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PubMed2001

Stability in incidence of acute appendicitis. A population-based longitudinal study.

UNLABELLED: BACKGROUND/AIM OF THE STUDY: During the past 50 years, a decrease in incidence of appendicitis has been reported. The various studies were retrospective and based on different data sources. In the present study, we analyze prospectively the incidence of acute appendicitis during a 10-year period in a well defined population of 265,000. METHODS: Prospective registration of all operations performed in patients with suspected acute appendicitis in the catchment area of a single institution. The diagnosis of acute appendicitis was based on histology in all cases. The annual incidence of acute appendicitis was calculated with regard to nonperforated and perforated acute appendicitis. MAIN RESULTS: Between 1989 and 1998, 2,861 patients underwent surgery for suspected acute appendicitis. In 2,232 (78%) patients, acute appendicitis was confirmed histologically. Mean annual incidence was 84/100,000 (95% confidence interval 80 to 88/100,000). Crude incidence remained stable during the study period, with the exception of a significant increase in 1991 followed by a significant decrease the next year. Nonperforated acute appendicitis showed a different incidence pattern as compared to perforated acute appendicitis. CONCLUSION: In our prospective study, the incidence of acute appendicitis remained stable in our well-defined study population during the study period of 10 years. This is in contrast to the majority of studies during the last decades.

Acute Disease↗
PubMed1999

Effect of computed tomography on patient management and costs in children with suspected appendicitis.

OBJECTIVE: Children evaluated in the emergency department for possible appendicitis are often admitted for observation, despite the widespread availability of accurate diagnostic studies, particularly computed tomography (CT). We sought to establish effective and efficient strategies for using CT to diagnose and manage children with possible appendicitis. DESIGN: Retrospective chart review and decision analysis. Setting. Emergency department of a large, urban tertiary care pediatric teaching hospital. PATIENTS: All patients admitted from January 1996 to August 1997 for suspected appendicitis. METHOD OF ANALYSIS: Three modeled strategies were empirically applied to the retrospective cohort of patients admitted for observation. Outcomes and costs under the modeled strategies were compared with those under current practice. The three strategies were: 1) to obtain CT scans on all patients and discharge those with normal findings; 2) to obtain CT scans and admit all patients; 3) to selectively obtain CT scans on those patients with a peripheral white blood cell count >10 000/mm(3) (10 x 10(9)/L) and admit all. The sensitivity and specificity of CT for diagnosing appendicitis were determined empirically from the data. A sensitivity analysis was performed. MAIN OUTCOME MEASURES: The number of preoperative inpatient observation days, total hospital costs, and the rates of both missed appendicitis and negative laparotomies. RESULTS: Of 609 patients hospitalized for possible appendicitis, 287 went directly to the operating room and 14 patients had known perforation and abscess. Three hundred eight children were observed and comprised the study cohort. Of the cohort, 112 (36.4%) underwent appendectomy and 26 (23.2%) of these had a normal appendix at pathology. Three patients were discharged from the hospital after observation and were subsequently readmitted with appendicitis (missed appendicitis). Among the 75 patients who had CT performed, the sensitivity and specificity of CT were both 97%. Under the current practice strategy, the cohort collectively accumulated 487 inpatient observation days and incurred a per patient cost of $5831. All three CT strategies would have reduced the total number of inpatient observation days, operations, negative laparotomies, as well as the per patient cost. The strategy of obtaining CT scans on all patients and then admitting them had the lowest rate of missed appendicitis. The additional cost of preventing each case of missed appendicitis under this strategy compared with the strategy of obtaining CT scans and sending home those with negative findings was $150,304. Even at the lowest reported sensitivity and specificity of CT in the literature, the ordering of the three strategies remained constant and continued to reduce total cost per patient. CONCLUSION: Compared with current practice, diagnostic strategies using CT could reduce costs and improve diagnosis, management, and outcomes for children with appendicitis.

Appendicitis↗
PubMed1992

Acute appendicitis in children: value of sonography in detecting perforation.

