Application of scoring systems with point-of-care ultrasonography for bedside diagnosis of appendicitis

doi:10.5847/wjem.j.1920-8642.2016.02.007

Abstract

Abstract:

BACKGROUND: Appendicitis is a common disease requiring surgery. Bedside ultrasound (BUS) is a core technique for emergency medicine (EM). The Alvarado score is a well-studied diagnostic tool for appendicitis. This study aimed to investigate the relationship between patients' symptoms, Alvarado score and ultrasound (US) findings, as performed by emergency physicians (EPs) and radiologists, of patients with suspected appendicitis.
METHODS: Three EM specialists underwent the BUS course and core course for appendicitis assessment. Patients suspected of having appendicitis were selected and their Alvarado and modified (m) Alvarado scores calculated. The specialists performed the BUS. Then, patients were given a formal US and surgery consultation if necessary. Preliminary diagnoses, admission or discharge from the emergency department (ED) and final diagnosis were documented. The patients were also followed up after discharge from the hospital.
RESULTS: The determined cut-off value was 2 for Alvarado and 3 for mAlvarado scores. The sensitivities of the two scores were 100%. Each score was used to rule out appendicitis. The results of EP-performed BUS were as follows: accuracy 70%, sensitivity 0.733, specificity 0.673, + LR 2.24, and - LR 0.40 (95%CI). Radiologists were better than EPs at diagnosing appendicitis and radiologists and EPs were equally strong at ruling out appendicitis by US. When US was combined with Alvarado and mAlvarado scores, EP US+Alvarado/mAlvarado scores ≤3 and radiology US+Alvarado/mAlvarado scores ≤4 perfectly ruled out appendicitis.
CONCLUSION: BUS performed by EPs is moderately useful in detecting appendicitis. Combined with scoring systems, BUS may be a perfect tool for ruling out decisions in EDs.

Key words: Bedside ultrasound, Alvarado score, Appendicitis

Erden Erol Ünlüer, Rıfat Urnal, Utku Eser, Serkan Bilgin, Mehmet Hacıyanlı, Orhan Oyar, Haldun Akoğlu, Arif Karagöz. Application of scoring systems with point-of-care ultrasonography for bedside diagnosis of appendicitis[J]. World Journal of Emergency Medicine, 2016, 7(2): 124-129.

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Alvarado score		Modified Alvarado score
Feature	Score	Feature	Score
Migration of pain	1	Migration of pain	1
Anorexia	1	Anorexia	1
Nausea/vomiting	1	Nausea/vomiting	1
Tenderness in right lower quadrant	2	Tenderness in right lower quadrant	2
Rebound pain	1	Rebound pain	1
Elevated temperature	1	Elevated temperature	1
Leucocytosis	2	Leucocytosis	2
Shift of white blood cell count to the left	1
Total	10	Total	9

Variables	mAlvarado ≥ 3 and Alvarado ≥ 2 value (95%CI)
Sensitivity (%)	100.00 (93.51-100.00)
Specificity (%)	4.44 (0.54-15.15)
AUC (accuracy)	0.52 (0.42-0.62)
+ LR	1.05 (0.98-1.11)
- LR	0
PPV (%)	56.12 (45.73-64.97)
NPV (%)	100.00 (15.81-100.00)

Variables	Sensitivity (95%CI)	Specificity (95%CI)	+ LR (95%CI)	- LR (95%CI)
US diameter>6 mm	0.733 (0.578-0.849)	0.673 (0.532-0.790)	2.24 (1.48-3.40)	0.40 (0.24-0.66)
US wall>2 mm	0.733 (0.578-0.849)	0.673 (0.532-0.790)	2.24 (1.48-3.40)	0.40 (0.24-0.66)
US compressibility	0.733 (0.578-0.849)	0.691 (0.550-0.804)	2.38 (1.54-3.66)	0.39 (0.23-0.64)
US periapp fluid	0.733 (0.578-0.849)	0.673 (0.532-0.790)	2.24 (1.48-3.40)	0.40 (0.24-0.66)
US McBurney	0.705 (0.546-0.828)	0.727 (0.588-0.835)	2.58 (1.61-4.14)	0.41 (0.25-0.65)

Variables	Accuracy (%)	Sensitivity (95%CI)	Specificity (95%CI)	+ LR (95%CI)	- LR (95%CI)
EP US	70.0	0.733 (0.578-0.849)	0.673 (0.532-0.790)	2.24 (1.48-3.40)	0.40 (0.24-0.66)
Radiology US	80.1	0.614 (0.455-0.753)	0.945 (0.837-0.986)	11.05 (3.59-34.00)	0.41 (0.28-0.60)

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