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• W2110102754 abstract "My interest in the appendix was kindled early in my career, and the incident responsible probably put paid to any pretensions I might have had about being a surgeon. My consultant decided it was time for me, a young house surgeon, to perform my first operation. An otherwise healthy 18-year-old woman was admitted with classic symptoms and signs of appendicitis. At surgery I was confronted by totally unfamiliar anatomy. After poking around for a while, and becoming very worried about what I had done, my consultant, with a sigh, took over. About an hour later, with the original incision considerably enlarged, he had laid open a large infected retroperitoneal cyst that extended beyond our view, leaving the normal appendix alone. The patient became septicaemic and was later transferred to a specialist unit. We never found out the aetiology of this abnormality. This incident occurred before the advent of CT and MRI, and when ultrasound was in its infancy. Nowadays both the presence and origin of the cyst would have been identified pre-operatively by elegant cross-sectional imaging. If appropriate, percutaneous drainage would have been performed and the patient spared a disfiguring scar. But would, and should, that happen? Imaging of suspected appendicitis evokes polarized views. On the one hand there is the experienced surgeon who not only believes imaging causes unnecessary delay but who also accepts a negative appendectomy rate. Conversely there are those who are more cautious and believe that avoiding unnecessary laparotomies or laparoscopies is paramount. This issue is not trivial as it has considerable resource implications; if imaging of suspected appendicitis becomes the norm, this will be an even more common demand on out-of-hours imaging. A number of questions need to be asked; how accurate is imaging at detecting appendicitis, what technique should be used and, most importantly, what is the risk:benefit balance for imaging? There is now a wealth of accuracy data in the literature [1–9]. In the USA there is a strong consensus that CT is the best approach, with most arguments revolving around whether a complete abdominal and pelvic examination or just a ‘‘focused scan’’ should be performed, and whether oral, rectal or intravenous (iv) contrast should be given alone or in combination. In the UK and Europe there is greater emphasis on ultrasound. The fundamental issues concerning all imaging include whether there is a sufficiently low false negative rate to justify avoiding an operation, whether the inevitable delay caused by imaging adds to morbidity, and whether, for techniques involving radiation, the long-term radiation penalty is less than the potential risk of a missed diagnosis or unnecessary laparotomy or laparoscopy. There are special factors in paediatric patients with suspected appendicitis that need to be considered separately. A great deal of literature concerns patients outside the paediatric age group and caution needs to be taken in using these data for deciding management protocols in children. CT using modern helical scanners with 5 mm collimation and workstation review has an overall accuracy of 93–99% in diagnosing appendicitis [2, 3, 6–9]. Identification of a normal appendix is important in positively ruling out appendicitis, and this is achieved in most patients using CT (95–100%). In this issue of BJR, Ege et al [10] report a diagnostic sensitivity of 96%, specificity of 98% and false negative rate of 2% in 296 patients with suspected appendicitis, using no oral, iv or rectal contrast media. Accuracy may be lower in children, presumably owing to their size and paucity of intra-abdominal fat in comparison with adults. False negative rates are generally between 1% and 3% for CT and probably higher for ultrasound. The success of ultrasound in detecting a normal appendix is normally reported at a much lower rate than CT [11–15]. If one assumes that all patients with possible appendicitis will go to theatre unless imaging rules out the diagnosis, (and this is a big assumption as there is no doubt that the threshold for investigation drops when that investigation becomes easily available), then false positive rates are less important than false negative rates. On the whole, false positives rates are low for both ultrasound and Received 2 July 2002 and accepted 3 July 2002. The British Journal of Radiology, 75 (2002), 717–720 E 2002 The British Institute of Radiology" @default.
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• W2110102754 date "2002-09-01" @default.
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• W2110102754 title "Imaging of appendicitis: a cautionary note" @default.
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