Best method of diagnosing appendicitis
Appendicitis is many diseases: recent posts on one best method of diagnosing appendicitis ignore something basic, which applies to surgical conditions generally. Here are some varieties of appendicitis which I hope others will recognise. [Level 5 or 6 evidence, i.e. anecdotage in my dotage, where dotage = failing older memory].
- – Classical abdo pain ->RIF, nausea, constipation, mild fever etc.
- – Variations if retrocaecal – masked tenderness, diarrhoea if retro-ileal, like left ureteric colic if inflamed tip of long appendix tickling left ureter [very rare – a case I missed over a weekend].
- – Young man who walks in, looks OK, mild features, gangrenous appx.
- – Appx abscess, mild features, presenting with established abscess
- – Violent pain plus other features, lily-white appendix. You protest to pathologist, and he obligingly finds “early appendicitis”.
- – Incidental appy, done in former years, pathologist reports “inflamed”.
- – Gangrenous appendix, history of milder similar attacks.
- – Normal appendix, history of mildere similar attacks.
This isn’t to try and excuse sloppy thinking or “open slather” but to ask for less dogmatism along the lines of one monolithic condition / one monolithic answer.
You can raise the same arguments about gall-stones, gastric ulcer, etc etc.
With breast cancer the spectrum runs from young woman with aggressive disseminated disease to old lady with Alzheimer’s and fibrotic little cancer which won’t do anything much, or which may surprise you by ulcerating if she survives two years.
But it’s more than one spectrum. It’s several different spectra, or several different axes, which may be quite independent of each other, or “orthogonal” to use part of the jargon of thinking in terms of systems and complexity.
Anyone medical can diagnose and treat the easy case of appendicitis. The difficult case will fool most of us at different times. What we need is some extra rules. One that I am learning is the Time Axis, which includes progress or response to treatment. In practical terms this means reviewing the possible appx case in 4-6 hours, or that evening or the next morning. When to review depends on the personal mental data base you build up over 2 years, 10 years, 30 years and learning of the data base built by others.
Somewhere in a cupboard I’ve got a slim book bought in a sale at a medical bookshop about 30 years ago called “The Seven Varieties of Appendicitis”. I remember one of the varieties proposed was Chronic Dyspepsia. Before others have an apoplectic fit, it’s not something I remember seeing, and I certainly acknowledge the bulldust factor in this area of discussion.
It is a nice belief but alas the Boston study punctures all such thoughts about the supremacy of the surgeon’s hands. The diagnostic accuracy of the surgeons in Boston was appallingly bad compared with the CT-scan which was 98 % correct. We can find all sorts of explanations for this difference but it is hard to deny the facts. What is needed is a RCT which compares the CT diagnosis with the clinical diagnosis. I just wonder if it is practical to do such a study.
It is true that the surgeons hands and mind do pick up virtually all clinically significant appendicitis and have them operated. Sometimes delayed.
There are several parallell problems involved. We wish, or at least some of us wish, to operate those with gangrene or perforation without delay and not at all operate those with spontaneously resolving appendicitis which takes care of itself without an operation.
You say that surgeons are capable of an accurate diagnosis in most all cases of appendicitis and there is enough evidence published in this respect. I am afraid this is not true. In most hospitals the surgeons operate 20-40% patients who turn out not to have appendicitis. And they also operate many more who do not need an operation despite a histological diagnosis of appendicitis.
Population statistics show that perforations (and therefore also gangrene) is stable over time periods, equal in different western societies, and equally common per population regardless of sex and age.
What is widely different is the incidence of operations for negative appendix and minor appendicitis. These operations have declined all over western societies from a maximum in the 1950s-1960s. For instance we now do only half of the number of appendectomies in my hosptital compared with 20 years ago. The population is the same. The perforations are the same. We have no reason to believe that appendicitis as such is less common. We just do not operate as readily as we used to.
The conclusion is obvious: Too many cases of minor appendicitis are operated still.
We all use the histological appendicitis as gold standard for the diagnosis. However there is controversy about mucosal inflammation and the diagnosis. If mucosal inflammation is accepted as diagnosis of appendicitis then more patients will have the diagnosis.
The conclusion is obvious: Histology is a graded diagnosis which fades into a degree of uncertainty. And, histology is not an indication post hoc for the operation. Pathologists should adopt a conservative histologic diagnosis. The gold standard becomes perhaps a bronze standard.
Returning to the CT diagnosis which was 98% accurate in Boston. It is far better than any clinician can provide. However, there was nothing in the article about criteria for the histological diagnosis. There was no population statistics. And it is simply not known if the CT diagnosis of appendicitis also is a clinical indication for an operation.
If I read the senses prevailing in the US correctly, a CT diagnosis or a histological diagnosis overtakes any clinical diagnosis. It will be construed as a clinical failure and cause for malpractice suite if a patient on clinical grounds is observed but subsequently should have a CT diagnosis or eventually an opertion with a histologic diagnosis of appendicitis.
So, we wish to re-establish the clinical diagnosis after this mortal CT-blow, it must be proven that clinicians can save more money by doing fewer operations and demanding fewer hospital days using their hands and minds than can the CT scan.
I can tell that a first requisite is that surgeons begin to ask the question: Who needs an operation for appendicitis? On this point surgeons must be more clever than the CT scan or the battle is lost.
I don’t think you could successfully be sued for subsequent diagnosis and treatment of unruptured appendicitis (unless the patient developed a later intra-abdominal abscess, but even this would be a stretch). What you can definitely be successfully sued for in the US is the subsequent diagnosis of a perforated appendicitis which lengthens hospital stay or more assuredly successfully (in the eyes of the plaintiffs lawyers) with major complications (pain, suffering, expense (usually above $250,000 in demonstrable expenses).
Despite that my experience in General Surgery is far less than most of the readers, I would like to say that I do agree with PO, because one of the main reasons for surgeon to have “hand” diagnosing less effective than diagnostic aids like CT is malpractice. Also, if all patients with such frequently encountered disease like appendicitis are each time referred to CT to prove or reject diagnosis, then how about the other much more difficult cases of abdominal catastrophy?
As far as I know there is only anecdotal evidence that CT scan or sonogram is not superior to pure “clinical” means, but this reminds me of a recent case, and I would like to hear your and others’ wisdom.
26 y.o. black male without significant PMH,PSH presented at our ER with complains of weakness, nausea, vomiting for 5 days. Pt denies abdominal pain. Vital signs stable, no orthostatic changes, afebrile. On PE patient has right lower quadrant tenderness on deep palpation. No guarding, no rebound, no indirect signs of appendicitis. WBC: 5,000, rest of labs is also within normal limits. At this point (please stay calm!) the ER doctor ordered a CT scan, which was read as consistent with appendicitis. (haziness of mesentery, some lymphnodes, some inflammatory changes at the iliocecal region (not Crohn’s) no contrast in appendix)
What would you do?
I would perform a laparoscopy and if the appendix was abnormal I would remove it. If not abnormal I would remove it only if it could be done easily with two applications of the Endo-GIA. Either way patient would probably go home in less than 36 hours.
I observe for a few hours and re-examine the patient.