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PubMed1994

Sex-specific diagnostic scores for acute appendicitis.

The role of clinical and computer-based decisions in the diagnosis of acute appendicitis was studied in connection with the survey of acute abdominal pain by the Research Committee of the World Organization of Gastroenterology (OMGE). One thousand three hundred and thirty-three patients presenting with acute abdominal pain were included in the study. Twenty-two preoperative clinical history variables, 14 clinical signs, and 3 tests were evaluated in a multivariate analysis to find the best combination of independent predictors of acute appendicitis for males and females. Independent predictors of acute appendicitis in males were tenderness, previous abdominal surgery, rebound, rigidity, location of pain at diagnosis, guarding, and body temperature. To sum up the contributions of the most significant diagnostic factors, a diagnostic score (DS) was built. When the male patients with a DS value between -2.00 and -0.48 were considered nondefined (n = 75, follow-up required before deciding to operate), the sensitivity of the computer-aided diagnosis in detecting acute appendicitis in males was 0.95, with a specificity of 0.89 and an efficiency of 0.91. In males whose leucocyte count was available (n = 476), previous abdominal surgery, leucocytosis, location of pain at diagnosis, tenderness, rigidity, rebound, guarding, rectal digital tenderness, and body temperature predicted significantly acute appendicitis. The DS reached a sensitivity of 0.94 (the cut-off level was -1.74), with a specificity of 0.80 and an efficiency of 0.84. (ABSTRACT TRUNCATED AT 250 WORDS)

Acute Disease↗
PubMed2004

The value of 5-hydroxy indole acetic acid measurement in spot urine in diagnosis of acute appendicitis.

OBJECTIVE: To assess the role of 5-Hydroxy Indole Acetic Acid (5-HIAA) levels in spot urine in diagnosis of acute appendicitis. DESIGN: A prospective, controlled study. SETTING: Ankara Numune Teaching and Research Hospital, Ankara, Turkey. SUBJECT: Twenty six patients with histologically proven acute appendicitis following appendectomy were included in the study. Control group with consisted of patients prepared for hernia repair in the same duration. In the preoperative period, urine samples were collected from every patient for measurement of 5-HIAA. RESULTS: The study group comprised 26 patients; 15 of those had high urine 5-HIAA levels, whereas 11 patients had values within normal range. None of ten control patients displayed positive test result. The test had 58% sensitivity and 48% specificity. In histopathological examination only two of ten patients with gangrenous appendicitis showed positive test result, whereas 13 of 16 patients with no histopathological gangrenous changes had high values. CONCLUSION: Urine 5-HIAA measurement has low sensitivity and specificity. The value of the test is even clearly lower in gangrenous appendicitis. This may be misleading in management of patients in late phase of appendicitis and in cases with perforation which is mainly responsible for morbidity.

Acute Disease↗
PubMed2004

Diagnostic value of plain abdominal radiographs in acute appendicitis in children.

OBJECTIVE: The plain film of the abdomen (PAX) is still utilised in the diagnosis of acute appendicitis (Aap). Aim of this study was to evaluate the value of PAX in the diagnosis of Aap in children, since it continues to be a controversial subject. DESIGN: A retrospective study. SETTING: Department of Paediatric Surgery, Gazi University Medical School. PATIENTS: The histopathological diagnoses and PAX of 213 children (mean age 9-6 years) operated for acute right-lower quadrant pain were evaluated retrospectively. There were 181 patients with Aap and 32 with normal appendix. METHODS: The rate of detection of overall thirteen roentgenographic criteria defined in various reports in medical literature as indicating appendicitis were noted and compared with histopathological diagnoses. The PAX which revealed one or more of these signs in combination was considered to be positive for Aap. Data was analysed statistically and sensitivity, specificity and positive and negative predictive values of PAX in the diagnosis of Aap were determined. RESULTS: Roentgenographic sign(s) were detected in 170 (79%) cases, 18 without Aap. The most frequent were lumbar scoliosis with left-sided convexity (50%) and small intestinal air-fluid levels (32%). In 39 cases, 25 with Aap, no sign(s) was detected. In all of the perforated cases, at least one of the determined criteria was seen. The percentage of roentgenographic signs found in cases with and without appendicitis was different significantly (p<0.01). The negative predictive value of PAX in the diagnosis of acute appendicitis was 32.5% and positive predictive value was 89%. CONCLUSION: PAX could he helpful in diagnosis in children with suspected acute appendicitis.

