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PubMed1999

Selective use of ultrasonography for acute appendicitis in children.

BACKGROUND: To evaluate the role of ultrasonography in children with equivocal signs of acute appendicitis, and correlate with initial clinical impression and pathological findings. METHODS: This is a prospective evaluation of all children presenting with a possible diagnosis of appendicitis during a 14-month study period. Patients with unequivocal clinical signs of appendicitis underwent appendectomy without ultrasonography. Patients with equivocal signs had documentation of the clinical impression and subsequent abdominal ultrasound. Statistical analysis of results was performed using the chi-square test (P <0.05 significant). RESULTS: Two hundred fifteen consecutive children were enrolled. Signs were unequivocal in 116 and equivocal in 99. Seven patients in the first group had a normal appendix at operation. Of the 99 patients with equivocal signs, there were 28 true positives, 3 false positives, 64 true negatives, and 4 false negatives. In equivocal cases, sensitivity of the initial clinical impression versus ultrasound was 50% and 88%, respectively (P <0.05). Specificity was 85% and 96%, respectively. The positive and negative predictive values improved from 63% to 90% and 78% to 94%, respectively, with the use of ultrasonography. CONCLUSIONS: The low false positive rate (6%) in clinically obvious cases of appendicitis does not, in our opinion, warrant ultrasonography. In clinically equivocal cases, ultrasonography is a fast, sensitive, and specific diagnostic modality to diagnose or rule out appendicitis, avoiding the need for prolonged observation and/or hospitalization.

Acute Disease↗
PubMed1999

Appendicitis in patients with previous spinal cord injury.

BACKGROUND: Acute abdominal emergencies are particularly dangerous in patients with impaired sensation. METHODS: Thirty patients with spinal cord injury who later developed appendicitis were identified in Department of Veterans Affairs computer files over a 5-year period; 26 were evaluable. RESULTS: The mean age was 55 years (range 27 to 79); all were males. Abdominal distention or discomfort was present in 16 of 26 (62%), while 2 of 26 (8%) presented in shock. A palpable right lower quadrant mass was present in 6 of 26 (23%). The mean initial white blood cell count was 18,000/mm3. Only 9 of 26 (35%) had the diagnosis of appendicitis made on admission. In 12 of 26, computed tomography was done; all correctly diagnosed appendicitis. The mean delay in diagnosis after hospitalization was 2 days (range 0 to 5). Perforated appendicitis was found at surgery in 24 of 26 (92%). Twenty-three of 26 (88%) underwent appendectomy; 3 of 26 (12%) underwent right colectomy. The 30-day mortality rate was 4%. Six of 26 (23%) developed a postoperative complication. The mean length of stay was 16 days. CONCLUSIONS: Acute appendicitis in spinal-cord-injured patients frequently presents late and complications are common. Computed tomography appears to be an excellent diagnostic modality. Some of the adverse outcomes which are related to preexisting spinal cord injury may be preventable with early intervention.

Acute Disease↗
PubMed2003

Childhood appendicitis in the United Kingdom: fifty years of progress.

The number of in-hospital deaths in children aged 0 to 14 years from acute appendicitis in England and Wales has fallen from an annual average of 36.2 in 1963 through 1967 to 1.8 in 1993 through 1997, and the case-fatality rate from 1.06 to 0.16 per 1,000 discharges, a reduction of 85%. During these 4 decades, the child population has fallen by 8.5%, and the number of children discharged from the hospital with a diagnosis of acute appendicitis by 63%. These data highlight a trend noted in Scotland in the first 50 years of the 20th century. Approximately three quarters of the fall in the number of deaths from acute appendicitis since 1963 is accounted for by a lower incidence of appendicitis in a slightly reduced child population. A quarter of the fall is caused by a marked decline in the hospital case-fatality rate during the last 30 years, likely to be related to improvements in clinical care. Delay in diagnosis is the main contributory factor in the residual small number of deaths each year. Despite the availability of numerous diagnostic aids, clinical acumen remains a fundamental component of expert management of acute appendicitis in children.

Adolescent↗
PubMed1990

Ultrasonography in the management of possible appendicitis in childhood.

