Appendicitis

Single-Center Retrospective Analysis of Neutrophil, Monocyte, and Platelet to Lymphocyte Ratios as Predictors of Complicated Appendicitis

Aim

We look at the ability of the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and monocyte-to-lymphocyte ratio (MLR) to differentiate between uncomplicated and complicated appendicitis.

Methods and materials

This was a retrospective, single-center study of 234 individuals diagnosed with acute appendicitis between January 1, 2020, and December 31, 2020. Patients were grouped into uncomplicated and complicated appendicitis subgroups. Patients with histologically or radiologically proven gangrenous or perforated appendicitis, as well as those with peritonitis or peri-appendiceal abscess development, comprise the complicated subgroup. Independent Mann-Whitney samples The U test was used to predict lab values of complicated appendicitis. Furthermore, the receiver operating characteristic (ROC) curve and area under the curve (AUC) were utilized to predict the sensitivity and specificity of laboratory results reported to have a significant connection with complex appendicitis

Results

The criteria were met by 186 patients, with a male-to-female proportion of 1.06:1, an average age of 36.4 years, and an average stay of 2.73 days. There were 95 individuals with complicated appendicitis. With 66.3%, perforated appendicitis was the most prevalent condition. The ratios of neutrophils to lymphocytes, monocytes to lymphocytes, and platelets to lymphocytes were linked with complicated appendicitis with a p-value of < 0.0001, and p-values = 0.015, and 0.015, respectively.

Conclusion

NLR, MLR, and PLR are valid, less onerous surrogate biomarkers for measuring the severity of acute complicated appendicitis and differentiating it from uncomplicated appendicitis.

A review of the function and evolution of the cecal appendix

Since its initial discovery in the 1500s, the cecal appendix has been an anatomical structure of great intrigue, notorious for its inconvenient tendency to become inflamed and often require surgical intervention. Appendicitis is one of the most common indications for emergency abdominal surgery, costing healthcare systems billions of dollars globally and causing tens of thousands of deaths annually. Yet, recent studies have indicated that the appendix may serve important protective functions in fortifying the body's immune response against invading pathogens and re-inoculating the gut with commensal bacteria after periods of gastrointestinal illness. While the cecal appendix was once believed to be a synapomorphy of hominoids (humans and other great apes), recent studies suggested that it is a recurrent trait found in several other species of primates, rodents, lagomorphs, marsupials, and monotremes. Mapping appendiceal and other gastrointestinal traits across a mammalian consensus phylogeny revealed that the cecal appendix has evolved independently numerous times throughout mammalian evolution, significantly more than would be expected due to chance alone, suggesting that the appendix is adaptively advantageous. However, attempts to identify an overarching ecological, behavioral, dietary, or environmental factor driving some species to evolve an appendix have been largely unsuccessful, indicating that the cecal appendix has a complex and diverse evolutionary history. This review discusses the current understanding of the pathophysiology, evolution, and possible functions of the appendix, both within humans and broadly across the class Mammalia.

Hyperbilirubinemia as a Possible Predictor of Appendiceal Perforation in Acute Appendicitis: A Prospective Study

Introduction: Acute appendicitis, a common abdominal surgical emergency, can mostly be diagnosed clinically by assessing the symptoms and physical findings but confirmation of the diagnosis solely depends upon the histopathological study of the resected appendix specimen, being supplemented by a few laboratory tests and ultrasonography (USG). In spite of all these available investigations, the diagnosis of acute appendicitis, because of its nebulous presentation and the variability of signs, remains a Herculean task for the surgeon.

Methods: This is a prospective study conducted on 125 patients diagnosed with acute appendicitis and posted for appendicectomy. Total serum bilirubin (TSB), and total leucocyte count (TLC) were done in all cases. USG of the abdomen was done in all the cases to confirm the diagnosis and to rule out other causes of acute abdomen. TLC more than 11 x 10³ cells/µL and TSB more than 1.1 mg/dL were considered positive. They were operated on and their diagnoses were confirmed post-operatively by histopathological examination. Patients were subdivided according to histopathological findings into: normal appendix (n = 11), uncomplicated acute appendicitis (n = 86), gangrenous appendicitis (n = 10) and perforated appendix (n = 18). Laboratory results, operative findings, and histopathological findings were compiled, analyzed, and compared with reference values.

Results: Out of 125 patients, 114 (91.2%) were histologically positive for acute appendicitis, while 11 (8.8%) had normal histology. TLC was elevated in 95 (76 %) patients and it was normal in 30 (24%) cases. Among the patients with leucocytosis, only 90 (94.74%) had positive histology for acute appendicitis, while the remaining five (5.26%) had normal histology. Among the 30 patients who had normal TLC, 24 had positive histology for acute appendicitis, while the remaining six had normal histology. The specificity, sensitivity, positive predictive value (PPV), and negative predictive value (NPV) were 78.95%, 54.55%, 94.74%, and 20%respectively. Similarly, 67 patients (53.6%) had elevated TSB, while it was within normal limits in 58 (46.4%) patients. From the patients with hyperbilirubinemia, 65 (97.01%) had positive histology for acute appendicitis, while the remaining two (2.99%) had normal histology. Among 58 patients who had normal TSB, 49 had positive histology for acute appendicitis, while the rest nine had normal histology. The specificity, sensitivity, PPV, and NPV are 57.02%, 81.82%, 97.01%, and 15.52% respectively. However, when both TLC and TSB were compared as markers of appendicular perforation, the sensitivity, specificity, PPV, and NPV of total serum bilirubin were found to be 89.29% against 21.43%; 53.49% vs. 2.33%; 38.46% vs. 6.67% and 93.88% vs. 8.33% of total leukocyte counts respectively.

