(PDF) Acute Appendicitis

ACUTE APPENDICITIS The Professional Medical Journal www.theprofesional.com ORIGINAL PROF-3013 DOI: 10.17957/TPMJ/15.3013 ACUTE APPENDICITIS; EFFICACY OF COMPLETE CLINICAL EVALUATION AND MODIFIED ALVARADO SCORING SYSTEM IN DIAGNOSE Dr. Khawar Saeed Jamali1, Dr. Humaid Ahmed2, Dr. Muhammad Jawed3, Dr. Ubedullah Shaikh4 1. MBBS, MCPS, FCPS Associate Professor of Surgery ABSTRACT… Objectives: The objective of this study was to compare the efficacy of Clinical Civil Hospital Karachi Evaluation and modified Alvarado scoring system in diagnosing acute appendicitis. Study 2. MBBS, MCPS, FCPS Design: Cross sectional study. Place and Duration of Study: This study was conducted at Assistant Professor of Surgery Civil Hospital Karachi Surgical Unit III of Civil Hospital Karachi from May 2010 to October 2010. Methodology: This 3. MBBS, FCPS, FRCS study consisted of eighty patients. Patients were divided in two groups. Group A for complete Assistant Professor Surgery & clinical evaluation comprising of 40 patients and Group B for modified Alvarado scoring system Bariatric Surgeon comprising of 40 patients. Inclusion criteria were all patients presenting with RIF pain, nausea, Surgical Unit-I Dow University Hospital OJHA vomiting, fever and/or anorexia, diagnosed as having acute appendicitis preoperatively and Campus Karachi undergoing emergency appendectomy during this period, age >12 years and both gender. 4. MBBS, (M.S General Surgery) Exclusion criteria included not willing for surgery, General anesthesia problem, pregnant female Senior Medical Officer Surgical Unit-I patients and those who did not give written consent. Results: A total of 80 patients were included Dow University Hospital OJHA in the study, placed alternatively into two groups of 40 patients each with majority being male Campus Karachi (n = 61, 76.3%). The mean age was 22.46 years. The positive predictive value for patients of Group A was 92.5% while for Group B was 77.5%. When diagnostic accuracy was compared on Correspondence Address: Dr. Khawar Saeed Jamali the basis of Gender for the two groups, the positive predictive value for male patients of Group Associate Professor of Surgery A and B was 90.09% and 89.28% respectively, but for females the positive predictive value B-302, “Mehran Heights”, Block 8 of Group A and B was 100% and 50% respectively. Conclusion: We conclude that modified Main Clifton Road, Karachi

Alvarado score can be used safely and effectively in diagnosing acute appendicitis in adult males especially as the score increases from seven to nine. Article received on: 08/07/2015 Key words: Acute appendicitis, clinical diagnosis, modified Alvarado score. Accepted for publication: 00/00/2015 Received after proof reading: Article Citation: Jamali KS, Ahmed H, Jawed M, Shaikh U. Acute appendicitis; efficacy of 00/00/0000 complete clinical evaluation and modified alvarado scoring system in diagnose. Professional Med J 2015;22(12):1601-1605. DOI: 10.17957/ TPMJ/15.3013 INTRODUCTION quent complications must be weighed against re- With a lifetime cumulative incidence of 8.6% and moval of a normal appendix in patients with other 6.7% for men and women, respectively, appendi- causes of abdominal pain.4 citis is the most frequent abdominal emergency.1 surgical teaching has advocated early appen- Subsequent complications basically occur due dectomy.2 The diagnosis of acute appendicitis is to delayed or even missed diagnosis.5 Even af- mostly made on clinical grounds. Typically, a pa- ter a few hours, gangrenous appendicitis with tient presents with pain in RIF which starts initially impending perforation can develop5 thereby in- in paraumblical region and then shifts to RIF. The creasing morbidity and mortality. At the other ex- pain is colicky in nature, followed by nausea and treme, significant clinical and financial costs are vomiting, and associated with anorexia and py- incurred by patients undergoing negative appen- rexia. Muscle guarding, rebound tenderness and dectomy during treatment of presumed appen- cough sign in the RIF present important signs in dicitis. These facts have to be considered when the clinical diagnosis of acute appendicitis.3 evaluating system level interventions to improve the management of appendicitis.6 In general, it However, despite more than a hundred years of is accepted that unnecessary surgery should be experience, accurate diagnosis still evades the avoided7 as surgery in itself is associated with its surgeon and avoiding perforation and subse- own morbidity and mortality. Professional Med J 2015;22(12): 