Purpose Population Intervention and Outcome Measures Results/ Recommendations Study Limitiations

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1 Bibliographic Cite PMID Link Literature Type Level of Evidence Purpose Population Intervention and Outcome Measures Results/ Recommendations Limitiations Al-Jiffry BO, Khayat S, Abdeen E, et al. A scoring Prospective The authors aimed to 155 consecutive patients who were admitted to the Outcome measure: Predictive accuracy of the scoring system. RESULTS: The common bile duct diameter, alkaline phosphatase of > LIMITATIONS: The retrospective validation cohort might have introduced selection and system for the prediction of cohort develop and validate a general surgery department of a military hospital 200 IU, elevated bilirubin levels, alanine transaminase of > 220 IU, and observational biases. The may have been underpowered because of the sample size of choledocholithiasis: a prospective cohort. clinical scoring system for with symptomatic gallstones, biliary pancreatitis, According to hospital protocol, all patients with uncomplicated male age of > 50 years were significantly associated with the developmental cohort. The delay between admission and the time of ERCP theoretically Ann Saudi Med. 2016;36(1): predicting obstructive jaundice, or cholangitis, who symptomatic gallstones (pure biliary colic) were offered laparoscopic choledocholithiasis and were included in the scoring system. Ninety- may have increased the number of negative ERCP results, but our false negative rate for ERCP choledocholithiasis. subsequently underwent biochemical testing and cholecystectomy. On-table intraoperative cholangiography (IOC) was performed six patients (35%) had scores of > 8 (high risk), 86 patients (32%) had was consistent with the previously reported rates. ultrasonography. among select patients who were undergoing definitive procedures (at the attending scores of 4-7 (intermediate risk), and 27 patients (10%) had scores of 1- physician s or consultant s discretion) via the trans-cystic approach. Patients with 3 (low risk). In the validation cohort, the positive predictive value for a obstructive jaundice were initially evaluated using ultrasonography, as well as MRCP score of > 8 was 91.7%, and the scoring system had an area under the if the ultrasonography findings were ambiguous. If choledocholithiasis or a dilated curve of CBD (>10 mm, in the absence of stone visualization) was identified, the patient was asked to undergo ERCP before definitive gall bladder surgery was offered. CONCLUSION: Scores of > 8 were strongly correlated with choledocholithiasis in the developmental and validation groups, which indicates that our scoring system may be useful for predicting the need for therapeutic ERCP. However, prospective validation in a large multicenter cohort is needed to fully understand the benefits of the system. Andersson M, Kolodziej B, Andersson RE, et al To analyze the impact of 3791 patients presenting with suspicion of Prospective interventional and nested randomized trial. Registration of clinical RESULTS: The baseline period included 1152 patients, and the Readers were not blinded or no comment was made about the blinding of the readers. clinical trial of Appendicitis implementing a risk appendicitis between September 2009 and January characteristics, treatments and outcomes started during the baseline period. The intervention period 2639, of whom 1068 intermediate-risk patients Baseline characteristics of the control and experimental groups are different and/or there was Inflammatory Response score-based stratification algorithm 2012 from age 10 years were included at 21 AIR score-based algorithm was implemented during the intervention period. were randomized. In low-risk patients, use of the AIR score-based no attempt to control for confounding effects. management of patients with suspected based on the Appendicitis emergency surgical centres and from age 5years at Intermediate-risk patients were randomized to routine imaging or selective imaging algorithm resulted in less imaging (19.2 versus 34.5 percent; P<0.001), appendicitis. Br J Surg. 2017;104(11): Inflammatory Response three university paediatric centres. after clinical reassessment. fewer admissions (29.5 versus 42.8 percent; P<0.001), and fewer (AIR) score, and compared negative explorations (1.6 versus 3.2 per cent; P=0.030) and routine imaging with operations for non-perforated appendicitis (6.8 versus 9.7 percent; selective imaging after P=0.034). Intermediate-risk patients randomized to the imaging and clinical reassessment. observation groups had the same proportion of negative appendicectomies (6.4 versus 6.7 percent respectively; P=0.884), number of admissions, number of perforations and length of hospital stay, but routine imaging was associated with an increased proportion of patients treated for appendicitis (53.4 versus 46.3 percent; P=0.020).; CONCLUSION: AIR score-based risk classification can safely reduce the use of diagnostic imaging and hospital admissions in patients with suspicion of appendicitis. Boonstra PA, van Veen RN, Stockmann HB. Less Evaluation To evaluate the 466 consecutive patients with suspected appendicitis Patients were divided in two groups based on year of treatment, 2008 and 2011, In 2008, 228 patients were treated for acute appendicitis. In 43%, The lack of inclusion of patients who presented at our emergency department with suspected negative appendectomies due to imaging in implementation of the attending the Kennemer Gasthuis Haarlem in the respectively. Patients who received pre-operative imaging, including patients who imaging was performed. In 2011, 238 patients were treated; in 99 % of appendicitis and had negative test results (e.g., laboratory tests or ultrasonography) and patients with suspected appendicitis. Surg guideline "diagnostics and years 2008 and 2011 were included. They were underwent US and/or a CT scan were registered in both years. Negative the cases, imaging was performed. A decrease in patients with consequently did not undergo surgery. For this reason, the authors could not calculate how Endosc. 