. If you're sure there's no way in hell, why did you order the imaging? Now you've got to cut
i think in the era of the CT scanner being in many ERs, the false positive is no longer supposed to be at 20% if your hospital is considered "ct experienced".

there is a letter to the editor from:

Raman SS, et al. Effect of CT on false positive diagnosis of appendicitis and perforation. NEJM 358(9):972-3, 2008 Feb 28

in which they analyze preoperative imaging and clinical outcomes in 1081 adults (616 men and 465 women) who underwent surgery for suspected appendicitis between 1996 and 2006 at their hospital...

highlights:

  • The annual rate of use of preoperative helical CT among patients who underwent surgery for suspected acute appendicitis increased from 20% in 1996 to 85% in 2006, reaching a peak of 93% in 2005 (P=0.001)
  • From 1996 to 2006, the overall rate of false positive diagnosis of appendicitis among adults decreased significantly, from 24% to 3% (P=0.001)
  • overall rate of pathologically proven appendiceal perforation decreased significantly, from 18% in 1996 to 5% in 2006(P<0.001).
 

meathooks

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It was explained to me that often the CT scans are less helpful in children since they lack a great deal of intra-abdominal fat, meaning you were less likely to see stranding. Or it could mean the CT scanners in my hospital are thousand-year old pieces of crap.
 

droliver

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I think with the kids it's mostly a practical matter in that it's hard to keep them from moving during the study or place a big enough IV for contrast
 
B

Blade28

I think with the kids it's mostly a practical matter in that it's hard to keep them from moving during the study or place a big enough IV for contrast
Plus you absolutely make sure there's a clear indication for the CT scan (i.e. will its results change your management one way or the other?) since you're exposing the kid to radiation.
 

46&2

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CT isn't necessary for kids, per one attending who lectured us. He quoted a retrospective study from Ohio State published in the Journal of Pediatric Surgery which showed no significant difference in negative appendectomies with increased usage of CT, though the overall rate decreased from 11% to 6% over 4 years. Of note, the estimated rate of malignancy for a single CT is about 1 in 1200; if you decrease the amount of radiation, however, you can still get an adequate CT in kids while dropping the rate of malignancy (study here).

The risk of perforation while waiting to perform the CT also needs to be weighed, in addition to the number of false negatives.

Ultrasound is about as sensitive as clinical exam (70-80%) per several studies. A study from McGill is pretty damming as far as U/S goes: longer waits, more complications, and more false positives. Women/girls of child-bearing age would be more of an exception.
 

SocialistMD

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The risk of perforation while waiting to perform the CT also needs to be weighed, in addition to the number of false negatives.
How high do you really think this risk is? The literature shows no difference in perforation when postponing middle-of-the-night appendectomies for up to 12 hours from admission. Does it take longer to get a CT scan?
 

46&2

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I don't think the risk of perforation while waiting for a CT is high, but why waste time, especially when the clinical diagnosis is unequivocal? In the study you quote, over 30% of the patients did not even get a CT- the clinical picture was compelling enough.

The paper also does not directly address the delays & complications incurred with ordering a CT. Others do.

Per one paper from a large university center, the delay is about 2.5 hours. In that same study, while delay in diagnosis did not correlate with higher rates of perforation, it did lead to higher postop compications- and that was with only a mean delay of 3 hours.

Another study from the University of Wisconsin also showed a mean 3 hr delay with a CT- and this study found double the risk of perforation. "Although not examined in this study, it is clear that prolonged time from first symptoms to definitive operation increases the risk of rupture in patients with appendicitis. In fact, the risk of rupture increases approximately 5% for each ensuing 12-h period after 36 h.8 In addition, multiple studies, including our own, have found that utilization of preoperative CT scan leads to a delay in definitive treatment. Some studies have found that obtaining a CT results in a delay to operative intervention as great as 6&#8211;12 h compared to patients that did not have preoperative imaging."

And the attending surgeon who comments at the end of the study you cite also has an interesting point.

"Finally, I must tell you my wife was not completely happy with this study. She had appendicitis at age 12, and her operation was delayed until the following morning. She is not much of a complainer, but she has made it clear it would have been her preference to have had surgery that night. Patients with delayed surgery do no worse, but nor do they do better than patients having an immediate operation, and it is the expectation of the lay public that an appendectomy will be done as soon as possible. How do we meet that expectation but still put the operation off until the next morning?"
 

46&2

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Of more help to the original poster, there is a simple Pediatric Appendicitis Score that was developed in England in 2001. It uses the typical criteria (e.g. RLQ pain, fever >38, WBC >10,000) and gives a score from 0-10. Greater than 6, go to the OR. Less than 3, go home. Anything in between, observation and/or imagery. A prospective study from Canda shows its effectiveness (in press by the Journal of Pediatrics).
 

SLUser11

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How high do you really think this risk is? The literature shows no difference in perforation when postponing middle-of-the-night appendectomies for up to 12 hours from admission. Does it take longer to get a CT scan?
I don't think the risk of perforation while waiting for a CT is high, but why waste time, especially when the clinical diagnosis is unequivocal? In the study you quote, over 30% of the patients did not even get a CT- the clinical picture was compelling enough.

The paper also does not directly address the delays & complications incurred with ordering a CT. Others do.

