Signs and Evidence

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Appendicitis

Calculated pretest-probability: 1.6 %
Relevant inclusion criteria: Acute abdominal pain Calculate probabilities!

Clinical signs

Nausea
 Positive likelihood ratio
7.00 ( Idris SA et al. )
(average) 7.00
Negative likelihood ratio
0.10 ( Idris SA et al. )
(average) 0.1
Migration of pain
 Positive likelihood ratio
3.60 ( Wagner JM et al. )
3.20 ( Hardin M et al. )
(average) 3.40
Negative likelihood ratio
0.40 ( Wagner JM et al. )
0.50 ( Hardin M et al. )
(average) 0.45
Psoas sign
 Positive likelihood ratio
3.20 ( Wagner JM et al. )
1.06 ( Idris SA et al. )
(average) 2.13
Negative likelihood ratio
0.90 ( Wagner JM et al. )
0.86 ( Idris SA et al. )
(average) 0.88
Fever
 Positive likelihood ratio
3.20 ( Wagner JM et al. )
1.06 ( Nshuti R et al. )
1.03 ( Idris SA et al. )
1.07 ( Al-gaithy Zuhoor K et )
(average) 1.59
Negative likelihood ratio
0.40 ( Wagner JM et al. )
0.99 ( Nshuti R et al. )
0.95 ( Idris SA et al. )
0.33 ( Al-gaithy Zuhoor K et )
(average) 0.67
Anorexia
 Positive likelihood ratio
3.17 ( Idris SA et al. )
1.05 ( Al-gaithy Zuhoor K et )
(average) 2.11
Negative likelihood ratio
0.07 ( Idris SA et al. )
0.53 ( Al-gaithy Zuhoor K et )
(average) 0.3
Rebound tenderness
 Positive likelihood ratio
3.00 ( David G. Bundy et )
2.41 ( Lamture YR et al. )
(average) 2.71
Negative likelihood ratio
0.28 ( David G. Bundy et )
0.48 ( Lamture YR et al. )
(average) 0.38
Vomiting
 Positive likelihood ratio
1.31 ( Idris SA et al. )
1.09 ( Al-gaithy Zuhoor K et )
(average) 1.20
Negative likelihood ratio
0.56 ( Idris SA et al. )
0.38 ( Al-gaithy Zuhoor K et )
(average) 0.47
Right lower quadrant pain
 Positive likelihood ratio
1.20 ( David G. Bundy et )
8.00 ( Hardin M et al. )
1.12 ( Idris SA et al. )
(average) 3.44
Negative likelihood ratio
0.56 ( David G. Bundy et )
0.28 ( Hardin M et al. )
0.29 ( Idris SA et al. )
(average) 0.38
Diarrhea
 Positive likelihood ratio
0.71 ( Idris SA et al. )
(average) 0.71
Negative likelihood ratio
1.78 ( Idris SA et al. )
(average) 1.78

Further signs

Ultrasound for appendicitis
 Positive likelihood ratio
4.94 ( Al-Ajerami Y et al. )
16.60 ( Al-Khayal KA et al. )
45.50 ( Toorenvliet BR et al. )
30.33 ( Neufeld D et al. )
14.17 ( Doria AS et al. )
(average) 22.31
Negative likelihood ratio
0.19 ( Al-Ajerami Y et al. )
0.18 ( Al-Khayal KA et al. )
0.09 ( Toorenvliet BR et al. )
0.09 ( Neufeld D et al. )
0.16 ( Doria AS et al. )
(average) 0.14
Leukocytosis (> 10000 / ml)
 Positive likelihood ratio
2.23 ( Al-gaithy Zuhoor K et )
1.60 ( Saaiq M et al. )
1.89 ( Dahmardehei M et al. )
2.91 ( Kamran H et al. )
(average) 2.16
Negative likelihood ratio
0.35 ( Al-gaithy Zuhoor K et )
0.21 ( Saaiq M et al. )
0.26 ( Dahmardehei M et al. )
0.32 ( Kamran H et al. )
(average) 0.29

Sources used:

1.David G. Bundy et al. Does This Child Have Appendicitis? JAMA. 2007 Jul 25; 298(4): 438–451.
2.Wagner JM et al. Does This Patient Have Appendicitis? JAMA. 1996;276(19):1589-1594
3.Hardin M et al. Acute Appendicitis: Review and Update. Am Fam Physician. 1999 Nov 1;60(7):2027-2034
4.Nshuti R et al. Clinical presentation of acute appendicitis in adults at the Chris Hani Baragwanath academic hospital. Int J Emerg Med. 2014; 7: 12
5.Lamture YR et al. The role of rebound tenderness in acute appendicitis and appendicular perforation. Int Surg J. 2017 Feb;4(2):725-727
6.Idris SA et al. The sensitivity and specificity of the conventional symptoms and signs in making adiagnosis of acute appendicitis. Sudan journal of medical sciences. 4. 55-61
7.Al-gaithy Zuhoor K et al. Clinical value of total white blood cells and neutrophil counts in patients with suspected appendicitis: retrospective study. World Journal of Emergency Surgery : WJES. 2012;7:32
8.Al-Ajerami Y et al. Sensitivity and specificity of ultrasound in the diagnosis of acute appendicitis. East Mediterr Health J. 2012 Jan;18(1):66-9
9.Al-Khayal KA et al. Computed tomography and ultrasonography in the diagnosis of equivocal acute appendicitis. A meta-analysis. Saudi Med J. 2007 Feb;28(2):173-80
10.Toorenvliet BR et al. Routine ultrasound and limited computed tomography for the diagnosis of acute appendicitis. World J Surg 34(10):2278, October 2010
11.Neufeld D et al. Management of acute appendicitis: an imaging strategy in children. Ped Surg Internat 26(2):167, February 2010
12.Doria AS et al. US or CT for diagnosis of appendicitis in children and adults? A meta-analysis. Radiology 241(1):83, October 2006
13.Saaiq M et al. Diagnostic Accuracy of Leukocytosis in Prediction of Acute Appendicitis. Journal of the College of Physicians and Surgeons Pakistan 2014, Vol. 24 (1): 67-69
14.Dahmardehei M et al. Diagnostic Value of Leukocytosis, ESR and CRP in Patients with Suspected Acute Appendicitis. Zahedan J Res Med Sci 2013 Jul; 15(7): 59-63
15.Kamran H et al. Role of total leukocyte count in diagnosis of acute appendicitis. J Ayub Med Coll Abbottabad 2008;20(3)
16.Hastings RS et al. Abdominal pain in the ED: a 35 year retrospective. Am J Emerg Med. 2011 Sep;29(7):711-6
17.Caporale N et al. Acute abdominal pain in the emergency department of a university hospital in Italy. United European Gastroenterology Journal 2016, Vol. 4(2) 297–304