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PubMed1987

Appendicitis revisited: a comparative study of Malawian and English appendices.

The incidence of appendicitis shows a marked variation between populations which has been attributed to dietary differences. Neural mechanisms and serotonin discharge from subepithelial neurosecretory cells have been previously implicated in pain referable to the appendix and appendicitis. Forty consecutive appendicectomy specimens from Malawi were studied by staining with haematoxylin and eosin, an alcian blue - PAS diastase sequence coupled with lead haematoxylin (PbH) and immunohistology for serotonin and NSE. The findings were compared with those in appendices removed at the Middlesex Hospital, London, to see if there were any differences between a population with a low risk of appendicitis (Malawi) and a high risk population (England). Acute transmural appendicitis was seen in fewer appendices from Malawi (27.5 per cent) than in English appendices (58 per cent). Subepithelial neurosecretory cells identified with PbH were present in 20 per cent of appendices from Malawi and 69 per cent of English appendices. These cells in both series showed immunohistochemical staining for serotonin. Nerve hyperplasia identified by staining for NSE in the appendix was present in 17.5 per cent and 81 per cent of non-inflamed appendices from Malawi and England respectively. Appearance of subepithelial neurosecretory cells and hyperplasia appear to be concomitants of an increased risk of appendicitis. Neural mechanisms may participate in adapting to a low residue diet and in some cases may generate appendicitis.

Appendicitis↗
PubMed2002

CT scan in the management of acute appendicitis.

BACKGROUND: Recent studies demonstrate a 98% accuracy of a CT scan in the diagnosis of acute appendicitis. We aimed to determine the accuracy and clinical value of CT scans in patients suspected of having acute appendicitis. PATIENTS AND MATERIALS: We reviewed outcomes of 125 patients over a 5-month period who had CT scans for the initial diagnosis of acute appendicitis. CT scan interpretations were correlated with surgical and pathologic findings. Follow-up was attempted in all patients who did not undergo appendectomy. RESULTS: CT scans and clinical courses were complete in 110 patients (88%); 14 patients were lost to follow-up and 1 was excluded. One patient had two CT scans. Thus, there were 111 CT scans available for review. Radiologic interpretation of these CT scans yielded 36 positive (33%), 67 negative (60%), and 8 indeterminate (7%), resulting in a sensitivity of 90%, a specificity of 89%, a PPV of 78%, and a NPV of 96%. CONCLUSIONS: CT scan may be useful in the diagnosis of acute appendicitis, but the reported high accuracy rate was not reproduced at our institution. CT scan was not clinically useful in 21% of patients. We conclude that a CT scan may be beneficial in the diagnosis of appendicitis with selected patients who have equivocal findings. Thus, at our institution, the accuracy of a CT scan does not justify its routine use in patients with clinical findings of appendicitis.

Adolescent↗
PubMedDate not supplied

Sonography of acute appendicitis in pregnancy.

BACKGROUND: Clinical evaluation of acute appendicitis is difficult in pregnant patients. Delay in diagnosis is associated with increased fetal mortality. The purpose of our study was to assess the value of sonography in the diagnosis of acute appendicitis in pregnant women. METHODS: We obtained sonograms in 22 pregnant women suspected of acute appendicitis. All sonograms were performed using graded-compression to detect an enlarged appendix. The sonographic criteria for acute appendicitis were detection of a noncompressible blindended and tubular multilayered structure of maximal diameter greater than 6 mm. RESULTS: The sonographic findings were correlated with surgical findings in seven cases and clinical follow-up in 15 cases. Acute appendicitis was diagnosed by sonography in three of 22 patients, and in all but one was confirmed by surgical and pathologic findings. In the remaining 19 patients, 15 improved on clinical followup; three were shown to have a normal appendix at surgery and one had focal acute inflammation at the tip of the appendix. CONCLUSIONS: Our experience suggests that graded-compression sonography is a useful procedure in pregnant patients suspected of acute appendicitis and has a similar accuracy as in nonpregnant women, especially in the first and second trimester.

Acute Disease↗
PubMedDate not supplied

Appendicitis diagnosis today: clinical and ultrasonic deductions.

