Andrzej Żyluk 1, Paweł Ostrowski 2

Transcription

1 POLSKI PRZEGLĄD CHIRURGICZNY 2011, 83, 3, /v An analysis of factors influencing accuracy of the diagnosis of acute appendicitis Andrzej Żyluk 1, Paweł Ostrowski 2 Department of General and Hand Surgery, Pomeranian Medical University in Szczecin 1 Kierownik: prof. dr hab. A. Żyluk 1 st Department of General Surgery, Regional Specialistic Hospital in Grudziądz 2 Kierownik: dr n. med. A. Morawski The aim of the study was to refresh the knowledge about the course of acute appendicitis, to confront the classical clinical picture with the practice, analyze its fluctuations and identify factors influencing these. Material and methods. All patients admitted to the Department of General Surgery in Grudziądz District Hospital with the suspicion of acute appendicitis, who underwent appendectomy and in whom the appendicitis was confirmed in pathologic examination were included in the study. There were 85 patients, 49 men (58%) and 36 women (42%) in a mean age of 30 years (range 10-75). Symptoms, signs and results of biochemical tests (leukocyte rate and CRP) were considered in the analysis. Results. The commonest constellation of symptoms and signs, occurring in at least of ¾ patients consisted of pain and tenderness localized in right lower quadrant (100%), which exacerbates at movements (98%), felling unwell (93%), loss of appetite (88%), and rebound tenderness in right lower quadrant (74%). Conclusions. No particular fluctuation of clinical features in relation to gender, age, duration of symptoms, biochemical parameters and morphological severity of the inflammation was observed. Relevant findings included relatively fast development (<12 hrs) of advanced appendicitis in 18% of adult patients and more than a half patients with normal body temperature, regardless true appendicitis. Key words: appendicitis, signs and symptoms, medical history taking Acute appendicitis (AA) is the most common inflammatory disease in the abdominal cavity. Its while the biochemical and picture examinations are of less great importance (1). Although computer tomography with the intravenous and oral contrasts allow to diagnose the disease with a great probability (accuracy >90%) this presence frequency amounts from 1 to 1, 5 cases in 1000 persons. It mainly refers to youngsters and children, less often to the old. Appendicectomy is the most commonly performed due to emergency recommendations abdominal operation. Diagnosis of the disease is based on clinical symptoms: an interview and subjective examination method is infrequently used in clinical practice (2, 3). In order to diagnose the AA properly, a specific constellation of symptoms and signs, as well as an order of their presence are the most essential issues. The onset of the disease is usually with a mild pain in the epigastrium or middle abdomen, nausea, loss of appetite and 1-2 episodes of vomiting. This stage, called a visceral pain phase lasts from a few to a dozen of hours, followed by migration of the pain into right lower quadrant (abbr. LRQ). Tenderness at deep palpation in LRQ is the most common cause of surgical referral of the patient with a suspicion of acute appendicitis. If the patient is not admitted, progressing inflammatory process makes both the general and local (irritation of peritoneum) signs more intensive. Such a classical clinical pat-

2 136 A. Żyluk, P. Ostrowski tern occurs approximately in a half of the cases of AA, but in the second half, both the symptoms and their order of presence can be different (1, 4). Personal observations of the authors suggest that the clinical picture of acute appendicitis has changed during the last two decades. The intention of this study was an analysis of all cases of acute appendicitis operated on in the surgical unit over a period of one year, to investigate the course of the disease and the scope of its diversity from the classical pattern. The objectives of the study was: (1) to determinate the most characteristic for true AA constellation of symptoms, (2) to investigate the diversity of the clinical picture of he disease according to selected parameters: sex, age, duration of the disease, inflammatory parameters and morphological advancement of inflammation, (3) to determine the relationship between morphological advancement of AA and selected clinical and biochemical parameters. Material and methods The study was conducted in the Department of General Surgery I of the Regional Specialist Hospital in Grudziądz, from January to December All patients admitted and operated on for acute appendicitis within this period were included. The study group consisted of 85 patients, 49 men (58%) and 36 women (42%), aged a mean of 30 years (range 10-75). None of included patients suffered from a systemic, or any other disease of abdominal cavity (e.g. Leśniowski-Crohn disease) which would interfere the