Elsevier

Current Surgery

Volume 60, Issue 3, May–June 2003, Pages 296-300
Current Surgery

Original report
Is the use of plain abdominal radiographs (PAR) a necessity for all patients with suspected acute appendicitis in emergency services?

https://doi.org/10.1016/S0149-7944(02)00732-8Get rights and content

Abstract

Purpose

Almost all patients with suspected appendicitis have plain abdominal radiographies (PAR) at the emergency departments. The aims of this study are to evaluate the ability of PAR to diagnose suspected acute appendicitis in patients and to predict length of hospital stay (LOS).

Methods

Three blinded radiologists retrospectively and separately reviewed the preoperative PARs of all patients with suspected appendicitis, who underwent surgery in our hospital for 1 year period based on 8 radiologic criteria. The patients were divided into 3 groups [acute appendicitis (group 1), perforated appendicitis (group 2), and negative appendectomy (group 3)] according to their perioperative and pathological findings. The relationship between the presence/absence of the PAR findings and the diagnosis and LOS were analyzed.

Results

The study consisted of 162 patients (103 men, 63.6%). There were 96 (60.5%), 45 (27.8%), and 19 (11.7%) patients in groups 1, 2, and 3, respectively. Although there were more men in the study overall (p < 0.001), there were more women in groups 2 and 3 than group 1 (p = 0.004, p < 0.001, respectively). Group 2 had the longest LOS, and Group 3 had the shortest LOS (p < 0.001). The generalized air-fluid level was more commonly observed in group 2 patients (7 of 45) than in group 1 patients (2 of 98) (p < 0.05). The LOS was longer in group 3 when the sentinel loop was present on the PAR (n = 3) (p = 0.017), and in group 2 when the colon cutoff sign was positive (n = 3) on the PAR (p = 0.006).

Conclusions

Our results suggest that PAR is rarely beneficial in the diagnosis of acute appendicitis and in the prediction of LOS. The PAR may not be a necessity for all patients with suspected acute appendicitis.

Introduction

Appendectomy is the most commonly performed operation in emergency services.1 Because of common occurrence of symptoms mimicking acute appendicitis, the diagnosis of acute appendicitis is a dilemma for the surgeon. Between 15% and 30% of patients suspected of having acute appendicitis undergo surgery that demonstrates neither appendicitis nor any other surgically correctable disease.2, 3, 4 In addition, diagnostic delay leads to appendiceal perforation in 10% to 15% of patients and considerable postoperative morbidity.5, 6 Therefore, the decision to perform surgery and the timing of that surgery are key factors to avoiding appendiceal perforation and subsequent complications and to minimize the number of negative appendectomies.

The decision to perform surgery in patients with suspected acute appendicitis is particularly dependent on the results of a plain abdominal radiograph (PAR). The PAR is universally used in emergency services as an initial imaging technique in almost every patient with abdominal pain. Indeed, almost all patents with suspected appendicitis have a PAR in an emergency department. A number of signs in a PAR can be observed in patients with acute appendicitis (eg, air-fluid level or colon cutoff sign), but most of them are nonspecific and can be seen in healthy people or patients with diseases that do not require surgery.7 In addition, even the most common signs are observed in only 50% of all patients with appendicitis.8

Because of our increasing reliance on costly diagnostic tests, there is a pressing need to investigate the clinical utility of various procedures and to establish criteria for the optimum selection of patients who are to undergo such examinations.9 This is especially important with respect to relatively low-cost services such as laboratory tests and radiographic examinations, which are major contributors to the increased cost of medical care.10, 11 It is estimated that more than 4 million PARs are performed each year in the United States at a cost of more than $300 million.7

The aim of this study was to determine the ability of the PAR to diagnose suspected acute appendicitis in patients who underwent surgery at an emergency department at a major teaching hospital in Turkey. We also evaluated the ability of the PAR to predict the patients’ length of stay (LOS) after the surgery.

Section snippets

Materials and methods

This study consisted of all patients with suspected acute appendicitis who underwent surgery at Kartal Education and Research Hospital between January 1, 1999 and January 1, 2000. Hospital Education Planning Committee approved the study. We excluded patients who did not undergo a presurgical PAR. The eligible patients were divided into 3 groups according to their perioperative clinical observations and pathologic examination of the resected specimens. Group 1 consisted of patients with

Results

During the study period, a total of 181 patients underwent surgery for suspected acute appendicitis. We excluded 19 patients who did not have a PAR because of suspected pregnancy (n = 8, 42.1%) or clinician’s preference (n = 11, 57.9%). Therefore, the study consisted of 162 patients (89.5% of all 181 patients). Of these patients, 103 were men and 59 were women [median age was 19 years (5–62)]; 98 (60.5%) were in group 1, 45 (27.8%) were in group 2, and 19 (11.7%) were in group 3.

Table 2

Discussion

The aims of this study were to evaluate the value of the PAR in the diagnosis of suspected acute appendicitis and determine the relationship between the PAR findings and LOS. We found that the PAR helped the clinician diagnose the condition in less than 10% of all patients (mostly those with perforated appendices). The PAR was not helpful in predicting the LOS. As expected, the patients with perforated appendicitis had a longer LOS than did those with acute appendicitis who in turn had a longer

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