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. 2019 Jun 26;7(12):1393-1402.
doi: 10.12998/wjcc.v7.i12.1393.

Clinical differentiation of acute appendicitis and right colonic diverticulitis: A case-control study

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Clinical differentiation of acute appendicitis and right colonic diverticulitis: A case-control study

Yosuke Sasaki et al. World J Clin Cases. .

Abstract

Background: Acute right colonic diverticulitis (ARCD) is an important differential diagnosis of acute appendicitis (AA) in Asian countries because of the unusually high prevalence of right colonic diverticula. Due to qualitative improvement and the high penetration rate of computed tomography (CT) scanning in Japan, differentiation of ARCD and AA mainly depends on this modality. But cost, limited availability, and concern for radiation exposure make CT scanning problematic. Differential findings of ARCD from AA are based on several small studies that used univariate comparisons from Korea and Taiwan. Previous studies on clinical and laboratory differences between AA and ARCD are limited.

Aim: To determine clinical differences between AA and ARCD for differentiation of these two diagnoses by creating a logistic regression model.

Methods: We performed an exploratory single-center retrospective case-control study evaluating 369 Japanese patients (age ≥ 16 years), 236 (64.0%) with AA and 133 (36.0%) with ARCD, who were hospitalized between 2012 and 2016. Diagnoses were confirmed by CT images. We compared age, sex, onset-to-visit interval, epigastric/periumbilical pain, right lower quadrant (RLQ) pain, nausea/vomiting, diarrhea, anorexia, medical history, body temperature, blood pressure, heart rate, RLQ tenderness, peritoneal signs, leukocyte count, and levels of serum creatinine, serum C-reactive protein (CRP), and serum alanine aminotrans-ferase. We subsequently performed logistic regression analysis for differentiating AA from ARCD based on the results of the univariate analyses.

Results: In the AA and ARCD groups, median ages were 35.5 and 41.0 years, respectively (p=0.011); median onset-to-visit intervals were 1 [interquartile range (IQR): 0-1] and 2 (IQR: 1-3) days, respectively (P < 0.001); median leukocyte counts were 12600 and 11500/mm3, respectively (P = 0.002); and median CRP levels were 1.1 (IQR: 0.2-4.1) and 4.9 (IQR: 2.9-8.5) mg/dL, respectively (P < 0.001). In the logistic regression model, odds ratios (ORs) were significantly high in nausea/vomiting (OR: 3.89, 95%CI: 2.04-7.42) and anorexia (OR: 2.13, 95%CI: 1.06-4.28). ORs were significantly lower with a longer onset-to-visit interval (OR: 0.84, 95%CI: 0.72-0.97), RLQ pain (OR: 0.28, 95%CI: 0.11-0.71), history of diverticulitis (OR: 0.034, 95%CI: 0.005-0.20), and CRP level > 3.0 mg/dL (OR: 0.25, 95%CI: 0.14-0.43). The regression model showed good calibration, discrimination, and optimism.

Conclusion: Clinical findings can differentiate AA and ARCD before imaging studies; nausea/vomiting and anorexia suggest AA, and longer onset-to-visit interval, RLQ pain, previous diverticulitis, and CRP level > 3.0 mg/dL suggest ARCD.

Keywords: Abdominal pain; Acute abdomen; Appendicitis; C-reactive protein; Clinical difference; Diverticulitis; Right lower quadrant pain.

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Conflict of interest statement

Conflict-of-interest statement: The authors have no conflicts of interest to declare.

Figures

Figure 1
Figure 1
Receiver operating characteristic curve of C-reactive protein for predicting acute right colonic diverticulitis. C-reactive protein (CRP) was categorized as low: ≤ 3.0 mg/dL or high: > 3.0 mg/dL because receiver operating characteristic analysis of CRP for predicting acute right colonic diverticulitis shows that a CRP level of 3.0 mg/dL has the best corrective classification as much as 71.0% (area under curve, 0.76; sensitivity, 75.2%; specificity, 68.6%). ROC: Receiver operating characteristic.
Figure 2
Figure 2
Forest plot of the logistic regression model for differentiating acute appendicitis from acute right colonic diverticulitis. aLonger onset-to-visit interval, right lower quadrant pain, history of diverticulitis, and high serum C-reactive protein level (>3.0 mg/dL) at the time of visit have significantly low odds ratios (ORs), which suggests that acute right colonic diverticulitis (ARCD) is more likely rather than acute appendicitis (AA) (left side of the figure). bNausea/vomiting and anorexia have significantly high ORs, which suggests that AA is more likely rather than ARCD (right side of the figure). AA: Acute appendicitis; ARCD: Acute right colonic diverticulitis; CRP: C-reactive protein; OR: Odds ratio; RLQ: Right lower quadrant.
Figure 3
Figure 3
Receiver operating characteristic curve of the logistic regression model for differentiating acute appendicitis from acute right colonic diverticulitis. Receiver operating characteristic curve of the regression model for differentiating acute appendicitis from acute right colonic diverticulitis shows good discrimination, with an area under the curve as high as 0.86, as shown above. ROC: Receiver operating characteristic.

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