CT of appendicoliths in adult appendicitis: clinical significance and characteristics of overlooked cases.

OBJECTIVES: Accurate computed tomography (CT) identification of appendicoliths in adults with acute appendicitis is crucial as it may preclude nonoperative management due to high risk of failure and complications. This investigation aimed to identify the significance of appendicoliths in acute appendicitis and to evaluate the performance of portovenous-phase (PVP) CT and the consequences of overlooked appendicoliths. METHODS: CT examinations of 324 consecutive patients (mean age 51.9 years, 112 men) with pathologically confirmed acute appendicitis were retrospectively included. Two radiologists independently reviewed the images, and disagreement was resolved by a consensus. RESULTS: Appendicoliths were identified in 134/324 patients, of which 75 had complicated appendicitis. Among 190 patients without appendicoliths, 52 had complicated appendicitis. An appendicolith was independently associated with complicated appendicitis (adjusted odds ratio 2.289; 95% CI: 1.343-3.902; p = 0.002). The larger minimum diameter was significantly associated with complication. The 4.5-/6.0-mm cutoffs for minimum and maximum diameters of appendicoliths demonstrated 82.7%/85.3% sensitivity and 35.6%/33.9% specificity in predicting complications. The PVP alone had 82.1-88.1% sensitivity, respectively per patient and per appendicolith, and a 100% specificity in the detection of appendicoliths, as compared with combined noncontrast and PVP. PVP overlooked 28/237 appendicoliths (11.8%) corresponding to 24/134 patients (17.9%). Of the 24 patients with overlooked appendicoliths, 16 had complicated appendicitis but 14 were correctly categorized by findings other than appendicoliths. In total, 2/127 patients (1.6%) with complicated appendicitis were misdiagnosed as having uncomplicated appendicitis. CONCLUSIONS: Appendicoliths in acute appendicitis were strongly associated with complications. While PVP overlooked some appendicoliths, only 1.6% of complicated appendicitis were misclassified when considering other CT findings. CLINICAL RELEVANCE STATEMENT: This study found a strong association between appendicoliths and complications. Its presence may preclude conservative management. Although portovenous-phase CT overlooked some appendicoliths, the combination with other CT findings allowed correct classification in a vast majority of cases. KEY POINTS: • Accurate identification of appendicoliths is crucial for nonoperative management decisions in adult acute appendicitis. • Appendicoliths are strongly associated with complications in adult acute appendicitis. • Portovenous-phase CT overlooked some appendicoliths, but only a small percentage of patients with complicated appendicitis were misclassified when considering other CT findings.

Validation of scoring systems for the prediction of complicated appendicitis in adults using clinical and computed tomographic findings.

OBJECTIVES: The study aimed to evaluate scoring systems for predicting complicated appendicitis in adults diagnosed with acute appendicitis on computed tomography. METHODS: Three hundred twenty-five consecutive adult patients (mean age 51.9 ± 19.6 years, 212 women) diagnosed with acute appendicitis on computed tomography were retrospectively included. Clinical and imaging findings were compared between patients with and without complicated appendicitis, and independent associations were identified. As C-reactive protein was not available for most patients, 5 out of 8 scoring systems were modified. They, and a newly proposed system, were compared via area under the receiver operating characteristics (ROC) curve (AUC), Additionally, the latter was internally validated. Pairwise comparison was performed, and diagnostic performance of these scoring systems was obtained. RESULTS: One hundred twenty-seven patients (36.8%) had complicated appendicitis. Significant independent associations were found between complicated appendicitis and duration of symptoms > 12 h, appendicolith, periappendiceal fat stranding, periappendiceal fluid, and extraluminal air (p values < 0.001 to 0.037; AUCs of 0.824-0.829). AUCs of 9 scoring systems ranged from 0.692 to 0.831. Of these, modified Atema, Kim HY, and proposed scores had similarly high and non-significantly different AUCs (0.793-0.831) on pairwise comparison. Their sensitivities, specificities, and accuracies were 73.0-90.6%, 48.5-70.6%, and 64.3-72.3%, respectively. Internal validity test demonstrated high AUCs (0.826-0.844) with one of the proposed scores using odds ratio having 100% sensitivity and 100% negative predictive value. CONCLUSIONS: Few scoring systems, including proposed ones, had high AUCs, sensitivity, and reasonable specificities, which could potentially aid in safely selecting adult patients with acute appendicitis for nonoperative management. CRITICAL RELEVANCE STATEMENT: The study suggests few scoring systems for predicting complicated appendicitis with high AUCs and reasonable sensitivities, potentially aiding in selecting patients for nonoperative management. KEY POINTS: • The study evaluated existing and proposed new scoring systems to predict complicated appendicitis in adults with acute appendicitis on computed tomography. • Several factors were found to be significantly associated with complicated appendicitis, including duration of symptoms, appendicolith, periappendiceal fat stranding, periappendiceal fluid, and extraluminal air. • The modified Atema, Kim HY, and newly proposed scoring systems performed well, potentially aiding in nonoperative management selection.

