Abdominal emergencies during pregnancy

Validation of the Appendicitis Inflammatory Response (AIR) score during pregnancy: A nested case-control study

OBJECTIVES

Appendicitis poses diagnostic challenges. A correct diagnosis is important during pregnancy to avoid unnecessary surgery on the one hand and delayed surgery on the other hand, as both may negatively affect pregnancy outcomes. Clinical scores for risk-stratified management of suspected appendicitis are well established in adults but have not been validated during pregnancy. This nested case-control study evaluated the diagnostic accuracy of the Appendicitis Inflammatory Response (AIR) score and imaging during pregnancy.

METHODS

By cross-linking national Swedish health registries from a defined geographical area, we identified a cohort of 154 women who underwent appendectomy for suspected appendicitis during pregnancy and a matched cohort of 232 pregnant women admitted for acute abdominal pain and suspected appendicitis but with a discharge diagnosis of nonspecific abdominal pain (NSAP). All variables were extracted from medical records. The diagnostic value of AIR score and imaging was estimated for patients with a final diagnosis of appendicitis compared with patients with negative appendectomy and NSAP patients.

RESULTS

The final diagnoses for the operated patients were uncomplicated and complicated appendicitis in 49.4% and 26.6%, respectively, and negative appendectomy in 24.0%. Nearly half of all the patients underwent diagnostic imaging (41%), mainly by ultrasonography. The sensitivity and specificity of diagnostic imaging were 44.9% (95% CI 32.9%-57.4%) and 42.2% (95% CI 31.9%-53.1%), respectively. The area under the receiver operating characteristic curve of AIR score was 0.88 (95% CI 0.84-0.92) for all appendicitis and 0.90 (95% CI 0.84-0.95) for complicated appendicitis. The sensitivity for complicated appendicitis was 100% at a score of ≥4. The specificity for all appendicitis was 97% at a score of ≥9.

CONCLUSIONS

The results of this study suggest that the AIR score may be a suitable diagnostic tool for risk stratification of pregnant women with abdominal pain and suspected appendicitis but further validation among pregnant women is needed.

Treatment effects of laparoscopy versus laparotomy on heterotopic pregnancy after in vitro fertilization and embryo transfer

OBJECTIVE

To compare the treatment effects of laparoscopy versus laparotomy on heterotopic pregnancy (HP) after in vitro fertilization-embryo transfer (IVF-ET).

METHODS

The retrospective case-control study enrolled 109 patients diagnosed with HP after IVF-ET treatment in our hospital from January 2009 to March 2020. All patients received surgical treatment by either laparoscopy or laparotomy. Data for general characteristics, diagnostic features, surgical parameters, as well as perinatal and neonatal outcomes were collected.

RESULTS

Sixty-two patients received laparoscopy and 47 received laparotomy. Significantly lower percentage of large hemoperitoneum (P = 0.001), shorter surgery duration (P < 0.001), less intraoperative blood loss (P = 0.001), higher rates of general anesthesia (P < 0.001), and lower cesarean section rates for singletons (P = 0.003) were found in the laparoscopy group. The perinatal and neonatal outcomes were comparable between the two groups. When interstitial pregnancy was considered alone, the surgical blood loss was significantly reduced in the laparoscopy group (P = 0.021), but there was no significant difference in hemoperitoneum, surgery duration, or perinatal and neonatal outcomes in singletons.

CONCLUSION

Both laparoscopy and laparotomy are effective surgical treatments for HP after IVF-ET. Laparoscopy is minimally invasive but laparotomy can be an alternative in emergency situations.

Successful Outcome in an Operated Case of Small Bowel Obstruction: Unmasking the Culprit

Abdominal distension, constipation, and vomiting are just a few of the symptoms of small bowel obstruction (SBO), a disorder with several well-known frequent causes. Patients may now be more carefully chosen for surgical intervention and frequent causes of SBO can be quickly detected thanks to recent advancements in both imaging modalities and minimally invasive procedures. Despite these developments, it must be emphasized that diagnosing unusual causes of SBO remains challenging. This study describes a 38-year-old female patient who was diagnosed with a capsulated submucosal leiomyoma and later treated surgically.

Meckel's Diverticulum as a Cause of Small Bowel Obstruction Complicated with Gangrene in the Third Trimester of Pregnancy: A Case Report

Acute abdomen during pregnancy is rare. Despite advances in diagnostic imaging, preoperative diagnosis in the pregnant population due to anatomical and physiological changes can pose difficulties. Diagnosis and surgery delays increase the risk of adverse outcomes for both maternal and fetal health. In symptomatic cases, explorative surgery might be essential for correct diagnosis and patient treatment. Here, we present Meckel's diverticulum as an unusual cause of small bowel obstruction complicated with gangrene in a 34-week pregnant patient. The diagnosis was only apparent during explorative surgical laparotomy.

