ORIGINAL CONTRIBUTION

Diagnostic Value and Effect of Bedside

Ultrasound in Acute Appendicitis in the
Emergency Department
Faruk Gungor, MD, Taylan Kilic, MD, Kamil Can Akyol, MD, Gizem Ayaz, MD,
Umut Cengiz Cakir, MD, Mehmet Akcimen, MD, and Cenker Eken, MD

ABSTRACT
Objective: Early and accurate diagnosis of acute appendicitis (AA) with ultrasound (US) can minimize the
morbidity and mortality of the patients. In this regard, US can help emergency physicians (EPs) in the diagnosing
process and clinical decision making for AA. Therefore, we primarily aimed to evaluate the effectiveness of point-
of-care US (POCUS) in clinical decision making of EPs for the diagnostic evaluation for AA in the emergency
department (ED).

Methods: The study sample consisted of patients aged > 18 years who presented to the ED with abdominal
pain and underwent diagnostic evaluation for AA. All patients were examined initially with POCUS by EPs and
then with radiology-performed US (RADUS) by radiologists. Pre- and post-POCUS median diagnostic certainty
values (MDCVs) for AA were determined with visual analog scale (VAS) scores (0 = not present, 100 = certainly
present) by POCUS performers. Definitive diagnoses were determined by surgery, pathologic evaluation of
appendectomy specimens, or clinical follow-up results. The sensitivity, specificity, positive likelihood ratio (PLR),
and negative likelihood ratio (NLR) for POCUS and RADUS together with pre- and post-POCUS VAS scores for
MDCVs were compared.

Results: A total of 264 patients were included into the final analysis and 169 (64%) had a diagnosis of AA. The
sensitivity, specificity, PLR, and NLR of US examinations were 92.3% (95% confidence interval [CI] = 87.2%–
95.8%), 95.8% (89.5%–98.8%), 21.9 (8.4–57.2), and 0.08 (0.05–0.1) for POCUS and 76.9% (69.8–83%), 97.8%
(84.9–99.7%), 36.4 (9.25–144.3), and 0.24 (0.18–0.31) for RADUS, respectively. Pre-POCUS and post-POCUS
VAS scores for MDCVs were 60 (interquartile range [IQR] = 50–65) and 95 (IQR = 20–98), respectively (p = 0.000).

Conclusion: Point-of-care ultrasonography, when performed in ED for the diagnosis of AA, has high sensitivity
and specificity and had a positive impact on the clinical decision making of EPs.

A cute appendicitis (AA) results from inflammation

of the appendix and is among the most common
causes of acute abdominal pain that requires surgery.
AA has 7.0% prevalence, and its incidence peaks
between the ages of 10 and 30.1,2
Diagnosis of AA depends on patient history, physi-
cal examination findings, laboratory tests, and radio-
logic imaging studies. Although it is a common
condition, its diagnosis can be challenging due to atyp-
ical presentation and the limitations of physical exami-
nations and inconclusive diagnostic tests.3 However,
diagnostic imaging studies prior to surgery may
decrease complications such as appendiceal perforation
and negative appendectomy rates.4–6 For many clini-
cians, computed tomography (CT) is thought to be the
criterion standard method in the diagnosis of AA.

From the Department of Emergency Medicine, Antalya Training and Research Hospital (FG, TK, KCA, GA, UCC, MA), and the Department of
Emergency Medicine, Akdeniz University Medical Faculty (CE), Antalya, Turkey.
Received April 26, 2016; revision received January 28, 2017; accepted January 29, 2017.
The authors have no relevant financial information or potential conflicts to disclose.
Supervising Editor: Taylor Bowen.
Address for correspondence and reprints: Faruk Gungor, MD; e-mail: drfarukgungor@gmail.com.
ACADEMIC EMERGENCY MEDICINE 2017;24:578–586.