1601-1605. www.theprofesional.com 1601 ACUTE APPENDICITIS 2 Diagnosis of acute appendicitis can become a dectomy during this period. These patients were cause of great confusion for the attending sur- divided into Group A: Those patients diagnosed geon.8 The main reason for this is its protean with acute appendicitis on the basis of complete manifestations, which may simulate almost any clinical evaluation by consultant. Group B: Those other acute abdominal illness and in turn may be patients diagnosed with acute appendicitis on mimicked by a variety of other conditions.9 the basis of Modified Alvarado Scoring System. All patients presenting with pain in right iliac Several studies in the past have advocated a fossa, nausea, vomiting, fever and/or anorexia structured data form for better assessment of and having final diagnosis of acute appendicitis acute appendicitis8,10 so that diagnosis of acute above the age of 12 years, who were aware of appendicitis is not delayed due to doctor’s inex- the study and gave written consent to participate perience or lack of necessary investigations while in the study were included in this study. Those other studies have annulled their value and have who were unfit for general anesthesia, those who concluded that a complete clinical evaluation did not give written consent and pregnant female is superior to these structured data forms.11,12,13 patients were excluded from the study. The modified Alvarado scoring system is one such structured data form that combines a few For Group A, a complete clinical evaluation based signs and symptoms of patients along with only on the traditional history and physical examina- one laboratory investigation to allow quicker di- tion was performed and reviewed by the consul- agnosis of acute appendicitis. Alvarado in 1986 tant on call, the Performa being filled while the proposed his scoring system to diagnose acute patient evaluation was ongoing. For Group B, all appendicitis on the basis of certain clinical pa- 7 parameters of modified Alvarado scoring sys- rameters.14 This was later modified by Kalan et al tem were assessed and recorded to reach a final who excluded one of the parameters, DLC, and diagnosis of acute appendicitis. Investigations thus created the modified Alvarado score.15 Its were carried out in both groups. In Group A, they usefulness in reducing the rate of negative ap- were only done for anesthesia purposes and did pendectomies has been established and refuted not have influence on diagnosis while for Group in different studies.14 B only leukocytosis was considered as it is part of the modified Alvarado score. All these patients The aim of this study was to compare the efficacy underwent emergency appendectomy on the ba- of complete clinical evaluation, based on tradi- sis of above evaluations and their final diagnosis tional clinical methods including complete clinical was confirmed by histo pathological report, the history and physical examination, with that of the results of which were recorded when the patient modified Alvarado’s scoring system in the diag- came for his/her follow up. nosis of acute appendicitis in order to find out if such a score should be used for early diagnosis RESULTS of acute appendicitis, and hence not only avoid Out of the 80 patients, the majority was found to the significant mortality and morbidity associated be male (Fig-1). For all patients, the mean age with delay, but also avoid unnecessary operations was found to be 22.46+ 9.38 years, Most of the and its associated clinical and financial burden. patients were between 13 to 20 years of age (Fig- 2). MATERIAL & METHODS This study was conducted at Surgical Unit III of For patients of Group A, who underwent diagno- Civil Hospital Karachi from May 2010 to October sis by complete clinical evaluation, 37 (92.5%) 2010. All patients presenting with right iliac fos- patients were found to have acute appendicitis on sa pain, nausea, vomiting, fever and/or anorex- histopathological diagnosis. For Group B, evalu- ia, diagnosed as having acute appendicitis pre- ated by modified Alvarado score, 31 (77.5%) pa- operatively and undergoing emergency appen- tients were found to have a positive diagnosis (Ta- Professional Med J 2015;22(12): 1601-1605. www.theprofesional.com 1602 ACUTE APPENDICITIS 3 ble-I). The positive predictive values for complete Acute Not Acute clinical evaluation and modified Alvarado score Appendicitis Appendicitis were thus 92.5% and 77.5% respectively. f (%)* F (%)* Total cases (n* = 80) 68 (85%) 12 (15%) When the patients were segregated on