OBJECTIVE: We determined the sonographic features of perforating appendicitis in children in order to determine the best criteria for establishing the diagnosis. MATERIALS AND METHODS: Sonograms of the right lower quadrants of 71 children with proved appendicitis were reviewed to determine the value of sonography in distinguishing between nonperforating and perforating appendicitis. The sonographic signs evaluated included the presence or absence of an appendix, an echogenic submucosal layer, increased periappendiceal echogenicity, free or loculated periappendiceal or pelvic fluid collections, and appendicoliths. The sonographic findings were correlated with the surgical and pathologic findings. RESULTS: Forty-five patients had nonperforating appendicitis, and 26 had perforating appendicitis. A sonographically visible appendix was present in all patients with nonperforating appendicitis and in 10 (38%) of 26 patients with perforation. An echogenic submucosa was noted in 27 (60%) of 45 patients with uncomplicated appendicitis but in only three (30%) of 10 patients with a visible appendix and perforating appendicitis (p < .05). In 19 of 26 patients with perforating appendicitis, sonography showed loculated periappendiceal or pelvic fluid collections; no patient with nonperforating appendicitis had a loculated fluid collection (p < .05). No statistically significant association was found between the presence or absence of perforation and free pelvic fluid, prominent periappendiceal fat, or an appendicolith. CONCLUSION: Our results indicate that sonography can be helpful in the diagnosis of perforating appendicitis. The best predictors of perforation are absence of the echogenic submucosal layer and the presence of a loculated fluid collection.

Acute Disease↗
PubMed1999

Appendicitis in pregnancy: diagnosis, management and complications.

BACKGROUND: Acute appendicitis is the most common surgical emergency in pregnancy. The purpose of this study is to investigate the clinical presentation, management and outcome in patients who underwent appendectomy during pregnancy. MATERIAL AND METHODS: The case records of 56 women who underwent appendectomy during pregnancy between January 1985 and December 1997 were reviewed and analyzed. RESULTS: The incidence of appendicitis in pregnancy was one in 766 births. The preoperative diagnosis was correct in 75% of the cases. Uterine contractions and a history of diffuse or periumbilical pain migrating to the right lower abdominal quadrant were significantly more frequent among women with appendicitis compared to those patients where the appendectomy revealed a normal appendices. Abdominal pain, nausea, vomiting, leukocyte count, CRP and body temperature were not helpful in establishing the correct diagnosis. There was no maternal morbidity related to the appendectomy. Pregnancy complications were found to be considerable: 4/12 (33%) who underwent appendectomy for appendicitis during the first trimester aborted spontaneously. Second trimester appendectomy for appendicitis was followed by premature delivery in 4/28 (14%). However, no pregnancy complications were observed following third trimester appendectomy for appendicitis. We found no increase in pregnancy complications in cases with perforated appendicitis. CONCLUSION: Appendicitis in pregnancy should be suspected when a pregnant woman complains of new abdominal pain. No laboratory finding was found to be diagnostic for acute appendicitis during pregnancy. Considerable fetal loss was found after appendectomy during pregnancy in the first and second trimester. No increase in pregnancy complications in cases with perforated appendicitis was observed. The combination of symptoms and clinical judgement is still vital in deciding which patient needs surgical treatment. Based on the results in the present study we recommend prophylactic antibiotic treatment in all laparotomies during pregnancy when appendicitis is suspected.

Abortion, Spontaneous↗
PubMed2000

Appendicitis in pregnancy.

