European Journal of Cardiovascular Medicine

The most common etiology for acute abdomen with surgical emergency being Acute appendicitis for which appendicectomy being performed by a surgeon on basis of their clinical diagnostic skills; along with commonly used diagnostic aid being the ultrasound imaging done by radiologist not only to confirm but also to rule out mimics or see for complications to plan surgery and if required further imaging if deemed clinically appropriate.

Owing to onus of delayed diagnosis or delayed appropriate care many published studies have a very high negative appendicectomy rates varying from 11 to 30% due to a tendency of over diagnosis of clinical scenario ^[1-10]. Altogether for diagnosis of appendicitis with recent trends utilizing CECT abdomen & laparoscopy with added financial costs over traditional diagnostic score, laboratory investigations and ultrasound. Many studies have suggested combined approach of two or more diagnostic aids to yield better accuracy and help to mitigate incidences of prolonged observation, negative appendicectomy and perforated appendix and its sequelae and indirectly curb the financial burden on healthcare and patient care.

Ohmann C et al evaluated ten distinct diagnostic scoring

systems for acute appendicitis ^[10,11] and they concluded that “an adequate scoring system” should yield:

• Less than 15 % negative appendicectomy rate
• Not more than 35% perforated appendix
• < 15% missed perforation rate
• rate less than 5%of missed appendicitis

Of all diagnostic scoring systems The Alvarado score proved to be a benchmark amongst all.

Alvarado in the year 1986 reported scoring system with substantiates results for adult surgical patients. The left shift of Neutrophil maturation incorporated the Classical Alvarado score (score 1) yielding a total score of 10. However, in 1994 Kalan omitted this parameter and produced a Modifies Score. There are mixed results regarding the efficacy of modified Alvarado score (MAS) ^[5-7] This study was undertaken to evaluate the accuracy of MAS, USG abdomen and the combined use of both MAS and USG. It is based on the hypothesis that the frequency of inflamed appendix is more in patients having MAS seven or more, than patients having MAS six or below Aim of the study is that a simple and structured scoring system like MAS and USG Abdomen will aid junior doctors; which would not only help in decreasing the incidence of negative appendicectomies but also to determine further plan for suspected cases of acute appendicitis. Composition of MAS, includes distribution of score (1-9) on symptoms, signs and investigations (Table 1); with interpretation of total score yield for probability results for Diagnosis of acute appendicitis (Table 2)

ULTRASONOGRAPHY: In 1986, Julian BCM Puyiaert documented how sonographic graded compression technique helped in better diagnosis of acute appendicitis, with ultrasound having its utility when clinical signs are equivocal or indeterminate. The classic finding of direct demonstration of inflamed appendix with ultrasound classic appearance of non-compressible aperistaltic tubular blind ended structure at the site of maximum tenderness or in right iliac fossa. ^[12-14]

The characteristic findings being:

1. Tubular blind ending non-peristaltic structure Visualization of incompressible nature :appendix
2. More than 6mm in total diameter on cross section with Target appearance or mural wall thickness  of greater than 2mm
3. Diffuse hypo echoic in nature ( risk of high chances for perforation)
4. Lumen filled with echogenic or anechoic  contents
5. Loss of wall stratification
6. Presence of appendicolith
7. Periappendiceal mass or fluid presence
8. Pericaecal fat stranding or inflammation to mesoappendix

 A false positive diagnosis is possible in patients with perforated peptic ulcer, sigmoid diverticulitis or Crohn’s disease because in these conditions, the appendix may be relatively thickened due to adjacent extrinsic inflammatory disease.

Sometimes appendix may be not visible on ultrasound secondary to recent radio-therapy, spontaneous   primary bacterial peritonitis or secondary to peritoneal dialysis. Many a times false negative results could be due to Over-looking the underlying inflamed appendix; Vis a Vis in the experts’ hands, the inflamed appendix can be seen in 90% patients without perforated appendicitis, 85% with an appendiceal mass and 55% in cases of perforated appendicitis. The application of Graded compression technique however can be of limited success in patients with appendiceal perforation with Peritonism. Additionally, adynamic ileus with dilated gas filled bowel loops may obscure appendix from visualization ^[12-19].

COLOUR DOPPLER ULTRASONOGRAPHY:

 The following features are described:  

1. Hyperaemia in and around the appendix.
2. Arterial waveform reveals Decreased resistance flow.
3. Pulsatality or continuity in venous flow

 Patriquin et al ^[15] have demonstrated that acute appendicitis is accompanied by inflammatory hypervascularity reflected as an increased number of colour signals and higher diastolic Doppler shifts as compared with those found in normal persons. For ischemic areas of appendix: No Doppler shifts were identified.

Table 1. Modified Alvarado score

Table 2. Interpretation of score of modified Alvarado score

Our research study was retrospective review analysis of thesis done for diagnosis of acute appendicitis utilizing Modified Alvarado Scoring System & assessing its effectiveness by comparing with final histopathological findings; & utility of Ultrasound as a guide for diagnosis along with its utility for reducing incidences of negative appendicectomy rate by prudent combination of Modified Alvarado Score (MAS) and Ultrasound.

