Incidental Appendiceal Tumors During Appendectomy: A Nineteen-Year Retrospective Review at a Municipal Hospital

Non-operative management of appendicitis (NOMA) has recently gained popularity, but a concern is that NOMA might miss appendiceal neoplasms. We conducted a retrospective review of 1694 appendectomies done for acute appendicitis at our institution between January 2001 and December 2019 to study the incidence and distribution of appendiceal tumors. We identified 24 appendiceal neoplasms (1.43%), including 9 Low Grade Appendiceal Mucinous Neoplasms (LAMNs), 6 neuroendocrine tumors (NETs), 6 mucoceles, and one each of adenocarcinoma, endometrioma, and neurofibroma. Tumor occurrence had two age peaks, with LAMNs prominent in the 5th and 6th decades of life and NETs in the 2nd and 3rd decades. All patients under age 40 had benign disease. Presence of appendicoliths was independent of the presence of neoplasms. All cases were managed per National Comprehensive Cancer Network (NCCN) guidelines, with twenty cases cured by appendectomy alone. Given these, we conclude that NOMA is safe for patients under 40.

Mucosal appendicitis: How can it be differentiated from nonappendicitis?

OBJECTIVES

Mucosal appendicitis is defined by neutrophilic infiltration limited to the mucosa, with no transmural invasion; it is currently a controversial entity. The aim of our study was to determine whether mucosal appendicitis represents an early stage of acute appendicitis (AA) or should be considered a negative appendectomy.

METHODS

A retrospective study was performed of children with suspected AA who underwent surgical treatment between 2017 and 2020. The participants were divided into 2 groups according to histologic appendiceal findings: mucosal appendicitis (MA) and negative appendicitis (NA). Demographic, clinical, ultrasound, and laboratory features were compared between the groups.

RESULTS

A total of 1269 patients with suspected appendicitis in whom appendectomy was performed were included, with a median age of 10.5 years. Mucosal appendiceal inflammation was histologically confirmed in 30 cases (MA group), while no inflammation or other pathologic findings were observed in 25 cases (NA group), with no differences in demographic, clinical, or ultrasound features between the groups. Those in the MA group presented with significantly higher leukocyte and neutrophil counts and higher neutrophil to lymphocyte ratios (NLRs) than those in the NA group (P < .001). The NLR was the parameter with the highest area under the curve (0.736) for the diagnosis of MA. A cutoff of 3.20 was established, with a maximum sensitivity and specificity of 62.5% and 78.9%, respectively.

CONCLUSIONS

Mucosal appendicitis presents with laboratory and histologic inflammatory features that can be distinguished from nonappendicitis and should therefore be considered a pathologic entity within the spectrum of AA. Preoperative leukocyte and neutrophil counts and NLRs may help reduce the number of negative appendectomies.

Incidental appendiceal neoplasms: Single-centre results

BACKGROUND

Histopathological examination of appendectomy specimens may reveal malignancies. Based on these results, either appendectomy is sufficient or sometimes a further treatment protocol can be needed. In this study, malignancy-diagnosed cases on appendectomy specimen were examined.

METHODS

Patients who underwent appendectomy between January 2013 and December 2018 with a pre-diagnosis of acute appendicitis were evaluated retrospectively and those cases with malignancy were included in the study. Patients' age, sex, tumor type, tumor diameter, tumor grade, tumor localization, surgical margin, Ki-67 index, state of lymphovascular invasion, state of peri-neural invasion, and follow-up period duration were recorded.

RESULTS

On examination of 2336 appendectomy specimens, 16 patients (0.7%) were found to have neuroendocrine tumors (NET), 11 patients (0.5%) were found to have low-grade mucinous neoplasm (LAMN), and five patients (0.2%) were found to have primary appendix carcinomas. Appendix tumors usually present with acute appendicitis symptoms. Despite re-operation with right hemicolectomy (RHC) being required in the treatment of adenocarcinoma cases, appendectomy provides adequate treatment in most cases with NET and LAMN. With these tumors, which usually have a benign prognosis, it is important to perform the necessary screening in the postoperative period and not to interrupt follow-up.

The human vermiform appendix: morphological and anatomical review

The article covers aspects of morphological, anatomical, embryological, histological aspects and origin, types, blood supply, innervation, lymph drainage of human vermiform appendix. The purpose of the study is to understand real function and to summarize this information for positive impact on clinical decision in case of appendicitis. Although characteristic features of normal and diseased appendix have been reported for many previous centuries, it still the most common challenge facing every day in operation room. The appendectomy, commonest surgical emergency procedure, may cause little confusion in surgeons due to highly variable situations of it inside the abdominal cavity. However, the recent imaging techniques have increased ability of surgeon for crucial diagnosis of the diseased appendix.

Perforated Carcinoid Tumor of the Appendix: Need for Guidelines for Management With Respect to Prognostic Factors

Carcinoid tumors, one of the most common malignant lesions involving the appendix, are typically found incidentally during routine appendectomies. While up to 20% of acute appendicitis cases present with perforation, the incidence of perforation among patients with undiagnosed carcinoid tumors of the appendix is unknown. In addition, there is no consensus on the management of carcinoid tumors in the perforated appendix or its impact on prognosis. We present a case of a 42-year-old woman presented with perforated appendicitis. Final pathology demonstrated the presence of a 1.1 cm, well-differentiated grade 1 neuroendocrine tumor at the tip of the appendix extending into the subserosa, without evidence for lymphovascular invasion. Given the depth of tumor invasion and the relatively young age of the patient, the decision was made to perform an interval completion right hemicolectomy for lymph node sampling. Only a few cases have been reported in the available literature, and it remains unclear whether appendiceal perforation represents an independent negative prognostic factor for patient survival. Additional data from cohort studies are needed to determine the true incidence, prognosis, and optimal management of newly diagnosed carcinoid tumors in the perforated appendix. Furthermore, clear consensus guidelines are needed to identify the subgroup of patients who would benefit from interval or primary right hemicolectomy.

Diagnostic performance of magnetic resonance imaging for diagnosing acute appendicitis during pregnancy

OBJECTIVE

This retrospective study evaluated the diagnostic efficacy of magnetic resonance imaging (MRI) for identifying acute appendicitis during pregnancy.

PATIENTS AND METHODS

This retrospective study enrolled a total of 46 pregnant patients with clinically suspected acute appendicitis who underwent 1.5 T MRI and received a final pathological diagnosis. We evaluated the imaging characteristics associated with patients diagnosed with acute appendicitis, including the appendix diameter, the appendix wall thickness, intra-appendiceal fluid collection, and peri-appendiceal fat infiltration. A bright appendix on T1-weighted 3-dimensional imaging was identified as a negative sign for appendicitis.

RESULTS

Peri-appendiceal fat infiltration had the highest specificity of 97.1% for diagnosing acute appendicitis, whereas increasing appendiceal diameter had the highest sensitivity of 91.7%. The cut-off values for increasing appendiceal diameter and appendiceal wall thickness were 6.55 mm and 2.7 mm, respectively. Using these cut-off values, appendiceal diameter had a sensitivity (Se), specificity (Sp), positive predictive value (PPV), and negative predictive value (NPV) of 91.7%, 91.2%, 78.4%, and 96.9%, respectively, whereas these values for appendiceal wall thickness were 75.0%, 91.2%, 75.0%, and 91.2%. The combination of increasing appendiceal diameter and appendiceal wall thickness resulted in an area under the receiver operating characteristic curve value of 0.958 with Se, Sp, PPV, and NPV values of 75.0%, 100.0%, 100.0%, and 91.9%, respectively.

CONCLUSIONS

All five MRI signs examined in this study had significant diagnostic value for detecting acute appendicitis during pregnancy, with p-values <0.01. The combined use of increasing appendiceal diameter and appendiceal wall thickness displayed the excellent ability to diagnose acute appendicitis in pregnant women.

