HOW TO APPROACH THE PATIENT SUSPECTED OF HAVING ACUTE APPENDICITIS, INTRODUCING NEW CRITERIA: (TWO OUT OF THREE)

Background: Acute appendicitis is the most common cause of acute surgical abdomen. Inspite of the introduction of ultrasonography, computed tomography scanning and laparo-scopy in the years 1987-1997 the difficulty in accurate diagnosis of acute appendicitis has remained the same. Our way of reaching a decision for operating in a patient suspected of hav-ing acute appendicitis (which will follow) has superiority to other introduced so far approaches.
Methods: 3046 patients suspected of having acute appendicitis were evaluated during the years 2003-2005 at Shohada Medical Center. We have adopted a 3 point system, giving 1 point each to history, physical examination and laboratory tests if they meet the criteria:
1. Typical history gets 1 point if: an abdominal pain shift from epigastrium or periumbilical area to RLQ accompanying anorexia, nausea and vomiting depending on age.
2. Typical physical findings: RLQ tenderness associated with rebound tenderness,
3. Laboratory tests: leukocytosis between 10,500 to 18,000/mm3 along with normal urinaly-sis or leukocyturia without presence of bacteria. In pregnancy where leukocyteosis exists shift to the left is considered positive.
Each of the criteria gets zero or 1 point if it meets that mentioned above and those who get two or three points will be operated on, otherwise the patient will be observed for 12 hours until his symptoms improve or progress to have two or three point criteria when he or she will be operated on. The results of histopathological examination of appendix have been used for the accuracy of this method.
Results: Among 3046 patients, 1241 (41%) were operated on rightaway with diagnosis of acute appendicitis since they had 2 or 3 points on arrival. From these 1213 (97/1%) had acute appendicitis. 1805 (59%) patients who didn't get at least 2 points were observed for 12 hours, during this period 115 (6.4%) patients, who got at least two points were operated on, and 92 (80.5%) patients had non-perforated appendicitis; and the others were dis-charged since their symptoms improved. None of the patients, who were observed, devel-oped perforation of appendix or peritonitis. Sensitivity and specificity of this method was 100% and 97.1% with positive and negative predictive values of 93.3% and 95.5%. So this method is a safe way of approaching patients suspected of having acute appendicitis.
Conclusion: The 2 out of 3 points criteria for approaching the patients suspected of hav-ing acute appendicitis provide a nonexpensive, noninvasive, simple, rapid and accurate method for diagnosis of acute appendicitis.

Keywords
Acute appendicitis, Diagnostic criteria, Two out of three points (T.O.T).