Guest guest Posted July 18, 2004 Report Share Posted July 18, 2004 Wah! Wah! Mukunda! Tumhare Appendix da jawaab nahi! Kishore Shah 1974 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 19, 2004 Report Share Posted July 19, 2004 >>>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 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 19, 2004 Report Share Posted July 19, 2004 >>>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 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 19, 2004 Report Share Posted July 19, 2004 >>>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 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 20, 2004 Report Share Posted July 20, 2004 Yup,you are right Kishore,R/O appendicitis is definitely a part of the workup of all " Rt.Adnexal masses " which present with acute abdomen.....and is definitely best done on US.......(and i hope that clarifies Ashoks doubts too.)For some reason that point had totally slipped out of my mind........so can i say i'm not impressed anymore,but definitely admiring your thoroughness!!......) Neeti'86 > > > Well, it was quite educative to receive two contrasting mails to my > reply that I do Ultra Sonographies and rule out appendicitis. > > Ashok was shocked, and Neeti was impressed. > > I personally think that you should neither be shocked nor impressed. > Today, USG is an integral part of a Gynaec's diagnosis. In fact, with > the USG so close at hand, I am frightened that soon I may loose my > clinical skills as I rely more and more on the machine. > > I need to clarify to both of you that USG as a diagnostic tool was > discovered by Dr, Ian , a Gynaecologist. Ruling out appendicitis > is an essential part in confusing Pelvic Inflammations, Ovarian > torsions and Ectopic pregnancies. > > And, yes Neeti, I do appendicectomies too. It was my routine with all > abdominal Hysterectomies. However, nowadays, most of the > Hysterectomies that I do are Vaginal, hence there is no scope of > removing the appendix. The logic was that once the abdomen is opened, > it is best not to leave that troublesome part behind, unless your are > aiming at earning some more at a repeat surgery. > > I don't know about the US, but here in India, you need to know a > little about all your related branches. > > Naturally, I leave the complicated USGs to the radiologist. > > And Neeti, thanks for your informative write up. I agree with you. The > finger is better at diagnosing the appendicitis than the machine. Yes, > but as a Gynaec I have the advantage of using a USG machine, with > abdominal palpation, PV and PR too! Gives me an added edge, or should > I say, finger? > > Kishore Shah 1974 > > PS: Interestingly, my computer's spell check has suggested that I > replace Sonographies with Pornographies. Hmm! Not a bad idea! Quote Link to comment Share on other sites More sharing options...
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