2015;29(8): treatment in acute selected from the digital hospital registration system, appendectomy was defined as removal of a histological normal appendix or negative negative appendectomy was seen from 19 % in 2008 to 5 % in many patients were spared from negative appendectomy due to the change in pre-operative appendicitis" in surgery registration system, and pathology diagnostic laparoscopy. Primary outcome was the rate of negative appendectomy Financial analysis showed a reduction in costs favoring The workup. Single reader or no inter-reader reliability was calculated. Observational evidence, department database. These databases contained all and the secondary outcome was the rate of perforated appendicitis, furthermore, a increased use of pre-operative imaging in patients with suspected generalizability of population,or/rr/hr not reported for comparison. patients who underwent surgery with post-operative financial analysis was performed to evaluate the cost-effectiveness of the increased acute appendicitis resulted in a cost-effective way to decrease the specimen evaluations. Diagnostic laparoscopies in use of imaging in patients with suspected appendicitis. number of patients with negative appendectomies. patients with suspected acute appendicitis were also included. Cho JH, Kim TN, Chung HH, et al. Comparison of Comparative To investigate the The authors retrospectively analyzed the Ranson, Acute Physiology and Chronic Health Evaluation (APACHE)-II, and bedside RESULTS: Of 161 patients, 21 (13%) were classified as severe AP, and 3 Per the authors: "Although the data used in this were collected prospectively, some scoring systems in predicting the severity of prognostic usefulness of prospectively collected clinical database from index for severity in acute pancreatitis (BISAP) scores, and computed tomography (1.9%) died. Statistically significant cutoff values for prediction of clinical data, including CRP, were missing due to lack of availability. In this, the number of acute pancreatitis. World J Gastroenterol. several existing scoring consecutive patients (n=161) with AP in the authors severity index (CTSI) of all patients were calculated. Serum C-reactive protein (CRP) severe AP were Ranson > 3, BISAP>=2, APACHE-II > 8, CTSI > 3, and cases of severe AP and mortalities was lower compared to other large scale clinical studies; 2015;21(8): systems in predicting the institution between January 2011 and December levels were measured at admission (CRPi) and after 24 h (CRP24). Severe AP was CRP24 > AUCs for Ranson, BISAP, APACHE-II, CTSI, and CRP24 in therefore, comparison of prognostic value of various scoring systems was somewhat difficult." severity of acute The mean age of a total of 161 patients was defined as persistent organ failure for more than 48 h. The predictive accuracy of predicting severe AP were 0.69 (95%CI: ), 0.74 (95%CI: pancreatitis (AP) ± 16.1 years and 102 patients (63%) were male. each scoring system was measured by the area under the receiver-operating curve 0.80), 0.78 (95%CI: ), 0.69 (95%CI: ), and 0.68 Sixteen patients (10%) had a history of previous (AUC). (95%CI: ), respectively. APACHE-II demonstrated the highest pancreatitis attack. Causes of AP included biliary accuracy for prediction of severe AP, however, no statistically (54%), alcohol (22%), idiopathic (21%), and others significant pairwise differences were observed between APACHE-II (3%). Twenty one patients (13%) developed and the other scoring systems, including CRP24. persistent organ failure for more than 48 h and were classified as severe AP according to the Atlanta CONCLUSION: Various scoring systems showed similar predictive Classification. Thirteen patients (8%) were classified accuracy for severity of AP. Unique models are needed in order to as moderately severe AP and 127 patients (79%) as achieve further improvement of prognostic accuracy. mild AP. Delhaye M, Van Steenbergen W, Cesmeli E, et al. Belgian consensus on chronic pancreatitis in adults and children: Statements on diagnosis and nutritional, medical, and surgical treatment. Acta Gastroenterol Belg. 2014; 77(1): Consensus paper To issue statements on diagnosis and nutritional, medical, and surgical treatment for chronic pancreatitis. Adults and children with chronic pancreatitis. N/A The authors state that clinicians should attempt to classify patients N/A into one of the six etiologic groups according to the TIGARO classification system. MRI/MRCP, if possible with secretin enhancement, is considered the imaging modality of choice for the diagnosis of early-stage disease. MRI is more sensitive than CT for detecting early CP stages, as signal changes can be picked up prior to morphological changes. MRCP allows for excellent visualization of the pancreatic ducts, with secretin enhancement providing an even better visualization of abnormalities of the pancreatic duct and its branches. Endoscopic ultrasound, which is more invasive, is the most sensitive method for detecting minimal structural changes indicative of CP, and may provide add-on value in uncertain cases.

2 Fung AK, Ahmeidat H, McAteer D, et al Validation To retrospectively validate Three hundred and sixty-seven patients (34.6%) had Hospital and radiology records were reviewed to identify patients with acute According to the CT findings, there was one case with grade 1, 1. This could be criticised for its retrospective nature, lack of strict treatment protocol to Validation of a grading system for complicated a CT grading system for CT performed for acute diverticulitis during the complicated diverticulitis confirmed by CT. A consultant gastrointestinal radiologist, eighteen patients with grade 2, four with grade 3 and twenty-one with streamline patients management according to the CT staging and also because patients were diverticulitis in the prediction of need for acute complicated period. Forty-four patients (12.0%) had acute blinded to the clinical outcomes of patients, assigned a score according to the CT grade 4 diverticulitis. Three patients with grade 2, three patients with treated by a group of surgeons with diverse experience, subspecialty interests and views on operative or percutaneous intervention. Ann R diverticulitis in the complicated diverticulitis (abscess and/or free grading system. grade 3 and ten patients with grade 4 disease underwent acute the man- agement of complicated acute diverticulitis. 2. The authors also acknowledge that Coll Surg Engl. 2015;97(3): prediction of the need for intraperitoneal air) confirmed on CT. There were 22 radiological or surgical intervention. The use of a CT grading system for the absolute number of patients was relatively small. 3. In addition, the authors appreciate operative or percutaneous women (50%) and the overall median age was 59 acute complicated diverticulitis did not predict the need for acute that only one consultant radiologist with a specialist interest in gastrointestinal imaging intervention. years (range: years). radiological or operative intervention in this small. Decision reviewed the CT and carried out the retrospective scoring. Single reader or no inter-reader making guided by the patient's clinical condition still retains a primary reliability was calculated. role in the management of acute complicated diverticulitis. Ginsburg D, Paroder V, Flusberg M, et al. Diagnosis of acute cholecystitis: why do patients get multiple studies? Emerg Radiol. 