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An unusual case of appendicitis in the second trimester of pregnancy is presented. The underlying pathology was shrouded by incomplete abortion. The patient's condition worsened after her uterus was evacuated and it was only at laparotomy that a ruptured appendix was discovered. The need for vigilance in suspecting appendicitis is heightened so as to reduce morbidity and mortality from appendicitis in pregnancy.
Acute appendicitis is the commonest nongynaecological surgical problem occurring during pregnancy. Almost 10 year's experience at a large teaching hospital is supplemented with an extensive review of the literature to offer guidelines for diagnosis and management. Symptoms, signs and investigations are unhelpful in diagnosis. The overwhelming message is that because perinatal mortality rises from less than 3% in both uncomplicated appendicitis and negative laparotomy, to 20% in perforated disease, the maxim regarding acute appendicitis--if in doubt, take it out--is never more true than in pregnancy.
OBJECTIVES: To determine if there are racial/ethnic differences in the rates of appendiceal rupture among the children of two large states. Because rupture is primarily due to delayed diagnosis, differences would suggest disparities in timely access to quality emergency care. METHODS: This was an observational, cross-sectional analysis of full-year samples of acute appendicitis cases from California and New York children 4 to 18 years old. Racial/ethnic groups were compared for risk of appendiceal rupture adjusted for biological factors both before and after adjustment for the following socioeconomic, hospital, and admission characteristics: income, insurance, hospital type, and admission source. Results were interpreted in light of census data on the proportion of immigrants in each racial/ethnic group. RESULTS: Compared with white children with acute appendicitis, Hispanic and Asian children have higher odds of rupture in California, whereas Asian and black/African American children have higher odds in New York. These differences roughly parallel the within-state proportion of immigrant children in these groups. Adjustments for family, socioeconomic, and hospital characteristics attenuate but do not eliminate disparities. CONCLUSIONS: The authors found evidence of significant racial/ethnic disparities in rate of appendiceal rupture, an important and preventable outcome, in two large but dissimilar states. Immigrant groups may be most at risk for delayed emergency care. Future research should focus on immigration and acculturation as risk factors for appendicitis rupture in children.
Three cases of appendicitis associated with presence of Schistosoma haematobium eggs in the appendix tissue are reported. The patients (two males and one female) were all from Ghana and had immigrated to Italy a few years previously. It is difficult to attribute the cause of the appendicitis to the parasite; it is more probable that the appendicular location of the eggs occurred accidentally many years earlier in an endemic zone of the country of origin, and that recently bacterial agents were able to provoke the present appendicitis. Since it is probable that with the increase in the number of immigrants to Europe from endemic countries (sub-Saharan Africa in particular) other similar cases may occur, it is important that the surgeon and the pathologist be aware of this pathology, which has so far been considered unusual.
Appendicitis is said to be uncommon and difficult to diagnose in cystic fibrosis. The clinical and radiological features in nine patients with cystic fibrosis who had appendicitis were studied. All but one of the patients had an appendiceal abscess at surgery. Four patients had a delay in diagnosis of greater than three days before the correct diagnosis was made. This delay may have been due to a more indolent presentation or because these patients were initially considered to have distal intestinal obstruction syndrome. Appendicitis should be considered in the differential diagnosis if a contrast enema demonstrates extrinsic compression of the caecum. Ultrasound, computed tomography, and gallium scans were found to be of limited help in our series.
Hospital discharge rates after acute appendicitis were analysed in relation to the provision of household amenities and diet in 73 areas of England and Wales, nine health board areas in Scotland, and all eight health board areas of Eire. The rates of acute appendicitis correlated with the percentage of households lacking amenities, in particular fixed baths and hot water systems. Consumption of green vegetables was an additional influence on the geographical distribution of the disease. These findings support a relation between appendicitis and hygiene, which would explain both the rise and fall of the disease during this century.
OBJECTIVES: To determine whether diagnosis by graded compression ultrasonography improves clinical outcomes for patients with suspected appendicitis. DESIGN: A randomised controlled trial comparing clinical diagnosis (control) with a diagnostic protocol incorporating ultrasonography and the Alvarado score (intervention group). SETTING: Single tertiary referral centre. PARTICIPANTS: 302 patients (age 5-82 years) referred to the surgical service with suspected appendicitis. 160 patients were randomised to the intervention group, of whom 129 underwent ultrasonography. Ultrasonography was omitted for patients with extreme Alvarado scores (1-3, 9, or 10) unless requested by the admitting surgical team. MAIN OUTCOME MEASURES: Time to operation, duration of hospital stay, and adverse outcomes, including non-therapeutic operations and delayed treatment in association with perforation. RESULTS: Sensitivity and specificity of ultrasonography were measured at 94. 7% and 88.9%, respectively. Patients in the intervention group who underwent therapeutic operation had a significantly shorter mean time to operation than patients in the control group (7.0 v 10.2 hours, P=0.016). There were no differences between groups in mean duration of hospital stay (53.4 v 54.5 hours, P=0.84), proportion of patients undergoing a non-therapeutic operation (9% v 11%, P=0.59) or delayed treatment in association with perforation (3% v 1%, P=0.45). CONCLUSION: Graded compression ultrasonography is an accurate procedure that leads to the prompt diagnosis and early treatment of many cases of appendicitis, although it does not prevent adverse outcomes or reduce length of hospital stay.
