Predicting need for additional CT scan in children with a non-diagnostic ultrasound for appendicitis in the emergency department

Objective

This study aimed to determine which children with suspected appendicitis should be considered for a computerized tomography (CT) scan after a non-diagnostic ultrasound (US) in the Emergency Department (ED).

Routine versus Selective Abdominal Computed Tomography Scan in the Evaluation of Right Lower Quadrant Pain: A Randomized Controlled Trial

Objectives
To determine the role of abdominal computed tomography (CT) imaging in patients with right lower quadrant (RLQ) pain. The authors hypothesized that selective use of abdominal CT would reduce imaging without increasing the rates of negative appendectomy and perforated appendicitis.
Methods
A prospective randomized clinical trial was conducted in a community teaching emergency department. Adult patients with acute RLQ abdominal pain with suspected acute appendicitis were included. Patients were randomized to mandatory (all patients) or selective (based on clinical evaluation) abdominal CT imaging. The primary outcome was the negative appendectomy rate.
Results
A total of 152 patients were randomized to selective ( n = 80) and mandatory ( n = 72) intervention groups. The mean (±SD) age was 34.1 (±3.5) years, and 48% were female. CT imaging was performed in 54 of 80 patients (68%; 95% confidence interval [CI] = 56% to 78%) in the selective group and in 70 of 72 patients (97%; 95% CI = 90% to 100%) in the mandatory group. There was a trend to a decreased rate of negative appendectomy in the mandatory group (1/39 [2.6%]; 95% CI = 0.5% to 13.2%) as compared with the selective group (6/43 [13.9%]; 95% CI = 6.6% to 27.3%), with a difference in prevalence rates of 11.3% (95% CI =−3.5% to 26.3%). There was also a trend to a decreased perforated appendix rate in the mandatory group (4/39 [10.3%]) as compared with the selective group (7/38 [18.4%]), with a difference in prevalence rates of 8.2% (95% CI =−8.0% to 24.4%).
Conclusions
In this small sample of adult patients with RLQ abdominal pain and suspected acute appendicitis, CT imaging was performed less frequently in the selective group and there was a trend with mandatory CT imaging to reduced rates of negative appendectomy and perforated appendices.     

Diagnostic accuracy of combined WBC,ANC and CRP in adult emergency department patients suspected of acute appendicitis

ObjectivesTo assess the sensitivity, specificity, and negative predictive value (NPV) of normal total white blood cell count (WBC) and normal absolute neutrophil count (ANC) combined with a normal proprietary C-reactive protein (pCRP) level in adult emergency department (ED) patients with abdominal pain suspected of possible acute appendicitis.MethodsWe prospectively enrolled patients ≥18 years of age at seven U.S. emergency departments with ≤72 h of abdominal pain and other signs and symptoms suggesting possible acute appendicitis. Sensitivity, specificity, and NPV for normal WBC and ANC combined with normal pCRP were correlated with the final diagnosis of acute appendicitis.ResultsWe enrolled 422 patients with a prevalence of acute appendicitis of 19.1%. The combination of normal WBC and pCRP exhibited a sensitivity of 97.5% (95% CI, 91.3–99.3%), an NPV of 98.8% (95% CI, 95.9–99.7%) and a specificity of 50.0% (95% CI, 44.7–55.3%) for acute appendicitis. Normal ANC and pCRP resulted in a sensitivity of 100% (95% CI, 95.4–100%), a negative predictive value of 100% (95% CI, 97.5–100%) and a specificity of 44.4% (95% CI, 39.2–49.7%) for acute appendicitis. Normal WBC and pCRP correctly identified 171 of 342 (50.0%) patients who did not have appendicitis with 2 (2.5%) false negatives, while normal ANC and pCRP identified 150 of 338 (44.3%) of patients without appendicitis with no false negatives.ConclusionThe combination of normal WBC and ANC with normal pCRP levels exhibited high sensitivity and negative predictive value for acute appendicitis in this prospective adult patient cohort. Confirmation and validation of these findings with further study using commercially available CRP assays is needed.     

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.     