A pregnant lady with compound bowel obstruction managed with thoracic epidural as sole anesthesia in a resource-restricted setting: a case report

BACKGROUND

Preserving the mother's safety, sustaining the pregnancy state, and achieving the optimal fetal outcome are the major priorities when managing obstetric patients for non-obstetric surgery. Only necessary and urgent surgeries are carried out during pregnancy due to the effects of anesthesia and surgery on the fetus. Compound bowel obstruction (small and large bowel obstruction) is rare, especially during the third trimester of pregnancy. Besides this, the procedure (laparotomy) was done with awake opioid-based thoracic epidural anesthesia as the sole anesthesia. This case report of awake laparotomy for major abdominal surgery is the first of its kind with an excellent feto-maternal outcome.

CASE PRESENTATION

A 30-year-old African pregnant lady presented to the emergency department with a chief complaint of abdominal pain and vomiting for an 8-hour duration; associated with this, she had a history of blurred vision, lightheadedness, loss of appetite, low-grade fever, and constipation. Later, she was diagnosed with large bowel obstruction and underwent an emergency laparotomy, managed with a thoracic epidural sole anesthesia.

CONCLUSION

A multidisciplinary team approach is greatly recommended to safeguard a sufficient standard of care for both the mother and fetus. The provision of regional anesthesia for patients with high risks in perioperative periods is crucial for a better postoperative outcome. We have confidence that thoracic epidural anesthesia can be used as another anesthetic option for major abdominal surgery in a resource-restricted setting for patients who are expected to have a significant risk of perioperative adverse events under general anesthesia.

Does one of the two most commonly used scoring systems have a decisive advantage over the other in diagnosing acute appendicitis in pregnant women?

This study aimed to compare the accuracy and reliability of Alvarado Score (AS) and Appendicitis Inflammatory Response Score (AIRS) in pregnant women undergoing surgery for acute appendicitis (AA). The files of 53 pregnant women with a diagnosis of AA who underwent surgery in our clinic between February 2014 and December 2018 were examined retrospectively. The patients were divided into 3 groups as follows: first trimester between 0 and 14 weeks, second trimester between 15 and 28 weeks, and third trimester between 29 and 42 weeks. The AS and AIRS values were calculated according to preoperative physical examination and laboratory results. The mean age of the patients was 28.58 (18-44) years. According to the pathology results, appendicitis was detected in 16 of 23 patients in the first trimester, in 22 of 25 patients in the second trimester, and in 2 of 5 patients in the third trimester. The AIRS was ≥ 9 in 9 patients and the AS was ≥ 7 in 19 of the 23 patients in the 1st trimester, while the AIRS was ≥ 9 in 11 patients and the AS was ≥ 7 in 19 of the 25 patients in the 2nd trimester. However, in the 3rd trimester, the AIRS was ≥ 9 in 2 patients and AS was ≥ 7 in 4 of the 5 patients. In conclusion, when the data obtained from the present study were evaluated, it was determined that both AS and AIRS are effective methods for diagnosing AA in pregnant women.

Role of Ultrasound in the Assessment and Differential Diagnosis of Pelvic Pain in Pregnancy

Pelvic pain (PP) is common in pregnant women and can be caused by several diseases, including obstetrics, gynaecological, gastrointestinal, genitourinary, and vascular disorders. Timely and accurate diagnosis as well as prompt treatment are crucial for the well-being of the mother and foetus. However, these are very challenging. It should be considered that the physiological changes occurring during pregnancy may confuse the diagnosis. In this setting, ultrasound (US) represents the first-line imaging technique since it is readily and widely available and does not use ionizing radiations. In some cases, US may be conclusive for the diagnosis (e.g., if it detects no foetal cardiac activity in suspected spontaneous abortion; if it shows an extrauterine gestational sac in suspected ectopic pregnancy; or if it reveals a dilated, aperistaltic, and blind-ending tubular structure arising from the cecum in suspicious of acute appendicitis). Magnetic resonance imaging (MRI), overcoming some limits of US, represents the second-line imaging technique when an US is negative or inconclusive, to detect the cause of bowel obstruction, or to characterize adnexal masses.

