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PubMed1991

[Ultrasonic diagnosis in suspected acute appendicitis: probable or certain indications for surgery?].

The diagnostic accuracy and the clinical impact of routine ultrasonography performed by 4 surgeons, were prospectively studied in 366 unselected patients admitted for suspected acute appendicitis. Clinical and sonographic findings on admission were correlated with laparotomy findings, pathological outcome and clinical as well as follow-up data. The overall sensitivity, specificity and accuracy of the clinical diagnosis of acute appendicitis were 55.3%, 94.6% and 84.2% respectively (positive predictive value (PPV) 75.8%, negative predictive value (NPV) 87.3%). Ultrasound enabled visualization of the disease in 67 of 85 (prevalence 23.3%) patients with a histologically confirmed acute appendicitis; false positive results were recorded in 7 cases (sensitivity 78.8%, specificity 97.5%, accuracy 93.1%, PPV 90.5%, NPV 93.8%). Ultrasound was particularly useful in patients presenting with equivocal or highly unsuspective signs of acute appendicitis: of 38 patients with an acute appendicitis in this group ultrasonography enabled to make the diagnosis in 26. The combined approach of clinical evaluation and routine ultrasonography markedly improved the diagnostic accuracy (sensitivity 85.9%, specificity 96.4%, accuracy 94%) and substantially reduced the negative laparotomy rate (7.9%) in patients with suspected acute appendicitis. It is concluded, that ultrasonographic evaluation of the patient with suspected acute appendicitis performed by surgeons is of great assistance in surgical practice.

Abdomen, Acute↗
PubMedDate not supplied

[Appendicitis in children: clinical observation in 88 surgical cases].

From February 1983 to December 1987, appendectomy was done in 106 children for the presumptive diagnosis of appendicitis with or without perforation at VGH-Taichung. Subsequent pathological findings confirmed suppurative appendicitis in 53 patients (48.1%), and perforated appendicitis in 37 patients (34.9%). There were 18 (17.0%) normal appendices. The age of patients ranged from 2 to 14 years, with an average of 8.9 years. Only 9.1% of the patients were under 5 years of age. The perforation rate was 62.5% in children under 5 years of age, and 59.4% in children 5 to 8 years old, both of them had a higher incidence than children over 8 years of age (27.1%, P less than 0.05). The mean duration of symptoms was 76.2 hours in children with perforated appendicitis, which was significantly longer than that in children with suppurative appendicitis (28.7 hrs, P less than 0.05). The use of triple combination of antibiotics in the treatment of perforated appendicitis has been proved to significantly decrease the incidence of postoperative wound complications. Early diagnosis, prompt surgical intervention, and recognition and treatment of residual septic foci were proved appropriate means of treatment of appendicitis.

Adolescent↗
PubMed1989

Compression ultrasonography as an aid in the differential diagnosis of appendicitis.

