Limits...
The accuracy of pre-appendectomy computed tomography with histopathological correlation: a clinical audit, case discussion and evaluation of the literature.

Collins GB, Tan TJ, Gifford J, Tan A - Emerg Radiol (2014)

Bottom Line: There were many secondary pathologies, including neoplasia, tuberculosis and endometriosis.In five cases, a discrepancy was "understandable" but clinically insignificant.Overall, in comparison to the medical literature, the degree of clinico-histopathological correlation was good.

View Article: PubMed Central - PubMed

Affiliation: Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge Biomedical Campus, Hills Road, Cambridge, CB2 0QQ, UK, collinsgeorge@gmail.com.

ABSTRACT
The increasing use of computed tomography (CT) in acute appendicitis makes recognising the radiological hallmarks of the condition and its mimics vital. The differential diagnosis includes both appendiceal and nonappendiceal pathologies. The correlation between pre-appendectomy CT and post-appendectomy histopathology was audited retrospectively. Cases of clinico-histopathological discrepancy underwent blind peer-review, and possible improvements were discussed in the context of the medical literature. A grade for discrepancy was given based on the RADPEER scoring system, and interesting or discrepant cases were examined more closely to identify targets for education. Of the 199 procedures, 4 appendectomies were negative (histologically normal), 182 were positive (primary appendicitis) and 13 were incidental (another primary process caused inflammation). The positive predictive value for pre-appendectomy CT was 91.5 %, and the negative appendectomy rate was 2 %. There were many secondary pathologies, including neoplasia, tuberculosis and endometriosis. Although no CT reports missed a diagnosis that should be made "almost all of the time" and in 96 % of cases, the second, blinded radiologist agreed with the initial assessment, in 3 cases, a missed diagnosis altered clinical management; 2 were "understandable" misses but 1 was not. In five cases, a discrepancy was "understandable" but clinically insignificant. Overall, in comparison to the medical literature, the degree of clinico-histopathological correlation was good. Although identifying areas for improvement was challenging, after a pictorial review of four cases and a discussion of the medical literature, we present our audit results and some valuable learning points for use in the CT assessment of suspected acute appendicitis.

Show MeSH

Related in: MedlinePlus

a A 32-year-old male with enteritis masquerading as acute appendicitis (case 2; see b). Contrast-enhanced coronal images demonstrate a fluid-filled small bowel loop with mural thickening and enhancement in keeping with enteritis (white arrows). Ascites is noted within the perisplenic region and pelvis. b A 32-year-old male with enteritis (case 2; see b). Contrast-enhanced axial CT image demonstrates a small air locule (white arrow) at the tip of a blind-ending tubular structure (open white arrows) within the right iliac fossa with a slightly thickened and enhancing wall, suggesting possible perforation of an acutely inflamed appendix. Intraluminal dense material was in keeping with an appendicolith (black arrow)
© Copyright Policy - OpenAccess
Related In: Results  -  Collection


getmorefigures.php?uid=PMC4225066&req=5

Fig2: a A 32-year-old male with enteritis masquerading as acute appendicitis (case 2; see b). Contrast-enhanced coronal images demonstrate a fluid-filled small bowel loop with mural thickening and enhancement in keeping with enteritis (white arrows). Ascites is noted within the perisplenic region and pelvis. b A 32-year-old male with enteritis (case 2; see b). Contrast-enhanced axial CT image demonstrates a small air locule (white arrow) at the tip of a blind-ending tubular structure (open white arrows) within the right iliac fossa with a slightly thickened and enhancing wall, suggesting possible perforation of an acutely inflamed appendix. Intraluminal dense material was in keeping with an appendicolith (black arrow)

Mentions: A 32-year-old male presented with a 1-day history of crampy abdominal pain that started on the left but migrated suprapubically and to the right iliac fossa. There was rebound tenderness and guarding, and the white cell count was 12 × 109/L. On CT, there was “fluid in the pelvis, right iliac fossa (RIF), perihepatic and splenic regions, peritoneal enhancement in the RIF and right pelvic sidewall, a small air locule adjacent to an inflamed appendix and an appendicolith in the appendix” (Fig. 2a, b). There were also “dilated, prominent, fluid-filled small bowel loops” that were thought to represent localised ileus. The diagnosis of acute appendicitis was suggested, and perforation could not be excluded; however, after appendectomy, the histological findings demonstrated “no ulceration, transmural inflammation or serosal exudate to indicate acute appendicitis”. The second, blinded radiologist felt that the disproportionate volume of free fluid and the presence of inflamed small bowel should have suggested another pathology (e.g. enteritis) and that this was overlooked initially. This was likely to be clinically significant as an ascitic tap may have followed instead, followed by primarily conservative or medical rather than surgical management. It was, therefore, allocated a RADPEER score of 3b. The reliability of the appendicolith especially on CT is often overemphasised. Appendicoliths are present in only 23–46 % of those with acute appendicitis; the presence of an appendicolith has no diagnostic significance, and it may be an incidental finding in asymptomatic patients. No research has suggested that those with an appendicolith are at increased risk of appendicitis [12–14].Fig. 2


The accuracy of pre-appendectomy computed tomography with histopathological correlation: a clinical audit, case discussion and evaluation of the literature.

