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Imaging of Acute Appendicitis in Adults and Children

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Imaging of Acute Appendicitis in Adults and Children Diagnostic Imaging Imaging of Acute Appendicitis in Adults and Children Bearbeitet von Caroline KEYZER, Pierre Alain Gevenois 1. Auflage 2011. Buch. IX, 256 S. Hardcover ISBN 978 3 642 17871 9 Format (B x L): 19,3 x 26 cm Gewicht: 688 g Weitere Fachgebiete > Medizin > Sonstige Medizinische Fachgebiete > Radiologie, Bildgebende Verfahren Zu Inhaltsverzeichnis schnell und portofrei erhältlich bei Die Online-Fachbuchhandlung beck-shop.de ist spezialisiert auf Fachbücher, insbesondere Recht, Steuern und Wirtschaft. Im Sortiment finden Sie alle Medien (Bücher, Zeitschriften, CDs, eBooks, etc.) aller Verlage. Ergänzt wird das Programm durch Services wie Neuerscheinungsdienst oder Zusammenstellungen von Büchern zu Sonderpreisen. Der Shop führt mehr als 8 Millionen Produkte. Clinical Presentation of Acute Appendicitis: Clinical Signs—Laboratory Findings—Clinical Scores, Alvarado Score and Derivate Scores David J. Humes and John Simpson Contents Abstract Appendicectomy is the most commonly performed 1 Clinical Presentation ............................................... 14 emergency operation worldwide with a lifetime risk 1.1 History........................................................................ 14 of appendicitis of 8.6% in males and 6.7% in 15 1.2 Examination ............................................................... females (Flum and Koepsell 2002; Addiss et al. 2 Laboratory Investigations....................................... 16 1990). The diagnosis of acute appendicitis is 3 Scoring Systems ....................................................... 17 predominantly based on clinical findings (Humes 3.1 Alvarado Score or MANTRELS Score .................... 17 and Simpson 2006). Whilst a clinical diagnosis can 3.2 Other Scoring Systems.............................................. 17 often be made there are groups of patients in whom 3.3 Pediatric Appendicitis Score (Samuel Score) .......... 18 3.4 Scoring Systems and the Use of Radiological the clinical diagnosis is difficult and these patients Investigations ............................................................. 19 provide a degree of diagnostic uncertainty. Studies reporting the mortality associated with appendicitis 4 Difficult Diagnostic Areas ....................................... 19 4.1 Abscess ...................................................................... 19 have demonstrated a significant increase in mortal- 4.2 Mass ........................................................................... 19 ity associated with perforation (Blomqvist et al. 4.3 Pregnancy................................................................... 19 2001). The rate of perforation is reported to increase 4.4 Chronic or Neuroimmune Appendicitis.................... 20 by 5% per 12 h period 36 h after the onset of 5 Conclusion ................................................................ 20 symptoms, therefore, expedient diagnosis and treat- References.......................................................................... 20 ment are required (Bickell et al. 2006). High rates of negative appendicectomy (operation without histo- logical confirmation of appendicitis) have been reported with some groups such as females of reproductive age having rates of up to 26% (Flum et al. 2001). Delayed or incorrect diagnosis there- fore has both clinical and economic consequences (Flum and Koepsell 2002) and this has resulted in considerable research to identify clinical, laboratory and radiological findings that are diagnostic of appendicitis and the development of clinical scoring systems (some computer aided) to guide the clini- D. J. Humes (&) Á J. Simpson cian in making the correct diagnosis. Thus reducing Department of Surgery, NIHR Nottingham Digestive the delay in diagnosis and decreasing the rates of Disease Centre and Biomedical Research Unit, negative appendicectomy. There is evidence that Nottingham University Hospital NHS Trust, QMC Campus, E Floor, West Block, Derby Road, despite the introduction of new specialist tests that Nottingham, NG7 2UH, UK the diagnosis of appendicitis has not improved on a e-mail: [email protected] C. Keyzer and P. A. Gevenois (eds.), Imaging of Acute Appendicitis in Adults and Children, 13 Medical Radiology. Diagnostic Imaging, DOI: 10.1007/174_2011_211, Ó Springer-Verlag Berlin Heidelberg 2011 14 D. J. Humes and J. Simpson population level (Flum et al. 2001). This chapter Box 1 Differential diagnosis of acute appendicitis aims to outline the presentation, investigation and Surgical diagnosis of acute appendicitis. Acute cholecystitis Perforated peptic ulcer Intestinal obstruction 1 Clinical Presentation Pancreatitis Intussusception The clinical