Surgeons, not CT or ultrasound, should diagnose appendicitis UC Davis study shows

November 05, 2001

Despite modern antibiotics, high-tech diagnostic machines and surgical advances, appendicitis still kills as many as 2,000 people in the United States each year.

But that toll could be reduced if emergency room and primary care doctors were quicker to call for surgical consultations in cases of suspected appendicitis, suggests a study by researchers at the UC Davis School of Medicine and Medical Center.

"No one in this day and age should have to die from something that is so simple to treat," says Hung Ho, associate professor of gastrointestinal and laparoscopic surgery and senior author of the study.

Appendicitis is usually a sudden, severe inflammation of the appendix, a worm-like appendage of the large intestine, no thicker than a pencil and no longer than a finger. The inflammation is most often due to a blockage caused by hardened feces that become trapped inside the appendix. If untreated, the appendix may rupture, spilling feces and bacterial infection into the entire abdominal cavity.

Because speed is essential in avoiding a ruptured appendix, Ho wanted to find out whether CT scans and ultrasound examinations hasten diagnosis of appendicitis. ER doctors increasingly rely on these advanced diagnostic tools when they suspect appendicitis, instead of calling in a surgeon to make the diagnosis.

Ho and his colleagues reviewed the medical charts of 766 consecutive patients with suspected acute appendicitis who had their appendix removed at UC Davis Medical Center between January 1995 and December 1999.

While the medical center's track record at managing appendicitis was as good as any reported in the medical literature, Ho turned up information that could further improve outcomes.

He found that ultrasound was only 43.4 percent accurate at diagnosing appendicitis -- no better than the flip of a coin. CT imaging was 74.5 percent accurate -- but a surgeon's clinical exam was even better, at 74.9 percent.

Most importantly, surgeons' determinations were faster. In Ho's study, patients had appendectomies within 10 hours when a surgeon made the diagnosis, 13 hours when ultrasound was ordered and 19 hours when a CT scan was performed.

"Neither CT nor ultrasound improves the diagnostic accuracy rate," Ho says. "In fact, they may delay surgical consultation and appendectomy."

For Sherellen Gerhart, a delay was almost deadly. Her bout with a simple case of appendicitis two years ago landed her in the hospital for eight days, confined her to her bed for another two weeks -- and very nearly killed her.

"I was very, very, very fortunate," says Gerhart, 32, a physician enrolled in a geriatrics training fellowship program at UC Davis Medical Center. Gerhart was working at a private hospital in Sacramento in October 1999 when she first started having abdominal pain. When the pain became severe, she stopped by the hospital emergency department. The ER doctor suspected appendicitis, and called in a radiologist to approve an ultrasound. But the radiologist didn't think Gerhart's symptoms warranted the test.

By the next day, Gerhart, delirious with fever and pain, had a friend drive her to the emergency department at UC Davis Medical Center. There an emergency department physician right away called for a surgical consultation. Ho, who happened to be the attending surgeon that morning, operated immediately. Gerhart's appendix had perforated, and infection had spread. "She nearly died," Ho says.

Of the 250,000 cases of acute appendicitis that occur in the United States each year, an estimated 17 to 39 percent perforate and about 1 percent die.

Ho has made it something of a mission to reduce these rates. Ho was in his first year of medical school when a college friend died from late complications of a delay in diagnosis of acute appendicitis. Three years later Ho's uncle, a previously healthy man in his 50s, also died of a perforated appendix.

Over the past decade, several studies have suggested CT and ultrasound might reduce the rate of unnecessary appendectomy, in which surgeons operate on a patient with suspected appendicitis but find a normal appendix. In response, emergency department physicians increasingly have been ordering imaging tests before calling for a surgical consultation.

In the Oct. 10 issue of the Journal of the American Medical Association, a group of University of Washington researchers also conclude that this trend should be reversed. "Contrary to expectation," the Washington researchers reported, "... diagnosis of appendicitis has not improved with the availability of advanced diagnostic testing." In fact, the Washington researchers found, misdiagnosis increased among women of reproductive age and patients older than 65.

Ho reported his findings in the May issue of Archives of Surgery. In it, he recommends that surgical consultation should be the first step for any patient with the classic symptoms of appendicitis--primarily pain that begins around the navel, then moves over and down to the lower right portion of the abdomen.

But Ho warns that only half of the appendicitis patients in his study had "classic" symptoms. When in doubt, he recommends that patients receive a diagnostic laparoscopy, in which a tiny camera is introduced into the abdomen through a small incision in the belly. If appendicitis is present, the appendix can be removed laparoscopically.

Today Gerhart is a few months away from completing her geriatrics fellowship, back to her rigorous work-out routine and grateful to the UC Davis surgeon who saved her life.

"You don't need technology to diagnose appendicitis. You need a surgeon who puts his hands on the patient," she says. "I learned that from Dr. Ho."

University of California - Davis Health System

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