Acute appendicitis manifests as two microbiome state types with oral pathogens influencing severity

Mounting evidence suggests that acute appendicitis (AA) is not one but two diseases: complicated appendicitis, which is associated with necrosis leading to perforation or periappendicular abscess, and uncomplicated appendicitis, which does not necessarily result in perforation. Even though AA is the most frequent cause of surgery from abdominal pain, little is known about the origins and etiopathogenesis of this disease, much less regarding the different disease types. In this study, we investigated the microbiome (inter-domain amplicon and metagenome sequencing) of samples from the appendix, rectum and peritoneum of 60 children and adolescents with AA to assess the composition and potential function of bacteria, archaea and fungi. The analysis of the appendix microbial community revealed a shift depending on the severity of the AA. This shift was reflected by two major community state types that represented the complicated and uncomplicated cases. We could demonstrate that complicated, but not uncomplicated, appendicitis is associated with a significant local expansion of oral, bacterial pathogens in the appendix, most strongly influenced by necrotizing Fusobacterium spp., Porphyromonas and Parvimonas. Uncomplicated appendicitis, however, was characterized by gut-associated microbiomes. Our findings support the hypothesis that two disease types exist in AA, which cannot be distinguished beyond doubt using standard clinical characterization methods or by analysis of the patient's rectal microbiome. An advanced microbiome diagnosis, however, could improve non-surgical treatment of uncomplicated AA.

Appendiceal Neuroendocrine Tumor Mimicking Acute Appendicitis

Appendiceal carcinoids are the most frequent tumors arising from the appendix, comprising between 32 and 57% of all the appendiceal tumors. The gross appearance of the appendix showed perforation at the tip with 30 ml of periappendicular collection. On histopathological examination, carcinoid tumor on the tip of appendix was found with tumor cells arranged in tubules, acini and nests infiltrating the muscularis propria and sub serosa. Perineural and vascular invasion was not seen. Immunohistochemistry for Synaptophysin was positive with Ki-67 labelling index of 2%. We present a case of appendiceal neuroendocrine tumor with the chief complaint of acute appendicitis.

Outcomes of the Macroscopically Normal Appendix Left in Situ in Patients with Suspected Appendicitis

BACKGROUND

Right iliac fossa (RIF) pain is a common indication for laparoscopy to diagnose and treat appendicitis. When a macroscopically normal appendix is found, there is no standard consensus regarding excision. Some surgeons remove the appendix due to the risk of microscopic inflammation and to avoid a future, repeat laparoscopy for possible appendicitis. Alternatively, others leave the appendix in situ to avoid morbidity from a potentially unnecessary procedure. We aimed to evaluate the outcomes of patients with macroscopically normal appendices left in situ.

METHODS

All emergency laparoscopies without appendicectomy between January 1st 2010- December 31st 2020 were identified from theatre records. All operative notes were individually evaluated and comments on the macroscopic appearance of the appendix and any intra-operative pathology were recorded. Only patients undergoing laparoscopy for suspected appendicitis with macroscopically normal appendices were included.

RESULTS

A total of 120 patients [median age 21.68 (range 9-90.8) years] were included. The cohort was predominantly female (n=105, 87.5%). Forty-eight patients (40.0%) had a positive finding during index laparoscopy. During a median duration of 94.5 (range 8-131) months' follow-up, 16 patients (13.33%) underwent a repeat laparoscopy for recurrent RIF pain. Thirteen (10.8% of total cohort) subsequently underwent an appendicectomy. Histology confirmed acute appendicitis in six cases (4.17% of entire cohort). On subanalysis of smaller cohort, index laparoscopies with no positive findings (n=72), nine patients (12.5%) underwent appendicectomy with two (2.7%) appendices demonstrating appendicitis on histological examination.

CONCLUSION

87% of the total cohort with a normal appendix at laparoscopy for RIF pain did not undergo further laparoscopy. Less than 5% of the total cohort and 2.7% of subanalysis cohort had an appendicectomy for histologically-proven appendicitis within the follow-up period. From the evidence in this study, we conclude that leaving the appendix in situ unless macroscopically inflamed is a viable alternative to excision.

Did the severity of appendicitis increase during the COVID-19 pandemic?

BACKGROUND

This study aimed to assess the severity of appendicitis during the coronavirus disease 2019 (COVID-19) pandemic, as patients with appendicitis may procrastinate seeking medical attention during the pandemic.

METHODS

Information on patients with appendicitis who were treated at the Taipei City Hospital during the COVID-19 pandemic (January 1, 2020 to June 30, 2020) was retrieved. Patients who were diagnosed with appendicitis and treated at the same hospital from January 1, 2019 to July 1, 2019 were designated as the control group. Multivariate logistic regression analysis was conducted to assess changes in the severity of appendicitis (at a 2-week interval) between the two groups.

RESULTS

We identified 307 (study group: 149; control group: 158) consecutive patients with appendicitis. The mean age was 46.2 +- 19.8 years. Between the two groups, there were no significant differences in age, sex, comorbidity, surgery type (laparoscopic or open appendectomy) or surgery time. The number of patients in the study group decreased between January 29, 2020 and April 21, 2020, which paralleled the period of spikes in the confirmed COVID-19 cases and restricted daily activities. The percentage of uncomplicated and complicated appendicitis (excluding mild appendicitis or normal appendix) in the study group increased between February 26 and March 10, as well as between April 8 and April 21. In the multivariate regression analysis, the odds of uncomplicated and complicated appendicitis increased in three bi-weeks for the study group but not in the control group.

CONCLUSION

The severity of acute appendicitis might increase during the COVID-19 pandemic, because patients with mild appendicitis (or abdominal pain) may hesitate to seek help.

PECULIARITIES OF MORPHOETIOPATHOGENESIS OF ACUTE APPENDICITIS AND CONSEQUENCES AFTER APPENDECTOMY

OBJECTIVE

The aim: To study the features of morphoethiopathogenesis of acute appendicitis and the consequences after appendectomy.

PATIENTS AND METHODS

Materials and methods: 10 preparations of human appendix were studied, from which 5 appendixes were normal in people who died in adulthood and old age and 5 processes were taken intraoperatively during appendectomy. Morphometric characteristics of the tissue structures of the preparations were compared with the systematic review data, the literature search by the following keywords: morphoethiopathy", "vermiform process", "lymphoepithelial formations", "digestive system", "lymphoid nodule", "Peyer's patches", "mucous membrane".

RESULTS

Results: Pathogenesis of acute appendicitis - it is a consistent, staged process that is completely subject to the laws of exudative inflammation in response to microbial aggression. Removal of the appendicular process should be approached carefully and based on possible immunological consequences. Removal of the appendix as an immunocompetent organ Unreasonable removal of pathohistological unchanged appendix has medical consequences (can lead to consequences such as colon cancer) and not only.

CONCLUSION

Conclusions: Our results suggest that the vermiform appendix retains its active function throughout human life. The study provides an overview with current knowledge about the etiology, pathogenesis and possible consequences of appendectomy as the main method of treatment of acute appendicitis. The search for ways to prevent appendicitis can be successful only by finding out the causes and factors that in some individuals cause the inability of the appendix to resist bacterial invasion. Appendix is necessary to fully support the immune responses of the digestive tract, but it belongs to the category of those organs, the loss of which during forced surgery does not cause significant damage to the body.

