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1
Vagholkar, Ketan. "Stump appendicitis." International Surgery Journal 7, no. 7 (June 25, 2020): 2461. http://dx.doi.org/10.18203/2349-2902.isj20202872.
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Appendectomy is one of the commonest abdominal operation performed all over the world. Stump appendicitis is one of the uncommon complications of appendectomy. The diagnosis of stump appendicitis is delayed due to low index of suspicion by virtue of the fact that an appendectomy has already been done. The clinical presentation exactly simulates acute appendicitis. Contrast enhanced computed tomography is diagnostic. Completion appendectomy either open or laparoscopic is the mainstay of treatment. Awareness regarding the possible aetiology, diagnosis and management is essential for avoiding delay in the diagnosis.
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Santos, David A., Jesse Manunga, Donald Hohman, Elisa Avik, and Edward W. Taylor. "How Often does Computed Tomography Change the Management of Acute Appendicitis?" American Surgeon 75, no. 10 (October 2009): 918–21. http://dx.doi.org/10.1177/000313480907501011.
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Computed tomography (CT) diagnoses appendicitis accurately, but few studies evaluate how often CT changes the management of appendicitis. Consultations for appendicitis were evaluated by surgeons and assigned to groups: high, indeterminate, and low suspicion. After assignment, CT was reviewed if completed or ordered if desired by the surgeon and changes in plans were noted. One hundred patients were evaluated for appendicitis, 70 received appendectomy. Our negative appendectomy rate was 4 of 70 (5.7%). In the high suspicion group, 63 patients had 23 CT scans performed and 2 CT scans were negative, avoiding unnecessary operation and changing management in 2 of 63 (3.2%). The intermediate suspicion group included 27 patients and 26 CT scans performed; 11 were positive resulting in nine positive appendectomies and changing management in 9 of 27 (33%). The low suspicion group had 7 CT scans performed; two were positive leading to two positive appendectomies and changing management in 2 of 10 (20%). CT promoted 10 of 100 patients to the interval appendectomy pathway with no failures in delayed operative management. CT rarely changes management in patients highly suspicious for appendicitis, but may have a role in selecting patients for interval appendectomy. CT frequently changes management if the clinical diagnosis is indeterminate.
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Park, Jong Seob, Jin Ho Jeong, Jong In Lee, Jong Hoon Lee, Jea Kun Park, and Hyoun Jong Moon. "Accuracies of Diagnostic Methods for Acute Appendicitis." American Surgeon 79, no. 1 (January 2013): 101–6. http://dx.doi.org/10.1177/000313481307900138.
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The objectives were to evaluate the effectiveness of ultrasonography, computed tomography, and physical examination for diagnosing acute appendicitis with analyzing their accuracies and negative appendectomy rates in a clinical rather than research setting. A total of 2763 subjects were enrolled. Sensitivity, specificity, positive predictive value, and negative predictive value and negative appendectomy rate for ultrasonography, computed tomography, and physical examination were calculated. Confirmed positive acute appendicitis was defined based on pathologic findings, and confirmed negative acute appendicitis was defined by pathologic findings as well as on clinical follow-up. Sensitivity, specificity, positive predictive value, and negative predictive value for ultrasonography were 99.1, 91.7, 96.5, and 97.7 per cent, respectively; for computed tomography, 96.4, 95.4, 95.6, and 96.3 per cent, respectively; and for physical examination, 99.0, 76.1, 88.1, and 97.6 per cent, respectively. The negative appendectomy rate was 5.8 per cent (5.2% in the ultrasonography group, 4.3% in the computed tomography group, and 12.2% in the physical examination group). Ultrasonography/computed tomography should be performed routinely for diagnosis of acute appendicitis. However, in view of its advantages, ultrasonography should be performed first. Also, if the result of a physical examination is negative, imaging studies after physical examination can be unnecessary.
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Dearing, Daniel D., Jamesa Recabaren, and Magdi Alexander. "Can Computed Tomography Scan be Performed Effectively in the Diagnosis of Acute Appendicitis without the Added Morbidity of Rectal Contrast?" American Surgeon 74, no. 10 (October 2008): 917–20. http://dx.doi.org/10.1177/000313480807401007.
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The highest degrees of accuracy have been demonstrated for CT scans using rectal contrast in diagnosing appendicitis. However, the administration of rectal contrast is associated with patient discomfort and rarely, rectosigmoid perforation (0.04%). Additionally, the commonly accepted negative appendectomy rate is around 16 per cent. We performed a retrospective review of radiology, operative, and pathology reports of consecutive patients undergoing appendectomy or CT examination for appendicitis during 2006. CT scans were performed without rectal contrast. The accuracy of each type of inpatient CT examination and negative appendectomy rates were determined. Two hundred and thirty-eight patients underwent appendectomy. One hundred and thirty-four appendectomy patients (56%) received a preoperative CT scan. The negative appendectomy rates were 6.3 per cent overall, 8.7 per cent without CT examination and 4.5 per cent with CT (P = 0.3). Two hundred and forty-five inpatient CT scans were performed for suspected appendicitis with a sensitivity of 90 per cent, specificity of 98 per cent, accuracy of 94 per cent, positive predictive value of 98 per cent, and negative predictive value of 91 per cent. CT scanning without rectal contrast is effective for the diagnosis of acute appendicitis making rectal contrast, with its attendant morbidity, unnecessary. The previously acceptable published negative appendectomy rate is higher than that found in current surgical practice likely due to preoperative CT scanning.
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Mcgory, Marcial, Davids Zingmond, Darshani Nanayakkara, Melinda A. Maggard, and Clifford Y. Ko. "Negative Appendectomy Rate: Influence of CT Scans." American Surgeon 71, no. 10 (October 2005): 803–8. http://dx.doi.org/10.1177/000313480507101001.
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Negative appendectomy rate varies significantly depending on patient age and sex. However, the impact of computed tomography (CT) scans on the diagnosis of appendicitis is unknown. The goal of this study was to examine the negative appendectomy rate using a statewide database and analyze the association of receipt of CT scan. Using the California Inpatient File, all patients undergoing appendectomy in 1999–2000 were identified (n = 75,452). Demographic and clinical data were analyzed, including procedure approach (open vs laparoscopic) and appendicitis type (negative, simple, abscess, peritonitis). Patients with CT scans performed were identified to compare the negative appendectomy rate. For the entire cohort, appendicitis type was 59 per cent simple, 10 per cent with abscess, 18.7 per cent with peritonitis, and 9.3 per cent negative. Males had a lower rate of negative appendicitis than females (6.0% vs 13.4%, P < 0.0001). The use of CT scans was associated with an overall lower negative appendectomy rate for females, especially in the <5 years and >45 years age categories. Use of CT scans in males does not appear to be efficacious, as the negative appendectomy rates were similar across all age categories. In conclusion, use of CT was associated with lower rate of negative appendectomy, depending on patient age and sex.
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Vu Huynh, D. O., Fariborz Lalezarzadeh, Shokry Lawandy, David T. Wong, and Victor C. Joe. "Abdominal Computed Tomography in the Evaluation of Acute and Perforated Appendicitis in the Community Setting." American Surgeon 73, no. 10 (October 2007): 1002–5. http://dx.doi.org/10.1177/000313480707301017.
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Several studies report sensitivity and specificity of abdominal computed tomography scans (CT) for the evaluation of acute appendicitis as high as 98 per cent. Despite increased utilization of CT, the rate of negative appendectomy has remained constant at 10 to 20 per cent. The objective of this study was to assess the effectiveness of CT in the evaluation of acute and perforated appendicitis in an academic community-based setting. A retrospective review of 550 patient charts with International Classification of Diseases-9 (ICD-9) codes for acute and perforated appendicitis from January 2002 to October 2005 was performed. Sensitivity of CT was 87 per cent with a positive predictive value of 92 per cent. Specificity was 42 per cent with a negative predictive value of 29 per cent. Negative appendectomy rates were similar with or without CT (11% vs 13%, respectively). Our data suggests that CT used liberally in everyday practice in a community-based setting to evaluate acute appendicitis may not have as strong of a diagnostic value as those used in protocol-driven research studies. Further prospective studies are needed to formulate criteria to better delineate the role of CT in the evaluation of acute appendicitis.
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Hall, Nigel, Abidur Rahman, Francesco Morini, Alessio Pini Prato, Florian Friedmacher, Antti Koivusalo, Ernest van Heurn, Agostino Pierro, and Augusto Zani. "European Paediatric Surgeons' Association Survey on the Management of Pediatric Appendicitis." European Journal of Pediatric Surgery 29, no. 01 (August 15, 2018): 053–61. http://dx.doi.org/10.1055/s-0038-1668139.
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Aim To define patterns in the management of pediatric appendicitis. Methods A total of 169 delegates from 42 (24 European) countries completed a validated survey administered at the EUPSA 2017 annual congress. Results In the work-up of children with suspected acute appendicitis, most surgeons rely on full blood count (92%), C-reactive protein (82%), and abdominal ultrasonography (76%), but rarely on computed tomography scans or magnetic resonance imaging. In suspected simple appendicitis, most surgeons (76%) do not perform appendectomy at night in clinically stable patients and start antibiotic preoperatively (64%), but only 15% offer antibiotic therapy alone (no appendectomy). In suspected perforated appendicitis, 96% start antibiotic preoperatively, and 92% perform an appendectomy. Presence of phlegmon/abscess is the main contraindication to immediate surgery. In case of appendix mass, most responders (75%) favor a conservative approach and perform interval appendectomy always (56%) or in selected cases (38%) between 2 and 6 months from the first episode (81%). Children with large intraperitoneal abscesses are managed by percutaneous drainage (59% responders) and by surgery (37% responders). Laparoscopy is the preferred surgical approach for both simple (89%) and perforated appendicitis (81%). Most surgeons send the appendix for histology (96%) and pus for microbiology, if present (78%). At the end of the operation, 58% irrigate the abdominal cavity only if contaminated using saline solution (93%). In selected cases, 52% leave a drain in situ. Conclusion Some aspects of appendicitis management lack consensus, particularly appendix mass and intraperitoneal abscess. Evidence-based guidelines should be developed, which may help standardize care and improve clinical outcomes.
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Karapolat, Banu. "Can RIPASA Scoring System Predict the Pathological Stage of Acute Appendicitis?" Emergency Medicine International 2019 (August 1, 2019): 1–5. http://dx.doi.org/10.1155/2019/8140839.