Conclusion: Elevated total serum bilirubin could be used as a better predictor of appendiceal perforation in acute appendicitis.

Clinical, surgical, and pathological findings in client-owned rabbits with histologically confirmed appendicitis: 19 cases (2015-2019)

OBJECTIVE

To report clinical, surgical, and pathological findings in client-owned rabbits with histologically confirmed appendicitis.

ANIMALS

19 rabbits.

PROCEDURES

Medical records for client-owned rabbits that had a histologic diagnosis of appendicitis were reviewed.

RESULTS

Median age of the rabbits at presentation was 24.0 months (range, 4 to 84 months). Seventeen cases occurred during the summer and fall seasons. Decreased appetite (17/19 rabbits), abnormal rectal temperature (hyperthermia, 9/16 rabbits; hypothermia, 4/16 rabbits), hypocalcemia (8/11 rabbits), and hypoglycemia (7/15 rabbits) were common signs. Abdominal ultrasonography and CT findings were suggestive of appendicitis in 6 of 8 rabbits and in 1 of 2 rabbits, respectively. Of the 6 rabbits that received medical treatment, 3 died at 48 hours, 1 died at 24 hours after hospitalization, and 1 died at 10 days after presentation; 1 rabbit was alive at 1,030 days after presentation. Of the 8 rabbits that underwent appendectomy, 3 died before discharge from the hospital and 1 died 113 days after surgery; 4 rabbits were alive at 315, 334, 1,433, and 1,473 days after presentation. The remaining 5 rabbits either died or were euthanized before treatment could be instituted. In each of the 19 rabbits, the appendix had evidence of severe inflammation with mucosal ulceration, heterophilic inflammation, and necrotic debris.

CLINICAL RELEVANCE

For rabbits with decreased appetite and an apparently painful abdomen, hyperthermia, hypocalcemia, or hypoglycemia, appendicitis should be considered as a differential diagnosis. Further comparisons of medical and surgical treatments are required to establish treatment recommendations for rabbits with appendicitis.

Association between the computed tomography findings and operative time for interval appendectomy in children

PURPOSE

The purpose was to evaluate the association between operative time and findings noted on computed tomography (CT) immediately before interval appendectomy.

MATERIALS AND METHODS

Forty-two children who underwent CT before interval appendectomy were included. We evaluated the association between operative time and these image findings: (1) appendicolith, (2) increased intra-abdominal fat density around the appendix, (3) location of the appendix, (4) ascites, (5) abscess formation and (6) maximum appendix outer wall diameter. Appendix location was classified as (#1) just below the anterior abdominal wall; (#2) retrocaecal or retro-ascending colon and (#3) pelvic. Results were analysed using Pearson's correlation coefficient or Mann-Whitney U test.

RESULTS

The mean patient age and operative time were 116.24 ± 38.66 months (range, 31-195) and 67.76 ± 31.23 min (range, 30-179), respectively. Ascites was detected in only one case, and no abscess occurred in any patient; therefore, these findings were not analysed. Factors that significantly prolonged the operative time included increased intra-abdominal fat density around the appendix (absent, 59.43 ± 22.14 [range, 30-108] vs. present, 84.43 ± 40.13 [range, 32-179] min; P = 0.03) and retrocaecal or retro-ascending colon appendix (location 1, 40.83 ± 8.35 [range, 30-50]; location 2, 99.25 ± 18.56 [range, 74-135]; location 3, 64.54 ± 30.22 [range, 30-179] min; P < 0.01). There was a weak but significant association between maximum appendix outer wall diameter and operative time (R = 0.353; P = 0.02).

CONCLUSION

These pre-operative CT findings are important predictors of operative time for interval appendectomy. Radiologists and surgeons should use these specific image findings to predict the operative time and need for additional procedures during an interval appendectomy.

A Cross-Sectional Study of Neutrophil-to-Lymphocyte Ratio in Diagnosing Acute Appendicitis in Hospital Melaka

Background

Acute appendicitis is one of the most common surgical emergencies. However, its proper diagnosis is complicated. This study aims to evaluate the ability of the neutrophil-to-lymphocyte ratio (NLR) to diagnose acute appendicitis in pre-operative state.

Methods

Histopathological examination of appendicectomies conducted between 2016 and 2017 in Melaka Hospital, Malaysia were traced and categorised into three groups: i) G1 (normal appendix), ii) G2 (acute appendicitis) and iii) G3 (perforated appendicitis). The reports were randomised and a total of 338 samples were collected. NLR values were compared between the three different groups and analysed.

Results

The median values of NLR for G1, G2 and G3 were 2.37, 5.25 and 9.27, respectively. We found a statistically significant difference in NLR between G1 and G2 (P < 0.001), and G2 and G3 (P < 0.001). The diagnostic values of NLR for acute appendicitis and perforated appendicitis were 3.11 (sensitivity: 75.23%, specificity: 68.70%) and 6.17 (sensitivity: 76.32%, specificity: 58.72%), respectively. There was a substantial correlation between NLR and disease severity, and a moderate correlation between NLR and duration of admission.

Conclusion

NLR, with a sensitivity of 75.23% and specificity of 68.70%, is a useful and reliable adjunct in diagnosing acute appendicitis. Hence, it will help in reducing the rate of negative appendicectomies.