One hundred thirty-four children referred to the pediatric surgical service with the diagnosis of possible acute appendicitis underwent abdominal ultrasonography within 24 hours of admission. A final diagnosis of appendicitis was made in 45, and of gynecological disease in 11 children. One child had pancreatitis, another jejunal perforation, and a third gross mesenteric lymphadenopathy. In 75 children the clinical picture completely resolved without a definitive diagnosis being made. Clinical diagnosis of gynecological disease showed two false-negatives, and three false-positives, whereas the ultrasonographic diagnosis was accurate in all patients. The sensitivity of the pediatric surgical diagnosis at the time of admission for acute appendicitis was 49% (23 false-negatives) and the specificity was 95% (three false-positives). Ultrasonographic diagnosis of appendicitis had a sensitivity of 89% (five false-negatives) and a specificity of 92% (five false-positives). There was a negative laparotomy rate of 0.7% (one patient) using both clinical evaluation and ultrasonography. These data suggest that abdominal ultrasonography in the child with possible appendicitis is an important diagnostic adjunct.

Abdominal Pain↗
PubMed1997

Have the evaluation and treatment of acute appendicitis changed with new technology?

The evaluation and treatment of acute appendicitis remain essentially unchanged for the majority of individuals who present with this disease. Although advancements have been made in laboratory analysis as well as imaging via ultrasonography and CT, nothing can replace careful evaluation by an experienced surgeon. Appendicitis remains a diagnosis based primarily on history and physical examination, with further studies being useful adjuncts in atypical cases--more likely to occur in the very young or very old and most cost effective when ordered by the surgical consultant. Improvement in outcomes has not been demonstrated with routine use of "new technology." The treatment of acute appendicitis continues to be early surgical intervention. Although laparoscopic appendectomy may offer advantages in women of childbearing age and in obese individuals, its routine use is not indicated based upon current reports in the literature. Debate continues regarding the optimal treatment of the periappendiceal mass. Further clinical research regarding early operation compared with intravenous antibiotics with or without drainage, as well as comparison of outcomes with or without interval appendectomy, needs to be performed. With continued research and definition of populations likely to benefit from advances in technology, a more focused application will be possible. This will lead to improved outcomes and decreased overall cost. The issue of delay in treatment, a major determinant of morbidity associated with appendicitis, warrants further evaluation and should be addressed on a population-specific basis. Emphasis should remain on the early clinical diagnosis of acute appendicitis with its associated low morbidity and mortality.

Acute Disease↗
PubMed1997

The accessory cell populations in ulcerative colitis: a comparison between the colon and appendix in colitis and acute appendicitis.

We present an immunohistochemical study of accessory cells in acute appendicitis and ulcerative colitis (UC). By comparing these two diseases, it is possible to distinguish between changes associated with inflammatory bowel disease and those resulting from nonspecific intestinal inflammation. Nine total colectomy specimens from patients with UC, in which the appendix was also involved, were compared with nine cases of acute appendicitis. Accessory cells were stained for CD68 (PGMI), ACPI (acid cysteine proteinase inhibitor), S100 protein, MAC387 (calgranulin), CD1a, factor XIIIa, and WR18 (HLA class II). In ulcerative colitis, but not acute appendicitis, there was extension of a network of S100 positive dendritic cells into the crptal mucosa, and these S100-positive dendritic cells were closely aligned with the epithelium. The epithelium in UC, but not in acute appendicitis, showed intense upregulation of HLA class II, and this was particularly marked at the crypt bases. Dendritic, MAC387-positive cells were seen only in UC. In both diseases there were abundant ACPI-positive accessory cells in the cryptal areas, a population normally restricted to the dome areas. Factor XIIIa- and PGM1-positive cells, although abundant in both conditions, had distributions similar to those that we had previously shown in normal controls. No CD1a-positive cells were identified in either UC or acute appendicitis. We hypothesize that S100 identifies a subpopulation of activated macrophages. The concentration of this subpopulation, in close contact with the epithelium, which also shows altered expression of HLA class II antigens, suggests that a component of the immune response is targeting this area in UC. In addition, we also suggest that the identification of MAC387-positive dendritic cells in UC reflects increased macrophage turnover in inflammatory bowel disease.

Antigen-Presenting Cells↗
PubMed1991

Clinical features of misdiagnosed appendicitis in children.