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Introduction. Being one of the scoring systems used in the diagnosis of acute appendicitis, the RIPASA score can be used easily with a high diagnostic accuracy. Objective. To evaluate the possible relationship between RIPASA scores and the histopathological examination results of appendectomy materials. Materials and Methods. This study retrospectively reviews 242 patients who were operated in our clinic between January 2016 and January 2018 with a prediagnosis of acute appendicitis, and the RIPASA scores calculated in the preoperative period were compared to the histopathological examination results of the appendectomy specimens. Results. The patients consisted of 124 (51.2%) females and 118 (48.8%) males. The ages of the patients ranged from 15 to 81 years. The patients were divided into 3 groups based on their RIPASA scores as low-score (4-7), intermediate-score (7.5-11.5), and high-score (12 and over) groups. There were 20 (52.6%) catarrhal-stage appendicitis cases and 17 (44.7%) normal appendixes in the low-score group; there were 70 (83.3%) catarrhal-stage appendicitis cases, 9 (10.7%) suppurative-stage appendicitis cases, 4 (4.8%) gangrenous-stage appendicitis cases, and 1 (1.2%) perforated appendicitis case in the intermediate-score group. In the high-score group, there were 53 (44.2%) suppurative-stage appendicitis cases, 51 (42.5%) gangrenous-stage appendicitis cases, 11 (9.2%) perforated appendicitis cases, and 5 (4.2%) catarrhal-stage appendicitis cases. A strong positive correlation was found between the RIPASA scores of the patients and the pathological stage of appendicitis (r=0.889; p<0.001). Conclusion. The RIPASA scoring system can make a correct and prompt diagnosis of acute appendicitis including its possible pathological stage without any need for a computed tomography.
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Khadilkar, Reina, Ashwini Anil Panditrao, and Ramteja Inturi. "A comparative study of laparoscopic appendectomy versus open appendectomy." International Surgery Journal 7, no. 1 (December 26, 2019): 138. http://dx.doi.org/10.18203/2349-2902.isj20195959.
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Background: Obstruction of appendiceal lumen resulting in acute appendicitis is diagnosed by clinical examination, supported by raised neutrophil count, computed tomography and/or ultrasonography.Appendectomy one of the most commonly done surgeries is the standard line of management for acute appendicitis. Trend is towards greater utilization of laparoscopic appendectomy despite lack of consensus on superiority of laparoscopic procedure, hence imperative to prove scientifically the effectiveness of the two methods. The aim of the present study was a comparative study of laparoscopic appendectomy versus open appendectomy.Methods: A prospective cohort study of 100 cases of acute appendicitis above 16 years of age with no co morbidities was carried out in Dr. D. Y. Patil Medical College, Hospital and Research Centre from July 2017 to September 2019.Results: Mean age was 28.82 years, 64 (64%) males and 36 (36%) females, pain in abdomen (100%) being most common complaint followed by fever (77%) with positive correlation with severity of appendicitis (Alvarado score) and with total leukocyte count. Mean duration of surgery and hospital stay in laparoscopic appendectomy was lesser than open and difference was statistically highly significant (p=0.000). No difference in pain score observed. Retrocaecal (58%) was the most common position, slightly higher rate of complications in open appendectomy, no conversion of laparoscopic to open. Subjective level of satisfaction score (0-10) in laparoscopic appendectomy was higher than in open and difference was statistically highly significant (p=0.000).Conclusions: Laparoscopic appendectomy had advantages like better cosmesis, shorter duration of procedure and hospital stay, fewer post-operative complications and early return to work with disadvantage of steep learning curve, while open appendectomy, does not require special instruments, and is performed under direct three-dimensional vision.
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P. B., Sudarshan, and Reshma S. "Mucocele of the appendix: a rare case report." International Surgery Journal 4, no. 2 (January 25, 2017): 789. http://dx.doi.org/10.18203/2349-2902.isj20170233.
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Appendiceal mucocele is a rare disease. Sometimes it is discovered accidentally and sometimes it resembles acute appendicitis. Correct diagnosis before surgery is important for the selection of adequate surgical treatment to avoid intraoperative and postoperative complications. Ultrasonography, and particularly computed tomography, should be used extensively for this purpose. If mucocele is treated incorrectly, pseudomyxoma peritonei may develop. We present a case of 22 year old man who was admitted to the emergency department with the signs of acute appendicitis. Emergency open appendectomy was performed. At the time of surgery, a cystic mass was found at the tip of the inflammed appendix. No free fluid was found in the peritoneal cavity. Diagnosis of Mucocele of appendix was suspected. Appendectomy was done and specimen sent for histopathological examination. No lymphadenopathy. Histopathologic diagnosis was subacute appendicitis, mucocele of appendix with simple mucous cyst. Patient is on regular follow-up.
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Shaymardanov, R. S., R. F. Gubaev, S. Z. Sharafiev, I. I. Nuriev, and K. D. Gafurov. "Case of atypical retroperitoneal suppurative complication of acute appendicitis." Kazan medical journal 98, no. 5 (October 15, 2017): 838–40. http://dx.doi.org/10.17750/kmj2017-838.
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The article presents a case of an occasional extraperitoneal suppurative complication of acute appendicitis due to atypical clinical manifestation and diagnostic complexity. A 56-year-old male was hospitalized to the urological emergency department of Emergency Hospital №2 in December, 2014, with low back pain suggestive of renal colic. Renal ultrasound revealed cavitary lesion with liquid content in right lumbar region. Pus was drawn off by tapping. Further on, the abcess was opened 6 times during 2 following years. X-ray computed tomography of abdomen showed that the apex of appendix was located in lumbar (Petit) hernia and communicated with purulent cavity. Planned appendectomy was performed on January, 10, 2017. Convalescence. Histological finding (11.01.2017) was simple appendicitis. The reported case is of clinical interest as a rare compication of acute appendicitis developed in appendix located in lumbar (Petit) hernia; X-ray computed tomography of the abdomen is the most informative instrumental method for the diagnosis of acute appendicitis and its complications.
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Pakula, Andrea M., Ruby Skinner, Amber Jones, Ray Chung, and Maureen Martin. "Role of Drains in Laparoscopic Appendectomy for Complicated Appendicitis at a Busy County Hospital." American Surgeon 80, no. 10 (October 2014): 1078–81. http://dx.doi.org/10.1177/000313481408001036.
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Laparoscopic appendectomy (LA) has become the treatment of choice for acute appendicitis with equal or better outcomes than traditional open appendectomy (OA). LA in patients with a gangrenous or perforated appendicitis carries increased rate of pelvic abscess formation when compared with OA. We hypothesized routine placement of pelvic drains in gangrenous or perforated appendicitis decreases pelvic abscess formation after LA. Three hundred thirty-one patients undergoing LA between January 2007 and June 2011 were reviewed. Patients with perforated or gangrenous appendicitis were included. Group I had a Jackson-Pratt (JP) drain(s) placed and Group II had no JP drain. Data included patient demographics, emergency department laboratory values and vital signs, and computed axial tomography scan findings, intra-abdominal or pelvic abscess postoperatively, interventional radiology drainage, and length of stay. Clinic follow-up notes were reviewed. One hundred forty-eight patients were identified. Forty-three patients had placement of JP drains (Group I) and 105 patients had no JP drain (Group II). Three patients (three of 43 [6%]) in Group I developed pelvic abscess and 21 of 105 (20%) patients in Group II developed pelvic abscesses requiring subsequent drainage. This was statistically significant. Patient demographics, temperature, and mean white blood count before surgery were similar. Presurgery computed tomography (CT) with appendicolith and CT with abscess were more prevalent in Group I. The use of JP drainage in patients with perforated or gangrenous appendicitis during LA has decreased rates of pelvic abscess. This was demonstrated despite the drain group having appendicolith or abscess on preoperative CT.
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Mishra, Braja Mohan, Pramit Ballav Panigrahi, Sandeep Mishra, and Abinasha Mohapatra. "Alvarado score and computerized tomography scan as impact indicator in intervening negative appendectomy rate." International Surgery Journal 7, no. 4 (March 26, 2020): 1223. http://dx.doi.org/10.18203/2349-2902.isj20201401.
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Background: The objective of this study is to study the impact of combined use of Alvarado score and computed tomography (CT) scan on negative appendectomy rate.Methods: This prospective observational study comprising of patients presenting with clinical features of appendicitis admitted to department of general surgery, VIMSAR, Burla from November 2017 to October 2019, where Alvarado score and ultrasonography (USG) findings are mismatching each other. Alvarado scores calculated and categorized in 2 groups as negative (score <4) and positive (score ≥4). These patients were also subjected to USG and categorized as negative (USG -ve) and positive (USG +ve). Those patients having discrepancy in both the findings were subjected to CT scan. On histopathological examination, inflamed appendix in 63 (97%) patients and non-inflamed in 2 (3%). Rest patients were either discharged (both -ve) or operated (both +ve). Results: Total 84 patients showed discrepancy between Alvarado score and USG findings and are subjected to CT scan abdomen and pelvis. CT scan was positive for appendicitis in 65 cases (where appendectomy done) and negative for appendicitis in 19 cases (where the diagnosis is different). patient. Thus, negative appendectomy (NAR) is 3% in this study.Conclusions: Alvarado score and ultrasonography could not be used as absolute tool in doubtful and equivocal cases, where combined use of CT scan with Alvarado score and USG has definitely has an edge by diagnosing the differentials and reducing NAR followed by reduction in cost and length of hospital stay.
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Kryzauskas, Marius, Donatas Danys, Tomas Poskus, Saulius Mikalauskas, Eligijus Poskus, Valdemaras Jotautas, Virgilijus Beisa, and Kestutis Strupas. "Is acute appendicitis still misdiagnosed?" Open Medicine 11, no. 1 (January 1, 2016): 231–36. http://dx.doi.org/10.1515/med-2016-0045.
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AbstractObjectiveThe optimal diagnostics and treatment of acute appendicitis continues to be a challenge. A false positive diagnosis of appendicitis may lead to an unnecessary operation, which has been appropriately termed negative appendectomy. The aim of our study was to identify the effectiveness of preoperative investigations in preventing negative appendectomy.MethodsA retrospective study was performed on adult patients who underwent operation for suspected acute appendicitis from 2008 to 2013 at Vilnius University Hospital Santariskiu Klinikos. Patients were divided into two groups: group A underwent an operation, where appendix was found to be normal (non-inflamed); group B underwent an appendectomy for inflamed appendix. Groups were compared for preoperative data, investigations, treatment results and pathology findings.Results554 patients were included in the study. Preoperative laboratory tests results of hemoglobin, hematocrit concentrations and white blood cell count were significantly higher in group B (p<0.001). Ultrasonography was performed for 78 % of patients in group A and 74 % in group B and did not provide any statistically significant results. Comparing Alvarado score results, there were more patients with Alvarado score less than 7 in group A than in group B. In our large series we could find only four independent risk factors, and they could only account for 24 % of cases.ConclusionsIn summary, acute appendicitis is still often misdiagnosed and the ratio of negative appendectomies remains rather high. Additional investigations such as observation and computed tomography should be used to prevent this.