2016;23(1): To establish factors All patients with pathologically proven acute The subjects were separated into groups based on modality of the first. For affecting total number of cholecystitis between 1/1/2005 and 1/1/2014 at the each subject, report of the first was reviewed for report's confidence in imaging studies performed authors' institution who had at least one imaging diagnosis of AC (scored 1-5 on Likert scale: 5 = definitely AC, 1 = definitely no AC), for acute cholecystitis (AC) (US, CT, cholescintigraphy) within 7 days prior recommendation of additional, clinical history concerning for AC (history of prior to surgery. to surgery were included in the. Of the 596 right upper quadrant pain, cholelithiasis, and/or "rule out AC"). patients included, 219 (36.7 %), 339 (56.9 %), and 38 (6.4 %) subjects were in the CT, US, and cholescintigraphy groups, respectively. (First US: Average age 46.7 years, 80.2% female. First CT: Average age 55.5 years, 60.7% female. First cholescintigraphy: Average age 51.6 years, 65.8% female.) There were 219, 339, and 38 subjects in CT, US, and cholescintigraphy Limitations of this include extracting information from written diagnostic reports and groups, respectively, with mean confidence scores of 3.7 (+/- 1.2), 3.7 assigning a score based on the wording of the report which introduces bias due to the (+/- 1.1), and 4.7 (+/- 0.9), respectively (p < 0.001). Prior to surgery, considerable heterogeneity and style of reporting of imaging findings by multiple readers. only one was performed in 21.9 % (48/219) of CT group, 70.2 % Additionally, the assignment of the categories for any given phrasing of the findings was (238/339) of US group, and 71.1 % (27/38) of cholescintigraphy group somewhat subjective. Another important limitation was that the authors were unable to (p < ). Compared to the US group, the odds of undergoing account for possible point of care US performed by ED physicians prior to additional diagnostic additional were 11.8 times higher (p < 0.001) in CT group and 1.7 imaging. Bedside US exams are increasingly performed by ED physicians and findings noted on times higher (p = 0.229) in cholescintigraphy group, adjusting for age, bedside, US may have influenced the type of imaging test ordered. Furthermore, the authors sex, time interval between first and the surgery, confidence were unable to accurately account for analgesic administration prior to US. Pain medications score, recommendation of follow-up, and clinical history could potentially mask a sonographic Murphy sign and thus may have influenced confidence of concerning for AC. Patients with AC and CT as the first are more the reporting radiologist in diagnosis of AC. Additionally, non-consecutive recruitment may likely to undergo additional imaging studies prior to surgery as have introduced selection bias into the, and not all patients received the reference compared to US or cholescintigraphy. ("gold") standard or patients received different reference standards. Hahn B, Bonhomme K, Finnie J, et al. Does a Retrospective To determine if AAA Subjects were included if they met the following A retrospective (approved by institutional review board) of emergency RESULTS: During the period, 606 subjects were enrolled. This has several limitations. The was retrospective, and therefore, the results are normal screening ultrasound of the abdominal cohort rupture can reliably be criteria: age > 65years; an initial CT or US as an ED department (ED) patients in an urban academic center was performed. The Demographic data are listed in Table 1. Three subjects (0.5%) subject to all biases associated with a retrospective. This issue would have been avoided aorta reduce the likelihood of rupture in excluded in individuals patient, inpatient, or outpatient for any indication, incidence of ruptured AAA on the second CT or US with a history of normal aortic exhibited an abnormal-sized aorta on ED evaluation. None of these in a prospective. This was undertaken at a single institution; therefore, the emergency department patients? Clin Imaging. with abdominal pain who which identified an abdominal aorta < 3cm; and a caliber was identified. three subjects had an AAA intervention. The average size of the practices identified may not be generalizable to other populations. It is conceivable that a 2016;40(3): have had a normal caliber second CT or US during an ED visit. N=606. abnormal aorta in these three subjects was 3.3 cm (S.D. 0.17). multicenter may have produced different results. aorta on CT or US after the age of 65years CONCLUSION: Based on these results, it appears that AAA and rupture may reliably be excluded in ED patients with abdominal pain who have previously had a normal caliber aorta on CT or US after the age of 65years. A prospective, multicenter would help validate these findings Hendriks IG, Langen RM, Janssen L, et al. Does Retrospective To evaluate the effect of 1102 patients who underwent acute appendectomy Retrospectively all pathology results were studied, which were classified as A significant decline in the percentage of negative appendectomies A prospective concerning the Alvarado Score was also conducted in the same hospital the Use of Diagnostic Imaging Reduce the Rate implementation of the from January 2007 until October 2012 were included. "appendicitis acuta" or "appendix sana" from January 2007 until October To was found from an average of 18.0% before implementation of the from January 2011 onwards. Because of this, it might be possible that there was more of Negative Appendectomy? Acta Chir Belg Dutch Society of Gender males, n (%) Before guideline evaluate the perforation rate in acute appendicitis, surgery reports of all patients guideline towards an average of 9.2% after implementation of the attention for properly diagnosing patients suspected of acute appendicitis. This might have 2015;115(6): Surgeons guideline for implementation (BGI) (52.8) After guideline included in the were studied. Both percentages of negative appendectomies guideline (p<0.001). The percentage of patients with appendicitis in influenced our results in a positive manner. Patients with indeterminate results from the diagnosis and treatment of implementation (AGI) 266 (51.0) females, n (%) - BGI and perforation rate were compared for the periods before and after the which the appendix perforated remained about the same; 20.9% diagnostic test were excluded or no comment was made about how indeterminate results acute appendicitis. 