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Imaging for Acute Appendicitis

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1 Imaging for Acute Appendicitis
LT David Bruner LCDR Todd Parker Staff Emergency Physicians April 2009

2 Objectives Cases Imaging choices Reconsider Cases/Discussion
Consider what you would do Imaging choices US CT Non-contrast vs oral contrast vs rectal MRI Reconsider Cases/Discussion

3 Case 1 15 yo male - 1 day worsening abdominal pain
Periumbilical  migrated to RLQ Nausea, vomiting, anorexia, hurts to walk, no fever RLQ guarding / rebound / Heel Tap / Rovsing Labs: WBC – 8.9 H/H – 12/37 UA – 12 WBC, Pos Leuk Est, rare bacteria What imaging, if any?

4 Case 2 8 yo f - >24 hrs of worsening RLQ pain
Diarrhea and nausea, subjective fever Urinary frequency / abdominal pain with micturition T – P – BP – 108/62 RLQ TTP at McBurney’s point Guard/mild rebound UA Negative WBC – Pending

5 Case 3 37 yo man - 30 hours of worsening RLQ pain
N/V and Fever to 100.5 No urinary symptoms PMHx of kidney stones – but this is different Wife and daughter recently sick with N/V/D RLQ TTP with guarding and rebound UA Negative Does he need a CT? If so, what kind

6 Case 4 31 yo female - 2 days worsening pain
Epigastric at first, now only RLQ Nausea, subjective fever, menses No urinary symptoms Positive McBurney’s, Rovsing, Heel Tap No CMT or adnexal masses felt HCG negative, UA negative Imaging?

7 Case 4-1 Same as Case 4 except . . . . Imaging? No vaginal bleeding
HCG Positive ED US reveals IUP at 10 weeks Imaging?

8 Case 5 73 yo female 30 hours lower abdominal pain and nausea No vomiting /diarrhea, fever, bloody stool, or dysuria Hx of HTN Otherwise negative PMHx and PSHx Bilateral Lower Quad TTP R > L, mild guarding P – T – BP – 135/76

9 Clearly Imaging Reduces NAR
Wagner et al., Surgery. 2008; 144(2) Retrospective review of four-year time periods before and after frequent CT NAR decreased 16% to 6% NAR decreased mostly due to adult women No change in NAR with kids (8%) Adult male decreased from 9% to 5% (NSS) Adult women decreased 20% to 7% Guss et al., “Impact of Abdominal Helical CT on the Rate of Negative Appendicitis” JEM 2008; 34(1) Retrospective review of before and after frequent CT Decrease in NAR from 15.5% to 7.6% 12% CT rate before readily available, 81% after Acceptable Negative Appendectomy Rate (NAR)? Historically 10-20% Higher % acceptable in women and peds With increased imaging 5-10% NAR Significantly increased pre-operative CT From 32% to 95% - Wegner study Kim, K. et al, “The Impact of Helical CT on Negative Appendectomy Rate: A Multi-Center Comparison; JEM 2008; 34(1) CT Rate and NAR inversely related NAR decreased 20% to 6% Limited by no follow up on negative scans

10 Findings on US for appendicitis
Ultrasound Very safe! No radiation, no contrast required Sensitivity and Specificity: Adult - Sensitivity – 74-83%, Specificity – 93-97% Pediatrics – Sensitivity -88%, Specificity – 94% Variables: Body habitus, Location, Skill If can’t visualize – need to move on to the next step Findings on US for appendicitis Non-compressible appendix Appendix >6mm diameter Signs of perforation Free fluid Abscess

11 Computed Tomography High overall accuracy, Sens, Spec, NPV, and PPV
Available at all hours Risks: Radiation Contrast problems Allergic reactions Nephrotoxicity

12 Oral Contrast Cons Pros Large volume contrast
What if vomiting? If not, probably will Risk of aspiration Aren’t they NPO? Increases difficulty of assessing bowel wall 2 hour delay Delays surgical decision Risk of perforation 4-8 hrs to advance Sensitivity 94-98% / specificity 95-99% Alternative diagnoses May see extravasation Better if little intra- abdominal fat Fluid collections Comfort with reading contrasted vs non- contrasted

