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PubMed2005

[Is procalcitonin able to help in pediatric appendicitis diagnosis?].

BACKGROUND: Appendicitis clinical diagnosis in children is difficult and the acute inflammatory markers hyperleucocytis and CRP do not contribute to it. OBJECTIVE: To study the predictive value of procalcitonin (PCT) and to assess variations of its serum level according to inflammatory lesions in paediatric appendicitis. PATIENTS AND METHOD: Among 101 children aged two and 15, hospitalized for painful abdominal syndromes, 70 underwent operation for acute appendicitis and appendiceal peritonitis, 31 had no operation. PCT was evaluated in all children, normal serum concentration was <0,5 microg/L. Every appendicectomy part has been examined through histological analysis to confirm the diagnosis and the histological lesions have been classified into three categories according to their severity. RESULTS: Out of 70 appendix analysed at histology, 68 (97%) were healthy and 2 (3%)were unhealthy. Among the 68 cases of healthy appendix, 19 had a PCT higher than 0,5 microg/L and among 33 cases of unhealthy appendix 4 had a PCT higher than 0,5 microg/L. The PCT mean of healthy children was not significantly different from unhealthy appendix population, appendicitis prevalence was 0,67, PCT sensitivity 28%: IC 95% [18-40], specificity 88%: IC 95% [72-97], positive predictive value 83%: IC 95% [61-95], and negative predictive value 37%: IC 95% [26-49]. PCT mean increases with the severity of inflammatory lesions of the appendix (P=0,0051). CONCLUSION: PCT has not a good predictive value in acute paediatric appendicitis but remains a good indicator of severity in paediatric appendicitis.

Abdominal Pain↗
PubMed2004

CT is useful for identifying patients with complicated appendicitis.

BACKGROUND AND AIMS: We often come across patients with complicated appendicitis (perforation, abscess formation, or peritonitis) and it is essential to get accurate and detailed information on these patients preoperatively. In this study, we investigated whether or not preoperative computed tomography is useful for identifying these patients. PATIENTS AND METHODS: Plain and intravenously-contrasted helical computed tomography was obtained preoperatively in 94 (75%) of 125 patients who underwent appendectomy. Twenty-eight (30%) of the 94 patients had complicated appendicitis (Compli(+) group). We compared clinical factors and computed tomography findings of the Compli(+) group with those of 66 other patients (Compli(-) group). RESULTS: There was no significant difference between the Compli(+) and Compli(-) groups in gender, white blood cell count, the present rate of an enlarged appendix, or appendicolith. Fat stranding and free fluid on computed tomography were significantly associated with complicated appendicitis by both univariate and multilogistic regression analysis. Fourteen (70%) of the 20 patients with fat stranding and free fluid on computed tomography had complicated appendicitis and only 1 (4%) of the 28 Compli(+) patients had neither fat stranding nor free fluid on computed tomography. CONCLUSION: Our study has indicated that fat stranding and free fluid on computed tomography are significant for complicated appendicitis and helical computed tomography is a powerful tool for identifying patients with complicated appendicitis preoperatively.

Adult↗
PubMed2004

The optimal initial management of children with suspected appendicitis: a decision analysis.

BACKGROUND/PURPOSE: As abdominal imaging has improved, the use of computed tomography (CT) and ultrasonography (US) for evaluating children with suspected appendicitis has increased. The purpose of this study was to determine the optimal management strategy for evaluating children with suspected appendicitis given the current accuracy of abdominal imaging. METHODS: Decision analysis was used to evaluate 5 management strategies: discharge, observation, CT, US, and appendectomy. Probabilities and time variables were obtained from publications and a chart review. Each approach was evaluated for its impact on length of stay, hospital charges, cost effectiveness and its capacity to minimize perforation and avoid negative appendectomy (risk-benefit). RESULTS: Discharge was preferred when the probability of appendicitis was low (<0.09 to <0.47), imaging when in an intermediate range and surgery when high (>0.61 to >0.91). A role for observation was found only when the anticipated time of inpatient observation was brief (<9 hours). Although CT was more expensive than US, CT was more cost effective for preventing negative appendectomy and perforation and achieved a better risk-benefit. CONCLUSIONS: CT has an important role in the management of suspected appendicitis. Among children with a low or high likelihood of appendicitis, the cost of imaging tests required to prevent the complications of appendicitis is high.

