Diagnostic accuracy of laboratory and ultrasound findings in patients with a non-visualized appendix

Ultrasound (US) and laboratory testing are initial diagnostic tests for acute appendicitis. A diagnostic dilemma develops when the appendix is not visualized on US. Objective: To determine if specific US findings and/or laboratory results predict acute appendicitis when the appendix is not visualized. Methods: A prospective study was conducted on children (birth-18?yrs) presenting to the pediatric emergency department with suspected acute appendicitis who underwent right lower quadrant US.Children with previous appendectomy, US at another facility, or eloped were excluded. US findings analyzed: inflammatory changes, right lower quadrant and lower abdominal fluid, tenderness during US exam and lymph nodes. Diagnoses were confirmed via surgical pathology. Results 1252 subjects were enrolled, 60.8% (762) had appendix visualized and 39.1% (490) did not. In children where the appendix was not seen, 6.7% [33] were diagnosed with appendicitis. Among patients with a non-visualized appendix, the likelihood of appendicitis was significantly greater if: inflammatory changes in the RLQ (OR 18.0, 95% CI 4.5–72.1), CRP >0.5?mg/dL (OR 2.64, 95% CI 1.0–6.8), or WBC?>?10 (OR 4.36, 95% CI 1.66–11.58). Duration of abdominal pain >3?days was significantly less likely associated with appendicitis in this model (OR 0.34, 95% CI 0.003–0.395). Combined, the absence inflammatory changes, CRP?<?0.5?mg/dL, WBC?<?10, and pain, ≤3?days had a NPV of 94.0%. Conclusion When the appendix is not visualized on US, predictors for appendicitis include the presence of inflammatory changes in the RLQ, an elevated WBC/CRP and abdominal pain <3?days.     

钙卫蛋白和缺血修饰白蛋白在成人急性阑尾炎诊断中的价值

目的:探讨钙卫蛋白（calprotectin,S100A8/A9）和缺血修饰白蛋白（ischemia modified albumin,IMA）对急性阑尾炎（acute appendicitis,AA）和非单纯性急性阑尾炎患者的早期评估价值。方法:收集2018年5月到2019年10月组织学确诊的阑尾炎患者和同期在本院体检中心健康对照者资料,根据术后病理资料,将阑尾炎分为单纯性阑尾炎组和非单纯性阑尾炎组。符合正态分布的计量资料结果以均数±标准差（Mean±SD）表示,组间比较采用成组 t检验,比较分组后的S100A8/A9、IMA,C反应蛋白（CRP）,降钙素原（PCT）和血常规参数。通过ROC曲线下面积（AUC）评判S100A8/A9、IMA指标对急性阑尾炎和非单纯性急性阑尾炎的早期评估效能。 结果:阑尾炎组（ n=62）和健康对照组（ n=57）性别、年龄、血小板计数（PLT）、红细胞计数（RBC）差异无统计学意义（ P>0.05）,阑尾炎组白细胞计数（WBC）、CRP、PCT、中性粒细胞与淋巴细胞比率（NLR）、S100A8/A9、IMA水平均高于健康对照组（均 P<0.05）。S100A8/A9（≥366.9 μg/L）、IMA（≥0.29）、S100A8/A9联合IMA预测急性阑尾炎AUC分别为0.735、0.891、0.913。非单纯性阑尾炎组患者WBC与单纯性阑尾炎组相比,差异无统计学意义（ P>0.05）。非单纯性阑尾炎组CRP、PCT、NLR、S100A8/A9及IMA水平显著高于单纯性阑尾炎组,差异有统计学意义（ P<0.05）。S100A8/A9（≥532.9 μg/L）、IMA（≥0.41）、S100A8/A9联合IMA预测非单纯性急性阑尾炎AUC分别为0.866、0.873、0.936。 结论:S100A8/A9和IMA可以作为AA诊断的生物标志物,对急性阑尾炎和非单纯性急性阑尾炎的评估具有一定临床价值。     

