Scandinavian Journal of Surgery **: *** ***, ****

ACUTE APPENDICITIS: THE RELIABILITY OF DIAGNOSIS

BY CLINICAL ASSESSMENT ALONE

V. Kalliakmanis1, E. Pikoulis2, I. G. Karavokyros2, E. Felekouras2, P. Morfaki3,

G. Haralambopoulou3, T. Panogiorgou1, E. Gougoudi2, T. Diamantis2,

A. Lepp niemi4, C. Tsigris2

Department of Surgery, Agrinion General Hospital, Agrinion, Greece

1

First Department of Surgery, Medical School, University of Athens, Athens, Greece

2

Department of Pathology Agrinion General Hospital, Agrinion, Greece

3

Department of Surgery, Meilahti Hospital, University of Helsinki, Finland

4

ABSTRACT

Background and Aims: This prospective study aimed to review the trustworthiness of

the initial clinical assessment in acute appendicitis without employment of imaging mo-

dalities, laparoscopy or any other adjunct diagnostic test.

Patients and Methods: 717 patients were operated on for appendicitis by six different

surgeons. Initial clinical and laboratory examination were evaluated in relation to the

intraoperative and the pathological appreciation of the appendiceal inflammation.

Results: 598 patients were found to have appendicitis, 34 a different condition, 41 had

both appendicitis and an additional condition and 44 no pathology. 6 % of the laparoto-

mies and 11 % of the appendectomies were unnecessary. The severity of the inflamma-

tion correlated significantly with periumbilical pain, pain migrating to right lower quad-

rant, loss of appetite, fever, rebound tenderness, local rigidity, polymorphonuclear pre-

dominance on deferential, polymorhonucleosis and leukocytosis. Leukocytosis was less

frequent in aged patients. All the six surgeons were found to be equally reliable, al-

though they all underestimated the setting compared to the pathologists. Patients with

a long duration of symptoms had milder forms of inflammation and increased percent-

age of unanticipated abdominal conditions.

Conclusions: Appendicitis can be reliably diagnosed clinically without employment

of adjunct tests. These can be reserved for equivocal cases.

Key words: Acute appendicitis; acute abdomen; acute appendicitis diagnosis

INTRODUCTION lead to appendiceal perforation with increased mor-

bidity and hospital stay (1 4). A safe alternative

seems to be appendectomy as soon as the condition

Diagnosing acute appendicitis clinically still remains

is suspected, a strategy that increases the number of

a common surgical problem (1). Accurate diagnosis

unnecessary appendectomies (4, 5). A timelier and

can be aided by additional testing or expectant man-

more accurate diagnosis has been attempted by the

agement or both. These might delay laparotomy and

employment of additional laboratory tests (6 12),

scoring systems (13 17), ultrasound imaging (18 20),

Correspondence:

CT Scan, (21 23) scintigraphy (24 27) MRI (28) and

I. G. Karavokyros, M.D.

laparoscopy (29 36). None of these methods stands

Anastasiou 12, Ampelokipoi

alone as they all come in support of, and are second-

115 24 Athens, Greece

ary to a primary clinical assessment.

Email: abqk2a@r.postjobfree.com

202 V. Kalliakmanis, E. Picoulis, I. G. Karavokyros et al.

Our aim in this prospective non randomized study tion was to compare the surgeons of this study only and

the scales were universally applied to them all; this error

was to review the initial diagnostic evaluation of sus-

may be overlooked. Similarly and for comparison reasons,

pected acute appendicitis by history, physical exam-

we calculated the deviation between the intraoperative and

ination and plain laboratory tests. Furthermore, we

the pathological assessment in each patient by subtracting

addressed to the relationship between the surgeon s one from the other. Obviously, in cases of coincidence the

intraoperative impression of appendiceal inflamma- subtraction outcome was zero, otherwise it ranged from 1

tion and its severity as assessed in histopathology. to 5. The subtraction outcomes of the patients treated by

each particular surgeon were summed up and named as

deviation score for this certain surgeon. We assessed

each surgeon s diagnostic accuracy by dividing the total

PATIENTS AND METHODS

number of patients treated by him with his deviation score .

