Classification of acute appendicitis (CAA): treatment directed new classification based on imaging (ultrasound,
Jörg C Hoffmann1, Claus-Peter Trimborn2, Michael Hoffmann3
1Medizinische Klinik I mit Schwerpunkt Gastroenterologie, Diabetologie, Rheumatologie und Onkologie, St. Marien- und St. Annastiftskrankenhaus, Salzburger Straße 15, D67067, Ludwigshafen, Germany. joerg.hoffmann@st-marienkrankenhaus.de.
Insights
A new classification of acute appendicitis (AA) using imaging differentiates between complicated and uncomplicated cases. This system aids in selecting patients for nonoperative management, improving diagnostic accuracy for acute abdominal pain.
Area of Science:
- Radiology
- Gastroenterology
- Surgical Pathology
Background:
- Acute appendicitis (AA) is a common cause of acute abdominal pain.
- Current risk stratifications lead to up to 30% negative appendectomies and unaddressed perforations.
- Preoperative classification via imaging is crucial for accurate diagnosis and treatment.
Purpose of the Study:
- To classify acute appendicitis (AA) using imaging (ultrasound/US, computed tomography/CT), surgical pathology, and histopathology.
- To differentiate between complicated and uncomplicated AA.
- To illustrate a new classification of acute appendicitis (CAA) with typical imaging examples and integrate it into a diagnostic and therapeutic algorithm.
Main Methods:
- Searched Medline, Embase, and Cochrane Library for studies post-1970 on AA.
- Included studies investigating clinical scores, pathology, US, CT, MRI, and treatment.
- Utilized author's image database for typical US and CT images.
Main Results:
- Defined five main types of AA: normal (type 0), nonvisualized (type X), uncomplicated (type 1), complicated without perforation (type 2), and complicated with perforation (type 3).
- Introduced a notation system for imaging modality (e.g., p3b for free perforation on pathology).
- Presented standardized reporting and algorithms for AA management, classifying imaging features of imminent perforation and likely recurrence as complicated AA.
Conclusions:
- Imaging is mandatory for suspected acute appendicitis (AA).
- The new classification of acute appendicitis (CAA) effectively distinguishes uncomplicated from complicated forms.
- CAA enables nonoperative management in selected patients with uncomplicated AA.
Purpose:
Acute appendicitis (AA) is amongst the most common causes of acute abdominal pain. In spite of progress based on risk stratifications, "negative" appendectomies are performed in up to 30% of patients whilst the appendix perforates in others. Preoperative classification of AA based on imaging is therefore recommended. The aim was to classify AA based on imaging (ultrasound/US, computed tomography/CT), surgical pathology, and/or histopathology in order to differentiate between complicated and uncomplicated AA. A new classification of acute appendicitis (CAA) shall be illustrated by typical US and CT images and be employed in a diagnostic and therapeutic algorithm.
Methods:
Medline, Embase, and the Cochrane Library were searched. Any study after 1970, which investigated clinical scores, pathology, US, CT, magnetic resonance imaging, and treatment of AA, was included. Typical images were taken from the author's image database.
Results:
Five main types of AA are defined, normal appendix (type 0), nonvisualised appendix (type X), uncomplicated AA (type 1), complicated AA without perforation (type 2), and complicated AA with perforation (type 3). The imaging modality is indicated by an additional letter, e.g., type p3b for free perforation on pathology. Standardised reporting of the appendix evaluation by US and CT is presented, as well as algorithms for AA management. Imaging features indicating imminent perforation, as well as likely recurrence, were both classified as complicated AA.
Conclusion:
Imaging is mandatory in suspected AA. The CAA clearly separates uncomplicated from complicated forms of AA allowing nonoperative management in selected patients with uncomplicated forms of AA.
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