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A highly sensitive and specific combined clinical and sonographic score to diagnose appendicitis

Reddy, Swathi B. MD; Kelleher, Michael MD; Bokhari, S.A. Jamal MBBS; Davis, Kimberly A. MD; Schuster, Kevin M. MD

Journal of Trauma and Acute Care Surgery: October 2017 - Volume 83 - Issue 4 - p 643–649
doi: 10.1097/TA.0000000000001551
Original Articles

BACKGROUND Computed tomography (CT) scanning reduces the negative appendectomy rate however it exposes the patient to ionizing radiation. Ultrasound (US) does not carry this risk but may be nondiagnostic. We hypothesized that a clinical-US scoring system would improve diagnostic accuracy.

METHODS We conducted a retrospective review of all patients (age, >15 years) who presented through the emergency department with suspected appendicitis and underwent initial US. A US score was developed using odds ratios for appendicitis given appendiceal diameter, compressibility, hyperemia, free fluid, and focal or diffuse tenderness. The US score was then combined with the Alvarado score. Final diagnosis of appendicitis was assigned by pathology reports.

RESULTS Three hundred patients who underwent US as initial imaging were identified. Thirty-two patients with evident nonappendiceal pathology on US were excluded. In 114 (38%), the appendix was not visualized and partially visualized in 36 (12%). Fifty-seven (21.3%) had an appendectomy with 1 (1.7%) negative. Six nonvisualized appendicies underwent appendectomy, with no negative cases. Sensitivity and specificity for the sonographic score were 86% and 90%, respectively, at a score of 1.5. The combined score demonstrated 98% sensitivity and 82% specificity at 6.5, and 95% sensitivity, and 87% specificity at a score of 7.5. Sensitivity and specificity were confirmed by bootstrap resampling for validation. Area under receiver operating characteristic (ROC) curves for our new US score were similar to the ROC curve for the Alvarado score (91.9 and 91.1, p = 0.8). The combined US and Alvarado score yielded an area under the ROC curve of 97.1, significantly better than either score alone (p = 0.017 and p < 0.001, respectively).

CONCLUSION Our scoring system based entirely on US findings was highly sensitive and specific for appendicitis, and it significantly improved when combined with the Alvarado score. After prospective evaluation, the combined US-Alvarado score might replace the need for computed tomography imaging in a majority of patients.

LEVEL OF EVIDENCE Diagnostic Test, Level III.

From the Department of Surgery (S.B.R., K.A.D., K.M.S.); and Department of Radiology and Biomedical Imaging (M.K., J.B.), Yale School of Medicine, New Haven, Connecticut.

Submitted: August 2, 2016, Revised: April 14, 2017, Accepted: April 19, 2017, Published online: April 28, 2017.

This paper was presented as a podium presentation at the 75th Annual Meeting of AAST and Clinical Congress of Acute Care Surgery, September 14–17, 2016, Waikoloa, HI.

Address for reprints: Kevin M. Schuster, MD, Department of Surgery, Yale School of Medicine, 330 Cedar Street, BB310, PO Box 208062, New Haven, CT 06520-8062; email:

© 2017 Lippincott Williams & Wilkins, Inc.