clinical picture of AA. Thirteen of the patients suffered from systemic diseases such as coronary disease, arterial hypertension or diabetes (type 2), and 9 had already undergone abdominal surgery for other reasons. None of the preliminary included patients was excluded during the study. Diagnosis of acute appendicitis Diagnosis of AA, decision of the admission and the operation were made by a qualified surgeon (specialist) from the Department of Surgery, based on the history, examination and the results of biochemical studies. Each of the patients with preliminary diagnosed AA had a questionnaire completed, consisting of the following items: Symptoms: pain in RLQ, feeling unwell, exacerbation of pain at movement, loss of appetite, duration of symptoms <48 hours or >48 hours, nausea, pain in RLQ at rest, migration of the pain into RLQ, vomiting, radiation of pain, complaints related to uration Signs: tenderness at deep palpation in RLQ, rebound tenderness in RLQ, Rowsing s sign, Goldflam s sign, temperature. Biochemical tests: leukocyte ratio, and serum CRP concentration The findings were recorded in the Excel calculation sheet creating a data base. In some patients (n=38) the ultrasonography was performed, however due to the lack of possibility to perform it in each case these results were not taken into consideration. Intra-operative and histopathological assessment Intra-operatively, a morphological evaluation of the appendix was made with determination of the stage of the inflammation in a fourgrade scale: simple, phlegmonotic, gangraenotic and gangraenotic with perforation. The presence of periappendicular mass or abscess was also noted. Moreover, the presence of enlarged lymph nodes in the mesentery of the small intestine as well as the presence of the Meckel s diverticulum were also evaluated. All resected appendixes were given pathological examination in the laboratory of Department of Pathomorphology in the same hospital. Histopathological staging was based on evaluation of macro- and microscopic changes in the wall of the appendix and the character of cellular inflammatory infiltration and the result was given in the same graduation as the macroscopic evaluation. The result of histopathological examination was considered the definitive argument for the diagnosis of acute appendicitis. Analysis of the material Data from 85 patients who had their appendixes removed because of acute, histopathologicallly confirmed appendicitis, were analyzed. In order to calculate the clinical picture with reference to selected parameters

3 An analysis of factors influencing accuracy of the diagnosis of acute appendicitis 137 the obligatory approved ranges of values were used: age ( 20 or >20 years), duration of the disease ( 48 or >48 hours), number of leucocytes ( 12 G/l or > 12 G/l) and CRP volume ( 20 mg/dl or >20 mg/dl). Statistical calculations were made using the chi 2 test with the Yate s correction, with p<0.05 as being statistically significance. To evaluate relationship between the advancement of the appendicitis and selected parameters recorded as continuous variables, the Kruskal-Wallis s test was used. Results Table 1 summarizes the most frequent symptoms and signs of acute appendicitis in the analyzed group The most typical, occurring in at least 3/4 of the patients constellation of the features characterizing true acute appendicitis were: pain and tenderness on deep palpation in RLQ (present in all patients), exacerbation of pain at movement, feeling unwell, loss of appetite, constant character of the pain (not colic type), rebound tenderness in RLQ, and duration of symptoms less than 2 days. Other symptoms and signs considered typical for acute appendicitis, such as migration of pain into RLQ, increased temperature Table 1. The commonest clinical and biochemical features in analyzed group of 85 patients. Abbreviation LRQ indicates right lower quadrant Feature Number of patients % Pain localized in LRQ Pain at pressing in LRQ Exacerbation of pain at movements Feeling unwell Loss of apetite Constant character of the pain Duration of symptoms <48 hrs Rebound tenderness (+) in LRQ Nausea Leucocyte rate >12 G/l Pain in LRQ at rest Migration of pain into LRQ Tachycardia >90/min CRP concentration >20 mg/dl Vomiting Temperature C in the range C and the Rowsing s sign were less frequently found. Leukocyte rate of 12 G/l was a relevant parameter while the CRP >20 mg/dl was less significant. No particular diversity of the clinical picture of the disease with regard to sex, age, duration of the disease (tab. 2), biochemical parameters and the morphological advancement of appendicitis were noted. The only statistically significant relationship was found between the advancement of the appendicitis and presence of rebound tenderness in RLQ (chi 2 test p=0.02, tab. 3). Detailed analysis of selected parameters Twenty-eight patients (33% of