Laparoscopic treatment of perforated appendicitis

PubMed Central

Lin, Heng-Fu; Lai, Hong-Shiee; Lai, I-Rue

2014-01-01

The use of laparoscopy has been established in improving perioperative and postoperative outcomes for patients with simple appendicitis. Laparoscopic appendectomy is associated with less wound pain, less wound infection, a shorter hospital stay, and faster overall recovery when compared to the open appendectomy for uncomplicated cases. In the past two decades, the use of laparoscopy for the treatment of perforated appendicitis to take the advantages of minimally invasiveness has increased. This article reviewed the prevalence, approaches, safety disclaimers, perioperative and postoperative outcomes of the laparoscopic appendectomy in the treatment of patients with perforated appendicitis. Special issues including the conversion, interval appendectomy, laparoscopic approach for elderly or obese patient are also discussed to define the role of laparoscopic treatment for patients with perforated appendicitis. PMID:25339821

Clinical use of MRI for the evaluation of acute appendicitis during pregnancy.

PubMed

Patel, Darshan; Fingard, Jordan; Winters, Sean; Low, Gavin

2017-07-01

The purpose of this study was to determine the diagnostic accuracy of MRI for detecting acute appendicitis in pregnancy in a multi-institution study involving general body MR readers with no specific expertise in MR imaging of the pregnant patient. Retrospective review of MRI examinations on PACS in 42 pregnant patients was evaluated for acute right lower quadrant pain. Three fellowship-trained general body radiologists analyzed the MRI examinations in consensus and attempted to localize the appendix, assess for features of appendicitis, and exclude alternative etiologies for the right lower quadrant pain. Of the 42 MRI examinations, the readers noted 6 cases of acute appendicitis, 16 cases of a normal appendix, and 20 cases involving non-visualization of the appendix but where there were no secondary features of acute appendicitis. Based on the surgical data and clinical follow-up, there were 3 true-positive cases, 3 false-positive cases, 34 true-negative cases, and 2 false-negative cases of acute appendicitis on MRI. This yielded an accuracy of 88.1%, sensitivity of 60%, specificity of 91.9%, positive predictive value of 50%, and negative predictive value of 94.4% for the detection of acute appendicitis in the pregnant patient on MRI. Alternative etiologies for the right lower quadrant pain on MRI included torsion of an ovarian dermoid in 1 case and pyelonephritis in 1 case. MRI is an excellent modality for excluding acute appendicitis in pregnant patients presenting with right lower quadrant pain.

False-negative and false-positive errors in abdominal pain evaluation: failure to diagnose acute appendicitis and unnecessary surgery.

PubMed

Graff, L; Russell, J; Seashore, J; Tate, J; Elwell, A; Prete, M; Werdmann, M; Maag, R; Krivenko, C; Radford, M

2000-11-01

To test the hypothesis that physician errors (failure to diagnose appendicitis at initial evaluation) correlate with adverse outcome. The authors also postulated that physician errors would correlate with delays in surgery, delays in surgery would correlate with adverse outcomes, and physician errors would occur on patients with atypical presentations. This was a retrospective two-arm observational cohort study at 12 acute care hospitals: 1) consecutive patients who had an appendectomy for appendicitis and 2) consecutive emergency department abdominal pain patients. Outcome measures were adverse events (perforation, abscess) and physician diagnostic performance (false-positive decisions, false-negative decisions). The appendectomy arm of the study included 1, 026 patients with 110 (10.5%) false-positive decisions (range by hospital 4.7% to 19.5%). Of the 916 patients with appendicitis, 170 (18.6%) false-negative decisions were made (range by hospital 10.6% to 27.8%). Patients who had false-negative decisions had increased risks of perforation (r = 0.59, p = 0.058) and of abscess formation (r = 0.81, p = 0.002). For admitted patients, when the inhospital delay before surgery was >20 hours, the risk of perforation was increased [2.9 odds ratio (OR) 95% CI = 1.8 to 4.8]. The amount of delay from initial physician evaluation until surgery varied with physician diagnostic performance: 7.0 hours (95% CI = 6.7 to 7.4) if the initial physician made the diagnosis, 72.4 hours (95% CI = 51.2 to 93.7) if the initial office physician missed the diagnosis, and 63.1 hours (95% CI = 47.9 to 78.4) if the initial emergency physician missed the diagnosis. Patients whose diagnosis was initially missed by the physician had fewer signs and symptoms of appendicitis than patients whose diagnosis was made initially [appendicitis score 2.0 (95% CI = 1.6 to 2.3) vs 6.5 (95% CI = 6.4 to 6.7)]. Older patients (>41 years old) had more false-negative decisions and a higher risk of perforation or

Unusual presentation of a familiar pathology: chronic appendicitis.

PubMed

Sierakowski, Kyra; Pattichis, Andrew; Russell, Patrick; Wattchow, David

2016-02-11

We present a case of a man who experienced night sweats, abdominal pain and fever for over 3 months, with incomplete response to broad-spectrum intravenous antibiotics. Although CT imaging was insufficient to identify the cause for his chronic abdominal pain, the abnormality of a 'misty mesentery' was crucial in guiding further investigation. The final diagnosis of chronic appendicitis was made through laparoscopic and pathological examination. This case highlights the utility of a collaborative diagnostic effort between disciplines. Chronic appendicitis can cause lingering abdominal pain. Early recognition and appropriate referral can save patients months and even years of unnecessary suffering. 2016 BMJ Publishing Group Ltd.

Streptococcal Pharyngitis and Appendicitis in Children.

PubMed

Nielsen, Jason W; Abel, Stuart A; Kenney, Brian

2018-01-01

Several pathologies, including pharyngitis, are associated with abdominal pain that can mimic appendicitis. We sought to further understand the link between appendicitis-like symptoms and streptococcal (strep) pharyngitis. All patients undergoing ultrasound imaging for appendicitis in our emergency department during 2013 were reviewed (n = 1572). A total of 207 patients were identified who underwent both ultrasound for appendicitis and testing for strep pharyngitis. Demographic and outcomes data between rule out appendicitis patients who underwent strep testing and those who did not were compared. Strep testing was more common in younger patients (mean age = 8.26 vs 10.26 years P < .001) and evenly matched by gender (104 male, 103 female). Of the 207 patients tested for strep pharyngitis, 8 (3.9%) patients had appendicitis and 35 (16.9%) patients tested positive for strep pharyngitis. No cases of concurrent strep pharyngitis and appendicitis were identified. The negative appendectomy rate in the strep pharyngitis tested group was 38.5% (5/13), compared with 7.7% (23/296) ( P = .003) in the nontested group. The appendicitis rate among the strep tested group was 3.8% (8/207) compared with 20% (273/1365) in the nontested group ( P < .001). Patients undergoing testing for strep pharyngitis were younger, had lower rates of appendicitis, and had a higher rate of negative appendectomy. A diagnosis of concurrent appendicitis and strep pharyngitis is rare. In cases of patients with sufficient symptoms to warrant testing for strep pharyngitis a diagnosis of appendicitis is less likely and surgical intervention leads to higher negative appendectomy rates.

Enterobius vermicularis: a rare cause of appendicitis.

PubMed

Gialamas, Eleftherios; Papavramidis, Theodossis; Michalopoulos, Nick; Karayannopoulou, Georgia; Cheva, Angeliki; Vasilaki, Olga; Kesisoglou, Isaak; Papavramidis, Spiros

2012-01-01

Although appendicitis is one of the most common causes of emergency surgery, parasites are rarely found associated with inflammation of the appendix. The aim of this study is to establish the prevalence of Enterobius vermicularis in surgically removed appendices, as well as to determine its possible role in the pathogenesis of appendicitis. A retrospective analysis of all the appendices removed during the last 20 years at a tertiary university hospital. Appendices removed during the course of another intra-abdominal procedure were excluded from the study. All 1085 surgical specimens removed from patients with clinical appendicitis were evaluated. Enterobius vermicularis was found in seven appendices (0.65%) with clinical symptoms of appendicitis. The parasite was most frequently identified in appendices without pathological changes (6/117). There was no case of chronic appendicitis presenting E. vermicularis infestation, while the parasite was rarely related to histological changes of acute appendicitis (1/901). The results suggest that the presence of E. vermicularis in the appendix might cause appendiceal pain (colic), but can rarely be associated with pathologic findings of acute appendicitis.

An unusual presentation of perforated appendicitis in epigastric region☆

PubMed Central

Odabasi, Mehmet; Arslan, Cem; Abuoglu, Hasan; Gunay, Emre; Yildiz, Mehmet Kamil; Eris, Cengiz; Ozkan, Erkan; Aktekin, Ali; Muftuoglu, M.A. Tolga

2013-01-01

INTRODUCTION Atypical presentations of appendix have been reported including backache, left lower quadrant pain and groin pain from a strangulated femoral hernia containing the appendix. We report a case presenting an epigastric pain that was diagnosed after computed tomography as a perforated appendicitis on intestinal malrotation. PRESENTATION OF CASE A 27-year-old man was admitted with a three-day history of epigastric pain. Physical examination revealed tenderness and defense on palpation of epigastric region. There was a left subcostal incision with the history of diaphragmatic hernia repair when the patient was 3 days old. He had an intestinal malrotation with the cecum fixed at the epigastric region and the inflamed appendix extending beside the left lobe of liver. DISCUSSION While appendicitis is the most common abdominal disease requiring surgical intervention seen in the emergency room setting, intestinal malrotation is relatively uncommon. When patients with asymptomatic undiagnosed gastrointestinal malrotation clinically present with abdominal pain, accurate diagnosis and definitive therapy may be delayed, possibly increasing the risk of morbidity and mortality. CONCLUSION Atypical presentations of acute appendicitis should be kept in mind in patients with abdominal pain in emergency room especially in patients with previous childhood operation for diaphragmatic hernia. PMID:24441442

Perforated Appendicitis After Colonoscopy

PubMed Central

Johnston, Paul

2008-01-01

Background: Acute appendicitis is a rare complication of colonoscopy that has been reported only 12 times in the English-language literature and is usually associated with obstruction of the appendiceal lumen with fecal matter during colonoscopy. None of the previous reports have described findings of perforation of the appendix within 24 hours of colonoscopy. Methods: We present the case report of a patient who underwent urgent laparotomy within 16 hours of colonos-copy for findings of free intraabdominal air and peritonitis from acute perforated appendicitis. Results: Laparoscopy confirmed 2 perforations of the appendix and diffuse peritonitis. Laparotomy was necessary to perform appendectomy, exclude a right colonic injury, and control intraabdominal sepsis. Conclusion: In patients with abdominal pain who have had a recent colonoscopy, a high index of suspicion is necessary for accurate diagnosis of perforated appendicitis. Perforation can occur hours after colonoscopy even when a biopsy is not performed. PMID:18765066

Appendicitis

MedlinePlus

... Staying Safe Videos for Educators Search English Español Appendicitis KidsHealth / For Teens / Appendicitis What's in this article? ... out, had appendicitis and needed surgery. What Is Appendicitis? Appendicitis is an inflammation of the appendix. The ...

Total antioxidant capacity in children with acute appendicitis.

PubMed

Kaya, M; Boleken, M E; Kanmaz, T; Erel, O; Yucesan, S

2006-02-01

This study aimed to investigate antioxidant capacity by using a novel automated method in children with acute appendicitis. Blood samples were obtained from consecutive patients with acute appendicitis (appendicitis group, n = 12) and acute abdominal pain due to non surgical disease (non-appendicitis group, n = 11), and from patients with inguinal hernia (healthy group, n = 12) as the control group. At admission, total antioxidant capacity (TAC) levels of plasma were evaluated in all patients by a method recently developed by Erel. Four other major individual plasma antioxidant components, the levels of total protein, albumin, uric acid and bilirubin, were also evaluated. Total antioxidant capacity in patients with acute appendicitis was statistically compared with the two other groups. While the TAC level in the appendicitis group was significantly greater than in the non-appendicitis group, no significant difference was found in healthy groups (p < 0.05, p > 0.05, 1.94 +/- 0.38, 1.40 +/- 0.36, and 1.99 +/- 0.35 respectively). Individual components of total antioxidant capacity, i.e. total protein, albumin, uric acid and bilirubin concentrations, were also higher in the patients with acute appendicitis than those of the other two control groups. Our data show that children with acute appendicitis do not have deficient blood plasma antioxidant capacity. These results provide evidence that acute appendicitis results in more induction of antioxidative response than non-surgical diseases.

Risk Factors for Complications in Acute Appendicitis among Paediatric Population.

PubMed

Poudel, R; Bhandari, T R

2017-01-01

Appendicitis is one of the most common causes of acute abdomen in children. Patients who are diagnosed early and undergo an appendectomy before perforation have a good outcome. However, it is difficult to diagnose in young children because its clinical manifestations may be atypical. The aim of this study was to determine the risk factors for complications in acute appendicitis in paediatric population. We performed a cross sectional study on children (age ≤18 years) who underwent appendectomy for suspected appendicitis from January 2014 to December 2015. Medical records of patients who met inclusion criteria were reviewed. Preoperative, operative and post-operative data were analyzed. The main outcome measure was intraoperative confirmation of gangrenous or perforated appendicitis. Multivariate logistic regression analysis was performed, and the main predictors of interest were patient's age, duration of pain and total leucocyte count. Total 73 paediatric patients (46 males) with mean age 13±3.8 were studied. In multivariate logistic regression analysis, patients having pain duration more than 72 hours and patients with leucocyte count >15000/mm3 were more likely to have complicated appendicitis [(OR:14.6), (95% CI= 2.40 - 89.77), (P= 0.004)] and [(OR=16.38), (95% CI = 1.836-146), (P = 0.012)] respectively. However, the age of the patient is not independently associated with complicated appendicitis. Increase in total leucocyte count and duration of the presentation can be a good marker of complicated appendicitis.

Predictors of Nondiagnostic Ultrasound for Appendicitis.

PubMed

Keller, Christine; Wang, Nancy E; Imler, Daniel L; Vasanawala, Shreyas S; Bruzoni, Matias; Quinn, James V

2017-03-01

Ionizing radiation and cost make ultrasound (US), when available, the first imaging study for the diagnosis of suspected pediatric appendicitis. US is less sensitive and specific than computed tomography (CT) or magnetic resonance imaging (MRI) scans, which are often performed after nondiagnostic US. We sought to determine predictors of nondiagnostic US in order to guide efficient ordering of imaging studies. A prospective cohort study of consecutive patients 4 to 30 years of age with suspected appendicitis took place at an emergency department with access to 24/7 US, MRI, and CT capabilities. Patients with US as their initial study were identified. Clinical (i.e., duration of illness, highest fever, and right lower quadrant pain) and demographic (i.e., age and sex) variables were collected. Body mass index (BMI) was calculated based on Centers for Disease Control and Prevention criteria; BMI >85th percentile was categorized as overweight. Patients were followed until day 7. Univariate and stepwise multivariate logistic regression analysis was performed. Over 3 months, 106 patients had US first for suspected appendicitis; 52 (49%) had nondiagnostic US results. Eighteen patients had appendicitis, and there were no missed cases after discharge. On univariate analysis, male sex, a yearly increase in age, and overweight BMI were associated with nondiagnostic US (p < 0.05). In the multivariate model, only BMI (odds ratio 4.9 [95% CI 2.0-12.2]) and age (odds ratio 1.1 [95% CI 1.02-1.20]) were predictors. Sixty-eight percent of nondiagnostic US results occurred in overweight patients. Overweight and older patients are more likely to have a nondiagnostic US or appendicitis, and it may be more efficient to consider alternatives to US first for these patients. Also, this information about the accuracy of US to diagnose suspected appendicitis may be useful to clinicians who wish to engage in shared decision-making with the parents or guardians of children regarding

Barium appendicitis after upper gastrointestinal imaging.

PubMed

Novotny, Nathan M; Lillemoe, Keith D; Falimirski, Mark E

2010-02-01

Barium appendicitis (BA) is a rarely seen entity with fewer than 30 reports in the literature. However, it is a known complication of barium imaging. To report a case of BA in a patient whose computed tomography (CT) scan was initially read as foreign body ingestion. An 18-year-old man presented with right lower quadrant pain after upper gastrointestinal imaging 2 weeks prior. A CT scan was obtained of his abdomen and pelvis that revealed a finding that was interpreted as a foreign body at the area of the terminal ileum. A plain X-ray study of the abdomen revealed radiopaque appendicoliths. Pathology confirmed the diagnosis of barium appendicitis. BA is a rare entity and the pathogenesis is unclear. Shorter intervals between barium study and presentation with appendicitis usually correlate with fewer complications. Copyright (c) 2010 Elsevier Inc. All rights reserved.

Appendicitis

MedlinePlus

... function. A blockage inside of the appendix causes appendicitis. The blockage leads to increased pressure, problems with ... to pass gas Low fever Not everyone with appendicitis has all these symptoms. Appendicitis is a medical ...

Necrotizing fasciitis caused by perforated appendicitis: a case report.

PubMed

Hua, Jie; Yao, Le; He, Zhi-Gang; Xu, Bin; Song, Zhen-Shun

2015-01-01

Acute appendicitis is one of the most common causes of acute abdominal pain. Accurate diagnosis is often hindered due to various presentations that differ from the typical signs of appendicitis, especially the position of the appendix. A delay in diagnosis or treatment may result in increased risks of complications, such as perforation, which is associated with increased morbidity and mortality rates. Necrotizing fasciitis caused by perforated appendicitis is extremely rare. We herein report a case of 50-year-old man presenting with an appendiceal abscess in local hospital. After ten days of conservative treatment with intravenous antibiotics, the patient complained about pain and swelling of the right lower limb and computed tomography (CT) demonstrated a perforated appendix and gas and fluid collection extending from his retroperitoneal cavity to the subcutaneous layer of his right loin and right lower limb. He was transferred to our hospital and was diagnosed with necrotizing fasciitis caused by perforated appendicitis. Emergency surgery including surgical debridement and appendectomy was performed. However, the patient died of severe sepsis and multiple organ failure two days after the operation. This case represents an unusual complication of a common disease and we should bear in mind that retroperitoneal inflammation and/or abscesses may cause necrotizing fasciitis through lumbar triangles.

Appendicitis

MedlinePlus

... Staying Safe Videos for Educators Search English Español Appendicitis KidsHealth / For Kids / Appendicitis What's in this article? ... would it need to be removed? What Is Appendicitis? Your appendix (say: uh-PEN-dix) is a ...

[Chronic appendicitis due to multiple fecaliths. A case report].

PubMed

Montiel-Jarquín, Álvaro José; Ramírez-Sánchez, Celso; García-Cano, Eugenio; González-Hernández, Nicolás; Rodríguez-Pérez, Fabiola; Alvarado-Ortega, Ivan

2017-12-01

The appendix inflammatory process is the most common cause of chronic abdominal pain in the right lower quadrant. The frequency of appendiceal lumen obstruction by fecalith ranges from 10 to 20%; few cases of obstruction by multiple fecaliths had been reported. Sixty-nine years old male, diabetic and hypertensive in control, he underwent bowel resection 30 years previously. He completed 6 months with intermittent, mild pain in the right lower quadrant abdomen; 14 days prior to admission with increasing pain, nausea, vomiting, constipation, abdominal distension and absence of peristalsis; 12,750 leukocytes, neutrophils 90%; plain abdominal radiography without specific bowel pattern, TAC with 3 dense images in right lower quadrant; exploratory laparotomy was performed and perforated appendix with 3 free fecaliths was found. Histopathological report showed fibrosis and lymphocytic infiltrate in the muscle layer of the cecal appendix consistent with chronic appendicitis. The most common obstruction of the appendix lumen is by a single fecalith. In this case the patient had chronic appendicitis secondary to appendiceal lumen obstruction by multiple fecaliths. Reviewing the international literature any case of chronic appendicitis associated with the presence of multiple fecaliths was found. Copyright © 2016 Academia Mexicana de Cirugía A.C. Publicado por Masson Doyma México S.A. All rights reserved.

Appendiceal diverticulum associated with chronic appendicitis

PubMed Central

Zubieta-O’Farrill, Gregorio; Guerra-Mora, José Raúl; Gudiño-Chávez, Andrés; Gonzalez-Alvarado, Carlos; Cornejo-López, Gilberto Bernabe; Villanueva-Sáenz, Eduardo

2014-01-01

INTRODUCTION Appendiceal diverticulosis is a rare entity, with a global incidence between 0.004% and 2.1% of all appendectomies. It has been related with an elevated risk of perforation in comparison to acute appendicitis, as well as an increased risk for synchronic appendicular cancer in 48% of the cases, and colonic cancer in 43%. The incidence of chronic appendicitis has been reported in 1.5% of all appendicitis cases. PRESENTATION OF CASE We present a 73-year-old female, with no relevant familial history, who presented due to a four-month-long oppressive, moderate pain in the lower right abdominal quadrant without irradiation or any other accompanying symptoms. DISCUSSION The documented incidence of appendiceal diverticula and chronic appendicitis by themselves is low; therefore the presence of both entities at the same time is extremely rare. CONCLUSION We present a case in which both diagnoses concurred in the same patient. The relevance of this case relies on the importance of the adequate knowledge of these pathologies, so we can approach them correctly. Although it does not represent an absolute surgical emergency, appendectomy represents the first therapeutic option. PMID:25460447

Valentino's syndrome a perforated peptic ulcer mimicking acute appendicitis.

PubMed

Wijegoonewardene, Sandeep Indika; Stein, Joel; Cooke, David; Tien, Alan

2012-06-28

The authors present a case of a 30-year-old female who presented with symptoms and signs suggestive of appendicitis accompanied by elevated inflammatory markers. The patient was consented and taken to theatre for laparoscopic apendicectomy. At operation, the appendix was found to be normal but with surrounding turbid fluid in the right paracolic gutter and subhepatic space. On further inspection, a perforated pre pyloric ulcer was discovered. This was managed laparoscopically with a peritoneal lavage and falciform ligament patch repair. The patient made a good recovery and was discharged 2 days later. At 6 week follow-up the patient had an upper gastrointestinal (GI) endoscopy which showed complete healing of the ulcer. At 6 week follow-up the patient had an upper GI endoscopy which showed complete healing of the ulcer.

[Perforated appendicitis with purulent peritonitis in the third semester of pregnancy].

PubMed

Sparić, Radmila; Stefanović, Aleksandar; Kadija, Sasa; Zizić, Vojislav

2005-01-01

Acute appendicitis is the most common non-obstetric reason of abdominal pain in the pregnancy, causing significant increase of maternal and fetal morbidity and mortality. This is a case report of a patient in the third trimester of pregnancy in whom perforated appendicitis caused purulent peritonitis. She was operated as an emergency case and cesarean section was performed. After the surgery and antibiotic administration according to drug susceptibility test, her postoperative course was uneventful. Delayed diagnosis of the acute appendicitis leads to increased rate of appendicular perforation, with numerous maternal and fetal complications. In cases of suspected appendicitis during pregnancy, surgical exploration is indicated, either by laparoscopy or laparotomy. Laparotomy is the method of choice in cases after 20 weeks of pregnancy and whenever signs of diffuse peritonitis are present.

[Acute appendicitis and coinfection with enterobiasis and taeniasis: a case report].

PubMed

Çallı, Gülhan; Özbilgin, Mücahit; Yapar, Nur; Sarıoğlu, Sülen; Özkoç, Soykan

2014-01-01

Parasites are rarely associated with inflammation of the appendix. Generally, parasites cause acute abdominal pain via blocking the gut lumen. In this article, we presented a case of appendicitis where Enterobius vermicularis was detected in the surgical specimen and Taenia was detected in the stool. A 31 year old male patient was admitted to the emergency room with severe abdominal pain, which has begun two days ago. On physical examination, tenderness was positive on palpation of the right lower abdominal quadrant and the patient was operated on with the diagnosis of acute appendicitis. Histopathological examination of the patient's appendectomy material revealed numerous parts of parasites resembling Enterobius vermicularis and slight mucosal erosion. On parasitological examination of the patient's stool, Taenia eggs and adult forms were determined. Antiparasitic therapy was started with niclosamide for taeniasis and albendazole for enterobiasis. Parasitic infections can mimic acute appendicitis clinically. Radiological and laboratory findings do not help to distinguish the diagnosis of acute appendicitis. In the histopathological examination of the appendix, the findings of acute inflammation of the appendix wall may not be defined. For patients with normal histopathological examination, screening for parasites should be done, and anti-parasitic treatment should be started after appendectomy.

Appendicitis

MedlinePlus

... this page: //medlineplus.gov/ency/article/000256.htm Appendicitis To use the sharing features on this page, please enable JavaScript. Appendicitis is inflammation of the appendix. The appendix is ...

Incidence of acute appendicitis in Kumasi, Ghana.

PubMed

Ohene-Yeboah, M; Abantanga, F A

2009-03-01

Acute appendicitis is a leading cause of surgical admissions for abdominal pain in many hospitals. To report the incidence of acute appendicitis in Kumasi and highlight the increasing admissions rates of the disease in the metropolis. A combined prospective and retrospective analysis of hospital records was performed to obtain data on the age and sex of each patient, and the total number of patients who had appendectomies performed for acute appendicitis. Data were obtained from the major hospitals in Kumasi including Komfo Anokye Teaching Hospital (KATH), the Kwame Nkrumah University of Science and Technology Hospital simply known as University Hospital (UH), the Seventh Day Adventist Hospital (SDAH), the Animwa Medical Centre, the Kumasi South Hospital and the South Suntresu Health Centre for the period January 2000 to December 2005. There were a total of 1266 patients 869 (68.6%) males and 397 (31.4%) females with an overall male to female ratio of 2.2:1.The yearly incidence of acute appendicitis in Kumasi was 1.8 per 10,000 of the population. The peak incidence was in the 25-29 year age groups in both sexes. Appendicitis was twice as common in the male and in all age groups. The admission rates at the start of the study were 1.7/10,000 and 0.8/10,000 for male and females respectively and 3.4/10,000 and 1.4/10.000 for male and females at the conclusion of the study. In Kumasi acute appendicitis occurs in all age groups of both sexes. Males are more affected than females. Admission rates from the disease are rising in both sexes most likely due to increasing hospital attendance.

Hyperbilirubinaemia a predictive factor for complicated acute appendicitis: a study in a tertiary care hospital.

PubMed

Jamaluddin, Muhammad; Hussain, Syed Mohammad Abbas; Ahmad, Humaid

2013-11-01

To study the role of hyperbilirubinaemia as a predictive factor for appendiceal perforation in acute appendicitis. The prospective, descriptive study was conducted at the Abbasi Shaheed Hospital and the Karachi Medical and Dental College, Karachi, from January 2010 to June 2012. It comprised all patients coming to the surgical outpatient department and emergency department with pain in the right iliac fossa with duration less than seven days. They were clinically assessed for signs and symptoms of acute appendicitis and relevant tests were conducted. Patients were diagnosed as a case of acute appendicitis on the basis of clinical and ultrasound findings, and were prepared for appendicectomy. Per-operative findings were recorded and specimens were sent for histopathology to confirm the diagnosis. SPSS version 10 was used to analyse the data. Of the 71 patients, 37 (52.10%) were male and 34 (47.90%) were female. The age range was 3-57 years, and most of the patients (n = 33; 46.5%) were between 11 and 20 years. Besides, 63 (89%) patients had pain in the right iliac fossa of less than four-days duration, while 8 (11%) had pain of longer duration.Total leukocyte count was found to be elevated in 33 (46.5%) patients, while total serum bilirubin was elevated in 41 (57.70%). Ultrasound of abdomen showed 9 (12.70%) patients having normal appearance of appendix and 59 (83.30%) had inflamed appendix. Four (5.60%) patients had no signs of inflammation on naked eye appearance per operatively. Histopathology of appendix showed 10 (14.10%) patients had non-inflammatory appendix. Patients with signs and symptoms of acute appendicitis and a raised total serum bilirubin level indicated a complication of acute appendicitis requiring an early intervention to prevent peritonitis and septicaemia. A raised serum bilirubin level is a good indicator of complicated acute appendicitis, and should be included in the assessment of patients with suspected complicated acute appendicitis.

Pattern of acute appendicitis in Mekelle, Ethiopia.

PubMed

Hagos, Mekonnen

2014-07-01

Acute appendicitis is one of the commonly encountered emergencies in the practice of general surgery but there are no much study regarding the magnitude and its pattern in Ethiopia and in Mekelle hospital in particular. This study was aimed at assessing the magnitude, pattern and outcomes of acute appendicitis. Between September 2008 to August 2010, 196 patients with acute appendicitis were admitted to Mekelle hospital. In this descriptive retrospective audit, case notes were obtained from medical records office and information entered included patient demographics, clinical symptoms, white blood cell count level and operative funding. Post-operative complications and operative outcomes were also recorded. Adequate records have been maintained in the hospital on patients undergoing appendectomy. There were 196 patients during the study period from all age groups with clinical suspicion of acute appendicitis who underwent appendectomy. The age ranged from 4 to 80 years (mean - 22 years). There were 143 (73%) males and females accounting for 53 (27%). The sex ratio was (M: F; 2.9:1). Majority of patients with acute appendicitis were between 20 - 29 years of age, accounting for 76 (38.7%), predominantly males affected than females. The other age group affected was between 10-19 years of age accounting for 56 (28.5%), again with male predominance. The frequent clinical presentation's of acute appendicitis were abdominal pain 196 (100.0%), vomiting 107 (54.6%) and anoxia 97 (49.5%). The duration of presentation ranged from 12 hours to 5 days (Mean- 3.5 days). This study has depicted that acute appendicitis is the commonest emergency surgical condition affecting the young in the study area. Early presentation, early diagnosis and prompt treatment have shown to attribute to lower rate of complications, likewise decreasing mortality. The other observed fact was the negative appendectomy which was more frequent in females in their reproductive age group. Additional modern

Characteristic clinical features of Aspergillus appendicitis: Case report and literature review.

PubMed

Gjeorgjievski, Mihajlo; Amin, Mitual B; Cappell, Mitchell S

2015-11-28

This work aims to facilitate diagnosing Aspergillus appendicitis, which can be missed clinically due to its rarity, by proposing a clinical pentad for Aspergillus appendicitis based on literature review and one new case. The currently reported case of pathologically-proven Aspergillus appendicitis was identified by computerized search of pathology database at William Beaumont Hospital, 1999-2014. Prior cases were identified by computerized literature search. Among 10980 pathology reports of pathologically-proven appendicitis, one case of Aspergillus appendicitis was identified (rate = 0.01%). A young boy with profound neutropenia, recent chemotherapy, and acute myelogenous leukemia presented with right lower quadrant pain, pyrexia, and generalized malaise. Abdominal computed tomography scan showed a thickened appendiceal wall and periappendiceal inflammation, suggesting appendicitis. Emergent laparotomy showed an inflamed, thickened appendix, which was resected. The patient did poorly postoperatively with low-grade-fevers while receiving antibacterial therapy, but rapidly improved after initiating amphotericin therapy. Microscopic examination of a silver stain of the appendectomy specimen revealed fungi with characteristic Aspergillus morphology, findings confirmed by immunohistochemistry. Primary Aspergillus appendicitis is exceptionally rare, with only 3 previously reported cases. All three cases presented with (1)-neutropenia, (2)-recent chemotherapy, (3)-acute leukemia, and (4)-suspected appendicitis; (5)-the two prior cases initially treated with antibacterial therapy, fared poorly before instituting anti-Aspergillus therapy. The current patient satisfied all these five criteria. Based on these four cases, a clinical pentad is proposed for Aspergillus appendicitis: clinically-suspected appendicitis, neutropenia, recent chemotherapy, acute leukemia, and poor clinical response if treated solely by antibacterial/anti-candidial therapy. Patients presenting with

A Clinical Score to Predict Appendicitis in Older Male Children.

PubMed

Kharbanda, Anupam B; Monuteaux, Michael C; Bachur, Richard G; Dudley, Nanette C; Bajaj, Lalit; Stevenson, Michelle D; Macias, Charles G; Mittal, Manoj K; Bennett, Jonathan E; Sinclair, Kelly; Dayan, Peter S

2017-04-01

To develop a clinical score to predict appendicitis among older, male children who present to the emergency department with suspected appendicitis. Patients with suspected appendicitis were prospectively enrolled at 9 pediatric emergency departments. A total of 2625 patients enrolled; a subset of 961 male patients, age 8-18 were analyzed in this secondary analysis. Outcomes were determined using pathology, operative reports, and follow-up calls. Clinical and laboratory predictors with <10% missing data and kappa > 0.4 were entered into a multivariable model. Resultant β-coefficients were used to develop a clinical score. Test performance was assessed by calculating the sensitivity, specificity, positive predictive value, negative predictive value, and likelihood ratios. The mean age was 12.2 years; 49.9% (480) had appendicitis, 22.3% (107) had perforation, and the negative appendectomy rate was 3%. In patients with and without appendicitis, overall imaging rates were 68.6% (329) and 84.4% (406), respectively. Variables retained in the model included maximum tenderness in the right lower quadrant, pain with walking/coughing or hopping, and the absolute neutrophil count. A score ≥8.1 had a sensitivity of 25% (95% confidence interval [CI], 20%-29%), specificity of 98% (95% CI, 96%-99%), and positive predictive value of 93% (95% CI, 86%-97%) for ruling in appendicitis. We developed an accurate scoring system for predicting appendicitis in older boys. If validated, the score might allow clinicians to manage a proportion of male patients without diagnostic imaging. Copyright © 2016 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.

Appendiceal outer diameter as an indicator for differentiating appendiceal mucocele from appendicitis.

PubMed

Lien, Wan-Ching; Huang, Shih-Pei; Chi, Chun-Lin; Liu, Kao-Lang; Lin, Ming-Tsan; Lai, Ting-I; Liu, Yueh-Ping; Wang, Hsiu-Po

2006-11-01

Patients with appendiceal mucocele (AM) commonly present with features indicative of acute appendicitis. In emergency departments, accurate preoperative diagnosis is crucial to prompt appropriate treatment. This study investigates the clinical and sonographic characteristics of AM, which may prove useful in preoperatively differentiating AM from appendicitis. This case-control study compares the clinical and sonographic findings of 16 histologically confirmed AM with sex- and age-matched control subjects (n = 64) with appendicitis by a 1:4 ratio. Conditional logistic regression was applied to estimate the odds ratio (OR) and 95% confidence intervals (CI) of clinical and sonographic parameters associated with AM. Univariate analysis demonstrated that the larger appendiceal outer diameter by sonography was positively correlated with diagnosis of AM (OR, 2.31; 95% CI, 1.42-3.72) and right lower quadrant abdominal pain was negatively correlated (OR, 0.38; 95% CI, 0.17-0.82). However, multiple regression analysis suggested that only outer diameter remained significant (OR, 2.21; 95% CI, 1.36-3.59) after adjusting for age, sex, and right lower quadrant pain. An outer diameter of 15 mm or more was predictive of AM diagnosis, with a sensitivity of 83% and specificity of 92%. When the threshold is set at 15 mm, appendiceal outer diameter by sonography is a useful preoperative measurement for differentiating between AM and acute appendicitis.

Stump appendicitis 10 years after appendectomy, a rare, but serious complication of appendectomy, a case report.

PubMed

Van Paesschen, Carl; Haenen, Filip; Bestman, Raymond; Van Cleemput, Marc

2017-02-01

We describe a case of stump appendicitis with the formation of abdominal abscesses in a 41-year-old patient 10 years prior appendectomy. The patient consulted with fever (38.1 °C) and abdominal pain, located at the right iliac fossa. Imaging studies showed signs of abscesses, located at the right iliac fossa, without clear origin of these abscesses. The abscesses were drained through diagnostic laparoscopy, no bowel perforation or clear origin of the abscedation was found during laparoscopy. During postoperative stay, the inflammatory parameters rose and the abscesses reoccurred. Re-laparoscopy was performed, the abscesses were drained and on careful inspection and adhesiolysis, a perforated stump appendicitis was revealed, covered underneath layers of fibrous tissue. Stump appendicitis is a rare complication seen after appendectomy and is generally not considered a possible etiology in patients presenting with fever and right iliac fossa abdominal pain with a history of appendectomy. This often delays the correct diagnosis and results in an associated increased incidence of complications. We describe a case of stump appendicitis occurring 10 years after initial appendectomy.

Missed appendicitis after self-induced abortion.

PubMed

Punguyire, Damien; Iserson, Victor Kenneth

2011-01-01

Female lower abdominal pain poses diagnostic difficulties for clinicians, especially when little more than the history and physical examination are available. A girl presented with constant lower abdominal pain after taking misoprostol for pregnancy termination. She was eventually referred to a rural District Hospital, where a laparotomy demonstrated acute appendicitis. After treating herself for a self-diagnosed pregnancy with illegally provided misoprostol, this patient presented with persistent lower abdominal pain. The differential diagnosis included ectopic pregnancy and all other causes of female abdominal pain. Yet diagnosing two diseases in the same anatomical area at the same time contradicts diagnostic parsimony. System problems in resource-poor areas can limit access to healthcare services and encourage dispensing potentially dangerous medications without clinicians' authorization. It is dangerous to rely on patients' self-diagnoses while neglecting other diagnoses. More than one diagnosis may be needed to explain temporally and anatomically related symptoms.

[Coexistence of acute appendicitis and dengue fever: A case report].

PubMed

Osuna-Ramos, Juan Fidel; Silva-Gracia, Carlos; Maya-Vacio, Gerardo Joel; Romero-Utrilla, Alejandra; Ríos-Burgueño, Efrén Rafael; Velarde-Félix, Jesús Salvador

2017-12-01

Dengue is the most important human viral disease transmitted by mosquitoes. It can be asymptomatic or it can present in any of its 3clinical forms: Dengue fever, dengue haemorrhagic fever and dengue shock syndrome. However, some atypical manifestations have been reported in surgical emergencies caused by acute appendicitis in patients with dengue fever. We report the case of an 18-year-old Mexican male who presented to the emergency department of the General Hospital of Culiacan, Sinaloa, with symptoms of dengue fever, accompanied by crampy abdominal pain with positive Rovsing and Dunphy signs. Dengue infection was confirmed by a positive NS1 antigen test performed by enzyme-linked immunosorbent assay. An abdominal ultrasound revealed an appendicular process; as the abdominal pain in the right side kept increasing, an open appendectomy was performed. Abundant inflammatory liquid was observed during the surgery, and the pathology laboratory reported an oedematous appendix with fibrinopurulent plaques, which agreed with acute ulcerative appendicitis. The patient was discharged fully recovered without complications during the follow-up period. Acute abdominal pain can be caused in some cases by dengue infection. This can be confusing, which can lead to unnecessary surgical interventions, creating additional morbidities and costs for the patient. This unusual and coincident acute appendicitis with dengue highlights the importance of performing careful clinical studies for appropriate decision making, especially in dengue endemic regions during an outbreak of this disease. Copyright © 2016 Academia Mexicana de Cirugía A.C. Publicado por Masson Doyma México S.A. All rights reserved.

Imaging of Posttraumatic Arthritis, Avascular Necrosis, Septic Arthritis, Complex Regional Pain Syndrome, and Cancer Mimicking Arthritis.

PubMed

Rupasov, Andrey; Cain, Usa; Montoya, Simone; Blickman, Johan G

2017-09-01

This article focuses on the imaging of 5 discrete entities with a common end result of disability: posttraumatic arthritis, a common form of secondary osteoarthritis that results from a prior insult to the joint; avascular necrosis, a disease of impaired osseous blood flow, leading to cellular death and subsequent osseous collapse; septic arthritis, an infectious process leading to destructive changes within the joint; complex regional pain syndrome, a chronic limb-confined painful condition arising after injury; and cases of cancer mimicking arthritis, in which the initial findings seem to represent arthritis, despite a more insidious cause. Copyright © 2017 Elsevier Inc. All rights reserved.

A new adult appendicitis score improves diagnostic accuracy of acute appendicitis - a prospective study

PubMed Central

2014-01-01

Background The aim of the study was to construct a new scoring system for more accurate diagnostics of acute appendicitis. Applying the new score into clinical practice could reduce the need of potentially harmful diagnostic imaging. Methods This prospective study enrolled 829 adults presenting with clinical suspicion of appendicitis, including 392 (47%) patients with appendicitis. The collected data included clinical findings and symptoms together with laboratory tests (white cell count, neutrophil count and C-reactive protein), and the timing of the onset of symptoms. The score was constructed by logistic regression analysis using multiple imputations for missing values. Performance of the constructed score in patients with complete data (n = 725) was compared with Alvarado score and Appendicitis inflammatory response score. Results 343 (47%) of patients with complete data had appendicitis. 199 (58%) patients with appendicitis had score value at least 16 and were classified as high probability group with 93% specificity.Patients with score below 11 were classified as low probability of appendicitis. Only 4% of patients with appendicitis had a score below 11, and none of them had complicated appendicitis. In contrast, 207 (54%) of non-appendicitis patients had score below 11. There were no cases with complicated appendicitis in the low probability group. The area under ROC curve was significantly larger with the new score 0.882 (95% CI 0.858 – 0.906) compared with AUC of Alvarado score 0.790 (0.758 – 0.823) and Appendicitis inflammatory response score 0.810 (0.779 – 0.840). Conclusions The new diagnostic score is fast and accurate in categorizing patients with suspected appendicitis, and roughly halves the need of diagnostic imaging. PMID:24970111

std::string Append

DTIC Science & Technology

2015-10-01

UNCLASSIFIED AD-E403 689 Technical Report ARWSE-TR-14026 STD::STRING APPEND Tom Nealis...DATES COVERED (From – To) 4. TITLE AND SUBTITLE STD::STRING APPEND 5a. CONTRACT NUMBER 5b. GRANT NUMBER 5c. PROGRAM ELEMENT NUMBER 6...DISTRIBUTION/AVAILABILITY STATEMENT Approved for public release; distribution is unlimited. 13. SUPPLEMENTARY NOTES 14. ABSTRACT Appending

[A Case of Retroperitoneal Abscess Due to Acute Appendicitis during Neo-Adjuvant Chemotherapy for Breast Cancer].

PubMed

Oba, Takaaki; Maeno, Kazuma; Ito, Kenichi; Ishizone, Satoshi; Hanaoka, Takaomi

2017-11-01

When acute appendicitis occurs in patients treated with chemotherapy, neutropenia and abdominal complaints caused by chemotherapy can contribute to the diagnostic difficulty, masking the increase in white blood cell(WBC)counts and physical findings of acute appendicitis. A 43-year-old premenopausal woman who was diagnosed with stage IIIA left breast cancer was scheduled for neoadjuvant chemotherapy includingfluorouracil plus epirubicin plus cyclophosphamide(FEC), followed by docetaxel and trastuzumab(DOC plus HER). The patient developed fever and lower abdominal pain on day 17 of DOC plus HER cycle 1, and was diagnosed with acute gastroenteritis in the emergency room. These symptoms were almost improved 4 days later, and then cycle 2 was performed as scheduled. WBC counts decreased to 1,530 cells/mL due to DOCinduced myelosuppression on day 8 of cycle 2 when the patient developed lower abdominal pain again. However, WBC counts increased to 21,680 cells/mL on day 13 of cycle 2. Computed tomography scans revealed an intraperitoneal abscess due to acute appendicitis, and consequently urgent operation was performed. It is necessary to understand that patients with acute appendicitis duringchemotherapy can present less clinical findings.

Duodenal Obstruction Caused by Acute Appendicitis with Intestinal Malrotation in a Child.

PubMed

Biçer, Şenol; Çelik, Ali

2015-08-27

In patients with intestinal malrotation, the diagnosis of acute appendicitis can be difficult due to atypical presentation. Duodenal obstruction caused by acute appendicitis with the presence of malrotation has rarely been reported in children. We report the case of a 14-year-old male patient with bilious vomiting and abdominal distension. A diagnosis could not be made by computed tomography, ultrasonography, or endoscopy. We observed a dilated stomach and malrotation in laparotomy. The caecum was in the right upper quadrant, and an inflamed appendix was located in the subhepatic region. After the appendectomy, the cecum was mobilized and fixed in the right lower quadrant. In children with intestinal malrotation, acute appendicitis can present as duodenal obstruction without abdominal pain, and standard imaging methods can miss the correct diagnosis.

A rare case of perforated "sub-hepatic appendicitis" - a challenging differential diagnosis of acute abdomen based on the combination of appendicitis and maldescent of the caecum.

PubMed

Chiapponi, Costanza; Jannasch, Olof; Petersen, Manuela; Lessel, Wiebke; Bruns, Christiane; Meyer, Frank

2017-01-01

Unusual locations of the appendix vermiformis can result in delay in appropriate diagnosis and treatment of appendicitis. So an inflamed appendix in a sub-hepatic caecum caused by caecal maldescent for example can mimic cholecystitis, the pain being localized in the right upper quadrant. Here, we present a case of perforated sub-hepatic appendicitis with peritonitis, requiring open ileocaecal resection. Review of the existing literature has demonstrated that this pathology is uncommon, yet not so rare as one might presume. In conclusion, surgeons should be aware of this possibility in the diagnostic and therapeutic management of acute abdomen. Copyright © 2016. Published by Elsevier GmbH.

Hydronephrosis in Acute Uncomplicated Appendicitis.

PubMed

Schok, T; Austen, S; Lewicz, R B C B; Zande, F H R van der; Peters, N A L R; Janzing, H M J

2015-01-01

Right-sided hydronephrosis as a sign of appendicitis occurs rarely in the literature. To our knowledge, this is the first published account of the occurrence of right-sided hydronephrosis as a result of uncomplicated appendicitis. We describe a 15 year old patient referred to the emergency department with suspected appendicitis. Additional ultrasound examination showed a right-sided hydronephrosis. This finding was discussed with the urologist who noted the hydronephrosis as a chance finding. Because of persistent clinical suspicion of appendicitis, a diagnostic laparoscopy was performed. A retrocaecal appendicitis with secondary hydronephrosis was found. Right-sided hydronephrosis may be a sign of acute uncomplicated (retrocaecal) appendicitis. It is important to keep sight of these findings, especially in view of the emphasis on imaging techniques in the current Dutch guideline on appendicitis.

Hydronephrosis in acute uncomplicated appendicitis.

PubMed

Schok, T; Austen, S; Lewicz, R B C B; van der Zande, F H R; Peters, N A L R; Janzing, H M J

2015-01-01

Right-sided hydronephrosis as a sign of appendicitis occurs rarely in the literature. To our knowledge, this is the first published account of the occurrence of right-sided hydronephrosis as a result of uncomplicated appendicitis. We describe a 15 year old patient referred to the emergency department with suspected appendicitis. Additional ultrasound examination showed a right-sided hydronephrosis. This finding was discussed with the urologist who noted the hydronephrosis as a chance finding. Because of persistent clinical suspicion of appendicitis, a diagnostic laparoscopy was performed. A retrocaecal appendicitis with secondary hydronephrosis was found. Right-sided hydronephrosis may be a sign of acute uncomplicated (retrocaecal) appendicitis. It is important to keep sight of these findings, especially in view of the emphasis on imaging techniques in the current Dutch guideline on appendicitis. Copyright© Acta Chirurgica Belgica.

Appendectomy for asymptomatic appendicitis during caesarean section - an interesting case report.

PubMed

Panteleris, N; Daniilidis, A; Stamkopoulou, A; Kogeorgos, S; Chatzis, P; Assimakopoulos, E

2016-01-01

The authors present an interesting case report of an appendectomy during caesarean section in an asymptomatic pregnant woman, which highlights the need of peritoneal cavity check during every caesarean section. A 32-year-old para 0 woman at 34 weeks of gestation attended to the present clinic because of a feeling of reduced fetal movements in the last 24 hours. She underwent a non-stress test (NST), that was non-reassuring and no contractions were recorded. The woman underwent a caesarean section, which revealed a large phlegmonic appendix. Appendectomy was decided after the closure of the uterine cavity. The woman was treated with appendectomy. Histology came back as an appendicitis three days later. Acute appendicitis during pregnancy may be associated with serious maternal and fetal complications. It is also associated with a high risk of premature delivery. In the absence of lower abdominal pain and inflammatory changes, the incidence of acute appendicitis is low, but exists. In every caesarean section at any week of gestation, we should check the peritoneal cavity and especially the appendix, as appendicitis is the most pregnant woman who mentions preterm contractions or/and reduced fetal movements.

Spontaneous Extraperitoneal Bladder Rupture Because of Chronic Appendicitis

PubMed Central

Morganstern, Bradley A.; Viviano, Robert; Elsamra, Sammy

2013-01-01

A 62-year-old man presented to the emergency department with an episode of syncope after 2-3 weeks of diffuse abdominal pain, now complaining of a severe increase in pain concurrent with >24 hours of no urine output. His workup showed an idiopathic extraperitoneal rupture of the bladder on computed tomography, which was handled conservatively with Foley insertion. Repeated follow-up and imaging showed no resolution or etiology over 2 months. The patient underwent exploratory laparotomy that showed an elongated appendix with a chronic tip appendicitis that had induced bladder rupture by chronic inflammatory changes. After repair, the patient had no further complaints. PMID:26955533

Single-port laparoscopic surgery in acute appendicitis: retrospective comparative analysis for 618 patients.

PubMed

Kang, Byung Mo; Hwang, Ji Woong; Ryu, Byoung Yoon

2016-11-01

Transumbilical single-port laparoscopic appendectomy (SPLA) is a promising procedure that features less pain, faster recovery of postoperative bowel function and superior cosmetic results. We performed a retrospective comparative analysis of SPLA versus conventional laparoscopic surgery (CLA) to evaluate the safety and efficacy in acute appendicitis. From December 2008 to November 2013, laparoscopic surgery was performed on 636 patients with acute appendicitis at the Department of Surgery, Chuncheon Sacred Heart Hospital. Under approval of Institutional Review Board, data concerning baseline characteristics, operative outcomes, postoperative complications and postoperative functional recovery were compared between both procedures. After exclusion of 18 patients, 618 patients treated for acute appendicitis were included. SPLA was performed in 375 patients and CLA in 243 patients. Complicated appendicitis was more prevalent in the CLA group (26.3 %) than in the SPLA group (17.1 %) (p = 0.005). There was no difference between groups in operation time (p = 0.235), postoperative duration of hospital stay (p = 0.672) and readmission rate (p = 0.688). The rate of postoperative complications was similar in both groups (10.7 % in SPLA vs. 11.1 % in CLA, p = 0.862). In subgroup analysis of complicated appendicitis, more patients needed conversion to open surgery in the SPLA group (15.6 vs. 1.6 %, p = 0.005). In uncomplicated appendicitis, SPLA can be performed safely and efficiently. However, more selective indication for SPLA should be applied in cases of complicated appendicitis because of the greater risk of open conversion.

Gangrenous Appendicitis in a Boy with Mobile Caecum.

PubMed

Keskin, Suat; Keskin, Zeynep; Gunduz, Metin; Sekmenli, Taner; Kivrak, Hatice Yazar

2015-04-01

A mobile caecum and ascending colon is an uncommon congenital disorder, and it is even rarer as the cause of an acute abdomen during childhood. This report presents the case of a 6-year-old boy with acute gangrenous appendicitis with a mobile caecum and ascending colon. Data from the surgical course, as well as laboratory and imaging studies, were acquired and carefully examined. Emergency ultrasound (US) was performed and revealed no signs of appendicitis in the right lower quadrant. Serial imaging study, including non-enhanced computed tomography (CT), was performed. An imaging study identified epigastric appendicitis with mobile caecum. Surgery was executed under general anesthesia with a median incision extending from the epigastrium to the suprapubic region. The caecum was mobile and placed in the right epigastric area, next to the left lobe of the liver and gallbladder. The gangrenous appendix was discovered posterior to the caecum and transverse colon, enlarging to the left upper quadrant. Appendectomy was executed, the gangrenous appendix was confirmed pathologically, and the patient was released 4 days later. In the US, if there are unusual clinical findings or no findings in patients with abdominal pain, CT is beneficial in determining the location of the caecum and appendix and preventing misdiagnosis in children.

Acute Appendicitis, Somatosensory Disturbances ("Head Zones"), and the Differential Diagnosis of Anterior Cutaneous Nerve Entrapment Syndrome (ACNES).

PubMed

Roumen, Rudi M H; Vening, Wouter; Wouda, Rosanne; Scheltinga, Marc M

2017-06-01

Anterior cutaneous nerve entrapment syndrome (ACNES) is a neuropathic abdominal wall pain syndrome typically characterized by locally altered skin sensations. On the other hand, visceral disease may also be associated with similar painful and altered skin sensations ("Head zones"). Aim of the study was to determine if patients with acute appendicitis demonstrated somatosensory disturbances in the corresponding right lower quadrant Head zone. The presence of somatosensory disturbances such as hyperalgesia, hypoesthesia, altered cool perception, or positive pinch test was determined in 100 patients before and after an appendectomy. Potential associations between altered skin sensations and various items including age, sex, history, body temperature, C-reactive protein (CRP), leukocyte count, and type of appendicopathy (normal, inflamed, necrotic, or perforated) were assessed. A total of 39 patients demonstrated at least one right lower abdominal quadrant skin somatosensory disturbance before the laparoscopic appendectomy. However, locoregional skin sensation normalized in all but 2 patients 2 weeks postoperatively. No differences were found concerning patient characteristics or type of appendicopathy between populations with or without altered lower abdominal skin sensations. A substantial portion of patients with acute appendicitis demonstrate right lower abdominal somatosensory disturbances that are similar as observed in acute ACNES. Both may be different sides of the same coin and are possibly expressions of segmental phenomena as described by Head. McBurney's point, a landmark area of maximum pain in acute appendicitis, is possibly a trigger point within a Head zone. Differentiating acute appendicitis from acute ACNES is extremely difficult, but imaging and observation may aid in the diagnostic process.

Massive ovarian edema, due to adjacent appendicitis.

PubMed

Callen, Andrew L; Illangasekare, Tushani; Poder, Liina

2017-04-01

Massive ovarian edema is a benign clinical entity, the imaging findings of which can mimic an adnexal mass or ovarian torsion. In the setting of acute abdominal pain, identifying massive ovarian edema is a key in avoiding potential fertility-threatening surgery in young women. In addition, it is important to consider other contributing pathology when ovarian edema is secondary to another process. We present a case of a young woman presenting with subacute abdominal pain, whose initial workup revealed marked enlarged right ovary. Further imaging, diagnostic tests, and eventually diagnostic laparoscopy revealed that the ovarian enlargement was secondary to subacute appendicitis, rather than a primary adnexal process. We review the classic ultrasound and MRI imaging findings and pitfalls that relate to this diagnosis.

The pathology of acute appendicitis.

PubMed

Carr, N J

2000-02-01

Although acute appendicitis is frequent, it is subject to common misconceptions. Furthermore, there is little good evidence to support some of our beliefs. This report reviews the role of the anatomic pathologist in diagnosis when acute appendicitis is suspected clinically and discusses what is known of its pathology. The conclusions that can be legitimately drawn from the literature are emphasized. A classification is proposed that incorporates intraluminal inflammation, acute mucosal inflammation, acute mucosal and submucosal inflammation, suppurative (phlegmonous) appendicitis, gangrenous appendicitis, and periappendicitis, and the significance of each of these diagnoses is discussed. The etiology and pathogenesis of acute appendicitis is reviewed. Contrary to popular belief, the best evidence indicates that obstruction is unlikely to be the primary cause, at least in the majority of cases. Ancillary techniques in the diagnosis of appendicitis, including laparoscopy and peritoneal aspiration cytology, are discussed.

Health outcomes in US children with abdominal pain at major emergency departments associated with race and socioeconomic status.

PubMed

Wang, Louise; Haberland, Corinna; Thurm, Cary; Bhattacharya, Jay; Park, K T

2015-01-01

Over 9.6 million ED visits occur annually for abdominal pain in the US, but little is known about the medical outcomes of these patients based on demographics. We aimed to identify disparities in outcomes among children presenting to the ED with abdominal pain linked to race and SES. Data from 4.2 million pediatric encounters of abdominal pain were analyzed from 43 tertiary US children's hospitals, including 2.0 million encounters in the emergency department during 2004-2011. Abdominal pain was categorized as functional or organic abdominal pain. Appendicitis (with and without perforation) was used as a surrogate for abdominal pain requiring emergent care. Multivariate analysis estimated likelihood of hospitalizations, radiologic imaging, ICU admissions, appendicitis, appendicitis with perforation, and time to surgery and hospital discharge. Black and low income children had increased odds of perforated appendicitis (aOR, 1.42, 95% CI, 1.32- 1.53; aOR, 1.20, 95% CI 1.14 - 1.25). Blacks had increased odds of an ICU admission (aOR, 1.92, 95% CI 1.53 - 2.42) and longer lengths of stay (aHR, 0.91, 95% CI 0.86 - 0.96) than Whites. Minorities and low income also had lower rates of imaging for their appendicitis, including CT scans. The combined effect of race and income on perforated appendicitis, hospitalization, and time to surgery was greater than either separately. Based on race and SES, disparity of health outcomes exists in the acute ED setting among children presenting with abdominal pain, with differences in appendicitis with perforation, length of stay, and time until surgery.

[Synchronous acute cholecystolithiasis and perforated acute appendicitis. Case report].

PubMed

Padrón-Arredondo, Guillermo; de Atocha Rosado-Montero, Manuel

2016-01-01

Acute appendicitis and acute cholecystitis are among the most common diagnoses that general surgeons operate on. However, it is rarely described in its synchronous form. A 43 year-old woman attending the clinic for right upper quadrant pain of 11 days duration. The patient refers to intermittent radiating pain in the right side, with positive Murphy, tachycardia, and fever. The laboratory results showed white cells 16,200/mm(3), glucose 345 mg/dl, abnormal liver function tests. Acute cholecystitis was reported with ultrasound. A Masson-type incision was made, noting an enlarged pyogenic gallbladder with thickened walls, sub-hepatic abscess of approximately 300 ml, greenish-yellow colour, and foetid. An anterograde subtotal cholecystectomy is performed due to difficulty in identifying elements of Calot triangle due to the inflammatory process, opening it and extracting stones. The right iliac fossa is reviewed, finding a plastron and a sub-serous retrocaecal appendix perforated in its middle third with free fecalith and an abscess in the pelvic cavity. An anterograde appendectomy was performed and the patient progressed satisfactorily, later being discharged due to improvement. In this patient, with a history of recurrent episodes of gallbladder pain and disseminated acute abdominal pain without peritoneal irritation, clinical suspicion was exacerbated cholecystitis with probable empyema of the gallbladder. Open surgery approach for this patient allowed access to both the appendix and gallbladder in order to perform a complete exploration of the abdominal cavity. The synchronous presentation of cholecystolithiasis and complicated appendicitis has not been reported in the literature. Copyright © 2015 Academia Mexicana de Cirugía A.C. Published by Masson Doyma México S.A. All rights reserved.

