• Mohammad Akbar Ali Mardan
  • Tariq Saeed Mufti
  • Irfan Uddin Khattak
  • Nagendra Chilkunda
  • Abdulmonem A. Alshayeb
  • Ahmad Moussa Mohammad
  • Zia ur Rehman


Background: Misdiagnosis of acute appendicitis is a common and crucial problem in generalsurgery. Graded compression ultrasonography is one of the new diagnostic technique that isreported to have improve the diagnostic accuracy and clinical outcome. The aim of current study isto assess the role of this diagnostic modality in the management of acute appendicitis. Methods:This is a cohort observational study comparing the adverse outcome in two different groups ofpatients admitted with suspected acute appendicitis at two different hospitals in two differentcountries. The first group of 200 patients at Ayub Teaching Hospital Abbottabad, Pakistan, wasmanaged without preoperative ultrasonography. In the second group of 200 patients admitted atNajran General Hospital Najran Saudi Arabia, graded compression abdominal ultrasonographywas routinely performed preoperatively. Diagnostic accuracy of the protocol in each group wasmeasured statistically and rates of negative appendicectomy and perforation were determined.Results: Addition of routine ultrasonography in clinical assessment for acute appendicitisdecreases the sensitivity but significantly increases the specificity of the protocol thereby reducingthe false positive rate translating into decreased negative appendicectomy rate. Rate of negativeappendicectomy was 22.5% in group one and 4.7% in group two.Perforation rate was 15.6% ingroup 1 and 15% in group two. Conclusion: Proper clinical assessment is the mainstay ofdiagnosis in acute appendicitis and addition of routine ultrasound by graded compressiontechnique can improve the diagnostic accuracy and adverse outcome.Key Words : Acute Appendicitis, Ultrasonography, Diagnosis,


Stephens PL, Mazzucco JJ.Comparison of ultrasound and the

Alvarado score for the diagnosis of acute appendicitis.

Conn.Med. 1999 Mar; 63(3):137-140.

Berry J Jr, Malt RA. Appendicitis near its centenary. Ann

Surg 1984; 200(5):567-75

Addiss DG, Shaffer N, Fowler BS, Tauxe RV. The

epidemiology of appendicitis and appendectomy in the

United States. Am J Epidemiology 1990; 132:910-925

Flum DR, Koepsell T. The clinical and economic correlates

of misdiagnosed appendicitis. Nationwide analysis. Arch

Surg. 2002;137(7):799-804.

Douglas CD, Macpherson NE, Davidson PM, Gani JS.

Randomized controlled trial of ultrasonography in diagnosis

of acute appendicitis ,incorporating the Alvarado score. BMJ.

; 321(7266); 919-22

Franke C, Böhner H, Yang Q, Ohmann C, Röher HD.

Ultrasonography for the diagnosis of acute appendicitis:

results of a prospective multicenter trial. World J Surg1999;

(2):141 -146

Seal A. Appendicitis: a historical review. Can J Surg 1981;


Puylaert JB. Acute appendicitis: US evaluation using graded

compression. Radiology. 1986; 158(2):355-60

Chesbrough RM, Burkhard TK, Balsara ZN, Goff WB 2nd,

Davis DJ. Self-localization in US of appendicitis: an addition

to graded compression. Radiology 1993; 187(2):349-51

Lim HK, Lee WJ, Kim TH, Namgung S, Lee SJ, Lim JH.

Appendicitis: usefulness of color Doppler US. Radiology

; 201(1):221-25

Quillin SP, Siegel MJ. Appendicitis: efficacy of color

Doppler sonography. Radiology 1994; 191(2):557-60

Silberman VA. Appendectomy in a large metropolitan

hospital: Retrospective analysis of 1,013 cases. Am J Surg

; 142(5):615-18

Hale DA, Molloy M, Pearl RH, Schutt DC, Jaques DP.

Appendectomy: a contemporary appraisal. Ann Surg 1997;


Zielke A, Hasse C, Sitter H, Rothmund M. Influence of

ultrasound on clinical decision making in acute appendicitis:

a prospective study. Eur J Surg 1998; 164(3):201-9.

