I.M. Sechenov First Moscow State Medical University First results of modified diagnostic scale use in suspected acute appendicitis A.G. Natroshvili, A.M. Shulutko

Negative appendectomy Acute appendicitis Most common indication for emergency surgery Lifetime risk 8,6% in men and 6,7% in women Still a diagnostic challenge Early surgical intervention is traditional gold standard for preventing perforation Negative appendectomy rate 15-30% leads to morbidity and even mortality1 Negative appendectomy Perforation Flum DR, Koepsell T: The clinical and economic correlates of misdiagnosed appendicitis: nationwide analysis. Arch Surg 2002, 137(7):799–804

What about CT? High sensitivity and specificity Reduces the number of negative appendectomies May delay appendectomy in clinically typical cases and even elevate risk of perforation Increased use of CT can be associated with elevated risk of cancer, especially in young patients with greatest incidence of appendicitis

Scoring systems Alvarado A (1986) A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med 15(5):557–564 Andersson M, Andersson RE: The appendicitis inflammatory response score: a tool for the diagnosis of acute appendicitis that outperforms the Alvarado score. World J Surg 2008, 32(8):1843–1849.

Time of decision making Scoring systems Ideal scoring system Time of decision making Accuracy Need of imaging

Aim Retrospective study To design a new scoring system with easily available variables for more accurate diagnosis of acute appendicitis Recognize patients in need of urgent surgery without delay Avoid unnecessary risks and costs of surgery in non-appendicitis patients Avoid unnecessary ionizing radiation by use of safe ultrasonography Prospective study To determine the diagnostic value of our scale

Methods (retrospective study, data collection) 231 consecutive patients admitted to University Hospital with RLQ pain Basic data collection by surgeons Clinical findings Tenderness, guarding in RLQ, body temperature Symptoms Pain in RLQ, migration of pain, vomiting, anorexia Laboratory findings WBC count, proportion of neutrophils Ultrasonography

Methods (retrospective study, data collection) Ultrasonography Performed by 3 surgeons and 3 radiologists Direct signs: visualization of blind-shaped non- compressible tubular structure in RLQ >6 mm in diameter, wall thickness >2 mm Non-direct (secondary) signs Free fluid in RLQ or pelvis Inflammation of local fat tissue Partially visualized appendix Focal or diffuse tenderness elicited by ultrasound probe

Methods (retrospective study, data collection) 231 consecutive patients admitted to University Hospital with RLQ pain Basic data collection by surgeons Clinical findings Tenderness, guarding in RLQ, body temperature Symptoms Pain in RLQ, migration of pain, vomiting, anorexia Laboratory findings WBC count, proportion of neutrophils Ultrasonography Details of in-hospital delay, histological findings and final diagnoses retrieved from hospital patient data database Decision to operate was made by the surgeon on duty on the basis of clinical suspicion. No scoring systems were used during data collection period. Optional CT or method for appendectomy were at surgeon’s discretion Diagnosis was based on histological examination showing transmural infiltration of neutrophils in the appendix or safe discharge home without readmission with appendicitis in 30 days

Results (retrospective study, data collection)

Results (retrospective study, data collection) Diagnostic value of signs and symptoms Se Sp Acc +PV -PV RLQ pain 95,3 28 62,5 58,2 85 Pain migration 78 65 71,7 70,1 73,7 Blumberg sign 78,9 98,5 88,4 98,2 81,6 Fever 42,9 80,2 61,1 69,6 57,1 Vomiting 30,8 81,7 55,6 64 52,8 WBC ≥ 10х10*9/л 74,3 61 67,8 66,8 69,2 WBC ≥ 15х10*9/л 30,3 93,1 60,9 82,3 55,9 Segmented neutrophil ≥ 70% 86,4 41,4 64,5 60,8 Segmented neutrophil ≥ 85% 23,4 89,7 70,4 52,6

Results (retrospective study, data collection) Diagnostic value of ultrasonography in suspected appendicitis (n=231) Sensitivity 77,7% Specificity 96,0% Accuracy 85,7% Positive prognostic value 76,0% Negative prognostic value 96,2% Positive likehood ratio 4,3 Negative likehood ratio 0,05

Results (retrospective study, data collection) Diagnostic scale Variable Amount  Points RLQ pain +/- 2 Vomiting 1 Pain migration Blumberg sign 3 Body temperature ≥37,2°С Segmented neutrophils 70-84% ≥85% WBC 10,0-14,9 х 109/л ≥15,0 х 109 Ultrasonography Direct visualization of inflamed appendix 4 Secondary signs Other pathology -4 Points Probability of appendicitis ≥8 High 4-7 Intermediate ≤3 Low

Results (retrospective study, data collection) Diagnostic scale: results 2h

Results (retrospective study, data collection) Diagnostic scale: results 2h

Results (retrospective study, data collection) “Virtual” diagnostic value of diagnostic scale in suspected appendicitis (n=231) Sensitivity 93,1% Specificity 91,5% Accuracy 92,2% Positive prognostic value 89,5% Negative prognostic value 94,4% Positive likehood ratio 11,0 Negative likehood ratio 0,08

Results (retrospective study, data collection) “Virtual” diagnostic value of diagnostic scale in suspected appendicitis (n=231) Compared to ultrasonography alone

Materials and methods (prospective study) 40 consecutive patients admitted to University Hospital with RLQ pain Age/Sex Male Female <20 6 (42,8%) 9 (57,2%) 20-29 9 (100%) 30-39 5 (71,4%) 2 (28,6%) 40-49 2 (33,3%) 4 (66,7%) 50-59 1 (100%) 60-69 2 (100%) ≥70 Total 13 (32,5%) 27 (67,5%)

Materials and methods (prospective study) Decision making about surgery was based on results of diagnostic scale only 40 consecutive patients admitted to University Hospital with RLQ pain Initial examination, ultrasonography and appendectomy were performed by the same surgeon in all patients Patients with moderate possibility of appendicitis (4-7 points) were reexamined in 2 hours, underwent CT / diagnostic laparoscopy

Materials and methods (prospective study) Physical examination CBD Ultrasonography Diagnostic scale ≤3 points 3-7 points ≥7 points Reexamination in 2h Outpatient Appendectomy No change CT/laparoscopy

Results (prospective study) Diagnostic scale: results 2h 2h

Results (prospective study) Diagnostic scale: results 2h 1 – lymphadenitis 1 – salpingitis 2 – no pathology 2h

Results (prospective study) Diagnostic value of diagnostic scale in suspected appendicitis (n=40) Sensitivity 96% Specificity 93, 3% Accuracy 95% Positive prognostic value Negative prognostic value Positive likehood ratio  14,3 Negative likehood ratio  0,04

Results (prospective study) Diagnostic value of diagnostic scale in suspected appendicitis (n=40) Compared to ultrasonography and clinical decision

Conclusion Specific ultrasonography + sensitive clinical evaluation = high accuracy CT or laparoscopy use can be limited, except in cases with intermediate risk and unclear presentation Further prospective validation should be performed prior to recommending this scoring system for wide use