Eosinophilic acute appendicitis caused by Strongyloides stercoralis and Enterobius vermicularis in an HIV-positive patient.

PubMed

Cruz, Dennis Baroni; Friedrisch, Bruno Kras; Fontanive Junior, Vilmar; da Rocha, Vívian Wünderlich

2012-03-27

A 29 year old female HIV-positive patient presented in emergency with acute right lower quadrant abdominal pain, fever, tenderness and positive Blumberg sign. Laboratorial tests revealed eosinophilia, anaemia and leukocytosis. She underwent exploratory laparotomy followed by appendectomy. The pathological analysis of the appendix revealed acute appendicitis, accentuated eosinophilia and infestation by Strongyloides stercoralis and Enterobius vermicularis. She did well after surgery and adequate treatment. To the authors' knowledge, this is the first case of eosinophilic acute appendicitis caused by these two parasitic worms reported in the medical literature.

Eosinophilic acute appendicitis caused by Strongyloides stercoralis and Enterobius vermicularis in an HIV-positive patient

PubMed Central

Cruz, Dennis Baroni; Friedrisch, Bruno Kras; Fontanive Junior, Vilmar; da Rocha, Vívian Wünderlich

2012-01-01

A 29 year old female HIV-positive patient presented in emergency with acute right lower quadrant abdominal pain, fever, tenderness and positive Blumberg sign. Laboratorial tests revealed eosinophilia, anaemia and leukocytosis. She underwent exploratory laparotomy followed by appendectomy. The pathological analysis of the appendix revealed acute appendicitis, accentuated eosinophilia and infestation by Strongyloides stercoralis and Enterobius vermicularis. She did well after surgery and adequate treatment. To the authors’ knowledge, this is the first case of eosinophilic acute appendicitis caused by these two parasitic worms reported in the medical literature. PMID:22605801

Safety and feasibility of same-day discharge for uncomplicated appendicitis: A prospective cohort study.

PubMed

Gee, Kristin; Ngo, Sandra; Burkhalter, Lorrie; Beres, Alana L

2018-05-01

Appendicitis is the most common gastrointestinal pediatric surgical emergency. With the introduction of laparoscopic techniques in the 1990s, recovery, pain, and hospital stay after laparoscopic procedures have been significantly reduced. While many laparoscopic procedures are performed as outpatient surgeries, pediatric appendectomy patients continue to be hospitalized for postoperative observation. Our goal was to evaluate the safety and feasibility of same day discharge after laparoscopic appendectomy for uncomplicated appendicitis. After IRB approval, all pediatric patients undergoing laparoscopic appendectomy during 2016 for noncomplicated appendicitis were eligible for the study. Decision for same day discharge was based on surgeon preference and parental agreement. Data regarding demographics, admission and discharge times, outcomes of complications, readmissions, return to the ED, and nonscheduled clinic visits were collected. A total of 1321 appendectomies were performed during the study period, of which 849 were uncomplicated and 382 were discharged same day. There were 2 readmissions, 4 superficial surgical site infections, 10 patients with nausea or vomiting, and 33 patients with pain control issues, 9 of whom presented to the ED. Same day discharge for laparoscopic noncomplicated appendectomy is a safe and feasible alternative to postoperative admission and observation. This has the potential to yield significant healthcare cost savings. Level II, Prospective Cohort Study. Copyright © 2018. Published by Elsevier Inc.

WSES Jerusalem guidelines for diagnosis and treatment of acute appendicitis.

PubMed

Di Saverio, Salomone; Birindelli, Arianna; Kelly, Micheal D; Catena, Fausto; Weber, Dieter G; Sartelli, Massimo; Sugrue, Michael; De Moya, Mark; Gomes, Carlos Augusto; Bhangu, Aneel; Agresta, Ferdinando; Moore, Ernest E; Soreide, Kjetil; Griffiths, Ewen; De Castro, Steve; Kashuk, Jeffry; Kluger, Yoram; Leppaniemi, Ari; Ansaloni, Luca; Andersson, Manne; Coccolini, Federico; Coimbra, Raul; Gurusamy, Kurinchi S; Campanile, Fabio Cesare; Biffl, Walter; Chiara, Osvaldo; Moore, Fred; Peitzman, Andrew B; Fraga, Gustavo P; Costa, David; Maier, Ronald V; Rizoli, Sandro; Balogh, Zsolt J; Bendinelli, Cino; Cirocchi, Roberto; Tonini, Valeria; Piccinini, Alice; Tugnoli, Gregorio; Jovine, Elio; Persiani, Roberto; Biondi, Antonio; Scalea, Thomas; Stahel, Philip; Ivatury, Rao; Velmahos, George; Andersson, Roland

2016-01-01

Acute appendicitis (AA) is among the most common cause of acute abdominal pain. Diagnosis of AA is challenging; a variable combination of clinical signs and symptoms has been used together with laboratory findings in several scoring systems proposed for suggesting the probability of AA and the possible subsequent management pathway. The role of imaging in the diagnosis of AA is still debated, with variable use of US, CT and MRI in different settings worldwide. Up to date, comprehensive clinical guidelines for diagnosis and management of AA have never been issued. In July 2015, during the 3rd World Congress of the WSES, held in Jerusalem (Israel), a panel of experts including an Organizational Committee and Scientific Committee and Scientific Secretariat, participated to a Consensus Conference where eight panelists presented a number of statements developed for each of the eight main questions about diagnosis and management of AA. The statements were then voted, eventually modified and finally approved by the participants to The Consensus Conference and lately by the board of co-authors. The current paper is reporting the definitive Guidelines Statements on each of the following topics: 1) Diagnostic efficiency of clinical scoring systems, 2) Role of Imaging, 3) Non-operative treatment for uncomplicated appendicitis, 4) Timing of appendectomy and in-hospital delay, 5) Surgical treatment 6) Scoring systems for intra-operative grading of appendicitis and their clinical usefulness 7) Non-surgical treatment for complicated appendicitis: abscess or phlegmon 8) Pre-operative and post-operative antibiotics.

Developing and evaluating an automated appendicitis risk stratification algorithm for pediatric patients in the emergency department.

PubMed

Deleger, Louise; Brodzinski, Holly; Zhai, Haijun; Li, Qi; Lingren, Todd; Kirkendall, Eric S; Alessandrini, Evaline; Solti, Imre

2013-12-01

To evaluate a proposed natural language processing (NLP) and machine-learning based automated method to risk stratify abdominal pain patients by analyzing the content of the electronic health record (EHR). We analyzed the EHRs of a random sample of 2100 pediatric emergency department (ED) patients with abdominal pain, including all with a final diagnosis of appendicitis. We developed an automated system to extract relevant elements from ED physician notes and lab values and to automatically assign a risk category for acute appendicitis (high, equivocal, or low), based on the Pediatric Appendicitis Score. We evaluated the performance of the system against a manually created gold standard (chart reviews by ED physicians) for recall, specificity, and precision. The system achieved an average F-measure of 0.867 (0.869 recall and 0.863 precision) for risk classification, which was comparable to physician experts. Recall/precision were 0.897/0.952 in the low-risk category, 0.855/0.886 in the high-risk category, and 0.854/0.766 in the equivocal-risk category. The information that the system required as input to achieve high F-measure was available within the first 4 h of the ED visit. Automated appendicitis risk categorization based on EHR content, including information from clinical notes, shows comparable performance to physician chart reviewers as measured by their inter-annotator agreement and represents a promising new approach for computerized decision support to promote application of evidence-based medicine at the point of care.

Meckel's Diverticulum with Small Bowel Obstruction Presenting as Appendicitis in a Pediatric Patient

PubMed Central

Gonzalez, Adolfo; Corpron, Cynthia

2011-01-01

Background: Meckel's diverticulum is a congenital anomaly resulting from incomplete obliteration of the omphalomesenteric duct. The incidence ranges from 0.3% to 2.5% with most patients being asymptomatic. In some cases, complications involving a Meckel's diverticulum may mimic other disease processes and obscure the clinical picture. Methods: This case presents an 8-year-old male with abdominal pain, nausea, and vomiting and an examination resembling appendicitis. Results: A CT scan revealed findings consistent with appendicitis with dilated loops of small bowel. During laparoscopic appendectomy, the appendix appeared unimpressive, and an inflamed Meckel's diverticulum was found with an adhesive band creating an internal hernia with small bowel obstruction. The diverticulum was resected after the appendix was removed. Conclusion: The incidence of an internal hernia with a Meckel's diverticulum is rare. A diseased Meckel's diverticulum can be overlooked in many cases, especially in those resembling appendicitis. It is recommended that the small bowel be assessed in all appendectomy cases for a pathological Meckel's diverticulum. PMID:22643517

Factors predictive of complicated appendicitis in children.

PubMed

Pham, Xuan-Binh D; Sullins, Veronica F; Kim, Dennis Y; Range, Blake; Kaji, Amy H; de Virgilio, Christian M; Lee, Steven L

2016-11-01

The ability to predict whether a child has complicated appendicitis at initial presentation may influence clinical management. However, whether complicated appendicitis is associated with prehospital or inhospital factors is not clear. We also investigate whether hyponatremia may be a novel prehospital factor associated with complicated appendicitis. A retrospective review of all pediatric patients (≤12 y) with appendicitis treated with appendectomy from 2000 to 2013 was performed. The main outcome measure was intraoperative confirmation of gangrenous or perforated appendicitis. A multivariable analysis was performed, and the main predictors of interest were age <5 y, symptom duration >24 h, leukocytosis (white blood cell count >12 × 10 3 /mL), hyponatremia (sodium ≤135 mEq/L), and time from admission to appendectomy. Of 392 patients, 179 (46%) had complicated appendicitis at the time of operation. Univariate analysis demonstrated that patients with complicated appendicitis were younger, had a longer duration of symptoms, higher white blood cell count, and lower sodium levels than patients with noncomplicated appendicitis. Multivariable analysis confirmed that symptom duration >24 h (odds ratio [OR] = 5.5, 95% confidence interval [CI] = 3.5-8.9, P < 0.01), hyponatremia (OR = 3.1, 95% CI = 2.0-4.9, P < 0.01), age <5 y (OR = 2.3, 95% CI = 1.3-4.0, P < 0.01), and leukocytosis (OR = 1.9, 95% CI = 1.0-3.5, P = 0.04) were independent predictors of complicated appendicitis. Increased time from admission to appendectomy was not a predictor of complicated appendicitis (OR = 0.8, 95% CI = 0.5-1.2, P = 0.2). Prehospital factors can predict complicated appendicitis in children with suspected appendicitis. Hyponatremia is a novel marker associated with complicated appendicitis. Delaying appendectomy does not increase the risk of complicated appendicitis once intravenous antibiotics are administered. This information may help guide

Management of Pediatric Perforated Appendicitis: Comparing Outcomes Using Early Appendectomy Versus Solely Medical Management.

PubMed

Bonadio, William; Rebillot, Katie; Ukwuoma, Onyinyechi; Saracino, Christine; Iskhakov, Arthur

2017-10-01

There is controversy regarding whether children with perforated appendicitis should receive early appendectomy (EA) versus medical management (MM) with antibiotics and delayed interval appendectomy. The objective of this study was to compare outcomes of children with perforated appendicitis who receive EA versus MM. Case review of consecutive children <18 years of age with perforated appendicitis who received either EA or MM during an 8-year period. Criteria for hospital discharge included patient being afebrile for at least 24 hours, pain-free and able to tolerate oral intake. Of 203 patients diagnosed with perforated appendicitis, 122 received EA and 81 received MM. All received parenteral antibiotic therapy initiated in the emergency department and continued during hospitalization. There were no significant differences between groups in mean patient age, mean complete blood count total white blood cells count, gender distribution, rates of emergency department fever or rates of intra-abdominal infection (abscess or phlegmon) identified on admission. Compared with patients receiving MM, those receiving EA experienced significantly fewer (1) days of hospitalization, parenteral antibiotic therapy and in-hospital fever; (2) radiographic studies, percutaneous drainage procedures and placement of central venous catheters performed; (3) post admission intra-abdominal complications and (4) unscheduled repeat hospitalizations after hospital discharge. Only 1 EA-managed patient developed a postoperative wound infection. Children with perforated appendicitis who receive EA experience significantly less morbidity and complications versus those receiving MM. The theoretical concern for enhanced morbidity associated with EA management of perforated appendicitis is not supported by our analysis.

Incidence of Appendicitis over Time: A Comparative Analysis of an Administrative Healthcare Database and a Pathology-Proven Appendicitis Registry

PubMed Central

Clement, Fiona; Zimmer, Scott; Dixon, Elijah; Ball, Chad G.; Heitman, Steven J.; Swain, Mark; Ghosh, Subrata

2016-01-01

Importance At the turn of the 21st century, studies evaluating the change in incidence of appendicitis over time have reported inconsistent findings. Objectives We compared the differences in the incidence of appendicitis derived from a pathology registry versus an administrative database in order to validate coding in administrative databases and establish temporal trends in the incidence of appendicitis. Design We conducted a population-based comparative cohort study to identify all individuals with appendicitis from 2000 to2008. Setting & Participants Two population-based data sources were used to identify cases of appendicitis: 1) a pathology registry (n = 8,822); and 2) a hospital discharge abstract database (n = 10,453). Intervention & Main Outcome The administrative database was compared to the pathology registry for the following a priori analyses: 1) to calculate the positive predictive value (PPV) of administrative codes; 2) to compare the annual incidence of appendicitis; and 3) to assess differences in temporal trends. Temporal trends were assessed using a generalized linear model that assumed a Poisson distribution and reported as an annual percent change (APC) with 95% confidence intervals (CI). Analyses were stratified by perforated and non-perforated appendicitis. Results The administrative database (PPV = 83.0%) overestimated the incidence of appendicitis (100.3 per 100,000) when compared to the pathology registry (84.2 per 100,000). Codes for perforated appendicitis were not reliable (PPV = 52.4%) leading to overestimation in the incidence of perforated appendicitis in the administrative database (34.8 per 100,000) as compared to the pathology registry (19.4 per 100,000). The incidence of appendicitis significantly increased over time in both the administrative database (APC = 2.1%; 95% CI: 1.3, 2.8) and pathology registry (APC = 4.1; 95% CI: 3.1, 5.0). Conclusion & Relevance The administrative database overestimated the incidence of appendicitis

The immune impact of mimic endoscopic retrograde appendicitis therapy and appendectomy on rabbits of acute appendicitis.

PubMed

Liu, Suqin; Pei, Fenghua; Wang, Xinhong; Li, Deliang; Zhao, Lixia; Song, Yanyan; Chen, Zhendong; Liu, Bingrong

2017-09-12

This study was conducted to evaluate the immune impact of mimic endoscopic retrograde appendicitis therapy and appendectomy on rabbits of acute suppurative appendicitis and to determine whether TLR4/MYD88/NF-κB signaling pathway was activated in this process. 48 rabbits were assigned into 4 groups: group I, the mimic endoscopic retrograde appendicitis therapy group; group II, the appendectomy group; group III, the model group; and group IV, the blank group. White blood cells decreased, while levels of C-reactive protein, tumor necrosis factor-α, interleukin-6, interleukin-4, and interleukin-10 increased on the 2 nd day in group I and II. IgA in feces decreased at 2 weeks, while fecal microbiota changed at 2 and 4 weeks after appendectomy. CD8 + cells in appendix of group I increased within 8 weeks. Upregulated expression of TLR4, MYD88, and nuclear NF-κB were detected on the 2 nd day in group I and II. Mimic endoscopic retrograde appendicitis therapy and appendectomy are effective ways for acute suppurative appendicitis. Mimic endoscopic retrograde appendicitis therapy was more preferable due to its advantage in maintaining intestinal immune function. TLR4/MYD88/NF-κB signaling pathway was activated in acute phase of appendicitis.

Diagnosis of Acute Appendicitis by Endoscopic Retrograde Appendicitis Therapy (ERAT): Combination of Colonoscopy and Endoscopic Retrograde Appendicography.

PubMed

Li, Yingchao; Mi, Chen; Li, Weizhi; She, Junjun

2016-11-01

Acute appendicitis is the most common abdominal emergency, but the diagnosis of appendicitis remains a challenge. Endoscopic retrograde appendicitis therapy (ERAT) is a new and minimally invasive procedure for the diagnosis and treatment of acute appendicitis. To investigate the diagnostic value of ERAT for acute appendicitis by the combination of colonoscopy and endoscopic retrograde appendicography (ERA). Twenty-one patients with the diagnosis of suspected uncomplicated acute appendicitis who underwent ERAT between November 2014 and January 2015 were included in this study. The main outcomes, imaging findings of acute appendicitis including colonoscopic direct-vision imaging and fluoroscopic ERA imaging, were retrospectively reviewed. Secondary outcomes included mean operative time, mean hospital stay, rate of complication, rate of appendectomy during follow-up period, and other clinical data. The diagnosis of acute appendicitis was established in 20 patients by positive ERA (5 patients) or colonoscopy (1 patient) alone or both (14 patients). The main colonoscopic imaging findings included mucosal inflammation (15/20, 75 %), appendicoliths (14/20, 70 %), and maturation (5/20, 25 %). The key points of ERA for diagnosing acute appendicitis included radiographic changes of appendix (17/20, 85 %), intraluminal appendicoliths (14/20, 70 %), and perforation (1/20, 5 %). Mean operative time of ERAT was 49.7 min, and mean hospital stay was 3.3 days. No patient converted to emergency appendectomy. Perforation occurred in one patient after appendicoliths removal was not severe and did not require invasive procedures. During at least 1-year follow-up period, only one patient underwent laparoscopic appendectomy. ERAT is a valuable procedure of choice providing a precise yield of diagnostic information for patients with suspected acute appendicitis by combination of colonoscopy and ERA.

Abdominal 64-MDCT for suspected appendicitis: the use of oral and IV contrast material versus IV contrast material only.

PubMed

Anderson, Stephan W; Soto, Jorge A; Lucey, Brian C; Ozonoff, Al; Jordan, Jacqueline D; Ratevosian, Jirair; Ulrich, Andrew S; Rathlev, Niels K; Mitchell, Patricia M; Rebholz, Casey; Feldman, James A; Rhea, James T

2009-11-01

The objective of our study was to compare the diagnostic accuracy of IV contrast-enhanced 64-MDCT with and without the use of oral contrast material in diagnosing appendicitis in patients with abdominal pain. We conducted a randomized trial of a convenience sample of adult patients presenting to an urban academic emergency department with acute nontraumatic abdominal pain and clinical suspicion of appendicitis, diverticulitis, or small-bowel obstruction. Patients were enrolled between 8 am and 11 pm when research assistants were present. Consenting subjects were randomized into one of two groups: Group 1 subjects underwent 64-MDCT performed with oral and IV contrast media and group 2 subjects underwent 64-MDCT performed solely with IV contrast material. Three expert radiologists independently reviewed the CT examinations, evaluating for the presence of appendicitis. Each radiologist interpreted 202 examinations, ensuring that each examination was interpreted by two radiologists. Individual reader performance and a combined interpretation performance of the two readers assigned to each case were calculated. In cases of disagreement, the third reader was asked to deliver a tiebreaker interpretation to be used to calculate the combined reader performance. Final outcome was based on operative, clinical, and follow-up data. We compared radiologic diagnoses with clinical outcomes to calculate the diagnostic accuracy of CT in both groups. Of the 303 patients enrolled, 151 patients (50%) were randomized to group 1 and the remaining 152 (50%) were randomized to group 2. The combined reader performance for the diagnosis of appendicitis in group 1 was a sensitivity of 100% (95% CI, 76.8-100%) and specificity of 97.1% (95% CI, 92.7-99.2%). The performance in group 2 was a sensitivity of 100% (73.5-100%) and specificity of 97.1% (92.9-99.2%). Patients presenting with nontraumatic abdominal pain imaged using 64-MDCT with isotropic reformations had similar characteristics for the

Preconsultation use of analgesics on adults presenting to the emergency department with acute appendicitis

PubMed Central

Chong, C; Wang, T; Chen, C; Ma, H; Chang, H

2004-01-01

Objective: 279 cases of appendicitis were reviewed and compared for the difference between those patients who received pain medication before consulting a surgeon and those who were not treated with analgesics. Methods: All patients aged 15 years and older who underwent appendicectomy for appendicitis between 1 July 2001 and 30 June 2002 were divided into group 1 (those who received preconsultaion use of analgesics) and group 2 (those who were not treated with analgesics). The following measures were compared: age, sex, symptom duration, initial vital signs, white blood cell counts, frequency of imaging studies, time to operative intervention, and operative findings. Continuous and categorical variables were analysed using t and χ2 tests, respectively. Results: A total of 279 patients were included for analysis. Patient details (age, sex, symptom duration) of the two study groups were similar. There was no statistically significant difference between group 1 and group 2 with respect to vital signs (systolic blood pressure, pulse rate, respiratory rate, body temperature), white blood cell counts, and frequency of imaging studies (ultrasound, computed tomography). There was no significant difference in the rate of perforated appendicitis between the two study groups although a shorter median time to operative intervention has been found in the group who received analegesia. Conclusion: The preconsultation use of analgesics in ED patients with a final diagnosis of appendicitis is not associated with a longer delay to operative intervention and is not associated with an increased rate of perforated appendicitis. PMID:14734373

A Case Report of Heel Pain Mimicking Plantar Fasciitis and Osteosarcoma: A Unique Presentation of a Nora's Lesion.

PubMed

Rushing, Calvin J; Rogers, Diana E; Spinner, Steven M; Gajzer, David C

Bizarre parosteal osteochondromatous proliferation, otherwise known as "Nora's lesion," is a rare benign neoplasm first described by Nora in 1983. The exact etiology of this neoplasm remains unknown, and its presentation in the lower extremity presents a diagnostic challenge, as both clinical and radiologic features cannot fully differentiate it from other neoplasms. We present the case of a 48-year-old female with plantar heel pain secondary to Nora's lesion mimicking plantar fasciitis and periosteal osteosarcoma. Following bone biopsy for histopathologic analysis, the patient's symptoms spontaneously resolved, and she returned to activity with complete resolution of symptoms 18 months post biopsy. Bizarre parosteal osteochondromatous proliferation as an etiology for plantar heel pain has not been previously described in the literature. Although rare, it should be considered in the differential diagnosis for patients presenting with plantar heel pain, especially after failed conservative treatment. Following diagnostic confirmation by histopathology, complete surgical excision is the treatment of choice. Copyright © 2017 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.

Early Uncomplicated Appendicitis-Who Can We Treat Nonoperatively?

PubMed

Horattas, Mark C; Horattas, Ileana K; Vasiliou, Elya M

2018-02-01

This study evaluated nonoperative treatment for mild appendicitis and reviewed selection criteria to be used in introducing this option into clinical practice. A retrospective review of 73 consecutive cases of appendicitis treated by a single surgeon from 2011 to 2013 was completed. Patients who were diagnosed with mild appendicitis meeting the criteria of an APPENDICITIS scoring algorithm proposed in this manuscript were considered for nonoperative management. An additional 17 patients with mild appendicitis were offered and successfully treated nonoperatively between 2014 and 2016 and reviewed. Of these original 73 patients, 37 had moderate to severe appendicitis and directly underwent appendectomy. The remaining patients were diagnosed with mild appendicitis and considered eligible for nonoperative management. Of these, 14 patients were offered nonoperative therapy. Thirteen responded successfully; one patient responded partially, but later opted for surgery. In 2014, this scoring system and preliminary results were shared with the other surgeons in our department. Nonoperative management was then selectively adopted by a few of the surgeons from 2014 to 2016 with another 17 patients (APPENDICITIS score of 0 or 1) being offered and successfully managed nonoperatively. Patients with mild or early appendicitis can be successfully managed nonoperatively. A proposed APPENDICITIS scoring system may provide a helpful mnemonic for successfully selecting patients for this option.

The computed tomography appearance of recurrent and chronic appendicitis.

PubMed

Rao, P M; Rhea, J T; Novelline, R A; McCabe, C J

1998-01-01

The objective of this study was to determine computed tomography (CT) appearance of recurrent and chronic appendicitis. In 100 consecutive appendiceal CT examinations of proven appendicitis, 18 patients met criteria for recurrent (multiple discrete episodes) or chronic (continuous symptoms > 3 weeks, pathological findings) appendicitis. CT findings were reviewed. Ten patients had recurrent appendicitis, 3 had chronic appendicitis, 3 had both, and 2 had pathological chronic appendicitis. CT findings in 18 recurrent/chronic cases were identical to 82 acute appendicitis cases, including pericecal stranding (both 100%), dilated (> 6 mm) appendix (88.9% versus 93.9%), apical thickening (66.7% versus 69.5%), adenopathy (66.7% versus 61.0%), appendolith(s) (50% versus 42.7%), arrowhead (27.8% versus 22.0%), abscess (11.1% versus 11.0%), phlegmon (11.1% versus 6.1%), and fluid (5.6% versus 19.5%). CT findings in recurrent and chronic appendicitis are the same as those in acute appendicitis. Appendiceal CT can be beneficial for evaluating patients with suspected recurrent or chronic appendicitis.

Use of Computed Tomography to Determine Perforation in Patients With Acute Appendicitis.

PubMed

Gaskill, Cameron E; Simianu, Vlad V; Carnell, Jonathan; Hippe, Daniel S; Bhargava, Puneet; Flum, David R; Davidson, Giana H

Urgent appendectomy has long been the standard of care for acute appendicitis. Six randomized trials have demonstrated that antibiotics can safely treat appendicitis, but approximately 1 in 4 of these patients eventually requires appendectomy. Overall treatment success may be limited by complex disease including perforation. Patients׳ success on antibiotic therapy may depend on preoperative identification of complex disease on imaging. However, the effectiveness of computed tomography (CT) in differentiating complex disease including perforated from nonperforated appendicitis remains to be determined. The purpose of this study was to assess the preoperative diagnostic accuracy of CT in determining appendiceal perforation in patients operated for acute appendicitis. We performed a retrospective review of pathology and radiology reports from consecutive patients who presented to the emergency department with suspicion for acute appendicitis between January 2012 and May 2015. CT scans were re-reviewed by abdominal imaging fellowship-trained radiologists using standardized criteria, and the radiologists were blinded to pathology and surgical findings. Radiologists specifically noted presence or absence of periappendiceal gas, abscess, appendicolith, fat stranding, and bowel wall thickening. The overall radiologic impression as well as these specific imaging findings was compared to results of pathology and operative reports. Pathology reports were considered the standard for diagnostic accuracy. Eighty-nine patients (65% male, average age of 34 years) presenting with right lower quadrant pain underwent CT imaging and prompt appendectomy. Final pathology reported perforation in 48% (n = 43) of cases. Radiologic diagnosis of perforation was reported in 9% (n = 8), correctly identifying perforation in 37.5% (n = 3), and incorrectly reporting perforation in 62.5% of nonperforated cases per pathology. Radiology missed 93% (n = 40) of perforations postoperatively diagnosed

Acute right lower abdominal pain in women of reproductive age: Clinical clues

PubMed Central

Hatipoglu, Sinan; Hatipoglu, Filiz; Abdullayev, Ruslan

2014-01-01

AIM: To study possible gynecological organ pathologies in the differential diagnosis of acute right lower abdominal pain in patients of reproductive age. METHODS: Following Clinical Trials Ethical Committee approval, the retrospective data consisting of physical examination and laboratory findings in 290 patients with sudden onset right lower abdominal pain who used the emergency surgery service between April 2009 and September 2013, and underwent surgery and general anesthesia with a diagnosis of acute appendicitis were collated. RESULTS: Total data on 290 patients were obtained. Two hundred and twenty-four (77.2%) patients had acute appendicitis, whereas 29 (10%) had perforated appendicitis and 37 (12.8%) had gynecological organ pathologies. Of the latter, 21 (7.2%) had ovarian cyst rupture, 12 (4.2%) had corpus hemorrhagicum cyst rupture and 4 (1.4%) had adnexal torsion. Defense, Rovsing’s sign, increased body temperature and increased leukocyte count were found to be statistically significant in the differential diagnosis of acute appendicitis and gynecological organ pathologies. CONCLUSION: Gynecological pathologies in women of reproductive age are misleading in the diagnosis of acute appendicitis. PMID:24744594

Demographic characteristics and seasonal variations of acute appendicitis.

PubMed

Bal, Ahmet; Ozkececi, Ziya Taner; Turkoglu, Ozgur; Ozsoy, Mustafa; Celep, Ruchan Bahadir; Yilmaz, Sezgin; Arikan, Yüksel

2015-01-01

The most common disease required emergency surgical operation is acute appendicitis. Appendectomy is the most common surgical procedure in the world and remains important due to be an efficient treatment method. We aimed to determine seasonal variations of acute appendicitis in our regions and identify the demographical and regional differences. We analyzed retrospectively data of the patients who were admitted to the Afyon Kocatepe University hospital and Sivrihisar State hospital between 2003 and 2012. 839 patients' data were analyzed. Mean age of the all patients was 33 ± 14.7 year. Acute appendicitis was seen more frequent in autumn and spring (P > 0.05). There was no significant difference between seasons in Afyon Kocatepe university hospital, while appendicitis was seen more common in autumn than winter in Sivrihisar state hospital (P < 0.05). There was not any relationship with the monthly average temperature, humidity, total precipitation amount and frequency of appendicitis (P > 0.05). Although appendicitis has a seasonal variation, other environmental factors and impact of nutritional habit should not be ignored. Etiology of appendicitis is still multifactorial. In the future multiparameter nationwide studies can present country-specific etiology of appendicitis. Appendectomy, Appendicitis, Seasonal variations.

Acute appendicitis in patients with sickle cell disease.

PubMed

Al-Nazer, Mona A; Al-Saeed, Hussain H; Al-Salem, Ahmed H

2003-09-01

Patients with sickle cell disease (SCD) often present with abdominal pain, usually attributed to vaso-occlusive crisis, but not rarely, it may be caused by other surgical conditions. Acute appendicitis although common in patients with SCD, it is rare and has a rapid course with a high incidence of perforation. Over a period of 7 years from 1995 to 2001, only 8 patients with SCD out of 1563 (0.5%) patients with acute appendicitis underwent operation at Qatif Central Hospital, Qatif, Kingdom of Saudi Arabia. Their histological slides were reviewed and the findings were compared to those with sickle cell trait (9 patients) and control group (28 patients). All patients with SCD and in spite of a short duration of symptoms had a moderate to severe inflammation and the vessels were packed with sickle red blood cells (RBCs) except one who had an intact mucosa, extensive transmural hemorrhage and congested blood vessels with sickled RBCs without inflammatory cell infiltrate. The mucosa was intact in only one patient with SCD when compared to 5 (55.6%) in those with sickle cell trait and 6 (21.4%) in the control group and in the majority (87.5%) of those with SCD there were moderate to severe mucosal ulcerations when compared to those with sickle cell trait (44.4%) or controls (64.3%). In patients with SCD, acute appendicitis is rare, and these appendicular changes were a sequelae of blockage of appendiceal vessels by sickled RBCs leading to congestion, edema, and ischemia with subsequent mucosal ulceration and marked inflammatory cell infiltrate.

Fiber Intake and Childhood Appendicitis.

ERIC Educational Resources Information Center

Brender, Jean D.; And Others

1985-01-01

Parents of 135 children with appendicitis and of 212 comparison children were interviewed about their children's diet. Results suggest that a liberal intake of whole-grain breads and cereals may decrease the risk of appendicitis during childhood. (KH)

A RETROSPECTIVE ANALYSIS OF ACUTE APPENDICITIS, RUPTURED APPENDICITIS AND THE LEVEL OF LEUKOCYTOSIS IN PAEDIATRIC SURGICAL PATIENTS OF NELSON MANDELA CENTRAL HOSPITAL.

PubMed

Mtimba, L; Dhaffala, A; Molaoa, S Z

2017-06-01

Appendicectomy is the most commonly performed operation worldwide. The diagnosis is predominantly based on clinical findings. Some patients will clinically be unclear if ruptured or acute inflamed appendicitis; the level of white cell count has been used as the predictor for ruptured appendicitis. This was a retrospective chart review of paediatric surgical patients admitted at Nelson Mandela Central Hospital, Mthatha South Africa. A total of 214 patients with a diagnosis of acute appendicitis. Overall, the ruptured appendicitis was 62% and 38% were inflamed appendicitis. Nature of the acute appendicitis: White cell count, Inflamed, Ruptured, Total p-value < 9.9 21 30 51 0.075, 10-14.9 28 54 82 0.0, 15-19.9 17 29 46 0.012, 20-29.9 5 26 31 0.0 > 30 0 4 4. This study has demonstrated that in patients who are diagnosed with acute appendicitis clinically, the normal white cell count does not necessarily rule out ruptured acute appendicitis. But the risks of ruptured acute appendicitis increase with the increase level of white cell count.

Concurrent presentation of appendicitis and acute cholecystitis: diagnosis of rare occurrence

PubMed Central

Gandhi, Jamish; Tan, Jeffrey

2015-01-01

A 67-year-old woman presented with a 2-day history of central abdominal pain migrating to the right upper and lower abdomen. On examination she was normothermic but tachycardic. Inflammatory markers were noted to be elevated with a white cell count of 18.5×109/L and C reactive protein of 265 mg/L. A CT scan revealed dual pathology of appendicitis and acute cholecystitis, which was confirmed intraoperatively and histologically. PMID:26396122

Delta neutrophil index: A reliable marker to differentiate perforated appendicitis from non-perforated appendicitis in the elderly.

PubMed

Shin, Dong Hyuk; Cho, Young Suk; Kim, Yoon Sung; Ahn, Hee Cheol; Oh, Young Taeck; Park, Sang O; Won, Moo-Ho; Cho, Jun Hwi; Kim, Young Myeong; Seo, Jeong Yeol; Lee, Young Hwan

2018-01-01

Delta neutrophil index (DNI) is a new inflammatory marker and the present study aimed to evaluate the predictive value of the DNI for the presence of a perforation in elderly with acute appendicitis. This retrospective observational study was conducted on 108 consecutive elderly patients (≥65 years old) with acute appendicitis treated over a 24-month period. Sixty-nine of the 108 patients (median, IQR: 72, 67-77 years) were allocated to the perforated appendicitis group (63.9%) and 39 to the non-perforated appendicitis group (36.1%). WBC, neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio and DNI were significantly higher in the perforated group. In multiple logistic regression analyses, initial DNI was the only independent marker that can significantly predict the presence of perforation in multiple regression [odds ratio 9.38, 95% confidence interval (2.51-35.00), P=.001]. Receiver operator characteristic curve analysis showed that DNI is a good predictor for the presence of appendiceal perforation at an optimal cut-off for DNI being 1.4% (sensitivity 67.7%, specificity 90.0%, AUC 0.807). Clinicians can reliably differentiate acute perforated appendicitis from non-perforated appendicitis by DNI level of 1.4 or more in elderly patients. © 2017 Wiley Periodicals, Inc.

Cost-effectiveness of routine imaging of suspected appendicitis.

PubMed

D'Souza, N; Marsden, M; Bottomley, S; Nagarajah, N; Scutt, F; Toh, S

2018-01-01

Introduction The misdiagnosis of appendicitis and consequent removal of a normal appendix occurs in one in five patients in the UK. On the contrary, in healthcare systems with routine cross-sectional imaging of suspected appendicitis, the negative appendicectomy rate is around 5%. If we could reduce the rate in the UK to similar numbers, would this be cost effective? This study aimed to calculate the financial impact of negative appendicectomy at the Queen Alexandra Hospital and to explore whether a policy of routine imaging of such patients could reduce hospital costs. Materials and methods We performed a retrospective analysis of all appendicectomies over a 1-year period at our institution. Data were extracted on outcomes including appendix histology, operative time and length of stay to calculate the negative appendicectomy rate and to analyse costs. Results A total of 531 patients over 5 years of age had an appendicectomy. The negative appendicectomy rate was 22% (115/531). The additional financial costs of negative appendicectomy to the hospital during this period were £270,861. Universal imaging of all patients with right iliac fossa pain that could result in a 5% negative appendicectomy rate would cost between £67,200 and £165,600 per year but could save £33,896 (magnetic resonance imaging), £105,896 (computed tomography) or £132,296 (ultrasound) depending on imaging modality used. Conclusions Negative appendicectomy is still too frequent and results in additional financial burden to the health service. Routine imaging of patients with suspected appendicitis would not only reduce the negative appendicectomy rate but could lead to cost savings and a better service for our patients.

Spinal cord compression in a patient with a pain pump for failed back syndrome: a chalk-like precipitate mimicking a spinal cord neoplasm: case report.

PubMed

Wadhwa, Rishi K; Shaya, Mark R; Nanda, Anil

2006-02-01

The use of intrathecal morphine has been effective with few complications for chronic intractable pain of both benign and malignant origins. A rare but serious problem that exists is the formation of an inflammatory mass at the catheter tip of the pain pump. We report the case of a 67-year-old female patient with failed back syndrome who presented with sensory complaints and back pain. Magnetic resonance imaging revealed impingement on the thoracic cord by a mass. The mass was originally thought to be a spinal cord tumor; however, operation and chemical analysis of the mass showed that it was a bupivacaine precipitate at the tip of the catheter of the pain pump. This is the first such case, to our knowledge, of a bupivacaine precipitate mimicking a spinal cord tumor.

Utility of Immature Granulocyte Percentage in Pediatric Appendicitis

PubMed Central

Mathews, Eleanor K.; Griffin, Russell L.; Mortellaro, Vincent; Beierle, Elizabeth A.; Harmon, Carroll M.; Chen, Mike K.; Russell, Robert T.

2014-01-01

Background Acute appendicitis is the most common cause of abdominal surgery in children. Adjuncts are utilized to help clinicians predict acute or perforated appendicitis, which may affect treatment decisions. Automated hematologic analyzers can perform more accurate automated differentials including immature granulocyte percentages (IG%). Elevated IG% has demonstrated improved accuracy for predicting sepsis in the neonatal population than traditional immature to total neutrophil count (I/T) ratios. We intended to assess the additional discriminatory ability of IG% to traditionally assessed parameters in the differentiation between acute and perforated appendicitis. Materials and Methods We identified all patients with appendicitis from July 2012 to June 2013 by ICD-9 code. Charts were reviewed for relevant demographic, clinical, and outcome data, which were compared between acute and perforated appendicitis groups using Fischer’s exact and t-test for categorical and continuous variables, respectively. We utilized an adjusted logistic regression model utilizing clinical lab values to predict the odds of perforated appendicitis. Results 251 patients were included in the analysis. Those with perforated appendicitis had a higher white blood cell (WBC) count (p=0.0063), C-reactive protein (CRP) (p<0.0001), and IG% (p=0.0299). In the adjusted model, only elevated CRP (OR 3.46, 95% CI 1.40-8.54) and presence of left shift (OR 2.66, 95% CI 1.09-6.46) were significant predictors of perforated appendicitis. The c-statistic of the final model was 0.70, suggesting fair discriminatory ability in predicting perforated appendicitis. Conclusions IG% did not provide any additional benefit to elevated CRP and presence of left shift in the differentiation between acute and perforated appendicitis. PMID:24793450

The Introduction of Adult Appendicitis Score Reduced Negative Appendectomy Rate.

PubMed

Sammalkorpi, H E; Mentula, P; Savolainen, H; Leppäniemi, A

2017-09-01

Implementation of a clinical risk score into diagnostics of acute appendicitis may provide accurate diagnosis with selective use of imaging studies. The aim of this study was to prospectively validate recently described diagnostic scoring system, Adult Appendicitis Score, and evaluate its effects on negative appendectomy rate. Adult Appendicitis Score stratifies patients into three groups: high, intermediate, and low risk of appendicitis. The score was implemented in diagnostics of adult patients suspected of acute appendicitis in two university hospitals. We analyzed the effects of Adult Appendicitis Score on diagnostic accuracy, imaging studies, and treatment. The study population was compared with a reference population of 829 patients suspected of acute appendicitis originally enrolled for the study of construction of the Adult Appendicitis Score. This study enrolled 908 patients of whom 432 (48%) had appendicitis. The score stratified 49% of all appendicitis patients into high-risk group with specificity of 93.3%. In the low-risk group, prevalence of appendicitis was 7%. The histologically confirmed negative appendectomy rate decreased from 18.2% to 8.7%, p<0.001, compared to the original dataset. Adult Appendicitis Score is a reliable tool for stratification of patients into selective imaging, which results in low negative appendectomy rate.

Hyperbilirubinaemia: its utility in non-perforated appendicitis.

PubMed

Sandstrom, Anna; Grieve, David A

2017-07-01

The diagnosis of acute appendicitis is made using clinical findings and investigations. Recent studies have suggested that serum bilirubin, a cheap and simple biochemical test, is a positive predictor in the diagnosis of appendiceal perforation and may be more specific than C-reactive protein (CRP) and white cell count (WCC). The aim of this study was to investigate the utility of the serum bilirubin level in patients with suspected acute but non-perforative appendicitis. A retrospective chart review of 213 patients who presented with suspected appendicitis in a 6-month period to Nambour General Hospital was performed. Serum bilirubin, WCC and CRP were recorded and analysed as to their utility in relation to the final diagnosis. A total of 196 patients underwent an appendicectomy and 41 of these were negative. The specificity of hyperbilirubinaemia for appendicitis overall was 0.83 with a positive predictive value (PPV) of 0.86, compared with CRP (specificity 0.40, PPV 0.75) and WCC (specificity 0.67, PPV 0.85). The area under the receiver operating characteristic curve for bilirubin was 0.6289 compared to 0.6171 for CRP and 0.7219 for WCC. A subgroup analysis of those with complicated appendicitis demonstrated a PPV for bilirubin of 0.66 compared to 0.58 for WCC and 0.34 for CRP in agreement with the literature. Subgroup analysis of hyperbilirubinaemia in simple appendicitis demonstrated a PPV of 0.81 compared to CRP (0.71) and WCC (0.82). Bilirubin had a higher specificity than CRP and WCC overall in patients with appendicitis. Hyperbilirubinaemia had a high PPV in patients with simple appendicitis. © 2015 Royal Australasian College of Surgeons.

Leiomyomatosis peritonealis disseminata presenting as omental torsion.

PubMed

Tan, Chjoong Howe Alvin; Ho, Bernard Chi Shern; Shelat, Vishalkumar; Tan, Cher Heng

2012-04-01

Leiomyomatosis peritonealis disseminata is usually asymptomatic or mimics widespread malignancy; acute presentation is rare. We describe a patient with right iliac fossa and lower abdominal pain. Two masses were detected via computed tomography, but at surgery, one of these implanted leiomyomas had undergone acute omental torsion. This case illustrates a rare complication of omental leiomyoma torsion clinically mimicking acute appendicitis.

Inflammatory Myofibroblastic Tumor Mimicking Apical Periodontitis.

PubMed

Adachi, Makoto; Kiho, Kazuki; Sekine, Genta; Ohta, Takahisa; Matsubara, Makoto; Yoshida, Takakazu; Katsumata, Akitoshi; Tanuma, Jun-ichi; Sumitomo, Shinichiro

2015-12-01

Inflammatory myofibroblastic tumors (IMTs) are rare. IMTs of the head and neck occur in all age groups, from neonates to old age, with the highest incidence occurring in childhood and early adulthood. An IMT has been defined as a histologically distinctive lesion of uncertain behavior. This article describes an unusual case of IMT mimicking apical periodontitis in the mandible of a 42-year-old man. At first presentation, the patient showed spontaneous pain and percussion pain at teeth #28 to 30, which continued after initial endodontic treatment. Panoramic radiography revealed a radiolucent lesion at the site. Cone-beam computed tomographic imaging showed osteolytic lesions, suggesting an aggressive neoplasm requiring incisional biopsy. Histopathological examination indicated an IMT. The lesion was removed en bloc under general anesthesia, and the patient manifested no clinical evidence of recurrence for 24 months. Lesions of nonendodontic origin should be included in the differential diagnosis of apical periodontitis. Every available diagnostic tool should be used to confirm the diagnosis. Cone-beam computed tomographic imaging is very helpful for differential diagnosis in IMTs mimicking apical periodontitis. Copyright © 2015 American Association of Endodontists. Published by Elsevier Inc. All rights reserved.

[History of surgical treatment of appendicitis].

PubMed

Meljnikov, Igor; Radojcić, Branka; Grebeldinger, Slobodan; Radojcić, Nikola

2009-01-01

Most of the history of appendicitis and appendectomy has been made during the past two centuries. Jacopo Berengario da Carpi gave the first description of this structure in 1522. Gabriele Fallopio, in 1561, appears to have been the first writer to compare the appendix to a worm. In1579 Caspar Bauhin proposed the ingenious theory that the appendix served in intrauterine life as a receptacle for the faexes. Many of anatomists added more or less insignificant ideas concerning the structure of the appendix and entered upon useless controversy concerning the name, function, position of the appendix vermiformis. The first successful appendectomy was performed in 1735 by Claudius Amyand. Geillaume Dupuytren considered that acute inflammation of the right side of the abdomen arose from disease of the caecum and not the appendix. As surgeons were wary of opening the abdomen for examination, early stages of appendicitis remained unknown. John Parkinson was able to give a good description of fatal appendicitis in 1812. Surgeons began draining localised abscesses which had already formed. In 1880 Robert Lawson Tait made the first diagnosis of appendicitis and surgically removed the appendix. In 1886 Reginald Heber Fitz published a study on appendicitis and named the procedure an appendectomy. In 1889, Tait split open and drained an inflamed appendix without removing it. Charles McBurney proposed his original muscle splitting operation in 1893 and this was modified by Robert Fulton Weir in 1900. Today we have a multiplicity of signs and symptoms, helping to diagnose appendicitis, and there are a lot of techniques for operation with little essential difference throughout. Kurt Semm performed the first laparoscopic appendectomy in 1981 which became a new gold standard in surgical treatment of acute and chronic appendicitis.

Predicting need for additional CT scan in children with a non-diagnostic ultrasound for appendicitis in the emergency department.

PubMed

Nishizawa, Takuya; Maeda, Shigenobu; Goldman, Ran D; Hayashi, Hiroyuki

2018-01-01

This study aimed to determine which children with suspected appendicitis should be considered for a computerized tomography (CT) scan after a non-diagnostic ultrasound (US) in the Emergency Department (ED). We retrospectively reviewed patients 0-18year old, who presented to the ED with complaints of abdominal pain, during 2011-2015 and while in the hospital had both US and CT. We recorded demographic and clinical data and outcomes, and used univariate and multivariate methods for comparing patients who did and didn't have appendicitis on CT after non-diagnostic US. Multivariate analysis was performed using logistic regression to determine what variables were independently associated with appendicitis. A total of 328 patients were enrolled, 257 with non-diagnostic US (CT: 82 had appendicitis, 175 no-appendicitis). Younger children and those who reported vomiting or had right lower abdominal quadrant (RLQ) tenderness, peritoneal signs or White Blood Cell (WBC) count >10,000 in mm 3 were more likely to have appendicitis on CT. RLQ tenderness (Odds Ratio: 2.84, 95%CI: 1.07-7.53), peritoneal signs (Odds Ratio: 11.37, 95%CI: 5.08-25.47) and WBC count >10,000 in mm 3 (Odds Ratio: 21.88, 95%CI: 7.95-60.21) remained significant after multivariate analysis. Considering CT with 2 or 3 of these predictors would have resulted in sensitivity of 94%, specificity of 67%, positive predictive value of 57% and negative predictive value of 96% for appendicitis. Ordering CT should be considered after non-diagnostic US for appendicitis only when children meet at least 2 predictors of RLQ tenderness, peritoneal signs and WBC>10,000 in mm 3 . Copyright © 2017 Elsevier Inc. All rights reserved.

A Novel Reporting System to Improve Accuracy in Appendicitis Imaging

PubMed Central

Godwin, Benjamin D.; Drake, Frederick T.; Simianu, Vlad V.; Shriki, Jabi E.; Hippe, Daniel S.; Dighe, Manjiri; Bastawrous, Sarah; Cuevas, Carlos; Flum, David; Bhargava, Puneet

2015-01-01

OBJECTIVE The purpose of this study was to ascertain if standardized radiologic reporting for appendicitis imaging increases diagnostic accuracy. MATERIALS AND METHODS We developed a standardized appendicitis reporting system that includes objective imaging findings common in appendicitis and a certainty score ranging from 1 (definitely not appendicitis) through 5 (definitely appendicitis). Four radiologists retrospectively reviewed the preoperative CT scans of 96 appendectomy patients using our reporting system. The presence of appendicitis-specific imaging findings and certainty scores were compared with final pathology. These comparisons were summarized using odds ratios (ORs) and the AUC. RESULTS The appendix was visualized on CT in 89 patients, of whom 71 (80%) had pathologically proven appendicitis. Imaging findings associated with appendicitis included appendiceal diameter (odds ratio [OR] = 14 [> 10 vs < 6 mm]; p = 0.002), periappendiceal fat stranding (OR = 8.9; p < 0.001), and appendiceal mucosal hyperenhancement (OR = 8.7; p < 0.001). Of 35 patients whose initial clinical findings were reported as indeterminate, 28 (80%) had appendicitis. In this initially indeterminate group, using the standardized reporting system, radiologists assigned higher certainty scores (4 or 5) in 21 of the 28 patients with appendicitis (75%) and lower scores (1 or 2) in five of the seven patients without appendicitis (71%) (AUC = 0.90; p = 0.001). CONCLUSION Standardized reporting and grading of objective imaging findings correlated well with postoperative pathology and may decrease the number of CT findings reported as indeterminate for appendicitis. Prospective evaluation of this reporting system on a cohort of patients with clinically suspected appendicitis is currently under way. PMID:26001230

The sonographic features of neonatal appendicitis: A case report.

PubMed

Si, Shu-Yu; Guo, Yi-Yi; Mu, Jian-Feng; Yan, Chao-Ying

2017-11-01

Neonatal appendicitis is extremely rare, and preoperative diagnosis is challenging. This study aimed to investigate the utility of ultrasound for the diagnosis of neonatal appendicitis. Four cases of neonatal appendicitis were included in this case series. One was a female infant and the other 3 were male infants; they were aged from 10 to 17 days. Neonatal appendicitis. Four newborns in our hospital were diagnosed with neonatal appendicitis by abdominal ultrasound. Their sonographic features were summarized and compared with surgical and pathological findings. In these infants, abdominal ultrasound demonstrated ileocecal bowel dilatation, intestinal and bowel wall thickening, and localized encapsulated effusion in the right lower quadrant and the abscess area, which was assumed to surround the appendix. Ultrasound is helpful for the diagnosis of neonatal appendicitis.

Outcomes of Nonoperative Management of Uncomplicated Appendicitis.

PubMed

Bachur, Richard G; Lipsett, Susan C; Monuteaux, Michael C

2017-07-01

Nonoperative management (NOM) of uncomplicated pediatric appendicitis has promise but remains poorly studied. NOM may lead to an increase in resource utilization. Our objective was to investigate the trends in NOM for uncomplicated appendicitis and study the relevant clinical outcomes including subsequent appendectomy, complications, and resource utilization. Retrospective analysis of administrative data from 45 US pediatric hospitals. Patients <19 years of age presenting to the emergency department (ED) with appendicitis between 2010 and 2016 were studied. NOM was defined by an ED visit for uncomplicated appendicitis treated with antibiotics and the absence of appendectomy at the index encounter. The main outcomes included trends in NOM among children with uncomplicated appendicitis and frequency of subsequent diagnostic imaging, ED visits, hospitalizations, and appendectomy during 12-month follow-up. 99 001 children with appendicitis were identified, with a median age of 10.9 years. Sixty-six percent were diagnosed with nonperforated appendicitis, of which 4190 (6%) were managed nonoperatively. An increasing number of nonoperative cases were observed over 6 years (absolute difference, +20.4%). During the 12-month follow-up period, NOM patients were more likely to have the following: advanced imaging (+8.9% [95% confidence interval (CI) 7.6% to 10.3%]), ED visits (+11.2% [95% CI 9.3% to 13.2%]), and hospitalizations (+43.7% [95% CI 41.7% to 45.8%]). Among patients managed nonoperatively, 46% had a subsequent appendectomy. A significant increase in NOM of nonperforated appendicitis was observed over 6 years. Patients with NOM had more subsequent ED visits and hospitalizations compared with those managed operatively at the index visit. A substantial proportion of patients initially managed nonoperatively eventually had an appendectomy. Copyright © 2017 by the American Academy of Pediatrics.

Parasitic Appendicitis From Past to Present in Turkey

PubMed Central

Engin, O; Calik, S; Calik, B; Yildirim, M; Coskun, G

2010-01-01

Background Understanding the etiology of appendicitis is important for developing effective treatments the relationship between parasitic appendicitis and various socio-cultural factors were examined, particularly with respect to the incidence of literacy. The aim of the article was to research the relations between parasitic appendicitis and literacy ratio in population. Methods Cases of parasitic appendicitis resulting in surgery performed at Buca Seyfi Demirsoy Large State Hospital Surgery Clinic between 2002 and 2009 were retrospectively reviewed and classified according to age, sex, type of parasite, morbidity, and mortality. Studies conducted in different regions of Turkey as well as in other countries were reviewed to determine if there was a relationship between parasitic appendicitis and literacy. Results Of the 1,969 appendectomy cases reviewed, nine were classified as parasitic appendicitis (0.45%). Enterobius vermicularis was observed in seven cases and Taenia spp. in two. The average age was 26.4 yr. No morbidity or mortality was found. Conclusion The data were compared with a retrospective review of studies conducted in the same regions and a decrease in the rate of parasitic appendicitis was observed during the period between the two reviews. It was determined that a low literacy rate was associated with an increase in the incidence of parasitic appendicitis. Observations made between different countries also produced similar results. In countries where the incidence of parasitic appendiciticis was greater than 1.5%, the literacy rate was less than 88%. To avoid appendectomy resulting from parasites, it is important to increase education and literacy. In some areas, individuals with appendicitis undergo surgery due to a lack of education or poor literacy. PMID:22347256

AIR SCORE ASSESSMENT FOR ACUTE APPENDICITIS

PubMed Central

VON-MÜHLEN, Bruno; FRANZON, Orli; BEDUSCHI, Murilo Gamba; KRUEL, Nicolau; LUPSELO, Daniel

2015-01-01

Background: Acute appendicitis is the most common cause of acute abdomen. Approximately 7% of the population will be affected by this condition during full life. The development of AIR score may contribute to diagnosis associating easy clinical criteria and two simple laboratory tests. Aim: To evaluate the score AIR (Appendicitis Inflammatory Response score) as a tool for the diagnosis and prediction of severity of acute appendicitis. Method: Were evaluated all patients undergoing surgical appendectomy. From 273 patients, 126 were excluded due to exclusion criteria. All patients were submitted o AIR score. Results: The value of the C-reactive protein and the percentage of leukocytes segmented blood count showed a direct relationship with the phase of acute appendicitis. Conclusion: As for the laboratory criteria, serum C-reactive protein and assessment of the percentage of the polymorphonuclear leukocytes count were important to diagnosis and disease stratification. PMID:26537139

Fast track pathway for perforated appendicitis.

PubMed

Frazee, Richard; Abernathy, Stephen; Davis, Matthew; Isbell, Travis; Regner, Justin; Smith, Randall

2017-04-01

Perforated appendicitis is associated with an increased morbidity and length of stay. "Fast track" protocols have demonstrated success in shortening hospitalization without increasing morbidity for a variety of surgical processes. This study evaluates a fast track pathway for perforated appendicitis. In 2013, a treatment pathway for perforated appendicitis was adopted by the Acute Care Surgery Service for patients having surgical management of perforated appendicitis. Interval appendectomy was excluded. Patients were treated initially with intravenous antibiotics and transitioned to oral antibiotics and dismissed when medically stable and tolerating oral intake. A retrospective review of patients managed on the fast track pathway was undertaken to analyze length of stay, morbidity, and readmissions. Thirty-four males and twenty-one females with an average age of 46.8 years underwent laparoscopic appendectomy for perforated appendicitis between January 2013 and December 2014. Pre-existing comorbidities included hypertension 42%, diabetes mellitus 11%, COPD 5% and heart disease 2%. No patient had conversion to open appendectomy. Average length of stay was 2.67 days and ranged from 1 to 12 days (median 2 days). Postoperative morbidity was 20% and included abscess (6 patients), prolonged ileus (3 patients), pneumonia (1 patient), and congestive heart failure (1 patient). Five patients were readmitted for abscess (3 patients), congestive heart failure (1 patient), and pneumonia (1 patient). A fast track pathway for perforated appendicitis produced shorter length of stay and acceptable postoperative morbidity and readmission. This offers the potential for significant cost savings over current national practice patterns. Copyright © 2016 Elsevier Inc. All rights reserved.

Nonspecific abdominal pain is a safe diagnosis.

PubMed

Pennel, David John Laurie; Goergen, Nina; Driver, Chris P

2014-11-01

The aim of this study is to assess if a clinical diagnosis of nonspecific abdominal pain (NSAP) is safe and if patients with this initial diagnosis are likely to require further investigation or surgical intervention. 3323 patients admitted with NSAP from July 1990 to September 2012 utilizing a prospective database of all surgical admissions were included. Readmission over the period of the study and specifically within 30 days of their initial presentation was identified together with any invasive investigation or surgical intervention. 319 children (9.6%) were subsequently readmitted with abdominal pain at some point during the study period. Of these, 78 (2.3%) were readmitted within 30 days. 118 (3.5%) children subsequently had an operation or invasive investigation some point following their initial admission. Of these 33 (0.6%) had the procedure within 3 months of the initial admission. 13 patients had an appendicectomy within 3 months of the initial presentation. Of these histology confirmed appendicitis in 8 patients. This gives an overall incidence of "missed" appendicitis of 0.2 % (8/3323). This study confirms that a clinical diagnosis of nonspecific abdominal pain (NSAP) is safe in a pediatric population and the risk of "missing" appendicitis is only 0.2%. Patients and/or parents can be confidently reassured that the risk of missing organic pathology is very low. Copyright © 2014 Elsevier Inc. All rights reserved.