Meta-analysis of unplanned readmission to hospital post-appendectomy: an opportunity for a new benchmark

BACKGROUND

Appendicitis is the most common cause of acute abdominal pain requiring surgical intervention. While many studies report readmission, a meta-analysis of readmission post-appendectomy has not been published. This meta-analysis was undertaken to determine rates and predictors of hospital readmission following appendectomy and to potentially provide a metric benchmark.

METHODS

An ethically approved PROSPERO-registered (ID CRD42017069040) meta-analysis following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, using databases PubMed and Scopus, was undertaken for studies published between January 2012 and June 2017. Articles relating to outcomes and readmissions after appendectomy were identified. Those scoring >15 for comparative studies and >10 for non-comparative studies, using Methodological Index for Non-Randomized Studies criteria were included in the final analysis. The odds ratios (OR) using random-effects, Mantel-Haenszel method with 95% confidence intervals (CI), were computed for each risk factor with RevMan5.

RESULTS

A total of 1757 articles reviewed were reduced to 45 qualifying studies for a final analysis of 836 921 appendectomies. 4.3% (range 0.0-14.4%) of patients were readmitted within 30 days. Significant preoperative patient factors for increased readmission were diabetes mellitus (OR 1.93, CI 1.63-2.28, P < 0.00001), complicated appendicitis (OR 3.6, CI 2.43-5.34, P < 0.00001) and open surgical technique (OR 1.39, CI 1.08-1.79, P < 0.00001). Increased readmission was not associated with gender, obesity or paediatric versus general surgeons or centres.

CONCLUSION

This meta-analysis identified that readmission is not uncommon post-appendectomy, occurring in one in 25 cases. The mean readmission rate of 4.3% may act as a quality benchmark for improving emergency surgical care. Targeting high-risk groups with diabetes or complicated appendicitis and increasing use of laparoscopic technique may help reduce readmission rates.

Different Clinical Features and Lower Scores in Clinical Scoring Systems for Appendicitis in Preschool Children: Comparison with School Age Onset

PURPOSE

To clarify the clinical features of appendicitis in preschool children and to explore clinical appendicitis scoring systems in this age group.

METHODS

We retrospectively collected data on 142 children, aged 10 years or younger, with confirmed diagnosis of appendicitis based on surgical and pathologic findings. Enrolled subjects were divided into two groups: Group 1 (preschool children aged ≤5 years, n=41) and Group 2 (school children aged >5 to ≤10 years, n=101). Data analyzed included clinical presentation, laboratory findings, the pediatric appendicitis score (PAS), and the modified Alvarado score (MAS).

RESULTS

The most common presenting symptom was abdominal pain in both groups (92.7% vs. 97.0%). Other presenting symptoms were as follows: fever (65.9%), vomiting (68.3%), right lower quadrant (RLQ) localization (24.4%), anorexia (14.6%), and diarrhea (7.3%) in Group 1, and RLQ localization (74.3%), vomiting (71.3%), anorexia (52.5%), fever (47.5%), and diarrhea (11.9%) in Group 2. Perforation and abscess occurred more frequently in Group 1 than in Group 2 (43.9% vs. 12.9%, p<0.001; 34.1% vs. 5.0%, p<0.001; respectively). PAS and MAS were lower in Group 1 than in Group 2 (4.09±1.97 vs. 6.91±1.61, p=0.048; 4.65±1.79 vs. 6.51±1.39, p=0.012; respectively).

CONCLUSION

In preschool children, appendicitis often presents with atypical features, more rapid progression, and higher incidence of complications. This age group is more likely to have lower PAS and MAS than those of school children.

A Fatal Case of Acute Appendicitis

Appendicitis continues to be the most common acute surgical emergency. We report a fatal case of acute appendicitis, illustrating that the early presentation of appendicitis is non-specific and that serial examination is the key to the diagnosis to avoid a fatal outcome. We also present an evidence-based approach to the diagnosis of acute appendicitis in the emergency department and highlight the pearls and pitfalls of diagnosing acute appendicitis.

Clinical and Ultrasonographic Diagnosis of Acute Appendicitis

Appendicitis is one of the most common acute abdominal conditions encountered in the Emergency Department. It is a surgical condition that can affect any person of any age and often with varying clinical presentations. In the majority of cases, the diagnosis is straightforward. However in some, the diagnosis requires a heightened clinical suspicion. The application of adjuvant laboratory tests and diagnostic imaging helps to reduce the associated complications, morbidity and mortality of delayed diagnosis.

Water permeability is a measure of severity in acute appendicitis

Acute appendicitis is the most common indication for pediatric abdominal emergency surgery. Determination of the severity of appendicitis on clinical grounds is challenging. Complicated appendicitis presenting with perforation, abscess or diffuse peritonitis is not uncommon. The question remains why and when acute appendicitis progresses to perforation. The aim of this study was to assess the impact of water permeability on the severity of appendicitis. We show that AQP1 expression and water permeability in appendicitis correlate with the stage of inflammation and systemic infection parameters, leading eventually to perforation of the appendix. AQP1 is also expressed within the ganglia of the enteric nervous system and ganglia count increases with inflammation. Severity of appendicitis can be correlated with water permeability measured by AQP1 protein expression and increase of ganglia count in a progressive manner. This introduces the question if regulation of water permeability can present novel curative or ameliorating therapeutic options.

