14 Jun

The role of radiological imaging in the diagnosis of acute appendicitis: SUMMARY Part 1

The timely diagnosis of acute appendicitis is still mainly determined by the clinical acumen of attending physicians and surgeons. Diagnostic algorithms — including scoring systems, leukocyte counts and radiological imaging — may have adjunctive roles. Patients with classical clinical presentations should be operated on urgently, without resorting to prior imaging, unless complications that might affect the course of surgery are suspected. Plain abdominal radiographs are of little value, except if certain nonappendiceal disorders are considered likely. Barium enema examinations are cumbersome and have been supplanted by cross-sectional imaging techniques. Nuclear imaging has been disappointing, because most techniques require long periods of time and the scans are often indeterminate. MRI remains unproven, and resources are unlikely to be readily available for this indication.

Ultrasonography is safe and relatively inexpensive. Good diagnostic accuracy can be achieved by expert personnel who employ graded compression, but the technique is highly dependent on the skill, experience and persistence of the operator. It may be especially useful when evaluating children (because of their low body mass) and women (because of their proclivity to gynecological disorders). The inability to identify the normal appendix, and the high false-negative rate in retrocecal appendicitis are important drawbacks. Its sensitivity is too low for it to be of value in patients who are clinically likely to have appendicitis, but it does seem to be beneficial in equivocal cases. Colour Doppler ultrasonography may offer a small advantage when conventional techniques yield inconclusive results.
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CT is highly accurate, especially when conducted by experienced personnel. Highly refined techniques, such as helical CT, thin collimation and the use of rectal contrast, seem to enhance its effectiveness. It is superior to ultrasonography in obese patients and in those with perforation or other complications. Because the normal appendix can usually be identified, appendicitis can be ruled out with more confidence. For it to be valuable as a diagnostic technique without causing important delays in management, however, the equipment and specialized radiology staff need to be continuously available.

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