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PubMed1981

Retrocecal appendicitis.

The clinical presentation of 105 cases of retrocecal appendicitis was reviewed. Thirty-six percent of the patients had the classic appendicitis scenario of periumbilical pain localizing to the right lower quadrant, accompanied by anorexia, nausea and vomiting, and tenderness and guarding in the right lower quadrant. The remaining 64 percent had subtle variations of this presentation. Retrocecal appendicitis did not have a distinctive clinical pattern in our series. Twelve of the 105 retrocecal appendices were also retroperitoneal. The diagnosis was delayed in four patients and two had flank pain. Five of the twelve appendices were either gangrenous or perforated. Although the number of patients is small, we conclude that the traditional type of retrocecal appendicitis can occur in the retroperitoneal subgroup but that his anatomic variation is infrequent. The incidence in our series was 2.5 percent.

Adolescent↗

PubMed1981

Acute appendicitis. Prospective trial concerning diagnostic accuracy and complications.

In a prospective trial comprising 202 patients operated on because of suspicion of acute appendicitis, the diagnostic accuracy was 70 percent based on histologic examination of all removed appendices. The diagnostic accuracy was lowest in women less than 50 years old and in young patients (aged 20 years or less), being about 60 percent in both of these groups. The reasons were gynecologic disorders and uncharacteristic abdominal pains, respectively. Twenty-three of the 142 patients with acute appendicitis had perforation (16 percent). The frequency of perforation was significantly higher in patients more than 50 years old. Postoperative complications were seen in 11 percent of the patients. There was no significant difference in the frequency of complications in patients with a normal appendix and no other surgical abdominal disorder and patients with nonperforated appendicitis. However, there was a statistically significant difference between these two groups and the group with perforated appendicitis. In the latter group, postoperative complications occurred in 39 percent of the patients as opposed to 4 percent and 8 percent, respectively, in the former groups.

Acute Disease↗

PubMed1994

Management of perforated appendicitis in children: a decade of aggressive treatment.

Perforated appendicitis in children continues to be associated with significant morbidity. In 1976, a treatment algorithm was begun at the authors' institution, which included immediate appendectomy, antibiotic irrigation of the peritoneal cavity, transperitoneal drainage through the wound, and 10-day treatment with intravenous ampicillin, clindamycin, and gentamicin. Initial results with this scheme in 143 patients demonstrated a 7.7% incidence of major complications and no deaths. From 1981 through 1991, the authors continued to use this treatment plan in all patients with perforated appendicitis. Three hundred seventy-three patients with perforated appendicitis were treated, and the rate of major complications was 6.4%. Infectious complications occurred in 18 patients (4.8%) and included intraabdominal abscesses (5 patients, 1.3%), phlegmon treated with an extended course of antibiotics (6 patients, 1.6%), wound infections (5 patients, 1.3%), and enterocutaneous fistula requiring further operations (2 patients, 0.5%). There were six cases of small bowel obstruction (1.6%), which required operative intervention. There were no deaths. The average length of stay for all patients was 11.4 days (range, 8 to 66 days). Utilization of transperitoneal drainage and choice of antibiotic therapy continue to be sources of controversy in the surgical literature. However, the treatment plan used in the present study resulted in the lowest complication rate reported to date, and the authors conclude that this scheme is truly the "gold standard" for treatment of perforated appendicitis. New treatment plans using laparoscopic appendectomy, different or shorter courses of antibiotics, or not using drains should have complication rates that are as low as, or lower than this one to be considered as useful alternatives.

Adolescent↗

PubMed1990

Identification of human appendicitis by in vitro nuclear magnetic resonance.

The spin-lattice relaxation time, T1 as determined by nuclear magnetic resonance techniques, correlates positively with tissue water content. The latter relationship has been observed in rabbits with experimentally induced appendicitis whose inflamed appendiceal tissues had significantly higher T1's and water contents than tissue from normal controls. The present experiment studied these relationships in humans. Tissue water content and T1 were measured on appendiceal tissue from 10 patients with documented appendicitis and from 6 controls without the disease. All T1's were determined within 30-60 min of removal of the appendix at operation. The mean in vitro T1 of appendiceal tissue from patients with appendicitis was significantly higher than that of controls (527 +/- 15 msec versus 430 +/- 17 msec, mean +/- SEM, P less than 0.002). In addition, a strong positive correlation was noted between T1 and tissue water content (r = 0.70, P less than 0.01). Based on these findings, the use of in vivo magnetic resonance imaging techniques to detect human appendicitis noninvasively warrants investigation.