Prospective randomized study of analgesic use for ED patients with right lower quadrant abdominal pain

Giving an analgesic to patients with right lower quadrant (RLQ) pain causes greater alteration of abdominal signs predictive of appendicitis than placebo. A randomized double-blinded controlled trial of 68 patients who received either tramadol or placebo. Absence or presence of seven abdominal signs (tenderness on light and deep palpation, tenderness in the RLQ and elsewhere, rebound, cough, and percussion tenderness) and pain (100 mm Visual Analog Scale [VAS]) at 0 and 30 minutes were recorded. The predictive value of each physical finding (PF) was measured using an 11-point PF score weighted by likelihood ratios. There was significant reduction in mean VAS of 14.2 mm (95% CI 5.6 to 22.8) in analgesic group versus 6.5 mm (95% CI 1.6 to 11.4) in placebo group. The analgesic group had less normalization of signs as measured by the PF score in all patients [32 of 154 (20.8%) versus 40 of 121 (33.1 %) (P = .031)] and in those with proven appendicitis [4 of 33 (12.1%) versus 10/22 (45.5%) (P = .014)]. Parenteral use of tramadol in emergency department patients with RLQ pain resulted in significant levels of pain reduction without concurrent normalisation of abdominal examination findings indicative of acute appendicitis.     

The predictors of perforated appendicitis in the pediatric emergency department: A retrospective observational cohort study

ObjectiveAppendiceal perforation has significant effects on perioperative morbidity and postoperative outcome. The present study aimed to identify possible predictive factors associated with perforated appendicitis (PA) in children at admission in the emergency department (ED).MethodsIn this retrospective observational cohort study, consecutive medical records of children <18 years old with surgically and histopathologically confirmed acute appendicitis (AA) over three years (2013–2015) were analyzed. Patients were divided into two groups: PA and non-perforated appendicitis (NPA). The differences between the two groups and potential predictors of PA were explored using univariate and multivariate analyses.ResultsDuring the study period, 295 patients underwent an appendectomy and had confirmatory AA diagnoses. Ninety-two patients had a PA (31.2%). In the univariate analysis, male gender, vomiting, diarrhea, fever, elevated white blood cell count (WBC) levels, and high C-reactive protein (CRP) were identified as predictors of PA. In the multivariate analysis, male gender (odds ratio [OR]: 3.133; 95% confidence interval [CI]: 1.610–6.096); vomiting (OR: 2.346; 95% CI: 1.141–4.822); diarrhea (OR: 4.549; 95% CI: 1.850–11.181); fever (OR: 3.429; 95% CI: 1.765–6.663); elevated WBC (OR: 2.962; 95% CI: 1.491–5.884) and elevated CRP (OR: 3.061; 95% CI: 1.267–7.396) were variables that predicted the PA in children.ConclusionOur data indicate that several clinical and biochemical parameters can reliably distinguish between pediatric PA and NPA at admission in the emergency department.     

Ultrasonography of the right lower quadrant

Whereas acute appendicitis is the most common cause of right lower quadrant (RLQ) pain, numerous other conditions may cause signs and symptoms that mimic acute appendicitis. These include other appendiceal diseases, inflammatory bowel diseases, nonbowel gastrointestinal conditions, urinary diseases, and, in females, gynecologic diseases and conditions associated with pregnancy. The important role of ultrasonography in the diagnosis of not only acute appendicitis but also each of the other conditions that cause RLQ pain is described. The ultrasound criteria for the positive, negative, and indeterminate appendix ultrasound examination and the sensitivity, specificity, and positive and negative predictive values of this modality are discussed. The limitations of ultrasound in such diagnoses are also discussed, and an algorithm for the management of patients with RLQ pain is suggested.     

A new clinical score to identify children at low risk for appendicitis

BackgroundBesides clinical signs and imaging, in recent years, biomarkers have proven to be a viable diagnostic resource for acute appendicitis (AA).ObjectiveThe objective of this study was to develop a clinical score including clinical signs and a combination of biomarkers to identify children with abdominal pain at low risk of AA.Design/methodsWe prospectively included children 2 to 14 years of age with abdominal pain suggestive of AA who presented to the emergency department between July 2016 and September 2017. A new score, the Pediatric Appendicitis Laboratory Score (PALabS) including clinical signs, leucocyte (WBC) and neutrophil (ANC) counts and plasma C-reactive protein (CRP) and calprotectin (CP) levels was developed and validated through secondary analyses of two distinct cohorts The validation sample included visits to a single pediatric emergency department from 2012 to 2013 and 2016 to 2017.ResultsThe derivation sample included 278 children, 35.9% of whom had AA and the validation sample included 255 children, 49% of whom had AA. Using logistic regression, we created a 6-part score that consisted of nausea (3 points), history of focal right lower quadrant pain (4 points), ANC of ≥7500/μL (7 points), WBC of ≥10,000/μL (4 points), CRP ≥ 10.0 mg/L (2 points) and CP ≥ 0.50 ≥ ng/mL (3 points). This score exhibited a high discriminatory power (area under the curve: 0.88; 95% confidence interval: 0.84 to 0.92) and outperformed the PAS and Kharbanda scores (area under the curve: 0.76; 95% confidence interval: 0.71 to 0.82 and 0.82; 95% confidence interval: 0.77 to 0.87, respectively). A PALabS ≤6 had a sensitivity of 99.2% (95% confidence interval [CI]: 95.6–99.9), negative predictive value of 97.6% (95% CI: 87.7–99.6), and negative likelihood ratio of 0.03 (95% CI: 0.00–0.18) in the validation set.ConclusionIn our validation cohort of patients with acute abdominal pain, the new score can accurately predict which children are at low risk of appendicitis and could be safely managed with close observation.     

