Computed Tomography-Based Clinical Diagnostic Pathway for Acute Appendicitis: Prospective Validation

Jared L. Antevil, Louis Rivera, Bret J. Langenberg, George Hahm, Michael A. Favata, Carlos V R Brown

Research output: Contribution to journalArticle

33 Citations (Scopus)

Abstract

Background: Despite our regular use of CT for suspected appendicitis, a recent study at our institution demonstrated a negative appendectomy (NA) rate similar to our rate 15 years earlier. Based on analysis of this data, a diagnostic pathway was implemented prospectively for adult patients with possible appendicitis. Study design: Rates of CT, NA, and perforation for nonpregnant patients over 14 years of age undergoing appendectomy between August 2001 and August 2002 (PRE) were compared with prospectively collected pathway data (PATH, August 2004 to August 2005). All PATH patients were evaluated by a surgeon before CT. All females underwent CT. CT was obtained in male patients with low suspicion or pain for longer than 48 hours. After negative CT, patients were discharged from the emergency department or admitted for observation. Results: There was a substantial decrease in NA rate after implementation of the pathway (4% PATH [8 of 183] versus 16% PRE [31 of 196], p < 0.001), without a change in the rate of perforation (11% PATH [20 of 175] versus 8% PRE [13 of 165], p = 0.28) or frequency of preoperative CT (59% PATH [108 of 183] versus 60% PRE [118 of 196], p = 0.84). Conclusions: Frequent appendiceal CT alone does not ensure surgical diagnostic accuracy. CT need not be used in all patients to achieve very low NA rates. An evidence-based diagnostic algorithm incorporating early surgical evaluation, objective criteria for preoperative CT, deterrence of early operation after negative CT, and use of CT to facilitate safe discharge led to substantial improvements in the care of our adult population presenting with possible appendicitis.

Original languageEnglish (US)
Pages (from-to)849-856
Number of pages8
JournalJournal of the American College of Surgeons
Volume203
Issue number6
DOIs
StatePublished - Dec 2006

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Critical Pathways
Appendicitis
Appendectomy
Tomography
Hospital Emergency Service
Observation
Pain
Population

ASJC Scopus subject areas

  • Surgery

Cite this

Computed Tomography-Based Clinical Diagnostic Pathway for Acute Appendicitis : Prospective Validation. / Antevil, Jared L.; Rivera, Louis; Langenberg, Bret J.; Hahm, George; Favata, Michael A.; Brown, Carlos V R.

In: Journal of the American College of Surgeons, Vol. 203, No. 6, 12.2006, p. 849-856.

Research output: Contribution to journalArticle

Antevil, Jared L. ; Rivera, Louis ; Langenberg, Bret J. ; Hahm, George ; Favata, Michael A. ; Brown, Carlos V R. / Computed Tomography-Based Clinical Diagnostic Pathway for Acute Appendicitis : Prospective Validation. In: Journal of the American College of Surgeons. 2006 ; Vol. 203, No. 6. pp. 849-856.
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abstract = "Background: Despite our regular use of CT for suspected appendicitis, a recent study at our institution demonstrated a negative appendectomy (NA) rate similar to our rate 15 years earlier. Based on analysis of this data, a diagnostic pathway was implemented prospectively for adult patients with possible appendicitis. Study design: Rates of CT, NA, and perforation for nonpregnant patients over 14 years of age undergoing appendectomy between August 2001 and August 2002 (PRE) were compared with prospectively collected pathway data (PATH, August 2004 to August 2005). All PATH patients were evaluated by a surgeon before CT. All females underwent CT. CT was obtained in male patients with low suspicion or pain for longer than 48 hours. After negative CT, patients were discharged from the emergency department or admitted for observation. Results: There was a substantial decrease in NA rate after implementation of the pathway (4{\%} PATH [8 of 183] versus 16{\%} PRE [31 of 196], p < 0.001), without a change in the rate of perforation (11{\%} PATH [20 of 175] versus 8{\%} PRE [13 of 165], p = 0.28) or frequency of preoperative CT (59{\%} PATH [108 of 183] versus 60{\%} PRE [118 of 196], p = 0.84). Conclusions: Frequent appendiceal CT alone does not ensure surgical diagnostic accuracy. CT need not be used in all patients to achieve very low NA rates. An evidence-based diagnostic algorithm incorporating early surgical evaluation, objective criteria for preoperative CT, deterrence of early operation after negative CT, and use of CT to facilitate safe discharge led to substantial improvements in the care of our adult population presenting with possible appendicitis.",
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