Acute appendicitis (AA) remains a diagnostic challenge as indicated by the high rate of unnecessary surgery. Blood samples, primarily C-reactive protein (CRP) and leucocyte counts, are used as a diagnostic supplement despite their relatively low sensitivities and specificities. However, their influence on diagnostic decision-making has not previously been investigated. The aim of the present study was to investigate if the results of CRP and leucocytes had any positive or negative influence on the decision-making of surgeons handling patients with suspected AA.This was a prospective, observational cohort study including patients (≥ 15 years of age) admitted on suspicion of AA. The surgeons were instructed to perform their physical examination and to register whether they found the patient more or less than 50% likely to have AA. Thereafter, the surgeons had to assess the blood results and re-evaluate their diagnosis. The surgeon's diagnosis before and after was compared with the final diagnosis defined by surgical findings or follow-up. The gold standard was any degree of appendicitis on histology.A total of 226 patients were included of whom 91 (40.3%) had appendicitis on histology. The surgeons changed their diagnosis in nine cases after assessing blood samples. The changes in the proportion of correct diagnoses, sensitivity, specificity and predictive values after assessing blood samples were not significant.The results of CRP and leucocyte counts did not influence clinical decision-making.Financial support was obtained from the Danish Council for Independent Research (Ref. no. 12-132020).Clinicaltrials.gov: NCT02304653.
The use of 18F-Fluoro-D-deoxy-glucose -positron emission tomography/computed tomography (FDG-PET/CT) in gastrointestinal (GI)-malignancies may not be as straightforward as in many other cancers, but the potential is clearly there in select clinical settings. The challenges include the relative non-specificity of FDG, the variable degrees of physiologic FDG-uptake, and the heterogeneous FDG-uptake in different cell types within the GI-domain, which all together hamper the use in primary diagnostics. In general, the literature is older, heterogeneous, and based on stand-alone PET, which is now largely considered obsolete. There is emerging evidence for use of hybrid PET/CT, but the literature is still relatively sparse. The main indications are preoperative staging of distant metastases, not only in limited disease but also before curative treatment of limited metastatic disease. Controversies remain concerning liver metastases but improved technology boast well for the future role of FDG-PET/CT not least concerning equivocal findings on conventional imaging. In our opinion, an important upcoming indication is early response assessment, perhaps mostly in the neoadjuvant settings of upper GI-malignancies, but standardization of response assessment criteria is lacking before a more widespread implementation is feasible. Finally, there seems to be a significant role in recurrence detection, especially in CRC.
