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Not All Patients Need a CT When the Appendix Is Not Seen on Ultrasound: A Scoping Review.

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Ultrasound (US) has a high negative predictive value (NPV) in adults when the appendix is not seen, likely over 90%. This suggests CT scans may not always be necessary for suspected appendicitis, especially with low clinical suspicion.

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Area of Science:

  • Radiology
  • Gastroenterology
  • Emergency Medicine

Background:

  • North American guidelines recommend CT scans when ultrasound (US) results for appendicitis are negative.
  • The negative predictive value (NPV) of US when the appendix is not visualized in adult patients requires clarification.

Purpose of the Study:

  • To evaluate the negative predictive value (NPV) of ultrasound in adult patients when the appendix is not visualized.

Main Methods:

  • A scoping review of MEDLINE and EMBASE was conducted following PRISMA-ScR guidelines.
  • Included studies focused on adult patients with unvisualized appendix on US, prioritizing those without secondary signs of appendicitis.
  • Reference standards included clinical follow-up, CT, and/or pathology.

Main Results:

  • Six studies involving 12-179 patients were reviewed.
  • NPVs ranged from 80-90% for indeterminate ultrasounds and 83-95% when secondary signs were excluded.
  • NPVs reached 96-100% in cases with low pre-test probability.

Conclusions:

  • Indeterminate ultrasounds for appendicitis in adults without secondary signs have an NPV of at least 90%.
  • When clinical suspicion is low, the NPV likely exceeds 95%.
  • The decision for a follow-up CT scan should be individualized based on clinical presentation.