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PubMed1980

Laparoscopy for questionable appendicitis: can it reduce the negative appendectomy rate?

Laparoscopy has been performed in 32 patients in whom the diagnosis of appendicitis was suspected, but in whom clinical findings were equivocal and insufficient to establish the diagnosis. These patients represented 13.6% of the total group of patients admitted with questionable appendicitis during this period. Fifty per cent of these 32 patients had unusual clinical features, such as a prolonged history of symptoms, significant intercurrent disease, prior treatment with antibiotics or steroids, etc. At laparoscopy, the diagnosis of acute appendicitis was made in 17 patients. Another disease was diagnosed in 8 patients, and 7 were judged to have no pathologic abnormalities. There were two false negative examinations and one false positive, but no ruptured appendices resulted. Twelve patients (37.5%) were spared operation by laparoscopy. The negative appendectomy rate was decreased from 10 to 1%.

Adolescent↗
PubMed1983

Scoring system to aid in diagnoses of appendicitis.

Problems related to the diagnosis of appendicitis are evidenced by the significant negative laparotomy rate. The present study sought to assess the feasibility of decreasing this diagnostic error by studying two groups of patients and identifying and weighing details of history, physical examination and laboratory findings utilizing 23 predictive factors. One hundred consecutive cases of proven appendicitis (AAp) were retrospectively reviewed and compared with 100 consecutive cases that had normal appendices removed because of erroneous preoperative diagnosis of appendicitis (NAp). Rates of occurrence for each predictive factor were determined separately for both groups. These were converted into weights which were then added to yield a diagnostic score for each patient. A cutoff point established the score which designated one group for observation and the other for surgery. Scores were assessed at three different points by balancing risks of missed diagnoses against benefits of avoiding unnecessary operations. Seven predictive factors had differentiating weights and reached statistical significance (p less than or equal to 0.05):-sex, age, duration of symptoms, GU symptoms, involuntary right lower quadrant muscle spasm, right-sided rectal mass, and white blood cell count. Using these seven predictors, at a "-3" cutoff, 38% NAPs would have been spared laparotomy and about 5% of the AAps would have been indicated for observation. Analysis indicated little risk in observing the 5% AAp (5/7 history less than or equal to 1 day), and progressive improvement for NAps with increasing time. This simple scoring system could have eliminated over one third of the unnecessary laparotomies in the present sample, indicating potential value as an aid in surgical decision-making.

Acute Disease↗
PubMed1985

Appendicitis in mature patients.

All patients greater than 50 years of age (N = 96) admitted with a pre- or postoperative diagnosis of acute appendicitis from 1971 to 1980 were reviewed. A comparative series of 91 patients aged 25 to 50 years was similarly reviewed. Noninflammatory diseases of the appendix and incidental appendectomies were excluded. Detailed study of symptoms, clinical presentation, laboratory evaluation, radiographic evaluation, concomitant diseases, hospital course, surgical findings, complications, and mortality were completed. Comparison of patients aged 25 to 50 to patients older than 50 years revealed a statistically significant increased incidence of perforation in the older group (p less than 0.0001). Sixty-five per cent of the older group showed greater incidence of perforation. Further analysis of this series yields the hypothesis that the increased incidence of perforation is related to a significant decrease in the frequency of classic presentation in the greater-than-50 age group, a significant decrease in frequency of correct admission diagnosis and a significant delay between admission and surgical procedure in the older group. A more rapid pathophysiologic progression of appendicitis with increasing age was noted. A much higher percentage of older patients was undiagnosed until the surgical procedure. In this group, there was a longer duration of symptoms, less frequent classic presentation, and decreased frequency of right lower quadrant guarding and tenderness as compared to patients with correct diagnosis prior to surgery. Complications were much more frequent in older patients and higher still in those with perforation. Analysis of findings by decade of life revealed an anticipated high incidence of perforated appendicitis in patients greater than 50, but also showed a continuation of the high incidence of perforation into the decade 40 to 50. There were three deaths in the entire study group (1.6%) all occurring in the older age group with postoperative sepsis.

Acute Disease↗
PubMed1991

Acute appendicitis following blunt abdominal trauma. Incidence or coincidence?

