Appendicitis: CT vs straight-to-surgery

A study suggests skipping the CT scan altogether in clear-cut cases:

Pre-operative CT is not necessary in cases with straightforward signs and symptoms of appendicitis, the investigator advised. “If, after a thorough physical examination, the diagnosis is still in question, then patients should be scanned.” These patients tend to be older, female and have symptoms that are not typical for acute appendicitis.

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  • RJS

    I have mixed feelings on this because of personal anecdote.

    I was 23 when I went to the ER with severe abdominal pain. It was a small country hospital, and the doc on duty was convinced I had appendicitis. I was convinced I did not, but I was exhausted from being in pain for 16 hours, and he was wearing me down. (We were having a “spirited” debate about it and the fentanyl was also making coherent discussion somewhat difficult for me.) Fortunately for me the surgeon had “gone off the mountain for the night” so I was “off the hook” and was transfered (by ambulance) to Loma Linda.

    CT scan with contrast showed that my appendix was fine. My pain went away on its own on the way down the mountain to Loma Linda, and never came back. I suspect I had a less than mediocre doctor because the first thing I heard when the tech was taking my history was a nurse ask him how often simethicone could be given and his reply was “Simethicone… that’s the same thing as cimetidine, isn’t it?”

    *Cringe*

    In his mind, I clearly had acute appendicitis. Who says who gets to make an obvious call? Obviously the physician should, but what if he’s wrong. Is defensive medicine the best practice in this case? I don’t know. FWIW, he was 100% convinced I had appendicitis. (Maybe he should read “How Doctors Think”.)

    Yeah, the plural of anecdote isn’t data, but it would have sucked to have unnecessary surgery on the other side of the country with no family and only one friend around.

    For what it’s worth, I still have my appendix.

  • Anonymous

    RJS:
    You really need to look historically at the treatment of appendicitis and understand it. In the old days (before CT scans regularly used) a certain number of normal appys was acceptable. Why, because, appendicitis can kill you…period. Though we now know an appendix is not a vestigal organ, as may of us know, you can live just fine without one. Missing an acute appy is a completely other story. Additionally, as any surgeon will tell you, a normal scan doesn’t “totally rule out” an acute appy. Maybe one of the surgeon’s here can give a story about it. Sadly, every time I meet an FMG with physcial exam skills much better than my own, I realize how much we over-rely on scans in this country.

  • Aggravated DocSurg

    I’m old-fashioned, and I still believe that the best method to diagnose appendicitis is a good history and physical examination. It is disheartening to be called to the ED at 3AM to see a patient who has a classic history, a classic examination, and an elevated WBC that are all consistent with appendicitis…..who has been in the ED since 6PM because a CT was ordered reflexively. CT scans are very helpful in many cases, but are clearly not always necessary, can delay care, and are sometimes falsely negative.

  • Anonymous

    RJS,

    Your history and physical could have been classic for appendicitis and the best doctor/surgeon in the world would not be able to refute it.

    Things become more obvious over time, and fortunately you did not need an operation. It would also have not been malpractice if the surgeon on the mountain was available and took out your normal appendix.

    And if your pain went away why did you need to get irradiated with a CT scan? You didn’t have an unnecessarry surgery, but you still ended up with an unnecessarry CT scan. So yeah it is defensive medicine, but the stakes are high with missed appendicitis. I am quite certain that you also consented to transfer and to the CT scan.

    And yes, I agree with 1;29 and Aggrdocsurg, that a normal CT doesn’t rule it out in 100% of cases.

  • Charity Doc

    I, too, like my surgical colleague Aggravated Docsurg, an am old fashioned doc relying the history and physical exam to diagnose an appendicitis. I will typically admit them to my observation unit in the ED and perform serial abdominal exams, or if they are reliable and have good social/family support, I will even send them home and give them detailed appy precautions with instructions to return in 4-6 hrs for a re-evaluation. I can say with certainty that an overwhelming majority of times when I consult a young surgeon about an obvious appy with all the classic signs…young male, RLQ pain with positive psoas signs, obturator signs, etc…including fever and leukocytosis, he will ask for a CT. I get a rectal contrast only, just to expedite things because by the time the patients finish the oral contrasts, the damn appendix may have already perforated. Poor patients having to endure the rectal assault by the CT tech just to show what I already suspected. I guess I could order a noncontrasted scan, but it’s the preference of our staff radiologist to use at least rectal contrast.

    The older surgeons, on the other hand, rarely ever asks for a CT on clear cut cases. Hence from my limitted experience and amateur deductions, Aggravated Docsurg must be an old fart!

  • Aggravated DocSurg

    Oh, my! I must be an old fart! Does 45 qualify?

  • Anonymous

    45 here also and I sound like an old curmudgeon sometimes in dealing with docs who don’t take histories and do exams. It is beyond sad what is going on and I grieve for my profession.

  • Happyman

    much better to take out two appendices instead of let one rupture and kill a patient, i think. this used to be taught regularly.

  • Happyman

    oops. please preface “appendices” with the word “normal” in my previous post – that clarifies my point i hope.

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