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Okur, Selahattin Koray, Yavuz Savaş Koca, İhsan Yıldız, and İbrahim Barut. "Right Hydronephrosis as a Complication of Acute Appendicitis." Case Reports in Emergency Medicine 2016 (2016): 1–3. http://dx.doi.org/10.1155/2016/3231862.
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Introduction. Acute appendicitis is the most common cause of acute abdomen, but atypical appendicitis may lead to delayed diagnosis and related complications. In this report, we present a very rare case of acute appendicitis causing right hydronephrosis.Case Report. A 54-year-old male patient who had been receiving antibiotic therapy due to the diagnosis of urinary tract infection for the last one week but had no clinical improvement was admitted to the emergency service. Abdominal computed tomography (CT) showed right hydronephrosis and a pelvic abscess. After appendectomy and abscess drainage had been performed, hydronephrosis was completely recovered.Discussion. The use of appendicitis scoring systems, abdominal ultrasonography (USG), abdominal CT, and diagnostic laparoscopy can be useful for the diagnostic process in patients presenting with acute abdomen. In our patient, we considered that the surgical treatment was delayed since the symptoms of acute appendicitis were suppressed by the antibiotic therapy that was being administered due to the complaints including symptoms of urinary tract infections.Conclusion. Atypical appendicitis may cause a delay in the diagnosis of acute appendicitis and thus may lead to serious complications such as right hydronephrosis, prolonged hospital stay, increased morbidity and mortality, and increased antibiotic resistance.
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Bondi, Moshe, Rafael Miller, Andrew Zbar, Yenon Hazan, Zvi Appelman, Benjamin Caspi, and Eli Mavor. "Improving the Diagnostic Accuracy of Ultrasonography in Suspected Acute Appendicitis by the Combined Transabdominal and Transvaginal Approach." American Surgeon 78, no. 1 (January 2012): 98–103. http://dx.doi.org/10.1177/000313481207800144.
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Transabdominal ultrasound has a lower diagnostic yield in acute appendicitis than computed tomography (CT) scanning. The addition of transvaginal sonography in women with suspected appendicitis has shown improvement in the efficacy of diagnosis, potentially providing the option of selective CT use and reducing overall investigative cost and surgical delay. Two hundred ninety-two women who underwent combined transabdominal and transvaginal ultrasound for suspected acute appendicitis were evaluated. Patients were divided into two groups; Group 1 including patients with a positive sonographic diagnosis of appendicitis who underwent operation and Group 2 including patients with a negative sonographic diagnosis. Of the 157 women in Group 1, the diagnosis of appendicitis was histologically confirmed in 144 patients with five cases having a normal appendix in whom eight other pathologies were found. Of the 135 women with negative ultrasound examinations, 14 underwent surgery in which four cases of appendicitis were found. The sensitivity of the combined approach was 97.3 per cent, the specificity 91 per cent, the positive predictive value 91.7 per cent, and the negative predictive value 97 per cent. Combined ultrasound has a high predictive value for the diagnosis of appendicitis and may assist in reduction of the use of CT scanning for diagnosis and in the negative appendectomy rate.
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Huang, Hsin-Ju, and Ming-Jen Tsai. "Pictorial quiz: A 2-year-old boy with abdominal pain." Hong Kong Journal of Emergency Medicine 26, no. 5 (January 29, 2019): 314–16. http://dx.doi.org/10.1177/1024907919825677.
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A 2-year-old boy presented with abdominal pain and non-coffee-ground emesis for 1 day. He was afebrile and without decreased activity. Examination showed lower abdominal tenderness, but psoas and obturator signs were negative. Laboratory test showed mildly elevated C-reactive protein (1.321 mg/dL) without leukocytosis. An abdominal X-ray revealed a high-attenuation-calcified lesion near the right sacroiliac joint which was highly suspected as an appendicolith. Subsequent abdominal computed tomography proved an appendicitis with appendicolith inside. He underwent laparoscopic appendectomy and was discharged uneventfully 4 days later. Acute appendicitis is a commonly misdiagnosed pediatric emergency because of the atypical presentations. Appendicoliths are presented in more than half of pediatric appendicitis and are highly associated with perforation. Surgery is recommended instead of antibiotics therapy alone to manage appendicolith-related appendicitis. A careful interpretation of the plain abdominal films and keeping a high suspicion are vital to early diagnosis of this disease.
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Bayhan, Zulfu, Sezgin Zeren, Ertugrul Kargi, Faik Yaylak, Mehmet Korkmaz, Bekir Sanal, Bercis Imge Ucar, Aysenur Deger, and Cengiz Kocak. "Does Neutrophil to Lymphocyte Ratio Predict Hospital Stay in Appendectomy Patients?" International Surgery 101, no. 5-6 (May 1, 2016): 222–26. http://dx.doi.org/10.9738/intsurg-d-15-00249.1.
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We aimed to investigate the relationship between neutrophil to lymphocyte ratio (NLR) and the postoperative length of hospital stay. In addition, the impact of radiologic and histopathologic findings on hospital stay was also evaluated. This was a retrospective study; 103 patients with appendicitis were included. Diagnosis was confirmed with computerized tomography (CT) scans, ultrasonography, and histopathologic examination. Correlations between the length of hospital stay and age; sex; NLR; c-reactive peptide (CRP) levels; appendix diameter on CT scan or ultrasonography; appendix localization; and pathology reports were evaluated. The length of hospital stay was not related to age or sex. The length of hospital stay after appendectomy was correlated with appendix diameter on CT scan and phlegmonous appendicitis, but it was not associated with NLR, CRP levels, or appendix diameter on ultrasonography. This is a pioneer study, given there is no comprehensive study to date evaluating the association between NLR levels and the length of hospital stay of patients with acute appendicitis. NLR is not associated with the length of hospital stay. Appendix diameter with CT scan and appendix pathology reports are correlated with the length of postoperative hospital stay in appendectomy patients.
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Burjonrappa, Sathyaprasad, and Dana Rachel. "Pediatric Appendectomy: Optimal Surgical Timing and Risk Assessment." American Surgeon 80, no. 5 (May 2014): 496–99. http://dx.doi.org/10.1177/000313481408000522.
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Appendicitis is one of the most common pediatric surgical problems. In the older surgical paradigm, appendectomy was considered to be an emergent procedure; however, with changes to resident work hours and other economic factors, the operation has evolved into an urgent and deliberately planned intervention. This paradigm shift in care has not necessarily seen universal buy-in by all stakeholders. Skeptics worry about the higher incidence of complications, particularly intra-abdominal abscess (IAA), associated with the delay to appendectomy with this strategy. Development of IAA after pediatric appendectomy greatly burdens the healthcare system, incapacitates patients, and limits family functionality. The risk factors that influence the development of IAA after appendectomy were evaluated in 220 children admitted to a large urban teaching hospital over a recent 1.5-year period. Preoperative risk factors included in the study were age, sex, weight, ethnicity, duration and nature of symptoms, white cell count, and ultrasound or computed tomography scan findings (appendicolith, peritoneal fluid, abscess, phlegmon), failed nonoperative management, antibiotics administered, and timing. Intraoperative factors included were timing of appendectomy, surgical and pathological findings of perforation, open or laparoscopic procedure, and use of staple or Endoloop to ligate the appendix. Postoperative factors included were duration and type of antibiotic therapy. There were 94 (43%) perforated and 126 (57%) nonperforated appendicitis during the study period. The incidence of postoperative IAA was 4.5 per cent (nine of 220). Children operated on after overnight antibiotics and resuscitation had a significantly lower risk of IAA as compared with children managed by other strategies ( P < 0.0003). Of the preoperative factors, only the presence of a fever in the emergency department ( P < 0.001) and identification of complicated appendicitis on imaging ( P < 0.0001) were significant risk factors for postoperative abscess development. Perforated appendicitis carries a higher risk of development of IAA that is not reduced by an emergent operative or delayed nonoperative management strategy. The timing of appendectomy appears to be an extremely important factor in reducing the incidence of IAA after all presentations of appendectomy. The role of resuscitation and antibiotics in limiting the effects of the inflammatory cascade and development of laboratory markers that accurately measure the latter need to be the focus of further research in this field.
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Mukherjee, Pratik, Daniel Wu Peng, and Ashish Chawla. "Watch What You Swallow!—A Rare Cause of Not So Rare Entity Presenting to the Emergency Room." Journal of Gastrointestinal and Abdominal Radiology 02, no. 01 (June 2019): 049–52. http://dx.doi.org/10.1055/s-0038-1676408.
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AbstractForeign-body ingestion is a rare cause for acute appendicitis. The authors report a case of a 48-year-old man who presented with abdominal pain for 3 days. Computed tomography (CT) revealed a foreign body in the appendix with peri-appendicular inflammatory changes. The patient underwent a successful appendectomy with complete recovery.
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Fujiwara, Kenji, Atsushi Abe, Toshihiro Masatsugu, Tatsuya Hirano, Kiyohisa Hiraka, and Masayuki Sada. "Usefulness of several factors and clinical scoring models in preoperative diagnosis of complicated appendicitis." PLOS ONE 16, no. 7 (July 27, 2021): e0255253. http://dx.doi.org/10.1371/journal.pone.0255253.
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Background The preoperative distinction between uncomplicated and complicated appendicitis is important to determine the appropriate treatments, such as antibiotics, surgery, or interval appendectomy. Computed tomography (CT) plays an important role; however, combining clinical and imaging factors may make preoperative evaluation more reliable. This study evaluated and analyzed cases and the usefulness of several preoperative factors and clinical scoring models to detect complicated appendicitis. Methods A total of 203 patients preoperatively diagnosed with acute appendicitis at our facility were included. Complicated appendicitis was defined as appendicitis with gangrene, perforated appendix, and/or abscess formation. Preoperative factors were collected from published clinical scoring models; patient information, symptoms, signs, results of laboratory tests, and findings of CT. Factors were analyzed using a chi-squared test and the Mann-Whitney U test. Results The preoperative factors were compared between 151 uncomplicated and 52 complicated appendicitis patients. The significant factors were age ≥40, duration of symptoms >24 hours, body temperature ≥37.3°C, high levels of CRP, findings in CT scan (appendix diameter ≥10 mm, stranding of the adjacent fat, presence of fluid collection, and suspicion of abscess or perforation). We also evaluated the usefulness of clinical scoring models for the detection of complicated appendicitis and found the Appendicitis Inflammatory Response score and two prediction models (Atema score and Imaoka score) showed significance (p < 0.05). High serum CRP level was significantly associated with complicated appendicitis (p < 0.001), and the predicted existence rates of complicated appendicitis were 52.7% for serum CRP level ≥50mg/L, 74.4% for ≥100mg/L, and 82.6% for ≥150mg/L. Conclusion The results demonstrated several preoperative factors and clinical scoring models to increase suspicion of complicated appendicitis. Specifically, high serum levels of CRP may be a useful factor in predicting complicated appendicitis prior to surgery when supported by clinical findings and imaging; however, further research is needed.