Acute Disease↗
PubMed2005

Association between tonsillectomy, adenoidectomy, and appendicitis.

INTRODUCTION: Tonsillectomy, with or without adenoidectomy, is one of the most frequent surgical procedures generally performed, especially in young patients. Several studies suggest that there is a relationship between tonsillectomy and altered MALT immune system. OBJECTIVE: To examine the possible association between tonsillectomy or adenoidectomy and the risk of subsequent appendicitis. MATERIAL AND METHOD: A cross-sectional study was performed in 650 patients admitted to the emergency department of a general hospital in Valencia, Spain. Previous history of tonsillectomy and/or adenoidectomy was related to a history of appendectomy. A descriptive study and an analysis of the relationship between previous operations and appendicitis was performed. A multivariable analysis controlled for age and sex was also performed, including the possible interaction of the gender variable. The independent effect of each of the procedures (tonsillectomy, adenoidectomy) was tested. RESULTS: The 25.5% of patients had undergone tonsillectomy and 11.5% adenoidectomy; 17.5% had had an appendectomy. On average, women were operated on more frequently than men. In the bivariate analysis, both tonsillectomy and adenoidectomy were significantly associated with subsequent appendectomy. In the multivariate analysis, this association was only maintained for tonsillectomy (OR: 3.23; 95% CI: 2.11-4.94). A stratified analysis controlling for sex showed a modification of this effect, with a higher association in women (OR: 5.20; 95% CI: 2.91-9.28) than in men (OR: 1.74; 95% CI: 0.90-3.39). CONCLUSIONS: A clear association has been found, especially in women, between previous tonsillectomy and subsequent acute appendicitis. Due to a lack of data on acute appendicitis there should be further studies to explain the findings of this study, as this could be the first described risk factor of acute appendicitis.

Adenoidectomy↗
PubMed1995

Laparoscopic surgery in women with a clinical diagnosis of acute appendicitis.

OBJECTIVES: To assess the routine use of diagnostic laparoscopy and laparoscopic appendicectomy in women with a clinical diagnosis of acute appendicitis. METHODS: Women who presented with a clinical diagnosis of acute appendicitis between 1 January 1992 and 31 August 1993 were prospectively assessed and 107 underwent diagnostic laparoscopy. RESULTS: Appendicitis was confirmed in 63 women (59%) and no diagnosis could be made in seven (6%). An alternative diagnosis, most commonly a gynaecological disorder, was made in 37 women (35%). Twenty-eight women with an alternative diagnosis (76%) did not require a laparotomy. Seventy-three patients had a laparoscopic appendicectomy, with an 8% conversion rate to an open operation. The morbidity rate for laparoscopic procedures was 3%, the median inpatient stay was two days and the median time to return to normal activities was eight days. CONCLUSIONS: Diagnostic laparoscopy should be performed in women who present with a clinical diagnosis of acute appendicitis to confirm the diagnosis, reduce the rate of unnecessary appendicectomy and avoid an unnecessary laparotomy. When acute appendicitis is confirmed, appendicectomy may be performed laparoscopically.

Activities of Daily Living↗
PubMed2000

Neuronal hypertrophy in acute appendicitis.

OBJECTIVE: The pathogenesis of appendicitis remains poorly understood. However, there is increasing evidence of involvement of the enteric nervous system in immune regulation and in inflammatory responses. This study was set up to characterize the status of the enteric nervous system in normal and in inflamed appendixes. METHODS: S100- and 2',2'-cyclic nucleotide 3' phosphodiesterase-positive Schwann cells, synaptophysin, and neuron-specific, enolase-positive nerve fibers and tryptase-positive mast cells were evaluated with immunohistochemical staining in surgically resected appendixes from 20 children with histologically proven acute appendicitis (HA), 10 histologically normal appendixes (HN) from patients with a clinical diagnosis of appendicitis, and 10 normal appendixes from patients undergoing elective abdominal surgery. Immunostained sections were subjected to quantitative image analysis. The number and size of ganglia and the number of nerve fibers, Schwann cells, and mast cells in each tissue compartment was quantitatively or semiquantitatively measured. RESULTS: Increased numbers of fibers, Schwann cells, and enlarged ganglia, widely distributed in the muscularis externa and submucosa, were seen in all HA appendixes and in 4 of 10 HN appendixes. The number and size of ganglia in muscularis externa and in the submucosa of appendixes with HA were significantly greater compared with those in control appendixes (P <.001). A significantly increased number of individually stained nerve fibers and Schwann cells (P <.05) were present in the muscularis externa in HA appendixes compared with control appendixes. Significantly increased numbers of tryptase-positive mast cells (P <.05) were present in the submucosa, muscularis, and especially in the lamina propria in HA specimens, compared with that of control tissue. CONCLUSIONS: The significant increase in neural components and mast cells in acute appendicitis is unlikely to develop during a single acute inflammatory episode. This suggests an underlying chronic abnormality as a secondary reaction to repeated bouts of inflammation, obstruction, or both. These results challenge our current understanding of the pathophysiological processes that give rise to acute appendicitis.