the whole group) were analyzed separately: with the disease lasting shorter (<12 hours, n=22) and longer (>72 hours, n=6) than usual (typical for acute appendicitis in adults) (1, 4). In the group with short history, 4 patients (18%) has a simple appendicitis, 15 phlegmonotic (68%) and 3 gangrenotic (14%), including one perforated. These 22 persons were slightly older (mean of 32 years) than the whole group (30 years), and except of two children (12 and 13 years), all of the patients were the adults, including one elderly (75 years). Two patients with the shortest, 6 hour history were 17 and 52 years old and in both cases the appendixes were the phlegmonotic. The next interesting finding was 3 gangrenotic appendixes (including one perforated) diagnosed in patients with the duration of the disease from 8 to 10 hours. In next 6 patients the complaints until the admission lasted over 72 hours. The average age of the subgroup of patients was 33 years (range 21-45) so it was higher than in the whole group. In 3 of these patients the appendixes were simple, in 2 phlegmonotic and one gangrenotic with perforation. Rebound tenderness in RLQ was noted in 63 patients, including 2/3 with simple one and 2/3 with phlegmonous appendicitis (tab. 3). Comparison of the occurrence of rebound tenderness in combined group of gangrenotic and perforated appendixes (21 of 22 95%) with occurrence in combined group of simple and phlegmonotic appendices (67%) reveals statistically significant difference, favoring the former group (test chi 2, p=0.02). Saying it in other words lack of the rebound tenderness in RKQ did not decrease probability of AA, but

4 138 A. Żyluk, P. Ostrowski Table 2. Comparison of frequency of symptoms and signs of acute appendicitis, in regard to duration of symptoms : 48 hrs (n=64) i >48 hrs (n=21). Statistical significance assessed with chi 2 test Feature Number of patients 48 h n=64 % Number of patients > 48 h n=21 % p Pain localized in LRQ ,86 Pain at pressing in LRQ ,86 Exacerbation of pain at movements ,93 Feeling unwell ,93 Loss of apetite ,92 Constant character of the pain ,75 Rebound tenderness (+) in LRQ ,92 Nudności / nausea ,51 Leucocyte rate >12 G/l ,85 Pain in LRQ at rest ,91 Migration of pain into LRQ ,93 Tachycardia >90/min ,65 CRP concentration >20 mg/dl ,17 Vomiting >0,95 Temperature C ,84 Table 3. Relationship between severity of inflammation of the appendix in pathological examination and presence of the rebound tenderness in LRQ Number of patients Severity of inflammation rebound tenderness (+) n=63 rebound tenderness (-) n=22 Catharralis n= % 6 33% Phlegmonotic n= % 15 33% Gangraenotic n= % 1 6% Perforated n= % - - it indicated significantly lower risk of advanced (gangrenotic and perforated) appendicitis. Comparison of the advancement of the appendicitis and temperature showed that almost half of the patients (43%) with changed appendicitis (phlegmonotic in most cases) had had a normal temperature. This finding indicates possibility of the lack of systemic reaction on progressing inflammation in the peritoneal cavity, in relatively numerous group of patients. However, progression of the inflammation to gangrene and perforation of the appendix caused such a reaction: all these patients had increased temperature, half of them (n=11) in the range of C, and the second half (n=11) over 38 C. However, average temperature in the whole group of 22 patients amounted 37.6 C (range 37.1 C 38.6 C), thus not exceed 38 C. The leukocyte rate >12 G/l was noted in 56 (66%) patients while the CRP concentration >20 mg/dl in 41 (48%) patients. The average leukocyte rate in the whole group amounted 13.1 G/l, and the average CRP 47 mg/dl. Eight patients (44%) with a simple appendicitis had leukocyte ratio >12 G/l, and 10 (56%) <12 G/l. Thirty-two of patients (71%) with phlegmonotic appendicitis had leukocyte rate >12 G/l, and 13 (29%) had <12 G/l. Sixteen patients (73%) with gangrenotic or perforated appendicitis had leukocyte rate >12 G/l, and 6 (27%) had <12 G/l. The relationship between the advancement of appendicitis and the leukocyte rate was not significant: average values were equal or higher than 12 G/l in all stages of appendicitis, and they were of 1-4 G/l higher in gangrenotic and perforated, than in the simple and phlegmonotic. Although this difference was not statistically significant, it was suggestive (relevant). The CRP concentration >20 mg/dl was confirmed in at least half of the patients which suggests weaker than the leukocyte rate diagnostic value of this test. However, the CRP in