ISSN 1069-6563 © 2017 by the Society for Academic Emergency Medicine

578 PII ISSN 1069-6563583 doi: 10.1111/acem.13169
ACADEMIC EMERGENCY MEDICINE • May 2017, Vol. 24, No. 5 • www.aemj.org
Nevertheless, CT has sensitivity and specificity of 72
to 97 and 92% to 98%, respectively.7,8 However, CT
has the advantage of demonstrating alternative abdomi-
nal emergencies apart from AA, although it has some
disadvantages due to ionizing radiation exposure; this
is particularly important in young adults and children,
and it also necessitates a contrast agent. According to
current data, 0.7% to 2.0% of all cancer cases are
attributed to CT-related radiation exposure.9,10 There-
fore, physicians generally prefer to use laboratory tests
and ultrasound (US) for the initial evaluation of
patients with low pretest probability for AA. US is a
noninvasive and reproducible diagnostic tool that does
not require any contrast agent nor radiation exposure.
Nonetheless, it is an operator-dependent method. The
sensitivity and specificity of US for the diagnosis of
AA are reported as being between 75 to 90 and 86%
to 95%, respectively.8,11,12
Point-of-care ultrasonography (POCUS) can be
described as an assessment method of patient condi-
tion using real-time US images. It is usually performed
after obtaining the relevant data about the patient in
light of his or her medical history, physical examina-
tion findings, and the resulting prediagnoses. It also
has the advantage of being a noninvasive and repeat-
able bedside diagnostic tool, which is also faster than
CT. POCUS is now a common diagnostic tool used
in many areas of emergency medicine such as trauma,
eye and orthopedic emergencies, and abdominal pain.
There is also evidence that POCUS might be a useful
tool for the diagnosis of AA.2,13,14
This study aims to evaluate the diagnostic accuracy
of POCUS on the diagnosis of AA in the emergency
department (ED) and its role in the clinical decision
process of emergency physicians (EPs). The secondary
goal is to compare the accuracy of POCUS performed
by EPs to the radiology-performed US (RADUS) by
radiologists.
METHODS
Study Design and Setting
This prospective observational clinical study with a
convenient sampling was conducted between May
2014 and May 2015 in an ED of a tertiary care hos-
pital with an annual volume of 200,000 patients. The
local ethical committee approved the study and
written informed consent was obtained from the
participants.
579
Selection of Participants
The study sample consisted of patients over the age of
18 years who presented to the ED with abdominal
pain and underwent diagnostic evaluation for AA,
having met the inclusion criteria. Pregnancy, unstable
vital signs, and lack of informed consent were the
exclusion criteria for the study. The treating physicians
established the eligibility of the patients through
patient history and physical examination findings.
Study Procedure
Eight US-certified EPs who have routinely performed
bedside US in the ED conducted POCUS for AA.
More rigorous training was also obtained through a 1-
hour theoretical lecture and hands-on training in five
patients with AA and in another five patients without
AA. The theoretical course included visual instructions
on the utilization of the graded compression tech-
nique, anatomical landmarks to visualize appendix,
and sonographic signs for normal appendix and AA.
The instructions were given by a certified US per-
former. EPs performing POCUS all had at least
5 years of experience and undertook 600 bedside US
examinations on average per year. RADUS performers
were at least 1-year experienced radiology residents
who had completed standard educational protocol for
their radiology residency program and were perform-
ing approximately 40 US examinations per day. They
worked under the supervision of attending radiologists
whenever they needed to consult such a supervisor.
They were blinded to the study while performing daily
routine practice and did not take the same training
course as the POCUS performers did. All POCUS
and RADUS performers decided to the adequacy of
the ultrasonographic images by themselves.
US Technique
An US machine (ESAOTE, MYLAB CLASS-C US)
with a high-frequency linear probe (LA 533/3.0–13.0
MHz linear transducer) was used for the study. The
appendix may be present in various localizations.
Therefore, a POCUS imaging protocol was applied to
all study patients (Table 1). Additionally, the imaging
protocol can be initiated from the point of maximum
tenderness in patients who can localize pain well. The
POCUS imaging protocol is shown in Figure 1.
Methods of Measurement
The treating physician recorded demographic data,
clinical signs and symptoms, the duration of
580
symptoms, and the physical examination findings of
patients into the data collection form. Before any diag-
nostic test or US was applied, focused clinical ques-
tioning and physical examination for AA were
performed by the POCUS performers. Then, based
on the findings from clinical history and physical
examination, clinical probability for AA was assessed
with a visual analog scale (VAS; diagnostic certainty
Table 1
POCUS Imaging Protocol
Step 1: The US examination is initiated at the level of the
umbilicus, in transverse plane, using graded compression
technique.
Step 2: Linear probe is moved toward lateral abdominal wall until
the ascending colon is identified.
Step 3: Following the lateral edge of ascending colon, the probe is
moved inferiorly until the end of cecum.
Step 4: Transducer is moved medially until the iliac artery and vein,
which are located just medial to psoas muscle, are identified.
Step 5: While keeping the psoas muscle and iliac vessels within
the image plane, the pelvis and umbilicus are scanned.
Step 6: For sagittal scanning, the probe is given a sagittal position,
and the end of cecum is identified at the long axis. Scanning is
performed while compressing the cecum with probe against
psoas muscle.
POCUS = point-of-care ultrasonography; US = ultrasound.
Figure 1. POCUS examination protocol. POCUS = point of care
ultrasonography. [Color figure can be viewed at wileyonlinelibrary.-
com]
Figure 2. Ultrasonographic images of appendix. (A) Normal appendix; (B) AA with target sign, longitudinal view, and appendicolith,
respectively.
Gungor et al • BEDSIDE ULTRASOUND IN ACUTE APPENDICITIS
value graded on 100-mm scale, with 0 indicating not
present, 100 certainly present) by the POCUS per-
formers. Additionally, the physician’s clinical decision
regarding emergency operation, hospitalization for clin-
ical follow-up, or discharge from ED was determined
by the POCUS performers and recorded into the data
collection form. The same POCUS performers then
evaluated the patient with POCUS and noted sono-
graphic findings into the data collection form. Finally,
according to the POCUS findings, they assessed the
patient’s VAS score for the second time and again
made a clinical decision. After the study, POCUS per-
formers categorized patients into low (0–30 mm),
moderate (31–70 mm), and high (71–100 mm) clini-
cal probability groups.
When the appendix was sonographically visualized,
the compressibility of appendix, maximum appendiceal
diameter, and secondary inflammatory findings (periap-
pendicular fluid collection, free fluid between intesti-
nes, increased wall thickness of appendix [≥3 mm],
sonographic McBurney sign, hyperemia in color flow
Doppler, and appendicolitis) were recorded in the
