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.     

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.     

Sonographic features of acute colonic diverticulitis: the "dome sign"

PURPOSE: This study was performed to clarify the sonographic features of acute colonic diverticulitis to enable its differentiation from appendicitis. METHODS: Of 119 patients who were referred to our hospitals for lower abdominal pain between June 1997 and December 1998 and underwent sonography, 12 patients had a definitive diagnosis of acute colonic diverticulitis and 4 patients a tentative diagnosis. Seventy-eight patients were diagnosed as having acute appendicitis, confirmed by appendectomy. In the 16 patients with diagnoses of diverticulitis, the sonographic and clinical features of acute colonic diverticulitis were studied. RESULTS: Among the 12 patients with definitive diagnoses of acute colonic diverticulitis, sonographic findings included localized thickening of the colonic wall (100%) and a hemispheric mass (the "dome sign") protruding at the thickened colonic wall (100%) and consisting of a hypoechoic wall (100%) and a central echogenic area (66%). The presence of diverticula was confirmed by barium-enema x-ray study in all 12 patients. The 4 patients with tentative diagnoses of acute colonic diverticulitis all had colonic wall thickening but no dome sign. Colonoscopy revealed colitis in 3 of these patients. All 16 patients recovered with conservative treatment, without laparotomy. CONCLUSIONS: Sonography was useful for differentiating acute colonic diverticulitis from appendicitis. The sonographic finding of the dome sign seems to be specific for acute colonic diverticulitis.     

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.     

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.     

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.     

C反应蛋白对急性阑尾炎和右侧尿路结石诊断的意义

目的探讨血清C反应蛋白（CRP）在急性阑尾炎中的诊断价值,以及在急性阑尾炎与右侧尿路结石鉴别诊断中的意义。方法回顾性分析我院急诊83例右下腹疼痛伴血尿患者CRP检查结果及最后确诊病历资料。结果 83例右下腹疼痛伴血尿患者,早期CRP〉8 mg/L 62例,均确诊为急性阑尾炎,其中6例诊断急性阑尾炎合并泌尿系结石,21例泌尿系结石者患者CRP未见明显升高。结论血清CRP的检测对急性阑尾炎的诊断,以及急性阑尾炎与右侧尿路结石的鉴别诊断有重要意义。     

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.     

Diagnosis and differential diagnosis of colonic diverticulitis.

A patient over 40 years of age who complains of lower abdominal pain, constipation or diarrhea or both, and increased flatulence should be suspected of having diverticulosis. When pain becomes more severe and persistent, diverticulitis must be considered. Diagnosis depends on roentgen demonstration of the presence of diverticula. Sigmoidoscopy and barium enema study are essential to exclude coexisting disease but in diverticulitis may need to be postponed until severe local and systemic signs of inflammation have subsided. A number of diseases can simulate diverticulitis, and differential diagnosis may present considerable difficulty. Irritable colon syndrome and acute appendicitis may be indistinguishable clinically from diverticulitis. Differentiation from carcinoma is usually not difficult, but exclusion of coexistent carcinoma may be impossible except by resection. Ulcerative colitis is also easily distinguished except when, rarely, it coexists. Crohn's disease of the colon is less easily differentiated, especially in patients over 40, in whom the two diseases often coexist. Other colonic diseases, such as ischemic colitis, and pelvic inflammatory diseases usually show characteristic features which make them readily distinguishable from diverticulitis.     

影响不典型阑尾炎超声诊断的Logistic二元回归分析

目的探讨导致不典型阑尾炎超声误诊及漏诊的影响因素。 方法回顾性分析被漏诊或误诊的急性不典型阑尾炎的临床、解剖及超声等特点,并进行二元因素赋值,通过Logistic回归分析比较以上因素对超声诊断阑尾炎影响。 结果经6步回归分析,发现大量肠气、右下腹积液、腹膜后位阑尾、右下腹局部回声增强是成人阑尾炎被超声误诊漏诊是主要原因,而肠系膜淋巴结显影及憩室炎是小儿阑尾炎误诊的主要因素（均P=0.000,且模型分类判对率均大于85%）。 结论右下腹回声增强、积液以及肠内气体干扰是导致超声误诊漏诊急性阑尾炎的主要原因,对于小儿急性右下腹痛应仔细鉴别其与肠系膜淋巴结炎及麦克尔憩室炎的区别。       

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).

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.     