Inflammation of the appendix is a common cause of acute abdominal pain. The etiology and pathophysiology of appendicitis have been well described. The initiating factor often is obstruction of the appendiceal lumen by inspissated stool, barium, food, parasites, or hyperplastic lymphoid tissue. Two patients have been identified who developed appendicitis temporally related to blunt abdominal trauma, without other clear etiology. Although absolute documentation of trauma as an etiologic factor in these cases is difficult, theoretical mechanisms for the occurrence are discussed. In the setting of right lower quadrant pain following mild to moderate blunt abdominal trauma, acute appendicitis should be considered as a possibility.

Abdominal Injuries↗
PubMed2000

Bacteriology of histopathologically defined appendicitis in children.

BACKGROUND: Acute appendicitis is the most common surgical emergency in childhood. However, the pathogenesis and detailed microbiology are obscure. OBJECTIVE: To determine in detail the bacterial etiology of appendicitis in children in relation to the histologic tissue pathology. STUDY DESIGN: Tissue samples obtained at surgery from 41 children with suspected acute appendicitis were examined histologically and by culture for aerobic and anaerobic bacteria. The patients were analyzed according to histopathologic and clinical findings. RESULTS: Aerobic and anaerobic species were isolated from 40 of 41 (98%) samples; on average, 14.1 isolates per specimen (10.4 anaerobes and 3.7 aerobes). Specimens from patients with gangrenous appendices yielded significantly higher numbers of anaerobic isolates per specimen than did specimens from patients with healthy appendices (11.7 vs. 7.7; P < 0.01). Bacteria belonging to the Bacteroides fragilis group were the most frequently isolated anaerobic microorganisms (95%). Other organisms frequently isolated in all histology groups were Peptostreptococcus micros (66%), Bilophila wadsworthia (63%), Fusobacterium nucleatum (44%), Eggerthella lenta (44%) and a hitherto undescribed bile-resistant, pigment-producing Gram-negative rod (41%). Of the aerobes Escherichia coli (88%) and Streptococcus anginosus group (former Streptococcus "milleri" group) organisms (61%) were the most frequent findings. CONCLUSIONS: The shift from histologically normal toward gangrenous appendices was clearly associated with markedly elevated anaerobic bacterial counts in terms of species. The unusually high frequencies of B. wadsworthia (75%) and the hitherto undescribed bile-resistant, pigment-producing Gram-negative rod (56%) in gangrenous appendices represent unique and different findings from those reported in adults.

Adolescent↗
PubMed1995

Acute appendicitis: a cause of recurrent abdominal pain in pediatric trauma.

When traumatic abdominal injury and acute appendicitis occur within a short period of time, the diagnosis can be difficult and may result in a delay in treatment of the appendicitis. We report the case of a four-year-old boy with documented intraabdominal injury from a motor vehicle crash who developed appendicitis while hospitalized and recovering from his injuries.

Abdominal Injuries↗
PubMed2000

Appendicitis in the young child: a continuing diagnostic challenge.

OBJECTIVE: The purpose of this review was to examine the presenting signs and symptoms of children 5 years of age or less who underwent operation for appendicitis. In addition, we sought to determine the rate of perforation of the appendix and the effect on outcome in this age group. METHODS: Medical records for the period September 1987 to September 1998 were reviewed for all children 5 years of age or less who underwent appendectomy for appendicitis. Data gathered included age at operation, gender, care sought prior to admission for appendectomy, duration of symptoms, signs and symptoms at the time of admission, and length of postoperative hospital stay. Symptoms of diarrhea, emesis, fever, pain, and anorexia were recorded. Physical signs of an abdominal mass, guarding, rebound tenderness, rigidity, and diffuse or focal tenderness were recorded. Diagnostic information included white blood cell count with differential, and radiographic imaging, if obtained. The presence or absence of perforation of the appendix, and abscess formation were based on the intraoperative impression of the operating surgeon. RESULTS: For the 11-year period, 120 patients 5 years of age or less required an operation for appendicitis and had a complete medical database. The mean age was 3.6 +/- 1.3 years; 53% were male. Patients underwent a separate medical evaluation prior to arriving at a definitive diagnosis in 44.2 % cases. The most common presenting symptom was abdominal pain (94%); the most common sign was abdominal tenderness (95.8%). Tenderness was generally diffuse if perforation had occurred (62%) or focal in the nonperforated group (61%). The duration of symptoms in patients with perforation was more than double that of the nonperforated patients (4.7 vs 2.1 days, respectively). The mean white blood cell count (WBC) was 18.3 +/- 7.4 cells/mm3, and did not differ significantly between the perforated and nonperforated groups. A left shift detected in the WBC differential was present in 91%. An abdominal radiograph was obtained in 87%, and demonstrated a fecalith in 18%. A preoperative ultrasound was obtained in 38%, a computed tomographic scan in 7%. At the time of surgery, 74% were found to have evidence of perforation. An abscess was found at the initial surgery in 47% of patients with appendiceal perforation, but in no patient in whom perforation had not occurred. The rate of perforation increased as the age of the patient decreased (100% perforation for age 1 (n = 10) to 69% for age 5, (n = 35). Perforation was associated with a longer hospital length of stay as compared to the nonperforated appendix (median 9 days vs. 3 days, respectively, P < 0.001). There were no deaths in this series. CONCLUSION: Appendiceal perforation continues to be a common occurrence in the young child and increases in frequency as the age of the patient decreases and the duration of symptoms lengthens. Perforation results in a significant increase in hospital length of stay and rate of abscess formation.