study form. Normal appendiceal diameter was
accepted as ≤ 6 mm (Figure 2A). Diagnostic criteria
for AA were the presence of aperistaltic and noncom-
pressible tubular structure with a diameter above 6
mm located at the right lower quadrant (Figure 2B).
Absence of secondary inflammatory findings, normal
appendiceal diameter, or inability to visualize appendix
(nondiagnostic sonography) were considered as nega-
tive for AA. Clinical management of the patients was
determined by the treating physician and consulting
general surgeon. The final clinical decision was made
by the consulting general surgeon.
For all study patients, an US examination was per-
formed by senior resident radiologists who were avail-
able 24/7 (RADUS). All POCUS examinations were
performed prior to any diagnostic test, diagnostic
ACADEMIC EMERGENCY MEDICINE • May 2017, Vol. 24, No. 5 • www.aemj.org
imaging workup, or surgical consultation. The radiolo-
gists and surgery consultants were blinded to the find-
ings of POCUS. When RADUS findings were not
diagnostic, or diagnosis could not be made upon the
evaluation of the patient, an abdominal CT scan was
performed as a further radiological imaging study in
the ED.
A blinded study assistant reviewed the POCUS and
RADUS findings, abdominal CT results, intraopera-
tive findings, and pathology reports presented in the
medical files of patients and also reviewed the final
diagnosis. Additionally, patients who were discharged
from ED or general surgery department (patients hos-
pitalized for clinical follow-up) without undergoing any
surgical intervention were called by phone on the 7th
and 30th days after discharge. They were asked
whether they had applied to any other health center,
received any additional treatment, or undergone any
operation.
Definitive diagnosis of AA was made based on
intraoperative findings or pathology results, whereas
definitive diagnosis of “no appendicitis” was made
upon negative abdominal CT results, intraoperative
findings, and pathology reports or relief of the
patients’ symptoms during the follow-up period includ-
ing hospital stay or after discharge from hospital (ED
or general surgery department).
Outcome Measures
The primary outcome measures were the diagnostic
value of POCUS for AA in the ED and the effect of
POCUS on the clinical decisions of EPs in the man-
agement of the patients. The secondary outcome mea-
sure was the consistency between POCUS and
RADUS results for the diagnosis of AA.
Data Analysis
The data were analyzed by MedCalc and SPSS. The
numerical data are presented as mean  standard
deviation (SD) or median (interquartile range [IQR]),
and the frequency data, as rates where appropriate.
The comparison of the two dependent groups for
numeric variables was performed by sign test. In addi-
tion, the comparison of the two independent groups
was performed by chi-square test. Comparison of the
two dependent groups for categorical variables was per-
formed by McNemar test, and normality analysis was
performed by Kolmogorov-Smirnov test. The inter-
rater agreement between EPs and radiologists was
depicted by Cohen’s kappa value. Diagnostic validity
581
of POCUS and RADUS was also depicted using sen-
sitivity and specificity. All the hypotheses were con-
structed as two-tailed and an alpha critical value of
0.05 was accepted as statistically significant.
RESULTS
There were 280 eligible patients for the study. A
total of 264 patients were enrolled into the final
analysis; 16 patients were excluded due to loss to fol-
low-up (Figure 3). The mean  SD age of the 264
patients included in the study was 30  10 years,
and 113 (42.8%) of them were female. Demographic
and clinical data, as well as the ultrasonographic
findings of POCUS and RADUS, are shown in
Table 2.
Of all the study patients, 186 (71%) were hospital-
ized, whereas 78 (29%) were discharged from the ED.
A total of 179 patients underwent an operation and
AA was confirmed in 169 (64%) of them by patho-
logic evaluation. Laparotomy was negative in 10
patients, in which POCUS was negative in seven of
them, and nondiagnostic in the other three patients.
In these 169 patients, POCUS was positive in 156
patients and nondiagnostic in 13 patients, whereas
RADUS was positive in 130 patients, normal in two
patients, and nondiagnostic in 37 patients. The appen-
dix could be visualized in 218 patients (83%) with
POCUS and in 190 patients (72%) with RADUS.
Comparison of POCUS and RADUS results are
shown in Table 3. There were four false-positive and
13 false-negative results with the POCUS examina-
tions, while there were two false-positive and 39 false-
negative results in the RADUS examinations. Defini-
tive diagnoses of patients with false-positive results
were an ileitis, a mesenteric lymphadenitis, a pelvic
inflammatory disease, and an ileus case in the
POCUS group, whereas there was an ileitis and a
mesenteric lymphadenitis case in the RADUS group.
Point-of-care US had sensitivity and specificity of
92.3 and 95.8%, whereas RADUS had sensitivity and
specificity of 76.9 and 97.8%, respectively. The diag-
nostic values of POCUS and RADUS are shown in
Table 4. There was a moderate consistency between
POCUS and RADUS results (kappa value = 0.667,
95% confidence interval [CI] = 0.579–0.755). The
inconsistency between two groups mainly originated
from the patients assigned as AA with POCUS but
not with RADUS (nondiagnostic, n = 32). Those 32
patients were finally diagnosed as AA.
582
Figure 3. Patient flow chart. POCUS = point of care ultrasonography.
Pre-POCUS and post-POCUS median diagnostic
certainty values of EPs for AA, determined by VAS
scores, were 60 (IQR = 50–65) and 95 (IQR = 20–
98), respectively (p = 0.000). The EPs’ clinical opinion
according to VAS changed significantly that 253
(96%) patients initially in the moderate probability
group decreased to 12 (5%) cases, and patients in the
low- and high-probability groups increased from five
(2%) and six (2%) cases to 92 (35%) and 160 (61%)
cases, respectively. Clinical probability groups with
and without AA before and after POCUS are shown
in Table 5.
Prior to POCUS examination, the clinical decisions
of EPs were discharge for 69 patients (26%), hospital-
ization for clinical follow-up for 163 patients (62%),
and emergency surgery for 32 patients (12%). After
POCUS examination, these numbers were modified
to 79 (30%), 25 (9%), and 160 (61%), respectively
(p = 0.203, p = 0.000, p = 0.000). Clinical decision
Gungor et al • BEDSIDE ULTRASOUND IN ACUTE APPENDICITIS
groups for the diagnosis of AA before and after
POCUS examination are shown in Table 6.
DISCUSSION
This study shows that focused right lower quadrant
US performed by EPs is highly sensitive and specific
in the diagnosis of AA, and POCUS, with clinically
important EPs’ clinical decision making. Previous stud-
ies reported the sensitivity and the specificity of bed-
side US performed by EPs in the diagnosis of AA as
being between 39 to 96.4 and 67.3% to 98.4%,
respectively.2,13–19 In a study combining POCUS and
scoring systems, the sensitivity and specificity of
POCUS for the diagnosis of AA were 73.3 and
67.3%, respectively.17 Although this was a well-
designed study with a well-structured training program,
the POCUS performers were inexperienced physicians
in terms of using bedside US and sample size of the
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Table 2
Demographic, Clinical, and Sonographic Characteristics of Patients With and Without AA