Misdiagnosis of appendicitis in nonpregnant women of childbearing age

A retrospective case series was conducted at a teaching hospital with an emergency department (ED) census of 100,000 patients per year to identify the incidence of, and factors associated with, the misdiagnosis of appendicitis in nonpregnant women aged 15 to 45 years. There were 174 nonpregnant women identified with a pathologic diagnosis of appendicitis. Clinical features were then compared between patients misdiagnosed (seen in prior 10 days and given an incorrect diagnosis) and those who were initially diagnosed correctly. The results showed that 33% of the women with appendicitis were initially misdiagnosed. The most common misdiagnoses included pelvic inflammatory disease, gastroenteritis, and urinary infections. Misdiagnosed women more frequently exhibited diffuse and bilateral lower abdominal pain and tenderness, cervical motion, and right adnexal tenderness. Misdiagnosed women also had a lower incidence of right lower quadrant pain and tenderness, and peritoneal signs. In addition, misdiagnosis was associated with an increased incidence of perforation, abscess formation, and an increase in the total length of hospitalization. In conclusion, the incidence of misdiagnosis of appendicitis in women of childbearing age is high. Women who are misdiagnosed have less typical symptoms and physical findings and more frequent abnormal pelvic findings than those who are diagnosed correctly. Emergency physicians should be aware that atypical signs and symptoms are associated with misdiagnosed appendicitis in nonpregnant women of childbearing age.     

Graded compression sonography of abdominal neoplasms mimicking acute appendicitis

Over a 3-year period nine patients (mean age of 43 years) with acute abdominal pain and unsuspected abdominal neoplasms were referred for graded compression sonography to rule out appendicitis. Six of the nine patients had right lower quadrant neoplasms involving the cecum, terminal ileum, iliacus muscle, or iliac lymph nodes. However, in three patients neoplasm was noted outside the right iliac fossa involving the liver, right kidney, and upper abdominal mesentery. This study underscores the fact that in patients without sonographic evidence of acute appendicitis, a survey of the upper abdomen and right flank should routinely be performed in addition to scanning the right iliac fossa and pelvis. In patients more than 50 years of age neoplasm must also be kept in mind in the differential diagnosis of appendicitis.     

Charles McBurney: McBurney's point

Charles McBurney published a treatise on appendicitis in 1891, in which he described the exact point on the abdomen at which tenderness was maximal in cases of acute appendicitis--the point now known as "McBurney's point." He also described his approach to both the diagnosis and management of appendicitis, which at the time consisted of careful observation, total disuse of the stomach, and early laparotomy. Since 1891, many advances in the diagnosis of acute appendicitis have been made. Emergency physicians evaluating patients with abdominal pain may rely on laboratory studies, particularly the white blood cell count, and abdominal imaging with either ultrasound or computed tomography in addition to the history and physical examination. Despite these advances, tenderness to palpation over McBurney's point remains a key finding on abdominal examination in the assessment of patients with abdominal pain.     

小儿急性阑尾炎的检体诊断特征分析

目的探讨不同年龄段的小儿急性阑尾炎腹部检体诊断特点。 方法将手术证实的431例小儿急性阑尾炎患儿分为新生儿组、婴幼儿组、学龄前组、学龄期组,对各组检体情况进行回顾性分析,总结其各自特点。 结果新生儿组3例(0.70%)以腹胀、精神差、肠鸣音改变等为主,婴幼儿组31例(7.19%)以叩痛、减速带试验阳性、反跳痛等为主,学龄前组162例(37.59%)以叩痛、反跳痛、肠鸣音改变等为主,学龄期组235例(54.52%)以叩痛、减速带试验阳性、反跳痛等为主。 结论各年龄段小儿急性阑尾炎的腹部检体诊断特点不相同,细致、准确的检体可提供重要诊断依据。     

The diagnosis of acute appendicitis: clinical assessment versus computed tomography evaluation

The goal of this study was to validate Alvarado's predictive model as a diagnostic test and to assess the effectiveness of computed tomography (CT) scan as a supplemental tool in the evaluation of acute appendicitis. Clinical and radiologic data of 215 patients with acute abdominal pain were evaluated. Clinical assessment was based on positive findings of migration of pain, anorexia, nausea and vomiting, tenderness of the lower right quadrant, rebound tenderness, fever, and leukocytosis with a left shift. Evaluation by CT scan had a sensitivity of 90.1% and a specificity of 94.1%. Clinical assessment based on the MANTRELS criteria had a sensitivity of 91.6% and a specificity of 84.7%. With the assistance of CT scan, sensitivity and specificity increased to 98.3% and 95.8%, respectively.     