Per one paper from a large university center, the delay is about 2.5 hours. In that same study, while delay in diagnosis did not correlate with higher rates of perforation, it did lead to higher postop compications- and that was with only a mean delay of 3 hours.

Another study from the University of Wisconsin also showed a mean 3 hr delay with a CT- and this study found double the risk of perforation.
Listen, you two: Nobody wants to hear about "facts" supported by "literature." We're here to blindly argue our biased opinions.

Now for my biased opinion:

I try (mostly out of arrogance regarding my doctor skillz) to diagnose most men (esp. young men) on physical exam alone. Probably 50% of them still get CTs for the following two reasons:

1. Not a good appendicitis story.
----Many of the guys like to especially break the rule about "if they're hungry then they don't have appendicitis." Ask a 20 year old fat dude with a red hot appy about food, and the response I usually get is. "Well....I could eat. What do you have?"

2. It was done prior to the surgical consult.

Women get thorough PE's also, including a pelvic, but ultimately end up with a CT almost always. If the CT is negative, they will usually get serial exams.

Pregnant women get Abdominal ultrasound or are diagnosed based on exam. I never even think to use U/S for anything else.

Kids get diagnosed based mostly on PE, and probably have the highest false positive rate in my experience.
 

SocialistMD

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I don't think the risk of perforation while waiting for a CT is high, but why waste time, especially when the clinical diagnosis is unequivocal? In the study you quote, over 30% of the patients did not even get a CT- the clinical picture was compelling enough.
Waiting is waiting. Be it for a CT scan or until the next morning, the appendix doesn't care when it decides whether or not to perforate. I wasn't saying CT scans are necessary in all cases, I was making the point that the delay waiting for the CT scan in most institutions isn't as long as the wait that many patients who come in after hours have when their procedure is delayed until the morning, yet that is an acceptable practice, backed by the literature.
Per one paper from a large university center, the delay is about 2.5 hours. In that same study, while delay in diagnosis did not correlate with higher rates of perforation, it did lead to higher postop compications- and that was with only a mean delay of 3 hours.
Not entirely. The second article you cited is more convincing of this point, but the authors kind of misrepresented their findings if that is how you interpreted the first one. They are trying to make the case for an early surgical consult and the avoidance of imaging prior to the surgical team being called. They are also trying to make the case for diagnostic laparoscopy over CT scanning, as they found a diagnosis 91% of the time (compared to 84% with CT scan; don't worry about the 42% negative exploration rate). Here are some blurbs from the article.
article (reformatted) said:
1. The perforation rate was not a function of a delay in evaluation, as the duration from the onset of pain to ED evaluation in perforated appendicitis was (similar to nonperforated cases). The mean ED evaluation was (not statistically different between perforated and nonperforated cases).
2. Patients with postoperative complications had longer ED evaluations than did those without.
3. Patients with perforated acute appendicitis had a 19.8% morbidity and patients without perofration, 6.4%. The overall wound infection rate was 3.5% higher in perforated cases than in nonperforated cases (P=0.006). The incidence of intra-abdominal abscess was higher in perforated cases than in non-perforated cases (P=0.01)
Basically, what they are trying to say is that a delay in diagnosis in the ED leads to postop complications, even though their data shows that (a) there was no difference in the time of evaluation between perforated patients and nonperforated patients and (b) patients with perforated appendicitis had more complications. How can 2 and 3 be true? Perhaps because >50% of patients presented with atypical symptoms, and many were watched for a prolonged period of time. What wasn't clearly explained is how many patients in the observation arm had complications. It is possible that the patients who had an atypical presentation had a longer evaluation in the ED, were admitted/observed and they are the ones who had complications. We don't know, because it wasn't published, so we can't really make those conclusions.

I'd also like to point out that it took them 10.3 hours (+/- 14.1 hours) to get the patient to the OR based on a H&P alone (when surgery was consulted 4.7 +/- 5.2 hours after ED admission) vs. 19.5hrs +/-31.3 hours when a CT scan was ordered (and surgery was consulted 8.0 +/- 12.7 hours after ED admission).
1. I've never seen it take 3 hours to get a CT scan at our adult or children's hospital (maybe I'm living in my ivory tower again).
2. Why did it take them 12 hours to get the patient to the OR when a CT scan was ordered in comparison to 5 hours when one wasn't ordered? That sounds more like the fault of the surgical team over the CT scan, as those numbers don't add up.

Again, your point is well-taken, I just don't think the first study you used is one of the strongest articles on this subject and I don't think it helps support your case.

Sorry, SLUser. I won't practice any more EBM for the rest of this thread. :)
 

Tristero

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i dunno the reference, but it has been shown by a couple studies that the rate of negative appys is the same based on clinical dx versus screening with US/CT. I think this is why some attendings may questions its utility, although I think especially CT can be a usefull adjunct.
 

SLUser11

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i dunno the reference, but it has been shown by a couple studies that the rate of negative appys is the same based on clinical dx versus screening with US/CT. I think this is why some attendings may questions its utility, although I think especially CT can be a usefull adjunct.
Ultrasound probably, but CT definitely decreases your false negative rate....that is, assuming you don't just take it out anyway after a negative CT.

I'd be interested to see your reference.
 

Tristero

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Ultrasound probably, but CT definitely decreases your false negative rate....that is, assuming you don't just take it out anyway after a negative CT.

I'd be interested to see your reference.

yeah thats somethign id liek to clarify as well...ill find out tomm and let you know