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PubMed2006

Computed tomography-based clinical diagnostic pathway for acute appendicitis: prospective validation.

BACKGROUND: Despite our regular use of CT for suspected appendicitis, a recent study at our institution demonstrated a negative appendectomy (NA) rate similar to our rate 15 years earlier. Based on analysis of this data, a diagnostic pathway was implemented prospectively for adult patients with possible appendicitis. STUDY DESIGN: Rates of CT, NA, and perforation for nonpregnant patients over 14 years of age undergoing appendectomy between August 2001 and August 2002 (PRE) were compared with prospectively collected pathway data (PATH, August 2004 to August 2005). All PATH patients were evaluated by a surgeon before CT. All females underwent CT. CT was obtained in male patients with low suspicion or pain for longer than 48 hours. After negative CT, patients were discharged from the emergency department or admitted for observation. RESULTS: There was a substantial decrease in NA rate after implementation of the pathway (4% PATH [8 of 183] versus 16% PRE [31 of 196], p < 0.001), without a change in the rate of perforation (11% PATH [20 of 175] versus 8% PRE [13 of 165], p = 0.28) or frequency of preoperative CT (59% PATH [108 of 183] versus 60% PRE [118 of 196], p = 0.84). CONCLUSIONS: Frequent appendiceal CT alone does not ensure surgical diagnostic accuracy. CT need not be used in all patients to achieve very low NA rates. An evidence-based diagnostic algorithm incorporating early surgical evaluation, objective criteria for preoperative CT, deterrence of early operation after negative CT, and use of CT to facilitate safe discharge led to substantial improvements in the care of our adult population presenting with possible appendicitis.

Acute Disease↗
PubMed2005

Acute appendicitis of the appendiceal stump.

We report a case of a 27-year-old man, status post open appendectomy as an infant, in whom the diagnosis of acute appendicitis of the appendiceal stump was made by computed tomography (CT). A coronal reformatted CT image demonstrated both the inflamed appendix and a normal terminal ileum. Although rare, stump appendicitis may present with signs and symptoms typical of acute appendicitis in patients status post appendectomy and should be considered in the differential diagnosis.

Abdominal Pain↗
PubMed2005

The utility of unenhanced computed tomography in appendicitis in children.

To evaluate the utility of unenhanced helical computed tomography (UHCT) in appendicitis in children, we performed a retrospective study of 112 consecutive patients. The radiologist's interpretation of the UHCT was compared with disease status using appendix pathology findings as the gold standard for diagnosis. The performance characteristics of UHCT were as follows: sensitivity 87.5% (95% CI: 75.8-94.8%), specificity 93.7% (95% CI: 85.4%-98.0%), positive predictive value 91.3% (95% CI: 83.2%-99.4%), negative predictive value 90.8% (95% CI: 83.7%-97.8%), overall diagnostic accuracy 90.9% (95% CI: 85.7-96.3%). Positive and negative likelihood ratios were 13.8 (95% CI: 5.3-35.8) and 0.13 (95% CI: 0.06-0.28), respectively. UHCT seems to be a very useful diagnostic test for the evaluation of childhood appendicitis when interpreted by experienced radiologists. The diagnostic accuracy of UHCT found in this study is comparable to that reported for contrast-enhanced CT as well as graded compression ultrasound in appendicitis in children.

Acute Disease↗
PubMed2004

The management of pediatric appendicitis: a survey of North American Pediatric Surgeons.

