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Appendicitis & CT

Ronald Simon trauma-list@trauma.org
Sun, 13 Apr 2003 12:37:49 -0400


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Wait a sec, with all due respect. Not all patients with acute 
appendicitis require a CT. No question there. BUT, there is a group of 
patients that CT does help with. Are you willing to accept an 80-90% neg 
exploration rate on female patients if you can improve that with a test 
that has very little morbidity and mortality and may actually be more 
cost effective than observation? I have below several snipets from the 
recent NEJM review article on appendicitis. Not a bad review. When a 
parent of a child asks you if there is anyway to reduce the 10% neg rate 
that you quote them when you get consent what do you say? No? which is 
clearly not true or do you tell them that you are willing to take a 
chance with their child. I would want a CT on my son if the diagnosis 
was in question. Like all tests there is proper use and abuse. To say 
the use of all CTs in acute AP is wrong is an overstatement.
Ron Simon
Dir of Trauma
Jacobi Medical Center

Volume 348:236-242 January 16, 2003 Number 3

NextNext <http://content.nejm.org/cgi/content/short/348/3/243>

Suspected Appendicitis

Erik K. Paulson, M.D., Matthew F. Kalady, M.D., and Theodore N. Pappas, 
M.D.


> When the history and findings on physical examination are consistent 
> with the diagnosis of appendicitis, appendectomy is often performed 
> without further evaluation. If the initial clinical presentation does 
> not suggest the need for immediate surgery, the patient may be 
> observed for 6 to 10 hours in order to clarify the diagnosis.20 
> <http://content.nejm.org/cgi/content/full/348/3/236#R20>,21 
> <http://content.nejm.org/cgi/content/full/348/3/236#R21> This practice 
> may reduce the rate of unnecessary laparotomy without increasing the 
> rate of appendiceal perforation.22 
> <http://content.nejm.org/cgi/content/full/348/3/236#R22>,23 
> <http://content.nejm.org/cgi/content/full/348/3/236#R23>,24 
> <http://content.nejm.org/cgi/content/full/348/3/236#R24> However, with 
> the improved diagnostic accuracy of computed tomography (CT), early 
> use of CT may result in lower overall costs and use of hospital 
> resources25 <http://content.nejm.org/cgi/content/full/348/3/236#R25> 
> than the observation strategy.

> Computed Tomography With improvements in CT, including multislice 
> spiral CT, the entire abdomen can be scanned at high resolution in 
> thin slices during a single period of breath-holding. Such scanning 
> virtually eliminates motion and misregistration artifacts and 
> routinely results in high-quality, high-resolution images of the 
> appendix and periappendiceal tissue. For patients with suspected 
> appendicitis, spiral CT has a sensitivity of 90 to 100 percent, a 
> specificity of 91 to 99 percent, a positive predictive value of 95 to 
> 97 percent, and an accuracy of 94 to 100 percent.33 
> <http://content.nejm.org/cgi/content/full/348/3/236#R33>,41 
> <http://content.nejm.org/cgi/content/full/348/3/236#R41>,42 
> <http://content.nejm.org/cgi/content/full/348/3/236#R42>,43 
> <http://content.nejm.org/cgi/content/full/348/3/236#R43>,44 
> <http://content.nejm.org/cgi/content/full/348/3/236#R44>,45 
> <http://content.nejm.org/cgi/content/full/348/3/236#R45>,46 
> <http://content.nejm.org/cgi/content/full/348/3/236#R46>,47 
> <http://content.nejm.org/cgi/content/full/348/3/236#R47>,48 
> <http://content.nejm.org/cgi/content/full/348/3/236#R48>,49 
> <http://content.nejm.org/cgi/content/full/348/3/236#R49> In a 
> retrospective review of 650 consecutive adults with clinical findings 
> suggestive of acute appendicitis, CT had a sensitivity of 97 percent, 
> a specificity of 98 percent, and an accuracy of 98 percent; 
> alternative disorders were diagnosed in 66 percent of patients.50 
> <http://content.nejm.org/cgi/content/full/348/3/236#R50>



KMATTOX@aol.com wrote:

> I do not understand why anyone anywhere at any time  would use CT to 
> DIAGNOSE acute appendicitis.    I personally believe that a quality 
> outcome measurement ought to be ANY physician that orders a CT to  
> rule out appendicitis should have to face a QA board and if the QA 
> board deems that it was unnecessary, that physician must pay for the 
> entire patient's hospitalization, by payroll  deductions.    
>
> k



