Work

Faecaliths do not predict severity of acute appendicitis

Year: 2022

Type: article

Abstract: Dear Editor Faecaliths have long been recognized to play a role in the pathophysiology of acute appendicitis1, but their impact on the natural history of appendicitis remains uncertain. Some studies have linked faecalith with worse clinical outcomes and a higher risk of perforation2. Khan and co-workers3,4 noted that a faecalith was twice as likely to be present in complicated appendicitis, and that larger or multiple appendicoliths were associated with acute appendicitis. However, Ramdass and colleagues5 found no significant correlation between gangrenous or perforated appendicitis and the presence of a faecalith. The authors hypothesized that a faecalith seen on CT was not associated with the severity of acute appendicitis. Images from abdominal CT scans performed for any reason in the emergency department of Hackensack University Medical Center, New Jersey, USA, from December 2020 to May 2021 were reviewed. Patients with a known history of appendicectomy were excluded. CT reports were screened for the diagnosis of faecalith or acute appendicitis. Flagged images were reviewed independently by a radiologist who was blinded to other clinical findings. Patient demographic and clinical characteristics were collected from the electronic medical record. CT images were considered positive if they demonstrated acute appendicitis or the presence of appendiceal faecalith(s). Perforation was determined from the operative or CT reports. Pathology reports were used to confirm the diagnosis of acute appendicitis. Two-sample Student’s t test was used to compare continuous variables between groups. Multiple logistic regression models were employed to control for other potential confounding factors. Statistical analysis was undertaken in SAS® version 9.4 for Windows® (SAS Institute, Cary, NC, USA). A total of 2689 abdominal/pelvic CT scans were performed during the study interval, of which 115 (4.3 per cent) showed evidence of acute appendicitis, and 50 (43.5 per cent) showed faecalith. Fifteen of the 2572 patients without acute appendicitis had findings of faecalith (Fig. 1a). Fifty patients had acute appendicitis and faecalith, and in nine (18 per cent) the appendix was perforated. Sixty-five patients had acute appendicitis without faecalith, and 10 (15 per cent) had a perforated appendix (Fig. 1b). Of the 106 patients who underwent appendicectomy, 51 had a finding of faecalith on CT, of whom 12 (24 per cent) had perforated appendicitis. The remaining 55 who underwent appendicectomy had no faecalith on CT, of whom six (18 per cent) had perforated appendicitis. Ten patients who had findings of appendicitis on CT were managed non-operatively. One of these ten patients was found to have a faecalith on CT, and none of the images were read as showing perforated appendices. Findings of appendicitis and faecalith on CT performed for any reason in the emergency department a All CT images screened and b positive for appendicitis on CT. *Some 117 CT images were screened as positive, but only 115 were read as positive for appendicitis by the study radiologist. The faecalith size on CT was larger in patients with than in those without appendicitis (median 6.6 (i.q.r. 4.7–8.1) and 4.5 (3.5–5.0 mm) respectively; P = 0.022). Among those with appendicitis, the median size was not statistically significantly different between the perforated and non-perforated groups (8.0 (7.1–8.5) versus 6.2 (4.6–7.5) mm; P = 0.062). The five largest measured faecaliths were in patients with non-perforated appendicitis. Nearly half of the patients with acute appendicitis had a faecalith on CT, compared with less than 1 per cent of those without acute appendicitis, supporting the association between faecalith and acute appendicitis. However, the majority (82 per cent) of the patients with acute appendicitis and faecalith on CT did not have a perforated appendix at the time of appendicectomy. The frequency of perforation was similar in patients with acute appendicitis with or without a CT finding of faecalith (18 versus 15 per cent), and faecalith size was not associated with the risk of perforation. In summary, the authors feel that the management of appendicitis should be based on clinical presentation, and the presence or absence of faecalith should not significantly influence clinicians’ decision-making in considering the risk of perforation. Disclosure. The authors declare no conflict of interest.

Source: British journal of surgery

DOI: 10.1093/bjs/znac118