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Sieren, Leah M., Jay N. Collins, Leonard J. Weireter, Rebecca C. Britt, Scott F. Reed, Timothy J. Novosel, and L. D. Britt. "The Incidence of Benign and Malignant Neoplasia Presenting as Acute Appendicitis." American Surgeon 76, no. 8 (August 2010): 808–11. http://dx.doi.org/10.1177/000313481007600822.
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Acute appendicitis remains the most common surgical emergency encountered by the general surgeon. It is most often secondary to lymphoid hyperplasia, however it can also result from obstruction of the appendiceal lumen by a mass. We sought to review our experience with neoplasia presenting as appendicitis. We retrospectively reviewed all patients admitted with the diagnosis of appendicitis to our Acute Care Surgery Service from July 1, 2007 to June 30, 2009. Patient demographics, duration of symptoms, lab findings, computed tomography findings, and pathology were all analyzed. Over the 2-year period, 141 patients underwent urgent appendectomy Ten patients (7.1%) were diagnosed with neoplasia on final pathology, including four women and six men with a mean age of 46.9 years and mean duration of symptoms of 12.6 days. Final pathology revealed four colonic adenocarcinoma; three mucinous tumors; one carcinoid; one endometrioma; and one patient had a combination of a mucinous cystadenoma, a carcinoid tumor, and endometriosis of the appendix. Six patients had concurrent appendicitis. Colonic and appendiceal neoplasia are not unusual etiologies of appendicitis. These patients tend to present at an older age and with longer duration of symptoms.
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Verma, Richa, Vadim Grechushkin, Dorothy Carter, Matthew Barish, Aurora Pryor, and Dana Telem. "Use and Accuracy of Computed Tomography Scan in Diagnosing Perforated Appendicitis." American Surgeon 81, no. 4 (April 2015): 404–7. http://dx.doi.org/10.1177/000313481508100432.
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Perforated appendicitis has major implications on patient care. The ability of computed tomography (CT) scan to distinguish perforation in the absence of phlegmon or abscess is unknown. The purpose of this study is to assess the use and accuracy of CT scans in diagnosing perforated appendicitis without phlegmon or abscess. A retrospective chart review of 102 patients who underwent appendectomy from 2011 to 2013 was performed. Patient demographics and operative and postoperative course were recorded. Two radiologists were then blinded to operative findings and CTscans reread and results correlated. Findings on CTscan were also analyzed for correlation with perforation. Univariate and multivariate statistical analysis was performed. Of the 102 patients, 49 were perforated and 53 nonperforated. Analysis of patient populations demonstrated patients with perforation were significantly older (45 vs 34 years, P = 0.002), had longer operative times (132 vs 81 minutes, P = 0.001), and longer length of stay (8.2 vs 1.5 days, P < 0.001). Nineteen perforations (37%) were correctly diagnosed by CT scan. The sensitivity of CT scan to detect perforation was 38 per cent, specificity 96 per cent, and positive predictive value of 90 per cent. After multivariate analysis of significant variables, three were demonstrated to significantly correlate with presence of perforation: presence of extraluminal air (odds ratio [OR], 28.9; P = 0.02); presence of intraluminal fecalith (OR, 5.7; P = 0.03); and wall thickness greater than 3 mm (OR, 3.2; P = 0.02). CT scan has a low sensitivity for diagnosing perforated appendicitis without abscess or phlegmon. Presence of extraluminal air bubbles, increased wall thickness, and intra-luminal fecalith should increase suspicion for perforation and are highly correlated with outcomes after appendectomy.
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Urade, Masaaki, and Toshihumi Shinbo. "Barium Appendicitis 1 Month After a Barium Meal." International Surgery 97, no. 4 (January 1, 2013): 296–98. http://dx.doi.org/10.9738/cc160.1.
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Abstract Because barium sulfate (BaSO4) is not harmful to the mucosa, it is widely used for gastrointestinal imaging. Barium appendicitis is a very rare complication of barium meals and barium enema. We report a case of acute appendicitis associated with retained appendiceal barium. A 47-year-old man presented with right lower abdominal pain after upper gastrointestinal imaging was performed using barium 1 month earlier. The abdominal plain roentgenogram showed an area of retained barium in the right lower quadrant. Multiplanar reconstruction of computed tomography scans showed barium retention in the appendix. Emergency appendectomy was performed. A cross section of the specimen revealed the barium mass. Barium-associated appendicitis is a very rare clinical entity but we should be cautious of this uncommon disease when we encounter barium deposits in the appendix after barium examination. This report is significant because barium was identified both macroscopically and microscopically.
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Khilji, Muhammad Faisal, and Qazi Zia Ullah. "Seat Belt Compression Appendicitis following Motor Vehicle Collision." Case Reports in Emergency Medicine 2017 (2017): 1–3. http://dx.doi.org/10.1155/2017/8245046.
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Appendicitis and trauma both present in emergency department commonly but their presentation together in the same patient is unusual. We present a case of a middle-aged man brought by emergency medical services (EMS) to the emergency department with complaints of abdominal pain after he was involved in motor vehicle collision. He was perfectly fine before the accident. His primary survey was normal. Secondary survey revealed tenderness in right iliac fossa with seat belt mark overlying it. Computerized tomography (CT) of the abdomen and pelvis was performed which showed 8 mm thickening of appendix with minimal adjacent fat stranding. There is also subcutaneous fat stranding of anterior lower abdominal wall possibly due to bruising. Impression of posttraumatic seat belt compression appendicitis was made. Laparoscopic appendectomy was done and patient recovered uneventfully. Histopathology showed inflamed appendix, proving it to be a case of seat belt compression appendicitis.
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Hernandez.Bustos, Uraik F., Jonathan Salgado-Vives, Enrique Chavez-Serna, Dante A. Saldivar-Vera, Elí D. Hernández-Gómez, Pedro A. Alvarado-Bahena, and Pedro A. Espinosa de los Monteros-Moranchel. "Mucosa-associated lymphoid tissue lymphoma of the appendix stump: a case report." International Journal of Research in Medical Sciences 8, no. 11 (October 28, 2020): 4108. http://dx.doi.org/10.18203/2320-6012.ijrms20204447.
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Primary lymphomas of the appendix occur in 0.015% of all gastrointestinal lymphomas. The most common manifestation is acute appendicitis secondary to luminal obstruction. The most common is immunophenotype B low-grade non-Hodgkin lymphoma. A 53-year-old male, with a previous three-week surgical history due to acute appendicitis, histopathological report of acute appendicitis and lymphoid hyperplasia. Later, he was admitted, with abdominal pain in the right iliac fossa, an abdominal ultrasound and simple abdominal tomography were performed, with suspicion of residual abscess. Surgical intervention is decided, observing paracecal tumor in the emergency site of the appendix, the tumor is removed. Pathological study that reports an appendicular base infiltrated by mucosa-associated lymphoma. The diagnosis of appendicular tumors is mostly, intraoperatively incidental. It is necessary to have the diagnostic possibility when performing an appendectomy, since it changes the prognosis and treatment of the patient.
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Saigusa, Susumu, Masaki Ohi, Satoshi Oki, Takashi Ichikawa, Minako Kobayashi, Yasuhiro Inoue, and Chikao Miki. "Delayed Awareness of the History of Barium Examination: Perforated Barium Appendicitis." Case Reports in Gastrointestinal Medicine 2017 (2017): 1–4. http://dx.doi.org/10.1155/2017/6316175.
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A 41-year-old man presented to our hospital with lower abdominal pain and a high-grade fever. Physical examination revealed rebound tenderness and guarding in the lower abdomen. Abdominal X-ray examination showed a radiopaque object in the right lower quadrant of the abdomen. Abdominal computed tomography (CT) demonstrated that the object had a strong artifact with over 10,000 Hounsfield units, as well as ascites around the terminal ileum. We diagnosed acute peritonitis with a suspicion of the perforation due to unknown foreign body and performed an emergency laparotomy. Operative findings showed a contained perforation of a phlegmonous appendicitis, and appendectomy was performed. The resected specimen demonstrated that the appendix contained a fecalith, and histopathological examination showed the crystal structure of barium sulfate in the lumen of the appendix. Unfortunately, we did not obtain the history of screening for gastric cancer using a barium examination one month prior to our appendectomy. Our experience demonstrates the importance of establishing a history of barium examinations of the gastrointestinal tract in a patient with a radiopaque object in the right lower quadrant of the abdomen for early diagnosis of barium appendicitis. Additionally, early diagnosis of barium appendicitis may affect the selection of surgical procedures.
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Cheekuri, Sadhan Kumar, Alok Mohanty, T. Ganesh, R. Kannan, and Robinson Smile. "Hyperbilirubinemia as a predictor of the severity of acute appendicitis - an observational study." International Surgery Journal 4, no. 4 (March 25, 2017): 1341. http://dx.doi.org/10.18203/2349-2902.isj20171138.
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Background: Appendicitis is the most common acute abdominal condition requiring emergency surgery, with a lifetime risk of 6%. Appendectomy continues to be one of the commonest procedures in general surgery, accounts for approximately 1% of all surgical operation. Despite the increased use of ultrasonography, computed tomography scanning and laparoscopy, the rate of misdiagnosis of appendicitis has remained constant (15.3%). The aim of this study was to whether Serum Bilirubin can be considered as a new laboratory marker to aid in the diagnosis of acute appendicitis and if so, does it have the predictive capacity to warn us about complicated appendicitis.Methods: This was prospective observational study done in Mahatma Gandhi Medical College and Research Institute, Pondicherry between November 2014 and August 2016. About 110 patients of acute appendicitis who had undergone appendicectomy were studied. Data was collected and analyzed critically.Results: Males 66 (60%) outnumbered females 44 (40%) and overall mean age was 26.61±12.37 years. Of the 110 patients, 9% were normal appendix, 59.09% were confirmed as acute appendicitis while 31.81% were diagnosed with complicated appendicitis on biopsy. The Sensitivity and Specificity of serum bilirubin as a marker in predicting Acute appendicitis and complicated appendicitis was 47.6% and 90.9% respectively. Similarly, the Positive predicative value and Negative predicative value for the same was 88.5% and 61.5% respectively with odds ratio 12.4 with significant p value <0.0001.Conclusions: Serum bilirubin is easily available test and cheap and can be estimated from the sample of blood drawn for routine blood investigations. Patients with clinical signs and symptoms of appendicitis and with hyperbilirubinemia should be identified as having a higher probability of complicated appendicitis. Hence, serum bilirubin levels have a predictive potential for the diagnosis of severity of acute appendicitis and need for early appendicectomy. If total serum bilirubin is added to already existing laboratory tests, then the diagnosis of complicated appendicitis in clinically suspected cases can be made with fair degree of accuracy, the need for CECT and MRI can be reduced and unnecessary delay in appendicectomy can be avoided.