5 An analysis of factors influencing accuracy of the diagnosis of acute appendicitis 139 the whole group amounted 47 mg/dl, which confirms assumption the higher than the commonly accepted normative value (5 mg/dl) as a cut-off of this parameter. The comparison of the CRP (expressed as a continuing variable) and the stage of appendicitis (tab. 4) showed biochemical parameters for diagnosing true acute appendicitis, reported the duration of symptoms from 7 to 12 hours a typical for this disease, as it was present in 259 their patients (8). The results of our study show that in some patients (4 of 22 18%) even after a Table 4. Relationship between some parameters: biochemical tests, duration of symptoms and temperature (continuous variables) and severity of the inflammation of the appendix in pathological examination CRP concentration Duration of Leukocyte rate G/l Severity of inflammation mg/dl symptoms (hrs) Temperature mean range mean range mean range mean range Catharralis n= ,9 36,0-38,5 Phlegmonotic n= ,9 36,4-38,1 Gangraenotic n= ,8 37,1-38,6 Perforated n= ,5 37,1-38,3 Stat. significance p=0,12 p=0,01 p=0,24 p=0,36 statistically significant relationship between these parameters: CRP concentration was statistically significantly higher in the combined group of gangrenotic and perforated than in phlegmonotic and simple appendixes (mean of 93 and 76 mg/dl vs 21 and 45 mg/dl, Kruskal Wallis s test, p=0.01). The result confirms the predictive value of CRP for diagnosis of AA, however in the light of our results just the values over 70 mg/dl are relevant. The cut-off value of CRP assumed at the level of CRP=20 mg/dl appeared to be too low and, therefore, was not a good discriminator of the inflammation of the appendix. Discussion The results obtained in this study confirm (in general) commonly known clinical pattern of acute appendicitis, however they also indicate certain diversities. It refers mainly to such classical symptoms as migration of the pain into right lower quadrant and increased temperature. Pain and tenderness at palpation in the RLQ were present in all 85 patients. It is an obvious result as these two symptoms are the most characteristic for acute appendicitis and are the common reason of surgical referral. In the literature, cases in which the tenderness at palpation in the RLQ is absent are very rare (1, 4, 5). Non-anatomical localization of inflammatory changed appendix e.g. reaching the right hypochondrium, the left lower quadrant or retrocaecal position may be associated with less typical symptoms and signs, with a lack of, or a very mild tenderness at palpation in RLQ (5, 6, 7). In more than 90% of patients the pain exacerbated at movements, feeling unwell and the loss of appetite were present. All these symptoms are described as the most frequently occurring in the course of acute appendicitis. In almost all patients movements at laying, i.e. turning from one side to another or a an attempt to stand up was associated with increase of the pain, while during lying calm it was hardly detectable. This detail connected with the description of pain is not emphasized in literature. Exacerbation of the pain at movements and coughing was reported by Anderson et al. (8, 9). Another feature of pain found in this study was its constant character (non- colic) and it is in agreement with the date from literature (1, 9, 10). In 3/4 of patients the duration of symptoms was shorter or equal to 2 days and nights which is also considered typical for the disease (1, 4-7, 11). The duration of symptoms amounted in the whole group approximately 38 hours (range 6-168). The interesting finding is high advancement of the appendicitis in some patients with duration of symptoms shorter than 12 hours. It is believed that this may be in children, however in adults is rather very uncommon (1, 4, 13). Anderson et al., who analyzed the predictive value of 21 clinical and

6 140 A. Żyluk, P. Ostrowski short history, lasting less than 22 hours, an advanced appendicitis may be expected. This finding seems to be relevant in our study. Six patients had 72 hours (range ) history at the admission. Slower progression of inflammatory changes in the appendix is described elderly, however the average age in this group was 33 years. In the patient with gangrenotic and perforated appendix the long, lasting 5 days history was the cause of advanced appendicitis, likewise in 2 patients with phlegmonotic appendixes. However, 3 patients with a 4-7 days history had simple appendixes, both in morphological and histopathological assessment. In accordance the literature and a common opinion, within 4 and 6 days, the appendicitis progresses to gangrenotic or perforated form (5, 6, 12, 13). Our results show great fluctuations in the progression of appendicitis seen in patients with atypical duration of the disease. This findings are nicely explained in the hypothesis of Anderson which suggests a dichotomy natural course of the disease. It can be either a progressive, developing very quickly and resulting in gangrene and perforation of the appendix within a few hours, or a mild (regressive) in which the inflammation is limited to the mucosa of the appendix, not invading the whole wall, can last few