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PubMed1996

Delayed appendectomy for appendicitis: causes and consequences.

This study was undertaken to describe the causes and consequences of delayed diagnosis and intervention in cases of appendicitis. The hospital records of adult patients undergoing appendectomy during a 4-year period (November 1989 to November 1993) were reviewed, with concentration on 40 patients who had a delay of 72 hours or more from initial symptoms to operation. The initial medical contact points for patients were walk-in clinics and community emergency departments. Definitive care was provided in a general hospital. Patients were adults with appendicitis who underwent an operation for definitive management 72 or more hours after the onset of symptoms. Length of hospital stay, reasons for delay in diagnosis, incidence of perforation, and complications were recorded. Delay in diagnosis and treatment was attributed to factors controlled by the patient in 15 cases (27.5%) and by the physician in 25 cases (62.5%). Perforation, postoperative complications, and hospital length of stay were related to the delay in diagnosis; with delay, the mean hospital length of stay was 9 days, the incidence of perforation was 90%, and major complications were recorded in 60% of the patients. Early diagnosis and surgical management for appendicitis remains an important and, at times, elusive goal. Delays of 72 hours or more have serious consequences. Patient education and the experience, intuitiveness, and persistence of the physician are important elements to improving these findings.

Adolescent↗
PubMed2003

The CT diagnosis of acute appendicitis.

In clinically equivocal cases of acute appendicitis, CT performed after the opacification of the terminal ileum and the cecum offers a significant improvement in diagnostic accuracy when compared to diagnosis based on clinical signs and symptoms alone. The method employed to opacify the bowel has been the subject of discussion in the literature. We believe that the oral administration of contrast, without the use of rectal or intravenous contrast, provides the best combination of diagnostic accuracy and convenience. The CT signs of acute appendicitis are described. Ways of minimizing the difficulties of diagnosing a ruptured appendix are discussed. Because of the radiation involved, CT should not be used routinely in acute appendicitis, but should be reserved for clinically equivocal cases.

Acute Disease↗
PubMed1999

Appendicitis and its mimickers.

Unenhanced helical CT is an accurate technique for the evaluation of patients with suspected acute appendicitis. This non-operator-dependent examination can be performed without the risk of intravenous contrast material or the delay associated with the use of oral and rectal contrast material. This article reviews the unenhanced helical CT findings of acute appendicitis and those entities that commonly mimic acute appendicitis clinically.

Acute Disease↗
PubMed1996

[Acute left-side appendicitis: diagnostic contribution of tomodensitometry].

BACKGROUND: Some cases of left-sided appendicitis related to malrotation or situs inversus have been reported. Another type of left-sided appendicitis is reported. CASE REPORT: A 9 year-old boy was admitted suffering from a 2-day history of severe left-sided abdominal pain of the lower quadrant with fever at 38 degrees C. He presented abdominal tenderness and guarding, maximal in the left lower quadrant. His leukocyte count was 22,000/mm3. Ultrasonography showed a digestive tubular structure with thick walls in the left lower quadrant. CT scan revealed a dilated right-sided appendix with localized perforation, whose extremity was located in the left lower quadrant along the lateral wall. The diagnosis was confirmed by median laparotomy. CONCLUSION: Left-sided appendicitis can also be related to a dilated right appendix with its extremity in the left lower-quadrant near the lateral wall. CT scan can then be helpful for diagnosis when ultrasonography remains unconclusive.

Appendicitis↗
PubMed1998

Ultrasonography in suspected acute appendicitis in childhood-report of 1285 cases.

OBJECTIVE: For the assessment of the diagnostic value of real-time ultrasonography (US) in children with suspected acute appendicitis (a.A.) the results of graded compression US are compared with clinical and histological final diagnoses. METHODS: In a prospective study over nearly 9 years we examined 1285 children aged 1-15 years (m=514, f=771). Using a 5-MHz curved array transducer the right lower quadrant was examined in a graded compression technique. RESULTS: Prevalence of histologically proven a.A. was remarkably low (9%). In diagnosis of acute appendicitis in childhood US achieves a sensitivity of 92%, specificity of 98%, a positive predictive value of 90% and a negative predictive value of 98%. The overall accuracy was 98%. Mesenteric lymphadenitis was seen in 181 cases (prevalence 12%) and terminal ileitis occasionally accompanied by mesenteric lymphadenitis was seen in 116 cases (prevalence 9%). CONCLUSION: In children with suspected appendicitis US of the abdomen gives great diagnostical value for differential diagnosis of a.A. and other more frequent inflammatory diseases of the ileocoecal region. Thus US provides further reliable information to the referring physician. Consequently it is necessary to perform US in each child with acute abdominal pain, even if clinical diagnosis seems to be well established.

