Diagnostic Error
Pat Croskerry, Karen S. Cosby, Mark L. Graber, Hardeep Singh in Diagnosis, 2017
Studies that evaluate the accuracy of physical findings in isolation may not fairly assess their clinical utility. Exam findings are sought based in part on the patient’s narrative account of illness, thus they have context. If the leg hurts, searching for the area of tenderness helps localize the problem (skin, subcutaneous tissue, muscle, bone, or joint) and refine the differential diagnosis. And at the very least, looking at the area of interest shows concern! In addition, the value of any one part of the exam is enhanced by the presence or absence of other physical findings. For example, when percussion dullness is noted over the spleen, the sensitivity of palpation for splenomegaly is improved to 87% [58]. While no single finding may be diagnostic, a combination of findings can be more predictive, and a combination of physical findings interpreted in light of the patient’s history can collectively improve diagnosis, as in the Alvarado score for appendicitis [59]. In addition, repeated examinations over time may be useful. Surgeons have long advocated for serial exams in the assessment of abdominal pain. With repeated examinations, a clinician is perhaps likely to become more confident in his exam, more aware of subtle abnormalities, or better able to detect changes as a condition worsens.
Appendicitis
Stephen M. Cohn, Matthew O. Dolich, Kenji Inaba in Acute Care Surgery and Trauma, 2016
The most recent meta-analysis published by Varadhan et al. [149] explored the efficacy of antibiotic treatment compared with appendectomy and includes four trials and 900 patients. They conclude that using antibiotic therapy as first-line treatment is worthy of consideration for all patients with early uncomplicated appendicitis and report a success rate of 63% at 1 year and a relative risk reduction in 31% for antibiotic treatment of uncomplicated cases compared with appendectomy. The NOTA (nonoperative treatment for acute appendicitis) study is the most recent prospective study published concerning this subject. A total of 159 patients with suspected appendicitis underwent observation and received a course of amoxicillin/clavulanate. Follow-up was conducted at set intervals up to 2 years. Initial assessment of patients included the use of clinical assessment scores such as Alvarado score. Ultrasound and CT scans were not part of routine work up and were obtained at the discretion of the consultant surgeon, 73% of enrolled patients received US, and 17% received CT imaging. Failure rates at 7 days were 11.9%, recurrence rates after 2 years were 13.8%, and overall efficacy rate of nonoperative treatment was 83%. The authors stress the importance of initial accurate clinical diagnosis and conclude that for select patients with suspected uncomplicated appendicitis initial antibiotic therapy is cost-effective as well as safe and efficacious [150].
Appendicitis
Stephen M. Cohn, Peter Rhee in 50 Landmark Papers, 2019
Today, the risk of appendicitis is about 10% in the US population, with a mean age of 31. About 20% of patients present with perforation. The appendix is retrocecal in 65% of cases, and pelvic in location in 31%, a fact which certainly contributes to its confusing and often atypical clinical presentation. While abdominal pain is universal, fever and leukocytosis are variable findings. Of note, pain medications have been proven to reduce patient discomfort without obscuring physical findings or delaying intervention (Attard et al., 1992). The Alvarado score has aided in stratifying patients at risk (Alvarado, 1986). CT is the preferred diagnostic imaging technique in adults, with an accuracy rate of about 95% (Rao et al., 1998) (similar to that found with surgeon evaluation alone). There has been a reduction in the removal of normal appendices in the CT era, but the appendiceal perforation rates have actually increased over the last 20 years. In addition, many patients who may have been observed prior to CT scanning are now undergoing removal of very “early” appendicitis. MRI is valuable during pregnancy, and studies have demonstrated that the appendix does not move cephalad (i.e., remains in the same position) during gestation, contrary to previously held beliefs. Fetal mortality is much higher with perforated appendicitis, but nontherapeutic appendectomy is not as dangerous. Therefore, early open appendectomy (laparoscopy doubles the fetal loss rate) is preferred during pregnancy when appendicitis is suspected.
Added value of CRP to clinical features when assessing appendicitis in children
Published in European Journal of General Practice, 2022
Guus C. G. H. Blok, Eelke D. Nikkels, Johan van der Lei, Marjolein Y. Berger, Gea A. Holtman
CRP levels were extracted automatically from laboratory results or manually from free-text entries. Data for age, gender, and body temperature were extracted automatically, while data for another 18 clinical features (symptoms and signs) described in seven clinical prediction rules were extracted by manual review [15]. Nausea and vomiting were combined into one variable consistent with most prediction rules. Elevated temperature and temperature ≥ 37.3 °C were combined into one variable according to the Alvarado score [16]. Based on a Dutch guideline, rebound tenderness, guarding, rigidity, and pain at jarring motions were combined as ‘peritoneal irritation’ [2,8]. Coders determined whether each clinical feature was present, absent, or not recorded (Supplementary Table 1). If in doubt, the coders discussed with an experienced GP (CGHB) or within the research team when doubt remained until consensus was reached.
Comparison of stump closure techniques during laparoscopic appendectomies for complicated appendicitis – results from Pol-LA (Polish laparoscopic appendectomy) multicenter large cohort study
Published in Acta Chirurgica Belgica, 2020
Anna Lasek, Michał Wysocki, Judene Mavrikis, Piotr Myśliwiec, Maciej Bobowicz, Natalia Dowgiałło-Wnukiewicz, Jakub Kenig, Tomasz Stefura, Maciej Walędziak, Michał Pędziwiatr
Males were the majority in Groups 1 and 3 (58%, 51.85% vs. 47%, p = .039, respectively). Similarly, patients in Groups 1 and 3 were older compared to Group 2 (median age 42 years, 30 years vs. 41 years, respectively in Group 1, 2, and 3 p < .001). Differences in diabetes mellitus rate was also noted between the groups (3.55%, 4.17%, 8.23%, p = .21). There were significant differences in the clinical picture of complicated appendicitis, as well. In Group 1, gangrenous appendicitis was found in 69.66% of cases, while in the remaining groups, it did not reach even one third. The highest percentage of perforated/autoamputated appendix (21.71%) and intraoperatively diagnosed intraperitoneal abscess (51.97%) were found in patients with stump closure via stapler. There were no differences in median BMI, ASA class, history of smoking, onset of symptoms, and median Alvarado score.
Related Knowledge Centers
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