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PubMed1991

Assessment of the reliability of the symptoms and signs of acute appendicitis.

The reliability of the signs and symptoms of acute appendicitis are reviewed. The wide variation in clinical findings when the different studies are compared can probably be explained by the huge quantity of retrospective studies. Migration of pain to the right iliac fossa and/or guarding/rigidity support the diagnosis of appendicitis. The diagnosis of appendicitis should be doubted when anorexia, nausea and vomiting are absent, when symptoms have persisted for more than 72 h without apparent perforation, or when tenderness in the right iliac fossa is absent. Presentation in proximity to menstruation, cervical dislocation tenderness and bilateral adnexal tenderness indicates pelvic inflammatory disease. Small children have high perforation rates because of their uniform response to many illnesses and relative inability to express themselves and cooperate. The clinical findings in young and old patients are similar, except for a higher rate of abdominal distension in old patients. With a more thorough knowledge of the signs and symptoms of acute appendicitis and a constant awareness of its possible presence, it should be possible to increase the diagnostic accuracy.

Abdominal Pain↗
PubMed1991

[Diagnostic significance of clinical symptoms versus ultrasonography in appendicitis. A prospective study].

The aim of the presented study was to find what importance ultrasonography has in the diagnosis of acute appendicitis compared to clinical findings and on the surgeon's decision regarding to laparotomy. 111 patients entering the emergency station with suspected appendicitis were evaluated in a prospective clinical study. Surgeon and radiologist had to commit themselves to the diagnosis, afterwards signs were discussed. Clinical accuracy over all was 89%. Pain migration and peritonitis signs corresponded significantly with appendicitis (p less than 0.0001). The appendix was well seen in sonographic examination in 32% (accuracy 80%), in 27% was doubtful (accuracy 70%), and in 41% the appendix could not be demonstrated. Diameter of a normal appendix was 8 mm compared to 12 mm for an inflamed appendix (p less than 0.05). Rates negative laparotomies decreased from 16% to 12.7%. The surgeon was not influenced by sonography in 75%. In 12% ultrasonography decided for laparotomy and in 4.5% sonography prevented operation. We conclude from our results, that sonography reduces the negative laparotomy rate. Ultrasonography is especially useful in doubtful clinical pictures. Clinical findings and experience remain of major importance in appendicitis-diagnosis.

Adolescent↗
PubMed1991

Childhood appendicitis: factors associated with its incidence and perforation in Ethiopian children.

Acute appendicitis is a common paediatric emergency necessitating surgical intervention. Factors contributing to the incidence of the disease and appendiceal perforation in all children with acute appendicitis admitted to the Ethio-Swedish Children's Hospital in Addis Abeba, Ethiopia from Jan 1983 to December 1987 were studied. There were a total of 278 cases of appendicitis, with matched controls, seen. The incidence of perforation was 67%. Statistically significant differences between cases and controls were seen for the educational status of the parents (p less than .001), the parental income (p less than .001) and the nutritional status of the patient (p less than .001). The risk of perforation increased with increased duration of the illness. Perforation was common in children with normal height and better parental education. The incidence of appendicitis appears to be related to improved socioeconomic status. Prospective studies to examine this and other associations are warranted.

Acute Disease↗
PubMed1991

Bacteriology of the appendix and the ileum in health and in appendicitis.

The bacteriology of the ileum and the appendix in appendicitis patients with or without perforation and compared with patients who had "incidental appendectomy" was studied. Of 42 appendicitis patients, 24 (57%) of them had anaerobic bacteria in the appendix compared with two of eight (25%) with normal appendix. Anaerobes were found in the ileal aspirates of 20 of 42 (47.6%) appendicitis patients and two of eight (25%) in normal persons. This suggests that anaerobic bacteria increasingly colonize the appendix and the ileum in cases of appendicitis.

Adolescent↗
PubMed1991

[Appendicitis in the aged].

From 1984 to 1989 78 patients over the age of 60 years were operated on acute appendicitis. Compared to appendicitis in younger people these older patients showed 3 times longer an interval between the first appearance of symptoms and their contact to the doctor, or surgical treatment. As result of this longer period appeared the high perforation rate 53.8%. In this group of patients with perforation the complication rate was 4 times higher than the intraoperative and histologically confirmed acute appendicitis. From these facts results a mortality rate of 4%. In the retrospective evaluation was also seen that there was no conclusion between the laboratory parameters, the physical symptoms and the degree of the inflammation of the evidence of perforation with local or diffused peritonitis. The inclusion of appendicitis in the differential diagnosis of acute abdominal pain in older people offers the chance of an earlier surgical treatment, so reducing the risk of postoperative complication and mortality.