Abdominal Pain↗
PubMed2003

Imaging in appendicitis: a review with special emphasis on the treatment of women.

OBJECTIVE: Acute abdominal pain in women often presents the clinician with a diagnostic dilemma, especially if it is lower abdominal pain. Appendicitis is frequently entertained as a diagnosis, but until recently, the gold standard diagnostic procedure was operation, carrying a high false-negative rate. In recent years, computed tomographic (CT) scan has been advocated as a diagnostic aid. The purpose of this systematic review was to evaluate the accuracy of CT scan in diagnosing appendicitis. DATA SOURCES: Investigators searched PubMed between January and July 2003 using the terms "CT scan" and "appendicitis" with the limits "All adults 19+ years" and "English [language]." In addition, reference lists of all obtained articles were reviewed for other potential citations. METHODS OF STUDY SELECTION: All prospective studies of adults published in English were considered. TABULATION, INTEGRATION, AND RESULTS: Initial searches and reviews yielded 248 citations. Twenty-three of the citations reported prospective studies; only two of these were randomized studies. Prospective studies report sensitivities ranging from 77% to 100%, specificities ranging from 83% to 100%, and accuracies ranging from 88% to 98% for the diagnosis of acute appendicitis. Information gained from CT scans in patients with suspected appendicitis results in alternative diagnosis in 6% to 36%. These values are similar for both men and women. CONCLUSION: The data support routine use of CT scan in both men and women for the diagnosis of appendicitis.

Appendicitis↗
PubMed2001

[Suspected acute appendicitis. Role of enhanced helical computed tomography. Prospective study of 100 patients].

AIM OF STUDY: To assess the diagnosis accuracy of helical computed tomography (CT) in patients with suspected appendicitis. PATIENTS AND METHODS: This prospective study included 100 consecutive patients hospitalized for suspected appendicitis. There were 57 men and 43 women with a median age of 30 years (range: 17-91). An enhanced helical CT was performed at admission, without digestive opacification. Four criteria were interpreted as positive signs for appendicitis: appendix enlarged > or = 7 mm, right lower quadrant inflammation, stercorolith, and peri-appendicular collection. The patient was managed by the surgeon without knowing the result of CT. The final diagnosis was made pathologically. RESULTS: Eighty-one patients were operated on laparoscopically for suspected appendicitis. Intraoperative diagnosis was corrected in three cases and 78 appendectomies were performed (73 histological appendicitis, six normal appendix). Final diagnosis was a medical disease in 19 patients. The findings of 67 CT were interpreted as positive (63 true positive and four false positive) and the findings of 33 CT were interpreted as negative (24 true negative, nine false negative). Sensitivity was 87%, specificity was 86%, positive predictive value was 94%, and negative predictive value was 73%. If the nine false negative cases with minimal lesions at pathological examination were considered as true negative, the rates would be 100%, 89%, 94%, 100%, respectively. CONCLUSION: Enhanced helical CT is a good imaging diagnostic tool for suspected appendicitis. It may reduce the number of patients admitted for observation and decrease the rate of negative appendectomy.

Abdominal Pain↗
PubMed1995

Ultrasound in the differential diagnosis of appendicitis.

The purpose of this study was to determine the accuracy of sonography in detecting diseases other than appendicitis in the clinical setting of suspected appendicitis. Six hundred and nine patients were evaluated using graded compression ultrasound (US). A broad spectrum of diseases was suggested in the group of patients who eventually turned out not to have appendicitis (n = 426), including gastrointestinal (154), gynaecological (32), biliary (11), urological (8), and miscellaneous (5) abnormalities. However, out of these there were three cases of incorrect sonographic diagnoses with serious sequelae. Appendicitis coincidental with another disease capable in itself of explaining the patients' symptoms was confirmed in seven out of 10 patients where sonographically suggested; in six patients out of this group only the suggested alternative condition was held responsible for the symptoms while the inflamed appendix was overlooked. US is of considerable value in establishing alternative diagnoses in patients with equivocal signs of appendicitis. However, one should always consider the possibility of co-existing appendicitis in patients where US has revealed another condition which could be held in itself responsible for the patient's symptoms.