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Ladd, Mitchell R., Lucas P. Neff, Robert D. Becher, Jared R. Gallaher, and Thomas Pranikoff. "Computerized Tomography in the Workup of Pediatric Appendicitis: Why are Children Scanned?" American Surgeon 78, no. 6 (June 2012): 716–21. http://dx.doi.org/10.1177/000313481207800629.
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Physicians increasingly use computerized tomography (CT) for the evaluation of suspected acute appendicitis (AA) in children despite increasing awareness of the potential dangers of CT-associated radiation exposure. Many studies demonstrate the value of CT in the diagnosis of AA, but none have determined what factors influence the decision to perform a CT. We investigated factors associated with the use of CT during initial workup of children who subsequently underwent appendectomy. This is a retrospective review of all patients aged 0 to 17 years who underwent appendectomy for AA by pediatric surgeons over 11 years. Both univariate and multivariable logistic regression models were created to predict use of CT. A total of 546 children underwent appendectomy for AA, of which 293 (53%) underwent CT. In univariate analysis, seven variables were significantly associated with the use of CT: female gender, Hispanic ethnicity, initial presentation to referring hospitals, lower Alvarado scores, delays from onset of symptoms to hospital presentation, migration, and rebound tenderness. In multivariable analysis, four variables significantly independently predicted the use of CT: initial presentation to a referring hospital [odds ratio (OR) 3.50), female gender (OR 1.49), increased latency from symptom onset to presentation (OR 1.34), and the presence of rebound tenderness (OR 0.23), which had a protective effect; the overall model was statistically significant ( P < 0.0001). This model is the first to define variables that significantly predict CT utilization in the pediatric population. Continued investigation will be necessary to develop effective algorithms for judicious use of CT for suspected AA.
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Lee, Steven L., and Hung S. Ho. "Acute Appendicitis: Is There a Difference between Children and Adults?" American Surgeon 72, no. 5 (May 2006): 409–13. http://dx.doi.org/10.1177/000313480607200509.
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Historically, the lack of classic symptoms and delay in presentation make diagnosing acute appendicitis more difficult in children, resulting in a higher perforation rate. Despite this, the morbidity of acute appendicitis is usually lower in children. We evaluated the current differences in clinical presentation, diagnostic clues, and the outcomes of acute appendicitis between the two age groups. A retrospective review of 210 consecutive cases of pediatric appendectomy and 744 adult cases for suspected acute appendicitis from January 1995 to December 2000. Pediatric patients were defined as being 13 years and younger. Pediatric patients were similar to adult patients with respect to duration of pain before presentation (2.4 ± 4.3 days vs 2.5 ± 7.3 days), number of patients previously evaluated (22.0 vs 17.7%), number of imaging tests (computed tomography or ultrasound; 32.9 vs 40.2%), and number of patients observed (16.7 vs 17.2%). However, pediatric patients required less time for emergency room evaluation (4.0 ± 2.7 hours vs 5.7 ± 4.9 hours, P = 0.0001). In children and adults, a history of classic, migrating pain had the highest positive predictive value (94.2 vs 89.6%), followed by a white blood cell count ≥12 x 109/L (91.5 vs 84.3%). The overall negative appendectomy rate was 10.0 per cent for children and 19.0 per cent for adults (P = 0.003); the perforation rate was 19.0 per cent and 13.8 per cent, respectively (P > 0.05). The perforation rate in children was not associated with a delay in presentation (perforated cases, 2.9 ± 3.3 days compared with nonperforated cases, 2.3 ± 4.6 days). Mortality and morbidity, including wound infection rate and intra-abdominal abscess rate, were similar. Contrary to traditional teaching, diagnosing acute appendicitis in children is similar to that in adults. A history of migratory pain together with physical findings and leukocytosis remain accurate diagnostic clues for children and adults. Perforation rate and morbidity in children is similar to those in adults. The outcomes of acute appendicitis in children are not associated with a delay in presentation or delay in diagnosis.
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Qassim, Sarah, Ali Lairy, and Sami Asfar. "Foreign Body Ingestion Followed by Appendiceal Perforation." Case Reports in Surgery 2021 (March 29, 2021): 1–3. http://dx.doi.org/10.1155/2021/8877671.
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Background. Foreign body ingestion is very common among specific groups, especially children. However, appendicitis and perforated appendix caused by a foreign body is rare. Case summary. A 40-year-old female presented with abdominal pain in the right lower quadrant of 10 days duration after accidentally ingesting a drilling bit during a dental procedure. She had right iliac fossa tenderness on physical examination. X-ray showed a pointed long metal object in the right lower quadrant. A contrast-enhanced computed tomography scan of the abdomen revealed a pointed metal object in the pelvis with inconclusive location. Diagnostic laparoscopy showed an inflamed appendix with the tip of the metal object perforating it. Appendectomy was performed. Histopathology showed an inflamed appendix. Conclusion. Foreign bodies that cause appendicitis are rare. However, they may become lodged at any site of the gastrointestinal tract and cause inflammation or perforation. This is a bizarre case of foreign body-induced appendicitis with perforation.
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Cherry, Brandon H., Denish Patel, and Joseph E. Ronaghan. "A Case of Valentino's Syndrome Presenting as Possible Appendicitis." International Surgery 104, no. 11-12 (November 1, 2019): 540–41. http://dx.doi.org/10.9738/intsurg-d-17-00136.1.
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Introduction We present a case of a 24-year-old female who presented with the signs and symptoms of acute appendicitis. Case report When computed tomography and ultrasound were not definitive for the diagnosis, the decision was made to perform a laparoscopic appendectomy. The appendix showed no gross signs of inflammation, so intraoperative esophagogastroduodenoscopy was used to examine for a perforated peptic ulcer. When no perforations were found, exploratory laparotomy was performed and revealed purulent fluid in the right colic gutter and a pinhole perforation in the first part of the duodenum. The defect was repaired and the abdominal space was washed thoroughly and closed. The patient recovered well and was discharged from the hospital in good health. Conclusion Valentino's syndrome is an uncommon cause of right lower quadrant pain and symptoms mimicking acute appendicitis.
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Otsuka, Ryota, Koichi Shinoto, Yasushi Okazaki, Kota Sato, Atsushi Hirano, Tetsuro Isozaki, Tomohide Tamachi, Tomoya Hirai, Shohei Yonemoto, and Hisahiro Matsubara. "Crohn’s Disease Presenting as Granulomatous Appendicitis." Case Reports in Gastroenterology 13, no. 3 (September 25, 2019): 398–402. http://dx.doi.org/10.1159/000503170.
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Granulomatous appendicitis is uncommon. It can be caused by infectious or systemic disorders, such as Crohn’s disease (CD) and sarcoidosis. It is therefore essential to investigate systematic causes of granulomatous appendicitis after surgery by appropriate examinations. It is also rare for acute appendiceal inflammation to develop due to active CD. We herein report a case of CD presenting as granulomatous appendicitis. The patient was a 28-year-old man who arrived at the emergency room with right lower abdominal pain. Computed tomography showed a low-density lesion with a clear boundary and a small high-density spot in its center behind the cecum. Acute appendicitis with abscess formation was suspected and conservative treatment was started. After 3 consecutive days of conservative treatment there was no improvement in his condition. We therefore performed open appendectomy. Histopathological examination showed numerous noncaseous epithelioid granulomas in the wall of the appendix. Specific staining revealed no evidence of acid-fast bacilli or fungi. During follow-up after discharge, colonoscopy demonstrated erosion from the cecum to the transverse colon. A colon biopsy showed severe inflammation with cryptitis, Paneth cells, and a granulomatous lesion. The patient was therefore diagnosed with CD and treatment with mesalazine was started. Careful examination is necessary to diagnose and properly treat patients with granulomatous inflammation of the appendix.
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Neff, Lucas P., Mitchell R. Ladd, Robert D. Becher, Ryan A. Jordanhazy, Jared R. Gallaher, and Thomas Pranikoff. "Computerized Tomography Utilization in Children with Appendicitis—Differences in Referring and Children's Hospitals." American Surgeon 77, no. 8 (August 2011): 1061–65. http://dx.doi.org/10.1177/000313481107700828.
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Increasingly, physicians rely on computerized tomography (CT) to aid in the workup of acute appendicitis (AA) in children despite the potential negative effects of CT-associated radiation exposure. Few studies have investigated the context or location in which the decision to perform CT for AA is made. We sought to determine where the decision to use CT was made during the initial workup of pediatric patients who later underwent an appendectomy. We reviewed the medical record of all patients at a children's hospital (CH) receiving appendectomy over 10.5 years. We abstracted clinical variables using an established clinical AA scoring system, demographics and outcome variables. Patients who underwent CT were compared with those who did not. Additionally, we identified the location where the CT was performed. Our children's hospital was compared with referring hospitals (RHs) with regard to utilization of CT imaging. Five hundred and forty-six patients underwent appendectomy for AA at CH. Of these, 50 per cent underwent CT. Patients who initially presented at the RHs underwent CT at a significantly higher rate than those first presenting to CH ( P < 0.0001). Moreover, we found that unlike at the RHs, patients with a higher AA score underwent CT at CH less often ( P < 0.0002). RHs used CT more often than CH to diagnose AA in our cohort. CH avoided CT for patients with higher Alvarado scores. Further research is needed to elucidate factors that lead healthcare providers to use CT for children with suspected AA to eliminate unnecessary CT-associated radiation exposure.
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Kabir, Syed Mohammad Umar, Magda Bucholc, Carol-Ann Walker, Opeyemi O. Sogaolu, Saqib Zeeshan, and Michael Sugrue. "Quality Outcomes in Appendicitis Care: Identifying Opportunities to Improve Care." Life 10, no. 12 (December 18, 2020): 358. http://dx.doi.org/10.3390/life10120358.
