DOI:10.2214/AJR.06.5043
AJR 2006; 186:E23
© American Roentgen Ray Society
Appropriate Use of CT Scanning in Acute Appendicitis
Don J. Emby
AngloGold Health Service
Gauteng, South Africa
The role of CT in the assessment of possible acute appendicitis has become
an important topic. Despite the fact that the role and cost effectiveness of
CT in this setting has been challenged
[1], its use appears to be on
the increase with its proponents holding sway. Unfortunately, arguments for
and against such investigation—whether CT can provide useful information
in the assessment of possible acute appendicitis—tend to mask the more
important question of when its use in this setting is appropriate. On the
whether-or-not side of the discussion, there can be little doubt that CT is
now an established and effective tool for evaluating patients with suspected
acute appendicitis, particularly for adult patients in instances in which
presentation is atypical. It is, however, on the when side of the discussion
that the risk-benefit ratio is far less clear.
The reason for the less clear indications about when CT should be used in
the assessment of possible acute appendicitis is the potential danger of
ionizing radiation to children and to young adults, especially females of
child-bearing age. In the case of acute appendicitis, one is dealing with a
condition in which the peak incidence is in the second and third decades of
life [2]. Despite the recent
AJR campaign to heighten awareness about the hazards of ionizing
radiation during the period of growth, most proponents of CT scanning in the
setting of suspected acute appendicitis seem to understate concerns about
radiation exposure. In addition, the role of sonar in diagnosing acute
appendicitis also seems to receive less attention than it deserves from the CT
scanning proponents. The use of IV contrast material is also not without risk
(or cost).
In their otherwise excellent article about the status of appendiceal CT,
Rhea et al. [3] mention the
issue of radiation in relation to risk of CT scanning versus the risk of
surgery. However, their quoted figures for morbidity and mortality of
appendectomy (from 1992) seem high for 2005. I must therefore take issue with
their comment that "female pediatric patients likely would have a lower
negative appendectomy rate with greater use of CT." Although this may be
true, the question that must be asked is the following: Would these female
pediatric patients be better off with a lower negative appendectomy rate
(which can be significantly reduced by sonar) or would they be better off for
not having their abdomen and pelvis (including ovaries) irradiated with the
associated lifelong increased risk of cancer?
References
- Hong JJ, Cohn SM, Ekeh AP, Newman M, Salama M, Leblang SD. A
prospective randomized study of clinical assessment versus computed tomography
for the diagnosis of acute appendicitis. Surg Infect2003; 4:231
-239[CrossRef]
- Braunwald E, Fauci AS, Kasper DL, Hauser SL, Longo DL, Jameson JL.
Harrison's principles of internal medicine, 5th ed.
New York, NY: McGraw-Hill, 2001:1705
- Rhea JT, Halpern EF, Ptak T, Lawrason JN, Sacknoff R, Novelline RA.
The status of appendiceal CT in an urban medical center 5 years after its
introduction: experience with 753 patients. AJR2005; 184:1802
-1808[Abstract/Free Full Text]
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