the basis Group A (n* = 40) 37 (92.5%) 3 (7.50%) of gender, the efficacy of diagnosis in males was almost similar. However for female patients, it was Group B (n* = 40) 31 (77.5%) 9 (22.50%) found that in Group A, all of them (n = 7) were Table-I. Efficacy of diagnosis of complete clinical correctly diagnosed with acute appendicitis while evaluation (Group A) and modified Alvarado score in Group B six out of 12 (50%) had been misdi- (Group B) using histopathology as gold standard *f = Frequency *% = Percentage agnosed. When calculated separately, the posi- *n = Number of patients tive predictive values for male patients of Group Positive Predictive Value Group A – 92.50% A and B were 90.90% and 89.28% respectively, Positive Predictive Value Group B – 77.50% but for females the values were 100% and 50% ed with 24-hour ultrasound and CT scan facilities. respectively. However, the use of these to augment diagnostic accuracy is hampered by operator dependency, lack of experienced reporting and their cost-ef- fectiveness.15,16 Thus for the most part surgeons working at CHK have to rely on their clinical acu- men to reach a final diagnosis in cases of acute abdomen, a situation not so dissimilar to many surgeons working around the world. 17 The diagnosis of acute appendicitis is essentially a clinical one18,19, but the ideal situation of a de- tailed clinical evaluation by an experienced clini- cian20 is not always possible and therefore meth- Fig-1. ods such as scoring systems have been found to be a great help to the less experienced in achiev- ing a quicker and more efficient diagnosis. This study demonstrates that the use of one such scoring system, the modified Alvarado score, can be of help in increasing diagnostic efficacy of acute appendicitis if applied under certain condi- tions. An explanation of this success may be the fact that the use of a scoring system submits the clinician to greater discipline in making the diag- nosis.20 Another reason is that this score, based on only a few clinical variables, is not only simple in its application, but also cheap and quick to ap- ply.21 Many studies and papers22 have been pub- Fig-2. Age Distributions. lished in the past identifying exactly what clinical and/or laboratory parameters are more predictive DISCUSSION in the diagnosis of acute appendicitis. Civil Hospital is the second largest Government Hospital in Karachi serving a large area of the City. It was not until recently that CHK was provid- Professional Med J 2015;22(12): 1601-1605. www.theprofesional.com 1603 ACUTE APPENDICITIS 4 Anderson RE in his meta-analysis of clinical and fied Alvarado score increases.27 laboratory diagnosis of appendicitis23 also sin- gled out the classic history of migration of pain CONCLUSION from mid-abdomen to RIF as having the most di- The modified Alvarado score can be used safely agnostic yield in the history. However, this import- and effectively in diagnosing acute appendicitis ant symptom is present in only 50% of patients. in adult males especially as the score increases from seven to nine. In adult females on the other Despite the above results, the efficacy of modi- hand reliance on the score alone can lead to mis- fied Alvarado score in our study was found to be diagnosis while a complete clinical evaluation by 77.5%, which was much lesser than that of the a consultant can be essentially enough to reach complete clinical evaluation (92.5%). Studies val- an acceptable level of diagnostic accuracy. idating the role of the score in diagnosis of acute Copyright© 30 Sep, 2015. appendicitis quote figures ranging from 76% to 89%. At the same time, clinical diagnosis has REFERENCES also been found to be superior to this score.24 In 1. Bergeron E. Clinical judgment remains of great value in diagnosis of acute appendicitis. Can J Surg 2006; order to evaluate this further; we segregated the 42: 96-100. patients on the basis of gender. This demonstrat- ed that while the efficacy of diagnosis was almost 2. Fahim F, Shirjeel S. 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Chan MY, Tan C, Chiu MT, Ng YY. Alvarado score: an AUTHORSHIP AND CONTRIBUTION DECLARATION Sr. # Author-s Full Name Contribution to the paper Author=s Signature 1 Dr. Khawar Saeed Jamali Conception and design 2 Dr. Hamaid Ahmed Statistical expertise, Critical revision of the article for important intellectual content 3 Dr. Muhammad Jawed Drafting of the article 4 Dr. Ubadullah Shaikh Critical revision of the article for important intellectual content Professional Med J 2015;22(12): 1601-1605. www.theprofesional.com 1605