The Role of D-Lactate in Differential Diagnosis of Acute Appendicitis

ABSTRACT

Introduction: Early diagnosis of acute appendicitis, known as the most frequent cause of acute surgical abdominal pathologies, dramatically decreases the related complications. D-lactate, produced by intestinal bacteria as a fermentation product, may be useful in diagnosing acute abdominal pathologies. The aim of this study was to investigate whether the presence of d-lactate would be a significant indicator in the early diagnosis of acute appendicitis. Methods: Eighty consecutive patients were prospectively included in this study. The patients were divided into four groups: acute appendicitis (group 1), perforated acute appendicitis (group 2), nonspecific abdominal pain (group 3), and acute abdomen other than acute appendicitis (group 4). For the control group, blood samples were taken in the same manner from 20 healthy subjects. Results: There was no significant difference in blood d-lactate levels between the simple acute appendicitis and acute perforated appendicitis groups (p > .05). The blood d-lactate levels in groups 1 and 2 were significantly higher than those in groups 3 and 4, and the control group (p < .001). The reliability of d-lactate was determined as 97% sensitivity, 93% specificity, 90% positive predictive and 95% negative predictive values, and 95% accuracy. Conclusions: Based on findings in this study, blood d-lactate level may be a valuable diagnostic marker for the diagnosis of acute appendicitis.     

急性阑尾炎CT检查的辅助诊断价值及鉴别诊断思路

目的分析急性阑尾炎及易与之混淆的其他急腹症的CT图像特征,探讨CT检查对急性阑尾炎诊断及鉴别诊断思路的辅助意义。方法收集2009年6月至2012年6月期间南方医科大学附属小榄医院收治的120例初步诊断为急性阑尾炎患者的CT影像资料,回顾性分析和对比CT征象,研究其与最终诊断之间的内在联系。结果120例患者中,单纯性阑尾炎15例,化脓性阑尾炎45例,阑尾坏疽、穿孔25例,阑尾脓肿10例;其他急腹症20例;5例未确诊。阑尾炎患者的术前CT征象因阑尾炎种类不同而略有区别,有56例发现粪石;而其他急腹症的CT征象有结肠管壁局限性增厚、肾输尿管高密度影、肾周筋膜增厚、子宫附件区囊性或实性肿物、肠系膜淋巴结肿大、腹水等。结论CT检查对急性阑尾炎诊断与鉴别诊断思路的形成具有重要的价值。     

Intravenous Contrast-enhanced Computed Tomography in the Diagnosis of Acute Appendicitis

This study evaluated the usefulness of routine, nonfocused intravenous contrast-enhanced computed tomography (CT) in diagnosing acute appendicitis. Also evaluated was the diagnostic value of several findings that were clinically associated with acute appendicitis. Although a number of studies have shown various techniques using CT to be accurate in the diagnosis of acute appendicitis, few studies have focused on CT with using only intravenous contrast material. Computed tomography scan criteria for acute appendicitis have been established chiefly on the basis of appendiceal findings. We, on the other hand, have often observed the following associated conditions during appendectomy: ascites, paresis of the intestine, or thickening of adjacent tissues. In this study, we reviewed the intravenous contrast-enhanced CT scans of 78 patients who had been diagnosed as having acute appendicitis and had subsequently undergone surgery. We also compared the CT scans with patients surgical and histological findings. As a way of evaluating clinical ancillary signs, we identified and analyzed individual CT findings that included abnormal appendix, calcified appendicolith, ascites, dilated intestine, and cecal wall thickening. The sensitivity, specificity, and accuracy of intravenous contrast-enhanced CT in surgical cases were found to be 91.9%, 87.5%, and 91.0%, respectively. Individual findings except for abnormal appendix were not significantly common among patients who had acute appendicitis. However, more positive findings were observed in patients who had appendicitis than in those who had normal appendixes. Intravenous contrast-enhanced CT scan is a useful technique in the diagnosis of acute appendicitis. The plurality of ancillary signs in CT scans also appears to be a helpful indicator in the diagnosis of acute appendicitis.     

Evaluation of the CT Scan as the First Examination for the Diagnosis and Therapeutic Strategy for Acute Cholecystitis

Background

The CT scan has supplanted the abdominal ultrasound for emergency examinations. A comparison of CT scan and ultrasound performance for the diagnosis and management of acute cholecystitis in acute care was proposed. The hypothesis is that the CT scan may be sufficient for the diagnosis of acute cholecystitis, which would allow faster progress to surgery.

Methods

The retrospective study of consecutive patients operated for acute cholecystitis or gallbladder distension with pre-operative imaging within 48 h in one centre.

