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Alvarado score Migration of pain 心窩部、臍周囲→右下腹部 1 MANTRELS score Anorexia 食欲不振 1 Nausea 嘔気、嘔吐 1 Tenderness in RLQ 右下腹部痛 1 Rebound tenderness 反跳痛 2 Elevated temperature 発熱＞37.3℃ 1 Leukocytosis WBC>10,000/µl 2 Shift of WBC count 白血球の左方移動 17点以上; Sn 24-95%, Sp 46-99%, LR 3.15-6点; Sn 4-43%4点以下; Sn 0-28%, Sp 6-87%, LR 0.1
Temperature ≥7.3°C 28 (14.7%) symptoms, and 93% of patients had tenderness in the right White blood cell count (/μL) 11 999.7 ± 4420.9 lower quadrant of the abdomen. The signs and symptoms研修医の印象とAlvarado scoreは White blood cell count ≥ 10 000/μL 126 (66.0%) used to calculate the Alvarado score are shown in Table 1. Segmented neutrophil (%) 76.8 ± 11.4 Of a total of 191 patients, 120 (62.8%) patients underwent Segmented neutrophil ≥75% 121 (63.4) surgical exploration and 71 (37.2%) were discharged home. Data are expressed mean ± SD or number (percentage) as appropriate. Of the 120 patients who underwent exploration, one patientどちらが有用か？ was compared using the χ 2 or Fisher exact test as was diagnosed with an ovarian torsion before operation and the surgery was performed by a gynecologist. The remaining American Journal of went to the operating room with the impression 119 patients Emergency Medicine (2010) 28, 766–770 appropriate. We performed receiver operating characteristic of acute appendicitis. Of these patients, 111 (93.2%) were curve analysis to compare the diagnostic characteristics of confirmed to have appendicitis by pathologic findings, and ER研修医, 外科研修医が右下腹部痛でER受診した191名を評価 EMR, SR, the Alvarado score, and the CT scan. The area under the curve (AUC) was calculated and a univariate Z test one was found to have a mucinous tumor. Telephone follow- up was completed on all patients who did not undergo was used to compare the AUC as described by Hanley and operation, and there was no additional case of acute McNeil . appendicitis within the 3-month follow-up period. 虫垂炎に対する診断能をROC curveで評価. Statistical analyses were conducted using SPSS software version 13.0 (SPSS Inc, Chicago, Ill). Medcalc (MedCalc Software, Belgium) was used to compare the AUC. A P value of less than .05 was considered statistically significant. AUCは, 3. Results CT; " " " 0.978[0.953-1.002] During the study period, 278 consecutive patients with pain to the right lower quadrant of the abdomen were Alvarado; " 0.735[0.661-0.809] enrolled. Of these patients, 87 were not evaluated by an SR before CT imaging and were excluded. Therefore, 191 ER研修医; " 0.698[0.622-0.773] patients were included into the final analysis. Their mean age was 37.3 ± 16.7 years and 87 patients (45.6%) were male. Nausea and vomiting were the most common presenting 外科研修医;" 0.657[0.579-0.735] Table 2 Comparison of the probability groups between EMR and SRs Group Surgery (N = 191)
cantly higher PPV (95% vs 71%). The US- aided identiﬁcation of a normal appen- dix was a signiﬁcantly more common ﬁnding for the exclusion of appendicitis 虫垂炎所見; 直径が9.3mm than was the normality of both WBC and CRP levels (72% vs 47%) and had a sig- niﬁcantly higher NPV (98% vs 84%). DISCUSSION The inability to visualize the normal ap- pendix is classically considered a major weakness of using US in the assessment Figure 1. (a) Transverse and (b) longitudinal US images obtained in a 27-year-old man with of patients suspected of having appendi- 正常の虫垂所見 appendicitis (arrows). The appendix has an anteroposterior diameter of 9.2 mm. citis, because it represents a serious limi- tation to conﬁdently excluding the diag- nosis of appendicitis (5). In their state-of- using US and 21 patients in whom it was cluded eight patients with ileocolitis (Fig the-art article, Birnbaum and Wilson (9) not identiﬁed. Of these latter 21 patients, 5), four patients with mesenteric adeni- claimed that in their experience and in two had a ﬁnal diagnosis of appendicitis, tis, one patient with mesenteric isch- that of others (11,15), a normal appendix thus giving the lack of visualization of emia, and one patient with pyelonephri- is visualized in only 0%– 4% of cases in the appendix at US an NPV of 90%; each tis. Cecal wall thickening (Fig 5) was the adult population, regardless of the US of these two patients was found to have detected at US in only 25% of patients technique used, and they stated that the an appendiceal perforation at surgery. with appendicitis and in more than 10% results of Rioux (12), who visualized a The 104 patients in whom the appendix of patients without appendicitis. Perito- normal appendix in 82% of patients was visualized constituted a group in neal ﬂuid was noted in 51% of patients without acute appendicitis, were “amaz-Figure 2.appendiceal US ﬁndings could be a normal appendix (arrows) in three different patients. which (a– c) Longitudinal US images show with appendicitis but also in almost 30% ing.” 