Crohn Disease Infrequently Affects the Appendix and Rarely Causes Granulomatous Appendicitis

Data from previous studies suggest Crohn disease of the appendix accounts for ∼25% of granulomatous appendicitis cases. However, we have found that granulomatous inflammation in appendectomy specimens rarely heralds Crohn disease. We suspect that appendiceal involvement by Crohn disease is uncommon, even when patients have severe ileocolonic inflammation. We performed this study to determine the prevalence and nature of appendiceal inflammation among patients with Crohn disease. We reviewed 100 ileocolic specimens with strictures and fistulizing Crohn disease for the nature and distribution of inflammatory changes in the appendix and compared them with 100 appendices on colectomy specimens from age-matched and sex-matched patients with ulcerative colitis. We also evaluated 27 additional cases of granulomatous appendicitis in appendectomy specimens to determine the frequency with which this finding represented Crohn disease. The appendix was usually normal (26%) or showed fibrous obliteration (50%) in ileocolic resection specimens from patients with Crohn disease. Mucosal inflammation was much less common in appendices from patients with Crohn disease than ulcerative colitis (6% vs. 28%, P<0.0001); only 4 cases contained epithelioid granulomata, 3 showed mural fibrosis and lymphoid aggregates, and 10 displayed only periappendiceal inflammation. None of the patients with granulomatous appendicitis in appendectomy specimens had, or developed, evidence of Crohn disease. We conclude that Crohn disease infrequently affects the appendix. Interval appendectomy and infection are more important considerations when appendectomy specimens feature granulomatous inflammation and/or mural lymphoid aggregates, especially if there is no history of idiopathic inflammatory bowel disease.

Chronic appendicitis: the process from pre-diagnosis to pathology

OBJECTIVE

Chronic appendicitis (CA) is a rare medical condition. CA is characterized by a less severe and almost continuous abdominal pain. It has a clinical picture lasting longer than 1-2 days and extending over weeks, months, even years. The exact etiology of CA is unclear. Certain resources have reported it as the cause of partial obstruction in the lumen of the appendix.

PATIENTS AND METHODS

Our study was carried out with the approval of the Clinical Research Ethics Committee. A retrospective analysis was performed between August 2018 and March 2020.

RESULTS

It was determined that 207 appendectomies were performed during the retrospective scan period. The data of 182 of these patients could be accessed fully and we could get answers to the criteria we thought. Only 8 of the patients screened were likely to be diagnosed with chronic appendicitis in the preoperative period. CA was found in 1 of the 8 patients (12.5%) who underwent surgery after a preliminary diagnosis of CA. Two patients were reported as malignant (25%), 3 patients (37.5%) as reactive lymphoid hyperplasia, and 1 patient as peri appendicitis (12.5%). Bleeding and congestion were reported in the last patient (12.5%).

CONCLUSIONS

The diagnosis of chronic appendicitis is made by pathological examination. It may not always be possible to consider "chronic appendicitis" as a preliminary diagnosis. This should still be kept in mind. In our opinion, it is a bit difficult to make a preliminary diagnosis of chronic appendicitis and make a surgical decision. We believe that controlled and prospective studies can shed more light on chronic appendicitis.

Acute Appendicitis Associated with Hantaan Virus Infection

Hantaviruses are Bunyaviridae viruses that cause hemorrhagic fever with renal syndrome. Appendicitis caused by Hantaan virus has not been reported previously. An 81-year-old man who underwent laparoscopic appendectomy for suspected appendicitis based on abdominal pain, fever, hypotension, and computed tomography findings. Based on a suspicion of hemorrhagic fever with renal syndrome, the patient's plasma was simultaneously analyzed using an indirect immunofluorescent antibody assay and nested reverse transcription-polymerase chain reaction (RT-PCR). The appendix tissue was also analyzed using nested RT-PCR and immunohistochemical (IHC) staining to identify the presence of Hantaan virus. Nested RT-PCR detected the presence of Hantaan virus, and indirect immunofluorescent antibody assay results revealed the presence of elevated antibody levels. Furthermore, IHC staining of the appendix tissue confirmed Hantaan virus antigens in the peripheral nerve bundle. Based on these findings, we confirmed the nerve tropism of the Hantaan virus. Hantaan virus in plasma and appendix tissue samples was confirmed using PCR and phylogenetic tree analysis. Moreover, we detected hypertrophy of the submucosa and periappendiceal adipose tissue nerve bundle along with Hantaan virus antigens in peripheral nerve bundles using IHC staining. Hence, we report that Hantaan virus infection may be accompanied by appendicitis.

Liver transplant versus non-liver transplant patients underwent appendectomy with presumed diagnosis of acute appendicitis: Case-control study

BACKGROUND

This study aims to compare liver transplant and non-liver transplant patients who underwent appendectomy with a presumed diagnosis of acute appendicitis.

METHODS

Demographic and clinicopathological features of 13 liver transplant recipients (transplant group) who underwent posttransplant appendectomy with a presumed diagnosis of acute appendicitis were compared with the features of 52 non-liver transplant patients (non-transplant group). They underwent appendectomy with a presumed diagnosis of acute appendicitis during the same time period. The transplant group was matched at random in a 1: 4 ratio with the non- transplant group. While the continuous variables were compared using the Mann Whitney-U test, categorical variables were compared with Fisher's exact test. A p-value of less than 0.05 was considered statistically significant.

RESULTS

A total of 65 patients aged between one year and 84 years were included in this study. While the age of the 52 patients (32 male and 20 female) in the non- transplant group ranged from 17 years to 84 years, the age of the 13 patients (nine male and four female) in the transplant group ranged from one year to 64 years. Statistically significant differences were noted between both groups concerning WBC (p=0.002), neutrophil (p=0.002), lymphocyte (p=0.032), platelets (p=0.032), RDW (p=0.001), CRP (p=0.009), PNR (p=0.042), WNR (p=0.03), and appendiceal length (p<0.001). The negative appendectomy rate was relatively higher in transplant than the non-transplant group but this difference was not statistically significant (30.8% vs. 21.2%; p=0.477). Perforated acute appendicitis occurred more frequently in the transplant group; however, this difference was not statistically significant (30.8% vs. 9.6%; p=0.070).

CONCLUSION

WBC and neutrophil were lower in the LT group; however, the CRP and RDW were higher in the LT group. Further, perforation and negative appendectomy rates were higher in the LT group, although this difference was not statistically significant.

Right hydronephrosis as a sign of complicated appendicitis

OBJECTIVE

Acute appendicitis is known for one of the most common cause of acute abdomen. However, it is still challenging to clearly distinguish complicated from uncomplicated appendicitis preoperatively. We investigated the association between right hydronephrosis and complicated appendicitis compared with other computed tomography (CT) findings of acute appendicitis.

MATERIALS AND METHODS

1275 patients who pathologically diagnosed with acute appendicitis were included. They were classified into the complicated appendicitis and uncomplicated appendicitis groups based on their histopathological results. We reviewed their CT findings, including right hydronephrosis, appendiceal wall defect, periappendiceal abscess, extraluminal or intraluminal free air, appendicolith, appendiceal dilatation, appendiceal wall thickening, periappendiceal infiltration, periappendiceal fluid collection, and ascites. Comparison between the two groups was performed and the diagnostic performance of each CT finding was evaluated. The location of appendix and periureteral extension of periappendiceal infiltration were evaluated in patients with right hydronephrosis.

RESULTS

Out of 1275 patients, 29 (2.3 %) patients showed right hydronephrosis. Right hydronephrosis was significantly related to complicated appendicitis with the odds ratio of 4.90 (95 % confidence interval, 1.62-14.83; P = 0.005). Right hydronephrosis yielded specificity of 99.3 %. All patients with right hydronephrosis accompanied with periappendiceal infiltration and 28 (96.6 %) patients showed periureteral extension. Subcecal and pelvic areas are the most common locations, with 11 (37.9 %) patients each.

CONCLUSION

The presence of right hydronephrosis was specific finding for complicated appendicitis and it could be considered as one of indirect sign of complicated appendicitis.

