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JBI Library of Systematic Reviews

Review title

Comparison of ultrasonography and computed tomography in the diagnosis of acute appendicitis

Reviewers

trainee6 1

trainee5 2

12

Review question/objective

The objective/s of this review is to evaluate the accuracy of ultrasonography and CT in diagnosis of

acute appendicitis.

Specific objective

1.To detect the acute appendicitis by ultrasonography.

2. To detect the acute appendicitis by CT.

3. To compare this diagnostic results .

The effectiveness of this study is to detect accuracy, specificity and sensitivity of ultrasonography and

CT in the diagnosis of acute appendicitis.

BackgroundAcute appendicitis is the most common abdominal surgical emergency that can affect individuals of allages. An accurate diagnosis of acute appendicitis can be established with great confi dence in themajority of patients, on the basis of history and physical examination. Sometimes, patients presentwith atypical clinical features and non-specifi c physical fi ndings, and evaluation of these patientsbecomes challenging. The aim of investigations in patients with atypical clinical features andnonspecific physical findings is to diagnose the condition as early as possible, in order to operatebefore appendiceal perforation and peritonitis develop. Many imaging modalities have been used toimprove the diagnostic accuracy in patients with acute appendicitis. In the past, radiographs ofabdomen and barium studies were done but they had a limited role in the diagnosis of acuteappendicitis. The newer techniques of ultrasonography (US) and computed tomography (CT)have shown great promise in evaluation of patients with suspected acute appendicitis.

US is a simple, rapid, non-invasive and inexpensive modality which is not associated with ionisingradiation. It can be used as a screening modality for initial evaluation of such patients. But US ishighly operator-dependent, and excessive bowel gas hinders proper evaluation of the appendix.Graded compression US, in particular, performs much better in experienced hands, requiring a highlevel of skill and expertise. In comparison, CT is readily available, is supposed to be operator-

independent, is relatively easy to perform, and has results that are easy to interpret. Unenhanced

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spiral CT provides global cross-sectional evaluation and important information regarding theappendix, mesentery and retroperitoneum. A distinct advantage of unenhancedspiral CT is the short examination time because it does not require patient preparation or contrastadministration. However, compared to US, CT is associated with the disadvantage of exposure toionising radiation. Both modalities are not only helpful in confirming the diagnosis of acuteappendicitis but also in excluding other conditions that mimic acute appendicitis. Bearing in mind theadvantages and limitations inherent in both US and CT, in experienced hands, these modalities havebeen effective in evaluating patients with suspected acute appendicitis. The purpose of the presentstudy was to evaluate the role of both graded compression US and unenhanced spiral CT in patientswith suspected acute appendicitis and to assess the utility of these investigations in patientmanagement.

This review aims to critically analyse and synthesize the best available evidence related to accurately

diagnosing the acute appendicitis. Patients admitted to hospitals for suspected appendicitis. Symptom

of appendicitis is fever, pain in RIF & vomiting. If we get early diagnosis, we will save the patients life.

If it is complicated it is dangerous for their life. CT has more radiation risks and more costly than

ultrasonography but it gets more accurate diagnosis. Therefore we preferred to do CT than

ultrasonography .

Inclusion criteria

Types of participants

The review will consider studies that include acute appendicitis who admitted to hospital.

Types of intervention(s)/phenomena of inter

Types of intervention byultrasonography and CT .

Types of outcome

This review will consider studies with the diagnosis of appendicitis and comfirmed by operative

findings.

Types of studies

This review will consider both experimental and including randomised controlled trials before and after

studies. All patients that admitted to hospital suspected with acute appendicitis.

Search strategy

The search strategy aims to find both published and unpublished studies. A three-step search strategywill be utilised in this review. An initial limited search of MEDLINE and CINAHL will be undertaken

followed by analysis of the text words contained in the title and abstract, and of the index terms used

to describe article. A second search using all identified keywords and index terms will then be

undertaken across all included databases. Thirdly, the reference list of all identified reports and

articles will be searched for additional studies. Studies published in english language will be

considered for inclusion in this review. Studies published from 2007 will be considered for inclusion in

this review.

The databases to be searched include:

MEDLINEPUbMed,

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CINAHL,

EMBASE,Dissertion

Abstract,Current Contents and other Specialist databases:

PsycINFO,Research&Trial registers ( CENTRAL,PEDro,current control trialled trials,OTseeker).

The search for unpublished studies will include:

Grey literature.