Appendicitis continues to be the most common nonobstetric surgical diagnosis in pregnancy. Historically, this diagnosis has been associated with an increased risk of fetal loss as well as maternal morbidity. The physiologic and anatomic changes in pregnancy have been thought to obscure and thus delay the diagnosis of acute appendicitis, contributing to its increased risk in pregnancy. Such increased risks have been well reported in literature. To further evaluate the overall incidence, to determine the factors contributing to delay in diagnosis, and to assess overall outcomes in appendicitis in pregnancy, we performed a retrospective contemporary evaluation of pregnant patients with the diagnosis of acute appendicitis during the period 1991-1998. Twenty-two patients had the combined admitting diagnoses of pregnancy and acute appendicitis among 44,845 deliveries for the same time period (incidence, 0.05%). Gestational stage at diagnosis was the first trimester in 5 patients (22%), second trimester in 6 patients (27%), and third trimester in 11 patients (50%). Nineteen patients (86%) had pathologically proven acute appendicitis. Sixteen patients (73%) presented with less than 24 hours of abdominal symptoms. Seventeen patients (77%) presented with findings of rebound and guarding on initial physical examination. Fifteen patients (68%) were taken to the operating room within 24 hours of presentation. Of these, 10 patients (68%) had acute perforated appendicitis. Overall, there were 12 cases of perforated appendicitis (55%), which is an incidence higher than what has been reported in literature. There were no instances of fetal mortality. Preterm labor occurred in 5 patients, all in their third trimester with perforated appendicitis. Our study found that our population paralleled the incidence of gestational appendicitis of 0.05-0.07 per cent; physical examination on presentation was the most reliable diagnostic tool for appendicitis; and there is a higher incidence of perforation with increased gestational age, which does not result in increased fetal mortality.

Appendicitis↗
PubMed2001

Ruptured appendicitis among children as an indicator of access to care.

OBJECTIVE: To determine factors associated with ruptured appendicitis among children, using administrative databases. Insurance-related differences in the risk of ruptured appendix among adults in California have previously been described (Braveman, Schaaf, Egerter, et al. 1994). DATA SOURCES/STUDY SETTING: State of Maryland Medicaid claims data for children < or = 18 years of age from 1989 to 1993 and hospital discharge data for children < or = 19 years of age from 1989 to 1994 were analyzed. STUDY DESIGN: Administrative data analysis pre- and post-implementation of a Medicaid managed care program called Maryland Access to Care. DATA COLLECTION/EXTRACTION METHODS: Medicaid claims and hospital discharge ICD-9-CM codes were used to define hospitalization for ruptured and nonruptured appendicitis. Linear regression was used to model trends. Logistic regression was used to model the probability of ruptured appendicitis. PRINCIPAL FINDINGS: Among the 374 Medicaid inpatient claims for appendicitis, 37 percent were for ruptured appendicitis. Among the 5,141 hospital discharges for appendicitis, 30 percent were for ruptured appendicitis. Using Medicaid claims data, the probability of ruptured appendicitis was inversely related to age (OR = 0.86, 95% CI 0.81-0.91), white race (OR = 0.35, 95% CI 0.17-0.71) and preventive care visits (OR = 0.19, 95% CI 0.05-0.77). Using hospital discharge data, age (OR = 0.91, 95% CI 0.90-0.93) and female gender (OR = 0.87, 95% CI 0.77-0.99) were significant covariates. Insurance-related covariates were not significant in multivariate models addressing the probability of ruptured appendicitis. CONCLUSIONS: During a period of rapid managed care growth, insurance type was not associated with an increased risk of ruptured appendicitis among children in this geographic area. Age, female gender, and the number of preventive care visits are inversely related to the risk of ruptured appendix among children. The protective effect of preventive care visits suggests that a primary care relationship facilitates access to care, thus reducing delay in the management of appendicitis.

Adolescent↗
PubMed2001

Perforated appendicitis in the child: contemporary experience.

BACKGROUND: Despite years of research and clinical experience with acute appendicitis, the rate of complications in the pediatric age group continues to be high. OBJECTIVE: To characterize the profile of the child with appendicitis complicated by perforation or intraabdominal abscess. METHODS: Between 1 January 1985 and 31 December 1997 in our department, 581 children under the age of 14 years were clinically diagnosed as suffering from "acute appendicitis." The final diagnoses were: while appendix in 28 cases (4.8%), acute non-complicated appendicitis in 472 (81%), and complicated appendicitis in 81 (13.9%), including 51 cases of free perforation (8.7%) and 30 cases of intraabdominal abscess (5.2%). We retrospectively reviewed the charts of all children with complicated appendicitis and those of 70 randomly selected children with non-complicated appendicitis, and compared patient age, gender, weight percentile, past medical history, and course of the illness. RESULTS: The children with complicated appendicitis were significantly younger (P = 4.8 x 10(-7)), they had higher oral and rectal temperatures (P = 7.9 x 10(-8)), higher platelet count (P = 0.0008) and lower hemoglobin level (P = 0.004). No difference was found in white blood count (P = 0.41). Total delay from symptom onset to surgery was 33 hours (SD 23) in the non-complicated group, 60 hours (SD 38) in the perforated appendicitis group, and 176 hours (SD 107) in the intraabdominal abscess group (P = 4.6 x 10(-8)). No difference in intra-hospital delay was found. CONCLUSIONS: Children with complicated appendicitis are characterized by younger age, longer delay from symptom onset to correct diagnosis, and typical laboratory findings. Delays in diagnosis can be avoided by first considering the diagnosis of acute appendicitis in the differential diagnosis when examining any child with abdominal pain.