Evaluation of some cellular biomarker proteins, oxidative stress and clinical indices as results of laparoscopic appendectomy for perforated appendicitis in children

Laparoscopic appendectomy for perforated appendicitis in children has the advantages of quick recovery, little influence of inflammatory and oxidative stress and low infection rate. Altogether 115 children with perforated appendicitis treated in our hospital from June 2018 to August 2019 were selected and divided into two groups according to different treatment methods. Laparoscopic appendectomy was used as the research group (RG) (67 cases) and open appendectomy (48 cases) as the control group (CG). The clinical indexes (operation time, intraoperative blood loss, ambulation time, incision length, postoperative exhaust time and length of stay) of the two groups were observed. The levels of C- reactive protein (CRP), procalcitonin (PCT), interleukin -6 (IL-6) and tumor necrosis factor-α (TNF-α) before and after treatment were detected by enzyme-linked immunosorbent assay (ELISA). The levels of oxidative stress factors (superoxide dismutase (SOD), malondialdehyde (MDA)) and the incidence of postoperative incision infection were observed in the two groups. A visual analogue scale (VAS) score was used to evaluate the postoperative pain in children. Logistic regression analysis was used to analyze the risk factors of postoperative incision infection in children. The improvement degree of clinical indicators in RG was significantly better than that in CG. The expression levels of CRP, PCT, IL-6 and TNF-α in RG were significantly lower than those in CG. The expression levels of SOD and MDA in RG were significantly better than those in CG. The postoperative incision infection rate in RG was significantly lower than that in CG. The postoperative VAS score in RG was significantly lower than that in CG. Logistic regression analysis results showed that the risk of incision infection was increased in children with operation time over 1h, incision length &gt;3cm, high CRP, high PCT, high IL-6, high TNF-α, high SOD and low MDA. Laparoscopic appendectomy for perforated appendicitis in children can effectively reduce intraoperative hemorrhage, postoperative pain, and the damage to the body of children, and can also reduce oxidative stress and inflammatory reaction in children.

Congruence of histological diagnosis with imaging and operation diagnosis in acute appendicitis

INTRODUCTION

The diagnostic process of acute appendicitis is based on clinical symptoms, evaluation of laboratory biomarkers of inflammation and imaging examinations results. Accurate preoperative diagnosis is a key factor in reducing the number of so-called negative appendectomies. The aim of our study was to evaluate the importance of ultrasound in the diagnostic algorithm of acute appendicitis. We also compared the accuracy of the intraoperative diagnosis evaluated by the surgeon with the histopathological findings.

METHODS

We performed a retrospective analysis of patients operated for acute appendicitis at our surgical department in time period from 2015 to 2017. We compared the results of preoperative imaging examinations (ultrasound, CT) and intraoperative diagnosis (from the surgical record) with final histopathological findings.

RESULTS

386 patients were operated on for acute appendicitis. Histopathological examination revealed 33 patients (9%) with no signs of inflammation, 309 patients (80%) with inflammatory changes, 37 cases (10%) with chronic appendicitis and 7 other histological findings (2%). Ultrasound was performed in 382 patients (99%). False negative ultrasound was obtained in 18 (6%) of 309 patients with histologically confirmed inflammation. Ultrasound gave a false positive finding in 16 (48%) of 33 patients whose histology revealed no signs of inflammation. Equivocal ultrasound was obtained in 104 patients (27%). Intraoperative diagnosis of appendix without inflammation was described by the surgeon in 27 patients (7%). Of these, 12 cases (44%) were histologically non-inflammatory, 7 cases (26%) with acute inflammation, 7 cases (26%) with chronic inflammation and 1 other finding (4%).

CONCLUSION

Ultrasound is a suitable imaging method to confirm the diagnosis of acute appendicitis but not to rule it out. Intraoperative assessment of the appendix by the surgeon is not reliable. Any appendix intraoperatively evaluated as showing no signs of inflammation should be removed.

Should MRI Be the Imaging Modality of Choice in Suspected Appendicitis During Pregnancy?

Aim The aim of this review was to evaluate the efficacy of magnetic resonance imaging (MRI) in determining appendicitis during pregnancy. Methods We retrospectively reviewed the clinical course for all pregnant patients with suspected appendicitis from 2013-2018. We evaluated the efficacy of MRI and Alvarado scoring and its impact on management. Results Twenty-nine pregnant patients with suspected appendicitis had an MRI. The majority (90%, n=26/29) had normal diagnostics with two patients (10.3%) having findings consistent with acute appendicitis. Two other patients proceeded to laparoscopy, one with an inconclusive MRI, and one patient with clinical appendicitis. We found no accurate correlation between pregnancy and Alvarado scoring. Conclusion MRI is a safe adjunct in accurately diagnosing appendicitis in pregnancy. Its routine use could help reduce rates of negative appendectomies and the potential risk to maternal and fetal health.

Analysis of CT characteristics in the diagnosis of Schistosoma japonicum associated appendicitis with clinical and pathological correlation: a diagnostic accuracy study

PURPOSE

To clarify unique non-contrast CT (NCCT) characteristics for early recognition of Schistosomal associated appendicitis (SAA) differentiating from Non-schistosomal associated appendicitis (NSA).

MATERIAL AND METHODS

Clinical and pathological data of 50 cases with SAA and 60 cases with NSA who underwent emergency appendectomy were retrospectively compared to pre-surgical NCCT features such as direct and indirect signs of acute appendicitis as well as appendicoliths, colon calcifications as diagnostic criteria. Statistical methods such as Chi-square (χ²), t-tests, Principal component analysis (PCA), Binary Logistic regression (LR) and Factor Analysis (FA) were utilized to observe differences and isolate recognizable CT features of SAA. Pre and post hoc diagnostic performance of all criteria was calculated as sensitivity, specificity, and the Odds Ratio (OR).

RESULTS

Age > 50 years, diameter > 13 mm, pneumatosis, peri appendiceal abscess, focal wall defect, perforation; Orbital, linear and point types of appendicular wall calcifications; sigmoid colon and cecal curvilinear calcifications were observed as unique characteristics with a sensitivity of 84-95% and specificity of 91-98% in predicting SAA by OR of 6.2 times. Pre and post hoc hypothetical analysis did not show any significance for all other factors.

CONCLUSION

Factors such as elderly age, CT features such as larger appendicular diameter, appendicular wall calcifications along with sigmoid colon, and cecal calcifications, signs of perforation or abscess are characteristic for early recognition of SAA.

Perforated necrotic appendix in Amyand's hernia treated with appendicectomy and simple suture repair of the inguinal hernia

A 50-year-old man was referred to the emergency department by his general practitioner with a tender right-sided irreducible inguinal hernia (previously reducible), right-sided testicular pain and scrotal swelling. Clinical examination revealed a non-reducible, tender right inguinal-scrotal hernia and swollen right scrotum. Blood tests showed raised inflammatory markers. The patient went on to have a CT scan which was reported to show an indirect right inguinal-scrotal hernia possibly containing terminal ileum and small bowel mesentery. The scan also showed increased infiltrate changes within the hernia sac suggesting incarceration with possible early strangulation but no obvious evidence of bowel obstruction. The patient was taken to the operating theatre and found to have a large right inguinal-scrotal hernia containing pus and a perforated necrotic appendix. He went to have an appendicectomy and sutured repair of the hernia. Postoperatively, the patient made a good recovery and was discharged 2 days postsurgery.

Unexpected complicated appendicitis in the elderly diagnosed with acute appendicitis

BACKGROUND

This study determined the prevalence of complicated appendicitis in elderly patients diagnosed preoperatively with uncomplicated appendicitis.

METHODS

Patients with a preoperative diagnosis of uncomplicated appendicitis at an academic hospital from 11/2013 to 05/2017 were reviewed. Patients ≥65 years were compared to those younger. Pathology reports were categorized as either uncomplicated or complicated (COMP). The primary outcome was the prevalence of COMP appendicitis.

RESULTS

The prevalence of COMP appendicitis increased with age after 20 years with an abrupt increase after 65 years. Patients ≥65 years were more likely to have COMP appendicitis (48.1% vs. 15.5%; OR: 5.1; p < 0.01) and prolonged stays (3.8 vs. 2.3 days; p < 0.01).

CONCLUSION

Nearly half of elderly patients had pathologic confirmation of complicated appendicitis despite no preoperative clinical or radiographic suspicion for complicated appendicitis. Nonoperative management of acute appendicitis in the elderly may not be appropriate due to the high rate of unexpected complicated appendicitis.