钙卫蛋白和缺血修饰白蛋白在成人急性阑尾炎诊断中的价值

目的:探讨钙卫蛋白（calprotectin,S100A8/A9）和缺血修饰白蛋白（ischemia modified albumin,IMA）对急性阑尾炎（acute appendicitis,AA）和非单纯性急性阑尾炎患者的早期评估价值。方法:收集2018年5月到2019年10月组织学确诊的阑尾炎患者和同期在本院体检中心健康对照者资料,根据术后病理资料,将阑尾炎分为单纯性阑尾炎组和非单纯性阑尾炎组。符合正态分布的计量资料结果以均数±标准差（Mean±SD）表示,组间比较采用成组 t检验,比较分组后的S100A8/A9、IMA,C反应蛋白（CRP）,降钙素原（PCT）和血常规参数。通过ROC曲线下面积（AUC）评判S100A8/A9、IMA指标对急性阑尾炎和非单纯性急性阑尾炎的早期评估效能。 结果:阑尾炎组（ n=62）和健康对照组（ n=57）性别、年龄、血小板计数（PLT）、红细胞计数（RBC）差异无统计学意义（ P>0.05）,阑尾炎组白细胞计数（WBC）、CRP、PCT、中性粒细胞与淋巴细胞比率（NLR）、S100A8/A9、IMA水平均高于健康对照组（均 P<0.05）。S100A8/A9（≥366.9 μg/L）、IMA（≥0.29）、S100A8/A9联合IMA预测急性阑尾炎AUC分别为0.735、0.891、0.913。非单纯性阑尾炎组患者WBC与单纯性阑尾炎组相比,差异无统计学意义（ P>0.05）。非单纯性阑尾炎组CRP、PCT、NLR、S100A8/A9及IMA水平显著高于单纯性阑尾炎组,差异有统计学意义（ P<0.05）。S100A8/A9（≥532.9 μg/L）、IMA（≥0.41）、S100A8/A9联合IMA预测非单纯性急性阑尾炎AUC分别为0.866、0.873、0.936。 结论:S100A8/A9和IMA可以作为AA诊断的生物标志物,对急性阑尾炎和非单纯性急性阑尾炎的评估具有一定临床价值。     

Preoperative diagnostic role of hyperbilirubinaemia as a marker of appendix perforation

This retrospective study investigated preoperative markers of appendix perforation in 351 acute appendicitis cases: group 1, appendicitis not histologically confirmed; group 2, appendicitis without perforation or gangrenous changes; and group 3, histologically confirmed perforated appendicitis with gangrenous changes. In group 3, symptom duration was significantly longer, and white blood cell (WBC) and bilirubin values significantly higher, than for the other groups. Symptom duration, gender, bilirubin and elevated WBC were significantly associated with early diagnosis of acute appendicitis in univariate analysis. Multivariate analysis identified increased WBC counts and male gender as independent variables for the early diagnosis of acute suppurative appendicitis, and symptom duration, total bilirubin and elevated WBC as independent variables for identifying appendix perforation amongst acute suppurative appendicitis patients. Receiver operating characteristic curve analysis showed good discrimination of bilirubin and moderate discrimination of WBC as markers of appendix perforation. It is concluded that assessment of preoperative total bilirubin is useful for the differential diagnosis of perforated versus acute suppurative appendicitis, whereas WBC assessment is effective for diagnosing the presence versus absence of appendicitis. Symptom duration, WBC and total bilirubin should be used as independent parameters in the early diagnosis of appendix perforation.     

