RESUMEN
BACKGROUND: Based on a study at our hospital in 1994, we established a practice guideline for appendicitis patients. The practice guideline was followed well except for an increased number of preoperative computed tomography (CT) scans. METHODS: Data collected from the previous study of 100 patients were compared with data from consecutive patients, 118 total, seen over a similar time period in the year 2000. RESULTS: The percentage of CT scans ordered for the diagnosis of patients who underwent appendectomy markedly increased from 11% in 1994 to 48.3% in 2000. (P <0.001) The percentage of normal appendixes removed did not change significantly from 12% in 1994 to 17.8% in 2000 (P = 0.317). Patients who had a CT scan were no less likely to have a normal appendix at surgery (P = 0.386) and a significant increase in preoperative Emergency Department length of stay (P <0.001). CT was accurate 80% of the time in 2000 and 81% of the time in 1994. Only 14 of 57 CT scans were ordered by surgeons. CONCLUSIONS: The use of preoperative abdominal CT scanning has not improved the accuracy of the diagnosis of appendicitis at our institution. It has resulted in a significant increase in Emergency Department preoperative length of stay and the finding of a normal appendix at surgery. As nonsurgeons ordered the majority of preoperative CT scans, earlier input by surgeons might increase the rate of accurate clinical diagnosis and decrease the number of CT scans ordered.
Asunto(s)
Apendicitis/diagnóstico por imagen , Tomografía Computarizada por Rayos X , Adulto , Apendicectomía , Apendicitis/cirugía , Femenino , Humanos , Masculino , Valor Predictivo de las Pruebas , Sensibilidad y EspecificidadRESUMEN
BACKGROUND: Abdominal computed tomographic (CT) scan is accepted as the primary diagnostic modality in stable patients with blunt abdominal trauma. A recent survey of 328 trauma surgeons demonstrated marked variation in the management of patients with head injuries and the finding of free intra-abdominal fluid without solid organ injury on CT scan. This study was undertaken to attempt to determine what to do when free fluid without solid organ injury is seen on abdominal CT scan in patients with blunt trauma. METHODS: Articles concerning the incidence and significance of free intra-abdominal fluid on CT scan of blunt trauma patients without solid organ injury were systematically reviewed. A MEDLINE search was performed using terms such as tomography-x-ray computed, wounds-nonpenetrating, small intestine/injuries, time factors, and abdominal trauma and diagnostic tests. Bibliographies of pertinent articles were reviewed. Appropriate articles were evaluated for quality and data were combined to reach a conclusion. RESULTS: Meta-analysis could not be performed because no randomized, prospective, controlled trials could be found. Forty-one articles were excluded from the analysis because they looked at only patients with known injuries to intestine, diaphragm, or pancreas and the investigation of the CT scan findings did not include negative scans. Ten articles, which described CT scan results for all patients presenting with blunt abdominal trauma for a defined period of time, formed the basis of this study. Isolated free fluid was seen in 463 (2.8%) of over 16,000 blunt trauma patients scanned. A therapeutic laparotomy was performed in only 122 (27%) of these patients. CONCLUSION: The isolated finding of free intra-abdominal fluid on CT scan in patients with blunt trauma and no solid organ injury does not warrant laparotomy. Alert patients may be followed with physical examination. Patients with altered mental status should undergo diagnostic peritoneal lavage.