STUDY OBJECTIVE: To compare clinical features of children with misdiagnosed appendicitis with those of children with appendicitis initially diagnosed correctly. DESIGN: Retrospective review of hospital, emergency department, and clinic records. SETTING: University medical center with annual ED census of 40,000 patients. PARTICIPANTS: Children less than 13 years old admitted between May 1, 1979, and April 30, 1989, with a discharge diagnosis of appendicitis. MEASUREMENTS: Records were reviewed for historical, physical examination, laboratory, and pathologic features for all patients on their initial presentation to a physician and on final presentation during which the correct diagnosis was made. Using chi 2 analysis and Student's test, clinical features of misdiagnosed patients and patients diagnosed correctly were compared. RESULTS: One hundred eighty-one cases were identified with 50 initially misdiagnosed. On initial presentation, misdiagnosed patients were younger and more likely to have vomiting before pain onset, constipation, diarrhea, dysuria, and signs and symptoms of upper respiratory infections. Misdiagnosed cases were less likely to have right lower quadrant tenderness and documentation of bowel sounds, peritoneal signs, and rectal examinations. On final presentation, misdiagnosed patients were more likely to have pain duration of more than two days, temperature of more than 38.3 C, and to appear lethargic and irritable (P less than .05 for all measurements). CONCLUSION: Clinical features of children with misdiagnosed appendicitis differ from those of children with appendicitis initially diagnosed correctly.

Appendicitis↗
PubMed2005

[Difficulty in diagnosing acute appendicitis in the presence of acute portal vein thrombosis: the role of CT scan. Report of 2 cases].

Acute appendicitis can cause of portal vein thrombosis. Diagnosis of appendicitis can be difficult because its symptoms may be masked by those of acute portal vein thrombosis. We report 2 cases of appendicitis associated with acute portal vein thrombosis whose diagnosis was delayed by several months. The delayed diagnosis of acute appendicitis in the presence of acute portal vein thrombosis can be avoided by using spiral-computed tomography and careful investigation of signs of appendicitis.

Acute Disease↗
PubMed2003

Imaging of acute appendicitis in children.

Acute appendicitis is the most common acute abdominal condition that results in surgical intervention in childhood. The clinical diagnosis of acute appendicitis in children can be challenging. Approximately one-third of children with the condition have atypical clinical findings and are initially managed nonoperatively. Complications associated with delayed diagnosis of this condition include perforation, abscess formation, peritonitis, sepsis, bowel obstruction, infertility, and death. The use of cross sectional imaging has proven useful for the evaluation of suspected acute appendicitis in children. Both graded compression sonography and CT have been widely utilized in the imaging assessment of the condition. The principal advantages of sonography are its lower cost, lack of ionizing radiation, and ability to assess ovarian pathology that can often mimic acute appendicitis in female patients. The principal advantages of CT include less operator dependency than sonography as reflected by a higher diagnostic accuracy, and enhanced delineation of disease extent in perforated appendicitis.

Acute Disease↗
PubMed2001

Decreased risk of acute appendicitis in patients with schizophrenia or manic-depressive psychosis.

The present study tests the hypothesis of a negative association between patients with schizophrenia, manic-depressive psychosis and acute appendicitis. Using the nation-wide Danish case registers the occurrence of acute appendicitis among up to 20,402 inpatients with schizophrenia and up to 10,281 inpatients with manic-depressive psychosis and ten individually matched control persons for each psychiatric patient was investigated. A case-control and follow-up design was applied. Persons who developed schizophrenia had a significantly decreased relative risk of acute appendicitis of 0.49 before and of 0.59 after first psychiatric admission. Similarly the occurrence of manic-depressive psychosis was associated with a decreased relative risk of acute appendicitis of 0.50 before and of 0.70 after first psychiatric admission. One or more unknown factors inversely affect the risk for the subsequent development of psychoses and acute appendicitis. Further studies of this relationship may help to clarify etiological or pathophysiological aspects of schizophrenia and manic-depressive psychosis.

Acute Disease↗
PubMed1997

Granulomatous appendicitis: Crohn's disease, atypical Crohn's or not Crohn's at all?

BACKGROUND: Crohn's disease isolated to the appendix has primarily been documented in case reports. We contribute a series with longterm followup and a literature review. STUDY DESIGN: A retrospective review of 1,133 consecutive appendectomy specimens over the 6-year period ending in 1994 identified seven patients with isolated granulomatous appendicitis. Two patients presented before the review period. These nine patients are reviewed and 156 patients identified in the world literature. RESULTS: Granulomatous appendicitis usually presents as an indolent course of appendicitis. No patient developed enterocutaneous fistula after appendectomy in our series. A mean followup of 7.3 years in our patients revealed no evidence of Crohn's disease. CONCLUSIONS: Granulomatous inflammatory disease isolated to the appendix differs from typical Crohn's disease with a decreased occurrence of enterocutaneous fistulas and rare recurrence. Consequently, isolated granulomatous appendicitis without small bowel or cecal involvement may not represent true Crohn's disease. Patients can be treated with minimal morbidity by appendectomy alone. If isolated granulomatous appendicitis does represent Crohn's disease, its longterm course in the majority of patients is extremely benign.