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Introduction: Appendicitis is one of the most common causes of acute abdominal pain requiring surgical intervention, but the variability of diagnosis and management continue to challenge the surgeons. Aim: This study assessed patients undergoing appendectomy to identify opportunities to improve diagnostic accuracy and outcomes. Methods: An ethically approved retrospective cohort study was undertaken between March 2016 and March 2017 at a single university hospital of all consecutive adult and paediatric patients undergoing appendectomy. Demographic data including age, gender, co-morbidities, presentation and triage timings along with investigation, imaging and operative data were analysed. Appendicitis was defined as acute based on histology coupled with intraoperative grading with the American Association for the Surgery of Trauma (AAST) grades. Complications using the Clavien–Dindo classification along with 30-day re-admission rates and the negative appendectomy rates (NAR) were recorded and categorised greater and less than 25%. The use of scoring systems was assessed, and retrospective scoring performed to compare the Alvarado, Adult Appendicitis Score (AAS) and the Appendicitis Inflammatory Response (AIR) score. Results: A total of 201 patients were studied, 115 male and 86 females, of which 136/201 (67.6%) were adults and 65/201 (32.3%) paediatric. Of the adult group, 83 were male and 53 were female, and of the paediatric group, 32 were male and 33 were female. Median age was 20 years (range: 5 years to 81 years) and no patient below the age of 5 years had an appendectomy during our study period. All patients were admitted via the emergency department and median time from triage to surgical review was 2 h and 38 min, (range: 10 min to 26 h and 10 min). Median time from emergency department review to surgical review, 55 min (range: 5 min to 6 h and 43 min). Median time to operating theatre was 21 h from admission (range: 45 min to 140 h and 30 min). Out of the total patients, 173 (86.1%) underwent laparoscopic approach, 28 (13.9%) had an open approach and 12 (6.9%) of the 173 were converted to open. Acute appendicitis occurred in 166/201 (82.6%). There was no significant association between grade of appendicitis and surgeons’ categorical NAR rate (p = 0.07). Imaging was performed in 118/201 (58.7%); abdominal ultrasound (US) in 53 (26.4%), abdominal computed tomography (CT) in 59 (29.2%) and both US and CT in 6 (3%). The best cut-off point was 4 (sensitivity 84.3% and specificity of 65.7%) for AIR score, 9 (sensitivity of 74.7% and specificity of 68.6%) for AAS, and 7 (sensitivity of 77.7% and specificity of 71.4%) for the Alvarado score. Twenty-four (11.9%) were re-admitted, due to pain in 16 (58.3%), collections in 3 (25%), 1 (4.2%) wound abscess, 1 (4.2%) stump appendicitis, 1 (4.2%) small bowel obstruction and 1 (4.2%) fresh rectal bleeding. CT guided drainage was performed in 2 (8.3%). One patient had release of wound collection under general anaesthetic whereas another patient had laparoscopic drain placement. A laparotomy was undertaken in 3 (12.5%) patients with division of adhesions in 1, the appendicular stump removed in 1 and 1 had multiple collections drained. Conclusion: The negative appendectomy and re-admission rates were unacceptably high and need to be reduced. Minimising surgical variance with use of scoring systems and introduction of pathways may be a strategy to reduce NAR. New systems of feedback need to be introduced to improve outcomes.
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Styrud, J., T. Josephson, and S. Eriksson. "Reducing negative appendectomy: evaluation of ultrasonography and computer tomography in acute appendicitis." International Journal for Quality in Health Care 12, no. 1 (February 1, 2000): 65–68. http://dx.doi.org/10.1093/intqhc/12.1.65.
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Kang, KyeongWon, Woo Jeong Kim, Kyuseok Kim, You Hwan Jo, Joong Eui Rhee, Jin Hee Lee, Yu-jin Kim, et al. "Effect of pain control in suspected acute appendicitis on the diagnostic accuracy of surgical residents." CJEM 17, no. 1 (January 2015): 54–61. http://dx.doi.org/10.2310/8000.2013.131285.
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AbstractObjectiveTo determine the influence of early pain relief for patients with suspected appendicitis on the diagnostic performance of surgical residents.MethodsA prospective randomized, double-blind, placebo-controlled trial was conducted for patients with suspected appendicitis. The patients were randomized to receive placebo (normal saline intravenous [IV]) infusions over 5 minutes or the study drug (morphine 5 mg IV). All of the clinical evaluations by surgical residents were performed 30 minutes after administration of the study drug or placebo. After obtaining the clinical probability of appendicitis, as determined by the surgical residents, abdominal computed tomography was performed. The primary objective was to compare the influence of IV morphine on the ability of surgical residents to diagnose appendicitis.ResultsA total of 213 patients with suspected appendicitis were enrolled. Of these patients, 107 patients received morphine, and 106 patients received placebo saline. The negative appendectomy percentages in each group were similar (3.8% in the placebo group and 3.2% in the pain control group, p=0.62). The perforation rates in each group were also similar (18.9% in the placebo group and 14.3% in the pain control group, p=0.75). Receiver operating characteristic analysis revealed that the overall diagnostic accuracy in each group was similar (the area under the curve of the placebo group and the pain control group was 0.63 v. 0.61, respectively, p=0.81).ConclusionsEarly pain control in patients with suspected appendicitis does not affect the diagnostic performance of surgical residents.
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Lim, Sung-Chul, Young Min Lee, Choon-Mee Kim, Na Ra Yun, and Dong-Min Kim. "Acute Appendicitis Associated with Hantaan Virus Infection." American Journal of Tropical Medicine and Hygiene 105, no. 3 (September 15, 2021): 801–6. http://dx.doi.org/10.4269/ajtmh.20-1468.
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ABSTRACT. Hantaviruses are Bunyaviridae viruses that cause hemorrhagic fever with renal syndrome. Appendicitis caused by Hantaan virus has not been reported previously. An 81-year-old man who underwent laparoscopic appendectomy for suspected appendicitis based on abdominal pain, fever, hypotension, and computed tomography findings. Based on a suspicion of hemorrhagic fever with renal syndrome, the patient’s plasma was simultaneously analyzed using an indirect immunofluorescent antibody assay and nested reverse transcription–polymerase chain reaction (RT-PCR). The appendix tissue was also analyzed using nested RT-PCR and immunohistochemical (IHC) staining to identify the presence of Hantaan virus. Nested RT-PCR detected the presence of Hantaan virus, and indirect immunofluorescent antibody assay results revealed the presence of elevated antibody levels. Furthermore, IHC staining of the appendix tissue confirmed Hantaan virus antigens in the peripheral nerve bundle. Based on these findings, we confirmed the nerve tropism of the Hantaan virus. Hantaan virus in plasma and appendix tissue samples was confirmed using PCR and phylogenetic tree analysis. Moreover, we detected hypertrophy of the submucosa and periappendiceal adipose tissue nerve bundle along with Hantaan virus antigens in peripheral nerve bundles using IHC staining. Hence, we report that Hantaan virus infection may be accompanied by appendicitis.
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Reistrup, Hugin, Siv Fonnes, Jacob Rosenberg, and Kristoffer Andresen. "Case Report: The importance of examining colon and rectum in patients with appendiceal cancer." F1000Research 10 (February 26, 2021): 152. http://dx.doi.org/10.12688/f1000research.50909.1.
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Appendiceal cancer is rare and is often diagnosed incidentally in patients undergoing appendectomy for acute appendicitis. However, patients with appendiceal cancer are at increased risk of synchronous malignancy. In this case report, we present a 58-year-old man initially diagnosed with acute appendicitis after presenting to the emergency department with abdominal pain. He had an appendectomy and was discharged the following day. Unexpectedly, the postoperative histopathologic examination showed a primary adenocarcinoma in the appendix. A computed tomography scan showed rectal wall thickening and the patient was referred to colonoscopy where an experienced endoscopist found a rectal tumor during the digital rectal examination prior to the colonoscopy. The tumor was initially missed by the newly qualified doctor who examined the patient during his first admittance to hospital. The patient’s two primary cancers were treated with a laparoscopic right hemicolectomy for the appendiceal cancer and a low anterior resection for the rectal cancer. This case supports the importance of a full colorectal workup in patients with appendiceal cancer. It also emphasizes the value of a thorough digital rectal examination and the need for improved focus on teaching and practice of the procedure.
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Mani, Vishnu R., Shantanu Razdan, Tonny Orach, Aleksandr Kalabin, Rinil Patel, Ali Elsaadi, Kiyoe Sullivan, and Federico Gattorno. "Omental Infarction with Acute Appendicitis in an Overweight Young Female: A Rare Presentation." Case Reports in Surgery 2019 (April 7, 2019): 1–5. http://dx.doi.org/10.1155/2019/8053931.
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Omental infarction is an uncommon cause of acute abdomen but one that clinically mimics more serious and common causes of acute abdomen like appendicitis and cholecystitis. Historically, it was diagnosed only intraoperatively during surgery for presumed appendicitis or other causes of acute abdomen. But with the increase in the use of imaging, especially abdominal computed tomography (CT) scan in the work-up for acute abdomen, more cases of omental infarction are being diagnosed preoperatively. This has also led to the observation that omental infarction is a self-limiting condition which can be managed conservatively. Currently, conservative management and surgery are the only treatment options for omental infarction with no consensus as to the best treatment modality. Having a patient with both acute appendicitis and omental infarction simultaneously is extremely rare with only two reported cases in the literature thus far. Here, we present a 10-year-old obese female who presented to our hospital with acute abdomen and was found to have acute appendicitis and omental infarction. The patient underwent laparoscopic appendectomy and resection of the infarcted omentum and had uneventful recovery and was discharged on the second postoperative day. In this report, we present a review of current literature on omental infarction and highlight the importance of imaging especially abdominal CT scan in the nonoperative diagnosis and treatment of omental infarction.
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Luksaite-Lukste, Raminta, Ruta Kliokyte, Arturas Samuilis, Eugenijus Jasiunas, Martynas Luksta, Kestutis Strupas, and Tomas Poskus. "Conditional CT Strategy—An Effective Tool to Reduce Negative Appendectomy Rate and the Overuse of the CT." Journal of Clinical Medicine 10, no. 11 (June 1, 2021): 2456. http://dx.doi.org/10.3390/jcm10112456.
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(1) Background: Diagnosis of acute appendicitis (AA) remains challenging; either computed tomography (CT) is universally used or negative appendectomy rates of up to 30% are reported. Transabdominal ultrasound (TUS) as the first-choice imaging modality might be useful in adult patients to reduce the need for CT scans while maintaining low negative appendectomy (NA) rates. The aim of this study was to report the results of the conditional CT strategy for the diagnosis of acute appendicitis. (2) Methods: All patients suspected of acute appendicitis were prospectively registered from 1 January 2016 to 31 December 2018. Data on their clinical, radiological and surgical outcomes are presented. (3) Results: A total of 1855 patients were enrolled in our study: 1206 (65.0%) were women, 649 (35.0%) were men, and the median age was 34 years (IQR, 24.5–51). TUS was performed in 1851 (99.8%) patients, and CT in 463 (25.0%) patients. Appendices were not visualized on TUS in 1320 patients (71.3%). Furthermore, 172 (37.1%) of 463 CTs were diagnosed with AA, 42 (9.1%) CTs revealed alternative emergency diagnosis and 249 (53.8%) CTs were normal. Overall, 519 (28.0%) patients were diagnosed with AA: 464 appendectomies and 27 diagnostic laparoscopies were performed. The NA rate was 4.2%. The sensitivity and specificity for TUS and CT are as follows: 71.4% and 96.2%; 93.8% and 93.6%. (4) Conclusion: A conditional CT strategy is effective in reducing NA rates and avoids unnecessary CT in a large proportion of patients. Observation and repeated TUS might be useful in unclear cases.