Abdomen, Acute↗
PubMed1990

[Laparoscopy in the diagnosis of acute appendicitis in children].

In the period between 1984 and 1988 laparoscopy was conducted 846 times in children with suspected acute appendicitis. In 301 children the diagnosis was confirmed in atypical forms of appendicitis. In 418 children laparoscopy revealed diseases which are recognized with great difficulties (mesadenitis, primary peritonitis, genital diseases, etc.), in which the final diagnosis is usually established during laparotomy. In 39 children laparoscopic diagnosis was conducted during intercurrent diseases in which the abdominal pain syndrome simulated the clinical picture of acute appendicitis. As the result of laparoscopic examination the number of operations for simple forms reduced from 38.3 to 6.2% and the timely diagnosis of acute appendicitis improved.

Abdomen, Acute↗
PubMed1990

[The echographic diagnosis of acute appendicitis and its complications].

The authors report their experience with emergency US in patients hospitalized for clinical suspicion of acute appendicitis or presenting with pain in the right lower abdominal quadrant. One hundred fifty-two patients were examined with US: 93/152 had pathologies of the right iliac region; 81 of them underwent surgery (50/81 appendectomies). In 27 of these patients the inflamed appendix presented with a typical US pattern. All of them had surgical confirmation. In 13/50 cases, US findings followed an atypical pattern (6 patients had a periappendiceal mass in the right iliac region, 3 had small amounts of fluid in the Douglas pouch, and 4 had gas-filled bowel loops of the ileum). The false negatives were 10/50. US sensitivity was 80%, and its specificity was 54%. The most common pathologic conditions are described whose symptoms mimic those of acute appendicitis. US role in inflamed acute appendicitis is still to be defined. Nonetheless, the authors suggest that US be performed on all patients with atypical pain in the lower abdominal quadrants, because of its high diagnostic accuracy in many common pathologies mimicking appendicitis, especially urinary and uterine adnexal pathologies.

Acute Disease↗
PubMed1990

Gangrenous and perforated appendicitis with peritonitis: treatment and bacteriology.

A comparison of single-agent antimicrobial therapy in the treatment of patients with perforated or gangrenous appendicitis and peritonitis was performed in a double-blind, randomized, prospective trial. Pathologic documentation of advanced appendicitis and positive intraoperative specimen cultures were required for inclusion in the study. Ceftizoxime (2 gm every 12 hours) and cefoxitin (2 gm every six hours) were compared. There were no significant differences between the treatment groups. Ninety-seven percent of patients treated with ceftizoxime and 89% of those treated with cefoxitin were cured or improved; there was no mortality in either group. By the use of optimal sampling, transport, and culture techniques, the number and diversity of bacteria recovered from these patients with advanced appendicitis were found to be much larger than previously suspected. Peritoneal fluid, abscess contents (if present), and appendiceal tissue (obtained so as to exclude the lumen) were cultured from all patients. An average number of 3.1 aerobic or facultative bacteria species and 8.5 anaerobic species were isolated from each specimen. Twenty-eight different genera and more than 55 species were encountered, including a previously undescribed fastidious gram-negative anaerobic bacillus. Bacteroides fragilis group and Escherichia coli were isolated from almost all specimens, and within the B fragilis group, eight species were represented. The recovery of such an unexpectedly large and diverse flora may be the reason for the therapeutic failures in these patients. We conclude that single-agent antimicrobial therapy in patients with advanced appendicitis and peritonitis is both safe and effective, and, with ceftizoxime, can be accomplished by a twice-daily dosing regimen.

Adult↗
PubMed1990

Appendectomy, appendicitis, and large bowel cancer.

A cohort of 167,561 persons who received multiphasic health checkups were followed up for cancer development. A history of appendectomy showed slightly negative nonsignificant associations with the development of cancer of the colon, rectum, and all sites combined. By inference, the relation of appendicitis with these cancers was also inverse. Upper 95% confidence limits were compatible only with small positive associations of appendectomy and appendicitis with these cancers. These data do not support the view that removing the appendix increases cancer risk by diminishing immunocompetency. A link between appendicitis and large bowel cancer has been noted in intersociety correlations and has been hypothesized to be due to prevention of both by a high-fiber diet. However, appendicitis does not appear to be a useful predictor of large bowel cancer within a developed society.

Adolescent↗
PubMed1990

[The value of sonography in the diagnosis of appendicitis. A prospective study of 100 patients].

