Imaging of appendicitis: Tips and tricks

Therapeutic effectiveness and influencing factors of laparoscopic appendectomy with mesoappendix dissection in the treatment of acute appendicitis

BACKGROUND

Acute appendicitis (AP) is a frequently encountered surgical emergency, and appendectomy is conventionally regarded as the predominant treatment modality. Nevertheless, the therapeutic efficacy of this surgical approach remains to be improved. Thus, the exploration and implementation of surgical refinements are necessary.

AIM

To elucidate the therapeutic effectiveness and influencing factors of laparoscopic appendectomy (LA) with mesoappendix dissection in the treatment of AP.

METHODS

First, 150 patients with AP who visited Shangrao Municipal Hospital between January 2022 and June 2024 were enrolled in this study. Among them, 72 patients were assigned to the control group to receive conventional LA, whereas 78 cases were included in the observation group for LA with mesoappendix dissection. Subsequently, indicators such as therapeutic effectiveness, surgical indices (operation time, intraoperative blood loss, and hospital stay), postoperative recovery indices (time to ambulation, gastrointestinal function recovery time, and time to food intake), incidence of adverse events (postoperative bleeding, pelvic infection, puncture site infection, and ileus), and serum inflammatory factors [tumor necrosis factor (TNF)-α, interleukin (IL)-6, and C-reactive protein (CRP)] were collected and comparatively analyzed, and the influencing factors of therapeutic effectiveness in patients with AP were analyzed.

RESULTS

Compared with the control group, the observation group had higher clinical therapeutic effectiveness, less operation time, intraoperative blood loss, and hospital stay; shorter time to ambulation, gastrointestinal function recovery, and food intake; and a lower total incidence of adverse events, and this difference is statistically significant. In addition, the expression levels of various serum inflammatory factors in the observation group were significantly reduced postoperatively, which were markedly lower than those in the control group. Moreover, sex, age, body mass index, time from acute onset to admission, family medical history, preoperative TNF-α, preoperative IL-6, preoperative CRP, and treatment modality were identified to be not independent factors affecting the therapeutic effectiveness of LA with mesoappendix dissection in patients with AP.

CONCLUSION

Overall, LA with mesoappendix dissection has a remarkable curative effect in treating patients with AP, which is worthy of clinical promotion.

Horseshoe appendix: A case report and literature review

RATIONALE

Horseshoe appendix is 1 of the rarest types of duplex appendix characterized by 1 appendix having 2 openings at the cecum. Clinically, it is extremely rare and is detected incidentally at surgery. Therefore, accurate and timely diagnosis is important for enhanced prognosis, treatment planning, and optimizing patient outcomes. This case report presents the first case of horseshoe appendix in France.

PATIENT CONCERNS

A French 15-year-old boy, presented to the emergency department with pain in the right iliac fossa that had been worsening for 4 days. Considering his symptoms, abdominal ultrasound, radiological examination, and computed tomography (CT) scan results, an acute appendix was suspected.

DIAGNOSES

Acute appendicitis (AA) with "horseshoe" type appendix.

INTERVENTIONS

Surgical intervention with exploratory laparoscopy was performed immediately.

OUTCOMES

We found a heterogeneous image, partially fluid in the right iliac fossa, measuring approximately 16 × 9 mm, with inflammatory remodeling of the fat upon contact. The radiological examination concluded that complicated AA was suspected. Finally, the pathological report revealed acute suppurative appendicitis with peritoneal reaction.

LESSONS

Horseshoe appendix is rare. Considering his symptoms, radiological examination, ultrasound, and CT scan results, an acute appendix was suspected. The patient was successfully treated using emergency surgery and antibiotics treatment thanks to further diagnosis via exploratory laparoscopy and pus microbial analysis.