Statistical comparison of the means of two samples was

This study included 717 patients who were admitted and performed by an F-test for variances and in continuity with

operated upon for acute appendicitis in a period of 48 t-test. Categorical data were analyzed by Chi-square. Cor-

months (January 2000 to December 2003) by the six sur- relation of variables was evaluated through Spearman s

geons of a rural hospital. All were appendectomized and rank Correlation Coefficient or Pearson s Correlation in

none was treated conservatively. We recorded the patient s cases of linear association.

sex, age, present and previous medical history, together

with the findings of clinical examination and laboratory

investigation. For a number of patients (almost half of those

RESULTS

reported as delayed presentations) surgical assessment

occurred while they were already hospitalized in non sur-

This study included a population of 717 patients (331

gical departments and under a presumptive treatment for

males and 386 females) with an age ranging from 8

different diagnosis. The symptoms and history of these

patients were sought in the standard manner; however we to 82 years-old (mean age 25,2 years old). The age

recorded the physical findings and laboratory values ob- and gender distribution are shown in Table 2 where

tained during the surgical assessment and not those of the it can readily be seen that the condition concerned

referring physicians . females of a younger age compared to males. Statis-

Special attention was paid on the signs of localized or

tical analysis of the male to female ratio between the

generalized peritoneal irritation i.e. Right Lower Quadrant

age groups demonstrated significant difference

(RLQ) tenderness, rebound tenderness, and muscle rigidi-

among the age groups (p

ty. Among the laboratory values we evaluated elevated

the relative frequencies of the commonest symptoms,

White Blood Cell Count (WBC > 1000 ml), Polymorphonu-

signs, and physical or laboratory findings that were

clear cell (PNM) predominance on smear deferential (PNM

present in each histopathological stage of the disease.

> 75 %), and elevated PNM absolute number (> 8000/ml).

Appendiceal inflammation was classified intraoperative- Histopathological severity correlated significantly

ly into six categories as appreciated by the surgeon; and (p 70 Total

Males 12-132-**-**-**-** 9 12 331

Females 09-210-**-**-**-** 6 09 386

717

Clinical diagnosis of acute appendicitis 203

TABLE 3

Relative frequencies of the symptoms, signs and laboratory findings in acute appendicitis classified according to the histological grading

of the inflammation.

Histopathological Severity Total Patients

1 2 3 4 5 6

Pain migrating to RLQ * 73.1 73.1 84.2 88.2 94.2 93.2 86.2 618

Loss of appetite * 35.9 52.7 50.9 53.6 75 71.2 59.0 423

Periumbilical pain * 53.8 38.7 55.3 58.3 71.2 63.6 58.6 420

Nausea 11.5 12.9 36.8 31.3 44.2 27.3 46.9 213

Upper abdominal pain 34.6 29 26.3 39.6 34.6 45.5 35.6 255

Fever * 26.9 41.9 36.8 54.2 51.9 54.5 33.5 336

Vomiting 11.5 12.9 36.8 41.3 44.2 27.3 29.7 240

RLQ tenderness 100 100 97.4 100 98.1 97.7 98.7 708

Rebound tenderness * 38.5 44.1 44.7 71.5 82.7 81.8 64.4 462

Local muscle rigidity * 3.8 6.5 10.5 22.9 26.9 38.6 20.5 147

Generalized rigidity 3.8 0 2.6 2.1 0 9.1 02.9 021

WBC > 10000/ml * 35.9 41.9 55.3 72.2 88.5 93.2 69.5 498

PMN > 8000/ml * 38.5 32.3 36.8 58.3 80.8 84.1 59.4 426

PMN > 75% * 34.6 35.5 28.9 62.5 75 70.5 54.8 393

* Correlation is significant at p 0.05).

As it can be seen in Table 6 intraoperative estima-

tion of the appendiceal inflammation differed sub-

stantially from the histopathological grading. It is

apparent that patients who according to the surgeon dominal condition responsible for the clinical picture.

had no (Stage 1) or mild appendicitis (Stage 2) were Finally, in 41 patients both appendiceal inflammation

in fact in a more severe setting than they were and a different intra-abdominal condition were met.

thought of. In proportion, those with histopatholog- In conclusion, 639 patients had appendicitis contrast-

icaly advanced appendicitis (stages 4 to 6) were in ing to 78 ones who had not. Unanticipated intra-ab-

reality in a milder condition. dominal conditions were met in 75 out of the 717 pa-

Table 7 summarizes all the laparotomy outcomes tients (10.46 %). As expected, the percentage of dif-

of the present study with their pathology confirma- ferent intra-abdominal conditions increased to 43.6 %

tions. In 44 out of the 717 appendectomized patients (p 72 hrs 39 (5.4) 06-21-03-03-003-** 69.2 %

Total 717 (69.9)

Clinical diagnosis of acute appendicitis 205

solely on history, physical examination and simple TABLE 9

laboratory tests and as our results indicate this tri- Various intra-abdominal situations met during appendectomy in cases

ple modality is effective and efficient in ordinary with delayed presentation (>72 hrs).

daily practice.