基部は正常径だが, tested. Table 2 shows (a) the frequency of patients without appendicitis. Right In contrast with this classic viewpoint, with which each appendiceal ﬁnding was lower abdominal quadrant adenopathy we visualized a normal appendix in 72%normal appendix visualization rate (12). interpreted as positive or negative, (b) the was present in 32% of patients with ap- of the patients without appendicitis,As a result, nonvisualization of the ap- TABLE 2 末端で肥大した虫垂 number of true-positive, true-negative, pendicitis and in 38% of patients without for the Diagnosisclose to the 64% appendix Appendiceal US and Doppler US Signs which is a rate of Appendicitispendix can only befalse-negative results, appendicitis. Combining the nonappen- visualization rate obtained by Retten- false-positive, and valid as an accurate Radiologyﬁnding to exclude appendicitis for sonog- and (c) the sensitivity, speciﬁcity, accu- diceal ﬁndings with appendiceal ﬁndings Lack of Finding and Diameter Ն Intraluminal bacher et al (19) in a population ofraphers whoand PPV of each appendiceal did not increase the NPV or PPV of indi- healthy subjects. The notion thatWall racy, NPV, can usually identify a normal Value 6 mm Compressibility Fluid Flow in theappendix.The two most accurate appen- vidual appendiceal ﬁndings, such as an normal appendix is seldom visualized at ﬁnding. Finding at US US evaluation ofappendicitis were a di- appendix 6 mm or larger55 diameter or 55 is based on reports published more diceal ﬁndings for the appendix ideally Positive in US 33 30includes of 6 mm or of theand a lack of noncompressibility of the50 ameter evaluation larger appendiceal Negative appendix. 49 71 74 than 10 years ago (10,14) or on data ob-wall and appendiceal content. with de- Finding at ﬁnal compressibility. In the patient We ap- diagnosis tained by sonographers who are not ra-cided to measure the outer appendiceal pendicitis and an outer appendiceal di- diologists with experience in US28 assess-diameter less than 6 mm, surgical wall Laboratory Findings 54 True-positive 53 29 ameter rather than appendiceal and True-negative 48 47 45 47 ment of the gastrointestinal tract (20).thickness forexamination First, as shown pathologic two reasons. revealed distalby Rioux (12), inﬂammation of the ap- The number False-negative 1 1 糞石と False-positive of true-positive, true-neg- 2 4 Technologic advances combined with in- 2 26 2 26 appendicitis, but, although the distal ap- ative, false-positive, and false-negative re- depth radiologic experience have dra- Value*pendiceal wall may be indistinguishable pendix was dilated in comparison with Figure 3. the sensitivity,(95, 100) shows ap- 100) Sensitivityfromproximal one,intraluminal pus, thus showsNPV, and PPV of the two laboratory (94, 100) hypoechoic both the proximal and racy, ap- 粘膜内Fluid貯留 sults and Longitudinal US image accu- (94, 98 speciﬁcity, 96 matically improved 63) use of US in the 53 (43, the 52 (43, 61) the Radiology 2004;230:472-8 Figure 3. Longitudinal US image pendicitis in a 43-year-old woman. This 96 a Speciﬁcity 98 (95, 100) was visualization 92 (87, 97) of a normal appendix. The 96 (94, 100)making measurement of the appendiceal false-negative diagnosis at US. The appendiceal 100) improvement94) PPV 98 WBC levels) are (94, (95, 100) 96 same 88 (82, has been (88, 98) 93 reported pendicitis in a 43-year-old woman. ﬁndings (ie, CRP and (95, 100) distal appendix measured less than 6 mm This was a NPV in Table 4. A WBC level above (94, 100) 98 96 with use of computed tomography 73) 63 (64, 72) 64 (55, (CT);wallUS (Fig 3). Second, the mucosal sur- diameter measured less than 6 mm, but after a at inaccurate. In the nonappendicitis shown false-negative diagnosis at US. The appendiceal