Appendicitis↗
PubMed1981

Appendicitis in a barium-filled appendix.

Fourteen cases of appendicitis developing in an appendix with prolonged retention of barium have been previously described. A 15th case is herein presented. Present reports are inadequate to determine the normal period of retention of barium in an appendix after contrast study. No conclusions can be drawn as to whether the retained barium causes appendicitis by a sequence of events or whether the retained barium merely demonstrates a previously existing abnormality in the appendix or has no pathologic significance. A patient in whom barium is retained in the appendix should, as a minimum step, be informed that appendicitis may develop and that he should consult his physician if abdominal symptoms develop. Interval appendectomy for the asymptomatic patient with prolonged retention of barium cannot be justified by the present body of case reports.

Adult↗
PubMed1988

Delayed diagnosis in pediatric appendicitis.

Delay in appendectomy occurs from failure to contact a physician, or from a physician's failure to make a proper diagnosis. In our study delay was due to physician error in 32 of 422 children who had appendectomy. Symptoms consistent with appendicitis were documented on the initial visit in each case, but 22 patients had a history of previous similar pain or recent viral illness to confuse the diagnosis. Misdiagnosis was responsible for the delay in 14 cases (gastroenteritis in ten and urinary tract infection in four). Antibiotics given before proper diagnosis in 22 instances increased diagnostic difficulty in 20. Late referral is increasing, perhaps because of a perceived innocuous nature of appendicitis. Complicated appendicitis was found in 26 children (81%), compared with 38% of the total experience. Their hospital stay averaged nine days, as opposed to 6.6 days in the nondelayed group. Failure of resolution of symptoms after therapy begins mandates reassessment to avoid progression of this common surgical disease.

Abscess↗
PubMed1992

Appendicitis complicating pregnancy.

In this series, nine pregnant patients had appendectomy. Seven patients had acute appendicitis; pyuria and symptoms suggesting urinary tract infection delayed diagnosis in one whose appendix perforated. Abdominal pain and nausea with or without vomiting were presenting symptoms in all of the patients. Tenderness in the right lower quadrant was present in six. Eight patients, including two with a normal appendix, had leukocytosis with a left shift. There was no fetal or maternal loss. In addition, I reviewed more than 900 other cases of appendectomy during pregnancy, as reported in the literature since 1960. Among 713 previously reported cases of confirmed appendicitis, rupture had occurred in 25%. There were five maternal deaths, all in the group of patients with perforation. Perinatal mortality was 4.8% among patients with acute inflammation only and 19.4% in those with perforative appendicitis. The diagnosis rests on clinical acumen, and prompt surgical intervention is the key to good outcome.

Acute Disease↗
PubMed1986

Matched case-control study of adjusted versus nonadjusted gentamicin dosing in perforated and gangrenous appendicitis.