Performance of computed tomography and its reliability for the diagnosis of transmural gastrointestional necrosis in a setting of acute ingestion of predominantly strong acid substances in adults.

OBJECTIVES: Computed tomography has become a critical component in evaluating adult patients with acute caustic ingestions and an alternative to endoscopy for detecting transmural gastrointestinal necrosis. This study assessed the performance and reliability of computed tomography findings of transmural gastrointestinal necrosis, given that the presence of the disease potentially signifies the need for surgery. METHODS: A retrospective database search was performed to identify consecutive adult patients with acute caustic ingestions who had computed tomography with endoscopy or surgery within 72 h of admission. Eight physicians reinterpreted computed tomography in two separate rounds. Diagnostic performance utilized eight rounds of radiologists' reinterpretations against reference endoscopic or surgical grades. Intra- and interobserver agreements were calculated. RESULTS: Seventeen patients (mean age, 45.6 years; 9 men; 46 esophageal and 34 gastric segments; 16 ingested strong acid substances) met the inclusion criteria. Eight patients (10 esophageal and 13 gastric segments) had transmural gastrointestinal necrosis. The highly differentiating findings between those with and without transmural gastrointestinal necrosis were esophageal wall thickening (100% vs. 42%, P = 0.001; 100% sensitive), gastric abnormal wall enhancement and fat stranding (100% vs. 57%, P = 0.006; 100% sensitive), and gastric absent wall enhancement (46% vs. 5%, P = 0.007; 100% specific). The intra- and interobserver percentage agreements were 47-100%, and 54-100%, which increased to 53-100%, and 60-100%, respectively, when considering only radiologists' reinterpretations. CONCLUSIONS: In a very small sample of adults who primarily ingested acid, contrast-enhanced computed tomography performed well when interpreted by a panel of radiologists.

Predictive ability of CT findings in the differentiation of complicated and uncomplicated appendicitis: a retrospective investigation of 201 patients undergone appendectomy at initial admission.

BACKGROUND: Paradigm shift toward nonoperative management (NOM) of adult appendicitis has made computed tomography (CT) more important than ever, particularly in differentiating complicated from uncomplicated disease. Complete surgical and pathological data of appendicitis in a place where appendectomy at initial admission is a standard of care would allow retrospective review of preoperative CT for performance and predictive ability in identifying those that may benefit from NOM in the future. RESULTS: The study included 201 CT scans of consecutive adult patients who presented for appendectomy at initial admission with pathologically confirmed acute appendicitis. Complicated appendicitis referred to gangrene or perforation on pathological or operative findings. The overall CT sensitivity, specificity and accuracy for differentiation of complicated from uncomplicated appendicitis were 87.2%, 75.7% and 81.1%, respectively. The most sensitive CT findings of complicated appendicitis were mucosal enhancement defect (83.2%; 95% CI 74.1-90.0) and moderate-to-severe periappendiceal fat stranding (96.8%; 95% CI 91.1-99.3), both independently predictive of complicated appendicitis with adjusted odds ratios (ORs) of 4.62 (95% CI 1.86-11.51) and 4.41 (95% CI 1.06-18.29), respectively. Phlegmon, fluid collection, extraluminal appendicolith, periappendiceal air and small bowel dilatation had specificity of 98.1-100%. Intraluminal appendicoliths were found more frequently in complicated appendicitis (52.6% vs. 22.6%) but not predictive for this diagnosis. Independent clinical predictors of complicated appendicitis were lack of pain migration (OR 2.06), neutrophilia ≥ 82% (OR (2.87) and symptoms ≥ 24 h (OR 5.84). CONCLUSIONS: CT findings were highly accurate in differentiating complicated from uncomplicated appendicitis among patients undergone appendectomy at initial admission.