Acute Disease↗
PubMedDate not supplied

Impact of journal articles and grand rounds on practice: CT scanning in appendicitis.

The purpose of this study was to determine whether a report in a high-impact journal published in January 1998 changed practice patterns and to further explore the impact of a review of the subject in a department of surgery grand rounds (January 2000). Charts from all patients undergoing appendectomy at our institution during three time periods (January to December 1997, January to December 1999, and January to June 2000) were reviewed. Rates of CT scanning, negative appendectomy, and perforated/gangrenous appendicitis were compared for the three periods to determine the impact of the journal article and the subject review during grand rounds on practice patterns and outcomes. Charts from 230 (88%) of 262 patients who underwent appendectomy during the time periods were available for review. Age, percentage of male patients, temperature on admission, and white blood cell count did not differ among the groups. The rate of CT scanning increased significantly from 1997 to 1999 and again in 2000 (6.7%, 43%, and 70%, respectively; P < 0.001), whereas the proportion of perforated/gangrenous appendicitis decreased significantly from 33% in 1997 and 31% in 1999 to 13% in 2000 (P = 0.012). The use of CT scanning in appendicitis increased both after publication of a report in a high-impact journal and after review during grand rounds. A rate of CT scanning above 45% appeared to affect outcomes as well.

Adult↗
PubMed2003

Granulomatous appendicitis.

Granulomatous inflammation of the appendix is uncommon. It can be caused by a variety of conditions, including systemic disorders such as Crohn's disease and sarcoidosis, and infections such as mycobacterium tuberculosis, yersinia pseudotuberculosis, parasites and fungi. Granulomatous appendicitis as an isolated pathological entity unassociated with systemic disease is rare. Isolated granulomatous inflammation of the appendix of unknown aetiology, otherwise known as idiopathic granulomatous appendicitis is extremely rare. Patients with this condition present with the typical signs and symptoms of acute appendicitis. We present a series of patients with isolated granulomatous inflammation of the appendix, and discuss the difficulties encountered in the management of this condition.

Adolescent↗
PubMed2003

Scrotal abscess originating from appendicitis: a case report.

There are numerous reports concerning the presentation of appendicitis as a urologic problem. However, scrotal abscess originating from appendicitis has rarely been described. We report a right scrotal abscess due to a preceding retroperitoneal abscess originating from retrocecal appendicitis. The scrotal abscess developed progressively following appendectomy. Scrotal exploration was carried out under the presumptive diagnosis of abscessed epididymo-orchitis. However, the patient remained febrile and had productive pus drained from the scrotum after exploration. Abdominal computerized tomography demonstrated that a large retroperitoneal abscess had accumulated at the appendectomy site. Percutaneous drainage of the retroperitoneal abscess resulted in resolution of the scrotal abscess. In cases of scrotal abscess following previous abdominal events (e.g. appendectomy), we recommend that abdominal origins should be carefully surveyed before scrotal exploration.

Abscess↗
PubMed2002

[Effect of new technologies on diagnosis and therapy of acute appendicitis].

Acute appendicitis remains a diagnosis based primarily on the history and the physical examination performed by an experienced surgeon. Ultrasonography and CT can be an useful adjunct, but they should not be used without context to the clinical picture. In therapy, open appendicectomy remains the golden standard. Laparoscopic appendectomy is reserved for special situations. Preoperative ultrasound is useful to decide upon the operative procedure. When the clinical picture and ultrasonography reveals acute appendicitis one can expect a minimal negative appendectomy- and laparotomy rate of 2.7% and 2.1%. In these situations open appendectomy is indicated. In the case where ultrasonography reveals no appendicitis, negative appendectomy rate is 31%. In this situation further abdominal exploration and thus diagnostic laparoscopy and laparoscopic appendectomy is indicated.

Acute Disease↗
PubMed2002

Schistosomal appendicitis in pregnancy.

Acute appendicitis is the most common acute surgical infection during pregnancy. Although usually pyogenic in origin, parasitic infections account for a small percentage of cases. Despite the relatively high prevalence of acute appendicitis in our environment, it is not commonly associated with schistosomiasis. We report here the association of pregnancy and appendicitis caused by Schistosoma haematobium. Schistosomiasis is very common complication of pregnancy in hyperendemic areas. Schistosome egg masses can lodge throughout the body and cause acute inflammation of the appendix, liver and spleen. Congestion of pelvic vessels during pregnancy facilitates passage of eggs into the villi and intervillous spaces, causing an inflammatory reaction. Tourism and immigration make this disease a potential challenge for practitioners everywhere.