A total of 111 patients referred with a diagnosis of suspected "appendicitis" were entered into a prospective study. The surgeon and radiologist in charge of ultrasonography made separate diagnoses, and their findings were then combined and discussed as indications for surgery. Clinically, a history of pain migration proved to be reliable (p < 0.0001) as a diagnostic indicator, in contrast to nausea and initial irregularity of bowels. The duration of symptoms was significantly shorter in patients with proved appendicitis than among patients with negative findings (median 24 hours compared with 41 hours, p < 0.04). Among patients with perforated appendicitis, the symptomatic history was prolonged (not significantly) by 3 hours. Peritoneal signs such as pain on percussion, rebound tenderness, guarding, and a leukocytosis of more than 13,000/mm3 were indicative of appendicitis (p = 0.0001 for each sign). Lively bowel sounds excluded the possibility of appendicitis (p = 0.001). Scanty bowel sounds, rectal tenderness, axillorectal temperature difference, and a left shift in leukocytes were of no diagnostic significance. The doctor's "clinical experience" is significant at the level of p < 0.03. On ultrasonography, the following signs were indicative of appendicitis: periappendicular infiltration (p = 0.0003), a visible "cockade," and an appendix larger than 12 mm in diameter (p = 0.04). For 75% of the patients the surgeon was sure of his own clinical diagnosis and did not allow himself to be influenced by the sonographic findings. In 12% of doubtful cases ultrasonographic results decisively favored operation, and in 4.5% (n = 5) it prevented an unnecessary laparotomy in the presence of positive clinical symptoms.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1996

Diagnostic value of C-reactive protein in children with perforated appendicitis.

UNLABELLED: The diagnostic value of serum C-reactive protein (CRP) levels in children with perforated appendicitis was prospectively studied in 78 consecutive patients with histologically confirmed appendicitis. The patients were divided into two groups: group A included 56 patients with perforated appendicitis and group B consisted of 22 patients with simple appendicitis. Serum CRP level and leucocyte count were assayed in all and abdominal ultrasonography was performed in 75. The mean age group A patient was significantly lower than that of group B patients (7.5 vs. 10.4 years, P < 0.001). Group A patients had a significantly higher mean serum CRP levels than group B patients (92 vs. 31 mg/l, P < 0.001), while the mean leucocyte count was comparable in the two groups. Of 75 examined patients, 73 (97%) had a pre-operative sonographic diagnosis of appendicitis. CONCLUSION: Perforation is a common complication in children with appendicitis, especially in those of young age and with prolonged pain duration. Greatly increased serum CRP levels (> or = 50 mg/l) and abdominal ultrasonography are important diagnostic aids in such patients.

Adolescent↗
PubMed1994

Diagnostic value of C-reactive protein in acute appendicitis.

Serum C-reactive protein was measured in 56 patients hospitalized with a suspected diagnosis of acute appendicitis. Based on these determinations, four groups of patients were defined: Group A = 26 patients with acute appendicitis who had a C-reactive protein level higher than 2.5 mg/dl. Group B = 4 patients with a C-reactive protein level lower than 2.5 mg/dl who, after surgery based on a presumed diagnosis of acute appendicitis, were found to have a normal appendix. Group C = 22 patients with nonspecific abdominal pain, 18 (72 percent) of whom had an elevated C-reactive protein level, although in only 4 (7.1 percent) were these levels higher than 2.5 percent mg/dl. Group D = 4 patients who had diseases other than acute appendicitis. It is concluded that an increase in C-reactive protein levels to more than 2.5 mg/dl is not a definite indicator of acute appendicitis. However, if the C-reactive protein level in blood drawn 12 hours after the onset of symptoms is less than 2.5 mg/dl, acute appendicitis can be excluded.

Acute Disease↗
PubMed1989

Laboratory aid in the diagnosis of acute appendicitis. A blinded, prospective trial concerning diagnostic value of leukocyte count, neutrophil differential count, and C-reactive protein.

