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PubMed1995

Idiopathic granulomatous appendicitis. Report of five cases, one of which presented as migratory arthritis.

The clinical presentation of acute appendicitis and the idiopathic granulomatous variety are, as a rule, indistinguishable. Five patients with idiopathic granulomatous appendicitis, treated during past decade, had histological acute and chronic appendicitis abounding with granulomas. Investigations not disclosing a systemic or enteric granulomatous disease and the patients' long-term complete postoperative recovery support the diagnosis of idiopathic granulomatous appendicitis.

Adult↗
PubMed1992

Imipenem-cilastatin vs. tobramycin and metronidazole for appendicitis-related infections.

The efficacy of imipenem-cilastatin was compared with that of tobramycin and metronidazole for the treatment of appendicitis-associated abdominal infections in children in an open, randomized trial. Two hundred eighteen patients between 2.5 and 16.8 years of age hospitalized for appendectomy because of suspected acute appendicitis were allocated to 5 treatment groups. The appendix was perforated in 54 (33.8%) of the 160 cases with appendicitis. All patients responded favorably to treatment. Infection in the wound occurred in 15 of 125 (12.0%) of those without preoperative antibiotic therapy and in 5 of 83 (6.0%) of those given imipenem preoperatively (P = 0.12; 95% confidence interval, -2.2 to 14.2%). C-reactive protein decreased significantly faster in those with perforated appendix treated with imipenem than in those treated with tobramycin and metronidazole (58.2 mg/liter vs. 89.4 mg/liter, P less than 0.05 on the third postoperative day). Imipenem-cilastatin was at least as effective and economically comparable as tobramycin and metronidazole for the treatment of appendicitis-associated infections in children.

Adolescent↗
PubMed1999

Determining duration of antibiotic use in children with complicated appendicitis.

BACKGROUND: The introduction of broad spectrum antibiotics has substantially decreased rates of mortality and morbidity associated with complicated appendicitis in children. The generally recommended therapy for children with complicated (gangrenous or perforated) appendicitis is administration of postoperative antibiotics for 3 to 14 days, but the decision as to the specific duration of treatment lies with the treating physician. AIM: This study evaluates whether the recommendation that the combination of the patient's being afebrile and eating and having a normal white blood cell (WBC) count and < or = 3% band forms can be used to decide when sufficient antibiotics have been given and can be safely discontinued. METHODS: Thirty-three consecutive patients seen in the pediatric surgical service with perforated or gangrenous appendicitis were studied prospectively. All patients received a standard protocol of resuscitation, appendectomy and broad spectrum antimicrobial therapy to be continued until they were eating, afebrile and had normal white blood cell counts with < or = 3% immature neutrophils (band forms). RESULTS: Thirty-two children were treated until they met all criteria when antibiotics were stopped and the patients were discharged. Of these patients 31 had unremarkable courses of recovery with no development of intraabdominal abscess or wound infection [predictive value of criteria, 97% (31 of 32)]. The remaining patient who met the criteria required rehospitalization for treatment of intraabdominal abscess. Another patient was discharged prematurely when he failed to meet the criterion of afebrility. Although he was eating and his WBC count was normal, he had a temperature of 38.5 degrees C during the 24 h before discharge. He was readmitted for surgical drainage of an intraabdominal abscess, yielding a 100% predictive value for the criterion mismatch (1 of 1). CONCLUSION: Based on our observations, when a patient with complicated appendicitis is afebrile for 24 h (temperature < 38 degrees C), is eating and has a WBC count with < or = 3% band forms, antibiotics can be safely discontinued with small risk of recurrent intraabdominal abscess.

Abdominal Abscess↗
PubMed1975

Radiologic aids in the diagnosis of appendicitis in children.

Chest and abdominal radiograms are most helpful in evaluating acute abdominal pain in children. When basilar pneumonia is found the likelihood of associated appendicitis is slim. Evidence of appendicolithiasis on abdominal films secures the diagnosis of acute appendicitis and should prompt the surgeon to early operative intervention, since the threat of appendiceal perforation is great. Barium enema is safe and informative when obscure clinical presentation or associated illness exists. The likelihood of appendicitis is great when the appendix fails to fill at the time of barium enema. Complete filling of the appendix excludes the possibility of acute appendicitis.

Adolescent↗
PubMed1987

Appendicitis in the first year of life: a rare but predictable cause of intraperitoneal pus in infants.

Appendicitis is the most common antecedent to peritonitis throughout life. Although quite uncommon during the first year of life, appendicitis is a recognizable entity, and beyond the neonatal period, remains the most common cause of peritoneal suppuration. The Royal Children's Hospital in Melbourne has experienced three cases of appendicitis in the first year of life since 1970. Clinical features helpful in diagnosis are presented, and management guidelines are discussed. When pus is suspected or found in an infant's abdomen, the general surgeon would be wise to presume the cause is appendicitis, despite its rarity.