Adolescent↗
PubMed2000

Historical changes in the postoperative treatment of appendicitis in children: impact on medical outcome.

BACKGROUND/PURPOSE: The introduction of managed care in the 1980s caused increased pressure to reduce costs for hospitalized patients. The authors hypothesized that these market forces have resulted in a decreased hospital stay and utilization of sophisticated diagnostic testing in children treated for appendicitis. If true, the impact of this paradigm shift on patient outcome is unknown. METHODS: Hospital records for 913 pediatric patients treated for appendicitis from 1974 to 1998 were reviewed retrospectively. Patients were stratified into those with perforated appendicitis (PA) and nonperforated appendicitis (NPA). Demographics, perioperative hospital course, diagnostic testing, complications, and long-term outcomes were analyzed after stratification into time intervals. RESULTS: Over time, children with NPA were treated with shorter antibiotic courses (P<.05) and were placed on a regular diet earlier (P<.05). These changes in treatment resulted in an earlier discharge (P<.05). The amount of time to become afebrile with a normal white blood cell count (WBC) did not change over time. Children with PA exhibited similar results with shorter antibiotic courses (P<.05), earlier dietary intake (P<.05) and earlier hospital discharge (P<.05) over time. In all children with appendicitis there was no significant difference in the rate of wound infections, abscesses requiring drains, readmission, or reoperations overtime. The utilization of abdominal radiographs (83%) and ultrasonography (USN; 40%) was high and remained unchanged over time. Utilization of computed tomography (CT scan) was low (4.3%) in the early decades and was not used as a preoperative test from 1991 to 1994. Given the high diagnostic accuracy of a pediatric surgeon for this disease, Bayesian analysis indicates that USN utilization rates should be 15%. CONCLUSIONS: The market pressures of managed care have resulted in a new treatment paradigm with an earlier discharge of all children with appendicitis. There has been no concomitant increase in the complication rate in either group as a result of this paradigm shift. Bayesian analysis indicates that USN and abdominal radiographs are overutilized in our institution.

Adolescent↗
PubMed1998

An evidenced-based clinical pathway for acute appendicitis decreases hospital duration and cost.

BACKGROUND/PURPOSE: In the pediatric population, appendicitis remains the most common surgical emergency encountered. The purpose of this study was to determine the impact of an evidence-based clinical pathway for acute appendicitis on patient care as well as hospital and home care costs at the authors' pediatric institution. METHODS: A prospective evaluation was conducted of an appendicitis clinical pathway (June 1996 through November 1996) compared with historical control patients (June 1994 through November 1994) not cared for by the pathway. RESULTS: Data (average +/- SD) for 120 pathway (P) patients were compared with 122 control (C) patients. Age (11.5 +/- 3.6 years for C v 11.2 +/- 3.9 years for P), rates of negative appendectomy (12.3% for C v 9.2% for P) and perforation (26.2% for C v 18.3% for P) were similar. Pathway patients with nonperforated appendicitis were more often discharged from the hospital within 24 hours (48% for C v 67% for P; P = .014) with lower hospital costs ($4,095 +/- $1,280 for C v $3,638 +/- $1,633 for P; P = .001). Pathway patients with perforated appendicitis had shorter hospitalization (185.2 +/- 59 hours for C v 113 +/- 44 hours for P; P = .0001) and lower hospital costs ($11,175 +/- $3,893 for C v $7,823 +/- $2,366 for P; P = .0001). CONCLUSION: An evidence-based appendicitis pathway decreased duration of hospitalization and cost without adversely affecting diagnosis or therapy. Clinical pathways for surgical diagnoses may prove useful as a means to minimize costs without compromising patient care.

Acute Disease↗
PubMed1999

Helical computed tomography in differentiating appendicitis and acute gynecologic conditions.