Towards remote assessment and screening of acute abdominal pain using only a smartphone with native accelerometers

Smartphone-based telehealth holds the promise of shifting healthcare from the clinic to the home, but the inability for clinicians to conduct remote palpation, or touching, a key component of the physical exam, remains a major limitation. This is exemplified in the assessment of acute abdominal pain, in which a physician's palpation determines if a patient's pain is life-threatening requiring emergency intervention/surgery or due to some less-urgent cause. In a step towards virtual physical examinations, we developed and report for the first time a "touch-capable" mHealth technology that enables a patient's own hands to serve as remote surrogates for the physician's in the screening of acute abdominal pain. Leveraging only a smartphone with its native accelerometers, our system guides a patient through an exact probing motion that precisely matches the palpation motion set by the physician. An integrated feedback algorithm, with 95% sensitivity and specificity, enabled 81% of tested patients to match a physician abdominal palpation curve with <20% error after 6 attempts. Overall, this work addresses a key issue in telehealth that will vastly improve its capabilities and adoption worldwide.

Delta neutrophil index as an early predictor of acute appendicitis and acute complicated appendicitis in adults

Background

This retrospective study aimed to evaluate the ability of the delta neutrophil index (DNI) to predict histologically normal appendicitis preoperatively and to differentiate between simple and complicated appendicitis.

Methods

The data from 650 patients were divided into positive and negative appendectomy groups (histologically normal appendicitis). The patients in the acute appendicitis group were further sub-divided into simple and complicated appendicitis groups.

Results

The DNI was significantly higher in the positive group than in the negative appendectomy group (0.4 vs. −0.4, p < 0.001) as well as in the complicated group compared with that in the simple appendicitis group (1.2 vs. 0.3, p < 0.001). The DNI independently predicted a positive appendectomy and an acute complicated appendicitis in multivariate logistic regression analysis [odds ratio (OR) 2.62, 95% confidence interval (CI) (1.11~6.16), p = 0.028 and odds ratio (OR) 4.10, 95% confidence interval (CI) (2.94~5.80), p < 0.001]. The optimum cut-off for a positive appendectomy and acute complicated appendicitis were 0.2 [area under curve (AUC) 0.709] and 0.6 (AUC 0.727).

Conclusions

We suggest that obtaining a preoperative DNI is a useful parameter to aid in the diagnosis of histologically normal appendicitis and to differentiate between simple and complicated appendicitis.

Diagnostic accuracy and prognostic utility of D Dimer in acute appendicitis in children

The objective was to determine the uselfulness of D Dimer (DD) as a diagnostic or prognostic marker in acute appendicitis (AA) in children using a prospective observational study in the pediatric emergency department of a tertiary hospital. We enrolled 135 patients aged 1-16 years presenting with abdominal pain consistent with AA, who required laboratory studies. We analyzed clinical, analytical variables and histopathology findings (when they underwent surgery). Statistical analysis was conducted using SPSS. 38.5% of the children were clinically diagnosed with AA (n = 52), confirmed by pathology in 51 patients. 55.8% were gangrenous appendicitis. Leucocyte count, C-reactive protein (CRP), and DD were higher in the AA group and in the gangrenous appendicitis group (p < 0.05), with highest values of DD in the gangrenous group. The area under the receiving operating characteristics (ROC) curve for DD in the diagnosis of AA is 0.66 (95% CI 0.56-0.75). For DD cut-off point of 230 ng/mL, sensitivity (Se) was 0.40, specificity (Sp) 0.80, positive predictive value (PPV) 0.57, and negative predictive value (NPV) 0.66. The area under the ROC curve for DD in children with gangrenous appendicitis is 0.93 (95% CI 0.87-1). A DD cut-off point of 230 ng/mL exhibited: Se = 0.69, Sp = 1, PPV = 1 and NPV = 0.72.

CONCLUSION

DD levels increase in patients with AA. Although it does not constitute a useful diagnostic marker, it could be a good prognostic marker.

Evaluating the Patient with Right Lower Quadrant Pain

Right lower quadrant pain is one of the most common indications for imaging evaluation of the abdomen in the emergency department setting. This article reviews important imaging findings associated with acute appendicitis as well as major differential considerations including: mesenteric adenitis, Meckel diverticulum, neutropenic colitis, right-sided diverticulitis, epiploic appendagitis, omental infarction, and inflammatory bowel diseaseRight lower quadrant pain is one of the most common indications for imaging evaluation of the abdomen in the emergency department setting. This article reviews important imaging findings associated with acute appendicitis as well as major differential considerations including: mesenteric adenitis, Meckel diverticulum, neutropenic colitis, right-sided diverticulitis, epiploic appendagitis, omental infarction, and inflammatory bowel disease.

Preoperative C-reactive protein predicts the severity and likelihood of complications following appendicectomy

INTRODUCTION

Diagnostic laparoscopy with appendicectomy (LA) has become the accepted method of investigation and treatment of appendicitis. However, concerns remain in cases of complicated appendicitis when many advocate conversion to an open procedure (LCOA) owing to the risk of complications. The aim of this study was to look for factors that could predict complications occurring in patients undergoing appendicectomy.

METHODS

Data inclusive of all consecutive appendicectomies over a two-year period were retrieved from the computerised theatre database. Clinical details including admission inflammatory markers, complications, severity (final pathology) and length of stay were collected from the discharge letter. Readmissions were identified as those hospital identifiers had a second set of admission dates and/or a second discharge letter.