274 (47.2) AGI 256 (49.0), Age, median (range) BGI 23 introduction of the new guideline (i.e vs ). before implementation of the guideline compared to 19.2% after were handled. OR/RR/HR not reported for comparison, observational evidence. (3-91) AGI 27 (2-94) implementation of the guideline (p=0.527). The data showed a significant decline in negative appendectomies without an increase of perforation rate after introduction of the new diagnostic guideline for acute appendicitis. Hernandez MC, Aho JM, Habermann EB, et al Validation To validate use of the 334 patients aged 18 years or older who presented Baseline demographics, procedure types were recorded, and AAST grades were RESULTS: Three hundred thirty-four patients with mean (+/-SD) age of This article has several limitations. It is a retrospective review of a single institution s Increased anatomic severity predicts outcomes: American Association for with acute appendicitis from January 2013 to January assigned based on intraoperative and radiologic findings. Outcomes including length 39.3 years (+/-16.5) were included (53% men), and all patients had experience. The size of the cohort is limited. All of the patients had crosssectional imaging, Validation of the American Association for the the Surgery of Trauma 2015 were included. The population had mean (±SD) of stay, 30-day mortality, and complications based on Clavien-Dindo categories and cross-sectional imaging. Two hundred ninety-nine underwent which does not occur for many patients in general practice that will often undergo ultrasound Surgery of Trauma's Emergency General (AAST) anatomic severity age of 39.3 years (±16.5) and 53% were men. 299 National Surgical Quality Improvement Program variables. Summary statistical appendectomy, and 85% completed laparoscopic. Thirty-day mortality imaging or no imaging, in particular younger, male patients. It is possible that a single reviewer Surgery score in appendicitis. J Trauma Acute grading system in patients (89.5%) patients underwent appendectomy, of which univariate, nominal logistic, and standard least squares analyses were performed rate was 0.9%, complication rate was 21%. Increased (median interpretation of the radiographic report by the radiologist may introduce possible bias. A Care Surg. 2017;82(1):73-9. with appendicitis and 85% were completed laparoscopically. comparing AAST grade with key outcomes. Bland-Altman analysis compared [interquartile range, IQR]) AAST grade was recorded in patients with great majority of the patients in this cohort had low-grade appendicitis as scored by the AAST determine if cross- operative findings with preoperative cross-sectional imaging to compare assigning complications (2 [1-4]) compared with those without (1 [1-1], p = system, confirming that appendicitis is often uncomplicated and that assigning five levels to sectional imaging grades ). For operative management, (median [IQR]) AAST grades were the disease may not reflect severity wholly as compared with a more discrete scoring system. correlates with disease significantly associated with procedure type: laparoscopic (1 [1-1]), Additionally, the data set did not have wide variability in patient comorbidity, mortality or severity at operation. open (4 [2-5]), conversion to open (3 [1-4], p = 0.001). Increased physiologic stress, and generalizing this system to a more diverse population may not be (median [IQR]) AAST grades were significantly associated in possible. nonoperative management: patients having a complication had a higher median AAST grade (4 [3-5]) compared with those without (3 [2-3], p = 0.001). Bland-Altman analysis comparing AAST grade and crosssectional imaging demonstrated no difference ( /- 0.02; p = 0.2; coefficient of repeatability 0.9). CONCLUSIONS: The AAST grading system is valid in our population. Increased AAST grade is associated with open procedures, complications, and length of stay. The AAST emergency general surgery grade determined by preoperative imaging strongly correlated to operative findings. LEVEL OF EVIDENCE: Epidemiologic/prognostic, level III.

3 Jensen MD, Kjeldsen J, Rafaelsen SR, et al Comparative High To determinate and A total of 50 patients with symptomatic pre-existing MRE and CTE were performed a median of 11 days before or after ileocolonoscopy A total of 35 patients had active small bowel CD (jejunum 0, ileum 1, Per the authors: "The prevalence of CD proximal to the terminal ileum was low, and we were Diagnostic accuracies of MR enterography and ; Meta- compare the sensitivities CD and a demand for small bowel imaging to support (range 2 33), and the median interval between radiological procedures and surgery (neo)- terminal ileum 34) and 20 had small bowel stenosis. The unable to determine the sensitivity and specificity of MRE and CTE for detection of proximal CT enterography in symptomatic Crohn's Analysis; and specificities of MRE changes in treatment strategy were included in this was 51 days (range 3 211). MRE and CTE were performed on the same day in sensitivity and specificity of MRE for detection of small bowel CD was disease." "We did not include objective measures of CD activity at MRE and CTE because no disease. Scand J Gastroenterol. and CTE for the detection prospective and blinded. 13 male and 37 alternating order and subsequently compared with the gold standard: pre-defined 74% and 80% compared to 83% and 70% with CTE (p 0.5). MRE and such indices were validated at the time this was initiated. Furthermore, we did not 2011;46(12): of small bowel lesions with female patients were included; patients' median age lesions at ileoscopy (n = 30) or surgery with (n = 12) or without (n = 3) intra- CTE detected small bowel stenosis with 55% and 70% sensitivities, attempt to distinguish inflammatory from fibrostenotic CD. Some studies have suggested that U.S. Gov't; emphasis on stenoses in was 39 (18-76). Montreal classification of Crohn's operative enteroscopy. respectively (p = 0.3) and 92% specificities. In symptomatic patients MRE and CTE can distinguish between fibrosis and inflammation." "Radiologists were Review this group of symptomatic Disease at inclusion: Ileal (L1) = 20, colonic (L2) = 5, with CD and high disease prevalence, positive predictive values are randomly assigned to MRE or CTE in a blinded fashion and variations in obtained sensitivities patients with established Ileocolonic (L3) = 25, isolated upper small bowel (L4) favorable but negative predictive values are low. Consequently, MRE and specificities compared to other studies cannot be explained by investigator-dependency Crohn's disease (CD). = 0; Disease behavior: non-stricturing/non- and CTE can be relied upon, if a positive result is obtained whereas a alone. The fact that CTE was a new modality in the Department of Radiology might have penetrating (B1) = 14, stricturing (B2) = 30; negative enterography should be interpreted with caution. favored MRE over CTE. Additional contrast was not given between radiological procedures and penetrating (B3) = 6; perianal disease (p) = 7; Median it cannot be ruled out that the sensitivities for detection of stenosis would have been better if duration of Crohn's = 10 years (0.3-36). procedures had been performed on separate days with optimal bowel filling. Our post hoc characterization of stenoses contains some insecurity because 5 out of 20 stenoses were assessed at ileocolonoscopy without balloon dilatation." Juvonen P, Lehtimaki T, Eskelinen M, et al. The Clinical Trial; To assess the need for 93 patients with acute abdominal pain from a Patients were randomized to the routine abdominal computed tomography CT (rct, RESULTS: Diagnostic accuracy improved