days wit ha spontaneous recovery (5, 12, 14). This concept explains both the presence of gangrenous and perforated appendixes in patients with a short history (<12 hours), as well as the simple appendixes in patients with complaints lasting longer than 72 hours. Rebound tenderness indicates irritation of the peritoneum by an inflammatory or purulent fluid, the contents of the digestive tract (at perforation), bile, urine and blood. In the course of appendicitis, rebound tenderness in RLQ suggests more advanced stage of appendicitis. In our material, lack of the presence of this sign in 22 patients indicated statistically significantly lower risk of gangrenous and perforated appendix. In the literature, positive rebound tenderness is reported in 60-80% patients with acute appendicitis (74% in this study) (6, 7, 12, 15, 16). In association with other peritoneal signs (guarding and rigidity in RLQ), rebound tenderness presents the high predictive value for the advanced AA (5, 7, 8, 9, 17). In the literature however, mesenteric lymphadenitis can be also associated with vigorous signs of peritoneal irritation (10). Thus, the presence of this sign in RLQ is not in all cases a strong evidence for true appendicitis. Migration of pain to right lower quadrant is considered one of the most characteristic symptoms of AA, but it was noted in our material in only 60% of patients (tab. 1), less common than in literature (70-75%) (1, 5, 6, 7, 10, 11, 16, 18). It is commonly believed that the disease begin with the phase of visceral pain at the epigastrium or mid-abdomen, with nausea, vomiting and feeling unwell, followed by migration of the pain in RLQ after a few hours. One of the possibilities of the lack this course in some patients may be a development of the appendicitis without earlier obstruction the lumen of the appendix by facolith or hypertrophic lymphatic tissue, followed by distension of the appendix, which is associated with visceral type of pain, located in the upper abdomen. Such a scenario does not always appear although there are no data about this in literature. However, it is a rational explanation of fact that approximately ¼ cases of AA (40% in our study) develop without this phase of visceral pain. It is not clear how it is in mesenteric lymphadenitis, however some data from literature suggest similar course in this disease (4, 7, 17, 18).Thus, a history of the migration of the pain into RLQ is not a definitive for the confirmation of acute appendicitis, likewise the lack of migration does not exclude it. Average increased temperature within the range of 37 C- 38 C is considered typical in the course of AA, as a systemic response to the progression of a mild inflammatory process in the peritoneal cavity. It is also believed, that progression of the inflammation is associated with a tendency to increase temperature over 38 C (1, 8, 9, 23, 24). However, most of our patients with acute appendicitis (n=49) had the temperature either <37 C (n=37) or >38 C (n=12). In this study, the considerable number of patients with AA having normal temperature is finding strongly inconsistent with data from the literature. According to Anderson et al., advanced appendicitis is associated with temperature increased over 38, 5 C, which was not seen in our study (8, 9, 14). Our results suggest a modest relevance of increased temperature as an indicator of acute appendicitis, except

7 An analysis of factors influencing accuracy of the diagnosis of acute appendicitis 141 of its advanced forms. In the majority of literature and in all clinical scales (e.g. Alvorado, Fenyo and Anderson) the increased temperature within C was considered a good discriminator of the disease (7, 12, 14). Comparison of our results with the literature Anderson et al., in two papers reported results of similar analysis of clinical and biochemical parameters, investigating their predictive value for AA in the group of 259 patients with a suspicion of the disease (8, 9). All patients were operated on and in 65 (25%) the appendix was found unchanged, whereas in 69 (27%) advanced appendicitis was found: in 41 (16%) gangrenotic, in 28 (11%) with perforation and in 125 (48%) only acute appendicitis. Multivariate analysis of predictive strength of these variables for the diagnosis of true appendicitis showed greater importance of physical examination findings, particularly the irritation of the peritoneum (receiver operating characteristic ROC=0.87), followed by biochemical parameters inflammation, temperature (ROC=0.85) and finally the history (ROC=0.78). The results of the analysis show similar predictive value for both groups of parameters: clinical and biochemical. This finding is not consistent with the belief of the majority of clinicians as well as with information form textbooks (10, 19). Fenyo et al., after an analysis of clinical features and leukocytes rate in 1167 