HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text Full Text (PDF) Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Raptopoulos, V. Articles by Kruskal, J. B. Search for Related Content PubMed PubMed Citation Articles by Raptopoulos, V. Articles by Kruskal, J. B.

Acute Appendicitis: Effect of Increased Use of CT on Selecting Patients Earlier¹

¹ From the Department of Radiology, Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Ave, Boston, MA 02215 (V.R., G.K., M.P.R., B.S., S.N.G., J.B.K.); and the Department of Radiology, Evangelismos Hospital, Leoforos Vassilisis Sofias, Athens, Greece (G.K.). From the 2000 RSNA scientific assembly. Received December 26, 2001; revision requested February 13, 2002; revision received April 18; accepted June 25. Address correspondence to V.R. (e-mail: vraptopo@caregroup.harvard.edu).

View larger version (111K): [in a new window]   Figure 1a. Six-grade CT scale of acute appendicitis. (a) Example of grade 0, or normal appendiceal findings. Transverse CT image obtained in a 23-year-old woman with lower abdominal pain for 1 day shows that although the appendix (arrow) is long and larger than 6 mm in diameter, it is filled with gas and has a thin nonenhancing wall. At surgical-pathologic examination, the appendix was normal. (b) Example of grade 1, or probable appendicitis. Transverse CT image obtained in a 32-year-old woman with acute onset of periumbilical pain for 6 hours shows the appendix (arrow) is 7 mm in diameter and has no perceptible lumen; the wall is not enhancing. The surgical-pathologic and CT findings correlated as probable appendicitis. (c) Example of grade 2, or appendicitis. Transverse CT image obtained in a 25-year-old man with 8 hours of generalized abdominal pain eventually localized to the right lower quadrant and mild leukocytosis but no tenderness shows the appendix (arrow) is 8 mm in diameter and filled with fluid. There is no gastrointestinally administered contrast material, but the wall is enhanced with intravenously administered contrast material. There is no periappendiceal stranding. (d) Example of grade 3, or appendicitis and periappendicitis. Transverse CT image obtained in a 42-year-old woman with right lower quadrant pain for a few hours and tenderness at physical examination shows the appendix (arrow) is 9 mm in diameter and filled with fluid; it has a thin but enhancing wall. Stranding of the periappendiceal fat is present. (e) Example of grade 4, or appendicitis with rupture. Transverse CT image obtained in a 30-year-old woman with 6 hours of lower abdominal pain and tenderness shows enlargement and enhancement of the base of the appendix (a) and periappendiceal fluid (arrow). (f) Example of grade 5, or complicated appendicitis. Transverse CT image obtained in a 22-year-old woman with 2 days of mild abdominal pain and increasing nausea and vomiting shows a complex mass (arrows) in the pelvis. The mass contained gas and at surgery was a complex inflammatory appendiceal abscess. There was mild abdominal tenderness, normal gynecologic examination results, and moderate leukocytosis.

View larger version (104K): [in a new window]   Figure 1b. Six-grade CT scale of acute appendicitis. (a) Example of grade 0, or normal appendiceal findings. Transverse CT image obtained in a 23-year-old woman with lower abdominal pain for 1 day shows that although the appendix (arrow) is long and larger than 6 mm in diameter, it is filled with gas and has a thin nonenhancing wall. At surgical-pathologic examination, the appendix was normal. (b) Example of grade 1, or probable appendicitis. Transverse CT image obtained in a 32-year-old woman with acute onset of periumbilical pain for 6 hours shows the appendix (arrow) is 7 mm in diameter and has no perceptible lumen; the wall is not enhancing. The surgical-pathologic and CT findings correlated as probable appendicitis. (c) Example of grade 2, or appendicitis. Transverse CT image obtained in a 25-year-old man with 8 hours of generalized abdominal pain eventually localized to the right lower quadrant and mild leukocytosis but no tenderness shows the appendix (arrow) is 8 mm in diameter and filled with fluid. There is no gastrointestinally administered contrast material, but the wall is enhanced with intravenously administered contrast material. There is no periappendiceal stranding. (d) Example of grade 3, or appendicitis and periappendicitis. Transverse CT image obtained in a 42-year-old woman with right lower quadrant pain for a few hours and tenderness at physical examination shows the appendix (arrow) is 9 mm in diameter and filled with fluid; it has a thin but enhancing wall. Stranding of the periappendiceal fat is present. (e) Example of grade 4, or appendicitis with rupture. Transverse CT image obtained in a 30-year-old woman with 6 hours of lower abdominal pain and tenderness shows enlargement and enhancement of the base of the appendix (a) and periappendiceal fluid (arrow). (f) Example of grade 5, or complicated appendicitis. Transverse CT image obtained in a 22-year-old woman with 2 days of mild abdominal pain and increasing nausea and vomiting shows a complex mass (arrows) in the pelvis. The mass contained gas and at surgery was a complex inflammatory appendiceal abscess. There was mild abdominal tenderness, normal gynecologic examination results, and moderate leukocytosis.