The prevailing sign of acute appendicitis in our Patients % in 39

study was RLQ tenderness; however it was of limit-

Intestinal perforation by foreign body 1 2.56

ed help as this sign is necessary for the diagnosis. Meckel s diverticulum 2 5.12

Our results support literature (13 15, 37) on the val- Ovarian Cyst 9 23.07

ue of rebound tenderness and RLQ rigidity because Crohn s disease 4 10.25

their frequency correlated significantly with the se- Mesenteric lymphadenitis 4 10.25

Carcinoid 1 2.56

verity of the inflammation. Similarly, we validated

the usefulness of leukocytosis, polymorphonucleosis Total 210 53.84

and PMN predominance on smear deferential (8 11);

and verified the lack of specificity of leukocytosis in

older patients (1, 38).

Resection of normal appendices in the general pop- probably intraoperatively even ten days after the

ulation after simple clinical assessment occurs in ap- onset of the setting (43). It seems therefore prudent

proximately 10 20 % of open appendectomies (8, 18, for the surgeon to exclude all possible different con-

22, 39, 40) and peaks to 18 38 % in the subpopula- ditions when the intraoperative findings are not im-

tion of fertile females (29 33). The various diagnos- pressive or when the patient reports a long history

tic adjuncts and especially laparoscopy decrease mis- and antibiotic treatment. On the other hand, if he

diagnosis, again mostly in fertile females (29 33). The proceeds into delayed laparotomy and meets evi-

present study did not employ any adjunct diagnos- dence of resolving inflammation, appendectomy

tic modality and was conducted on the general pop- must follow as the recurrence rate remains high (42,

ulation with fertile females being approximately half 43).

of the population included. Moreover all the partici- In conclusion clinical diagnosis of acute appendi-

pating surgeons appeared to be equally accurate in citis can be safely reached in most cases without ad-

their pre-operative diagnosis and intraoperative as- junct, sophisticated and costly testing. Careful con-

sessment. No difference existed in the percentage of sideration of the patient s history, physical signs and

mildly or severely inflamed appendices removed by plain laboratory evaluation will lead to reliable di-

each surgeon. Negative appendectomies amounted agnosis in nine out of ten conditions. Equivocal cas-

up to approximately 11 %, ranging well within the es may deserve special diagnostic tests in order to

literature when appendicitis is diagnosed clinically. avoid or to modify the surgical approach, however

Considering the various unanticipated intra-abdom- these should not become routine.

inal conditions necessitating therapeutic laparotomy,

unnecessary laparotomies approached 6 %. A further

decrease of negative explorations perhaps could have

REFERENCES

been achieved by imaging or adjunct testing. How-

ever, and in good agreement with others (16, 23, 40)

01. Harrison MW, Lindner DJ, Campbell JR, Campbell TJ: Acute

our results indicate that adjunct testing should not appendicitis in children: Factors affecting morbidity. Am J

become routine and be reserved for special occasions. Surg 1984;147:605 610

Exploratory laparoscopy in particular, although min- 02. Savrin RA, Clatworthy HW Jr: Appendiceal rupture: a con-

imally invasive, it remains an operation. A negative tinuing diagnostic problem. Pediatrics 1979;63:36 43

03. Scher KS, Coil JA: The continuing challenge of perforating

laparoscopy would spare the patient an appendec-

appendicitis. Surg Gynecol Obstet 1980;150: 535 538

tomy but not an operation. 04. Karakas SP, Guelfguat M, Leonidas JC, Springer S, Singh SP:

The two classification scales for the staging of ap- Acute appendicitis in children: comparison of clinical diag-

pendiceal inflammation employed in this study do nosis with ultrasound and CT imaging. Pediatr Radiol 2000;

30:94 98

not correspond to each other precisely. This can par-

05. Hoffmann J, Rasmussen OO: Aids in the diagnosis of acute

tially explain the diversity between the surgeon s and appendicitis. Br J Surg 1989; 76: 774 779

the pathologist s appreciation. On the other hand, 06. Oruc MT, Kulah B, Ozozan O, Ozer V, Kulacoglu, Turhan T,

underestimation of appendiceal inflammation by the Coskun F: The value of 5-hydroxyl indole acetic acid mea-

surement in spot urine in diagnosis of acute appendicitis. East

surgeon is well known (41) and supports our data.