significantly in the rct group Sparse data, poor follow up, incomplete reporting, limitation on generalizability of findings. need for surgery in acute abdominal pain: a surgical treatment in university teaching hospital. n=118), or selective abdominal CT group (sct, n=85) over a period of 16 months. (p<0.001). The surgeon's assessment of the need for surgery changed randomized of abdominal computed ; patients with acute Ninety-three of the randomized patients (45.8%) underwent the design and more often in the rct group than in the sct group (78.7% vs. 46.9%, tomography. In Vivo. 2014;28(3): abdominal pain in a were reached for follow-up at three months. p=0.002). The confidence to treat operatively increased significantly in prospective randomized the rct vs. the sct group (65.6% vs. 40.6%, p=0.028). The rct was the U.S. Gov't only independent parameter for the change of the assessment of surgery.; CONCLUSION: Routine CT allows for more confidence in decision making for the surgical treatment of patients with acute abdominal pain. Karkkainen, JM, Acosta, S. Acute mesenteric Review; Best N/A To identify how to improve N/A N/A The etiological categorization of AMI should be practical and guide the N/A ischemia (part I) - Incidence, etiologies, and Practice diagnostic performance, so therapy. Furthermore, the limitations of the diagnostic examinations how to improve early diagnosis. Baillieres Best that more patients get need to be understood with special emphasis on computed Pract Res Clin Gastroenterol. 2017;31(1):15-25 proper treatment for acute tomography findings on patients with slowly progressing "acute-on- mesenteric ischemia chronic" mesenteric ischemia (AMI). Kiewiet JJ, Andeweg CS, Laurell H, et al. External Prospective External validation and Patients with acute abdominal pain for < 7 days with Two derivation datasets were used crosswise for external validation. In addition, Predictive value of the emergency department triad was comparable There is substantial variance in the OR s of the variables includedin both tools across the validation of two tools for the clinical diagnosis Cohort comparison of the suspected acute diverticulitis (n=103). both tools were validated in a third independent cohort. Predictive values were to the clinical scoring tool. The positive predictive value of the different cohorts. Most striking is the high predictive value of CRP levels >50 mg/l and absence of acute diverticulitis without imaging. Dig Liver diagnostic accuracy of two reassessed and the Area Under the Curve expressed discriminatory capacity. emergency department triad (97%) decreased in the clinical scoring of vomiting in the ED triad cohort compared to the other two cohorts who have more similar Dis. 2014;46(2): predictive tools, the Performance was compared by calculating positive predictive values of the tool cohort (81%) and was excellent in the independent cohort OR s. Disease severity of the cohorts might play a role, however it cannot fully account for the emergency department emergency department triad in the validation cohorts and with a cut-off analysis for (100%), identifying 24%, 20% and 14% of the patients. A smaller differences found since the ED triad cohort and the IND cohort are more alike in terms of triad and the clinical the clinical scoring tool at a positive predictive value of 90%. proportion of patients with diverticulitis could be identified with the disease severity compared to the CS tool cohort. Differences in the way clinicians identify scoring tool in diagnosing clinical scoring tool (6%, 19% and 9%). The emergency department patients to be suspected of having acute diverticulitis could have led to selection bias. For acute diverticulitis. triad as well as the clinical scoring tool have significant predictive value example, the way primary care is organised differs between countries (ED triad cohortand CS in external cohorts of patients suspected of diverticulitis. These tools tool cohort versus IND cohort), which might have influenced patient selection. Unfortunately a can be used to select patients in whom additional imaging to diagnose large part of this selection process is not well described, so most factors remain elusive. acute diverticulitis may be omitted. Lahaye MJ, Lambregts DM, Mutsaers E, et al Retrospective To evaluate whether 1,556 consecutive patients with clinically suspected Retrospective of imaging use (none/us/ct and/or MRI) was recorded. RESULTS: After clinical examination by a surgeon, 509/756 patients in The suboptimal implementation means that the exact impact of the guidelines could not Mandatory imaging cuts costs and reduces the mandatory imaging is an appendicitis in (756 patients/group I) and Additional parameters were: complications, medical costs, surgical and group I and 540/800 patients in group II were still suspected of having precisely be defined in this. Furthermore, the present was limited due to its rate of unnecessary surgeries in the diagnostic effective strategy in (800 patients/group II). Men Before histopathological findings. The primary endpoint was the number of appendicitis. In group I, 58.5% received preoperative imaging (42% retrospective nature. Patients with indeterminate results from the diagnostic test were work-up of patients suspected of having suspected appendicitis for guideline (BG) 307 (40.6 %) After guideline (AG) 317 unnecessary surgeries before and after guideline implementation. US/12.8% CT/3.7% both), compared with 98.7% after the guidelines excluded or no comment was made about how indeterminate results were handled. Single appendicitis. Eur Radiol. 2015;25(5): reducing unnecessary (39.6 %) Women BG 449 (59.4 %) AG 483 (60.4 %) (61.6% US/4.4% CT/ 32.6% both). The percentage of unnecessary reader or no inter-reader reliability was calculated. Generalization is limited, incomplete surgery and costs. Age, y BG 31.6 (2 89 years) AG 31.6 (0 98 years) surgeries before the guidelines was 22.9%. After implementation, it reporting of test statistics. Mean age, y BG 31.6 (2 89 years) AG 31.6 (0 98 dropped significantly to 6.2% (p<0.001). The surgical complication rate years). After clinical examination by a surgeon, 509 dropped from 19.9% to 14.2%. The average cost-per-patient (67.3 %) patients in group I and 540 (67.5 %) patients decreased by 594 <euro> from 2,482 to 1,888 <euro> (CL:-1081; -143). in group II were still suspected of having appendicitis. CONCLUSION: Increased use of imaging in the diagnostic work-up of patients with clinically suspected appendicitis reduced the rate of negative appendectomies, surgical complications and costs.; KEY POINTS: * The 2010 Dutch guidelines recommend mandatory imaging in the work-up of appendicitis. * This led to a considerable increase in the use of preoperative imaging. * Mandatory imaging led to reduction in unnecessary surgeries and surgical complications. * Use of mandatory imaging seems to reduce health care costs.