OBJECTIVE: To determine the accuracy and effect of helical computed tomography (CT) in women clinically suspected of having either appendicitis or an acute gynecologic condition. METHODS: One hundred consecutive nonpregnant women suspected of having appendicitis or an acute gynecologic condition prospectively had helical CT. Interpretations were correlated with surgical and pathologic findings (41 cases) and clinical follow-up for at least 2 months (59 cases). The accuracy for confirming or excluding both appendicitis and acute gynecologic conditions was determined. The effect on patient care was determined by comparing pre-CT plans with actual treatment. RESULTS: Thirty-two women had appendicitis, 15 had acute gynecologic conditions, 27 had other specific diagnoses, and 26 had nonspecific abdominal pain. For diagnosing appendicitis or acute gynecologic conditions, CT had 100% and 87% sensitivity, 97% and 100% specificity, 94% and 100% positive predictive value, 100% and 98% negative predictive value, and 98% and 98% accuracy, respectively. After CT was done, 36 planned hospital admissions, 25 planned hospital observations, and six planned appendectomies were deferred; six women had alternative surgical procedures on the basis of CT results. One patient had an unnecessary appendectomy on the basis of CT findings. CONCLUSION: Helical CT is an excellent imaging option for differentiating appendicitis from most acute gynecologic conditions.

Acute Disease↗
PubMed1993

Clinical validity of ultrasound in children with suspected appendicitis.

STUDY OBJECTIVE: To determine the accuracy of diagnosing appendicitis in the pediatric population by using graded compression ultrasonography. DESIGN: Retrospective case review. SETTING: University-affiliated community hospital with an emergency department census of approximately 19,000 pediatric visits per year. TYPE OF PARTICIPANTS: Ninety-eight children (age less than 13 years) with clinically suspected appendicitis who had graded compression sonographic studies during the 24-month study period. INTERVENTIONS: Medical records were reviewed for patient demographics, presenting signs and symptoms, sonographic findings, surgical results, and hospital course. Patients who did not undergo surgery were followed up by telephone for a minimum of two months. RESULTS: Ninety-eight children (42 boys and 56 girls; age range, 2 to 12 years; mean age, 8.0 years) with clinical signs and symptoms of acute appendicitis were examined sonographically. Of the 26 patients whose appendicitis was verified at surgery, ultrasound was positive in 22, with an overall sensitivity of 85%. Of the 72 patients who did not have appendicitis, ultrasound was negative in 68, with a specificity of 94%. Two patients with false-positive ultrasound went to surgery and were found to have acute ileitis and perforated Meckel's diverticulum. The overall diagnostic accuracy was 91.8% (90 of 98). CONCLUSION: Use of ultrasound to diagnose acute appendicitis was performed with a sensitivity of 85% and a specificity of 94%. This allows the same accuracy in children as has been reported with adults.

Acute Disease↗
PubMed2000

Histological features of resolving acute, non-complicated phlegmonous appendicitis.

The histological features of resolving acute appendicitis are described. Formalin-fixed, paraffin-embedded appendices of 200 cases with acute, non-complicated phlegmonous appendicitis were reviewed. In 80 out of 200 cases, a histological picture characterized by a predominantly lymphocytic infiltrate of the subserosa and muscularis propria or the subserosa alone was found. In the affected muscularis propria, eosinophils were admixed with lymphocytes, and the cellular infiltrate showed a lesser degree than that of the classic phlegmonous appendicitis. A multifocal, rather than a diffuse pattern of infiltration was observed. Cases were divided into three groups. Group 1: appendices with the typical features of phlegmonous appendicitis: 120 cases, 60%. Group 2: appendices with a predominantly lymphocytic infiltrate in the muscularis propria, subserosa, or both, and no granulation tissue: 65 cases, 32.5%. Group 3: appendices with granulation tissue: 15 cases, 7.5%. Complicated appendicitis was excluded. Data on the duration of the clinical symptoms were derived from the clinical history. The differences between the mean duration time of groups 1 and 2, and of groups 2 and 3 were statistically significant. The findings support the contention that a mixed infiltrate of lymphocytes and eosinophils represents a regression phase of acute appendicitis.

Acute Disease↗
PubMed1999

Plain abdominal radiography in clinically suspected appendicitis: diagnostic yield, resource use, and comparison with CT.

