Annals of Emergency Medicine
Volume 55, Issue 1 , Pages 51-59.e1 , January 2010

Diagnostic Accuracy of Noncontrast Computed Tomography for Appendicitis in Adults: A Systematic Review

  • Veronica Hlibczuk, MD

      Affiliations

    • Division of Emergency Medicine, Columbia University Medical Center, New York–Presbyterian Hospital, New York, NY
    • Corresponding Author InformationAddress for correspondence: Veronica Hlibczuk, MD, Division of Emergency Medicine, Columbia University Medical Center, New York-Presbyterian Hospital, 622 West 168th St, PH1-137, New York, NY 10032; 212-305-2995, fax 212-305-6792
  • ,
  • Judith A. Dattaro, MD

      Affiliations

    • Division of Emergency Medicine, Weill Cornell Medical Center, New York–Presbyterian Hospital, New York, NY
  • ,
  • Zhezhen Jin, PhD

      Affiliations

    • Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY
  • ,
  • Louise Falzon, BA

      Affiliations

    • Mount Sinai Heart, Mount Sinai Medical Center, New York, NY
  • ,
  • Michael D. Brown, MD, MSc

      Affiliations

    • Division of Emergency Medicine, Michigan State University College of Human Medicine, Grand Rapids, MI

Received 25 March 2009 ,Revised 15 June 2009 ,Accepted 24 June 2009.