Adult↗
PubMedDate not supplied

Neonatal pyoscrotum and perforated appendicitis.

Neonatal appendicitis is so unusual that is has been considered nonexistent. We present the case of a 6 day old male with acute scrotal swelling who was found to have a perforated appendicitis inside a hernia sac. A literature review supports the impression that neonatal appendicitis is rare; however, when it occurs inside a hernia sac, it has a good prognosis.

Appendicitis↗
PubMed2001

Active observation of children with possible appendicitis does not increase morbidity.

BACKGROUND: Attempts to maximise diagnostic accuracy and reduce unnecessary surgery have led to the hospital observation of children with suspected appendicitis but unconvincing physical signs. However, morbidity associated with perforation necessitates the prompt management of acute appendicitis and increases anxiety concerning prolonged preoperative observation. METHODS: To assess the preoperative delay and subsequent complications associated with active observation of appendicitis, we reviewed the records of 378 children who had an appendicectomy performed at the Women's and Children's Hospital during a 4-year period. RESULTS: Active observation was associated with an overall diagnostic accuracy of 93%. The mean preoperative hospital time was 12 h. The incidence of gangrene or perforation was 32%, with a mean preoperative hospital time in this group of 7 h. In view of the short preoperative waiting time in this group, we do not believe perforation in hospital to have been a frequent occurrence. The overall incidence of postoperative infective complications was 4%, with an incidence of 12% following perforation. CONCLUSIONS: Children with advanced disease often have convincing signs on presentation and are not usually subjected to a significant delay. Active observation is not associated with high postoperative morbidity.

Adolescent↗
PubMed2002

Helical CT imaging of clinically suspected appendicitis: correlation of CT and histological findings.

PURPOSE: The diagnosis of appendicitis is traditionally made on the basis of clinical findings supported by laboratory results. The aim of our study was to determine the accuracy and feasibility of using a relatively new technique of computed tomography (CT) using only colonic contrast medium. MATERIALS AND METHODS: A total of 50 patients clinically diagnosed as having appendicitis were prospectively examined before surgery with thin-collimation helical CT from the L3 level to the acetabular roof with only rectally administered colon contrast medium. The hard copy CT images were reviewed jointly by two radiologists and a consensus was reached for each patient. The results were then compared with the surgical and histological findings at appendicectomy. RESULTS: There were 35 true-positives, one false-positive, 12 true-negatives and two false-negatives for CT. This yielded an accuracy of 94%, sensitivity of 95%, specificity of 92%, positive predictive value of 97% and negative predictive value of 86%. The appendix was identified in 45 patients (90%) and obscured by an inflammatory mass in the remaining five. An alternative diagnosis was found in 10 of 12 normal CT examinations (83%). CONCLUSION: Helical CT with rectal contrast medium is a quick, well tolerated and accurate test to diagnose appendicitis. It can offer alternative, possibly non-surgical diagnosis in patients who would otherwise have undergone laparotomy.

Administration, Rectal↗
PubMed2000

Perforated appendicitis: prospective outcome analysis for 150 children.

BACKGROUND/PURPOSE: Controversy persists in the management of perforated appendicitis with regard to antibiotic choice and duration, operative timing, drain utilization, and wound closure. For 2 decades at the authors' institution, patients were treated with ampicillin, gentamicin, and clindamycin for 10 inpatient days, with drains in the abdomen, resulting in lower complication rates than most other published series. Managed care pressures have led to less aggressive medical management regimens with length of stay and financial factors viewed as principal outcome measures with little emphasis on clinical outcomes. In addition, there are little prospective data on clinical outcomes. The authors sought to determine whether our previously documented excellent quality outcomes could be maintained when modifications aimed at decreasing cost and length of stay in our protocol were instituted. METHODS: The authors monitored prospectively clinical outcomes in patients with perforated appendicitis treated according to their clinical practice guidelines over a 43-month period. Patients received a single antibiotic, piperacillin-tazobactam, intravenously for 10 days. They were permitted to go home with a percutaneous intravenous catheter for the final 5 days if medical and social criteria were met. Other practices from our earlier protocol were continued, including immediate operation, placement of Penrose drains, and primary wound closure. RESULTS: Of 150 patients treated on our protocol, major complications included intraabdominal abscess in 5 (3.3%), cecal fistula in 2 (1.3%), phlegmon in 3 (2.0%), wound infection in 4 (2.7%), and no small bowel obstructions requiring operation. None of these complications, nor their aggregate, were significantly more common than those reported in 373 patients treated over 11 years on the authors' prior protocol (chi2, P > .05). CONCLUSIONS: Prospective outcome analysis of our protocol shows that a single broad-spectrum antibiotic (allowing portions of therapy to be delivered less expensively on an outpatient basis) effectively can treat postoperative appendicitis with very few infectious complications. These outcome data provide baseline against which future protocols can be compared. All treatment modifications aimed at decreasing costs must be analyzed to ensure quality of care is not unduly compromised.

