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Unenhanced CT for the diagnosis of appendicitis

This study examines the use of unenhanced CT scans in the emergency department for diagnosing appendicitis. The results show that unenhanced CT has comparable sensitivity and specificity to enhanced CT scans in the evaluation of suspected appendicitis.

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Unenhanced CT for the diagnosis of appendicitis

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  1. Unenhanced CT for the diagnosis of appendicitis Evidence in the ED Dustin Mark, MD

  2. Malone et al. 1993 • 211 consecutive ED pts ,aged 4 to 91 • 10mm cuts, L3 to pubis • Criteria for positive CT • >6mm thick appendix w/ inflammatory changes, or • Abnormal thickening of right lateroconal fascia • Outcome measures • Surgical path, “clinical follow-up” Amer J of Radiol. 1993; 160:763-66

  3. Malone et al. 1993 • 75/211 (35%) had appendicitis • 65/75 diagnosed by CT (87% sensitivity) • 2/10 with endoappendicitis • 4 false positive by CT (97% specificity) • 117 with clinical follow-up only • No missed cases of appendicitis • PPV = 94%, NPV = 93% Amer J of Radiol. 1993; 160:763-66

  4. Lane et al. 1997 • 109 consecutive ED patients, age > 18 • 5mm cuts, T12 to pubis • Criteria for positive CT • > 6mm appendix w/ inflammatory changes • Outcome measures • Surgical pathology • “clinical follow-up” Amer J Radiol. 1997;168:405-9

  5. Lane et al. 1997 • 41/109 (34%) had appendicitis • 37/41 diagnosed by CT (90% sensitivity) • 2 false positive by CT (97% specificity) • Review of missed cases showed that evidence of appendicitis was overlooked in 3 scans • No missed cases of appendicitis • PPV = 95%, NPV = 94% Amer J Radiol. 1997;168:405-9

  6. Lane et al. 1999 • 300 consecutive patients referred from ED or surgeons, age 8 to 86, 4 centers • 115/300 with appendicitis (38%) • 110/115 diagnosed by CT (96% sensitivity) • 4 false positive by CT (98% specificity) • Normal appendix seen on 139/181 true negative CTs (77%) • PPV = 96%, NPV = 98% Radiology 1999;213:341-6

  7. Ege et al. 2002 • 296 pts referred by surgeons • Age 16 to 69 years (mean 25) • 5mm cuts, L3 to pubis • Criteria for positive CT • >6mm appendix w/ inflammatory changes • Thickening of right lateroconal fascia • Outcome measures • Surgical pathology • Clinical follow-up to 3 months Brit J Radiol 2002;75:721-5

  8. Ege et al. 2002 • 108/296 with appendicitis (36%) • 104/108 diagnosed by CT (96% sensitivity) • All false negatives in “slender” people • 3 false positives (98% specificity) • Normal appendix seen on 145/188 true negative CTs (77%) • PPV = 97%, NPV =98% Brit J Radiol 2002;75:721-5

  9. In’t Hoff et al. 2004 • 103 consecutive ED patients • 5mm cuts T11 to pubis • Inclusion • Age > 16, range 16-82 years (mean 36) • Surgeon determines need for OR prior to imaging • Exclusion • Pregnancy, sepsis, acute pancreatitis, aortic aneurysm, bowel obstruction, pneumoperitoneum, contraindications to laparotomy or GA • Outcomes: surgical path for all plus 6 week follow-up Brit J of Surg 2004;91:1641-45

  10. In’t Hoff et al. 2004 • 87/103 with appendicitis (84%) • 83/87 diagnosed by CT (95% sensitivity) • Missed cases = 3 with appendix tip inflammation, 1 with perforation • No false positives (100% specificity) Brit J of Surg 2004;91:1641-45

  11. Summary • Test Characteristics (Cumulative) • Sensitivity 94% (399/426) • Specificity 98% (580/593)

  12. HUPism • Unenhanced CT of the abdomen has comparable sensitivity and specificity as compared to enhanced CT in the evaluation of suspected appendicitis

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