BACKGROUND/PURPOSE: Variation exists among pediatric surgeons in the management of pediatric appendicitis. The goal of this study was to determine current practice patterns and provide a foundation for evidence-based outcome studies that would standardize patient care. METHODS: Members of the American Pediatric Surgical Association (APSA) were surveyed. Data included preference of imaging, timing of operation, and opinions on interval appendectomy. Intraoperative principles surveyed included use of cultures, antibiotic irrigation, transperitoneal drains, and method of wound closure. Spectrum and duration of antibiotic coverage were assessed, as were discharge criteria. RESULTS: Survey response was 70%. A majority prefers computerized tomographic (CT) imaging and favors interval appendectomy in appropriate candidates. Seventy percent indicate a stable child with suspected appendicitis would be operated on in a semiurgent manner rather than emergently in their practice. Discrepancy exists in the type and duration of antibiotic coverage, impact of clinical parameters on antibiotic use, and utility of discharge criteria. CONCLUSIONS: This study consolidates current opinions on appropriate management of pediatric appendicitis, providing a foundation for evidence-based outcome studies capable of bringing conformity to the management of this surgical disease. Such studies would establish clinical practice guidelines that optimize resource utilization while maintaining quality care.

Adolescent↗
PubMed2006

A simple and more cost-effective antibiotic regimen for perforated appendicitis.

OBJECTIVE: Appendicitis is the most common abdominal emergency in children. When perforation is encountered, postoperative management is grounded upon the use of intravenous antibiotics. The 3-drug regimen of ampicillin, gentamicin, and clindamycin has long been the accepted standard by pediatric surgeons. Although effective and seemingly inexpensive, this regimen produces a cumbersome dosing schedule, which has inspired the search for a simpler regimen that does not compromise efficacy or expense. To this end, we have introduced a 2-drug regimen of ceftriaxone and Flagyl (Pharmacia Corporation, Chicago, Ill) with once-a-day dosing. METHODS: A retrospective review was conducted of the most recent 250 patients treated at our institution with perforated appendicitis. Patients treated since the implementation of this 2-drug regimen were compared with the recent historical cohort treated with triple antibiotic coverage. Parameters analyzed between the 2 groups included temperature curves for the first 5 postoperative days, abscess rate, length of hospitalization, length of intravenous antibiotic treatment, and medication charges. RESULTS: The 2-drug regimen was used in 57 patients (group 1) compared with 193 patients treated with triple antibiotic coverage (group 2). Maximum recorded temperature between the 2 groups was similar upon admission, but the mean maximum temperature in group 1 became significantly lower than group 2 from postoperative day 1 onward (P < .001). Postoperatively, an abscess developed in 8.8% of group 1 compared with 14.2% of group 2, which was not significantly different (P = .37). Mean length of stay was 6.8 days in group 1 and 7.8 days in group 2 (P = .03). Medication charges to the patient were 81.32 dollars per day in group 1 compared with 318.53 dollars per day in group 2, translating to 1186.05 dollars savings for 5 days. CONCLUSIONS: Once-a-day dosing with ceftriaxone and Flagyl provides adequate antibiotic coverage for the postoperative management of perforated appendicitis in children. This regimen allows patients to more rapidly defervesce compared with traditional triple antibiotic coverage; moreover, this simple regimen provides substantial advantages for administration and expense.

Adolescent↗
PubMed2007

Matched analysis of nonoperative management vs immediate appendectomy for perforated appendicitis.

BACKGROUND: The role of nonoperative therapy vs immediate appendectomy in the management of children with perforated appendicitis remains undefined. The objective of this study was to rigorously compare these management options in groups of patients with matched clinical characteristics. METHODS: Multicenter case-control study was conducted from 1998 to 2003. We compared patients treated nonoperatively vs those undergoing appendectomy to identify differences in 12 clinical parameters. We then generated a second control group of patients matched for these variables and compared the following outcomes in these clinically similar groups: complication rate, abscess rate, and length of stay (LOS). Analysis was performed according to intention-to-treat principles, using chi2, Fisher exact, and Student t tests. RESULTS: The only significant difference between patients treated nonoperatively and those treated by appendectomy was the duration of pain on presentation (6.8 vs 3.1 days of pain). We created a second control group of patients undergoing immediate appendectomy matched on duration of pain on presentation to patients treated nonoperatively. These groups continued to be clinically comparable for the other 11 parameters. Compared to this matched control group, the nonoperative group had fewer complications (19% vs 43%, P < .01), fewer abscesses (4% vs 24%, P < .01), and a trend for shorter LOS (6.5 +/- 5.7 vs 8.8 +/- 6.7 days, P = .08). CONCLUSIONS: When nonoperative management for perforated appendicitis was studied using appropriately matched clinical controls, we found that it resulted in a lower complication rate and shorter LOS in the subset of patients presenting with a long duration of pain. Our data suggest that nonoperative management should be prospectively evaluated in children with perforated appendicitis presenting with a history of pain exceeding 5 days.

