CENTRAL ASIAN JOURNAL OF MEDICAL AND NATURAL SCIENCES

Volume: 03 Issue: 02 | Mar-Apr 2022 ISSN: 2660-4159

http://cajmns.centralasianstudies.org

Ultrasound Examination for the Diagnosis of Acute

Appendicitis
1. Ataeva Saodat Khurshedovna Abstract: Objective: to determine the usefulness and
2. Umarkulov Zabur Zafarjonovich accuracy of ultrasound for the diagnosis of acute
appendicitis.
Methods. This retrospective study included 242 of 286
Received 19th Jan 2022, patients who underwent 2021 appendix ultrasound. The
Accepted 9th Feb 2022,
Online 3rd Mar 2022
ultrasound report, pathology report, and clinical records
were reviewed. The pathology report has been used as
the gold standard for diagnosing acute appendicitis.
1,2
Samarkand State Medical Institute, Results: The overall rate of visualization of the
Department of Medical Radiology, appendix was 41.7%. Fifty-six patients (23%) had a
Republic of Uzbekistan, Samarkand positive diagnosis of acute appendicitis on ultrasound,
45 (19%) had a negative diagnosis, and 141 (58%) had
an inconclusive diagnosis; 17 patients (7%) had an
alternative diagnosis suggested by ultrasound. Twenty-
nine patients (12%) underwent a CT scan based on the
ultrasound report, 6 of whom had a positive diagnosis of
acute appendicitis, 5 had a negative diagnosis, and 18
had an alternative diagnosis suggested by the CT scan.
Sensitivity, specificity, positive predictive value, and
negative predictive value of US for acute appendicitis
were 75.9%, 89.7%, 73.2%, and 91.0%, respectively,
after adjusted calculation for the US inconclusive group.
Conclusions. The results of ultrasonography of acute
appendicitis at the Queen Elizabeth Hospital in Hong
Kong are comparable to those reported in the literature.
Ultrasonography is a useful and safe imaging modality
for the investigation of acute appendicitis, and computed
tomography has an additional role in the diagnosis of
acute appendicitis and the management of patients with
right lower quadrant pain.
Keywords: appendicitis; Diagnostic imaging;
Ultrasound echography.

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INTRODUCTION
Acute appendicitis is a common problem, but diagnosis is often difficult. The accuracy of the clinical
examination ranges from 71% to 97%, depending on the experience of the surgeon. The perforation
rate reaches 35% if surgery is delayed. The reported incidence of appendectomy without appendicitis
(negative appendectomy) is 20% to 30%. However, imaging can reduce the rate of negative
appendectomy to 6–10%. Imaging assessment for suspected acute appendicitis in adults is becoming
increasingly popular. This study was performed to determine the applicability and accuracy of
ultrasonography (ultrasound) for the diagnosis of acute appendicitis.
Methods. This retrospective study included 286 patients with exam code 3102 (ultrasound) of the
radiological information system from June 1, 2006 to December 31, 2006. Forty-four patients were
excluded, most of whom were children with pyloric stenosis or intussusception. The study included
242 patients.
The US graded compression technique was used. US diagnostic criteria for acute appendicitis included
abnormal appendix morphology (>6 mm enlargement, lack of compressibility, and blind end) and
associated local tenderness on probe compression. The pathology report has been used as the gold
standard for diagnosing acute appendicitis. Patient outcomes were tracked from electronic records in
the Clinical Management System.
Results. The median age was 38.5 years (2 to 93 years). There were 65 men and 177 women with a
ratio of 1.0:2.7. At the time of the ultrasound, four patients were pregnant. All 4 patients were given an
inconclusive ultrasound diagnosis of acute appendicitis, in 2 of which the symptoms disappeared
spontaneously, and in 2 patients, they were discharged on their own against the doctor's
recommendations and were lost to follow-up.
213 patients were referred from the surgical department, 9 from the pediatric department, 10 from the
obstetrics and gynecology department and 10 from the medical department.
The appendix was visualized by ultrasound in 101 patients (41.7%). Thirty patients had a normal
appendix and 71 had an abnormal appendix.
Fifty-six patients (23%) had a positive ultrasound diagnosis of acute appendicitis, 45 (19%) had a
negative diagnosis, and 141 (58%) had an inconclusive diagnosis; 17 patients (7%) had an alternative
diagnosis proposed by the US.
Of the 56 patients who had a positive diagnosis of acute appendicitis on ultrasound, 41 (73%) had a
positive pathology, 9 patients (16%) had a negative pathology, and 6 (11%) had symptoms. this
disappeared with conservative treatment (Table 1). Pathological diagnoses for 9 patients with a
negative diagnosis included diverticulitis of the appendicular diverticulum (2), periappendicitis (1),
serositis (1), hyperplastic appendix polyp (1), acute pelvic inflammatory disease (1), intestinal
obstruction. due to adhesion (1) and absence of inflammation (2).
Of the 45 patients with a negative ultrasound diagnosis of acute appendicitis, none (0%) had a positive
pathology diagnosis; In 5 patients (11%) the diagnosis was pathologically negative, and in 40 (89%)
the symptoms disappeared with conservative treatment.
Of 141 patients with an inconclusive ultrasound diagnosis of acute appendicitis, 13 (9%) had a
positive pathological diagnosis; 14 patients (10%) had a pathology-negative diagnosis, 110 (78%) had
symptoms resolved with conservative management, 2 (1%) were discharged against medical advice
and were lost to follow-up, and 2 (1%) had inflammatory organ disease small pelvis.
Ultrasound suggested seventeen alternative diagnoses, including adnexal formation (11-5 on the right,
6 on the left), hydronephrosis on the right (1), hematoma of the rectus muscle on the right (1),

