The sensitivity and specificity of the conventional symptoms and signs in making a diagnosis of acute appendicitis
Keywords:
Appendicitis, Symptoms, Signs, Sensitivity, Specificity
Abstract
Introduction: Simple appendicitis can progress to perforation, which is associated with a much higher morbidity and mortality. So, surgeons have therefore been inclined to operate when the diagnosis is probable rather than wait until it is certain. Objective: This study is designed to evaluate the sensitivity and specificity of clinical examination in the diagnosis of acute appendicitis.
Methods: The study included 866 patients of acute appendicitis who had undergone appendicectomy with preoperative diagnosis of acute appendicitis. They were analyzed retrospectively. The parameters evaluated were age/gender, clinical presentation (signs and symptoms) and total white blood cell counts. The operative findings were recorded and the inflammation of the appendix was graded into normal, acutely inflamed and gangrenous.
Results: Clinical diagnosis was made correctly in 807 (93.2%) of the patients. White blood cells count ranged from 3.70 to 45.30 /mm3 (mean 17.5353 /mm3). It was <10,000/mm3 in 133 (15.4%) patients.
Conclusions: Clinical assessment is the best criterion to reach a confident diagnosis. Investigations may supplement the diagnosis but are never a substitute for it
References
1. Wilcox RT, Traverso LW. Have the evaluation and treatment of acute appendicitis changed with new technology? Surg Clin North Am 1997;77:1355-70.
2. Rao PM, Rhea JT, Novelline RA et al. Effect of computed tomography of the appendix on treatment of patients and use of hospital resources. N Engl J Med 1998;338: 141-6.
3. Walker SJ, West CR, Colmer MR. Acute appendicitis: does removal of a normal appendix matter, what is the value of diagnostic accuracy and is surgical delay important? Ann R Coll Surg Engl 1995; 77(5): 358-63.
4. Amir M, Shami IH. Analysis of early appendicectomies for suspected acute appendicitis. A prospective study. J Surg PIMS. 1992; 3 and 4: 25-8.
5. Khalid K, Ahmed N, Farooq O et al. Acute appendicitis- laboratory dependence can be misleading : audit of 211 cases. J Coll Physicians Surg Pakistan 2001; 11: 434-7.
6. Velanovich V, Savata R. Balancing the normal appendectomy rate with the perforated appendicitis rate: implications for quality assurance. Am Surg 1992;58:264-9
7. Guidry SP, Poole GV. The anatomy of appendicitis. Am Surg 1994;60:68-71
8. Adesunkanmi AR. Acute appendicitis: a prospective study of 54 cases. West Afr J Med 1993; 12(4): 197-200.
9. Wazir MA, Anwar AR, Zarin M. Acute Appendicitis, a retrospective study. J Postgrad Med Inst 1998; 12(1): 33-6.
10. Liu CD, McFadden DW. Acute abdomen and appendix. In: Greenfield LJ, et al., eds. Surgery: scientific principles and practice. 2d ed. Philadelphia: Lippincott-Raven, 1997:1246-61.
11. Wani MM., Yousaf MN., A. Khan M et al. Usefulness Of The Alvarado Scoring System With Respect To Age, Sex And Time Of Presentation, With Regression Analysis Of Individual Parameters. The Internet Journal of Surgery. 2007; 11(2)
12. Wagner JM, McKinney WP, Carpenter JL. Does this patient have appendicitis? JAMA 1996;276:1589-94.
13. Jahn H, Mathiesen FK, Neckelmann K et al. Comparison of clinical judgment and diagnostic ultrasonography in the diagnosis of acute appendicitis: experience with a score-aided diagnosis. Eur J Surg 1997;163:433-43.
14. Schwartz SI. Appendix. In: Schwartz SI, ed. Principles of surgery. 6th ed. New York: McGraw Hill, 1994:1307-18.
15. Graffeo CS, Counselman FL. Appendicitis. Emerg Med Clin North Am 1996;14:653-71.16. Colledge J., Toms AP., Franklin IJ et al. Assessment of peritonism in appendicitis. Ann R Coll Surg Engl 1996;78: 11-14.
17. Coleman C, Thompson JE, Bennion RS et al. White blood cell count is a poor predictor of severity of disease in the diagnosis of appendicitis. Am Surg 1998; 64: 983-5.
