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 Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 4  |  Issue : 1  |  Page : 11-14

Clinicopathological and ultrasonographic correlation of acute appendicitis in emergency: A prospective and retrospective study


1 Department of General Surgery, Government Medical College, Jagdalpur, Chhatisgarh, India
2 Department of General Surgery, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha, Maharastra, India
3 Department of Community Medicine, Government Medical College, Jagdalpur, Chhatisgarh, India

Date of Web Publication14-Jul-2014

Correspondence Address:
Rajat K Patra
Department of General Surgery, Government Medical College, Jagdalpur - 494 005, Chhatisgarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-9596.136703

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  Abstract 

Background: Evaluation of Acute Appendicitis needs a well conducted history and physical examination. But major factors contributing to high negative appendectomy rate are non-specificity of clinical findings, lack of readily available techniques allowing direct visualization of appendix. This study evaluated diagnostic accuracies of clinical and ultrasonographic in Acute Appendicitis.
Materials and Methods: The study was carried out in the department of surgery, Kasturba Hospital, MGIMS, Sevagram. Total of 38 patients were selected for the study. In the emergency department of surgery thorough clinical assessment, laboratory investigations, ultrasound findings were recorded for each patient. After confirming the diagnosis of Acute Appendicitis the patients had operative intervention and specimens were sent for histopathological study.
Results: Acute appendicitis was found more commonly among patients of 20-29 years of age with 37% in prospective and 42.9% in retrospective studies respectively. Modified Alvarado score (MAS) had sensitivity of 47.7% and 59.6%, specificity of 87.5% and 91.6% in both prospective and retrospective studies respectively. Ultrasonographic findings showed sensitivity of 82.1% and 92.7%, specificity of 76.4% and 72.7% in prospective and retrospective studies respectively.
Conclusion: When the diagnosis of acute appendicitis is clinically obvious based on strongly positive clinical signs, it can be an indication for operative treatment. However in the cases of equivocal diagnosis Ultrasonography should be used as an adjunct to clinical diagnosis and thereby decreasing the rates of negative laparotomies.

Keywords: Acute appendicitis, histopathology, ultrasonography


How to cite this article:
Patra RK, Gupta DO, Patil RR. Clinicopathological and ultrasonographic correlation of acute appendicitis in emergency: A prospective and retrospective study. Arch Int Surg 2014;4:11-4

How to cite this URL:
Patra RK, Gupta DO, Patil RR. Clinicopathological and ultrasonographic correlation of acute appendicitis in emergency: A prospective and retrospective study. Arch Int Surg [serial online] 2014 [cited 2024 Mar 1];4:11-4. Available from: https://www.archintsurg.org/text.asp?2014/4/1/11/136703


  Introduction Top


Acute abdominal pain remains a challenge to surgeons and physicians. Despite the advancements in the field of diagnosis, the surprises never cease. [1] In young men, limited number of alternative diagnosis usually permits a high degree of diagnostic accuracy. In contrast, young women commonly present with acute gynecological illnesses that closely mimic acute appendicitis. It is generally accepted that in men the negative appendectomy rate should be below 20% and rates of 10-15% are commonly reported. [2],[3] But negative appendectomy rates in ovulating women remain disturbingly high and range from 34-46%. [4],[5] In daily clinical practice, the use of a scoring system has been found to be associated with reduced rate of negative appendectomies. The classic Alvarado score included left shift of neutrophil maturation (Score 1), yielding total score of 10. However, in 1994 Kalan omitted this parameter and produced a modified score. There are mixed results regarding the efficacy of modified Alvarado score (MAS). [6],[7],[8] There have been numerous publications on the use of ultrasound as a diagnostic tool in patients with acute appendicitis. These studies demonstrate sensitivity of 75-94% and specificity of 87-96%.[9],[10],[11],[12]

Lewis et al., [3] in his study had shown rising level of unnecessary laparotomy for suspected appendicitis up to 25%. Some clinicians underestimate the importance of appendiceal pathology and do not subject it to histopathological examination. Although etiology and pathology of acute appendicitis remains incompletely understood, histopathological examination to all appendectomy specimens remains mandatory. [13] The objective of this study was to find out the accuracy of clinical and ultrasonographic examinations in the diagnosis of acute appendicitis based on histological examination of appendecectomy specimens.