The diagnostic value of C-reactive protein (CRP), total white blood cell (WBC) count, total neutrophil count, and neutrophil differential count were evaluated in a prospective blinded study of 204 patients submitted with the tentative diagnosis of acute appendicitis. The laboratory tests were performed on blood samples obtained at the time of admission, and the results were stored until the patients were discharged. One hundred patients were operated on: 59 had appendicitis, 3 had other surgically correctable diseases, and 38 had a superfluous exploration. All 104 nonoperated patients recovered spontaneously. The sensitivity, specificity, and predictive values of single tests and test combinations were calculated at different cutoff levels. Using standard reference intervals, WBC count demonstrated the best sensitivity (83 percent) and predictive value of a negative result (88 percent). Combining the tests by an "or" rule enhanced the sensitivity to 100 percent, employing WBC count or CRP or neutrophil percentage above the reference range (triple test), but at the expense of the predictive value of a positive test (37 percent). It was concluded that both single tests and combined tests are of limited value in predicting acute appendicitis. However, the same triple test combination proved a predictive value of a negative result at 100 percent (95 percent confidence limits 92 to 100 percent), indicating that acute appendicitis is unlikely when these tests are simultaneously negative. The triple test combination was valid in 32 percent of the patients who were free from appendicitis. In the study group, 10 of the patients (25 percent) who had a superfluous exploration had a negative triple test, and they might have avoided surgery if it had been used. Therefore, the triple test is recommended as a help in reducing the significant rate of negative laparotomies in patients suspected of having acute appendicitis.

Acute Disease↗
PubMed2002

[Status report on epidemiology of acute appendicitis].

The current incidence of appendicitis is about 100 per 100,000 person-years in Europe/America. Whereas the appendectomy rate is still decreasing, the incidence of appendicitis is now nearly stable. During the last 30 years the incidence of perforated appendicitis has not changed (approximately 20 per 100,000 person-years). Established risk factors for acute appendicitis are age (peak: 10-19 years), sex, and ethnic group/race. Classical theories (diet, hygiene) present illuminating models to explain the rise and fall of incidence in the last century; however, from a contemporary perspective the evidence is insufficient. The study of the epidemiology of appendicitis is complicated by the influence of referral, infrastructure, and surgical treatment strategy on the incidence of acute appendicitis. Therefore, there is a strong need for good prospective studies with high-quality data (e.g., studies directed by a central pathology department).

Acute Disease↗
PubMed2005

CT can reduce hospitalization for observation in children with suspected appendicitis.

BACKGROUND: There are no clinical or laboratory tests that can eliminate the possibility of appendicitis in a child with abdominal pain that suggests the diagnosis. The standard of care is to admit these children to the hospital for observation. More than twice as many children hospitalized for abdominal pain suggesting appendicitis are subsequently sent home after observation compared to those who undergo appendectomy. OBJECTIVE: To evaluate the ability of CT with rectal contrast medium (CTRC) to diagnose a normal appendix in children with abdominal pain. MATERIALS AND METHODS: A prospective cohort study in an urban pediatric emergency department. Children 6-17 years of age with abdominal pain were eligible when the attending physician planned to admit them for observation for possible appendicitis. All 94 patients underwent CTRC. CTRC results were compared to patient outcomes. RESULTS: Ninety-four children successfully underwent CTRC. Among the 53 patients with reflux of contrast medium into the ileum, the appendix was visualized in 43 (81.1%). Among all 94 cases, the appendix was visualized in 53 cases (55.7%); 43 studies were read as normal, and 10 showed appendicitis. Of the 43 with a normal appendix, 23 were discharged home, 18 were admitted but discharged uneventfully, and two underwent surgery for another diagnosis. When the appendix was visualized, the sensitivity, specificity, and negative and positive predictive values of CTRC were 100% (95% CI 66.4, 100.0), 97.7% (95% CI 88.0, 99.9), 100% (95% CI 91.8, 100.0), and 90% (95% CI 55.5, 99.8), respectively. The use of CTRC could have decreased the admission rate for observation for appendicitis by at least 41.8% and by more than 80% when the appendix could be seen. CONCLUSION: Our data suggest that when the appendix can be visualized, CTRC can accurately identify a normal appendix and reduce the number of children hospitalized for observation for possible appendicitis.

Abdominal Pain↗
PubMed2006

Acute amebic appendicitis.

