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Appropriate Use of CT Scanning in Acute Appendicitis

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

1. 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]
2. 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
3. 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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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Emby, D. J. Search for Related Content PubMed PubMed Citation Articles by Emby, D. J. Social Bookmarking                      What's this?