View larger version (114K): [in a new window]   Figure 1c. Six-grade CT scale of acute appendicitis. (a) Example of grade 0, or normal appendiceal findings. Transverse CT image obtained in a 23-year-old woman with lower abdominal pain for 1 day shows that although the appendix (arrow) is long and larger than 6 mm in diameter, it is filled with gas and has a thin nonenhancing wall. At surgical-pathologic examination, the appendix was normal. (b) Example of grade 1, or probable appendicitis. Transverse CT image obtained in a 32-year-old woman with acute onset of periumbilical pain for 6 hours shows the appendix (arrow) is 7 mm in diameter and has no perceptible lumen; the wall is not enhancing. The surgical-pathologic and CT findings correlated as probable appendicitis. (c) Example of grade 2, or appendicitis. Transverse CT image obtained in a 25-year-old man with 8 hours of generalized abdominal pain eventually localized to the right lower quadrant and mild leukocytosis but no tenderness shows the appendix (arrow) is 8 mm in diameter and filled with fluid. There is no gastrointestinally administered contrast material, but the wall is enhanced with intravenously administered contrast material. There is no periappendiceal stranding. (d) Example of grade 3, or appendicitis and periappendicitis. Transverse CT image obtained in a 42-year-old woman with right lower quadrant pain for a few hours and tenderness at physical examination shows the appendix (arrow) is 9 mm in diameter and filled with fluid; it has a thin but enhancing wall. Stranding of the periappendiceal fat is present. (e) Example of grade 4, or appendicitis with rupture. Transverse CT image obtained in a 30-year-old woman with 6 hours of lower abdominal pain and tenderness shows enlargement and enhancement of the base of the appendix (a) and periappendiceal fluid (arrow). (f) Example of grade 5, or complicated appendicitis. Transverse CT image obtained in a 22-year-old woman with 2 days of mild abdominal pain and increasing nausea and vomiting shows a complex mass (arrows) in the pelvis. The mass contained gas and at surgery was a complex inflammatory appendiceal abscess. There was mild abdominal tenderness, normal gynecologic examination results, and moderate leukocytosis.

View larger version (117K): [in a new window]   Figure 1d. Six-grade CT scale of acute appendicitis. (a) Example of grade 0, or normal appendiceal findings. Transverse CT image obtained in a 23-year-old woman with lower abdominal pain for 1 day shows that although the appendix (arrow) is long and larger than 6 mm in diameter, it is filled with gas and has a thin nonenhancing wall. At surgical-pathologic examination, the appendix was normal. (b) Example of grade 1, or probable appendicitis. Transverse CT image obtained in a 32-year-old woman with acute onset of periumbilical pain for 6 hours shows the appendix (arrow) is 7 mm in diameter and has no perceptible lumen; the wall is not enhancing. The surgical-pathologic and CT findings correlated as probable appendicitis. (c) Example of grade 2, or appendicitis. Transverse CT image obtained in a 25-year-old man with 8 hours of generalized abdominal pain eventually localized to the right lower quadrant and mild leukocytosis but no tenderness shows the appendix (arrow) is 8 mm in diameter and filled with fluid. There is no gastrointestinally administered contrast material, but the wall is enhanced with intravenously administered contrast material. There is no periappendiceal stranding. (d) Example of grade 3, or appendicitis and periappendicitis. Transverse CT image obtained in a 42-year-old woman with right lower quadrant pain for a few hours and tenderness at physical examination shows the appendix (arrow) is 9 mm in diameter and filled with fluid; it has a thin but enhancing wall. Stranding of the periappendiceal fat is present. (e) Example of grade 4, or appendicitis with rupture. Transverse CT image obtained in a 30-year-old woman with 6 hours of lower abdominal pain and tenderness shows enlargement and enhancement of the base of the appendix (a) and periappendiceal fluid (arrow). (f) Example of grade 5, or complicated appendicitis. Transverse CT image obtained in a 22-year-old woman with 2 days of mild abdominal pain and increasing nausea and vomiting shows a complex mass (arrows) in the pelvis. The mass contained gas and at surgery was a complex inflammatory appendiceal abscess. There was mild abdominal tenderness, normal gynecologic examination results, and moderate leukocytosis.