13 Rectal Contrast CT Gravity drip – little risk of perforation
Few minutes to perform scan As little as 15 minutes Accuracy equal to oral contrast No reported increased discomfort

14 Rectal contrast study 96/283 kids had rectal contrast 95% Sens and PPV
Berg ER, et al, Acad Emerg Med Oct; 13(10) Compared oral and rectal contrast CT in a randomized trial Showed decreased length of stay in the ED by one hour No increased patient discomfort between oral or rectal contrast Equal diagnostic accuracy. Stephen AE, et al., J Ped Surg. Mar 2003; 38(3) 96/283 kids had rectal contrast 95% Sens and PPV Missed cases still went to OR because of clinical scenario

15 Non-Contrast CT For diagnosis of appendicitis
No need to drink contrast – no delay No change in diagnostic accuracy with IV Contrast Sensitivity 94-98% Specificity – 95-99% Significant supporting evidence for non- contrast CT in suspected appendicitis

16 Lane MJ, et al, Radiology. 1999; 213
300 consecutive patients Non-contrast CT for appendicitis Compared with surgical pathology results 96% sensitive 99% specific 97% accuracy “Stacked the Deck”

17 Hoecker CC, et al, JEM. May 2005 Retrospective study 112 children
Atypical presentation (13% of total abd pain pts) CT’d without PO contrast (helical CT) 40% positive appendicitis rate Compared to those given PO contrast (prev studies) Equal sensitivity and specificity in both groups Overall 91% diagnostic accuracy

18 Lowe LH, et al., Am J Roent. Jan 2001
Retrospective cohort of 72 children with non-contrast CT (atypical PE) 97% sensitive (95% CI, %) 100% specific (95% CI, %) Only took 5 minutes to perform the study

19 Lowe, L. H., et al, Radiology 2001; 221
75 consecutive patients - non-contrast CT Atypical/Equivocal PE findings Compared residents’ and attendings’ reads Results: 91% agreement in reading studies 96% specificity and 88% accuracy in residents 98% specificity and 97% accuracy in attendings Attendings more confident of reads

20 Ege G, et al., Br J Radiology. 2002; 75
296 adults non-con CT for suspected appendicitis Equivocal Exams Only 45% positive for appendicitis Compared with surgical pathology or follow up 96% sens and 98% spec/ 97% PPV and 98% NPV Recommends non-con CT for diagnosis of appendicitis in adults Negative study requires observation or follow up

21 Anderson BA, et al, Am J Surg. Sep 2005
Study type # of studies Sens Spec Accuracy Rectal 5 97 Oral 2 83 95 92 Oral + Rectal 96 Oral + IV 7 93 NonCon 8 98 Oral vs None 92 vs 94 95 vs 97 92 vs 96 Systematic review of 23 studies (19 prospective, 4 retrospective) Over 3700 patients over 16 years old

22 IV Contrast Basak S, et al., J Clin Imag. 2002; 26.
Performed study without contrast then with contrast No difference in making the diagnosis with IV or no contrast Some even thought IV obscured the intra-abdominal structures Keyzer, C., et al, Am J Roent. August 2008 Equal agreement between resident and attending reads Equal ability to visualize the appendix

23 Alternative Diagnoses?
Likely the most compelling argument What are the data? No good head to head studies Plenty of data showing that both enhanced and unenhanced find alternative diagnoses Which is best?

24 Alternative Diagnoses in Non-Contrasted Studies
Malone, A. et al, Am J Roentgen 1993 35% alternative diagnosis Diverticulitis, Ovarian Cysts or masses, PID, IBD Lane MJ, et al, Radiology. 1999 21% alternative diagnosis Ureteral Calculi, Diverticulitis, Chron’s, Mesenteric Adenitis, Neoplasms Alternative diagnoses advocated by IV and Oral/Rectal contrast Epiploic appendagitis, diverticulitis, Meckel’s Torsion, gynecologic disorders, obstructive uropathy, RLL PNA How much advantage does contrasted vs non-contrasted study provide?