Adolescent↗

PubMed1993

Differentiating acute appendicitis from pelvic inflammatory disease in women of childbearing age.

A retrospective study was performed to evaluate the usefulness of various historical, clinical, and laboratory findings in differentiating acute appendicitis from pelvic inflammatory disease (PID) in women of childbearing age. The records of all female patients presenting to the emergency department with abdominal pain who were found to have histologically proven appendicitis (n = 80) or PID confirmed on endocervical culture (n = 71) were reviewed. Clinically useful indicators favoring appendicitis included the presence of anorexia and the onset of pain later than day 14 of the menstrual cycle. Indicators favoring PID included a history of vaginal discharge, urinary symptoms, prior PID, tenderness outside the right lower quadrant, cervical motion tenderness, vaginal discharge on pelvic examination, and positive urinalysis. Despite these indicators, differentiating acute appendicitis from PID remains difficult.

Acute Disease↗

PubMed2006

Appendiceal outer diameter as an indicator for differentiating appendiceal mucocele from appendicitis.

BACKGROUND: Patients with appendiceal mucocele (AM) commonly present with features indicative of acute appendicitis. In emergency departments, accurate preoperative diagnosis is crucial to prompt appropriate treatment. This study investigates the clinical and sonographic characteristics of AM, which may prove useful in preoperatively differentiating AM from appendicitis. METHODS: This case-control study compares the clinical and sonographic findings of 16 histologically confirmed AM with sex- and age-matched control subjects (n = 64) with appendicitis by a 1:4 ratio. Conditional logistic regression was applied to estimate the odds ratio (OR) and 95% confidence intervals (CI) of clinical and sonographic parameters associated with AM. RESULTS: Univariate analysis demonstrated that the larger appendiceal outer diameter by sonography was positively correlated with diagnosis of AM (OR, 2.31; 95% CI, 1.42-3.72) and right lower quadrant abdominal pain was negatively correlated (OR, 0.38; 95% CI, 0.17-0.82). However, multiple regression analysis suggested that only outer diameter remained significant (OR, 2.21; 95% CI, 1.36-3.59) after adjusting for age, sex, and right lower quadrant pain. An outer diameter of 15 mm or more was predictive of AM diagnosis, with a sensitivity of 83% and specificity of 92%. CONCLUSION: When the threshold is set at 15 mm, appendiceal outer diameter by sonography is a useful preoperative measurement for differentiating between AM and acute appendicitis.

Adult↗

PubMed2004

Cluster of acute hemorrhagic appendicitis among high school students in Wuhan, China.

BACKGROUND: Features of a cluster of acute appendicitis that occurred among a high school student population in China were investigated. METHODS: Epidemiologic data, medical records, and histologic slides of resected appendices were examined. RESULTS: During a period between April 10, 1997, and June 11, 1997, 11 cases occurred in a high school, with 10 cases among 290 students enrolled at the time. From the end of the initial cluster until June, 2000, 20 additional cases were encountered. Female cases (6.5%) are more frequent than male cases (1.9%). There was a clustering pattern. Many patients had a history of mutual contact before the onset of symptoms. Pathologically, the resected appendices exhibited diffuse or focal hemorrhages in the lamina propria or within hyperplastic lymphoid follicles, and infiltration by eosinophils and by lymphocytes. Appendical tissues were examined using immunohistochemistry, but no etiologic agent was identified. CONCLUSIONS: This cluster of acute appendicitis represented a special kind of appendicitis, with features of an infectious disease in epidemiology.

Adult↗

PubMed2007

Appendectomy for appendicitis in patients with schizophrenia.