RESULTS

During the 2-year study period, 517 appendicectomies were performed. Of these, 429 patients (83%) had LA and the remaining 88 (17%) had LCOA. The LA group had a mean age of 28 years (range: 2-86 years) and a mean C-reactive protein (CRP) level of 71 mg/l (range: 0-480 mg/l) while the LCOA group had a mean age of 46 years (range: 11-92 years) and a mean CRP level of 162 mg/l (range: 3-404 mg/l). These differences in age and CRP were significant (p<0.001). LA patients were less likely to have complications overall (22% vs 52%, p=0.015). Complications were independently more than twice as common with established inflammation with a CRP level of >150 mg/l (p<0.05).

CONCLUSIONS

A high preoperative CRP level predicts an increased rate of postoperative complication due to established inflammation and/or infection. This raises the question of whether we should be offering primary open appendicectomies to patients with a CRP level of >150 mg/l.

Acute appendicitis: investigating an optimal outer appendiceal diameter cut-point in a pediatric population

BACKGROUND

Acute appendicitis is the most common cause of abdominal pain in children requiring operative intervention. Among a number of sonographic criteria to aid in the diagnosis of appendicitis, an outer diameter >6 mm is the most objective and widely accepted. However, there is a lack of evidence-based standards governing this consensus.

STUDY OBJECTIVES

The aim of this study was to determine the outer appendiceal diameter that maximizes sensitivity and specificity in a pediatric population.

METHODS

A retrospective review of all urgent diagnostic ultrasounds (US) was performed over 2 years in children aged <18 years. The diagnostic accuracy of various cut-points was assessed by calculating the sensitivity and specificity and plotting a receiver operating characteristic (ROC) curve.

RESULTS

The study sample consisted of 398 patients in whom the appendix was visualized on US. The median outer appendiceal diameter was significantly higher in the surgical group compared to the nonsurgical group (9.4 mm; range = 8.1-12.0 vs. 5.5 mm; range = 4.4-6.5, p < 0.01). The optimal cut-point with the greatest area under the ROC curve was determined to be an outer appendiceal diameter of 7.0 mm.

CONCLUSIONS

In our patients, adopting a 7-mm rather than a 6-mm appendiceal diameter threshold would balance a greater number of missed cases of acute appendicitis for a reduction in the number of unnecessary surgeries.

The vermiform appendix: a review

New research on the vermiform appendix has shed light on its function. In further understanding the function of the appendix, this information should not negatively impact the clinical judgment in the event of appendicitis. Although the appendix and its pathology have been noted for centuries, it still presents a challenge in the operating room. The most common emergency surgical procedure performed is an appendectomy. Its highly variable position within the abdomen can cause confusion for clinicians. However, improved imaging modalities have heightened the physician's ability to diagnose disease of this organ. This article reviews germane literature regarding the human vermiform appendix.

Distinct sonographic features of acute appendicitis in sickle cell disease

BACKGROUND AND OBJECTIVES

The purpose of this study was to report sonographic findings of appendicitis in patients with positive screening tests for sickle cell compared to normal control patients.

DESIGN AND SETTING

A retrospective study of the medical records of 396 patients who underwent appendectomy during a 3-year period from March 2005-2008.

PATIENTS AND METHODS

The study included 216 males and 180 females, whose ages ranged from 7 to 55 years. Four patients (0.9%) had sickle cell disease (SCD), 101 had sickle cell trait (SCT) (25%) and 291 (74%) patients were without sickle cell anemia (control group).

RESULTS

Positive sonographic findings of appendicitis were identified in 95 (90%) SCT patients and in 253 (87%) control patients. The mean maximal mural thickness was higher in sickle cell patients (4.5 [1.4] mm) in comparison with the control group (3.0 [2.2] mm) (P < .0001). Appendicolith was significantly detected in 53% of the control group and in 8.5% of the sickle cell group (P < .0001). Color Doppler showed hypervascularity in 72% of patients with appendicitis in the control group with a significant difference compared to only 12 cases (11%) of SC patients (P < .05). Ultrasonography findings suggesting perforation were found in 35 sickle cell patients and in 75% (3 of the 4 patients) with SCD. Findings suggesting perforation were found only in 49 patients (17%) of the control group. Perforated appendix was significantly higher in sickle cell patients in preoperative US and intraoperatively (P < .05)

CONCLUSION

Positive sonographic findings of appendicitis in sickle cell patients are different from the general population. These findings include mural thickening with a low incidence of appendicolith and wall hypervascularity. Also sonographic features of perforation in sickle cell patients are more common suggesting a need for more urgent operative intervention.

Diagnosis of acute appendicitis

Appendicitis is the most common abdominal emergency. While the clinical diagnosis may be straightforward in patients who present with classic signs and symptoms, atypical presentations may result in diagnostic confusion and delay in treatment. Abdominal pain is the primary presenting complaint of patients with acute appendicitis. Nausea, vomiting, and anorexia occur in varying degrees. Abdominal examination reveals localised tenderness and muscular rigidity after localisation of the pain to the right iliac fossa. Laboratory data upon presentation usually reveal an elevated leukocytosis with a left shift. Measurement of C-reactive protein is most likely to be elevated. The advances in imaginology trend to diminish the false positive or negative diagnosis. Radiographic image of faecal loading image in the caecum has a sensitivity of 97% and a negative predictive value that is 98%. In experienced hands, ultrasound may have a sensitivity of 90% and specificity higher than 90%. Helical CT has reported a sensitivity that may reach 95% and specificity higher than 95%. Despite all medical advances, the diagnosis of acute appendicitis continues to be a medical challenge.

