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Disease Grading Systems in Emergency General Surgery

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Disease Grading Systems in Emergency General Surgery Eastern Association for the Surgery of Trauma 28th Annual Scientific Assembly Sunrise Session 12 Disease Grading Systems in Emerggency General Surgery January 16, 2015 Disney’s Contemporary Resort Lake Buena Vista, Florida Page 1 Disease Grading Systems in EGS Oliver Gunter MD MPH, Vanderbilt University Nathan Mowery MD, Wake Forest Medical Center Overview • Background of grading systems • AAST methodology • Sample case discussion – Appendicitis – Diverticulitis – Peptic ulcer disease • Controversies in disease grading The problem • EGS needs outcome data to further define it as a specialty • Outcome data will require standardization of the disease • Current grading systems to not address the acute disease process or do not fit into a standard nomenclature Page 2 What is the goal of grading system? • Clinical tool to guide therapy • Research tool • Create a language that everyone can share Requirments of a grading system • Must be universally applicable • Must be simple – May be radiologist or surgeon‐dependent • Fit the anatomic requirements, increasing severity Essentials of a EGS Grading System Page 3 Essentials of a EGS Grading System • Standard progression from minimal disease to fulminant disease • Granularity among levels of disease • Ability to classify non‐operative cases Process of creating a AAST system • Wanted a grade that just described the mechanical disease What to partner with a mechanical grade • Co‐morbidities • Charleson • Physiology • Apache • MODS? Page 4 Basic Format Chosen for mechanical disease grade Grade AAST Disease Grade Clinical and/or Imaging and/or Pathologic criteria Corresponding level of an Operative criteria endoscopic criteria existing system1 ILocal disease Confined to the organ Minimal abnormality II Local disease Confined to the organ Severe abnormality III Beyond the organ Locally advanced only IV Beyond the organ Regional extension VBeyond the organ Widespread involvement Diverticulitis -Hinchey • The Hinchey classification - proposed by Hinchey et al. in 1978[1] classifies a colonic perforation due to diverticular disease. • • Hinchey I - localised abscess (para-colonic) • • Hinchey II - pelvic abscess • • Hinchey III - purulent peritonitis (the presence of pus in the abdominal cavity) • • Hinchey IV - feculent peritonitis. Appendicitis • Case study Page 5 Anatomic description Imaging Appendicitis Imaging Criteria Grade Description Clinical Criteria Operative Criteria Pathologic Criteria (CT findings) Inflammatory changes Presence of neutrophils at Acutely inflamed appendix, Pain, elevated WBC and localized to appendix +/- Acutely inflamed the base of crypts, I intact RLQ tenderness appendiceal dilation +/- appendix, intact submucosa +/- in contrast non-filling muscular wall Appendiceal wall necrosis Mucosa and muscular Pain, elevated WBC and with contrast non- Gangrenous appendix, II Gangrenous appendix, intact wall digestion; not RLQ tenderness enhancement +/- air in intact identifiable on H&E appendiceal wall Above with local Gross perforation or focal Perforated appendix with Pain, elevated WBC and Above with evidence of III periappendiceal fluid +/- dissolution of muscular local contamination RLQ tenderness local contamination contrast extravasation wall Pain, elevated WBC and Perforated appendix with RLQ tenderness, may Regional soft tissue Above with abscess or IV periappendiceal phlegmon or have palpable mass, inflammatory changes, phlegmon in region of N/A abscess duration of history >X phlegmon or abscess appendix days Diffuse abdominal or Above with addition of Perforated appendix with pelvic inflammatory generalized purulent V Generalized peritonitis N/A generalized peritonitis changes +/- free intra- contamination away from peritoneal fluid or air appendix Page 6 Discussion • Disease grade? Perforated Gastric Ulcer • Case study Anatomic description Page 7 Imaging Perforated Peptic Ulcer Imaging Criteria Grade Description Clinical Criteria Operative Criteria Pathologic Criteria (CT findings) Discomfort in the Extraluminal gas with no Preservation of normal Perforation with minimal epigastric region associated inflammatory anatomy with dissection bowel wall inflammation Micro-perforation without chnages required to identify the I peritonitis perforation Tenderness confined to Extraluminal gas Presence of inflammation Perforation with bowel the right upper quadrant contained in a walled off and stigmata of wall inflammation Contained perforation with collection or the perforation with II localized peritonitis retroperitoneum contained collection Tenderness confined to Perforation with Inflammation and Perforation with bowel Perforation with localized the right upper quadrant