18. Rasmussen OO, Hoffman J. Assessment of the reliability of the symptoms and signs of acute appendicitis. J Roy Coll Surg Edinb 1991; 36: 372-6.
19. De Carvalho BR, Diogo-Filho A, Fernandes C et al. [Leukocyte count, C reactive protein, alpha-1 acid glycoprotein and erythrocyte sedimentation rate in acute appendicitis] Arch Gastroenterol 2003;40(1): 25-30.
20. Elangovan S. Clinical and laboratory findings in acute appendicitis in the elderly. J Am Board Fam Pract 1996;9:75-8.
21. Calder JD, Gajraj H. Recent advances in the diagnosis and treatment of acute appendicitis. Br J Hosp Med 1995;54:129-33.
22. Horton MD, Counter SF, Florence MG et al. A prospective trial of computed tomography and ultra sonography in diagnosing appendicitis in the atypical patient. Am J Surg 2000; 179: 379-81.
23. Bergeron E, Richer B, Gharib R et al. A. Appendicitis is a place for clinical judgement. Am J Surg 1999; 177: 460-2.
24. Saleem MI, and Al-Hashmey AM. Appraisal of the modified Alvarado score for acute appendicitis. Saudi Med J 2004 Sep; 25(9): 1229-31.
25. Ohmann C, Young Q, and Frank C. Diagnostic scores for acute appendicitis. Abdominal pain study group. Eur J Surg 1995; 16: 273-81.
26. Ross FP, Zarem HA, Morgan AP. Appendicitis in a community hospital. Arch Surg 1962; 85:1036-41.
27. Hobson T, Rosenman LD. Acute Appendicitis: when is it right to be wrong? Amer J Surg 1964; 108:306-12.
28. Lichtner S, Pflanz M. Appendectomy in the Federal Republic of Germany. Med Care 1971; 9:311-30.29. Chang FC, Hogle HH, Welling DR. The fate ofthe negative appendix. Amer J Surg 1973; 126:752-5.
30. Lewis FR, Holcroft JW, Beoy J et al. Appendicitis: a critical review of diagnosis and treatment in 1000 cases. Arch Surg 1975; 110:677-84.
31. Mason LB, Deyden WE. Primary appendectomy. Amer Surg 1976; 42:239-43.
32. Jess P, Bjerregaard B, Brynetz S, et al. Acute appendicitis: prospective trial concerning diagnostic accuracy and complications. Amer J Surg 1981; 41:232-4.
33. Van Way III CW, Murphy JR, Dunn EL et al. A feasibility study ofcomputer aided diagnosis in appendicitis. Surg Gynecol Obstet 1982; 155:685-8.
34. Arian GM, Sohu KM, Ahmed E et al. Role of Alvarado score in diagnosis of acute appendicitis. Pak J Surg 2001; 17: 41-6.
35. Khan I, Rehman AU. Application of Alvarado scoring system in the diagnosis of acute appendicitis. JAMA 2005; 17(3): 41-4.
2. Rao PM, Rhea JT, Novelline RA et al. Effect of computed tomography of the appendix on treatment of patients and use of hospital resources. N Engl J Med 1998;338: 141-6.
3. Walker SJ, West CR, Colmer MR. Acute appendicitis: does removal of a normal appendix matter, what is the value of diagnostic accuracy and is surgical delay important? Ann R Coll Surg Engl 1995; 77(5): 358-63.
4. Amir M, Shami IH. Analysis of early appendicectomies for suspected acute appendicitis. A prospective study. J Surg PIMS. 1992; 3 and 4: 25-8.
5. Khalid K, Ahmed N, Farooq O et al. Acute appendicitis- laboratory dependence can be misleading : audit of 211 cases. J Coll Physicians Surg Pakistan 2001; 11: 434-7.
6. Velanovich V, Savata R. Balancing the normal appendectomy rate with the perforated appendicitis rate: implications for quality assurance. Am Surg 1992;58:264-9
7. Guidry SP, Poole GV. The anatomy of appendicitis. Am Surg 1994;60:68-71
8. Adesunkanmi AR. Acute appendicitis: a prospective study of 54 cases. West Afr J Med 1993; 12(4): 197-200.
9. Wazir MA, Anwar AR, Zarin M. Acute Appendicitis, a retrospective study. J Postgrad Med Inst 1998; 12(1): 33-6.
10. Liu CD, McFadden DW. Acute abdomen and appendix. In: Greenfield LJ, et al., eds. Surgery: scientific principles and practice. 2d ed. Philadelphia: Lippincott-Raven, 1997:1246-61.