2',3'-Cyclic-Nucleotide Phosphodiesterases↗
PubMed1990

Graded compression ultrasound in the diagnosis of appendicitis. A comparison of diagnostic criteria.

Four sonographic diagnostic criteria for appendicitis, (1) any visualization, (2) appendiceal diameter greater than 6.0 mm, (3) muscular wall thickness greater than or equal to 3.0 mm, and (4) presence of a complex mass, were compared in a series of 200 patients clinically suspected of having appendicitis. The diagnosis of appendicitis was confirmed histopathologically and included all forms of appendicitis with mucosal invasion by inflammatory cells. The sensitivities of all the criteria were low (11% to 75%) and the usefulness of this test as a screening procedure is questioned. The combined criteria of an appendix with a muscular wall thickness (MWT) greater than or equal to 3.0 mm and visualization of a complex mass (CM) separate from the adnexa in females proved most useful as a diagnostic test (sensitivity, 68%; specificity, 98%). We conclude that the diagnosis of appendicitis is still difficult, despite the addition of graded compression ultrasound as a diagnostic test. We do not recommend its use as the only screening test, but do recommend it, rather, in a diagnostic role after the initial clinical screening.

Abdominal Pain↗
PubMed2002

Improved sonographic visualization of the appendix with a saline enema in children with suspected appendicitis.

OBJECTIVE: To determine whether abdominal sonography after a saline enema can identify the appendix that is not visualized at graded compression sonography in children with suspected appendicitis. METHODS: High-frequency compression sonography was prospectively performed in 120 consecutive children with suspected appendicitis; the appendix was not identified in 27 of these patients. Among the 27 patients with a nonvisualized appendix, abdominal sonography after a saline enema was performed in 12 to identify the appendix. RESULTS: Abdominal sonography after the saline enema revealed the appendix in all 12 children in whom the appendix was not visualized at graded compression sonography. A normal appendix was found in 11 children, and acute appendicitis confined to the appendiceal tip was found in 1. The appendix was located in the pelvis (n = 5), posterior to the cecum (n = 4), posterior to the ileum (n = 2), and anterior to the ileum (n = 1). The appendix could be identified by using a window of the saline-filled sigmoid colon (n = 5), saline-filled cecum (n = 4), and saline-filled terminal ileum (n = 2). CONCLUSIONS: Abdominal sonography after a saline enema is a helpful technique for depiction of the appendix that is not visible at graded compression sonography in children with suspected appendicitis. Key words: appendix, sonography; appendicitis; children, gastrointestinal tract.

Acute Disease↗
PubMed1999

Wound management in perforated appendicitis.

Open wound management after perforated appendicitis was common practice but, recently, primary closure has been advocated to reduce costs and morbidity. Hospital records from 319 adults who underwent appendectomy from 1993 to 1996 were reviewed to identify surgical wound infections (SWIs) and examine risk factors. Information about age, length of stay (LOS), operative time, white blood cell count, and antibiotic administration were obtained. Perforation was either noted at operation or identified microscopically by the pathologist. If primary wound closure was performed, patients with acute appendicitis and perforation had a 4-fold higher readmission rate, a 5-fold increase in SWI, and twice the LOS compared with patients with acute appendicitis without perforation. Patients with grossly perforated acute appendicitis had no difference in LOS if the wound was treated open or closed primarily. No patient with microscopic perforation and primary wound closure developed SWI. Primary wound closure after acute appendicitis was safe in the absence of clinical perforation. In the presence of clinical appendiceal perforation the wound should be left open.