  Materials and Methods Top


A prospective and retrospective study was carried out in the department of surgery, Kasturba Hospital, Mahatma Gandhi Institute of Medical Sciences (MGIMS), Sevagram, India. The prospective study was carried out from 1 st November 2009 to 31 st October 2011, and 150 study participants were included in the study. Retrospectively, data for 188 participants were gathered from 1 st October 2007 to 31 st October 2009. After adhering to selection criteria, a total of 338 participants were selected for the study. Ethical clearance from institutional committee board was obtained before start of the study.

Selection criteria

Inclusion criteria

  • All patients admitted with clinical diagnosis of acute appendicitis were included in this study.


Exclusion criteria

  • Patients found to have appendicular lump or diagnosis other than appendicitis were excluded from this study.
  • Patients not subjected to ultrasonography after diagnosis of acute appendicitis.


In the emergency department of surgery, thorough clinical assessment and laboratory investigations were done and MAS was calculated for each patient. [6] Patients with MAS of 7-9 were considered to have acute appendicitis. Those with MAS of 4-6 had high likelihood of appendicitis and MAS 1-3 were compatible with but not diagnostic. Informed consent was taken before the study.

Patients with clinical diagnosis of acute appendicitis were subjected to ultrasonography of the abdomen irrespective of the MAS. All studies were performed with a 3-12 MHz linear array transducer. Oblique, transverse, and longitudinal scans of the right lower quadrant were obtained by means of the graded compression ultrasonographic technique described by Puylaert. [10] An ultrasound examination of the remainder of the abdomen was performed if the appendix was not visualized in the right lower quadrant. The appendix was visualized as a tubular non-compressible structure that is reproducible and gives echoes on ultrasonography. The maximal cross-sectional diameter of the appendix was measured with electronic calipers.

Ultrasonography results were designated positive, normal and others, by using the following criteria. [14]

Positive - Appendix identified, tender, non-compressible or appendiceal phlegmon or abscess or presence of appendicolith.

Increased vascularity on color Doppler, free fluid in Right Iliac Fosaa (RIF), dilated aperistaltic bowel loop with probe tenderness in RIF.

If maximal cross-sectional diameter with compression exceeded 6 mm

Normal - Appendix not identified, no other relevant abnormality seen.

Others - When other abnormalities such as urological or gynecological diseases were seen.

History, clinical examination, laboratory investigations, and ultrasound findings were recorded in the pro forma made. After confirming the diagnosis of acute appendicitis, the patients with negative ultrasound examination but having high clinical suspicion were also operated on. The operative intervention was carried out within 6 h of admission. However, in few cases where the diagnosis was in doubt, the patients were kept under observation and reevaluated later. Intraoperative findings were recorded and appendices were sent for histopathological examination. Transmural polymorphonuclear leukocyte infiltration in histopathology was considered as the final diagnostic marker of acute appendicitis.

Statistical analysis

Data were entered and analyzed using Epi Info 2000. The 2 × 2 contingency tables were drawn, and sensitivity and specificity for each modality was obtained by comparing with the histological findings. Kappa statistic was applied to find the degree of agreement between the modalities.


  Results Top


A total of 338 cases were included in the study of which male patients predominate in both prospective 112 (74.7%) and retrospective study 139 (73.9%). Acute appendicitis was found more commonly among 20-29 years of age group with 56 (37%) in prospective and 80 (42.9%) retrospective study. All the patients were evaluated with the MAS. [Table 1] shows the distribution of cases. In the prospective study, most of the patients 71 (47.3%) presenting with acute abdomen had MAS 4-6, whereas in the retrospective data 101 (53.7%) cases had 7-9 score.
Table 1: Distribution of cases according to diagnostic modalities

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Whereas on ultrasonography 81.1% diagnosed with the acute appendicitis of which in prospectively 76% and nearly 85.1% were diagnosed in retrospective data. On histopathological evaluation, we identified 88.8% total acute appendicitis cases of which 89.3% were diagnosed in the prospective and 88.3% cases were diagnosed, retrospectively.