Does the Intestinal Parasite Enterobius vermicularis Cause Acute Appendicitis?

PubMed

Pirhan, Yavuz; Özen, Fatma Zeynep; Kılınç, Çetin; Güçkan, Rıdvan

2017-06-01

Although intestinal parasitic infections rarely cause acute appendicitis, they are common public health problems in undeveloped and developing countries. Parasitic infections should be kept in mind in patients clinically suspected of having acute appendicitis, and treatment procedures should be adopted according to the etiology. Herein we presented the cases of four patients with clinical findings of acute appendicitis. Patients were clinically suspected of having acute appendicitis, and Enterobius vermicularis was detected in the pathological examinations of specimens. Pinworm infections are common parasitic infections that may mimic appendicitis. The pathology of the four cases was noted when the file of 186 patients aged between 4 and 72 years who underwent surgery for acute appendicitis in my hospital was retrospectively reviewed. When the appendectomy specimen was examined histopathologically it was understood that acute appendicitis was caused by Enterobius vermicularis parasite. In Enterobius infections, performing systemic therapy for patients and their family members is sufficient. To prevent unnecessary appendectomy, this type of infection should be made to ask in the history and clinical findings of patients.

Acute isolated appendicitis due to Aspergillus carneus in a neutropenic child with acute myeloid leukemia.

PubMed

Decembrino, Nunzia; Zecca, Marco; Tortorano, Anna Maria; Mangione, Francesca; Lallitto, Fabiola; Introzzi, Francesca; Bergami, Elena; Marone, Piero; Tamarozzi, Francesca; Cavanna, Caterina

2016-01-01

We describe a case of isolated acute appendicitis due to Aspergillus carneus in a neutropenic child with acute myeloid leukemia (AML) treated according to the AIEOP AML 2002/01 protocol. Despite prophylaxis with acyclovir, ciprofloxacin and fluconazole administered during the neutropenic phase, 16 days after the end of chemotherapy the child developed fever without identified infective foci, which prompted a therapy shift to meropenem and liposomial amphotericin B. After five days of persisting fever he developed ingravescent abdominal lower right quadrant pain. Abdominal ultrasound was consistent with acute appendicitis and he underwent appendectomy with prompt defervescence. PAS+ fungal elements were found at histopathology examination of the resected vermiform appendix, and galactomannan was low positive. A. carneus, a rare species of Aspergillus formerly placed in section Flavipedes and recently considered a member of section Terrei, was identified in the specimen. Treatment with voriconazole was promptly started with success. No other site of Aspergillus localization was detected. Appendicitis is rarely caused by fungal organisms and isolated intestinal aspergillosis without pulmonary infection is unusual. To our knowledge, this is the first report of infection due to A. carneus in a child and in a primary gastrointestinal infection.

[The etiological aspects of acute abdominal pain in children].

PubMed

Dinu, C A; Moraru, D

2011-01-01

The study of the etiological aspects of acute abdominal pain in children, in order to perceive the clinical-etiological correlations and the disorders distribution related to age, gender and the origin of the patients. The criteria for including patients were age (between 0 and 18 years) and the presence of acute abdominal pain before or during the consultation with the physician. The research on acute abdominal pain in children was performed on the level of the Surgery and Pediatrics II clinical departments of the "Sf. Ioan" Children's Emergency Clinical Hospital in Galati, between 01.01.2009 - 01.01.2011. The clinical study performed on the patients registered in the studied groups focused on the identification, the evaluation of the symptoms of acute abdominal pain in children, diagnosing and treating it. The criteria for excluding patients were an age older than 18 years or the absence of acute abdominal pain as a symptom before or during the examination. The statistical analysis used the descriptive and analytical methods. The data was centralized and statistically processed in M.S.EXCEL and S.P.S.S. databases. The patients with acute abdominal pain represent a percentage of 92.9% (2358 cases) of the total number of patients who suffer from abdominal pain (N=2537). The highest frequency of cases is represented by acute appendicitis (1056 cases - 44.8%). In the 5-18 years age group, acute appendicitis, mesenteric lymphadenitis, ovarian follicular cysts, acute pyelenophritis and salpingitis are predominant. In the 0-4 years age group gastroenteritis, acute pharyngitis, reactive hepatitis and lower digestive bleeding are predominant. In females, acute appendicitis, gastroenteritis, gastroduodenitis and cystitis are predominant, whereas in males, peritonitis, sepsis through E. coli, the contusion of the abdominal wall and acute pharyngitis are predominant.

Randomized clinical trial of Appendicitis Inflammatory Response score-based management of patients with suspected appendicitis.

PubMed

Andersson, M; Kolodziej, B; Andersson, R E

2017-10-01

The role of imaging in the diagnosis of appendicitis is controversial. This prospective interventional study and nested randomized trial analysed the impact of implementing a risk stratification algorithm based on the Appendicitis Inflammatory Response (AIR) score, and compared routine imaging with selective imaging after clinical reassessment. Patients presenting with suspicion of appendicitis between September 2009 and January 2012 from age 10 years were included at 21 emergency surgical centres and from age 5 years at three university paediatric centres. Registration of clinical characteristics, treatments and outcomes started during the baseline period. The AIR score-based algorithm was implemented during the intervention period. Intermediate-risk patients were randomized to routine imaging or selective imaging after clinical reassessment. The baseline period included 1152 patients, and the intervention period 2639, of whom 1068 intermediate-risk patients were randomized. In low-risk patients, use of the AIR score-based algorithm resulted in less imaging (19·2 versus 34·5 per cent; P < 0·001), fewer admissions (29·5 versus 42·8 per cent; P < 0·001), and fewer negative explorations (1·6 versus 3·2 per cent; P = 0·030) and operations for non-perforated appendicitis (6·8 versus 9·7 per cent; P = 0·034). Intermediate-risk patients randomized to the imaging and observation groups had the same proportion of negative appendicectomies (6·4 versus 6·7 per cent respectively; P = 0·884), number of admissions, number of perforations and length of hospital stay, but routine imaging was associated with an increased proportion of patients treated for appendicitis (53·4 versus 46·3 per cent; P = 0·020). AIR score-based risk classification can safely reduce the use of diagnostic imaging and hospital admissions in patients with suspicion of appendicitis. Registration number: NCT00971438 ( http://www.clinicaltrials.gov). © 2017 BJS

Evaluation of the microbiome in children's appendicitis.

PubMed

Salö, Martin; Marungruang, Nittaya; Roth, Bodil; Sundberg, Tiia; Stenström, Pernilla; Arnbjörnsson, Einar; Fåk, Frida; Ohlsson, Bodil

2017-01-01

The role of the microbiome has been widely discussed in the etiology of appendicitis. The primary aim was to evaluate the microbiome in the normal appendix and in appendicitis specifically divided into the three clinically and histopathologically defined grades of inflammation. Secondary aims were to examine whether there were any microbiome differences between proximal and distal appendices, and relate the microbiome with histopathological findings. A prospective pilot study was conducted of children undergoing appendectomy for appendicitis. The diagnosis was based on histopathological analysis. Children with incidental appendectomy were used as controls. The proximal and distal mucosa from the appendices were analyzed with 16S rRNA gene sequencing. A total of 22 children, 3 controls and 19 appendicitis patients; 11 phlegmonous, 4 gangrenous, and 4 perforated appendices, were prospectively included. The amount of Fusobacterium increased and Bacteroides decreased in phlegmonous and perforated appendicitis compared to controls, but statistical significance was not reached, and this pattern was not seen in gangrenous appendicitis. No relation could be seen between different bacteria and the grade of inflammation, and there was a wide variation of abundances at phylum, genus, and species level within every specific group of patients. Further, no significant differences could be detected when comparing the microbiome in proximal and distal mucosa, which may be because the study was underpowered. A trend with more abundance of Fusobacteria in the distal mucosa was seen in appendicitis patients with obstruction (25 and 13 %, respectively, p = 0.06). The pattern of microbiome differed not only between groups, but also within groups. However, no statistically significant differences could be found in the microbiome between groups or clinical conditions. No correlation between a specific bacteria and grade of inflammation was found. In the vast majority of cases of

Diagnostic Accuracy of MRI Versus CT for the Evaluation of Acute Appendicitis in Children and Young Adults.

PubMed

Kinner, Sonja; Pickhardt, Perry J; Riedesel, Erica L; Gill, Kara G; Robbins, Jessica B; Kitchin, Douglas R; Ziemlewicz, Timothy J; Harringa, John B; Reeder, Scott B; Repplinger, Michael D

2017-10-01

Appendicitis is frequently diagnosed in the emergency department, most commonly using CT. The purpose of this study was to compare the diagnostic accuracy of contrast-enhanced MRI with that of contrast-enhanced CT for the diagnosis of appendicitis in adolescents when interpreted by abdominal radiologists and pediatric radiologists. Our study included a prospectively enrolled cohort of 48 patients (12-20 years old) with nontraumatic abdominal pain who underwent CT and MRI. Fellowship-trained abdominal and pediatric radiologists reviewed all CT and MRI studies in randomized order, blinded to patient outcome. Likelihood for appendicitis was rated on a 5-point scale (1, definitely not appendicitis; 5, definitely appendicitis) for CT, the unenhanced portion of the MRI, and the entire contrast-enhanced MRI study. ROC curves were generated and AUC compared for each scan type for all six readers and then stratified by radiologist type. Image test characteristics, interrater reliability, and reading times were compared. Sensitivity and specificity were 85.9% (95% CI, 76.2-92.7%) and 93.8% (95% CI, 89.7-96.7%) for unenhanced MRI, 93.6% (95% CI, 85.6-97.9%) and 94.3% (95% CI, 90.2-97%) for contrast-enhanced MRI, and 93.6% (95% CI, 85.6-97.9%) and 94.3% (95% CI, 90.2-97%) for CT. No difference was found in the diagnostic accuracy or interpretation time when comparing abdominal radiologists to pediatric radiologists (CT, 3.0 min vs 2.8 min; contrast-enhanced MRI, 2.4 min vs 1.8 min; unenhanced MRI, 1.5 min vs 2.3 min). Substantial agreement between abdominal and pediatric radiologists was seen for all methods (κ = 0.72-0.83). The diagnostic accuracy of MRI to diagnose appendicitis was very similar to CT. No statistically significant difference in accuracy was observed between imaging modality or radiologist subspecialty.

Complicated acute appendicitis presenting as a rapidly progressive soft tissue infection of the abdominal wall: a case report.

PubMed

Beerle, Corinne; Gelpke, Hans; Breitenstein, Stefan; Staerkle, Ralph F

2016-12-01

We report a case of a rare complication of acute appendicitis with perforation through the abdominal wall. The case points out that an intraabdominal origin should be considered in patients presenting with rapidly spreading soft tissue infections of the trunk. A 58-year-old European woman presented to our hospital with a 1-week history of severe abdominal pain accompanied by rapidly spreading erythema and emphysema of the lower abdomen. On admission, the patient was in septic shock with leukocytosis and elevation of C-reactive protein. Among other diagnoses, necrotizing fasciitis was suspected. Computed tomography showed a large soft tissue infection with air-fluid levels spreading through the lower abdominal wall. During the operation, we found a perforated appendicitis breaking through the fascia and causing a rapidly progressive soft tissue infection of the abdominal wall. Appendicitis was the origin of the soft tissue infection. The abdominal wall was only secondarily involved. Even though perforated appendicitis as an etiology of a rapidly progressive soft tissue infection of the abdominal wall is very rare, it should be considered in the differential diagnosis of abdominal wall cellulitis. The distinction between rapidly spreading subcutaneous infection with abscess formation and early onset of necrotizing fasciitis is often difficult and can be confirmed only by surgical intervention.

[A Two-Stage Right Hemicolectomy Case in Which the First Surgery Was Laparoscopic Ileocecal Resection Based on Preoperative Diagnosis of Acute Appendicitis].

PubMed

Kataoka, Satoshi; Naito, Kei; Miyagawa, Koji; Ishihara, Yosuke; Fuji, Nobuaki

2017-11-01

We report a case oftwo -stage right hemicolectomy in which the first surgery performed was laparoscopic ileocecal resection based on the preoperative diagnosis ofacute appendicitis. The second surgery was performed based on pathological diagnosis ofadvanced cecal cancer accompanied by appendicitis. A 49-year-old woman came to our hospital with a chief complaint of abdominal pain in the lower quadrant for 1 week. Blood test results indicated an inflammatory response, with white blood cells at 10,000/mL and C-reactive protein of1 7.5mg/dL. Abdominal computed tomography showed a swollen appendix and increased uptake in adipose tissue around the appendix. The patient was diagnosed with acute appendicitis, and emergency laparoscopic surgery was performed. Because the cecum wall was thickened and formed an inflammatory mass, ileocecal resection was performed. The pathological diagnosis was advanced cecal cancer accompanied by appendicitis, with metastasis to lymph node No. 201; thus, right hemicolectomy and D3 dissection were performed 14 days after the first surgery. No tumor was found in additional resected tissues. The final diagnosis was cecal cancer: adenocarcinoma tub1, SE, N1, M0, Stage III a. The patient received adjuvant chemotherapy with XELOX and remains relapse free. Acute appendicitis is induced by certain mechanisms that cause appendiceal obstruction. Unlike young patients, middle-aged and elderly patients rarely develop acute appendicitis because ofa tumor causing appendiceal obstruction, which often makes preoperative or perioperative diagnosis difficult. The presence of cancer, such as cecal cancer, should be considered when appendicitis is accompanied by severe inflammation in elderly patients.

Water permeability is a measure of severity in acute appendicitis.

PubMed

Pini, Nicola; Pfeifle, Viktoria A; Kym, Urs; Keck, Simone; Galati, Virginie; Holland-Cunz, Stefan; Gros, Stephanie J

2017-12-01

Acute appendicitis is the most common indication for pediatric abdominal emergency surgery. Determination of the severity of appendicitis on clinical grounds is challenging. Complicated appendicitis presenting with perforation, abscess or diffuse peritonitis is not uncommon. The question remains why and when acute appendicitis progresses to perforation. The aim of this study was to assess the impact of water permeability on the severity of appendicitis. We show that AQP1 expression and water permeability in appendicitis correlate with the stage of inflammation and systemic infection parameters, leading eventually to perforation of the appendix. AQP1 is also expressed within the ganglia of the enteric nervous system and ganglia count increases with inflammation. Severity of appendicitis can be correlated with water permeability measured by AQP1 protein expression and increase of ganglia count in a progressive manner. This introduces the question if regulation of water permeability can present novel curative or ameliorating therapeutic options.

Enterobius vermicularis causing symptoms of appendicitis in Nepal.

PubMed

Sah, Shatrughan Prasad; Bhadani, Punam Prasad

2006-07-01

This study set out to determine the prevalence of Enterobius vermicularis in surgically removed appendices and to assess the possible relation of the parasite to acute appendicitis. All 624 surgically removed appendices received in the Department of Pathology, BPKIHS, Dharan, Nepal during 2(1/2) years (August 1999-January 2002) were examined. E. vermicularis was identified in nine (1.62%) appendices from the patients with a clinical diagnosis of appendicitis. The parasite was most frequently seen in histologically normal appendices (6/71) and was rarely associated with histological change of acute appendicitis (3/539). No cases of E. vermicularis infestation occurred in appendices showing chronic inflammation or removed during the course of other surgical procedures. E. vermicularis was found more frequently in uninflamed and histologically normal appendices (8.45%) than those which were inflamed with histopathologic changes of acute appendicitis (0.56%). It may be a cause of symptoms resembling acute appendicitis although the mechanism for this does not involve mucosal invasion by the parasite.

Evaluation of acute pelvic pain in women.

PubMed

Kruszka, Paul S; Kruszka, Stephen J

2010-07-15

Diagnosis of pelvic pain in women can be challenging because many symptoms and signs are insensitive and nonspecific. As the first priority, urgent life-threatening conditions (e.g., ectopic pregnancy, appendicitis, ruptured ovarian cyst) and fertility-threatening conditions (e.g., pelvic inflammatory disease, ovarian torsion) must be considered. A careful history focusing on pain characteristics, review of systems, and gynecologic, sexual, and social history, in addition to physical examination helps narrow the differential diagnosis. The most common urgent causes of pelvic pain are pelvic inflammatory disease, ruptured ovarian cyst, and appendicitis; however, many other diagnoses in the differential may mimic these conditions, and imaging is often needed. Transvaginal ultrasonography should be the initial imaging test because of its sensitivities across most etiologies and its lack of radiation exposure. A high index of suspicion should be maintained for pelvic inflammatory disease when other etiologies are ruled out, because the presentation is variable and the prevalence is high. Multiple studies have shown that 20 to 50 percent of women presenting with pelvic pain have pelvic inflammatory disease. Adolescents and pregnant and postpartum women require unique considerations.

Stratified computed tomography findings improve diagnostic accuracy for appendicitis

PubMed Central

Park, Geon; Lee, Sang Chul; Choi, Byung-Jo; Kim, Say-June

2014-01-01

AIM: To improve the diagnostic accuracy in patients with symptoms and signs of appendicitis, but without confirmative computed tomography (CT) findings. METHODS: We retrospectively reviewed the database of 224 patients who had been operated on for the suspicion of appendicitis, but whose CT findings were negative or equivocal for appendicitis. The patient population was divided into two groups: a pathologically proven appendicitis group (n = 177) and a non-appendicitis group (n = 47). The CT images of these patients were re-evaluated according to the characteristic CT features as described in the literature. The re-evaluations and baseline characteristics of the two groups were compared. RESULTS: The two groups showed significant differences with respect to appendiceal diameter, and the presence of periappendiceal fat stranding and intraluminal air in the appendix. A larger proportion of patients in the appendicitis group showed distended appendices larger than 6.0 mm (66.3% vs 37.0%; P < 0.001), periappendiceal fat stranding (34.1% vs 8.9%; P = 0.001), and the absence of intraluminal air (67.6% vs 48.9%; P = 0.024) compared to the non-appendicitis group. Furthermore, the presence of two or more of these factors increased the odds ratio to 6.8 times higher than baseline (95%CI: 3.013-15.454; P < 0.001). CONCLUSION: Appendiceal diameter and wall thickening, fat stranding, and absence of intraluminal air can be used to increased diagnostic accuracy for appendicitis with equivocal CT findings. PMID:25320531

Validation of the diagnostic score for acute lower abdominal pain in women of reproductive age.

PubMed

Jearwattanakanok, Kijja; Yamada, Sirikan; Suntornlimsiri, Watcharin; Smuthtai, Waratsuda; Patumanond, Jayanton

2014-01-01

Background. The differential diagnoses of acute appendicitis obstetrics, and gynecological conditions (OB-GYNc) or nonspecific abdominal pain in young adult females with lower abdominal pain are clinically challenging. The present study aimed to validate the recently developed clinical score for the diagnosis of acute lower abdominal pain in female of reproductive age. Method. Medical records of reproductive age women (15-50 years) who were admitted for acute lower abdominal pain were collected. Validation data were obtained from patients admitted during a different period from the development data. Result. There were 302 patients in the validation cohort. For appendicitis, the score had a sensitivity of 91.9%, a specificity of 79.0%, and a positive likelihood ratio of 4.39. The sensitivity, specificity, and positive likelihood ratio in diagnosis of OB-GYNc were 73.0%, 91.6%, and 8.73, respectively. The areas under the receiver operating curves (ROC), the positive likelihood ratios, for appendicitis and OB-GYNc in the validation data were not significantly different from the development data, implying similar performances. Conclusion. The clinical score developed for the diagnosis of acute lower abdominal pain in female of reproductive age may be applied to guide differential diagnoses in these patients.

Acute appendicitis in children: not only surgical treatment.

PubMed

Caruso, Anna Maria; Pane, Alessandro; Garau, Roberto; Atzori, Pietro; Podda, Marcello; Casuccio, Alessandra; Mascia, Luigi

2017-03-01

An accurate diagnosis of acute appendicitis is important to avoid severe outcome or unnecessary surgery but management is controversial. The aim of study was to evaluate, in younger and older children, the efficacy of conservative management for uncomplicated appendicitis and the outcome of complicated forms underwent early surgery. Children with acute appendicitis were investigated by clinical, laboratory variables and abdominal ultrasound and divided in two groups: complicated and uncomplicated. Complicated appendicitis underwent early surgery; uncomplicated appendicitis started conservative treatment with antibiotic. If in the next 24-48h it was worsening, the conservative approach failed and patients underwent late surgery. A total of 362 pediatric patients were included. One hundred sixty-five underwent early appendectomy; 197 patients were at first treated conservatively: of these, 82 were operated within 24-48h for failure. The total percentage of operated patients was 68.2%. An elevated association was found between surgery and ultrasound. Conservative treatment for uncomplicated appendicitis had high percentage of success (58%). Complications in operated patients were infrequent. Our protocol was effective in order to decide which patients treat early surgically and which conservatively; specific red flags (age and onset) can identified patients at most risk of complications or conservative failure. treatment study. II. Copyright © 2016 Elsevier Inc. All rights reserved.

Is Enterobius vermicularis infestation associated with acute appendicitis?

PubMed

Akkapulu, N; Abdullazade, S

2016-08-01

Enterobius vermicularis might be seen in specimens of patients who underwent surgery due to acute appendicitis. There is still debate as to E. vermicularis infestation causes acute appendicitis. The primary aim of this study is to determine the incidence of E. vermicularis infestation, and the secondary aim is to determine the possible role of E. vermicularis in pathogenesis of appendicitis as well as the adequacy of demographic data and laboratory values in predicting infestation preoperatively. A retrospective investigation was conducted with all patients who underwent appendectomy due to acute appendicitis in a secondary care center. Patients with E. vermicularis were compared with 24 controls that underwent appendectomy during the same time period. Demographic data, preoperative white blood cell (WBC) count, eosinophil counts, and histopathological findings for both groups were analyzed and compared. Enterobius vermicularis was detected in the appendectomy materials in 9 of 1446 patients (0.62 %). Histopathologically, only one of nine patients had acute appendicitis while the others were diagnosed with lymphoid hyperplasia. There were no statistically significant differences between the groups except WBC count. However, the WBC count was significantly (p < 0.05) lower in the group which was detected E. vermicularis. Enterobius vermicularis is rarely associated with the histopathological findings of acute appendicitis. Also eosinophil count and elevation of white blood counts are inadequate for predicting preoperative E. vermicularis.

Appendicitis in Teens

MedlinePlus

... Español Text Size Email Print Share Appendicitis in Teens Page Content Article Body Early adolescence is prime ... with a small scar, but completely cured. Helping Teens To Help Themselves Youngsters should be encouraged to ...

Prospective evaluation of the ability of clinical scoring systems and physician-determined likelihood of appendicitis to obviate the need for CT.

PubMed

Golden, Sean K; Harringa, John B; Pickhardt, Perry J; Ebinger, Alexander; Svenson, James E; Zhao, Ying-Qi; Li, Zhanhai; Westergaard, Ryan P; Ehlenbach, William J; Repplinger, Michael D

2016-07-01

To determine whether clinical scoring systems or physician gestalt can obviate the need for computed tomography (CT) in patients with possible appendicitis. Prospective, observational study of patients with abdominal pain at an academic emergency department (ED) from February 2012 to February 2014. Patients over 11 years old who had a CT ordered for possible appendicitis were eligible. All parameters needed to calculate the scores were recorded on standardised forms prior to CT. Physicians also estimated the likelihood of appendicitis. Test characteristics were calculated using clinical follow-up as the reference standard. Receiver operating characteristic curves were drawn. Of the 287 patients (mean age (range), 31 (12-88) years; 60% women), the prevalence of appendicitis was 33%. The Alvarado score had a positive likelihood ratio (LR(+)) (95% CI) of 2.2 (1.7 to 3) and a negative likelihood ratio (LR(-)) of 0.6 (0.4 to 0.7). The modified Alvarado score (MAS) had LR(+) 2.4 (1.6 to 3.4) and LR(-) 0.7 (0.6 to 0.8). The Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) score had LR(+) 1.3 (1.1 to 1.5) and LR(-) 0.5 (0.4 to 0.8). Physician-determined likelihood of appendicitis had LR(+) 1.3 (1.2 to 1.5) and LR(-) 0.3 (0.2 to 0.6). When combined with physician likelihoods, LR(+) and LR(-) was 3.67 and 0.48 (Alvarado), 2.33 and 0.45 (RIPASA), and 3.87 and 0.47 (MAS). The area under the curve was highest for physician-determined likelihood (0.72), but was not statistically significantly different from the clinical scores (RIPASA 0.67, Alvarado 0.72, MAS 0.7). Clinical scoring systems performed equally well as physician gestalt in predicting appendicitis. These scores do not obviate the need for imaging for possible appendicitis when a physician deems it necessary. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

More than one-third of successfully nonoperatively treated patients with complicated appendicitis experienced recurrent appendicitis: Is interval appendectomy necessary?

PubMed

Tanaka, Yujiro; Uchida, Hiroo; Kawashima, Hiroshi; Fujiogi, Michimasa; Suzuki, Keisuke; Takazawa, Shinya; Deie, Kyoichi; Amano, Hizuru; Iwanaka, Tadashi

2016-12-01

Although nonoperative treatment (non-OPT) for complicated appendicitis is performed widely, the long-term outcomes and merits of interval appendectomy (IA) need to be evaluated. Between April 2007 and December 2013, all appendicitis patients with well-circumscribed abscess or phlegmon were required to select either laparoscopic surgery (OPT) or non-OPT with optional IA on admission. Optional IA was planned at ≥3months after non-OPT. For non-OPT, intravenous injection of antibiotics was continued until the serum C-reactive protein concentration decreased to <0.5mg/dL, with occasional drainage of abscesses. Thirty-three patients chose OPT, and 55 chose non-OPT. Among non-OPT patients, 16 selected IA. The success rate of non-OPT was 98.2%. Recurrence occurred in 13 (34.2%) of the 38 non-IA group patients. Although the non-IA group patients frequently had perforated appendicitis at recurrence, they visited the hospital earlier than at the initial appendicitis and had less inflammation. Readmission rate or complications in patients undergoing IA were not different compared with those of the patients in the non-IA group, who had recurrence at ≥3months, or with those of patients in the OPT group. Although many patients experienced recurrent appendicitis after successful nonoperative treatment, IA may not be necessary after non-OPT. Prospective comparative study, level II. Copyright © 2016 Elsevier Inc. All rights reserved.

Right Iliac Fossa Pain Treatment (RIFT) Study: protocol for an international, multicentre, prospective observational study

PubMed Central

2018-01-01

Introduction Patients presenting with right iliac fossa (RIF) pain are a common challenge for acute general surgical services. Given the range of potential pathologies, RIF pain creates diagnostic uncertainty and there is subsequent variation in investigation and management. Appendicitis is a diagnosis which must be considered in all patients with RIF pain; however, over a fifth of patients undergoing appendicectomy, in the UK, have been proven to have a histologically normal appendix (negative appendicectomy). The primary aim of this study is to determine the contemporary negative appendicectomy rate. The study’s secondary aims are to determine the rate of laparoscopy for appendicitis and to validate the Appendicitis Inflammatory Response (AIR) and Alvarado prediction scores. Methods and analysis This multicentre, international prospective observational study will include all patients referred to surgical specialists with either RIF pain or suspected appendicitis. Consecutive patients presenting within 2-week long data collection periods will be included. Centres will be invited to participate in up to four data collection periods between February and August 2017. Data will be captured using a secure online data management system. A centre survey will profile local policy and service delivery for management of RIF pain. Ethics and dissemination Research ethics are not required for this study in the UK, as determined using the National Research Ethics Service decision tool. This study will be registered as a clinical audit in participating UK centres. National leads in countries outside the UK will oversee appropriate registration and study approval, which may include completing full ethical review. The study will be disseminated by trainee-led research collaboratives and through social media. Peer-reviewed publications will be published under corporate authorship including ‘RIFT Study Group’ and ‘West Midlands Research Collaborative’. PMID:29331965

Methyl-orvinol-Dual activity opioid receptor ligand inhibits gastrointestinal transit and alleviates abdominal pain in the mouse models mimicking diarrhea-predominant irritable bowel syndrome.

PubMed

Zielińska, Marta; Jarmuż, Agata; Wasilewski, Andrzej; Cami-Kobeci, Gerta; Husbands, Stephen; Fichna, Jakub

2017-04-01

Diarrhea-predominant irritable bowel syndrome (IBS-D) is a functional disorder of the gastrointestinal (GI) tract. The major IBS-D symptoms include diarrhea, abdominal pain and discomfort. High density of opioid receptors (ORs) in the GI tract and their participation in the maintenance of GI homeostasis make ORs ligands an attractive option for developing new anti-IBS-D treatments. The aim of this study was to characterize the effect of methyl-orvinol on the GI motility and secretion and in mouse models mimicking symptoms of IBS-D. In vitro, the effects of methyl-orvinol on electrical field stimulated smooth muscle contractility and epithelial ion transport were characterized in the mouse colon. In vivo, the following tests were used to determine methyl-orvinol effect on mouse GI motility: colonic bead expulsion, whole GI transit and fecal pellet output. An antinociceptive action of methyl-orvinol was assessed in the mouse model of visceral pain induced by mustard oil. Methyl-orvinol (10 -10 to 10 -6 M) inhibited colonic smooth muscle contractions in a concentration-dependent manner. This effect was reversed by naloxone (non-selective opioid antagonist) and β-funaltrexamine (selective MOP antagonist). Experiments with a selective KOP receptor agonist, U50488 revealed that methyl-orvinol is a KOP receptor antagonist in the GI tract. Methyl-orvinol enhanced epithelial ion transport. In vivo, methyl-orvinol inhibited colonic bead expulsion and prolonged GI transit. Methyl-orvinol improved hypermotility and reduced abdominal pain in the mouse models mimicking IBS-D symptoms. Methyl-orvinol could become a promising drug candidate in chronic therapy of functional GI diseases such as IBS-D. Copyright © 2016 Institute of Pharmacology, Polish Academy of Sciences. Published by Elsevier Urban & Partner Sp. z o.o. All rights reserved.

Composition of the cellular infiltrate in patients with simple and complex appendicitis.

PubMed

Gorter, Ramon R; Wassenaar, Emma C E; de Boer, Onno J; Bakx, Roel; Roelofs, Joris J T H; Bunders, Madeleine J; van Heurn, L W Ernst; Heij, Hugo A

2017-06-15

It is now well established that there are two types of appendicitis: simple (nonperforating) and complex (perforating). This study evaluates differences in the composition of the immune cellular infiltrate in children with simple and complex appendicitis. A total of 47 consecutive children undergoing appendectomy for acute appendicitis between January 2011 and December 2012 were included. Intraoperative criteria were used to identify patients with either simple or complex appendicitis and were confirmed histopathologically. Immune histochemical techniques were used to identify immune cell markers in the appendiceal specimens. Digital imaging analysis was performed using Image J. In the specimens of patients with complex appendicitis, significantly more myeloperoxidase positive cells (neutrophils) (8.7% versus 1.2%, P < 0.001) were detected compared to patients with a simple appendicitis. In contrast, fewer CD8+ T cells (0.4% versus 1.3%, P = 0.016), CD20 + cells (2.9% versus 9.0%, P = 0.027), and CD21 + cells (0.2% versus 0.6%, P = 0.028) were present in tissue from patients with complex compared to simple appendicitis. The increase in proinflammatory innate cells and decrease of adaptive cells in patients with complex appendicitis suggest potential aggravating processes in complex appendicitis. Further research into the underlying mechanisms may identify novel biomarkers to be able to differentiate simple and complex appendicitis. Copyright © 2017 Elsevier Inc. All rights reserved.

Acute corneal hydrops mimicking full thickness perforation.

PubMed

Ch'ng, S W; Pillai, M B; Aazeem, S; Tu, K L

2012-05-11

A 26-year-old Caucasian female with keratoconus presented with an acutely painful and red left eye. Visual acuity on presentation was 3/60. Slit lamp examination revealed localised Descemet's membrane break with iris partially plugging it. There was a bulging stromal cyst which would intermittently flatten and reform. The appearance when the cyst was flattened mimicked a full thickness corneal perforation. However, no obvious overlying epithelial defect was detected and an intermittent leakage through micro-perforations in the corneal epithelium was the probable cause of the variable appearance. The anterior chamber reformed and iris plug freed following an insertion of a bandage contact lens and taped eyelid. On follow-up, the Descement's membrane had healed with visual acuity improving to 6/18. Our case illustrates the importance of identifying corneal hydrops mimicking a full thickness perforation as conservative management has a greater chance of recovery.

Sonographic Differentiation of Complicated From Uncomplicated Appendicitis: Implications for Antibiotics-First Therapy.

PubMed

Xu, Yingding; Jeffrey, R Brooke; Chang, Stephanie T; DiMaio, Michael A; Olcott, Eric W

2017-02-01

To evaluate sonographic findings as indicators of complicated versus uncomplicated appendicitis in the setting of known appendicitis, a necessary distinction in deciding whether to proceed with antibiotic therapy or with appendectomy. With Institutional Review Board approval and Health Insurance Portability and Accountability Act compliance, appendiceal sonograms of 119 patients with histopathologically proven appendicitis were retrospectively blindly reviewed to determine the presence or absence of the normally echogenic submucosal layer, the presence of mural hyperemia, periappendiceal fluid, appendicoliths, and hyperechoic periappendiceal fat and to determine the maximum outside diameter. Results were compared with the presence of complicated versus uncomplicated appendicitis on histopathologic examination and assessed by both univariate and mulitvariate logistic regression; confidence intervals (CIs) of proportions were assessed by the exact binomial test. Thirty-two (26.9%) of the 119 patients had complicated appendicitis, including 11 with gangrenous appendicitis without perforation and 21 with gangrenous appendicitis and perforation. Loss of the submucosal layer was the only independent significant indicator of complicated appendicitis in multivariate regression (P < .001) and provided sensitivity and specificity values of 100.0% (95% CI, 89.1%-100.0%) and 92.0% (95% CI, 84.1%-96.7%), respectively. Loss of the normally echogenic submucosal layer was the most useful sonographic finding for discriminating complicated from uncomplicated appendicitis, being the only finding independently and significantly associated with complicated appendicitis and, additionally, providing both high sensitivity and high specificity. This information may help a physician decide whether to proceed with antibiotic therapy or with appendectomy when treating a patient with appendicitis. © 2016 by the American Institute of Ultrasound in Medicine.

The Global Incidence of Appendicitis: A Systematic Review of Population-based Studies.

PubMed

Ferris, Mollie; Quan, Samuel; Kaplan, Belle S; Molodecky, Natalie; Ball, Chad G; Chernoff, Greg W; Bhala, Nij; Ghosh, Subrata; Dixon, Elijah; Ng, Siew; Kaplan, Gilaad G

2017-08-01

We compared the incidence of appendicitis or appendectomy across the world and evaluated temporal trends. Population-based studies reported the incidence of appendicitis. We searched MEDLINE and EMBASE databases for population-based studies reporting the incidence of appendicitis or appendectomy. Time trends were explored using Poisson regression and reported as annual percent change (APC) with 95% confidence intervals (CI). APC were stratified by time periods and pooled using random effects models. Incidence since 2000 was pooled for regions in the Western world. The search retrieved 10,247 citations with 120 studies reporting on the incidence of appendicitis or appendectomy. During the 21st century the pooled incidence of appendicitis or appendectomy (in per 100,000 person-years) was 100 (95% CI: 91, 110) in Northern America, and the estimated number of cases in 2015 was 378,614. The pooled incidence ranged from 105 in Eastern Europe to 151 in Western Europe. In Western countries, the incidence of appendectomy steadily decreased since 1990 (APC after 1989=-1.54; 95% CI: -2.22, -0.86), whereas the incidence of appendicitis stabilized (APC=-0.36; 95% CI: -0.97, 0.26) for both perforated (APC=0.95; 95% CI: -0.25, 2.17) and nonperforated appendicitis (APC=0.44; 95% CI: -0.84, 1.73). In the 21st century, the incidence of appendicitis or appendectomy is high in newly industrialized countries in Asia (South Korea pooled: 206), the Middle East (Turkey pooled: 160), and Southern America (Chile: 202). Appendicitis is a global disease. The incidence of appendicitis is stable in most Western countries. Data from newly industrialized countries is sparse, but suggests that appendicitis is rising rapidly.

Sensitivity and Specificity of Fenyö-Lindberg and Teicher Scores in the Diagnosis of Acute Appendicitis in Women

PubMed

Madžar, Zrinko; Kopljar, Mario; Madžar, Tomislav; Mesić, Marko; Mužina Mišić, Dubravka; Čiček, Slaven; Zovak, Mario

2016-12-01

The aim of the study was to assess diagnostic accuracy (sensitivity and specificity) of Fenyö-Lindberg and Teicher scores for distinguishing patients that need immediate surgical treatment from the others, in a female population from an urban setting. The study prospectively included 130 female patients admitted to the emergency department with abdominal pain indicating acute appendicitis. The scores and parameters of validity were calculated and compared to definitive diagnosis. For Fenyö-Lindberg score of -17 or less, 84.5% sensitivity, 55.6% specificity, 87.9% positive predictive value (PPV) and 48.4% negative predictive value (NPV) were recorded. For cut-off value greater or equal to -2, there was 59.2% sensitivity, 77.8% specificity, 91% PPV and 33.3% NPV. The Receiver Operating Characteristic (ROC) curve analysis of Fenyö-Lindberg score showed that the best single cut-off value for discriminating acute appendicitis in the study population was -15. For Teicher score, values greater than -3 yielded 89.3% sensitivity and 22.2% specificity, 81.4% PPV and 35.3% NPV. In conclusion, Fenyö-Lindberg score could be used as an additional tool to exclude appendicitis and avoid unnecessary appendectomies. Teicher score may help in recognizing patients with appendicitis. None of the two scores can indicate or decline appendectomy in all cases. Scoring systems may be useful for pointing to important clinical signs and symptoms in specific subpopulations.

Ultrasound Accuracy in Diagnosing Appendicitis in Obese Pediatric Patients.

PubMed

Love, Bryan E; Camelo, Monica; Nouri, Sarvenaz; Kriger, Diego; Ludi, Daniel; Nguyen, Henry

2017-10-01

The use of ultrasound to diagnose appendicitis in pediatric patients has been growing with the improvement of ultrasound technology and operator skills, but its utility in the increasingly obese pediatric population has not been thoroughly investigated. A retrospective review of all pediatric (≤18 years old) patients with appendicitis who were admitted at a single hospital from 2014 to 2016 was conducted. Patients were stratified into body mass index (BMI) percentile categories based on the centers for disease control guidelines. Comparisons were then made. There were 231 patients with an average BMI percentile of 72.6; 99 (42.9%) who had an ultrasound, of which 54 (54.5%) were positive for acute appendicitis, whereas 43 (43.4%) were nondiagnostic. In patients who had a nondiagnostic ultrasound, 37 had a CT demonstrating acute appendicitis. These were compared with 123 patients who had CT alone demonstrating acute appendicitis. The CT-only group was older (12 vs 9, P < 0.005), tended to be male (78 (63%) vs 15 (41%), P = 0.019), had fewer operations performed (81 (66%) vs 30 (81%), P = 0.048) but had no significant difference in BMI percentile (75.8 vs 71.7, P = 0.465). Ultrasound had a 100 per cent positive predictive value in obese and overweight children. Ultrasound is a reliable study in obese and overweight pediatric patients with acute appendicitis.

Prospective evaluation of the Sunshine Appendicitis Grading System score.

PubMed

Reid, Fiona; Choi, Julian; Williams, Marli; Chan, Steven

2017-05-01

Although there is a wealth of information predicting risk of post-operative intra-abdominal collection and guiding antibiotic therapy following appendicectomy, confusion remains because of lack of consensus on the clinical severity and definition of 'complicated' appendicitis. This study aimed to develop a standardized intra-operative grading system: Sunshine Appendicitis Grading System (SAGS) for acute appendicitis that correlates independently with the risk of intra-abdominal collections. Two-hundred and forty-six patients undergoing emergency laparoscopy for suspected appendicitis were prospectively scored according to the severity of appendicitis and followed up for complications including intra-abdominal collection. After termination of the study, the SAGS score was repeated by an independent surgeon based on operation notes and intra-operative photography to determine inter-rater agreement. The primary outcome measure was incidence of intra-abdominal collection, secondary outcome measures were all complications and length of stay. SAGS score demonstrated good inter-rater agreement (kappa K w 0.869; 95% CI 0.796-0.941; P < 0.001). A risk ratio of 2.594 (95% CI 0.655-4.065; P < 0.001) for intra-abdominal collection was found using SAGS score as a predictor. The discriminative ability of SAGS score was supported by an area under the curve value of 0.850 (95% CI 0.799-0.892; P < 0.001). SAGS score can be used to simply and accurately classify the severity of appendicitis and to independently predict the risk of intra-abdominal collection. It can therefore be used to stratify risk, guide antibiotic therapy, follow-up and standardize the definitions of appendicitis severity for future research. © 2015 Royal Australasian College of Surgeons.

Underestimated Amoebic Appendicitis among HIV-1-Infected Individuals in Japan.

PubMed

Kobayashi, Taiichiro; Watanabe, Koji; Yano, Hideaki; Murata, Yukinori; Igari, Toru; Nakada-Tsukui, Kumiko; Yagita, Kenji; Nozaki, Tomoyoshi; Kaku, Mitsuo; Tsukada, Kunihisa; Gatanaga, Hiroyuki; Kikuchi, Yoshimi; Oka, Shinichi

2017-01-01

Entamoeba histolytica is not a common causative agent of acute appendicitis. However, amoebic appendicitis can sometimes be severe and life threatening, mainly due to a lack of awareness. Also, its frequency, clinical features, and pathogenesis remain unclear. The study subjects were HIV-1-infected individuals who presented with acute appendicitis and later underwent appendectomy at our hospital between 1996 and 2014. Formalin-fixed paraffin-embedded preserved appendix specimens were reexamined by periodic acid-Schiff (PAS) staining and PCR to identify undiagnosed amoebic appendicitis. Appendectomies were performed in 57 patients with acute appendicitis. The seroprevalence of E. histolytica was 33% (14/43) from the available stored sera. Based on the medical records, only 3 cases were clinically diagnosed as amoebic appendicitis, including 2 diagnosed at the time of appendectomy and 1 case diagnosed by rereview of the appendix after the development of postoperative complications. Retrospective analyses using PAS staining and PCR identified 3 and 3 more cases, respectively. Thus, E. histolytica infection was confirmed in 9 cases (15.8%) in the present study. Apart from a significantly higher leukocyte count in E. histolytica-positive patients than in negative patients (median, 13,760 versus 10,385 cells/μl, respectively, P = 0.02), there were no other differences in the clinical features of the PCR-positive and -negative groups. In conclusion, E. histolytica infection was confirmed in 9 (15.8%) of the appendicitis cases. However, only 3, including one diagnosed after intestinal perforation, were diagnosed before the present analyses. These results strongly suggest there is frequently a failure to detect trophozoites in routine examination, resulting in an underestimation of the incidence of amoebic appendicitis. Copyright © 2016 Kobayashi et al.

Acute appendicitis-like symptoms as initial presentation of ovarian vein thrombosis.

PubMed

Prieto-Nieto, M I; Perez-Robledo, J P; Rodriguez-Montes, J A; Garci-Sancho-Martin, L

2004-07-01

Postpartum ovarian vein thrombosis is a rare condition, with an incidence rate being 1/600 deliveries. It most often arises in the right ovarian vein. A 33-year-old patient who had had normal vaginal delivery presented with fever, pain in the right iliac fossa, and leukocytosis on the sixth day after delivery. An antibiotic course was instituted but 3 days later symptoms reappeared. Diagnosis of acute appendicitis was made. At surgery through a McBurney incision, a woody tumoration consistent with ovarian vein thrombosis was found. Anticoagulation therapy with heparin and antibiotics were instituted. Phlebography and color Doppler sonography confirmed the presence of thrombosis of both the common femoral iliac and inferior vena cava. Fribrolysis with urokinase was performed. The patient has remained stable and symptom-free over a 4-year follow-up. Ovarian vein thrombosis typically presents with symptoms suggestive of acute appendicitis, as was the case in our patient. Color Doppler sonography is the favored diagnostic procedure, with CT being a supplementary tool. Surgery is not necessary and treatment consists of anticoagulants and antibiotics. Even though postpartum ovarian vein thrombosis is rare, early recognition of the condition is of paramount importance to institute the adequate treatment and avoid potential serious sequelae.

[Enterobius vermicularis causing symptoms of acute appendicitis].

PubMed

Antal, András; Kocsis, Béla

2008-08-01

The authors present a case of enterobiasis of the appendix. Enterobius infection is an uncommon cause of acute appendicitis. Preoperative diagnosis of pinworm infestation is almost impossible unless there is a strong clinical suspicion. Parasites may produce symptoms which resemble acute appendicitis. Careful observation of the appendix stump may lead to intraoperative diagnosis of enterobiasis. A quick diagnosis and appropriate treatment may prevent future complications.

CT diagnosis of a clinically unsuspected acute appendicitis complicating infectious mononucleosis.

PubMed

Zissin, R; Brautbar, O; Shapiro-Feinberg, M

2001-01-01

Acute appendicitis is a rare complication of infectious mononucleosis (IM). We describe a patient with IM and splenic rupture with a computerized tomography (CT) diagnosis of acute appendicitis during the acute phase of the infectious disease. Diagnostic imaging features of acute appendicitis were found on an abdominal CT performed for the evaluation of postoperative fever. Histologic examination confirmed the CT diagnosis of the clinically unsuspected acute appendicitis. Our case is unique both for the rarity of this complication and the lack of clinical symptoms.

Non-operative management of appendicitis in children.

PubMed

Hall, Nigel J; Eaton, Simon

2018-05-01

While appendicectomy has been considered the mainstay of treatment for children with acute appendicitis for many decades, there has been a great deal of recent interest in non-operative treatment (NOT) with antibiotics alone. Initial results suggest that many children with appendicitis can indeed be safely treated with NOT and can be spared the surgeon's knife. Many as yet unanswered questions remain, however, before NOT can be considered a realistic and reliable alternative to surgery. This review summaries current knowledge and understanding of the role of NOT in children with appendicitis and outlines and discusses the outstanding knowledge gaps. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

CRP in acute appendicitis--is it a necessary investigation?

PubMed

Amalesh, T; Shankar, M; Shankar, R

2004-01-01

Appendectomy is one of the commonest procedures in surgery. In spite of various investigations used to improve the accuracy of diagnosis, the rate of normal appendices removed is still about 15-30%. Many studies have investigated the role of C-reactive protein (CRP) in acute appendicitis, but with conflicting results. In a prospective, double blind study, blood for the measurement of serum C-reactive protein was collected pre-operatively from 192 children before going to the operating theatre for appendectomy. The histopathology was grouped into positive (acute appendicitis) and negative (normal appendix) and this was correlated with CRP values. CRP was normal in 14 out of 33 negative explorations (normal appendix on histopathology). The specificity and sensitivity of serum CRP was 42% and 91% respectively. The predictive value of a positive (raised CRP) and negative (normal CRP) test is 88% and 48% respectively. We conclude that neither raised nor normal CRP value is helpful in the diagnosis of acute appendicitis. CRP is not a good tool for helping the surgeon make the diagnosis of appendicitis and it should not be measured in suspected appendicitis.

Diagnosing Appendicitis: Evidence-Based Review of the Diagnostic Approach in 2014

PubMed Central

Shogilev, Daniel J.; Duus, Nicolaj; Odom, Stephen R.; Shapiro, Nathan I.

2014-01-01

Introduction Acute appendicitis is the most common abdominal emergency requiring emergency surgery. However, the diagnosis is often challenging and the decision to operate, observe or further work-up a patient is often unclear. The utility of clinical scoring systems (namely the Alvarado score), laboratory markers, and the development of novel markers in the diagnosis of appendicitis remains controversial. This article presents an update on the diagnostic approach to appendicitis through an evidence-based review. Methods We performed a broad Medline search of radiological imaging, the Alvarado score, common laboratory markers, and novel markers in patients with suspected appendicitis. Results Computed tomography (CT) is the most accurate mode of imaging for suspected cases of appendicitis, but the associated increase in radiation exposure is problematic. The Alvarado score is a clinical scoring system that is used to predict the likelihood of appendicitis based on signs, symptoms and laboratory data. It can help risk stratify patients with suspected appendicitis and potentially decrease the use of CT imaging in patients with certain Alvarado scores. White blood cell (WBC), C-reactive protein (CRP), granulocyte count and proportion of polymorphonuclear (PMN) cells are frequently elevated in patients with appendicitis, but are insufficient on their own as a diagnostic modality. When multiple markers are used in combination their diagnostic utility is greatly increased. Several novel markers have been proposed to aid in the diagnosis of appendicitis; however, while promising, most are only in the preliminary stages of being studied. Conclusion While CT is the most accurate mode of imaging in suspected appendicitis, the accompanying radiation is a concern. Ultrasound may help in the diagnosis while decreasing the need for CT in certain circumstances. The Alvarado Score has good diagnostic utility at specific cutoff points. Laboratory markers have very limited

Clinical results of laparoscopic appendectomy in patients with complicated and uncomplicated appendicitis

PubMed Central

Bat, Orhan; Kaya, Hakan; Çelik, Hamit Kafkas; Şahbaz, Nuri Alper

2014-01-01

Acute appendicitis is the most common surgical emergency. The aim of this study was to evaluate the clinical results of laparoscopic appendectomy (LA) for the treatment of uncomplicated and complicated appendicitis. A retrospective analysis was performed who had undergone laparoscopic appendectomy for complicated appendicitis between January 2010 to October 2013. The diagnosis of acute appendicitis was established with physical examination, laboratory tests, and ultrasound examination. The patients were analysed for age, sex, conversion rate,operation time, postoperative infectious complications and length of hospital stay. A total of 452 patients were operated with LA. There were 362 (80.1%) uncomplicated (Group I) and 90 (19.1%) complicated Group (II) appendicitis.The intraabdominal abscess rate was 14.35% in Group I and 19.5% in Group II. The wound infection and rate of incisional hernia were also higher in Group II. The postoperative complications including intraabdominal abscess, wound infection and incisional hernia after LA in complicated appendicitis found high. LA should be performed very carefully in complicated appendicitis. PMID:25419386

Sarcopenia in children with perforated appendicitis.

PubMed

López, Joseph J; Cooper, Jennifer N; Albert, Brett; Adler, Brent; King, Denis; Minneci, Peter C

2017-12-01

Decreased skeletal muscle mass, or sarcopenia, has been shown to be associated with worse postoperative recovery and a higher risk of complications in adult surgical patients. We hypothesized that pediatric patients with complicated appendicitis may experience sarcopenic changes over the course of their treatment. The medical records and computed tomography scans of 36 pediatric complex appendicitis patients who had both preoperative and postoperative computerized tomography scans at our hospital were reviewed. Changes in psoas muscle area were examined using linear mixed models with random patient-level intercept and time effects. The median change in body mass index among all patients from admission to discharge was -0.8 kg/m 2 (interquartile range: -1.3 to -0.2). The mean percentage change in psoas muscle area per day over the course of appendicitis-related treatment was -0.81% (95% confidence interval: -1.12 to -0.50) (P < 0.001). The relative decrease in psoas muscle area per day did not vary by initial body mass index, gender, or race (P > 0.10 for all interactions). Our data suggest that pediatric patients with complex appendicitis experience sarcopenic changes during their hospital admission. Given previous reports that sarcopenia is a significant predictor of worse surgical outcomes, more investigation is warranted to assess whether these changes are associated with postsurgical complications and to evaluate potential interventions that may prevent these changes. Copyright © 2017 Elsevier Inc. All rights reserved.

Increased incidence of bowel cancer after non-surgical treatment of appendicitis.

PubMed

Enblad, Malin; Birgisson, Helgi; Ekbom, Anders; Sandin, Fredrik; Graf, Wilhelm

2017-11-01

There is an ongoing debate on the use of antibiotics instead of appendectomy for treating appendicitis but diagnostic difficulties and longstanding inflammation might lead to increased incidence of bowel cancer in these patients. The aim of this population-based study was to investigate the incidence of bowel cancer after non-surgical treatment of appendicitis. Patients diagnosed with appendicitis but lacking the surgical procedure code for appendix removal were retrieved from the Swedish National Inpatient Register 1987-2013. The cohort was matched with the Swedish Cancer Registry and the standardised incidence ratios (SIR) with 95% confidence interval (95% CI) for appendiceal, colorectal and small bowel cancers were calculated. Of 13 595 patients with non-surgical treatment of appendicitis, 352 (2.6%) were diagnosed with appendiceal, colorectal or small bowel cancer (SIR 4.1, 95% CI 3.7-4.6). The largest incidence increase was found for appendiceal (SIR 35, 95% CI 26-46) and right-sided colon cancer (SIR 7.5, 95% CI 6.6-8.6). SIR was still elevated when excluding patients with less than 12 months since appendicitis and the incidence of right-sided colon cancer was elevated five years after appendicitis (SIR 3.5, 95% CI 2.1-5.4). An increased incidence of bowel cancer was found after appendicitis with abscess (SIR 4.6, 95% CI 4.0-5.2), and without abscess (SIR 3.5, 95% CI 2.9-4.1). Patients with non-surgical treatment of appendicitis have an increased short and long-term incidence of bowel cancer. This should be considered in the discussion about optimal management of patients with appendicitis. Copyright © 2017 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.

Neutral vs positive oral contrast in diagnosing acute appendicitis with contrast-enhanced CT: sensitivity, specificity, reader confidence and interpretation time

PubMed Central

Naeger, D M; Chang, S D; Kolli, P; Shah, V; Huang, W; Thoeni, R F

2011-01-01

Objective The study compared the sensitivity, specificity, confidence and interpretation time of readers of differing experience in diagnosing acute appendicitis with contrast-enhanced CT using neutral vs positive oral contrast agents. Methods Contrast-enhanced CT for right lower quadrant or right flank pain was performed in 200 patients with neutral and 200 with positive oral contrast including 199 with proven acute appendicitis and 201 with other diagnoses. Test set disease prevalence was 50%. Two experienced gastrointestinal radiologists, one fellow and two first-year residents blindly assessed all studies for appendicitis (2000 readings) and assigned confidence scores (1=poor to 4=excellent). Receiver operating characteristic (ROC) curves were generated. Total interpretation time was recorded. Each reader's interpretation with the two agents was compared using standard statistical methods. Results Average reader sensitivity was found to be 96% (range 91–99%) with positive and 95% (89–98%) with neutral oral contrast; specificity was 96% (92–98%) and 94% (90–97%). For each reader, no statistically significant difference was found between the two agents (sensitivities p-values >0.6; specificities p-values>0.08), in the area under the ROC curve (range 0.95–0.99) or in average interpretation times. In cases without appendicitis, positive oral contrast demonstrated improved appendix identification (average 90% vs 78%) and higher confidence scores for three readers. Average interpretation times showed no statistically significant differences between the agents. Conclusion Neutral vs positive oral contrast does not affect the accuracy of contrast-enhanced CT for diagnosing acute appendicitis. Although positive oral contrast might help to identify normal appendices, we continue to use neutral oral contrast given its other potential benefits. PMID:20959365

Uveal Melanoma Mimicking Advanced Coats' Disease in a Young Patient.

PubMed

Gupta, Naina; Terrell, William; Schoenfield, Lynn; Kirsch, Claudia; Cebulla, Colleen M

2016-04-01

To report a case and the unique histopathology of a necrotic uveal melanoma mimicking advanced Coats' disease in a young adult. A 26-year-old male presented with a blind, painful eye, total exudative retinal detachment, and bulbous aneurysms consistent with Coats' disease. No masses were visualized on ultrasound or CT scan, and the patient underwent enucleation of the eye. Histopathology of the involved eye confirmed a necrotic uveal melanoma with persistent spindle cells forming a collar around residual tumor vessels. Careful consideration is needed in approaching any patient with a blind, painful eye and opaque media, even in younger populations.

An Unusual Case of Caecal Volvulus due to Appendicitis, Successfully Managed by Caecopexy.

PubMed

Bhatti, Samiullah; Khan, Mahmood Ayyaz; Farooka, Waris; Butt, Usman Ismat; Rehman, Usman Ali; Malik, Awais Amjad

2017-03-01

Caecal volvulus is a rare cause of intestinal obstruction. Caecal volvulus precipitated by acute appendicitis is even rarer. We report an unusual case of caecal volvulus with acute appendicitis as a cause. A 55-year female presented in surgical emergency with 3 days history of abdominal pain, distension and absolute constipation; and 2 days history of vomiting. Her past surgical history was significant for hysterectomy 5 years back. On examination, abdomen was distended and bowel sounds exaggerated. X-ray abdomen erect showed a single large air fluid level in the right hemiabdomen. A preoperative diagnosis of intestinal obstruction due to adhesions was made and patient prepared for exploratory laparotomy. On exploration, a huge caecum was lying in the midline and was twisted around a band arising from the appendix and attached deep into the pelvis. The appendix was densely inflammed. The volvulus was de-twisted in a counter clockwise manner. Viability of the caecum was confirmed and appendectomy was done. Caecopexy was performed and abdomen was closed. Postoperative recovery of the patient was uneventful and she was safely discharged on 5th postoperative day.