Conventional diagnostic tools have hitherto demonstrated low levels of specificity in establishing the diagnosis of appendicitis. We conducted a retrospective study of all patients who underwent abdominal or pelvic compression ultrasonography during a 15 month period based on variable clinical suspicion of appendicitis. Ultrasonographic interpretations were correlated with surgical and pathologic findings and clinical follow-up study. The initial 76 prospective ultrasonographic readings, interpreted by multiple examiners, were labeled group 1. The criterion used to diagnose appendicitis in this group was visualization of a noncompressible target-like structure with a hypoechoic wall greater than 2 millimeters in diameter. Ultrasonography was found to be 66.7 per cent sensitive, 90.6 per cent specific and 86.8 per cent accurate in the diagnosis of appendicitis, with a positive predictive value of 57.1 per cent and a negative predictive value of 93.5 per cent. We reassembled 70 of the original ultrasonographic examinations and retrospectively reanalyzed these studies (group 2), using the most recently published criterion, which requires a maximal appendiceal diameter of greater than 6 millimeters. Ultrasonography was shown to be 80.0 per cent sensitive, 95.0 per cent specific and 92.9 per cent accurate in diagnosing appendicitis, with a positive predictive value of 72.7 per cent and a negative predictive value of 96.6 per cent. Ultrasonographic examination provided additional findings, predominantly gynecologic or obstetric, in 52 per cent of the women, leading to an alternative diagnosis in one-third of these patients with complaints of abdominal pain. Ultrasonographic study provided additional findings in 12 per cent of the men, leading to alternative diagnoses in 12 per cent. Ultrasonographic results directly influenced clinical management in 18 per cent of the patients. As suggested in the most recent literature, appendiceal ultrasonographic examination is a reliable ancillary technique in diagnosing or excluding appendicitis. It is indicated only in patients with an atypical or equivocal presentation; those with clinical grounds do not require ancillary diagnostic aids and should proceed immediately to surgical intervention. The predominant role of ultrasonography in evaluating appendicitis is not as an independent diagnostic determinant. Instead, it is most useful as a means of improving decision making when considered in combination with a thorough history and physical examination in those patients who represent diagnostic dilemmas.

Adolescent↗
PubMed1988

Concentrations of serotonin in plasma--a test for appendicitis?

We assessed the value of measuring serotonin (5-hydroxytryptamine) in plasma (by HPLC) in the diagnosis of acute appendicitis. Values for patients with subsequently confirmed appendicitis (11-145 nmol/L, median 70 nmol/L) significantly (P congruent to 0.005) exceeded those for patients with abdominal pain in whom appendicitis was only a possible diagnosis (2-45 nmol/L, median 20 nmol/L). The results for appendicitis patients were bimodally distributed, with low results found in patients where surgery revealed gangrenous appendicitis with little viable appendicular tissue. We conclude that measuring serotonin may be of value in confirming or excluding the diagnosis of early acute appendicitis where the physical signs are equivocal, and thus helps reduce unnecessary appendectomies. However, serotonin is of little help in diagnosing gangrenous appendicitis, where physical signs are more likely to be clearcut.

Appendectomy↗
PubMed1985

Childhood appendicitis: factors associated with perforation.

A retrospective study was performed to identify factors associated with perforation in 150 children with acute appendicitis. The children's parents were interviewed about the nature and timing of care, family history of appendicitis, and history of abdominal pain episodes, and the children's medical records were reviewed. Delay in treatment--the interval between first recognized symptoms of abdominal pain and surgery--was most predictive of perforation. A treatment delay of more than 36 hours was associated with a 65% or greater incidence of perforation. Mean delay for the group with perforation of the appendix was 66.7 hours compared with 35.8 hours for the group having appendicitis without perforation (P less than .01). Mean professional delay was significantly longer in the group with perforated appendicitis than in the group having appendicitis without perforation (P less than .01), but mean parental delay was not. Children aged 1 to 4 years and those aged 5 to 8 years had a 74% and 66% incidence of perforation, respectively, compared with a 30% to 42% incidence in older children (P less than .01). Age had a significant effect upon perforation even when adjusted for delay in treatment. Other factors associated with perforation were family history of appendicitis, social class, advice given by the first health professional contacted, and the presence of fecaliths. When all factors were considered simultaneously by using logistic regression techniques, delay in treatment, age, and absence of a family history of appendicitis were all significant predictors of perforation.

Acute Disease↗
PubMed1995

Use of the neutrophil:lymphocyte ratio in the diagnosis of appendicitis.