diagnosis of acute appendicitis relies Mesenteric adenitis upon a detailed history and thorough physical exam- Meckel’s diverticulitis ination. The differential diagnosis is that of the acute Colonic/appendicular diverticulitis abdomen as it can mimic the presentation of most Rectus sheath haematoma abdominal emergencies (Box 1). Urological Right ureteric colic 1.1 History Urinary tract infection Right pyelonephritis The principal presenting complaint of patients with Gynaecological acute appendicitis is abdominal pain. Murphy was the Ectopic pregnancy first to describe the sequence of colicky central Salpingitis/pelvic inflammatory disease abdominal pain followed by vomiting and migration of Ruptured ovarian follicle the pain to the right iliac fossa (Murphy 1904). This Torted ovarian cyst classical presentation is only seen in approximately Medical 50% of patients. The history of pain is usually 24 h of colicky peri-umbilical pain followed by migration of Pneumonia the pain to the right iliac fossa with a progression to a Gastroenteritis more constant severe pain (Wagner et al. 1996). This Diabetic ketoacidosis progression results from the initial pain being referred Terminal ileitis from the visceral innervation of the midgut followed by Porphyria more defined localization of the pain when the parietal Preherpetic pain on the right 10th and 11th dorsal nerves peritoneum is involved by the inflammatory process. Associated symptoms include loss of appetite and nausea but profuse vomiting is rarely a feature of simple appendicitis and may well represent the devel- opment of diffuse peritonitis following perforation. Box 2 Anatomical position of the appendix and possible Patients will often have a low grade fever. It is common changes in clinical presentation for patients to report no change in bowel habit but a Retrocaecal/Retrocolic (75%)—Right loin pain is often range of bowel habit disturbances may be associated present with tenderness on examination. Muscular rigidity and tenderness to deep palpation are often absent due to with the onset of pain. Cope reported that patients may protection from the overlying caecum. The psoas muscle may feel constipated and anticipate relief of pain with be irritated in this position leading to hip flexion and defecation but this does not occur (Cope 2000). exacerbation of the pain on hip extension (psoas stretch sign). The appendix can take a variety of anatomical Subcaecal and Pelvic appendix (20%)—Suprapubic pain and positions and as a result the clinical presentation is urinary frequency may predominate. Diarrhoea may be influenced by the surrounding structures that become present due to irritation of the rectum. Abdominal tenderness may be lacking but rectal or vaginal tenderness may be involved in the inflammatory process (Box 2). Those at present on the right. Microscopic haematuria and leucocytes the extremes of age often present a significant diag- may be present on urinalysis. nostic challenge as they may present with atypical Pre and Post-ileal (5%)—Signs and symptoms may be signs and symptoms (Paulson et al. 2003). Infants may lacking. Vomiting may be more prominent and diarrhoea due appear listless whilst the elderly may present with to irritation of the distal ileum. Clinical Presentation of Acute Appendicitis 15 confusion. A high index of suspicion is therefore tenderness, guarding and rigidity) (Andersson 2004) required to make the diagnosis in such cases. these were confirmed in a further systematic review A systematic review of the symptoms which are which demonstrated a LR += 4.0 for the presence of associated with acute appendicitis has revealed that rigidity (Wagner et al. 1996). two symptoms have a high positive likelihood ratio Findings on rectal or vaginal examination may be (LR+) when present for diagnosing acute appendici- normal although pain on the right on rectal exami- tis; a history of right lower quadrant pain (LR += 8.0, nation may indicate a pelvic appendix. A rectal 95% CI 7.3–8.5) and migration of initial periumbilical examination is part of a thorough assessment of the pain to the right lower quadrant (LR += 3.1, 95% CI patient with acute abdominal pain, however, the value 2.4–4.2) (Wagner et al. 1996). A further systematic of rectal examination in the diagnosis of appendicitis review and meta-analysis of studies of patients is debatable. In the presence of tenderness and admitted to hospital with suspected appendicitis guarding in the right iliac fossa in a study of 1,204 concluded that individual elements of the history were patients admitted to hospital with right lower quadrant of weak predictive value in the diagnosis of acute pain little extra information was gained. The presence appendicitis. Pain migration was the best individual of right sided pain on rectal examination was more predictor of acute appendicitis
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