BACKGROUND: Anecdotal evidence suggests that schizophrenia patients who require surgery have a high rate of adverse outcomes. We searched the Department of Veterans Affairs national datasets to determine the clinical course of schizophrenia patients with appendicitis who underwent appendectomy. METHODS: The Patient Treatment File (the nationwide inpatient database for the Department of Veterans Affairs) and the Beneficiary Identification and Records Location System were searched to identify all patients with International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic codes for schizophrenia or schizoaffective disorder diagnosed with appendicitis during fiscal years 1995 to 1999. Computer-based information was supplemented with chart-based data. We sought data on six common preoperative risk factors and 25 specific adverse outcomes, including death. RESULTS: There were 55 patients identified. The mean age was 49, and 96% were men. The median time from symptom onset to diagnosis of appendicitis was 3 days. A history of substance abuse was obtained in 16 (29%). Disruptive behavior was documented in 16 (29%). Restraints were used in 9 (9%). The appendix was perforated in 36 (66%) and gangrenous in 9 (16%). Thirty-one (56%) had > or = 1 complication; there were 2 in-hospital deaths (4%). CONCLUSIONS: This is the first report on this topic in the medical literature. Appendicitis is typically diagnosed late in schizophrenic patients. Adverse patient behaviors are frequent. The complication and death rates are high.

Appendectomy↗

PubMed2006

Laparoscopic versus open appendectomy for perforated appendicitis.

The role of laparoscopic appendectomy (LA) for perforated appendicitis is under investigation. A retrospective study was conducted to compare the outcomes of laparoscopic versus open appendectomy (OA) for perforated appendicitis. From January 2001 through December 2003, 229 patients with perforated appendicitis were treated at Far-Eastern Memorial Hospital. LA was successfully completed in 91 of 99 patients. OA was performed in 130 patients. Operation time was longer in the LA group (mean +/- SD = 96.1 +/- 43.1 vs. 67.8 +/- 32.2 minutes, P < 0.01). Return of oral intake was faster in the LA group (3.2 +/- 2.4 vs. 5.0 +/- 7.0 days, P < 0.01). The intravenous antibiotic usage period was shorter in the LA group (4.4 +/- 2.8 vs. 6.3 +/- 7.1 days, P < 0.01). The postoperative wound infection rates were 15.2 % (LA group) and 30.7% (OA group). The overall infectious complication rates were 19% in the LA group and 37% in the OA group (P < 0.01). Hospital stay days were shorter for the LA group (6.3 +/- 2.9 vs. 9.3 +/- 8.6 days, P < 0.01). Our results indicated that laparoscopic appendectomy is a safe and effective procedure for treating patients with perforated appendicitis.

Adult↗

PubMed2005

Misdiagnosis of appendicitis and the use of diagnostic imaging.

BACKGROUND: CT and ultrasound (US) are increasingly recommended to establish the diagnosis of appendicitis, but population-based rates of misdiagnosis (negative appendectomy [NA]) have not improved over time. The objective of this study was to determine the relationship between CT/US and NA in common practice. STUDY DESIGN: Using data from the Group Health Cooperative on all patients undergoing appendectomy between 1980 and 1999, a longitudinal study was conducted to determine the frequency of NA over time and a case-control, medical record-based study of a subset of patients from the 1990s was conducted to determine the accuracy of CT/US. RESULTS: Of 4,058 patients undergoing appendectomy (mean age 31 +/- 18.6 [SD] years, 49.6% women), 631 (15.5%) had an NA. The overall incidence of NA remained stable over time at 1.5/10,000 patient-years, as did the age and gender adjusted rate (incident rate ratio 0.95, 95% CI 0.97, 1.01). In 1999, nearly 40% of patients had either CT or US. The aggregate sensitivity of these tests was only 74.2% (95% CI 65.7, 83.7), with a positive predictive value of 95.1% (95% CI 91.5, 96.8). CT scans were 88.3% sensitive, with 97.2% positive predictive value (95% CI 92.9, 100). Ultrasounds were 69.5% sensitive, with a positive predictive value of 94.1% (95% CI 89.6, 96.4). More than one in five tests obtained in patients with NA were positive for appendicitis (21.7% for CT and 20.8% for US). CONCLUSIONS: The rate of NA was unchanged over time despite the introduction and use of CT/US, and this appeared to be related to the inconsistent performance characteristics of the tests. This study cautions against overreliance on CT/US in diagnosing appendicitis and emphasizes the need for test benchmarking in routine practice before establishing protocols for presumed appendicitis.