C反应蛋白检测在急性阑尾炎手术时机选择中的作用探讨

目的：探讨C反应蛋白对急性阑尾炎手术时机的指导作用。方法选择我院2012年7月至12月行阑尾切除术并同时检测了白细胞、中性粒细胞比例和C反应蛋白的患者101例,并对这些检测指标进行Logistic回归分析及ROC分析并绘制ROC曲线,分析白细胞计数、中性粒细胞比例和C反应蛋白在三种不同病理类型阑尾炎中的分布特点,并探讨三种检测指标对坏疽性阑尾炎的预测价值,从而指导是否采用手术治疗。结果 Logistic回归分析结果显示C反应蛋白是坏疽性阑尾炎患者进行手术的惟一独立危险因素,从箱状图中可以看出白细胞计数和中性粒细胞比例的分布范围在三种不同病理类型的阑尾炎中无明显界限,而在单纯性阑尾炎的C反应蛋白均在50 mg/L以下,约有75%的蜂窝织炎性阑尾炎的C反应蛋白水平在50 mg/L以下,ROC曲线也提示C反应蛋白对判断坏疽性阑尾炎的敏感性优于白细胞及中性粒细胞分类（曲线下面积分别为0.788、0.688和0.604）,其截断值为51.22 mg/L。结论C反应蛋白的水平与急性阑尾炎的病理类型相关,可以作为选择是否手术的一个参考指标。     

Diagnosing pediatric appendicitis: usefulness of laboratory markers

Objective

This study aimed to evaluate the utility of C-reactive protein (CRP), procalcitonin (PCT), d-lactate, and white blood cell (WBC) count as an aid to distinguish appendicitis from other diagnoses.

Methods

This prospective, observational study was conducted at an urban tertiary academic pediatric emergency department (ED). Subjects aged 1 to 18 years presenting with abdominal pain suspicious for acute appendicitis were enrolled. Data included history, physical examination, laboratory data (complete blood count, CRP, d-lactate, PCT [semiquantitative]), laboratory results, x-rays, surgical consultation notes, histopathology, and admission data. Stepwise logistic regression analysis was performed to identify independent risk factors.

Results

Two hundred nine subjects (59% male, 41% female) were enrolled over 6 months. One hundred fifteen subjects were histologically diagnosed with appendicitis; 94 subjects did not have appendicitis and were used as controls. Mean values of WBC, CRP, PCT, and absolute neutrophil count in subjects with definitive appendicitis were significantly higher than in subjects with no definitive appendicitis. d-Lactate levels were noncorrelative. Significant independent risk factors identified for definitive appendicitis included WBC count more than 12 cells × 1000/mm³ (adjusted odds ratio [AOR], 6.54), CRP level greater than 3 mg/dL (AOR, 3.44), presence of hopping pain (AOR, 2.69), and presence of pain with walking (AOR, 2.56). Odds ratio for definitive appendicitis and its 95% confidence interval was found to be 7.75 for subjects with both WBC more than 12 cells × 1000/mm³ and CRP greater than 3 mg/dL.

Conclusions

C-reactive protein with WBC is useful in distinguishing appendicitis from other diagnoses in pediatric subjects presenting to the ED. White blood cell count greater than >12 cells × 1000/mm³ and CRP greater than 3 mg/dL increases the likelihood of appendicitis. d-Lactate is not a useful laboratory adjunct.     

Pentraxin-3: A strong novel biochemical marker for appendicitis in children

IntroductionAppendicitis is the most common surgical disease evaluated by pediatric surgeons in the emergency department. Despite the history, physical examination, laboratory tests and imaging methods, the misdiagnosis may be observed often in children. Pentraxin-3 (PTX-3) is an acute phase protein which is produced directly in the inflammatory tissue. Our aim was to investigate the diagnostic value of PTX-3 levels in appendicitis in pediatric patients and compare it with the other serum parameters.MethodsEighty-eight patients (aged <18 years) were included in this study [Group 1 (n = 28) healthy volunteers, Group 2 (n = 28) patients with non-specific abdominal pain, Group 3 (n = 34) patients underwent appendectomy]. Serum white blood cell (WBC), absolute neutrophil count (ANC), neutrophil/lymphocyte ratio (NLR), C-reactive protein (CRP) and PTX-3 values were measured.ResultsMedian serum levels of WBC were higher in Group 2 and 3 than Group 1. ANS, NLR, CRP and PTX-3 were higher in Group 2 than Group 1 and were higher in Group 3 than the other groups. The highest sensitivity was found in NLR >3.5 [94.1 (95% CI = 80.3–99.3)] and PTX-3 > 5.6 ng/mL [91.8 (95% CI = 76.3–98.1)]. PTX-3 has the highest specificity among all of the parameters [90.7 (95% CI = 79.7–96.9)]. The area under the ROC curve showed that the diagnostic value of PTX-3 was greater than any other parameter [0.979 (95% CI = 0.92–0.99)].ConclusionIn this study, we have shown that PTX-3 is very useful with high sensitivity and specificity in the diagnosis of appendicitis compared to WBC, ANS, NLR and CRP as a first in the literature.     