Prävalenz beeinträchtigender Bauchschmerzen und Menstruationsbeschwerden

Background

There are no data available on the prevalence of disabling abdominal pain and menstrual cramp in adults in Germany.

Methods

Abdominal pain and menstrual cramp, additional somatic symptoms and depressive symptoms were assessed by the Patient Health Questionnaires (PHQ) 15 and 9 in persons ≥?14 years from a sample representative of the general German population. The association of disabling abdominal and menstrual cramp with demographic and clinical variables was tested by logistic regression analyses.

Results

A total of 2524 out of 4064 (62.1?%) contacted persons participated in the study. Of the participants 11.9?% reported suffering from slight abdominal pain and 0.9?% reported suffering from severe abdominal pain within the last 4 weeks. Female gender with an odds ratio (OR) of 2.23 (95?% confidence interval CI 1.67–2.98, p?<?0.001), younger age (OR 0.97, 95?% CI 0.96–0.98, p?<?0.001), physical symptom burden PHQ 15 (OR 1.33, 95?% CI 1.26–1.40, p?<?0.0001) and depression PHQ 9 (OR 1.13, 95?% CI 1.08–1.77, p?<?0.0001) were predictive for abdominal pain. Of the women aged 14–55 years 19.8?% reported to be slightly troubled by menstrual cramp and 3.9?% reported suffering from severe menstrual cramp within the last 4 weeks. Menstrual cramps were predicted by younger age (OR 0.96, 95?% CI 0.94–0.97, p?<?0.001), somatic symptom burden PHQ 15 (OR 1.24, 1.12–1.36, p?<?0.0001) and depression PHQ 9 (OR 1.08, 95?% CI 1.01–1.15, p?<?0.0001).

Conclusion

Persons in the general German population frequently reported slightly disabling abdominal pain and menstrual cramp; however, severely disabling abdominal pain and menstrual cramp were rarely reported. Abdominal pain and menstrual cramps were associated with additional somatic complaints and depression.     

Three times a charm… a case of repeat appendicitis status post two prior appendectomies

Background

Appendicitis is defined as the bacterial proliferation and inflammation of the vermiform appendix, typically caused by a fecalith . There have been a few cases reported in the literature of recurrent appendicitis status post an appendectomy, however there has been no reported case of a recurrence status post two prior appendectomies. We would like to present the first case of recurrent appendicitis status post two prior appendectomies.

Appendiceal outer diameter as an indicator for differentiating appendiceal mucocele from appendicitis

BACKGROUND: Patients with appendiceal mucocele (AM) commonly present with features indicative of acute appendicitis. In emergency departments, accurate preoperative diagnosis is crucial to prompt appropriate treatment. This study investigates the clinical and sonographic characteristics of AM, which may prove useful in preoperatively differentiating AM from appendicitis. METHODS: This case-control study compares the clinical and sonographic findings of 16 histologically confirmed AM with sex- and age-matched control subjects (n = 64) with appendicitis by a 1:4 ratio. Conditional logistic regression was applied to estimate the odds ratio (OR) and 95% confidence intervals (CI) of clinical and sonographic parameters associated with AM. RESULTS: Univariate analysis demonstrated that the larger appendiceal outer diameter by sonography was positively correlated with diagnosis of AM (OR, 2.31; 95% CI, 1.42-3.72) and right lower quadrant abdominal pain was negatively correlated (OR, 0.38; 95% CI, 0.17-0.82). However, multiple regression analysis suggested that only outer diameter remained significant (OR, 2.21; 95% CI, 1.36-3.59) after adjusting for age, sex, and right lower quadrant pain. An outer diameter of 15 mm or more was predictive of AM diagnosis, with a sensitivity of 83% and specificity of 92%. CONCLUSION: When the threshold is set at 15 mm, appendiceal outer diameter by sonography is a useful preoperative measurement for differentiating between AM and acute appendicitis.     

