20th July 1997

Your Health

Doctor’s CT scan dilemma

by Dr. Sanjiva Wijesinha

I remember once when, as young house officers at the Children’s Hospital, we were having difficulty making a diagnosis and puzzling over a patient who had been admitted with pain in the abdomen.

We sought the advice of the surgeon on duty that day - it happened to be Dr. Michael Abeyratne. He looked at the patient, felt the child’s tummy and said, "This is appendicitis - this child needs an operation."

He was right. When we asked him afterwards how he knew, he just smiled. That, as we realised, was experience.

I also remember the first time I was doing a weekend as a casualty officer in the OPD of a hospital in England. The consultant, Dr. Leonard Kiriella, said to me "There is an epidemic of diarrhoea and vomiting going around. Though the symptoms are quite severe they don’t need admission because the condition gets better in 24 hours with oral dehydration. But make sure you carefully examine them all because there will be at least one child having appendicitis among them."

There was.

These days high technology has finally caught on with the often tricky diagnosis of acute appendicitis. A spiral CAT scan, it seems, is the way to do it, with the patient being given a small amount of barium to drink before being scanned.

This test will, according to the research workers who have done it, tell you with almost perfect accuracy whether the patient in question has an inflamed appendix. The most significant conclusion of their study was that there were no false negatives - in other words, using this technique, no patient who had appendicitis failed to be diagnosed as appendicitis.

The research paper comes from the US, where surgeons are at great pains to ensure that they do not miss diagnoses such as appendicitis. The attitude there seems to be that it is better to do a whole lot of expensive tests in order to NOT miss a diagnosis, no matter how small the chances of such a diagnosis being present.

Anything that saves unnecessary surgery in the US is greeted with enthusiasm-since the cost of a single appendicectomy there is calculated to be equal to the cost of 20 such Spiral CT scans.

In England, the attitude is a trifle different. Since a modern CT system costs about a million US dollars, the cost-conscious Brits on the whole believe that CT scans should be reserved only for difficult cases.

Could the day not be far off before everybody in the States who is suspected of having an inflamed appendicitis is subjected to a Spiral CT scan before a decision is made to undertake surgery?

Perhaps the issues that will ultimately decide the future of this particular test will be the risks surgeons in that country undergo - the risk of getting sued for missing the diagnosis as well as the risk of being sued for performing an unnecessary operation.

The spectre of medical litigation has certainly altered attitudes in countries like the USA.

And when they think of how often people are suspected of having appendicitis, the lawyers there must be smiling almost as much as the CT salesmen.

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