Disseminated histoplasmosis mimicking an acute appendicitis

INTRODUCTION

Histoplasmosis can present in a myriad of clinical manifestations, which often makes its diagnosis difficult and occasionally, deceptive.

CASE REPORT

We describe a case of a 33 years old gentleman who was clinically diagnosed as acute appendicitis at initial presentation in view of a one-week history of fever, right lower quadrant abdominal pain- and guarding at right iliac fossa. He had thrombocytopenia and lymphopenia on presentation. Mesenteric lymphadenitis and small bowel lesion were found intraoperatively, which was respectively biopsied and resected. Histopathological result confirms disseminated histoplasmosis. Retroviral screen was positive. He was treated with amphotericin B for one week, subsequently switched to oral itraconazole, followed by initiation of highly active antiretroviral therapy (HAART).

DISCUSSION

This case illustrates the various nature of histoplasmosis presentation. A high index of suspicion is needed to clinch the diagnosis and subsequently institute prompt treatment as disseminated disease can be fatal if left untreated in an immunosuppressed host.

Multi-institutional trial of non-operative management and surgery for uncomplicated appendicitis in children: Design and rationale

Traditionally, children presenting with appendicitis are referred for urgent appendectomy. Recent improvements in the quality and availability of diagnostic imaging allow for better pre-operative characterization of appendicitis, including severity of inflammation; size of the appendix; and presence of extra-luminal inflammation, phlegmon, or abscess. These imaging advances, in conjunction with the availability of broad spectrum oral antibiotics, allow for the identification of a subset of patients with uncomplicated appendicitis that can be successfully treated with antibiotics alone. Recent studies demonstrated that antibiotics alone are a safe and efficacious treatment alternative for patents with uncomplicated appendicitis. The objective of this study is to perform a multi-institutional trial to examine the effectiveness of non-operative management of uncomplicated pediatric appendicitis across a group of large children's hospitals. A prospective patient choice design was chosen to compare non-operative management to surgery in order to assess effectiveness in a broad population representative of clinical practice in which non-operative management is offered as an alternative to surgery. The risks and benefits of each treatment are very different and a "successful" treatment depends on which risks and benefits are most important to each patient and his/her family. The patient-choice design allows for alignment of preferences with treatment. Patients meeting eligibility criteria are offered a choice of non-operative management or appendectomy. Primary outcomes include determining the success rate of non-operative management and comparing differences in disability days, and secondarily, complication rates, quality of life, and healthcare satisfaction, between patients choosing non-operative management and those choosing appendectomy.

Prevalence of Retrocaecal Appendix among Patients with Appendicitis in A Tertiary Care Hospital of Nepal

Introduction

Appendicitis is one of the most common causes of acute abdomen. The clinical presentation of appendicitis and its susceptibility to acute inflammation may be affected by the length and position of vermiform appendix. Length and position of appendix are variable. The aim of the study was to find the prevalence of retrocaecal appendix among patients undergoing appendectomy for appendicitis.

Methods

A descriptive cross-sectional study was performed in 264 patients undergoing appendectomy in Department of Surgery, Nobel Medical College, Biratnagar, Nepal from 1st May, 2018 to 15th May, 2019. Ethical approval was taken. Simple random sampling was done. The position of appendix was noted before appendectomy. Subgroup analysis was done on the basis of gender and length of appendix recorded in centimeters with a measuring scale immediately after removal of appendix. Data was collected in excel and was analyzed in SPSS version 16.

Results

Prevalence of retrocaecal appendix among patients with appendicitis was 95 (35.98%). Similarly, other positions noted were pelvic in 67 (25.37%), post-ileal in 61 (23.10%), pre-ileal in 11 (4.16%) and subcaecal in 30 (11.36%) individuals. The length of appendix ranged from 1.7 cm to 14.7 cm. The mean length was 8.67±2.44 cm.

Conclusions

The most common position of appendix in patients with appendicitis is retrocaecal position followed by pelvic position in both males and females.

Diagnostic yield of abdominal ultrasonography for the diagnosis of acute appendicitis: A global and subgroup analysis

INTRODUCTION AND AIMS

Abdominal ultrasonography is very useful for diagnosing acute appendicitis and has 59-96% sensitivity and 83-98% specificity. The aim of the present study was to determine the diagnostic yield of abdominal ultrasound imaging for acute appendicitis and identify the patient subgroups with the best results.

MATERIALS AND METHODS

Patients at a general hospital that underwent appendectomy due to the clinical suspicion of appendicitis, who also had a diagnostic radiologic study, within the time frame of January 2007 to December 2010, were analyzed. Ultrasound studies were considered positive when there were radiologic signs suggestive of acute appendicitis. The sensitivity, specificity, and predictive values of the diagnostic study were determined through the logistic regression method.

RESULTS

A total of 646 patients were operated on due to clinical suspicion of acute appendicitis. A diagnostic abdominal ultrasound study was carried out on 383 (59.3%) of those patients, resulting in 79% sensitivity (74-83, 95% CI), 58% specificity (39-75, 95% CI), 95% positive predictive value (92-97, 95% CI), and 20% negative predictive value (13-30, 95% CI).

CONCLUSIONS

Abdominal ultrasound imaging in patients with a high suspicion of appendicitis had a mediocre diagnostic yield, but better results could be achieved in different specific subgroups.

Sensitivity and specificity of computed tomography and ultrasound for the prediction of acute appendicitis at King Fahad Specialist Hospital in Buraidah, Saudi Arabia

Objectives:

To determine the sensitivity and specificity of computed tomography (CT) and ultrasound (US) in predicting acute appendicitis in relation to histopathology reports at King Fahad Specialist Hospital in Buraidah, Saudi Arabia.

Methods:

A retrospective cohort study included 500 medical records of patients diagnosed with acute appendicitis upon admission to King Fahad Specialist Hospital, Buraidah, Saudi Arabia, between January 2015 and January 2017.

Results:

Of the 200 patients, 187 (93.5%) were diagnosed with acute appendicitis by histopathology. Of these 187 patients, 57 (30.5%) underwent CT and 54 (29%) underwent US. Computed tomography correctly identified 86.0% of the patients as having acute appendicitis and incorrectly identified 14% as not having acute appendicitis. Similarly, US correctly identified 37% of the patients as having acute appendicitis, while the remaining 63% were incorrectly identified as not having acute appendicitis. Thirteen patients (6.5%) did not have acute appendicitis (confirmed by histology report). Six (46.15%) of these 13 patients underwent CT. Five of these 6 (83.3%) were incorrectly diagnosed with acute appendicitis by CT, whereas one of the 6 (16.7%) was identified as a true negative. On the other hand, US correctly identified 100% of the 13 patients as true negative.

Conclusion:

Computed tomography was shown to have sensitivity 86% and a specificity of 16.7% for the diagnosis of acute appendicitis. On the other hand, US had a sensitivity of 37% and a specificity of 100%. Therefore, we conclude that if imaging needed to confirm the diagnosis of appendicitis, CT is the choice. Ultrasound can be used only to exclude gynecological disorders.

Appendiceal Malignancy: The Hidden Risks of Nonoperative Management for Acute Appendicitis

One potential harm of nonoperative management for acute appendicitis is missed appendiceal cancer, a rare and often aggressive malignancy due to the frequency of late stage of diagnosis. Previous studies have reported an increasing incidence of appendiceal neoplasms in the population. This is a retrospective case-control study of 1007 adult patients, who presented to the University of North Carolina-Memorial Hospital (UNC-MH) between 2011 and 2015 with clinical signs and symptoms of appendicitis. We evaluated the incidence of primary appendiceal cancer in this population and determined factors that predict appendiceal cancer diagnosis using multivariate logistic regression analysis. The overall incidence of appendiceal neoplasm for adult patients presenting to UNC-MH with appendicitis from 2011 to 2015 was 2.3 per cent (23/1007). The incidence in patients without appendiceal perforation on pathology was 1.9 per cent (16/832). Age (odds ratio (OR) 1.03), number of days of abdominal pain (OR 1.16), self-reported fever (OR 2.08), appendiceal width (OR 1.95), and appendiceal wall thickness (OR 1.30) were predictors of appendiceal neoplasm diagnosis in patients that present with acute appendicitis. We recommend that an operative approach to acute appendicitis should remain the standard of care because operative management may not only be diagnostic but potentially therapeutic.

