1 GRAY SCALE ULTRASOUND AND COLOR DOPPLER IN DIAGNOSIS OF APPENDICITIS:All India Institute of Medical Sciences, Jodhpur Mahatma Gandhi Institute of Medical Sciences, Wardha GRAY SCALE ULTRASOUND AND COLOR DOPPLER IN DIAGNOSIS OF APPENDICITIS: A RADIODIAGNOSTIC STUDY WITH HISTOPATHOLOGICAL CORRELATION Author: Dr. Swarnava Tarafdar , Senior Resident, A.I.I.M.S., Jodhpur, Rajasthan Co Author : Dr. A.T.Tayade, Prof & Head, Department of Radiodiagnosis, M.G.I.M.S, Sevagram

2 Introduction ɸ Acute appendicitis is most common abdominal surgical emergency especially in age group 11 to 30 years. Patients may present with atypical clinical features & non-specific physical findings & evaluation of these patients becomes challenging if done only on clinical grounds. Delay in diagnosis can lead to complications such as perforation & peritonitis. On other hand clinician decision to operate can lead to the removal of a normal appendix in 15–30% of cases. “Even the most experienced surgeons may remove normal appendix or ‘sit on’ those that have perforated”

3 “Ultrasound fulfils all these requirements satisfactorily”Introduction A reliable modality is required which should be (i.e. with highest sensitivity & specificity). (i.e., the cost of the examination should be less than the consequences of treating the patient without the benefit of the information derived from the examination). both in length of the study and in availability of the diagnostic information). Accurate Cost effective Rapid Noninvasive “Ultrasound fulfils all these requirements satisfactorily”

4 Aim To evaluate the role of Gray scale ultrasound and Color Doppler in diagnosis of appendicitis. Objectives To characterise the appearance of appendicitis on Gray scale and Color Doppler ultrasound. To determine the efficiency of Gray scale alone and in combination with Color Doppler ultrasonography in diagnosing appendicitis. To compare the Gray scale and Color Doppler ultrasonographic features with clinical findings in diagnosing appendicitis. To correlate ultrasonographic findings prospectively with intraoperative and histopathological findings.

5 Materials and Methods STUDY SETTING STUDY DESIGN STUDY PERIODThis study was carried out in the Department of Radiodiagnosis. This is prospective study which include US evaluation of patients with clinically suspected appendicitis STUDY DESIGN STUDY PERIOD The study was conducted from May 2011 to Oct 2013 Clinically suspected acute appendicitis cases in years age group of both sexes STUDY POPULATION A total number of 426 patients referred from clinical departments with clinically suspected appendicitis. Approval for study was obtained by institutional ethical committee SAMPLE SIZE INCLUSION CRITERIA Clinically suspected acute appendicitis cases in years age group of both sexes EXCLUSION CRITERIA Diagnosed or follow up cases of right lower abdominal pain and patients who were managed only conservatively

6 Equipments used Linear Transducer Frequency range 3-12 MHzCurvilinear Transducer Frequency range 2-5 MHz PHILIPS HD11 XE 3D/4D Color Doppler Ultrasonography machine

7 Parameters assessed regarding the appendixOn Gray scale US : Probe tenderness in right iliac fossa: present/absent Diameter of appendix Appendicolith Continuity/Discontinuity of appendiceal wall Loss of echogenicity of appendiceal wall: present/absent Wall thickness Appendicular lump : present/absent Periappendiceal collection : present/absent Fluid collection with or without echoes periappendiceal air : present/absent Periappendiceal mesentry: echogenic/non echogenic Lymph nodes

8 Ultrasonography findingsNormal appendix - blind-ended, tubular, compressible intestinal loop which is continuous with the cecum and has a diameter of less than 6 mm Suppurative appendicitis - aperistaltic, noncompressible, blind-ended, tubular structure with laminated continuous wall arising from base of cecum. Appendicitis is characterised by a wall thickness > 2 mm & diameter > 6 mm

9 Ultrasonography findingsAppendicular abscess - localized fluid collection was seen which is walled off by adjacent greater omentum and small-bowel loops. When a complex, hypoechoic mass adjacent to cecum or appendix was present even though the inflamed appendix was not visualized, appendicular abscess will be suggestive. Gangrenous appendicitis focal loss of the echogenic submucosal layer of the appendiceal wall with surrounding echogenic fat. Perforated appendicitis - discontinuity in wall layers, asymmetry of wall thickness, presence of air or fluid collection with echoes within around appendix.

10 Periappendiceal collection Surrounding echogenic mesentryUltrasonography findings Appendicoliths - bright echogenic foci with distal acoustic shadowing, their visualization is another contributory finding in diagnosing appendictis Appendicular lump - large mass of non compressible echogenic fat was seen around appendix forming a mass. Periappendiceal collection Mesenteric LMN Surrounding echogenic mesentry

11 Mesenteric lymphadenopathyCommon Differential Diagnosis Mesenteric lymphadenopathy Colitis Right ureteric calculus Ovarian cyst

12 Color Doppler Ultrasonography findingsPresence or absence of Color Doppler signals & whether colour flow is increased or normal. It was classified as: (1) Normal colour flow in appendiceal wall (2) Increased colour flow (3) No colour flow Suppurative appendicitis shows greater circumferential flow in it’s wall than normal appendix Gangrenous appendicitis is diagnosed when Color Doppler signals disappear Inflamed surrounding mesentery & omentum shows increased flow on doppler

13 Data Entry and Statistical Analysisɸ Pre-tested & standardized performa was used to record the study observations. Data was entered in master chart on self coded form. Statistical analysis was done using descriptive & inferential statistics using chi square test and predictive values of diagnostic tests. Software used in analysis were SPSS 17.0 and Graph Pad Prism 5.0 and p<0.05 is considered as level of significance. Sensitivity, specificity, positive predictive value, negative predictive value, false positive rate and false negative rates of the Alvarado score, Gray scale US & Gray scale and Color Doppler US in combination was calculated by 2 x 2 tables using respective statistical formulas.

