Re: Re: Appendicitis

[Guest guest]

Dear Neeti,

(and other Radiologists - Raju?)

Now with the high frequency probes (7.5 mHz+), isn't it easier to

diagnose diseases of superficial structures like appendix and thyroid

/ testis?

Maybe, in the older days, clinical diagnosis was more reliable. But

with today's high definition machines and higher frequency flat

probes, USG has taken over the prime role.

I have a USG machine and we do rule out Appendicitis using the USG

machine.

Kishore Shah 1974

Re: Appendicitis

.............and despite knowing the fact that diagnosis

of appendicitis is best made clinically and the futility of USG

Neeti'86

[Guest guest]

WOW !

Thanks for the update...........that was thorough.

Also reassuring that we are still needed ( our clinical skills I mean )

<< " good patient history

coupled with clinical skills " >>

What with total body scan ads flooding the radio - We will tell you what all

diseases you are going to be afflicted with or may be afflicted with etc etc

Now we are very well trained in that at Sewagram especially with the paucity of

advanced radiologic proc in our time and/or absence of radiologists during our

time.

We just had the good old Xray and our own attendings to read them.

Ashok 1984 : ))

neeti_suri86 wrote:

>>>Now with the high frequency probes (7.5 mHz+),isn't it easier to

diagnose diseases of superficial structures like appendix and

thyroid / testis? Maybe, in the older days, clinical diagnosis was

more reliable. But with today's high definition machines and higher

frequency flat probes, USG has taken over the prime role.

I have a USG machine and we do rule out Appendicitis using the USG

machine.>>>

Dear Kishore,

I was expecting few surgeons to jump in and pounce upon

me in defence of their appendiceal practices but the question comes

from where you least expect it!!Wow!!!!Do you know how much i envy

you not only for your artistic talents but also for your uptodate

awareness on topics like USG...... and here we are talking not only

just the awareness but you are actually using those modalities to

rule out appendicitis? Whatelse are you upto,Kishore??Operating

appendicitis too??? Any more secrets???? BTW,are you doing CT scans

and MRIs too????....)

Now,coming back to your questions,yes,you are

absolutely right,it is easier to diagnose superficial structures

with higher freq probes,esp by using graded pressure techniques

(sensitivity increases if combined with doppler US)its possible to

diagnose a positive case of appendicitis,the criteria being

documenting a nonperistaltic,tubular structure of diameter> 6mm with

hyperechoic mesentery and hypoechoic lumen--suggestive of

inflammation.......but there are a few bigger IFs and BUTs to all

this----

1.As Ashok says,a negative study does not rule out the diagnosis of

appendicitis,so how good is that??

2.By the time an appendix meets the criteria to be given a

definitive diagnosis of appendicitis on USG----it should be

screaming and crying for deperate help--hey ,i'm inflamed don't

waste time and money,hurry take me to OR straight!What i mean is

clinical signs are so obvious that you don't need an ultrasound at

that stage.

3.Drawbacks of USG--a.Gases in the caecum

-b.Retrocecal appendix

-c.Early stages,when appendix not inflammed/

dilated enough--but its still appendicitis

-d.Noncooperative patient

-e.False positive....'coz inflammed ileum

i.e.ileitis can't be differentiated from appendicitis on USG.

-f.obese patients

4.Most of the studies done are on cases with high level of clinical

suspicion......with obvious clinical signs.

5.Literature doesn't suggest any different parameters for paediatric

population....so how specific is that trying to diagnose all cases

in a narrow criteria of lumen diameter>6mm...? its significance

increases even more in those borderline cases.....where other

diagnostic modalities are being called for 'coz of ambiguity of

clinical signs......!!

Any imaging solutions....?????? yes,these days(it wasn't

done in earlier days,though).....as Ashok puts it,Spiral CT with

contrast in the cecum with thinner sections is being done for its

higher sensitivity and specificity....but again the IFs/BUTs being---

radiation exposure in paediatric and pregnant patients and the cost

effectiveness of the procedure!!

So by all means even today,the diagnosing a case of

appendicitis continues to be on the basis of " good patient history

coupled with clinical skills " of an expert surgeon......even though

i would doubt hopping on Rt.foot and asking for appetite are the

good criterias for doing so as Ashok says,residents at his hospital

were doing it.

And to answer your question,Kishore/Ashok,no neither USG nor CT

scan are the investiations of choice for diagnosing/ruling out a

case of appendicitis.......clinical diagnosis is still the most cost

effective Gold Std.

Neeti'86

------------------------------

Website: www.mgims.org

------------------------------

[Guest guest]

WOW !

Thanks for the update...........that was thorough.

Also reassuring that we are still needed ( our clinical skills I mean )

<< " good patient history

coupled with clinical skills " >>

What with total body scan ads flooding the radio - We will tell you what all

diseases you are going to be afflicted with or may be afflicted with etc etc

Now we are very well trained in that at Sewagram especially with the paucity of

advanced radiologic proc in our time and/or absence of radiologists during our

time.

We just had the good old Xray and our own attendings to read them.

Ashok 1984 : ))

neeti_suri86 wrote:

>>>Now with the high frequency probes (7.5 mHz+),isn't it easier to

diagnose diseases of superficial structures like appendix and

thyroid / testis? Maybe, in the older days, clinical diagnosis was

more reliable. But with today's high definition machines and higher

frequency flat probes, USG has taken over the prime role.