View larger version (123K): [in a new window]   Figure 1e. Six-grade CT scale of acute appendicitis. (a) Example of grade 0, or normal appendiceal findings. Transverse CT image obtained in a 23-year-old woman with lower abdominal pain for 1 day shows that although the appendix (arrow) is long and larger than 6 mm in diameter, it is filled with gas and has a thin nonenhancing wall. At surgical-pathologic examination, the appendix was normal. (b) Example of grade 1, or probable appendicitis. Transverse CT image obtained in a 32-year-old woman with acute onset of periumbilical pain for 6 hours shows the appendix (arrow) is 7 mm in diameter and has no perceptible lumen; the wall is not enhancing. The surgical-pathologic and CT findings correlated as probable appendicitis. (c) Example of grade 2, or appendicitis. Transverse CT image obtained in a 25-year-old man with 8 hours of generalized abdominal pain eventually localized to the right lower quadrant and mild leukocytosis but no tenderness shows the appendix (arrow) is 8 mm in diameter and filled with fluid. There is no gastrointestinally administered contrast material, but the wall is enhanced with intravenously administered contrast material. There is no periappendiceal stranding. (d) Example of grade 3, or appendicitis and periappendicitis. Transverse CT image obtained in a 42-year-old woman with right lower quadrant pain for a few hours and tenderness at physical examination shows the appendix (arrow) is 9 mm in diameter and filled with fluid; it has a thin but enhancing wall. Stranding of the periappendiceal fat is present. (e) Example of grade 4, or appendicitis with rupture. Transverse CT image obtained in a 30-year-old woman with 6 hours of lower abdominal pain and tenderness shows enlargement and enhancement of the base of the appendix (a) and periappendiceal fluid (arrow). (f) Example of grade 5, or complicated appendicitis. Transverse CT image obtained in a 22-year-old woman with 2 days of mild abdominal pain and increasing nausea and vomiting shows a complex mass (arrows) in the pelvis. The mass contained gas and at surgery was a complex inflammatory appendiceal abscess. There was mild abdominal tenderness, normal gynecologic examination results, and moderate leukocytosis.

View larger version (125K): [in a new window]   Figure 1f. Six-grade CT scale of acute appendicitis. (a) Example of grade 0, or normal appendiceal findings. Transverse CT image obtained in a 23-year-old woman with lower abdominal pain for 1 day shows that although the appendix (arrow) is long and larger than 6 mm in diameter, it is filled with gas and has a thin nonenhancing wall. At surgical-pathologic examination, the appendix was normal. (b) Example of grade 1, or probable appendicitis. Transverse CT image obtained in a 32-year-old woman with acute onset of periumbilical pain for 6 hours shows the appendix (arrow) is 7 mm in diameter and has no perceptible lumen; the wall is not enhancing. The surgical-pathologic and CT findings correlated as probable appendicitis. (c) Example of grade 2, or appendicitis. Transverse CT image obtained in a 25-year-old man with 8 hours of generalized abdominal pain eventually localized to the right lower quadrant and mild leukocytosis but no tenderness shows the appendix (arrow) is 8 mm in diameter and filled with fluid. There is no gastrointestinally administered contrast material, but the wall is enhanced with intravenously administered contrast material. There is no periappendiceal stranding. (d) Example of grade 3, or appendicitis and periappendicitis. Transverse CT image obtained in a 42-year-old woman with right lower quadrant pain for a few hours and tenderness at physical examination shows the appendix (arrow) is 9 mm in diameter and filled with fluid; it has a thin but enhancing wall. Stranding of the periappendiceal fat is present. (e) Example of grade 4, or appendicitis with rupture. Transverse CT image obtained in a 30-year-old woman with 6 hours of lower abdominal pain and tenderness shows enlargement and enhancement of the base of the appendix (a) and periappendiceal fluid (arrow). (f) Example of grade 5, or complicated appendicitis. Transverse CT image obtained in a 22-year-old woman with 2 days of mild abdominal pain and increasing nausea and vomiting shows a complex mass (arrows) in the pelvis. The mass contained gas and at surgery was a complex inflammatory appendiceal abscess. There was mild abdominal tenderness, normal gynecologic examination results, and moderate leukocytosis.