Ileal perforation induced by a wire from a metal scouring pad in an infant

Foreign body ingestion is a common occurrence in the pediatric population. We present the case of a 1-year-old infant boy who presented with abdominal distention and shock. At laparotomy, he was found to have an ileal perforation caused by a wire from an aluminum scouring pad that his parents were not aware he had ingested. To our knowledge, this is the first case report of a scouring pad-related perforation. This report emphasizes the danger of ingesting fragments of a metal scouring pad and the importance of considering foreign body impaction in the workup of pediatric gastrointestinal perforation.

Prospective validation of two systems of classification for the diagnosis of acute appendicitis

OBJECTIVES

The objectives of this study were (1) to validate the Alvarado score and pediatric appendicitis score (PAS) in a prospectively identified pediatric cohort and (2) to assess abdominal ultrasonography (AUS) as a tool to increase the diagnostic reliability of both scores.

PATIENTS AND METHODS

Prospective study conducted from January 10, 2008, to January 1, 2009. All patients attended at the emergency department with suspected acute appendicitis (AA) who had a blood sample collected were included. Items from both scores were recorded. The performance of an AUS, the decision to admit the patient, and the therapeutics were decided by the physician, disregarding the scores values. Nonadmitted patients were contacted by telephone.

RESULTS

Ninety-nine patients were included. Mean age was 11 years, and 62.6% were males. Appendectomy was performed in 44.4% patients. The area under the receiver operating characteristic curve for the Alvarado score was 0.96 and that for PAS was 0.97. Not a single patient with an Alvarado score less than 5 or PAS less than 4 had AA. All patients with an Alvarado score greater than 8 or PAS greater than 7 had AA. For both scores, the optimum cutoff point was 6 (sensibility of 90.4% and specificity of 91.2% for the Alvarado score and sensibility of 88.1% and specificity of 98.2% for PAS). Abdominal ultrasonography was performed on 31 patients (sensibility of 84.6% and specificity of 94.4%). We studied the value of scores and AUS together. Assuming an Alvarado score from 1 to 4 and PAS from 1 to 3 as no AA, an Alvarado score from 9 to 10 and PAS from 8 to 9 as AA, and proceeding according to the AUS for intermediate values, a sensibility of 93.3% and 97.2% and a specificity of 100% and 97.6%, respectively, were obtained.

CONCLUSIONS

Both scores are a useful tool in the evaluation of children with possible AA. For extreme values of scores, the results really ensure their use in the emergency department. The AUS can help on decision making for intermediate values.

An approach to model Right Iliac Fossa pain using pain-only-parameters for screening acute appendicitis

Acute appendicitis (AA) is one of the commonest of multiple possible pathologies at the backdrop of Right Iliac Fossa (RIF) pain. RIF is the most common acute surgical condition of the abdomen. Even though AA is a recognized disease entity since decades, its diagnosis still lacks clinical confidence and mandates laboratory tests. Given the issue, this paper proposes a mathematical model using Pain-Only-Parameters (POP) obtained from available literature to screen AA. Weights have been assigned for each POP to create a training data matrix (N = 51) and used to calculate the cumulative effect or weighted sum, which is termed as the Pain Confidence Score (PCS). Based on PCS, a group of real-world patients (N = 40; AA and NA = 20 each) are classified as cases of AA or non-appendicitis (NA) with satisfactory results (sensitivity 85%, specificity 75%, precision 77%, and accuracy 80%). Most rural health centers (RHC) in developing nations lack specialist services and related infrastructure. Hence, such a tool could be useful in RHC to assist general physicians in screening AA and their timely referral to higher centers.

Osteomyelitis of the iliac crest: a rare complication following perforated appendicitis

BACKGROUND

Appendicitis is a common surgical emergency with numerous postoperative infective complications. We report an unusual case of iliac crest osteomyelitis as a late complication following emergency appendectomy for perforated gangrenous appendicitis.

METHODS

Review of the pertinent English language literature.

RESULTS

To the best of our knowledge, this is the first report in the English literature to describe iliac crest osteomyelitis as an infective complication of perforated gangrenous appendicitis. The diagnosis was made with the aid of magnetic resonance imaging and radioisotope bone scans. The complication was treated successfully with broad-spectrum intravenous antibiotics and physiotherapy.

CONCLUSION

Iliac crest osteomyelitis is indeed a rare complication of appendicitis. A heightened awareness and better understanding of this complication would necessitate early diagnosis and treatment.

Serotonin content of normal and inflamed appendix: a possible role of serotonin in acute appendicitis

The appendix is lined by a mucosa which has many neuroendocrine cells containing serotonin. Local release of serotonin can act as a mediator of inflammation. In this study we explored the serotonin content of the neuroendocrine cells of the appendixes removed for clinical diagnosis of appendicitis. Appendix specimens were divided into three groups: Acute appendicitis (AA), non-appendicitis (NA), and follicular hyperplasia (FH). Normal appendix specimens from patients undergoing elective abdominal surgery were used as the control group (NL). All sections were exposed to proteinase K, incubated with anti-serotonin, chromogranin A, and synaptophysin antibodies, and treated with the LSAB kit. Polygonal cells were seen within the crypt epithelium (enterochromaffin cell, EC) and within the lamina propria (subepithelial neuroendocrine cell, SNC). In AA, only 16 cases (64%) showed serotonin staining in non-destructed glands. There was a significant reduction in the number of ECs in AA compared to the FH (96%), NA (100%) and NL (100%) groups (P<0.001). Chromogranin and synaptophysin immunostaining also showed a significant reduction in the number of ECs in AA compared with the other three groups (P<0.001). SNC serotonin reactivity was lower in the AA group compared with the other groups (p<0.001). The inflamed appendix is markedly depleted of serotonin in the epithelium and lamina propria. Local serotonin release from ECs and SNCs in the appendix may act as an inflammatory mediator in appendicitis and is likely to be the source of raised blood serotonin in AA.