11. Wani MM., Yousaf MN., A. Khan M et al. Usefulness Of The Alvarado Scoring System With Respect To Age, Sex And Time Of Presentation, With Regression Analysis Of Individual Parameters. The Internet Journal of Surgery. 2007; 11(2)
12. Wagner JM, McKinney WP, Carpenter JL. Does this patient have appendicitis? JAMA 1996;276:1589-94.
13. Jahn H, Mathiesen FK, Neckelmann K et al. Comparison of clinical judgment and diagnostic ultrasonography in the diagnosis of acute appendicitis: experience with a score-aided diagnosis. Eur J Surg 1997;163:433-43.
14. Schwartz SI. Appendix. In: Schwartz SI, ed. Principles of surgery. 6th ed. New York: McGraw Hill, 1994:1307-18.
15. Graffeo CS, Counselman FL. Appendicitis. Emerg Med Clin North Am 1996;14:653-71.16. Colledge J., Toms AP., Franklin IJ et al. Assessment of peritonism in appendicitis. Ann R Coll Surg Engl 1996;78: 11-14.
17. Coleman C, Thompson JE, Bennion RS et al. White blood cell count is a poor predictor of severity of disease in the diagnosis of appendicitis. Am Surg 1998; 64: 983-5.
18. Rasmussen OO, Hoffman J. Assessment of the reliability of the symptoms and signs of acute appendicitis. J Roy Coll Surg Edinb 1991; 36: 372-6.
19. De Carvalho BR, Diogo-Filho A, Fernandes C et al. [Leukocyte count, C reactive protein, alpha-1 acid glycoprotein and erythrocyte sedimentation rate in acute appendicitis] Arch Gastroenterol 2003;40(1): 25-30.
20. Elangovan S. Clinical and laboratory findings in acute appendicitis in the elderly. J Am Board Fam Pract 1996;9:75-8.
21. Calder JD, Gajraj H. Recent advances in the diagnosis and treatment of acute appendicitis. Br J Hosp Med 1995;54:129-33.
22. Horton MD, Counter SF, Florence MG et al. A prospective trial of computed tomography and ultra sonography in diagnosing appendicitis in the atypical patient. Am J Surg 2000; 179: 379-81.
23. Bergeron E, Richer B, Gharib R et al. A. Appendicitis is a place for clinical judgement. Am J Surg 1999; 177: 460-2.
24. Saleem MI, and Al-Hashmey AM. Appraisal of the modified Alvarado score for acute appendicitis. Saudi Med J 2004 Sep; 25(9): 1229-31.
25. Ohmann C, Young Q, and Frank C. Diagnostic scores for acute appendicitis. Abdominal pain study group. Eur J Surg 1995; 16: 273-81.
26. Ross FP, Zarem HA, Morgan AP. Appendicitis in a community hospital. Arch Surg 1962; 85:1036-41.
27. Hobson T, Rosenman LD. Acute Appendicitis: when is it right to be wrong? Amer J Surg 1964; 108:306-12.
28. Lichtner S, Pflanz M. Appendectomy in the Federal Republic of Germany. Med Care 1971; 9:311-30.29. Chang FC, Hogle HH, Welling DR. The fate ofthe negative appendix. Amer J Surg 1973; 126:752-5.
30. Lewis FR, Holcroft JW, Beoy J et al. Appendicitis: a critical review of diagnosis and treatment in 1000 cases. Arch Surg 1975; 110:677-84.
31. Mason LB, Deyden WE. Primary appendectomy. Amer Surg 1976; 42:239-43.
32. Jess P, Bjerregaard B, Brynetz S, et al. Acute appendicitis: prospective trial concerning diagnostic accuracy and complications. Amer J Surg 1981; 41:232-4.
33. Van Way III CW, Murphy JR, Dunn EL et al. A feasibility study ofcomputer aided diagnosis in appendicitis. Surg Gynecol Obstet 1982; 155:685-8.
34. Arian GM, Sohu KM, Ahmed E et al. Role of Alvarado score in diagnosis of acute appendicitis. Pak J Surg 2001; 17: 41-6.
35. Khan I, Rehman AU. Application of Alvarado scoring system in the diagnosis of acute appendicitis. JAMA 2005; 17(3): 41-4.