[Table 2] shows that MAS had sensitivity of 47.7 and 59.6%, specificity of 87.5 and 91.6%, positive predictive value of 96.9 and 98%, and negative predictive value of 16.6 and 22.9% in the prospective and retrospective studies, respectively. Overall accuracy was 52 and 63.3% in prospective and retrospective study, respectively.
Table 2: Comparison of diagnostic accuracy of the MAS score and ultrasonographical diagnosis with histopathological findings

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Ultrasonographical findings showed sensitivity of 82.1 and 92.7%, specificity of 76.4 and 72.7%, positive predictive value of the 96.5 and 96.2%, and negative predictive value of 33.3 and 57.1% in the prospective and retrospective studies, respectively. Overall accuracy was 81.3 and 90.4% in both prospective and retrospective study, respectively.


  Discussion Top


In the present study, we compared the diagnostic accuracy of ultrasonography to MAS with histopathological findings. Though various diagnostic modalities are available, negative appendicectomy rates remain unnaturally high. Major factors contributing to this continued high negative appendectomy rate are non-specificity of clinical findings, lack of readily available techniques allowing direct visualization of appendix, and identification of specific diagnostic features of acute appendicitis. [15] A previous study has shown that lack of early diagnosis results in perforation and complications such as abdominal abscess, wound infection, infertility, and death. [16] The overall mortality rate for acute appendicitis is less than 1% but in elderly patient it is higher, ranging from 5-15% [4],[17],[18]

A total of 338 participants were included in this study. In the present study, male preponderance was found with male to female ratio of 2.8:1, which is nearly similar to Roy et al., [19] who reported male to female ratio as 2:1. Peak age of acute appendicitis was between 10-29 years. Berry et al. [2] reported that 48.9% of their patients were between 10-29 years age group, whereas Burns et al., [20] reported the peak incidence of acute appendicitis in age group of 15-24 years in their patients. The sensitivity of MAS ranges between 70-90% and specificity of MAS ranges between 75-85% in the diagnosis of acute appendicitis as reported by various authors. In the present study, sensitivity of MAS was 54.3%, which is less compared with other authors. However, it was more specific (89.4%) in diagnosing appendicitis that is nearly same as reported. The variation in the diagnostic accuracy of scoring system could be because of the geographical variations. The same score when applied in two different geographical regions has different accuracy. [21] Hence, it can be said that MAS should be used as an adjunct to clinical examination for improvement in clinical diagnosis of acute appendicitis.

In the present study, of 338 patients who underwent ultrasonography, appendix was visualized in 275 (81.3%) patients. Of these, 264 had acute appendicitis on histological examination giving a positivity of visualization of 96%. These results were similar to Jeffrey et al., [14] and Joshi et al., [22] who, in their studies have reported the positivity of visualization of appendix on ultrasonography 97.5 and 98%, respectively. Non-visualization of the appendix with sonography does not completely exclude acute appendicitis, particularly in the patients who are obese or where abdomen is difficult to compress. Therefore, patients in whom the appendix is not visualized and no other cause for abdominal pain is discovered should be carefully observed until their symptoms have subsided, whereas patients with compelling clinical symptoms should undergo an immediate surgery. [23] A negative appendicetomy rate of 11.2% was observed in present study. This is similar to the report by Ngodngamthaweesuk et al. [19] and Zulfikar et al. [24] of 11.8 and 10.8% respectively.


  Conclusion Top


A diagnosis of acute appendicitis obvious based on strongly positive clinical signs and high MAS scores can form the basis of the operative treatment of patients with acute appendicitis and in these cases ultrasonography may not be necessary. This only adds to the costs and prolongation of time between presentation and operative treatment. However, in the cases of equivocal diagnosis, ultrasonography should be used as an adjunct to clinical diagnosis and thereby decreasing the rates of negative laparotomies. Further, it helps in ruling out abdominal, gynecological, or obstetrical causes among females.