Adolescent↗
PubMed1988

Bacteriuria in appendicitis.

The value of bacteriologic findings in patients with acute appendicitis was studied. Routine urinary culture specimens were taken preoperatively from 194 children (mean age 11 +/- 3 years) undergoing emergency appendectomy. Bacteria were found in culture specimens of urine from 26 of 156 patients with acute appendicitis. The bacteriuria was correlated to the position of the appendix, the duration of disease, and the degree of inflammatory changes in the appendix. The results suggest direct spread of bacteria from the inflamed appendix to the urinary tract due to close anatomic relationship and to the severity of the inflammatory changes. That this spread of bacteria can have clinical significance cannot be excluded. Urinary sedimentation study is of no use in the diagnosis of acute appendicitis.

Appendectomy↗
PubMed1998

Is abdominal cavity culture of any value in appendicitis?

BACKGROUND: Intraperitoneal culturing during appendectomy is a routine procedure. Significant decrease in the mortality and dramatic improvement in the morbidity were achieved by using antibiotics perioperatively. The value of intraoperative abdominal cavity culture was assessed in our study. METHODS: A total of 499 patients formed two groups, those with acute nonperforated appendicitis (group A) and those with perforated appendicitis (group B). Intraoperative abdominal cavity culture were taken randomly in both groups. The perioperative morbidity, the validity, and the impact of positive culture on the antibiotic treatment were examined in both groups. RESULTS: Clinical diagnosed perforation was confirmed histologically in 176 patients (98.3% accuracy). Intraperitoneal cultures were obtained in 30.1% of the patients in group A and in 67.1% of group B. The majority of the patients in group A were treated preoperatively and postoperatively by a single antibiotic agent whereas 58.0% of the patients in group B were started on triple-agent antibiotics for significantly longer periods (22.4 +/- 9.4 versus 5.7 +/- 7.4 doses, respectively; P < 0.0001). No significant difference was found in both groups in the postoperative complication rate (wound infection, intra-abdominal abscess and small bowel obstruction) whether intra-abdominal culture was obtained or not (5.9% versus 4.7% in group A and 21.2% versus 21.9% in group B; P > 0.05). CONCLUSION: Traditional intraoperative abdominal cavity culture can be abandoned. In perforated appendicitis, colonic flora can be predicted, and antibiotic therapy should begun without any abdominal cavity culture results. This practical approach will save money and reduce laboratory work without affecting the patient's morbidity.

Abdominal Abscess↗
PubMed2005

[Adverse outcomes in the surgical treatment of acute appendicitis].