Perforated Meckel diverticulum

Perforation of a Meckel diverticulum (MD) is a rare complication that can often mimic appendicitis. This case report identifies a child who presented to our Emergency Department (ED) with right lower quadrant abdominal pain, free fluid and air in the abdomen and pelvis, and inflammatory changes visualized on Ultrasonography (US) and computer tomography (CT) scan. In our patient, ruptured appendicitis was suspected, and the diagnosis of ruptured MD was ultimately made by laparoscopy. This case demonstrates that a healthy degree of suspicion for complicated MD should be present when dealing with a questionable diagnosis of appendicitis, particularly in the pediatric population.     

Diagnostic accuracy of fibrinogen to differentiate appendicitis from nonspecific abdominal pain in children

Aim

The aim of this study was to assess the diagnostic accuracy of the biomarker fibrinogen (FB), along with the more traditional markers white blood cell count (WBC), absolute neutrophil count (ANC), and C-reactive protein (CRP), to discriminate appendicitis from nonspecific abdominal pain (NSAP) in children.

Clinical prediction rule to distinguish pelvic inflammatory disease from acute appendicitis in women of childbearing age

Objective

We aimed to develop a clinical prediction rule to distinguish pelvic inflammatory disease (PID) from acute appendicitis in women of childbearing age.

Methods

We reviewed medical records over a 4-year period of female patients of childbearing age who had presented with abdominal pain at an urban emergency department and had either appendicitis (n = 109) or PID (n = 72). A prediction rule was developed by use of recursive partitioning based on significant factors for the discrimination.

Results

The significant factors to favor PID over appendicitis were (1) no migration of pain (odds ratio [OR], 4.2; 95% confidence interval [CI], 1.5-11.5), (2) bilateral abdominal tenderness (OR, 16.7; 95% CI, 5.3-50.0), and (3) absence of nausea and vomiting (OR, 8.4; 95% CI, 2.8-24.8). The prediction rule could rule out appendicitis from PID with sensitivity of 99% (95% CI, 94-100%) when classified as a low-risk group by the following factors: (1) no migration of pain, (2) bilateral abdominal tenderness, and (3) no nausea and vomiting.

Conclusion

We developed a prediction rule for childbearing-aged women presenting with acute abdominal pain to distinguish acute appendicitis from PID based on 3 simple, clinical features: migration of pain, bilateral abdominal tenderness, and nausea and vomiting. Prospective validation is needed in other settings.     

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.     

Pediatric subhepatic appendicitis with elevated lipase

Appendicitis is the most common surgical emergency in children, of which most are located in the retrocecal space or pelvis. Appendicitis occurring in the subhepatic space is uncommon and may present with atypical features such as right upper quadrant pain, leading to delayed diagnosis and complications. We present a rare case of subhepatic appendicitis in an 11-year-old female, who presented with a three-day history of both right upper quadrant (RUQ) and right lower quadrant (RLQ) abdominal pain and serum lipase elevated four times the upper normal limit. The abdominal ultrasound was normal, except for prominent RLQ abdominal lymph nodes. Hours later, a computed tomography scan revealed a non-ruptured subhepatic appendicitis and normal pancreas. Our patient encounter demonstrates the need to be aware of the atypical presentations of pediatric appendicitis in general and subhepatic appendicitis in particular. Moreover, to our knowledge, this is the first reported case of elevated lipase (with a radiographically normal pancreas) in association with subhepatic appendicitis. Providers should be aware elevated serum lipase levels may be due to conditions other than pancreatitis and further evaluation should be considered if the elements of the clinical picture are incongruent.     

Unveiling appendicitis

The most common reason for performing abdominal surgery is appendicitis, which affects up to 12% of the population (Lemone & Burke, 2000). Appendicitis is acute inflammation of the vermiform appendix that is typically manifested by localised pain in the right lower quadrant of the abdomen (Holmes, 2001; Lemone & Burke, 2000; McCance & Huether, 2002; Wagner, McKinney & Carpenter, 1996). Abdominal pain is a very common complaint. However, pain in the lower right quadrant cannot be used as the gold standard in a nursing assessment as an indication of appendicitis. Approximately one third of patients with appendicitis will have pain that is spread across the abdomen similar to gastritis (Mattice, 1999). Therefore a more in depth nursing assessment is required. This paper looks at accurately assessing the other signs and symptoms of appendicitis. These may include changes in vital signs, behaviour and body positioning and a history of anorexia, nausea and vomiting. Unveiling appendicitis requires the performance of an accurate and thorough abdominal pain assessment. This competent assessment will assist in preventing complications such as perforation and peritonitis and ensure a better patient outcome (Wagner, et al., 1996; Wright, 1997).     