Abdominal Abscess↗
PubMedDate not supplied

A comparison between presenatation time and delay in surgery in simple and advanced appendicitis.

BACKGROUND: Acute appendicitis is the most common cause of acute abdomen. Serial examinations and investigations increase diagnostic accuracy. But this causes delay, which may result in gangrene and perforation. Our aim is to determine the affect of delay by the patient as well as by the physician on the stage of the disease as determined intraoperatively and to determine the percentage of negative appendectomies. METHODS: 102 consecutive patients presenting to the Mayo Hospital emergency, undergoing appendectomy between February and April, 2002 comprise the study group. Data was tabulated and analyzed. The delay by the patient in presenting to emergency was called the "patient's delay" and the in-hospital delay before the actual operation called the "physician's delay" were calculated. The appendicitis was divided into two groups i.e. "simple appendicitis" which included acutely inflamed appendices and grossly mildly or non inflamed but histopathologically inflamed appendicitis and "advanced appendicitis" which included gangrenous and perforated cases. RESULTS: The percentage of negative appendectomy in our center was 5.9%. Patients' delay averaged 2.59 days and 2.43 days in simple and advanced appendicitis. A prolonged average delay period of 6.12 day was seen in misdiagnosed cases. The mean delay was not significantly different. 86.3% of the patients were operated within 12 hours of presentation. The mean physician's delay was 9.24 hours. It was significantly shorter for advanced appendicitis as compared to simple appendicitis. CONCLUSIONS: Patient's delay was not associated with advanced appendicitis. It is recognizable clinically and gets operated two hours earlier on average. There is a significant lag period of observation leading to a physician delay in simple appendicitis, contributing possibly to, increased morbidity. However there is an increased need to use ultrasonography and CT in the emergency setting to diagnose appendicitis in case of doubt.

Acute Disease↗
PubMed1985

[Appendicitis in childhood].

Appendectomy was performed on 1,059 children at the University Clinic of Paediatric Surgery in Mainz from 1. 1. 1975 to 31. 6. 1983. For the retrospective examination of the indication for appendectomy histopathological and intraoperative findings were analysed and evaluated. Histologically five types of appendicitis were differentiated: 1. acute appendicitis (two forms: acute ulcero-phlegmonous appendicitis with or without perforation and acute superficial appendicitis), 2. chronic appendicitis, 3. lymphatic hyperplasia, 4. submucosal fibrosis, 5. rare diseases. In 618 cases (= 58.3%) acute appendicitis was diagnosed histologically. In another 203 cases (= 19.2%) intraoperative findings (e.g. Lymphadenitis mesenterialis, Meckel's diverticulum) were retrospectively collected; they caused symptoms similar to those of appendicitis. However, there remain retrospectively 22% of all appendectomised children with no indication for laparotomy. The statistical analysis of postoperative complications showed a significant dependance from the histopathological findings. The highest rate of complications was seen in cases with perforated (34%) or non-perforated (10%) ulcero-phlegmonous appendicitis. Children with acute superficial appendicitis had a complication-rate of 5%; those with lymphatic hyperplasia and submucosal fibrosis of 6% each. Relaparotomies were almost exclusively necessary in cases with acute appendicitis; septic and pulmonary complications were mostly seen either in infants with malformations or other perinatal risks, or in children with additional severe diseases. Therefore non-acute appendicitis justifies a wide indication for appendectomy because of a low complication-rate; this, however, is not valid for high-risk children (e.g. malformations). In these cases sonography might be useful for preoperative diagnosis.