Appendectomy↗

PubMed2006

How time affects the risk of rupture in appendicitis.

BACKGROUND: Increasing time between symptom onset and treatment may be a risk factor for a ruptured appendix, but little is known about how the risk changes with passing time. This study aimed to determine the changes in risk of rupture in patients with appendicitis with increasing time from symptom onset to treatment to help guide the swiftness of surgical intervention. STUDY DESIGN: We conducted a retrospective chart review of physician office, clinic, emergency room, and inpatient records of a random sample of 219 of 731 appendicitis patients operated on between 1996 and 1998 at 2 inner-city tertiary referral and municipal hospitals. Conditional risks of rupture were calculated using life table methods. Logistic regression was used to assess factors associated with rupture, and linear regression was used to assess factors affecting time from first examination to treatment. RESULTS: Rupture risk was < or = 2% in patients with less than 36 hours of untreated symptoms. For patients with untreated symptoms beyond 36 hours, the risk of rupture rose to and remained steady at 5% for each ensuing 12-hour period. Rupture was greater in patients with 36 hours or more of untreated symptoms (estimated relative risk [RR]=6.6; 95% CI: 1.9 to 8.3), age 65 years and older (RR=4.2; 95% CI: 1.9 to 6.1), fever > 38.9 degrees C (RR=3.6; 95% CI: 1.2 to 5.7), and tachycardia (heart rate > or = 100 beats/minute; RR=3.4; 95% CI: 1.8 to 5.4). Time between first physician examination and treatment was shorter among patients presenting to the emergency department (median, 7.1 hours versus 10.9 hours; p<0.0001), and those for whom a physician's leading diagnostic impression was appendicitis (6.3 hours versus 11.3 hours; p<0.0001). Patients sent for CT scan experienced longer times to operation (18.6 hours versus 7.1 hours; p<0.0001). CONCLUSIONS: Risk of rupture in ensuing 12-hour periods rises to 5% after 36 hours of untreated symptoms. Physicians should be cautious about delaying surgery beyond 36 hours from symptom onset in patients with appendicitis.

Adolescent↗

PubMed2004

Delayed versus immediate surgery in acute appendicitis: do we need to operate during the night?

BACKGROUND/PURPOSE: Over the last 4 years, the authors changed their management of acute nonperforated appendicitis from emergent surgery within the first 2 to 6 hours of admission to initiation of antibiotic therapy with operation within 24 hours of admission in those seen in the late evening or early morning. They examined, therefore, whether a delay in operation for acute appendicitis would affect outcome measures of patient morbidity and resource use. METHODS: The medical records of 126 patients with acute appendicitis occurring between 1998 and 2001 were retrospectively reviewed. Incidence of perforation at surgery, length of stay (LOS), hospital charges, operating time, and complications as a function of duration between emergency room (ER) triage and operation (ER-OR) or admission and operation (Admit-OR) were analyzed by Student's t test, and regression analysis with P less than.05 considered significant. RESULTS: Thirty-eight children (26%) were operated on within 6 hours of ER triage, whereas the remaining 88 children (74%) were operated on between 6 and 24 hours from ER triage. No significant difference was noted in perforation rate, LOS, costs, or operative time, nor were substantial changes in complications noted between those with an ER-OR < or =6 hours and greater than 6 hours. Likewise, no significant differences in these outcome measures were noted for Admit-OR greater than 6 when compared with < or =6 hours. Only costs with ER-OR greater than 12 hours and LOS with Admit-OR greater than 6 hours were significantly (without Bonferroni correction) different than < or = 6 hours. Multivariable linear regression analysis identified only LOS as a significant predictor of time to OR. CONCLUSIONS: In children with acute appendicitis, delaying surgery until the daytime hours did not significantly affect operating time, perforation rate, or complications. Delayed management allows greater efficiency and effective use of physician and hospital resources, including decreased resident involvement in operations during the night.