References 

  1. Birnbaum BA, Wilson SR. Appendicitis at the millennium. Radiology. 2000;215:337–348
  2. Paulson EK, Kalady MF, Pappas TN. Suspected appendicitis. N Engl J Med. 2003;348:236–243
  3. Rao PM, Rhea JT, Novelline RA, et al. Effect of computed tomography of the appendix on treatment of patients and use of hospital resources. N Engl J Med. 1998;338:141–146
  4. Kim K, Rhea JE, Lee CC, et al. Impact of helical computed tomography in clinically evident appendicitis. Emerg Med J. 2008;25:477–481
  5. Balthazar EJ, Rofsky NM, Zucker R. Appendicitis: the impact of computed tomography imaging on negative appendectomy and perforation rates. Am J Gastroenterol. 1998;93:768–771
  6. Antevil JA, Rivera L, Langenberg BL, et al. Computed tomography-based clinical diagnostic pathway for acute appendicitis: prospective validation. J Am Coll Surg. 2006;203:849–856
  7. Lane MJ, Liu DM, Huynh MD, et al. Suspected acute appendicitis: nonenhanced helical CT in 300 consecutive patients. Radiology. 1999;213:341–346
  8. Vadeboncoeur TF, Heister RR, Behling CA, et al. Impact of helical computed tomography on the rate of negative appendicitis. Am J Emer Med. 2006;24:43–47
  9. Anderson BA, Salem L, Flum DR. A systematic review of whether oral contrast is necessary for the computed tomography diagnosis of appendicitis in adults. Am J Surg. 2005;190:474–478
  10. Doria AS, Moineddin R, Kellenberger CJ, et al. US or CT for diagnosis of appendicitis in children and adults? (a meta-analysis). Radiology. 2006;241:83–94
  11. Terasawa T, Blackmore C, Bent S, et al. Systematic review: computed tomography and ultrasonography to detect acute appendicitis in adults and adolescents. Ann Intern Med. 2004;141:537–546
  12. Weston AR, Jackson TJ, Blamey S. Diagnosis of appendicitis in adults by ultrasonography or computed tomography: a systematic review and meta-analysis. Int J Technol Assessm Health Care. 2005;21:368–379
  13. Leeflang MMG, Deeks JJ, Gatsonis C, et al. Cochrane Diagnostic Test Accuracy Working Group Systematic reviews of diagnostic test accuracy. Ann Intern Med. 2008;149:889–897
  14. Whiting P, Rutjes A, Reitsma J, et al. The development of QUADAS: a tool for the quality assessment of studies of diagnostic accuracy included in systematic reviews. BMC Med Res Methodol. 2003;3:25
  15. Rutjes AW, Reitsma JB, Di Nisio M, et al. Evidence of bias and variation in diagnostic accuracy studies. CMAJ. 2006;174:469–476
  16. Dinnes J, Deeks J, Kirby J, et al. A methodological review of how heterogeneity has been examined in systematic reviews of diagnostic test accuracy. Health Technol Assess. 2005;9:iii, 1-113
  17. Reitsma JB, Glas AS, Rutjes AW, et al. Bivariate analysis of sensitivity and specificity produces informative summary measures in diagnostic reviews. J Clin Epidemiol. 2005;58:982–990
  18. Review Manager (RevMan) [computer program]. Version 5.0.16. Copenhagen, Denmark: Nordic Cochrane Centre, Cochrane Collaboration; 2008;
  19. Terrin N, Schmid CH, Lau J. In an empirical evaluation of the funnel plot, researchers could not visually identify publication bias. J Clin Epidemiol. 2005;58:894–901
  20. Tatsioni A, Zarin DA, Aronson N, et al. Challenges in systematic reviews of diagnostic technologies. Ann Intern Med. 2005;142(12 pt 2):1048–1055
  21. Bendeck SE, Nino-Murcia M, Berry GJ, et al. Imaging for suspected appendicitis: negative appendectomy and perforation rates. Radiology. 2002;225:131–136
  22. Brontvein AT, Egorov VI, Vitko NK, et al. Radiodiagnosis of acute appendicitis. Khirurgiia (Mosk). 2002;12:13–16
  23. D'Ippolito G, Netto de Mello GG, Szejnfeld J. The value of unenhanced CT in the diagnosis of acute appendicitis. Sao Paulo Med J (Rev Paul Med). 1998;116:1838–1845
  24. Kailidou E, Pikoulis E, Katsiva V, et al. Spiral computerized tomography: a diagnostic aid in patients with atypical acute appendicitis. Acta Chir Belg. 2006;106:47–51
  25. Keyzer C, Tack D, de Maertelaer V, et al. Acute appendicitis: comparison of low-dose and standard-dose unenhanced multi-detector row CT. Radiology. 2004;232:164–172
  26. Malone AJ, Wolf CR, Malmed AS, et al. Diagnosis of acute appendicitis: value of unenhanced CT. AJR Am J Roentgenol. 1993;160:763–766
  27. Morris KT, Kavanagh M, Hansen P, et al. The rational use of computed tomography scans in the diagnosis of appendicitis. Am J Surg. 2002;183:547–550
  28. Styrud J, Josephson T, Eriksson S. Reducing negative appendectomy: evaluation of ultrasonography and computer tomography in acute appendicitis. Int J Qual Health Care. 2000;12:65–68
  29. Torbati SS, Guss DA. Impact of helical computed tomography on the outcomes of emergency department patients with suspected appendicitis. Acad Emerg Med. 2003;10:823–829
  30. Van Breda Vriesman AC, Kole BJ, Puylaert JBCM. Effect of ultrasonography and optional computed tomography on the outcome of appendectomy. Eur Radiol. 2003;13:2278–2282
  31. Yetkin G, Basak M, Işgör A, et al. Can negative appendectomy rate be decreased by using spiral computed tomography without contrast material?. Acta Chir Belg. 2002;102:334–337
  32. Yeung KW, Sheu RS, Chen CY, et al. Evaluation of significance of clinical information and intravenous contrast administration for diagnostic accuracy during emergent abdominal computed tomographic examination. Emerg Radiol. 1997;4:276–282
  33. Yüksekkaya R, Akgül E, İnal M, et al. Unenhanced spiral CT in the diagnosis of acute appendicitis. Tani Girisim Radyol. 2004;10:131–139