INTRODUCTION: Acute appendicitis of amebic origin is considered a rare cause of acute appendicitis. METHODS: The clinical notes for 4093 patients over the age of 16 who had undergone appendectomy were reviewed. Particular attention was paid to the histopathologic results, separating out those cases where trophozoites were seen in the appendix. These cases were considered to be of amebic origin. RESULTS: A total of 93 cases reported lesions suggestive of amebiasis (2.3%). This study analyzed 86 of these cases. Comparing the cases in this study against the cases of patients with acute appendicitis in general (excluding the cases of amebic origin), no differences were found in relation to the distribution or presentation according to sex or in the degree of inflammation of the appendix, the incidence of surgical wound infection, or general complications. By contrast, the study noted a statistically significant difference in the age at presentation: Acute appendicitis of amebic origin presents principally among those under 20 years of age and is accompanied by a higher frequency of fecal fistula (2.3%). CONCLUSIONS: Acute appendicitis of amebic origin is not seen frequently, and in general it does not behave any differently from other cases of acute appendicitis, except in its earlier presentation and its greater incidence of fecal fistula. The condition is suspected clinically whenever a cecum of hard, "cardboard-like" consistency is discovered.

Acute Disease↗
PubMed2006

Appendectomy versus antibiotic treatment in acute appendicitis. a prospective multicenter randomized controlled trial.

BACKGROUND: Appendectomy has been the treatment for acute appendicitis for over 120 years. Antibiotic treatment has occasionally been used in small uncontrolled studies, instead of operation, but this alternative has never before been tried in a multicenter randomized trial. PATIENTS AND METHODS: Male patients, 18-50 years of age, admitted to six different hospitals in Sweden between 1996 and 1999 were enrolled in the study. No women were enrolled by decision of the local ethics committee. If appendectomy was planned, patients were asked to participate, and those who agreed were randomized either to surgery or to antibiotic therapy. Patients randomized to surgery were operated on with open surgery or laparoscopically. Those randomized to antibiotic therapy were treated intravenously for 2 days, followed by oral treatment for 10 days. If symptoms did not resolve within 24 hours, an appendectomy was performed. Participants were monitored at the end of 1 week, 6 weeks, and 1 year. RESULTS: During the study period 252 men participated, 124 in the surgery group and 128 in the antibiotic group. The frequency of appendicitis was 97% in the surgery group and 5% had a perforated appendix. The complication rate was 14% in the surgery group. In the antibiotic group 86% improved without surgery; 18 patients were operated on within 24 hours, and the diagnosis of acute appendicitis was confirmed in all but one patient, and he was suffering from terminal ileitis. There were seven patients (5%) with a perforated appendix in this group. The rate of recurrence of symptoms of appendicitis among the 111 patients treated with antibiotics was 14% during the 1-year follow-up. CONCLUSIONS: Acute non-perforated appendicitis can be treated successfully with antibiotics. However, there is a risk of recurrence in cases of acute appendicitis, and this risk should be compared with the risk of complications after appendectomy.

Adolescent↗
PubMed2005

A diagnostic score for children with suspected appendicitis.

BACKGROUND/PURPOSE: Appendicectomy is an operation that is often performed without certainty of diagnosis. This study aimed to construct and to validate a prognostic score for the diagnosis of acute appendicitis in children. METHODS: Data for 35 symptoms and signs were prospectively recorded for 131 consecutive children with suspected appendicitis. Logistic regression analysis of the variables yielded a diagnostic score: gender (male 2 points, female 0) + intensity of abdominal pain (severe 2, mild or moderate 0) + relocation of pain (yes 4, no 0) + vomiting (yes 2, no 0) + pain in the right lower abdominal quadrant (yes 4, no 0) + fever (yes 3, no 0) + guarding (yes 4, no 0) + bowel sounds (abnormal 4, normal 0) + rebound tenderness (yes 7, no 0). The cut-off level for recommendation of appendicectomy was > or =21, and the cut-off level for non-appendicitis was < or =15. The score was prospectively validated on 109 children. RESULTS: In the validation sample, based on clinical judgment, unnecessary appendicectomy was performed in ten (27%) children, and one (4%) child was misdiagnosed as not having appendicitis. By application of the score, unnecessary appendicectomies would have been reduced to four (13%), and three children (11%) with appendicitis would have been discharged. CONCLUSION: The use of a predictive mathematical model may facilitate the diagnosis of appendicitis to avoid unnecessary operations.