4 Lietzen E, Ilves I, Salminen P, et al. Clinical and Multicenter To evaluate whether 1321 patients with a clinical suspicion of acute Retrospective analysis of a prospectively collected data in our randomized CT confirmed the diagnosis of acute appendicitis in 73% (n=970) and in The limitations of the present include the retrospective design. laboratory findings in the diagnosis of right patients with clinically appendicitis, who underwent computed tomography multicenter trial comparing surgery and antibiotic treatment for acute 27% (n=351) it revealed no or other diagnosis. Acute appendicitis Patients with indeterminate results from the diagnostic test were excluded or no comment lower quadrant abdominal pain: outcome suspected acute (CT). uncomplicated appendicitis (APPAC trial). Age, gender, body temperature, pain patients had significantly higher WBC levels than patients without was made about how indeterminate results were handled. Non-consecutive recruitment. analysis of the APPAC trial. Clin Chem Lab Med. appendicitis, but negative scores, duration of symptoms, white blood cell count (WBC) and C-reactive protein appendicitis (median 12.2 and 10.0, respectively, p<0.0001), whereas Readers were not blinded or no comment was made about the blinding of the readers. Single 2016;54(10): CT scan, had different (CRP) were recorded on admission. CRP levels did not differ between the two groups. Ideal cut-off points reader or no inter-reader reliability was calculated. Generalization is limited, inclusion of clinical or laboratory were assessed with receiver operating characteristic (ROC) curves, but people outside original APPAC trial. characteristics from neither these markers or neither their combination nor any clinical patients with a positive CT characteristic could accurately differentiate between patients with finding for acute acute appendicitis and those without. The proportion of patients with appendicitis. normal WBC count and CRP was significantly (p=0.0007) lower in patients with acute appendicitis than in patients without appendicitis. CONCLUSIONS: Both clinical findings and laboratory tests are unable to reliably distinguish between patients with acute appendicitis and those without. If both WBC count and CRP are normal, acute appendicitis is very unlikely. The current results emphasize the role of CT imaging in patients with suspected acute appendicitis. Lietzen E, Mallinen J, Gronroos JM, et al. Is Multicenter To compare antibiotic 705 (444 men and 261 women) patients who had Data in the present were collected prospectively in our randomized antibiotic RESULTS: CA2 patients had significantly greater C-reactive protein Patients with indeterminate results from the diagnostic test were excluded or no comment preoperative distinction between complicated ; treatment for complicated or uncomplicated acute appendicitis on treatment for uncomplicated acute appendicitis trial (APPAC) comparing surgery levels (mean 122 and 47, respectively, P <.001) and longer duration of was made about how indeterminate results were handled. Readers were not blinded or no and uncomplicated acute appendicitis feasible uncomplicated acute CT as well as patients > 60 years old and those who and antibiotic treatment for uncomplicated acute appendicitis. Patients with symptoms than uncomplicated acute appendicitis patients; 81% of comment was made about the blinding of the readers. Single reader or no inter-reader without imaging? Surgery. 2016;160(3): appendicitis trial (APPAC) declined to participate in the APPAC trial. 368 uncomplicated acute appendicitis (n = 368) were compared with all complicated CA2 patients and 38% of uncomplicated acute appendicitis patients reliability was calculated. to surgery and antibiotic patients had uncomplicated acute appendicitis acute appendicitis patients (n = 337), and subgroup analyses were performed had symptoms >24 hours before admission (P <.001). In receiver treatment for (group UA), and 337 patients had complicated acute between uncomplicated acute appendicitis and an appendicolith appendicitis (CA1; operating characteristic analysis, C-reactive protein and temperature uncomplicated acute appendicitis on abdominal CT (group CA). Of the 337 n = 256) and uncomplicated acute appendicitis and perforation and/or abscess had clinically significant results only in comparison with uncomplicated appendicitis CA patients, 256 had appendicolith appendicitis (CA2; n = 78). Age, sex, body temperature (degreec), duration of symptoms, white acute appendicitis and CA2 (area under the curve >0.7), but no (group CA1); 78 had perforation and/or blood cell count (E9/L), and C-reactive protein (mg/l) were recorded on admission. optimum cutoff points could be identified.; periappendicular abscess (group CA2); and 3 patients Receiver operating characteristic curves were calculated for white blood cell count, had appendiceal tumor on CT. Mean age UA 36.8 C-reactive protein, and temperature. CONCLUSION: In clinical decision making, neither clinical findings nor (12.4), CA 37.6 (13.0), CA (13.0) CA (12.5). laboratory markers are reliable enough to estimate the severity of the acute appendicitis accurately or to determine the presence of an appendicolith. The current results emphasize the role of computed tomography in the differential diagnosis of complicated and uncomplicated acute appendicitis. Lietzen E, Salminen P, Rinta-Kiikka I, et al. The Comparative To assess the accuracy of 1065 patients who underwent computed Data were collected prospectively in a randomized controlled trial comparing There were 700 true-positive, 327 true-negative, 14 false-positive, and Single reader or no inter-reader reliability was calculated Accuracy of the Computed Tomography computed tomography in tomography for suspected appendicitis. Out of the surgery and antibiotic treatment for uncomplicated acute appendicitis. The on-call 24 false-negative cases. The sensitivity and the specificity of computed Diagnosis of Acute Appendicitis: Does the Multicenter diagnosing acute 1065 patients, 714 had acute appendicitis and 351 radiologist preoperatively analyzed these computed tomography images. In this tomography were 96.7% (95% confidence interval, ) and Experience of the Radiologist Matter? appendicitis with a special had other or no diagnosis on computed tomography., the radiologists were divided into experienced (consultants) and 95.9% (95% confidence interval, ), respectively. The rate of Scandinavian Journal of Surgery: SJS. reference to radiologist inexperienced (residents) ones, and the comparison of interpretations was made false computed tomography diagnosis was 4.2% for experienced 2018;107(1):43-7. experience. between these two radiologist groups. consultant radiologists and 2.2% for inexperienced resident radiologists (p = 0.071). Thus, the experience of the radiologist had no effect on the accuracy of computed tomography diagnosis. The accuracy of computed tomography in diagnosing acute appendicitis was high. The experience of the radiologist did not improve the diagnostic accuracy. The results emphasize the role of computed tomography as an accurate modality in daily routine diagnostics for acute appendicitis in all clinical emergency settings. Millet I, Sebbane M, Molinari N, et al. Systematic unenhanced CT for acute abdominal symptoms in the elderly patients improves both emergency department diagnosis and prompt clinical management. Eur Radiol. 