Collins GB, Tan TJ, Gifford J, Tan A - Emerg Radiol (2014)

a A 32-year-old male with enteritis masquerading as acute appendicitis (case 2; see b). Contrast-enhanced coronal images demonstrate a fluid-filled small bowel loop with mural thickening and enhancement in keeping with enteritis (white arrows). Ascites is noted within the perisplenic region and pelvis. b A 32-year-old male with enteritis (case 2; see b). Contrast-enhanced axial CT image demonstrates a small air locule (white arrow) at the tip of a blind-ending tubular structure (open white arrows) within the right iliac fossa with a slightly thickened and enhancing wall, suggesting possible perforation of an acutely inflamed appendix. Intraluminal dense material was in keeping with an appendicolith (black arrow)
© Copyright Policy - OpenAccess
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC4225066&req=5

Fig2: a A 32-year-old male with enteritis masquerading as acute appendicitis (case 2; see b). Contrast-enhanced coronal images demonstrate a fluid-filled small bowel loop with mural thickening and enhancement in keeping with enteritis (white arrows). Ascites is noted within the perisplenic region and pelvis. b A 32-year-old male with enteritis (case 2; see b). Contrast-enhanced axial CT image demonstrates a small air locule (white arrow) at the tip of a blind-ending tubular structure (open white arrows) within the right iliac fossa with a slightly thickened and enhancing wall, suggesting possible perforation of an acutely inflamed appendix. Intraluminal dense material was in keeping with an appendicolith (black arrow)
Mentions: A 32-year-old male presented with a 1-day history of crampy abdominal pain that started on the left but migrated suprapubically and to the right iliac fossa. There was rebound tenderness and guarding, and the white cell count was 12 × 109/L. On CT, there was “fluid in the pelvis, right iliac fossa (RIF), perihepatic and splenic regions, peritoneal enhancement in the RIF and right pelvic sidewall, a small air locule adjacent to an inflamed appendix and an appendicolith in the appendix” (Fig. 2a, b). There were also “dilated, prominent, fluid-filled small bowel loops” that were thought to represent localised ileus. The diagnosis of acute appendicitis was suggested, and perforation could not be excluded; however, after appendectomy, the histological findings demonstrated “no ulceration, transmural inflammation or serosal exudate to indicate acute appendicitis”. The second, blinded radiologist felt that the disproportionate volume of free fluid and the presence of inflamed small bowel should have suggested another pathology (e.g. enteritis) and that this was overlooked initially. This was likely to be clinically significant as an ascitic tap may have followed instead, followed by primarily conservative or medical rather than surgical management. It was, therefore, allocated a RADPEER score of 3b. The reliability of the appendicolith especially on CT is often overemphasised. Appendicoliths are present in only 23–46 % of those with acute appendicitis; the presence of an appendicolith has no diagnostic significance, and it may be an incidental finding in asymptomatic patients. No research has suggested that those with an appendicolith are at increased risk of appendicitis [12–14].Fig. 2

Bottom Line: There were many secondary pathologies, including neoplasia, tuberculosis and endometriosis.In five cases, a discrepancy was "understandable" but clinically insignificant.Overall, in comparison to the medical literature, the degree of clinico-histopathological correlation was good.

View Article: PubMed Central - PubMed

Affiliation: Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge Biomedical Campus, Hills Road, Cambridge, CB2 0QQ, UK, collinsgeorge@gmail.com.

ABSTRACT
The increasing use of computed tomography (CT) in acute appendicitis makes recognising the radiological hallmarks of the condition and its mimics vital. The differential diagnosis includes both appendiceal and nonappendiceal pathologies. The correlation between pre-appendectomy CT and post-appendectomy histopathology was audited retrospectively. Cases of clinico-histopathological discrepancy underwent blind peer-review, and possible improvements were discussed in the context of the medical literature. A grade for discrepancy was given based on the RADPEER scoring system, and interesting or discrepant cases were examined more closely to identify targets for education. Of the 199 procedures, 4 appendectomies were negative (histologically normal), 182 were positive (primary appendicitis) and 13 were incidental (another primary process caused inflammation). The positive predictive value for pre-appendectomy CT was 91.5 %, and the negative appendectomy rate was 2 %. There were many secondary pathologies, including neoplasia, tuberculosis and endometriosis. Although no CT reports missed a diagnosis that should be made "almost all of the time" and in 96 % of cases, the second, blinded radiologist agreed with the initial assessment, in 3 cases, a missed diagnosis altered clinical management; 2 were "understandable" misses but 1 was not. In five cases, a discrepancy was "understandable" but clinically insignificant. Overall, in comparison to the medical literature, the degree of clinico-histopathological correlation was good. Although identifying areas for improvement was challenging, after a pictorial review of four cases and a discussion of the medical literature, we present our audit results and some valuable learning points for use in the CT assessment of suspected acute appendicitis.

Show MeSH
Related in: MedlinePlus