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CAJMNS Volume: 03 Issue: 02 | Mar-Apr 2022
hepatobiliary diagnosis (suspicious ileus of the gallbladder, confirmed by subsequent computer
studies). tomography [CT], acute cholecystitis, or a large liver tumor; 3) and a mass in the right upper
quadrant (1) that turned out to be caecal carcinoma on subsequent surgery.
Twenty-nine patients (12%) underwent CT based on the USG report, 6 of them had a positive
diagnosis of acute appendicitis, 5 had a negative diagnosis, and 18 were offered an alternative
diagnosis. Of the 16 patients advised by a radiologist to undergo a CT scan performed by ultrasound, 3
did not undergo a follow-up CT—1 had an appendectomy with a negative pathological diagnosis, and
2 had symptoms resolved with conservative management. Of the 13 patients who subsequently
underwent CT, 3 had CT-confirmed appendicitis, 1 had a complicated rupture, and 10 had a negative
diagnosis of acute appendicitis but were provided with alternative diagnoses. Alternative diagnoses
included genitourinary diagnosis: acute pyelonephritis (1), right ovarian tumor (1), pelvic
inflammatory disease (1), right lower quadrant cystic lesion (clinically bleeding corpus luteum cyst;
1), and left adnexal mass (1); and gastrointestinal diagnoses: caecal cancer (1), caecal diverticulitis (2),
biliary ileus (1), ileal thickening and enlarged lymph nodes (mesenteric adenitis; 1).
Of the 16 patients (7%) who underwent a clinician-recommended CT scan after an ultrasound
examination, 3 had a positive diagnosis of acute appendicitis, 5 had a negative diagnosis with no
significant pathology, and 8 had a negative diagnosis but had alternative diagnoses. provided.
Alternative diagnoses included pneumoperitoneum (1), cervical cancer with right hydronephrosis and
hydroureter (1), right ovarian mass (1), small bowel volvulus (1), ascending colon diverticulitis (1),
inflammatory changes in the right abdominal cavity (omental torsion during surgery; 1), acute
cholecystitis (1) and tuberculous peritonitis (1).
Table 1. Diagnostic accuracy of ultrasonography of acute appendicitis.
Diagnostics Ultrasound diagnostics Pathological diagnosis Number of patients
Truly Positive Positive 41
Negative or disappeared after
False positive Positive 15
conservative treatment
Negative or disappeared after
True negative Negative 45
conservative treatment
False positive Negative Positive 0
Table 2. Calculation of sensitivity, specificity, positive and negative predictive value of ultrasound
examination of acute appendicitis.
Formula Payment Result
Sensitivity TP/(TP+FN) 41/(41+0) 100%
Specificity TN/(FP+TN) 45/(15+45) 75,0%
Positive Predictive Value TP/(TP+FP) 41/(41+15) 73,2%
Negative Predictive Value TN/(FN+TN) 45/(0+45) 100%
Abbreviations: FN = false negative; FP = false positive; TN = true negative; TP = true positive.
Overall, 6 patients had a positive CT diagnosis of acute appendicitis, 5 had a negative diagnosis, and
18 had alternative diagnoses.
The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of US
for acute appendicitis were calculated after excluding patients with an inconclusive US diagnosis.
Sensitivity, specificity, PPV, and NPV for acute appendicitis were 100%, 75.0%, 73.2%, and 100%,
respectively (Table 2).