A matched case-control study of the efficacy of gentamicin dosage adjustment through the use of pharmacokinetic analysis of serum drug concentrations in patients treated by appendectomy for perforated or gangrenous appendicitis was performed. Two groups of patients were compared. In one group gentamicin was initiated preoperatively at 1.5 mg/kg Intravenous Piggy Back (IVPB) every 8 h. Postoperatively, serum levels were obtained to maintain peak concentrations within a range of 6-8 micrograms/ml. The comparison group was given gentamicin without measurement of drug levels. Both groups received clindamycin 600 mg IVPB every six h. Matched cases and control subjects were compared, controlling for pathologic state of the appendicitis, age, and sex. The patients were predominantly young men with normal renal function. More patients in the nonadjusted group had infectious complications than in the dose-adjusted group. There were seven failures (11.3%) in the nonadjusted group compared with only one failure (1.6%) in the dose-adjusted group, a significant difference (p = 0.03). Among the nonadjusted group, the complications were four abdominal abscesses, two wound infections, and one persistent high fever. There was no evidence of nephrotoxicity in either group. Our recommendations are that patients who are to undergo appendectomy for perforated/gangrenous appendicitis should be treated with clindamycin and gentamicin at a dose of 1.5 mg/kg. With normal renal function, an interval of 8 h is appropriate. Serum gentamicin levels should be obtained and the dose adjusted to maintain peak concentrations of 6-8 micrograms/ml.

Adult↗
PubMed2000

Effectiveness of imaging studies in acute appendicitis: a simplified decision model.

Computed tomography (CT) and ultrasonography (US) have been proposed as non-invasive diagnostic aids in patients with suspected acute appendicitis. Currently, clear guidelines about the indications to use these techniques are lacking. Using the concepts of decision analysis, a model was created to calculate the effectiveness of US and CT in patients with clinically suspected appendicitis. The perspective chosen was the health of individual patients. The model makes use of published data and provides a critical threshold probability (ctp). Decisions in individual cases can be made by comparing ctp with the clinical probability of disease. The calculated ctp-values for US and CT were 0.58 and 0.74, respectively. In other words, on average, US (CT) is indicated only if the expert clinician considers the probability of disease to be smaller than 58% (74%). It is concluded that in patients with suspected acute appendicitis, selective rather than routine use of imaging studies is recommended. The exact value of the decision threshold should be determined in function of the local situation.

Acute Disease↗
PubMed2003

The role of the emergency medicine resident using the Alvarado score in the diagnosis of acute appendicitis compared with the general surgery resident.

PURPOSE: To compare the accuracy of diagnosing appendicitis between emergency medicine residents using the Alvarado score and general surgery residents using ultrasonography and their clinical provision. METHODS: A total of 358 patients (192 men and 166 women) were admitted to the emergency service with suspected appendicitis. Each patient was evaluated by an emergency medicine resident and then by a general surgeon independently. Age, sex, operational data, diagnosis, and the Alvarado scores were measured. RESULTS: The sensitivity and specificity of the Alvarado score were 95.4% (95% confidence interval 91-99%) and 45.7% (95% confidence interval 37.4-54%), respectively. There was a significant difference between the sexes in the predictive values of a positive test (P=0.045) and a negative test (P=0.02). There was no statistical difference between the emergency medicine residents and general surgery residents in terms of positive and negative predicitive values (P>0.05 each). CONCLUSION: There was no statistical difference between the emergency medicine residents using the Alvarado score and the general surgery residents in terms of suspecting the diagnosis of appendicitis.

Abdominal Pain↗
PubMed2006

Update on appendicitis: diagnosis and presurgical management.

PURPOSE OF REVIEW: Practitioners who see pediatric patients with acute complaints are commonly faced with making the diagnosis of appendicitis. While sometimes the history and physical examination are sufficient, frequently some diagnostic confirmation will be necessary. While diagnostic imaging is frequently useful, it may not be easily obtained. Blood tests are more readily available, with less cost and risk, but unclear diagnostic accuracy. Other questions for the initial examiner are when to consult the surgeon and if analgesia administration will obscure the diagnosis. RECENT FINDINGS: Abdominal computed tomography scans and ultrasound scans have been shown to be accurate in the diagnosis of acute appendicitis. The literature has begun to focus on which patients should undergo imaging studies. Several clinical decision rules that may be helpful in identifying low-risk patients have been derived. Analgesia given before establishing a diagnosis does not appear to change outcomes. SUMMARY: A careful history and physical examination will identify a minority of pediatric appendicitis cases. When diagnostic testing is needed, computed tomography scanning has the best test performance, but also carries the risk of radiation. Elimination of a portion of low-risk patients may reduce unnecessary imaging.

