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DDW: CT Scan Slows Time to Appendectomy
WASHINGTON -- If the classic signs of appendicitis are present, there's no need for a confirmatory CT-scan, a researcher said here.
WASHINGTON, May 24 -- If the classic signs of appendicitis are present, there's no need for a confirmatory CT-scan, a researcher said here.
In fact, waiting for a CT scan was associated with a significantly higher risk of perforated appendix (P=0.015) in a single-institution retrospective analysis, according to Herbert Chen, M.D., of the University of Wisconsin at Madison.
Although a CT scan can be relatively rapid, it was associated with a significantly greater time (P<0.001) from ER to OR, Dr. Chen said during Digestive Disease Week.
He hopes the study "will change people's attitudes" toward the use of CT in cases of suspected appendicitis, Dr. Chen said. He noted that some smaller studies have reported similar results. (ACEP: CT No Help in Suspected Appendicitis)
With 411 patients over a three-year period, Dr. Chen said, "ours has the advantage of large numbers."
Over the three years, he said, 256 patients (62%) with suspected acute appendicitis had a pre-operative CT scan, while 155 went directly to surgery with no prior imaging.
Those who did not get a CT scan were younger (mean of 31 years versus 37) and more likely to be male (66%) - differences that were significant at P<0.001 and P=0.001, respectively.
There was no difference in the length of surgery or white blood cell count, but significantly:
- The time from presentation to the operating room was 8.2 hours for those getting a CT scan, compared with 5.1 hours for others.
- The risk of perforation was 17% in those getting a CT scan, compared with 8%.
- The rate of negative procedures - no appendicitis found during surgery - was not significantly different between the groups.
Dr. Chen said physicians should be "very selective" about who gets sent for a CT scan, because a delayed surgery is associated with an increased risk of complications.
"I would say if someone comes in with the straightforward signs and symptoms that we as surgeons are all taught, that patient should not have a CT scan," he said.
If the diagnosis is in doubt - usually in older patient and women - a CT scan can be useful, he said.
Dr. Chen said he thinks the increasing use of CT for appendicitis is a function of doctors not wanting to miss anything, possibly because of legal issues.
"We have seen a dramatic increase in the utilization of CT scanning," he said. "Everyone wants to get the diagnosis right."
But it's unlikely things will change, said Gregory Ginsberg, M.D., of the University of Pennsylvania, who moderated a press conference at which Dr. Chen discussed his study.
"That horse has left the barn," Dr. Ginsberg said. He noted that the study was retrospective and so represents "clinical decisions" taken by physicians at the time.
But he agreed with Dr. Chen that CT should take second place to a doctor's clinical judgment.
"I want to underscore that diagnostic imaging is adjunctive," he said, "but does not replace thoughtful consideration in the eyes and hands of an experienced clinician."