OBJECTIVES: To describe adverse outcomes after appendectomy for acute appendicitis and to analyze the association between these outcomes and specific characteristics of the patient and hospital admission. MATERIAL AND METHODS: We studied a cohort of 792 patients who underwent appendectomy for acute appendicitis. Postoperative complications, reoperations and deaths were prospectively studied and all readmissions were retrospectively identified. Logistic regression was used to evaluate the relationship between complications and patient characteristics, as well as hospital admission. RESULTS: Postsurgical complications developed in 9.8% of the patients. These complications mainly consisted of surgical wound infection (4.2%) and intra-abdominal complications (2.1%). A total of 0.7% of patients underwent reoperation during admission, 0.5% were admitted to the intensive care unit and five patients (0.6%) died in hospital. The rate of operation-related readmissions in the following year was 3.2%. Length of hospital stay was longer in patients with complications than in those without complications (9.6 and 3.5 days, respectively). Postoperative complications were associated with older age (45-65 years, OR 3.62, p < 0.001; more than 65 years OR 8.68, p < 0.001) and acute appendicitis complicated with peritonitis or perforation (OR 3.69, p < 0.005). Readmissions related to previous surgery were associated only with complications during the first admission (OR 18.79, p < 0.001). CONCLUSIONS: In appendectomy, the most frequent adverse outcomes are surgical wound infection and intra-abdominal complications, which are associated with older patients and perforations. This subgroup of patients at high risk requires closer surveillance.

Adolescent↗
PubMedDate not supplied

[Appendicitis: yes or no to laparoscopic approach?].

Whether or not there is a benefit to laparoscopy versus open surgery in the management of acute appendicitis remains a subject of controversy despite the publication of numerous randomized studies. Operative time is longer for the laparoscopic approach. The incidence of abdominal wall abscess is decreased for laparoscopy but the incidence of deep intra-abdominal abscess may be increased, especially in the case of complicated appendicitis. Post-operative pain is diminished and resumption of normal activity is quicker with the laparoscopic approach. Hospitalization is shorter but the cost of hospital care is higher; nevertheless, the global cost may be less - particularly for patients whose return to work is hastened by a laparoscopic approach. Laparoscopy diminishes the number of normal appendectomies, particularly in women of reproductive age where the diagnosis may be unclear. Laparoscopic appendectomy is practicable and has advantages over open appendectomy under certain circumstances. These advantages are most evident in the young female, the working patient, and the obese patient. Overall, the advantages of laparoscopy are, at best, modest and clinical benefit is not always demonstrable. The risk of deep abscess, particularly in patients with perforated or gangrenous appendicitis, remains an unknown and should be evaluated by further studies.

Adult↗
PubMed2003

Perforated appendicitis in children: is there a best treatment?

PURPOSE: This study was performed to provide outcome data for the development of evidenced-based management techniques for children with appendicitis in the authors' hospital. METHODS: This is a retrospective analysis of 1,196 consecutive children with appendicitis over a 5-year period (1996 to 2001) at a metropolitan hospital. RESULTS: The median age was 9 years (7 months to 18 years). The perforation rate was 38.9%, and the nonappendicitis rate was 5.6%. Predictors of perforation included age less than 8 years, Hispanic ethnicity, generalized abdominal tenderness, rebound tenderness, and increased number of bands. In perforated cases, the median length of stay was 5 days, and the complication rate was 13.5%. There was no difference in complication rates related to type or timing of antibiotics or related to the individual surgeon. There was no difference in infection rates related to type of wound management. CONCLUSIONS: Children with perforated appendicitis are treated effectively by a less expensive broad-spectrum antibiotic regimen, expeditious operation by open or laparoscopic technique, primary wound closure, and postoperative intravenous antibiotics until they are afebrile for 24 hours and have a white blood cell count of less than 12,000/mm3. This approach is to be used in our prospective, randomized analysis of children treated on or off a clinical pathway.

Adolescent↗
PubMed1986

The avoidable excesses in the management of perforated appendicitis in children.