Adolescent↗
PubMed1995

Increased morbidity of appendicitis with advancing age.

The early diagnosis of acute appendicitis before progression to gangrene or abscess formation is recognized as important to minimize morbidity from this common disease process. As our population ages, the challenge for expedient diagnosis and intervention in older age groups will become more significant. Prompted by recent unexpected complications occurring in elderly patients, we reviewed 100 consecutive admissions with the diagnosis of appendicitis to a tertiary Veterans Administration hospital. All patients were males and were arbitrarily divided into three age groups: less than 50, 50-70, and greater than 70 years of age. There were no patients less than 20 years old. Operative findings were classified as simple acute appendicitis, ruptured or perforated appendicitis, appendicitis associated with intra-abdominal abscess, and finally other when the operative diagnosis differed from appendicitis. Of the 37 patients less than 50 years of age, 28 were found to have simple acute appendicitis, making this by far the most common finding in this age group (P < 0.05). Only two of the 18 patients aged 50-70 with appendicitis demonstrated simple acute appendicitis, with the remainder having progressed to perforation or abscess formation (P < 0.05). Patients greater than 70 years of age were significantly more likely than any other age group to manifest appendicitis associated with intra-abdominal abscess (10 of 19, P < 0.05). Eight patients died in this series, six of whom were more than 70 years of age. In most cases, mortality was directly attributable to infectious complications of perforated appendicitis. There were no deaths in the under 50 age group.(ABSTRACT TRUNCATED AT 250 WORDS)

Abdominal Abscess↗
PubMed1994

Chronic and recurrent appendicitis are uncommon entities often misdiagnosed.

Those having chronic and recurrent appendicitis represent a small portion of patients with disorders of the appendix. We present a series of nine patients who underwent appendectomy for chronic or recurrent appendicitis at The Johns Hopkins Hospital, Baltimore, Maryland, between July 1984 and October 1992. There were seven women and two men (median age of 30 years, range of 15 to 63 years). All patients presented with pain in the right lower quadrant or lower abdomen of three or more weeks duration (mean of 16.0 +/- 8.4 months, range of three weeks to seven years), had no alternative diagnosis to account for the symptoms, had pathologic evidence of chronic inflammation or fibrosis of the appendix and had complete relief of the symptoms after appendectomy. Although the patients presented herein had clinical and pathologic evidence for recurrent or chronic appendicitis, careful review of the course of each patient before surgical referral revealed at least one episode of acute pain in the abdomen consistent with acute appendicitis managed by nonoperative means. This suggests that, while recurrent acute appendicitis and chronic appendicitis do occur, they can be avoided by the accurate diagnosis and operative management of acute appendicitis. We conclude that acute appendicitis can resolve spontaneously and recur repeatedly in the same individual; in the evaluation of a patient with abdominal pain, a history of prior similar episodes of pain should never dissuade one from considering the diagnosis of acute appendicitis, and recurrent acute appendicitis and chronic appendicitis should be considered in the differential diagnosis of recurrent pain in the lower abdomen.

Acute Disease↗
PubMed1998

[The diagnostic value of echography in appendicitis in children].

OBJECTIVE: The purpose of this study was to analyze the possible usefulness of ultrasonography for the diagnosis of acute appendicitis in children and to compare this technique with the clinical signs classically employed in the evaluation of pain in the right lower quadrant (RLQ) in the emergency ward. PATIENTS AND METHODS: We prospectively analyzed 112 patients younger than 14 years with suspected appendicitis. After a careful clinical record and physical and complementary studies were performed, we performed a ultrasonography of the RLQ on all patients a tubular, non-mobile, non-compressible image with a target image measuring 6 mm or more on the cut section was considered suggestive of appendicitis. After the initial clinical-radiological evaluation, the patients were either operated or included in a follow-up group. None of them were dismissed. The confirmation of the diagnosis of appendicitis was histological. RESULTS: Only 4 of the 14 factors analyzed showed a significant association with acute appendicitis (leukocytosis, left shift, abdominal RX film suggesting inflammation in the RLQ and ultrasonography positive for appendicitis), with ultrasonography being the technique with the highest diagnostic reliability (77.7% sensitivity and 94.8% specificity). The age of the patients with appendicitis was significantly lower than that of the patients without appendicitis. Nevertheless, we did not find any relationship between advanced appendicitis and factors such as age or time of evolution. CONCLUSIONS: After a clinical-ultrasonography evaluation, our negative appendectomy rate was 7% and the perforation/gangrenous appendicitis rate was 29%. We conclude that ultrasonography performed by trained professionals is a useful tool in the differential diagnosis of appendicitis in children.