Acute Disease↗
PubMed1999

A new economic benchmark for surgical treatment of appendicitis.

Cost reduction in the management of common surgical diseases such as appendicitis has become paramount for the survival of children's hospitals. We designed a clinical pathway to treat appendicitis with the goal of reducing cost and hospital length of stay (LOS) while maintaining quality of care. From September 1995 through December 1996, patients with nonperforated appendicitis (NPApp) and perforated appendicitis with peritonitis (PApp) were enrolled into a clinical pathway. NPApp patients were discharged when tolerating a regular diet. PApp patients were discharged if the following criteria were met: temperature < 38.5 degrees C for 24 hours, WBC < 14,000 on postoperative day 3, tolerating diet, and transition to oral analgesics accomplished. Hospital LOS and actual hospital costs in pathway patients were compared with those of historic controls. Patients with appendicitis from the Pediatric Health Information Systems (PHIS) database, a consortium of 20 children's hospitals in the United States, served as concurrent controls. Hospital LOS and hospital charges in PHIS NPApp and PApp patients from our institution were compared with national PHIS database patients. Mean LOS and hospital costs for both NPApp and PApp pathway patients were significantly decreased compared with historic controls (P < 0.05). Mean LOS and hospital charges in our institution's PHIS NPApp and PApp patients were also significantly decreased compared with the national PHIS database (P < 0.05). Innovative approaches such as these are necessary for the survival of children's hospitals in an increasingly cost competitive healthcare market.

Anti-Infective Agents↗
PubMed2000

Would measurement of C-reactive protein reduce the rate of negative exploration for acute appendicitis?

BACKGROUND: Appendicectomy for suspected acute appendicitis is a common procedure. The rate of normal appendices unnecessarily removed remains high (15-30%) despite several techniques and investigations used to improve the diagnostic accuracy. Many studies investigated the role of raised C-reactive protein in improving the diagnosis of acute appendicitis, but with conflicting results. This study emphasies the impact of a normal (rather than raised) serum C-reactive protein in reducing the rate of negative explorations. METHODS: In a double blind study, blood for the measurement of serum C-reactive protein (CRP) was collected pre-operatively from 78 patients just before going to the operating room for appendicectomy. The histopathology of the 78 appendices were grouped into positive (acute appendicitis) and negative (normal appendix). White blood count (WBC), CRP and the histopathology findings were correlated. RESULTS: In patients with histopathologically proven acute appendicitis both the WBC count and serum CRP level were significantly raised (P = 0.025 and P < 0.000,1 respectively). Serum CRP level was normal in 13 out of 15 negative explorations (normal appendix on histopathology). The specificity and sensitivity of serum CRP was 86.6% and 93.6%, respectively. CONCLUSION: A normal pre-operative serum CRP measurement in patients with suspected acute appendicitis is most likely associated with a normal appendix. Deferring surgery in this group of patients would probably reduce the rate of unnecessary appendicectomies.

Adolescent↗
PubMed2000

A prospective evaluation of the combined use of the modified Alvarado score with selective laparoscopy in adult females in the management of suspected appendicitis.

BACKGROUND: A diagnostic scoring system such as the modified Alvarado score, combined with selective laparoscopy in adult females, can be used in the assessment of acute abdominal pain suggestive of appendicitis. METHOD: A total of 84 consecutive patients presenting to our surgical team with suspected appendicitis were assessed prospectively using the modified Alvarado score. The definitive management of this study group was instigated according to a set algorithm based on the score. The algorithm included the use of diagnostic laparoscopy in adult female patients with scores suggestive of appendicitis. A negative appendicectomy rate was obtained from those undergoing appendicectomy using this approach and compared to that obtained from the 97 patients that had undergone appendicectomy under the care of the other surgical teams in our unit during the study period. RESULTS: The rate of negative appendicectomy in the study group was 0% compared to 18% in the control group (P < 0.05); 10% of adult female women had negative diagnostic laparoscopies for appendicitis thus saving this group an unnecessary appendicectomy. This was achieved without an increase in total in-patient stay. CONCLUSION: An algorithm combining the modified Alvarado score with selective laparoscopy is recommended for widespread use in the management of suspected acute appendicitis.