14 Results ɸ A total number of 425 patients in age group of 11 to 30 years were evaluated US. Out of total 425 cases, 289 patients were operated. The surgery was done on basis of ultrasound diagnosis in 175 cases and on strong clinical suspicion of appendicitis in 114 cases The removed appendix was sent for histopathological evaluation. The operated cases were divided into two groups: (1) Appendicitis (2) No appendicitis, on basis of histopathological finding i.e. whether positive or negative for appendicitis. In 136 cases US diagnosis was other than appendicitis like mesenteric adenitis, ileitis and colitis, right ureteric stone, ovarian cyst etc. So, out of 425 cases, 289 cases were included in study & 136 cases were excluded from the study. 425 patients(11-30) 289(optd)( ) +136(

15 Distribution of 289 operated cases on basis of Distribution of clinically suspected 425 appendicitis cases on basis of US diagnosis Distribution of 289 operated cases on basis of US & Histopathological diagnosis US Diagnosis (Color Doppler + Gray scale) ( n=289) Final Histopathological Diagnosis (Gold Standard) Ultrasonographic diagnosis Cases Normal 144 Appendicitis 175 Positive Negative 136 Positive 170(TP) 5(FP) Others (mesenteric adenitis, ileitis and colitis, right ureteric stone, ovarian cyst etc.) Negative 20(FN) 94(TN) Total 425

16 Distribution of 136 cases diagnosed other than appendicitis on Ultrasonography (differential diagnosis of clinically suspected appendicitis) S. no. US findings No. of cases Percentage 1 Mesenteric adenitis 46 34 2 ileitis/Colitis 21 15 3 Right ureteric stone 19 14 4 Ovarian cysts 18 13 5 Abdominal TB 5 4 6 Acute cholecystitis 5 4 7 Right pyelonephritis 5 4 8 Pancreatitis 4 3 9 Gastritis/duodenitis 4 3 10 Meckel’s diverticulitis 3 3 11 Calculus Right kidney 3 2 12 Cystitis 3 2 Total 136 100

17 Distribution of 289 operated cases according to theirPresenting symptoms Presenting signs Per centage of patients Symptoms Signs p < 0.05 p < 0.05

18 Distribution of 289 cases according to Laboratory investigationSex distribution in 190 cases of histopathologically proved appendicitis Distribution of 289 cases according to Laboratory investigation p < 0.05

19 Distribution of 289 cases according to their US findingsp < 0.05

20 Efficacy in diagnosis of appendicitisAlvarado score Gray scale ultrasonological examination Per centage (%) Per centage (%)

21 Gray scale combined with Color Doppler examinationEfficacy in diagnosis of appendicitis Gray scale combined with Color Doppler examination Per centage (%)

22 Discussions Alvarado score (Clinical) 140 80 50 19 289 Gray scale USDetected patients correctly Ruled out appendicitis correctly Missed cases Falsely diagnosed Total Alvarado score (Clinical) 140 80 50 19 289 Gray scale US 170 80 20 19 289 Gray scale & Color doppler US 170 94 5 20 289

23 USG Gray scale + Color dopplerDiscussions USG Gray scale + Color doppler Alvarado score (clinical) Gray scale USG Sensitivity 89.9% 74% 89.5% Specificity 94.4% 80.8% 81% 97% PPV 88% 89.9% NPV 82.4% 61.5% 80%

24 Conclusions ɸ Appendicitis is more common in males than in females in 11 to 30 years age group patients with male female ratio 1.5:1 Clinical features such as pain, nausea , vomiting and anorexia are more commonly seen in appendicitis patients Tenderness in right iliac fossa, rebound tenderness, muscle guarding, Psoas sign and obturator sign are common clinical signs in diagnosing appendicitis. Leukocytosis is more common feature in appendicitis than in no appendicitis. ɸ ɸ ɸ

25 Conclusions ɸ US findings such as periappendiceal echogenic mesentry, probe tenderness in RIF, thickened appendiceal wall, MOD ≥ 6, periappendiceal fluid collection and appendicolith are common in appendicitis than in no appendicitis cases. Mesenteric adenitis is more common in no appendicitis cases than in appendicitis cases. Clinical diagnosis based on symptomatology alone is not sufficient to make or confirm the diagnosis of appendicitis, thus necessitating the need to be subjected for US for confirmation of the diagnosis. Gray scale US alone is superior to Alvarado scoring in diagnosing appendicitis. ɸ ɸ

26 Conclusions ɸ Gray scale and Color Doppler US when used in combination has highest efficacy in diagnosing appendicitis in comparison when Gray scale US , Color Doppler and Alvarado score are used alone. Thus, US should be first investigation of choice in patients with clinically suspected appendicitis. Color Doppler should be used in combination with Gray scale US for improving diagnostic efficacy. ɸ ɸ

27 Thank You

28 Questions ? Significance of study Ultrasonography Findings(slide 4) Ultrasonography Findings (slide 8-10) Introduction (slide 2-3) Data Entry and Statistical Analysis (slide 13) Color Doppler Ultrasonography findings (slide 12) Materials and Methods (slide 5) Statistical block(results) (slide 15-21) Parameters assessed regarding the appendix (slide 7) Equipments Used (slide 6) Questions ? Common Differential Diagnosis (slide 11) Results (slide 14-21) Discussions (slide 22-26) Conclusions (slide 27-29)