中性粒细胞与淋巴细胞比值预测急性胰腺炎严重程度的意义

目的探讨中性粒细胞与淋巴细胞比值（NLR）预测急性胰腺炎严重程度的意义。方法采集60例急性胰腺炎患者的外周血标本,将其分为轻症型急性胰腺炎（MAP）组和重症急性胰腺炎（SAP）组。检测各组患者外周血中WBC,中性粒细胞、淋巴细胞及NLR水平。评估其与急性胰腺炎严重程度之间的关系。结果 SAP组与MAP组患者WBC、中性粒细胞、淋巴细胞及NLR水平比较,差异均具有统计学意义（P〈0.05）。60例急性胰腺炎患者WBC及NLR预测SAP的受试者工作特征曲线下面积（AUC）均不低于0.7。NLR较WBC预测SAP的诊断临界（CO）值、敏感性、特异性、AUC具有更大的价值,而中性粒细胞及淋巴细胞在SAP的早期诊断中意义不大。结论 NLR在预测急性胰腺炎的不良预后中优于WBC。     

Utility of applying white blood cell cutoffs to non-diagnostic MRI and ultrasound studies for suspected pediatric appendicitis

BackgroundNon-contrast magnetic resonance imaging (MRI) and ultrasound studies in pediatric patients with suspected appendicitis are often non-diagnostic. The primary objective of this investigation was to determine if combining these non-diagnostic imaging results with white blood cell (WBC) cutoffs improves their negative predictive values (NPVs).MethodsA retrospective chart review was conducted including patients ≤18 years old with suspected appendicitis who had MRI performed with or without a preceding ultrasound study in a pediatric emergency department. Imaging results were sorted into 2 diagnostic and 5 non-diagnostic categories. NPVs were calculated for the non-diagnostic MRI and ultrasound categories with and without combining them with WBC cutoffs of <10.0 and <7.5 × 10⁹/L.ResultsOf the 612 patients with MRI studies included, 402 had ultrasound studies performed. MRI with incomplete visualization of a normal appendix without secondary signs of appendicitis had an NPV of 97.9% that changed to 98.1% and 98.2% when combined with WBC cutoffs of <10.0 and <7.5, respectively. Ultrasound studies with incomplete visualization of a normal appendix without secondary signs had an NPV of 85.3% that improved to 94.8% and 96.5% when combined with WBC cutoffs of <10.0 and <7.5, respectively.ConclusionsIn pediatric patients with suspected appendicitis, MRI studies with incomplete visualization of a normal appendix without secondary signs have a high NPV that does not significantly change with the use of these WBC cutoffs. In contrast, combining WBC cutoffs with ultrasound studies with the same interpretation identifies low-risk groups.     

Serum amyloid A protein levels as a possible aid in the diagnosis of acute appendicitis in children.

Hematological and biochemical tests, including white blood cell count (WBC), C-reactive protein (CRP) and other acute-phase reactants, have been used in the diagnosis of acute appendicitis. However, there is controversy among physicians about the value of this practice in children. The objective of our study was to evaluate serum amyloid A protein (SAA) levels in children with confirmed acute appendicitis and to compare the sensitivity and specificity of this marker of inflammation with those for WBC and CRP. A prospective cohort study of 60 children admitted with abdominal pain to rule out appendicitis was used in the study. Of these, 42 underwent surgery, while 18 children who had spontaneous amelioration within 24 h of admission were not operated on and served as controls. WBC and serum SAA and CRP levels were obtained preoperatively. Serum concentrations of the analytes were determined with particle-enhanced immunonephelometric methods. Patients with acute appendicitis had WBC, SAA and CRP levels higher than those of the control group (p<0.001). There was no appendicitis patient with a normal SAA value, while 21.4% of the patients had CRP values within the normal range. The performance of each test was measured by receiver-operating characteristic curves. Area under the curve (AUC) values were 0.849 for WBC, 0.868 for CRP and 0.964 for SAA. The sensitivity and specificity of these methods were 76% and 75% for WBC>10.0 x 10(9) /L, 62% and 94% for CRP>10 mg/L and 86% and 83% for SAA >45.0 mg/L, respectively. Circulating SAA levels have better discriminatory value than WBC or CRP in the assessment of acute appendicitis in children. Thus, this test appears to be of higher value than the current standards of care in the diagnosis of this condition.     

