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Young Women, Not Men, Require Pre-Surgical Imaging for Suspected Appendicitis: Presented at RSNA

By Ed Susman

CHICAGO, IL -- December 6, 2004 -- An evidence based treatment algorithm suggests that pre-surgical imaging is not necessary for young men suffering symptoms of acute appendicitis.

However, the treatment guideline developed by researchers at the Boston University Medical Campus, Boston, Massachusetts, United States, advises that young women undergo an ultrasound imaging screen before going to the operating room.

Sarah Bixby, MD, senior assistant resident, Boston University Medical Campus, said that 92% of the time clinician's physical examination of a young man with suspected appendicitis is accurate and therefore "young men can be sent straight to surgery without imaging."

In an oral presentation at the Radiological Society of North America 90^th Scientific Assembly and Annual Meeting, Dr. Bixby said that use of ultrasound to evaluate young women also gives a 92% accuracy rate. The accuracy in older men and women or in very thin patients requires evaluation with computed tomography (CT), she said.

When a pregnant woman presents with right side abdominal pain and other symptoms suggestive of appendicitis -- especially if the woman is in her first or second trimester -- Dr. Bixby said the decision tree becomes more extensive. Ultrasound is a good choice for assessing abdominal pain in early pregnancy but later in pregnancy magnetic resonance imaging (MRI) is more reliable.

The treatment algorithm was developed after scrutiny of 295 men and 205 women who underwent consecutive patients appendectomies, ranging in age from 2 days to 86 years. The average age was 30 years. The majority (280 patients) in the study under went CT evaluation prior to surgery; the next largest group (135 patients) had no screening; ultrasound was used to evaluate 70 patients and 15 were given a test with MRI.

Results show that 80% of patients who had surgery with no preoperative imaging had pathology-proven acute appendicitis; among men, the positive rate was 92%, she said. There were 70 patients who underwent appendectomy based on ultrasound alone; in this group, 70% were women (mean age 19 years). Fifty-nine patients had ultrasound studies that indicated appendicitis and "92% had pathology-proven appendicitis."

Among 151 men and 129 women who had CT evaluation prior to surgery, appendicitis was detected in 93% and the appendix was inflamed in 97%.

Among the 15 patients in the MRI group, 12 were positive for appendicitis. All of the MRI patients were women and seven were pregnant. "In all cases the MR diagnosis was correct," Dr. Bixby said.

During the discussion, Claude Sirlin, MD, assistant professor of interventional radiology, University of California, San Diego, United States, cautioned about sending young men to surgery without imaging.

"In the San Diego area we have a significant number of HIV-positive young men and I would be concerned about simply sending them to surgery on the basis of clinical evaluation," he said. He noted, too, that other conditions, including inflammatory bowel disease, can present with clinical symptoms very similar to acute appendicitis.


[Presentation title: "A Modern Algorithmic Approach to the Diagnosis of Acute Appendicitis Using Multi-Modality Imaging." Abstract SSC10-03]

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