Ultrasound for Appendicitis: Performance and Integration with Clinical Parameters

PubMed Central

Löfvenberg, Fanny

2016-01-01

Objective. To evaluate the performance of ultrasound in pediatric appendicitis and the integration of US with the pediatric appendicitis score (PAS) and C-reactive protein (CRP). Method. An institution-based, retrospective study of children who underwent abdominal US for suspected appendicitis between 2012 and 2015 at a tertiary pediatric surgery center. US results were dichotomized, with a nonvisualized appendix considered as a negative examination. Results. In total, 438 children were included (mean 8.5 years, 54% boys), with an appendicitis rate of 29%. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for US were 82%, 97%, 92%, and 93%, respectively, without significant age or gender differences. Pediatric radiologists had significantly higher sensitivity compared to general radiologists, 88% and 71%, respectively (p < 0.01), but no differences were seen for specificity, PPV, and NPV. The sensitivity, NPV, and negative likelihood ratio for the combination of negative US, PAS < 5, and CRP < 5 mg/L were 98%, 98%, and 0.05 (95% CI 0.03–0.15). Conclusion. US may be a useful tool for evaluating children with suspected appendicitis, regardless of age or gender, and should be the first choice of imaging modalities. Combining US with PAS and CRP may reduce several unnecessary admissions for in-hospital observation. PMID:28044133

Can platelet indices be used as predictors of complication in subjects with appendicitis?

PubMed

Ceylan, Bahadır; Aslan, Turan; Çınar, Ahmet; Ruhkar Kurt, Ayşe; Akkoyunlu, Yasemin

2016-12-01

We examined the changes of mean platelet volume (MPV) and platelet distribution width (PDW) in subjects with appendicitis and whether MPV and PDW could be used to predict the development of complication due to appendicitis. The healthy control group, the cases of appendicitis with perforation, and the cases of appendicitis without perforation were compared with regard to MPV and PDW. We determined whether MPV and PDW were independent variables predictive of the development of complication in subjects with appendicitis. This retrospective case-control study included a total of 362 patients (249 of which were male (68.8 %) and 113 were female (31.2 %); median age, 30 [range, 18-84 years]). One hundred and ninety-two subjects (53 %) presented with appendicitis and 170 (47 %) comprised the healthy control group. Sixty-six (18.2 %) of the subjects with appendicitis developed complication. MPVs were lower in subjects of appendicitis without complication compared to the subjects of appendicitis with complication and the control group (MPV, 9.78 ± 0.99 vs. 10.20 ± 1.21 and 10.14 ± 1.03, respectively [p = 0.005]). The PDW levels were not different between the three groups. Independent variables predictive of the presence of complication included increased MPV and time from onset of symptoms to hospital presentation (odds ratio[confidence interval], p-value: 1.507[1.064-2.133], 0.021 and 18.887[5.139-69.410], 0.0001, respectively). Our findings suggested these, MPV values in cases of appendicitis without complication were lower than the cases with complication and healthy control and MPV is a predictor of the development of complication in subjects with appendicitis.

[Fatal course of acute appendicitis associated with infectious mononucleosis].

PubMed

Spelde, A G; Ruys, G J; Steffelaar, J W; Bakker, N C

1992-07-25

The case history is presented of a 10-year-old boy with a fatal combination of acute appendicitis and infectious mononucleosis, in the literature a particularly rare combination. The boy died of a perforative peritonitis. His appendicitis appeared not to be a complication of the infectious mononucleosis.

Postpolypectomy Electrocoagulation Syndrome: A Mimicker of Colonic Perforation

PubMed Central

Benson, Brian C.; Myers, Jonathan J.; Laczek, Jeffrey T.

2013-01-01

Postpolypectomy electrocoagulation syndrome is a rare complication of polypectomy with electrocautery and is characterized by a transmural burn of the colon wall. Patients typically present within 12 hours after the procedure with symptoms mimicking colonic perforation. Presented is the case of a 56-year-old man who developed abdominal pain six hours after colonoscopy during which polypectomy was performed using snare cautery. CT imaging of the abdomen revealed circumferential thickening of the wall of the transverse colon without evidence of free air. The patient was treated conservatively as an outpatient and had resolution of his pain over the following four days. Recognition of the diagnosis and understanding of the treatment are important to avoid unnecessary exploratory laparotomy or hospitalization. PMID:23956889

Can common serum biomarkers predict complicated appendicitis in children?

PubMed

Zani, Augusto; Teague, Warwick J; Clarke, Simon A; Haddad, Munther J; Khurana, Sanjeev; Tsang, Thomas; Nataraja, Ramesh M

2017-07-01

As appendicitis in children can be managed differently according to the severity of the disease, we investigated whether commonly used serum biomarkers on admission could distinguish between simple and complicated appendicitis. Admission white blood cell (WBC), neutrophil (NEU), and C-reactive protein (CRP) levels were analysed by ROC curve, and Kruskal-Wallis and contingency tests. Patients were divided according to age and histology [normal appendix (NA), simple appendicitis (SA), complicated appendicitis (CA)]. Of 1197 children (NA = 186, SA = 685, CA = 326), 7% were <5 years, 55% 5-12, 38% 13-17. CA patients had higher CRP and WBC levels than NA and SA (p < 0.0001). NEU levels were lower in NA compared to SA or CA (p < 0.0001), but were similar between SA and CA (p = 0.6). CA patients had higher CRP and WBC levels than SA patients in 5-12- (p < 0.0001) and 13-17-year groups (p = 0.0075, p = 0.005), but not in <5-year group (p = 0.72, p = 0.81). We found CRP >40 mg/L in 58% CA and 37% SA (p < 0.0001), and WBC >15 × 10 9 /L in 58% CA and 43% SA (p < 0.0001). Admission CRP and WBC levels may help the clinician predict complicated appendicitis in children older than 5 years of age. Early distinction of appendicitis severity using these tests may guide caregivers in the preoperative decision-making process.

Addison's Disease Mimicking as Acute Pancreatitis: A Case Report.

PubMed

Chaudhuri, Sayani; Rao, Karthik N; Patil, Navin; Ommurugan, Balaji; Varghese, George

2017-04-01

Over past two decades there has been significant improvement in medical field in elucidating the underlying pathophysiology and genetics of Addison's disease. Adrenal insufficiency (Addison's disease) is a rare disease with an incidence of 0.8/100,000 cases. The diagnosis may be delayed if the clinical presentation mimics a gastrointestinal disorder or psychiatric illness. We report a case of Addison's disease presenting as acute pain in abdomen mimicking clinical presentation of acute pancreatitis.

An evaluation of the relationship between Enterobius vermicularis infestation and acute appendicitis in a paediatric population--A retrospective cohort study.

PubMed

Fleming, C A; Kearney, D E; Moriarty, P; Redmond, H P; Andrews, E J

2015-06-01

Enterobius vermicularis is an often unexpected finding in appendectomy specimen, most commonly seen in paediatric cases. Predicting the presence of E. vermicularis in the setting of appendectomy is important to avoid unnecessary appendectomy and associated morbidity. We sought to identify the incidence of E. vermicularis in a paediatric population undergoing appendectomy for clinically suspected acute appendicitis and identify predictive factors for E. vermicularis. This study was performed in an 800-bed University Teaching Hospital, in the Republic of Ireland. We identified all paediatric appendectomies performed at our institute from January to December 2012 using prospectively maintained operating theatre logbooks. In-hospital Histopathology database, medical notes and operative findings were reviewed for each patient and relevant data recorded. Statistical analysis was performed using IBM SPSS, version 21. In total 182 paediatric appendectomies were performed during the year 2012 for clinically suspected acute appendicitis. Demographics included: Mean age 11.14 years (3-16), gender 1M: 1F. 58.8% of procedures were completed laparoscopically, 39% open and 2.2% were converted. The negative appendectomy rate was 22.5%. The annual incidence of E. vermicularis in acute appendicitis specimen from a paediatric cohort at our institute was 7% (1 in 14). In specimen containing E. vermicularis, 69% had no evidence of appendicitis and of those that had, no gangrene or perforation was seen. The presence of E. vermicularis in paediatric patients with RIF pain may be predicted by Eosinophilia (p = 0.016), normal WCC (p = 0.034) and normal Neutrophil count (p = 0.014). E. vermicularis is responsible for 7% of acute appendicitis. It is responsible for a significantly higher negative appendectomy rate which if predicted may avoid unnecessary appendectomy and associated morbidity. Copyright © 2015. Published by Elsevier Ltd.

The Reliability of a Standardized Reporting System for the Diagnosis of Appendicitis.

PubMed

Simianu, Vlad V; Shamitoff, Anna; Hippe, Daniel S; Godwin, Benjamin D; Shriki, Jabi E; Drake, Frederick T; O'Malley, Ryan B; Maximin, Suresh; Bastawrous, Sarah; Moshiri, Mariam; Lee, Jean H; Cuevas, Carlos; Dighe, Manjiri; Flum, David; Bhargava, Puneet

Computed tomography (CT) is a fast and ubiquitous tool to evaluate intra-abdominal organs and diagnose appendicitis. However, traditional CT reporting does not necessarily capture the degree of uncertainty and indeterminate findings are still common. The purpose of this study was to evaluate the reproducibility of a standardized CT reporting system for appendicitis across a large population and the system's impact on radiologists' certainty in diagnosing appendicitis. Using a previously described standardized reporting system, eight radiologists retrospectively evaluated CT scans, blinded to all clinical information, in a stratified random sample of 237 patients from a larger cohort of patients imaged for possible appendicitis (2010-2014). Receiver operating characteristic (ROC) curves and the area under the ROC curve (AUC) were used to evaluate the diagnostic performance of readers for identifying appendicitis. Two-thirds of these scans were randomly selected to be independently read by a second reader, using the original CT reports to balance the number of positive, negative and indeterminate exams across all readers. Inter-reader agreement was evaluated. There were 113 patients with appendicitis (mean age 38, 67% male). Using the standardized report, radiologists were highly accurate at identifying appendicitis (AUC=0.968, 95%CI confidence interval: 0.95, 0.99. Inter-reader agreement was >80% for most objective findings, and certainty in diagnosing appendicitis was high and reproducible (AUC=0.955 and AUC=0.936 for the first and second readers, respectively). Using a standardized reporting system resulted in high reproducibility of objective CT findings for appendicitis and achieved high diagnostic accuracy in an at-risk population. Predictive tools based on this reporting system may further improve communication about certainty in diagnosis and guide patient management, especially when CT findings are indeterminate. Copyright © 2017 Elsevier Inc. All rights

Imaging in pediatric appendicitis is key to a low normal appendix percentage: a national audit on the outcome of appendectomy for appendicitis in children.

PubMed

Bolmers, M D; van Rossem, C C; Gorter, R R; Bemelman, W A; van Geloven, A A W; Heij, H A

2018-05-01

A laparoscopic approach for emergency appendectomy is increasingly used, in pediatric patients as well. The objective of this study is to audit the current state of diagnostic work-up, surgical techniques and its outcome in children with acute appendicitis. A prospective consecutive observational cohort study was carried out in a 2-month study period. All patients under 18 years that were operated for suspected acute appendicitis were included. Primary outcome was the infectious complication rate after open and laparoscopic approach; secondary outcomes were preoperative use of imaging and post-operative predictive value of imaging, normal appendix rate and children with a postoperative ileus. A total of 541 children were operated for suspected acute appendicitis in 62 Dutch hospitals. Preoperative imaging was used in 98.9% of children. The normal appendix rate was 3.1%. In 523 children an appendectomy was performed. Laparoscopy was used in 61% of the patients and conversion rate was 1.7%. Complicated appendicitis was diagnosed in 29.4% of children. Overall 30-day complication rate was 11.9% and similar after open and laparoscopic. No difference was found in superficial surgical site infections, nor in intra-abdominal abscesses between the open and laparoscopic approach. Complicated appendicitis is an independent risk factor for infectious complications. The laparoscopic approach is most frequently used, except for young children. Superficial surgical site infections are more frequent after open surgery only in patients with complicated appendicitis. The normal appendix rate is low, most likely because of routine preoperative imaging.

Sympathetically maintained pain presenting first as temporomandibular disorder, then as parotid dysfunction.

PubMed

Giri, Subha; Nixdorf, Donald

2007-03-01

Complex regional pain syndrome (CRPS) is a chronic condition characterized by intense pain, swelling, redness, hypersensitivity and additional sudomotor effects. In all 13 cases of CRPS in the head and neck region reported in the literature, nerve injury was identified as the etiology for pain initiation. In this article, we present the case of a 30-year-old female patient with sympathetically maintained pain without apparent nerve injury. Her main symptoms--left-side preauricular pain and inability to open her mouth wide--mimicked temporomandibular joint arthralgia and myofascial pain of the masticatory muscles. Later, symptoms of intermittent preauricular pain and swelling developed, along with hyposalivation, which mimicked parotitis. After an extensive diagnostic process, no definitive underlying pathology could be identified and a diagnosis of neuropathic pain with a prominent sympathetic component was made. Two years after the onset of symptoms and initiation of care, treatment with repeated stellate ganglion blocks and enteral clonidine pharmacotherapy provided adequate pain relief.

Analysis of Recurrence Management in Patients Who Underwent Nonsurgical Treatment for Acute Appendicitis

PubMed Central

Liang, Tsung-Jung; Liu, Shiuh-Inn; Tsai, Chung-Yu; Kang, Chi-Hsiang; Huang, Wei-Chun; Chang, Hong-Tai; Chen, I-Shu

2016-01-01

Abstract The recurrence rate for acute appendicitis treated nonoperatively varies between studies. Few studies have adequately evaluated the management of these patients when appendicitis recurs. We aimed to explore the recurrence rate and management of patients with acute appendicitis that were first treated nonoperatively. We identified patients in the Taiwan National Health Insurance Research Database who were hospitalized due to acute appendicitis for the first time between 2000 and 2010 and received nonsurgical treatment. The recurrence and its management were recorded. Data were analyzed to access the risk factors for recurrence and factors that influenced the management of recurrent appendicitis. Among the 239,821 patients hospitalized with acute appendicitis for the first time, 12,235 (5.1%) patients were managed nonoperatively. Of these, 864 (7.1%) had a recurrence during a median follow-up of 6.5 years. Appendectomy was performed by an open and laparoscopic approach in 483 (55.9%) and 258 (29.9%) patients, respectively. The remaining 123 (14.2%) patients were again treated nonsurgically. Recurrence was independently associated with young age, male sex, percutaneous abscess drainage, and medical center admission by multivariable analysis. In addition, age <18, a (CCI) <2, medical center admission, and a longer time to recurrence were correlated with using laparoscopy to treat recurrence. Neither type of appendicitis, percutaneous abscess drainage, nor length of first time hospital stay had an influence on the selection of surgical approach. In conclusion, a laparoscopic appendectomy can be performed in recurrent appendicitis cases, and its application may not be related to previous appendicitis severity. PMID:27015200

Risk of appendicitis in patients with incidentally discovered appendicoliths.

PubMed

Khan, Muhammad Sohaib; Chaudhry, Mustafa Belal Hafeez; Shahzad, Noman; Tariq, Marvi; Memon, Wasim Ahmed; Alvi, Abdul Rehman

2018-01-01

An appendicolith-related appendiceal obstruction leading to appendicitis is a commonly encountered surgical emergency that has clear evidence-based management plans. However, there is no consensus on management of asymptomatic patients when appendicoliths are found incidentally. The objective of this study was to determine the risk of appendicitis in patients with an incidental finding of the appendicolith. A retrospective matched cohort study of patients with appendicolith discovered incidentally on computed tomographic scan from January 2008 to December 2014 at our institution was completed. The size and position of the appendicolith were ascertained. The study group was matched by age and gender to a control group. Both groups were contacted and interviewed regarding development of appendicitis. In total, 111 patients with appendicolith were successfully contacted and included in the study. Mean age was found to be 38 ± 15 y with 36 (32%) of the study population being females. Mean length of appendix was 66 ± 16 mm, and mean width was 5.8 ± 0.9 mm. Mean size of the appendicolith was 3.6 ± 1.1 mm (1.4-7.8 mm). Fifty-eight percent of appendicoliths was located at the proximal end or whole of appendix, 31% at mid area, and 11% at the distal end of appendix. All patients of the study and control groups were contacted, and at a mean follow-up of 4.0 ± 1.7 y, there was no occurrence of acute appendicitis in either group. Patients with incidentally discovered appendicolith on radiological imaging did not develop appendicitis. Hence, the risk of developing acute appendicitis for these patients does not seem higher than the general population. Copyright © 2017 Elsevier Inc. All rights reserved.

Fibromatosis of the breast mimicking an abscess: case report of unusual sonographic features.

PubMed

Lee, So Min; Lee, Ji Young; Lee, Byung Hoon; Kim, Su Young; Joo, Mee; Kim, Jae Il

2015-01-01

Fibromatosis of the breast, also known as a desmoid tumor, is extremely rare and most often appears as an aggressive lesion mimicking breast carcinoma. It lacks metastatic potential but can grow aggressively in a localized area. Ultrasonography often shows an irregular spiculated hypoechoic mass with posterior acoustic shadowing. We discuss a case of breast fibromatosis that presented as a painful palpable breast mass in a 32-year-old woman and mimicked an abscess in the sonogram. We found that this lesion displayed atypical sonographic features such as a heterogeneous echoic mass with an internal anechoic area. Copyright © 2015 Elsevier Inc. All rights reserved.

[Perforated neonatal appendicitis in a preterm newborn].

PubMed

Vakrilova, L; Georgiev, Tz; Hitrova, St; Slancheva, B

2014-01-01

Abstract: Appendicitis is common in paediatric surgical praxis, but extremely rare in newborn infants. We report a premature male newborn from a twin pregnancy with gestational age of 31(+4) weeks, birth-weight 1580g, who underwent a laparotomy because of perforation. The baby was admitted to NICU after birth with transitory respiratory failure and early onset neonatal sepsis. MS-Staphylococcus epidermidis was isolated from blood culture, gastric contents and all peripheral specimens, C-reactive protein values were elevated after birth and significantly increased before surgery; thrombocytopenia and mild anemia were found. The control blood culture showed Candida albicans. At day 25 after birth life threatening deterioration occurred: feculent vomiting, progressing distension and palpable rigidity of the abdomen, absence of peristalsis, respiratory distress. Abdominal radiograph showed significantly distension of the intestines, air liquid levels, and discrete signs of pneumoperitoneum. The baby was transferred to the surgery with the diagnosis NEC with perforation. Appendicitis acuta gangrenosa perforativa and peritonitis fibrinopurulenta totalis were found intra-operatively but without signs of NEC. Appendectomy and sanitation of the abdominal cavity were carried out. The histological result confirmed gangrenous perforative appendicitis and purulent necrotic peritonitis. The postoperative course was unremarkable. The boy was transferred to the neonatology on day 33 of life and discharged home 12 days later. Despite of the low incidence of neonatal appendicitis, it should be taken into consideration if unclear abdominal symptoms occur in the neonatal period. Early surgical intervention contribute to a reduction of potential complications.

Novel orally available salvinorin A analog PR-38 inhibits gastrointestinal motility and reduces abdominal pain in mouse models mimicking irritable bowel syndrome.

PubMed

Sałaga, M; Polepally, P R; Sobczak, M; Grzywacz, D; Kamysz, W; Sibaev, A; Storr, M; Do Rego, J C; Zjawiony, J K; Fichna, J

2014-07-01

The opioid and cannabinoid systems play a crucial role in multiple physiological processes in the central nervous system and in the periphery. Selective opioid as well as cannabinoid (CB) receptor agonists exert a potent inhibitory action on gastrointestinal (GI) motility and pain. In this study, we examined (in vitro and in vivo) whether PR-38 (2-O-cinnamoylsalvinorin B), a novel analog of salvinorin A, can interact with both systems and demonstrate therapeutic effects. We used mouse models of hypermotility, diarrhea, and abdominal pain. We also assessed the influence of PR-38 on the central nervous system by measurement of motoric parameters and exploratory behaviors in mice. Subsequently, we investigated the pharmacokinetics of PR-38 in mouse blood samples after intraperitoneal and oral administration. PR-38 significantly inhibited mouse colonic motility in vitro and in vivo. Administration of PR-38 significantly prolonged the whole GI transit time, and this effect was mediated by µ- and κ-opioid receptors and the CB1 receptor. PR-38 reversed hypermotility and reduced pain in mouse models mimicking functional GI disorders. These data expand our understanding of the interactions between opioid and cannabinoid systems and their functions in the GI tract. We also provide a novel framework for the development of future potential treatments of functional GI disorders. Copyright © 2014 by The American Society for Pharmacology and Experimental Therapeutics.

Cogan's syndrome mimicking acute Lyme arthritis.

PubMed

Schwegmann, J P; Enzenauer, R J

1995-05-01

A pediatric case of Cogan's syndrome mimicking acute Lyme arthritis is described. A 12-year-old black boy was admitted to the pediatric service for presumed right knee septic arthritis. Symptoms included acute pain and swelling with decreased range-of-motion. Although the patient's right knee symptoms and positive Lyme serology were consistent with a diagnosis of Lyme arthritis, the presence of sensorineural hearing loss and interstitial keratitis with inflammatory arthritis suggested a diagnosis of Cogan's syndrome. Subsequent Western blot analysis was negative for Borrelia burgdorferi antigens. The patient had dramatic clinical improvement of musculoskeletal and ophthalmologic complaints shortly after receiving high-dose corticosteroids, although residual sensorineural hearing loss persisted.

Diagnosing perforated appendicitis in pediatric patients: a new model.

PubMed

van den Bogaard, Veerle A B; Euser, Sjoerd M; van der Ploeg, Tjeerd; de Korte, Niels; Sanders, Dave G M; de Winter, Derek; Vergroesen, Diederik; van Groningen, Krijn; de Winter, Peter

2016-03-01

Studies have investigated sensitivity and specificity of symptoms and tests for diagnosing appendicitis in children. Less is known with regard to the predictive value of these symptoms and tests with respect to the severity of appendicitis. The aim of this study was to determine the predictive value of patient's characteristics and tests for discriminating between perforated and nonperforated appendicitis in children. Pediatric patients who underwent an appendectomy at Spaarne Hospital Hoofddorp, the Netherlands, between January 1, 2009 and December 31, 2013, were included. Baseline patient's characteristics, history, physical examination, laboratory data and results of ultrasounds were collected. Univariate and multivariate logistic regressions were used to determine predictors of perforation. In total, 375 patients were included in this study of which 97 children (25.9%) had significant signs of perforation. Univariate analysis showed that age, duration of complaints, temperature, vomiting, CRP, WBC, different findings on ultrasound and the diameter of the appendix were good predictors of a perforated appendicitis. The final multivariate prediction model included temperature, CRP, clearly visible appendix and free fluids on ultrasound and diameter of the appendix and resulted in an area under the curve (AUC) of 0.91 showing sensitivity and specificity of respectively 85.2% and 81.2%. This prediction model can be used for identification of 'high-risk' children for a perforated appendicitis and might be helpful to prevent complications and longer hospitalization by bringing these children to theater earlier. Copyright © 2016 Elsevier Inc. All rights reserved.

Reduced risk of UC in families affected by appendicitis: a Danish national cohort study.

PubMed

Nyboe Andersen, Nynne; Gørtz, Sanne; Frisch, Morten; Jess, Tine

2017-08-01

The possible aetiological link between appendicitis and UC remains unclear. In order to investigate the hereditary component of the association, we studied the risk of UC in family members of individuals with appendicitis. A cohort of 7.1 million individuals was established by linkage of national registers in Denmark with data on kinship and diagnoses of appendicitis and UC. Poisson regression models were used to calculate first hospital contact rate ratios (RR) for UC with 95% CIs between individuals with or without relatives with a history of appendicitis. During 174 million person-years of follow-up between 1977 and 2011, a total of 190 004 cohort members developed appendicitis and 45 202 developed UC. Individuals having a first-degree relative with appendicitis before age 20 years had significantly reduced risk of UC (RR 0.90; 95% CI 0.86 to 0.95); this association was stronger in individuals with a family predisposition to UC (RR 0.66; 95% CI 0.51 to 0.83). Individuals with a first-degree relative diagnosed with appendicitis before age 20 years are at reduced risk of UC, particularly when there is a family predisposition to UC. Our findings question a previously hypothesised direct protective influence of appendicitis on inflammation of the large bowel. Rather, genetic or environmental factors linked to an increased risk of appendicitis while being protective against UC may explain the repeatedly reported reduced relative risk of UC in individuals with a history of appendicitis. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Diabetes increases the risk of an appendectomy in patients with antibiotic treatment of noncomplicated appendicitis.

PubMed

Tsai, Ming-Chieh; Lin, Herng-Ching; Lee, Cha-Ze

2017-07-01

This retrospective cohort study examined whether diabetic patients have a higher risk for recurrent appendicitis during a 1-year follow-up period after successful antibiotic treatment for patients with acute uncomplicated appendicitis than nondiabetic patients using a population-based database. We included 541 appendicitis patients who received antibiotic treatment for acute appendicitis. We individually tracked each patient for a 1-year period to identify those who subsequently underwent an appendectomy during the follow-up period. Cox proportional hazard regressions suggested that the adjusted hazard ratio of an appendectomy during the 1-year follow-up period was 1.75 for appendicitis patients with diabetes than appendicitis patients without diabetes. We found that among females, the adjusted hazard ratio of an appendectomy was 2.18 for acute appendicitis patients with diabetes than their counterparts without diabetes. However, we failed to observe this relationship in males. We demonstrated a relationship between diabetes and a subsequent appendectomy in females who underwent antibiotic treatment for noncomplicated appendicitis. Copyright © 2016 Elsevier Inc. All rights reserved.

[The Alvarado score validation in diagnosing acute appendicitis in children at Braga Hospital].

PubMed

Gonçalves, Jean Pierre; Cerqueira, Arnaldo; Martins, Sofia

2011-12-01

Acute appendicitis (AA) is the leading cause of emergency abdominal surgery in children. The diagnosis is essentially clinical, but some methodologies, such as Alvarado score (AS), have been developed in order to avoid non-therapeutic laparotomy (15-30%). AS ≥ 5 or 6 is compatible with AA and is an indication for the patient to remain on observations, if AS ≥ 7 a laparotomy procedure may be indicated. To validate the AS for the AA diagnosis of children admitted at Braga Hospital. A validation study of diagnostic method (AS) using the histological examination as a gold standard. The study population consisted of 192 children (4-17 years) with abdominal pain that underwent appendectomy in the last 20 months (December 2008 to July 2010). It was determined the values of sensitivity (S), specificity (Sp), positive predictive value (PPV), negative predictive value (NPV), likelihood ratio (LR) and the ROC curve for three different cut-off points (SA =5, 6 and 7). We found that as the cut-off point of AS decreases progressively the sensitivity and specificity increases and reduces the VPN and VPP. Assuming a cut-off value of 5, only 18 children would be false negatives, instead of the 67 children if the cut-off point was 7 points. The analysis of ROC curves demonstrated a greater area under the curve for a cut-off equal to or greater than 5 (AUC = 70%). We recommend using a cut-off value of 5 points, since only 18 children with AA were initially classified as appendicitis unlikely, this value would increase to 67 patients for the SA value of ≥ 7. The AS is a valuable tool in screening children with abdominal pain for the diagnosis of AA. Nonetheless the diagnosis and final decision must be based on clinical and systematic reassessment of patients.

Mimicry of Appendicitis Symptomatology in Congenital Anomalies and Diseases of the Genitourinary System and Pregnancy

PubMed Central

Dalpiaz, Amanda; Gandhi, Jason; Smith, Noel L.; Dagur, Gautam; Schwamb, Richard; Weissbart, Steven J.; Khan, Sardar Ali

2017-01-01

Introduction Appendicitis is a prevailing cause of acute abdomen, but is often difficult to diagnose due to its wide range of symptoms, anatomical variations, and developmental abnormalities. Urological disorders of the genitourinary tract may be closely related to appendicitis due to the close proximity of the appendix to the genitourinary tract. This review provides a summary of the urological complications and simulations of appendicitis. Both typical and urological symptoms of appendicitis are discussed, as well as recommended diagnostic and treatment methods. Methods Medline searches were conducted via PubMed in order to incorporate data from the recent and early literature. Results Urological manifestations of appendicitis affect the adrenal glands, kidney, retroperitoneum, ureter, bladder, prostate, scrotum, and penis. Appendicitis in pregnancy is difficult to diagnose due to variations in appendiceal position and trimester-specific symptoms. Ultrasound, CT, and MRI are used in diagnosis of appendicitis and its complications. Treatment of appendicitis may be done via open appendectomy or laparoscopic appendectomy. In some cases, other surgeries are required to treat urological complications, though surgery may be avoided completely in other cases. Conclusion Clinical presentation and complications of appendicitis vary among patients, especially when the genitourinary tract is involved. Appendicitis may mimic urological disorders and vice versa. Awareness of differential diagnosis and proper diagnostic techniques is important in preventing delayed diagnosis and possible complications. MRI is recommended for diagnosis of pregnant patients. Ultrasound is preferred in patients exhibiting typical symptoms. PMID:28413377

Asthma and risk of appendicitis in children: a population-based case-control study

PubMed Central

Hasassri, M. Earth; Jackson, Eric R.; Ghawi, Husam; Ryoo, Eell; Wi, Chung-Il; Bartlett, Mark G.; Volcheck, Gerald W.; Moir, Christopher R.; Ryu, Euijung; Juhn, Young J.

2017-01-01

Objective To assess whether asthma is associated with risk of appendicitis in children. Methods We used a population-based case-control study design utilizing a comprehensive medical record review and predetermined criteria for appendicitis and asthma. All children (age<18 years) who resided in Olmsted County, Minnesota, and developed appendicitis between 2006 and 2012 were matched to controls (1:1) with regard to birthday, gender, registration date, and index date. Asthma status was ascertained using predetermined criteria. Active (current) asthma was defined as the presence of asthma symptoms or asthma-related events (eg, medication use, clinic visits, emergency department, or hospitalization) within one year prior to the index date. Inactive asthma was defined as subjects without these events. A conditional logistic regression model was used. Results Among the 309 appendicitis cases identified, when stratified by asthma status, active asthma was associated with significantly increased risk of appendicitis when compared to inactive asthma (OR=2.48; 95% CI, 1.22–5.03) and to no asthma (OR=1.88; 95% CI, 1.07–3.27) (overall p-value=0.035). When controlling for potential confounders such as gender, age, and smoking status, active asthma was associated with a higher odds of developing appendicitis compared to non-asthmatics (adjusted OR=1.75, 95% CI 0.99–3.11) whereas inactive asthma was not (overall p-value=0.049). Tobacco smoke exposure within three months was associated with an increased risk of appendicitis (adjusted OR=1.66; 95% CI, 1.02, 2.69). Among asthma medications, leukotriene receptor antagonists reduced the risk of appendicitis (OR=0.18; 95% CI, 0.04–0.74). Conclusions Active asthma may be an unrecognized risk factor for appendicitis in children while a history of inactive asthma does not pose such risk. Further investigation exploring the underlying mechanisms is warranted. PMID:27964827

Acoustic Neuroma Mimicking Orofacial Pain: A Unique Case Report

PubMed Central

Srinivas, Naveen; Mendigeri, Vijaylaxmi; Puranik, Surekha R.

2016-01-01

Acoustic neuroma (AN), also called vestibular schwannoma, is a tumor composed of Schwann cells that most frequently involve the vestibular division of the VII cranial nerve. The most common symptoms include orofacial pain, facial paralysis, trigeminal neuralgia, tinnitus, hearing loss, and imbalance that result from compression of cranial nerves V–IX. Symptoms of acoustic neuromas can mimic and present as temporomandibular disorder. Therefore, a thorough medical and dental history, radiographic evaluation, and properly conducted diagnostic testing are essential in differentiating odontogenic pain from pain that is nonodontogenic in nature. This article reports a rare case of a young pregnant female patient diagnosed with an acoustic neuroma located in the cerebellopontine angle that was originally treated for musculoskeletal temporomandibular joint disorder. PMID:28053796

Abdominal pain in children with sickle cell disease.

PubMed

Rhodes, Melissa M; Bates, David Gregory; Andrews, Tina; Adkins, Laura; Thornton, Jennifer; Denham, Jolanda M

2014-02-01

The differential diagnosis of abdominal pain is broad in any child, and further complicated in children with sickle cell disease (SCD). Acute causes of abdominal pain may require emergent surgery, such as for appendicitis or obstruction caused by a bezoar. Rapid intervention is necessary and life-saving in children with SCD and acute splenic or hepatic sequestration. The majority of children with SCD presenting to the physician's office or emergency department will have subacute reasons for their abdominal pain, including but not limited to constipation, urinary tract infection, peptic ulcer disease, and cholecystitis. Vaso-occlusive pain often presents in children as abdominal pain, but is a diagnosis of exclusion. The case of a 10-year-old girl with intermittent abdominal pain is used as a starting point to review the pathophysiology, diagnosis, and treatment of the most acute and common causes of abdominal pain in children with SCD.

Epidemiology of appendicitis and appendectomy for the low-income population in Taiwan, 2003-2011.

PubMed

Lin, Kai-Biao; Chan, Chien-Lung; Yang, Nan-Ping; Lai, Robert K; Liu, Yuan-Hung; Zhu, Shun-Zhi; Pan, Ren-Hao

2015-02-13

Although numerous epidemiological studies on appendicitis have been conducted worldwide, only a few studies have paid attention to the effect of socioeconomic status on appendicitis, particularly studies focusing on the low-income population (LIP). We analyzed the epidemiological features of appendicitis in Taiwan using data from the National Health Insurance Research Database from 2003 to 2011. All cases diagnosed as appendicitis were enrolled. Between 2003 and 2011, 2,916 patients from the LIP and 209,206 patients from the normal population (NP) were diagnosed with appendicitis. Our finding revealed that the ratios of comorbidities, complicated appendicitis, and readmissions in LIP patients were slightly higher than those of NP patients. LIP patients were more likely to live in suburban and rural areas, and hence a higher proportion of them were hospitalized in a district or regional hospital compared with NP patients. The crucially finding was that the overall incidence ratios of appendicitis, acute appendicitis, and perforated appendicitis in the LIP were substantially higher than those in the NP (36.25%, 35.33%, and 37.28%, respectively). The mean LOS in LIP patients was longer than that of NP patients. The overall case-fatality ratio of appendectomy in the LIP was higher when compared with the NP (0.41% versus 0.12%, p < 0.05). We also observed that appendicitis was occurred frequently in male patients, with a higher incidence for those aged 15-29 years in both the LIP and NP. The incidences of incidental appendectomy showed a decreasing trend in both the LIP and NP. Finally, a valuable discovery was that the total hospital cost was comparable between the laparoscopic appendectomy (LA) and open appendectomy (OA) (1,178 ± 13 USD versus 1,191 ± 19 USD, p < 0.05) in LIP patients because they saved more hospitalization costs than NP patients when the previous one chose the LA. This study confirmed that a lower socioeconomic status has significantly negative

Primary lymphoma of appendix presenting as acute appendicitis: A case report.

PubMed

Caristo, Giuseppe; Griseri, Guido; Fornaro, Rosario; Langone, Antonio; Franceschi, Angelo; Errigo, Veronica; Ferrari, Cecilia; Casaccia, Marco; Frascio, Marco; Schirru, Angelo

2018-05-07

Primary lymphomas of appendix are extremely rare tumors. The incidence is 0.015% of all gastrointestinal lymphomas. We present a case of a 75 year-old male patient who presented with acute abdominal pain in the lower right quadrant and fever. The patient received laparotomic appendectomy. The definitive histopathological examination revealed the presence of diffuse large cell B-lymphoma of the appendix. The neoplasms of appendix usually manifest clinically with sign and symptoms of acute appendicitis from luminal obstruction (30-50%). Preoperative diagnosis is difficult and often occurs through histopathological examination. Primary appendiceal lymphoma is rare and there are no clear guidelines for therapy. Primary surgical resection followed by post-operative chemotherapy showed high efficacy. The histopathological examination of all appendectomy is essential. Copyright © 2018 The Authors. Published by Elsevier Ltd.. All rights reserved.

The Association Between Barium Examination and Subsequent Appendicitis: A Nationwide Population-Based Study.

PubMed

Li, Hao-Ming; Yeh, Lee-Ren; Huang, Ying-Kai; Lin, Cheng-Li; Kao, Chia-Hung

2017-01-01

The incidence and association between appendicitis and barium examination (BE) remain unclear. Such potential risk may be omitted. We conducted a longitudinal, nationwide, population-based cohort study to investigate the association between BE and appendicitis risk. From the Taiwan National Health Insurance Research Database, a total of 24,885 patients who underwent BE between January 1, 2000 and December 31, 2010 were enrolled in a BE cohort; an additional 98,384 subjects without BE exposure were selected as a non-BE cohort, matched by age, sex, and index date. The cumulative incidences of subsequent appendicitis in the BE and non-BE cohorts were assessed using the Kaplan-Meier curves and log-rank test. Cox proportional hazards regression analyses were employed to calculate the appendicitis risk between the groups. The cumulative incidence of appendicitis was higher in the BE cohort than in the non-BE cohort (P = .001). The overall incidence rates of appendicitis for the BE and non-BE cohorts were 1.19 and 0.80 per 1000 person-years, respectively. After adjustment for sex, age, and comorbidities, the risk of appendicitis was higher in the BE cohort (adjusted hazard ratio = 1.46, 95% confidence interval = 1.23-1.73) compared with the non-BE cohort, especially in the first 2 months (adjusted hazard ratio = 9.72, 95% confidence interval = 4.65-20.3). BE was associated with an increased, time-dependent appendicitis risk. Clinicians should be aware of this potential risk to avoid delayed diagnoses. Copyright © 2016 Elsevier Inc. All rights reserved.

The RIPASA score is sensitive and specific for the diagnosis of acute appendicitis in a western population.

PubMed

Malik, Muhammad Usman; Connelly, Tara M; Awan, Faisal; Pretorius, Frederik; Fiuza-Castineira, Constantino; El Faedy, Osama; Balfe, Paul

2017-04-01

The definitive diagnosis of acute appendicitis (AA) requires histopathological examination. Various clinical diagnostic scoring systems attempt to reduce negative appendectomy rates. The most commonly used in Western Europe and the USA is the Alvarado score. The Raja Isteri Pengiran Anak Saleha appendicitis (RIPASA) score achieves better sensitivity and specificity in Asian and Middle Eastern populations. We aimed to determine the diagnostic accuracy of the RIPASA score in Irish patients with AA. All patients who presented to our institution with right iliac fossa pain and clinically suspected AA between January 1 and December 31, 2015, were indentified from our hospital inpatient enquiry database and retrospectively studied. Operating theatre records and histology reports confirmed those who underwent a non-elective operative procedure and the presence or absence of AA. SPSS version 22 was used for statistical analysis. Standard deviation is provided where appropriate. Two hundred eight patients were included in the study (106/51% male, mean age 22.7 ± 9.2 years). One hundred thirty-five (64.9%) had histologically confirmed AA (mean symptom duration = 36.19 ± 15.90 h). At a score ≥7.5, the previously determined score most likely associated with AA in Eastern populations, the RIPASA scoring system demonstrated a sensitivity of 85.39%, specificity of 69.86%, positive predictive value of 84.06%, negative predictive value of 72.86% and diagnostic accuracy of 80% in our cohort. The RIPASA score is a useful tool to aid in the diagnosis of acute appendicitis in the Irish population. A score of ≥7.5 provides sensitivity and specificity exceeding that previously documented for the Alvarado score in Western populations. WHAT DOES THIS PAPER ADD TO THE LITERATURE?: This is the first study evaluating the utility of the RIPASA score in predicting acute appendicitis in a Western population. At a value of 7.5, a cut-off score suggestive of appendicitis in the

Appendicitis in mature patients.

PubMed Central

Burns, R P; Cochran, J L; Russell, W L; Bard, R M

1985-01-01

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

Left-sided appendicitis: review of 95 published cases and a case report.

PubMed

Akbulut, Sami; Ulku, Abdullah; Senol, Ayhan; Tas, Mahmut; Yagmur, Yusuf

2010-11-28

To give an overview of the literature on left-sided acute appendicitis (LSAA) associated with situs inversus totalis (SIT) and midgut malrotation (MM). We present a new case of LSAA with SIT and a literature review of studies published in the English language on LSAA, accessed via PubMed and Google Scholar databases. Ninety-five published cases of LSAA were evaluated and a 25-year-old female, who presented to our clinic with left lower abdominal pain caused by LSAA, is reported. In the reviewed literature, fifty-seven patients were male and 38 were female with an age range of 8 to 82 years and a median age of 29.1 ± 15.9 years. Sixty-six patients had SIT, 23 had MM, three had cecal malrotation, and two had a previously unnoted congenital abnormality. Fifty-nine patients had presented to the hospital with left lower, 14 with right lower and seven with bilateral lower quadrant pain, and seven subjects complained of left upper quadrant pain. The diagnosis was established preoperatively in 49 patients, intraoperatively in 19, and during the postoperative period in five; 14 patients were aware of having this anomaly. The data of eight patients were not unavailable. Eleven patients underwent laparoscopic appendectomy, which was combined with cholecystectomy in two cases. Histopathological examination of the appendix specimens revealed adenocarcinoma in only two of 95 patients. The diagnosis of left lower quadrant pain is based on well-established clinical symptoms, physical examination and physician's experience.

Ambient Ozone Concentrations and the Risk of Perforated and Nonperforated Appendicitis: A Multicity Case-Crossover Study

PubMed Central

Tanyingoh, Divine; Dixon, Elijah; Johnson, Markey; Wheeler, Amanda J.; Myers, Robert P.; Bertazzon, Stefania; Saini, Vineet; Madsen, Karen; Ghosh, Subrata; Villeneuve, Paul J.

2013-01-01

Background: Environmental determinants of appendicitis are poorly understood. Past work suggests that air pollution may increase the risk of appendicitis. Objectives: We investigated whether ambient ground-level ozone (O3) concentrations were associated with appendicitis and whether these associations varied between perforated and nonperforated appendicitis. Methods: We based this time-stratified case-crossover study on 35,811 patients hospitalized with appendicitis from 2004 to 2008 in 12 Canadian cities. Data from a national network of fixed-site monitors were used to calculate daily maximum O3 concentrations for each city. Conditional logistic regression was used to estimate city-specific odds ratios (ORs) relative to an interquartile range (IQR) increase in O3 adjusted for temperature and relative humidity. A random-effects meta-analysis was used to derive a pooled risk estimate. Stratified analyses were used to estimate associations separately for perforated and nonperforated appendicitis. Results: Overall, a 16-ppb increase in the 7-day cumulative average daily maximum O3 concentration was associated with all appendicitis cases across the 12 cities (pooled OR = 1.07; 95% CI: 1.02, 1.13). The association was stronger among patients presenting with perforated appendicitis for the 7-day average (pooled OR = 1.22; 95% CI: 1.09, 1.36) when compared with the corresponding estimate for nonperforated appendicitis [7-day average (pooled OR = 1.02, 95% CI: 0.95, 1.09)]. Heterogeneity was not statistically significant across cities for either perforated or nonperforated appendicitis (p > 0.20). Conclusions: Higher levels of ambient O3 exposure may increase the risk of perforated appendicitis. PMID:23842601

Efficacy of Strain Elastography in Diagnosis and Staging of Acute Appendicitis in Pediatric Patients.

PubMed

Arslan, Harun; Akdemir, Zülküf; Yavuz, Alpaslan; Gökçal, Fahri; Parlakgümüş, Cemal; İslamoglu, Necat; Akdeniz, Hüseyin

2018-02-11

BACKGROUND In the present study, the role and efficiency of strain elastography (SE) were evaluated in diagnosis and staging of acute appendicitis in pediatric patients. MATERIAL AND METHODS We enrolled 225 pediatric patients with suspected clinical and laboratory findings of acute appendicitis. Gray-scale sonographic findings were recorded and staging was made by the colorization method of SE imaging. Appendectomy was performed in all patients and the results of the surgical pathology were compared with the imaging findings. The sensitivity, specificity, and accuracy of SE imaging were determined in terms of evaluating the "acute appendicitis". RESULTS Sonographic evaluation revealed acute appendicitis in 100 patients. Regarding the SE analysis, cases with appendicitis were classified into 3 groups as: mild (n=17), moderate (n=39), and severe (n=44). The pathological evaluation revealed 95 different stages of appendicitis and normal appendix in 5 cases: acute focal (n=10), acute suppurative (n=46), phlegmonous (n=27), and perforated (n=12), regarding the results of surgical pathology. Five patients with pathologically proven "normal" appendix were noted as "mild stage appendicitis" based on gray scale and SE analysis. In total, when gray-scale and SE results were compared with pathology results regardless of the stage of appendicitis, sensitivity, specificity, positive predictive value, negative predictive value, and accuracy rates were 96%, 96%, 95%, 96.8%, and 96%, respectively. No statistically significant difference was detected between other groups (P<0.05). CONCLUSIONS In acute appendicitis, the use of SE imaging as a supportive method for the clinical approach can be useful in diagnosis, and its results are closely correlated with the histopathologic stage of appendix inflammation.

A hybrid approach to appendicitis with right external iliac artery pseudo aneurysm: A case report.

PubMed

Chandler, Benjamin T; Ryer, Evan J; Keyser, Benjamin M; Elmore, James R

2017-01-01

While acute appendicitis is a common surgical problem, the simultaneous occurrence of appendicitis and an infected iliac artery pseudoaneurysm is exceedingly rare. We report the successful treatment of an infected right external iliac artery pseudo aneurysm in the 1setting of acute appendicitis. The patient is an 83-year-old male who presents with severe sepsis, right lower quadrant and right leg pain. Additional past medical history is significant for rectal cancer status post resection and radiation therapy in 1997. Computed tomography (CT) on admission revealed a right iliopsoas muscle abscess, an inflamed Appendix and a pseudo aneurysm arising from the right external iliac artery. After consultations by multiple specialties, the plan was to proceed with percutaneous drainage of the abscess, antibiotic therapy and subsequent repair of the pseudoaneurysm. CT guided drainage of the iliopsoas abscess was performed with return of hemorrhagic fluid. Due to the concern of contained pseudoaneurysm rupture, the patient was taken for expedited repair. Due to the patient's frailty and hostile abdomen, we performed embolization of the right external iliac artery pseudoaneurysm with Amplatzer I plugs (St. Jude Medical, St. Paul MN) and left common femoral to right superficial femoral bypass with cryopreserved cadaveric femoral vein. Following pseudoaneurysm exclusion, continued percutaneous drainage and antibiotic therapy, the patient has done well with no further evidence of infection. Repair of infected pseudo aneurysms can prove challenging. Ongoing infection, a hostile surgical abdomen and patient frailty further complicates the treatment of these patients. This case displays a minimally invasive approach to this rare but morbid condition. Copyright © 2017 The Author(s). Published by Elsevier Ltd.. All rights reserved.

Addison’s Disease Mimicking as Acute Pancreatitis: A Case Report

PubMed Central

Chaudhuri, Sayani; Rao, Karthik N; Ommurugan, Balaji; Varghese, George

2017-01-01

Over past two decades there has been significant improvement in medical field in elucidating the underlying pathophysiology and genetics of Addison’s disease. Adrenal insufficiency (Addison’s disease) is a rare disease with an incidence of 0.8/100,000 cases. The diagnosis may be delayed if the clinical presentation mimics a gastrointestinal disorder or psychiatric illness. We report a case of Addison’s disease presenting as acute pain in abdomen mimicking clinical presentation of acute pancreatitis. PMID:28571196

Antibiotics-First Versus Surgery for Appendicitis: A US Pilot Randomized Controlled Trial Allowing Outpatient Antibiotic Management.

PubMed

Talan, David A; Saltzman, Darin J; Mower, William R; Krishnadasan, Anusha; Jude, Cecilia M; Amii, Ricky; DeUgarte, Daniel A; Wu, James X; Pathmarajah, Kavitha; Morim, Ashkan; Moran, Gregory J

2017-07-01

Randomized trials suggest that nonoperative treatment of uncomplicated appendicitis with antibiotics-first is safe. No trial has evaluated outpatient treatment and no US randomized trial has been conducted, to our knowledge. This pilot study assessed feasibility of a multicenter US study comparing antibiotics-first, including outpatient management, with appendectomy. Patients aged 5 years or older with uncomplicated appendicitis at 1 US hospital were randomized to appendectomy or intravenous ertapenem greater than or equal to 48 hours and oral cefdinir and metronidazole. Stable antibiotics-first-treated participants older than 13 years could be discharged after greater than or equal to 6-hour emergency department (ED) observation with next-day follow-up. Outcomes included 1-month major complication rate (primary) and hospital duration, pain, disability, quality of life, and hospital charges, and antibiotics-first appendectomy rate. Of 48 eligible patients, 30 (62.5%) consented, of whom 16 (53.3%) were randomized to antibiotics-first and 14 (46.7%) to appendectomy. Median age was 33 years (range 9 to 73 years), median WBC count was 15,000/μL (range 6,200 to 23,100/μL), and median computed tomography appendiceal diameter was 10 mm (range 7 to 18 mm). Of 15 antibiotic-treated adults, 14 (93.3%) were discharged from the ED and all had symptom resolution. At 1 month, major complications occurred in 2 appendectomy participants (14.3%; 95% confidence interval [CI] 1.8% to 42.8%) and 1 antibiotics-first participant (6.3%; 95% CI 0.2% to 30.2%). Antibiotics-first participants had less total hospital time than appendectomy participants, 16.2 versus 42.1 hours, respectively. Antibiotics-first-treated participants had less pain and disability. During median 12-month follow-up, 2 of 15 antibiotics-first-treated participants (13.3%; 95% CI 3.7% to 37.9%) developed appendicitis and 1 was treated successfully with antibiotics; 1 had appendectomy. No more major complications

Unusual causes of abdominal pain: sickle cell anemia.

PubMed

Ahmed, Shahid; Shahid, Rabia K; Russo, Linda A

2005-04-01

Sickle cell disease is characterized by chronic hemolytic anemia and vaso-occlusive painful crises. The vascular occlusion in sickle cell disease is a complex process and accounts for the majority of the clinical manifestation of the disease. Abdominal pain is an important component of vaso-occlusive painful crises. It often represents a substantial diagnostic challenge in this population of patients. These episodes are often attributed to micro-vessel occlusion and infarcts of mesentery and abdominal viscera. Abdominal pain due to sickle cell vaso-occlusive crisis is often indistinguishable from an acute intra-abdominal disease process such as acute cholecystitis, acute pancreatitis, hepatic infarction, ischemic colitis and acute appendicitis. In the majority of cases, however, no specific cause is identified and spontaneous resolution occurs. This chapter will focus on etiologies, pathophysiology and management of abdominal pain in patients with sickle cell disease.

Association between climatic elements and acute appendicitis in Japan.

PubMed

Sato, Yasuto; Kojimahara, Noriko; Kiyohara, Kosuke; Endo, Motoki; Yamaguchi, Naohito

2017-05-01

In Japan, it has been reported that an increase in atmospheric pressure is associated with a higher incidence of acute appendicitis. The aim of this epidemiologic study was to investigate the association between climatic elements and the incidence of acute appendicitis. A case-crossover design was used in the present study. Two wk before diagnosis was used for the target period. The same 2-wk period, but 1, 2, and 3 y before diagnosis, was used for the control period. The study participants were patients with acute appendicitis (10-29 y) from 14 facilities in the Greater Tokyo Area. Mean of the observed values for atmospheric pressure, temperature, relative humidity, and hours of sunshine calculated for each target and control period were used as climatic elements to investigate trends 1 and 2 wk before diagnosis. The year of diagnosis, a statistically significant moderate upward trend in atmospheric pressure was observed during the 2-wk period before diagnosis of acute appendicitis (tau = 0.47; P = 0.0213), whereas a weak nonsignificant downward trend was observed 1 y before diagnosis (tau = -0.29; P = 0.1596), and weak nonsignificant upward trends were observed 2 (tau = 0.24; P = 0.2505) and 3 y (tau = 0.28; P = 0.1634) before diagnosis. An association was found between atmospheric pressure and the incidence of acute appendicitis. However, no significant differences were found in relation to sex or age. These findings suggest that changes in atmospheric pressure are associated with the likelihood of patients visiting the hospital. Copyright © 2016 Elsevier Inc. All rights reserved.

Asthma and Risk of Appendicitis in Children: A Population-Based Case-Control Study.

PubMed

Hasassri, M Earth; Jackson, Eric R; Ghawi, Husam; Ryoo, Eell; Wi, Chung-Il; Bartlett, Mark G; Volcheck, Gerald W; Moir, Christopher R; Ryu, Euijung; Juhn, Young J

2017-03-01

To assess whether asthma is associated with risk of appendicitis in children. We used a population-based case-control study design using a comprehensive medical record review and predetermined criteria for appendicitis and asthma. All children (age younger than 18 years of age) who resided in Olmsted County, Minnesota, and developed appendicitis between 2006 and 2012 were matched to controls (1:1) with regard to birthday, gender, registration date, and index date. Asthma status was ascertained using predetermined criteria. Active (current) asthma was defined as the presence of asthma symptoms or asthma-related events (eg, medication use, clinic visits, emergency department, or hospitalization) within 1 year before the index date. Inactive asthma was defined as subjects without these events. A conditional logistic regression model was used. Among the 309 appendicitis cases identified, when stratified according to asthma status, active asthma was associated with significantly increased risk of appendicitis compared with inactive asthma (odds ratio [OR] = 2.48; 95% confidence interval [CI], 1.22-5.03) and to no asthma (OR = 1.88; 95% CI, 1.07-3.27; overall P = .035). When controlling for potential confounders such as gender, age, and smoking status, active asthma was associated with a higher odds of developing appendicitis compared with nonasthmatic patients (adjusted OR = 1.75; 95% CI, 0.99-3.11) whereas inactive asthma was not (overall P = .049). Tobacco smoke exposure within 3 months was associated with an increased risk of appendicitis (adjusted OR = 1.66; 95% CI, 1.02-2.69). Among asthma medications, leukotriene receptor antagonists reduced the risk of appendicitis (OR = 0.18; 95% CI, 0.04-0.74). Active asthma might be an unrecognized risk factor for appendicitis in children whereas a history of inactive asthma does not pose such risk. Further investigation exploring the underlying mechanisms is warranted. Copyright © 2016 Academic Pediatric

Bedside Ultrasonography as an Adjunct to Routine Evaluation of Acute Appendicitis in the Emergency Department

PubMed Central

Lam, Samuel H.F.; Grippo, Anthony; Kerwin, Chistopher; Konicki, P. John; Goodwine, Diana; Lambert, Michael J.

2014-01-01

Introduction Appendicitis is a common condition presenting to the emergency department (ED). Increasingly emergency physicians (EP) are using bedside ultrasound (BUS) as an adjunct diagnostic tool. Our objective is to investigate the test characteristics of BUS for the diagnosis of appendicitis and identify components of routine ED workup and BUS associated with the presence of appendicitis. Methods Patients four years of age and older presenting to the ED with suspected appendicitis were eligible for enrollment. After informed consent was obtained, BUS was performed on the subjects by trained EPs who had undergone a minimum of one-hour didactic training on the use of BUS to diagnose appendicitis. They then recorded elements of clinical history, physical examination, white blood cell count (WBC) with polymophonuclear percentage (PMN), and BUS findings on a data form. We ascertained subject outcomes by a combination of medical record review and telephone follow-up. Results A total of 125 subjects consented for the study, and 116 had adequate image data for final analysis. Prevalence of appendicitis was 40%. Mean age of the subjects was 20.2 years, and 51% were male. BUS was 100% sensitive (95% CI 87–100%) and 32% specific (95% CI 14–57%) for detection of appendicitis, with a positive predictive value of 72% (95% CI 56–84%), and a negative predictive value of 100% (95% CI 52–100%). Assuming all non-diagnostic studies were negative would yield a sensitivity of 72% and specificity of 81%. Subjects with appendicitis had a significantly higher occurrence of anorexia, nausea, vomiting, and a higher WBC and PMN count when compared to those without appendicitis. Their BUS studies were significantly more likely to result in visualization of the appendix, appendix diameter >6mm, appendix wall thickness >2mm, periappendiceal fluid, visualization of the appendix tip, and sonographic Mcburney’s sign (p<0.05). In subjects with diagnostic BUS studies, WBC, PMN

Meta‐analysis of antibiotics versus appendicectomy for non‐perforated acute appendicitis

PubMed Central

Sallinen, V.; Akl, E. A.; You, J. J.; Agarwal, A.; Shoucair, S.; Vandvik, P. O.; Agoritsas, T.; Heels‐Ansdell, D.; Guyatt, G. H.

2016-01-01

Abstract Background For more than a century, appendicectomy has been the treatment of choice for appendicitis. Recent trials have challenged this view. This study assessed the benefits and harms of antibiotic therapy compared with appendicectomy in patients with non‐perforated appendicitis. Methods A comprehensive search was conducted for randomized trials comparing antibiotic therapy with appendicectomy in patients with non‐perforated appendicitis. Key outcomes were analysed using random‐effects meta‐analysis, and the quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Results Five studies including 1116 patients reported major complications in 25 (4·9 per cent) of 510 patients in the antibiotic and 41 (8·4 per cent) of 489 in the appendicectomy group: risk difference −2·6 (95 per cent c.i. –6·3 to 1·1) per cent (low‐quality evidence). Minor complications occurred in 11 (2·2 per cent) of 510 and 61 (12·5 per cent) of 489 patients respectively: risk difference −7·2 (−18·1 to 3·8) per cent (very low‐quality evidence). Of 550 patients in the antibiotic group, 47 underwent appendicectomy within 1 month: pooled estimate 8·2 (95 per cent c.i. 5·2 to 11·8) per cent (high‐quality evidence). Within 1 year, appendicitis recurred in 114 of 510 patients in the antibiotic group: pooled estimate 22·6 (15·6 to 30·4) per cent (high‐quality evidence). For every 100 patients with non‐perforated appendicitis, initial antibiotic therapy compared with prompt appendicectomy may result in 92 fewer patients receiving surgery within the first month, and 23 more experiencing recurrent appendicitis within the first year. Conclusion The choice of medical versus surgical management in patients with clearly uncomplicated appendicitis is value‐ and preference‐dependent, suggesting a change in practice towards shared decision‐making is necessary. PMID:26990957

Meta-analysis of antibiotics versus appendicectomy for non-perforated acute appendicitis.