Gastrointestinal perforation and the acute abdomen

The acute abdomen accounts for up to 40% of all emergency-surgical hospital admissions and is considered in the differential in the more than 7 million visits to the emergency department annually for abdominal pain in the United States. A large percentage of these cases are secondary to perforation or impending gastrointestinal perforation. Gastrointestinal perforation causes considerable mortality and usually requires emergency surgery.Rapid diagnosis and treatment of these conditions is essential to reduce the high morbidity and mortality of late-stage presentation. Successful treatment requires a thorough understanding of the anatomy, microbiology, and pathophysiology of this disease process and in-depth knowledge of the therapy, including resuscitation,antibiotics, source control, and physiologic support.

New CT criterion for acute appendicitis: maximum depth of intraluminal appendiceal fluid

OBJECTIVE

The purpose of this study was to evaluate whether a new criterion-maximum depth of the intraluminal appendiceal fluid-is useful to differentiate between a normal appendix with diameter greater than 6 mm and appendicitis without periappendiceal inflammation.

MATERIALS AND METHODS

The study included 59 patients showing a normal appendix with diameter greater than 6 mm and having no adjacent lesions (noncomplicated-normal-appendix group), 30 patients showing a normal appendix with diameter greater than 6 mm and having adjacent lesions (complicated-normal-appendix group), and 38 patients showing appendicitis without periappendiceal inflammation (appendicitis group). The following specific CT findings were retrospectively evaluated: maximum appendiceal diameter greater than 6 mm, maximum appendiceal wall thickness greater than 3 mm, appendiceal wall enhancement, focal cecal wall thickening, adjacent adenopathy, appendicolith, and maximum depth of the intraluminal appendiceal fluid.

RESULTS

The mean maximum depth of the intraluminal appendiceal fluid in the appendicitis group was significantly higher than in the two groups with a normal appendix (Mann-Whitney U test: p < 0.001). When using maximum depth of the intraluminal appendiceal fluid greater than 2.6 mm for a criterion of appendicitis, sensitivity and specificity for differentiation between the appendicitis group and the other two groups with a normal appendix were both greater than 80%. In contrast, when using another CT a criterion, either sensitivity or specificity was 50% or less.

CONCLUSION

The new CT criterion based on the maximum depth of the intraluminal appendiceal fluid greater than 2.6 mm is particularly useful for differentiating appendicitis without periappendiceal inflammation from a normal appendix with a diameter greater than 6 mm.

Acute abdominal pain

Acute abdominal pain is a complaint seen commonly in the outpatient setting that has a broad and often confusing differential diagnosis. Although many presentations can be managed on an outpatient basis, several gastrointestinal causes of abdominal pain demand thoughtful consideration with subsequent referral to a higher level of care for appropriate diagnosis and treatment. To achieve this goal, outpatient physicians must have an understanding of the mechanisms of abdominal pain, as well as the common gastrointestinal causes that carry potentially higher morbidity and mortality.

Acute abdominal pain

Because there are many causes of acute abdominal pain, a systematic approach by the evaluating physician is necessary to narrow the differential diagnosis. It is vital that the physician have an understanding of the mechanisms of pain generation and be familiar with the presentations of common diseases that cause abdominal pain. Recognizing the red flags in the history and physical examination and the initial imaging and laboratory findings helps to determine which patients may have a serious underlying disease process, and therefore warrant more expedited evaluation and treatment.

Impact of helical computed tomography on the rate of negative appendicitis

OBJECTIVE

To assess the impact of helical computed tomography (HCT) on the rate of negative appendicitis (NA).

METHODS

A before-and-after comparison study comparing data from a prospective consecutive case series to data from a retrospective chart review. The prospective series included all patients presenting to the ED during a 19-month period, during which patients with suspected appendicitis were managed in accordance with a guideline that stipulated HCT in selected cases. The retrospective group included patients taken to the operating room (OR) with a preoperative diagnosis of appendicitis over a 4-year time frame before the use of HCT. The primary outcome variable was the rate of NA.

RESULTS

During the HCT era, 104 of 310 patients, 71 (68%; 95% confidence interval [CI], 59-76) men and 33 (32%; 95% CI, 24-41) women, were taken to the OR with a diagnosis of appendicitis. Fourteen (13.5%; 95% CI, 8-21) were NA. During the pre-HCT period, 445 patients, 280 (62.9%; 95% CI, 58-67) men and 165 (37.1%; 95% CI, 33-42) women were taken to the OR with the preoperative diagnosis of appendicitis, and 66 (14.8%; 95% CI, 12-19) were NA.

CONCLUSION

At the study institution, the selective use of HCT did not result in a significant decline in the rate of NA.

Antibiotics versus placebo for prevention of postoperative infection after appendicectomy

BACKGROUND

Appendicitis is the most common cause of acute abdominal pain requiring surgical intervention. The cause of appendicitis is unclear and the mechanism of pathogenesis continues to be debated. Despite improved asepsis and surgical techniques, postoperative complications, such as wound infection and intraabdominal abscess, still account for a significant morbidity. Several studies implicate that postoperative infections are reduced by administration of antimicrobial regimes.