Acute Disease↗
PubMed1999

Ultrasonography and limited computed tomography in the diagnosis and management of appendicitis in children.

CONTEXT: Limited computed tomography with rectal contrast (CTRC) has been shown to be 98% accurate in the diagnosis of appendicitis in the adult population, but data are lacking regarding the accuracy and effectiveness of this technique in diagnosing pediatric appendicitis. OBJECTIVE: To determine the diagnostic value of a protocol involving ultrasonography and CTRC in the diagnosis and management of appendicitis in children and adolescents. DESIGN, SETTING, AND PARTICIPANTS: Prospective cohort study of 139 children and adolescents aged 3 to 21 years (2 patients were older than 18 years) who had equivocal clinical findings for acute appendicitis and who presented to the emergency department of a large, urban, pediatric teaching hospital between July and December 1998. Interventions Children were first evaluated with pelvic ultrasonography. If the result was definitive for appendicitis, laparotomy was performed; if ultrasonography was negative or inconclusive, CTRC was obtained. Patients who did not undergo laparotomy had telephone follow-up at 2 weeks and medical records of all patients were reviewed 4 to 6 months after study completion. MAIN OUTCOME MEASURES: Specificity, sensitivity, positive predictive value, negative predictive value, and accuracy of tests based on final diagnoses; surgeons' estimated likelihood of appendicitis on a scale of 1 to 10 for each case and their case management plans before imaging, after ultrasonography, and after CTRC. RESULTS: A total of 108 patients underwent both ultrasonography and CTRC examinations. The protocol had a sensitivity of 94%, specificity of 94%, positive predictive value of 90%, negative predictive value of 97%, and accuracy of 94%. A normal appendix was identified by ultrasonography in 2 (2.4%) of 83 patients without appendicitis and by CTRC in 62 (84%) of 74 patients. A negative ultrasonography result did not change the surgeons' clinical confidence level in excluding appendicitis (P= .06), while a negative CTRC result did have a significant effect (P<.001). Positive results obtained for either ultrasonography or CTRC significantly affected surgeons' estimated likelihood of appendicitis (P=.001 and P<.001, respectively). Ultrasonography resulted in a beneficial change in patient management in 26 (18.7%) of 139 children while CTRC correctly changed management in 79 (73.1%) of 108. CONCLUSIONS: These data show that CTRC following a negative or indeterminate ultrasonography result is highly accurate in the diagnosis of appendicitis in children.

Adolescent↗
PubMed1991

Ultrasonography in the diagnosis of acute appendicitis.

Ultrasonography with graded compression was performed in 525 patients with clinical signs of acute appendicitis. Of 207 patients with surgically proven appendicitis the inflamed appendix (diameter greater than or equal to 6 mm) had been visualized sonographically in 177 (86 per cent). The score for non-perforated appendicitis (91 per cent) was higher than for perforated appendicitis (55 per cent). Twenty-four patients in whom an inflamed appendix was seen on ultrasonography did not undergo surgery because of rapidly subsiding symptoms ('abortive appendicitis'). Four of these 24 developed recurrent appendicitis warranting surgery. Two underwent elective appendectomy and 18 have remained symptom-free. Of 155 patients with a subsequently confirmed alternative condition, ultrasonography made the correct diagnosis in 140: bacterial ileocaecitis (69), mesenteric lymphadenitis (eight), gynaecological conditions (34), urological conditions (eight), caecal diverticulitis (six), perforated peptic ulcer (six), Crohn's disease (two) and miscellaneous conditions (seven). Of 139 patients in whom no definite diagnosis was made ultrasonography showed no abnormalities in 138. In four patients a false positive sonographic diagnosis of appendicitis was made and in two patients with appendicitis an alternative condition was incorrectly diagnosed. During the last 3 years of the study the negative appendicectomy rate was 7 per cent and delay beyond 6 h after admission occurred in only 2 per cent of patients with surgically proven appendicitis. When used to complement the clinical diagnosis ultrasonography improves the diagnostic accuracy and patient management in those suspected of having acute appendicitis.