Appendicitis, No Appendicitis,
Characteristics n = 169 (64%) n = 95 (36%) p-value
Demographics, clinical
Age (y) 30 (10) 31 (11) 0.260
Sex, male 112 (66) 39 (41) 0.000
Symptom duration (days) 1 (1–2) 1 (1–2) 0.570
Fever (≥37.3°C) 12 (7) 3 (3) 0.174
Nausea, vomiting 110 (65) 73 (77) 0.043
Rebound 134 (79) 33 (35) 0.000
RLQ tenderness 169 (100) 95 (100) 1
Migratory pain 86 (51) 15 (16) 0.000
Anorexia 104 (62) 52 (55) 0.267
WBC count (9103/mL) 13,900 (11,950–16,400) 9,000 (8,000–12,100) 0.000
WBCs, left shift 131 (78) 39 (41) 0.000
ANC (9103/mL) 10,200 (8,650–12,950) 5,800 (4,600–8,900) 0.000
POCUS findings
Periappendicular fluid collection 116 (69) 4 (4) 0.000
Wall thickness increase (≥3 mm) 145 (85) 4 (4) 0.000
Sonographic McBurney sign 146 (86) 14 (15) 0.000
Hyperemia with color flow Doppler 37 (22) 0 0.000
Free fluid between intestines 4 (2) 32 (34) 0.000
Appendicolitis 112 (66) 0 0.000
RADUS findings
Periappendicular fluid collection 92 (54) 1 (1) 0.000
Wall thickness increase (≥3 mm) 104 (62) 1 (1) 0.000
Sonographic McBurney sign 118 (70) 9 (10) 0.000
Hyperemia with color flow Doppler 19 (11) 0 0.000
Free fluid between intestines 19 (11) 31 (33) 0.000
Appendicolitis 69 (41) 0 0.000

