Treatment for Appendicitis With Appendicolith by the Stone Size and Serum C-Reactive Protein Level

Risk prediction and effect evaluation of complicated appendicitis based on XGBoost modeling

PURPOSE

The distinction between complicated appendicitis (CAP) and uncomplicated appendicitis (UAP) remains challenging. The purpose of this study was to construct a safe and economical diagnostic model that can accurately and rapidly differentiate between CAP and UAP.

METHODS

Patient data from 773 appendectomies were retrospectively collected, important features were selected using random forests, and the data were divided into training and test sets in a 3:1 ratio. An integrated learning algorithm, Extreme Gradient Boosting (XGBoost), was introduced to predict the risk of CAP and compared with Support Vector Machine (SVM), Random Forest (RF), and Decision Tree (CART) algorithms. A comprehensive comparison of the four algorithms was performed using model performance metrics such as the area under the receiver's operating characteristic curve (AUC), sensitivity, specificity, accuracy, precision, negative predictive value(NPV), positive predictive value(PPV),calibration curves, and clinical decision curve analysis (DCA).

RESULT

The results show that all four prediction models exhibit some predictive ability. The XGBoost model showed the best prediction with AUC, accuracy, sensitivity, specificity,NPV and PPV of 0.914, 0.855, 0.865, 0.846,0.848 and 0.897, respectively, followed by the SVM model with results of AUC, accuracy, sensitivity, specificity,NPV and PPV of 0.882, 0.819, 0.865, 0.779, 0.770 and 0.871, respectively. XGBoost and SVM models show very good calibration. The XGBoost model showed better net clinical benefit compared to the DCA curves of the other models.

CONCLUSION

Predictive models based on the XGBoost algorithm have good performance in predicting the risk of acute appendicitis progressing to complicated appendicitis, which helps to optimize clinical decision making.

Acute peritonitis caused by a giant appendicolith: A rare case report and a literature review

INTRODUCTION

Giant appendicoliths, which are calcified deposits larger than 2 cm found in the appendix, are uncommon and often linked to appendicitis, as well as complications like perforation or abscess formation. The occurrence of a giant appendicolith leading to peritonitis without accompanying appendicitis is rare, presenting a distinct diagnostic and therapeutic challenge.

PRESENTATION OF CASE

A 77-year-old male with beta-thalassemia minor came in with acute pain in the right lower quadrant, along with nausea and vomiting. Upon examination, he showed signs of peritoneal irritation, including rebound tenderness and guarding. Laboratory tests indicated mild leukopenia and normal inflammatory markers. Imaging studies identified a 5 cm appendicolith and localized free fluid suggestive of perforation, along with signs of superimposed peritonitis. Surgical intervention revealed a distended appendix containing the giant appendicolith and an ileocecal perforation, but histopathological analysis showed no evidence of acute appendicitis. The patient underwent an appendectomy and repair of the perforation, resulting in an uneventful recovery.

DISCUSSION

Giant appendicoliths can lead to significant mechanical irritation and complications such as perforation, even in the absence of the typical inflammatory response associated with appendicitis. The diagnostic difficulty arises from the lack of fever and elevated inflammatory markers, which are usually present in cases of acute appendicitis.

CONCLUSION

Giant appendicoliths should be included in the differential diagnosis for acute abdominal pain, even when appendicitis is not evident. This case highlights the necessity of thorough approaches for accurate diagnosis and effective treatment.

Clinical outcomes and optimal indications for nonoperative management of acute appendicitis in adult patients: a comprehensive literature review

Appendectomy as the standard treatment for acute appendicitis has been challenged by accumulating evidence supporting nonoperative management with antibiotics as a potential primary treatment. This review aimed to summarize the clinical outcomes and the optimal indications for nonoperative management of acute appendicitis in adults. Current evidence suggests that uncomplicated and complicated appendicitis have different pathophysiologies and should be treated differently. Nonoperative management for uncomplicated appendicitis was not inferior to appendectomy in terms of complications and length of stay, with less than a 30% failure rate at 1 year. The risk of perforation and postoperative complications did not increase even if nonoperative management failed. Complicated appendicitis with localized abscess or phlegmon could also be treated conservatively, with a success rate of more than 80%. An interval appendectomy following successful nonoperative management is recommended only for patients over the age of 40 years to exclude appendiceal malignancy. The presence of appendicoliths increased the risk of treatment failure and complications; thus, it may be an indication for appendectomy. Nonoperative management is a safe and feasible option for both uncomplicated and complicated appendicitis. Patients should be informed that nonoperative management may be a safe alternative to surgery, with the possibility of treatment failure.