Acute Disease↗

PubMed2005

Perforated appendicitis in a child with Henoch-Schönlein purpura.

Henoch-Schönlein purpura (HSP) is a common childhood vasculitis. Abdominal pain is a common feature of HSP, often leading to surgical consultation for evaluation of possible intussusception. Appendicitis is a rare complication of HSP, and in each of the 3 reported cases, appendectomy preceded the appearance of the purpuric rash. More often, unnecessary laparotomies are performed on patients in whom appendicitis is suspected, but who subsequently develop the characteristic purpura. This is the first reported case of appendicitis developing in a patient with the established HSP rash. This case is also the first report of perforated appendicitis in HSP. Clinical vigilance and serial physical and ultrasonographic examinations are needed to detect conditions necessitating surgery in patients with HSP.

Appendectomy↗

PubMed2005

Spot urine 5-hydroxyindoleacetic acid levels in the early diagnosis of acute appendicitis.

BACKGROUND/PURPOSE: The significance of spot urine 5-hydroxyindoleacetic acid (5-HIAA) levels in the early diagnosis of acute appendicitis (AA) is questioned. METHODS: Forty young, pigmented, male rabbits were divided into 4 groups. Groups are summarized as follows: group 1, control (n = 10); group 2, laparotomy, sham (n = 10); group 3, peritonitis with cecal ligation and puncture (n = 10); and group 4, experimental appendicitis (n = 10). Spot urine samples were obtained for 5-HIAA determination, and appendectomy materials were examined histopathologically and peritoneal fluid cultures were obtained after 12 hours in the study groups. The results were analyzed statistically with 1-way analysis of variance and Scheffé and Tukey's HSD tests. RESULTS: The mean 5-HIAA levels in the control group was 5.7 +/- 0.6 mg/L, whereas it is 5.9 +/- 0.9 mg/L, 6.6 +/- 0.6 mg/L, 9.4 +/- 0.9 mg/L in the sham, peritonitis, and appendicitis groups, respectively. The levels of 5-HIAA in the appendicitis group were higher than those in the other groups, which was statistically significant (P < .001). CONCLUSIONS: Spot urine 5-HIAA determination may be a practical, objective, and noninvasive method in the early diagnosis of AA. Because other radiological and laboratory tests can be insufficient, especially in the early period of AA, this test may be used effectively instead. Clinical studies are necessary for further conclusions.

Acute Disease↗

PubMed2005

The influence of advanced radiographic imaging on the treatment of pediatric appendicitis.

PURPOSE: Since 1998, the use of advanced radiographic imaging with computed tomography (CT) and/or diagnostic ultrasound (US) has increased dramatically for the diagnosis of acute appendicitis in children. This study investigates the impact of this imaging on the evaluation, management, and outcome of pediatric patients who underwent appendectomy for suspected appendicitis. METHODS: Retrospective review of 197 consecutive children with a preoperative diagnosis of acute appendicitis, from January 2002 through May 2004, undergoing appendectomy at a university-affiliated community hospital by pediatric and general surgeons. RESULTS: Patients were divided into two groups: imaged (n = 106; 54%) and nonimaged (n = 91; 46%). Groups were similar with respect to age, sex, temperature, white blood count, and insurance status. Ninety-seven imaged patients had CT, 6 had US, and 3 had both CT and US. Seventy-one percent of imaging studies were ordered by emergency department physicians and 24% by treating surgeons. Average wait from emergency department triage to operative incision for the imaged and nonimaged groups was 12.1 and 5.4 hours, respectively (P < .0001). Both groups had similar perforation rates (imaged: 15.1%, nonimaged: 14.6%). Negative appendectomy rates were 10.4% (imaged) and 4.4% (nonimaged). Average hospital charges were 11,791 dollars (imaged) and 9360 dollars (nonimaged) (P = .001). Time on antibiotics, complication rates, and length of stay were similar for both groups. CONCLUSIONS: More than half of pediatric patients with suspected appendicitis now undergo advanced imaging and experience a significant delay in surgical treatment with a 26% increase in hospital charges and no clear-cut improvement in diagnostic accuracy nor outcome, when compared with evaluation by the treating surgeons.