Adolescent↗
PubMed1997

Leukaemia and lymphoma of the appendix presenting as acute appendicitis or acute abdomen. Four case reports with a review of the literature.

Leukaemic and lymphomatous infiltration of the appendix is rare and even rarer is acute appendicitis as the initial manifestation. From our routine biopsy material we collected four cases of haematological malignancies presenting as acute appendicitis or acute abdomen, caused or accompanied by tumoral infiltration of the appendix. Appendicitis was the initial manifestation that allowed diagnosis of the underlying disease. The clinical histories and histological examinations of the appendices and of one autopsy are described. We report the first detailed description of acute myeloid leukaemia involving the appendix, and three cases of lymphomatous infiltration of the appendix presenting with appendicitis, and give an overview of the literature. In these days of budgetary cuts in national health services, where one may be tempted not to have seemingly commonplace cases of appendicitis histologically verified, our cases emphasize that careful histopathological examination of all appendectomy specimens should be mandatory. Despite the fact that leukaemia and lymphoma of the appendix are rare, our cases illustrate that these must be included in the differential diagnosis of acute appendicitis and that physicians and surgeons have to be aware of these conditions.

Abdomen, Acute↗
PubMed2004

Laparoscopic appendectomy for complicated appendicitis: an evaluation of postoperative factors.

BACKGROUND: The use of laparoscopic appendectomy for complicated appendicitis is controversial. Outcomes were compared between patients who had complicated appendicitis and those who had uncomplicated appendicitis. METHODS: Consecutive patients (n = 304) who underwent laparoscopic appendectomy were studied. Patients undergoing open appendectomies also were compared ad hoc. Analgesia use, length of hospital stay, return to activity, and complication rates for the complicated and uncomplicated appendicitis subgroups were analyzed. RESULTS: Complete data were available for 243 patients (80%). There were no statistical differences in characteristics between the two groups. The operating times, lengths of hospital stay, return to activity times, complication rates, and analgesia requirements, both in the hospital and after discharge, were equivalent. A greater number of complicated cases required open conversion. Considering those with complicated appendicitis, the open group had a significantly longer mean hospital stay and a higher complication rate than those treated with laparoscopic appendectomy. CONCLUSIONS: The minimally invasive laparoscopic technique is safe and efficacious. It should be the initial procedure of choice for most cases of complicated appendicitis.

Abdominal Abscess↗
PubMed2001

Comparison of laparoscopic, open, and converted appendectomy for perforated appendicitis.

BACKGROUND: Perforated appendicitis is associated with a significant risk of postoperative abdominal and wound infection. Only a few controversial studies evaluate the role of laparoscopy in perforated appendicitis. The significance of conversion from laparoscopy to open appendectomy for perforated appendicitis is not well defined. Statistical analysis was performed using Student's t-test. METHODS: Data on 52 patients with perforated appendicitis were prospectively collected and retrospectively reviewed. Among these patients, 18 had laparoscopic appendectomies (LA); 24 had open appendectomies (OA); and 10 had converted appendectomies (CA). The indications for either method were based on the attending surgeons's philosophy. Laparoscopic appendectomy was performed using a retrograde stapler technique. Operative time, hospital stay, ability to tolerate a liquid diet, and postoperative infectious complications were documented. RESULTS: No statistically significant difference in the operative time in minutes was found between the LA (114 +/- 29.3), CA (120.0 +/- 32.2), and OA (105.8 +/- 64.1) groups (p = NS). There was no statistically significance difference in length of stay (days) between the LA (9.2 +/- 4.1), OA (10.5 +/- 3.3), and CA (10.0 +/- 1.8) groups. The wound infection rate was less frequent in the LA group (0%) than in 0A (14%) and CA (10%) groups. The rate of intra-abdominal abscess infections (IAAs) and ileus were 22% and 28%, respectively, in LA group, 38% and 29%, respectively, in OA group, and 60% and 50%, respectively, in CA group. CONCLUSIONS: No difference in the rate of postoperative intra-abdominal abscesses exists between laparoscopic and open appendectomy for perforated appendicitis. Wound infections and ileus complicate the postoperative course of patients after laparoscopic appendectomy less frequently than after open appendectomy. The conversion of laparoscopic to open appendectomy for perforated appendicitis is associated with increased postoperative morbidity.