During a five-year period from 1979 to 1985, 100 consecutive children with perforated appendicitis were managed at our institution. These patients were divided into two groups, which were determined by length of illness and physical findings. Group A consisted of 88 children with signs and symptoms of peritonitis from appendiceal perforation. They were treated with fluid resuscitation, antipyretics, and triple antibiotics (ampicillin, gentamicin, clindamycin), and appendectomy within a few hours of hospitalization. Saline lavage was used. Group B was composed of 12 patients with a periappendiceal mass without generalized peritonitis who had symptoms of 6 to 12 days duration. They were treated nonoperatively with triple antibiotics and underwent interval appendectomy 4 to 6 weeks later. The complication rate for Group A was 6.8%. This included three wound infections (3.4%), one intra-abdominal abscess (1.1%), one patient with pneumonia and ileus (1.1%), and a small bowel obstruction (1.1%). These results are equivalent to the lowest complication rate reported in the literature, in which the treatment included transperitoneal drainage, antibiotic lavage, and parenteral antibiotics. Group B patients had a 16.7% complication rate, which included one small bowel obstruction and one recurrent intra-abdominal abscess. Our method of management resulted in the lowest complication rate reported to date in children with perforated appendicitis. Transperitoneal drainage, delayed wound closure, and antibiotic lavage were not used. Subcuticular incisional closure resulted in minimal wound care and excellent cosmetic results. The experience demonstrates that with proper timing of surgery and appropriate use of contemporary antibiotics, the morbidity of perforated appendicitis can be limited and excesses of treatment can be avoided.

Acute Disease↗
PubMed1989

Fertility following perforated appendicitis in girls.

A study was undertaken to determine fertility status in a group of adult females who as children had been operated on for perforated appendicitis between 1957 to 1975. The 389 girls operated on for perforated appendicitis were reviewed. Their ages ranged from 10 months to 13 years at the time of appendicectomy. Of these girls, 276 were now 20 to 43 years old, and they were contacted by means of a mail questionnaire, and personal interview wherever necessary. It proved possible to contact 181 women; 102 of them were married and 79 were unmarried. Eight-four of the married women (82%) had one or more children. Nine unmarried women also had one or more children. Eighteen married women who have no children were studied in detail. Five women were on contraceptives, two desired pregnancy but had not conceived, and one patient was separated from her husband. Two patients had conceived and aborted, and two were married to infertile men. Of the remaining six patients who had been investigated for infertility, no demonstrable cause of infertility was found in three. Of the other three patients, one showed evidence of bilateral tubal occlusion secondary to pelvic inflammatory disease, one has had a right ectopic pregnancy followed by two abortions, and the third patient was found to have a pituitary adenoma. Our data show that perforated appendicitis before puberty has little if any role in the aetiology of tubal infertility.

Adult↗
PubMed1996

Recurrent appendicitis after initial conservative management of appendiceal abscess.

Therapy for children with appendiceal abscess remains controversial. The authors present two such cases initially treated conservatively, without interval appendectomy, that later had recurrent appendicitis. An 8-year-old boy presented with fever, abdominal pain, and a right-lower-quadrant abscess (noted by ultrasonography). During laparotomy, the abscess was drained and the appendix was not found. He was lost to follow-up but returned 2 1/2 years later with perforated appendicitis. An appendectomy was performed, and image-guided drainage of a postoperative abscess was required. A 10-year-old girl presented with fever and right-lower-quadrant pain. Computed tomography showed a multiloculated mass. During laparotomy, the cecum was found to be densely adherent to the pelvic organs and bowel, so the surrounding abscess was drained. Interval appendectomy was refused. The patient returned 8 months later with recurrent acute appendicitis and an appendiceal abscess requiring appendectomy and drainage. Although initial drainage alone of appendiceal abscess is efficacious, the authors strongly advocate interval appendectomy as a critical component of the complete management of this entity.

Abscess↗
PubMed1999

The impact of intraoperative culture on treatment and outcome in children with perforated appendicitis.

