Use of Computed Tomography to Determine Perforation in Patients With Acute Appendicitis
Use of Computed Tomography to Determine Perforation in Patients With Acute Appendicitis
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DOI：
10.1067/j.cpradiol.2016.12.002
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发表时间：
2018-01-01
影响因子：
1.4
通讯作者：
Davidson, Giana H.
中科院分区：
文献类型：
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作者：
Gaskill, Cameron E.;Simianu, Vlad V.;Davidson, Giana H.
目的：急诊阑尾切除术长期以来一直是急性阑尾炎的标准治疗方法。六项随机试验表明，抗生素可安全治疗阑尾炎，但这些患者中约有四分之一最终仍需进行阑尾切除术。总体治疗成功率可能因包括穿孔在内的复杂病情而受限。患者抗生素治疗的成功可能取决于术前影像学对复杂病情的识别。然而，计算机断层扫描（CT）在区分包括穿孔性阑尾炎和非穿孔性阑尾炎在内的复杂病情方面的有效性仍有待确定。本研究的目的是评估CT在确定急性阑尾炎手术患者阑尾穿孔方面的术前诊断准确性。
方法：我们对2012年1月至2015年5月期间因疑似急性阑尾炎就诊于急诊科的连续患者的病理和影像学报告进行了回顾性研究。由接受过腹部影像专科培训的放射科医生使用标准化标准重新评估CT扫描结果，且放射科医生对病理和手术结果不知情。放射科医生特别记录阑尾周围气体、脓肿、阑尾粪石、脂肪条索影和肠壁增厚的有无。将整体影像学印象以及这些特定的影像学发现与病理和手术报告结果进行比较。病理报告被视为诊断准确性的标准。
结果：89例（65%为男性，平均年龄34岁）因右下腹疼痛接受CT成像并立即进行阑尾切除术的患者。最终病理报告48%（n = 43）的病例存在穿孔。放射学诊断穿孔的比例为9%（n = 8），正确识别穿孔的比例为37.5%（n = 3），根据病理结果，在非穿孔病例中错误报告穿孔的比例为62.5%。放射学漏诊了病理术后诊断的93%（n = 40）的穿孔。没有一种次要发现（脂肪条索影、直径>13毫米、脓肿、盲肠壁增厚、阑尾周围气体、单纯液体积聚、阑尾粪石和蜂窝织炎）在预测穿孔性阑尾炎方面具有临床可靠的敏感性或特异性。外科医生报告的穿孔与病理报告的穿孔仅在28%的病例中一致。
结论：CT在确定急性阑尾炎穿孔方面的作用有限，应探索提高识别复杂阑尾炎患者准确性的方法，因为这可能有助于提高抗生素治疗失败风险的预测，并有助于指导患者和医疗提供者在治疗方案的共同决策。（C）2017爱思唯尔公司。保留所有权利。
Purpose: Urgent appendectomy has long been the standard of care for acute appendicitis. Six randomized trials have demonstrated that antibiotics can safely treat appendicitis, but approximately 1 in 4 of these patients eventually requires appendectomy. Overall treatment success may be limited by complex disease including perforation. Patients' success on antibiotic therapy may depend on preoperative identification of complex disease on imaging. However, the effectiveness of computed tomography (CT) in differentiating complex disease including perforated from nonperforated appendicitis remains to be determined. The purpose of this study was to assess the preoperative diagnostic accuracy of CT in determining appendiceal perforation in patients operated for acute appendicitis.Methods: We performed a retrospective review of pathology and radiology reports from consecutive patients who presented to the emergency department with suspicion for acute appendicitis between January 2012 and May 2015. CT scans were re-reviewed by abdominal imaging fellowship trained radiologists using standardized criteria, and the radiologists were blinded to pathology and surgical findings. Radiologists specifically noted presence or absence of periappendiceal gas, abscess, appendicolith, fat stranding, and bowel wall thickening. The overall radiologic impression as well as these specific imaging findings was compared to results of pathology and operative reports. Pathology reports were considered the standard for diagnostic accuracy.Results: Eighty-nine patients (65% male, average age of 34 years) presenting with right lower quadrant pain underwent CT imaging and prompt appendectomy. Final pathology reported perforation in 48% (n = 43) of cases. Radiologic diagnosis of perforation was reported in 9% (n = 8), correctly identifying perforation in 37.5% (n = 3), and incorrectly reporting perforation in 62.5% of nonperforated cases per pathology. Radiology missed 93% (n = 40) of perforations postoperatively diagnosed by pathology. There was no secondary finding (fat stranding, diameter > 13 mm, abscess, cecal wall thickening, periappendiceal gas, simple fluid collection, appendicolith, and phlegmon) with a clinically reliable sensitivity or specificity to predict perforated appendicitis. Surgeon's report of perforation was consistent with the pathology report of perforation in only 28% of cases.Conclusions: The usefulness of a CT for determining perforation in acute appendicitis is limited, and methods to improve precision in identifying patients with complicated appendicitis should be explored as this may help for improving risk prediction for failure of treatment with antibiotic therapy and help guide patients and providers in shared decision-making for treatment options. (C) 2017 Elsevier Inc. All rights reserved.