associated collection that contamination of wall inflammation peritonitis and localized fluid is not contained in a peritoneal cavity confined III collection in lesser sac or anatomic space or abscess to the right upper right upper quadrant but not disseminated quadrant Diffuse peritonitis Perforation with Perforation with Perforation with bowel disseminated air and fluid disseminated succus or wall inflammation Free perforation with purulent peritonitis IV peritonitis Diffuse peritonitis Perforation with Perforation with Destructive erosion of Perforation with duodenal disseminated air and fluid disseminated succus or involved structures destruction ± penetration into with loss of local purulent peritonitis and V adjacent organs and anatomic planes at the site erosion into adjacent generalized peritonitis of perforation structures Discussion • Disease grade? Page 8 Diverticulitis • Case study Anatomic description Imaging Page 9 Diverticulitis Imaging Criteria Grade Description Clinical Criteria Operative Criteria Pathologic Criteria (CT findings) Colonic inflammation Pain Mesenteric stranding N/A N/A Elevated WBC count Colon wall thickening Minimal/No tenderness I Colon microperforation or Local tenderness (single Pericolic phlegmon Pericolic phlegmon Inflamed colon with pericolic phlegmon without or multiple areas) Foci of air (single or No abscess microscopic abscess No peritonitis multiple locations) perforation No abscess II Localized pericolic abscess Localized peritonitis Pericolic abscess Pericolic abscess Perforation III Distant and/or multiple Localized peritonitis at Abscess/phlegmon away Abscess/phlegmon away N/A abscesses multiple locations from the colon from the colon IV Free colonic perforation with Generalized peritonitis Free air and free fluid Perforation with generalized N/A generalized peritonitis fecal and purulent V contamination Discussion • Disease grade? Controversies in disease scoring Page 10 Validation of the Grading System • Inter‐observer reliability • Dependent on radiographic, anatomic, and pathologic analysis • Analogous to AAST Organ Injury Scale – Basis for multiple future studies ICD Mapping • Would be necessary if automated coding were to occur • Needs the ICD codes to deliver enough granularity to place the patients into mechanical grades • There exists the ability to petition ICD‐10 codes to refine the code definitions. Diverticulitis Clinical Imaging Criteria Operative Pathologic ICD-9-CM ICD-10-CM Grade Description Criteria (CT findings) Criteria Criteria Codes Codes Colonic Pain Mesenteric N/A N/A 562.11 or 562.13 K57.32 or K57.33 inflammation Elevated WBC stranding or K57.52 or count Colon wall K57.53 or K57.92 I Minimal/No thickening or K57.93 tenderness Colon Local tenderness Pericolic phlegmon Pericolic phlegmon Inflamed colon 562.11 or 562.13 K57.32 or K57.33 microperforation (single or multiple Foci of air (single No abscess with or K57.52 or or pericolic areas) or multiple microscopic K57.53 or K57.92 II phlegmon No peritonitis locations) perforation or K57.93 without abscess No abscess Localized Localized Pericolic abscess Pericolic abscess Perforation (562.11 or K57.20 or K57.21 pericolic abscess peritonitis 562.13) and or K57.40 or (567.22 or 569.5) K57.41 or K57.80 III or K57.81 Distant and/or Localized Abscess/phlegmon Abscess/phlegmon N/A (562.11 or K57.20 or K57.21 multiple peritonitis at away from the away from the 562.13) and or K57.40 or abscesses multiple locations colon colon (567.22 or 567.31 K57.41 or K57.80 IV or 567.38) or K57.81 Free colonic Generalized Free air and free Perforation with N/A (562.11 or K57.20 or K57.21 perforation with peritonitis fluid generalized fecal 562.13) and or K57.40 or generalized and purulent (567.21 or K57.41 or K57.80 V peritonitis contamination 567.29) or K57.81 Page 11 Applicable ICD codes ICD-9-CM code descriptions: 562.11 Diverticulitis of colon (without mention of hemorrhage) 562.13 Diverticulitis of colon with hemorrhage 567.21 Peritonitis (acute) generalized 567.22 Peritoneal abscess 567.29 Other suppurative peritonitis 567.31 Psoas muscle abscess ICD-10-CM code descriptions: K57.20 Diverticulitis of large intestine with perforation and abscess without bleeding K57.21 Diverticulitis of large intestine with perforation and abscess with bleeding K57.32 Diverticulitis of large intestine without perforation or abscess without bleeding K57.33 Diverticulitis of large intestine without perforation or abscess with bleeding K57.40 Diverticulitis of both small and large intestine with perforation and abscess without bleeding K57.41 Diverticulitis of both small and large intestine with perforation and abscess with bleeding K57.52 Diverticulitis of both small and large intestine without perforation or abscess without bleeding K57.53 Diverticulitis of both small and large intestine without perforation or
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