Acute Disease↗
PubMed2000

Stump appendicitis.

There has been a recent increase in interest in stump appendicitis with the rapid development of laparoscopic appendectomy. The objective of this study is to determine the frequency, management, and prevention of stump appendicitis in a retrospective review of 2185 cases of appendectomy and right colectomy at the Massachusetts General Hospital from 1960 to 1998. Three patients with stump appendicitis were identified. Patients presented with epigastric or periumbilical pain that radiated to the right lower quadrant. All had focal abdominal signs and a mild to moderate leukocytosis, and all underwent right colectomy. Pathology noted appendiceal stumps 5 mm deep. Two additional patients with chronic abdominal pain had cecal filling defects on barium enema. Endoscopically, these appendiceal stumps were 7 mm deep with impacted fecaliths and pathologic changes consistent with early inflammation. The stumps were resected by snare electrocautery. Stump appendicitis is a very rare entity. Its incidence may be minimized with accurate visualization of the appendiceal base and creation of an appendiceal stump less than 3 mm in depth. There is no correlation between simple ligation or inversion of the stump and stump appendicitis. There should not be a sudden increase in the incidence of this entity if laparoscopic appendectomy is performed properly.

Adult↗
PubMed2000

Nuclear factor kappaB activation in acute appendicitis: a molecular marker for extent of disease?

Nuclear factor-kappaB (NF-kappaB) has been demonstrated to regulate the transcription of target genes and stimulate inflammatory cytokine responses in a variety of inflammatory diseases. Preliminary studies have demonstrated that NF-kappaB is activated early in acute inflammation and sepsis and may serve as an indicator of clinical severity. The present study was designed to evaluate the degree of activation of NF-kappaB in patients with acute appendicitis and correlate activation with clinical extent of disease. Ten patients with acute appendicitis and five control patients (elective inguinal hernia repair) were evaluated by assaying NF-kappaB activity preoperatively and 12 to 18 hours postoperatively. Assaying of NF-kappaB was determined by binding activity for consensus probes in nuclear extracts from peripheral mixed white blood cells obtained by venous puncture. The bands of NF-kappaB activity from gel electrophoresis were quantified with a phosphor imager and reported as units of integrated intensity. The preoperative NF-kappaB activity was increased in all patients with appendicitis versus the controls [mean 151 (range 97-189) vs mean 50.3 (range 13.7-77); P < 0.0001]. The increased NF-kappaB activity also correlated with length of time of symptoms before operation. The patients who were symptomatic for less than 24 hours had an average NF-kappaB value of 103 (range 97-105) versus 171.4 (range 152-189) (P < 0.0001) in those who were symptomatic 24 or more hours. The NF-kappaB activity did not correlate with the white blood cell count. Postoperative NF-kappaB binding activity in the appendicitis patients dropped to minimal levels (mean 50.3), even lower than the control patients' baseline values (mean 55.6). Control patients demonstrated low baseline values preoperatively and a slight rise postoperatively [mean 50.3 (range 13.7-77) vs mean 100 (range 45-186)]. We conclude the following: (1) NF-kappaB binding activity is elevated in patients with acute appendicitis and correlates with symptoms longer than 24 hours. (2) This increased activity returns to baseline values within 18 hours after appendectomy. (3) Molecular indicators of inflammation may have a role in both staging surgical inflammatory conditions and predicting ultimate outcome.

Acute Disease↗
PubMed2001

Clinical features and outcome of appendicitis in children younger than three years of age.