Genetic association and differential expression of PITX2 with acute appendicitis

Appendicitis affects 9% of Americans and is the most common diagnosis requiring hospitalization of both children and adults. We performed a genome-wide association study of self-reported appendectomy with 18,773 affected adults and 114,907 unaffected adults of European American ancestry. A significant association with appendectomy was observed at 4q25 near the gene PITX2 (rs2129979, p value = 8.82 × 10-14) and was replicated in an independent sample of Caucasians (59 affected, 607 unaffected; p value = 0.005). Meta-analysis of the associated variant across our two cohorts and cohorts from Iceland and the Netherlands (in which this association had previously been reported) showed strong cumulative evidence of association (OR = 1.12; 95% CI 1.09-1.14; p value = 1.81 × 10-23) and some evidence for effect heterogeneity (p value = 0.03). Eight other loci were identified at suggestive significance in the discovery GWAS. Associations were followed up by measuring gene expression across resected appendices with varying levels of inflammation (N = 75). We measured expression of 27 genes based on physical proximity to the GWAS signals, evidence of being targeted by eQTLs near the signals according to RegulomeDB (score = 1), or both. Four of the 27 genes (including PITX2) showed significant evidence (p values < 0.0033) of differential expression across categories of appendix inflammation. An additional ten genes showed nominal evidence (p value < 0.05) of differential expression, which, together with the significant genes, is more than expected by chance (p value = 6.6 × 10-12). PITX2 impacts morphological development of intestinal tissue, promotes an anti-oxidant response, and its expression correlates with levels of intestinal bacteria and colonic inflammation. Further studies of the role of PITX2 in appendicitis are warranted.

[Analysis of high risk factors for acute complex appendicitis in adults]

OBJECTIVE

To explore the high risk factors of adult complex appendicitis, and to provide a reference for the development of a reasonable treatment strategy for acute appendicitis.

METHODS

A retrospective case-control study was conducted to collect clinical data of 312 adult patients with acute appendicitis confirmed by pathology undergoing appendectomy, including open and laparoscopic surgery, from May 2011 to August 2016 at Affiliated Hospital of Qingdao University. Age <14 years old, pregnant women, complicating abscess around the appendix, AIDS, blood system diseases, autoimmune diseases, inflammatory bowel disease or progressive cancer patients were excluded. According to the intra-operative findings and pathological types, patients were divided into complex appendicitis(112 cases, including gangrene and perforation) and non-complex appendicitis (200 cases, including simple and non-perforated appendicitis, ie suppurative appendicitis). After comparing the clinical data of these two groups, statistically significant variables were induded for multivariate logistic regression analysis to identify risk factors of complex appendicitis, and to establish a regression model. Enter method was applied to establish the regression equation: P=ExpiΣBiXi/1+ExpΣBiXi, and to calculate the relative risk of each variable. Meanwhile, retrospective and prospective verification was performed on this predictive model (cases of acute appendicitis from September 2016 to December 2017 were further collected). The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of complex appendicitis were calculated with the regression model.

RESULTS

Comparison of the clinical data between the complex appendicitis group and the non-complex appendicitis group showed that differences of 10 preoperative indexes were statistically significant, including period from abdominal pain to admission [(59.1±42.6) hours vs. (47.5±34.4) hours, t=3.051, P=0.002], white blood cell count [(12.9±3.7)×10⁹/L vs. (9.2±4.0)×10⁹/L, t=9.755, P<0.001], neutrophil count [(9.8±4.0)× 10⁹/L vs.(7.1±3.9)×10⁹/L, t=6.020, P<0.001], neutrophil percentage[(84.5±8.7)% vs.(68.2±16.0)%, t=12.754, P<0.001], C-reactive protein levels [(86.0±45.4) μg/L vs. (55.9±35.8) μg/L, t=7.614, P<0.001], serum albumin levels [(334.0±4.8) g/L vs. ( 41.0±4.3) g/L, t=16.055, P<0.001], vomiting ratio [44.6%(50/112) vs. 23.5%(47/200), χ²=14.980, P<0.001], high fever(≥39°C) ratio [16.1%(18/112) vs. 7.5%(15/200), χ²=5.577, P=0.022], the proportion of patients ≥60 years old [22.3%(25/112) vs. 13.0%(26/200), χ²=4.562, P=0.038] and previous history of appendicitis [16.1%(18/112) vs. 7.5%(15/200), χ²=5.577, P=0.022]. The above 10 variables were included in the logistic regression model for multivariate analysis. The results showed that six variables were associated with complex appendicitis. According to their strength, they were old age (≥60 years old) X1(OR=5.094), high fever (≥39°C) X2(OR=4.464), neutrophil count X6 (OR=1.269), neutrophil percentage X4 (OR=1.077), C-reactive protein level X5 (OR=1.027), and serum albumin level X3 (OR=0.763). A predictive regression model was established: P=1/[1+e^{(0.557+1.628X1+1.496X2-2.7X3+0.74X4+0.27X5+0.238X6)}], whose sensitivity and specificity of judging complex appendicitis were 76.8%(86/112) and 90.0%(180/200),respectively. Sensitivity and specificity for predictive value of complex appendicitis in further prospective validation of the model were 76.2%(48/63) and 81.1% (30/37), respectively.

CONCLUSIONS

Age ≥ 60 years old, body temperature ≥39°C, increased neutrophil count, neutrophil percentage and C-reactive protein levels, and hypoalbuminemia are risk factors for complex appendicitis. The establishment of predictive model may help determine complex appendicitis.

Death caused by appendicular knotting and small-bowel strangulation in a child: A case report and review

Acute appendicitis is one of the most common surgical emergencies in paediatrics. However, acute appendicitis in early infancy is an uncommon condition. Furthermore, strangulation of the small intestine through appendicular knotting is described as very unusual in the literature and is generally not well-diagnosed in the clinical context. This article reports the case of a 23-month-old girl who entered the emergency department with a three-day history of abdominal symptoms and who died in less than 24 hours without receiving surgical intervention. The case turned judicial at the request of the parents who claimed lack of clarity in the diagnosis. A medico-legal autopsy was ordered to clarify the cause and manner of death. The autopsy documented herniation, strangulation and torsion of a 70 cm segment of the jejunum/ileum through an appendicular knot caused by the attachment of the distal end of the inflamed appendage to the ileum. The case is relevant because it is the first case of death by appendicular knot and strangulation of small bowel in an infant reported in the literature. The importance of autopsy to clarify the clinical diagnosis is noted.

Diagnostic prediction of complicated appendicitis by combined clinical and radiological appendicitis severity index (APSI)

OBJECTIVES

To develop a routinely applicable severity index for the management of acute appendicitis in adults using combined clinical and radiological parameters and retroperitoneal space planes (RSP).

METHODS

Two hundred consecutive patients with histologically proven acute appendicitis and available presurgical CT scans were analysed retrospectively. Two radiologists assessed all CT scans for morphologic sings of appendicitis and six RSP. Clinical parameters were age, body temperature, C-reactive protein (CRP), white blood cell count, and duration of symptoms. Radiological parameters were appendix diameter and wall thickness, periappendiceal fat stranding and fluid, intraluminal and extraluminal air, thinning of appendiceal wall, caecal wall thickening, appendicolith and abscess formation.