Appendicitis↗
PubMed2006

Computed tomography diagnosis of acute appendicitis: advantages of reviewing thin-section datasets using sliding slab average intensity projection technique.

OBJECTIVES: We sought to compare sliding slab mode and standard stack mode in the computed tomography (CT) diagnosis of acute appendicitis. MATERIALS AND METHODS: Contrast-enhanced CT was performed in 85 patients, 35 of whom had appendicitis. Four readers retrospectively reviewed 5-mm thick transverse sections (4-mm increment) using the stack mode and 2-mm thick sections (1-mm increment) with the sliding slab, average intensity projection. The sliding slab mode started with a 5-mm thick transverse slab, but the readers were encouraged to change the viewing angle and the slab thickness. RESULTS: In sliding slab mode, the readers changed the viewing angle in 89 of 340 observations (24%) and decreased the slab thickness in 26 observations (8%). Although the receiver operating characteristic analysis did not show a significant difference (P = 0.18), the sliding slab mode enhanced the pooled sensitivity (93.6% vs. 98.6%, P = 0.02), specificity (92.0% vs. 97.5%, P = 0.01), and mean confidence for the diagnosis (P < 0.001) or exclusion (P = 0.002) of acute appendicitis; reduced inconclusive interpretations (5.6% vs. 1.8%, P = 0.01); and visualized the appendix more clearly (P < 0.001). CONCLUSIONS: Compared with the stack mode, the sliding slab mode enhances diagnostic confidence and more clearly visualizes the appendix.

Acute Disease↗
PubMed2003

Gangrenous appendicitis in a strangulated obturator hernia.

Only two cases of appendicitis in strangulated obturator hernia have been previously reported. In the present case, an 83-year-old woman had fatal anaerobic myonecrosis of the thigh that resulted from gangrenous appendicitis in the right obturator foramen. Early diagnosis, prompt surgical intervention, and perioperative resuscitation are critical for survival in a case of appendicitis in a strangulated obturator hernia with thigh sepsis, especially when it occurs in an elderly, emaciated female patient.

Aged↗
PubMed1996

Metastasis from small cell carcinoma of the lung producing acute appendicitis.

A case of acute gangrenous appendicitis with perforation caused by metastatic small cell carcinoma of the lung in a 65 year old man is reported. The manifestation of appendicitis occurred more than 4 years after the diagnosis of the bronchogenic carcinoma. With longer survival of patients with disseminated tumors it is probable that new manifestations of those malignancies will be discovered. Acute appendicitis due to metastasis from a distant neoplasm should be considered in the differential diagnosis of right lower abdominal pain in the oncology patient.

Abdomen, Acute↗
PubMed2005

Optimum duration of prophylactic antibiotics in acute non-perforated appendicitis.

BACKGROUND: The effect of extended prophylactic antibiotic therapy on postoperative infective complications such as wound infection and intra-abdominal abscess for non-perforated appendicitis is poorly defined. METHODS: In a randomized controlled trial of 269 patients aged 15-70 years with non-perforated appendicitis undergoing open appendicectomy; 92 received single dose preoperative (group A), 94 received three-dose (group B) and 83 received 5-day perioperative (group C) regimens of cefuroxime and metronidazole. Postoperative infective complication was the primary endpoint. Secondary outcomes included length of hospital stay and complications related to antibiotic therapy. RESULTS: The rate of postoperative infective complication was not significantly different among the groups (6.5% group A, 6.4% group B, 3.6% group C). The duration of antibiotic therapy had no significant effect on the length of hospital stay. Complications related to antibiotic treatment were significantly more common for 5-day perioperative antibiotic group (C) compared with single dose preoperative antibiotic group (A) (P = 0.048). CONCLUSION: Single dose of preoperative antibiotics is adequate for prevention of postoperative infective complications in patients with non-perforated appendicitis undergoing open appendicectomy. Prolonging the use of antibiotics can lead to unnecessary antibiotic related complications.

Adolescent↗