PubMed

Sallinen, V; Akl, E A; You, J J; Agarwal, A; Shoucair, S; Vandvik, P O; Agoritsas, T; Heels-Ansdell, D; Guyatt, G H; Tikkinen, K A O

2016-05-01

For more than a century, appendicectomy has been the treatment of choice for appendicitis. Recent trials have challenged this view. This study assessed the benefits and harms of antibiotic therapy compared with appendicectomy in patients with non-perforated appendicitis. A comprehensive search was conducted for randomized trials comparing antibiotic therapy with appendicectomy in patients with non-perforated appendicitis. Key outcomes were analysed using random-effects meta-analysis, and the quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Five studies including 1116 patients reported major complications in 25 (4·9 per cent) of 510 patients in the antibiotic and 41 (8·4 per cent) of 489 in the appendicectomy group: risk difference -2·6 (95 per cent c.i. -6·3 to 1·1) per cent (low-quality evidence). Minor complications occurred in 11 (2·2 per cent) of 510 and 61 (12·5 per cent) of 489 patients respectively: risk difference -7·2 (-18·1 to 3·8) per cent (very low-quality evidence). Of 550 patients in the antibiotic group, 47 underwent appendicectomy within 1 month: pooled estimate 8·2 (95 per cent c.i. 5·2 to 11·8) per cent (high-quality evidence). Within 1 year, appendicitis recurred in 114 of 510 patients in the antibiotic group: pooled estimate 22·6 (15·6 to 30·4) per cent (high-quality evidence). For every 100 patients with non-perforated appendicitis, initial antibiotic therapy compared with prompt appendicectomy may result in 92 fewer patients receiving surgery within the first month, and 23 more experiencing recurrent appendicitis within the first year. The choice of medical versus surgical management in patients with clearly uncomplicated appendicitis is value- and preference-dependent, suggesting a change in practice towards shared decision-making is necessary. © 2016 The Authors. BJS published by John Wiley & Sons Ltd on behalf of BJS Society Ltd.

Diagnostic performance and useful findings of ultrasound re-evaluation for patients with equivocal CT features of acute appendicitis.

PubMed

Kim, Mi Sung; Kwon, Heon-Ju; Kang, Kyung A; Do, In-Gu; Park, Hee-Jin; Kim, Eun Young; Hong, Hyun Pyo; Choi, Yoon Jung; Kim, Young Hwan

2018-02-01

To evaluate the diagnostic performance of ultrasound and to determine which ultrasound findings are useful to differentiate appendicitis from non-appendicitis in patients who underwent ultrasound re-evaluation owing to equivocal CT features of acute appendicitis. 62 patients who underwent CT examinations for suspected appendicitis followed by ultrasound re-evaluation owing to equivocal CT findings were included. Equivocal CT findings were considered based on the presence of only one or two findings among the CT criteria, and ultrasound re-evaluation was done based on a predefined structured report form. The diagnostic performance of ultrasound and independent variables to discriminate appendicitis from non-appendicitis were assessed. There were 27 patients in the appendicitis group. The overall diagnostic performance of ultrasound re-evaluation was sensitivity of 96.3%, specificity of 91.2% and accuracy of 91.9%. In terms of the performance of individual ultrasound findings, probe-induced tenderness showed the highest accuracy (86.7%) with sensitivity of 74% and specificity of 97%, followed by non-compressibility (accuracy 71.7%, sensitivity 85.2% and specificity 60.6%). The independent ultrasound findings for discriminating appendicitis were non-compressibility (p = 0.002) and increased flow on the appendiceal wall (p = 0.001). Ultrasound re-evaluation can be used to improve diagnostic accuracy in cases with equivocal CT features for diagnosing appendicitis. The presence of non-compressibility and increased vascular flow on the appendix wall are useful ultrasound findings to discriminate appendicitis from non-appendicitis. Advances in knowledge: Ultrasound re-evaluation is useful to discriminate appendicitis from non-appendicitis when CT features are inconclusive.

Characteristics of mesenteric lymphadenitis in comparison with those of acute appendicitis in children.

PubMed

Gross, Itai; Siedner-Weintraub, Yael; Stibbe, Shir; Rekhtman, David; Weiss, Daniel; Simanovsky, Natalia; Arbell, Dan; Hashavya, Saar

2017-02-01

Mesenteric lymphadenitis (ML) is considered as one of the most common alternative diagnosis in a child with suspected acute appendicitis (AA). In this retrospective study, patients diagnosed with ML (n = 99) were compared in terms of demographic, clinical, and laboratory findings to patients diagnosed with AA (n = 102). This comparison was applied for both lymph nodes smaller and larger than 10 mm. When compared to patients with AA, patients with ML had significantly longer duration of symptoms prior to emergency department (ED) presentation (2.4 ± 2.6 vs 1.4 ± 1.4 days, P = 0.002) and multiple ED presentations (1.3 ± 0.7 vs 1.05 ± 0.3, P < 0.001) and had longer duration of stay in the ED (9.2 ± 5.9 vs 5.2 ± 4 h, P < 0.001), respectively. They also had significantly lower WBC (10.16 ± 4.7 × 10 3 /dl vs 15.8 ± 4.4 × 10 3 /dl, P < 0.001) with lymphocyte predominance (24.6 ± 14 vs 13 ± 8.7%, P < 0.001) and lower CRP levels (0.48 vs 1.6 mg/dl). Migration of pain (28 vs 7%), vomiting (62 vs 34%), and classic abdominal findings of AA (72 vs 20%) were all significantly more common for children with AA. When comparing lymph node size, no significant difference was found between those presenting with small and large nodes. This study highlights multiple clinical and laboratory findings that differentiate ML and AA. Moreover, the absence of any difference with regard to the lymph nodes size might suggest that lymph nodes enlargement is a non-specific finding. What is Known : • Mesenteric lymphadenitis is a very common diagnosis in children with suspected acute appendicitis. • Despite its prevalence, only few studies addressed the clinical characteristics of this clinical entity and their comparison with acute appendicitis. What is New: • Mesenteric lymphadenitis and acute appendicitis could be differentiated by multiple clinical and laboratory parameters. • No significant difference was found between those

Patient-centered outcomes research in appendicitis in children: Bridging the knowledge gap.

PubMed

Chau, Danielle B; Ciullo, Sean S; Watson-Smith, Debra; Chun, Thomas H; Kurkchubasche, Arlet G; Luks, Francois I

2016-01-01

Patient-centered outcomes research (PCOR) aims to give patients a better understanding of the treatment options to enable optimal decision-making. As nonoperative alternatives are now being evaluated in children for acute appendicitis, we surveyed patients and their families regarding their knowledge of appendicitis and evaluated whether providing basic medical information would affect their perception of the disease and allow them to more rationally consider the treatment alternatives. Families of children aged 5-18 presenting to the Emergency Department with suspected appendicitis were recruited for a tablet-based interactive educational survey. One hundred subjects (caregivers and patients ≥ 15 years) were questioned before and after an education session about their understanding of appendicitis, including questions on three hypothetical treatment options: urgent appendectomy, antibiotics alone, or initial antibiotics followed by elective appendectomy. Subjects were clearly informed that urgent appendectomy is currently the standard of care. Only 14% of respondents correctly identified the mortality rate of appendicitis (17 deaths/year according to the 2010 US census) when compared with other extremely rare causes of death. Fifty-four and 31% thought it was more common than death from lightning (40/year) and hunting-associated deaths (44/year), respectively. Eighty-two percent of respondents believed it "likely" or "very likely" that the appendix would rupture if operation was at all delayed, and 81% believed that rupture of the appendix would rapidly lead to severe complications and death. In univariate analysis, this perception was significantly more prevalent for mothers (odds ratio, (OR) 5.19, confidence interval (CI) 1.33-21.15), and subjects who knew at least one friend or relative who had a negative experience with appendicitis (OR 5.53, CI 1.40-25.47). Following education, these perceptions changed significantly (53% still believed that immediate

T1 bright appendix sign to exclude acute appendicitis in pregnant women.

PubMed

Shin, Ilah; An, Chansik; Lim, Joon Seok; Kim, Myeong-Jin; Chung, Yong Eun

2017-08-01

To evaluate the diagnostic value of the T1 bright appendix sign for the diagnosis of acute appendicitis in pregnant women. This retrospective study included 125 pregnant women with suspected appendicitis who underwent magnetic resonance (MR) imaging. The T1 bright appendix sign was defined as a high intensity signal filling more than half length of the appendix on T1-weighted imaging. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of the T1 bright appendix sign for normal appendix identification were calculated in all patients and in those with borderline-sized appendices (6-7 mm). The T1 bright appendix sign was seen in 51% of patients with normal appendices, but only in 4.5% of patients with acute appendicitis. The overall sensitivity, specificity, PPV, and NPV of the T1 bright appendix sign for normal appendix diagnosis were 44.9%, 95.5%, 97.6%, and 30.0%, respectively. All four patients with borderline sized appendix with appendicitis showed negative T1 bright appendix sign. The T1 bright appendix sign is a specific finding for the diagnosis of a normal appendix in pregnant women with suspected acute appendicitis. • Magnetic resonance imaging is increasingly used in emergency settings. • Acute appendicitis is the most common cause of acute abdomen. • Magnetic resonance imaging is widely used in pregnant population. • T1 bright appendix sign can be a specific sign representing normal appendix.

Early appendectomy reduces costs in children with perforated appendicitis.

PubMed

Church, Joseph T; Klein, Edwin J; Carr, Benjamin D; Bruch, Steven W

2017-12-01

Perforated appendicitis can be managed with early appendectomy, or nonoperative management followed by interval appendectomy. We aimed to identify the strategy with the lowest health care utilization and cost. We retrospectively reviewed the medical records of all children ≤18 years old with perforated appendicitis admitted to a single institution between January 2009 and March 2016. After excluding immunosuppressed patients and transfers from outside hospitals, we grouped the remaining patients by early or interval appendectomy. Cost accounting data were obtained from our institutional database. The primary outcome was total hospital cost over 2 y from initial admission for appendicitis. Other outcomes analyzed included initial admission costs, number of admissions, emergency room and clinic visits, percutaneous procedures, cross-sectional and overall imaging studies, and length of stay. A total of 203 children with perforated appendicitis were identified. After exclusion of immunosuppressed patients and outside hospital transfers, 94 patients were included in the study. Thirty-nine underwent early appendectomy and 55 initial nonoperative management; of these, 54 underwent elective interval appendectomy. Five of 55 patients (9%) failed initial nonoperative management and required earlier-than-planned appendectomy. Total cost over 2 y was significantly lower with early appendectomy than initial nonoperative management ($19,300 ± 14,300 versus $26,000 ± 17,500; P = 0.05). Early appendectomy resulted in fewer hospital admissions, clinic visits, invasive procedures, and imaging studies. Early appendectomy results in lower hospital costs and less health care utilization compared with initial nonoperative management with elective interval appendectomy. A prospective study will shed more light on this question and can assess the role of nonoperative management without interval appendectomy in children with perforated appendicitis. Copyright © 2017 Elsevier

Limited Abdominal Sonography for Evaluation of Children With Right Lower Quadrant Pain.

PubMed

Munden, Martha M; Wai, Shannon; DiStefano, Michael C; Zhang, Wei

2017-01-01

To determine whether a complete abdominal sonographic examination is necessary in the evaluation of children with right lower quadrant pain that is suspicious for appendicitis in the emergency department and whether performing a limited, more-focused study would miss clinically important disease. With Institutional Review Board approval, a retrospective study was performed of 704 patients, from ages 5-19 years, presenting to the emergency department with right lower quadrant pain that was suspicious for appendicitis who underwent a complete abdominal sonographic examination. Data were extracted from the complete abdominal sonographic examination to see whether abnormalities were noted in the pancreas, spleen, and left kidney. Patients' medical charts were reviewed to see whether any positive findings in these organs were clinically important. Of the 65 studies with a finding that would have been missed with a limited study, only 6 were found to be clinically important. Of those, 5 were managed medically and 1 surgically. The chance of missing a potentially important finding using a limited study with our group of patients was 65 of 704 patients (9.2%), with a 95% confidence interval of 7.2% to 11.7%. The chance of missing an abnormality that was clinically important was 6 of 704 patients (0.85%), with a 95% confidence interval of 0.35% to 1.94%. In children older than 5 years with abdominal pain that is suspicious for appendicitis, performing only a limited abdominal sonographic examination that excludes the pancreas, left kidney, and spleen will yield a miss rate for clinically important disease that is acceptably low to justify the savings of examination time. © 2016 by the American Institute of Ultrasound in Medicine.

Benefits of an abridged antibiotic protocol for treatment of gangrenous appendicitis.

PubMed

Shbat, Layla; Emil, Sherif; Elkady, Sherif; Baird, Robert; Laberge, Jean-Martin; Puligandla, Pramod; Shaw, Kenneth

2014-12-01

We previously reported a validated, objective definition of gangrenous, nonperforated appendicitis. In this study, we compared a cohort of children with gangrenous appendicitis treated with abridged antibiotics (AA) to another treated with prolonged antibiotics (PA). In 2012, our service changed its standard of care for gangrenous appendicitis from PA to AA. In PA, patients received postoperative triple antibiotics until ileus resolved, they were afebrile (<37.5°C) for 24hours, and achieved a normal WBC count. In AA, patients received two doses of postoperative triple antibiotics. A PA cohort during a 12-month period (February 2010-January 2011) was compared to an AA cohort during another 12-month period (April 2012-March 2013). Twenty patients were treated with AA and 38 patients with PA. AA patients had a significantly shorter overall length of stay (2.1±1.58 vs. 3.18±1.09days, p=0.003), as well as a significantly shorter postoperative stay (1.85±1.42 vs. 2.95±1.14days, p=0.002). There were no differences between the AA and PA cohorts in wound infections (0%), intraabdominal infections (0%), or appendicitis-related readmissions (0%). Abridged postoperative antibiotics for gangrenous appendicitis significantly shorten hospital stay without increasing complications. Copyright © 2014 Elsevier Inc. All rights reserved.

Race and acute abdominal pain in a pediatric emergency department.

PubMed

Caperell, Kerry; Pitetti, Raymond; Cross, Keith P

2013-06-01

To investigate the demographic and clinical factors of children who present to the pediatric emergency department (ED) with abdominal pain and their outcomes. A review of the electronic medical record of patients 1 to 18 years old, who presented to the Children's Hospital of Pittsburgh ED with a complaint of abdominal pain over the course of 2 years, was conducted. Demographic and clinical characteristics, as well as visit outcomes, were reviewed. Subjects were grouped by age, race, and gender. Results of evaluation, treatment, and clinical outcomes were compared between groups by using multivariate analysis and recursive partitioning. There were 9424 patient visits during the study period that met inclusion and exclusion criteria. Female gender comprised 61% of African American children compared with 52% of white children. Insurance was characterized as private for 75% of white and 37% of African American children. A diagnosis of appendicitis was present in 1.9% of African American children and 5.1% of white children. Older children were more likely to be admitted and have an operation associated with their ED visit. Appendicitis was uncommon in younger children. Constipation was commonly diagnosed. Multivariate analysis by diagnosis as well as recursive partitioning analysis did not reflect any racial differences in evaluation, treatment, or outcome. Constipation is the most common diagnosis in children presenting with abdominal pain. Our data demonstrate that no racial differences exist in the evaluation, treatment, and disposition of children with abdominal pain.

MRI for appendicitis in pregnancy: is seeing believing? clinical outcomes in cases of appendix nonvisualization.

PubMed

Al-Katib, Sayf; Sokhandon, Farnoosh; Farah, Michael

2016-12-01

The primary objective of this study was to determine the clinical outcomes in cases of appendix nonvisualization with MRI in pregnant patients with suspected appendicitis and the implications of appendix nonvisualization for excluding appendicitis. Fifty-eight pregnant patients with suspected appendicitis evaluated with MRI at three centers from a single institution were retrospectively reviewed by three radiologists with varying levels of abdominal imaging experience. All scans were performed on a 1.5-Tesla Siemens unit. Cases were evaluated for diagnostic quality, visualization of the appendix, presence of appendicitis, and alternate diagnoses. Clinical outcomes were gathered from the electronic medical record. Of the 58 patients who underwent MRI for suspected appendicitis, 50 cases were considered adequate diagnostic quality by all three radiologists. The rate of appendix visualization among the three radiologists ranged from 60 to 76% (p = 0.44). The appendix was nonvisualized by at least one of the three radiologists in 25 cases (50%). Of these, none had a final diagnosis of appendicitis including one patient who underwent appendectomy. MRI suggested an alternate diagnosis in 6 (24%) patients with appendix nonvisualization. For the three reviewers, the agreement level on whether or not the appendix was visualized on the MRI had a Light's kappa value of 0.526, indicating a "moderate" level of agreement (p value < 0.01). Despite only moderate level of interobserver agreement for appendix visualization, appendix nonvisualization on MRI in pregnant patients with suspected appendicitis confers a significant reduction in the risk of appendicitis compared to all comers as long as the study is adequate diagnostic quality and there are no secondary signs of appendicitis present.

Hospital preference of laparoscopic versus open appendectomy: Effects on outcomes in simple and complicated appendicitis.

PubMed

Tashiro, Jun; Einstein, Stephanie A; Perez, Eduardo A; Bronson, Steven N; Lasko, David S; Sola, Juan E

2016-05-01

We hypothesize that laparoscopic (LA) or open appendectomy (OA) outcomes are associated with hospital procedure preference. We queried Kids' Inpatient Database (1997-2009) for simple (ICD-9-CM 540.9) and complicated (540.0, 540.1) appendicitis. On PS-matched analysis of simple appendicitis (91,118 LA vs. 97,496 OA), LA had increased transfusion (1.7) rates, but lower wound infection (0.6) and perforation/laceration (0.3) rates. LA had shorter length of stay (LOS; 1.7 vs. 2.1days), but higher total charges (TC; 19,501 vs. 13,089 USD) and cost (7121 vs. 5968) vs. OA. For complicated appendicitis (28,793 LA vs. 30,782 OA), LA had increased nausea/vomiting rates (1.9), but lower wound infection (0.5) and transfusion (0.6) rates. LA had shorter LOS (5.1 vs. 5.9), but higher TC (32,251 vs. 28,209). MVA demonstrated shorter LOS (0.9) for LA at laparoscopic-preferring hospitals vs. open-preferring hospitals for simple appendicitis. For complicated appendicitis, higher complication rates (1.1) were associated with OA at laparoscopic-preferring hospitals. Laparoscopic-preferring hospitals had higher TC in all categories. Complications and resource utilization for appendicitis are associated with surgical technique and hospital procedure preference. Laparoscopic-preferring hospitals had higher complication rates with OA for complicated appendicitis and higher charges regardless of appendectomy technique or appendicitis type. 2c, Outcomes Research. Copyright © 2016 Elsevier Inc. All rights reserved.

Secondary Signs May Improve the Diagnostic Accuracy of Equivocal Ultrasounds for Suspected Appendicitis in Children

PubMed Central

Partain, Kristin N.; Patel, Adarsh; Travers, Curtis; McCracken, Courtney; Loewen, Jonathan; Braithwaite, Kiery; Heiss, Kurt F.; Raval, Mehul V.

2016-01-01

Introduction Ultrasound (US) is the preferred imaging modality for evaluating appendicitis. Our purpose was to determine if including secondary signs (SS) improves diagnostic accuracy in equivocal US studies. Methods Retrospective review identified 825 children presenting with concern for appendicitis and with a right lower quadrant (RLQ) US. Regression models identified which SS were associated with appendicitis. Test characteristics were demonstrated. Results 530 patients (64%) had equivocal US reports. Of 114 (22%) patients with equivocal US undergoing CT, those with SS were more likely to have appendicitis (48.6% vs 14.6%, p<0.001). Of 172 (32%) patients with equivocal US admitted for observation, those with SS were more likely to have appendicitis (61.0% vs 33.6%, p<0.001). SS associated with appendicitis included fluid collection (adjusted odds ratio (OR) 13.3, 95% Confidence Interval (CI) 2.1–82.8), hyperemia (OR=2.0, 95%CI 1.5–95.5), free fluid (OR=9.8, 95%CI 3.8–25.4), and appendicolith (OR=7.9, 95%CI 1.7–37.2). Wall thickness, bowel peristalsis, and echogenic fat were not associated with appendicitis. Equivocal US that included hyperemia, a fluid collection, or an appendicolith had 96% specificity and 88% accuracy. Conclusion Use of SS in RLQ US assists in the diagnostic accuracy of appendicitis. SS may guide clinicians and reduce unnecessary CT and admissions. PMID:27039121

Pediatric patients transferred for operative management of appendicitis: are they at a disadvantage?

PubMed

Farach, Sandra M; Danielson, Paul D; Walford, N Elizabeth; Harmel, Richard P; Chandler, Nicole M

2015-09-01

Many pediatric patients are initially diagnosed with appendicitis at referring hospitals and are subsequently transferred to pediatric facilities. We aimed to compare outcomes of patients transferred to a pediatric referral center to those who present primarily for operative management of appendicitis. A retrospective review of 326 patients with operative appendicitis from July 2012 to July 2013 was performed. Demographic data, clinical parameters, and outcomes were analyzed. Transferred (n=222, 68%) and primary patients (n=104, 32%) were similar except for mean age (primary 12.4 vs. transferred 11.2 years, p<0.01). Computed tomography scans were performed in 80% of transferred compared to 40% of primary patients. Primary patients were more likely to present between the hours of 09:00 and 17:59 (52%), while transferred arrived equally across all hours. Both groups were more likely to present with acute appendicitis (primary 56% vs. transfer 61%, p=NS). There was no difference in time of diagnosis to time of appendectomy, length of hospital stay, or 30 day complications (primary 8.6% vs. transfer 5.8%, p=NS). Patients transferred for definitive care of appendicitis are not found to have more advanced disease or have increased complications; however, they are exposed to significantly more ionizing radiation during evaluation for appendicitis. Copyright © 2015 Elsevier Inc. All rights reserved.

Comparison of Alvarado score evaluation and clinical judgment in acute appendicitis.

PubMed

Abou Merhi, Bassem; Khalil, Mahmoud; Daoud, Nabil

2014-01-01

Acute appendicitis is the most common surgical emergency in children, but its diagnosis is sometimes difficult. The aim of this study is to evaluate retrospectively the Alvarado score in relation to the surgical management based on clinical judgment. Medical files of 232 children who underwent appendectomy at Makassed General Hospital from January 1997 till December 2006 were reviewed. Demographic characteristics, symptoms and signs, laboratory results and imaging findings for all children were recorded. The positive predictive value of our clinical judgment was 86.4% and the negative appendectomy rate was 13.6% based on the pathology results. The reliability of Alvarado score in our population found a PPV of 80.7% and a negative appendectomy rate of 11.3%. A multivariate analysis revealed that anorexia, neutrophils left shift and rebound tenderness are significantly correlated with a correct diagnosis of appendicitis (p = 0.012, 0.023 and 0.046 respectively). Although, Alvarado score provides measurably useful diagnostic information in evaluating children with suspected appendicitis, we found that good clinical judgment remain the main stay of correct diagnosis of appendicitis.

Second date appendectomy: Operating for failure of nonoperative treatment in perforated appendicitis.

PubMed

Lotti, Marco

2017-06-01

Nonoperative treatment of acute appendicitis is embraced by many surgical teams, driven by low to moderate quality randomized studies that support noninferiority of antibiotics versus appendectomy for treatment of acute uncomplicated appendicitis. Several flaws of these studies have emerged, especially in the recruitment strategy and in the diagnostic criteria that were used. The growing confidence given to antibiotics, together with the lack of reliable criteria to distinguish between uncomplicated and perforated appendicitis, exposes patients with perforated appendicitis to the likelihood to be treated with antibiotics instead of surgery. Among them, those patients who experience a temporary relief of symptoms due to antibiotics, followed by early recurrence of disease when antibiotics are discontinued, are likely to undergo appendectomy at their second date. Second date appendectomy, i.e. the removal of the appendix when acute inflammation relapses within the scar of a previously unhealed perforated appendicitis, is the unwanted child of the nonoperative treatment and a new challenge for both the surgeon and the patient. Between June and July 2016, two patients were readmitted and operated for failure of nonoperative treatment with antibiotics. A video is presented, which focuses on the different anatomic presentation and technical challenges between prompt and second date laparoscopic appendectomy. When proposing nonoperative treatment for acute appendicitis, surgeons should be aware and inform their patients that if the appendix is perforated and an incomplete healing and early recurrence occur, a second date appendectomy could be a more challenging operation compared to a prompt appendectomy. Copyright © 2016 Elsevier Inc. All rights reserved.

Correlation between the serum and tissue levels of oxidative stress markers and the extent of inflammation in acute appendicitis

PubMed Central

Dumlu, Ersin Gürkan; Tokaç, Mehmet; Bozkurt, Birkan; Yildirim, Murat Baki; Ergin, Merve; Yalçin, Abdussamed; Kiliç, Mehmet

2014-01-01

OBJECTIVES: To determine the serum and tissue levels of markers of impaired oxidative metabolism and correlate these levels with the histopathology and Alvarado score of acute appendicitis patients. METHOD: Sixty-five acute appendicitis patients (mean age, 31.4±12.06 years; male/female, 30/35) and 30 healthy control subjects were studied. The Alvarado score was recorded. Serum samples were obtained before surgery and 12 hours postoperatively to examine the total antioxidant status, total oxidant status, paraoxonase, stimulated paraoxonase, arylesterase, catalase, myeloperoxidase, ceruloplasmin, oxidative stress markers (advanced oxidized protein products and total thiol level) and ischemia-modified albumin. Surgical specimens were also evaluated. RESULTS: The diagnoses were acute appendicitis (n = 37), perforated appendicitis (n = 8), phlegmonous appendicitis (n = 12), perforated+phlegmonous appendicitis (n = 4), or no appendicitis (n = 4). The Alvarado score of the acute appendicitis group was significantly lower than that of the perforated+phlegmonous appendicitis group (p = 0.004). The serum total antioxidant status, total thiol level, advanced oxidized protein products, total oxidant status, catalase, arylesterase, and ischemia-modified albumin levels were significantly different between the acute appendicitis and control groups. There was no correlation between the pathological extent of acute appendicitis and the tissue levels of the markers; additionally, there was no correlation between the tissue and serum levels of any of the parameters. CONCLUSIONS: The imbalance of oxidant/antioxidant systems plays a role in the pathogenesis acute appendicitis. The Alvarado score can successfully predict the presence and extent of acute appendicitis. PMID:25518019

Early appendectomy shortens antibiotic course and hospital stay in children with early perforated appendicitis.

PubMed

Tsai, Hsin-Yu; Chao, Hsun-Chin; Yu, Wan-Ju

2017-10-01

The optimal management of perforated appendicitis in the pediatric population has been controversial. This study aimed to compare the therapeutic efficacy between conservative treatment (CS) and early appendectomy (EA) in pediatric perforated appendicitis, and to determine whether surgical intervention is an optimal treatment modality for early perforated appendicitis in children. Patients treated between January 2012 and April 2014, aged 0-18 years, with an imaging-based diagnosis of perforated appendicitis were retrospectively reviewed. Patients were classified into nonabscess and abscess groups by image findings, and were further categorized into CS and EA groups by treatment modality. Early perforated appendicitis was defined as having duration of symptoms≤7 days, C-reactive protein level≤200 mg/L, maximum abscess diameter≤5 cm, and absence of general peritonitis, and unstable vital signs. The clinical features and therapeutic outcomes were compared between CS and EA in each group. A total of 326 patients had confirmed appendicitis, including 116 patients with an image diagnosis of perforation. The CS group had a significantly longer duration of symptoms, larger abscesses, and higher serum C-reactive protein levels at presentation (all p<0.05). Patients in the EA group had a shorter antibiotic course and length of hospitalization, and a lower rate of antibiotic escalation than those in the CS group (p<0.001, p<0.001, and p<0.05, respectively). In patients with early perforated appendicitis, the CS and EA groups showed no difference in baseline disease severity. Patients in the EA group also had a shorter antibiotic course and length of hospitalization than those in the CS group (p<0.001 and p<0.001, respectively). Compared with CS, EA shortens the antibiotic course and hospital stay in pediatric early perforated appendicitis, even in the presence of small abscesses. Copyright © 2017. Published by Elsevier B.V.

Cost analysis of nonoperative management of acute appendicitis in children.

PubMed

Mudri, Martina; Coriolano, Kamary; Bütter, Andreana

2017-05-01

The purpose of this study was to determine if nonoperative management of acute appendicitis in children is more cost effective than appendectomy. A retrospective review of children (6-17years) with acute appendicitis treated nonoperatively (NOM) from May 2012 to May 2015 was compared to similar patients treated with laparoscopic appendectomy (OM) (IRB#107535). Inclusion criteria included symptoms ≤48h, localized peritonitis, and ultrasound confirmation of acute appendicitis. Variables analyzed included failure rates, complications, length of stay (LOS), and cost analysis. 26 NOM patients (30% female, mean age 12) and 26 OM patients (73% female, mean age 11) had similar median initial LOS (24.5h (NOM) vs 16.5h (OM), p=0.076). Median total LOS was significantly longer in the NOM group (34.5h (NOM) vs 17.5 (OM), p=0.01). Median cost of appendectomy was $1416.14 (range $781.24-$2729.97). 9/26 (35%) NOM patients underwent appendectomy for recurrent appendicitis. 4/26 (15%) OM patients were readmitted (postoperative abscess (n=2), Clostridium difficile colitis (n=1), postoperative nausea/vomiting (n=1)). Median initial hospital admission costs were significantly higher in the OM group ($3502.70 (OM) vs $1870.37 (NOM), p=0.004)). However, median total hospital costs were similar for both groups ($3708.68 (OM) vs $2698.99 (NOM), p=0.065)). Although initial costs were significantly less in children with acute appendicitis managed nonoperatively, total costs were similar for both groups. The high failure rate of nonoperative management in this series contributed to the total increased cost in the NOM group. 3b. Copyright © 2017 Elsevier Inc. All rights reserved.

Nonoperative management in children with early acute appendicitis: A systematic review.

PubMed

Xu, Jane; Adams, Susan; Liu, Yingrui Cyril; Karpelowsky, Jonathan

2017-09-01

Appendectomy has remained the gold standard treatment of acute appendicitis for more than 100years. Nonoperative management (NOM) has been shown to be a valid treatment alternative for acute uncomplicated appendicitis in adults. A systematic review of available evidence comparing operative management (OM) and NOM in children with acute uncomplicated appendicitis was performed. Systematic searches of MedLine, Embase, and a clinical trial register (https://clinicaltrials.gov/) were performed in March 2016. Only articles that studied NOM for uncomplicated appendicitis in children were included. Data generation was performed independently by two authors, and quality was assessed using the rating schema by the Oxford Centre for Evidence-Based Medicine. 15 articles were selected: four retrospective analyses, four prospective cohort studies, four prospective nonrandomized comparative trials and one randomized controlled trial (RCT). Initial success of the NOM groups (a cure within two weeks of intervention) ranged from 58 to 100%, with 0.1-31.8% recurrence at one year. Although present literature is scarce, publications support the feasibility of further studies investigating NOM of acute uncomplicated appendicitis in children. Higher quality prospective RCTs with larger sample sizes and robust randomization methods, studying the noninferiority of NOM with antibiotics compared with OM are required to establish its utility. This manuscript is a systematic review and thus assigned the lowest evidence used from the manuscripts analyzed which is a Level IV. Copyright © 2017. Published by Elsevier Inc.

Clinical and Histologic Mimickers of Celiac Disease.

PubMed

Kamboj, Amrit K; Oxentenko, Amy S

2017-08-17

Celiac disease is an autoimmune disorder of the small bowel, classically associated with diarrhea, abdominal pain, and malabsorption. The diagnosis of celiac disease is made when there are compatible clinical features, supportive serologic markers, representative histology from the small bowel, and response to a gluten-free diet. Histologic findings associated with celiac disease include intraepithelial lymphocytosis, crypt hyperplasia, villous atrophy, and a chronic inflammatory cell infiltrate in the lamina propria. It is important to recognize and diagnose celiac disease, as strict adherence to a gluten-free diet can lead to resolution of clinical and histologic manifestations of the disease. However, many other entities can present with clinical and/or histologic features of celiac disease. In this review article, we highlight key clinical and histologic mimickers of celiac disease. The evaluation of a patient with serologically negative enteropathy necessitates a carefully elicited history and detailed review by a pathologist. Medications can mimic celiac disease and should be considered in all patients with a serologically negative enteropathy. Many mimickers of celiac disease have clues to the underlying diagnosis, and many have a targeted therapy. It is necessary to provide patients with a correct diagnosis rather than subject them to a lifetime of an unnecessary gluten-free diet.

[Usefulness of imaging examinations in preoperative diagnosis of acute appendicitis].

PubMed

Nitoń, Tomasz; Górecka-Nitoń, Aleksandra

2014-01-01

Acute appendicitis (AA) is the cause one of most operations perform in department of general surgery on emergency ward. Frequency of acute appendicitis range from 6-8% of population. Clinical presentation is frequently unspecified and despite common occurence leads to many difficulties in diagnosis. Diagnosis of acute appendicitis includes clinical examination, laboratory tests, diagnostic scoring systems, computer programs as physisian aids and imaging examinations. About 30-45% patients suspected of acute appendicitis have untypical clinical presentation and here use of US or CT is very helpful. Longstanding use of US resulted in high AA evaluation accuracy with high sensitivity (75-90%) and specificity (84-100%). CT demonstrates above 95% ratio of correct diagnoses, reduces negative appendectomy rates and perforation rates as well as unnecessary observations. CT sensitivity and specificity CT is estimated between 83-100% among different authors. Expedited AA diagnosis, surgery and reduced hospitalization time are possible advantages of imaging tests. Additionally these tests can detect alternative deseases imitating acute appnedicitis. Use of imaging tests especially CT is beneficial in fertile women because of frequent genito-urinary disorders leading to the most diagnostic errors. However thera are contraindications in use of CT, for example it can not be performed in early pregnancy etc...

Systematic review of nonoperative versus operative treatment of uncomplicated appendicitis.

PubMed

Gorter, Ramon R; The, Sarah-May M L; Gorter-Stam, Marguerite A W; Eker, Hasan H; Bakx, Roel; van der Lee, Johanna H; Heij, Hugo A

2017-08-01

To compare the risk of complications between initial nonoperative treatment and appendectomy of uncomplicated (simple) appendicitis in children. Systematic literature search. Eligible for inclusion were both and randomized controlled trials and cohort studies including children in which the outcome of nonoperative treatment of uncomplicated appendicitis was reported with a minimum follow-up period of one year. Two authors extracted data independently and assessed quality. Primary outcome parameter was the percentage of children experiencing complications. Secondary outcomes were early failures, recurrent appendicitis and appendectomies, for all indications and on request. Five of the 2051 articles screened were eligible for inclusion, including 147 children (nonoperative treatment) and 173 children (appendectomy) with one year follow-up. Percentage of children experiencing complications ranged from 0 to 13% versus 0-17% for nonoperative and appendectomy, respectively. Nonoperative treatment avoided an appendectomy in 62-81% of the children after one year follow-up. The evidence base for initial nonoperative treatment of acute uncomplicated appendicitis in children is by far insufficient. It suggests that the percentage of patients experiencing complications in the initial nonoperative treatment group is comparable to the appendectomy group, and it may avoid an appendectomy in the large majority of children after one year follow-up. Systematic review. 1. Copyright © 2017 Elsevier Inc. All rights reserved.

Scoring system for differentiating perforated and non-perforated pediatric appendicitis.

PubMed

Blumfield, Einat; Yang, Daniel; Grossman, Joshua

2017-10-01

Appendicitis is the most common indication for emergency pediatric surgery and its most significant complication is perforation. Perforated appendicitis (PA) may be managed conservatively, whereas non-perforated appendicitis (NP) is managed surgically. Recent studies have shown that ultrasound (US) is effective for differentiating between PA and NP, and does not expose pediatric patients to ionizing radiation. The purpose of this study is to enhance the accuracy of differentiation with a novel scoring system based on clinical, laboratory, and US findings. This retrospective study included 243 patients aged 2-17 years who presented between 2006 and 2013 with surgically proven appendicitis, of whom 60 had perforation. Clinical and laboratory data were collected and US images evaluated by a pediatric radiologist. To create the scoring system, point values were assigned to each parameter. A randomly selected training sample of 137 subjects was used to create a scoring prediction model. The model was tested on the remaining 106 patients. Scores of ≥6, ≥11, and ≥15 yielded specificities of 64, 91, and 99%, and sensitivities of 96, 61, and 29%, respectively (p < 0.001). We have designed a scoring system incorporating clinical, laboratory, and sonographic findings which can differentiate PA from NP with high specificity.

Imaging trends in suspected appendicitis-a Canadian perspective.

PubMed

Tan, Victoria F; Patlas, Michael N; Katz, Douglas S

2017-06-01

The purpose of our study was to assess trends in the imaging of suspected appendicitis in adult patients in emergency departments of academic centers in Canada. A questionnaire was sent to all 17 academic centers in Canada to be completed by a radiologist who works in emergency radiology. The questionnaires were sent and collected over a period of 4 months from October 2015 to February 2016. Sixteen centers (94%) responded to the questionnaire. Eleven respondents (73%) use IV contrast-enhanced computed tomography (CT) as the imaging modality of choice for all patients with suspected appendicitis. Thirteen respondents (81%) use ultrasound as the first modality of choice in imaging pregnant patients with suspected appendicitis. Eleven respondents (69%) use ultrasound (US) as the first modality of choice in patients younger than 40 years of age. Ten respondents (67%) use ultrasound as the first imaging modality in female patients younger than 40 years of age. When CT is used, 81% use non-focused CT of the abdomen and pelvis, and 44% of centers use oral contrast. Thirteen centers (81%) have ultrasound available 24 h a day/7 days a week. At 12 centers (75%), ultrasound is performed by ultrasound technologists. Four centers (40%) perform magnetic resonance imaging (MRI) in suspected appendicitis in adult patients at the discretion of the attending radiologist. Eleven centers (69%) have MRI available 24/7. All 16 centers (100%) use unenhanced MRI. Various imaging modalities are available for the work-up of suspected appendicitis. Although there are North American societal guidelines and recommendations regarding the appropriateness of the multiple imaging modalities, significant heterogeneity in the first-line modalities exist, which vary depending on the patient demographics and resource availability. Imaging trends in the use of the first-line modalities should be considered in order to plan for the availability of the imaging examinations and to consider plans for

Acute appendicitis: proposal of a new comprehensive grading system based on clinical, imaging and laparoscopic findings.

PubMed

Gomes, Carlos Augusto; Sartelli, Massimo; Di Saverio, Salomone; Ansaloni, Luca; Catena, Fausto; Coccolini, Federico; Inaba, Kenji; Demetriades, Demetrios; Gomes, Felipe Couto; Gomes, Camila Couto

2015-01-01

Advances in the technology and improved access to imaging modalities such as Computed Tomography and laparoscopy have changed the contemporary diagnostic and management of acute appendicitis. Complicated appendicitis (phlegmon, abscess and/ or diffuse peritonitis), is now reliably distinguished from uncomplicated cases. Therefore, a new comprehensive grading system for acute appendicitis is necessary. The goal is review and update the laparoscopic grading system of acute appendicitis and to provide a new standardized classification system to allow more uniform patient stratification. During the last World Society of Emergency Surgery Congress in Israel (July, 2015), a panel involving Acute Appendicitis Experts and the author's discussed many current aspects about the acute appendicitis between then, it will be submitted a new comprehensive disease grading system. It was idealized based on three aspect of the disease (clinical and imaging presentation and laparoscopic findings). The new grading system may provide a standardized system to allow more uniform patient stratification for appendicitis research. In addition, may aid in determining optimal management according to grade. Lastly, what we want is to draw a multicenter observational study within the World Society of Emergency Surgery (WSES) based on this design.

Acute appendicitis in preschoolers: a study of two different populations of children.

PubMed

Gardikis, Stefanos; Giatromanolaki, Alexandra; Kambouri, Katerina; Tripsianis, Gregorios; Sivridis, Efthimios; Vaos, George

2011-07-25

To assess the incidence and the risk factors implicated in acute appendicitis in preschoolers in our region. Over a 7-year period, 352 children underwent appendectomy for suspected acute appendicitis. Of these, data for 23 children were excluded because no inflammation of the appendix was found on subsequent histology. Of the remaining 329, 82 were ≤ 5 years old (i.e., preschool children) and 247 were 5-14 years old. These two groups of children were further divided according to their religion into Muslims and Christian Orthodox: 43 of the children aged ≤ 5 years were Muslims and 39 were Christian Orthodox. A household questionnaire was designed to collect data concerning age, gender, type of residence area, living conditions, vegetable consumption, and family history of surgery for acute appendicitis as preschool children. The removed appendices were also assessed histologically for the amount of lymphoid tissue. Acute appendicitis of preschoolers developed more frequently in Muslims (39.4%) than in Christians (17.7%; p < 0.001). The lack of inside toilet facilities at home, overcrowded living conditions, living in rural areas, and the amount of appendix lymphoid tissue were significantly more frequent among the Muslim preschool children (p < 0.05), while there were no statistically significant differences between Muslim and Christian children with regard to gender, the family history of acute appendicitis, or the vegetable consumption (p > 0.05). In our region, the percentage of preschool-aged Muslim children with acute appendicitis was remarkably high. One possible explanation for this finding could be the higher amount of lymphoid tissue in the wall of the appendix in Muslim preschool children together with their low standard of hygiene.

Systematic Review and Meta-Analysis of CT Features for Differentiating Complicated and Uncomplicated Appendicitis.

PubMed

Kim, Hae Young; Park, Ji Hoon; Lee, Yoon Jin; Lee, Sung Soo; Jeon, Jong-June; Lee, Kyoung Ho

2018-04-01

Purpose To perform a systematic review and meta-analysis to identify computed tomographic (CT) features for differentiating complicated appendicitis in patients suspected of having appendicitis and to summarize their diagnostic accuracy. Materials and Methods Studies on diagnostic accuracy of CT features for differentiating complicated appendicitis (perforated or gangrenous appendicitis) in patients suspected of having appendicitis were searched in Ovid-MEDLINE, EMBASE, and the Cochrane Library. Overlapping descriptors used in different studies to denote the same image finding were subsumed under a single CT feature. Pooled diagnostic accuracy of the CT features was calculated by using a bivariate random effects model. CT features with pooled diagnostic odds ratios with 95% confidence intervals not including 1 were considered as informative. Results Twenty-three studies were included, and 184 overlapping descriptors for various CT findings were subsumed under 14 features. Of these, 10 features were informative for complicated appendicitis. There was a general tendency for these features to show relatively high specificity but low sensitivity. Extraluminal appendicolith, abscess, appendiceal wall enhancement defect, extraluminal air, ileus, periappendiceal fluid collection, ascites, intraluminal air, and intraluminal appendicolith showed pooled specificity greater than 70% (range, 74%-100%), but sensitivity was limited (range, 14%-59%). Periappendiceal fat stranding was the only feature that showed high sensitivity (94%; 95% confidence interval: 86%, 98%) but low specificity (40%; 95% confidence interval, 23%, 60%). Conclusion Ten informative CT features for differentiating complicated appendicitis were identified in this study, nine of which showed high specificity, but low sensitivity. © RSNA, 2017 Online supplemental material is available for this article.

Randomized clinical trial of antibiotic therapy for uncomplicated appendicitis.

PubMed

Park, H C; Kim, M J; Lee, B H

2017-12-01

Uncomplicated appendicitis may resolve spontaneously or require treatment with antibiotics or appendicectomy. The aim of this randomized trial was to compare the outcome of a non-antibiotic management strategy with that of antibiotic therapy in uncomplicated appendicitis. Patients presenting to a university teaching hospital with CT-verified uncomplicated simple appendicitis (appendiceal diameter no larger than 11 mm and without any signs of perforation) were randomized to management with a no-antibiotic regimen with supportive care (intravenous fluids, analgesia and antipyretics as necessary) or a 4-day course of antibiotics with supportive care. The primary endpoint was rate of total treatment failure, defined as initial treatment failure within 1 month and recurrence of appendicitis during the follow-up period. Some 245 patients were randomized within the trial, and followed up for a median of 19 months. The duration of hospital stay was shorter (mean 3·1 versus 3·7 days; P < 0·001) and the medical costs lower (€1181 versus 1348; P < 0·001) among those randomized to therapy without antibiotics. There was no difference in total treatment failure rate between the groups: 29 of 124 (23·4 per cent) in the no-antibiotic group and 25 of 121 (20·7 per cent) in the antibiotic group (P = 0·609). Eighteen patients (9 in each group) had initial treatment failure, 15 of whom underwent appendicectomy and three received additional antibiotics. Thirty-six patients (20 in the no-antibiotic group, 16 in the antibiotic group) experienced recurrence, of whom 30 underwent appendicectomy and six received further antibiotics. Treatment failure rates in patients presenting with CT-confirmed uncomplicated appendicitis appeared similar among those receiving supportive care with either a no-antibiotic regimen or a 4-day course of antibiotics. Registration number: KCT0000124 ( http://cris.nih.go.kr). © 2017 BJS Society Ltd Published by John Wiley & Sons Ltd.

A preclustering-based ensemble learning technique for acute appendicitis diagnoses.

PubMed

Lee, Yen-Hsien; Hu, Paul Jen-Hwa; Cheng, Tsang-Hsiang; Huang, Te-Chia; Chuang, Wei-Yao

2013-06-01

Acute appendicitis is a common medical condition, whose effective, timely diagnosis can be difficult. A missed diagnosis not only puts the patient in danger but also requires additional resources for corrective treatments. An acute appendicitis diagnosis constitutes a classification problem, for which a further fundamental challenge pertains to the skewed outcome class distribution of instances in the training sample. A preclustering-based ensemble learning (PEL) technique aims to address the associated imbalanced sample learning problems and thereby support the timely, accurate diagnosis of acute appendicitis. The proposed PEL technique employs undersampling to reduce the number of majority-class instances in a training sample, uses preclustering to group similar majority-class instances into multiple groups, and selects from each group representative instances to create more balanced samples. The PEL technique thereby reduces potential information loss from random undersampling. It also takes advantage of ensemble learning to improve performance. We empirically evaluate this proposed technique with 574 clinical cases obtained from a comprehensive tertiary hospital in southern Taiwan, using several prevalent techniques and a salient scoring system as benchmarks. The comparative results show that PEL is more effective and less biased than any benchmarks. The proposed PEL technique seems more sensitive to identifying positive acute appendicitis than the commonly used Alvarado scoring system and exhibits higher specificity in identifying negative acute appendicitis. In addition, the sensitivity and specificity values of PEL appear higher than those of the investigated benchmarks that follow the resampling approach. Our analysis suggests PEL benefits from the more representative majority-class instances in the training sample. According to our overall evaluation results, PEL records the best overall performance, and its area under the curve measure reaches 0.619. The

Comparison of Alvarado Score Evaluation and Clinical Judgment in Acute Appendicitis

PubMed Central

Merhi, Bassem Abou; Khalil, Mahmoud; Daoud, Nabil

2014-01-01

ABSTRACT Background: Acute appendicitis is the most common surgical emergency in children, but its diagnosis is sometimes difficult. The aim: of this study is to evaluate retrospectively the Alvarado score in relation to the surgical management based on clinical judgment. Methods: Medical files of 232 children who underwent appendectomy at Makassed General Hospital from January 1997 till December 2006 were reviewed. Demographic characteristics, symptoms and signs, laboratory results and imaging findings for all children were recorded. Results: The positive predictive value of our clinical judgment was 86.4% and the negative appendectomy rate was 13.6% based on the pathology results. The reliability of Alvarado score in our population found a PPV of 80.7% and a negative appendectomy rate of 11.3%. A multivariate analysis revealed that anorexia, neutrophils left shift and rebound tenderness are significantly correlated with a correct diagnosis of appendicitis (p = 0.012, 0.023 and 0.046 respectively). Conclusion: Although, Alvarado score provides measurably useful diagnostic information in evaluating children with suspected appendicitis, we found that good clinical judgment remain the main stay of correct diagnosis of appendicitis. PMID:24783903

Time to Appendectomy and Risk of Complicated Appendicitis and Adverse Outcomes in Children.

PubMed

Serres, Stephanie K; Cameron, Danielle B; Glass, Charity C; Graham, Dionne A; Zurakowski, David; Karki, Mahima; Anandalwar, Seema P; Rangel, Shawn J

2017-08-01

Management of appendicitis as an urgent rather than emergency procedure has become an increasingly common practice in children. Controversy remains as to whether this practice is associated with increased risk of complicated appendicitis and adverse events. To examine the association between time to appendectomy (TTA) and risk of complicated appendicitis and postoperative complications. In this retrospective cohort study using the Pediatric National Surgical Quality Improvement Program appendectomy pilot database, 2429 children younger than 18 years who underwent appendectomy within 24 hours of presentation at 23 children's hospitals from January 1, 2013, through December 31, 2014, were studied. The main exposure was TTA, defined as the time from emergency department presentation to appendectomy. Patients were further categorized into early and late TTA groups based on whether their TTA was shorter or longer than their hospital's median TTA. Exposures were defined in this manner to compare rates of complicated appendicitis within a time frame sensitive to each hospital's existing infrastructure and diagnostic practices. The primary outcome was complicated appendicitis documented at operation. The association between treatment delay and complicated appendicitis was examined across all hospitals by using TTA as a continuous variable and at the level of individual hospitals by using TTA as a categorical variable comparing outcomes between late and early TTA groups. Secondary outcomes included length of stay (LOS) and postoperative complications (incisional and organ space infections, percutaneous drainage procedures, unplanned reoperation, and hospital revisits). Of the 6767 patients who met the inclusion criteria, 2429 were included in the analysis (median age, 10 years; interquartile range, 8-13 years; 1467 [60.4%] male). Median hospital TTA was 7.4 hours (range, 5.0-19.2 hours), and 574 patients (23.6%) were diagnosed with complicated appendicitis (range, 5

A Case of Painful Hashimoto Thyroiditis that Mimicked Subacute Thyroiditis

PubMed Central

Seo, Hye Mi; Kim, Miyeon; Bae, Jaeseok; Kim, Jo-Heon; Lee, Jeong Won; Lee, Sang Ah; Koh, Gwanpyo

2012-01-01

Hashimoto thyroiditis (HT) is an autoimmune thyroid disorder that usually presents as a diffuse, nontender goiter, whereas subacute thyroiditis (SAT) is an uncommon disease that is characterized by tender thyroid enlargement, transient thyrotoxicosis, and an elevated erythrocyte sedimentation rate (ESR). Very rarely, patients with HT can present with painful, tender goiter or fever, a mimic of SAT. We report a case of painful HT in a 68-year-old woman who presented with pain and tenderness in a chronic goiter. Her ESR was definitely elevated and her thyroid laboratory tests suggested subclinical hypothyroidism of autoimmune origin. 99mTc pertechnetate uptake was markedly decreased. Fine needle aspiration biopsy revealed reactive and polymorphous lymphoid cells and occasional epithelial cells with Hürthle cell changes. Her clinical symptoms showed a dramatic response to glucocorticoid treatment. She became hypothyroid finally and is now on levothyroxine therapy. PMID:22570820

The diagnosis of acute appendicitis in a pediatric population: to CT or not to CT.

PubMed

Stephen, Antonia E; Segev, Dorry L; Ryan, Daniel P; Mullins, Mark E; Kim, Samuel H; Schnitzer, Jay J; Doody, Daniel P

2003-03-01

The aim of this study was to determine if focused appendiceal computed tomography with colon contrast (FACT-CC) increases the accuracy of the preoperative diagnosis of acute appendicitis in children. A 5-year retrospective review was conducted of a university hospital database of 283 patients (age 0.8 to 19.3 years; mean, 11.3 years) treated with appendectomy for presumed acute appendicitis. Of the 283 patients in whom appendectomies were performed, 268 were confirmed by pathologic analysis of the specimen to have acute appendicitis for a diagnostic accuracy in our institution of 94.7%. Ninety-six patients (34%) underwent FACT-CC scans as part of their preoperative evaluation. The sensitivity of the computed tomography (CT) scan was 94.6%, and the positive predictive value was 95.6%. In girls older than 10 years, CT imaging was not significantly more accurate in predicting appendicitis than examination alone (93.9% v. 87.5%; P =.46). Preoperative FACT-CC did not increase the accuracy in diagnosing appendicitis when compared with patients diagnosed by history, physical examination and laboratory studies. If there was a strong suspicion of appendicitis, a negative CT scan did not exclude the diagnosis of appendicitis. However, focused appendiceal CT scan is a sensitive test with a high positive predictive value and may be useful in a patient with an atypical history or examination. Copyright 2003, Elsevier Science (USA). All rights reserved.

Scalene Myofascial Pain Syndrome Mimicking Cervical Disc Prolapse: A Report of Two Cases

PubMed Central

Abd Jalil, Nizar; Awang, Mohammad Saufi; Omar, Mahamarowi

2010-01-01

Scalene myofascial pain syndrome is a regional pain syndrome wherein pain originates over the neck area and radiates down to the arm. This condition may present as primary or secondary to underlying cervical pathology. Although scalene myofascial pain syndrome is a well known medical entity, it is often misdiagnosed as being some other neck pain associated with radiculopathy, such as cervical disc prolapse, cervical spinal stenosis and thoracic outlet syndrome. Because scalene myofascial pain syndrome mimics cervical radiculopathy, this condition often leads to mismanagement, which can, in turn, result in persistent pain and suffering. In the worst-case scenarios, patients may be subjected to unjustifiable surgical intervention. Because the clinical findings in scalene myofascial pain syndrome are “pathognomonic”, clinicians should be aware of ways to recognize this disorder and be able to differentiate it from other conditions that present with neck pain and rediculopathy. We present two cases of unilateral scalene myofascial pain syndrome that significantly impaired the patients’ functioning and quality of life. This case report serves to create awareness about the existence of the syndrome and to highlight the potential morbidity due to clinical misdiagnosis. PMID:22135529

Initial non-operative management of uncomplicated appendicitis in children: a protocol for a multicentre randomised controlled trial (APAC trial)

PubMed Central

Knaapen, Max; van der Lee, Johanna H; Bakx, Roel; The, Sarah-May L; van Heurn, Ernst W E; Heij, Hugo A; Gorter, Ramon R

2017-01-01

Introduction Based on epidemiological, immunological and pathology data, the idea that appendicitis is not necessarily a progressive disease is gaining ground. Two types are distinguished: simple and complicated appendicitis. Non-operative treatment (NOT) of children with simple appendicitis has been investigated in several small studies. So far, it is deemed safe. However, its effectiveness and effect on quality of life (QoL) have yet to be established in an adequately powered randomised trial. In this article, we provide the study protocol for the APAC (Antibiotics versus Primary Appendectomy in Children) trial. Methods and analysis This multicentre, non-inferiority, randomised controlled trial randomises children aged 7–17 years with imaging-confirmed simple appendicitis between appendectomy and NOT. Patients are recruited in 15 hospitals. The intended sample size, based on the primary outcome, rate of complications and a non-inferiority margin of 5%, is 334 patients. NOT consists of intravenous antibiotics for 48–72 hours, daily blood tests and ultrasound follow-up. If the patient meets the predefined discharge criteria, antibiotic treatment is continued orally at home. Primary outcome is the rate of complications at 1-year follow-up. An independent adjudication committee will assess all complications and their relation to the allocated treatment. Secondary outcomes include, but are not limited to, delayed appendectomies, QoL, pain and (in)direct costs. The primary outcome will be analysed both according to the intention-to-treat principle and the per-protocol principle, and is presented with a one-sided 97.5% CI. We will use multiple logistic and linear regression for binary and continuous outcomes, respectively, to adjust for stratification factors. Ethics and dissemination The protocol has been approved by the Medical Ethics Review Committee of the Academic Medical Center, Amsterdam. Data monitoring is performed by an independent institute and a Data

Relationship between Enterobius vermicularis and the incidence of acute appendicitis.

PubMed

Ramezani, Mohammad Arash; Dehghani, Mahmoud Reza

2007-01-01

The objective of this study was to evaluate the relationship between Enterobius vermicularis and the occurrence of acute appendicitis. Over a ten year period of time, all appendix specimens received by the department of pathology were reviewed for pathologic changes and the existence of E. vermicularis. Logistic regression was carried out to determine the odds ratio (OR) of the relationship between E. vermicularis and acute appendicitis. A total of 5048 specimens were reviewed. E. vermicularis was found in 144 (2.9%) cases. After separating by sex and adjusting for age logistic regression analysis showed the OR of E. vermicularis appendiceal infestation was 1.275 (95% CI = 0.42-3.9) for males and 1.678 (95% CI = 0.61-4.65) for females. Age was an independent risk factor for acute appendicitis in males (OR = 1.01, 95% CI = 1.003-1.017) and females (OR = 1.012, 95% CI = 1.005-1.02).

[Acute appendicitis: clinico-diagnostic and therapeutic considerations].

PubMed

Carditello, A; Bartolotta, M; Bonavita, G; Lentini, B; Sturniolo, G

1985-04-01

Since january 1970-december 1982, 58 patients underwent emergently appendectomy for acute appendicitis. 31 (53,4 percent) where males; the average age was 21 +/- 2,3 years (M +/- SEM). The duration of symptoms ranged from 1-6 hours (10,3 percent of cases) to over 48 hours, before the hospital admission (15,4 percent of cases). 27 patients (46,5 percent) had a clinical examination at home by a physician. 21 patients (36,4 percent) came to hospital emergency unit without previous physical examination; 10 (17,2 percent) were transferred from other departments. In 6,9 percent of cases was present a perforated appendicitis with peritonitis. During operation, in 50 percent of patients was performed a therapeutic peritoneal lavage. In 63,7 percent of cases multiple drains were placed in peritoneal cavity. In all patients was effected postoperative antibiotic profilaxis. The mortality rate was 3,4 percent. General complications were observed more in patients with perforated appendicitis. This review suggests the following remarcable data: morbidity of this disease is still high; the physical examination is more important than laboratory work (especially in the elderly patients, which are often immunodepressed and in children, with leucocitosis-lack at hospital admission); early surgery is the most important factor to the improvement of prognosis in these cases and the results of surgical treatment are improved by large vertical incisions, peritoneal lavage and application of multiple intracavitary drains.

The management of acute appendicitis in liver transplant patients: How effective is the Alvarado score?