Data are reported as mean (SD), number (%), or median (IQR).

ANC = absolute neutrophil count; IQR = interquartile range; POCUS = point-of-care ultrasonography; RADUS = radiology-performed
ultrasonography; RLQ = right lower quadrant; WBC = white blood cell.

Table 3 small. In another study by Chen et al.,13 although the

Comparison of POCUS Versus RADUS Results sensitivity of POCUS was found to be 96.4%, the
study was performed by resident EPs without a clear
RADUS
diagnostic definition of AA with US. Furthermore, the
Nonvisualized Total, POCUS examinations were performed after all the
POCUS Normal Positive (Nondiagnostic) n (%)
diagnostic workup results, and only the patients who
Appendicitis negative
Normal 46 0 12 58 (22) were discharged from hospital and then returned to
Positive 2 1 1 4 (2)
Nonvisualized 8 1 24 33 (12)
the study center were followed up for AA, raising
(nondiagnostic) questions regarding the study’s results. In a study per-
Appendicitis positive
Positive 1 123 32 156 (59) formed in a rural hospital with limited resources,
Nonvisualized 1 7 5 13 (5) Topin et al.19 found a sensitivity and specificity of 88
(nondiagnostic)
Total, n (%) 58 (22) 132 (50) 74 (28) 264 (100) and 96% for POCUS, respectively. POCUS perform-
ers of the study were highly experienced EPs with the
Note that the patients who were diagnosed as AA by POCUS
and had the definitive diagnosis of AA were determined nondiag-
use of goal-directed focused US examinations, but all
nostic for AA by RADUS (sixth column and sixth row). the study was conducted by the same EPs, and
POCUS = point-of-care ultrasonography; RADUS = radiology-
performed ultrasonography. POCUS examinations were performed after gathering
all the history and clinical examinations of the
patients, and laboratory results, raising the possibility
study was small. In another study, Fathi et al.18 found of bias. Moreover, all the definitive diagnoses were
a sensitivity and specificity of 44.18 and 85.18%, made by surgery reports due to the unavailability of
respectively. In this study, the POCUS performers histopathologic examination. In our study, sensitivity
were residents and attending EPs without a training and specificity of POCUS were higher in comparison
program, and sample size of the study was, again, to the former studies. The main reason for this may
584 Gungor et al • BEDSIDE ULTRASOUND IN ACUTE APPENDICITIS