I have a USG machine and we do rule out Appendicitis using the USG

machine.>>>

Dear Kishore,

I was expecting few surgeons to jump in and pounce upon

me in defence of their appendiceal practices but the question comes

from where you least expect it!!Wow!!!!Do you know how much i envy

you not only for your artistic talents but also for your uptodate

awareness on topics like USG...... and here we are talking not only

just the awareness but you are actually using those modalities to

rule out appendicitis? Whatelse are you upto,Kishore??Operating

appendicitis too??? Any more secrets???? BTW,are you doing CT scans

and MRIs too????....)

Now,coming back to your questions,yes,you are

absolutely right,it is easier to diagnose superficial structures

with higher freq probes,esp by using graded pressure techniques

(sensitivity increases if combined with doppler US)its possible to

diagnose a positive case of appendicitis,the criteria being

documenting a nonperistaltic,tubular structure of diameter> 6mm with

hyperechoic mesentery and hypoechoic lumen--suggestive of

inflammation.......but there are a few bigger IFs and BUTs to all

this----

1.As Ashok says,a negative study does not rule out the diagnosis of

appendicitis,so how good is that??

2.By the time an appendix meets the criteria to be given a

definitive diagnosis of appendicitis on USG----it should be

screaming and crying for deperate help--hey ,i'm inflamed don't

waste time and money,hurry take me to OR straight!What i mean is

clinical signs are so obvious that you don't need an ultrasound at

that stage.

3.Drawbacks of USG--a.Gases in the caecum

-b.Retrocecal appendix

-c.Early stages,when appendix not inflammed/

dilated enough--but its still appendicitis

-d.Noncooperative patient

-e.False positive....'coz inflammed ileum

i.e.ileitis can't be differentiated from appendicitis on USG.

-f.obese patients

4.Most of the studies done are on cases with high level of clinical

suspicion......with obvious clinical signs.

5.Literature doesn't suggest any different parameters for paediatric

population....so how specific is that trying to diagnose all cases

in a narrow criteria of lumen diameter>6mm...? its significance

increases even more in those borderline cases.....where other

diagnostic modalities are being called for 'coz of ambiguity of

clinical signs......!!

Any imaging solutions....?????? yes,these days(it wasn't

done in earlier days,though).....as Ashok puts it,Spiral CT with

contrast in the cecum with thinner sections is being done for its

higher sensitivity and specificity....but again the IFs/BUTs being---

radiation exposure in paediatric and pregnant patients and the cost

effectiveness of the procedure!!

So by all means even today,the diagnosing a case of

appendicitis continues to be on the basis of " good patient history

coupled with clinical skills " of an expert surgeon......even though

i would doubt hopping on Rt.foot and asking for appetite are the

good criterias for doing so as Ashok says,residents at his hospital

were doing it.

And to answer your question,Kishore/Ashok,no neither USG nor CT

scan are the investiations of choice for diagnosing/ruling out a

case of appendicitis.......clinical diagnosis is still the most cost

effective Gold Std.

Neeti'86

------------------------------

Website: www.mgims.org

------------------------------

[Guest guest]

Thanks Dr Kalantri.

You are able to retrieve relevant articles so fast....it feels that you have all

articles stored in your computer !!

Its an art and also needs one to be so studious !!

Proud student,

Ashok 1984

Dr SP Kalantri wrote:

Dear Raju,

Here is a summary of recent article that deals with diagnostic accuracy for

radio-imaging. JAMA few years back published an extremely useful article

that evaluated the diagnostic accuracy of history and physical examination

for diagnosing appendicitis. I shall retrieve the article from the library

today and shall get back to you soon.

SP

Appendicitis: evaluation of sensitivity, specificity, and predictive values

of US, Doppler US, and laboratory findings.

Kessler N, Cyteval C, Gallix B, Lesnik A, Blayac PM, Pujol J, Bruel JM,

Taourel P.

Department of Radiology, Lapeyronie Hospital, France. [Radiology. 2004 Feb;

230(2):472-8]

PURPOSE: To evaluate the sensitivity, specificity, negative predictive value

(NPV), and positive predictive value (PPV) of ultrasonography (US), Doppler

US, and laboratory findings in the diagnosis of appendicitis. MATERIALS AND

METHODS: A total of 125 consecutive patients suspected of having

appendicitis were prospectively included for US appendiceal (diameter

enlarged to 6 mm or greater, intraluminal fluid, lack of compressibility)

and periappendiceal (periileal inflammatory changes, cecal wall thickening,

periileal lymph nodes, peritoneal fluid) evaluation, Doppler US evaluation

(appendiceal wall signal), and laboratory assessment (leukocytosis,

C-reactive protein [CRP]). Definite diagnoses were established at surgery in

61 patients, at endoscopy with biopsy in two patients, and at clinical

follow-up in 62 patients. RESULTS: The prevalence of appendicitis was 46%.

The appendix was identified with US in 86% of the patients, which included

96% of patients with and 72% of patients without appendicitis. The most

accurate appendiceal finding for appendicitis was a diameter of 6 mm or

larger, with a sensitivity, specificity, NPV, and PPV of 98%. The lack of

visualization of the appendix with US had an NPV of 90%. The most accurate

periappendiceal finding of appendicitis was the presence of inflammatory fat

changes, with an NPV of 91% and a PPV of 76%, whereas other findings had

both NPV and PPV less than 65%. An increase in both white blood cell (WBC)

count and CRP level had a PPV of 71%, whereas combined normal WBC count and

CRP value had an NPV of 84%. CONCLUSION: A threshold 6-mm diameter of the

appendix under compression is the most accurate US finding for appendicitis

and has high NPV and PPV.

Re: Appendicitis

>

>

> ............and despite knowing the fact that diagnosis

> of appendicitis is best made clinically and the futility of USG

>

> Neeti'86

>

>

>

>

>

>

> ------------------------------

> Website: www.mgims.org

> ------------------------------

>

>

>