Adolescent↗
PubMed2001

Clinical versus sonographic evaluation of acute appendicitis in children: a comparison of patient characteristics and outcomes.

PURPOSE: Abdominal sonography has gained popularity in establishing the diagnosis of appendicitis in children with equivocal clinical presentations. However, no clear outcome benefits have been demonstrated to date. The authors conducted a retrospective study to compare the characteristics and outcomes of patients undergoing appendectomy after clinical evaluation only with those undergoing the procedure after sonography. METHODS: The charts of 454 consecutive patients undergoing appendectomy for acute appendicitis between January 1, 1998 and December 4, 1999 were reviewed. Patients operated on after clinical evaluation only were compared with patients operated on after abdominal sonography. RESULTS: Forty-two percent of patients (n = 191) constituted the sonography group. When compared with the clinical group, these patients had higher prevalence of female gender (52% v 38%; P =.004), longer symptom duration (2.2 +/- 2.5 v 1.6 +/- 1.6 days; P =.003), higher incidence of preoperative in-patient observation (19% v 4%; P <.001), longer duration between evaluation and operation (8.0 +/- 3.9 v 4.9 +/- 2.9 hours; P <.001), higher incidence of normal appendices on pathologic examination (13% v 6%; P =.006), and higher incidence of postoperative abscesses or phlegmons (4.4% v 1.2%; P =.04). The groups did not differ significantly in age, hospital stay, incidence of complicated appendicitis, or incidence of wound infection. CONCLUSIONS: Patients undergoing sonography before appendectomy have a longer delay before operation, a higher rate of misdiagnosis, and more postoperative complications. Limiting sonography to truly equivocal cases and using it early in the diagnostic workup may improve outcomes in this group of patients.

Abscess↗
PubMed2002

The sustained impact of an evidenced-based clinical pathway for acute appendicitis.

Appendicitis is a frequent pediatric surgical condition for which there is great variability among practitioners regarding diagnosis and postoperative management. With this in mind, the authors designed and implemented an evidence-based appendicitis clinical pathway at their institution. Establishment of the pathway resulted in decreased hospital cost, reduced hospital stay, and fewer unnecessary laboratory tests. The purpose of the current study was to determine the sustainability of the pathway beyond its initial implementation phase. The authors showed that several, but not all, favorable outcomes of the pathway were sustained. These data suggest that a clinical pathway for appendicitis at the authors' institution results in sustained beneficial effects in some but not all outcome parameters. Ongoing monitoring of pathway compliance, continued education of practitioners and nursing personnel, and identification of key pathway team member(s) responsible for the pathway system might result in a greater long-term impact of these guidelines.

Appendicitis↗
PubMed2000

Mechanic intestinal obstruction--a possible presentation of perforated appendicitis.

A 61-year-old man presented with diffuse abdominal pain, diarrhea, vomiting and fever. On the initial diagnosis of gastroenteritis the patient received the antibiotic ofloxacine for one week. On admission plain abdominal radiograph suggested a mechanic intestinal obstruction. In computed tomography a conglomerate tumor in the ileocecal region was seen and the patient underwent laparotomy. The conglomerate tumor was mobilized and an abscess opened, which was caused by a perforated appendicitis. After the operation the patient improved immediately and had an uneventful postoperative course. He was released and did not suffer from gastrointestinal symptoms the following 16 months of follow-up. The present case shall set forth that perforated appendicitis can clinically present as intestinal obstruction. Although a rare complication, perforated appendicitis should therefore even be considered in cases of mechanic intestinal obstruction of unknown cause.

Abscess↗
PubMed2003

[Acute appendicitis after colonoscopy: causality or coincidence?].

Complications due to diagnostic colonoscopy are very rare. Perforation is the most frequent colon-related event. So far only ten cases of acute appendicitis after colonoscopy have been reported in the literature. We present the case of a 79-year-old man who developed acute appendicitis after diagnostic colonoscopy. Diagnosis was aggravated by the fact that in the patient's history an appendectomy had been performed 65 years earlier. Because of the rarity of this event it is doubtful whether the endoscopic examination was causal or coincidental. However, in cases of pain after colonoscopy, appendicitis has to be included in the differential diagnosis.

Abdomen, Acute↗