View larger version (25K): [in a new window]   Figure 2a. Graphs illustrate frequency distribution of CT grades for consecutive patients who underwent CT before appendectomy in (a) 1997 (n = 50) and (b) 2000 (n = 50). (a) In 1997, the distribution was skewed, with a peak in higher grades and a mean of 3.6 ± 1.2. The horizontal box plot shows the median CT grade was 4, and the interquartile range was between 3 and 5. (b) In 2000, the distribution shifted to almost normal, with a mean of 2.8 ± 1.0. The horizontal box plot shows that the median CT grade decreased to the middle grade of 3, and the interquartile range was between 2 and 3.

View larger version (24K): [in a new window]   Figure 2b. Graphs illustrate frequency distribution of CT grades for consecutive patients who underwent CT before appendectomy in (a) 1997 (n = 50) and (b) 2000 (n = 50). (a) In 1997, the distribution was skewed, with a peak in higher grades and a mean of 3.6 ± 1.2. The horizontal box plot shows the median CT grade was 4, and the interquartile range was between 3 and 5. (b) In 2000, the distribution shifted to almost normal, with a mean of 2.8 ± 1.0. The horizontal box plot shows that the median CT grade decreased to the middle grade of 3, and the interquartile range was between 2 and 3.

View larger version (16K): [in a new window]   Figure 3a. Box plots of surgical-pathologic grades show the median (thick horizontal line), interquartile range (box), and range (of all grades, vertical lines) for patients who underwent appendectomy in 1997 and 2000. (a) All patients who underwent appendectomy (n = 237) are included. The median surgical-pathologic grade for the 152 patients in the 1997 group was 3.0 (interquartile range, 2.0-3.8). This is significantly (P = .05) higher than the median grade for the 85 patients in the 2000 group, 2.5 (interquartile range, 2.0-3.5). (b) Only those patients who underwent CT before appendectomy (50 in each group) are included. The median grade for 1997 was 3.5 (interquartile range, 3.0-4.5). This is significantly (P < .003) higher than the median grade for 2000, 2.6 (interquartile range, 2-4).

View larger version (17K): [in a new window]   Figure 3b. Box plots of surgical-pathologic grades show the median (thick horizontal line), interquartile range (box), and range (of all grades, vertical lines) for patients who underwent appendectomy in 1997 and 2000. (a) All patients who underwent appendectomy (n = 237) are included. The median surgical-pathologic grade for the 152 patients in the 1997 group was 3.0 (interquartile range, 2.0-3.8). This is significantly (P = .05) higher than the median grade for the 85 patients in the 2000 group, 2.5 (interquartile range, 2.0-3.5). (b) Only those patients who underwent CT before appendectomy (50 in each group) are included. The median grade for 1997 was 3.5 (interquartile range, 3.0-4.5). This is significantly (P < .003) higher than the median grade for 2000, 2.6 (interquartile range, 2-4).

View larger version (23K): [in a new window]   Figure 4. Regression plot for patients who underwent CT before appendectomy (n = 100) shows excellent correlation (Spearman rank correlation, 0.83) between the surgical-pathologic (Surg/Path) and CT grades (Y = 0.468 + 0.854X, r2 = 0.7). The solid line is the regression line, the lines of small dashes are the 95% CI, and the lines of long and short dashes are the 95% prediction interval.