PubMed

Ince, Volkan; Barut, Bora; Ozdemir, Fatih; Ersan, Veysel; Kutluturk, Koray; Gonultas, Fatih; Onur, Asim; Isik, Burak; Kutlu, Ramazan; Yilmaz, Sezai

2017-01-01

The incidence of acute appendicitis after liver transplantation (LT) is extremely low, reported to be 0.09% to 0.49%, but the efficacy of the Alvarado score in this patient group has not been studied. This study was an investigation of the clinical management of patients who developed acute appendicitis after LT and the usefulness of the Alvarado score in the diagnosis. The study was performed using the data of 7 patients treated for acute appendicitis who were among 1990 patients who underwent LT between March 2002 and July 2017. The Alvarado score of the patients was calculated and reliability was analyzed. In this study, the incidence of acute appendicitis in LT patients was 0.35%. All of the patients were in the adult age group; 86% were male. The mean age was 46.4±10.7 years and the timeframe for the development of appendicitis after transplantation was a median of 12 months (range: 4-101 months). The median Alvarado score was 7 (range: 5-9). All of the patients had an Alvarado score above 5 and 71% had a score of 7 or more. Acute appendicitis is very rare in LT patients. As with non-transplant patients, Alvarado scoring can be safely performed in LT patients.

The management of acute appendicitis in liver transplant patients: How effective is the Alvarado score?

PubMed Central

Ince, Volkan; Barut, Bora; Ozdemir, Fatih; Ersan, Veysel; Kutluturk, Koray; Gonultas, Fatih; Onur, Asim; Isik, Burak; Kutlu, Ramazan; Yilmaz, Sezai

2017-01-01

OBJECTIVE: The incidence of acute appendicitis after liver transplantation (LT) is extremely low, reported to be 0.09% to 0.49%, but the efficacy of the Alvarado score in this patient group has not been studied. This study was an investigation of the clinical management of patients who developed acute appendicitis after LT and the usefulness of the Alvarado score in the diagnosis. METHODS: The study was performed using the data of 7 patients treated for acute appendicitis who were among 1990 patients who underwent LT between March 2002 and July 2017. The Alvarado score of the patients was calculated and reliability was analyzed. RESULTS: In this study, the incidence of acute appendicitis in LT patients was 0.35%. All of the patients were in the adult age group; 86% were male. The mean age was 46.4±10.7 years and the timeframe for the development of appendicitis after transplantation was a median of 12 months (range: 4-101 months). The median Alvarado score was 7 (range: 5-9). All of the patients had an Alvarado score above 5 and 71% had a score of 7 or more. CONCLUSION: Acute appendicitis is very rare in LT patients. As with non-transplant patients, Alvarado scoring can be safely performed in LT patients. PMID:29270576

Platelet indices and netrophil to lymphocyte ratio in adults with acute appendicitis.

PubMed

Kostakis, I D; Machairas, N; Damaskos, C; Doula, C; Tsaparas, P; Charalampoudis, P; Spartalis, E; Sotiropoulos, G C; Kouraklis, G

2016-03-01

A study was performed in adults with acute appendicitis and matched controls to assess the utility of the platelet indices and neutrophil to lymphocyte ratio, as a diagnostic adjunct. Data were retrospectively collected from a complete blood count test of 155 adult patients (72 men and 83 women) with histologically proven acute appendicitis upon admission, and of 50 healthy adults (20 men and 30 women). The parameters for white blood cells and platelets were compared between the two groups, and for each gender separately. A higher white blood cell count, neutrophil count, neutrophil percentage, neutrophil to lymphocyte ratio and lower lymphocyte percentage was reported in patients with acute appendicitis than that in the healthy controls, with high areas under the curve (AUC), sensitivities, specifi cities, positive predictive values (PPVs) and moderate negative predictive values (NPVs). The lymphocyte count was lower in patients than it was in the healthy controls. The platletcrit was lower in the female patients than that in the female controls, whereas a difference was not detected in the male participants. Differences were not detected with regard to platelet count, mean platelet volume and platelet distribution width for both genders. The neutrophil to lymphocyte ratio increases and lymphocyte percentage decreases in acute appendicitis, and can be used as an additional diagnostic marker. Plateletcrit, and therefore total platelet mass, is reduced in women with acute appendicitis, indicating the involvement of platelets in its pathophysiology. However, it is neither a reliable predictor or excluder of the disease.

Resource savings and outcomes associated with outpatient laparoscopic appendectomy for nonperforated appendicitis.

PubMed

Gurien, Lori A; Burford, Jeffrey M; Bonasso, Patrick C; Dassinger, Melvin S

2017-11-01

Postoperative admission for acute appendicitis utilizes health care system resources. We evaluated outcomes and hospital charges for children with nonperforated appendicitis who underwent outpatient laparoscopic appendectomy. A retrospective chart review was performed for patients ≤18years old who underwent laparoscopic appendectomy for acute appendicitis in 2015. Patients were categorized into discharge from postanesthesia care unit (PACU) (outpatient), admission for <24-h, and admission for >24-h. Continuous variables were compared using analysis of variance and categorical variables were compared using chi-square test, with p<0.05 considered significant. Of the 171 patients identified, 63 (37%) were discharged from the PACU, 94 (55%) were admitted <24-h, and 14 (8%) were admitted >24-h. There were no differences in postoperative emergency department/clinic visits, complications, or readmissions. Hospital charges for admission <24-h and >24-h were $1007 and $2237 more per patient than the PACU-discharge group, respectively. Outpatient laparoscopic appendectomies became more common over time, occurring in only 20% of patients with acute appendicitis in the first quarter of the year versus 49% of patients in the last quarter. Outpatient laparoscopic appendectomy for nonperforated appendicitis in children is a safe practice that decreases length of stay and hospital charges. Adoption of an outpatient strategy allows for better standardization of care and can lead to savings in health care resources. III (Treatment: retrospective comparative study). Copyright © 2017 Elsevier Inc. All rights reserved.

Acute pancreatitis during sickle cell vaso-occlusive painful crisis.

PubMed

Ahmed, Shahid; Siddiqui, Anita K; Siddiqui, Rina K; Kimpo, Miriam; Russo, Linda; Mattana, Joseph

2003-07-01

Sickle cell disease is characterized by chronic hemolytic anemia and vaso-occlusive painful crisis. The vascular occlusion in sickle cell disease is a complex process and accounts for the majority of the clinical manifestations of the disease. Abdominal pain is an important component of vaso-occlusive painful crisis and may mimic diseases such as acute appendicitis and cholecystitis. Acute pancreatitis is rarely included as a cause of abdominal pain in patients with sickle cell disease. When it occurs it may result form biliary obstruction, but in other instances it might be a consequence of microvessel occlusion causing ischemia. In this series we describe four cases of acute pancreatitis in patients with sickle cell disease apparently due to microvascular occlusion and ischemic injury to the pancreas. All patients responded to conservative management. Acute pancreatitis should be considered in the differential diagnosis of abdominal pain in patients with sickle cell disease. Copyright 2003 Wiley-Liss, Inc.

Lessons Learned With Laparoscopic Management of Complicated Grades of Acute Appendicitis

PubMed Central

Gomes, Carlos Augusto; Junior, Cleber Soares; Costa, Evandro de Freitas Campos; Alves, Paula de Assis Pereira; de Faria, Carolina Vieira; Cangussu, Igor Vitoi; Costa, Luisa Pires; Gomes, Camila Couto; Gomes, Felipe Couto

2014-01-01

Background Laparoscopy has not been consolidated as the approach of first choice in the management of complicated appendicitis. Methodological flaws and absence of disease stratification criteria have been implicated in that less evidence. The objective is to study the safe and effectiveness of laparoscopy in the management of complicated appendicitis according to laparoscopic grading system. Method From January 2008 to January 2011, 154 consecutive patients who underwent a laparoscopic appendectomy for complicated appendicitis were evaluated in the prospective way. The patient’s age ranged from 12 to 75 years old (31.7 ± 13.3) and 58.3% were male. Complicated appendicitis refers to gangrenous and/or perforated appendix and were graded as 3A (segmental necrosis), 3B (base necrosis), 4A (abscess), 4B (regional peritonitis) and 5 (diffuse peritonitis). The outcomes including operative time, infection complication, operative complications and conversion rate were chosen to evaluate the procedure. Results The grade 3A was the most frequent with 50 (32.4%) patients. The mean operative time was 69.4 ± 26.3 minutes. The grade 4A showed the highest mean operative time (80.1 ± 26.7 minutes). The wound and intra-abdominal infection rates were 2.6 and 4.6%, respectively. The base necrosis was the most important factor associated with the conversion (5.2%). The grades 4A and 5 were associated with greater possibility of intra-abdominal collection. There were no operative complications. Conclusion The laparoscopic management of all complicated grades of acute appendicitis is safe and effective and should be the procedure of first choice. The laparoscopic grading system allows us to assess patients in the same disease stage. PMID:24883151

Acute appendicitis presenting with Klebsiella pneumoniae septicemia due to bacterial translocation.

PubMed

Salemis, Nikolaos S

2009-10-01

Bacterial translocation (BT) is defined as the passage of viable bacteria from the gastrointestinal tract, across the intestinal wall, to the mesenteric lymph nodes or other extranodal sites and bloodstream. It has been shown in both animal and human studies and has been implicated as a source of sepsis in susceptible patients. Herein, a rare case of acute appendicitis in a nonimmunocompromised patient who presented with manifestations of Klebsiella pneumoniae septicemia, is described. Translocation of Klebsiella pneumoniae through the compromised appendix mucosa leading in dissemination of the infection into the bloodstream was likely the main causative factor for the atypical and toxic presentation of acute appendicitis. Thorough clinical investigation ruled out other sources of infection. Emergency physicians should be aware that septicemia may be the dominant presentation of acute appendicitis, due to dissemination of the infection into the bloodstream, secondary to bacterial translocation.

Can the efficiency of modified Alvarado scoring system in the diagnosis acute appendicitis be increased with tenesmus?

PubMed

Bulus, Hakan; Tas, Adnan; Morkavuk, Baris; Koklu, Seyfettin; Soy, Derya; Coskun, Ali

2013-01-01

Acute appendicitis is one of the main pathological conditions requiring emergency surgical intervention. The most widely accepted scoring system is modified Alvarado scoring system (MASS). In this study we aimed to improve the efficiency of MASS by adding a new parameter and to evaluate its efficiency in the diagnosis of acute appendicitis. This study included 158 patients who underwent acute appendectomy in Keçiören Training and Research Hospital General Surgery Department. In addition to criteria of MASS, all patients were questioned about the presence of tenesmus. The validity of MASS and MASS with additional parameter was evaluated with respect to sensitivity, specificity and positive and negative predictive values. Accuracy rates of MASS, clinical findings, ultrasonography and MASS with additional parameter in the diagnosis of acute appendicitis were 64, 76, 85 and 80 %. False positivity rates for clinical findings, MASS and MASS with additional parameter in the diagnosis of acute appendicitis were 17, 26 and 10 %, respectively. Sensitivity and specificity of clinical findings in the diagnosis of acute appendicitis were 83 and 66 %, respectively. Sensitivity and specificity of MASS in the diagnosis of acute appendicitis were 74 and 39 %, respectively, and those of MASS with additional parameter were appendicitis increased to 83 and 66 %, respectively. MASS is a simple, cheap and objective scoring system and does not require expertise. When tenesmus is added to standard MASS, rates of accuracy, sensitivity and specificity become better than those in MASS in the diagnosis of acute appendicitis.

Differential diagnosis and treatment of periodontitis-mimicking actinomycosis.

PubMed

Kim, Nam Ryang; Park, Jun-Beom; Ko, Youngkyung

2012-12-01

Actinomycosis is an uncommon chronic granulomatous disease that presents as a slowly progressive, indolent, indurated infiltration with multiple abscesses, fistulas, and sinuses. The purpose of this article is to report on a case of actinomycosis with clinical findings similar to periodontitis. A 46-year-old female presented with recurrent throbbing pain on the right first and second molar of the mandible three weeks after root planing. Exploratory flap surgery was performed, and the bluish-gray tissue fragment found in the interproximal area between the two molars was sent for histopathology. The diagnosis from the biopsy was actinomycosis. The clinical and radiographic manifestations of this case were clinically indistinguishable from periodontitis. The patient did not report any symptoms, and she is scheduled for a follow-up visit. The present study has identified periodontitis-mimicking actinomycosis. Actinomycosis should be included in the differential diagnosis in cases with periodontal pain and inflammation that do not respond to nonsurgical treatment for periodontitis. More routine submissions of tissue removed from the oral cavity for biopsies may be beneficial for differential diagnosis.

Association of Health Care Utilization With Rates of Perforated Appendicitis in Children 18 Years or Younger.

PubMed

Baxter, Katherine J; Nguyen, Hannah T M H; Wulkan, Mark L; Raval, Mehul V

2018-06-01

The pediatric perforated appendix rate is a quality metric measured by the Agency for Healthcare Research and Quality (AHRQ) that reflects access to care. The association of health care utilization prior to presentation with appendicitis is unknown. To determine whether increased health care utilization prior to presentation with appendicitis is associated with lower perforated appendicitis rates in children. Retrospective cohort study of privately insured children drawn from large employer and insurance company administrative data found in the Truven MarketScan national insurance claims database. Cases of appendicitis were identified among 38 348 children 18 years or younger from January 1, 2010, through December 31, 2013, with corresponding primary health care encounters from January 1, 2009, through December 31, 2012. In all, 19 109 eligible children were identified using International Classification of Diseases, Ninth Revision (ICD-9) diagnosis codes for appendicitis after excluding those patients who did not have continuous insurance coverage during the study period. Statistical analysis was performed from September 1, 2016, to October 15, 2017. Health care utilization was determined by the number of outpatient clinic encounters for each patient in the 1 to 12 months before presentation with appendicitis. Perforated appendicitis was defined according to the AHRQ by using ICD-9 codes for perforation and hospital length of stay of 3 or more days. Logistic regression models were used for perforated appendicitis after adjustment for age, sex, income, gastrointestinal comorbidities, geographic region, and insurance type. We identified 38 348 children 18 years or younger with ICD-9 diagnosis codes for appendicitis, and 19 109 children remained for analysis after applying exclusion criteria. Of these, 11 422 were boys (59.8%); the mean (SD) age was 12.4 (3.9) years. Of the 19 109 children identified who underwent appendectomy, 5509 (28.8%) presented with

Granulomatous mastitis caused by histoplasma and mimicking inflammatory breast carcinoma.

PubMed

Osborne, B M

1989-01-01

Two cases of a lobular, necrotizing granulomatous process causing a unilateral painful breast mass mimicking carcinoma are presented for comparison. While the morphologic appearance in each case was that of lobular granulomatous mastitis, the etiologic agent in one case appeared to be Histoplasma capsulatum, based on Grocott methenamine silver staining, and represents the second reported case of histoplasmosis involving only breast parenchyma. Awareness of the rare entity, granulomatous mastitis, is important for the pathologist because the definitive diagnosis is made microscopically. Thorough evaluation of the breast tissue is essential for its management and should eventually contribute to the clarification of its etiology.

Antibiotic Therapy vs Appendectomy for Treatment of Uncomplicated Acute Appendicitis: The APPAC Randomized Clinical Trial.

PubMed

Salminen, Paulina; Paajanen, Hannu; Rautio, Tero; Nordström, Pia; Aarnio, Markku; Rantanen, Tuomo; Tuominen, Risto; Hurme, Saija; Virtanen, Johanna; Mecklin, Jukka-Pekka; Sand, Juhani; Jartti, Airi; Rinta-Kiikka, Irina; Grönroos, Juha M

2015-06-16

An increasing amount of evidence supports the use of antibiotics instead of surgery for treating patients with uncomplicated acute appendicitis. To compare antibiotic therapy with appendectomy in the treatment of uncomplicated acute appendicitis confirmed by computed tomography (CT). The Appendicitis Acuta (APPAC) multicenter, open-label, noninferiority randomized clinical trial was conducted from November 2009 until June 2012 in Finland. The trial enrolled 530 patients aged 18 to 60 years with uncomplicated acute appendicitis confirmed by a CT scan. Patients were randomly assigned to early appendectomy or antibiotic treatment with a 1-year follow-up period. Patients randomized to antibiotic therapy received intravenous ertapenem (1 g/d) for 3 days followed by 7 days of oral levofloxacin (500 mg once daily) and metronidazole (500 mg 3 times per day). Patients randomized to the surgical treatment group were assigned to undergo standard open appendectomy. The primary end point for the surgical intervention was the successful completion of an appendectomy. The primary end point for antibiotic-treated patients was discharge from the hospital without the need for surgery and no recurrent appendicitis during a 1-year follow-up period. There were 273 patients in the surgical group and 257 in the antibiotic group. Of 273 patients in the surgical group, all but 1 underwent successful appendectomy, resulting in a success rate of 99.6% (95% CI, 98.0% to 100.0%). In the antibiotic group, 70 patients (27.3%; 95% CI, 22.0% to 33.2%) underwent appendectomy within 1 year of initial presentation for appendicitis. Of the 256 patients available for follow-up in the antibiotic group, 186 (72.7%; 95% CI, 66.8% to 78.0%) did not require surgery. The intention-to-treat analysis yielded a difference in treatment efficacy between groups of -27.0% (95% CI, -31.6% to ∞) (P = .89). Given the prespecified noninferiority margin of 24%, we were unable to demonstrate noninferiority of

Right Lower Quadrant Pain in a Young Female: Ultrasound Diagnosis of Rectus Abdominis Tear.

PubMed

Minardi, Joseph; Shaver, Erica; Monseau, Aaron; Pratt, Adam; Layman, Shelley M

2015-11-01

Right lower quadrant pain in young females presents a frequent diagnostic challenge for emergency physicians, with a broad differential and several important diagnoses. Using an "ultrasound first" imaging strategy can help decrease the use of computed tomography scans, with associated savings in radiation exposure, cost, and other resource use. We report a case of right lower quadrant pain in a young woman. After her initial history and physical examination, appendicitis was the leading differential. A bedside ultrasound was performed, leading to the uncommon diagnosis of rectus abdominis muscle tear. The sonographic findings of a muscle tear include increase in size, loss of linear, homogeneous architecture, and decreased echogenicity. Making this diagnosis at the bedside using ultrasound obviated the need for further imaging, avoiding unnecessary radiation exposure, and decreasing emergency department length of stay and overall cost, while leading to a tailored treatment plan. Why Should an Emergency Physician Be Aware of This? Rectus abdominis tear is a cause of right lower quadrant pain that may mimic appendicitis and should be considered in patients with this complaint. The ability to make this diagnosis with bedside ultrasound may assist in several important patient-oriented outcomes. Copyright © 2015 Elsevier Inc. All rights reserved.

Posterior Epidural Migration of an Extruded Lumbar Disc Mimicking a Facet Cyst: A Case Report

PubMed Central

Yoo, Young Sun; Ju, Chang Il; Kim, Dong Min

2015-01-01

Dorsal extradural migration of extruded disc material is clinically uncommon. We report a rare case of posterior epidural migration of an extruded lumbar disc mimicking a facet cyst. A 32-year-old man was admitted to our institute with a 2-week history of severe low back pain and radiating pain in the left leg. The magnetic resonance (MR) images revealed a dorsally located, left-sided extradural cystic mass at the L2-3 level. The initial diagnosis was an epidural facet cyst because of the high signal intensity on MR images and its location adjacent to the facet joint. Intraoperatively, an encapsulated mass of soft tissue adherent to the dural sac was observed and excised. The pathological diagnosis was degenerated disc material. After surgery, the patient experienced complete relief from leg pain. PMID:25883662

Effectiveness of a Staged US and Unenhanced MR Imaging Algorithm in the Diagnosis of Pediatric Appendicitis.

PubMed

Dibble, Elizabeth H; Swenson, David W; Cartagena, Claudia; Baird, Grayson L; Herliczek, Thaddeus W

2018-03-01

Purpose To establish, in a large cohort, the diagnostic performance of a staged algorithm involving ultrasonography (US) followed by conditional unenhanced magnetic resonance (MR) imaging for the imaging work-up of pediatric appendicitis. Materials and Methods A staged imaging algorithm in which US and unenhanced MR imaging were performed in pediatric patients suspected of having appendicitis was implemented at the authors' institution on January 1, 2011, with US as the initial modality followed by unenhanced MR imaging when US findings were equivocal. A search of the radiology database revealed 2180 pediatric patients who had undergone imaging for suspected appendicitis from January 1, 2011, through December 31, 2012. Of the 2180 patients, 1982 (90.9%) were evaluated according to the algorithm. The authors reviewed the electronic medical records and imaging reports for all patients. Imaging reports were reviewed and classified as positive, negative, or equivocal for appendicitis and correlated with surgical and pathology reports. Results The frequency of appendicitis was 20.5% (407 of 1982 patients). US alone was performed in 1905 of the 1982 patients (96.1%), yielding a sensitivity of 98.7% (386 of 391 patients) and specificity of 97.1% (1470 of 1514 patients) for appendicitis. Seventy-seven patients underwent unenhanced MR imaging after equivocal US findings, yielding an overall algorithm sensitivity of 98.2% (400 of 407 patients) and specificity of 97.1% (1530 of 1575 patients). Seven of the 1982 patients (0.4%) had false-negative results with the staged algorithm. The negative predictive value of the staged algorithm was 99.5% (1530 of 1537 patients). Conclusion A staged algorithm of US and unenhanced MR imaging for pediatric appendicitis appears to be effective. The results of this study demonstrate that this staged algorithm is 98.2% sensitive and 97.1% specific for the diagnosis of appendicitis in pediatric patients. © RSNA, 2017.

Appendicitis-like clinical image elicited by Enterobius vermicularis: case report and review of the literature.

PubMed

Vleeschouwers, W; Hofman, Ph; Gillardin, J P; Meert, V; Van Slycke, S

2013-01-01

A 17-year-old female patient presented with the clinical features of an acute appendicitis. During laparoscopic exploration a macroscopically normal appendix was found. Since there were no intra-abdominal abnormalities found, the appendix was resected. Anatomopathology demonstrated Enterobius vermicularis, a pinworm infecting only humans, and mostly living in the caecum. This parasite is responsible for possibly the most common helminthic infection in the developed world. Its role in the pathogenesis of acute appendicitis is controversial, but more recent studies indicate a stronger association between enterobiasis and appendicitis. Often, enterobius mimics appendicitis by obstructing the lumen of the appendix, thereby causing appendiceal colic. This case report stresses the importance of microscopic examination of all appendectomy resection specimens. In case of enterobius infestation, systemic therapy of patient and family is necessary.

Gangrenous appendicitis in children: a prospective evaluation of definition, bacteriology, histopathology, and outcomes.

PubMed

Emil, Sherif; Gaied, Fady; Lo, Andrea; Laberge, Jean-Martin; Puligandla, Pramod; Shaw, Kenneth; Baird, Robert; Bernard, Chantal; Blumenkrantz, Miriam; Nguyen, Van-Hung

2012-09-01

The definition and treatment of gangrenous appendicitis are not agreed upon. We performed a prospective study in children to evaluate an objective definition of gangrenous appendicitis, as well as associated bacteriology, histopathology, and outcomes. Five staff pediatric surgeons prospectively enrolled patients in the study at the time of appendectomy if the following five criteria were met: gray or black discoloration of the appendiceal wall; absence of fecalith outside the appendix; absence of visible hole in the appendix; absence of gross purulence or fibrinous exudate remote from the appendix; and absence of intraoperative appendiceal leak. Peritoneal fluid was cultured, and a standard histopathologic review was undertaken. Persistence of fever (>37.5°C) and ileus was documented daily. Patients were continued postoperatively on ampicillin, gentamicin, and metronidazole until they tolerated diet, manifested a 24-h afebrile period, and had a normal leukocyte count. Hospital stay, readmissions, and infectious complications were recorded. The study took place over a 12-mo period. Thirty-eight patients were enrolled, representing 17% of all patients with appendicitis treated during the year. Average age was 10.8 ± 3.5 y. Peritoneal cultures were positive in 53% of cases. Gangrene was documented histologically in 61% of specimens. Hospital stay was 3.2 ± 1.1 d. There were no postoperative infectious complications or readmissions related to the disease. Neither culture results nor histologic gangrene had a statistically significant effect on hospital stay. An objective definition of gangrenous appendicitis is reproducible and has good histopathologic association. Recovery from gangrenous appendicitis is not influenced by culture or pathology results, and postoperative complications are rare. Limiting postoperative antibiotics to 24 h in gangrenous appendicitis may significantly decrease the cost of treatment without increasing morbidity. Copyright © 2012 Elsevier

Comparison of Antibiotic Therapy and Appendectomy for Acute Uncomplicated Appendicitis in Children

PubMed Central

Huang, Libin; Yin, Yuan; Yang, Lie; Wang, Cun; Zhou, Zongguang

2017-01-01

Importance Antibiotic therapy for acute uncomplicated appendicitis is effective in adult patients, but its application in pediatric patients remains controversial. Objective To compare the safety and efficacy of antibiotic treatment vs appendectomy as the primary therapy for acute uncomplicated appendicitis in pediatric patients. Data Sources The PubMed, MEDLINE, EMBASE, and Cochrane Library databases and the Cochrane Controlled Trials Register for randomized clinical trials were searched through April 17, 2016. The search was limited to studies published in English. Search terms included appendicitis, antibiotics, appendectomy, randomized controlled trial, controlled clinical trial, randomized, placebo, drug therapy, randomly, and trial. Study Selection Randomized clinical trials and prospective clinical controlled trials comparing antibiotic therapy with appendectomy for acute uncomplicated appendicitis in pediatric patients (aged 5-18 years) were included in the meta-analysis. The outcomes included at least 2 of the following terms: success rate of antibiotic treatment and appendectomy, complications, readmissions, length of stay, total cost, and disability days. Data Extraction and Synthesis Data were independently extracted by 2 reviewers. The quality of the included studies was examined in accordance with the Cochrane guidelines and the Newcastle-Ottawa criteria. Data were pooled using a logistic fixed-effects model, and the subgroup pooled risk ratio with or without appendicolith was estimated. Main Outcomes and Measures The primary outcome was the success rate of treatment. The hypothesis was formulated before data collection. Results A total of 527 articles were screened. In 5 unique studies, 404 unique patients with uncomplicated appendicitis (aged 5-15 years) were enrolled. Nonoperative treatment was successful in 152 of 168 patients (90.5%), with a Mantel-Haenszel fixed-effects risk ratio of 8.92 (95% CI, 2.67-29.79; heterogeneity, P = .99; I2�

Laparoscopy In Unexplained Abdominal Pain: Surgeon's Perspective.

PubMed

Abdullah, Muhammad Tariq; Waqar, Shahzad Hussain; Zahid, Muhammad Abdul

2016-01-01

Unexplained abdominal pain is a common but difficult presenting feature faced by the clinicians. Such patients can undergo a number of investigations with failure to reach any diagnosis. The objective of this study was to evaluate the use of laparoscopy in the diagnosis and management of patients with unexplained abdominal pain. This cross-sectional study was conducted at Pakistan Institute of Medical Sciences Islamabad from January 2009 to December 2013. This study included 91 patients of unexplained abdominal pain not diagnosed by routine clinical examination and investigations. These patients were subjected to diagnostic laparoscopy for evaluation of their conditions and to confirm the diagnosis. These patients presented 43% of patients undergoing investigations for abdominal pain. Patients diagnosed with gynaecological problems were excluded to see surgeon's perspective. The findings and the outcomes of the laparoscopy were recorded and data was analyzed. Unexplained abdominal pain is common in females than in males. The most common laparoscopic findings were abdominal tuberculosis followed by appendicitis. Ninety percent patients achieved pain relief after laparoscopic intervention. Laparoscopy is both beneficial and safe in majority of patients with unexplained abdominal pain. General surgeons should acquire training and experience in laparoscopic surgery to provide maximum benefit to these difficult patients.

Intra-Appendiceal Air at CT: Is It a Useful or a Confusing Sign for the Diagnosis of Acute Appendicitis?

PubMed Central

Cho, Hyun Suk; Woo, Ji Young; Lee, Yul; Yang, Ik; Hwang, Ji-Young; Kim, Han Myun; Kim, Jeong Won

2016-01-01

Objective To investigate the significance of intra-appendiceal air at CT for the evaluation of appendicitis. Materials and Methods We retrospectively analyzed 458 patients (216 men, 242 women; age range, 18-91 years) who underwent CT for suspected appendicitis. Two independent readers reviewed the CT. Prevalence, amount, and appearance of intra-appendiceal air were assessed and compared between the patients with and without appendicitis. Performance of CT diagnosis was evaluated in two reading strategies: once ignoring appendiceal air (strategy 1), and the other time considering presence of appendiceal air as indicative of no appendicitis in otherwise indeterminate cases (strategy 2), using receiver operating characteristic (ROC) analysis. Results Of the 458 patients, 102 had confirmed appendicitis. The prevalence of intra-appendiceal air was significantly different between patients with (13.2%) and without (79.8%) appendicitis (p < 0.001). The amount of appendiceal air was significantly lesser in patients having appendicitis as compared with the normal group, for both reader 1 (p = 0.011) and reader 2 (p = 0.002). Stool-like appearance and air-fluid levels were more common in the appendicitis group than in the normal appendix for both readers (p < 0.05). Areas under the ROC curves were not significantly different between strategies 1 and 2 in reader 1 (0.971 vs. 0.985, respectively; p = 0.056), but showed a small difference in reader 2 (0.969 vs. 0.986, respectively; p = 0.042). Conclusion Although significant differences were seen in the prevalence, amount, and appearance of intra-appendiceal air between patients with and without appendicitis, it has a limited incremental value for the diagnosis of acute appendicitis. PMID:26798214

Computed tomography use among children presenting to emergency departments with abdominal pain.

PubMed

Fahimi, Jahan; Herring, Andrew; Harries, Aaron; Gonzales, Ralph; Alter, Harrison

2012-11-01

To evaluate trends in and factors associated with computed tomography (CT) use among children presenting to the emergency department (ED) with abdominal pain. This study was a cross-sectional, secondary analysis of the National Hospital Ambulatory Medical Care Survey data from 1998 to 2008. We identified ED patients aged <19 years with abdominal pain and collected patient demographic and hospital characteristics, and outcomes related to imaging, hospital admission, and diagnosis of appendicitis. Trend analysis was performed over the study period for the outcomes of interest, and a multivariate regression model was used to identify factors associated with CT use. Of all pediatric ED visits, 6.0% were for abdominal pain. We noted a rise in the proportion of these patients with CT use, from 0.9% in 1998 to 15.4% in 2008 (P < .001), with no change in ultrasound/radiograph use, diagnosis of appendicitis, or hospital admission. Older and male patients were more likely to have a CT scan, whereas black children were one-half as likely to undergo a CT scan compared with white children (odds ratio: 0.50 [95% confidence interval: 0.31-0.81]). Admitted children had much higher odds of undergoing a CT scan (odds ratio: 4.11 [95% confidence interval: 2.66-6.35]). There was a plateau in CT use in 2006 to 2008. There was a dramatic increase in the utilization of CT imaging in the ED evaluation of pediatric patients with abdominal pain. Some groups of children may have a differential likelihood of receiving CT scans.

The use of pre- or postoperative antibiotics in surgery for appendicitis: a systematic review.

PubMed

Daskalakis, K; Juhlin, C; Påhlman, L

2014-03-01

The aim of this study was to review the literature regarding the use of pre- and/or postoperative antibiotics in the management of appendicitis, using data obtained from PubMed and the Cochrane Library. A literature search was conducted using the terms "appendicitis" combined with "antibiotics." Studies were selected based on relevance for the evidence on prophylactic and postoperative treatment with regard to the route and duration of drug administration and the findings of surgery. Patients with acute appendicitis should receive preoperative, broad-spectrum antibiotics. The use of postoperative antibiotics is only recommended in cases of perforation, and treatment should then be given intravenously, for a minimum period of 3-5 days for adult patients, until clinical signs such as fever resolve and laboratory parameters such as C-reactive protein curve and white blood cell (WBC) start to decline. Preoperative antibiotic prophylaxis is recommended in all patients with acute appendicitis, whereas postoperative antibiotics only in cases of perforation.

Cost-effectiveness analysis of weekday and weeknight or weekend shifts for assessment of appendicitis.

PubMed

Doria, Andrea S; Amernic, Heidi; Dick, Paul; Babyn, Paul; Chait, Peter; Langer, Jacob; Coyte, Peter C; Ungar, Wendy J

2005-12-01

Assessment of appendicitis during a weeknight or weekend shift (after-hours period, AHP) might be more costly and less effective than its assessment on a weekday shift (standard hours period, SHP) because of increased costs (staff premium fees) and perforation risk (longer delays and less experience of fellows). The objectives were to compare the costs and effectiveness of assessing children with suspected appendicitis who required a laparotomy and had US or CT after-hours with those of assessing children during standard hours, and to evaluate the importance of diagnostic imaging (DI) within the overall costs. We retrospectively microcosted resource use within six areas of a tertiary hospital (emergency [ED], diagnostic imaging (DI), surgery, wards, transport, and pathology) in a tertiary hospital. About 41 children (1.8-17 years) in the AHP and 35 (2.9-16 years) in the SHP were evaluated. Work shift effectiveness was measured with a histological score that assessed the severity of appendicitis (non-perforated appendicitis: scores 1-3; perforated appendicitis: score 4). The SHP was less costly and more effective regardless of whether the calculation included US or CT costs only. For a salary-based fee schedule, 733 US dollars were saved per case of perforated appendicitis averted in the SHP. For a fee-for-service payment schedule, 847 dollars were saved. Within the overall budget, the highest costs were those incurred on the ward for both shifts. The average cost per patient in DI ranged from 2 to 5% of the total costs in both shifts. Most perforation cases were found in the AHP (31.7%, AHP vs. 17.1%, SHP), which resulted in higher ward costs for patients in the AHP. A higher proportion of severe cases was seen in the AHP, which led to its higher costs. As a result, the SHP dominated the AHP, being less costly and more effective regardless of the fee schedule applied. The DI costs contributed little to the overall cost of the assessment of appendicitis.

Optimizing the interpretation of CT for appendicitis: modeling health utilities for clinical practice.

PubMed

Blackmore, C Craig; Terasawa, Teruhiko

2006-02-01

Error in radiology can be reduced by standardizing the interpretation of imaging studies to the optimum sensitivity and specificity. In this report, the authors demonstrate how the optimal interpretation of appendiceal computed tomography (CT) can be determined and how it varies in different clinical scenarios. Utility analysis and receiver operating characteristic (ROC) curve modeling were used to determine the trade-off between false-positive and false-negative test results to determine the optimal operating point on the ROC curve for the interpretation of appendicitis CT. Modeling was based on a previous meta-analysis for the accuracy of CT and on literature estimates of the utilities of various health states. The posttest probability of appendicitis was derived using Bayes's theorem. At a low prevalence of disease (screening), appendicitis CT should be interpreted at high specificity (97.7%), even at the expense of lower sensitivity (75%). Conversely, at a high probability of disease, high sensitivity (97.4%) is preferred (specificity 77.8%). When the clinical diagnosis of appendicitis is equivocal, CT interpretation should emphasize both sensitivity and specificity (sensitivity 92.3%, specificity 91.5%). Radiologists can potentially decrease medical error and improve patient health by varying the interpretation of appendiceal CT on the basis of the clinical probability of appendicitis. This report is an example of how utility analysis can be used to guide radiologists in the interpretation of imaging studies and provide guidance on appropriate targets for the standardization of interpretation.

Acute appendicitis in the public and private sectors in Cape Town, South Africa.

PubMed

Yang, Estin; Cook, Colin; Kahn, Delawir

2015-07-01

South Africa has a low incidence of acute appendicitis, but poor outcomes. However, South African studies on appendicitis focus solely on public hospitals, neglecting those who utilize private facilities. This study aims to compare appendicitis characteristics and outcomes in public and private hospitals in South Africa. A prospective cohort study was conducted among two public and three private hospitals in the Cape Town metropole, from September 2013 to March 2014. Hospital records, operative notes, and histology results were reviewed for patients undergoing appendectomy for acute appendicitis. Patients were interviewed during their hospitalization and followed up at monthly intervals until normal function was attained. A total of 134 patients were enrolled, with 73 in the public and 61 in the private sector. Education and employment were higher among private sector patients. Public sector patients had a higher rupture rate (30.6 vs 13.2 %, p = 0.023). Times to presentation were not statistically different between the two cohorts. Public sector patients had longer hospital stays (5.3 vs 2.9 days, p = 0.036) and longer return to work times (23.0 vs 12.1 days, p < 0.0001). Although complication rates were similar, complications in public hospitals were more severe. Public sector patients in South Africa with appendicitis have higher rupture rates, worse complications, longer hospital stays, and longer recoveries than private sector patients. Patients with perforation had longer delays in presentation than patients without perforation.

Biomarkers of acute appendicitis: systematic review and cost-benefit trade-off analysis.

PubMed

Acharya, Amish; Markar, Sheraz R; Ni, Melody; Hanna, George B

2017-03-01

Acute appendicitis is the most common surgical emergency and can represent a challenging diagnosis, with a negative appendectomy rate as high as 20 %. This review aimed to evaluate the clinical utility of individual biomarkers in the diagnosis of appendicitis and appraise the quality of these studies. A systematic review of the literature between January 2000 and September 2015 using of PubMed, OvidMedline, EMBASE and Google Scholar was conducted. Studies in which the diagnostic accuracy, statistical heterogeneity and predictive ability for severity of several biomarkers could be elicited were included. Information regarding costs and process times was retrieved from the regional laboratory. European surgeons blinded to these reviews were independently asked to rank which characteristics of biomarkers were most important in acute appendicitis to inform a cost-benefit trade-off. Sensitivity testing and the QUADAS-2 tool were used to assess the robustness of the analysis and study quality, respectively. Sixty-two studies met the inclusion criteria and were assessed. Traditional biomarkers (such as white cell count) were found to have a moderate diagnostic accuracy (0.75) but lower costs in the diagnosis of acute appendicitis. Conversely, novel markers (pro-calcitonin, IL 6 and urinary 5-HIAA) were found to have high process-related costs including analytical times, but improved diagnostic accuracy. QUADAS-2 analysis revealed significant potential biases in the literature. When assessing biomarkers, an appreciation of the trade-offs between the costs and benefits of individual biomarkers is needed. Further studies should seek to investigate new biomarkers and address concerns over bias, in order to improve the diagnosis of acute appendicitis.

Prospective Observational Study on acute Appendicitis Worldwide (POSAW).

PubMed

Sartelli, Massimo; Baiocchi, Gian L; Di Saverio, Salomone; Ferrara, Francesco; Labricciosa, Francesco M; Ansaloni, Luca; Coccolini, Federico; Vijayan, Deepak; Abbas, Ashraf; Abongwa, Hariscine K; Agboola, John; Ahmed, Adamu; Akhmeteli, Lali; Akkapulu, Nezih; Akkucuk, Seckin; Altintoprak, Fatih; Andreiev, Aurelia L; Anyfantakis, Dimitrios; Atanasov, Boiko; Bala, Miklosh; Balalis, Dimitrios; Baraket, Oussama; Bellanova, Giovanni; Beltran, Marcelo; Melo, Renato Bessa; Bini, Roberto; Bouliaris, Konstantinos; Brunelli, Daniele; Castillo, Adrian; Catani, Marco; Che Jusoh, Asri; Chichom-Mefire, Alain; Cocorullo, Gianfranco; Coimbra, Raul; Colak, Elif; Costa, Silvia; Das, Koray; Delibegovic, Samir; Demetrashvili, Zaza; Di Carlo, Isidoro; Kiseleva, Nadezda; El Zalabany, Tamer; Faro, Mario; Ferreira, Margarida; Fraga, Gustavo P; Gachabayov, Mahir; Ghnnam, Wagih M; Giménez Maurel, Teresa; Gkiokas, Georgios; Gomes, Carlos A; Griffiths, Ewen; Guner, Ali; Gupta, Sanjay; Hecker, Andreas; Hirano, Elcio S; Hodonou, Adrien; Hutan, Martin; Ioannidis, Orestis; Isik, Arda; Ivakhov, Georgy; Jain, Sumita; Jokubauskas, Mantas; Karamarkovic, Aleksandar; Kauhanen, Saila; Kaushik, Robin; Kavalakat, Alfie; Kenig, Jakub; Khokha, Vladimir; Khor, Desmond; Kim, Dennis; Kim, Jae I; Kong, Victor; Lasithiotakis, Konstantinos; Leão, Pedro; Leon, Miguel; Litvin, Andrey; Lohsiriwat, Varut; López-Tomassetti Fernandez, Eudaldo; Lostoridis, Eftychios; Maciel, James; Major, Piotr; Dimova, Ana; Manatakis, Dimitrios; Marinis, Athanasio; Martinez-Perez, Aleix; Marwah, Sanjay; McFarlane, Michael; Mesina, Cristian; Pędziwiatr, Michał; Michalopoulos, Nickos; Misiakos, Evangelos; Mohamedahmed, Ali; Moldovanu, Radu; Montori, Giulia; Mysore Narayana, Raghuveer; Negoi, Ionut; Nikolopoulos, Ioannis; Novelli, Giuseppe; Novikovs, Viktors; Olaoye, Iyiade; Omari, Abdelkarim; Ordoñez, Carlos A; Ouadii, Mouaqit; Ozkan, Zeynep; Pal, Ajay; Palini, Gian M; Partecke, Lars I; Pata, Francesco; Pędziwiatr, Michał; Pereira Júnior, Gerson A; Pintar, Tadeja; Pisarska, Magdalena; Ploneda-Valencia, Cesar F; Pouggouras, Konstantinos; Prabhu, Vinod; Ramakrishnapillai, Padmakumar; Regimbeau, Jean-Marc; Reitz, Marianne; Rios-Cruz, Daniel; Saar, Sten; Sakakushev, Boris; Seretis, Charalampos; Sazhin, Alexander; Shelat, Vishal; Skrovina, Matej; Smirnov, Dmitry; Spyropoulos, Charalampos; Strzałka, Marcin; Talving, Peep; Teixeira Gonsaga, Ricardo A; Theobald, George; Tomadze, Gia; Torba, Myftar; Tranà, Cristian; Ulrych, Jan; Uzunoğlu, Mustafa Y; Vasilescu, Alin; Occhionorelli, Savino; Venara, Aurélien; Vereczkei, Andras; Vettoretto, Nereo; Vlad, Nutu; Walędziak, Maciej; Yilmaz, Tonguç U; Yuan, Kuo-Ching; Yunfeng, Cui; Zilinskas, Justas; Grelpois, Gérard; Catena, Fausto

2018-01-01

Acute appendicitis (AA) is the most common surgical disease, and appendectomy is the treatment of choice in the majority of cases. A correct diagnosis is key for decreasing the negative appendectomy rate. The management can become difficult in case of complicated appendicitis. The aim of this study is to describe the worldwide clinical and diagnostic work-up and management of AA in surgical departments. This prospective multicenter observational study was performed in 116 worldwide surgical departments from 44 countries over a 6-month period (April 1, 2016-September 30, 2016). All consecutive patients admitted to surgical departments with a clinical diagnosis of AA were included in the study. A total of 4282 patients were enrolled in the POSAW study, 1928 (45%) women and 2354 (55%) men, with a median age of 29 years. Nine hundred and seven (21.2%) patients underwent an abdominal CT scan, 1856 (43.3%) patients an US, and 285 (6.7%) patients both CT scan and US. A total of 4097 (95.7%) patients underwent surgery; 1809 (42.2%) underwent open appendectomy and 2215 (51.7%) had laparoscopic appendectomy. One hundred eighty-five (4.3%) patients were managed conservatively. Major complications occurred in 199 patients (4.6%). The overall mortality rate was 0.28%. The results of the present study confirm the clinical value of imaging techniques and prognostic scores. Appendectomy remains the most effective treatment of acute appendicitis. Mortality rate is low.

Standardized ultrasound templates for diagnosing appendicitis reduce annual imaging costs.

PubMed

Nordin, Andrew B; Sales, Stephen; Nielsen, Jason W; Adler, Brent; Bates, David Gregory; Kenney, Brian

2018-01-01

Ultrasound is preferred over computed tomography (CT) for diagnosing appendicitis in children to avoid undue radiation exposure. We previously reported our experience in instituting a standardized appendicitis ultrasound template, which decreased CT rates by 67.3%. In this analysis, we demonstrate the ongoing cost savings associated with using this template. Retrospective chart review for the time period preceding template implementation (June 2012-September 2012) was combined with prospective review through December 2015 for all patients in the emergency department receiving diagnostic imaging for appendicitis. The type of imaging was recorded, and imaging rates and ultrasound test statistics were calculated. Estimated annual imaging costs based on pretemplate ultrasound and CT utilization rates were compared with post-template annual costs to calculate annual and cumulative savings. In the pretemplate period, ultrasound and CT rates were 80.2% and 44.3%, respectively, resulting in a combined annual cost of $300,527.70. Similar calculations were performed for each succeeding year, accounting for changes in patient volume. Using pretemplate rates, our projected 2015 imaging cost was $371,402.86; however, our ultrasound rate had increased to 98.3%, whereas the CT rate declined to 9.6%, yielding an annual estimated cost of $224,853.00 and a savings of $146,549.86. Since implementation, annual savings have steadily increased for a cumulative cost savings of $336,683.83. Standardizing ultrasound reports for appendicitis not only reduces the use of CT scans and the associated radiation exposure but also decreases annual imaging costs despite increased numbers of imaging studies. Continued cost reduction may be possible by using diagnostic algorithms. Copyright © 2017 Elsevier Inc. All rights reserved.

Measuring Anatomic Severity in Pediatric Appendicitis: Validation of the American Association for the Surgery of Trauma Appendicitis Severity Grade.

PubMed

Hernandez, Matthew C; Polites, Stephanie F; Aho, Johnathon M; Haddad, Nadeem N; Kong, Victor Y; Saleem, Humza; Bruce, John L; Laing, Grant L; Clarke, Damian L; Zielinski, Martin D

2018-01-01

To assess whether the American Association for the Surgery of Trauma (AAST) grading system accurately corresponds with appendicitis outcomes in a US pediatric population. This single-institution retrospective review included patients <18 years of age (n = 331) who underwent appendectomy for acute appendicitis from 2008 to 2012. Demographic, clinical, procedural, and follow-up data (primary outcome was measured as Clavien-Dindo grade of complication severity) were abstracted. AAST grades were generated based on intraoperative findings. Summary, univariate, and multivariable regression analyses were performed to compare AAST grade and outcomes. Overall, 331 patients (46% female) were identified with a median age of 12 (IQR, 8-15) years. Appendectomy was laparoscopic in 90% and open in 10%. AAST grades included: Normal (n = 13, 4%), I (n = 152, 46%), II (n = 90, 27%), III (n = 43, 13%), IV (n = 24 7.3%), and V (n = 9 2.7%). Increased AAST grade was associated with increased Clavien-Dindo severity, P =.001. The overall complication rate was 13.6% and was comprised by superficial surgical site infection (n = 13, 3.9%), organ space infection (n = 15, 4.5%), and readmission (n = 17, 5.1%). Median duration of stay increased with AAST grade (P < .0001). Nominal logistic regression identified the following as predictors of any complication (P < .05): AAST grade and febrile temperature at admission. The AAST appendicitis grading system is valid in a single-institution pediatric population. Increasing AAST grade incrementally corresponds with patient outcomes including increased risk of complications and severity of complications. Determination of the generalizability of this grading system is required. Copyright © 2017 Elsevier Inc. All rights reserved.

Diagnostic imaging for acute appendicitis: interfacility differences in practice patterns.

PubMed

Michailidou, Maria; Sacco Casamassima, Maria G; Karim, Omar; Gause, Colin; Salazar, Jose H; Goldstein, Seth D; Abdullah, Fizan

2015-04-01

To evaluate trends and factors associated with interfacility differences in imaging modality selection in the diagnosis and management of children with suspected acute appendicitis. We conducted a retrospective review of diagnostic imaging selection and outcomes in patients <20 years of age who underwent appendectomy at a single Children's Hospital from June 2008 to June 2013. These results were then compared with those of referring hospitals. A total of 232 children underwent appendectomy during the study period. Imaging results contributed to diagnostic and management decisions in 95.3 % of cases. CT scan was utilized as first-line imaging in 50 % of cases. CTs were preferentially performed at referring institutions (78 vs. 46 %, p < 0.001). Children were five times more likely to undergo CT at referring institutions (OR = 5.5, CI 3.0-10.2). Adjusting for demographics and Alvarado score, diagnostic imaging choice was independent of patient's clinical status. This study demonstrates that initial presentation to a referring hospital independently predicts the use of CT scan for suspected acute appendicitis. Further efforts should be undertaken to develop a clinical pathway that minimizes radiation exposure in the diagnosis of acute appendicitis, with focus on access to pediatric abdominal ultrasound.

Home Antibiotics at Discharge for Pediatric Complicated Appendicitis: Friend or Foe?

PubMed

Anderson, K Tinsley; Bartz-Kurycki, Marisa A; Kawaguchi, Akemi L; Austin, Mary T; Holzmann-Pazgal, Galit; Kao, Lillian S; Lally, Kevin P; Tsao, Kuojen

2018-04-20

The role of home antibiotics (HA) at discharge in children after perforated appendicitis is unclear. This study evaluates the outcomes of complicated appendicitis in patients being discharged with or without HA after initial operation and inpatient treatment. The 2015 and 2016 NSQIP-Pediatric database was queried for patients younger than 18 years of age with complicated appendicitis. Home antibiotics were prescribed or not (no home antibiotics [NHA]). Patients were stratified based on presence or absence of predischarge surgical site infection (SSI) and postoperative day of discharge (≤5 days or >5 days). The primary end point was 30-day postdischarge composite morbidity, including emergency department visit, readmission, postdischarge reoperation, and SSI. Multivariable logistic regression was used to adjust for baseline covariables. Of 6,412 patients with complicated appendicitis, the majority were discharged with HA (HA 56.4%; NHA 43.6%). Patients receiving HA had higher preoperative leukocytosis, longer procedures, higher incidence of sepsis, more predischarge SSIs, and longer length of stay than the NHA cohort (all p < 0.01), suggesting greater severity of illness. In adjusted multivariable models, HA patients without a predischarge SSI had higher postdischarge morbidity (adjusted odds ratio [aOR] 1.22; 95% CI 1.04 to 1.44), as did HA patients discharged ≤5 days post operation (aOR 1.28; 95% CI 1.04 to 1.57) compared with NHA patients. Composite morbidity was similar between NHA and HA patients with predischarge SSIs (aOR 1.06; 95% CI 0.56 to 2.00) or who were discharged >5 days post operation (aOR 1.14; 95% CI 0.89 to 1.46). Although the majority of pediatric patients with complicated appendicitis are discharged with HA, NSQIP-Pediatric data suggest there is no evidence of a significant benefit. There might be a cohort of patients with more severe disease who require continued antibiotics. Copyright © 2018 American College of Surgeons. Published by

Imaging for Appendicitis: Should Radiation-induced Cancer Risks Affect Modality Selection?

PubMed Central

Kiatpongsan, Sorapop; Meng, Lesley; Eisenberg, Jonathan D.; Herring, Maurice; Avery, Laura L.; Kong, Chung Yin

2014-01-01

Purpose To compare life expectancy (LE) losses attributable to three imaging strategies for appendicitis in adults—computed tomography (CT), ultrasonography (US) followed by CT for negative or indeterminate US results, and magnetic resonance (MR) imaging—by using a decision-analytic model. Materials and Methods In this model, for each imaging strategy, LE losses for 20-, 40-, and 65-year-old men and women were computed as a function of five key variables: baseline cohort LE, test performance, surgical mortality, risk of death from delayed diagnosis (missed appendicitis), and LE loss attributable to radiation-induced cancer death. Appendicitis prevalence, test performance, mortality rates from surgery and missed appendicitis, and radiation doses from CT were elicited from the published literature and institutional data. LE loss attributable to radiation exposure was projected by using a separate organ-specific model that accounted for anatomic coverage during a typical abdominopelvic CT examination. One- and two-way sensitivity analyses were performed to evaluate effects of model input variability on results. Results Outcomes across imaging strategies differed minimally—for example, for 20-year-old men, corresponding LE losses were 5.8 days (MR imaging), 6.8 days (combined US and CT), and 8.2 days (CT). This order was sensitive to differences in test performance but was insensitive to variation in radiation-induced cancer deaths. For example, in the same cohort, MR imaging sensitivity had to be 91% at minimum (if specificity were 100%), and MR imaging specificity had to be 62% at minimum (if sensitivity were 100%) to incur the least LE loss. Conversely, LE loss attributable to radiation exposure would need to decrease by 74-fold for combined US and CT, instead of MR imaging, to incur the least LE loss. Conclusion The specific imaging strategy used to diagnose appendicitis minimally affects outcomes. Paradigm shifts to MR imaging owing to concerns over

Utility of Magnetic Resonance Imaging for the Diagnosis of Appendicitis During Pregnancy: A Canadian Experience.

PubMed

Burns, Michael; Hague, Cameron J; Vos, Patrick; Tiwari, Pari; Wiseman, Sam M

2017-11-01

The objective of the study was to evaluate the performance of magnetic resonance imaging (MRI) for the diagnosis of appendicitis during pregnancy. We conducted a retrospective review of all MRI scans performed at our institution, between 2006 and 2012, for the evaluation of suspected appendicitis in pregnant women. Details of the MRI scans performed were obtained from the radiology information system as well as details of any ultrasounds carried out for the same indication. Clinical and pathological data were obtained by retrospective chart review. The study population comprised 63 patients, and 8 patients underwent a second MRI scan during the same pregnancy. A total of 71 MRI scans were reviewed. The appendix was identified on 40 scans (56.3%). Sensitivity of MRI was 75% and specificity was 100% for the diagnosis of appendicitis in pregnant women. When cases with right lower quadrant inflammatory fat stranding or focal fluid, without appendix visualization, were classified as positive for appendicitis, MRI sensitivity increased to 81.3% but specificity decreased to 96.4%. MRI is sensitive and highly specific for the diagnosis of appendicitis during pregnancy and should be considered as a first line imaging study for this clinical presentation. Copyright © 2017 Canadian Association of Radiologists. Published by Elsevier Inc. All rights reserved.

Lack of utility of measuring serum bilirubin concentration in distinguishing perforation status of pediatric appendicitis.

PubMed

Bonadio, William; Bruno, Santina; Attaway, David; Dharmar, Logesh; Tam, Derek; Homel, Peter

2017-06-01

Pediatric appendicitis is a common, potentially serious condition. Determining perforation status is crucial to planning effective management. Determine the efficacy of serum total bilirubin concentration [STBC] in distinguishing perforation status in children with appendicitis. Retrospective review of 257 cases of appendicitis who received abdominal CT scan and measurement of STBC. There were 109 with perforation vs 148 without perforation. Although elevated STBC was significantly more common in those with [36%] vs without perforation [22%], the mean difference in elevated values between groups [0.1mg/dL] was clinically insignificant. Higher degrees of hyperbilirubinemia [>2mg/dL] were rarely encountered [5%]. Predictive values for elevated STBC in distinguishing perforation outcome were imprecise [sensitivity 38.5%, specificity 78.4%, PPV 56.8%, NPV 63.4%]. ROC curve analysis of multiple clinical and other laboratory factors for predicting perforation status was unenhanced by adding the STBC variable. Specific analysis of those with perforated appendicitis and percutaneously-drained intra-abdominal abscess which was culture-positive for Escherichia coli showed an identical rate of STBC elevation compared to all with perforation. The routine measurement of STBC does not accurately distinguish perforation status in children with appendicitis, nor discern infecting organism in those with perforation and intra-abdominal abscess. Copyright © 2017 Elsevier Inc. All rights reserved.

Pediatric appendicitis rupture rate: a national indicator of disparities in healthcare access.

PubMed

Jablonski, Kathleen A; Guagliardo, Mark F

2005-05-04

BACKGROUND: The U.S. National Healthcare Disparities Report is a recent effort to measure and monitor racial and ethnic disparities in health and healthcare. The Report is a work in progress and includes few indicators specific to children. An indicator worthy of consideration is racial/ethnic differences in the rate of bad outcomes for pediatric acute appendicitis. Bad outcomes for this condition are indicative of poor access to healthcare, which is amenable to social and healthcare policy changes. METHODS: We analyzed the KID Inpatient Database, a nationally representative sample of pediatric hospitalization, to compare rates of appendicitis rupture between white, African American, Hispanic and Asian children. We ran weighted logistic regression models to obtain national estimates of relative odds of rupture rate for the four groups, adjusted for developmental, biological, socioeconomic, health services and hospital factors that might influence disease outcome. RESULTS: Rupture was a much more burdensome outcome than timely surgery and rupture avoidance. Rupture cases had 97% higher hospital charges and 175% longer hospital stays than non-rupture cases on average. These burdens disproportionately affected minority children, who had 24% - 38% higher odds of appendicitis rupture than white children, adjusting for age and gender. These differences were reduced, but remained significant after adjusting for other factors. CONCLUSION: The racial/ethnic disparities in pediatric appendicitis outcome are large and are preventable with timely diagnosis and surgery for all children. Furthermore, estimating this disparity using the KID survey is a relatively straightforward process. Therefore pediatric appendicitis rupture rate is a good candidate for inclusion in the National Healthcare Disparities Report. As with most other health and healthcare disparities, efforts to reduce disparities in income, wealth and access to care will most likely improve the odds of favorable

Diagnostic Performance of Ultrasonography for Pediatric Appendicitis: A Night and Day Difference?