Acute Disease↗
PubMed2005

Imaging of acute appendicitis: US as the primary imaging modality.

BACKGROUND: The investigation of the acute abdomen in infants and children has evolved during the last two decades, placing imagers at the forefront of the evaluation and diagnosis of acute right lower quadrant abdominal problems. US and CT have recently been shown to be equally accurate in the diagnosis of acute appendicitis, but not everyone agrees. OBJECTIVE: To demonstrate the efficacy of triaging patients with acute abdominal problems that suggest appendicitis with US as the primary imaging modality. MATERIALS AND METHODS: We retrospectively reviewed the prospective imaging diagnoses in 622 children who presented to our emergency room (ER) and clinics with acute abdominal symptoms suggestive of appendicitis. We documented whether US or CT was performed and noted the diagnoses made. All of the patients had plain films. In addition, all patients undergoing surgical appendectomy during this time were also documented so as not to miss any cases of appendicitis. None was missed. RESULTS: There were 622 consecutive patients in our study. Three patients, diagnosed as normal, were eventually excluded because of lack of follow-up. In all, 152 patients were evaluated clinically and with plain films only. They were not subject to surgical exploration or further imaging. None returned with appendicitis. Eighty-one patients were directly subject to laparotomy after clinical and plain film evaluation. Of these patients, 20% had a normal appendix. Of the remaining 389 patients, 386 had US and three had CT alone. Four patients had both CT and US because of an inconclusive US examination. Three patients had CT alone because of their size. In total, 137 patients were diagnosed with appendicitis with US and/or CT. Four of these patients (3%) had normal appendices. Forty-two patients (less three lost to follow-up) were diagnosed as normal, and none returned with findings of appendicitis. Nine others had conditions other than acute appendicitis. Three had surgically proven, nonrelated conditions, and of the other six, one had pancreatitis and five nonsurgical adnexal problems. In all, 201 patients were diagnosed (with US) with mesenteric adenitis-enteritis, and none returned with findings of appendicitis. CONCLUSION: We attained a high degree of diagnostic accuracy in patients presenting with findings suggestive of appendicitis using US as the primary imaging modality. Our false-positive appendectomy rate was 3%. Therefore, triage of the acute abdomen with US supported by CT when required has considerable merit, especially when considering that US is noninvasive and does not use ionizing radiation.

Abdomen, Acute↗
PubMedDate not supplied

Incidence of acute nonperforated and perforated appendicitis: age-specific and sex-specific analysis.

This prospective study was performed to investigate epidemiological characteristics in terms of the age- and sex-specific incidence in patients with perforated and nonperforated appendicitis. The study population comprised 1486 consecutive patients who underwent appendectomy for suspected acute appendicitis between 1989 and 1993. Two patient cohorts [n = 544 (37%)] were analyzed with regard to prehospitalization duration of symptoms and in-hospital observation time. The crude incidence of acute appendicitis was 86 per 100,000 per year. Although the incidence of nonperforated appendicitis was highest among adolescents and young adults (13-40 years of age), perforated appendicitis occurred at almost the same incidence in all sex and age groups. The diagnostic accuracy was 76%. Perforated appendicitis occurred in 19%, with higher rates in small children and the elderly, irrespective of gender. A high diagnostic accuracy was not associated with an increased rate of perforation. In small children and the elderly, the diagnostic accuracy was low and the perforation rate high. Patients with perforation had a significantly longer duration of symptoms as well as in-hospital observation time than did patients with nonperforated appendicitis. Perforated appendicitis showed a different incidence pattern than nonperforated appendicitis and was associated with a significantly longer duration of symptoms and in-hospital observation time, probably due to patient-related factors. We suggest this observation deserves attention regarding clinical diagnosis and treatment decision-making for patients with suspected acute appendicitis.