 
  References Top

1.Ellis BW. Hamilton Bailey's Emergency Sugery. 12 th ed. Oxford: Betternwarth-Heinemann 1995. p. 438-51.  Back to cited text no. 1
    
2.Berry J Jr, Malt RA. Appendicitis near its centenary. Ann Surg 1984;200:567-75.  Back to cited text no. 2
    
3.Lewis FR, Holcroft JW, Boey J, Dunphy JE. Appendicitis: A critical review of diagnosis and treatment in 1,000 cases. Arch Surg 1975;110:677-84.  Back to cited text no. 3
    
4.Fitz RH. Perforating inflammation of the vermiform appendix: With special 74 reference to its early diagnosis and treatment. Am J Med Sci 1886;92:321-46.  Back to cited text no. 4
    
5.Buchman TG, Zuidema GD. Reasons for delay of the diagnosis of acute appendicitis. Surg Gynecol Obstet 1984;158:260-6.  Back to cited text no. 5
    
6.Horzic M, Salamon A, Kopljar M, Skupnjak M, Cupurdija K, Vanjak D. Analysis of scores in diagnosis of acute appendicitis in women. Coll Antropol 2005;29:133-8.  Back to cited text no. 6
    
7.Al-Hashemy AM, Seleem MI. Appraisal of the modified Alvarado Score for acute appendicitis in adults. Saudi Med J 2004;25:1229-31.  Back to cited text no. 7
    
8.Sadiq M, Amir S. Efficacy of modified Alvarado scoring system in the diagnosis of acute appendicitis. J Postgrad Med Inst 2002;16:72-7.  Back to cited text no. 8
    
9.Abu-Yousef MM, Bleicher JJ, Maher JW, Urdaneta LF, Franken EA Jr, Metcalf AM. High resolution sonography of acute appendicitis. AJR Am J Roentgenol 1987;149:53-8.  Back to cited text no. 9
    
10.Puylaert JB, Rutgers PH, Lisang RI, de Vries BC, van der Werf SD, Dörr JP, et al. A prospective study of ultrasonography in the diagnosing of appendicits. N Engl J Med 1987;317:666-9.  Back to cited text no. 10
    
11.Jones PF. Practicalities in the management of the acute abdomen. Br J Surg 1990:77:365-7.  Back to cited text no. 11
    
12.Pearsons RH. Ultrasonography for diagnosing appendicitis. BMJ 1988;297:309-10.  Back to cited text no. 12
    
13.Petroianu A, Oliveia-Neto JE, Alberti LR. Comparative incidence of acute appendicitis in a mixed population, related to skin color. Arq Gastronterol 2004;41:24-6.  Back to cited text no. 13
    
14.Jeffrey RB Jr, Laing FC, Townsend RR. Acute Appendicitis: Sonographic criteria based on 250 cases. Radiology 1988;167:327-9.  Back to cited text no. 14
    
15.Acute appendicitis high - Resolution real time US findings from the Dept. of Radiology and Surgery, University of California, San Francisco, RSNA Annual meeting 1986.  Back to cited text no. 15
    
16.Walker AR, Segal I. What causes appendicitis? J Clin Gastroenterol 1990;12:127-9.  Back to cited text no. 16
    
17.Fenyo G. Acute abdominal disease in the elderly: Experience from two series in Stockholm. Am J Surg 1982;143:751-4.  Back to cited text no. 17
    
18.Balsano N, Cayten CG. Surgical emergencies of the abdomen. Emerg Med Clin North Am 1990;8:399-410.  Back to cited text no. 18
    
19.Ngodngamthaweesuk N, Tunthangtham A, Sakonya D. Acuteppendicitis: A 5-year review of histopathology and clinical presentation. Thai J Surg 2003;24:81-4.  Back to cited text no. 19
    
20.Burns RP, Joseph LC, William LR, Bard RM. Appendicitis in mature patients. Ann Surg 1995;201:695-704.  Back to cited text no. 20
    
21.Yegane P, Peyvandi H, Hajinasrollah E, Salehei N, Ahmadei M. Evaluation of the Modified Alvarado Score in Acute Appendicitis among Iranian patients. Acta Medica Iranica 2008;46:501-6.  Back to cited text no. 21
    
22.Joshi HM, Patel VB, Dave AN. Ultrasonographic evaluation of acute appendicitis. Indian J Radiol Imaging 1996;6:75-8.  Back to cited text no. 22
    
23.Brown JJ. Acute appendicitis: The radiologist's role. Radiology 1991;180:13-4.  Back to cited text no. 23
    
24.Zulfikar I, Khanzada TW, Sushel C, Samad A. Review of the pathologic diagnoses of appendectomy specimens Annals 2009;15:168-70.  Back to cited text no. 24
    



 
 
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