Results

Between 2015 and 2017, a total of 341 cholecystectomies were performed in our centre. The analysis involved 120 patients. Ultrasound had better sensitivity than the CT scan, respectively, 79.4% [70.5–86.6] and 52.3% [42.5–62.1], but less specificity, with 61.5% [31.6–86.1] and 92.3% [64.0–99.8], respectively. However, there was a significant difference in favour of the CT scan for the diagnosis of complicated cholecystitis (p 0.004). The positive likelihood ratio of complicated cholecystitis is better at CT scan (7.8) [2.7–23.1] than in ultrasound (1.0) [0.1–9.7]. CT scan and ultrasound are equivalent for the diagnosis of acute cholecystitis, but CT scan is more efficient for the diagnosis of complicated cases (Youden index J 0.3 vs 0.001).

Conclusion

It is possible to place the surgical indication of cholecystectomy on the only data of the CT scan. We propose a decision-making algorithm that uses the CT scan to make the diagnosis and decide on emergency treatment for complicated cases or that allows us to propose a delayed surgery for simple cholecystitis.

     

骨盆创伤的CT检查(附50例CT与X线平片检查对照)

目的分析急性骨盆损伤的CT征象,评价CT在骨盆损伤诊断中的应用价值和局限性。方法50例骨盆损伤的患者进行X线、薄层CT检查,分析CT检查征象,并与X线平片对照。结果50例中CT发现骨盆各骨骨折157处,X线显示骨折113处,X线平片及CT的检出率差异有显著性意义(χ2=38·72,P<0·01);CT发现关节脱位27处,X线显示脱位16处,X线平片及CT的检出率差异有显著性意义(χ2=9·09,P<0·01)。X线平片中有3处阳性征象CT检查未能显示。结论CT检查在显示骨、关节的骨折、脱位,盆腔脏器及软组织的损伤,判断骨盆骨折的严重程度等方面优于X线平片,并适合多发伤及危重患者同时进行多项检查时应用,为救治严重创伤患者的一种快速、准确的放射检查手段。     

妊娠合并急性阑尾炎的早期诊断和外科治疗（附26例报告）

目的总结妊娠合并急性阑尾炎的临床特点及手术效果。方法妊娠合并急性阑尾炎26例,平均发病时间28.2（4-72）h。术前明确诊断23例,术前疑诊3例。均行阑尾切除术,入院至手术平均时间4.7（1.8-44）h。结果术后2例切口感染,1例应患者要求行药物流产,余无流产、早产、胎儿宫内窘迫及死胎发生。所有病例均获随访,平均10.5（9-12）个月,1例术后4月发生轻度粘连性肠梗阻,保守治愈。结论妊娠合并急性阑尾炎临床特点不典型,但根据病史、体检,结合B超检查作出早期诊断亦不困难,一旦确诊应尽早手术,以保证母婴安全。     

Clinical Decision-making, Ultrasonography, and Scores for Evaluation of Suspected Acute Appendicitis

Diagnosing acute appendicitis (aA) remains difficult. This study evaluated the utility of ultrasonography (US) compared to clinical decision-making alone and scoring systems to establish the indication for laparotomy in patients in whom aA was suspected. The prospectively documented data of 2209 patients admitted for suspicion of aA, who underwent US by one of 12 surgeons, formed a database in which the diagnostic and procedural performance of clinical decision-making, US, two scoring systems (Ohmann and Eskelinen scores), and clinical algorithms taking account of clinical and either US findings or score results, were retrospectively evaluated. The results of either modality were correlated with final diagnoses obtained by laparotomy in 696 patients, of whom 540 had aA (prevalence 24.45%) and follow-up data in the remainder. US had the highest specificity (97%, compared to 93% for the Ohmann and Eskelinen scores and 94% for the clinical evaluation and algorithms) and lowest overall rate of false-positive findings (negative laparotomy rate 7.6%). The scores were accurate in refuting the diagnosis of aA but otherwise not superior to US. The best overall diagnostic and procedural results were obtained with the algorithms that combined the results of either US or the Ohmann score with clinical evaluation, which produced the most favorable numbers of negative laparotomies, potential perforations, and missed cases of aA. US is the diagnostic standard of reference for patients with a possible diagnosis of aA. It yields diagnostic results superior to those of scoring systems and provisional clinical evaluation. However, the benefits of US by ultrasonographically trained surgeons are only fully appreciated within the context of clinical algorithms. The joint evaluation of score results and clinical evaluation may deliver information of similar accuracy.     