C-reactive protein and digestive pathologies: A narrative review for daily clinical use

The aim of this narrative review is to familiarize clinicians, especially digestive surgeons, to adequately use of serum C-reactive protein as a reliable noninvasive biomarker in diverse practical clinical situations. We hope that the review will help clinicians for their decision-making when facing various digestive diseases including operative and nonoperative pathologies such as anastomotic leakage, pancreatitis, emergency situation, and digestive cancer management and prognosis.

Appendicolith as a Sign of Complicated Appendicitis: A Myth or Reality? A Retrospective Study

INTRODUCTION

Appendicolith can be incidentally detected on abdominal computer tomography (CT) without any signs of appendicitis. However, it has also been found to be a risk factor for failure of nonoperative management in acute appendicitis. The present retrospective study aimed to evaluate whether appendicolith predicts complicated appendicitis in patients with any appendicitis.

METHODS

A retrospective chart review was conducted for patients undergoing appendectomy from January 2016 to December 2018. Appendicolith was considered to be present when it was described in a CT scan.

RESULTS

Of the 267 patients, appendicolith was found in 120 cases, while there were no in 147 cases in preoperative CT scans. In the case of complicated appendicitis (gangrenous or gangrenous perforated appendicitis), appendicolith was visible in CT scans in 57.7% of the patients. Of the patients with uncomplicated appendicitis, 38.3% had appendicolith in CT scan (p = 0.002). In univariate logistic regression analysis, based on the finding of the histological specimen, appendicolith was associated with complicated appendicitis (OR: 2.12; 95% CI: 1.28-3.51; p = 0.004). When adjusting for sex, age group (age ≤50 vs. >50 years), and duration of symptoms (≤24 vs. >24 h), the odds ratio was 3.52 (95% CI: 1.88-6.58; p < 0.001).

CONCLUSION

Our study found that appendicolith can be considered an independent risk factor for complicated appendicitis. Therefore, in the presence of appendicolith, surgical treatment should probably be preferred over nonsurgical treatment in acute appendicitis.

Routine colonoscopy with a surprise in the cecum: It's a giant appendicolith! A Case report and review of the literature

Giant appendicoliths (defined as appendiceal stones larger than 2 cm in size) are rare findings, with less than 20 well-documented reported cases. Appendicoliths, in general, are linked to an increased risk of appendicitis and associated complications. However, little information is available on the clinical impact of giant appendicoliths. We present a case of a giant appendicolith accidentally discovered during screening colonoscopy. With more than 4 cm, this appendicolith is one of the largest of the few reported so far. In contrast to all other cases of giant appendicoliths, the patient did not exhibit any symptoms. Additionally, we provide an overview of giant appendicolith cases, discussing their clinical features, diagnosis, and treatment.

Appendicolith classification: physical and chemical properties of appendicoliths in patients with CT diagnosed acute appendicitis - a prospective cohort study

OBJECTIVE

Appendicoliths are associated with a more complicated course of acute appendicitis and failure of non-operative treatment. We aimed to update the appendicolith classification originally described in 1966 and to assess the association of appendicolith characteristics with appendicitis severity.

DESIGN

This prospective predefined MAPPAC-trial (ClinicalTrials.gov NCT03257423) substudy included patients with CT diagnosed appendicitis presenting with an appendicolith. CT visible appendicoliths were harvested at surgery, measured and characterised by morphological examination complemented with micro-CT and micro-X-ray fluorescence spectroscopy. Patients were categorised into two groups: appendicolith appendicitis without other complications and appendicolith appendicitis with complications (appendiceal gangrene, perforation and/or abscess). The association of appendicolith classification and characteristics with appendicitis severity was evaluated.