In patients with right lower quadrant pain, the total white cell count is an unreliable predictor of appendicitis. It has been reported that the lymphocyte count can fall in acute appendicitis. This study was undertaken to investigate whether the neutrophil:lymphocyte ratio is a more sensitive indicator than the total leucocyte count. A retrospective study was performed of patients undergoing appendectomy for suspected appendicitis over a 2-year period. A total of 402 patients were identified; histopathology confirmed appendicitis in 367 (91%). Other significant pathology was found in 13 (3.2%). Twenty-two (5.5%) had a histologically normal appendix and recovered uneventfully with no other diagnosis being made. A total of 298 (79%) patients with appendicitis had an elevated preoperative total white cell count. The neutrophil:lymphocyte ratio was calculated for each patient. Using an upper limit of 3.5:1, it was found that 324 (88%) of patients with appendicitis had a ratio equal to or greater than this value. This was significantly different from the proportion with a raised total leucocyte count (P = 0.001). We suggest that the simple calculation of the neutrophil:lymphocyte ratio may provide a parameter that is more sensitive than the total leucocyte count in the prediction of appendicitis.

Acute Disease↗
PubMedDate not supplied

Clinical and laboratory findings in acute appendicitis in the elderly.

BACKGROUND: Early diagnosis and surgery are important factors by which the morbidity and mortality of acute appendicitis in elderly patients can be lowered. This study was conducted to determine clinical and laboratory results that are commonly associated with acute appendicitis in elderly patients. METHODS: A retrospective chart review was conducted of patients aged 60 years or older who underwent appendectomy or laparotomy for suspected acute appendicitis during a 5-year period in a metropolitan county. Acute appendicitis was confirmed by the pathology report. RESULTS: Elevated band cells and right lower quadrant pain were predictors of acute appendicitis in clinically suspected cases. Band cells greater than 6 percent had an excellent positive predictive value, as all patients with elevated band cells had acute appendicitis. With increasing white cell count and temperature, specificity increased, sensitivity decreased, and the positive predictive value remained high. CONCLUSIONS: It is essential to have a high degree of suspicion to recognize acute appendicitis in an afebrile elderly patient who has abdominal pain, a mildly elevated white cell count, and band cells in the upper limits of normal.

Acute Disease↗
PubMed1996

Does this patient have appendicitis?

Appendicitis is a common cause of abdominal pain for which prompt diagnosis is rewarded by a marked decrease in morbidity and mortality. The history and physical examination are at least as accurate as any laboratory modality in diagnosing or excluding appendicitis. Those signs and symptoms most helpful in diagnosing or excluding appendicitis are reviewed. The presence of a positive psoas sign, fever, or migratory pain to the right lower quadrant suggests an increased likelihood of appendicitis. Conversely, the presence of vomiting before pain makes appendicitis unlikely. The lack of the classic migration of pain, right lower quadrant pain, guarding, or fever makes appendicitis less likely. This article reviews the literature evaluating the operating characteristics of the most useful elements of the history and physical examination for the diagnosis of appendicitis.

Abdomen, Acute↗
PubMedDate not supplied

Acute appendicitis in children in a community hospital: a five year review.

OBJECTIVE: To review appendectomy cases in children at a small community hospital and to compare with experience at larger centers. DESIGN: A five-year retrospective study. SETTING: Bartlett Regional Hospital, Juneau, Alaska. PATIENTS AND METHODS: Records of children age 14 and younger who underwent appendectomy from 1991 through 1996 were reviewed; 79 charts were found. Cases were grouped as simple appendicitis, advanced appendicitis, and appendectomy without appendicitis. Variables considered included: length of symptoms at first contact, time from onset until surgery, presence or absence of classical symptoms, post-operative complications, length of hospital stay. RESULTS AND CONCLUSION: 51 cases (64.6%) of simple appendicitis, 22 cases (27.9%) of advanced disease, and 6 cases (7.6%) of normal appendix occurred. Advanced disease was high (66.7%) in children less than 5, and low (22.7%) in ages 10-14. Parental delay > 48 hours in seeking care was a significant factor in advanced disease, professional delay (time from first exam until surgery) was not. Post-surgical complications occurred in 7 (31.8%) cases of advanced disease and in none of the cases with simple appendicitis. Advanced disease cases had an average hospital stay of 8.59 days (+/-2.92) vs. 3.86 days (+/-1.46) for simple appendicitis. Review of appendicitis in children at this hospital compared favorably with the experience at larger medical centers.

