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Home > List Archives

Appendicitis & CT

trauma-list@trauma.org trauma-list@trauma.org
Sun, 13 Apr 2003 16:33:46 EDT


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In a message dated 4/13/2003 2:14:11 PM Eastern Daylight Time, 
Traumamd@nyc.rr.com writes:

> 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
> 
> 
Ron--
Your review has the same flaw that virtually all studies of this issue 
contain--that is, that accuracy of the test is not the issue, but that is all 
it concentrates on--the crucial question is if such testing is NECESSARY in a 
given setting, and no study I am aware of has compared the CT findings with 
the physical findings of the patient.  If a patient with 18 hours of lower 
abvdomnal pain which migrated to the RLQ at about 12 hours, with a mild fever 
and leukocytosis, and a physical exam showing RLQ peritonitis is subjected to 
CT, of course it will be very accurate at showing appendicitis--BUT, it was 
not necessary, as we all would have made the diagnosis and taken this patient 
to surgery ANYWAY--AND, I would submit we would all agree that anyone who 
withheld surgery because of a negative CT in THIS patient would be wrong!  
Thus, the CT is accurate, but that has no relation to the fact it was 
unnecessary, with all the attendant dangers of unnecessary testing (i.e. 
ruling out appendicitis just because there is an ovarian cyst--as if females 
with ovarian cysts cannot have appendicitis!).  Thus, the point that just 
cannot penetrate radiologists or those who do not actually see patients 
is--accuracy is not the issue, but whether a test adds anything useful over 
and above the physical findings.  Similarly, a patient who presents with 7 
days of symptoms and fever, leukocytosis, tender RLQ mass--gee, is it really 
a surprise that CT will show us an appendiceal mass/phlegmon/abscess???  Once 
again--accurate, but unnecessary.
You also (so conveniently) failed to quote any of the studies showing CT to 
be worthless for the diagnosis of appendicitis--including the 
population-based study of the state of Washington showing NO reduction in the 
overall rate of perforated appendicits or negative appendectomies with the 
statewide use of CT--quite compelling.
ERF


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<HTML><FONT FACE=3Darial,helvetica><FONT  SIZE=3D2 FAMILY=3D"SANSSERIF" FACE=
=3D"Arial" LANG=3D"0">In a message dated 4/13/2003 2:14:11 PM Eastern Daylig=
ht Time, Traumamd@nyc.rr.com writes:<BR>
<BR>
<BLOCKQUOTE TYPE=3DCITE style=3D"BORDER-LEFT: #0000ff 2px solid; MARGIN-LEFT=
: 5px; MARGIN-RIGHT: 0px; PADDING-LEFT: 5px">Wait a sec, with all due respec=
t. 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 t=
o accept an 80-90% neg exploration rate on female patients if you can improv=
e that with a test that has very little morbidity and mortality and may actu=
ally be more cost effective than observation? I have below several snipets f=
rom 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 th=
at 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 the=
ir 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>
</BLOCKQUOTE><BR>
Ron--<BR>
Your review has the same flaw that virtually all studies of this issue conta=
in--that is, that accuracy of the test is not the issue, but that is all it=20=
concentrates on--the crucial question is if such testing is NECESSARY in a g=
iven setting, and no study I am aware of has compared the CT findings with t=
he physical findings of the patient.&nbsp; If a patient with 18 hours of low=
er abvdomnal pain which migrated to the RLQ at about 12 hours, with a mild f=
ever and leukocytosis, and a physical exam showing RLQ peritonitis is subjec=
ted to CT, of course it will be very accurate at showing appendicitis--BUT,=20=
it was not necessary, as we all would have made the diagnosis and taken this=
 patient to surgery ANYWAY--AND, I would submit we would all agree that anyo=
ne who withheld surgery because of a negative CT in THIS patient would be wr=
ong!&nbsp; Thus, the CT is accurate, but that has no relation to the fact it=
 was unnecessary, with all the attendant dangers of unnecessary testing (i.e=
. ruling out appendicitis just because there is an ovarian cyst--as if femal=
es with ovarian cysts cannot have appendicitis!).&nbsp; Thus, the point that=
 just cannot penetrate radiologists or those who do not actually see patient=
s is--accuracy is not the issue, but whether a test adds anything useful ove=
r and above the physical findings.&nbsp; Similarly, a patient who presents w=
ith 7 days of symptoms and fever, leukocytosis, tender RLQ mass--gee, is it=20=
really a surprise that CT will show us an appendiceal mass/phlegmon/abscess?=
??&nbsp; Once again--accurate, but unnecessary.<BR>
You also (so conveniently) failed to quote any of the studies showing CT to=20=
be worthless for the diagnosis of appendicitis--including the population-bas=
ed study of the state of Washington showing NO reduction in the overall rate=
 of perforated appendicits or negative appendectomies with the statewide use=
 of CT--quite compelling.<BR>
ERF<BR>
<BR>
</FONT></HTML>
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