1. 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

2. 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

3. 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

4. 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.

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

6. 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

7. 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

8. 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

9. 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

10. Results (retrospective study, data collection)

11. 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

12. 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

13. 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

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

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

16. 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

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

18. 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%)

19. 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

20. 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

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

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

23. 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

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

25. 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