This study determined the diagnostic utility and hospital resource impact of plain abdominal radiography in emergency department patients with suspected appendicitis. The authors reviewed medical records of 821 consecutive patients hospitalized for suspected appendicitis; 78% had plain abdominal radiography. Sixty-four percent had appendicitis. Radiographic findings were noted in 51% of patients with, and 47% of patients without appendicitis; no individual radiographic finding was sensitive or specific. Specific conditions were suggested in 10% of impressions; these failed to correlate with final clinical diagnoses 57% of the time. Hospital cost per abdominal radiograph was $67; cost per specific, correct radiographic diagnosis was $1,593. This is compared with $270 per appendiceal computed tomography scan (based on recent literature data). The authors conclude that plain abdominal radiographs in patients with suspected appendicitis are neither sensitive nor specific, are frequently misleading, are costly per specific and correct diagnosis, and should not be routinely obtained on patients with suspected appendicitis.

Adolescent↗
PubMed2001

Appendicitis masquerading as tumor: a case of two diagnoses.

Acute appendicitis remains one of the most difficult diagnoses to make in the Emergency Department. We present a puzzling and unusual case. A 47-year-old man had several hours of acute abdominal pain in the right upper quadrant, point tenderness in the right midquadrant on examination, and normal chemistries. Early appendicitis was suspected and a computed tomography (CT) scan of the abdomen was obtained. Appendicitis was not seen. What was evident was a retroperitoneal lipoma estimated to weigh 10 pounds. The general surgeon was consulted who believed that operation was necessary in light of the patient's continuing abdominal pain and the presence of the mass. Masses this large could cause pain from local compression of structures, or ischemia of the mass from outgrowing its blood supply. In surgery, a lipoma was observed that filled most of the retroperitoneum and displaced all the contents of the abdomen, including the cecum and its appendix. Also present was an acute appendicitis. On retrospective analysis of the CT scan, the appendicitis was evident but atypically located in the epigastrium. This case illustrates once again that the CT scan is a useful diagnostic adjunct for the diagnosis of new onset abdominal pain and specifically for appendicitis.

Acute Disease↗
PubMed1997

Rapid detection of acute appendicitis with Tc-99m-labeled intact polyvalent human immune globulin.

BACKGROUND: Acute appendicitis remains problematic for emergency clinicians. A rapid and definitive test is needed for detecting acute appendicitis before surgical intervention. The purpose of this clinical trial was to determine the efficacy of Tc-99m-labeled intact polyvalent human immune globulin (Tc-99m IgG) in the evaluation of acute appendicitis. STUDY DESIGN: Thirty-five patients with clinically suspected acute appendicitis were evaluated with Tc-99m IgG. After the intravenous injection of 25 mCi (92.5 MBq) of Tc-99m IgG, anterior flow, single photon emission computerized tomography (SPECT) and planar delayed images of the abdomen were obtained. Any abnormal focal uptake of Tc-99m IgG in the right lower quadrant was considered to be a positive scan. RESULTS: Twenty-one patients with a positive Tc-99m IgG scan underwent laparotomy and were found to have acute appendicitis. Of the 14 patients who had negative scans, 7 underwent surgery. In this series, Tc-99m IgG study yielded 21 true-positive, 12 true-negative, and 2 false-negative results with a sensitivity, specificity, and accuracy of 91%, 100%, and 94%, respectively. The positive and negative predictive values were 100% and 86%, respectively. There were no false-positive results. CONCLUSIONS: Tc-99m IgG scintigraphy can provide the clinicians a simple, rapid, and definitive test for the diagnosis of acute appendicitis.

Acute Disease↗
PubMed1996

Use of sonography in diagnosing acute appendicitis: comparison of a teaching hospital and a community hospital.

RATIONALE AND OBJECTIVES: We examined patterns of use of sonography in the workup of appendicitis at two hospitals: a 715-bed university-affiliated teaching hospital and a 240-bed nonteaching hospital. In light of increasing concern over the use of health care dollars, we wanted to determine whether the use of sonography in the workup of appendicitis would be more frequent at a teaching than at a nonteaching hospital. METHODS: We examined all cases of appendicitis seen in the emergency room of the teaching hospital in 1993 and all cases of appendicitis seen in the emergency room of the nonteaching hospital in 1992-1993. Exclusionary criteria included pregnancy, altered mental status, or multiple discharge diagnoses. The diagnosis of appendicitis was verified by pathology reports. RESULTS: At the teaching hospital, the use of sonography was 38.5% (65 of 169); at the nonteaching hospital, sonography usage was 39.4% (61 of 155). CONCLUSION: There appears to be no significant difference between teaching and nonteaching hospitals in the frequency of use of sonography in diagnosing patients with appendicitis.