Improving sonographic visualisation of the appendix in a regional referral hospital

Ultrasound is a first-line and often preferred imaging modality in the diagnosis of acute appendicitis. When the appendix is not visualised during a dedicated appendix ultrasound study, patients may require a CT study, which uses ionising radiation, or undergo conservative clinical observation with the inherent risk of clinical deterioration, perforation and sepsis. Median baseline data, at our hospital imaging department, revealed a rate of combined normal and abnormal appendix visualisation of 34.5% which is below the reported visualisation rates in the North American literature and well below the rates reported in the global literature. We embarked on a formal quality improvement (QI) project to improve the rates of appendix visualisation in our hospital ultrasound department. Using the Model of Improvement framework and a team approach, we generated and trialled multiple plan-do-study-act interventions over a project term of 12 months. In the second half of the project term, we saw a sustained rise in appendix visualisation exceeding our original stretch goal of 75% visualisation which was sustained 6 months after the formal project end (p<0.001). This rise was accompanied by a commensurate increase in sonographer confidence in appendix visualisation. In our case, the Model of Improvement methodology proved successful in solving our complex problem of sonographic appendix under-visualisation. The learnings of this QI project have been widely shared and spread according to the ethos of QI.

Risk Factors for Postoperative Intra-Abdominal Abscess in Pediatric Perforated Appendicitis Following Laparoscopic Appendectomy: A Multicenter Analysis

BACKGROUND

Perforated appendicitis in children is a frequently encountered and significant surgical condition. The treatment of choice is laparoscopic appendectomy, but this carries a risk of postoperative intra-abdominal abscess (IAA). The purpose of this study was to determine risk factors linked to the occurrence of IAA following laparoscopic surgery in pediatric perforated appendicitis.

METHODS

This retrospective cohort study analyzed 137 children with perforated appendicitis who received laparoscopic appendectomy at four tertiary hospitals between March 2018 and December 2022. Data on patient demographics, preoperative clinical characteristics, and surgical details were collected. Independent risk factors for IAA formation were determined using logistic regression analysis.

RESULTS

The overall incidence of postoperative IAA was 10.9%. Prolonged symptom duration and elevated CRP levels were associated with higher IAA rates. Patients who developed IAAs experienced prolonged postoperative fevers and longer hospital stays. Significant risk factors for IAA identified through multivariable analysis included a higher severity grade of appendicitis (≥Grade IV, OR 5.9, p = 0.034) and the presence of a free appendicolith during surgery (OR 5.549, p = 0.01). Of the patients who developed IAAs, nine (60%) improved with conservative treatment, while six (40%) required invasive procedures.

CONCLUSIONS

A higher severity grade of appendicitis (≥Grade IV) and the presence of a free appendicolith are significant predictors of postoperative IAAs in pediatric perforated appendicitis. Recognizing these factors can help guide clinical management and postoperative care, potentially reducing the incidence of this complication.

Diagnostic value of biochemical markers in prediction of perforation in acute appendicitis: a cross-sectional study

Background

Acute appendicitis, despite being the most common surgery, can result in increased morbidity and mortality in the case of perforated appendicitis. Identifying a perforation early can reduce the impact on the patient. Bilirubin, C-reactive protein (CRP), and white blood cell (WBC) count have been shown to indicate perforation in appendicitis.

Methods

A cross-sectional analytical study was conducted to observe the association between preoperative bilirubin, CRP, and white cell count with the histological findings of either the presence or absence of perforation of the appendix. The eligibility criteria included all patients above 18 years with appendicitis who were managed surgically in the study hospital, Shree Birendra Hosptial, between 1 December 2021 to 30 May 2022. The study was conducted after the approval from the ethics committee.

Results

Out of 150 patients, 112 had open surgery and 38 underwent laparoscopic appendectomy. One hundred thirty-four had non-perforated appendix and 16 cases had perforated appendix. The older age group was associated with appendiceal perforation more than the younger age group. Patients with a duration of symptoms less than 24 h and more than 72 h developed perforated appendicitis less frequently. The odds of encountering perforated appendicitis increased by 2.644 times per 0.972 rise in total bilirubin (P= 0.004) and the odds of encountering perforated appendicitis increased by 6.474 times per 1.868 rise in conjugated bilirubin (P= 0.003). There was no significant difference in total leucocyte count and neutrophil percentage among perforated and non-perforated groups.

Conclusion

The diagnostic value of the CRP, total bilirubin, and conjugated bilirubin levels was strong and significant when used in combination rather than their individual performance in the diagnosis of perforated acute appendicitis.