NLR、血清总胆红素和钠联合检测对急性阑尾炎严重程度的预测价值

目的探讨中性粒细胞与淋巴细胞比值(NLR)、血清总胆红素(TBIL)和钠(Na)对急性阑尾炎严重程度的预测价值。方法选取2018年10月至2021年2月在皖西卫生职业学院附属医院住院并行阑尾切除术的271例急性阑尾炎患者为研究对象。根据术后病理诊断将患者分为单纯性阑尾炎组(228例)和复杂性阑尾炎组(43例),比较2组患者的临床资料和各项检测指标。采用多因素Logistic回归模型分析复杂性阑尾炎的危险因素,采用受试者工作特征(ROC)曲线分析NLR、血清TBIL和Na单独及联合检测对复杂性阑尾炎的预测价值。结果复杂性阑尾炎组的术前体温、白细胞计数、中性粒细胞计数、单核细胞与淋巴细胞比值、血小板与淋巴细胞比值、NLR及血清TBIL、直接胆红素、间接胆红素水平均高于单纯性阑尾炎组(P<0.05),而淋巴细胞计数和血清Na水平均低于单纯性阑尾炎组(P<0.05)。多因素Logistic回归模型分析显示,NLR、血清TBIL和Na是复杂性阑尾炎的独立危险因素(OR=1.225、0.487、1.296,P<0.05)。Pearson相关分析显示,急性阑尾炎患者NLR、血清TBIL水平均与血清Na呈负相关(r=-0.255、-0.207,P<0.05),NLR与血清TBIL无相关性(r=0.076,P>0.05)。ROC曲线分析显示,NLR+TBIL+Na联合检测预测复杂性阑尾炎的曲线下面积为0.954,高于TBIL、Na、NLR单独检测的0.777、0.789、0.799(P<0.05);NLR+TBIL+Na联合检测预测复杂性阑尾炎的特异度和灵敏度分别为82.50%和95.30%。结论NLR、TBIL和Na是复杂性阑尾炎的独立危险因素,三者联合检测对复杂性阑尾炎具有较好的预测价值。     

Urinary 5-hydroxy indole acetic acid as a test for early diagnosis of acute appendicitis

OBJECTIVES: Acute appendicitis (AA) is the most common abdominal emergency. The appendix has abundant serotonin containing cells. Upon inflammation, serotonin is released in the blood and converted into 5-HIAA (5-hydroxy indole acetic acid). Measurement of the urine 5-HIAA (U-5-HIAA) could be a reliable marker of inflammation of the appendix. We have compared the powers of test performance of spot U-5-HIAA and spot U-5-HIAA/creatinin with other routine laboratory tests used for the diagnosis of acute appendicitis. DESIGN AND METHODS: Urine, serum, and blood samples of 110 patients who were admitted and observed in the emergency units of two university hospitals were studied. 5-HIAA was measured using HPLC, C-reactive protein by immunoturbidometry, WBC by electronic cell counting, and urine creatinine by the Jaffe method. Diagnostic accuracy of the various tests was evaluated by receiver operating characteristic (ROC) analysis. FINDINGS: The mean of spot U-5-HIAA in 39 patients with AA (nongangrenous) was 32 +/- 2.6 micromol/L, which was much higher than the mean of 40 non-appendicitis patients (NA) (5.5 +/- 0.6), 10 follicular hyperplasia (7.5 +/- 2.1), and 50 healthy control cases (4.1 +/- 0.5) with P < 0.001. The concentration of U-5-HIAA in 21 patients with gangrenous appendicitis (GA) (13.8 +/- 2.1) was also higher than NA patients and healthy individuals but lower than AA cases (P < 0.05). Considering 10 micromol/L as the cutoff point, this test shows 84% sensitivity and 88% specificity, with 90% and 81% positive and negative predictive values, respectively. The area under ROC curve (AUC) of U-5-HIAA in the diagnosis of AA (AUC = 0.903) was much larger than AUCs of U-5-HIAA/Cr (0.787), WBC (0.703), and CRP (0.660). CONCLUSION:: Urinary secretion of 5-HIAA increases significantly in acute appendicitis and measurement of spot U-5-HIAA gives higher diagnostic accuracy than other routine laboratory tests. While the inflammation progresses to necrosis of the appendix, the concentration of 5-HIAA decreases. This decrease could be a warning sign of perforation of the appendix.     