Acute Disease↗
PubMed2005

Appendicitis in childhood hematologic malignancies: analysis and comparison with typhilitis.

BACKGROUND/PURPOSE: Recognition of appendicitis in the child with hematologic malignancy may be difficult particularly in the setting of neutropenia and multiple medications causing an altered inflammatory response. Typhilitis may produce a similar constellation of clinical findings causing further diagnostic confusion. This review compares the relative frequency of these two conditions in children with hematologic malignancy with a focus on the clinical presentation, distinguishing features, surgical management, and outcome for patients with appendicitis. METHODS: This institutional review board-approved retrospective study evaluated 464 pediatric patients treated for hematologic malignancy at our institution from 1997 to 2003. From this cohort, we identified all children with a diagnosis of appendicitis or typhilitis. Data include demographics, clinical presentation, laboratory studies, and computed tomography (CT) scan findings. Groups were compared using the Fisher exact test. Significance was defined as P < .05. RESULTS: Eight (1.7%) of 464 children were diagnosed with typhilitis and 7 (1.5%) with appendicitis. There were no demographic differences between patients with appendicitis and typhilitis. Distinguishing clinical features in children with typhilitis included presence of fever and diarrhea. Clinical presentation in children with appendicitis was atypical in 5 of 7 cases yielding an incorrect preoperative diagnosis in all 5. Radiographic evaluation by CT scan accurately defined typhilitis, but not appendicitis. An operation was performed on all 7 children with appendicitis with no operative morbidity or mortality. CONCLUSIONS: Appendicitis and typhilitis occur with similar frequency in children with leukemia and lymphoma. Typhilitis is accurately diagnosed with clinical findings of fever, diarrhea, abdominal pain, and typical CT scan findings. Appendicitis tends to present with atypical findings, but can be successfully managed with standard surgical care.

Adolescent↗
PubMed1999

The role of computed tomography in the diagnosis of acute appendicitis.

BACKGROUND: Routine contrast-enhanced computed tomography (CECT) has been described as an accurate diagnostic imaging modality in patients with acute appendicitis. However, most patients with acute appendicitis can be diagnosed by clinical findings and physical exam alone. The role of CECT in patients suspected of having appendicitis but with equivocal clinical exams remains ill defined. METHODS: One hundred and seven consecutive patients who were thought to have appendicitis but with equivocal clinical findings and/or physical exams were imaged by CECT over a 12-month period. Oral and intravenous contrast-enhanced, spiral abdominal and pelvic images were obtained using 7-mm cuts. CECT images were interpreted by a board-certified radiologist. Main outcome measures included CECT sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy in the diagnosis of acute appendicitis, comparing CECT with ultrasound, and determining the impact of CECT on the clinical management of this patient population. RESULTS: A group of 107 patients consisting of 44 males (41%) and 63 females (59%) with a median age of 33 years (range 13 to 89 years) were imaged with CECT to evaluate suspected appendicitis. Of the 107 CECTs performed, 11 false-positive and 3 false-negative readings were identified, resulting in a sensitivity of 92%, specificity of 85%, PPV of 75%, NPV of 95%, and an overall accuracy of 90%. Forty-three patients were imaged with ultrasound and CECT, and CECT had significantly better sensitivity and accuracy (30% versus 92% and 69% versus 88%, P<0.01). With regard to clinical management, 100% (36/36) of patients with appendicitis, and 4.2% (3/71) of patients without appendicitis underwent appendectomy. Therefore, the overall negative appendectomy rate was 7.6% (3/39). CONCLUSIONS: CECT is a useful diagnostic imaging modality for patients suspected of having acute appendicitis but with equivocal clinical findings and/or physical exams. CECT is more sensitive and accurate than ultrasound and is particularly useful in excluding the diagnosis of appendicitis in those without disease.

Adult↗