Appendicitis Diagnosis: Ensemble Machine Learning and Explainable Artificial Intelligence-Based Comprehensive Approach

Appendicitis is a condition wherein the appendix becomes inflamed, and it can be difficult to diagnose accurately. The type of appendicitis can also be hard to determine, leading to misdiagnosis and difficulty in managing the condition. To avoid complications and reduce mortality, early diagnosis and treatment are crucial. While Alvarado’s clinical scoring system is not sufficient, ultrasound and computed tomography (CT) imaging are effective but have downsides such as operator-dependency and radiation exposure. This study proposes the use of machine learning methods and a locally collected reliable dataset to enhance the identification of acute appendicitis while detecting the differences between complicated and non-complicated appendicitis. Machine learning can help reduce diagnostic errors and improve treatment decisions. This study conducted four different experiments using various ML algorithms, including K-nearest neighbors (KNN), DT, bagging, and stacking. The experimental results showed that the stacking model had the highest training accuracy, test set accuracy, precision, and F1 score, which were 97.51%, 92.63%, 95.29%, and 92.04%, respectively. Feature importance and explainable AI (XAI) identified neutrophils, WBC_Count, Total_LOS, P_O_LOS, and Symptoms_Days as the principal features that significantly affected the performance of the model. Based on the outcomes and feedback from medical health professionals, the scheme is promising in terms of its effectiveness in diagnosing of acute appendicitis.

Young-onset colon adenocarcinoma masquerading as acute appendicitis

This case report presents the findings of colon adenocarcinoma in a young adult male who presented with vague abdominal pain as his only complaint, suspicious of appendicitis. The patient underwent abdominal computed tomography (CT) imaging for further evaluation of his abdominal pain. CT findings showed pericecal fat stranding and prominent lymph nodes concerning for acute appendicitis, but the appendix could not be adequately visualized; due to the indeterminate CT findings, general surgery proceeded to perform an exploratory laparotomy on the patient and removed an appendiceal mass-like structure that was revealed to be invasive adenocarcinoma of the colon per pathology. This case report details the radiological and pathological findings of colorectal adenocarcinoma presenting similarly to acute appendicitis and demonstrates that colorectal adenocarcinoma must be considered on the list of differentials in young adults presenting with abdominal pain and unclear CT imaging.

Predictive values of indirect ultrasound signs for low risk of acute appendicitis in paediatric patients without visualisation of the appendix on ultrasound

BACKGROUND AND OBJECTIVES

The ability to rule appendicitis in or out using ultrasound is limited by studies where the appendix is not visualised. We determined whether the absence of indirect ultrasound signs can rule out appendicitis in children undergoing a radiology-performed ultrasound in which the appendix is not visualised METHODS: This was a single-centre retrospective observational study of patients aged 3-13 with a clinical suspicion of acute appendicitis evaluated in a Paediatric Emergency Department in Spain from 1 January 2013 to 31 December 2019. For those patients who had formal ultrasound, direct and indirect findings of ultrasound were abstracted from the ultrasound report. The surgical pathology report was established as the gold standard in patients who underwent an appendectomy. In those who did not, appendicitis was considered not to be present if there was no evidence in their charts that they had undergone an appendectomy or conservative therapy for appendicitis during the episode. The main outcome variable was the diagnosis of acute appendicitis. For patients undergoing ultrasound, the independent association of each indirect ultrasound sign with the diagnosis of appendicitis in patients without a visualised appendix was analysed using logistic regression.

RESULTS

We included 1756 encounters from 1609 different episodes. Median age at the first visit of each episode was 10.1 years (IQR, 7.7-11.9) and 921 (57.2%) patients were men. There were 730 (41.6%) encounters with an Alvarado score ≤3, 695 (39.6%) with a score 4-6 and 331 (18.9%) with a score ≥7. Appendicitis was diagnosed in 293 (17.8%) episodes. Ultrasonography was performed in 1115 (61.6%) encounters, with a visualised appendix in 592 (53.1%).The ultrasound findings independently associated with appendicitis in patients without a visualised appendix were the presence of free intra-abdominal fluid in a small quantity (OR:5.0 (95% CI 1.7 to 14.6)) or in an abundant quantity (OR:30.9 (95% CI 3.8 to 252.7)) and inflammation of the peri-appendiceal fat (OR:7.2 (95% CI 1.4 to 38.0)). The absence of free fluid and inflammation of the peri-appendiceal fat ruled out acute appendicitis in patients with an Alvarado score <7 with a sensitivity of 84.6% (95% CI 57.8 to 95.7) and a negative predictive value of 99.4% (95% CI 97.8 to 99.8).