Sonography of acute appendicitis in pregnancy

Background: Clinical evaluation of acute appendicitis is difficult in pregnant patients. Delay in diagnosis is associated with increased fetal mortality. The purpose of our study was to assess the value of sonography in the diagnosis of acute appendicitis in pregnant women. Methods: We obtained sonograms in 22 pregnant women suspected of acute appendicitis. All sonograms were performed using graded-compression to detect an enlarged appendix. The sonographic criteria for acute appendicitis were detection of a noncompressible blindended and tubular multilayered structure of maximal diameter greater than 6 mm. Results: The sonographic findings were correlated with surgical findings in seven cases and clinical follow-up in 15 cases. Acute appendicitis was diagnosed by sonography in three of 22 patients, and in all but one was confirmed by surgical and pathologic findings. In the remaining 19 patients, 15 improved on clinical follow-up; three were shown to have a normal appendix at surgery and one had focal acute inflammation at the tip of the appendix. Conclusions: Our experience suggests that graded-compression sonography is a useful procedure in pregnant patients suspected of acute appendicitis and has a similar accuracy as in nonpregnant women, especially in the first and second trimester.     

Predictive value of C-reactive protein at different cutoff levels in acute appendicitis

Determining the different cutoff values of C-reactive protein (CRP) on the basis of how long the patient's symptoms were present can be used to early predict acute appendicitis. We analyzed retrospectively from 2001 to 2004 the hospital records of 568 patients who underwent appendectomies for suspected appendicitis. Receiver operating characteristic analysis has shown that CRP measurement can increase the diagnostic accuracy in acute appendicitis. The cutoff values of CRP concentration taken as the first, second, and third days after onset of symptoms that distinguish acute appendicitis from other acute abdominal diseases were 1.5, 4.0, and 10.5 mg/dL, respectively; the values that distinguish perforated appendicitis from other acute abdominal diseases were 3.3 mg/dL (first day), 8.5 mg/dL (second day), and 12.0 mg/dL (third day). The different cutoff values of CRP concentration may serve as a useful predictive parameter in the early diagnosis of acute appendicitis on the first 3 days after the onset of symptoms.     

Utility of the immature granulocyte percentage for diagnosing acute appendicitis among clinically suspected appendicitis in adult

Background

Acute appendicitis is the most common cause of abdominal surgical emergencies that present at the emergency department (ED). Although early phase of acute appendicitis cannot induce systemic inflammatory responses, it may induce proliferation immature granulocyte before leukocytosis is occurred. Based on this, we hypothesized that IG% may be beneficial for detecting appendicitis, in addition to classic inflammatory markers including the WBC count, a left shift in neutrophils, and CRP, at no additional cost.

Methods

A retrospective observational study was conducted in a tertiary‐care, university‐affiliated hospital emergency department in adults (>18 years old) with suspected appendicitis from January 1, 2015 to December 31, 2016. The diagnostic performance of IG% and other inflammatory markers, namely white blood cell (WBC) count, proportion of neutrophils, and C‐reactive protein (CRP), for acute appendicitis was evaluated.