be the heterogenicity in the previous studies in terms conducts 600 bedside US examinations on average
of methodology, experience levels and training status per year. Meanwhile, the technology of US devices has
of the POCUS performers, imaging protocols for the been advancing, resulting in better image quality, and
POCUS examinations, and sample size of the studies. new US protocols have been developed for each dis-
In our study, methodology was well defined with a ease process. Also, US has become an indispensable
good sample size, and each performer was instructed part of the EPs, like a stethoscope, while many educa-
with a standard and practical training course following tional institutions and ED associations now have
an imaging protocol prior to the study. Also, each mandatory POCUS training in their curricula.20
POCUS performer was an experienced clinician who Therefore, EPs have gained considerable experience in
its use. Moreover, although there are a few possible
differential diagnoses in a specific body area, clinicians
Table 4 are able to get closer to the most accurate diagnosis,
Diagnostic Values of POCUS and RADUS
due to the history and clinical examination findings of
POCUS (n = 264) RADUS (n = 264) the patient. This might cause some advantage and bias
Sensitivity 92.3% (87.2%–95.8%) 76.9% (69.8%–83%) in favor of EPs.
(95% CI) Sensitivity, specificity, and appendiceal visualization
Specificity 95.8% (89.5%–98.8%) 97.8% (84.9%–99.7%)
(95% CI) rate of RADUS for the diagnosis of AA have been
PLR (95% CI) 21.9 (8.4–57.2) 36.4 (9.25–144.3) reported to be 51.3 to 100, 60 to 100, and 22% to
NLR (95% CI) 0.08 (0.05–0.1) 0.24 (0.18–0.31)
98%, respectively.1,8,11,12,21–24 In our study, these rates
NLR = negative likelihood ratio; PLR = positive likelihood ratio; were found to be 76.9, 97.8, and 72%, respectively.
POCUS = point of care ultrasonography; RADUS = radiology-per-
formed ultrasonography. Accordingly, these results are compatible with the liter-
ature. However, the specificity, sensitivity, and normal
appendiceal visualization rate of RADUS performers
Table 5
were lower than those of the POCUS performers.
Clinical Probability Groups for the Diagnosis of AA Before and After This was mainly due to the inexperience of the
POCUS Examination
RADUS performers, who were senior residents. Also,
radiologists were blinded to the study design. If they
Appendicitis No Appendicitis Total
(n) (n) (n) had been informed about the study, they may have
Pre-POCUS spent more time and paid more attention to the
Low probability 1 4 5
Moderate 163 90 253
RADUS examinations and normal appendiceal visual-
probability ization. In our hospital, radiologists are extremely
High probability 5 1 6
Post-POCUS busy, with a rate of 40 US examinations per day. This
Low probability 3 89 92 may affect the examination time for a patient and
Moderate 10 2 12
probability could cause certain points to be overlooked, especially
High probability 156 4 160 given the busy and overcrowded environment. Addi-
AA = acute appendicitis; POCUS = point of care ultrasonography.
tionally, radiologists tended to evaluate patients for
only a few possible differential diagnoses without

Table 6
Clinical Decision Groups for the Diagnosis of AA Before and After POCUS Examination

Discharge Hospitalization for Clinical Emergency

from ED Follow-up Surgery
Pre-POCUS Post-POCUS Pre-POCUS Post-POCUS Pre-POCUS Post-POCUS
Appendicitis 50 74 41 16 4 5
negative
Appendicitis 19 5 122 9 28 155
positive
Total (n) 69 79 163 25 32 160

AA = acute appendicitis; POCUS = point-of-care ultrasonography.