Modified Alvarado Score:

The Original scoring methodical basis of Alvarado (Table 3) compounded on three symptoms & signs along with two lab values ^[5-7].

However our research is based upon the fact that: excluding one lab parameter of “shift to left of Neutrophil maturation” as this was not available on emergency basis, hence the modified version of the original Alvarado scoring method being utilized, thus our patients were scored out of 9 rather than 10 on basis as the “Modified version of the Alvarado Score” (MAS).

The lab value of critical nature utilized in our study for leucocytosis with Total Leukocyte Count (TLC) more than 10,000 per cubic mm of blood and Oral temperature threshold of higher than 37.3° Centigrade were considered to calculate Modified Alvarado Score (MAS).

Table 3: Alvarado score

Ultrasonography (USG): USG of every patient was performed with 5MHz or 7.5MHz linear array transducer to diagnose appendicitis and with 3.5MHz convex Transducer to rule out any other abdominal pathology.USG criteria for diagnosis of acute appendicitis was:

• Visualization of appendix ● Diameter ≥ 6 mm ● Wall thickness ≥ 3 mm
• Increased peri-appendiceal echogenicity ● Loss of contour ● Free fluid
• Localized ileus adynamic ● Tenderness over Mc Burney’s point

Plan of treatment: (Table 4)

All patients with MAS ≥ 7 were posted for emergency surgery and those with MAS ≤ 6 underwent USG. If USG was suggestive of appendicitis than these patients were posted for emergency surgery. If USG was normal than they were managed conservatively.

Table 4 Plan of Treatment

The Surgery was performed either utilizing general or spinal anesthesia after patients underwent standard of care for preparation as per emergency and elective nature of case protocol: nil by mouth, intravenous fluids and broad-spectrum antibiotics, preop analgesics & antacids and electrolytes balance care. Grid Iron ^[20] or Lanz or Mid Line Laparotomy incision was taken ^[21-24]. Appendicectomy specimens were sent for histopathological examination. Post operatively patients are kept nil orally, till bowel sounds return, parenteral fluids, electrolytes, antibiotics, analgesics and antacids were continued.  Operative wound care and dressing was done in post operative period. Postoperative observation and careful identification for any post op complications and sos treatment whenever indicated was done; while suture removal was done as standard of practice on 6-10 days and the patients were discharged after histo-path report and Confirmation of clinical and operative diagnosis of acute appendicitis with histopathological corelation in all operated cases ^[25-29].

CLINICAL SYMPTOMATOLOGY:

1. MIGRATORY PAIN IN RIGHT ILIAC FOSSA (RIF): In this study, pain at the umbilicus site was presenting symptoms in 52% of the cases which later on migrated towards Right Iliac Fossa (RIF). The onset of pain distribution site is as follows. (table 5) & Figure 1.

Table 5: Pain distribution at the time of onset

• ANOREXIA: Anorexia nearly always accompanies appendicitis. In this study, all of the patients (100 %) complained of anorexia.
• NAUSEA AND VOMITING: The 2nd frequent symptomatology included nausea only (67 patients), vomiting only (21 patients) and both nausea with vomiting (12 patients).

PHYSICAL SIGNS:

1. RIGHT ILIAC FOSSA (RIF) TENDERNESS: Clinical area of maximum tenderness elicited at RIF or at /near Mcburney’s point corresponding to site of inflamed appendix; was appreciated in 98% of patients and was the most consistent finding.
2. REBOUND TENDERNESS: The phenomenon of rebound tenderness due to local involvement of peritoneum or deeply placed inflamed appendix was noted in 72% of the patients.
3. INCREASE IN TEMPERATURE: Pyrexia of low grade was noted in 71% of the patients with remainder 29% of the patients had normal temperature.
4. MURPHY’S TRIAD: Triad of Murphy’s consisting of pain followed by nausea / vomiting followed by fever was noted in 69% of the cases under purview.

INVESTIGATIONS:

1. WHITE BLOOD CELL (WBC) COUNT: In our study 56% of cases had WBC count of greater than 10,000 cells/cumm. (Table 6)

Table 6: white blood cell count

2. ULTRASONOGRAPHY FINDINGS: all the cases were subjected to Ultrasonography and the findings were noted. Figure 2.

MANAGEMENT:

MODIFIED ALVARADO SCORE: Of the 100 cases 72 cases had score 7 or more than 7. Out of the rest 28 cases, 16 cases were having score of 6, 9 cases were having score of 5, 2 cases were having score of 4 and one case was having score of 3 (table7) & Graph 3.

Table 7: Modified Alvarado score:

One patient with MAS 5 and USG negative was managed conservatively but due to rising pulse was operated; Laparotomy was done and was found to have perforated pelvic appendicitis

Other patient with MAS 5and USG positive i.e. suggestive of appendicitis was operated and was found to have abdominal Koch’s with Tuberculous appendicitis.