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Balthazar, Emil J., Neil M. Rofsky, and Ryan Zucker. "Appendicitis: the impact of computed tomography imaging on negative appendectomy and perforation rates." American Journal of Gastroenterology 93, no. 5 (May 1998): 768–71. http://dx.doi.org/10.1111/j.1572-0241.1998.222_a.x.
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Kehagias, Ioannis, Apollon Zygomalas, Georgios Markopoulos, Thanasis Papandreou, and Pantelis Kraniotis. "Diagnosis and Treatment of Mucinous Appendiceal Neoplasm Presented as Acute Appendicitis." Case Reports in Oncological Medicine 2016 (2016): 1–6. http://dx.doi.org/10.1155/2016/2161952.
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Appendiceal mucocele is a rare cause of acute abdomen. Mucinous appendiceal neoplasms represent 0.2–0.7% of all appendix specimens. The aim of this study is to report a case of a mucinous appendiceal neoplasm presented as acute appendicitis, discussing the clinical and surgical approach in the emergency setting. A 72-year-old female patient was admitted to the emergency department with a clinical examination indicative of acute abdomen. The patient underwent abdominal computed tomography scan which revealed a cystic lesion in the right iliac fossa measuring 8.3 × 5.2 × 4.1 cm, with calcified walls, and a mean density indicative of high protein content. The patient was taken to the operating room and a right hemicolectomy was performed. The postoperative course was unremarkable. The histopathological examination revealed a low-grade mucinous appendiceal neoplasm with negative regional lymph nodes. Ultrasound and CT are useful in diagnosing appendiceal mucocele and synchronous cancers in the emergency setting. The initial operation should include appendectomy and resection of the appendicular mesenteric fat along with any fluid collection for cytologic examination. During urgent appendectomy it is important to consider every mucocele as malignant in order to avoid iatrogenic perforation causing pseudomyxoma peritonei. Although laparotomy is recommended, the laparoscopic approach is not contraindicated.
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Lee, Fu-Chou, Junn-Liang Chang, Hung-Ming Chen, Wan-Chen Tsai, and Po-Jen Hsiao. "Mantle Cell Lymphoma Presenting as Acute Abdominal Syndrome: A Rare Case Report and Literature Review." Healthcare 9, no. 8 (August 5, 2021): 1000. http://dx.doi.org/10.3390/healthcare9081000.
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Background: Acute abdominal syndrome can be caused by several possible reasons. The most common causes are perforation of a gastroduodenal ulcer, peritonitis, intestinal obstructions, and perforation of an appendix or fallopian tube. Fever and pain can be caused by an appendicitis or sigmoiditis. Appendiceal lymphoma is a rare disease that is usually found incidentally during appendectomy. Most of the cases are non-Hodgkin’s lymphomas. Mantle cell lymphoma is an aggressive B-cell non-Hodgkin’s lymphoma with a poorer prognosis than other B-cell lymphomas; thus, a definitive diagnosis is essential. Case Summary: A 60-year-old man presented with right lower quadrant pain. He denied any nausea, vomiting or anorexia and was afebrile. The physical examination revealed right lower quadrant abdomen tenderness. The computed tomography scan revealed periappendiceal fatty stranding with a swollen appendix, approximately 2 cm in diameter and prominent paraaortic, portacaval and mesenteric lymph nodes. A diagnosis of acute appendicitis was made, and laparoscopic appendectomy was performed immediately. The subsequent pathological examination revealed severe congestion with lymphoid hyperplasia. The immunohistochemistry stains revealed positive staining for cluster of differentiation (CD) CD20, B-cell lymphoma-2 (Bcl-2), cyclin D1, SRY-box transcription factor-11 (SOX-11), immunoglobulin D (IgD) and immunoglobulin M (IgM) but negative staining for CD3, CD5, CD10 and CD23. 18F-FDG positron emission tomography showed peripheral lymph node involvement, while the bone marrow biopsy showed negative findings. Therefore, a diagnosis of mantle cell lymphoma, Ann Arbor stage IVA, was made. The patient received postoperative combination chemotherapy and remained in a stable condition over a 1-year follow-up period. Conclusion: We report an uncommon case that initially presented as acute appendicitis, for which a final diagnosis of mantle cell lymphoma was made. In comparison with other B-cell lymphomas, mantle cell lymphoma has a poorer prognosis, and positive immunochemical staining of cyclin D1 and SOX-11 is useful for differentiating mantle cell lymphoma from other appendiceal lymphomas and treating patients appropriately. Physicians and nursing staff should be also aware of the associated complications and management in these patients.
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Propst, Robert, Yan Chen Wongworawat, Evelyn Choo, Camilla Cobb, and Anwar Raza. "Metastatic prostate adenocarcinoma and high-grade appendiceal mucinous neoplasm mimicking acute appendicitis in a post-radiation therapy patient." SAGE Open Medical Case Reports 9 (January 2021): 2050313X2098842. http://dx.doi.org/10.1177/2050313x20988421.
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Prostate cancer is the most common visceral malignancy diagnosed in males. Surveillance for post-treatment neoplasms is very crucial. Here we report the first case of recurrent metastatic prostate cancer presenting as acute appendicitis in a background of a high-grade appendiceal mucinous neoplasm. In addition, this case also includes an unusually early presentation of a secondary primary malignancy after radiation therapy. A 70-year-old male with a history of prostate adenocarcinoma status post-proton radiation therapy presented with recurrent poorly differentiated prostate adenocarcinoma with disease progression and extra-prostatic extension. He underwent salvage proton therapy and testosterone replacement therapy. Two years later, the patient presented with right lower quadrant pain. A computed tomography scan showed perforated acute appendicitis with intra-abdominal abscess, which was treated with interval appendectomy. Upon histologic analysis, metastatic prostatic adenocarcinoma was noted in the appendiceal wall and mesoappendix. In addition, an incidental background of high-grade appendiceal mucinous neoplasm was found. Four months later, he presented with persistent abdominal pain, rapid weight loss, fatigue, and fever for 3 months. An abdominal CT scan revealed a 6.1 cm rectal mass. Pathologic analysis diagnosed an aggressive post-radiation spindle cell sarcoma, intermediate to high grade. The patient opted for palliative care. This case shows that a clinical presentation of acute appendicitis in an older patient may sometimes portend a neoplastic rather than infectious etiology. Clinical history and patient epidemiology should always be considered when evaluating an older patient with clinical signs and symptoms of acute appendicitis.
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Stulberg, Eric, Alexander Zheutlin, Raymond Strobel, Katherine He, and Adelyn Beil. "2412 Cost effectiveness analysis of operative Versus antibiotic management for uncomplicated appendicitis." Journal of Clinical and Translational Science 2, S1 (June 2018): 79–80. http://dx.doi.org/10.1017/cts.2018.279.
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OBJECTIVES/SPECIFIC AIMS: (1) Evaluate the relative incremental cost-effectiveness [cost per quality-adjusted life year (QALY) gained] of antibiotics, laparotomy, and laparascopy for the initial treatment of uncomplicated appendicitis. (2) Detect if the relative incremental cost-effectiveness of each treatment differs by age, namely in pediatric patients, adult patients, and geriatric patients. (3) Use deterministic and probabilistic sensitivity analyses to assess the robustness of our findings when varying multiple model parameters. METHODS/STUDY POPULATION: Study Population and Analytic Approach: The population under analysis is a simulated population of those aged 1–90 diagnosed with uncomplicated appendicitis with computed tomography (CT) in the emergency department. Pregnant women and those younger than 1 year old were excluded from our analysis. We simulated our population through a Markov state-transition simulation model. Using this model, we estimated the lifelong costs and effects on QALYs from the use of antibiotics, laparoscopy, and laparotomy for a given hypothetical individual with uncomplicated appendicitis. This model allowed for the incorporation of both the short-term and long-term effects of each respective treatment option. The primary outcome of the model was the cost per additional QALY gained. The analysis was conducted using a healthcare perspective. A 100 age-year time horizon was used. A 3% discount rate was applied to both the costs and effects in the model. Transition states are depicted. Surgical state rates were derived from HCUP. Treatment failure of antibiotics was defined as recurrent appendicitis within one year of antibiotic treatment. This was determined using results from prior RCTs and a Cochrane review of antibiotic management for uncomplicated appendicitis. Recurrent appendicitis was defined as recurrent appendicitis after 1 year of antibiotic treatment, using rates of appendicitis applied to the general population by age group. National age-adjusted mortality rates were applied to account for death due to causes unrelated to appendicitis. To assess differential results by age, different acute and long-term outcome, cost, and state transition rates were applied to 3 age groups: a pediatric group (1–17 years old), an adult group (18–64 years old), and a geriatric group (65+ years old). As an individual progressed through the model until age 100, the respective parameters would change to adjust for the transitions between the 3 life stages. Outcomes After Appendicitis: Lifetime QALYs were incorporated throughout the study for short-term and long-term health states. There is limited availability of QALY data in the literature pertaining to the health states specific to appendicitis. Due to this limitation, however, calculated quality of life (QoL) indices for 2015 created by Wu et al. were utilized for this study. QALYs were subsequently derived by multiplying QoL by the appropriate duration of time spent in a respective health status. Transition rates between health states were abstracted from the existing literature. Costs: Direct medical costs were obtained from HCUP statistics from the 2014 fiscal year for all age groups in the nationwide network. This database contains all costs of care related to surgical appendicitis intervention, however it lacks costs associated with antibiotic-only management. To account for these costs, data was extracted from current available literature, and the resulting average was applied to our model. Sensitivity Analysis: One-way analyses by cost of procedure and effectiveness of antibiotic protocol were undertaken to account for regional variation in costs and improvements in antibiotic therapy, respectively. For cost of procedure sensitivity analysis, costs were varied by 1 standard deviation below and above the mean cost per treatment group per age. These costs were then compared to a designated reference group. Antibiotic sensitivity analysis was conducted by reducing the effectiveness of antibiotics from the maximum reported effectiveness down to 0, with the goal of obtaining a level of effectiveness at which antibiotics were no longer cost-effective. A probabilistic Monte-Carlo sensitivity analysis was then employed to determine the percent likelihood of each treatment arm being cost-effective at a level of $100,000 per additional QALY. The probabilistic sensitivity analysis was then repeated to determine the percent likelihood of each treatment arm being the dominant option, in that it lowers costs and adds QALYs. RESULTS/ANTICIPATED RESULTS: Our model examined the cost-effectiveness of 3 different treatment options for patients with acute uncomplicated appendicitis: laparoscopic appendectomy, laparotomy appendectomy, and an antibiotic regimen. We first examined