Are Cesarean Section and Appendectomy in Pregnancy and Puerperium Interrelated? A Cohort Study

Introduction

It is not known whether appendectomy for acute appendicitis (AA) increases the Cesarean section (CS) rate and whether CS increases the likelihood of AA and appendectomy in the early puerperium. In this study, delivery type and delivery outcomes and appendectomy during pregnancy and puerperium were analyzed.

Methods

This cross-sectional retrospective study was performed on 11,513 women, delivered during 2015–2020. Inclusion criteria were patients undergoing appendectomy for AA during pregnancy and the first 6 weeks after delivery. Evaluating parameters were age, parity, gestational week at birth, delivery type, and babies' birth weight.

Results

Thirty-two patients underwent appendectomy: 12 during pregnancy (2 in the first trimester, 6 in the second trimester, 4 in the third trimester) and 20 women during puerperium. 58.2% of pregnant women and 65% of puerperal women were submitted to CS.

Discussion

Half of the women who underwent appendectomy for AA during pregnancy may require urgent CS. The cause of acute abdomen in the postpartum period, especially in the first week, could be AA, especially in women delivered by CS.

Unilateral adrenal infarction in pregnancy with associated acute hypoadrenalism and subsequent spontaneous biochemical and radiological resolution

Adrenal infarction is a rare cause of abdominal pain during pregnancy, and if missed, it can result in devastating clinical consequences for the mother and the child. The authors report a case of a young female who presented with severe abdominal pain and nausea. The biochemistry showed raised inflammatory markers and significant lactic acidosis. As the cause of the symptoms was not clear and the patient continued to deteriorate, a contrast‐enhanced CT abdomen and pelvis was done which was suggestive of an acute left adrenal infarction. Subsequently, the patient was confirmed to have biochemical hypoadrenalism and required replacement doses of hydrocortisone until recovery of the adrenal glucocorticoid reserve and anticoagulation for the duration of pregnancy. We discuss the workup including diagnostic imaging, follow‐up, and considerations for future pregnancies in this case.

Strangled gravidic uterus, an exceptional complication of umbilical hernia during pregnancy, a case report

Introduction

Strangulated pregnancy is a very rare presentation in which the intra umbilical strangulated form is exceptional. To our knowledge, we report the first Moroccan case and one of less than 10 cases published in the literature of a strangulated gravid uterus; in a woman admitted for treatment of umbilical pain.

Case presentation

Through this presentation, we report a sporadic case of hernial strangulation during pregnancy containing an evolving pregnancy in the umbilical harness bag. The suspicion of this diagnosis was clinical and the confirmation made by ultrasound and abdominal MRI for confirmation. The objectives of this publication are threefold: i), to report this new exceptional case ii), to highlight the place of imaging in the management of hernial pathology iii), and to recommend surgical treatment of umbilical hernias in women of childbearing age in order to avoid surgical complications and maternal and fetal morbidity and mortality.

Conclusion

Our case report shows that we should consider this very rare presentation of strangulated pregnancy. Our work also reports another new case to the poor published literature on this subject and emphasizes the importance of surgical management of parietal pathology by focusing on the parietal impact of physiological change during pregnancy.

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Atypical presentation of the strangled uterus.

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A strangled umbilical hernia containing a pregnant uterus being one of less than 10 cases reported in the literature.

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Take into consideration the possibility of complication of parietal pathology during pregnancy.

Laparoscopic Versus Open Appendectomy for Appendicitis in Pregnancy: Systematic Review and Meta-Analysis

OBJECTIVES

The clinical safety, efficacy and feasibility of laparoscopic appendectomy (LA) compared with open appendectomy (OA) in pregnancy are still controversial. Herein, we are aiming to compare the clinical outcomes of LA and OA in patients with acute appendicitis during their pregnancy.

MATERIALS AND METHODS

This was a systematic review and meta-analysis of studies comparing laparoscopic and OA in pregnancy identifying using PubMed, Web of science, Embase, The Cochrane Library, Ovid and Scopus. Two independent reviewers extracted data on surgical complication, fetal loss, preterm delivery, hospital stay, Apgar score in both groups.