CONCLUSIONS

Patients with an Alvarado score <7 and without a visualised appendix on ultrasound but who lack free fluid and inflammation of the peri-appendiceal fat are at very low risk of acute appendicitis.

Uncommon Presentation of a Perforated Appendicitis Leading to Duodenal Fistula: Case Report and Literature Review

Multiple types of fistulas associated with the appendix have been reported; however, duodenal fistula resulting from perforated acute appendicitis has only been documented in one previous case. In this report, we present the case of an 18-year-old male patient who was diagnosed to have a complicated appendicitis in its normal position with abscess formation. He was started on IV antibiotics and underwent a CT-guided drainage of the abscess with drain placement. Two days later due to biliary output from the drain, CT fistulography and diagnostic laparoscopy were performed that revealed the presence of a duodenal fistula. The potential for duodenal fistula formation in patients with complicated appendicitis must always be taken into consideration. Consequently, it is crucial to establish an appropriate management plan aimed at preventing additional serious complications arising from duodenal perforation.

Impact of Education and Experience on Radiographers' Ability to Diagnose Acute Appendicitis: A Survey in Private Malaysian Hospitals

Background

Acute appendicitis is a global surgical emergency. Radiographic modalities usually identify acute appendicitis, although radiographers' competence is questionable. This study examines how clinical radiographers' education and experience affect their ability to identify acute appendicitis using computed tomography (CT), magnetic resonance imaging (MRI) and ultrasonography (USG) characteristics. The study also aimed to determine which variable strongly influences their knowledge level.

Methods

The study surveyed radiographers with a four-part self-administered questionnaire containing demographic information and eight knowledge-based questions about the appearance of acute appendicitis in MRI, CT and USG, separately. Before distribution, the questionnaire was validated and checked the reliability.

Results

Clinical radiographers' knowledge about using MRI to diagnose acute appendicitis was strongly affected by education and experience (η2 = 0.13 and 0.14; P < 0.05), with bachelor's degree holders scoring higher regardless of experience. Radiographers with more than 5 years of experience knew more about CT and USG features to identify acute appendicitis (η2 = 0.40 and 0.27; P < 0.05). Radiographers with a bachelor's degree and greater experience had higher overall knowledge of MRI, CT and USG to diagnose acute appendicitis (η2 = 0.51 and 0.11; P < 0.05). With adjusted R2 = 54% (F [2, 44] = 27.94; P < 0.001), education and experience highly predicted the overall knowledge level.

Conclusion

The study found gaps in radiographers' knowledge of the radiographic appearance of acute appendicitis. Clinical radiographers' education level and years of experience substantially affect their knowledge level. In addition, experience is a good predictor than education level for overall knowledge level. Therefore, the study emphasises the importance of continuing education and training for radiographers to diagnose acute appendicitis quickly and accurately.

Imaging of Gastrointestinal Tract Ailments

Gastrointestinal (GI) disorders comprise a diverse range of conditions that can significantly reduce the quality of life and can even be life-threatening in serious cases. The development of accurate and rapid detection approaches is of essential importance for early diagnosis and timely management of GI diseases. This review mainly focuses on the imaging of several representative gastrointestinal ailments, such as inflammatory bowel disease, tumors, appendicitis, Meckel's diverticulum, and others. Various imaging modalities commonly used for the gastrointestinal tract, including magnetic resonance imaging (MRI), positron emission tomography (PET) and single photon emission computed tomography (SPECT), and photoacoustic tomography (PAT) and multimodal imaging with mode overlap are summarized. These achievements in single and multimodal imaging provide useful guidance for improved diagnosis, staging, and treatment of the corresponding gastrointestinal diseases. The review evaluates the strengths and weaknesses of different imaging techniques and summarizes the development of imaging techniques used for diagnosing gastrointestinal ailments.