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Wait a sec, with all due respect. Not all patients with acute appendicitis
require a CT. No question there. BUT, there is a group of patients that CT
does help with. Are you willing to accept an 80-90% neg exploration rate
on female patients if you can improve that with a test that has very little
morbidity and mortality and may actually be more cost effective than observation?
I have below several snipets from the recent NEJM review article on appendicitis.
Not a bad review. When a parent of a child asks you if there is anyway to
reduce the 10% neg rate that you quote them when you get consent what do
you say? No? which is clearly not true or do you tell them that you are willing
to take a chance with their child. I would want a CT on my son if the diagnosis
was in question. Like all tests there is proper use and abuse. To say the
use of all CTs in acute AP is wrong is an overstatement.<br>
Ron Simon<br>
Dir of Trauma<br>
Jacobi Medical Center<br>
<br>
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            <th align="right" valign="top" nowrap="nowrap">Volume 348:236-242</th>
 						<td nowrap="nowrap"><img alt="" width="30" height="30"
 src=http://www.trauma.org/index.php/community/list/url/http:list.ftech.net/pipermail/trauma-list/2003-April/"http://content.nejm.org/icons/spacer.gif">
            </td>
 						<th valign="top" nowrap="nowrap">January 16, 2003</th>
 						<td nowrap="nowrap"><img alt="" width="30" height="30"
 src=http://www.trauma.org/index.php/community/list/url/http:list.ftech.net/pipermail/trauma-list/2003-April/"http://content.nejm.org/icons/spacer.gif">
            </td>
 						<th align="left" valign="top" nowrap="nowrap">Number 3</th>
 					</tr>
        </tbody>
      </table>
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 					<td valign="top" align="right" nowrap="nowrap"><a
 href=http://www.trauma.org/index.php/community/list/url/http:list.ftech.net/pipermail/trauma-list/2003-April/"http://content.nejm.org/cgi/content/short/348/3/243"><font
 size="-1" face="arial,helvetica">Next</font><img alt="Next" width="9"
 height="8" hspace="4" border="0"
 src=http://www.trauma.org/index.php/community/list/url/http:list.ftech.net/pipermail/trauma-list/2003-April/"http://content.nejm.org/icons/v2_toc_arrownext.gif">
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<p>  </p>
<center><b><font size="+2" face="Arial, Helvetica, sans-serif">Suspected
<font color="#336699"><strong>Appendicitis</strong></font></font></b><br>
</center>
  	 	