Between October 1988 and July 1989 100 consecutive patients with suspected appendicitis were seen at the surgical clinic, University Hospital of Aachen. All patients underwent ultrasonographic examination corresponding to a prospective study protocol in order to determine the value of ultrasound for the diagnosis of acute appendicitis. The sonographic findings were correlated with the histologic diagnosis or the clinical course, respectively. We found a sensitivity of 100% for appendiceal mass, of 88% for phlegmonous appendicitis and of 25% for catarrhal appendicitis. The overall sensitivity was 49% and the overall specificity rate was 97%. The overall accuracy rate was 64%. The predictive value of a positive test was 97% and the predictive value of a negative finding was 46%. The morphologic changes during the progress of inflammation of the appendix and their sonographic visualisation were discussed. A differentiated concept was developed to integrate the sonographic findings in the therapeutic decision.

Abscess↗
PubMed1989

Is there evidence for a racial difference in misdiagnosis in patients explored for appendicitis?

A retrospective review was conducted to determine if there were identifiable racial markers in patients who were explored and misdiagnosed as having appendicitis. Between May 1983 and May 1987, 100 patients were explored for appendicitis. There were 65 whites and 35 blacks with a male predominance in each group. The age range was 4 to 70 years with a mean of 47 years; 30% of each group was in the pediatric age range (less than 17 years old). Eight patients had a normal appendix including two blacks: a 20-year-old male with no pathologic diagnosis and a 42-year-old female with a ruptured cornual pregnancy. Although the sample size was small, there was a trend toward a lower white blood cell count in blacks when appendicitis was confirmed at surgery (11,000 cells/microL +/- 3,000 v 17,000 cells/microL +/- 3,000). The following conclusions can be drawn: (1) the accuracy of diagnosis should be considerably lower than the 20% commonly quoted; (2) the likelihood of an incorrect diagnosis appears to be higher in adults in both groups without a sexual predilection; and (3) there may be a trend toward a higher initial white blood count in whites compared with blacks with acute appendicitis.

Adolescent↗
PubMed1985

The role of Pseudomonas species in patients treated with ampicillin and Sulbactam for gangrenous and perforated appendicitis.

A prospective, randomized, double-blinded comparison of Sulbactam and ampicillin and clindamycin and gentamicin is described. The combination of ampicillin and Sulbactam was not as effective in the management of perforated appendicitis and gangrenous appendicitis as was clindamycin and gentamicin. While both combinations of antibiotics had good anaerobic activity and failures were not associated with the recovery of Bacteroides fragilis group organisms, infectious complications were seen in patients from whom Pseudomonas were isolated. These pseudomonads were not nosocomially acquired and were found especially in patients with perforated appendicitis. We concluded that the combination of clindamycin and gentamicin, although less convenient to administer to the patient, remains the adjunctive antibiotic management of choice for perforated or gangrenous appendicitis. The epidemiologic factors of Pseudomonas species as a primary pathogen in peritonitis deserves further attention.

Adult↗
PubMed1988

Inflammation parameters in the diagnosis of acute appendicitis.

The role of the common parameters of inflammation in the diagnosis of acute appendicitis was studied by measuring axillary temperature (Tax), blood leukocyte (Leuk) and lymphocyte fraction (Lymph), serum C-reactive protein (CRP) and ESR in 354 patients with clinical diagnosis of acute appendicitis. Laparotomy showed normal appendix in 97 cases, but deduction of 14 with other surgically correctable disorders gave the negative appendectomy rate 83/354 (23.4%). The appendix had perforated in 9.9%. Tax, Leuk, Lymph and CRP could significantly differentiate acute appendicitis from the other cases, with respective sensitivity (and false positive) percentages 88.7 (66.0), 78.5 (24.7), 84.4 (48.5) and 52.7 (24.7). Although such statistical differences are not particularly helpful in preoperative diagnosis of individual cases, none of the 37 patients with simultaneously normal Leuk, Lymph and CRP had obvious appendicitis (2 probably had incipient inflammation). If laparotomy had not been performed in these 37 cases, almost half of the unnecessary operations could have been avoided, thereby reducing the negative appendectomy rate to 15.2%, with 11.7% perforation rate.

Abdomen, Acute↗
PubMed1988

[Complications of acute appendicitis and the duration of temporary disability].

According to the data of the surgical unit of the Central Clinical Hospital, Ministry of Social Security, MPR during 1977-1983 294 patients had complications (26%) out of 1112 patients with acute appendicitis and appendectomy who were treated in this unit. The common complications are localized, while general and uncommon peritonitis had a diffuse form. An average hospitalization of patients with acute appendicitis complications makes up 18.6 beds per day, patients without acute appendicitis complications--9.8 beds per day. Complicated forms of acute appendicitis are the basic cause of an increased duration of hospitalization of patients and longer duration of timely disablement.