Initial keywords to be used will be:

Appendicitis ,ultrasonography , CT

Assessment of methodological quality

Papers selected for retrieval will be assessed by two independent reviewers for methodological

validity prior to inclusion in the review using standardised critical appraisal instruments from the

Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI)

(Appendix V). Any disagreements that arise between the reviewers will be resolved through

discussion, or with a third reviewer.

Data collection

Data will be extracted from papers included in the review using the standardised data extraction tool

from JBI-MAStARI (Appendix VI). The data extracted will include specific details about the

interventions, populations, study methods and outcomes of significance to the review question and

specific objectives.

Data synthesis

Quantitative data will, where possible be pooled in statistical meta-analysis using JBI-MAStARI. All

results will be subject to double data entry. Effect sizes expressed as odds ratio (for categorical data)and weighted mean differences (for continuous data) and their 95% confidence intervals will be

calculated for analysis. Heterogeneity will be assessed statistically using the standard Chi-square and

also explored using subgroup analyses based on the different study designs included in this review.

Where statistical pooling is not possible the findings will be presented in narrative form including

tables and figures to aid in data presentation where appropriate.

Conflicts of interest

References

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1. Balthazar EJ, Megibow AJ, Hulnick D, et al. CT of appendicitis. AJR Am J Roentgenol 1986;147:705-10.2. Balthazar EJ, Birnbaum BA, Yee J, et al. Acute appendicitis: CT and US correlation in 100 patients.Radiology 1994; 190:31-5.3. Birnbaum BA, Jeffrey RB Jr. CT and sonographic evaluation of acute right lower quadrantabdominal pain. AJR Am J Roentgenol 1998; 170:361-71.4. Crombe A, Weber F, Gruner L, et al. [Abdominopelvic ultrasonography in suspected acuteappendicitis: prospective study in adults]. Ann Chir 2000; 125:57-61. French.5. Jacobs JE, Birnbaum BA, Macari M, et al. Acute appendicitis: comparison of helical CT diagnosisfocused technique with oral contrast material versus nonfocused technique with oral and intravenouscontrast material. Radiology 2001; 220:683-90.6. Pickuth D, Spielmann RP. Unenhanced spiral CT for evaluating acute appendicitis in daily routine. Aprospective study. Hepatogastroenterology 2001; 48:140-2.7. Wijetunga R, Tan BS, Rouse JC, Bigg-Wither GW, Doust BD. Diagnostic accuracy of focusedappendiceal CT in clinically equivocal cases of acute appendicitis. Radiology 2001; 221:747-53.8. Franke C, Bohner H, Yang Q, Ohmann C, Roher HD. Ultrasonography for diagnosis of acuteappendicitis: results of a prospective multicenter trial. World J Surg 1999; 23:141-6. Comment in:World J Surg 2000; 24:496-7.9. Pickuth D, Heywang-Kobrunner SH, Spielmann RP. Suspected acute appendicitis: isultrasonography or computed tomography the preferred imaging technique? Eur J Surg 2000;166:315-9. Comment in: Eur J Surg 2000; 166:910.10. Wise SW, Labuski MR, Kasales CJ, et al. Comparative assessment of CT and sonographictechniques for appendiceal imaging. AJR Am J Roentgenol 2001; 176:933-41.11. Kaiser S, Frenckner B, Jorulf HK. Suspected appendicitis in children: US and CT a prospectiverandomized study. Radiology 2002; 223:633-8.12. Styrud J, Josephson T, Eriksson S. Reducing negative appendectomy: evaluation ofultrasonography and computer tomography in acute appendicitis. Int J Qual Health Care 2000;12:658.13. Puylaert JB. Acute appendicitis: US evaluation using graded compression. Radiology 1986;158:355-60.

14. Jeffrey RB Jr, Laing FC, Lewis FR. Acute appendicitis: high-resolution real-time US findings.Radiology 1987; 163:11-4.15. Rioux M. Sonographic detection of the normal and abnormal appendix. AJR Am J Roentgenol1992; 158:773-8.16. Rao PM, Rhea JT, Novelline RA, Mostafavi AA, McCabe CJ. Effect of computed tomography ofthe appendix on treatment of patients and use of hospital resources. N Engl J Med 1998; 338:141-6.Comment in: N Engl J Med 1998; 338: 190-1, N Engl J Med 1998; 338: 1847-8.17. Poortman P, Lohle PN, Schoemaker CM, et al. Comparison of CT and sonography in thediagnosis of acute appendicitis: a blinded prospective study. AJR Am J Roentgenol 2003; 181:1355-9

Appendix I: Appraisal instruments

MAStARI Appraisal instrument

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Appendix II: Data extraction instruments

MAStARI data extraction instrument

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