Results

Of 403 patients, 204 (50.6%) were diagnosed with acute appendicitis and 45 (22.0%) had complicated appendicitis. All inflammatory markers, including WBC count, proportion of neutrophils, IG%, and CRP, were statistically different between the appendicitis and nonappendicitis group (P < .01). However, IG% was not clinically useful because the median IG% was the same (0.3 vs 0.3) between the appendicitis and nonappendicitis group. Moreover, the area under the curve for IG% was smaller than for other inflammatory markers (0.57, 0.51‐0.63, P < .02).

Conclusion

The diagnostic ability of IG% for appendicitis is insufficient, and it brings no additional benefit over other inflammatory markers.

     

Utility of Symptom Duration and C-Reactive Protein,White Blood Cell Count,and Absolute Neutrophil Count in the Evaluation of Pediatric Appendicitis

BackgroundAppendicitis is a common pediatric surgical emergency, and the diagnosis may be delayed or missed because of nonspecific findings in children. Not all patients with abdominal pain need to be imaged for appendicitis, and laboratory evaluation may improve diagnostic accuracy in this population.ObjectiveTo determine if C-reactive protein (CRP) and symptom duration could be used to improve diagnosis of appendicitis compared with white blood cell count (WBC) and absolute neutrophil count (ANC).MethodsThis was a retrospective chart review from June 2017 to 2019 at our tertiary academic children's hospital. A consecutive sample of all children <18 years of age being evaluated for appendicitis who had magnetic resonance imaging ordered were included. The diagnostic accuracy of WBC, ANC, and CRP were compared for patients with symptom duration ≤1 day compared with symptom duration for >1 day.ResultsFive hundred thirty-nine patients were identified. The sensitivity and specificity of WBC (10,000 cells/μL) was 87.1% and 65.2%, respectively; ANC (7,500 cells/μL) was 86.5% and 70.8%, respectively; and CRP (0.5 mg/dL) were 73.7% and 58.1%, respectively. At >1 day of symptom duration, the specificity of WBC and ANC increased to 74.9% and 80.9%, respectively, and the sensitivity of CRP increased to 88.9%. Three patients with appendicitis (2.8%) had no laboratory abnormalities.ConclusionsNo laboratory test studied has adequate characteristics to be used alone. CRP adds minimal sensitivity beyond WBC and ANC when symptoms are >1 day but with poor specificity, making it of limited utility.     

Comparison between technetium 99m hexamethylpropyleneamine oxide labeled white blood cell abdominal scan and abdominal sonography to detect appendicitis in adult patients with atypical clinical presentation

BACKGROUND: Acute appendicitis is much more serious in the elderly, and early diagnosis is very important. However, the diagnosis of acute appendicitis in older patients is often difficult because these patients may present with atypical clinical manifestations. METHODS: We conducted a prospective study to evaluate and compare the value of technetium 99m hexamethylpropyleneamine oxide (Tc 99m HMPAO) labeled white blood cell (WBC) abdominal scan and abdominal sonography in the diagnosis of acute appendicitis in older patients with an atypical clinical presentation. Forty-nine patients (age > 50 years) with acute abdominal pain and suspected appendicitis, but with atypical findings, were included in this study. RESULTS: Twenty-seven patients received laparotomy for final surgical and pathologic diagnoses. The remaining 22 patients did not receive surgery and showed no evidence of appendicitis after at least 1 month of follow-up. Two patients had false-positive WBC scan findings and two patients had false-negative WBC scan findings. The overall sensitivity, specificity, and accuracy for WBC scans in diagnosing appendicitis were 92.0%, 91.7%, and 91.8%, respectively. The overall sensitivity, specificity, and accuracy for abdominal sonography in diagnosing appendicitis were 84.0%, 95.8%, and 89.8%, respectively. CONCLUSION: The Tc 99m HMPAO WBC scan provides a more sensitive and accurate method for diagnosing appendicitis in older patients with equivocal clinical examinations when compared with abdominal sonography.     

