Learning curve and period of experience required for the competent diagnosis of acute appendicitis using abdominal computed tomography: a prospective observational study

송주현,조하진,박종학,문성우,김주영,김수진,최성혁 대한응급의학회 2017 Clinical and Experimental Emergency Medicine Vol.4 No.4

Objective To assess the learning curve of novice residents in diagnosing acute appendicitis using abdominal computed tomography (CT) scans. Methods This prospective observational study was conducted within a 4-month period from March 1 to June 30, 2015. After CT scans for right lower quadrant pain or similar acute abdomen were evaluated, postgraduate year 1 (PGY-1) residents completed an interpretation checklist. The primary outcome was evaluation of the learning curve for competent CT scan interpretation under suspicion of acute appendicitis. Secondary outcomes were cumulative numbers of accurate abdominal CT interpretations regardless of initial clinical impression and training period. Results PGY-1 residents recorded a total of 230 interpretation checklists. There were 53, 51, 46, 44, and 36 checklists recorded by individual residents and 92, 92, 91, 91, and 61 respective training days in the emergency department, excluding rotation periods in other departments. After 16 to 20 interpretations of abdominal CT scans performed under suspicion of acute appendicitis, the residents could diagnose acute appendicitis with more than 95% accuracy. Overall, the sensitivity and specificity for diagnosing acute appendicitis were 97% (95% confidence interval, 94 to 100) and 83% (95% confidence interval, 80 to 87), respectively. After 61 to 80 abdominal CT interpretations regardless of suspicion of acute appendicitis and after 41 to 50 days in training, PGY-1 emergency department residents could diagnose acute appendicitis with more than 95% accuracy. Conclusion PGY-1 residents require 16 to 20 checklist interpretations to acquire acceptable abdominal CT interpretation. After performing 61 to 80 CT scans regardless of suspicion of acute appendicitis, they could diagnose acute appendicitis with acceptable accuracy.

소아 급성 충수염 진단에 초음파 내측 저에코선의 유용성

김봉수,최국명,김승형,박지강,김광식,강현욱,강기수 대한영상의학회 2007 대한영상의학회지 Vol.57 No.5

Purpose: We wanted to evaluate the usefulness of the inner hypoechoic band in pediatric appendices as an ultrasonographic criterion to exclude or confirm acute appendicitis. Materials and Methods: Among the 169 consecutive children with right lower abdominal pain, the 149 appendices depicted on US were prospectively evaluated for an inner hypoechoic band in the appendiceal walls. The sensitivity, specificity, positive and negative predictive values and accuracy were assessed for loss of the inner hypoechoic band as a diagnostic criterion for acute appendicitis. Results: The appendices in 12 (25%) patients with acute appendicitis show entire inner hypoechoic bands and those in 36 patients (75%) did not. The appendices in 97 (96%) patients without acute appendicitis showed entire inner hypoechoic bands, and those in 4 (4%) did not. The loss of inner hypoechoic band confirmed acute appendicitis with a sensitivity of 75%, a specificity of 96%, positive and negative predictive values of 89% and 90%, respectively, and an accuracy of 89%. The thickness of the inner hypoechoic band in patients without appendicitis was significantly higher than that in patients with appendicitis (p = 0.03). Conclusion: The visualization of entire thickened inner hypoechoic band in the appendiceal wall helps to rule out acute appendicitis. However, the loss of the inner hypoechoic band is suggestive of acute appendicitis. 목적: 소아에서 급성 충수염을 배제하거나 진단하는 기준으로써 충수 벽의 내측 저에코선이 유용한지를 알아보고자 하였다. 대상과 방법: 우 하복부 통증을 주소로 하여 초음파를 시행한 169명의 연속적인 환아들 중 충수를 발견할 수 있었던 149명을 대상으로 충수 벽의 내측 저에코선을 전향적으로 분석하였다. 내측 저에코선의 소실을 급성 충수염에 대한 진단기준으로 했을 때 민감도, 특이도, 양성예측도, 음성예측도 및 정확도를 구하였다. 결과: 급성 충수염이 있었던 환아의 12예(25%)에서 전장에 걸쳐 내측 저에코선이 보였고, 36예(75%)에서는 소실이 있었다. 반면, 급성 충수염이 없었던 환아 중 97예(96%)에서 전장에 걸쳐 내측 저에코선이 보였고, 단 4예(4%)만이 소실이 있었다. 급성 충수염을 진단하는 기준을 내측 저에코선의 소실로 했을 때 민감도 75%; 특이도 96%; 양성예측도 89%; 음성예측도 90%; 정확도 89%였다. 급성 충수염이 없었던 예의 내측 저에코선의 두께는 있었던 예보다 통계적으로 유의하게 두꺼웠다(p = 0.03). 결론: 우하복부 통증을 호소하는 환아의 초음파에서 충수 벽의 두꺼운 내측 저에코선이 전장에 걸쳐 관찰되는 것은 급성 충수염을 배제하는데 도움이 되었다. 그러나 내측 저에코선의 소실은 급성 충수염을 시사하는 소견이었다.