Adolescent↗
PubMed1996

Laparoscopic diagnosis of acute appendicitis in women.

STUDY OBJECTIVE: To evaluate the efficacy of laparoscopy in confirming the diagnosis of acute appendicitis, to distinguish between acute surgical and gynecologic pathology, and to establish indications for surgical intervention. DESIGN: Assessment of 1000 consecutive emergency diagnostic laparoscopies. SETTING: A state university hospital in Moscow, Russia. PATIENTS: One thousand women with suspected appendicitis. INTERVENTIONS: Diagnostic laparoscopies performed under local anesthesia in all 1000 women, followed by open surgery in 405. MEASUREMENT AND MAIN RESULTS: Laparoscopy confirmed acute appendicitis in 282 of 1000 women and acute gynecologic diseases in 433. Laparoscopic diagnosis of appendicitis was incorrect in only nine women. The only serious complication of laparoscopy was perforation of the small bowel, which was due to dense adhesions in the abdominal cavity in a woman who had undergone several earlier surgeries. CONCLUSIONS: Diagnostic laparoscopy under local anesthesia was very useful in women with acute appendicitis and gynecologic diseases. It was associated with few complications, was inexpensive, and was well tolerated by the patients.

Acute Disease↗
PubMed2001

Resident interpretation of emergency CT scans in the evaluation of acute appendicitis.

PURPOSE: Radiology resident interpretation of computed tomographic (CT) scans at academic institutions often guides management of cases of suspected acute appendicitis in the emergency department. The purpose of this study was to compare resident and faculty interpretation of CT scans obtained for acute appendicitis. MATERIALS AND METHODS: From December 16, 1999, to July 13, 2000, CT was performed in 103 consecutive patients between the hours of 9:00 PM and 8:00 AM who were suspected of having acute appendicitis. The authors compared the residents' preliminary written interpretations with both the final reports written by the faculty and the surgical findings. The faculty interpreting the CT scans were aware of resident interpretations but were not aware that a study was being conducted. RESULTS: The final faculty interpretation and the preliminary resident interpretation were identical in 96 of the 103 patients (93%; 95% confidence interval: 87.8%, 97.2%). In only one patient was a scan originally interpreted as negative interpreted as positive by the faculty member. Clinically, the patient did not have acute appendicitis, and surgery was not perforrmed. CONCLUSION: In the diagnosis of acute appendicitis, image interpretations made by adequately trained radiology residents can be expected to closely match those of the radiology faculty, and the practice of after-hours interpretation of such studies by radiology residents is safe.

Acute Disease↗
PubMed2005

Watchful waiting versus interval appendectomy for patients who recovered from acute appendicitis with tumor formation: a cost-effectiveness analysis.

BACKGROUND: Interval appendectomy after conservative treatment of appendicitis with tumor formation remains controversial. The purpose of this study was to evaluate the efficacy of interval appendectomy based on a cost-effectiveness analysis. METHODS: This was a retrospective study including appendicitis patients with tumor formation who received conservative treatment at first admission to Taipei Veterans General Hospital between January 1998 and December 2003. Demographic data, rate of recurrent appendicitis, and medical costs were analyzed. RESULTS: Of the 165 patients, 1 died after an acute myocardial infarction. The rate of recurrence of appendicitis after conservative treatment was 25.5%. The median cost of follow-up after conservative treatment was NT24,344 dollars. The median cost of interval appendectomy was NT47,746 dollars. The median cost of appendectomy after recurrent appendicitis was NT62,135 dollars. Routine interval appendectomy in all 164 patients would have cost NT7,830,344 dollars. The follow-up protocol with appendectomy after recurrence cost NT5,655,220 dollars. An additional NT2,175,124 dollars (38%) would have been needed for routine interval appendectomy compared with the follow-up policy, an extra NT13,263 dollars per person. CONCLUSION: Routine interval appendectomy would increase the cost per patient by 38% compared with follow-up and appendectomy after recurrence. Routine interval appendectomy is not a cost-effective intervention.

Acute Disease↗
PubMed2005

Acute appendicitis in patients with acquired immunodeficiency syndrome.