OBJECTIVES

This review evaluated the use of antibiotics compared to placebo or no treatment in patients undergoing appendectomy. Will these patients benefit from antimicrobial prophylaxis? The outcomes were described according to the nature of the appendix, as either simple appendicitis (including the non-infectious stage) and complicated appendicitis. The efficacy of different antibiotic regimens were not evaluated.

SEARCH STRATEGY

We searched The Cochrane Central Register of Controlled Trials (Cochrane Library 2005 issue 1); Pubmed ; EMBASE; and the Cochrane Colorectal Cancer Group Specialised Register (April 2005). In addition, we manually searched the reference lists of the primary identified trials.

SELECTION CRITERIA

We evaluated Randomised Controlled Trials (RCTs) and Controlled Clinical Trials (CCTs) in which any antibiotic regime were compared to placebo in patients suspected of having appendicitis, and undergoing appendectomy. Both studies on children and adults were reviewed. The outcome measures of the studies were: Wound infection, intra abdominal abscess, length of stay in hospital, and mortality.

DATA COLLECTION AND ANALYSIS

Eligibility and trial quality were assessed, recorded and cross-checked by two reviewers.

MAIN RESULTS

Forty-five studies including 9576 patients were included in this review. The overall result is that the use of antibiotics is superior to placebo for preventing wound infection and intraabdominal abscess, with no apparent difference in the nature of the removed appendix. Studies exclusively on children and studies examining topical application reported results in favour to the above, although the results were not significant.

AUTHORS' CONCLUSIONS

Antibiotic prophylaxis is effective in the prevention of postoperative complications in appendectomised patients, whether the administration is given pre-, peri- or post-operatively, and could be considered for routine in emergency appendectomies.

Acute pelvic pain: Evaluation and management

Acute pelvic pain in women is often a diagnostic dilemma. Obstetrical, gynecological, urological or gastrointestinal causes must be considered. Stabilization, immediate therapy and early consultation are often indicated. If no etiology is found, conservative management with frequent re-evaluation is adequate.

Urinary 5-hydroxy indole acetic acid as a test for early diagnosis of acute appendicitis

OBJECTIVES

Acute appendicitis (AA) is the most common abdominal emergency. The appendix has abundant serotonin containing cells. Upon inflammation, serotonin is released in the blood and converted into 5-HIAA (5-hydroxy indole acetic acid). Measurement of the urine 5-HIAA (U-5-HIAA) could be a reliable marker of inflammation of the appendix. We have compared the powers of test performance of spot U-5-HIAA and spot U-5-HIAA/creatinin with other routine laboratory tests used for the diagnosis of acute appendicitis.

DESIGN AND METHODS

Urine, serum, and blood samples of 110 patients who were admitted and observed in the emergency units of two university hospitals were studied. 5-HIAA was measured using HPLC, C-reactive protein by immunoturbidometry, WBC by electronic cell counting, and urine creatinine by the Jaffe method. Diagnostic accuracy of the various tests was evaluated by receiver operating characteristic (ROC) analysis.

FINDINGS

The mean of spot U-5-HIAA in 39 patients with AA (nongangrenous) was 32 +/- 2.6 micromol/L, which was much higher than the mean of 40 non-appendicitis patients (NA) (5.5 +/- 0.6), 10 follicular hyperplasia (7.5 +/- 2.1), and 50 healthy control cases (4.1 +/- 0.5) with P < 0.001. The concentration of U-5-HIAA in 21 patients with gangrenous appendicitis (GA) (13.8 +/- 2.1) was also higher than NA patients and healthy individuals but lower than AA cases (P < 0.05). Considering 10 micromol/L as the cutoff point, this test shows 84% sensitivity and 88% specificity, with 90% and 81% positive and negative predictive values, respectively. The area under ROC curve (AUC) of U-5-HIAA in the diagnosis of AA (AUC = 0.903) was much larger than AUCs of U-5-HIAA/Cr (0.787), WBC (0.703), and CRP (0.660).

CONCLUSION

: Urinary secretion of 5-HIAA increases significantly in acute appendicitis and measurement of spot U-5-HIAA gives higher diagnostic accuracy than other routine laboratory tests. While the inflammation progresses to necrosis of the appendix, the concentration of 5-HIAA decreases. This decrease could be a warning sign of perforation of the appendix.

Diagnosing suspected acute nonclassic appendicitis with sulesomab, a radiolabeled antigranulocyte antibody imaging agent

PURPOSE

The aim of this study was to investigate the potential role of a technetium 99m-labeled antigranulocyte murine antibody Fab' fragment (sulesomab) as a diagnostic imaging agent in children with suspected acute nonclassic appendicitis.

METHODS

Serial planar images at 15 to 30 minutes, 1, 2, and 4 hours and single-photon emission computed tomography (SPECT) images were acquired after sulesomab injection. In 40 children with suspected acute nonclassic appendicitis, imaging results were confirmed surgically in 21 patients, whereas 19 nonsurgical patients resolved presenting signs and symptoms and were considered to not have appendicitis.

RESULTS

Sulesomab imaging had 95% sensitivity, 90% specificity, 95% negative predictive value, and 90% positive predictive value for acute appendicitis. In 78% of patients, sulesomab accurately detected or excluded acute appendicitis and would have changed management plans. No patients had adverse events, and no human antimurine antibody response occurred in 18 evaluable patients.

CONCLUSIONS

Sulesomab was well tolerated with no side effects and with no apparent immunogencity. Appendicitis was rapidly and accurately detected. In pediatric patients with suspected nonclassic appendicitis, management decisions incorporating sulesomab imaging provided benefit in separating surgical from nonsurgical patients.