Acute Disease↗
PubMed1986

Perforating appendicitis. A nine-year survey of treatment and results.

This is a clinical study of 193 adult cases of perforating appendicitis during a nine-year period of treatment. There were 77 females (39.9%) and 116 males (60.1%) with ages of 15 years and above. Throughout the study period, the yearly perforation frequency ranged from 10.0 to 23.1% (mean 16.7%) of all cases with proven appendicitis. Perforation was equally common in both sexes, females: 15.5%, males: 17.6% of the appendicitis cases. In elderly patients (greater than or equal to 60 years of age) perforation was much more common; 37 out of 77 cases with proven appendicitis (48.1%). Compared to different ages (patients under and above 60 years of age), clinical and laboratory findings were found equal. Duration of symptoms showed no differences for younger and elderly patients. Preoperative delay in the hospital of at least 6 hours occurred in 39.9% of all patients, and was found equally common in patients younger than 60 years (39.1%) and in those from 60 years and older (43.2%). There were no fatalities in the study group. Postoperative septical complications predominated over non-septical (32.6 versus 9.3%), and were equally common in both sexes and in patients of different ages. The frequency of occurrence of septical complications was not significantly influenced by the duration of symptoms or by the duration of operation, furthermore, septical complications were equally frequent throughout the study period, although the use of antibiotics changed towards drugs more potent to cover anaerobic bacteria (28.1% infections for the period 1972-1976 versus 29.8% for the period 1977-1981).(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1986

[Treatment of acute perforated appendicitis with intraperitoneal cefazolin].

Until recently intra-abdominal sepsis following surgery for perforated appendicitis has remained a frequent occurrence. In 1975 Fowler reported an incidence of one intra-abdominal abscess in 36 perforated appendicitis treated with a protocol consisting of saline irrigation at surgery, followed by intraperitoneal administration of cephaloridine q. 6 hours for 48 hours. The same antibiotic was then given i.v. for 72 hours. He concluded that this method was an effective way to minimize post-op intra-abdominal abscess, and that the intraperitoneal route was more effective, for this purpose, than systemic administration. More recently, with better knowledge of the role of anaerobes, improved results have also been obtained by adding clindamycin or metronidazole to the antibiotic regimen. A prospective study based on two groups of patients randomly assigned to two protocols was undertaken. The study group consisted of 45 children operated for perforated appendicitis with abscess or generalized peritonitis. These patients were treated with Fowler's protocol. Because it is less nephrotoxic and is active against the same organisms, cefazolin was used instead of cephaloridine. The control group consisted of 43 patients, also operated for perforated appendicitis, treated with saline irrigation at surgery, with either i.v. gentamycin or tobramycin and clindamycin or metronidazole for an average of 7.8 +/- 3.1 days. Both groups were fairly well matched in terms of age, sex, severity of disease, and bacterial flora. They showed an identical 6% post-op intra-abdominal sepsis rate. Days before afebrile, days under gastric suction, complications and average hospital stay were comparable in both groups. The wound infection rate was 20% in the study group and 9% in the control group.(ABSTRACT TRUNCATED AT 250 WORDS)

Abscess↗
PubMed1987

Appendicitis in children. Accuracy of the barium enema.

The barium enema (BE) may be useful in the diagnosis of atypical appendicitis in children. We analyzed our experience with 18 children in whom appendicitis was suspected and BE was performed. All of the children underwent surgical exploration. Nonfilling of the appendix with cecal indentation, extravasation of barium from the appendix, or both, were considered positive signs of an inflamed appendix on BE. Using these criteria, 12 of 14 cases of proved appendicitis were true positive and two were equivocal. Four children were proved not to have appendicitis; one of these patients had a true-negative BE, two had equivocal BEs, and there was one false-positive BE (Schönlein-Henoch purpura). Extravasation of barium into the peritoneal cavity was noted in one patient; this was a rare complication.

Adolescent↗
PubMed1986

Recurrent and chronic appendicitis.

The records of 205 patients who underwent appendectomy were reviewed to determine the incidence of recurrent and chronic appendicitis. Twenty-one patients (10 per cent) met the criteria for diagnosis of recurrent appendicitis. Three patients (1.5 per cent) had a diagnosis of chronic appendicitis based upon clinical history and pathologic findings of lymphocytic or eosinophilic infiltration of the appendiceal wall. The diagnosis of recurrent or chronic appendicitis should be considered in patients presenting with recurrent pain of the right lower abdominal quadrant.

Adolescent↗