ACADEMIC EMERGENCY MEDICINE • May 2017, Vol. 24, No. 5 • www.aemj.org
familiarity to the patients’ history and clinical examina-
tion findings, unlike the EPs, who were seeking the
most accurate possible diagnosis with POCUS. More-
over, the normal appendiceal visualization rate of the
radiologist may not represent the actual picture. This
is because they focus on the pathologic findings, not
paying attention to the visualization of normal anatom-
ical structures and often recommend in their reports
to interpret the ultrasonography results with the clini-
cal context of the patients. They also recommend to
go on with further imaging modalities whenever the
ultrasonography results are inconsistent with the clini-
cal context of the patients.
There was a moderate agreement between EPs and
radiologists. This was originated from the high num-
ber of nondiagnostic results (74 cases; 32 cases of
them were diagnosed as AA by POCUS) in the
RADUS group, and it was mainly due to the lack of
experience in the RADUS performers, who were
senior radiology residents and blinded to the study.
Also, there was a known benefit among the POCUS
performers, namely, their familiarity with the patients’
history and clinical examination findings.
In a study, Tzanakis et al.25 achieved high levels of
sensitivity, specificity, and accuracy (95.4, 97.4, and
96.5%, respectively) in the diagnosis of AA by using
scoring systems based on symptoms, clinical and labo-
ratory findings, and US results. In our study, we had
not planned to establish a scoring model. However,
POCUS increased the diagnostic certainty rate of the
EPs in predicting AA, from 60% to 95%, also suggest-
ing less need for a scoring model. The majority of pre-
POCUS cases were in the moderate probability group,
whereas almost all patients in this group fell into low-
and high-probability groups after POCUS. These
results indicate that clinical history and physical exami-
nation findings in combination with POCUS may
greatly enhance EPs’ diagnostic predictions.
There are limited data regarding the effect of
POCUS on EPs’ clinical decision making and patient
management in the ED. A clinical study involving
patients presenting to the ED with isolated right upper
quadrant pain showed that a focused US examination
performed after clinical history and physical examina-
tion helped physicians to make clearer decisions in the
clinical management of the patients.26 However, it did
not have any effect on the patients’ final outcomes,
such as additional treatment in the ED, discharge
from the ED, hospitalization, or emergency operation.
Similarly, in the patients presented to the ED with
585
abdominal pain, Bassler et al.27 found that the bed-
side abdominal US performed by experienced EPs did
not have a significant effect on the certainty of physi-
cians’ decisions regarding diagnosis, treatment, and
discharge. In another study involving patients who pre-
sented to the ED with acute pelvic pain, there was a
significant effect of the bedside transvaginal US on the
EPs’ preliminary diagnoses. However, it did not show
any statistically significant effect on the final outcomes,
such as discharge from the ED, hospitalization, or
emergency operation.28 In our study, bedside POCUS
performed for AA significantly contributed to the
determination of patients who required emergency
operation or who needed to be hospitalized for clinical
follow-up. Although the number of the patients in the
emergency surgery group was increased greatly after
POCUS, the number of the patients in the discharged
from the ED group did not change much. However,
the number of the patients with the diagnosis of AA
in the discharged from the ED group decreased from
19 cases (27.5%) to five cases (6.3%).
LIMITATIONS
Ultrasound is a user-dependent tool, which may affect
the external validation of the study. Since the POCUS
performers were not blind to the aim of the study,
and had known the patients as their clinicians, they
were in an advantageous position in the diagnostic
process in comparison to the radiologists. Conse-
quently, this may cause bias in favor of the EPs. A
more objective interpretation on the diagnostic compe-
tencies of the EPs and radiologists could be made if
both were blinded to the patients. However, the pre-
sent methodology is more pragmatic. Another issue is
that the radiologists in our study were residents, while
the EPs were experienced attending physicians. More-
over, the RADUS performers did not receive the same
standard training and imaging protocol as the EPs. If
the radiology group had consisted of attending radiolo-
gists, then the results might be different. Unfortu-
nately, the adequacy of the ultrasonographic images in
both groups was not controlled. All the performers
decided on the adequacy of the images by themselves.
CONCLUSION
Point-of-care ultrasonography performed in the ED
had high sensitivity and specificity for the diagnosis of
acute appendicitis and significantly altered the clinical
586
decisions of emergency physicians. These data support
the use of a standard training and imaging protocol,
for emergency physicians to use bedside ultrasound to
assist with the diagnosis and exclusion of acute appen-
dicitis in the ED setting.
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