RESULTS

Of 78 patients with a CT appendicolith, 41 appendicoliths were collected and classified based on the degree of hardness into three classes. The hardest appendicoliths (class 3) were less common (19.5%) presenting with a stone-hard outer layer and concentrically layered inner structure around a core. The layered inner structure was also observed in class 2 appendicoliths, but was absent in soft, class 1 appendicoliths. Appendicolith hardness or measures (maximum length, diameter and weight) were not associated with appendicitis severity. The spatial distribution of the main inorganic elements of calcium and phosphorus varied within most appendicoliths.

CONCLUSION

This updated classification confirms categorisation of CT visible appendicoliths into three classes based on their physical and chemical characteristics. The data on clinical and aetiopathological characteristics of appendicoliths is scarce and using this systematic classification would add to this understanding.

CT of appendicoliths in adult appendicitis: clinical significance and characteristics of overlooked cases

OBJECTIVES

Accurate computed tomography (CT) identification of appendicoliths in adults with acute appendicitis is crucial as it may preclude nonoperative management due to high risk of failure and complications. This investigation aimed to identify the significance of appendicoliths in acute appendicitis and to evaluate the performance of portovenous-phase (PVP) CT and the consequences of overlooked appendicoliths.

METHODS

CT examinations of 324 consecutive patients (mean age 51.9 years, 112 men) with pathologically confirmed acute appendicitis were retrospectively included. Two radiologists independently reviewed the images, and disagreement was resolved by a consensus.

RESULTS

Appendicoliths were identified in 134/324 patients, of which 75 had complicated appendicitis. Among 190 patients without appendicoliths, 52 had complicated appendicitis. An appendicolith was independently associated with complicated appendicitis (adjusted odds ratio 2.289; 95% CI: 1.343-3.902; p = 0.002). The larger minimum diameter was significantly associated with complication. The 4.5-/6.0-mm cutoffs for minimum and maximum diameters of appendicoliths demonstrated 82.7%/85.3% sensitivity and 35.6%/33.9% specificity in predicting complications. The PVP alone had 82.1-88.1% sensitivity, respectively per patient and per appendicolith, and a 100% specificity in the detection of appendicoliths, as compared with combined noncontrast and PVP. PVP overlooked 28/237 appendicoliths (11.8%) corresponding to 24/134 patients (17.9%). Of the 24 patients with overlooked appendicoliths, 16 had complicated appendicitis but 14 were correctly categorized by findings other than appendicoliths. In total, 2/127 patients (1.6%) with complicated appendicitis were misdiagnosed as having uncomplicated appendicitis.

CONCLUSIONS

Appendicoliths in acute appendicitis were strongly associated with complications. While PVP overlooked some appendicoliths, only 1.6% of complicated appendicitis were misclassified when considering other CT findings.

CLINICAL RELEVANCE STATEMENT

This study found a strong association between appendicoliths and complications. Its presence may preclude conservative management. Although portovenous-phase CT overlooked some appendicoliths, the combination with other CT findings allowed correct classification in a vast majority of cases.

KEY POINTS

• Accurate identification of appendicoliths is crucial for nonoperative management decisions in adult acute appendicitis. • Appendicoliths are strongly associated with complications in adult acute appendicitis. • Portovenous-phase CT overlooked some appendicoliths, but only a small percentage of patients with complicated appendicitis were misclassified when considering other CT findings.

Diagnosis and Management of the Largest Documented Appendicolith in Literature: A Case Report

This case report depicts the diagnosis and management of the largest documented appendicolith found in the medical literature so far, measuring 4.5 cm. A 44-year-old male patient presented with a distended abdomen, right lower quadrant (RLQ) pain, constipation, and the inability to consume solid food. Laboratory tests revealed leukocytosis and elevated C-reactive protein (CRP) levels. Abdominal X-rays showed a densely calcified structure in the right lower quadrant, and further imaging confirmed the diagnosis of appendicolithiasis. The surgical indication for appendectomy was determined, and an open surgical procedure was performed due to the severity of inflammation, minimal perforation, and extensive adhesions. The surgically removed appendix with the appendicolith was analyzed histologically, confirming appendicolithiasis, periappendicitis, perforation, and serositis. The patient was discharged in stable condition after postoperative management. Giant appendicoliths are rare and associated with an increased risk of complications. Diagnosis is typically clinical but can be enhanced by imaging modalities.