Receiver operating characteristic analysis of leukocyte counts in operations for suspected appendicitis

Study Objective

There has been no clear-cut value of the white blood cell (WBC) count in differential diagnosis of acute appendicitis in emergency medicine. Therefore, the aim of this study was to assess the preoperative WBC counts in 3 groups of patients operated on for a clinical suspicion of acute appendicitis with different findings at appendectomy: uninflamed appendix, uncomplicated acute appendicitis, or complicated acute appendicitis.

Methods

The medical records of 540 patients who underwent appendectomy for suspected acute appendicitis during a 17-month period were retrospectively reviewed. Data for 3 groups of patients were analyzed to calculate the sensitivity and specificity of the WBC count in the diagnosis of acute appendicitis, and we calculated likelihood ratios for 2 cut-points with either high sensitivity or high specificity. Receiver operating characteristic curves were used to evaluate the WBC count in relation to the true diagnosis and severity of acute appendicitis.

Results

We were able to identify patients with appendicitis on a statistically significant level using receiver operating characteristic curves of WBC counts (area under the curve = 0.756, P < .001), but the WBC count had no diagnostic value in differentiating between uncomplicated and complicated groups (area under the curve =0.55, P = .086). Likelihood ratio ranged from 1.79 (95% confidence interval, 1.17-2.3) for WBC count of more than 10 500 cells/mm³ to 3.20 (95% confidence interval, 2.72-3.24) for WBC count of more than 14 300 cells/mm³.

Conclusion

White blood cell count is helpful in the diagnosis and exclusion of appendicitis. However, there is no value to differentiate advanced appendicitis.     

Acute appendicitis mimicking infectious enteritis: diagnostic value of sonography.

OBJECTIVE: To verify the role of sonography in screening of acute appendicitis in patients admitted to an infectious disease unit for suspected acute infectious enteritis. METHODS: One hundred eighty consecutive patients (102 male and 78 female; age range, 5-72 years; mean age, 31 years) admitted for suspected infectious enteritis or typhoid fever were prospectively studied with abdominal sonography within 48 hours after admission. None of the patients had peritoneal irritation. Forty-six patients (25%) had white blood cell counts of more than 10,000/mm3 (range, 10,300-18,000/mm3). The diagnosis of acute appendicitis was made when a detectable appendix with an anteroposterior diameter of greater than 7 mm could be seen on sonography. RESULTS: Eleven (6%) of 180 patients had thickened appendixes (anteroposterior diameter range, 7-14 mm); 2 of them had periappendiceal abscesses. Four (36%) of 11 patients with acute appendicitis had high white blood cell counts. All sonographic diagnoses of acute appendicitis and periappendiceal abscesses were confirmed at surgery. Sonography ruled out acute appendicitis in 169 patients. In all of them, clinical and sonographic follow-up excluded the diagnosis of acute appendicitis. Normal appendixes were shown on sonography in 38 (22%) of 169 cases and were not detectable in 131 (78%) of 169. CONCLUSIONS: Sonography of the appendix is a useful method for early assessment of acute appendicitis in patients thought to have enteritis or typhoid fever.     

急性阑尾炎术前超声定位的临床应用及其价值

目的 探讨急性阑尾炎术前超声定位和体表标记法的临床应用及其价值。方法 选取68例经超声检查已明确显示病变阑尾的患者，在超声观察下用防水色笔描记阑尾在腹壁相应体表投影的整体形态，手术切口3cm限定于阑尾的体表投影处，将超声定位结果与手术病理检查结果相比较。结果 超声诊断急性阑尾炎68例，术前超声对病变阑尾的定位均与手术所见相符，其中阑尾盆位14例，盲肠下位13例，盲肠后位11例，回盲前位14例，回盲后位11例，异位阑尾5例。术前超声定位使阑尾切除手术操作方便，明显缩短了术中寻找阑尾的时间，患者出血少，术后恢复快。结论 术前超声定位为症状典型和非典型急性阑尾炎诊断及外科处理提供了客观的影像依据，有助于手术医师在阑尾切除术中快速找到阑尾顺利完成手术。