RESULTS

Twenty-seven studies with total of 6497 patients (4464 in open and 2031 in laparoscopic group) were included. LA was associated with lower rate of wound infection [odds risk (OR)=3.13, 95% confidence interval (CI): 1.77-5.56, P<0.0001] overall complications (OR=2.15, 95% CI: 1.47-3.14, P<0.0001) and shorter hospitalization (mean difference=0.72, 95% CI: 0.43-1.02, P<0.00001) compared with open group. LA was in a lower risk for 5-minute Apgar score (mean difference=0.09, 95% CI: 0.02-0.17, P=0.01) group than open group. No difference was found regarding preterm delivery between 2 groups. LA was associated with higher fetal loss (OR=0.57, 95% CI: 0.41-0.79, P=0.0007) compared with open surgery. However, laparoscopy was not associated with increased fetal loss after 2010 (OR=0.74, 95% CI: 0.44-1.24, P=0.26) compared with open group.

CONCLUSIONS

LA in pregnancy seems to be feasible with acceptable outcome, especially in patients with early and mid-trimester period, with sophisticated hands and experienced centers.

Ovarian torsion in a twin pregnancy at 32 weeks and 6 days: A case-report

BACKGROUND

Ovarian torsion during pregnancy is a rare event and occurs mostly during the first trimester. This is the first case describing the diagnosis and management of an ovarian torsion at 33 weeks in a twin pregnancy with a normal term delivery.

CASE SUMMARY

The patient presented with irregular uterine contraction due to an acute abdominal pain in the right iliac fossa. A cyst was discovered during the ultrasound scan on the right ovary and a torsion was highly suspected. A small laparotomy facing the ovarian mass after an ultrasound guidance was chosen. The patient finally delivered at 37 weeks.

CONCLUSION

The clinic holds a preponderant place in the diagnosis of ovarian torsion. Our surgical approach by laparotomy under ultrasound guidance was less risky than by laparoscopy.

Clinical Outcomes of Acute Appendicitis During Pregnancy: Conservative Management and Appendectomy

PURPOSE

We have described the epidemiology, diagnostic modality, treatment patterns, and outcomes of acute appendicitis during pregnancy.

METHODS

Using a nationwide claim-based database in Japan, we analyzed the data of pregnant patients who were diagnosed with appendicitis between January 2005 and May 2019. Patient characteristics, imaging studies, length of hospital stay, proportion of fetal losses, complications, and type of antibiotics were examined.

RESULTS

The study included 169 patients, of whom 113 patients (67%) underwent conservative management, and appendectomies were performed on 56 patients (open 25% and laparoscopic 8%). The proportion of ultrasonography, computed tomography, and magnetic resonance imaging were 97%, 17%, and 5% (for conservative management); 88%, 39%, and 13% (for appendectomy); 86%, 38%, and 21% (for open appendectomy); and 93%, 43%, and 14% (for laparoscopic appendectomy), respectively. The proportion of complicated appendicitis was 6% in conservative management and 41% in appendectomy (40% in open appendectomy and 43% in laparoscopic appendectomy), respectively. The incidence of fetal loss was 4% in conservative management, 5% in appendectomy (2% in open appendectomy, and 14% in laparoscopic appendectomy). However, there was only one fetal loss (in laparoscopic appendectomy) in the same case of hospitalization. There were no maternal deaths or serious complications after any treatment.

CONCLUSION

All treatments showed acceptable outcomes in appendicitis during pregnancy. Conservative management is considered an acceptable option, especially in uncomplicated cases of appendicitis in pregnant women.

Treatment of slow transit constipation-induced ileus during pregnancy by colectomy with ileorectal anastomosis: A case report

INTRODUCTION

Slow transit constipation is a major cause of chronic constipation. During pregnancy, changes in hormone levels and the physical effects of an enlarged uterus could cause new onset slow transit constipation or aggravate a pre-existing constipation. The management of slow transit constipation-induced ileus during pregnancy is a medical dilemma.

PATIENT CONCERNS

A 28-year-old pregnant woman presented to the emergency department with a 7-day history of worsening bloating and abdominal colic. The patient was in her third trimester (27 weeks). She had a 5-year history of constipation which had worsened with her pregnancy, and neither flatus nor stool could be passed.

DIAGNOSIS

Based on the constipation history and computed tomography, a slow transit constipation-induced ileus was confirmed.

INTERVENTIONS

As medications for the management of constipation and endoscopic efforts to remove the blockage were ineffective and the patient's symptoms worsened, Cesarean section and colectomy with ileorectal anastomosis were performed.

OUTCOMES

After the procedure, the patient recovered and defecated well. At the 6-month follow-up, the patient reported that she defecated two to three times per day without difficulty.

CONCLUSION

Pregnancy can worsen pre-existing constipation and cause ileus. In cases where drug treatment is unsuccessful, colectomy, and ileorectal anastomosis may be necessary.