the cost-effectiveness of each of these strategies in comparison to laparotomy. Laparoscopic appendectomy was shown to be superior to laparotomy in regards to costs and QALYs for patients ages 18 to 65+, while there was very little difference for patients ages 1–17. For those aged 1–17, laparoscopy had an additional cost of $90.00 with an associated gain of 0.1 QALYs compared with laparotomy. For those aged 18–64, laparoscopy had a net cost-savings of $3437.03 with an associated gain of 0.13 QALYs compared with laparotomy. For those aged 65+, laparoscopy had a net cost-savings of $5713.55 with an associated gain of 0.13 QALYs compared to laparotomy. Antibiotic management was superior to laparotomy as it relates to both costs and QALYs for all 3 age cohorts. For those aged 1–17, antibiotic management had a net cost-savings of $5972.55, with an associated gain of 0.6 QALYs compared with laparotomy. For those aged 18–64, antibiotic management had a net cost-savings of $6621.00 with an associated gain of 0.5 QALYs compared with laparotomy. For those aged 65+, antibiotic management had a net cost-savings of $11,953.00 with an associated gain of 0.21 QALYs compared with laparotomy. We then assessed the cost-effectiveness of antibiotics relative to laparoscopy. In all 3 age groups, antibiotics added QALYs and were cost-saving. For those aged 1–17, antibiotic management had a net cost-savings of $6062.55, with an associated gain of 0.6 QALYs compared with laparotomy. For those aged 18–64, antibiotic management had a net cost-savings of $3183.97 with an associated gain of 0.5 QALYs compared with laparotomy. For those aged 65+, antibiotic management had a net cost-savings of $6239.45 with an associated gain of 0.21 QALYs compared with laparotomy. Sensitivity Analysis: We first examined the effect of varying costs on our results. Costs for all interventions were varied by 1 standard deviation above and below the average costs used in our original model, yielding 3 cost estimate levels: high cost (1 standard deviation above), middle cost (average cost reported in model), low cost (1 standard deviation below). For all 3 cost estimate levels of antibiotics, antibiotics persistently dominated laparotomy for all 3 age groups. Laparoscopy dominated at all cost levels in age groups 18–64 and 65+ but had a positive ICER for both high and medium cost levels in the 1–17 age group. We then varied effectiveness (one minus the failure rate) of antibiotic treatment in each age group to assess at what level of effectiveness to antibiotics become dominant relative to laparotomy. In ages 1–17, antibiotic treatment became dominant at 43.8%; in ages 18–64, antibiotic treatment became dominant at 33%; and in ages 65+, there was no level of antibiotic effectiveness that did not result in this therapy being dominant over laparotomy. Probabilistic Monte-Carlo sensitivity analysis is pending, but we anticipate antibiotics having a high likelihood of being both cost-effective and dominant relative to the other 2 treatment options. DISCUSSION/SIGNIFICANCE OF IMPACT: We performed a cost-effective analysis comparing surgery versus antibiotic management for uncomplicated appendicitis. Our study found that antibiotic therapy was the dominant strategy in all age groups as it yielded lower costs and additional QALYs gained compared with laparotomy and laparoscopy. Appendicitis is the most common surgical emergencies worldwide, with a lifetime risk of 6.9% in females and 8.6% in males (Körner 1997). For over 100 years, open appendectomy had been the established treatment for appendicitis, but current management has evolved with the advent of laparoscopy and now growing use of antibiotics for treatment of appendicitis. There is growing interest in nonoperative management of uncomplicated appendicitis, given both an aging population that is increasingly frail and vulnerable to surgical complications and concerns over skyrocketing medical costs. Our model showed that antibiotic-only management was cost-effective in all age groups. This has important implications for management of appendicitis, where current management is to offer antibiotic-only management only in the “rare cases” where the patient is unfit for surgery or refuses surgery. Our data show that medical management of appendicitis not only is cheaper, but also provides more QALYs in all age groups. Our study has several limitations. First, we conducted our analysis under the assumption that all patients will be cured of appendicitis following surgical intervention. Some patients following appendectomy will develop symptoms of appendicitis and be diagnosed with “stump appendicitis,” which can occur in stumps as short as 0.5cm and can present as late as 50 years following initial surgery (Kanona, 2012). Additionally, any intraperitoneal surgery can lead to late complications such as small bowel obstruction from adhesions following surgery. Thus, our assumption that patients following appendectomy will return to the general population’s QALYs and mortality rate is not necessarily an accurate reflection of all clinical courses. However, the overwhelming majority of appendectomy patients recover fully post-surgery and we do not believe the above complications would significantly change our analysis. We also assumed that all patients with recurrent appendicitis following medical management would undergo surgery. However, patients who underwent nonoperative management at initial appendicitis may be more likely to be ineligible for surgery or refuse surgery during this second case of appendicitis. In addition, data were sparse for QALYs for the complications of open and laparoscopic surgery. We estimated these numbers from the EQ-5D, which while perhaps not accurate, we believe to be the best approximation given the available data. The next steps in evaluating the use of nonoperative management in uncomplicated appendicitis would be to validate the use of nonoperative management in elderly populations and to develop more accurate diagnostic criteria for uncomplicated Versus complicated appendicitis. Additionally, with increasing attention on antibiotic-resistant micro-organisms, policy decisions on the use of nonoperative management must also consider antibiotic stewardship. While one dose of perioperative antibiotics is indicated for appendectomy, treatment strategies from trial protocols for antibiotic-only management require significantly more antibiotics—some protocols require 1–3 days of IV antibiotics followed by up to 10 days of oral antibiotics. This study provides a cost-effectiveness analysis of treatment options for acute uncomplicated appendicitis among varying age groups. Our analysis demonstrates the benefit of antibiotics for initial therapy in the management of acute uncomplicated appendicitis. While the historic gold standard of laparotomy still is present as the first line treatment option in many physicians’ minds, new evidence indicates that the advancement of other methods, whether surgical via laparoscopic removal of the appendix or medical via improved antibiotic regimens, suggests better alternatives exist. Our study builds upon a growing body of literature supporting initial treatment of acute uncomplicated appendicitis with antibiotics, before surgical intervention.
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Anderson, Kathryn T., Luke R. Putnam, Dean H. Pham, Tiffany G. Ostovar-Kermani, Akemi L. Kawaguchi, Mary T. Austin, Kevin P. Lally, and Tiffany G. Ostovar-Kermani. "Negative Appendectomy Rates Do Not Increase with Reduced Computed Tomography Use in Pediatric Appendicitis." Journal of the American College of Surgeons 223, no. 4 (October 2016): e158. http://dx.doi.org/10.1016/j.jamcollsurg.2016.08.402.
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Lole Harris, Benjamin Howell, Jason Leo Walsh, and Sarfraz A. Nazir. "Super-mesenteric-vein-expia-thrombosis, the clinical sequelae can be quite atrocious." International Journal of Adolescent Medicine and Health 28, no. 4 (November 1, 2016): 445–49. http://dx.doi.org/10.1515/ijamh-2015-0040.
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Abstract Superior mesenteric vein (SMV) thrombosis is a rare, potentially life-threatening complication of intra-abdominal infection. Here we present a case of massive SMV thrombosis secondary to appendicitis in a 13-year-old boy. He presented with vague abdominal pain and associated symptoms, persistently elevated serum inflammatory markers and a pyrexia of unknown origin. Sonography proved inconclusive, and a definitive diagnosis was made by abdominal contrast-enhanced computed tomography. He was treated with antibiotics and anticoagulation before interval elective laparoscopic appendectomy. The non-specific nature of the presenting symptoms makes SMV thrombosis an important differential to consider when dealing with such patients.
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Rosen, Matthew, Andrew Chalupka, Kathryn Butler, Alok Gupta, and Stephen R. Odom. "Pathologic Findings Suggest Long-term Abnormality after Conservative Management of Complex Acute Appendicitis." American Surgeon 81, no. 3 (March 2015): 297–99. http://dx.doi.org/10.1177/000313481508100333.
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Perforated or phlegmonous appendicitis is often treated with antibiotics and drainage as needed. The rationale, risk of recurrence, timing, or even the necessity of subsequent elective interval appendectomy (IA) is debated. We retrospectively reviewed all appendectomies performed at Beth Israel Deaconess Medical Center between 1997 and 2011. We determined if the appendix was removed emergently or as IA. Demographic characteristics, hospital length of stay, computed tomography (CT) results, and operation type (open or laparoscopic) were determined. In IA specimens, narrative pathology reports were assessed for evidence of anatomic, acute, or chronic abnormality. A total of 3562 patients had their appendix removed during this time period. Thirty-four patients were identified as having IA. Of these, only three (8.8%) had a pathologically normal appendix. All three patients were female and all had initially abnormal CTscans. Eight specimens (23.5%) had evidence of chronic and 10 (29.4%) had evidence of acute appendicitis. An additional 10 (29.4%) specimens contained a combination of acute and chronic inflammation. Mean time to operation in the IA group was 57.1 days (range, nine to 234 days) after index diagnosis by CTscan. Given the high percentage of IA specimens with acute or chronic appendicitis and the extremely high proportion (91%) of patients with pathologically abnormal specimens, it appears that IA may be justified in most cases.
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Demetrashvili, Zaza, Mamuka Chkhaidze, Kakhi Khutsishvili, Gega Topchishvili, Tamar Javakhishvili, Irakli Pipia, and Vakhtang Qerqadze. "Mucocele of the Appendix: Case Report and Review of Literature." International Surgery 97, no. 3 (October 1, 2012): 266–69. http://dx.doi.org/10.9738/cc139.1.
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Abstract Appendiceal mucocele is a rare disease. Sometimes it is discovered accidentally and sometimes it resembles acute appendicitis. Correct diagnosis before surgery is very important for the selection of adequate surgical treatment to avoid intraoperative and postoperative complications. Ultrasonography, and particularly computed tomography, should be used extensively for this purpose. If mucocele is treated incorrectly pseudomyxoma peritonei, which is characterized by malignant process, may develop. We present a case of a 54-year-old man who was admitted to the emergency department with the signs of acute appendicitis. Open surgery was performed. At the time of surgery, a cystic mass of the appendix with dimensions 7 × 4 ×3 cm, with inflamed walls, but without perforation was discovered in the right iliac fossa. No discharge was found in the peritoneal cavity. Diagnosis of mucocele was suspected. Only appendectomy was performed because no pathologic process was found in the base of the appendix and lymph nodes were not increased in size. Hystopathologic diagnosis was mucinous cystadenoma. After 2 years, the patient is feeling well.