Negatif apendektomilerden kaçýnmanýn yolu: Ultrasonografi bunu baþarabilir mi?

AMAÇ: Akut apandist tanýsý, genellikle semptomlar ve fizik muayene bulgularý ile konulabilmektedir. Fakat, apandist tanýsýný kesinleþtirmek her zaman kolay olmamaktadýr. Bu çalýþmada, akut apandist tanýsýnda ultrasonografinin (USG), beyaz kan hücresi (WBC) ve C-reaktif protein (CRP) bulgularýyla birlikte kullanýmýnýn apandist tanýsýndaki yerini göstermeyi amaçladýk.
GEREÇ VE YÖNTEM: Ocak 2014–Ocak 2016 arasýnda, merkezimizde akut apandist tanýsý ile ameliyat olan 470 hastanýn bilgileri geriye dönük olarak tarandý. Hastalarýn patoloji sonuçlarý, CRP ve WBC düzeyleri ve USG sonuçlarý istatistiksel olarak karþýlaþtýrýldý. Hastalar patoloji sonuçlarýna göre, lenfoid hiperplazi (LH), komplike olmayan akut apandist (KOAA) ve komplike akut apandist (KAA) olarak üç grubu ayrýldý.
BULGULAR: Üç yüz otuz bir erkek 139 kadýn hastanýn ortalama yaþý 32.29±11.44 olarak saptandý. Ortalama WBC düzeyi, LH grubunda 12.31 103/uL (±4.47), KOAA grubunda 13.3 103/uL (±3.87) iken KAA grubunda 14.08 103/uL (±4.11) olarak saptandý (p=0.016). Ortalama CRP düzeyi LH grubunda 14.27 mg/L (±19.38) iken, KOAA grubunda 36.93 mg/L (±59.44) ve KAA grubunda 40.84 mg/L (±66.68) olarak saptandý (p=0.008). Sonografik olarak ölçülen ortalama apendiks çapý LH grubunda 4.86 (±3.93) iken, KOAA grubunda 6.98 mm (±4.08) ve KAA grubunda 7.63 mm (±3.92) olarak saptandý (p=0.0001). Tüm deðiþkenler altgruplar arasýnda analiz edildiðinde USG bulgularýnýn tüm gruplar arasýnda da anlamlý farka sahip olduðu gözlemlendi.
TARTIÞMA: Akut apandisit tanýsý alan hastalarýn WBC ve CRP deðerlerinin istatistiksel olarak anlamlý oranda yüksek olduðu fakat bu bulgunun kesin taný için yeterli olmadýðý gözlendi. Ultrasonografi bulgularýnýn hem enflamasyonun þiddetini belirlemede hem de apandist tanýsý konulmasýnda etkin olduðu görüldü. Ultrasonografinin akut apandist þüphesi bulunan hastalarda laboratuvar testleri ile kombine edilerek standart görüntüleme incelemesi olarak uygulanmasý gerektiðini düþünmekteyiz. Bu taný sisteminin negatif apendektomi oranýný azaltacaðýna inanmaktayýz.

How to avoid negative appendectomies: Can US achieve this?

BACKGROUND: Clinical diagnosis of acute appendicitis is based primarily on symptoms and physical findings. However, diagnosis of appendicitis is not always straightforward. The aim of this study was to demonstrate the diagnostic effectiveness of ultrasonography (US) in these cases in combination with white blood cell count (WBC) and C-reactive protein (CRP) level.
METHODS: Retrospective analysis of data collected on 470 consecutive patients who underwent appendectomy at the same institution between January 2014 and January 2016 was conducted. Data included demographic features, preoperative WBC and CRP levels, and US measurement of diameter of appendix. Patients were divided into 3 groups: lymphoid hyperplasia (LH), non-complicated acute appendicitis (NCAA), and complicated acute appendicitis (CAA), according to postoperative histopathological examination results.
RESULTS: There were 331 male and 139 female patients with mean age of 32.29±11.44 years included in the study. Mean WBC level was 12.31103/μL (±4.47 103/μL), 13.3 103/μL (±3.87 103/μL) and 14.08 103/μL (±4.11 103/μL) in LH, NCAA, and CAA groups, respectively (p=0.016). Mean CRP level was 14.2±19 mg/L, 36.9±59 mg/L, and 40.8±66 mg/L in LH, NCAA, and CAA groups, respectively (p=0.008). Mean outer diameter of the vermiform appendix on US was 4.8 mm (±3.9 mm), 6.9 mm (±4.08 mm) and 7.6 mm (±3.92 mm) in LH, NCAA, and CAA groups, respectively (p<0.01). When all variables were compared with each other, there were statistically significant differences in US findings according to group.
CONCLUSION: WBC count and CRP level were higher in patients with acute appendicitis, but these findings alone were insufficient for definitive diagnosis. US findings were effectual both in diagnosis and demonstration of severe inflammation. US should be combined with laboratory tests and used as standard initial imaging in diagnostic pathway of patients with clinically suspected appendicitis. The authors of this study believe that this diagnostic pathway will reduce negative appendectomy rate.