Acute Disease↗
PubMed1994

Enterobius vermicularis: a possible cause of symptoms resembling appendicitis.

The role of Enterobius vermicularis in appendicitis has been disputed. The aims of this retrospective study were to determine the prevalence of E. vermicularis in surgically removed appendices and to relate this to the age and sex of the patient, the time of the year, the presence of symptoms and the histological findings. The study included all appendices received in this laboratory during the 5 year period from 1984 through to 1988. There were 1867 appendices during this period of which 1108 were acutely inflamed and 759 were not inflamed (although 149 of these showed other pathological changes). The mean age distribution of all patients was 22.8 years. Enterobius vermicularis was identified in 63 appendices (3.4%). Infestation was more frequent in female (4.6%) than in male (1.9%) patients. The peak age was 12.8 years in females and 12.1 years in males. Of 63 patients who had E. vermicularis, 98% presented with symptoms of acute or recurrent appendicitis, yet 40 had no histological evidence of appendicitis or mucosal invasion by the parasite and only four had other possible explanations for abdominal pain. In an analysis of the subgroup of 147 patients who had incidental appendectomy at the time of laparotomy for other reasons, only one had E. vermicularis. It is concluded that E. vermicularis occurs more frequently in uninflamed appendices. It may be a cause of symptoms resembling acute appendicitis although the mechanism for this does not involve mucosal invasion by the parasite.

Acute Disease↗
PubMed1995

Pregnancies complicated by acute appendicitis.

Appendicitis is one of the most common acute abdominal conditions that requires operation during pregnancy. The maternal and fetal complications occurring in such situations are well known. However, the diagnostic and therapeutic challenges of acute appendicitis complicating pregnancy persist in current surgical practice. Thirty-eight obstetric cases who had an appendicetomy performed during pregnancy between 1986 and 1993, were reviewed. In 31 cases, acute appendicitis was proven at laparatomy, and by subsequent histopathology. In the confirmed cases, seven occurred in the first trimester, 12 in the second trimester, eight in the third trimester and four in the immediate postpartum period. Two miscarriages occurred in the first trimester group, and two late abortions and two preterm (26 and 28 weeks) deliveries occurred in the second trimester group. In the third trimester/postpartum group, all babies survived, but four patients had Caesarean sections with the appendicetomy and the incidence of perforated/gangrenous appendices was highest. Perinatal outcome was worst, with the highest fetal wastage rate if the acute appendicitis occurred in the second trimester, although maternal morbidity appeared to be the same across different gestational periods.

Abortion, Spontaneous↗
PubMed1998

Appendicitis in HIV-positive patients.

BACKGROUND: The aim of the present study was to review the experience of appendicitis in human immunodeficiency virus (HIV)-positive patients. METHODS: A retrospective analysis of all HIV-positive patients operated on for suspected acute appendicitis during a 10-year period at St Vincent's Hospital was performed. These patients were compared to a group of 60 age- and sex-matched patients with no HIV risk factors who were operated on during the same time period. RESULTS: On presentation the clinical findings were similar in both groups, with two notable exceptions. No HIV-positive patient had an elevated white cell count. The present study demonstrated a significant delay in presentation of the HIV-positive group to the Emergency Department, possibly explaining the higher appendiceal perforation rate in this group. There were no cases of HIV-related diseases mimicking acute appendicitis. There was no mortality, and morbidity was higher in the seropositive group. CONCLUSIONS: HIV-positive patients with a history suggestive of acute appendicitis should not be treated differently from the normal population. Morbidity and mortality can be minimized by prompt surgical treatment.

Acute Disease↗
PubMed1998

Does the use of ultrasonography improve the outcome of children with appendicitis?

OBJECTIVE: To determine whether the use of ultrasonography (US) improves the outcome of children with appendicitis. METHODS: All cases of patients (<17 years old) with pathologically confirmed appendicitis treated in the ED between July 1992 and December 1995 were retrospectively reviewed. RESULTS: 231 charts met criteria for analysis. 100 (43%) patients had US prior to surgery. Age, race, and insurance status were similar for children in the US and non-US groups; there were no differences between the groups at presentation in mean temperature, mean WBC count, or percentage of children with vomiting, diarrhea, abdominal tenderness, or guarding. Those in the non-US group were more often male (71%, p=0.002) and more frequently had right lower quadrant pain (65%, p=0.003). Time from ED triage to the OR was 17.1 hours (US group) vs 10.4 hours (non-US group) (p=0.002). The perforation rates and the complication (abscess, wound infection, wound dehiscence) rates were similar for children in the two groups. Hospital charges were higher in the US group than in the non-US group ($14,123 vs $13,021, p=0.007). CONCLUSION: The use of US did not result in early diagnosis of appendicitis, nor was it associated with a reduction in perforation or complication rates. Among children with clinical evidence of appendicitis, US was associated with a delay in surgery and an increase in hospital charges.

