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Invited Commentary |

Is There a Role for Abdominal Computed Tomographic Scans in Appendicitis?—Invited Commentary

Jack Pickleman, MD
Arch Surg. 1998;133(4):377. doi:10.1001/archsurg.133.4.377.
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This reviewer always gets a bit uneasy when a group of clinicians and radiologists team up to tout a new diagnostic procedure for an old disease. There now exist dozens of articles in the surgical literature proclaiming the clinical and economic advantages of the performance of ultrasonography, barium enema, nuclear medicine scans, and laparoscopy in the treatment of patients with suspected acute appendicitis. The present article presents a persuasive case for the use of CT scanning in patients with signs and symptoms insufficient to warrant emergency department discharge or appendectomy. Of the 149 patients studied, 52 underwent immediate appendectomy; 97, or nearly two thirds of the group, were "equivocal" and underwent CT scans. This seems like a very high percentage of equivocal cases, suggesting to me that a bit more clinical rigor might have been exercised in the management of these cases. Having said that, I must admit that the authors have proved their case that CT scans are highly accurate in diagnosing appendicitis and delineating other pathological processes. I am less convinced by their data that a significant lowering of the negative appendectomy rate would result from the performance of this study in all such patients. I am even less convinced that routine use of CT scans would translate into any cost savings, as witnessed by their Scrooge-like Medicare reimbursement figures. The take-home value of this article is that CT scanning may be useful in a small subset of patients, often female or elderly, who manifest truly equivocal signs of appendicitis. Do not let the foregoing imply that I do not respect that 6-cm beast that lurks in everyone's abdominal cavity. Like all surgeons, I have spent many nights slaying the beast, being fooled by the beast, and occasionally being significantly embarrassed by it. But after each such misadventure, I admonish myself, not that I should have ordered 1 more preoperative test but rather that I should have not so quickly read Cope's Early Diagnosis of the Acute Abdomen.

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