Minilaparoscopy without General Anesthesia for the Diagnosis of Acute Appendicitis

The timely diagnosis of intra-abdominal pathology continues to be an elusive problem. Delays in diagnosis and therapeutic decision making are continuing dilemmas in patients who are females of childbearing age, elderly, obese or immunosuppressed. Minilaparoscopy without general anesthesia potentially can provide an accurate, cost-effective method to assist in the evaluation of patients with acute abdominal pain.Laparoscopy without general anesthesia is not a new technique, but with the combination of two emerging factors— 1) the introduction of new technology with the development of improved, smaller laparoscopes and instruments, and 2) the shifting of emphasis on healthcare to a more cost-effective managed care environment--its value and widespread utilization is being reconsidered.We report the case of a 22 year old female with an acute onset of increasing abdominal and pelvic pain. Despite evaluation by general surgery, gynecology, emergency room staff, as well as, non-invasive testing, a clear diagnosis could not be made. In view of this, minilaparoscopy without general anesthesia was performed and revealed an acute, retrocecal appendicitis. The diagnosis was made with the assistance from the conscious patient. The utilization of this technique greatly expedited the treatment of this patient. Full-sized laparoscopic equipment was then used to minimally invasively remove the diseased appendix under general anesthesia. Both procedures were well tolerated by the patient.     

A New Approach to Accurate Diagnosis of Acute Appendicitis

This study aimed (1) to develop a simple scoring system incorporating ultrasound (US) examination and clinical or laboratory predictors for increasing diagnostic accuracy in acute appendicitis (AA), and (2) to evaluate the performance of the scoring system as compared to that of previous models. Fifteen variables including US assessment for patients admitted with suspected AA were considered in multivariate analysis using the finding of AA at operation as the end point (internal study). The new score, together with 11 previous ones, was applied to a prospective independent population of subjects with suspected AA, and the respective performances were compared (external validation study). Among 303 patients (170 males, mean age 28.3 ± 13.3 years) of the internal study, 161 went on to surgery, and 130 had AA at operation. Four independent correlates of AA were identified and used for the derivation of the following integer-based scoring system: number of points = 6 for US demonstrating AA + 4 for tenderness in the right lower quadrant + 3 for rebound tenderness + 2 for leukocyte count >12,000/μl. In the external study (201 subjects, 105 males, mean age 28.7 ± 11.9 years, 109 operated, 87 with AA), when the cut-off of ≥ 8 points for AA was used, sensitivity, specificity, accuracy, and area under the curve of the proposed score were 95.4%, 97.4%, 96.5%, and 93%, respectively, exceeding noticeably the previous models. The proposed scoring system introduces a quantitative combination of the clinical evaluation with US imaging and a marker of inflammatory response, which may enhance the diagnostic accuracy for subjects with suspected AA especially in geographical areas where CT scanning is not readily available on a 24-hour basis.     

Routine Ultrasound and Limited Computed Tomography for the Diagnosis of Acute Appendicitis

Background  

Acute appendicitis continues to be a challenging diagnosis. Preoperative radiological imaging using ultrasound (US) or computed tomography (CT) has gained popularity as it may offer a more accurate diagnosis than classic clinical evaluation. The optimal implementation of these diagnostic modalities has yet to be established. The aim of the present study was to investigate a diagnostic pathway that uses routine US, limited CT, and clinical re-evaluation for patients with acute appendicitis.     

Computed Tomography in the Diagnosis of Acute Appendicitis: Definitive or Detrimental?

Objectives Utilization of computed tomography (CT) scans in patients with presumed appendicitis was evaluated at a single institution to determine the sensitivity of this diagnostic test and its effect on clinical outcome. Methods Adult patients (age > 17 years) with appendicitis were identified from hospital records. Findings at surgery, including the incidence of perforation, were correlated with imaging results. Results During a 3-year period, 411 patients underwent appendectomy for presumed acute appendicitis at our institution. Of these patients, 256 (62%) underwent preoperative CT, and the remaining 155 (38%) patients did not have imaging before the surgery. The time interval between arrival in the emergency room to time in the operating room was longer for patients who had preoperative imaging (8.2 ± 0.3 h) compared to those who did not (5.1 ± 0.2 h, p < 0.001). Moreover, this possible delay in intervention was associated with a higher rate of appendiceal perforation in the CT group (17 versus 8%, p = 0.017). Conclusions Preoperative CT scanning in patients with presumed appendicitis should be used selectively as widespread utilization may adversely affect outcomes. The potential negative impact of CT imaging includes a delay in operative intervention and a potentially higher perforation rate. This paper was presented at the SSAT Annual Meeting, May 19–23, 2007.     

CT Scan Diagnosis of Bleeding Peptic Ulcer after Gastric Bypass

Investigation of the bypassed stomach in patients with suspected peptic ulcer disease presents a major challenge to bariatric surgeons. Various methods have been suggested for visualization of the duodenum and bypassed stomach. These include endoscopy via percutaneous gastrostomy access, retrograde endoscopy and virtual gastroscopy using CT scan. We present a case of peptic ulcer bleeding diagnosed with the help of conventional CT scan. To the best of our knowledge, this is the second such case reported in the literature and the first in the bariatric population.