Acute Disease↗
PubMed1998

[The value of C-reactive protein in the diagnosis of acute appendicitis in children].

OBJECTIVE: The aim of this study was to evaluate the usefulness of C-reactive protein values in the diagnosis of acute appendicitis, either as a single test or in combination with total white cell count. PATIENTS AND METHODS: Two hundred and thirty-one children with suspected appendicitis were analyzed. C-reactive protein and total white cell counts were measured and compared with the duration of symptoms and histological diagnosis. Both tests were compared by receiver-operating characteristic curves and the probability for the use of both tests together was calculated. RESULTS: Ninety out of 231 patients had abdominal pain that did not demand surgery. One hundred and forty-one children had histologically confirmed appendicitis (subgroups: 101 acute, 25 gangrenous and 15 perforated appendices). Mean C-reactive protein levels at admission were 25.1, 55 and 66.7 mg/L, respectively in these histological subgroups and 14.9 mg/L in the non-appendicitis group (p < 0.001). The total white cell count was also statistically significant. Both tests were equally valuable in patients whose symptoms had a duration of more than 12 hours. The total white cell count was more valuable in patients with less than 12 hours of symptoms. The likelihood ratio for appendicitis was 2.72 for a C-reactive protein greater than 20 mg/l and a total white cell count above 15,000/mm3. The likelihood ratio of not having appendicitis was 0.37 when both tests were below these values. CONCLUSIONS: Measurement of C-reactive protein is useful in the diagnosis of acute appendicitis, mainly in cases with more than 12 hours of evolution. The combined tests improved the predictive values.

Acute Disease↗
PubMed1998

[The clinical picture of acute appendicitis in children].

The authors describe 3860 child patients operated on account of acute appendicitis and analyse the data with regard to age, sex, year of incidence and surgical finding. The highest incidence of acute appendicitis is between 8 and 11 years with a peak at the age of 10 years. It is more frequent in boys (58.3%) than in girls (43.7%), the ratio being 1.3:1. It occurs more often during the cold months (46.5%), in autumn (27.3%) and in winter (25.7%). The number of gangrenous appendicitis is 34.7%-56.7% in boys and 43.5% in girls. The highest rate of missed appendicitis is at the age of the highest incidence (15.2%) with a peak at the age of 10 years (17.8%) and in January (13.3%). The highest incidence of perforated appendicitis is also at the age of the highest incidence (14.9%) with the peak at the age of 8 years (15.6%) and in June (13.5%). Perforation is more frequent in boys (58.1%) than in girls (49.9%). The number of "negative" appendicitis is 15.8%. Prevention of acute appendicitis still remains open due to lack of knowledge of its etiopathogenesis.

Acute Disease↗
PubMed1998

[Diagnosis of appendicitis in early childhood].

89 preschool children, 2-4 years old, treated under the diagnosis of appendicitis were analyzed, 46 of them were operated. In 40% of those children the diagnosis of an acute nonperforated appendicitis could have been ensured, in 40% the diagnosis of a perforated appendicitis was found, in 20% the laparotomy was negative. In cases of an acute nonperforated appendicitis typical symptoms were vomiting (100%), general stomach-ache (89%) and fever (61%). In most cases of an perforated appendicitis the state of patients was reduced drastically (80%), in 50% an ileus could be observed. Duration of anamnesis was less than 24 hours with all the children who suffered from acute nonperforated appendicitis and with one fourth of the children suffering from perforated appendicitis.

Acute Disease↗
PubMedDate not supplied

Acute appendicitis and dietary fibre intake.