Appendicitis↗
PubMed1998

Appendicitis: the impact of computed tomography imaging on negative appendectomy and perforation rates.

OBJECTIVES: The purposes of this study were to investigate the use of computed tomography (CT) imaging in patients with suspected acute appendicitis and to evaluate the impact of CT on negative appendectomy and perforation rates. In patients clinically diagnosed of acute appendicitis the reported overall negative appendectomy rate is about 15-20%; 10% in men and 25-45% in women of childbearing age. This is associated with a perforation rate of 21-23%. METHODS: This is a retrospective analysis of 146 consecutive patients presenting with clinical symptoms suspicious of appendicitis over a 2-yr period in whom CT examinations were performed before therapy was instituted. The overall negative appendectomy and perforation rates were calculated for the entire group, as well as for the 54 women aged 15-50 yr in the childbearing cohort. RESULTS: The negative appendectomy rate was 4% in 122 patients operated on and the perforation rate was 22%. Among 36 women 15-50 yr of age operated on, the negative appendectomy rate was 8.3% and the perforation rate was 19%. Surgery was avoided in 24 patients, 18 of whom were women of childbearing age. CONCLUSIONS: The judicious use of CT imaging in patients with equivocal clinical presentation suspected of having appendicitis led to a significant improvement in the preoperative diagnosis. It resulted in a substantial decrease in the negative appendectomy rate compared to previously published reports, without incurring an increase in the perforation rate.

Acute Disease↗
PubMed2000

The impact of diagnostic delay on the course of acute appendicitis.

BACKGROUND: The diagnosis of acute appendicitis is often delayed, which may complicate the further course of the disease. AIMS: To review appendectomy cases in order to determine the incidence of diagnostic delay, the underlying factors, and impact on the course of the disease. METHODS: Records of all children who underwent appendectomy from 1994 to 1997 were reviewed. The 129 cases were divided into group A (diagnostic period within 48 hours) and group B (diagnostic period 48 hours or more). RESULTS: In the group with diagnostic delay, significantly more children had first been referred to a paediatrician rather than to a surgeon. In almost half of the cases in this group initial diagnosis was not appendicitis but gastroenteritis. The perforation rate in group A was 24%, and in group B, 71%. Children under 5 years of age all presented in the delayed group B and had a perforation rate of 82%. The delayed group showed a higher number of postoperative complications and a longer hospitalisation period. CONCLUSIONS: Appendicitis is hard to diagnose when, because of a progressing disease process, the classical clinical picture is absent. The major factor in diagnostic delay is suspected gastroenteritis. Early surgical consultation in a child with deteriorating gastroenteritis is advised. Ultrasonographs can be of major help if abdominal signs and symptoms are non-specific for appendicitis.

Adolescent↗
PubMed1969

Acute abdominal pain in childhood, with special reference to cases not due to acute appendicitis.

Appendicitis is not the only common cause of acute abdominal pain in childhood. Almost equally common is an acute episode which in its early stages resembles acute appendicitis but which subsides without treatment in 24 to 48 hours. The clinical features of this syndrome are contrasted with those of appendicitis. The two conditions cannot always be distinguished on clinical grounds, leading to admission to hospital for observation and the finding of a normal appendix in 14% of operations for suspected appendicitis. Reasons are given for abandoning attempts to diagnose acute mesenteric adenitis at the bedside.

Abdomen, Acute↗
PubMed1977

Computer-aided prediction of gangrenous and perforating appendicitis.

The clinical details of 100 patients with proved acute appendicitis were compared with those of 100 patients with perforating or gangrenous appendicitis. Twenty features were found to be significantly different between the two groups. This information was incorporated into a computer data base and used in the differential diagnosis of abdominal pain. A program written to predict the probability that gangrene or perforation was present in patients with appendicitis gave a diagnostic accuracy over 91%. A clinical scoring index, which accurately predicted the state of the appendix in 88% of patients, was constructed from the significant differences between the two groups. When clinical scoring or computer analysis predicts a high probability of perforation or gangrene in patients with appendicitis, surgery should be performed without delay.

Acute Disease↗
PubMed1981

Acute appendicitis in nine British towns.

The incidence of acute appendicitis was compared among residents in nine towns in England and Wales, the towns having been chosen so that three were in the north, three in the central latitude band, and three in the south. Each group of three towns comprised one with "better,' one with "intermediate,' and one with "worse' socioeconomic conditions. The data were derived from hospital records for the years 1974-7. Hospital discharge rates for acute appendicitis were higher in the three northern towns in both sexes and all age groups. There was no consistent variation with the socioeconomic state of the towns. The distribution of appendicitis in the nine towns differed from that of other "diseases of Western civilisation' and so weighs against the hypothesis of similar dietary influences in the aetiology of acute appendicitis and these other diseases. These findings are being followed up by dietary surveys in the towns.