25 Why Scan at All? Kalliakmans V, et al., Scan J Surg. 2005; 94(3)
717 adults evaluated for appendicitis by 6 surgeons Normal practice patterns - recorded decisions 11% Negative appendectomy rate based on history, physical, and labs CT did not change diagnostic accuracy except in cases of atypical history and physical Recommends only using CT in equivocal cases

26 CT in Pediatrics Increased lifetime cancer risk
Less intra-abdominal fat Is a negative CT enough? Garcia K, et al, Radiology. Feb 2009 1139 pediatric cases over 4 years CT results compared to surgical pathology or follow up All except 8 had CT with IV contrast only NPV (non-visualized appendix) – 98.7% NPV (Visualized) – 99.8% NPV (Partially visualized) – 100%

27 What About MRI? Pros: No radiation and can do reconstructions
Cons: Cost, Time, not always available 24/7 Highly accurate, operator dependent Sensitivity 93-99% Specificity % Less robust evidence, but most studies show reliable and reproducible diagnostic accuracy Caution with gadolinium if pregnant

28 Pregnancy and Appendicitis
Pedrosa, I et al, Radiology. Mar 2006 51 consecutive pregnant pts suspicion for appendicitis Underwent MRI if US inconclusive 4 had appendicitis – MRI correctly dx all 3 inconclusive – clinically resolved spontaneously Sens – 100% / Spec – 93.6% / Accuracy – 94% Pedrosa, I et al, Radiology. Mar 2009 148 consecutive pregnant pts suspicion for appendicitis Underwent MRI, 140/148 had ultrasound first 14 had appendicitis – MRI correctly dx all, U/S 5/14 9 False-Positives Sens – 100% / Spec – 93% / PPV – 61% / NPV – 100% Same incidence as non-pregnant Questionable evidence of appendix moving out of RLQ Risk of surgery/anesthesia is less than risk of mortality to mother and fetus if appendicitis is missed or perforation occurs Want to avoid radiation risks to fetus – right? US may miss appendix in a different location MRI has good sensitivity and specificity in appendicitis

29 Cases What did you decide to do?

30 Case 1 – 15 yo male with 1 day of pain, migration, and peritonitis
No imaging – take to the OR Kalliakmans V, et al., Scan J Surg. 2005; 94(3 Guss DA, et al., JEM. 2008; 34(1) Wagner PL, et al., Surgery Aug; 144(2) All showed no improved negative appy rate for males with pre-operative CT scanning. “The routine use of CT for adult male and pediatric patients with a clinical picture suggestive of acute appendicitis should therefore be discouraged.”

31 Case 2 – 8 yo girl, 1 day of pain, peritoneal signs, fever
Actual case US done first Then an MRI was performed Then went to the OR Recommendation in this case US or straight to the OR CT vs MRI if still unsure

32 Another case 13 year old girl Ultrasound Positive Appy
Straight to the OR

33 Case 3 – 37 yo male, 36 hours of pain, RLQ ttp, fever, hx of stones
Non-contrast CT What if his WBC count was 19.5 with a left shift? No imaging To the OR?

34 Case 4 – 31 yo female, good exam, negative urine
Do you want to avoid radiation? Could start with US Could go directly to CT Little reason for MRI

35 Case 4-1 - Pregnant US first MRI vs CT Serial exams
Dose of radiation thought to be teratogenic and increase risk of cancer in fetuses is 50 mGy ACOG gives CT a level 2 recommendation - Must weigh risks and benefits Patel SJ, Reede DL, Katz DS, et al., RadioGraphics. 2007; McCollough CH, Schuler BA, Atwell TD, et al., Radiographics. 2007; 27: Ratnaplalan S, Bona N, Chandra K, American Journal of Roentgenography May; 182: American College of Radiology. ACoR bylaws. Reston, VA: American College of Radiology, 2005. ACOG Committee on Obstetric Practice. Guidelines for Diagnostic Imaging during Pregnancy. ACOG Committee Opinion no 299, September Obstetrics and Gynecology 2004; 104:

36 Case 5 – 73 yo woman Non-contrast CT What if her Creatinine is 2.2?
Does she need IV Contrast

37 Take home points Classic presentations do not require imaging
Reserve imaging for equivocal cases Abdominal CT estimated increase cancer risk 1 in 2000 CT not shown to decrease NAR in men and children Multiple studies suggest oral contrast provides no added value – no need to make them drink Consider US first for kids, women, and pregnant MRI is a reasonable alternative if available Can CT pregnant women safely – inform of risks Consider Informed Consent in certain cases

38 Discussion

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