Difficulties in indicating appendectomy; diagnosis of appendicitis in patients with normal white blood cell count

Year 2020, Volume: 33 Issue: 1, 35 - 38, 31.01.2020

Veli Vural

https://doi.org/10.5472/marumj.681990

Abstract

Objectives: Even after 130 years have passed since the first appendectomy, diagnosing acute appendicitis can still be challenging. The objective of this study was to investigate clinical, imaging and laboratory findings of patients diagnosed with acute appendicitis in order to determine whether white blood cell count is helpful in the diagnosis.
Materials and Methods: Parameters of Alvarado score, patients’ complaints, physical examination and laboratory findings were recorded. Appendiceal diameters of patients detected with ultrasound (US) were also recorded.
Results: Of the 98 patients, 89 patients (91%) had an appendiceal diameter wider than 8 mm and 9 patients (9%) had an appendiceal diameter of 8 mm and smaller in the preoperative US. Pathology was normal in 8 out of 9 patients (89%) with a diameter of 8 mm and below; and 9 out of 89 patients (9%) with a diameter above 8 mm (p<0.05). Sensitivity and specificity of the 8-mm cut-off was 99% and 47% respectively. Positive and negative predictive values were 90% and 89% respectively. Conclusion: Distribution of pathology results with respect to appendiceal-diameters revealed that there was an obvious threshold between normal and pathology-proven appendicitis. This outcome highlights the importance of imaging in the diagnosis.

Keywords

Appendicitis, Diagnostic ultrasound, White blood cell count

References

• [1] Seal A. Appendicitis: a historical review.  Can J Surg 1981;24:427-33.
• [2] Andersson RE, Hugander A, Thulin AJ. Diagnostic accuracy and perforation rate in appendicitis: association with age and sex of the patient and with appendicectomy rate. Eur J Surg 1992;158:37-41.
• [3] Hale DA, Molloy M, Pearl RH, Schutt DC, Jaques DP. Appendectomy: a contemporary appraisal.  Ann Surg  1997;225:52-61.  doi: 10.1097/00000.658.19970300000003.
• [4] Cuschieri J, Florence M, Flum DR, et al. Negative appendectomy and imaging accuracy in the Washington state surgical care and outcomes assessment program. Ann Surg 2008;248:557-63. doi: 10.1097/SLA.0b013e318187aeca.
• [5] Wagner PL, Eachempati SR, Soe K, Pieracci FM, Shou J, Barie PS. Defining the current negative appendectomy rate: for whom is preoperative computed tomography making an impact? Surgery 2008;144:276-82. doi: 10.1016/j. surg.2008.03.040.
• [6] Poortman P, Oostvogel HJ, de Lange-de Klerk ES, Cuesta MA, Hamming JF. The use of imaging in the case of suspected acute appendicitis: opinion of Dutch surgeons. Ned Tijdschr Geneeskd 2009;153:B376.
• [7] Alvarado A. A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med 1986;15:557-64. doi: 10.1016/ S0196-0644(86)80993-3.
• [8] Owen TD, Williams H, Stiff G, Jenkinson LR, Rees BI. Evaluation of the Alvarado score in acute appendicitis. J R Soc Med 1992;85:87-8.
• [9] Douglas CD, Macpherson NE, Davidson PM, Gani JS. Randomised controlled trial of ultrasonography in diagnosis of acute appendicitis, incorporating the Alvarado score. BMJ 2000;321(7266):919-22. doi: 10.1136/bmj.321.7266.919.
• [10] Andersson RE. Meta-analysis of the clinical and laboratory diagnosis of appendicitis.  Br J Surg 2004;91:28-37. doi: 10.1002/bjs.4464.
• [11] 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;32:1843-9. doi: 10.1007/s00268.008.9649-y.
• [12] Lahaye MJ, Lambregts DM, Mutsaers E, et al. Mandatory imaging cuts costs and reduces the rate of unnecessary surgeries in the diagnostic work-up of patients suspected of having appendicitis.  Eur Radiol 2015;25:1464-70. doi: 10.1007/s00330.014.3531-0.
• [13] Raja AS, Wright C, Sodickson AD, et al. Negative appendectomy rate in the era of CT: an 18-year perspective.  Radiology 2010;256:460-5. doi: 10.1148/radiol.10091570.
• [14] Willekens I, Peeters E, De Maeseneer M, de Mey J. The normal appendix on CT: does size matter? PLoS One 2014;9:e96476. doi: 10.1371/journal.pone.0096476.
• [15] Daly CP, Cohan RH, Francis IR, Caoili EM, Ellis JH, Nan B. Incidence of acute appendicitis in patients with equivocal CT findings. Am J Roentgenol 2005;184:1813-20. doi: 10.2214/ ajr.184.6.01841813.
• [16] Ortega-Deballon P, Ruiz de Adana-Belbel JC, HernandezMatias A, Garcia-Septiem J, Moreno-Azcoita M. Usefulness of laboratory data in the management of right iliac fossa pain in adults. Dis Colon Rectum 2008;51:1093-9. doi: 10.1007/ s10350.008.9265-9.
• [17] Atema JJ, Gans SL, Beenen LF, et al. Accuracy of White Blood Cell Count and C-reactive protein levels related to duration of symptoms in patients suspected of acute appendicitis. Acad Emerg Med 2015;22:1015-24. doi: 10.1111/acem.12746.
• [18] Krajevski S, Brown J, Phang PT, Raval M, Brown JC. Impact of computed tomography of the abdomen on clinical outcomes in patients with acute right lower quadrant pain: a metaanalysis. Can J Surg 2011;54:43-53. doi: 10.1503/cjs.023509.
• [19] Pickhardt PJ, Lawrence EM, Pooler BD, Bruce RJ. Diagnostic performance of multidetector computed tomography for suspected acute appendicitis. Ann Intern Med 2011;154:78996. doi: 10.7326/0003-4819-154-12-201106.210.00006.
• [20] Doria AS, Moineddin R, Kellenberger CJ, et al. US or CT for diagnosis of appendicitis in children and adults? A Meta-Analysis  Rad 2006;241:83-94. doi: 10.1148/ radiol.241.105.0913.
• [21] Rosen MP, Ding A, Blake MA, et al. ACR Appropriateness Criteria® right lower quadrant pain – suspected appendicitis. J Am Coll Radiol 2011;8:749-55. doi: 10.1016/j.jacr.2011.07.010.
• [22] Park HC, Jang MY, Kim IG, et al. Distal appendiceal dilatation in equivocal appendicitis may be a useful sign for prediction of normal appendix. Am Surg. 2010;76:211-4.
• [23] Alder AC, Fomby TB, Woodward WA, Haley RW, Sarosi G, Livingston EH. Association of viral infection and appendicitis. Arch Surg 2010;145:63-71. doi: 10.1001/archsurg.2009.250.
• [24] Lamps LW. Infectious causes of appendicitis. Infect Dis Clin North Am 2010;24:995-1018. doi: 10.1016/j.idc.2010.07.012.