Acute Disease↗
PubMed1962

The influence of sex and age on appendicitis in children and young adults.

A study has been made of the influence of age and sex on the incidence of cases of appendicitis and of fatal appendicitis in children and young adults. Appendicitis is uncommon in children under the age of 5, but the proportion of cases complicated by peritonitis is large, and the death rate in the population of this age is relatively high. Appendicitis is very common in adolescents, but here the proportion of cases complicated by peritonitis is small. However, because of the frequency of the condition, the death rate in the general population of this age is high, with a maximum at about the age of 15 years. These findings are compatible with the suggestion that the appendix during the 'teens is particularly liable to obstruct and hence to become inflamed because of the large proportion of lymphoid tissue which it contains. Inflammation of the appendix is more common in males than in females, and this male excess is greater in infants and pre-school children than it is in children of school age.

Acute Disease↗
PubMed1991

Housing and appendicitis in Anglesey.

STUDY OBJECTIVE: The aim was to test the hypothesis that provision of household amenities such as domestic hot water systems and bathrooms changed hygiene which thereby triggered the epidemic of appendicitis in Anglesey after the second world war. DESIGN: The study was a cross sectional survey with histories of housing and appendicectomy obtained from Anglesey residents by postal questionnaire. The main outcome measure was reported appendicectomy. SETTING: Four general practices in Anglesey. SUBJECTS: 2531 men and women born during 1923-62 and randomly selected from age-sex registers. Overall response rate was 73.7%. MAIN RESULTS: Subjects born into households with amenities--piped water, hot water systems, and bathrooms had, if anything, a reduced risk of appendicectomy. However, those who subsequently moved to houses that lacked amenities were at significantly higher risk than people born into houses without amenities who later acquired them. CONCLUSIONS: Provision of household amenities was not the important trigger to the epidemic of appendicitis which occurred in Anglesey after the second world war. Rather, the trigger may have been reduction in domestic crowding caused by the falling birth rate. Findings among those who moved house support other evidence that after infancy household amenities protect against appendicitis and contributed to the fall in appendicitis rates in Anglesey after 1965.

Adult↗
PubMed1984

Appendicitis--a study of incidence, death rates and consumption of hospital resources.

The incidence of appendicitis in a population of 1.07 million is estimated based on discharge rates compiled by the Central Bureau of Statistics for the years 1977 and 1978. A crude incidence rate of 140 per 100,000 inhabitants is found with a male dominance (153 v. 126). The lowest incidence rate is found in the age group 0-4, whereas the highest rates are found for patients 15-24 years of age. Seventy-four per cent of all appendicitis cases is found in the age group 5-34 years. The mean length of stay was 6.5 days, but with differences between the counties studied of up to 60%. A yearly death rate of 0.30-0.37% with a male dominance is revealed. Appendicitis cases consume only 1.2% of all hospital discharges but 11.8% of all discharges for gastrointestinal diseases. A comparison with previous studies is performed and it is suggested that most of the reported reduction in incidence rates for appendicitis most probably is caused by a more reliable data base in the recent years.

Adolescent↗
PubMed2001

Suspected appendicitis in children: focused CT technique for evaluation.

PURPOSE: To determine the accuracy of a focused computed tomographic (CT) technique with oral and intravenous contrast materials for the diagnosis of appendicitis. MATERIALS AND METHODS: Ninety-three abdominal-pelvic contrast material-enhanced CT scans obtained during 6 years in 54 girls and 39 boys (age range, 1-18 years) with right lower quadrant pain were retrospectively reviewed. The detected abnormal findings were recorded as being in the region above the upper pole of the right kidney, between the upper pole of the right kidney and the lower pole of the right kidney (RLP), or below the iliac crest. Sensitivity, specificity, and positive and negative predictive values were calculated. chi(2) analysis was performed to determine whether there were significant differences among patient groups according to region of detected disease. RESULTS: Fifty-five scans were abnormal: 38 showed appendicitis; and 17, other diseases. No scans, except two that showed pneumonia, had key findings above the RLP. Nineteen scans showed key findings between the RLP and the iliac crest. Thirty-three scans had diagnostic findings only below the iliac crest. The sensitivity (97%), specificity (93%), positive predictive value (90%), and negative predictive value (98%) of interpretation with all images for the diagnosis of appendicitis were the same as those of interpretation with only the focused images. CONCLUSION: CT performed to diagnose appendicitis can be limited to the region below the RLP.

Administration, Oral↗