2017;27(2): To assess the added-value 401 consecutive patients 75 years of age or older, ED diagnosis and intended management before CT, after unenhanced CT, and after RESULTS: Systematic unenhanced CT significantly improved the of systematic unenhanced admitted to the ED with acute abdominal symptoms, contrast CT if requested, were recorded. Diagnosis and management accuracies accurate diagnosis (76.8% to 85%, p=1.1x10^-6) and abdominal computed and investigated by early systematic unenhanced were evaluated and compared before CT (clinical strategy) and for two conditional management (88.5% to 95.8%, p=2.6x10^-6) rates tomography (CT) on abdominal CT scan. Median age: 85 years (IQR=81 90 strategies (current practice and systematic unenhanced CT). An expert clinical panel compared to current practice. It allowed diagnosing 30.3% of acute emergency department y), 152 (38 %) males and 249 (62 %) females. assigned a final diagnosis and management after a 3-month follow-up. unsuspected pathologies, 3.4% of which were unexpected surgical (ED) diagnosis and procedure requirement. management accuracy CONCLUSIONS: Systematic unenhanced abdominal CT improves ED compared to current diagnosis accuracy and appropriate management in elderly patients practice, in elderly patients presenting with acute abdominal symptoms compared to current with non-traumatic acute practice. abdominal symptoms. KEY POINTS: * Systematic unenhanced CT improves significantly diagnosis accuracy compared to current practice. * Systematic unenhanced CT optimizes appropriate hospitalization by increasing the number of discharged patients. * Systematic unenhanced CT allows detection of about one-third of acute unsuspected abdominal conditions. * It should allow boosting emergency department management decision-making confidence in old patients. First, it was conducted in a single centre with a high rate of CT requested in the standard management (78 %). Secondly, there was a high number of physicians with varying levels of experience answering questionnaires, which could have led to variations in their CT prescription practices.thirdly, the intended treatment prior to CT was not defined by a senior surgeon, which may have led to overestimation of intended admission for surgery before CT. Lastly, we did not investigate US as a potential routine test that could also affect the diagnosis and management accuracy. Patients with indeterminate results from the diagnostic test were excluded or no comment was made about how indeterminate results were handled. Narrow included population; generalization is limited. Priola AM, Priola SM, Volpicelli G, et al Prospective To assess the accuracy of 181 patients (108 males, 73 females) with surgically Prospective analysis. Two experienced radiologists evaluated MDCT images RESULTS: In 158/181 cases, CT was totally concordant with surgical Small number of patients; readers were not blinded or no comment was made about the Accuracy of 64-row multidetector CT in the Cohort 64-row computed treated acute abdomen, aged 17 to 88 years (mean independently. Consensus was reached by conference, and disagreements were repertoire. Partial concordance was found in 15 cases. Overall blinding of the readers diagnosis of surgically treated acute abdomen. tomography (CT) in the age 58.7 years). adjudicated by a third more experienced radiologist (more than 20 years of sensitivity was 87.3% when only cases of complete concordance were Clin Imaging. 2013;37(5): differential diagnosis of experience on CT abdominal imaging in emergency radiology). Radiologic readings considered, 95.6% if also partial concordance cases were included. acute abdomen in the were compared with surgical findings, inclusive of histology data, or autopsy. CONCLUSION: CT showed high reliability in the differential diagnosis of emergency department. Conditions of complete concordance or incorrect diagnosis were considered. acute abdomen surgically treated, although associated conditions can sometimes be missed.

5 Scrima A, Lubner MG, King S, et al. Value of Retrospective The purpose was to assess 179 nonconsecutive adults (mean age, 55.8 years; 86 Cases reviewed by three board-certified radiologists. In addition to assessing RESULTS: Among all 179 patients with suspected SBO, 56 (31.3%) All patients with suspected SBO were included, not only patients with confirmed SBO. MDCT and clinical and laboratory data for the value of a large panel men and 93 women) admitted to the University of individual CT features, each radiologist scored the overall likelihood of each main underwent surgical intervention within 72 hours, 10 (5.6%) had Another limitation was that information from the history and physical examination of these predicting the need for surgical intervention in of clinical and MDCT Wisconsin Hospital for suspected small-bowel outcome measure using a 5-point scale. All relevant clinical and laboratory data ischemia at surgery, and nine (5.0%) required small-bowel resection. patients was not included. Because of the small sample size of patients with bowel ischemia suspected small-bowel obstruction. AJR Am J variables in patients with obstruction (SBO). were abstracted from electronic medical record review. Univariate and multivariate On univariate analysis, multiple CT findings were highly significant (p < and resection, we placed less emphasis on these subanalyses. Another limitation is that this is Roentgenol. 2017;208(4): suspected small-bowel analyses were performed. 0.01) for predicting the main surgical outcomes, including degree of a single-institution retrospective investigation. Finally, laboratory values were evaluated at only obstruction (SBO) for obstruction, 5-point radiology likelihood scores, and the presence of a a single time point when the patient presented. Trends over time were not assessed, which predicting urgent surgical transition point, closed loop, and mesenteric congestion. None of the may have lent greater significance to these values. Non-consecutive recruitment. intervention (< 72 hours), objective clinical or laboratory variables (including serum lactate level) bowel ischemia, and bowel reached this level of significance. At multivariate analysis, forward resection. stepwise logistic regression with 0.05 significance level cutoff included both degree of obstruction (p < 0.001) and closed loop (p < 0.01), with the presence of a transition point showing a trend toward significance (p = 0.081). CONCLUSION: A number of findings at abdominal MDCT are associated with the need for surgery and other important surgical outcomes in patients with suspected SBO. Overall radiologist impression of need for surgical intervention was a better predictor than any clinical or laboratory parameter. Signoretti