The role of neutrophil lymphocyte ratio to leverage the differential diagnosis of familial Mediterranean fever attack and acute appendicitis

( Adem Kucuk ),( Mehmet Fatih Erol ),( Soner Senel ),( Emir Eroler ),( Havvanur Alparslan Yumun ),( Ali Ugur Uslu ),( Asiye Mukaddes Erol ),( Deniz Tihan ),( Ugur Duman ),( Tevfik Kucukkartallar ),( Y 대한내과학회 2016 The Korean Journal of Internal Medicine Vol.31 No.2

Background/Aims: Familial Mediterranean fever (FMF) is an autosomal recessive disorder characterized by attacks of fever and diffuse abdominal pain. The primary concern with this presentation is to distinguish it from acute appendicitis promptly. Thus, we aimed to evaluate the role of neutrophil lymphocyte ratio (NLR) to leverage the differential diagnosis of acute FMF attack with histologically proven appendicitis. Methods: Twenty-three patients with histologically confirmed acute appendicitis and 88 patients with acute attack of FMF were included in the study. NLR, C-reactive protein and other hematologic parameters were compared between the groups. Results: Neutrophil to lymphocyte ratio was significantly higher in patients with acute appendicitis compared to the FMF attack group (8.24 ± 6.31 vs. 4.16 ± 2.44, p = 0.007). The performance of NLR in diagnosing acute appendicitis with receiver operating characteristic analysis with a cut-off value of 4.03 were; 78% sensitivity, 62% specificity, and area under the curve 0.760 (95% confidence interval, 0.655 to 0.8655; p < 0.001). Conclusions: This study showed that NLR, the simple and readily available in-flammatory marker may have a useful role in distinguishing acute FMF attack from acute appendicitis.

소아기 급성충수염의 임상적 고찰

유재홍 최신의학사 1993 最新醫學 Vol.36 No.9

비전형적인 증상을 가진 급성 충수염 의심환자의 진단에서 복부 컴퓨터 단층촬영의 역할

최인석,예병국,한군택,심문섭 대한대장항문학회 2002 Annals of Coloproctolgy Vol.18 No.3

급성 충수염으로 수술한 후 확진된 다른 장관질환

박월미,이연주,오미옥,홍순원,강중구,이홍수 大韓家庭醫學會 1994 Korean Journal of Family Medicine Vol.15 No.9-10

급성 충수염 환자에서 발생한 후복막 농양

장제호(Je Ho Jang),황기태(Ki-Tae Hwang),정중기(Jung Kee Chung),정인목(In Mok Jung),허승철(Seung Chul Heo),안영준(Young Joon Ahn),안혜성(Hye Seong Ahn) 대한외과학회 2010 Annals of Surgical Treatment and Research(ASRT) Vol.78 No.1

Although acute appendicitis is one of the most common surgical diseases, very rare but serious complications can occur including retroperitoneal abscess complicated by acute appendicitis. The early diagnosis of retroperitoneal abscess is often difficult and delayed because its clinical course is often insidious and does not present with typical symptoms of acute appendicitis. We experienced a 65-year-old male patient who was diagnosed with acute appendicitis with retroperitoneal abscess. As the retroperitoneal abscess was not fully removed via emergency operation, postoperative percutaneous drainage was performed but not effective. Retroperitoneal abscess can be cured by 2nd operation with retroperitoneal approach. We report here an unusual case of retroperitoneal abscess complicated by acute appendicitis.

Acute appendicitis after liver transplantation: A single center experience and review of the literature

Indah Jamtani,Sara Kim,Jeong-Moo Lee,Kwang-Woong Lee,Suk Kyun Hong,Kwangpyo Hong,Eui Soo Han,Nam-Joon Yi,Kyung-Suk Suh 한국간담췌외과학회 2020 Annals of hepato-biliary-pancreatic surgery Vol.24 No.1