PubMed

Mangona, Kate Louise M; Guillerman, R Paul; Mangona, Victor S; Carpenter, Jennifer; Zhang, Wei; Lopez, Monica; Orth, Robert C

2017-12-01

For imaging pediatric appendicitis, ultrasonography (US) is preferred because of its lack of ionizing radiation, but is limited by operator dependence. This study investigates the US diagnostic performance during night shifts covered by radiology trainees compared to day shifts covered by attending radiologists. Appy-Scores (1 = completely visualized normal appendix; 2 = partially visualized normal appendix; 3 = nonvisualized appendix with no inflammatory changes in the expected region of the appendix; 4 = equivocal; 5a = nonperforated appendicitis; 5b = perforated appendicitis) from 2935 US examinations (2161:774, day-to-night) from July 2013 to 2014 were correlated with the intraoperative diagnoses and the clinical follow-up. The diagnostic performance of trainees and attendings was compared with Fisher exact test. Interobserver agreement was measured by Cohen kappa coefficient. Appendicitis prevalence was 25.3% (day) and 22.5% (night). Sensitivity, specificity, accuracy, negative predictive value, and positive predictive vale were 94.0%, 93.7%, 93.8%, 97.9%, and 83.4% during the day and 92.0%, 91.2%, 91.3%, 97.5%, and 75.2% at night. Specificity (P = .048) and positive predictive value (P = .011) differed, with more false positives at night (7%) than during the day (4.7%). Trainee and attending agreement was high (k = 0.995), with Appy-Scores of 1, 4, and 5a most frequently discordant. US has a high diagnostic performance and interobserver agreement for pediatric appendicitis when interpreted by radiology trainees during night shifts or attending radiologists during day shifts. However, lower specificity and positive predictive value at night warrants a thorough trainee education to avoid false-positive examinations. Published by Elsevier Inc.

Chronic active Epstein-Barr virus infection mimicking Henoch-Schönlein purpura.

PubMed

Guissa, Vanessa R; Aragão, Paula A; Marques, Heloisa H; Jacob, Cristina M; Silva, Clovis A

2010-01-01

Chronic active Epstein-Barr virus (CAEBV) infection is characterized by chronic or recurrent symptoms for at least 3 months, such as fever, hepatosplenomegaly and lymphadenopathy. The diagnosis is established due to the presence of anti-EBV antibodies or isolation of this infectious agent in affected tissues. Three cases of CAEBV infection mimicking Henoch-Schönlein purpura (HSP) were described. CASE 1: Female 3-year old patient with cervical adenomegaly, anemia and fever developed palpable purpura, haematuria and arthritis. CAEBV infection was established by serology test. She received methylprednisolone and acyclovir. She had generalized lymphadenopathy, hepatomegaly, splenomegaly, disseminated intravascular coagulation and deceased. CASE 2: Male 12-year old patient with persistent anemia, lymphadenopathy, hepatomegaly and splenomegaly had CAEBV infection diagnosis by serology test. He developed purpura and arthritis and received methylprednisolone. CASE 3: Male 13-year old patient had purpura, abdominal pain, haematuria, hepatomegaly, splenomegaly, lymphadenopathy, anemia and elevated liver enzymes. The cervical lymph node biopsy was positive to EBV infection. He received methylprednisolone and acyclovir, developing acute fulminant hepatitis and death. CAEBV infection mimicking HSP was rarely observed in our population.

Regional variation in rates of pediatric perforated appendicitis.

PubMed

Sarda, Samir; Short, Heather L; Hockenberry, Jason M; McCarthy, Ian; Raval, Mehul V

2017-09-01

While trends in perforated appendicitis (PA) rates have been studied, regional variability in pediatric admissions for PA remains unknown. A retrospective, cross-sectional analysis of the 2006-2012 Kids' Inpatient Database was conducted to examine variation in PA admission rates by region of the United States and insurance status. PA rates were calculated and reported as per 1000 admissions in accordance with national quality measure specifications. National PA rates per 1000 admissions for 2006, 2009, and 2012 were 313.9, 279.2, and 309.1, respectively. Similarly, all regions demonstrated a statistically significant decrease in PA rates between 2006 and 2009 (p<0.001), where the increase in rates between 2009 and 2012 was only statistically significant in the Midwest [Odds Ratio (OR) 1.07; 95% Confidence Interval (95%CI) 1.03-1.12] and West (OR 1.10; 95% CI 1.07-1.14). The Northeast consistently experienced the lowest PA rates. The odds of PA were highest among uninsured patients (OR 1.35; 95% CI 1.31-1.29). The South had the highest proportion of uninsured children, and these patients had the highest odds of perforation (OR 1.57; 95% CI 1.21-2.02). For children with appendicitis, geographic region and insurance status appear to be associated with perforation upon presentation. Understanding regional variation in pediatric PA rates may inform health policymakers in the constantly evolving insurance coverage landscape. Level III Treatment Study - Retrospective comparative study of appendicitis presentation in children by region of the country. Copyright © 2017 Elsevier Inc. All rights reserved.

The Stranded Stone: Relationship Between Acute Appendicitis and Appendicolith

PubMed Central

Aljefri, Ahmad; Al-Nakshabandi, Nizar

2009-01-01

Background/Aim: To examine the relationship between acute appendicitis and the presence of an appendicolith in abdominal CT scans of patients attending emergency services. Materials and Methods: Abdominal CT scan reports were retrospectively reviewed for 267 patients through the PACS database. A 16-slices MDCT GE Light Speed scanner (Milwaukee WI) was used with a scanning protocol of 5 mm axial collimation and a pitch of 1.0, along with oral contrast material (Gastrografin 3.7% diatrizoate meglumine) and 140 mL of intravenous (IV) nonionic contrast material (Omnipaque). Particular attention was given to the study protocol, patients' age, and gender. Statistical Analysis: We used MS-EXCEL and SPSS version 12.0 to perform chi-square and Fisher's exact tests. Bookends and Papers, components in Mac OS X software, were used for literature reviews and the organization of results. Results: Two hundred and sixty-seven abdominal CT scan reports were examined along side their respective images on a GE Centricity workstation. Thirty-four (12.7%) were labeled as acute appendicitis cases based on the CT findings and the rest were assigned other diagnoses. Twenty-six of the 267 CT scan reports were plain studies and 241 were contrast-enhanced scans. Less than half of the patients (123, 46.1%) were males and 144 (53.9%) were females. Thirteen males (48.1%) and 14 (51.9%) females were found to have an appendicolith. Only 3% in the ≤ 11 years' age group, in contrast to 40% in the 11-20 years' age group, was diagnosed with appendicitis. The incidence in other age groups was as follows: 19% in the 21-30, 14% in the 31-40, 2.5% in the 41-50, 8% each in the 51-60 and 61-70, and none in the ≥71 years' age groups. Conclusions: We conclude that the presence of an appendicolith i) has no particular predilection for gender or age, and ii) is not associated with a diagnosis of appendicitis. PMID:19794272

The Association Between Ventriculo-Peritoneal Shunt and Acute Appendicitis in Patients with Traumatic Brain Injury: A 14-Year, Population-Based Study.

PubMed

Lim, Sher-Wei; Ao, Kam-Hou; Ho, Chung-Han; Tseng, Chien-Jen; Wang, Jhi-Joung; Chio, Chung-Ching; Kuo, Jinn-Rung

2017-07-01

The association between preexisting ventriculoperitoneal (VP) shunt and the risk of new-onset acute appendicitis in patients with traumatic brain injury (TBI) is not well established. The aim of the present study was to determine the relationships between VP shunt and acute appendicitis in patients with TBI. A longitudinal cohort study matched by a propensity score in patients with TBI with (4781 patients) or without (9562 patients) VP shunt was conducted using the National Health Insurance Research Database in Taiwan between January 1993 and December 2013. The main outcome studied was diagnosis of acute appendicitis. The cumulative probability of acute appendicitis was not different between these 2 groups (P = 0.6244). A Cox model showed central nervous system (CNS) infection to be an independent predictor of acute appendicitis with an adjusted hazard ratio of 2.98. Patients with TBI with both a VP shunt and a CNS infection had a greater risk of developing new-onset acute appendicitis (hazard ratio 4.25; 95% confidence interval 1.84-9.81) compared patients with TBI without a VP shunt or CNS infection. We concluded that VP shunt is not a risk factor in the development of appendicitis in patients with TBI. Patients with TBI with a shunt and a CNS infection may have a greater risk of developing acute appendicitis. Therefore, care in avoiding CNS infection is a key for the prevention acute appendicitis in this patient population. Copyright © 2017 Elsevier Inc. All rights reserved.

Culture-Independent Evaluation of the Appendix and Rectum Microbiomes in Children with and without Appendicitis

PubMed Central

Davenport, Katherine P.; Fraser, Claire M.; Sandler, Anthony D.; Zeichner, Steven L.

2014-01-01

Purpose The function of the appendix is largely unknown, but its microbiota likely contributes to function. Alterations in microbiota may contribute to appendicitis, but conventional culture studies have not yielded conclusive information. We conducted a pilot, culture-independent 16S rRNA-based microbiota study of paired appendix and rectal samples. Methods We collected appendix and rectal swabs from 21 children undergoing appendectomy, six with normal appendices and fifteen with appendicitis (nine perforated). After DNA extraction, we amplified and sequenced 16S rRNA genes and analyzed sequences using CLoVR. We identified organisms differing in relative abundance using ANOVA (p<0.05) by location (appendix vs. rectum), disease (appendicitis vs. normal), and disease severity (perforated vs. non-perforated). Results We identified 290 taxa in the study's samples. Three taxa were significantly increased in normal appendices vs. normal rectal samples: Fusibacter (p = 0.009), Selenomonas (p = 0.026), and Peptostreptococcus (p = 0.049). Five taxa were increased in abundance in normal vs. diseased appendices: Paenibacillaceae (p = 0.005), Acidobacteriaceae GP4 (p = 0.019), Pseudonocardinae (p = 0.019), Bergeyella (p = 0.019) and Rhizobium (p = 0.045). Twelve taxa were increased in the appendices of appendicitis patients vs. normal appendix: Peptostreptococcus (p = 0.0003), Bilophila (p = 0.0004), Bulleidia (p = 0.012), Fusobacterium (p = 0.018), Parvimonas (p = 0.003), Mogibacterium (p = 0.012), Aminobacterium (p = 0.019), Proteus (p = 0.028), Actinomycineae (p = 0.028), Anaerovorax (p = 0.041), Anaerofilum (p = 0.045), Porphyromonas (p = 0.010). Five taxa were increased in appendices in patients with perforated vs. nonperforated appendicitis: Bulleidia (p = 0.004), Fusibacter (p = 0.005), Prevotella (p = 0.021), Porphyromonas (p = 0.030), Dialister (p = 0.035). Three taxa

Use of an appendicitis medical information sheet in the pediatric primary care system.

PubMed

Oyachi, Noboru; Yagasaki, Hideaki; Suzuki, Takeyuki; Higashida, Kosuke; Komai, Takayuki; Hasuda, Norio; Takano, Kunio; Obana, Kazuko

2016-10-01

Accurate and prompt diagnosis is required for the primary evaluation of pediatric appendicitis. Among pediatricians and surgeons working in Yamanashi Prefecture, the pediatric appendicitis medical information (PAMI) sheet was edited in April 2011 to reflect the diagnostic results of the pediatric primary and emergency medical service and used as a referral document for surgical consultation to secondary hospitals. The PAMI sheet consisted of sections for history taking, symptoms, physical signs and laboratory findings without a scoring system. For 32 consecutive months starting in April 2011, 59 patients hospitalized for suspected appendicitis were retrospectively reviewed. In particular, a total of 17 referral patients evaluated with the PAMI sheet were assessed in order to evaluate the utility of the form. The pediatric surgeons were able to easily determine patient condition from the PAMI sheet. In total, 13 of 17 patients had appendicitis. According to the physical findings of the 17 studied patients, the judgment of right lower quadrant tenderness (κ = 0.63) and guarding (κ = 1.00) was consistent between the pediatric surgeons and primary attending pediatricians. The PAMI sheet aids in the collection of detailed history and objective data with a high level of accuracy, and provides useful referral diagnostic information to the secondary-level hospitals. © 2016 Japan Pediatric Society.

CONTRACT Study - CONservative TReatment of Appendicitis in Children (feasibility): study protocol for a randomised controlled Trial.

PubMed

Hutchings, Natalie; Wood, Wendy; Reading, Isabel; Walker, Erin; Blazeby, Jane M; Van't Hoff, William; Young, Bridget; Crawley, Esther M; Eaton, Simon; Chorozoglou, Maria; Sherratt, Frances C; Beasant, Lucy; Corbett, Harriet; Stanton, Michael P; Grist, Simon; Dixon, Elizabeth; Hall, Nigel J

2018-03-02

Currently, the routine treatment for acute appendicitis in the United Kingdom is an appendicectomy. However, there is increasing scientific interest and research into non-operative treatment of appendicitis in adults and children. While a number of studies have investigated non-operative treatment of appendicitis in adults, this research cannot be applied to the paediatric population. Ultimately, we aim to perform a UK-based multicentre randomised controlled trial (RCT) to test the clinical and cost effectiveness of non-operative treatment of acute uncomplicated appendicitis in children, as compared with appendicectomy. First, we will undertake a feasibility study to assess the feasibility of performing such a trial. The study involves a feasibility RCT with a nested qualitative research to optimise recruitment as well as a health economic substudy. Children (aged 4-15 years inclusive) diagnosed with acute uncomplicated appendicitis that would normally be treated with an appendicectomy are eligible for the RCT. Exclusion criteria include clinical/radiological suspicion of perforated appendicitis, appendix mass or previous non-operative treatment of appendicitis. Participants will be randomised into one of two arms. Participants in the intervention arm are treated with antibiotics and regular clinical assessment to ensure clinical improvement. Participants in the control arm will receive appendicectomy. Randomisation will be minimised by age, sex, duration of symptoms and centre. Children and families who are approached for the RCT will be invited to participate in the embedded qualitative substudy, which includes recording of recruitment consultants and subsequent interviews with participants and non-participants and their families and recruiters. Analyses of these will inform interventions to optimise recruitment. The main study outcomes include recruitment rate (primary outcome), identification of strategies to optimise recruitment, performance of trial treatment

Accuracy of Point-of-care Ultrasonography for Diagnosing Acute Appendicitis: A Systematic Review and Meta-analysis.

PubMed

Matthew Fields, J; Davis, Joshua; Alsup, Carl; Bates, Amanda; Au, Arthur; Adhikari, Srikar; Farrell, Isaac

2017-09-01

The use of ultrasonography (US) to diagnose appendicitis is well established. More recently, point-of-care ultrasonography (POCUS) has also been studied for the diagnosis of appendicitis, which may also prove a valuable diagnostic tool. The purpose of this study was through systematic review and meta-analysis to identify the test characteristics of POCUS, specifically US performed by a nonradiologist physician, in accurately diagnosing acute appendicitis in patients of any age. We conducted a thorough and systematic literature search of English language articles published on point-of-care, physician-performed transabdominal US used for the diagnosis of acute appendicitis from 1980 to May, 2015 using OVID MEDLINE In-Process & Other Non-indexed Citations and Scopus. Studies were selected and subsequently independently abstracted by two trained reviewers. A random-effects pooled analysis was used to construct a hierarchical summary receiver operator characteristic curve, and a meta-regression was performed. Quality of studies was assessed using the QUADAS-2 tool. Our search yielded 5,792 unique studies and we included 21 of these in our final review. Prevalence of disease in this study was 29.8%, (range = 6.4%-75.4%). The sensitivity and specificity for POCUS in diagnosing appendicitis were 91% (95% confidence interval [CI] = 83%-96%) and 97% (95% CI = 91%-99%), respectively. The positive and negative predictive values were 91 and 94%, respectively. Studies performed by emergency physicians had slightly lower test characteristics (sensitivity = 80%, specificity = 92%). There was significant heterogeneity between studies (I 2 = 99%, 95% CI = 99%-100%) and the quality of the reported studies was moderate, mostly due to unclear reporting of blinding of physicians and timing of scanning and patient enrollment. Several of the studies were performed by a single operator, and the education and training of the operators were variably reported. Point-of-care US has relatively

FREQUENCY OF WOUND INFECTION IN NON-PERFORATED APPENDICITIS WITH USE OF SINGLE DOSE PREOPERATIVE ANTIBIOTICS.

PubMed

Ali, Kishwar; Latif, Humera; Ahmad, Sajjad

2015-01-01

Antibiotics are used both pre and post-operatively in acute appendicitis for preventing wound infection. It has been observed that the routine use of post-operative antibiotics is not necessary in cases of non-perforated appendicitis as only prophylactic antibiotics are sufficient to prevent wound infection. The aim of this study was to see the frequency of wound infection in non-perforated appendicitis with single dose preoperative antibiotics only. This observational study was conducted at the Department of Surgery, Ayub Medical College, Abbottabad from May to November 2014. A total of 121 patients with non-perforated appendicitis were included in the study. Only single dose preoperative antibiotics were used. The patients were followed for wound infection till 8th post-operative day. 121 patients, 56 (46.28%) male and 65 (53.72%) female were included in the study. The mean age of patients was 27.41 +/- 7.12 years with an age range of 18 to 45 years. In the entire series, 7 (5.78%) patients developed wound infection. The infection was minor which settled with conservative therapy. Prophylactic antibiotics were found efficacious in 114 (94.21%) patients. There was no significant association between wound infection and age and gender. Single dose preoperative antibiotics were found effective in controlling post-operative wound infection without the need of extending the antibiotics to post-operative period in cases of non-perforated appendicitis.

The value of laparoscopy in acute pelvic pain.

PubMed Central

Anteby, S O; Schenker, J G; Polishuk, W Z

1975-01-01

Laparoscopy was performed in 223 patients with acute pelvic pain but without a definite diagnosis. The clinically suspected diagnosis was confirmed by laparoscopy in only 57 patients (25%). Laparotomy was thus avoided in 145 patients (65%). The endoscopic findings in the three clinical entities included here are presented: tubal pregnancy, acute appendicitis or torsion of adnexal mass. This study emphasizes the poor correlation between the clinical diagnosis based on history, pelvic examination and physical signs, and the final laparoscopic findings. The value of laparoscopy in evaluation of acute pelvic disease is stressed. PMID:124158

Spectral Doppler Waveforms for Diagnosis of Appendicitis: Potential Utility of Point Peak Systolic Velocity and Resistive Index Values.

PubMed

Shin, Lewis K; Jeffrey, R Brooke; Berry, Gerald J; Olcott, Eric W

2017-12-01

Purpose To test the hypothesis that appendiceal spectral Doppler waveforms can distinguish patients with and patients without appendicitis. Materials and Methods In this retrospective study, Doppler waveforms were obtained from intramural appendiceal arteries identified with color Doppler imaging in 60% (93 of 155) of consecutive patients whose appendices were visualized at graded compression ultrasonography (US) performed for suspected appendicitis (53 male and 40 female; age, 1-56 years; mean, 14.5 years) over the 5-month period from November 2015 through March 2016. Point, non-angle-corrected peak systolic velocity (PSV) and resistive index (RI) values were compared between patients with and patients without appendicitis by utilizing histopathologically proven appendicitis and 6-week clinical follow-up as diagnostic reference standards. Data were assessed by using the Student t test, exact binomial distribution, two-sample test of proportions, and receiver operating characteristic analysis. Results Among the 93 patients, 36 (38.7%) had proven appendicitis (mean PSV, 19.7 cm/sec; mean RI, 0.69) and 57 patients (61.2%) did not (mean PSV, 7.1 cm/sec, P < .0001; mean RI, 0.50, P < .0001). The area under the receiver operating characteristic curve for the diagnosis of appendicitis was 0.97 (95% confidence interval [CI]: 0.95, 1.00) for PSV and 0.86 (95% CI: 0.78, 0.95; P = .011) for RI. Chosen discriminatory criteria of PSV greater than 10 cm/sec and RI greater than 0.65 yielded specificity for appendicitis of 94.7% and 96.5% with sensitivity of 88.9% and 63.9% (P = .013) and negative predictive value of 93.1% and 80.9% (P = .045), respectively. Original clinical graded compression US interpretations based on established US findings demonstrated specificity of 96.2% and sensitivity of 100.0%. Considering the subset of 20 patients whose maximum outer diameter measured 6-8 mm, the discriminatory criteria of PSV greater than 10 cm/sec and RI greater than 0.65 yielded

MRI of suspected appendicitis during pregnancy: interradiologist agreement, indeterminate interpretation and the meaning of non-visualization of the appendix.

PubMed

Tsai, Richard; Raptis, Constantine; Fowler, Kathryn J; Owen, Joseph W; Mellnick, Vincent M

2017-11-01

To determine the degree of interradiologist agreement between the MRI features of appendicitis during pregnancy, the outcomes associated with an indeterminate interpretation and the negative predictive value of non-visualization of the appendix. Our study was approved by the institutional review board at the Washington University in St. Louis, Missouri (WUStL) and was HIPAA (Health Insurance Portability and Accountability Act of 1996)-compliant. The informed consent requirement was waived. Cases of suspected appendicitis during pregnancy evaluated using MRI were retrospectively identified using search queries. Scans were re-reviewed by two radiologists (7 and 9 years experience, respectively) to evaluate the interradiologist agreement of different MRI features of appendicitis during pregnancy (visualization of the appendix, appendiceal diameter, appendiceal wall thickening, periappendiceal fat stranding, fluid-filled appendix and periappendiceal fluid). The radiologists were blinded to patient outcome, patient intervention, laboratory data, demographic data and the original MRI reports. Clinical outcomes were documented by surgical pathology or clinical observation. Interradiologist agreement was analysed using Cohen's κ, while patient demographic and clinical data was analysed using Student's t-testing. 233 females with suspected appendicitis during pregnancy were evaluated using MRI over a 13-year period (mean age, 28.4 years; range, 17-38 years). There were 14 (6%) positive examinations for appendicitis during pregnancy, including 1 patient whose MRI was interpreted as negative, proven by surgical pathology. The presence of periappendiceal soft-tissue stranding and the final overall impression had the most interradiologist agreement (к = 0.81-1). There were no pregnant patients found to have acute appendicitis who had an indeterminate MR interpretation or when the appendix could not be visualized. The final impression by the two retrospectively reviewing

Postoperative antibiotic use and the incidence of intra-abdominal abscess in the setting of suppurative appendicitis: a retrospective analysis.

PubMed

Bae, Esther; Dehal, Ahmed; Franz, Vanessa; Joannides, Michael; Sakis, Nicholas; Scurlock, Joshua; Nguyen, Patrick; Hussain, Farabi

2016-12-01

Although guidelines exist for postoperative antibiotic use in acute appendicitis that is perforated, gangrenous, or simple/uncomplicated, there are less data about its use in suppurative appendicitis. Here, we targeted this subgroup of patients to determine whether postoperative antibiotic administration affects incidence of intra-abdominal abscess formation. We retrospectively examined 1,192 patients who underwent laparoscopic appendectomy for acute appendicitis at Kaiser Permanente Fontana Hospital between August 2010 and August 2013. Suppurative appendicitis was described for 143 (12%) patients. Fifty-two patients received postoperative antibiotics for at least 1 week on discharge home, 91 did not. Of 143 patients with suppurative appendicitis, 1 (1.9%) who received postoperative antibiotics came back with an intra-abdominal abscess within 1 month. Of the 91 patients in the no antibiotic group, 1 (1.1%) came back with an intra-abdominal abscess. The administration of postoperative antibiotic in the setting of suppurative appendicitis has no effect on the rate of intra-abdominal abscess formation. Routine postoperative antibiotics may not be necessary in this patient population, and more evidence is needed to justify its use. Copyright © 2016 Elsevier Inc. All rights reserved.

The prevalence of appendiceal fecaliths in patients with and without appendicitis. A comparative study from Canada and South Africa.

PubMed Central

Jones, B A; Demetriades, D; Segal, I; Burkitt, D P

1985-01-01

Appendicitis is more common in developed than in developing societies and appendiceal fecaliths are thought to have an etiologic role in the disease. The geographic distribution of appendiceal fecaliths was investigated by systematic, intraoperative palpation of the appendix in patients in Toronto, Canada and Johannesburg, South Africa. The incidences of fecaliths found on pathologic sectioning of the appendix in appendicitis patients in both societies were compared. In the Canadian population, the prevalence of fecaliths in patients whose appendices were palpated incidentally was 32% versus 52% for those with appendicitis (p less than 0.01). In the African population, the prevalence of fecaliths in patients whose appendices were palpated incidentally was four per cent versus 23% for those with appendicitis (p = 0.04). The difference in prevalence of incidental appendiceal fecaliths in the two populations was statistically significant (p less than 0.005). The prevalence of fecaliths is higher in developed countries, such as Canada, than in developing countries, such as Africa, and is also higher in patients with than in those without appendicitis. These data support the theory that the low-fiber diets consumed in developed countries lead to fecalith formation, which then predisposes to appendicitis. PMID:2990360

Differential diagnosis of jaw pain using informatics technology.

PubMed

Nam, Y; Kim, H-G; Kho, H-S

2018-05-21

This study aimed to deduce evidence-based clinical clues that differentiate temporomandibular disorders (TMD)-mimicking conditions from genuine TMD by text mining using natural language processing (NLP) and recursive partitioning. We compared the medical records of 29 patients diagnosed with TMD-mimicking conditions and 290 patients diagnosed with genuine TMD. Chief complaints and medical histories were preprocessed via NLP to compare the frequency of word usage. In addition, recursive partitioning was used to deduce the optimal size of mouth opening, which could differentiate TMD-mimicking from genuine TMD groups. The prevalence of TMD-mimicking conditions was more evenly distributed across all age groups and showed a nearly equal gender ratio, which was significantly different from genuine TMD. TMD-mimicking conditions were caused by inflammation, infection, hereditary disease and neoplasm. Patients with TMD-mimicking conditions frequently used "mouth opening limitation" (P < .001), but less commonly used words such as "noise" (P < .001) and "temporomandibular joint" (P < .001) than patients with genuine TMD. A diagnostic classification tree on the basis of recursive partitioning suggested that 12.0 mm of comfortable mouth opening and 26.5 mm of maximum mouth opening were deduced as the most optimal mouth-opening cutoff sizes. When the combined analyses were performed based on both the text mining and clinical examination data, the predictive performance of the model was 96.6% with 69.0% sensitivity and 99.3% specificity in predicting TMD-mimicking conditions. In conclusion, this study showed that AI technology-based methods could be applied in the field of differential diagnosis of orofacial pain disorders. © 2018 John Wiley & Sons Ltd.

Antibiotics versus appendectomy in the management of acute appendicitis: a review of the current evidence

PubMed Central

Fitzmaurice, Gerard J.; McWilliams, Billy; Hurreiz, Hisham; Epanomeritakis, Emanuel

2011-01-01

Background Acute appendicitis remains the most common cause of the acute abdomen in young adults, and the mainstay of treatment in most centres is an appendectomy. However, treatment for other intra-abdominal inflammatory processes, such as diverticulitis, consists initially of conservative management with antibiotics. The aim of this study was to determine the role of antibiotics in the management of acute appendicitis and to assess if appendectomy remains the gold standard of care. Methods A literature search using MEDLINE and the Cochrane Library identified studies published between 1999 and 2009, and we reviewed all relevant articles. The articles were critiqued using the Public Health Resource Unit (2006) appraisal tools. Results Our search yielded 41 papers, and we identified a total of 13 papers within the criteria specified. All of these papers, while posing pertinent questions and demonstrating the role of antibiotics as a bridge to surgery, failed to adequately justify their findings that antibiotics could be used as a definitive treatment of acute appendicitis. Conclusion Appendectomy remains the gold standard of treatment for acute appendicitis based on the current evidence. PMID:21651835

Antibiotics versus appendectomy in the management of acute appendicitis: a review of the current evidence.

PubMed

Fitzmaurice, Gerard J; McWilliams, Billy; Hurreiz, Hisham; Epanomeritakis, Emanuel

2011-10-01

Acute appendicitis remains the most common cause of the acute abdomen in young adults, and the mainstay of treatment in most centres is an appendectomy. However, treatment for other intra-abdominal inflammatory processes, such as diverticulitis, consists initially of conservative management with antibiotics. The aim of this study was to determine the role of antibiotics in the management of acute appendicitis and to assess if appendectomy remains the gold standard of care. A literature search using MEDLINE and the Cochrane Library identified studies published between 1999 and 2009, and we reviewed all relevant articles. The articles were critiqued using the Public Health Resource Unit (2006) appraisal tools. Our search yielded 41 papers, and we identified a total of 13 papers within the criteria specified. All of these papers, while posing pertinent questions and demonstrating the role of antibiotics as a bridge to surgery, failed to adequately justify their findings that antibiotics could be used as a definitive treatment of acute appendicitis. Appendectomy remains the gold standard of treatment for acute appendicitis based on the current evidence.

Diagnosis and management of acute appendicitis. EAES consensus development conference 2015.

PubMed

Gorter, Ramon R; Eker, Hasan H; Gorter-Stam, Marguerite A W; Abis, Gabor S A; Acharya, Amish; Ankersmit, Marjolein; Antoniou, Stavros A; Arolfo, Simone; Babic, Benjamin; Boni, Luigi; Bruntink, Marlieke; van Dam, Dieuwertje A; Defoort, Barbara; Deijen, Charlotte L; DeLacy, F Borja; Go, Peter Mnyh; Harmsen, Annelieke M K; van den Helder, Rick S; Iordache, Florin; Ket, Johannes C F; Muysoms, Filip E; Ozmen, M Mahir; Papoulas, Michail; Rhodes, Michael; Straatman, Jennifer; Tenhagen, Mark; Turrado, Victor; Vereczkei, Andras; Vilallonga, Ramon; Deelder, Jort D; Bonjer, Jaap

2016-11-01

Unequivocal international guidelines regarding the diagnosis and management of patients with acute appendicitis are lacking. The aim of the consensus meeting 2015 of the EAES was to generate a European guideline based on best available evidence and expert opinions of a panel of EAES members. After a systematic review of the literature by an international group of surgical research fellows, an expert panel with extensive clinical experience in the management of appendicitis discussed statements and recommendations. Statements and recommendations with more than 70 % agreement by the experts were selected for a web survey and the consensus meeting of the EAES in Bucharest in June 2015. EAES members and attendees at the EAES meeting in Bucharest could vote on these statements and recommendations. In the case of more than 70 % agreement, the statement or recommendation was defined as supported by the scientific community. Results from both the web survey and the consensus meeting in Bucharest are presented as percentages. In total, 46 statements and recommendations were selected for the web survey and consensus meeting. More than 232 members and attendees voted on them. In 41 of 46 statements and recommendations, more than 70 % agreement was reached. All 46 statements and recommendations are presented in this paper. They comprise topics regarding the diagnostic work-up, treatment indications, procedural aspects and post-operative care. The consensus meeting produced 46 statements and recommendations on the diagnostic work-up and management of appendicitis. The majority of the EAES members supported these statements. These consensus proceedings provide additional guidance to surgeons and surgical residents providing care to patients with appendicitis.

Differentiating perforated from non-perforated appendicitis on contrast-enhanced magnetic resonance imaging.

PubMed

Rosenbaum, Daniel G; Askin, Gulce; Beneck, Debra M; Kovanlikaya, Arzu

2017-10-01

The role of magnetic resonance imaging (MRI) in pediatric appendicitis is increasing; MRI findings predictive of appendiceal perforation have not been specifically evaluated. To assess the performance of MRI in differentiating perforated from non-perforated appendicitis. A retrospective review of pediatric patients undergoing contrast-enhanced MRI and subsequent appendectomy was performed, with surgicopathological confirmation of perforation. Appendiceal diameter and the following 10 MRI findings were assessed: appendiceal restricted diffusion, wall defect, appendicolith, periappendiceal free fluid, remote free fluid, restricted diffusion within free fluid, abscess, peritoneal enhancement, ileocecal wall thickening and ileus. Two-sample t-test and chi-square tests were used to analyze continuous and discrete data, respectively. Sensitivity and specificity for individual MRI findings were calculated and optimal thresholds for measures of accuracy were selected. Seventy-seven patients (mean age: 12.2 years) with appendicitis were included, of whom 22 had perforation. The perforated group had a larger mean appendiceal diameter and mean number of MRI findings than the non-perforated group (12.3 mm vs. 8.6 mm; 5.0 vs. 2.0, respectively). Abscess, wall defect and restricted diffusion within free fluid had the greatest specificity for perforation (1.00, 1.00 and 0.96, respectively) but low sensitivity (0.36, 0.25 and 0.32, respectively). The receiver operator characteristic curve for total number of MRI findings had an area under the curve of 0.92, with an optimal threshold of 3.5. A threshold of any 4 findings had the best ability to accurately discriminate between perforated and non-perforated cases, with a sensitivity of 82% and specificity of 85%. Contrast-enhanced MRI can differentiate perforated from non-perforated appendicitis. The presence of multiple findings increases diagnostic accuracy, with a threshold of any four findings optimally discriminating between

Acute suppurative appendicitis associated with Enterobius vermicularis: an incidental finding or a causative agent? A case report.

PubMed

Efared, Boubacar; Atsame-Ebang, Gabrielle; Soumana, Boubacar Marou; Tahiri, Layla; Hammas, Nawal; El Fatemi, Hinde; Chbani, Laila

2017-10-06

Histological acute appendicitis patterns associated with Enterobius vermicularis is an extremely rare finding. The exact role of this parasite in acute appendicitis is controversial as usually resected specimens show no evidence of histological inflammation. We present herein a case of a 21-year-old male Arabic patient who presented with clinical syndrome of acute appendicitis. Emergency appendectomy was performed and the histopathological examination of the resected specimen showed the presence of E. vermicularis as well as intense acute inflammatory patterns such as mucosal ulceration and suppurative necrosis. The post-operative course was uneventful and the patient was discharged with appropriate anti-helmintic drug prescription. Acute appendicitis due to E. vermicularis is a very rare occurrence. The histopathological analysis of resected specimens should pay special attention to search for this parasite for adequate post-operative treatment of patients.

Comparison of Antibiotic Therapy and Appendectomy for Acute Uncomplicated Appendicitis in Children: A Meta-analysis.

PubMed

Huang, Libin; Yin, Yuan; Yang, Lie; Wang, Cun; Li, Yuan; Zhou, Zongguang

2017-05-01

Antibiotic therapy for acute uncomplicated appendicitis is effective in adult patients, but its application in pediatric patients remains controversial. To compare the safety and efficacy of antibiotic treatment vs appendectomy as the primary therapy for acute uncomplicated appendicitis in pediatric patients. The PubMed, MEDLINE, EMBASE, and Cochrane Library databases and the Cochrane Controlled Trials Register for randomized clinical trials were searched through April 17, 2016. The search was limited to studies published in English. Search terms included appendicitis, antibiotics, appendectomy, randomized controlled trial, controlled clinical trial, randomized, placebo, drug therapy, randomly, and trial. Randomized clinical trials and prospective clinical controlled trials comparing antibiotic therapy with appendectomy for acute uncomplicated appendicitis in pediatric patients (aged 5-18 years) were included in the meta-analysis. The outcomes included at least 2 of the following terms: success rate of antibiotic treatment and appendectomy, complications, readmissions, length of stay, total cost, and disability days. Data were independently extracted by 2 reviewers. The quality of the included studies was examined in accordance with the Cochrane guidelines and the Newcastle-Ottawa criteria. Data were pooled using a logistic fixed-effects model, and the subgroup pooled risk ratio with or without appendicolith was estimated. The primary outcome was the success rate of treatment. The hypothesis was formulated before data collection. A total of 527 articles were screened. In 5 unique studies, 404 unique patients with uncomplicated appendicitis (aged 5-15 years) were enrolled. Nonoperative treatment was successful in 152 of 168 patients (90.5%), with a Mantel-Haenszel fixed-effects risk ratio of 8.92 (95% CI, 2.67-29.79; heterogeneity, P = .99; I2 = 0%). Subgroup analysis showed that the risk for treatment failure in patients with appendicolith increased, with a

Safety and efficacy of antibiotics compared with appendicectomy for treatment of uncomplicated acute appendicitis: meta-analysis of randomised controlled trials

PubMed Central

Varadhan, Krishna K; Neal, Keith R

2012-01-01

Objective To compare the safety and efficacy of antibiotic treatment versus appendicectomy for the primary treatment of uncomplicated acute appendicitis. Design Meta-analysis of randomised controlled trials. Population Randomised controlled trials of adult patients presenting with uncomplicated acute appendicitis, diagnosed by haematological and radiological investigations. Interventions Antibiotic treatment versus appendicectomy. Outcome measures The primary outcome measure was complications. The secondary outcome measures were efficacy of treatment, length of stay, and incidence of complicated appendicitis and readmissions. Results Four randomised controlled trials with a total of 900 patients (470 antibiotic treatment, 430 appendicectomy) met the inclusion criteria. Antibiotic treatment was associated with a 63% (277/438) success rate at one year. Meta-analysis of complications showed a relative risk reduction of 31% for antibiotic treatment compared with appendicectomy (risk ratio (Mantel-Haenszel, fixed) 0.69 (95% confidence interval 0.54 to 0.89); I2=0%; P=0.004). A secondary analysis, excluding the study with crossover of patients between the two interventions after randomisation, showed a significant relative risk reduction of 39% for antibiotic therapy (risk ratio 0.61 (0.40 to 0.92); I2=0%; P=0.02). Of the 65 (20%) patients who had appendicectomy after readmission, nine had perforated appendicitis and four had gangrenous appendicitis. No significant differences were seen for treatment efficacy, length of stay, or risk of developing complicated appendicitis. Conclusion Antibiotics are both effective and safe as primary treatment for patients with uncomplicated acute appendicitis. Initial antibiotic treatment merits consideration as a primary treatment option for early uncomplicated appendicitis. PMID:22491789

Primary omental gangrene mimicking appendicular perforation peritonitis-A case report.

PubMed

Kumar, A; Shah, J; Vaidya, P

2016-01-01

Primary omental torsion is a rare cause of acute abdomen in adults and presents with variable signs and symptoms. Establishing a preoperative diagnosis may be difficult in the emergency setting. It is rarely diagnosed preoperatively as it mimics common surgical emergencies such as acute appendicitis, appendicular perforation, acute cholecystitis and perforated peptic ulcers and can lead to the clinical deterioration of patient if missed A 47 years old male was taken to the operating room with a diagnosis of appendicular perforation peritonitis and during surgery was found to have a primary omental gangrene with pyoperitoneum, for which omentectomy and peritoneal lavage was performed. Torsion of the omentum is a condition in which the organ twists on its long axis to such an extent that its vascularity is compromised. Omental torsion can be primary (idiopathic) or secondary, depending on an underlying cause. Primary omental torsion was first described by Eitel in 1899. However, very few cases have been reported. Our case was a rare case presenting with omental gangrene with pyoperitoneum mimicking appendicular perforation peritonitis. Primary omental torsion is a rare diagnosis. A high index of clinical suspicion is required for a preoperative diagnosis. In doubtful cases a CT scan may be helpful. Surgical excision of the omentum remains the treatment of choice; however, conservative management may be attempted in an uncomplicated omental torsion. Copyright © 2016 The Authors. Published by Elsevier Ltd.. All rights reserved.

Enterobius Vermicularis-Associated Pelvic Inflammatory Disease in a Child.

PubMed

Mentessidou, Anastasia; Theocharides, Constantine; Patoulias, Ioannis; Panteli, Christina

2016-04-01

Enterobius vermicularis is the most highly prevalent intestinal worm in childhood and is generally considered of low pathogenicity. Little is known about the inflammatory complications of the female genital tract induced by E. vermicularis in childhood. A case of E. vermicularis-associated pelvic inflammatory disease with right salpingitis mimicking acute abdomen due to appendicitis in an 11-year-old girl is presented. E. vermicularis-related pelvic inflammatory disease should be included in the differential diagnosis of abdominal pain in children. Increased awareness is necessary to avoid an unnecessary surgery and to choose the correct antibiotic treatment. Copyright © 2016 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.

Antibiotics vs. Appendectomy for Acute Uncomplicated Appendicitis in Adults: Review of the Evidence and Future Directions.

PubMed

Huston, Jared M; Kao, Lillian S; Chang, Phillip K; Sanders, James M; Buckman, Sara; Adams, Charles A; Cocanour, Christine S; Parli, Sarah E; Grabowski, Julia; Diaz, Jose; Tessier, Jeffrey M; Duane, Therese M

2017-07-01

Acute appendicitis is the most common abdominal surgical emergency in the United States, with a lifetime risk of 7%-8%. The treatment paradigm for complicated appendicitis has evolved over the past decade, and many cases now are managed by broad-spectrum antibiotics. We determined the role of non-operative and operative management in adult patients with uncomplicated appendicitis. Several meta-analyses have attempted to clarify the debate. Arguably the most influential is the Appendicitis Acuta (APPAC) Trial. According to the non-inferiority analysis and a pre-specified non-inferiority margin of -24%, the APPAC did not demonstrate non-inferiority of antibiotics vs. appendectomy. Significantly, however, the operations were nearly always open, whereas the majority of appendectomies in the United States are done laparoscopically; and laparoscopic and open appendectomies are not equivalent operations. Treatment with antibiotics is efficacious more than 70% of the time. However, a switch to an antimicrobial-only approach may result in a greater probability of antimicrobial-associated collateral damage, both to the host patient and to antibiotic susceptibility patterns. A surgery-only approach would result in a reduction in antibiotic exposure, a consideration in these days of focus on antimicrobial stewardship. Future studies should focus on isolating the characteristics of appendicitis most susceptible to antibiotics, using laparoscopic operations as controls and identifying long-term side effects such as antibiotic resistance or Clostridium difficile colitis.

Bone tumor mimickers: A pictorial essay

PubMed Central

Mhuircheartaigh, Jennifer Ni; Lin, Yu-Ching; Wu, Jim S

2014-01-01

Focal lesions in bone are very common and many of these lesions are not bone tumors. These bone tumor mimickers can include numerous normal anatomic variants and non-neoplastic processes. Many of these tumor mimickers can be left alone, while others can be due to a significant disease process. It is important for the radiologist and clinician to be aware of these bone tumor mimickers and understand the characteristic features which allow discrimination between them and true neoplasms in order to avoid unnecessary additional workup. Knowing which lesions to leave alone or which ones require workup can prevent misdiagnosis and reduce patient anxiety. PMID:25114385

The role of preoperative graded compression ultrasound in detecting acute appendicitis and influencing the negative appendectomy rate.

PubMed

Shirah, Bader Hamza; Shirah, Hamza Asaad; Alhaidari, Wael Awad; Elraghi, Mohamed Ali; Chughtai, Mohammad Azam

2017-01-01

The diagnosis of acute appendicitis is mainly clinical and is correct in about 80% of patients, but 20-33% present with atypical findings, which resulted in a negative appendectomy rate of 20-30%. The graded compression ultrasound method in the diagnosis of acute appendicitis was reported with a sensitivity of 89%, and specificity of 95%. In this study, we aim to evaluate the graded compression ultrasonography in the diagnosis of acute appendicitis, its influence on the clinical judgment to operate, and its role in lowering the negative appendectomy rate. 1073 patients treated surgically for acute appendicitis between January 2005 and December 2014 were reviewed. Ultrasound findings, histopathological diagnosis, and positive or negative appendectomy rates were analyzed. 647 (60.3%) patients were males and 426 (39.7%) females. The mean age was 26.5 years. Positive ultrasound findings were recorded in 892 (83.13%), while negative findings were recorded in 181 (16.87%). Positive appendectomy was recorded in 983 (91.6%), while negative appendectomy was recorded in 90 (8.4%). The sensitivity was 83%, specificity was 100%, and the rate of negative appendectomy was 8.39%. Graded compression technique of ultrasound is a useful modality, in addition to the clinical judgment of the surgeon and clinical findings, in detecting true positive cases of acute appendicitis, and thus reducing the negative appendectomy rate. Values of 100% specificity, and 8.4% negative appendectomy rate, or better, could be achieved, when an experienced surgeon and a professional radiologist collaborate in the diagnosis of acute appendicitis.

Accuracy of low dose CT in the diagnosis of appendicitis in childhood and comparison with USG and standard dose CT.

PubMed

Yi, Dae Yong; Lee, Kyung Hoon; Park, Sung Bin; Kim, Jee Taek; Lee, Na Mi; Kim, Hyery; Yun, Sin Weon; Chae, Soo Ahn; Lim, In Seok

Computed tomography should be performed after careful consideration due to radiation hazard, which is why interest in low dose CT has increased recently in acute appendicitis. Previous studies have been performed in adult and adolescents populations, but no studies have reported on the efficacy of using low-dose CT in children younger than 10 years. Patients (n=475) younger than 10 years who were examined for acute appendicitis were recruited. Subjects were divided into three groups according to the examinations performed: low-dose CT, ultrasonography, and standard-dose CT. Subjects were categorized according to age and body mass index (BMI). Low-dose CT was a contributive tool in diagnosing appendicitis, and it was an adequate method, when compared with ultrasonography and standard-dose CT in terms of sensitivity (95.5% vs. 95.0% and 94.5%, p=0.794), specificity (94.9% vs. 80.0% and 98.8%, p=0.024), positive-predictive value (96.4% vs. 92.7% and 97.2%, p=0.019), and negative-predictive value (93.7% vs. 85.7% and 91.3%, p=0.890). Low-dose CT accurately diagnosed patients with a perforated appendix. Acute appendicitis was effectively diagnosed using low-dose CT in both early and middle childhood. BMI did not influence the accuracy of detecting acute appendicitis on low-dose CT. Low-dose CT is effective and accurate for diagnosing acute appendicitis in childhood, as well as in adolescents and young adults. Additionally, low-dose CT was relatively accurate, irrespective of age or BMI, for detecting acute appendicitis. Therefore, low-dose CT is recommended for assessing children with suspected acute appendicitis. Copyright © 2017. Published by Elsevier Editora Ltda.

Evaluation of modified Alvarado scoring system and RIPASA scoring system as diagnostic tools of acute appendicitis.

PubMed

Shuaib, Abdullah; Shuaib, Ali; Fakhra, Zainab; Marafi, Bader; Alsharaf, Khalid; Behbehani, Abdullah

2017-01-01

Acute appendicitis is the most common surgical condition presented in emergency departments worldwide. Clinical scoring systems, such as the Alvarado and modified Alvarado scoring systems, were developed with the goal of reducing the negative appendectomy rate to 5%-10%. The Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) scoring system was established in 2008 specifically for Asian populations. The aim of this study was to compare the modified Alvarado with the RIPASA scoring system in Kuwait population. This study included 180 patients who underwent appendectomies and were documented as having "acute appendicitis" or "abdominal pain" in the operating theatre logbook (unit B) from November 2014 to March 2016. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), diagnostic accuracy, predicted negative appendectomy and receiver operating characteristic (ROC) curve of the modified Alvarado and RIPASA scoring systems were derived using SPSS statistical software. A total of 136 patients were included in this study according to our criteria. The cut-off threshold point of the modified Alvarado score was set at 7.0, which yielded a sensitivity of 82.8% and a specificity of 56%. The PPV was 89.3% and the NPV was 42.4%. The cut-off threshold point of the RIPASA score was set at 7.5, which yielded a 94.5% sensitivity and an 88% specificity. The PPV was 97.2% and the NPV was 78.5%. The predicted negative appendectomy rates were 10.7% and 2.2% for the modified Alvarado and RIPASA scoring systems, respectively. The negative appendectomy rate decreased significantly, from 18.4% to 10.7% for the modified Alvarado, and to 2.2% for the RIPASA scoring system, which was a significant difference (P<0.001) for both scoring systems. Based on the results of this study, the RIPASA score is a simple scoring system with better sensitivity and specificity than the modified Alvarado scoring system in Asian populations. It consists of 14

Oral desmoplastic melanoma mimicking inflammatory hyperplasia.

PubMed

Jou, Adriana; Miranda, Fábio V; Oliveira, Márcia G; Martins, Manoela D; Rados, Pantelis V; Filho, Manoel S

2012-06-01

Desmoplastic melanoma (DM) arising in the oral cavity is a rare neoplasm that may be confused with a variety of non-melanocytic benign or malignant lesions. To present a case of DM in the oral mucosa mimicking fibrous inflammatory hyperplasia, discusses the difficulties involved in the diagnosis and offers a literature review on the clinicopathologic and immunohistochemincal aspects of this neoplasm. A 62-year-old white male, smoker, was referred with a chief complaint of pain and swelling in the palate. The oral examination revealed multiple brown-to-black patches and a non-pigmented sessile nodule located on the mucosa of the hard palate. The clinical diagnosis of the pigmented lesions was either oral melanosis or melanoma. The nodular lesion was clinically diagnosed as fibrous inflammatory hyperplasia. Incisional biopsy was performed on the pigmented lesion and the microscopic sections revealed a melanotic macule. The nodular lesions histologically revealed an amelanotic desmoplastic melanoma. Reactive lesions close to a pigmented area should be investigated with great care. © 2010 The Gerodontology Society and John Wiley & Sons A/S.

C-reactive Protein may Predict the Recurrence of Appendicitis in Children Formerly with Appendiceal Mass after Successful Non-operative Treatment.

PubMed

Chang, Yi-Jung; Chao, Hsun-Chin; Chen, Chyi-Liang; Chen, Shin-Yann; Yan, Dah-Chin; Tsai, Ming-Han

2017-08-01

This study identified factors associated with the recurrence of appendicitis in children with appendiceal masses after successful nonsurgical treatment. In this retrospective study, children who were diagnosed as having appendiceal masses after undergoing conservative treatment between 2000 and 2014 were enrolled and the medical records of those who did not undergo an interval appendectomy were reviewed. The clinical features and outcomes of patients with and those without recurrent appendicitis were compared. Regression analysis was used to identify risk factors of appendicitis recurrence. Seventy patients were included and successfully discharged after receiving nonsurgical treatment for appendiceal masses. Of the patients, 35 (50.0%) developed recurrent appendicitis and 85.7% (30/35) recurrences developed within 3 months. Multivariate analyses showed that patients with a higher serum C-reactive protein (CRP) level and peritonitis more frequently developed recurrence. The appendicitis recurrence rate was significantly higher in the patients with CRP levels of ≥103 mg/L with an odds ratio of 16.9 or in those with peritonitis with an odds ratio of 4.9. Children with appendiceal masses who develop peritonitis or have CRP levels of ≥103 mg/L have a higher recurrence rate of appendicitis and should undergo an interval appendectomy. Copyright © 2017. Published by Elsevier B.V.

Melorheostosis mimicking synovial osteochondromatosis.

PubMed

Wadhwa, Vibhor; Chhabra, Avneesh; Samet, Jonathan D

2014-01-01

Melorheostosis is an uncommon, sporadic, sclerosing bone lesion that may affect the adjacent soft tissues. It has been associated with many entities such as osteopoikilosis, soft tissue vascular malformations, bone and soft tissue tumors, nephrotic syndrome, segmental limb contractures, osteosarcoma, desmoid tumor, and mesenteric fibromatosis. Synovial osteochondromatosis is a benign neoplasia of the hyaline cartilage presenting as nodules in the subsynovial tissue of a joint or tendon sheath. The intra-articular extension of melorheostosis mimicking synovial osteochondromatosis has not been reported before. In this article, the authors describe an unusual case mimicking synovial chondromatosis arising as a result of melorheostosis and their characteristic imaging findings.

Improving ultrasound for appendicitis through standardized reporting of secondary signs.

PubMed

Partain, Kristin N; Patel, Adarsh U; Travers, Curtis; Short, Heather L; Braithwaite, Kiery; Loewen, Jonathan; Heiss, Kurt F; Raval, Mehul V

2017-08-01

Our aim was to implement a standardized US report that included secondary signs of appendicitis (SS) to facilitate accurate diagnosis of appendicitis and decrease the use of computed tomography (CT) and admissions for observation. A multidisciplinary team implemented a quality improvement (QI) intervention in the form of a standardized US report and provided stakeholders with monthly feedback. Outcomes including report compliance, CT use, and observation admissions were compared pretemplate and posttemplate. We identified 387 patients in the pretemplate period and 483 patients in the posttemplate period. In the posttemplate period, the reporting of SS increased from 5.4% to 79.5% (p<0.001). Despite lower rates of appendix visualization (43.9% to 32.7%, p<0.001) with US, overall CT use (8.5% vs 7.0%, p=0.41) and the negative appendectomy rate remained stable (1.0% vs 1.0%, p=1.0). CT utilization for patients with an equivocal ultrasound and SS present decreased (36.4% vs 8.9%, p=0.002) and admissions for observations decreased (21.5% vs 15.3%, p=0.02). Test characteristics of RLQ US for appendicitis also improved in the posttemplate period. A focused QI initiative led to high compliance rates of utilizing the standardized US report and resulted in lower CT use and fewer admissions for observation. Study of a Diagnostic Test Level of Evidence: 1. Copyright © 2017 Elsevier Inc. All rights reserved.

Gouty involvement of the patella and extensor mechanism of the knee mimicking aggressive neoplasm. A case series.

PubMed

Kester, Christopher; Wallace, Matthew T; Jelinek, James; Aboulafia, Albert

2018-06-01

Gout is a common inflammatory crystal deposition disease that occurs in many joints throughout the body. Active gout is most often associated with painful synovitis causing searing joint pains, but gout can also produce large masses of space-occupying deposits called tophi. Tophi are most frequently seen in juxta-articular locations with or without bony erosion and are often misdiagnosed as degenerative joint disease. Soft tissue deposits and tendon involvement are also known manifestations of gout, but can present with indeterminate and alarming findings on imaging. We present three cases of tophaceous gout mimicking aggressive neoplasms in the extensor mechanism of the knee. All cases presented as extensor tendon masses eroding into the patella, with imaging findings initially concerning for primary musculoskeletal malignancy.

Impact of Percutaneous Drainage on Outcome of Intra-abdominal Infection Associated With Pediatric Perforated Appendicitis.

PubMed

Bonadio, William; Langer, Miriam; Cueva, Julie; Haaland, Astrid

2017-10-01

Perforated appendicitis can result in potentially serious complications requiring prolonged medical care. The optimal approach to successfully managing this condition is controversial. Review of 80 consecutive cases of pediatric acute perforated appendicitis with intra-abdominal infection (IAI) medically managed with parenteral antibiotics and percutaneous drainage (PD) during a 7-year period. All patients received broad spectrum parenteral antibiotic therapy. One-third were hospitalized for >2 weeks. IAI was identified on admission in 60% compared with developing during hospitalization in 40% of cases. Before performing PD, the mean duration of antibiotic therapy in those who developed IAI during hospitalization was 6 days. IAI cultures yielded 127 bacterial isolates; polymicrobial infection occurred in 65% of cases. Only 7% of aspirates were sterile. The most common pathogens were Escherichia coli (82%), of which 5 isolates exhibited extended-spectrum β-lactamase production, and streptococci (40%). At the time of PD, 60% were febrile (mean duration of in-hospital fever, 7.5 days); 67% defervesced within 24 hours after the procedure. Posthospitalization abdominal complications (recurrent IAI or appendicitis) occurred in one-third of patients. Children with perforated appendicitis and IAI often have a complicated and prolonged clinical course. Medical management consisting solely of parenteral antibiotic therapy is frequently ineffective in resolving IAI. Rapid clinical improvement commonly follows PD.

Abdominal-pelvic scanning parameters revisited: a case for Z-axis reduction in patients with clinical suspicion for acute appendicitis.

PubMed

Patel, Darshan C; Huang, Yu-Hui; Meyer, Jonathan; Sepahdari, Amir

2017-12-01

The purpose of this study was to determine if CT for appendicitis can be abbreviated to begin at the top of the L2 vertebral body level and still maintain the detection rate of appendicitis and other symptomatic pathology without omitting significant incidental findings. Retrospective review of CT abdomen-pelvis exams for suspected appendicitis over a 5-month period was performed. The Z-axis scan length of the original full scans and theoretical limited scans from the top of L2 were recorded and calculated. Images were reviewed for incidental findings above the L2 vertebral body level and categorized by severity per American College of Radiology (ACR) white paper guidelines. Final diagnoses based on imaging findings were also recorded. One hundred nineteen patients (46 males, 73 females, mean age 29 ± 14) were included. Appendicitis was present in 26 cases (22%). Using a theoretical scan beginning at the top of the L2 vertebral body, none of the findings leading to diagnosis of appendicitis would have been missed. A total of 30 incidental findings were found above the L2 vertebral body. Per ACR white paper guidelines, 26 of these findings did not require additional imaging follow-up. Additional follow-up imaging was recommended for 3 of the findings above L2, and 1 right adrenal metastasis was found above L2 in a patient with previously undiagnosed NSCLC. This patient coincidentally also had appendicitis. No symptomatic pathology would have been missed had the scans begun at the top of the L2 vertebral body. Such an abbreviated scan would have resulted in a mean Z-axis reduction of 12.9 cm (30.3%). CT using abbreviated Z-axis scan length can reduce radiation dose and provide necessary imaging needed to diagnose appendicitis or other symptomatic pathology without omitting significant incidental findings.

Sugar-Responsive Layer-by-Layer Film Composed of Phenylboronic Acid-Appended Insulin and Poly(vinyl alcohol).

PubMed

Takei, Chihiro; Ohno, Yui; Seki, Tomohiro; Miki, Ryotaro; Seki, Toshinobu; Egawa, Yuya

2018-01-01

Previous studies have shown that reversible chemical bond formation between phenylboronic acid (PBA) and 1,3-diol can be utilized as the driving force for the preparation of layer-by-layer (LbL) films. The LbL films composed of a PBA-appended polymer and poly(vinyl alcohol) (PVA) disintegrated in the presence of sugar. This type of LbL films has been recognized as a promising approach for sugar-responsive drug release systems, but an issue preventing the practical application of LbL films is combining them with insulin. In this report, we have proposed a solution for this issue by using PBA-appended insulin as a component of the LbL film. We prepared two kinds of PBA-appended insulin derivatives and confirmed that they retained their hypoglycemic activity. The LbL films composed of PBA-appended insulin and PVA were successfully prepared through reversible chemical bond formation between the boronic acid moiety and the 1,3-diol of PVA. The LbL film disintegrated upon treatment with sugars. Based on the results presented herein, we discuss the suitability of the PBA moiety with respect to hypoglycemic activity, binding ability, and selectivity for D-glucose.

Generalized Appended Product Indicator Procedure for Nonlinear Structural Equation Analysis.

ERIC Educational Resources Information Center

Wall, Melanie M.; Amemiya, Yasuo

2001-01-01

Considers the estimation of polynomial structural models and shows a limitation of an existing method. Introduces a new procedure, the generalized appended product indicator procedure, for nonlinear structural equation analysis. Addresses statistical issues associated with the procedure through simulation. (SLD)

A Feasibility Study of Real-Time Remote CT Reading for Suspected Acute Appendicitis Using an iPhone.