J Ayub Med Coll Abbottabad 2007; 19(3)

Schuler JG, Shortsleeve MJ, Goldenson RS, Perez-Rossello

JM, Perlmutter RA, Thorsen A. Is there a role for abdominal

computed tomographic scans in appendicitis? Arch Surg

; 133(4):373-6.

Borgstein PJ, Gordijn RV, Eijsbouts QA, Cuesta MA. Acute

appendicit is--a clear-cut case in men, a guessing game in

young women. A prospective study on the role of

laparoscopy. Surg Endosc. 1997;11(9):923-7.

Thorell A, Grondal S, Schedvins K, Wallin G. Value of

diagnostic laparoscopy in fertile women with suspected

appendicitis. Eur J Surg. 1999;165(8):751-4.

Chan I, Bicknell SG, Graham M. Utility and diagnostic

accuracy of sonography in detecting appendicitis in a

community hospital. Am J Roentgenol. 2005; 184(6): 1809 –

Rettenbacher T, Hollerweger A, Macheiner P, Gritzmann N,

Daniaux M, Schwamberger K et al. Ovoid shape of the

vermiform appendix: a criterion to exclude acute

appendicitis-evaluation with US. Radiology. 2003;226(1):95-

Rodriguez DP, Vargas S, Callahan MJ, Zurakowski D,

Taylor GA. Appendicitis in young children:Imaging

experience and clinical outcomes. Am J Roentgenol


Gisler M, Rouse G, DeLange M. Sonography of appendicitis:

A Review. JDMS.1989;5(2):57-60.

Puig S,Hormann M,Rebhandl W,Felder-Puig R,Prokop

M,Paya K.US as primary diagnostic tool in relation to

negative appendicectomy:six years


Lee JH, Jeong YK, Hwang JC, Ham SY, Yang SO. Graded

compression sonography with adjuant use of posterior

compression technique in the sonographic diagnosis of acute

appendicitis. AJR Am J Roentgenol.2002;178(4):863-8.

Paulson EK, Kalady MF, Pappas TN. Clinical practice.

Suspected Appendicitis. N Engl J Med. 2003; 348(3): 236-42

Chen SC, Chen KM, Wang SM, Chang KJ. Abdominal

sonography screening of clinically diagnosed or suspected

appendicitis before surgery. World J Surg 1998; 22(5):449-

Velanovich V, Satava R. Balancing the normal

appendectomy rate with the perforated appendicitis rate:

implications for quality assurance. Am Surg. 1992;


Malik KA, Khan A,Waheed I. Evaluation of Alvarado score

in diagnosis of acute appendicitis.J Coll Physicians Surg

Pakistan 2000;10(10):392-4.

Khan I , ur Rehman A. Application of Alvarado scoring

system in diagnosis of acute appendicitis. J Ayub Med Coll

Abbottabad. 2005;17(3): 41-4.

Kessler N, Cyteval C, Gallix B, Lesnik A, Blayac PM, Pujol

J et al. Appendicitis: evaluation of sensitivity, specificity, and

predictive values of US, Doppler US, and laboratory

findings. Radiology. 2004; 230(2):472-8

Ooms HW, Koumans RK, Ho Kang You PJ, Puylaert JB.

Ultrasonography in the diagnosis of acute appendicitis. Br J

Surg. 1991;78(3): 315-8.

Bendeck SE, Nino-Murcia M , Berry GJ, Jeffrey RB Jr.

Imaging for suspected appendicitis: Negative

appendicectomy and perforation rates.Radiology. 2002;

(1): 131-6.

Lee SL, Walsh AJ, Ho HS. Computed tomography and

ultrasonography do not improve and may delay the diagnosis

and treatment of acute appendicitis. Arch Surg.


Lee JH, Jeong YK, Park KB, Park JK, Jeong AK, Hwang

GC. Operator-dependent techniques for graded compression

sonography to decect the appendix and diagnose acute

appendicitis. Am J Roentgenol. 2005; 184(1): 91-7.

Mufti TS, Akhtar S, Khan K, Raziq F, Rehman Z, Ahmed I

Diagnostic accuracy in acute appendicitis; comparison

between clinical impression and ultrasound findings: J Ayub

Med Coll Abbottabad 1996; 8(1):13-15.

Most read articles by the same author(s)

1 2 > >>