  34. Wise SW, Labuski MR, Kasales CJ, et al. Comparative assessment of CT and sonographic techniques for appendiceal imaging. AJR Am J Roentgenol. 2001;176:933–941
  35. Cakirer S, Basak M, Colakoglu B, et al. Diagnosis of acute appendicitis with unenhanced helical CT: a study of 130 patients. Emerg Radiol. 2002;9:155–161
  36. Christopher FL, Lane M, Ward JA, et al. Unenhanced helical CT scanning of the abdomen and pelvis changes disposition of patients presenting to the emergency department with possible acute appendicitis. J Emerg Med. 2002;23:1–7
  37. Gamanagatti S, Vashsht S, Kapoor A, et al. Comparison of graded compression ultrasonography and unenhanced spiral computed tomography in the diagnosis of acute appendicitis. Singapore Med J. 2007;48:80–87
  38. Heaston DR, McClellan JS, Heaston DK. Community hospital experience in 600+ consecutive patients who underwent unenhanced helical CT for suspected appendicitis [abstract]. AJR Am J Roentgenol. 2000;174:53
  39. Hershko DD, Awad N, Fischer D, et al. Focused helical CT using rectal contrast material only as the preferred technique for the diagnosis of suspected acute appendicitis: a prospective, randomized, controlled study comparing three different techniques. Dis Colon Rectum. 2007;50:1223–1229
  40. Lane MJ, Katz DS, Ross BA, et al. Unenhanced helical CT for suspected acute appendicitis. AJR Am J Roentgenol. 1997;168:405–409
  41. Peck J, Peck A, Peck C, et al. The clinical role of noncontrast helical computed tomography in the diagnosis of acute appendicitis. Am J Surg. 2000;180:133–136
  42. Poortman P, Lohle PNM, Schoemaker CMC, et al. Comparison of CT and sonography in the diagnosis of acute appendicitis: a blinded prospective study. AJR Am J Roengenol. 2003;181:1355–1359
  43. Togawa A, Kimura F, Chiku T, et al. Simple way to improve accuracy in diagnosis of quadrant inflammatory disease: how to avoid adverse laparotomy by using plain CT. Hepatogastroenterology. 2005;52:135–138
  44. Ashraf K, Ashraf O, Bari V, et al. Role of focused appendiceal computed tomography in clinically equivocal acute appendicitis. J Pak Med Assoc. 2006;56:200–203
  45. Ege G, Akman H, Sahin A, et al. Diagnostic value of unenhanced helical CT in adult patients with suspected acute appendicitis. Br J Radiol. 2002;75:721–725
  46. Horton MD, Counter SF, Florence MG, et al. A prospective trial of computed tomography and ultrasonography for diagnosing appendicitis in the atypical patient. Am J Surg. 2000;179:379–381
  47. in't Hof KH, van Lankeren W, Krestin GP, et al. Surgical validation of unenhanced helical computed tomography in acute appendicitis. Br J Surg. 2004;91:1641–1645
  48. Keyzer C, Zalcman M, De Maertelaer V, et al. Comparison of US and unenhanced multi-detector row CT in patients suspected of having acute appendicitis. Radiology. 2005;236:527–534
  49. Stacher R, Portugaller H, Preidler KW, et al. Acute appendicitis in unenhanced spiral CT: diagnostic luxury or benefit [in German]?. Rofo. 1999;171:26–31
  50. Tamburrini S, Brunetti A, Brown M, et al. Acute appendicitis: diagnostic value of nonenhanced CT with selective use of contrast in routine clinical settings. Eur Radiol. 2007;17:2055–2061
  51. Irwig L, Macaskill P, Glasziou P, et al. Meta-analytic methods for diagnostic test accuracy. J Clin Epidemiol. 1995;48:119–130
  52. van Randen A, Bipat S, Zwinderman A, et al. Acute appendicitis: meta-analysis of diagnostic performance of CT and graded compression US related to prevalence of disease. Radiology. 2008;249:97–106
  53. Lee S, Coughlin B, Wolfe J, et al. Prospective comparison of helical CT of the abdomen and pelvis without and with oral contrast in assessing acute abdominal pain in adult emergency department patients. Emerg Radiol. 2006;12:150–157
  54. van Randen A, Laméris W, Nio CY, et al. Inter-observer agreement for abdominal CT in unselected patients with acute abdominal pain. Eur Radiol. 2009;19:1394–1407
  55. in't Hof K, Krestin G, Steijerberg E, et al. Interobserver variability in CT scan interpretation for suspected acute appendicitis. Emerg Med J. 2009;26:92–94
  56. Togawa A, Kimura F, Chiku T, et al. Simple way to improve accuracy in diagnosis of quadrant inflammatory disease: how to avoid adverse laparotomy by using plain CT. Hepatogastroenterology. 2005;52:135–138

 Supervising editor: Allan B. Wolfson, MD

 Author contributions: VH and JAD conceived the study and reviewed and assessed all relevant studies. VH, JAD, and MDB supervised the conduct of the systematic review and data collection. VH, JAD, and LF conducted the search of all relevant electronic databases, meeting abstracts, and bibliographies. ZJ and MDB provided statistical advice. VH, JAD, ZJ, and MDB analyzed the data. VH and JAD drafted the article, and all authors contributed substantially to its revision. VH takes responsibility for the paper as a whole.

 Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The authors have stated that no such relationships exist. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement.

 Earn CME Credit: Continuing Medical Education is available for this article at: http://www.ACEP.EMedHome.com.

 Reprints not available from the authors.

 Publication date: Available online September 5, 2009.

 Please see page 52 for the Editor's Capsule Summary of this article.

 Provide feedback on this article at the journal's Web site, www.annemergmed.com.

PII: S0196-0644(09)01140-8

doi: 10.1016/j.annemergmed.2009.06.509

Annals of Emergency Medicine
Volume 55, Issue 1 , Pages 51-59.e1 , January 2010