It has been postulated that acute appendicitis is the first serious disease to emerge with the adoption of fibre-depleted diets. The incidence of acute appendicitis is rising in Africa and this has been attributed to socio-economic advancement and the adoption of low residue diets. The aim of this study was to determine whether income levels and the level of dietary fibre intake play any role in the rising incidence of acute appendicitis in Ghana. Between June and November 1997 patients aged 13 years and above with acute appendicitis were studied. Their monthly net income levels or those of their parents if they were minors were ascertained and a dietary fibre questionnaire completed on each patient in order to assess his or her dietary fibre intake. The clinical details of each patient were recorded on a proforma. One hundred and seventy-three patients, 128 males and 45 females, mean age 29.2 (range 13-75) years were studied. 14 percent presented within 6 h, 46.8 percent within 24 h and 41.6 percent after 2 or more days. 53.2 percent had acute appendicitis and 42.8 percent presented with complicated appendicitis. The appendix was normal in 4.0 percent. Two patients died (1.2 percent). 61.3 percent of patients were low income earners and 38.7 percent were high income earners. The overall dietary fibre intake was 39.4 g per day with no significant difference in fibre consumption between low income earners (39.0 g/day) and high income earners (43.5 g/day). We conclude that dietary fibre may not be the important factor in acute appendicitis and other luminal and/or morphological factors may be predisposing factors.

Acute Disease↗
PubMed1965

ACUTE APPENDICITIS.

Acute appendicitis still is a cause of considerable morbidity and now and then of death. The diagnostic accuracy in 316 patients operated on for acute appendicitis at Holy Cross Hospital was 76 per cent. In 24 of 239 cases of proved acute appendicitis, perforation had occurred, and the morbidity in those cases was three times that in the cases without perforation. Review of the cases did not reveal any clear-cut diagnostic criteria that might be used to predict perforation.A study of 30 patients with mesenteric lymphadenitis who were inadvertently operated on in the belief they had appendicitis, revealed that this condition is most likely to occur in young females with only a slight increase in the number of leukocytes. Although positive diagnosis of acute appendicitis is a difficult problem, the morbidity associated with needless operation is so much less than that which occurs in acute perforated appendicitis, that prompt exploration in any questionable case seems warranted.

Acute Disease↗
PubMed1996

Role of the primary care provider in expediting care of children with acute appendicitis.

OBJECTIVE: To assess the role of the primary care provider (PCP) in the diagnosis and treatment of acute appendicitis in children by determining whether there were differences in the treatment and outcome of children whose parents contacted the PCP before taking the child to the hospital compared with those who did not. DESIGN: Retrospective review of medical records of pediatric patients discharged from the hospital with the diagnosis of acute appendicitis. SETTING: An urban children's hospital. METHODS: The medical records of children treated for acute appendicitis from July 1, 1990, through June 30, 1994, were identified through review of hospital discharge data and divided into 2 groups based on whether the children's parents had contacted the PCP before their arrival at the hospital. Contact with the PCP was determined by record review or telephone interview with the parent. The 2 groups were then studied for differences in treatment and outcome. Statistical analysis was by the X2 test and the Student t test, as appropriate, with the level of significance determined at P < .05. RESULTS: During the 4-year period, 343 children underwent appendectomy. Medical records were available for review for 321 children (94%). After review, records of 38 children were excluded because the primary problem was not acute appendicitis. Of the 283 children whose records were included in the study, the parents of 160 had contacted the PCP before arrival at the hospital (group 1, those who called) and the parents of 99 had not called (group 2, those who did not call). It could not be determined whether a call had been made for 24 children. The mean age of the children in group 1 was 124 months and in group 2 was 126 months (P = .74). Of group 1, 24% arrived at the hospital on a Saturday or Sunday, compared with 40% of group 2 (P = .007). Children in group 1 who arrived at the hospital during the weekend were operated on a mean (SD) of 4.7 hours (3.7 hours) after arrival at the hospital, compared with 10.6 hours (17.1 hours) for children in group 2 (P = .04). The mean (SD) interval between arrival at the hospital and operation on weekdays (Monday through Friday) was similar in both groups: 12 hours (20.6 hours) in group 1 and 13.7 hours (25.6 hours) in group 2 (P = .63). Appendiceal perforation was less likely in children in group 1 (62/160 [39%]) than in those in group 2 (53/99 [54%]; P = .03). Parents of 50 (89%) of 56 children who belonged to a health maintenance organization called the PCP compared with 96 (62%) of the 156 with fee-for-service insurance and 10 (26%) of the 38 with Medicaid (P < .001). No difference was noted in the interval between arrival at the hospital and operation or incidence of appendiceal perforation according to type of insurance. CONCLUSIONS: Children with appendicitis whose parents contacted the PCP before arrival at the hospital were less likely to have appendiceal perforation than those whose parents did not call the PCP, irrespective of insurance status. Children whose parents called the PCP before arrival at the hospital during the weekend were operated on more promptly than were children whose parents did not call the PCP. Contact with the PCP was associated with more expeditious care of children with acute appendicitis.