Adolescent↗

PubMed2006

Appendicitis in the child with a ventriculo-peritoneal shunt: a 30-year review.

PURPOSE: Each year, about 270 children are treated at our hospital for appendicitis, and there are 200 ventriculo-peritoneal (VP) shunt procedures. The incidence of primary peritonitis after a VP shunt is 8% to 12%. The purpose of this article is to try and differentiate these 2 entities. METHODS: From 1973 to 2003 inclusive, appendicitis was diagnosed in 8 children with a VP shunt at our hospital; there were 7 boys and 1 girl with 5 acute appendicitis and 3 ruptured appendices. The first case was diagnosed on purely clinical grounds, whereas the last 7 were confirmed by ultrasonography and/or computed tomography. RESULTS: All 8 had appendectomy and the shunt was exteriorized in the 3 children with a ruptured appendix. There were no postoperative problems, and the 8 children remained well. CONCLUSION: Acute appendicitis can and does rarely occur in children with VP shunts; however, in such situations, the correct diagnosis can be confirmed by imaging. The shunt must be temporarily exteriorized if the appendix is ruptured.

Adolescent↗

PubMed2003

Increased CT scan utilization does not improve the diagnostic accuracy of appendicitis in children.

BACKGROUND/PURPOSE: Appendicitis continues to present a diagnostic dilemma in children of all ages leading to increased utilization of radiographic studies. Focused computed tomography (CT) scanning has become the diagnostic test of choice in many hospitals. The purpose of this study was to critically evaluate the use of radiographic studies for the evaluation of acute appendicitis in children and to determine if diagnostic accuracy has improved. METHODS: Children undergoing appendectomy for acute appendicitis were reviewed from 1997 to 2001. Diagnostic workup (CT scan, ultrasound [US], or no radiographic study) was recorded as were the final pathology results. RESULTS: Six hundred sixteen appendectomies were performed. Mean age was 10.4 +/- 4.1 years, and 60% were boys. Overall, 184 children (30%) underwent CT scanning, 104 (17%) had US performed, and 310 (50%) had no radiographic study (18 patients had both CT and US performed). A pathologically normal appendix was removed in 7% (14 of 202) of CT patients, 11% (14 of 122) of US patients, and 8% (26 of 310) of patients without a study. The frequency of CT scanning increased from 1.3% of all children in 1997 to 58% in 2001, whereas utilization of US decreased from 40% to 7%. Over the same period, the overall negative appendectomy rate did not change significantly from 8% to 7%. CONCLUSIONS: With increased utilization of focused CT scanning, the negative appendectomy rate has remained unchanged. History and physical examination by an experienced surgeon is as accurate as CT in correctly diagnosing acute appendicitis in children.

Adolescent↗

PubMed2000

Nonoperative management of perforated appendicitis without periappendiceal mass.

BACKGROUND: Initial nonoperative treatment for patients with periappendiceal mass has been shown to be safe and effective. Our goal was to evaluate the safety and efficacy of initial nonoperative management for perforated appendicitis not accompanied by a palpable mass. METHODS: The study population consisted of 77 patients with appendicitis treated initially nonoperatively between 1992 and 1998. All had localized abdominal tenderness and computed tomography findings of abscess or phlegmon. None had a palpable abdominal mass. Outcome parameters evaluated were rate of failure, complication, and recurrence. RESULTS: There were 49 males and 28 females with a mean age of 35 years (range 16 to 75). Initial nonoperative management was successful in 95% of patients. Complications occurred in 12% of patients. Recurrent appendicitis developed in 6.5% of patients after an average follow-up of 30 weeks. CONCLUSIONS: Perforated appendicitis patients with localized abdominal tenderness and abscess or phlegmon can safely and effectively be treated in an initial nonoperative fashion.

Abdominal Abscess↗