Impact of computed tomography of the abdomen on clinical outcomes in patients with acute right lower quadrant pain: a meta-analysis

• Published in: Canadian Journal of Surgery 2011-02, Vol.54 (1), p.43-53
• Main Authors: Krajewski, Susan, MD, MPH, Brown, Jacqueline, MD, Te Phang, P. rry, MD, Raval, Manoj, MD, MSc, Brown, Carl J., MD, MSc
• Format: Article
• Language: English
• Subjects: Abdominal pain; Abdominal Pain - diagnosis; Abdominal Pain - diagnostic imaging; Adult; Appendectomy - methods; Appendectomy - statistics & numerical data; Appendicitis; Appendicitis - diagnosis; Appendicitis - diagnostic imaging; Appendicitis - surgery; Care and treatment; Clinical outcomes; Diagnosis; Female; Follow-Up Studies; Humans; Male; Meta-analysis; Patient outcomes; Physical Examination - methods; Preoperative Care - methods; Studies; Surgery; Tomography; Tomography, X-Ray Computed - methods; Treatment Outcome; Unnecessary Procedures - statistics & numerical data
• ISSN: 0008-428X; 1488-2310
• DOI: 10.1503/cjs.023509

Background Clinical evaluation alone is still considered adequate by many clinicians who treat patients with appendicitis. The impact of computed tomography (CT) on clinical outcomes remains unclear, and there is no consensus regarding the appropriate use of CT in these patients. We sought to evaluate the impact of abdominal CT on the clinical outcomes of patients presenting with suspected appendicitis. Methods We conducted a systematic review of the literature to identify studies that examined clinical outcomes related to the use of abdominal CT in the diagnosis of acute appendicitis. Inclusion criteria were studies of adult patients with suspected appendicitis that evaluated the impact of abdominal CT on negative appendectomy rates, perforation rates or time to surgery. Two independent investigators reviewed all titles and abstracts and extracted data from 28 full-text articles. Statistical analysis was conducted using Review Manager 5.0.10 software. Results The negative appendectomy rate was 8.7% when using CT compared with 16.7% when using clinical evaluation alone ( p < 0.001). There was also a significantly lower negative appendectomy rate during the CT era compared with the pre-CT era (10.0% v. 21.5%, p < 0.001). Time to surgery was evaluated in 10 of the 28 studies, 5 of which demonstrated a significant increase in the time to surgery with the use of CT. Appendiceal perforation rates were unchanged by the use of CT (23.4% in the CT group v. 16.7% in the clinical evaluation group, p = 0.15). Similarly, the perforation rate during the CT era was not significantly different than that during the pre-CT era (20.0% v. 19.6%, p = 0.74). Conclusion This meta-analysis supports the hypothesis that the use of preoperative abdominal CT is associated with lower negative appendectomy rates. The use of CT in the absence of an expedited imaging protocol may delay surgery, but this delay is not associated with increased appendiceal perforation rates. Routine CT in all patients presenting with suspected appendicitis could reduce the rate of unnecessary surgery without increasing morbidity.