patients with a suspicion of AA concluded that the migration of pain into RLQ occurred in 68% of patients with true appendicitis and in 30% of persons with no AA, exacerbation of symptoms and signs with time occurred in 75% and 55% of patients, respectively, rebound tenderness in 79% and 45%, rigidity in 40% and 14% and exacerbation of pain at coughing in 84% and 56%. These symptoms and signs occurred statistically significantly more often (chi 2 test, p<0.0001) in patients with confirmed acute appendicitis, however, they were also present in a proportion of subjects without the disease (7). The results of our study are consistent with findings of these authors: migration of pain in 60% of patients, rebound tenderness in 74% and exacerbation of pain at movement (likewise at coughing) in 98%. Gurleyik et al., compared accuracy of CRP concentration with an examination performed by a surgeon (based on history and clinical signs). Clinical diagnosis of AA was made in 108 patients, who next underwent laparotomy. In 90 (83%) the diagnosis was confirmed, but in 18 (17%) the appendix was unchanged. In 87 (97%) with true acute appendicitis the CRP was >5 mg/dl, and in 3 (3%) was <5 mg/ dl, what is considered a false negative. The CRP concentration was normal in 16 of 18 persons (89%) with the unchanged appendix, but in two (11%) was increased (false positive). The results of this study show that CRP is a good discriminator for the acute appendicitis (20). Anderson calculated the predictive value for various levels of leukocyte rate, using a parameter called likehood ratio (LR). For leukocyte rate L>10 G/l, LR amounted 2.5, for leukocyte rate L>12G/l, LR =2.8, for leukocyte rate L>14 G/l, LR=2.9, and for leukocyte rate L>15 G/l, LR=3.5. The leukocyte rate L>15 G/l showed particularly high predictive value for the advanced appendicitis and amounted LR=7.2 (11). These results can be interpreted as showing moderate usefulness of leukocyte rate in diagnosing AA, but also as very accurate discriminator of advanced appendicitis when it exceeds 15 G/l. In the another study, the leukocyte rate and CRP were investigated in patients with suspicion of acute appendicitis, showing that in those with eventually true AA (diagnosed intra-operatively), within 24 hour observation leukocyte rate tended to decrease, while CRP level to elevate (21). Thus, repeated CRP investigation may be relevant in diagnosing doubtful cases, during clinical observation. Our results show moderate predictive value of biochemical tests of inflammation for the diagnosis of AA. Only leukocyte rate >12 G/l, and CRP >70 mg/dl were strong indicators of acute appendicitis. In our country a traditional, 4-grade staging of the advancement of acute appendicitis is used. In English literature the categorical staging is applied: acute appendicitis and advanced appendicitis (8, 9, 11, 14). Simple and phlegmonotic appendicitis is included in the former and gangrenotic and perforated in the latter. Anderson hypothesized that these forms have different natural history from the onset of the inflammation: the advanced appendici-

8 142 A. Żyluk, P. Ostrowski tis progresses very quickly is already advanced in early phase of the disease, while the simple appendicitis may persist for a few days and recover spontaneously. Anderson et al., showed that the rate of perforated appendixes is constant from the beginning and increases only a little with time. On the other hand, the rate of acute appendicitis (slightly advanced), but requiring operational treatment due to persistent symptoms drops with time (11, 22, 23, 24). The results of our survey, in which 4 of 22 patients (18%) with a disease lasting less than 12 hours had gangrenous appendixes (including one perforated) confirms validity of this theory in adults. One may hypothesized that in majority of patients in whom histopathological examination revealed simple appendixes the spontaneous regression of the inflammation and recovery might be expected. In such a situation only the patients in which the symptoms were stable or increasing would be qualified for operations. As probably the majority of surgeons, the authors faced with acute appendicitis having different from a classical course. This was reason of the interest of investigating the course of the disease based on scientific methodology, determination how frequently the classical course described in textbooks is observed in clinical practice, which is it variability. Both the discussed papers and our results show that there is no one commonly accepted diagnostic algorithm for AA. The specificity of the disease makes the course of 20-30% cases different from a classical pattern in terms of information derived from history, examination and biochemical tests. Accurate diagnosis of acute appendicitis is an essential problem not only form the perspective of an individual patient, but also a