Appendectomy↗
PubMed1989

Appendicitis and appendicectomy in a Melanesian population.

A prospective study of patients with appendicitis has been conducted over a 3-year period in the Melanesian population of the North Solomons. Patients presented with suspected appendicitis at an annual rate of 39 per 100,000 population. Appendicitis was confirmed at operation at an annual rate of 22 per 100,000 population. The disease was considerably more frequent in male than in female patients. The annual appendicectomy rate was 29 per 100,000 population. Thirty per cent of patients presented with signs of late or complicated appendicitis, while 37 per cent of patients submitted to operation were found to have advanced appendicitis. The incidence and pattern of appendicitis in the North Solomons are quite different from those seen in the urbanized populations of developed countries.

Acute Disease↗
PubMed1994

Practical score to aid decision making in doubtful cases of appendicitis.

During recent years different procedures have been used to assist in diagnosis of questionable cases of appendicitis. Among these methods, there are few scoring systems that have been shown to be effective. The aim of this study was to create a scoring system and to test its accuracy in the preoperative diagnosis of acute appendicitis. Clinical data from 360 patients who had undergone appendicectomy were collected to identify attributes that distinguished patients having a negative laparotomy from those with appendicitis. Seven independent criteria were identified. Using Bayesian methodology a weight was given to each criterion and an overall score calculated. A cut-off point was identified to separate patients for surgery and those for observation. The scoring system was applied prospectively to 166 consecutive patients; 134 had appendicitis and 32 a normal appendix (19.3 per cent error diagnosis). For the 166 patients the method suggested surgery in 113, 107 (94.7 per cent) of whom were found to have appendicitis. The system suggested observation in hospital in 38 cases. For the whole group the scoring system showed a sensitivity of 80 per cent and specificity of 81 per cent. Scoring systems from a local database could become the ideal complementary method in the diagnosis of suspected acute appendicitis.

Acute Disease↗
PubMed1995

Randomized controlled trial of appendicectomy versus antibiotic therapy for acute appendicitis.

In a prospective controlled study the effect of antibiotics as the only treatment in acute appendicitis was evaluated. Of 40 patients admitted with a duration of abdominal pain of less than 72 h, 20 received antibiotics intravenously for 2 days followed by oral treatment for 8 days and 20 considered as controls were randomized to surgery. All patients treated conservatively were discharged within 2 days, except one who required surgery after 12 h because of peritonitis secondary to perforated appendicitis. Seven patients were readmitted within 1 year as a result of recurrent appendicitis and underwent surgery, when appendicitis was confirmed. The diagnostic accuracy within the operated group was 85 per cent. One patient had perforated appendicitis at operation. Antibiotic treatment in patients with acute appendicitis was as effective as surgery. The patients had less pain and required less analgesia, but the recurrence rate was high.

Acute Disease↗