急性结肠憩室炎154例临床特征及复发因素分析

目的分析急性结肠憩室炎的临床特征并探讨导致复发的可能因素。方法回顾性收集2015年1月至2019年10月北京大学第一医院急诊科收治的急性结肠憩室炎患者为研究对象,收集的临床资料包括性别、年龄、病变位置、首次外周血白细胞计数(WBC)和中性粒细胞百分比(NE%)、世界急诊外科学学会(WSES)分级、治疗方法及治疗后复发情况等。将研究对象依据治疗后是否复发分为未复发组和复发组,比较两组在临床资料上的差异。结果共入组154例,未复发组99例,复发组55例。①男97例,女57例,男女比例1.70∶1.00。年龄16~89岁,平均年龄(46.44±15.26)岁。60岁以下患者125例(81.2%);②急性右半结肠憩室炎(acute right-sided colonic diverticulitis,ARCD)143例(92.9%);急性左半结肠憩室炎(acute left-sided colonic diverticulitis,ALCD)11例(7.1%);③ARCD患者中主诉腹痛142例(99.3%)、发热29例(20.3%),有转移性右下腹痛表现的44例(30.8%),查体为右下腹压痛125例(86.7%)。ALCD患者中腹痛10例(90.9%)、发热5例(45.5%)、腹泻3例(27.2%)、便血1例(9.1%),查体为左腹部压痛(包括左侧腹弥漫性压痛3例)11例(100.0%);④未复发组与复发组年龄、性别、腹痛、发热、便血、腹泻、恶心呕吐、病变位置、首次外周血WBC及NE%差异无统计学意义(P>0.05);⑤0级患者97例(63.0%),治疗后复发36例(37.1%);1A级患者29例(18.8%),复发6例(20.7%);1B级患者7例(4.6%),复发4例(57.1%);2A级患者9例(5.8%),复发5例(55.6%);2B级患者7例(4.6%),复发3例(42.9%);3级患者4例(2.6%),手术治疗2例,复发1例(25.0%);4级患者1例(0.6%),行手术治疗,未复发;⑥未复发组与复发组WSES分级差异无统计学意义(Z=-0.118,P>0.05);复发组的憩室粪石(23.6%vs.5.1%,χ²=11.832,P=0.001)和炎症累及阑尾(45.5%vs.10.1%,χ²=25.163,P=0.000)的比例较高,差异有统计学意义(P<0.05);⑦复发时WSES分级较初发时未升高42例,复发时WSES分级升高的为13例。憩室有粪石的患者复发后WSES分级更易升高(69.2%vs.9.5%,χ²=19.607,P=0.000),差异有统计学意义(P<0.05)。复发后WSES分级未升高患者与升高患者炎症累及阑尾差异无统计学意义(47.6%vs.38.5%,χ²=0.336,P>0.05)。结论急性结肠憩室炎以男性多见,60岁以下患者为主。ARCD更为常见,临床表现主要为右下腹痛,可表现为转移性右下腹痛。憩室有粪石或炎症累及阑尾的患者治疗后复发率高,憩室有粪石的患者复发后WSES分级易升高。     

Right-sided Diverticulitis Mimics Appendicitis

Background

Right-sided diverticulitis is a rare source of right lower quadrant pain in Western society; however, it is quite common in Asian societies. Right-sided diverticulitis presents very similarly to appendicitis, with right lower quadrant pain, fever, nausea, and laboratory abnormalities, and is often seen in young patients.

Objectives

In this report, we present a case of right-sided diverticulitis. We review right-sided diverticulitis’ diagnosis and management. It is important to diagnose right-sided diverticulitis because it is a good mimic of appendicitis and ideally should be diagnosed before a patient has unnecessary surgery.

Case Report

A 26-year-old Asian woman presented for evaluation of right lower quadrant pain and fever. She was initially thought to have appendicitis clinically, but had right-sided diverticulitis diagnosed by computed tomography (CT) scan. She was admitted and received intravenous antibiotics and bowel rest. Her right-sided diverticulitis resolved in 3 days.

Conclusions

Severe right lower quadrant pain in young patients of Asian descent can be right-sided diverticulitis. Right-sided diverticulitis is a benign condition managed medically that mimics appendicitis. CT imaging seems to be the best way to avoid unnecessary surgery.     

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.