Update on acute appendicitis: Typical and untypical findings

Acute appendicitis is the most common indication for emergency abdominal surgery throughout the world and a common reason for consultation in emergency departments. In recent decades, diagnostic imaging has played a fundamental role in identifying acute appendicitis, helping to reduce the rate of blind laparotomies and hospital costs. Given the results of clinical trials supporting the use of antibiotic therapy over surgical treatment, radiologists need to know the diagnostic criteria for complicated acute appendicitis to be able to recommend the best treatment option. This review aims not only to define the diagnostic criteria for appendicitis in different imaging modalities (ultrasonography, computed tomography, and magnetic resonance imaging), but also to explain the diagnostic protocols, atypical presentations, and other conditions that can mimic appendicitis.

The utility of spectral Doppler evaluation of acute appendicitis

PURPOSE

The use of spectral Doppler, peak systolic velocity (PSV), and resistive index (RI) imaging criteria to improve the accuracy of acute appendicitis diagnosis is hypothesized.

METHODS

Graded compression ultrasound was performed for suspected patients. The spectral Doppler evaluation was conducted while observing the appendix. A total of 152 patients (82 males and 70 females, ages 4-63 years, mean age of 24.5 years) were examined using the spectral Doppler waveform between 2018 and 2019. RI and PSV values of patients with and without appendicitis were compared to histopathologic findings. SPSS 26 was used to analyze the data, including using descriptive statistics and measures of sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV).

RESULTS

Appendicitis was confirmed in 95 patients (62.5%) and rejected in 57 patients (37.5%). For the diagnosis of appendicitis, the area under the curve (AUC) of receiver operating characteristic (ROC) for RI (0.92 with 95% confidence interval (CI): 0.88, 0.97; P = 0.001) and PSV (0.96, with 95% CI: 0.93, 1.00; P = 0.001) was calculated. The discriminatory RI ≥ 0.49 demonstrated high sensitivity (90.5%) and low specificity (86%), and the discriminatory PSV ≥ 9.6 cm/s had high specificity (94.7%) and sensitivity (94.7%) for appendicitis.

CONCLUSION

By incorporating spectral Doppler criteria into routine graded compression ultrasound, the diagnostic accuracy of acute appendicitis was increased. In comparison, high PSV and RI values of the appendix with a cut-off point of 9.6 cm/s and 0.49 differ significantly between positive and negative appendectomy patients.

Diagnosis and Management of Acute Appendicitis in Adults: A Review

IMPORTANCE

Acute appendicitis is the most common abdominal surgical emergency in the world, with an annual incidence of 96.5 to 100 cases per 100 000 adults.

OBSERVATIONS

The clinical diagnosis of acute appendicitis is based on history and physical, laboratory evaluation, and imaging. Classic symptoms of appendicitis include vague periumbilical pain, anorexia/nausea/intermittent vomiting, migration of pain to the right lower quadrant, and low-grade fever. The diagnosis of acute appendicitis is made in approximately 90% of patients presenting with these symptoms. Laparoscopic appendectomy remains the most common treatment. However, increasing evidence suggests that broad-spectrum antibiotics, such as piperacillin-tazobactam monotherapy or combination therapy with either cephalosporins or fluroquinolones with metronidazole, successfully treats uncomplicated acute appendicitis in approximately 70% of patients. Specific imaging findings on computed tomography (CT), such as appendiceal dilatation (appendiceal diameter ≥7 mm), or presence of appendicoliths, defined as the conglomeration of feces in the appendiceal lumen, identify patients for whom an antibiotics-first management strategy is more likely to fail. CT findings of appendicolith, mass effect, and a dilated appendix greater than 13 mm are associated with higher risk of treatment failure (≈40%) of an antibiotics-first approach. Therefore, surgical management should be recommended in patients with CT findings of appendicolith, mass effect, or a dilated appendix who are fit for surgery, defined as having relatively low risk of adverse outcomes or postoperative mortality and morbidity. In patients without high-risk CT findings, either appendectomy or antibiotics can be considered as first-line therapy. In unfit patients without these high-risk CT findings, the antibiotics-first approach is recommended, and surgery may be considered if antibiotic treatment fails. In unfit patients with high-risk CT findings, perioperative risk assessment as well as patient preferences should be considered.

CONCLUSIONS AND RELEVANCE

Acute appendicitis affects 96.5 to 100 people per 100 000 adults per year worldwide. Appendectomy remains first-line therapy for acute appendicitis, but treatment with antibiotics rather than surgery is appropriate in selected patients with uncomplicated appendicitis.