BACKGROUND: Acute appendicitis is the most common surgically amenable cause of acute abdominal pain in children. We analyzed our past experience of appendectomies in children and present the clinical characteristics of appendicitis in children younger than 3 years of age. A better understanding of appendicitis in early childhood would allow us to achieve an earlier diagnosis. METHODS: A group of 475 children from 4 months to 15 years of age who underwent appendectomy for appendicitis was studied over a 5-year period from July 1994 to June 1999. Excluding cases with negative pathological findings (n = 34), they were divided into 2 age groups: group I (< or = 3 years old) and group II (> 3 years old). Medical records were reviewed and comparisons between clinical findings, laboratory data, pathology findings, and complications were made. RESULTS: Of 441 cases enrolled in our study, 24 (5.4%) were 3 years of age or younger. Of all children older than 3 years of age, 32 (7.1%) had negative pathological findings compared to children younger than 3 years of age (7.7%). The duration of symptoms prior to diagnosis in group I was 3.6 days compared to group II at 2.0 days. Children from group I frequently showed a higher incidence of fever (90% vs. 53.4%), abdominal distention (50% vs. 9.8%), perforation (50% vs. 40.1%), and missed first impression (29% vs. 2.4%) than those from group II. Children of group I also had a higher complication rate (41.7% vs. 11.5%). CONCLUSIONS: In early childhood the symptoms and signs of appendicitis usually are nonspecific. There is a longer duration before diagnosis, more instances of fever and abdominal distention, less right lower quadrant pain, less local tenderness and rebounding pain, and no obturator sign. Close observation and on-going evaluation of patients are essential.

Appendicitis↗
PubMedDate not supplied

Acute appendicitis: the role of enterotoxigenic strains of Bacteroides fragilis and Clostridium difficile.

BACKGROUND: The aim of this study was to investigate whether there is a relationship between enterotoxin-producing B. fragilis strains and toxigenic C. difficile strains and the pathogenesis of acute appendicitis. MATERIAL AND METHODS: Post-appendectomy tissues from 34 patients with histopathologically confirmed phlegmonous or gangrenous appendicitis were studied. RESULTS: Among 86 anaerobes isolated, the B. fragilis group was most frequently isolated: 34 B. fragilis strains were cultured from 21 post-appendectomy tissues. Two enterotoxin-producing B. fragilis strains were found. Enterotoxin titers (1:10 and 1:160, respectively) were measured on HT29/C cells. The presence of the enterotoxin gene was confirmed by PCR in DNA extracted from both strains. Among 21 DNA samples isolated from those post-appendectomy tissues from which B. fragilis strains were cultured, the presence of the enterotoxin gene was confirmed in only one case (the corresponding B. fragilis strain enterotoxin titer was 1:160). A unique toxigenic C. difficile strain was also cultured from the tissue of an adult patient with gangrenous non-perforated appendicitis. The presence of toxin A and toxin B genes was confirmed by PCR in DNA extracted from the C. difficile strain, but these genes were not found in the DNA extracted from the corresponding tissue. CONCLUSION: The presence of enterotoxigenic B. fragilis and toxigenic C. difficile strains was shown in post-appendectomy tissue from patients with phlegmonous and gangrenous appendicitis, and the B. fragilis enterotoxin gene was detected directly in the corresponding tissue. Further investigations (including immunologic aspects) require to confirm the role of these toxins in pathogenesis of acute appendicitis.

Adult↗
PubMed2001

The Alvarado score and acute appendicitis.

INTRODUCTION: This is a retrospective study to assess the accuracy of the Alvarado score in predicting appendicitis for patients with right iliac fossa pain. MATERIALS AND METHODS: This is a retrospective study of consecutive patients with suspected appendicitis. The Alvarado score was computed from the admission notes and correlated with the final outcome of the patient. Patients discharged without surgery were reviewed in the outpatient's clinic to ascertain that they did not need surgery. RESULTS: There were 148 patients in the study and 63 had appendectomies with intention to treat appendicitis. The normal appendicectomy rate was 21%. The number of patients with score 1-4, 5-6, 7-8 and 9-10 were 46, 40, 44 and 18, respectively, while the number of appendicitis in each group were 0, 2 (5%), 30 (68%) and 18 (100%), respectively. The positive and negative predictive values of Alvarado's scores of 7 or more were 77% and 97.6%, respectively. CONCLUSION: Alvarado score is a useful tool in the diagnosis of appendicitis, especially at both ends of the scale.

Acute Disease↗
PubMed2001

[The role of helminthiasis in the etiology of acute appendicitis].

279 vermiform processes removed for different form of appendicitis were studied hystologically with obligatory analysis of appendix content. High rate of helminth intestation (27.2%) in vermiform processes removed in acute appendicitis surgery confirms an important role of small helminths (Enterobius, Trichocephalis and their larvae) in acute appendicitis development. The incidence of acute appendicitis and helminths interstation in children is higher than in adults. All the patients with acute appendicitis need helminthological examination and etiotropic treatment because appendectomy eliminates the complication but not the cause of intestinal disease.

Acute Disease↗