Acute Disease↗
PubMed2000

The pathology of acute appendicitis.

Although acute appendicitis is frequent, it is subject to common misconceptions. Furthermore, there is little good evidence to support some of our beliefs. This report reviews the role of the anatomic pathologist in diagnosis when acute appendicitis is suspected clinically and discusses what is known of its pathology. The conclusions that can be legitimately drawn from the literature are emphasized. A classification is proposed that incorporates intraluminal inflammation, acute mucosal inflammation, acute mucosal and submucosal inflammation, suppurative (phlegmonous) appendicitis, gangrenous appendicitis, and periappendicitis, and the significance of each of these diagnoses is discussed. The etiology and pathogenesis of acute appendicitis is reviewed. Contrary to popular belief, the best evidence indicates that obstruction is unlikely to be the primary cause, at least in the majority of cases. Ancillary techniques in the diagnosis of appendicitis, including laparoscopy and peritoneal aspiration cytology, are discussed.

Acute Disease↗
PubMed2005

Diagnosis of appendicitis with left lower quadrant pain.

Abdominal pain is one of the most common chief complaints of patients presenting to the emergency department and, among the diagnoses of abdominal pain, appendicitis is the most common surgical disorder. Traditionally, the diagnosis of appendicitis is based on well-established clinical criteria combined with physician experience. However, appendicitis presenting with rare and misleading left lower quadrant (LLQ) pain may result in an initial false-negative diagnosis by the physician and even result in failure to order the subsidiary examination of computed tomography (CT) or ultrasound, so increasing the risk of perforation/abscess formation and prolonged hospital stay. In this report, we present 2 cases of atypical appendicitis with LLQ pain where the correct diagnosis was not initially considered. One patient had right-sided appendicitis; the inflamed appendix was 12 cm in length and projected into the LLQ. Local peritonitis developed during observation. With the aid of CT, the diagnosis was established in time. The other patient had left-sided appendicitis with situs inversus totalis. Adverse outcomes with appendiceal rupture and abscess formation occurred due to inadvertent physical examinations and inadequate observation. Early clinical suspicion and adequate observation are indicated in patients with uncertain clinical features. However, in patients with unresolved clinical symptoms and/or local peritonitis that develop during observation, imaging studies play a significant role in preoperative diagnosis and determination of proper treatment.

Abdominal Pain↗
PubMed2002

Laparoscopy in children with complicated appendicitis.

BACKGROUND/PURPOSE: Laparoscopic appendectomy is an accepted way of dealing with suspected uncomplicated appendicitis in children. The role of laparoscopy in complicated acute appendicitis is more controversial. The purpose of this trial was to compare laparoscopic appendectomy with open appendectomy in children with complicated appendicitis. METHODS: A total of 102 children with suspected acute appendicitis were selected randomly to undergo either a laparoscopic or an open appendectomy. The outcomes of 25 children with complicated appendicitis, 13 in the laparoscopic group and 12 in the open appendectomy group, were analyzed. Children, their parents, and research nurses were blinded to which procedure had been performed and remained blinded until the control visit 7 days after the operation. All 25 children completed a 30-day follow-up. RESULTS: There were no differences in terms of patients' age, sex, weight, height, and appendiceal histology between the 2 groups. All laparoscopic procedures were completed without conversion. The mean (+/-SD) operating time was 63 (+/-31) minutes in the laparoscopic group and 37 (+/-18) minutes in the open appendectomy group (mean difference 26 minutes, 95% CI 5 to 47 minutes, P =.02). There were 2 major complications in the laparoscopic group in children with appendiceal masses. One child had an entero-cutaneous fistula of the residual appendiceal tip that needed open reoperation. Another child had a pelvic abscess that resolved with antibiotic treatment. Superficial wound infections were encountered in 2 patients in the open appendectomy group. CONCLUSIONS: Laparoscopic appendectomy is an alternative to open procedure in children with complicated appendicitis. Good surgical judgement is necessary in patients with an established appendiceal abscess.

Acute Disease↗