RESULTS

One hundred and three patients (51%) had histologically proven complicated appendicitis. Based on three clinical (age ≥52 years, body temperature ≥37.5°C, duration of symptoms ≥48 h) and four computed tomography (CT) findings (appendix diameter ≥14 mm, presence of periappendiceal fluid, extraluminal air, perityphlitic abscess), the APSI was developed using regression coefficients of multivariate logistic regression analyses with a maximum of 10 points. A score of ≥4 points predicted complicated appendicitis with a positive predictive value of 92% and a negative predictive value of 83%. Substantial to excellent interobserver agreement was found for the four radiological parameters of the APSI [intraclass correlation coefficient (ICC), 0.78-0.83]. The RSP evaluation presented no added value for the diagnosis of complicated appendicitis.

CONCLUSIONS

Using APSI, an accurate and simple prediction of complicated appendicitis in adults was possible. The RSP count was not useful for the diagnosis of complicated appendicitis.

KEY POINTS

• Appendicitis severity score provides an accurate and simple prediction of complicated appendicitis • Appendicitis severity score ≥4 accurately predicted complicated appendicitis (PPV 92%;NPV 83%) • Evaluation of retroperitoneal space planes was not useful in diagnosing complicated appendicitis.

Occult Appendiceal Neoplasms in Acute and Chronic Appendicitis: A Single-Institution Experience of 1793 Appendectomies

The incidence of appendiceal neoplasms may have been underreported in the past. Patients undergoing incidental appendectomies or appendectomies for chronic appendicitis may be at higher risk for an incidental appendiceal neoplasm. To determine the incidence of occult appendiceal neoplasms and identify risk factors associated with this pathology, a retrospective review of a pathology specimen database was conducted from November 2007 to December 2011, in a single tertiary care hospital center. All patients with appendectomies were included for analysis (n = 1793). Pathology specimens were grouped based on the indication for appendectomy, and the incidence of appendiceal neoplasms, and patient variables among the groups were compared using χ2 test and Student's t test. A total of 1793 appendectomy specimens met criteria for evaluation. The total number of appendiceal neoplasms was 31 (1.7%). There were 14 neoplasms in 1337 (1.0%) cases of acute appendicitis with 2 in 41 (4.9%) cases of chronic and 15 in 415 (3.6%) cases, where an incidental appendectomy was performed (P < 0.001). Patients with carcinoid tumors were significantly younger than patients with noncarcinoid tumors (P = 0.0001). Indication for operation was the only significant factor for predicting an appendiceal tumor on final pathology. Patients who undergo interval or incidental appendectomies may be at higher risk of appendiceal neoplasm compared with those performed for other indications. Younger patients may be at a higher risk of occult appendiceal carcinoid neoplasms than other age groups. Pathologic diagnosis in specific high-risk patient groups may be the only way to effectively capture these tumors for optimal treatment.

The sonographic features of neonatal appendicitis: A case report

RATIONALE

Neonatal appendicitis is extremely rare, and preoperative diagnosis is challenging. This study aimed to investigate the utility of ultrasound for the diagnosis of neonatal appendicitis.

PATIENT CONCERNS

Four cases of neonatal appendicitis were included in this case series. One was a female infant and the other 3 were male infants; they were aged from 10 to 17 days.

DIAGNOSES

Neonatal appendicitis.

INTERVENTIONS

Four newborns in our hospital were diagnosed with neonatal appendicitis by abdominal ultrasound. Their sonographic features were summarized and compared with surgical and pathological findings.

OUTCOMES

In these infants, abdominal ultrasound demonstrated ileocecal bowel dilatation, intestinal and bowel wall thickening, and localized encapsulated effusion in the right lower quadrant and the abscess area, which was assumed to surround the appendix.

LESSONS

Ultrasound is helpful for the diagnosis of neonatal appendicitis.

IMMUNOHISTOCHEMICAL ANALYSIS OF APPENDIX CELL WALL INFILTRATE IN ACUTE PHLEGMONOUS APPENDICITIS

The purpse of the study was to analyze the content of the mucous infiltrate of cells of the lamina propria of the appendix using immunohistochemical analysis in patients with acute phlegmonous appendicitis. The research included 21 patients with acute phlegmonous appendicitis. The control group consisted of 15 persons lacking the inflammation of the intraperitoneal cavity. Primary monoclonal (MC) antibodies (AB) of the mouse used in the immunohistochemical (IHC) research included the following: Ki-67, CD3, CD4, CD8, CD20, CD45, CD45R0, and CD68 (DAKO, Denmark), as well as EnVision+ System-HRP (DAB) optical system. The research has shown that acute phlegmonous appendicitis is characterized by statistically reliable increased infiltration (p<0.001) by B-lymphocytes (CD20), memory T-cells (CD45R0), Ki-67+ cells, macrophages (CD68), T-lymphocytes (CD3), T-helper cells (CD4), cytotoxic T-lymphocytes (CD8), and CD45 cells of the lamina propria of the appendix when compared with the control group. Development of acute phlegmonous appendicitis is characterized by enhance infiltration of the lamina propria by B-lymphocytes (CD20), macrophages (CD68), memory T-cells, and high proliferation activity of the mononuclear cells (Ki-67 index).

Diverticulitis of the cecal appendix: a case report

Appendicular diverticulosis is a rare condition. It is important to know its insidious form of presentation for its early diagnosis and treatment, thus diminishing morbimortality. In case of incidental findings, an appendicectomy will be performed to prevent complications and the development of malignancy.

C-reactive protein as a predictor of severity of appendicitis

BACKGROUND

Complex (perforated or gangrenous) appendicitis has a high rate of morbidity in South Africa.

METHOD

The study retrospectively reviewed results from January 2013 to December 2015 at Paarl Hospital in the Western Cape province. All patients who had their appendices surgically removed due to suspected appendicitis and who had preoperative results for CRP and WCC were included. Using the area under the Receiver Operated Characteristics curve we compared the inflammatory markers of 2 groups with histologically proven appendicitis: those with complex (perforated or gangrenous appendix) and those with uncomplicated appendicitis (inflamed appendix). Youden's J statistic was used to determine the optimal cut-off value above which complex appendicitis would be the most likely diagnosis.

RESULTS

A total of 591 patients were identified, 385 had results for both WCC and CRP. CRP (AUC 72%) proved to be a fair and WCC (AUC 58%) a poor predictor of complex appendicitis. Cut-off values for CRP and WCC were found to be 215 mg/l and 16.80 109 cells/l respectively. At these threshold values CRP (sensitivity 51.4%, specificity 85.7%, p-value < 0.001, positive predictive value 80.2%, negative predictive value 61%, positive likelihood ratio 3.6 and diagnostic odds ratio 6.35) proved to be much better than WCC (sensitivity 43%, specificity 73.8%, p-value = 0.022, positive predictive value 64.9%, negative predictive value 53.4%, positive likelihood ratio 1.64 and diagnostic odds ratio 2.11) in predicting complex appendicitis.

CONCLUSION

CRP is superior to WCC in the differentiation between uncomplicated and complex appendicitis. Using a cut-off value of CRP 215 mg/l is statistically significant in diagnosing complex appendicitis. This value should be used cautiously as many more studies are needed to confirm these findings.

Tuberculous appendicitis. A case report

Double localization of tuberculosis is a rare finding among immunocompetent patients. Intestinal tuberculosis is a rare condition and its diagnosis remains a challenge to the physician. We present the case of a 21 year old male patient with intestinal tuberculosis in which the first manifestation was an acute appendicitis. Ultrasound findings were an abscessed appendicular mass. The surgical intervention found a granulomatous aspect of the peritoneum and total necrosis of the appendix. Histopathological examination confirmed the diagnosis and the pulmonary radiography detected the concomitant pulmonary tuberculosis.

Retrospective study of 24 cases of acute appendiceal diverticulitis: CT findings and pathological correlations

PURPOSE

Appendiceal diverticulitis is relatively rare and is difficult to distinguish clinically and radiologically from acute appendicitis. The aim of this study was to describe the computed tomography (CT) findings of acute appendiceal diverticulitis.