Major Variation in the Incidence of Appendicitis Before, During and After Pregnancy: A Population-Based Cohort Study

BACKGROUND

Previous studies indicate a low incidence of appendicitis in third-trimester pregnancy, suggesting a protecting effect of pregnancy. This large population-based cohort study analyzes the association of appendicitis with pregnancy in more detail. The aim of the study was to investigate the incidence of appendicitis and negative appendectomy before, during and after pregnancy.

METHODS

Cross-linking between two Swedish health registries provided data on appendectomy for all women in Sweden giving birth between 1973 and 2013. We analyzed the incidence rates (IR) of perforated and non-perforated appendicitis and negative appendectomy before, during and after pregnancy, and secular trends during the study period. Standardized incidence ratios (SIR) were estimated using age-, sex- and period-specific IR from the background population in Sweden.

RESULTS

Some 3,888,452 pregnancies resulted in birth during the study period. An appendectomy was registered for 27,575 women in the interval starting one year before and ending two years after pregnancy. The incidence of appendicitis varied substantially during and after pregnancy. SIR for perforated appendicitis was 0.47 (95% CI 0.38-0.59) in the third trimester, 3.89 (2.92-5.18) peripartum, 2.20 (1.89-2.55) in the puerperium and 1.27 (1.19-1.36) in the year postpartum. The pattern was similar for non-perforated appendicitis. Negative appendectomy decreased postpartum. Incidence rate of non-perforated appendicitis and negative appendectomy decreased for both pregnant and non-pregnant women during the study period.

CONCLUSIONS

The findings in this study suggest a protecting effect of pregnancy on the development of appendicitis, which is followed by a rebound effect after birth.

[Acute appendicitis during pregnancy]

Acute appendicitis is the most frequent surgical disease complicating pregnancy. Accurate diagnosis is difficult due to atypical and misleading clinical manifestations. Surgeons frequently do not know about advantages and disadvantages of different diagnostic methods applied during pregnancy. Treatment of acute appendicitis in pregnant women remains the real challenge for surgeons. There are enough researches indicating on benefits and risks of both open and laparoscopic operations. The main risk is due to fetal loss after laparoscopic procedure. Safety of diagnostic techniques and laparoscopic procedures, surgical tactics and independent risk factors of pregnancy loss are touched in the article.

[Complicated appendicitis during pregnancy]

AIM

To analyze incidence, diagnosis and treatment of complicated appendicitis in pregnant women and to determine the optimal surgical approach.

MATERIAL AND METHODS

Retrospective cohort analysis included 338 pregnant women who underwent appendectomy in 2012-2016. Complicated appendicitis (abscess, local or common peritonitis and their combinations) was diagnosed in 22 cases. The main perioperative variables (duration of the disease, time of surgery, length of hospital-stay, incidence of wound complications, etc.), clinical and laboratory symptoms, results of ultrasound diagnosis and pregnancy outcomes were analyzed. Statistical analysis was carried out in Stata 14.2. Fisher's exact test, Mann-Whitney-Wilcoxon's U-test and multivariate regression analysis were used to compare data.

RESULTS

The incidence of complicated appendicitis in pregnant women was 6.51%. There are no clinical symptoms which would be significantly more common in complicated appendicitis during pregnancy. Complicated course prolongs surgery and hospital-stay, however duration of postoperative analgesia depends on surgical technique as a rule. There were 27% of laparoscopic interventions that is lower compared with women with uncomplicated appendicitis. The percentage of conversions was higher too.

CONCLUSION

Clinical diagnosis of complicated appendicitis during pregnancy even by using of ultrasound is not satisfactory and requires the involvement of other objective methods, such as MRI. Laparoscopic intervention is not contraindicated in pregnant women with complicated appendicitis and determine better treatment outcomes than open surgery.

Delaying laparoscopic surgery in pregnant patients with an equivocal acute appendicitis: a step-wise approach does not affect maternal or fetal safety

BACKGROUND

Accurate and timely diagnoses of acute appendicitis (AA) during pregnancy avoids maternal and fetal morbidity and mortality. We present our experience of using an initial transabdominal ultrasound (US) performed at presentation to diagnose AA in pregnant patients as well as the value of a delayed repeat study in those who remain equivocal. We explore the sensitivity and specificity of this algorithm as well as the maternal and fetal safety of this approach.