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.     

Clinical differentiation between acute renal infarction and acute ureteral stone in the emergency department: A single-center retrospective case-control study

BackgroundFew studies have compared renal infarction (RI) and ureteral stone (US), so there is insufficient evidence for emergency clinicians (ECs) to quickly suspect RI during the first assessment. Therefore, we compared the initial clinical presentation and laboratory findings of these diseases in the emergency department (ED) to determine a factor that may indicate RI.MethodsThis single-center retrospective case-control study included 42 patients with acute RI and 210 with US who visited the ED from 2014 to 2020. Medical record data from first ED arrival were investigated, and clinical presentations, blood and urine test results obtained in the ED were compared and analyzed using logistic regression analysis.ResultsECs never suspected the initial diagnosis of RI as RI. The most common initial diagnosis was US (40.5%). Among patients with US, 150 patients (71.4%) were suspected of having US (p < 0.001). Abdominal pain (61.9%) was the most common chief complaint in the RI group, and flank pain (73.8%) was the most common in the US group (p < 0.001). 27 factors showed significant differences between the groups. Among those, age ≥ 70 years (odds ratio [OR]: 311.2, 95% confidence interval [CI]: 2.0–47,833.1), history of A-fib (OR: 149872.8, 95% CI: 289.4–7.8E+07), fever ≥37.5 °C (OR: 297.3, 95% CI: 3.3–27,117.8), Cl⁻ ≤ 103 mEq/L (OR: 9.0, 95% CI: 1.0–80.1), albumin ≤4.3 g/dL (OR: 26.6, 95% CI: 2.1–330.3), LDH ≥500 IU/L (OR: 17.9, 95% CI: 1.8–182.5), and CRP ≥0.23 mg/dL (OR: 7.5, 95% CI: 1.1–52.3) showed significantly high ORs, whereas urine RBCs (OR: 0, 95% CI: 0–0.02) showed a low OR (p < 0.05). The regression model showed good calibration (chi-square: 6.531, p = 0.588) and good discrimination (area under the curve = 0.9913).ConclusionsWhen differentiating acute RI from US in the ED, age ≥ 70 years, history of A-fib, fever ≥37.5 °C, LDH ≥500 IU/L, Cl⁻ ≤ 103 mEq/L, albumin ≤4.3 g/dL, CRP ≥0.23 mg/dL and negative urine RBC result suggest the possibility of RI.     

Single and Combined Diagnostic Value of Clinical Features and Laboratory Tests in Acute Appendicitis

Objectives:  The objective was to evaluate the diagnostic accuracy of clinical features and laboratory test results in detecting acute appendicitis.
Methods:  Clinical features and laboratory test results were prospectively recorded in a consecutive series of 1,101 patients presenting with abdominal pain at the emergency department (ED) in six hospitals. Likelihood ratios (LRs) and the areas under the receiver operating characteristic curve (AUC) were calculated for the individual features. Variants of clinical presentation, based on different combinations of clinical features, were investigated and the accuracies of combinations of clinical features were evaluated.
Results:  The discriminative power (AUC) of the individual features in patients with suspected appendicitis ranged from 0.50 to 0.65. For five of the 23 predictor sets, the accuracy for appendicitis was more than 85%. This accuracy was only found in male patients. The relative frequency of these predictor sets ranged from 2% to 13% of patients with suspected appendicitis. A combination of the clinical features migration of pain to the right lower quadrant (RLQ), and direct tenderness in the RLQ, was present in only 28% (120/422) of clinically suspected patients, of whom no more than 85 patients had appendicitis (71%). A "classical" presentation (combination of migration of pain to the RLQ, tenderness in the RLQ, and rigidity) occurred in only 6% (25/422) of patients with suspected appendicitis and yielded an accuracy of 100% in males but only 46% in females.
Conclusions:  The discriminative power (AUC) of individual clinical features and laboratory test results for appendicitis was weak in patients with suspected appendicitis. Combinations of clinical features and laboratory tests with high diagnostic accuracy are relatively infrequent in patients with suspected appendicitis.