African Med J 2004;81:40 41

All the surgeons enrolled underestimated the severe- 07. Taha AS, Grant V, Kelly RW: Urine analysis for interleukin-8

ly inflamed appendices. The observed overestimation in the non invasive diagnosis of acute and chronic inflamma-

of the mildly or non-inflamed ones is the outcome of tory diseases. Postgrad Med J 2003;79:159 163

proportion maintenance. 08. Asfar S, Safar H, Khourseed M, Dashti H, al- Bader A: Would

measurement of C-reactive protein reduce the rate of nega-

Unforeseen conditions were met in one out of ten tive exploration for acute appendicitis? JRColl Surg Edinb

patients. They have been responsible for the clinical 2000;45:21 24

picture in 43 % of the patients without acute appen- 09. Hallan S, Asberg A: The accuracy of C-reactive protein in di-

dicitis and in more than half of those operated late. agnosing acute appendicitis a meta analysis. Scan J Clin Lab

Invest 1997;57:373 80

Most patients of those with delayed operation have

10. Goodwin AT, Swift RI, Bartlett MJ, Fernando BS, Chadwick

already been pre-treated with antibiotics. This SJ: Can serum interleukin-6 levels predict the outcome of pa-

could have down-staged inflammation (42) but a di- tients with right iliac fossa pain? Ann R Coll Surg Engl 1997;

lated appendix can be detected sonographically and 79:130 133

206 V. Kalliakmanis, E. Picoulis, I. G. Karavokyros et al.

11. Vermeulen B, Morabia A, Unger PF: Influence of white cell 27. Wong DW, Vasinrapee P, Spieth ME, Cook RE, Ansari AN,

count on surgical decision making in patients with abdomi- Jones M Jr, Mandal A: Rapid detection of acute appendicitis

nal pain in the right lower quadrant. Eur J Surg 1995;161:483 with Tc-99m-labeled intact polyvalent human immune glob-

486. ulin. J Am Coll Surg 1997;185:534 543

12. Albu E, Miller BM, Choi Y, Lakhanpal S, Murthy RN, Gerst 28. Incesu L, Coskun A, Selcuk MB, Akan H, Sozubir S, Bernay F

PH: Diagnostic value of C-reactive protein in acute appendi- Acute appendicitis: MR imaging and sonographic correlation.

citis. Dis Colon Rectum 1994;37:49 51 AJR Am J Roentgenol 1997;168:316 318

13. Christian F, Christian GP: A simple scoring system to reduce 29. Larsson PG, Henriksson G, Olsson M, Boris J, Stroberg P,

the negative appendicectomy rate. Ann R Coll Surg Engl. 1992; Tronstad SE, Skullman S: Laparoscopy reduces unnecessary

74:281 285 appendicectomies and improves diagnosis in fertile women.

14. Eskelinen M, Ikonen J, Lipponen P: The value of history-tak- A randomized study. Surg Endosc 2001;15:200 202

ing, physical examination, and computer assistance in the 30. Lamparelli MJ, Hoque HM, Pogson CJ, Ball AB: A prospec-

diagnosis of acute appendicitis in patients more than 50 years tive evaluation of the combined use of the modified Alvara-

old. Scand J Gastroenterol 1995;30:349 355 do score with selective laparoscopy in adult females in the

15. Alvarado A: A practical score for the early diagnosis of acute management of suspected appendicitis. Ann R Coll Surg Engl

appendicitis. Ann Emerg Med 1986;15;557-***-****;82:192 195

16. Ohmann C, Franke C, Yang Q: Clinical benefit of a diagnostic 31. Bruwer F, Coetzer M, Warren BL: Laparoscopic versus open

score for appendicitis: results of a prospective interventional surgical exploration in premenopausal women with suspect-

study. German Study Group of Acute Abdominal Pain. Arch ed acute appendicitis Afr J Surg 2003;41:82 85

Surg 1999;134:993 996 32. Navarra G, Ascanelli S, Turini A, Carcoforo P, Tonini G, Poz-

17. Zielke A, Sitter H, Rampp T, Schafer E, Mobius E, Lorenz W, za E: Laparoscopic appendectomy versus open appendecto-

Rothmund M: Can diagnostic scoring systems help decision my in suspected acute appendicitis in female patients Ann Ital

making in primary care of patients with suspected acute ap- Chir 2002;73:59 63

pendicitis? Zielke Dtsch Med Wochenschr. 1999;124:545 550 33. Borgstein PJ, Gordijn RV, Eijsbouts QA, Cuesta MA: Acute

18. Douglas CD, Macpherson NE, Davidson PM, Gani JS: Ran- appendicitis a clear-cut case in men, a guessing game in

domised controlled trial of ultrasonography in diagnosis of young women. A prospective study on the role of laparosco-

acute appendicitis, incorporating the Alvarado score. BMJ py. Surg Endosc. 1997;11:923 927