METHODS

Of the 225 patients identified within the study period who underwent laparoscopic appendectomy, 216 met the inclusion criteria and were retrospectively analyzed. If the US performed on presentation revealed AA, surgery was performed. Patients with a non-diagnostic US were admitted with surgery performed if there was clinical and/or biochemical deterioration. Patients who remained equivocal underwent a repeat delayed study. The results of the initial versus delayed studies were compared. Maternal and fetal complications were recorded and contrasted.

RESULTS

Of the 216 patients included, 164 (75.9%) had AA, 14 (6.5%) had complicated AA and 38 (17.6%) had a normal appendix. Initial US was diagnostic for 125/216 (57.9%) of patients and 19/34 (55.8%) of patients who underwent a delayed repeat study. The remaining patients underwent empirical surgery. The pooled sensitivity and specificity of US for the cohort was 79.2% and 92.1%, respectively. There was no difference in proxies of maternal or fetal safety between the groups.

CONCLUSION

US is a useful tool for diagnosing AA in pregnancy. In this cohort, performing a delayed repeat US during a period of observation in those patients who remained otherwise equivocal increased the diagnostic yield of the US. Delaying surgery in this specific group of patients does not affect maternal or fetal safety.

Neutrophil-lymphocyte ratio, gamma-glutamyl transpeptidase, lipase, high-density lipoprotein as a panel of factors to predict acute pancreatitis in pregnancy

Acute pancreatitis in pregnancy (APIP) is a rare but dangerous complication. APIP has common symptoms with acute abdomen. Assessment of an acute abdomen is more complicated during pregnancy because the gravid uterus could mask most of symptomatic signs. It has been a challenge to diagnose APIP by physical examination or diagnostic imaging. Case studies on APIP are also limited for analysis on the risk factors associated with the disease. This retrospective study evaluated a series of risk factors from a relatively substantial number of APIP cases to determine early predictors or prognosis markers for APIP.Fifty-nine APIP patients together with 179 random normal pregnant women in Shengjing Affiliated Hospital of China Medical University were included for this retrospective study. Medical parameters of blood test in biochemistry and hematology were compared between 2 groups using t test. Multivariate logistic regression analysis was performed to investigate the relationship between various factors and APIP using Statistical Applied Software (SAS student version).Compared with normal pregnant women, APIP patients have elevated values in alanine aminotransferase (ALT), aspartate aminotransferase (AST), blood urea nitrogen, creatinine, C-reactive protein, direct bilirubin, fibrin degradation products, gamma-glutamyl transpeptidase (GGT), glucose, lipase, pH and decreased values in albumin, fibrinogen, high-density lipoprotein (HDL), hemoglobin, low-density lipoprotein cholesterol (LDL-D), and total proteins from their blood tests. In addition, APIP patients have decreased numbers in red cells but increased numbers in white blood cells and increased ratio of neutrophil/lymphocyte (N/L). Among these factors, N/LR, GGT, lipase, and HDL are significantly associated with APIP. This study suggests that the combination of those factors serve as a panel of indicators for early-onset prognosis of APIP.GGT, lipase, HDL, and N/LR can serve as a panel of factors to predict APIP. More case studies are important to further evaluate the predicting power of this panel factors in APIP.

Accuracy of ultrasonography in diagnosing acute appendicitis during pregnancy based on surgical findings

Background: Acute appendicitis is the most common nonobstetric surgical problem in pregnancy. Common signs and symptoms of appendicitis are less reliable during pregnancy due to physiological changes; thus, the role of imaging becomes prominent. Thus, in the present study, we aimed at assessing the accuracy of sonography in diagnosing acute appendicitis during pregnancy. Methods: In this prospective analytic study, among 1000 patients diagnosed and treated as acute appendicitis, clinical and sonographic findings of 58 consecutive pregnant patients, who underwent appendectomy, were recorded and analyzed. All surgically resected samples were evaluated and confirmed through histological evaluation. Sonographic criteria were utilized to judge the results for appendicitis. Diagnostic test performance characteristics (sensitivity, specificity, predictive values, and likelihood ratios) were calculated. Results: The mean age of the patients was 27.1±4.9 years, and the most common clinical symptom was right lower quadrant pain. There was no significant difference in the mean leukocyte count between the appendicitis group and normal appendix group (p=0.768). Left shift was also unrelated with the appendix pathology (p= 0.549). The sensitivity, specificity, predictive values (positive and negative), and likelihood ratios (positive and negative) were 80%, 75%, 91.4%, 52.9%, 3.2, and 0.26, respectively during all trimesters of pregnancy. Conclusion: Ultrasonography is the initially preferred imaging modality in pregnant women suspected of having acute appendicitis with an acceptable sensitivity; however, application of other imaging modalities such as CT scan or MRI is recommended after inconclusive ultrasonography results.