society, burdening the budget of health service and constituting an important part of work of surgical departments. Thus, the efforts to improve the accuracy of diagnosing acute appendicitis are justified as they meet the social demand. Also, from the surgeon s perspective, avoiding diagnostic mistakes is essential both in medicolegal and professional ambition contexts. Gaining experience and going towards the highest accuracy of the diagnosis is essentially associated with systematic analysis of our own and institutional results. This study is the result of this approach. Conclusions 1. The most characteristic, occurring in at least 3/4 patients features characterizing true acute appendicitis were: tenderness at deep palpation and pain in right lower quadrant, exacerbating at movements, feeling unwell, loss of appetite and rebound tenderness in RLQ. 2. No particular diversity of the clinical picture of the disease with regard to sex, age, duration of symptoms, biochemical parameters and morphological advancement of appendicitis was shown. Relatively rapid (<12 hours) development of advanced appendicitis in a proportion (18%) of adult patients and normal temperature found in more than a half of the patients with acute appendicitis were considered relevant findings references 1. Żyluk A, Ostrowski P: Rozpoznawanie ostrego zapalenia wyrostka robaczkowego przegląd piśmiennictwa. Pol Przegl Chir 2010; 5(82); Rao PM, Rhea JT, Novelline RA et al.: Helical CT technique for the diagnosis of appendicitis: prospective evaluation of focused appendix CT examination. Radiology 1997; 202: Stroman DL, Bayouth CV, Kuhn JA et al.: The role of computed tomography in the diagnosis of acute appendicitis. Am J Surg 1999; 178: Jones FP: Suspected acute appendicitis: trends in management over 30 years. Br J Surg 2001; 88: Anderson RE: Meta-analysis of the clinical and laboratory diagnosis of appendicitis. Br J Surg 2004; 91: Ohmann C, Franke C, Yang Q: Clinical benefit of a diagnostic score for appendicitis. Arch Surg 1999; 134: Fenyo G, Lindberg G, Blind P et al.: Diagnostic decision support in suspected acute appendicitis: validation of simplified scoring system. Eur J Surg 1997; 163: Anderson RE, Hugander AP, Ghazi SH et al.: Diagnostic value of disease history, clinical presentation and inflammatory parameters of appendicitis. World J Surg 1999; 23:

9 An analysis of factors influencing accuracy of the diagnosis of acute appendicitis Anderson RE, Hugander AP, Ravn H et al.: Repeated clinical and laboratory examinations in patients with an equivocal diagnosis of appendicitis. World J Surg 2000; 24: Ferguson CM: Acute appendicitis. W: Morris PJ, Malt RA (red.). Oxford textbook of surgery, vol. 1. Oxford University Press, Oxford 1994, str Anderson RE: The natural history and traditional management of appendicitis revisited: spontaneous resolution and predominance of prehospital perforations imply that a correct diagnosis is more important than an early diagnosis. World J. Surg 2007; 31: Alvorado A: A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med 1986; 15: Izbicki JR, Knoefel WF, Wilker DK et al.: Accurate diagnosis of acute appendicitis: a retrospective and prospective analysis of 686 patients. Eur J Surg 1992; 158: Anderson M, Anderson RE: The appendicitis inflammatory response score: a tool for the diagnosis of acute appendicitis that outperforms the Alvorado score. World J Surg 2008; 32: Wagner JM, McKinney WP, Carpenter JL: Does this patient have appendicitis? JAMA 1996; 276: Jones PF: Active observation in the management of acute abdominal pain in children. BMJ 1976; ii: Wilcox RT, Traverso LW: Have the evaluation and treatment of acute appendicitis changed with new technology? Surg Clin North Am 1997; 77: Korner H, Sondenaa K, Soreide JA et al.: The history is important in patients with suspected acute appendicitis. Dig Surg 2000; 17: Vermeulen B, Morabia A, Unger P-F: Influence of white cells count on surgical decision making in patients with abdominal pain in right lower quadrant. Eur J Surg 1995; 161: Gurleyik E, Gurleyik G, Unalmiser S: Accuracy of serum C-reactive protein measurements in diagnosis of acute appendicitis compared with surgeon s clinical impression. Dis Colon Rectum 1995; 38: Eriksson S, Granstrom L, Calstrom A: The diagnostic value of repetitive preoperative analysis of C-reactive protein and total leukocytes count in patients with suspected acute appendicitis. Scand J Gastroenterol 1994; 29: Anderson R, Hugander A, Thulin A et al.: Indications for operation in suspected appendicitis and incidence of perforation. BMJ 1994; 308: Migraine S, Atri M, Bret PM et al.: Spontaneously resolving appendicitis: clinical and sonographic documentation. Radiology 1997; 205: Kirschenbaum M, Mishra V, Kuo D et al.: Resolving appendicitis: role of CT. Abdom Imaging 2003; 28: Received: r. Adress correspondence: Szczecin, ul. Unii Lubelskiej 1