Backgrounds/Aims: Acute appendicitis is one of the most common emergent disease in the general population requiring surgical treatment. However, only a few cases of appendicitis after liver transplantation (LT) were reported. We described experiences of acute appendicitis after LT in single center. Methods: From March 1988 to July 2019, we reviewed retrospectively all the patients who diagnosed with acute appendicitis after LT at the Seoul National University Hospital. We described and analyzed clinical outcomes of appendectomy after LT. Results: A total of 12 patients out of 2,237 LT patients underwent appendectomy due to acute appendicitis. The mean age was 48±12 years. Nine patients (75%) underwent deceased donor liver transplantation (DDLT) and three patients (25%) underwent living donor liver transplantation (LDLT). The mean days from transplantation to the onset of acute appendicitis was 739 (range 57-4,496) days. Every patients underwent appropriate appendectomy within 1 days after visiting hospital. Leukocytosis was seen in three patients (25%). Seven patients (58%) underwent laparoscopic appendectomy and five patients (42%) underwent open appendectomy. The total operative time was 47.5 (range 25–135) minutes. The median postoperative hospitalization was 4 (range 2-11) days. There was no postoperative complications documented. There was no significant difference of clinical outcomes between laparoscopic appendectomy group and open appendectomy group. Conclusions: Early surgical management achieved satisfactory postoperative results without graft dysfunction after LT. Laparoscopic appendectomy also could be applicable with safe and feasible outcomes even in post-LT recipients.

Diagnosis of Acute Appendicitis Using Scoring System

Bin Soo Kim,Dong Hee Ryu,Tae Hwa Kim,Il Ung Jeong,Jun Ho Song,Sung Il Cho,Jin Kweon Kim,Yong Sik Jeong,Sang Jeon Lee 대한외과학회 2010 Annals of Surgical Treatment and Research(ASRT) Vol.79 No.3

Purpose: This study evaluated the usefulness of a new scoring system in diagnosing acute appendicitis which expresses the patient’s symptoms, physical examination, and laboratory findings more clearly and objectively. Methods: A prospective study was conducted with 314 patients who were hospitalized with suspicion of acute appendicitis. After analyzing the symptoms, physical examination, and laboratory findings, 10 meaningful variables were selected, each of which were scored separately. The diagnostic value of the new scoring system was evaluated, and analyzed in comparison to the preexisting Alvarado score. Results: Ten variables including vomiting, migration pain, fever, Dunphy’s sign, Rovsing’s sign, tenderness, rebound tenderness, increased white blood cell counts, increased neutrophil proportion, and increased CRP levels were associated with acute appendicitis. The new scoring system is developed by applying 1 point for each variable, with a total score of 10 points. In the new scoring system, a score above 5 points had sensitivity of 0.75, specificity of 0.73, positive predictive value of 0.92, and diagnostic accuracy of 0.71. The area under the receiver operating characteristic curve was 0.80, which is larger than 0.72 of the preexisting Alvarado score, and thus has a higher diagnostic accuracy. As acute appendicitis progresses, the average score tends to become significantly higher (P=0.001). Conclusion: The new scoring system, which objectively reflects the clinical variables of the patient’s symptoms, physical examination and laboratory findings, will be useful in accurately diagnosing acute appendicitis and in quickly deciding a therapeutic policy in patients with right lower abdominal pain.

Intra-Appendiceal Air at CT: Is It a Useful or a Confusing Sign for the Diagnosis of Acute Appendicitis?

홍혜숙,조현숙,우지영,이열,양익,황지영,김한면,김정원 대한영상의학회 2016 Korean Journal of Radiology Vol.17 No.1

Objective: To investigate the significance of intra-appendiceal air at CT for the evaluation of appendicitis. Materials and Methods: We retrospectively analyzed 458 patients (216 men, 242 women; age range, 18–91 years) who underwent CT for suspected appendicitis. Two independent readers reviewed the CT. Prevalence, amount, and appearance of intra-appendiceal air were assessed and compared between the patients with and without appendicitis. Performance of CT diagnosis was evaluated in two reading strategies: once ignoring appendiceal air (strategy 1), and the other time considering presence of appendiceal air as indicative of no appendicitis in otherwise indeterminate cases (strategy 2), using receiver operating characteristic (ROC) analysis. Results: Of the 458 patients, 102 had confirmed appendicitis. The prevalence of intra-appendiceal air was significantly different between patients with (13.2%) and without (79.8%) appendicitis (p < 0.001). The amount of appendiceal air was significantly lesser in patients having appendicitis as compared with the normal group, for both reader 1 (p = 0.011) and reader 2 (p = 0.002). Stool-like appearance and air-fluid levels were more common in the appendicitis group than in the normal appendix for both readers (p < 0.05). Areas under the ROC curves were not significantly different between strategies 1 and 2 in reader 1 (0.971 vs. 0.985, respectively; p = 0.056), but showed a small difference in reader 2 (0.969 vs. 0.986, respectively; p = 0.042). Conclusion: Although significant differences were seen in the prevalence, amount, and appearance of intra-appendiceal air between patients with and without appendicitis, it has a limited incremental value for the diagnosis of acute appendicitis.