2000;321:919 922 34. Laine S, Rantala A, Gullichsen R, Ovaska J: Laparoscopic ap-

19. Rettenbacher T, Hollerweger A, Gritzmann N, Gotwald T, pendectomy-is it worthwhile? A prospective, randomized

Schwamberger K, Ulmer H, Nedden DZ: Appendicitis: should study in young women. Surg Endosc 1997;11:95 97

diagnostic imaging be performed if the clinical presentation 35. Zaninotto G, Rossi M, Anselmino M, Costantini M, Pianalto

is highly suggestive of the disease? Gastroenterology 2002; S, Baldan N, Pizzato D, Ancona E: Laparoscopic versus con-

123:992 998 ventional surgery for suspected appendicitis in women. Surg

20. Zielke A, Hasse C, Sitter H, Rothmund M: Influence of ultra- Endosc 1995;9:337 340

sound on clinical decision making in acute appendicitis: a pro- 36. Olsen JB, Myren CJ, Haahr PE: Randomized trial on the value

spective study. Eur J Surg 1998;164:201 209 of diagnostic laparoscopy before appendectomy. Ugeskr

21. Lane MJ, Liu DM, Huynh MD, Jeffrey RB Jr, Mindelzun RE, Laeger 1995;157:584 585

Katz DS: Suspected acute appendicitis: nonenhanced helical 37. Alshehri MY, Ibrahim A, Abuaisha N, Malatani T, Abu-Eshy

CT in 300 consecutive patients. Radiology. 1999;213:341 346 S, Khairulla S, Bahamdan K: Value of rebound tenderness in

22. Walker S, Haun W, Clark J, McMillin K, Zeren F, Gilliland T: acute appendicitis. East Afr Med J 1995;72:504 506

The value of limited computed tomography with rectal con- 38. Lau WY, Fan ST, Yiu TF, Chu KW, Lee JMH: Acute appendi-

trast in the diagnosis of acute appendicitis. Am J Surg 2000; citis in the elderly. Surg Gynecol Obstet 1985;161:157 160

180:450 455 39. Martin LC, Puente I, Sosa JL, Bassin A, Breslaw R, McKenney

23. Hong JJ, Cohn SM, Ekeh AP, Newman M, Salama M, Leblang MG, Ginzburg E, Sleeman D: Open versus laparoscopic ap-

SD; Miami Appendicitis Group: A prospective randomized pendectomy. A prospective randomized comparison. Ann

study of clinical assessment versus computed tomography for Surg 1995;222:256 262

the diagnosis of acute appendicitis. Surg Infect (Larchmt) 40. Browder W, Smith JW, Vivoda LM, Nichols RL: Nonperfora-

2003;4:231 239. tive appendicitis: a continuing surgical dilemma. J Infect Dis

24. Rypins EB, Evans DG, Hinrichs W, Kipper SL: Tc-99m-HM- 1989;159:1088 1094

PAO white blood cell scan for diagnosis of acute appendicitis 41. Sarfati MR, Hunter GC, Witzke DB, Bebb GG, Smythe SH,

in patients with equivocal clinical presentation. Ann Surg Boyan S, Rappaport WD: Impact of adjunctive testing on the

1997;226:58 65 diagnosis and clinical course of patients with acute appendi-

25. Barron B, Hanna C, Passalaqua AM, Lamki L, Wegener WA, citis. Am J Surg 1993;166:660 665

Goldenberg DM: Rapid diagnostic imaging of acute, nonclas- 42. Eriksson S, Granstrom L: Randomized controlled trial of ap-

sic appendicitis by leukoscintigraphy with sulesomab, a tech- pendicectomy versus antibiotic therapy for acute appendici-

netium 99m-labeled antigranulocyte antibody Fab fragment. tis. Br J Surg 1995;82:166 169

LeukoScan Appendicitis Clinical Trial Group. Surgery. 1999; 43. Eriksson S, Tisell A, Granstrom L: Ultrasonographic findings

125:288 296 after conservative treatment of acute appendicitis and open

26. Colak T, Gungor F, Ozugur S, Bozan H, Yildiz A, Boz A, Ka- appendicectomy. Acta Radiol 1995;36:173 177

rayalcin B, Akaydin M, Melikoglu M: The value of 99mTc-

HMPAO labelled white blood cell scintigraphy in acute ap-

Received: January 10, 2005

pendicitis patients with an equivocal clinical presentation. Eur

Accepted: April 6, 2005

J Nucl Med 2001;28:575 580

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