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Zentralbl Chir 2017; 142(04): 395-403
DOI: 10.1055/s-0043-114414
Übersicht
Georg Thieme Verlag KG Stuttgart · New York

Stellenwert der chirurgischen Sonografie in der Diagnostik der akuten Appendizitis: Literaturübersicht und ein praxisnaher Diagnosealgorithmus

The Relevance of Surgeon-performed Ultrasound For the Detection of Acute Appendicitis: a Review of the Literature and a Practical Diagnostic Algorithm
Christian Rainer Beltzer
1   Allgemein-, Viszeral- und Thoraxchirurgie, Bundeswehrkrankenhaus Ulm
,
Christoph Zischek
1   Allgemein-, Viszeral- und Thoraxchirurgie, Bundeswehrkrankenhaus Ulm
,
Roland Schmidt
1   Allgemein-, Viszeral- und Thoraxchirurgie, Bundeswehrkrankenhaus Ulm
,
Benedikt Friemert
2   Unfallchirurgie und Orthopädie, Rekonstruktive und Septische Chirurgie, Sporttraumatologie, Bundeswehrkrankenhaus Ulm
,
Gerhard Achatz
2   Unfallchirurgie und Orthopädie, Rekonstruktive und Septische Chirurgie, Sporttraumatologie, Bundeswehrkrankenhaus Ulm
,
Hans-Georg Palm
2   Unfallchirurgie und Orthopädie, Rekonstruktive und Septische Chirurgie, Sporttraumatologie, Bundeswehrkrankenhaus Ulm
› Author Affiliations
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Publication History

Publication Date:
24 August 2017 (online)

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Zusammenfassung

Hintergrund Der Stellenwert der Sonografie (Ultraschall, US) bei der Diagnostik der akuten Appendizitis ist umstritten. Unklar ist, welche Wertigkeit der US im Vergleich zu anderen bildgebenden Verfahren wie der Computertomografie (CT) und der Magnetresonanztomografie (MRT) besitzt, aber auch, ob zwischen chirurgisch durchgeführter Sonografie („surgeon-performed ultrasound“, SPUS) und der radiologischen Sonografie („radiologist-performed ultrasound“, RPUS) Unterschiede bestehen. Ziel unserer Studie ist es, anhand einer aktuellen Literaturrecherche einen US-gestützten Algorithmus aufzuzeigen, mit dessen Hilfe die Entscheidung zu weiterer Diagnostik oder Operation vereinfacht werden kann.

Material und Methoden Es wurde eine Literaturrecherche in MEDLINE (PubMed®) der Jahre 2010 bis 2016 durchgeführt. Insgesamt wurden 53 relevante Volltextartikel ausgewertet.

Ergebnisse Der US wird vielfach als integraler Bestandteil im diagnostischen Algorithmus der akuten Appendizitis eingesetzt. SPUS und RPUS unterscheiden sich in Bezug auf Sensitivität, Spezifität, positiv und negativ prädiktivem Wert (PPV, NPV) nicht statistisch signifikant. Der SPUS bietet gegenüber dem RPUS den Vorteil der simultanen klinischen Einschätzung des Patienten durch den Chirurgen während der sonografischen Untersuchung („Sonopalpation“), wodurch die diagnostische Treffsicherheit nochmals erhöht werden kann. Die Strahlenexposition durch CT konnte aufgrund des vermehrt eingesetzten und gut verfügbaren US bereits deutlich reduziert werden.

Schlussfolgerung Der SPUS sollte als integraler Bestandteil eines strukturierten diagnostischen Algorithmus, wie beschrieben, bei allen Patienten mit Verdacht auf akute Appendizitis als erstes bildgebendes Verfahren zur Anwendung kommen. Nur bei nicht möglicher sonografischer Visualisierung der Appendix in Verbindung mit spezifischen klinischen und/oder laborchemischen Kriterien empfiehlt sich eine zusätzliche Diagnostik mittels CT oder MRT.

Abstract

Background The relevance of ultrasound (US) in diagnosing acute appendicitis is controversial. The validity of US in comparison with other imaging techniques, such as computed tomography (CT) and magnetic resonance imaging (MRI), is unclear, as is the difference between surgeon-performed ultrasound (SPUS) and radiologist-performed ultrasound (RPUS). On the basis of a review of current literature, our study aimed to develop a US-based algorithm to simplify the choice between additional diagnostic measures and surgery.

Methods MEDLINE (PubMed®) was searched for literature published between 2010 and 2016. A total of 53 relevant full-text articles were eventually evaluated.

Results Ultrasound (US) is an established part of algorithms used to diagnose acute appendicitis and has already replaced CT as the imaging technique of choice. The differences between SPUS and RPUS with regard to sensitivity, specificity, and positive and negative predictive values (PPV, NPV) are not statistically significant. The benefit of SPUS over RPUS is the simultaneous clinical assessment of the patient by the surgeon while the sonogram is performed (sonopalpation), which can increase diagnostic accuracy even further. Radiation exposure as a result of CT could be avoided or significantly reduced through the routine use of US, which is increasingly being used and is widely available.

Conclusions SPUS should be the first imaging technique used to diagnose patients with suspected appendicitis. Additional diagnosis using CT or MRI is only recommended if sonographic imaging of the appendix is impossible in combination with specific clinical and laboratory criteria. A structured diagnostic approach with obligatory use of (SP)US, as described in the diagnostic algorithm, should be used for detection of acute appendicitis.

Schlüsselwörter

akute Appendizitis - chirurgische Sonografie - diagnostischer Algorithmus - Alvarado-Score - diagnostische Genauigkeit

Key words

acute appendicitis - surgeon-performed ultrasound - diagnostic algorithm - Alvarado score - diagnostic accuracy
 

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