The role of schistosomes in the pathologenesis of acute appendicitis in an endemic area was investigated. Of 1600 appendicectomies received in our laboratory, 26 showed appendiceal schistosomiasis, which prompted what we believe to be the first detailed histopathological evaluation of all appendices with schistosomal infestation, without prior knowledge of the clinical and operative diagnoses. The results suggest that there are two types of schistosomal appendicitis, each with distinct clinicopathological features and different pathogenetic mechanisms. They could be called obstructive and granulomatous schistosomal acute appendicitis, respectively.
During 1979-82 hospital discharge rates after emergency admission for acute appendicitis were higher in Eire (17.4 per 10,000 population) than in England (10.3), Scotland (11.1), or Wales (12.3). Comparison of food consumption between the four countries, and between the health board areas of Eire and regions of Scotland, shows that appendicitis rates are highest in communities that consume more potatoes, sugar, and cereals, and less non-potato vegetables and fruit. The rates are also related to mortality from enteric and respiratory infections, to general practice consultations for infective disease, and to postneonatal mortality. This is evidence in favour of the hygiene hypothesis for the aetiology of appendicitis.
The extension of piped water supplies in Anglesey, North Wales, 30 years ago and the consequent introduction of domestic hot water systems was followed by an epidemic of appendicitis. This occurred while appendicitis rates were falling elsewhere in Britain. The diet of Anglesey is unremarkable. This is further evidence that epidemics of appendicitis occur during the transition to 'western' hygiene, an important component of which is the provision of domestic hot water systems and fixed baths.
A case of carcinoma of the caecum is reported, which presented as acute appendicitis, although the carcinoma did not obstruct either the lumen of the appendix or the colon. The prognosis for caecal or proximal colonic neoplasm presenting as appendicitis is poor. This is in part due to the association being missed at the initial laparotomy. It is suggested that a more aggessive attitude should be taken in the pre- and post-operative management of any patient over 50 years of age who presents with appendicitis. The difficulties of identifying a small tumour at laparotomy even if the mucosa can be palpated are emphasized.
Acute appendicitis is the most common condition requiring emergent abdominal surgery in childhood. The clinical diagnosis of acute appendicitis is often not straightforward because approximately one-third of children with the condition have atypical clinical findings. The delayed diagnosis of this condition has serious consequences, including appendiceal perforation, abscess formation, peritonitis, sepsis, bowel obstruction, and death. Cross-sectional imaging with ultrasonography (US) and computed tomography (CT) have proved useful for the evaluation of suspected acute appendicitis. There has been a great deal of variability in the utilization of these modalities for such diagnosis in the pediatric population. The principal advantages of US are its lower cost, lack of ionizing radiation, and ability to assess vascularity through color Doppler techniques and to provide dynamic information through graded compression. The principal advantages of CT include less operator dependency than US, as reflected by a higher diagnostic accuracy, and enhanced delineation of disease extent in a perforated appendix.
PURPOSE: To determine retrospectively the sensitivity and specificity of computed tomographic (CT) signs in differentiating acute nonperforated appendicitis from perforated appendicitis and to compare CT findings with the length of hospital stay. MATERIALS AND METHODS: Institutional Review Board approval was obtained for this study, and patient informed consent was obtained for record review for research purposes. Two radiologists were blinded to patient identification but were informed that all patients presented to the emergency department with abdominal pain and underwent appendectomy. Radiologists independently reviewed CT images of 86 consecutive patients (45 males, 41 females; mean age, 33.7 years; age range, 8.2-87.1 years) who presented to the emergency department with acute abdominal pain, who underwent CT after initial emergency department assessment, and who underwent appendectomy within the subsequent 24 hours. Individual findings and confidence level for the diagnosis of perforated appendicitis were noted. Consensus interpretation was performed with a third radiologist. The consensus CT findings were correlated with the surgical and pathologic findings by using chi(2) or Fisher exact tests for univariate analysis and logistic regression for multiple variable analysis. Wilcoxon rank sum tests were used to assess the association between consensus CT findings and length of hospital stay. RESULTS: Twenty-one (24%) of the 86 patients had appendiceal perforation. Extraluminal air and either moderate or severe periappendiceal inflammatory stranding were statistically significant independent predictors for perforation (P < .001). A focal defect in enhancing appendiceal wall was significantly associated with perforation (P < .001) and had a sensitivity of 58.8% and specificity of 85.7% on consensus review, with eight false-positive results. There was a strong association between the degree of periappendiceal inflammatory stranding and the length of hospital stay (P < .001). CONCLUSION: Extraluminal air and moderate or severe periappendiceal inflammatory stranding are statistically significant independent predictors for appendiceal perforation and are associated with increased hospital stay.