Acute intestinal obstruction due to extrinsic compression by previa myoma and ectopic pregnancy: a case report

BACKGROUND

Acute intestinal obstruction during pregnancy is a rare digestive surgical emergency with significant maternal and fetal mortality. Diagnosis is difficult, often delaying the management. Here, we report an exceptional association of mechanical acute intestinal obstruction due to compression by previa uterine leiomyoma, and a ruptured ectopic pregnancy.

CASE PRESENTATION

This is the case report of a 43-year-old primiparous black woman from a rural area, who was admitted to the surgical emergency department for acute intestinal obstruction. At examination on admittance, our patient had a bad general condition with clinical anemia. She had an occlusive syndrome that had been evolving for 3 days. A physical examination of her abdomen showed a widespread distension with an irregular and polylobed solid mass occupying the whole of the lower-umbilical and hypogastric area. A rectal examination found an empty rectum, and the mass was perceptible in Douglas's pouch. At the vaginal examination, we found the same mass and a finger holster was clean. The diagnosis of intestinal occlusion by a tumor was retained. The laparotomy revealed a distended intestine, a ruptured right tubal ectopic pregnancy and a polymyomatous uterus. The most massive previa leiomyoma was adhering and compressing the rectal and sigmoidal hinge. A total hysterectomy was performed and histopathological examination of specimens confirmed myoma and ectopic pregnancy. The surgical follow-up was uneventful, and our patient was discharged on postoperative day 12.

CONCLUSIONS

The etiological diagnosis of acute intestinal obstruction during pregnancy is not easy, especially in the context of a low-income country where the means of biological and radiological diagnosis are lacking. A laparotomy is required before diagnosis of acute surgical abdomen and its management will depend on the intraoperative findings and the condition of the patient.

Laparoscopy in the second and third trimesters of pregnancy for abdominal surgical emergencies

OBJECTIVE

To assess complications and outcomes of pregnancies following laparoscopic abdominal surgery during the second and third trimesters of pregnancy.

MATERIAL AND METHODS

Retrospective single-center study of 23 cases of laparoscopic surgery in the second or third trimesters of pregnancy between January 2005 and May 2016.

RESULTS

The laparoscopies were performed between 15 and 33 weeks of gestation, a mean of 23 weeks+2 days, with 6 cases in the 3rd trimester. The operations were: 11 cholecystectomies, 6 appendectomies, 1 intestinal occlusion (volvulus on a gastric band), 3 adnexal torsions, 1 ovarian cyst and 1 paratubal cyst with torsion. No secondary laparotomy was required. The postoperative courses were favorable in most cases. However, 3 appendectomies were complicated, one by chorioamnionitis and miscarriage at 20½ weeks of gestation and 2 by right iliac fossa abscesses requiring percutaneous radiological drainage, one of these women delivered a healthy term baby and the other had chorioamnionitis and preterm delivery at 34 weeks, followed by neonatal death.

CONCLUSION

Laparoscopy can be safely performed for surgical indications in the second and third trimesters of pregnancy. In case of abdominal symptoms, a timely diagnosis is required to decide whether or not to operate and imaging should not be withheld particularly in case of suspected appendicitis which has a high risk of complications.

The role of preoperative graded compression ultrasound in detecting acute appendicitis and influencing the negative appendectomy rate

PURPOSE

The diagnosis of acute appendicitis is mainly clinical and is correct in about 80% of patients, but 20-33% present with atypical findings, which resulted in a negative appendectomy rate of 20-30%. The graded compression ultrasound method in the diagnosis of acute appendicitis was reported with a sensitivity of 89%, and specificity of 95%. In this study, we aim to evaluate the graded compression ultrasonography in the diagnosis of acute appendicitis, its influence on the clinical judgment to operate, and its role in lowering the negative appendectomy rate.

METHODS

1073 patients treated surgically for acute appendicitis between January 2005 and December 2014 were reviewed. Ultrasound findings, histopathological diagnosis, and positive or negative appendectomy rates were analyzed.

RESULTS

647 (60.3%) patients were males and 426 (39.7%) females. The mean age was 26.5 years. Positive ultrasound findings were recorded in 892 (83.13%), while negative findings were recorded in 181 (16.87%). Positive appendectomy was recorded in 983 (91.6%), while negative appendectomy was recorded in 90 (8.4%). The sensitivity was 83%, specificity was 100%, and the rate of negative appendectomy was 8.39%.

