Scan helico est plus precis que les judgements cliniques dans le diagnostic de
l'appendicite, meme dans les cas qui apparaitraient cliniquement evidents...
La valeur predictive positive de l'impression clinique du medecin examinateur
est de 73% et la valeur predictive negative et de 56%, alors que celles du scan
helico sont de 96% et 96%.
mais bon, il faudrait qu'on ait le luxe d'avoir toujours des radiologues
specialistes en scan et le scan serait toujours lu par 2 radiologues...
Ceci dit, le scan a probablement une indication plus forte pour les femmes qui
ont des taux de fausses positiveset negatives plus eleves, sauf si le
chirurgien est tres sur de lui!
et au prix de 1,000 mrem de radiation....
les tiers-payeurs et les soi-disants tres bons cliniciens n'aiment surement pas
cette etude, mais va-t-elle avoir une implication medico-legale?
discussion ouverte
Kim K et al. Impact of helical computed tomography in clinically evident
appendicitis. Emerg Med J 2008 Aug; 25:477.
Department
of Emergency Medicine, Seoul National University Bundang Hospital, 300
Gumi-dong, Bundang-gu, Seongnam-si, Gyeongi-do 463-707, Korea.
OBJECTIVES:
To determine the utility of multidetector computed tomography (MDCT) in
patients with clinically evident acute appendicitis and to compare the
test characteristics of overall clinical impression, Alvarado scores,
and MDCT in suspected appendicitis. METHODS: A prospective
observational cohort study was conducted in two urban emergency
departments (ED). Consecutive patients with suspected acute
appendicitis were clinically evaluated by an emergency physician who
was asked to determine whether appendicitis was clinically evident or
not. Elements of the Alvarado scores were collected and all patients
then underwent MDCT and a decision to operate, observe, or discharge
the patients was made by a surgeon. The final diagnosis was based on
surgical pathology or clinical follow-up. The test characteristics of
clinical impression, Alvarado scores and MDCT were then calculated and
the rates at which acute appendicitis was falsely diagnosed based on
clinical impression and MDCT were compared using McNemar's test.
RESULTS: Of 157 study patients, 71 were considered to have clinically
evident appendicitis before MDCT and 91 had findings of acute
appendicitis on MDCT. 19 of the 71 patients with clinically evident
appendicitis did not have appendicitis. 14 of 52 patients with an
Alvarado score > or = 8 also did not have appendicitis. Three of 91
patients with acute appendicitis based on MDCT did not have
appendicitis. The specificities of clinical impression and Alvarado
score > or = 8 were 71.6% and 79.1%, respectively, and these were
significantly lower than that of MDCT (95.5%, p<0.05). CONCLUSION:
The performance of abdominal MDCT in patients with a high degree of
clinical suspicion for acute appendicitis reduces the number of false
positives and has the potential to reduce negative appendectomies.