Adult↗
PubMed2000

Immunocytochemical analysis of cellular infiltrates in human appendicitis.

This study was conducted to determine the immunologic cellular composition in human appendicitis and its association with the development of perforated appendicitis. Appendiceal specimens from 27 patients with acute appendicitis were immunostained to detect lymphocyte surface markers. Moreover, the lymphocyte surface markers of peripheral blood were analyzed by laser flow cytometry in 12 patients. Helper T lymphocytes (CD4) were present in all the patients, while B lymphocytes (CD19), natural killer (NK) cells (CD56), and cytotoxic T lymphocytes (CD8) were present in 7 (70%), 10 (100%), and 9 patients (90%) with perforated appendicitis, and in 12 (63.2%), 10 (58.8%), and 6 (54.5%) patients without perforation, respectively. There were significant differences between the patients with a perforated appendix and those without perforation, in the positivity rate for CD8 and CD56 cells (P < 0.05). The number of cells positive for CD56, being NK cells, in the blood from the patients with perforation was significantly lower than that in the blood from those without perforation (P < 0.05). The infiltration of a greater number of cytotoxic T lymphocytes and NK cells was observed in the appendices from patients with perforated appendicitis than in those from patients with nonperforated appendicitis.

Adolescent↗
PubMed2004

Rapid CT scan visualization of the appendix and early acute non-perforated appendicitis using an improved oral contrast method.

The purpose of this study was to optimize detection of the normal appendix in the clinical exclusion of acute nonperforated appendicitis using an improved and rapid method of bowel opacification in conjunction with the CT examination. A prospective evaluation of 100 consecutive patients, ranging from 13 to 50 years in age, was performed over a 4-month period using water-soluble oral contrast medium consisting of a fixed dose of diatrizoate salts administered as a prepared beverage in the emergency ward 50 min prior to performing a CT scan to evaluate clinical signs and symptoms of early acute appendicitis. The appendix was visualized in 84% (84 of 100) of patients, with a mean transit time of 50 min. The appendix filled with oral contrast medium in 89% (75 of 84) patients, and this sign was reliable in excluding appendicitis. In no instance did a contrast-filled appendix prove to represent appendicitis. The earliest signs of appendicitis were seen in 8% (8 of 100) patients. CT scan findings included absence of a contrast- or air-containing appendix with appendiceal thickening and infiltration of the periappendiceal mesenteric fat. CT scan utilizing a fixed dosage of orally administered water-soluble contrast containing diatrizoate salts, with a mean transit time of 50 min, provides a rapid and efficient means of visualizing the appendix in the clinical exclusion of appendicitis in the emergency setting.

Acute Disease↗
PubMed2005

Predictive value of C-reactive protein at different cutoff levels in acute appendicitis.

Determining the different cutoff values of C-reactive protein (CRP) on the basis of how long the patient's symptoms were present can be used to early predict acute appendicitis. We analyzed retrospectively from 2001 to 2004 the hospital records of 568 patients who underwent appendectomies for suspected appendicitis. Receiver operating characteristic analysis has shown that CRP measurement can increase the diagnostic accuracy in acute appendicitis. The cutoff values of CRP concentration taken as the first, second, and third days after onset of symptoms that distinguish acute appendicitis from other acute abdominal diseases were 1.5, 4.0, and 10.5 mg/dL, respectively; the values that distinguish perforated appendicitis from other acute abdominal diseases were 3.3 mg/dL (first day), 8.5 mg/dL (second day), and 12.0 mg/dL (third day). The different cutoff values of CRP concentration may serve as a useful predictive parameter in the early diagnosis of acute appendicitis on the first 3 days after the onset of symptoms.

Adolescent↗