CONCLUSION

Graded compression technique of ultrasound is a useful modality, in addition to the clinical judgment of the surgeon and clinical findings, in detecting true positive cases of acute appendicitis, and thus reducing the negative appendectomy rate. Values of 100% specificity, and 8.4% negative appendectomy rate, or better, could be achieved, when an experienced surgeon and a professional radiologist collaborate in the diagnosis of acute appendicitis.

Imaging trends in suspected appendicitis-a Canadian perspective

PURPOSE

The purpose of our study was to assess trends in the imaging of suspected appendicitis in adult patients in emergency departments of academic centers in Canada.

METHODS

A questionnaire was sent to all 17 academic centers in Canada to be completed by a radiologist who works in emergency radiology. The questionnaires were sent and collected over a period of 4 months from October 2015 to February 2016.

RESULTS

Sixteen centers (94%) responded to the questionnaire. Eleven respondents (73%) use IV contrast-enhanced computed tomography (CT) as the imaging modality of choice for all patients with suspected appendicitis. Thirteen respondents (81%) use ultrasound as the first modality of choice in imaging pregnant patients with suspected appendicitis. Eleven respondents (69%) use ultrasound (US) as the first modality of choice in patients younger than 40 years of age. Ten respondents (67%) use ultrasound as the first imaging modality in female patients younger than 40 years of age. When CT is used, 81% use non-focused CT of the abdomen and pelvis, and 44% of centers use oral contrast. Thirteen centers (81%) have ultrasound available 24 h a day/7 days a week. At 12 centers (75%), ultrasound is performed by ultrasound technologists. Four centers (40%) perform magnetic resonance imaging (MRI) in suspected appendicitis in adult patients at the discretion of the attending radiologist. Eleven centers (69%) have MRI available 24/7. All 16 centers (100%) use unenhanced MRI.

CONCLUSIONS

Various imaging modalities are available for the work-up of suspected appendicitis. Although there are North American societal guidelines and recommendations regarding the appropriateness of the multiple imaging modalities, significant heterogeneity in the first-line modalities exist, which vary depending on the patient demographics and resource availability. Imaging trends in the use of the first-line modalities should be considered in order to plan for the availability of the imaging examinations and to consider plans for an imaging algorithm to permit standardization across multiple centers. While this study examined the imaging trends specifically in Canada, there are implications to other countries seeking to streamline imaging protocols and determining appropriateness of the first-line imaging modalities.

Appendicitis in Diabetics: Predictors of Complications and Their Incidence

Appendicitis is the most common surgical emergency encountered by the general surgeon. Literature has demonstrated that diabetics may manifest atypical signs of infection, often clouding the diagnostic picture. We conducted a 3-year retrospective analysis of adults with appendicitis to determine differences in presentation, diagnosis, treatment, and outcomes for diabetic versus nondiabetic patients. Demographics, symptoms, imaging, procedure(s), complications, and length of stay (LOS) were obtained via chart review. Factors were compared between patients with and without diabetes using chi-squared test, t test, or Mann-Whitney U test (significance at P ≤ 0.05). Multivariate regression analysis identified variables predicting longer LOS or perforation at diagnosis. Overall, 339 patients met inclusion criteria [303 were nondiabetic (ND), 36 were diabetic (D)]. On univariate analysis, diabetics were more likely to have other comorbid illnesses: obesity ( P < 0.001), chronic kidney disease ( P = 0.003), hypertension ( P < 0.001), coronary artery disease ( P < 0.001), peripheral vascular disease (PVD, P = 0.31), and chronic obstructive pulmonary disease ( P = 0.002). Diabetics presented with lower white blood cell counts (mean 14.2 ND, 11.9 D, P = 0.02), and were more likely to present with perforation (18.5% ND, 38.9% D, P = 0.008). LOS was longer in diabetics (1.0 day for ND, 3.0 day for D, P < 0.001). Complications were more frequent in diabetics (19.4% D vs 8.6% ND), which trended toward but failed to reach significance ( P = 0.066). On multivariate analysis, however, old age was the only characteristic associated with perforation [odds ratio: 1.05 (1.02–1.06), P < 0.001], whereas diabetes, chronic obstructive pulmonary disease, and older age predicted longer LOS ( P ≤ 0.001). Diabetics present a more complicated clinical picture having significantly more comorbidities and a trend toward postoperative complications necessitating a higher index of suspicion to detection complications. Further study is needed to evaluate the optimal diagnostic and management approach in this challenging population.