BACKGROUND: We report our experience with patients who had acquired immunodeficiency syndrome (AIDS) and who presented with signs and symptoms suggesting acute appendicitis. METHODS: Observational data are documented for 9 patients with AIDS who underwent surgery for acute appendicitis. RESULTS: Of the 9 patients, 6 (66.7%) had acute appendicitis without perforation, while the other 3 (33.3%) had perforated appendicitis. An elevated preoperative temperature was found in 4 patients without perforation (66.7%), and in 1 patient with perforation (33.3%). An elevated white blood cell count was found in all 6 patients without perforation (100%), but in none with perforation (0%). The mean interval from surgical referral to laparotomy was 61.1 hours, the mean hospital stay was 9.3 days, and the perioperative mortality rate was 22.2%. CONCLUSION: Our experience should alert emergency medical staff who care for AIDS patients to the need for early diagnosis and prompt surgical treatment of appendicitis.

Acquired Immunodeficiency Syndrome↗
PubMed2003

[The value of ultrasound diagnosis in "acute appendicitis" patient admission].

UNLABELLED: The rate of unnecessary appendectomy is frequently criticized. Today, sonography and CT-scan are helpful tools to minimize this rate. Which value has the ultrasonography in the decision making today? METHODS: Retrospective analysis of 132 patients undergoing appendectomy in respect of sonography and rate of histologically confirmed appendicitis from 1.1.95-31.12.98. Prospective analysis of 99 patients admitted for acute appendicitis in respect of pre- and posttest-probability (after sonography) by the responsible surgeon from 1.1.99-31.12.00. RESULTS: Retrospective part: 122/132 patients had an acute appendicitis (92%). Sonography was performed in 64% of the patients. There was only one wrongly positive sonography. Prospective part: 76/99 patients were operated on. 70/76 had an acute appendicitis (92%). Sonography was performed in 87%. Six patients presented a histologically normal appendix: In two of them no increase of the probability after sonography was noted, in three of them an slight increase of only 20%, and in one of them a decrease of 20% even. CONCLUSION: Sonography with a pre- and posttest-probability is recommended in clinically doubtful cases. In our experience the physician performing the sonography is almost always right. But the diagnosis of an acute appendicitis remains a combination of clinical and sonographic evaluation.

Acute Disease↗
PubMed2001

Frequency of portal and systemic bacteremia in acute appendicitis.

BACKGROUND: Acute appendicitis is the most common condition requiring an emergency abdominal operation in childhood. In the present study, we analyzed the frequency of portal and systemic bacteremia in 42 patients with acute appendicitis and determined the microbial agents responsible for an acute appendicitis and for portal and systemic bacteremia. METHODS: Appendectomies were performed on 50 young patients (5-18 years of age), as well as clinical and bacteriological tests. Six independent samples from each patient isolated from the peripheral vein, superior mesenteric vein, appendix and peritoneum were obtained prior to surgery, during surgery and after surgery for biochemical, immunologic and bacteriologic examination. RESULTS: Pathohistology confirmed the diagnosis of appendicitis in 42 patients, while in the other eight patients there were no obvious pathologic findings, so they served as a control group. Of 50 patients with a clinical appearance of acute appendicitis, in 19 patients (38%) we detected portal bacteremia in the mesenteric vein, while in only three cases (6%) did we find systemic bacteremia detected from the peripheral vein. Furthermore, bacteriologic analysis revealed that Bacteroides spp. and Escherichia coli were the predominant species isolated. CONCLUSIONS: The results presented in this paper suggests that portal bacteremia did not influence peripheral blood reactions. Furthermore, in the present study we have found a positive correlation between the smear and bacteremia of the superior mesenteric vein, but not with the bacteremia of systemic blood.

Adolescent↗
PubMed2000

Is acute appendicitis another inflammatory condition associated with highly active antiretroviral therapy (HAART)?

OBJECTIVE: To report the occurrence of acute appendicitis as a possible manifestation of the immune restoration inflammatory syndrome (IRIS) following the commencement of highly active antiretroviral therapy (HAART) in HIV patients. DESIGN: Case-note review of HIV patients on HAART with acute appendicitis. METHODS: Review of HIV markers, antiretroviral therapy and abdominal ultrasound results of four HIV patients with acute appendicitis and the histopathology reports on the appendix in two of the patients. RESULTS: From a population of approximately 350 HIV patients on HAART, we found four patients who developed acute appendicitis within 6 months of commencing or changing HAART. CONCLUSION: Acute appendicitis occurring in HIV patients on HAART may represent a variant of IRIS. Further immunohistopathological and epidemiological evaluation will be needed to define this relationship fully.

Acute Disease↗