Four patients (2 males and 2 females) had MAS of 8 and USG negative for appendicitis were operated. The two male patients had inflamed Meckel’s diverticulitis and out of the two female’s one had terminal ileitis and one had Tubo-ovarian mass. All these four patients had normal appendix.

Fig. 3: Modified Alvarado Score (MAS)

APPENDICECTOMY: Of the 100 patients, 96 patients underwent open appendicectomy and 4 patients underwent laparoscopic appendicectomies.

INTRAOPERATIVE FINDINGS: Figure 4

After opening the peritoneum, the condition of the appendix, the position of the appendix, the presence of local or general peritonitis and any other findings were noted.

In present study, acute inflamed and congested appendix was the most common intraoperative finding and was seen in 80 patients, while the most common position of the appendix was retro-caecal.

Incidence of perforated appendix was 21% in semsi et al series of 100 emergency appendicectomy, while it was noted to be 84% In Martin Breumen (1970) series and 9.9% were found to be gangrenous in nature.

The histopath findings of surgical specimen of pathological appendix (Table 8) and sensitivity & specificity of Modified Alvarado score, ultrasound i.e. Ultrasonography (USG) findings and combined approach in diagnosis of acute appendicitis (Table 9) are as follows:

Table 8: Histopathology

Table 9: To compare the overall sensitivity and specificity of Modified Alvarado score, USG and combined diagnostic approach.

Diagnostic accuracy in case of acute appendicitis should be high because negative appendicectomy carries significant morbidity. There is a greater risk for abdominal adhesions after appendicectomy for healthy appendix as compared with that of acute appendicitis. History, clinical examination, WBC count and abdominal USG are helpful to achieve a more accurate diagnosis.     Moreover one cannot rely on any single investigation, but a combination of thorough physical examination along with investigations is essential for accurate diagnosis of acute appendicitis.

ULTRASONOGRAPHY: 64% of cases revealed graded USG probe tenderness at the McBurney’s point one of characteristic finding associated with diagnosis of acute appendicitis. 89% of cases demonstrated graded probe tenderness in study by Puylaert BCM et al ¹³. Inflamed swollen appendix was visualized in 87% of the patients. Free fluid was visualized in 91% of the patients. Perforated appendix was visualized in 6% of the cases. Normal appendix was visualized in 5 % of the cases (from Table 10, 11)

Table 10: Visualization of normal appendix by USG by various authors

Table 11:  Value of USG in the diagnosis of acute appendicitis by various authors

In the present study, USG showed an overall sensitivity of 98.95%, a specificity of 80%, and a negative appendicectomy rate of 1.05% and a diagnostic accuracy of 98%. (Ref: table 9)

 In above studies the sensitivity is fairly less than our study. As a highly sensitive test is required for the diagnosis of a condition where the consequences of false negative test are serious, therefore the sensitivity of 98.95% for USG suggest it to be an effective diagnostic tool in the diagnosis of acute appendicitis.

MODIFIED ALVARADO SCORE (MAS): 42% of males while 30% of females had score of 7 or more than 7 in present study. (Ref: Table 7 and graph 3) and Table 12.

Table 12: Modified Alvarado score 7 or more than 7 by various authors

HISTOPATHOLOGY: In the present study, 95% of the patients had histopathologically confirmed appendicitis of which 13 % had acute perforated appendicitis and 2% had acute gangrenous appendicitis. Normal appendix was seen in 4% of the cases. (Ref: Table 8 and graph 4) and Table 13.

Table 13: Histopathological report showing acute appendicitis by various Authors

To prove the diagnostic accuracy, negative appendicectomy rate, sensitivity and specificity of Modified Alvarado score, USG and the combined diagnostic approach used in present study, the histopathological confirmation is needed.

COMBINED DIAGNOSTIC APPROACH USING MODIFIED ALVARADO SCORE AND USG: In the present study, the combined diagnostic approach has a negative appendicectomy rate of 5.05%, sensitivity of 98.94%and diagnostic accuracy of 94 %.( Ref: table 9) and Table 14.

On comparing our USG results with our combined diagnostic approach, both have a similar sensitivity of 98.95% in USG and 98.94% in combined diagnostic approach. Both have a comparable high diagnostic accuracy of 98% in USG and 94% in combined diagnostic approach. But our combined diagnostic approach has high negative appendicectomy rate of 5.05% and that of USG is 1.05%.

Table 14: Combined diagnostic approach using MAS and USG by various authors.

Our study findings not only helps to decrease both morbidity and Postop complications and to diagnose early stages of acute appendicitis along with providing an inexpensive way of confirming   acute appendicitis by combined approach of Modified Alvarado Score (MAS) with Ultrasound findings ^[28,29].

It is recommended that modified Alvarado score should be introduced and practice in emergency department as this simple scoring system will be of great help ^[26]; along with leucocytosis, other inflammatory variables like C - reactive protein (CRP) should be studied and included in the Alvarado score to increase its sensitivity and diagnostic accuracy.

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