<center><font size="+1"><i> 	 	 			Erik K. Paulson, M.D., Matthew F. Kalady,
M.D., and Theodore N. Pappas, M.D. 		 	</i></font></center>
<br>
<blockquote type="cite">  When the history and findings on physical examination
are consistent<sup> </sup>with the diagnosis of <font color="#336699"><strong>appendicitis</strong></font>,
appendectomy is often performed<sup> </sup>without further evaluation. If
the initial clinical presentation<sup> </sup>does not suggest the need for
immediate surgery, the patient<sup> </sup>may be observed for 6 to 10 hours
in order to clarify the diagnosis.<a
 href=http://www.trauma.org/index.php/community/list/url/http:list.ftech.net/pipermail/trauma-list/2003-April/"http://content.nejm.org/cgi/content/full/348/3/236#R20"><sup>20</sup></a><sup>,</sup><a
 href=http://www.trauma.org/index.php/community/list/url/http:list.ftech.net/pipermail/trauma-list/2003-April/"http://content.nejm.org/cgi/content/full/348/3/236#R21"><sup>21</sup></a><sup>
  </sup>This practice may reduce the rate of unnecessary laparotomy<sup>
  </sup>without increasing the rate of appendiceal perforation.<a
 href=http://www.trauma.org/index.php/community/list/url/http:list.ftech.net/pipermail/trauma-list/2003-April/"http://content.nejm.org/cgi/content/full/348/3/236#R22"><sup>22</sup></a><sup>,</sup><a
 href=http://www.trauma.org/index.php/community/list/url/http:list.ftech.net/pipermail/trauma-list/2003-April/"http://content.nejm.org/cgi/content/full/348/3/236#R23"><sup>23</sup></a><sup>,</sup><a
 href=http://www.trauma.org/index.php/community/list/url/http:list.ftech.net/pipermail/trauma-list/2003-April/"http://content.nejm.org/cgi/content/full/348/3/236#R24"><sup>24</sup></a><sup>
  </sup>However, with the improved diagnostic accuracy of computed tomography<sup>
  </sup>(CT), early use of CT may result in lower overall costs and<sup>
  </sup>use of hospital resources<a
 href=http://www.trauma.org/index.php/community/list/url/http:list.ftech.net/pipermail/trauma-list/2003-April/"http://content.nejm.org/cgi/content/full/348/3/236#R25"><sup>25</sup></a>
than the observation strategy.</blockquote>
<blockquote type="cite"><strong>Computed Tomography</strong>  With improvements
in CT, including multislice spiral CT, the<sup> </sup>entire abdomen can
be scanned at high resolution in thin slices<sup> </sup>during a single period
of breath-holding. Such scanning virtually<sup> </sup>eliminates motion and
misregistration artifacts and routinely<sup> </sup>results in high-quality,
high-resolution images of the appendix<sup> </sup>and periappendiceal tissue.
For patients with suspected <font color="#336699"><strong>appendicitis</strong></font>,<sup>
  </sup>spiral CT has a sensitivity of 90 to 100 percent, a specificity<sup>
  </sup>of 91 to 99 percent, a positive predictive value of 95 to 97<sup>
  </sup>percent, and an accuracy of 94 to 100 percent.<a
 href=http://www.trauma.org/index.php/community/list/url/http:list.ftech.net/pipermail/trauma-list/2003-April/"http://content.nejm.org/cgi/content/full/348/3/236#R33"><sup>33</sup></a><sup>,</sup><a
 href=http://www.trauma.org/index.php/community/list/url/http:list.ftech.net/pipermail/trauma-list/2003-April/"http://content.nejm.org/cgi/content/full/348/3/236#R41"><sup>41</sup></a><sup>,</sup><a
 href=http://www.trauma.org/index.php/community/list/url/http:list.ftech.net/pipermail/trauma-list/2003-April/"http://content.nejm.org/cgi/content/full/348/3/236#R42"><sup>42</sup></a><sup>,</sup><a
 href=http://www.trauma.org/index.php/community/list/url/http:list.ftech.net/pipermail/trauma-list/2003-April/"http://content.nejm.org/cgi/content/full/348/3/236#R43"><sup>43</sup></a><sup>,</sup><a
 href=http://www.trauma.org/index.php/community/list/url/http:list.ftech.net/pipermail/trauma-list/2003-April/"http://content.nejm.org/cgi/content/full/348/3/236#R44"><sup>44</sup></a><sup>,</sup><a
 href=http://www.trauma.org/index.php/community/list/url/http:list.ftech.net/pipermail/trauma-list/2003-April/"http://content.nejm.org/cgi/content/full/348/3/236#R45"><sup>45</sup></a><sup>,</sup><a
 href=http://www.trauma.org/index.php/community/list/url/http:list.ftech.net/pipermail/trauma-list/2003-April/"http://content.nejm.org/cgi/content/full/348/3/236#R46"><sup>46</sup></a><sup>,</sup><a
 href=http://www.trauma.org/index.php/community/list/url/http:list.ftech.net/pipermail/trauma-list/2003-April/"http://content.nejm.org/cgi/content/full/348/3/236#R47"><sup>47</sup></a><sup>,</sup><a
 href=http://www.trauma.org/index.php/community/list/url/http:list.ftech.net/pipermail/trauma-list/2003-April/"http://content.nejm.org/cgi/content/full/348/3/236#R48"><sup>48</sup></a><sup>,</sup><a
 href=http://www.trauma.org/index.php/community/list/url/http:list.ftech.net/pipermail/trauma-list/2003-April/"http://content.nejm.org/cgi/content/full/348/3/236#R49"><sup>49</sup></a><sup>
  </sup>In a retrospective review of 650 consecutive adults with clinical<sup>
  </sup>findings suggestive of acute <font color="#336699"><strong>appendicitis</strong></font>,
CT had a sensitivity<sup> </sup>of 97 percent, a specificity of 98 percent,
and an accuracy<sup> </sup>of 98 percent; alternative disorders were diagnosed
in 66 percent<sup> </sup>of patients.<a
 href=http://www.trauma.org/index.php/community/list/url/http:list.ftech.net/pipermail/trauma-list/2003-April/"http://content.nejm.org/cgi/content/full/348/3/236#R50"><sup>50</sup></a></blockquote>
<br>
<br>
<a class="moz-txt-link-abbreviated" href="mailto:KMATTOX@aol.com">KMATTOX@aol.com</a> wrote:<br>
<blockquote type="cite" cite=http://www.trauma.org/index.php/community/list/url/http:list.ftech.net/pipermail/trauma-list/2003-April/"mid1ab.132e3985.2bc8ae6e@aol.com"><font
 face="arial,helvetica"><font size="2" family="SANSSERIF" face="Arial"
 lang="0">I do not understand why anyone anywhere at any time&nbsp; would use
CT to DIAGNOSE acute appendicitis.&nbsp;&nbsp;&nbsp; I personally believe that a quality
outcome measurement ought to be ANY physician that orders a CT to&nbsp; rule out
appendicitis should have to face a QA board and if the QA board deems that
it was unnecessary, that physician must pay for the entire patient's hospitalization,
by payroll&nbsp; deductions.&nbsp;&nbsp;&nbsp;&nbsp; <br>
 <br>
 k</font></font></blockquote>
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