PURPOSE: To prospectively compare the diagnostic performance of ultrasonography (US) and unenhanced multi-detector row computed tomography (CT) in patients suspected of having acute appendicitis by using surgery or clinical follow-up as the reference standard. MATERIALS AND METHODS: The institutional review board approved the research protocol. Written informed consent was obtained from all patients or, for those who were adolescents, from their parents. Ninety-four patients (59 female and 35 male patients) aged 16-81 years (mean, 38 years) who were suspected of having acute appendicitis underwent both US and unenhanced multi-detector row CT of the entire abdomen. The examinations were performed within 1-2 hours of each other. US and CT images were obtained and prospectively interpreted by a different radiologist from a group of abdominal radiologists or a group of residents and general radiologists. Radiologists proposed an overall diagnosis and an alternative diagnosis. Data from US and CT were compared, and the definite diagnosis was established with surgical findings (n = 40) or results of clinical follow-up (n = 54) as the reference standard. Comparisons were made for each group of radiologists and the patient's age, body mass index (BMI), and sex. Proportion comparisons were made by using the Pearson chi2 test or the Fisher exact test. Continuous variables were compared between groups with the Mann-Whitney U test. RESULTS: Thirty patients had definite appendicitis. The sensitivity, specificity, positive and negative predictive values, and accuracy were not significantly different between US and CT or between groups of radiologists (P values ranged from .389 to >.99), regardless of the patient's BMI (P values ranged from .073 to >.99). Misclassifications were compared with the definite alternative diagnosis and were not significantly different between US and CT or between groups of radiologists (P = .061-.592), regardless of patient age (P = .875) or sex (P = .151 and >.99 for male and female patients, respectively). The frequency of inconclusive examinations, however, was significantly higher with US than with CT, regardless of radiologist experience (P = .020 and <.001, respectively). CONCLUSION: Although the diagnostic performances of US and multi-detector row CT are comparable, more inconclusive images were obtained with US.
Ultrasound (US) examination during graded compression was performed in 60 consecutive patients with clinical signs of acute appendicitis. In 25 (89%) of 28 patients with confirmed appendicitis, the inflamed appendix was visualized by US. Perforation was predictable in six of seven patients. In 32 patients without appendicitis, the appendix was not visualized. Graded-compression US is the examination of choice if there is doubt whether an appendectomy should be performed.
In a patient who had received presurgical radiation therapy for extensive rectal carcinoma, ultrasonography with graded compression disclosed an inflamed appendix. The patient had no clinical signs of acute appendicitis. At laparotomy for resection of the rectal carcinoma, the appendix appeared grossly abnormal and was removed. Pathologic examination showed severe radiation enteritis of the appendix. The sonographic appearance of radiation appendicitis closely resembled that of acute appendicitis.
PURPOSE: To document findings in a subgroup of patients with acute appendicitis that spontaneously resolved. MATERIALS AND METHODS: From February 1989 through December 1995, nine patients were seen with a diagnosis of acute appendicitis that did not necessitate immediate surgery. Clinical, ultrasound (US), and pathologic findings were retrospectively reviewed. RESULTS: Four of the nine patients underwent elective appendectomy 15-84 days (mean, 52 days) after initial presentation, and five did not undergo surgery. Seven patients experienced spontaneous pain relief before admission to the hospital, and two improved within a few hours of being admitted. No patient had an indication of peritoneal irritation at physical examination. Four patients had a normal white blood cell count, and five had leukocytosis. Maximum appendiceal diameter was 9-12 mm. Five patients had inflamed periappendiceal fat. No patient had abscess or appendicolithiasis shown at US. A normal appendix was identified at follow-up (mean, 40 months; range, 1-60 months) in four of five patients who did not undergo elective appendectomy. Two patients experienced recurrent bouts of pain, and one of these patients underwent appendectomy before the planned elective procedure. CONCLUSION: On the basis of clinical, US, and pathologic findings, mild acute appendicitis spontaneously resolved in a subgroup of patients.
Acute appendicitis is a common clinical problem. Accurate and prompt diagnosis is essential to minimize morbidity. While the clinical diagnosis may be straightforward in patients who present with classic signs and symptoms, atypical presentations may result in diagnostic confusion and delay in treatment. Helical computed tomography (CT) and graded compression color Doppler ultrasonography (US) are highly accurate means of establishing the diagnosis. These imaging modalities have now assumed critical roles in the treatment of patients suspected to have appendicitis. The purpose of this article is threefold: to provide an update on new information regarding the pathophysiology, clinical diagnosis, and laparoscopic treatment of acute appendicitis; to describe the state-of-the art use of CT and US in diagnosing this disease entity; and to address the role of medical imaging in this patient population.