MB, F. Piciucchi, M. Iannicelli, E Evaluation To evaluate the diagnostic 155 patients with AP. The accuracy of each test for diagnosis of biliary AP was evaluated according to the Among 155 patients, the etiology was biliary in 52% and alcoholic in Valente, R. Zerboni, G. Capurso, G. Delle Fave, accuracy of repeated US final diagnosis. Comparison between tests was obtained by examining the areas 20%. The accuracy of the first US alone and of the 2 combined G. Repeated transabdominal ultrasonography is for biliary AP. under the receiver operating characteristic curves. examinations for a biliary etiology were 66% and 83%, respectively. a simple and accurate strategy to diagnose a Comparison of receiver operating characteristic curves showed a biliary etiology of acute pancreatitis. Pancreas. better performance of repeated US (difference between areas under 2014;43(7): the curve, 0.135; 95% confidence interval, ; P = 0.021). Magnetic resonance cholangiopancreatography had high specificity (93%) but low sensitivity (62%), with 76% accuracy. The accuracy of the combination of the 2 US examinations and of elevated alanine transferase was 87%. Repeated US is effective for biliary AP diagnosis. The combination of repeated US examinations and biochemical tests seems an effective approach, whereas magnetic resonance cholangiopancreatography might be restricted to selected cases. Thorisson A, Smedh K, Torkzad MR, et al. CT Multicenter To re-evaluate the 623 patients included in the AVOD and CT scan images were re-evaluated and graded by two independent reviewers for RESULTS: Of the 623 patients included in the, 602 CT scans were Limitations include inconsistent imaging protocol, no report of patient demographics, and a imaging for prediction of complications and ; computed tomography received a diagnosis of left-sided AUD based upon different signs of diverticulitis, including complications, such as extraluminal gas or obtained and re-evaluated. Forty-four (7 %) patients were found to small total number of complications. recurrence in acute uncomplicated (CT) scans of the patients clinical assessment and confirmed on an abdominal the presence of an abscess. have complications on the admitting CT scan that had been diverticulitis. Int J Colorectal Dis. included in the antibiotics CT. overlooked. Twenty-seven had extraluminal gas and 17 had an 2016;31(2): in uncomplicated abscess. Four of these patients deteriorated and required surgery, but diverticulitis (AVOD) the remaining patients improved without complications. Of the 18 to find out whether any CT patients in the no-antibiotic group, in whom signs of complications on findings or wrongly CT were overlooked, 15 recovered without antibiotics. No CT findings interpreted and whether in patients with uncomplicated diverticulitis could predict CT signs in acute complications or recurrence. uncomplicated CONCLUSION: No CT findings that could predict complications or diverticulitis (AUD) could predict complications or recurrence. recurrence were found. A weakness in the initial assessment of the CT scans to detect extraluminal gas and abscess was found but, despite this, the majority of patients recovered without antibiotics. This further supports the non-antibiotic strategy in uncomplicated diverticulitis. Zhang J, Li NP, Huang BC, et al. The Value of To assess the value of early 102 patients who met the following criteria: (1) age NECT was compared to B-ultrasound and MRCP for accuracy of detecting stones; Non enhanced CT (NECT) was 89.2% and 87.8% accurate in detecting Authors did not include a control group of patients who were not examined by NECTand were Performing Early Non-enhanced CT in ; abdominal non-enhanced 18 years, (2) mild acute gallstone pancreatitis (AGP) Early laparoscopic cholecystectomy was compared to late laparoscopic gallbladder stones and CBD stones, respectively; sensitivities were stratified for treatment based only on clinical indicators of pancreatitis severity.we decided Developing Strategies for Treating Acute computed tomography with no evidence of organ failure by clinical data and cholecystectomy. 88.4% and 85.3% respectively; Specificities were 100% and 100%, not to include such a group due to the risks of misdiagnosing a CBD stone or a patient s Gallstone Pancreatitis. J Gastrointest Surg. (NECT) in developing no peripancreatic fluid collection on NECT scans, (3) respectively. B-ultraound accuracies for detecting gallbladder and CBD worsening condition following LC." "...the main limitation of this is that it was not multi- 2016;20(3): U.S. Gov't strategies for treating patient is experiencing their first episode of AGP, and stones were 91.% and 48.8%, respectively; MRCP accuracies for centered and enrolled a relatively small number of patients. Moreover, all of the enrolled acute gallstone (4) patient has provided a signed written informed detecting gallbladder and CBD stones were 90% and 90%, respectively. patients lived in the same city (Shanghai). In this, CT demonstrated very high sensitivity pancreatitis (AGP). consent. 41 males and 61 females with mild cases of In the early and late laparoscopic cholecystectomy groups, all patients and specificity in diagnosing choledocholithiasis, suggesting therewere high levels of calcium in AGP were included; mean age was 62.8± 9.5 years, in both groups were cured, no LC-related complications occurred, and the gallstones of our patients. It is not known whether CT would have displayed such high range years; the early and late operative no case of AGP increased in severity following LC. The mean lengths of sensitivity and specificity if it were used for diagnosing choledocholithiasis in other regions of intervention groups were matched for age and gender (P>0.05). hospital stay and LC operation time were significantly shorter in the ELC group than the LLC group (P<0.05). China or other countries." "Another limitation is that we made decisions on whether or not to perform an early LC in cases of mild AGP based on the presence or absence of a peripancreatic fluid collection. The problem with this approach is that it is difficult to predict the best time to perform LC in AGP patients with a peripancreatic fluid collection, but who show no signs of organ failure or pancreatic necrosis, and seem to be experiencing a good recovery. Peripancreatic fluid collection was very common finding in this and detected in ~40 % of the non-enrolled patients. It might also be beneficial to perform a late LC during a patient s index hospitalization. Readers were not blinded or no comment was made about the blinding of the readers. Single reader or no inter-reader reliability was calculated. Not all patients received the reference ("gold") standard or patients received different reference standards. Reference standard was inadequate (explain why in the box below) NECT sensitivities, specificities, and accuracies were compared to MRCP and B-ultrasound; however, their was no control group in this -- all patients received NECT imaging with or without the MRCP (n=10) and with or without B-ultrasound (n=70).