BACKGROUND: Most protocols for the operative treatment of perforated appendicitis use a routine culture. Although isolated studies suggest that routine culture may not be necessary, these recommendations generally are not based on objective outcome data. METHODS: The authors reviewed the records of 308 children who underwent operative treatment for perforated appendicitis between 1988 and 1998 to determine if information gained from routine culture changes the management or improves outcome. Inclusion criteria included either gross or microscopic evidence of appendiceal perforation. RESULTS: Mean patient age was 7.5 years, 51% were boys, and there was no mortality. The majority of children (96%) underwent culture that was positive for either aerobes (21%), anaerobes (19%), or both (57%). Antibiotics were changed in only 16% of the patients in response to culture results. The use of empiric antibiotics, as compared with modified antibiotics, was associated with a lower incidence of infectious complication, shorter fever duration, and decreased length of hospitalization. We also investigated the relationship between culture isolates and antibiotic regimens with regard to outcome. The utilization of antibiotics suitable for the respective culture isolate or organism sensitivity was associated with an increased incidence of infectious complication and longer duration of both fever and length of hospitalization. Finally, the initial culture correlated poorly with subsequent intraabdominal culture (positive predictive value, 11%). CONCLUSION: These outcome data strongly suggest that the practice of obtaining routine cultures can be abandoned, and empiric broad spectrum antibiotic coverage directed at likely organisms is completely adequate for treatment of perforated appendicitis in children.

Adolescent↗
PubMed1999

Helical CT of appendicitis and diverticulitis.

The clinical diagnosis of appendicitis and diverticulitis remains challenging. Clinical diagnosis alone can lead to unnecessary hospitalizations and surgeries, prolonged periods of hospital observation, and delays prior to necessary medical or surgical treatment. Helical CT combined with recently reported techniques for imaging appendicitis and diverticulitis offers rapid and accurate confirmation or exclusion of these entities as well as identification of alternative conditions that can clinically mimic them. More routine use of helical CT holds great promise for improving patient care and lowering hospital resource use in patients with clinically suspected appendicitis and diverticulitis.

Appendicitis↗
PubMed1989

Incidence and sonographic diagnosis of bacterial ileocaecitis masquerading as appendicitis.

533 consecutive patients with suspected acute appendicitis or appendiceal mass were examined by ultrasonography to distinguish acute appendicitis from bacterial enteritis. In 61 (11.4%) ultrasonography revealed the characteristic picture associated with bacterial enteritis of the ileocaecal region--enlarged mesenteric lymph nodes and mural thickening of the terminal ileum and caecum--but no image of the appendix. In 41 of these a bacterial infection was confirmed: infection due to Yersinia enterocolitica in 21, Campylobacter jejuni in 15, Salmonella B in 3, Salmonella C in 1, and Yersinia pseudotuberculosis in 1. In the other 20 bacteriological tests were negative (10) or not done (10). Oral barium studies, done in 15 patients, showed thickening of the terminal ileum in all of them. Only 22 of the 61 patients had diarrhoea. Yersinia enteritis clinically simulated an appendiceal mass in 17 of 22 patients, 6 of the 61 patients underwent surgery, and in all of them the appendix removed was normal. The other 55 patients recovered with conservative treatment. In 26 a planned appendicectomy was cancelled because of the sonographic findings. Bacterial enteritis limited to the ileocaecal region (bacterial ileocaecitis) seems to be responsible for an appreciable number of unnecessary appendicetomies. It has characteristic sonographic features that distinguish it from appendicitis.

Adolescent↗
PubMed1986

A practical score for the early diagnosis of acute appendicitis.

We conducted a retrospective study of 305 patients hospitalized with abdominal pain suggestive of acute appendicitis. Signs, symptoms, and laboratory findings were analyzed for specificity, sensitivity, predictive value, and joint probability. The total joint probability, the sum of a true-positive and a true-negative result, was chosen as a diagnostic weight indicative of the accuracy of the test. Eight predictive factors were found to be useful in making the diagnosis of acute appendicitis. Their importance, according to their diagnostic weight, was determined as follows: localized tenderness in the right lower quadrant, leukocytosis, migration of pain, shift to the left, temperature elevation, nausea-vomiting, anorexia-acetone, and direct rebound pain. Based on this weight, we devised a practical diagnostic score that may help in interpreting the confusing picture of acute appendicitis.

Acute Disease↗