MATERIALS AND METHODS

Among the 1329 patients who underwent appendectomy at our institution between January 2010 and July 2015, 28 were diagnosed pathologically with appendiceal diverticulitis, including 24 patients who were evaluated by preoperative CT. The control group consisted of 38 patients without diverticulitis. Average age of patients, ratio of males to females, appendiceal diameter, presence of a diverticulum, diverticular enhancement, peri-appendiceal fat stranding, peri-appendiceal loculated fluid and perforation, and the presence of appendicolith were evaluated retrospectively.

RESULTS

Peri-appendiceal fat stranding (p < 0.005), appendiceal diameter (p < 0.005), and peri-appendiceal loculated fluid differed significantly between the diverticulitis and non-diverticulitis groups (p < 0.005).

CONCLUSION

Although relatively uncommon, appendiceal diverticulitis should be included in the differential diagnosis of acute appendicitis. It differs from typical acute appendicitis by the presence of an inflamed diverticulum, seen on CT. These patients are also more likely to have peri-appendiceal extra-luminal loculated fluid, peri-appendiceal fat stranding, and a larger diameter of the appendix. The latter finding is likely due to the increased intraluminal pressure.

Characteristics of mesenteric lymphadenitis in comparison with those of acute appendicitis in children

Mesenteric lymphadenitis (ML) is considered as one of the most common alternative diagnosis in a child with suspected acute appendicitis (AA). In this retrospective study, patients diagnosed with ML (n = 99) were compared in terms of demographic, clinical, and laboratory findings to patients diagnosed with AA (n = 102). This comparison was applied for both lymph nodes smaller and larger than 10 mm. When compared to patients with AA, patients with ML had significantly longer duration of symptoms prior to emergency department (ED) presentation (2.4 ± 2.6 vs 1.4 ± 1.4 days, P = 0.002) and multiple ED presentations (1.3 ± 0.7 vs 1.05 ± 0.3, P < 0.001) and had longer duration of stay in the ED (9.2 ± 5.9 vs 5.2 ± 4 h, P < 0.001), respectively. They also had significantly lower WBC (10.16 ± 4.7 × 10³/dl vs 15.8 ± 4.4 × 10³/dl, P < 0.001) with lymphocyte predominance (24.6 ± 14 vs 13 ± 8.7%, P < 0.001) and lower CRP levels (0.48 vs 1.6 mg/dl). Migration of pain (28 vs 7%), vomiting (62 vs 34%), and classic abdominal findings of AA (72 vs 20%) were all significantly more common for children with AA. When comparing lymph node size, no significant difference was found between those presenting with small and large nodes.

CONCLUSION

This study highlights multiple clinical and laboratory findings that differentiate ML and AA. Moreover, the absence of any difference with regard to the lymph nodes size might suggest that lymph nodes enlargement is a non-specific finding. What is Known : • Mesenteric lymphadenitis is a very common diagnosis in children with suspected acute appendicitis. • Despite its prevalence, only few studies addressed the clinical characteristics of this clinical entity and their comparison with acute appendicitis. What is New: • Mesenteric lymphadenitis and acute appendicitis could be differentiated by multiple clinical and laboratory parameters. • No significant difference was found between those presenting with small and large lymph nodes.

[LIFTING LAPAROSCOPY IN SIMULTANT SURGERY]

Results of treatment of 84 patients, to whom simultant operative interventions on abdominal, the small pelvis and retroperitoneal organs were performed for concomitant somatic diseases, were analyzed. The author’s technology of laparolifting was applied in 36 patients, and classical technology with carboxyperitoneum adjustment - in 48. Variants of optimal operative accesses were determined, structure and rate of postoperative complications, peculiarities of the early postoperative period course studied. Indisputable advantages of the lifting laparoscopic operations were established, including reduction of the postoperative complications rate and severity, the postoperative pain syndrome intensity, the concurrent chronic diseases exacerbation rate, and postoperative stationary stay.

Diagnostic value of platelet indices in acute appendicitis and comparison with histopathology

BACKGROUND

Acute appendicitis is one of the most common surgical emergencies. An early and accurate diagnosis of acute appendicitis is vital. Evidence for a link between platelets indices and inflammation disease comes from recent studies. We aimed to evaluate preoperative diagnostic values of platelet indices (Mean platelet volume-MPV, Platelet Distribution Width-PDW, Plateletcrit-PCT) and leukocyte count (WBC) in comparison with post-operative histopathology results in patients who underwent appendectomy.

METHODS

The 165 patients who underwent appendectomy, were evaluated retrospectively. Patients' demographic characteristics, imaging findings, preoperative laboratory markers and postoperative histopathology results were recorded. The patients were divided into three groups based on the histopathologic findings; perforated appendicitis, acute appendicitis without perforation and negative appendectomy group. The specificity, sensitivity, positive predictive value (PPV) and negative predictive value (NPV) of the laboratory markers were measured. Additionally potential correlation among laboratory markers analysed.

RESULTS

The negative appendectomy rate was 15.1% in 165 patients. The leukocyte count was statistically higher in acute appendicitis (14.9×103/μL) group than negative appendectomy (6.9×103/μL) group. There was also statistically significant difference between groups according to the PCT levels. The leukocyte count achieved sensitivity, specificity, PPV, and NPV of 95.9, 24, 99.1, and 92.7% respectively. A significant positive correlation between WBC and PCT were obtained. Inflammatory markers were not directly related to the severity of the disease.

CONCLUSIONS

Elevated leukocyte count and PCT levels support diagnosis of acute appendicitis in correlation with pathological findings. Thereby combination of the inflammatory markers, positive clinical and radiological findings would improve diagnostic accuracy in acute appendicitis.

KEY WORDS

Acute appendicitis, Inflammatory markers, Platelet indices.

Amoebiasis Presenting as Acute Appendicitis

We report a case of amoebic appendicitis without colitis symptoms. Acute appendicitis is commonly encountered by gastroenterologists in their daily practice. The number of cases of amoebiasis increases annually in Japan, and is thought to be associated with an increase in sexually transmitted disease or travel to endemic areas. However, acute amoebic appendicitis is rare and the prognosis is very poor compared to nonamoebic appendicitis. In our case, appendectomy was performed immediately after onset, and the patient was discharged without complications. It is difficult to differentiate between amoebic and nonamoebic appendicitis preoperatively, and the possibility of amoebic appendicitis should be kept in mind.

Measurement error in CT assessment of appendix diameter

BACKGROUND

Appendiceal diameter continues to be cited as an important criterion for diagnosis of appendicitis by computed tomography (CT).

OBJECTIVE

To assess sources of error and variability in appendiceal diameter measurements by CT.

MATERIALS AND METHODS

In this institutional review board-approved review of imaging and medical records, we reviewed CTs performed in children <18 years of age between Jan. 1 and Dec. 31, 2010. Appendiceal diameter was measured in the axial and coronal planes by two reviewers (R1, R2). One year later, 10% of cases were remeasured. For patients who had multiple CTs, serial measurements were made to assess within patient variability. Measurement differences between planes, within and between reviewers, within patients and between CT and pathological measurements were assessed using correlation coefficients and paired t-tests.

RESULTS

Six hundred thirty-one CTs performed in 519 patients (mean age: 10.9 ± 4.9 years, 50.8% female) were reviewed. Axial and coronal measurements were strongly correlated (r = 0.92-0.94, P < 0.0001) with coronal plane measurements significantly larger (P < 0.0001). Measurements were strongly correlated between reviewers (r = 0.89-0.9, P < 0.0001) but differed significantly in both planes (axial: +0.2 mm, P=0.003; coronal: +0.1 mm, P=0.007). Repeat measurements were significantly different for one reviewer only in the axial plane (0.3 mm difference, P<0.05). Within patients imaged multiple times, measured appendix diameters differed significantly in the axial plane for both reviewers (R1: 0.5 mm, P = 0.031; R2: 0.7 mm, P = 0.022).

CONCLUSION

Multiple potential sources of measurement error raise concern about the use of rigid diameter cutoffs for the diagnosis of acute appendicitis by CT.