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CAJMNS Volume: 03 Issue: 02 | Mar-Apr 2022
Discussion. Compared to data in the literature, there is inconsistency in the efficacy of ultrasound in
diagnosing acute appendicitis in this study. Gaitini et al. Reported sensitivity, specificity, PPV, and
NPV for acute appendicitis were 74.2%, 97.0%, 88.0%, and 93.0%, respectively. Chan et al. reported
sensitivity, specificity, PPV, and NPV for acute appendicitis as 83%, 95%, 86%, and 94%,
respectively. Other prospective studies have reported sensitivity of 77% to 89% and specificity of 84%
to 96%. The discrepancy in US performance with this study can be explained by the high percentage
of inconclusive diagnoses (58.3%), since the percentage of inconclusive diagnoses in other studies was
small (4%) 6 or absent.
Therefore, if a negative ultrasound diagnosis of acute appendicitis was redefined as no positive
diagnosis (negative and inconclusive diagnosis), the adjusted ultrasound sensitivity, specificity, PPV,
and NPV for acute appendicitis in this study would be 75.9%, 89.7%, 73.2% and 91.0% respectively
(Table 3). Then, the performance of ultrasound in this study is comparable to data reported in the
literature.
Table 3. Calculation of adjusted values for sensitivity, specificity, positive and negative predictive
value of ultrasound examination of acute appendicitis.
Formula Payment Result
Sensitivity TP/(TP+FN) 41/(41+13) 75,9%
Specificity TN/(FP+TN) 131/(15+131) 89,7%
Positive Predictive Value TP/(TP+FP) 41/(41+15) 73,2%
Negative Predictive Value TN/(FN+TN) 131/(131+13) 91%
Abbreviations: FN = false negative; FP = false positive; TN = true negative; TP = true positive.
In this study, 12% of patients subsequently underwent CT on the recommendation of the radiologist
performing the ultrasound or on the initiative of the clinicians. There was a high rate of confirmation
of the diagnosis of acute appendicitis and suggestion of an alternative diagnosis (82.8%). Thus, CT
complements US for diagnosing acute appendicitis and treating patients with right lower quadrant
pain.
This study has limitations. First, it was a retrospective study. Second, criteria for a positive ultrasound
diagnosis of acute appendicitis included local tenderness consistent with ultrasound abnormality, while
other large-scale studies only mentioned morphological criteria. This could reduce the number of false
positives, but potentially increase the number of inconclusive diagnoses of acute appendicitis. Third,
some patients exhibited self-limiting symptoms. Fourth, the position of the process, especially
retrokecal or pelvic, can affect imaging speed. However, the position of the application could not be
examined during this audit as it was not documented in most operational records. Fifth, factors
influencing the choice of US or CT by referring surgeons were not assessed. Sixth, obese body type,
which may affect the accuracy of the scan, was not assessed.
Staff training and modification of scanning technique may improve the effectiveness of ultrasound in
diagnosing acute appendicitis. The posterior manual compression technique has been shown to
increase the speed of process visualization and is useful for visualizing the retrochecal process. This
method involves forced external compression of the right lower quadrant of the abdomen on the
opposite side of the transducer in an anterior or anteromedial direction using the palm and 4 fingers of
the left hand. The technique allows compression of the posterior part of the caecum or the perikecal
space with or without anteromedial displacement of the structures of the right lower quadrant of the
intestine onto the psoas muscle. The grip force and position of the left hand are dynamically changed,
which helps to achieve sufficient depth by the high frequency transducer, thereby increasing the spatial
resolution.

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The overall performance of ultrasonography for the investigation of acute appendicitis in this study is
comparable to that reported in the literature. Ultrasound is a useful and safe imaging modality for
investigating acute appendicitis. CT complements US in the diagnosis of acute appendicitis and in the
management of patients with right lower quadrant pain.
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