PubMed

Kim, Changsun; Kang, Bossng; Choi, Hyuk Joong; Park, Joon Bum

2015-08-01

We aimed to evaluate the feasibility of an iPhone-based remote control system as a real-time remote computed tomography (CT) reading tool for suspected appendicitis using a third-generation (3G) network under suboptimal illumination. One hundred twenty abdominal CT scans were selected; 60 had no signs of appendicitis, whereas the remaining 60 had signs of appendicitis. The 16 raters reviewed the images using the liquid crystal display (LCD) monitor of a picture archiving and communication system (PACS) workstation, as well as using an iPhone connected to the PACS workstation via a remote control system. We graded the probability of the presence of acute appendicitis for each examination using a five-point Likert scale. The overall sensitivity and specificity for the diagnosis of suspected appendicitis using the iPhone and the LCD monitor were high, and they were not significantly different (sensitivity P = 1.00, specificity P = 0.14). The average areas under the receiver operating characteristic curves for all CT readings with the iPhone and LCD monitor were 0.978 (confidence interval 0.965-0.991) and 0.974 (0.960-0.988), respectively, and the two devices did not have significantly different diagnostic performances (P = 0.55). The inter-rater agreement for both devices was very good; the kappa value for the iPhone was 0.809 (0.793-0.826), and that for the LCD monitor was 0.817 (0.801-0.834). Each rater had moderate-to-very good intra-observer agreement between the two devices. We verified the feasibility of an iPhone-based remote control system as a real-time remote CT reading tool for identifying suspected appendicitis using a 3G network and suboptimal illumination.

Clinical Ultrasound Is Safe and Highly Specific for Acute Appendicitis in Moderate to High Pre-test Probability Patients.

PubMed

Corson-Knowles, Daniel; Russell, Frances M

2018-05-01

Clinical ultrasound (CUS) is highly specific for the diagnosis of acute appendicitis but is operator-dependent. The goal of this study was to determine if a heterogeneous group of emergency physicians (EP) could diagnose acute appendicitis on CUS in patients with a moderate to high pre-test probability. This was a prospective, observational study of a convenience sample of adult and pediatric patients with suspected appendicitis. Sonographers received a structured, 20-minute CUS training on appendicitis prior to patient enrollment. The presence of a dilated (>6 mm diameter), non-compressible, blind-ending tubular structure was considered a positive study. Non-visualization or indeterminate studies were considered negative. We collected pre-test probability of acute appendicitis based on a 10-point visual analog scale (moderate to high was defined as >3), and confidence in CUS interpretation. The primary objective was measured by comparing CUS findings to surgical pathology and one week follow-up. We enrolled 105 patients; 76 had moderate to high pre-test probability. Of these, 24 were children. The rate of appendicitis was 36.8% in those with moderate to high pre-test probability. CUS were recorded by 33 different EPs. The sensitivity, specificity, and positive and negative likelihood ratios of EP-performed CUS in patients with moderate to high pre-test probability were 42.8% (95% confidence interval [CI] [25-62.5%]), 97.9% (95% CI [87.5-99.8%]), 20.7 (95% CI [2.8-149.9]) and 0.58 (95% CI [0.42-0.8]), respectively. The 16 false negative scans were all interpreted as indeterminate. There was one false positive CUS diagnosis; however, the sonographer reported low confidence of 2/10. A heterogeneous group of EP sonographers can safely identify acute appendicitis with high specificity in patients with moderate to high pre-test probability. This data adds support for surgical consultation without further imaging beyond CUS in the appropriate clinical setting.

IgG4-related disease presenting with destructive sinonasal lesion mimicking malignancy.

PubMed

Chen, Bo-Nien

2016-11-01

IgG4-related disease is a newly recognized systemic fibroinflammatory disorder. We report a 36-year-old man who presented with intractable right nasal pain and frontal headache for 1 month. Computed tomography revealed an ill-defined lesion with bony erosion over the right anterior ethmoid sinus and middle turbinate. The lesion was resected through endoscopic anterior ethmoidectomy and middle turbinectomy. IgG4-related disease was definitively diagnosed according to histopathological features. Prednisolone was administered postoperatively. IgG4-related disease presenting with destructive sinonasal lesion mimicking malignancy is rare. Awareness is essential to avoid delayed diagnosis or unnecessary invasive intervention, because the disorder responds to glucocorticoid and immunosuppressant therapy.

Endoloops or endostapler use in laparoscopic appendectomy for acute uncomplicated and complicated appendicitis : No difference in infectious complications.

PubMed

van Rossem, Charles C; van Geloven, Anna A W; Schreinemacher, Marc H F; Bemelman, Willem A

2017-01-01

The most appropriate closure for the appendicular stump with either endoloops or an endostapler in laparoscopic appendectomy remains unclear and under debate because of limited and conflicting evidence. In a 2-month prospective, observational, resident-led nationwide cohort study, patients undergoing laparoscopic appendectomy for both uncomplicated and complicated appendicitis were analysed. Logistic regression analyses were performed for identifying the possible effect of stump closure type and other risk factors for infectious complications. Laparoscopic appendectomy for acute appendicitis was performed in 1369 patients in 62 hospitals; endoloops were used in 76.7 % and an endostapler in other patients. Median operating time was not different between endoloop and endostapler use (42.0 vs. 44.0 min, P = 0.243). A superficial surgical site infection was seen in 2.0 % after uncomplicated appendicitis and in 0.8 % after complicated appendicitis. The intra-abdominal abscess rate was 1.9 % after uncomplicated and 11.0 % after complicated appendicitis. No significant effect of stump closure type was observed for any infectious complication (OR 1.05; 95 % CI 0.625-1.766, P = 0.853) or an intra-abdominal abscess (OR OR 0.96; 95 % CI 0.523-1.768, P = 0.899). In multivariable analysis, complicated appendicitis was identified as the only independent risk factor for an intra-abdominal abscess (OR 6.26; 95 % CI 3.454-11.341, P < 0.001). The infectious complication rate is not influenced by the type of appendicular stump closure with either endoloops or an endostapler in this study. If technically feasible, closure with endoloops is advised for cost considerations.

Retroperitoneal Pseudoaneurysm Mimicking Ureteral Calculus: Pitfalls in Diagnosis.

PubMed

Kalabin, Aleksandr; Mani, Vishnu R; Dinesh, Anant; Landa, Marina; Davis-Joseph, Brian

2017-10-08

Arterial aneurysms (AA) can be classified as true aneurysms, characterized by the persistence of all three layers of the arterial wall with progressive dilation and wall thinning; arterial pseudoaneurysms (APAs) are characterized by a tear in the vessel wall and a periarterial hematoma formation. They could occur due to a visceral, retroperitoneal, or peripheral origin. Most AA/APA are usually found incidentally, and it is imperative to be vigilant in order to diagnose and manage them due to their potentially life-threatening complications. We present a case of a 35-year-old woman presenting with right-sided abdominal pain mimicking renal colic with an initial misdiagnosis of ureteral calculus. Post-cystoscopy, a misdiagnosis was confirmed, and subsequently, the patient had a right retroperitoneal mass excision. The histopathology report concluded the calcified retroperitoneal mass to be pseudoaneurysm. Such pitfalls in diagnosis are essential to be shared with the larger medical community for increased vigilance and optimal management of pseudoaneurysms.

Therapeutic touch and postoperative pain: a Rogerian research study.

PubMed

Meehan, T C

1993-01-01

This article details Meehan's research study concerning the conceptualization of therapeutic touch within Rogers' science of unitary human beings and an investigation of the effects of therapeutic touch on pain experience in postoperative patients. Using a single trial, single-blind, three-group design, 108 postoperative patients were randomly assigned to receive one of the following: therapeutic touch, a placebo control intervention which mimicked therapeutic touch, or the standard intervention of a narcotic analgesic. Using a visual analogue scale, pain was measured before and one hour following intervention. The hypothesis, that therapeutic touch would significantly decrease postoperative pain compared to the placebo control intervention, was not supported. Secondary analyses suggest that therapeutic touch may decrease patients' need for analgesic medication. Implications for further research and practice are suggested.

Performance characteristics of magnetic resonance imaging without contrast agents or sedation in pediatric appendicitis.

PubMed

Didier, Ryne A; Hopkins, Katharine L; Coakley, Fergus V; Krishnaswami, Sanjay; Spiro, David M; Foster, Bryan R

2017-09-01

Magnetic resonance imaging (MRI) has emerged as a promising modality for evaluating pediatric appendicitis. However optimal imaging protocols, including roles of contrast agents and sedation, have not been established and diagnostic criteria have not been fully evaluated. To investigate performance characteristics of rapid MRI without contrast agents or sedation in the diagnosis of pediatric appendicitis. We included patients ages 4-18 years with suspicion of appendicitis who underwent rapid MRI between October 2013 and March 2015 without contrast agent or sedation. After two-radiologist review, we determined performance characteristics of individual diagnostic criteria and aggregate diagnostic criteria by comparing MRI results to clinical outcomes. We used receiver operating characteristic (ROC) curves to determine cut-points for appendiceal diameter and wall thickness for optimization of predictive power, and we calculated area under the curve (AUC) as a measure of test accuracy. Ninety-eight MRI examinations were performed in 97 subjects. Overall, MRI had a 94% sensitivity, 95% specificity, 91% positive predictive value and 97% negative predictive value. Optimal cut-points for appendiceal diameter and wall thickness were ≥7 mm and ≥2 mm, respectively. Independently, those cut-points produced sensitivities of 91% and 84% and specificities of 84% and 43%. Presence of intraluminal fluid (30/33) or localized periappendiceal fluid (32/33) showed a significant association with acute appendicitis (P<0.01), with sensitivities of 91% and 97% and specificities of 60% and 50%. For examinations in which the appendix was not identified by one or both reviewers (23/98), the clinical outcome was negative. Rapid MRI without contrast agents or sedation is accurate for diagnosis of pediatric appendicitis when multiple diagnostic criteria are considered in aggregate. Individual diagnostic criteria including optimized cut-points of ≥7 mm for diameter and ≥2 mm for wall

Enteral Contrast in the Computed Tomography Diagnosis of Appendicitis

PubMed Central

Drake, Frederick Thurston; Alfonso, Rafael; Bhargava, Puneet; Cuevas, Carlos; Dighe, Manjiri K.; Florence, Michael G.; Johnson, Morris G.; Jurkovich, Gregory J.; Steele, Scott R.; Symons, Rebecca Gaston; Thirlby, Richard C.; Flum, David R.

2014-01-01

Objective Our goal was to perform a comparative effectiveness study of intravenous (IV)-only versus IV + enteral contrast in computed tomographic (CT) scans performed for patients undergoing appendectomy across a diverse group of hospitals. Background Small randomized trials from tertiary centers suggest that enteral contrast does not improve diagnostic performance of CT for suspected appendicitis, but generalizability has not been demonstrated. Eliminating enteral contrast may improve efficiency, patient comfort, and safety. Methods We analyzed data for adult patients who underwent nonelective appendectomy at 56 hospitals over a 2-year period. Data were obtained directly from patient charts by trained abstractors. Multivariate logistic regression was utilized to adjust for potential confounding. The main outcome measure was concordance between final radiology interpretation and final pathology report. Results A total of 9047 adults underwent appendectomy and 8089 (89.4%) underwent CT, 54.1% of these with IV contrast only and 28.5% with IV + enteral contrast. Pathology findings correlated with radiographic findings in 90.0% of patients who received IV + enteral contrast and 90.4% of patients scanned with IV contrast alone. Hospitals were categorized as rural or urban and by their teaching status. Regardless of hospital type, there was no difference in concordance between IV-only and IV + enteral contrast. After adjusting for age, sex, comorbid conditions, weight, hospital type, and perforation, odds ratio of concordance for IV + enteral contrast versus IV contrast alone was 0.95 (95% CI: 0.72–1.25). Conclusions Enteral contrast does not improve CT evaluation of appendicitis in patients undergoing appendectomy. These broadly generalizable results from a diverse group of hospitals suggest that enteral contrast can be eliminated in CT scans for suspected appendicitis. PMID:24598250

Medic - Abdominal Pain: A Decision Support Program for the Management of Acute Abdominal Pain. (User’s Manual)

DTIC Science & Technology

1989-10-11

presence of diverticular disease does not preclude development of acute appendicitis concxitantly. The initial medical treatment is the same as for...appendicitis see APPENDICITIS. c. Pelvic inflammatory disease see PID. d. Diverticulitis most commonly involves the descending (left) colon . Symptoms...Five additional categories are included for female patients. These are: pelvic inflammatory disease (PID), urinary tract infection (UTI), ovarian cyst

Sonography of suspected acute appendicitis in children: Evaluation of the progress in performance of senior residents.

PubMed

Gerbier, Pierre; Binet, Aurélien; Etancelin, Mathilde; Barteau, Emmanuel; Auger, Marie; Morales, Luciano; Bertrand, Philippe; Sirinelli, Dominique; Morel, Baptiste

2018-04-01

The objective of this study was to evaluate the progress in performance of senior residents in diagnosing acute appendicitis. Results were collected and compared of ultrasound examinations performed for suspected acute appendicitis by three senior residents and two faculty members over a six-month period in a university hospital setting. A grid with the sonographic findings was completed separately by the residents and the faculty members immediately after each examination. The duration of each examination was reported. The final ultrasound diagnosis was compared to the surgical and pathological results and to the clinical follow-up. The residents and faculty members performed 171 consecutive ultrasound examinations including 49 children with acute appendicitis and 122 with normal appendices. The accuracy of the diagnosis by the residents was 96%, and was similar to that of the faculty members (kappa=0.90) over the six months. The duration of the resident ultrasound examinations was significantly shorter during the second three-month period (p=0.01). No significant differences in diagnostic accuracy were demonstrated by the residents between the first and second three-month periods (p=0.06). The residents performed well when using sonography to diagnose acute appendicitis in children, and were faster during the second three-month period. I. Copyright © 2017 Elsevier Inc. All rights reserved.

Common acute childhood infections and appendicitis: a historical study of statistical association in 27 English public boarding schools, 1930-1934.

PubMed

Smallman-Raynor, M R; Cliff, A D; Ord, J K

2010-08-01

Although the involvement of common childhood infections in the aetiology of acute appendicitis has long been conjectured, supporting evidence is largely restricted to a disparate set of clinical case reports. A systematic population-based analysis of the implied comorbid associations is lacking in the literature. Drawing on a classic epidemiological dataset, assembled by the School Epidemics Committee of the United Kingdom's Medical Research Council (MRC) in the 1930s, this paper presents a historical analysis of the association between termly outbreaks of each of six common childhood infections (chickenpox, measles, mumps, rubella, scarlet fever and whooping cough) and operated cases of acute appendicitis in 27 English public boarding schools. When controlled for the potential confounding effects of school, year and season, multivariate negative binomial regression revealed a positive association between the level of appendicitis activity and the recorded rate of mumps (beta=0.15, 95% CI 0.07-0.24, P<0.001). Non-significant associations were identified between appendicitis and the other sample infectious diseases. Subject to data caveats, our findings suggest that further studies are required to determine whether the comorbid association between mumps and appendicitis is causal.

A case of scrotal swelling mimicking testicular torsion preceding Henoch-Schönlein vasculitis.

PubMed

Akgun, C

2012-01-01

Henoch-Schönlein purpura, is one of the most common types of multisystemic vasculitis seen in childhood. The major clinical manifestations are cutaneous purpura, arthritis, abdominal pain, gastrointestinal bleeding, and nephritis. Isolated central nervous system vasculitis, seizures, coma and hemorrhage, Guillan--Barré syndrome, ataxia and central and peripheral neuropathy, ocular involvement, orchitis, epididymitis or testicular torsion are medical or surgical complications. In this study, we report a 7-year-old boy with scrotal swelling mimicking testicular torsion with ultrasonographic and clinical findings that the typical clinical features of Henoch-Schönlein purpura including rashes and arthritis were developed after one week of surgery (Ref. 15).

Development and validation of a brief, descriptive Danish pain questionnaire (BDDPQ).

PubMed

Perkins, F M; Werner, M U; Persson, F; Holte, K; Jensen, T S; Kehlet, H

2004-04-01

A new pain questionnaire should be simple, be documented to have discriminative function, and be related to previously used questionnaires. Word meaning was validated by using bilingual Danish medical students and asking them to translate words taken from the Danish version of the McGill pain questionnaire into English. Evaluative word value was estimated using a visual analog scale (VAS). Discriminative function was assessed by having patients with one of six painful conditions (postherpetic neuralgia, phantom limb pain, rheumatoid arthritis, ankle fracture, appendicitis, or labor pain) complete the questionnaire. We were not able to find Danish words that were reliably back-translated to the English words 'splitting' or 'gnawing'. A simple three-word set of evaluative terms had good separation when rated on a VAS scale ('let' 17.5+/-6.5 mm; 'moderat' 42.7+/-8.6 mm; and 'staerk' 74.9+/-9.7 mm). The questionnaire was able to discriminate among the six painful conditions with 77% accuracy by just using the descriptive words. The accuracy of the questionnaire increased to 96% with the addition of evaluative terms (for pain at rest and with activity), chronicity (acute vs. chronic), and location of the pain. A Danish pain questionnaire that subjects and patients can self-administer has been developed and validated relative to the words used in the English McGill Pain questionnaire. The discriminative ability of the questionnaire among some common painful conditions has been tested and documented. The questionnaire may be of use in patient care and research.

Unexpected findings after surgery for suspected appendicitis rarely change treatment in pediatric patients; Results from a cohort study.

PubMed

Gorter, Ramon R; van Amstel, Paul; van der Lee, Johanna H; van der Voorn, Patick; Bakx, Roel; Heij, Hugo A

2017-08-01

To determine if non-operative treatment is safe in children with acute appendicitis, we evaluated the incidence of unexpected findings after an appendectomy in children, and the influence they have on subsequent treatment. A historical cohort study (January 2004-December 2014) was performed including children, aged 0-17 years, who underwent an appendectomy for the suspicion of acute appendicitis. Patients were divided based upon histopathological examination. Unexpected findings were reviewed, as well as the subsequent treatment plan. In total 484 patients were included in this study. In the overall group, unexpected findings were noted in 10 (2.1%) patients of which two patients intra-operatively with a non-inflamed appendix (Ileitis terminalis N=1 and ovarian torsion N=1) and in 8 patients on histopathological examination. The latter group consisted of 4 patients with concomitant simple appendicitis (parasitic infection N=3 and Walthard cell rest N=1), two with concomitant complex appendicitis (carcinoid N=1 and parasitic infection N=1) and two patients with a non-inflamed appendix (endometriosis N=1 and parasitic infection N=1). Treatment was changed in 4 patients (<1%). Results from this study corroborate the safety of non-operative strategy for acute simple appendicitis, as the occurrence of unexpected findings was low, with extremely few necessary changes of the treatment plan because of serious findings. Prognosis study. Level 2 (retrospective cohort study). Copyright © 2017 Elsevier Inc. All rights reserved.

Pediatric appendicitis and need for antibiotics at time of discharge: Does route of administration matter?

PubMed

Acker, Shannon N; Hurst, Amanda L; Bensard, Denis D; Schubert, Anna; Dewberry, Lindel; Gonzales, Danielle; Parker, Sarah K; Tong, Suhong; Partrick, David A

2016-07-01

Following complicated appendicitis, there are limited data available to guide the surgeon regarding antibiotic selection, specifically in regards to route of administration. We hypothesized that among children with appendicitis who are discharged home with antibiotic therapy, the post-discharge readmission and complication rates do not differ between those children who receive IV antibiotics and those who receive PO antibiotics. We performed a retrospective review of all children discharged home on antibiotics following appendectomy at a single institution between 11/10-10/14. We compared outcomes including ED and hospital readmission rates, and development of postoperative complications, between those children who were discharged on IV antibiotics and those discharged on PO antibiotics. 325 children were discharged with antibiotics following appendectomy (n=291 PO antibiotics group; n=34 IV group). On both univariate and multivariate analysis, rate of each complication did not differ between the two groups including inpatient readmission (5% PO vs. 6% IV; p=0.8), ED readmission (10% vs. 11%; p=0.8), postdischarge complications related to the operation (10% vs. 15%; p=0.4), or abscess development post-discharge (4% vs. 3%; p=1). Among children with complicated appendicitis who are discharged home with ongoing antibiotic therapy, our data demonstrate no differences in outcomes between those children who receive IV and PO antibiotics. Further data, collected in a prospective fashion, are needed to clarify the role of IV and PO antibiotics among children with perforated appendicitis. Copyright © 2016 Elsevier Inc. All rights reserved.

Economics of appendicitis: cost trend analysis of laparoscopic versus open appendectomy from 1998 to 2008.

PubMed

McGrath, Brian; Buckius, Michelle T; Grim, Rod; Bell, Theodore; Ahuja, Vanita

2011-12-01

Laparoscopic appendectomy (LA) has become more acceptable for the treatment of appendicitis over the last decade; however, its cost benefit compared to open appendectomy (OA) remains under debate. The purpose of this study is to evaluate the utilization of LA and its cost effectiveness based on total hospital charges stratified by complexity of disease and complications compared to OA. Nationwide Inpatient Sample data from 1998 to 2008 with the principal diagnosis of appendicitis were included. Appendicitis cases were divided by simple and complex (peritonitis or abscess) and subdivided by OA, LA, and lap converted to open (CONV). Total charges (2008 value), length of stay (LOS), and complications were assessed by disease presentation and operative approach. Between 1998 and 2008, 1,561,518 (54.3%) OA, 1,231,643 (42.8%) LA, and 84,662 (2.9%) CONV appendectomies were performed. LA had shorter LOS (2 d) than OA (3 d) and CONV (5 d) (P<0.001). CONV (7.4%) cases had more complications than OA (3.7%) and LA (2.6%). LA ($19,978) and CONV ($28,103) are costlier than OA ($15,714) based on normalized cost for simple and complex diseases (P<0.001). LA is more prevalent but its cost is higher in both simple and complex cases. Cost and complications increase if the case is converted to open. OA remains the most cost effective approach for patients with acute appendicitis. Copyright © 2011 Elsevier Inc. All rights reserved.

Correlation between the season, temperature and atmospheric pressure with incidence and pathogenesis of acute appendicitis.

PubMed

Karanikolić, Aleksandar; Karanikolić, Vesna; Djordjević, Lidija; Pešić, Ivan

2016-01-01

There is very little literature data on the correlation between the seasons, temperature and atmospheric pressure, and pathogenesis of acute appendicitis (AA). The aim of this research is to investigate the association between the seasons, changes in atmospheric temperature and pressure, and patients’ age and severity of the clinical form of AA in the city of Niš This study included 395 patients diagnosed with AA, who, during the two-year period, from July 1st 2011 to June 30th 2013, were hospitalized and operated on at the Department of General Surgery, Clinical Center in Niš, Serbia. The increased average daily values of barometric pressure by 1 millibar on the day when the event took place was associated (p < 0.05) with the decrease of total risk of the occurrence of appendicitis by 2.2% (0.2–4.1%). In all observed patients, each increase of the mean daily temperature by 1°C three days before the event took place (Lag 3) was associated (p < 0.05) with the increase of total risk of the occurrence of appendicitis by 1.3% (0.1–2.5%). According to the results of this research, we can conclude that patients’ sex, age and severity of the clinical form of AA are not in connection with the seasons, while there are certain connections between appendicitis occurrence and atmospheric temperature and pressure.

Unexpected findings at diagnostic laparoscopy: caecal incarceration with concurrent appendicitis in a patient with bilateral broad ligament defects

PubMed Central

Onida, S; Lynes, K; Whitehouse, PA

2010-01-01

Internal herniations through broad ligament defects are very rare. We present the first report of the triad of broad ligament defect, internal herniation of the caecum and appendicitis. A 36-year-old woman with phocomelia presented with right iliac fossa pain and vomiting. The patient had no previous history of trauma or surgery. Abdominal ultrasound showed a small amount of free fluid. At laparoscopy, bilateral broad ligament defects were found, with herniation of the caecum and an inflamed appendix through the right-sided defect. A laparoscopic salpingo-oophorectomy was required for reduction of the herniated bowel, and an appendicectomy was performed. Broad ligament defects may be congenital or acquired. In this case, in light of the limb abnormality and absence of previous surgery, a congenital aetiology is more likely. Ultrasound scan is not reliable and, although computed tomography may be of help, a diagnostic laparoscopy is the best investigation. PMID:20566032

Assessment of variation in care and outcomes for pediatric appendicitis at children's and non-children's hospitals.

PubMed

Tian, Yao; Heiss, Kurt F; Wulkan, Mark L; Raval, Mehul V

2015-11-01

Variation in care may indicate an opportunity for quality improvement and to decrease waste. Variation in appendicitis practice, resource use, and costs have not been well studied at non-children's hospitals (NCHs) where most children undergo care. The purpose of this study was to quantify variation in care for perforated pediatric appendicitis within and between children's hospitals (CHs) and NCH. Using the 2012 Kids' Inpatient Database, 11,216 children with perforated appendicitis were identified. Comparisons between CH and NCH were made in regard to operative approach (open versus laparoscopic), central line (CL) and total parenteral nutrition (PN) use, complication rates, length of stay (LOS), and total costs. NCHs cared for 8051 patients (72%) with perforated appendicitis. CHs were more likely to perform a laparoscopy compared to NCHs (odds ratio (OR) 10.2, 95% confidence interval (95% CI) 5.7-18.2), and to utilize CL or PN than NCHs (CL OR 2.4 (95% CI 1.5-3.8), PN OR 2.6 (95% CI 1.4-4.9)). Composite complication rates were lower at CH (OR 0.5 (95% CI 0.4-0.6)). While LOS was not different between CH and NCH in the fully adjusted model, costs were higher at CH (OR 6.8 (95% CI 3.9-12.2)). Low and high outliers could be identified for each variable and outcome of interest with no consistent performance regardless of CH or NCH status. Variation in operative approach, resource use, complications, LOS, and costs exist in the management of pediatric perforated appendicitis with greatest variation observed at NCH. Future quality improvement efforts should be tailored for implementation at both CH and high-volume NCH. Copyright © 2015 Elsevier Inc. All rights reserved.

Accurate diagnosis of acute abdomen in FMF and acute appendicitis patients: how can we use procalcitonin?

PubMed

Kisacik, Bunyamin; Kalyoncu, Umut; Erol, M Fatih; Karadag, Omer; Yildiz, Mustafa; Akdogan, Ali; Kaptanoglu, Bugra; Hayran, Mutlu; Ureten, Kemal; Ertenli, Ihsan; Kiraz, Sedat; Calguneri, Meral

2007-12-01

This study was conducted to define the value of procalcitonin (PCT) levels in the differential diagnosis of abdominal familial Mediterranean fever (FMF) attacks from acute appendicitis. From October 2006 to January 2007, 28 FMF (12 males, 16 females) patients with acute abdominal attacks and 34 patients (18 males) with acute abdomen who underwent operation with the clinical diagnosis of acute appendicitis were consecutively enrolled in this study. FMF patients with concurrent infectious diseases were excluded. PCT values were measured by an immunofluorescent method using the B.R.A.H.M.S. PCT kit (B.R.A.H.M.S. Diagnostica, Berlin, Germany). Erythrocyte sedimentation rate (ESR), C-reactive proteins (CRP) and leucocyte levels were also noted. Mean disease duration in FMF patients was 9.6 +/- 8.1 years (range 2-33 years) and all were on colchicine therapy with a mean colchicine dosage of 1.2 +/- 0.4 mg/day. Among the operated patients, 5 were excluded: 3 patients had normal findings and 2 had intestinal perforation (PCT levels were 2.69 and 4.93 ng/ml, respectively) at operative and pathologic evaluation. There were no significant differences between the two groups with respect to gender and age (p was not significant (NS) for all). Acute phase reactants and PCT levels were increased in patients with FMF compared to patients with acute appendicitis (0.529[0.12 +/- 0.96] vs 0.095 [0.01-0.80] p < 0.001, respectively). PCT levels higher than 0.5 ng/ml were found in 11% (3/28) of FMF patients compared to 62% (18/29) of acute appendicitis patients (p < 0.001). Our results suggest that PCT could be a useful test in the differentiation of abdominal FMF attacks from acute appendicitis, though it should not supplant more conventional investigations.

Herpes zoster sciatica mimicking lumbar canal stenosis: a case report.

PubMed

Koda, Masao; Mannoji, Chikato; Oikawa, Makiko; Murakami, Masazumi; Okamoto, Yuzuru; Kon, Tamiyo; Okawa, Akihiko; Ikeda, Osamu; Yamazaki, Masashi; Furuya, Takeo

2015-07-29

Symptom of herpes zoster is sometimes difficult to distinguish from sciatica induced by spinal diseases, including lumbar disc herniation and spinal canal stenosis. Here we report a case of sciatica mimicking lumbar canal stenosis. A 74-year-old Chinese male patient visited our hospital for left-sided sciatic pain upon standing or walking for 5 min of approximately 1 month's duration. At the first visit to our hospital, there were no skin lesions. A magnetic resonance imaging showed spinal canal stenosis between the 4th and 5th lumbar spine. Thus, we diagnosed the patient with sciatica induced by spinal canal stenosis. We considered decompression surgery for the stenosis of 4th and 5th lumbar spine because conservative therapy failed to relieve the patient's symptom. At that time, the patient complained of a skin rash involving his left foot for several days. A vesicular rash and erythema were observed on the dorsal and plantar surfaces of the great toe and lateral malleolus. The patient was diagnosed with herpes zoster in the left 5th lumbar spinal nerve area based on clinical findings, including the characteristics of the pain and vesicular rash and erythema in the 5th lumbar spinal dermatome. The patient was treated with famciclovir (1,500 mg/day) and non-steroidal anti-inflammatory drugs. After 1 week of medication, the skin rash resolved and pain relief was obtained. In conclusion, spinal surgeons should keep in mind herpes zoster infection as one of the possible differential diagnoses of sciatica, even if there is no typical skin rash.

Hip bone marrow edema presenting as low back pain: a case report.

PubMed

Mourad, Firas; Maselli, Filippo; Cataldi, Fabio; Pennella, Denis; Fernández-De-Las-Peñas, César; Dunning, James

2018-06-01

Nonspecific low back pain (LBP) is frequently managed by physiotherapists. However, physiotherapists in a direct access setting may encounter patients with serious medical conditions, such as Bone Marrow Edema Syndrome (BMES) of the hip with symptoms mimicking LBP. To our knowledge, this is the first case to describe hip BMES presenting as LBP. Diagnosis was based on the patient's symptoms in conjunction with magnetic resonance imaging (MRI). In order to avoid misdiagnosing the patient, primary care clinicians should be aware that BMES can mimic nonspecific LBP. To present a rare clinical presentation of BMES of the hip mimicking nonspecific LBP. To the best of the author's knowledge, this is the first case to describe hip BMES presenting as mechanical nonspecific LBP. This case report describes the history, examination findings, and clinical reasoning used for a patient with LBP as a chief complaint. Furthermore, the clinical presentation (i.e. pain location and its changes related to load) and the symptoms behavior (i.e. immediate symptoms decrease after few hip treatment sessions and quick worsening of the hip pain related to loading activities) after two treatment sessions increased the suspicion of an underlying medical condition of the hip joint and lead to the decision for additional evaluation. A MRI showed a serious hip BMES. This case report highlights the importance of including a comprehensive and continuous differential diagnostic process throughout the treatment period, looking for those risk factors (i.e. red flags) that warrant further investigation and referral to the appropriate physician. Physiotherapy diagnosis should include clinical reasoning, clinical presentation, and symptom behavior in addition to appropriate referral for medical assessment and diagnostic imaging when appropriate. Physiotherapists working within a direct access environment have the competence and responsibility to participate with other health professionals in the

Enterobius vermicularis and its role in paediatric appendicitis: protection or predisposition?

PubMed

Lala, Shareena; Upadhyay, Vipul

2016-09-01

E nterobius vermicularis is one of the most common parasitic infections of the gastrointestinal tract, and has been shown to infest up to 28% of children worldwide. The role of E . vermicularis in acute appendicitis has previously been questioned, with some studies identifying infection as a precursor for inflammation of the appendix, with others refuting such a link. A retrospective review was conducted of all appendices received for histological analysis at our unit from January 2002 to December 2011 (10-year period), removed in the course of acute appendicectomy in children aged 3 to 15 years. Appendices were categorized by degree of inflammation and infestation with E . vermicularis. Appendicectomy for clinical suspicion of acute appendicitis was performed in 2923 patients, 1694 (58%) male, median age 11.6 years. E . vermicularis was present in 4% of appendices; 25% of which showed concurrent acute inflammation. E . vermicularis infestation was more common in females (F : M 76% versus 24% of inflamed appendices and 66.7% versus 33.3% for non-inflamed appendices). European individuals showed higher representation in the E . vermicularis group than the total study population (79% versus 53% respectively). E . vermicularis was found to be more common in females and those of European descent. Seventy-seven percent of patients with E . vermicularis did not have concurrent acute inflammation of the appendix on histological examination. The question remains as to whether infestation is protective of inflammation or whether infestation causes appendiceal colic and subsequent appendicectomy of a non-inflamed appendix, thereby protective of the morbidity of acute appendicitis. © 2016 Royal Australasian College of Surgeons.

The Frequency of Enterobius Vermicularis Infections in Patients Diagnosed With Acute Appendicitis in Pakistan.

PubMed

Ahmed, Muhammad Umer; Bilal, Muhammad; Anis, Khurram; Khan, Ali Mahmood; Fatima, Kaneez; Ahmed, Iqbal; Khatri, Ali Mohammad; Shafiq-ur-Rehman

2015-02-24

The main aim of this study was to determine the frequency of Enterobius vermicularis infections and other unique histopathological findings in patients diagnosed with acute appendicitis. This retrospective study was conducted in a tertiary care hospital of Karachi, Pakistan over a time period of 9 years from 2005 to 2013. The recorded demographic and histopathological data for the 2956 appendectomies performed during this time frame were extracted using a structured template form. Negative and incidental appendectomies were excluded from the study. Out of the 2956 patients diagnosed with acute appendicitis, 84 (2.8%) patients had Enterobius vermicularis infections. Malignancy (n=2, 0.1%) and infection with Ascaris (n=1, 0.1%) was found very rarely among the patients.Eggs in lumen (n=22, 0.7%), mucinous cystadenoma (n=28, 1.0%), mucocele (n=11, 0.4%), lymphoma (n=9, 0.3%), obstruction in lumen (n=17, 0.6%) and purulent exudate (n=37, 1.3%) were also seldom seen in the histopathological reports. Enterobius vermicularis manifestation is a rare overall but a leading parasitic cause of appendicitis. Steps such as early diagnosis and regular de worming may help eradicate the need for surgeries.

The Frequency of Enterobius Vermicularis Infections in Patients Diagnosed With Acute Appendicitis in Pakistan

PubMed Central

Ahmed, Muhammad Umer; Bilal, Muhammad; Anis, Khurram; Khan, Ali Mahmood; Fatima, Kaneez; Ahmed, Iqbal; Khatri, Ali Mohammad; Shafiq-ur-Rehman

2015-01-01

Introduction: The main aim of this study was to determine the frequency of Enterobius Vermicularis infections and other unique histopathological findings in patients diagnosed with acute appendicitis. Materials: This retrospective study was conducted in a tertiary care hospital of Karachi, Pakistan over a time period of 9 years from 2005 to 2013. The recorded demographic and histopathological data for the 2956 appendectomies performed during this time frame were extracted using a structured template form. Negative and incidental appendectomies were excluded from the study. Results: Out of the 2956 patients diagnosed with acute appendicitis, 84 (2.8%) patients had Enterobius Vermicularis infections. Malignancy (n=2, 0.1%) and infection with Ascaris (n=1, 0.1%) was found very rarely among the patients. Eggs in lumen (n=22, 0.7%), mucinous cystadenoma (n=28, 1.0%), mucocele (n=11, 0.4%), lymphoma (n=9, 0.3%), obstruction in lumen (n=17, 0.6%) and purulent exudate (n=37, 1.3%) were also seldom seen in the histopathological reports. Conclusion: Enterobius Vermicularis manifestation is a rare overall but a leading parasitic cause of appendicitis. Steps such as early diagnosis and regular de worming may help eradicate the need for surgeries. PMID:26156929

Faecal retention: a common cause in functional bowel disorders, appendicitis and haemorrhoids--with medical and surgical therapy.

PubMed

Raahave, Dennis

2015-03-01

The present studies explored whether faecal retention in the colon is a causative factor in functional bowel disease, appendicitis, and haemorrhoids. Faecal retention was characterized by colon transit time (CTT) after radio-opaque marker ingestion and estimation of faecal loading on abdominal radiographs at 48 h and 96 h. Specific hypotheses were tested in patients (n = 251 plus 281) and in healthy random controls (n = 44). A questionnaire was completed for each patient, covering abdominal and anorectal symptoms and without a priori grouping. Patients with functional bowel disorders, predominantly women, had a significantly increased CTT and faecal load compared to controls. The CTT was significantly and positively correlated with segmental and total faecal loading. The faecal load was equal at 48 h and 96 h, mirroring the presence of permanent faecal reservoirs. In these first clinical studies to correlate bowel symptoms with CTT and colon faecal loading, abdominal bloating was significantly correlated with faecal loading in the right colon, total faecal load, and CTT. Abdominal pain was significantly and positively correlated to distal faecal loading and significantly associated with bloating. A new phenomenon with a high faecal load and a normal CTT was observed in a subset of patients (n = 90), proving faecal retention as hidden constipation. The CTT and faecal load were significantly higher in the right-side compared to the left and distal segments. Within the control group of healthy persons, the right-sided faecal load was significantly greater than the left and distal load. The CTT and faecal load significantly positively correlated with a palpable mass in the left iliac fossa and meteorism. Cluster analysis revealed that CTT and faecal load positively correlated with a symptom factor consisting of bloating, proctalgia and infrequent defecation of solid faeces. On the other hand, CTT and faecal load negatively correlated with a symptom factor comprising

Time-of-Day and Appendicitis: Impact on Management and Outcomes

PubMed Central

Drake, Frederick Thurston; Mottey, Neli E.; Castelli, Anthony A.; Florence, Michael G.; Johnson, Morris G.; Steele, Scott R.; Thirlby, Richard C.; Flum, David R.

2017-01-01

Background Observational research has shown that delayed presentation is associated with perforation in appendicitis. Many factors that impact the ability to present for evaluation are influenced by time-of-day; for example, child care, work, transportation, and primary care office hours. Our objective was to evaluate for an association between care processes or clinical outcomes and presentation time. Methods Prospective cohort of 7,548 adults undergoing appendectomy at 56 hospitals across Washington State. Relative to presentation time, patient characteristics, time to surgery, imaging use, negative appendectomy (NA), and perforation were compared using univariate and multivariate methodologies. Results Overall, 63% of patients presented between noon and midnight. More men presented in the morning; however, race, insurance status, co-morbid conditions, and WBC count did not differ by presentation time. Daytime presenters (6AM-6PM) were less likely to undergo imaging (94% vs. 98% p<0.05) and had a nearly 50% decrease in median pre-operative time (6.0h vs. 8.7h p<0.001). Perforation significantly differed by time-of-day. Patients who presented during the workday (9AM-3PM) had a 30% increase in odds of perforation compared to early morning/late night presenters (adjusted OR 1.29, 95%CI 1.05–1.59). NA did not vary by time-of-day. Conclusions Most patients with appendicitis presented in afternoon/evening. Socioeconomic characteristics did not vary with time-of-presentation. Patients who presented during the workday more often had perforated appendicitis compared to those who presented early morning or late night. Processes of care differed (both time-to-surgery and imaging use). Time-of-day is associated with patient outcomes, process of care, and decisions to present for evaluation; this has implications for surgical workforce planning and quality improvement efforts. PMID:27592212

Development of a core outcome set to determine the overall treatment success of acute uncomplicated appendicitis in children: a study protocol.

PubMed

Sherratt, Frances C; Eaton, Simon; Walker, Erin; Beasant, Lucy; Blazeby, Jane M; Young, Bridget; Crawley, Esther; Wood, Wendy W; Hall, Nigel J

2017-01-01

In recent years, there has been growing interest in alternatives to appendicectomy. In particular, non-operative treatment of appendicitis, with antibiotics alone, has been proposed as a potential treatment. A small number of randomised controlled trials (RCTs) in adults and, more recently, children suggest that antibiotic treatment may be a valid alternative to appendicectomy. However, there is currently insufficient data to justify its widespread use. Prior to performing further efficacy studies of the treatment of appendicitis in children, it is imperative to identify the most relevant outcome measures for inclusion in the design of comparative studies. This is of particular importance when evaluating a novel treatment approach since the outcomes of importance may differ from those commonly reported with traditional therapies.A review of the relevant literature and electronic resources failed to identify a core outcome set (COS) for children with appendicitis. We aim to define a COS for the measurement of treatment interventions in children (<18 years) with acute appendicitis. This project will entail: (1) a systematic review to identify previously reported acute uncomplicated appendicitis treatment outcomes; (2) assembly of stakeholder panels (paediatric and adult surgeons, patients and parents); (3) a three-stage Delphi process; and (4) a final consensus meeting to complete the COS. COS development is part of CONservative TReatment of Appendicitis in Children - a randomised controlled Trial (Feasibility) (CONTRACT) study, for which full ethical approval for CONTRACT has been granted. The COS development study is registered with the COMET Initiative in May 2017 (http://www.comet-initiative.org/studies/details/987).

Retroperitoneal Pseudoaneurysm Mimicking Ureteral Calculus: Pitfalls in Diagnosis

PubMed Central

Kalabin, Aleksandr; Dinesh, Anant; Landa, Marina; Davis-Joseph, Brian

2017-01-01

Arterial aneurysms (AA) can be classified as true aneurysms, characterized by the persistence of all three layers of the arterial wall with progressive dilation and wall thinning; arterial pseudoaneurysms (APAs) are characterized by a tear in the vessel wall and a periarterial hematoma formation. They could occur due to a visceral, retroperitoneal, or peripheral origin. Most AA/APA are usually found incidentally, and it is imperative to be vigilant in order to diagnose and manage them due to their potentially life-threatening complications. We present a case of a 35-year-old woman presenting with right-sided abdominal pain mimicking renal colic with an initial misdiagnosis of ureteral calculus. Post-cystoscopy, a misdiagnosis was confirmed, and subsequently, the patient had a right retroperitoneal mass excision. The histopathology report concluded the calcified retroperitoneal mass to be pseudoaneurysm. Such pitfalls in diagnosis are essential to be shared with the larger medical community for increased vigilance and optimal management of pseudoaneurysms. PMID:29226048

Use and accuracy of diagnostic imaging in the evaluation of pediatric appendicitis.

PubMed

Kotagal, Meera; Richards, Morgan K; Flum, David R; Acierno, Stephanie P; Weinsheimer, Robert L; Goldin, Adam B

2015-04-01

There are safety concerns about the use of radiation-based imaging (computed tomography [CT]) to diagnose appendicitis in children. Factors associated with CT use remain to be determined. For patients ≤18 years old undergoing appendectomy, we evaluated diagnostic imaging performed, patient characteristics, hospital type, and imaging/pathology concordance (2008-2012) using data from Washington State's Surgical Care and Outcomes Assessment Program. Among 2538 children, 99.7% underwent pre-operative imaging. 52.7% had a CT scan as their first study. After adjustment, age >10 years (OR 2.9 (95% CI 2.2-4.0), Hispanic ethnicity (OR 1.7, 95% CI 1.5-1.9), and being obese (OR 1.7, 95% CI 1.4-2.1) were associated with CT use first. Evaluation at a non-children's hospital was associated with higher odds of CT use (OR 7.9, 95% CI 7.5-8.4). Ultrasound concordance with pathology was higher for males (72.3 vs. 66.4%, p=.03), in perforated appendicitis (75.9 vs. 67.5%, p=.009), and at children's hospitals compared to general adult hospitals (77.3 vs. 62.2%, p<.001). CT use has decreased yearly statewide. Over 50% of children with appendicitis had radiation-based imaging. Understanding factors associated with CT use should allow for more specific QI interventions to reduce radiation exposure. Site of care remains a significant factor in radiation exposure for children. Copyright © 2015 Elsevier Inc. All rights reserved.

Berberine Improves Intestinal Motility and Visceral Pain in the Mouse Models Mimicking Diarrhea-Predominant Irritable Bowel Syndrome (IBS-D) Symptoms in an Opioid-Receptor Dependent Manner

PubMed Central

Pan, Qiuhui; Fichna, Jakub; Zheng, Lijun; Wang, Kesheng; Yu, Zhen; Li, Yongyu; Li, Kun; Song, Aihong; Liu, Zhongchen; Song, Zhenshun; Kreis, Martin

2015-01-01

Background and Aims Berberine and its derivatives display potent analgesic, anti-inflammatory and anticancer activity. Here we aimed at characterizing the mechanism of action of berberine in the gastrointestinal (GI) tract and cortical neurons using animal models and in vitro tests. Methods The effect of berberine was characterized in murine models mimicking diarrhea-predominant irritable bowel syndrome (IBS-D) symptoms. Then the opioidantagonists were used to identify the receptors involved. Furthermore, the effect of berberineon opioid receptors expression was established in the mouse intestine and rat fetal cortical neurons. Results In mouse models, berberine prolonged GI transit and time to diarrhea in a dose-dependent manner, and significantly reduced visceral pain. In physiological conditions the effects of berberine were mediated by mu- (MOR) and delta- (DOR) opioidreceptors; hypermotility, excessive secretion and nociception were reversed by berberine through MOR and DOR-dependent action. We also found that berberine increased the expression of MOR and DOR in the mouse bowel and rat fetal cortical neurons. Conclusion Berberine significantly improved IBS-D symptoms in animal models, possibly through mu- and delta- opioid receptors. Berberine may become a new drug candidate for the successful treatment of IBS-D in clinical conditions. PMID:26700862

A Novel Nitronyl Nitroxide with Salicylic Acid Framework Attenuates Pain Hypersensitivity and Ectopic Neuronal Discharges in Radicular Low Back Pain.

PubMed

Han, Wen-Juan; Chen, Lei; Wang, Hai-Bo; Liu, Xiang-Zeng; Hu, San-Jue; Sun, Xiao-Li; Luo, Ceng

2015-01-01

Evidence has accumulated that reactive oxygen species and inflammation play crucial roles in the development of chronic pain, including radicular low back pain. Nonsteroid anti-inflammatory drugs (NSAIDs), for example, salicylic acid, aspirin, provided analgesic effects in various types of pain. However, long-term use of these drugs causes unwanted side effects, which limits their implication. Stable nitronyl (NIT) nitroxide radicals have been extensively studied as a unique and interesting class of new antioxidants for protection against oxidative damage. The present study synthesized a novel NIT nitroxide radical with salicylic acid framework (SANR) to provide synergistic effect of both antioxidation and antiinflammation. We demonstrated for the first time that both acute and repeated SANR treatment exerted dramatic analgesic effect in radicular low back pain mimicked by chronic compression of dorsal root ganglion in rats. This analgesic potency was more potent than that produced by classical NSAIDs aspirin and traditional nitroxide radical Tempol alone. Furthermore, SANR-induced behavioral analgesia is found to be mediated, at least in partial, by a reduction of ectopic spontaneous discharges in injured DRG neurons. Therefore, the synthesized NIT nitroxide radical coupling with salicylic acid framework may represent a novel potential therapeutic candidate for treatment of chronic pain, including radicular low back pain.

Heterometallic appended {MMn(III)4} cubanes encapsulated by lacunary polytungstate ligands.

PubMed

Wu, Hai-Hong; Yao, Shuang; Zhang, Zhi-Ming; Li, Yang-Guang; Song, You; Liu, Zhu-Jun; Han, Xin-Bao; Wang, En-Bo

2013-01-14

The heterometallic appended {MMn(III)(4)} (M = Dy(3+) and K(+)) cubanes were firstly trapped by two diamagnetic POM shells, which were robust enough to construct inorganic crystalline tubular materials. Magnetic study reveals the presence of a SMM-like slow magnetic relaxation feature in the heterometallic cluster-containing POM.

Time-driven activity-based costing: A dynamic value assessment model in pediatric appendicitis.

PubMed

Yu, Yangyang R; Abbas, Paulette I; Smith, Carolyn M; Carberry, Kathleen E; Ren, Hui; Patel, Binita; Nuchtern, Jed G; Lopez, Monica E

2017-06-01

Healthcare reform policies are emphasizing value-based healthcare delivery. We hypothesize that time-driven activity-based costing (TDABC) can be used to appraise healthcare interventions in pediatric appendicitis. Triage-based standing delegation orders, surgical advanced practice providers, and a same-day discharge protocol were implemented to target deficiencies identified in our initial TDABC model. Post-intervention process maps for a hospital episode were created using electronic time stamp data for simple appendicitis cases during February to March 2016. Total personnel and consumable costs were determined using TDABC methodology. The post-intervention TDABC model featured 6 phases of care, 33 processes, and 19 personnel types. Our interventions reduced duration and costs in the emergency department (-41min, -$23) and pre-operative floor (-57min, -$18). While post-anesthesia care unit duration and costs increased (+224min, +$41), the same-day discharge protocol eliminated post-operative floor costs (-$306). Our model incorporating all three interventions reduced total direct costs by 11% ($2753.39 to $2447.68) and duration of hospitalization by 51% (1984min to 966min). Time-driven activity-based costing can dynamically model changes in our healthcare delivery as a result of process improvement interventions. It is an effective tool to continuously assess the impact of these interventions on the value of appendicitis care. II, Type of study: Economic Analysis. Copyright © 2017 Elsevier Inc. All rights reserved.

Accuracy and Radiation Dose Reduction of Limited-Range CT in the Evaluation of Acute Appendicitis in Pediatric Patients.

PubMed

Jin, Michael; Sanchez, Thomas R; Lamba, Ramit; Fananapazir, Ghaneh; Corwin, Michael T

2017-09-01

The purpose of this article is to determine the accuracy and radiation dose reduction of limited-range CT prescribed from the top of L2 to the top of the pubic symphysis in children with suspected acute appendicitis. We performed a retrospective study of 210 consecutive pediatric patients from December 11, 2012, through December 11, 2014, who underwent abdominopelvic CT for suspected acute appendicitis. Two radiologists independently reviewed the theoretic limited scans from the superior L2 vertebral body to the top of the pubic symphysis, to assess for visualization of the appendix, acute appendicitis, alternative diagnoses, and incidental findings. Separately, the same parameters were assessed on the full scan by the same two reviewers. Whole-body effective doses were determined for the full- and limited-range scans and were compared using the paired t test. The appendix or entire cecum was visualized on the limited scan in all cases, and no cases of acute appendicitis were missed on the simulated limited scan compared with the full scan. Two alternative diagnoses were missed with the limited scan: one case of hydronephrosis and one of acute acalculous cholecystitis. The mean effective dose for the original scan was 5.6 mSv and that for the simulated limited scan was 3.0 mSv, resulting in a dose reduction of 46.4% (p < 0.001). A limited-range CT examination performed from the top of L2 to the top of the pubic symphysis is as accurate as a full-range abdominopelvic CT in evaluating pediatric patients with suspected appendicitis and reduces the dose by approximately 46%.

A new technique for the diagnosis of acute appendicitis: abdominal CT with compression to the right lower quadrant.

PubMed

Kılınçer, Abidin; Akpınar, Erhan; Erbil, Bülent; Ünal, Emre; Karaosmanoğlu, Ali Devrim; Kaynaroğlu, Volkan; Akata, Deniz; Özmen, Mustafa

2017-08-01

To determine the diagnostic accuracy of abdominal CT with compression to the right lower quadrant (RLQ) in adults with acute appendicitis. 168 patients (age range, 18-78 years) were included who underwent contrast-enhanced CT for suspected appendicitis performed either using compression to the RLQ (n = 71) or a standard protocol (n = 97). Outer diameter of the appendix, appendiceal wall thickening, luminal content and associated findings were evaluated in each patient. Kruskal-Wallis, Fisher's and Pearson's chi-squared tests were used for statistical analysis. There was no significant difference in the mean outer diameter (MOD) between compression CT scans (10.6 ± 1.9 mm) and standard protocol (11.2 ± 2.3 mm) in patients with acute appendicitis (P = 1). MOD was significantly lower in the compression group (5.2 ± 0.8 mm) compared to the standard protocol (6.5 ± 1.1 mm) (P < 0.01) in patients without appendicitis. A cut-off value of 6.75 mm for the outer diameter of the appendix was found to be 100% sensitive in the diagnosis of acute appendicitis for both groups. The specificity was higher for compression CT technique (67.7 vs. 94.9%). Normal appendix diameter was significantly smaller in the compression-CT group compared to standard-CT group, increasing diagnostic accuracy of abdominal compression CT. • Normal appendix diameter is significantly smaller in compression CT. • Compression could force contrast material to flow through the appendiceal lumen. • Compression CT may be a CT counterpart of graded compression US.

Could an abdominal drainage be avoided in complicated acute appendicitis? Lessons learned after 1300 laparoscopic appendectomies.

PubMed

Schlottmann, Francisco; Reino, Romina; Sadava, Emmanuel E; Campos Arbulú, Ana; Rotholtz, Nicolás A

2016-12-01

Complicated appendicitis (CA) may be a risk factor for postoperative intra-abdominal abscess formation (IAA). In addition, several publications have shown an increased risk of postoperative collection after laparoscopic appendectomy. Most surgeons prefer to place a drain to collect contaminated abdominal fluid to prevent consequent abscess formation. We aimed to evaluate the utility of placing an intra-abdominal drain in laparoscopic appendectomy for complicated acute appendicitis. From January 2005 to June 2015 all charts of consecutive patients who underwent laparoscopic appendectomy for CA were revised. CA was defined as a perforated appendix with associated peritonitis. The sample was divided into two groups, G1: intra-abdominal drain and G2: no drain. Demographics, operative factors and 30-day postoperative complications were analyzed. In the study period 1300 laparoscopic appendectomies were performed. Laparoscopic findings showed that 17.3% of the surgeries were for complicated acute appendicitis (225 patients). Fifty-six patients (25%) were in G1 and 169 patients (75%) in G2. No significant differences in clinical presentation and demographics were found (p: NS). G1 had an increased conversion rate (G1: 19.6% vs. G2: 7.1%; p: 0.007). No differences were found in the overall morbidity (G1: 32.1% vs. G2: 21.3%, p: NS). The rate of postoperative IAA was 14.2% in G1 and 8.9% in G2 (p: NS). Length of stay was higher in G1 (G1: 5.2 days vs. G2 2.9 days, p: 0.001). There was no mortality in either group. The placement of intra-abdominal drain in complicated acute appendicitis may not present benefits and may even lengthen hospital stay. These observations suggest that there is no need of using a drain in laparoscopic appendectomy for complicated acute appendicitis. Copyright © 2016 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.

Tissue mimicking materials for dental ultrasound

PubMed Central

Singh, Rahul S.; Culjat, Martin O.; Grundfest, Warren S.; Brown, Elliott R.; White, Shane N.

2008-01-01

While acoustic tissue mimicking materials have been explored for a variety of soft and hard biological tissues, no dental hard tissue mimicking materials have been characterized. Tooth phantoms are necessary to better understand acoustic phenomenology within the tooth environment and to accelerate the advancement of dental ultrasound imaging systems. In this study, soda lime glass and dental composite were explored as surrogates for human enamel and dentin, respectively, in terms of compressional velocity, attenuation, and acoustic impedance. The results suggest that a tooth phantom consisting of glass and composite can effectively mimic the acoustic behavior of a natural human tooth. PMID:18396919

A preliminary study on how hypohydration affects pain perception.

PubMed

Bear, Tracey; Philipp, Michael; Hill, Stephen; Mündel, Toby

2016-05-01

Chronic pain is a prevalent health issue with one in five people suffering from some form of chronic pain, with loss of productivity and medical costs of chronic pain considerable. However, the treatment of pain can be difficult, as pain perception is complex and can be affected by factors other than tissue damage. This study investigated the effect of hypohydration (mild, voluntary dehydration from ∼24 h of limiting fluid intake, mimicking someone drinking less than usual) on a person's pain perception. Seventeen healthy males (age 27 ± 5 years) visited the laboratory on three occasions, once as a familiarization and then twice again while either euhydrated (urine specific gravity: 1.008 ± 0.005) or hypohydrated (urine specific gravity: 1.024 ± 0.003, and -1.4 ± 0.9% body mass). Each visit, they performed a cold pressor test, where their feet were placed in cold water (0-3 °C) for a maximum of 4 min. Measures of hydration status, pain sensitivity, pain threshold, and catastrophization were taken. We found that hypohydration predicted increased pain sensitivity (β = 0.43), trait pain catastrophizing, and baseline pain sensitivity (β = 0.37 and 0.47, respectively). These results are consistent with previous research, and suggest that a person's hydration status may be an important factor in their perception of acute pain. © 2016 Society for Psychophysiological Research.

A highly sensitive and specific combined clinical and sonographic score to diagnose appendicitis.

PubMed

Reddy, Swathi B; Kelleher, Michael; Bokhari, S A Jamal; Davis, Kimberly A; Schuster, Kevin M

2017-10-01

Computed tomography (CT) scanning reduces the negative appendectomy rate however it exposes the patient to ionizing radiation. Ultrasound (US) does not carry this risk but may be nondiagnostic. We hypothesized that a clinical-US scoring system would improve diagnostic accuracy. We conducted a retrospective review of all patients (age, >15 years) who presented through the emergency department with suspected appendicitis and underwent initial US. A US score was developed using odds ratios for appendicitis given appendiceal diameter, compressibility, hyperemia, free fluid, and focal or diffuse tenderness. The US score was then combined with the Alvarado score. Final diagnosis of appendicitis was assigned by pathology reports. Three hundred patients who underwent US as initial imaging were identified. Thirty-two patients with evident nonappendiceal pathology on US were excluded. In 114 (38%), the appendix was not visualized and partially visualized in 36 (12%). Fifty-seven (21.3%) had an appendectomy with 1 (1.7%) negative. Six nonvisualized appendicies underwent appendectomy, with no negative cases. Sensitivity and specificity for the sonographic score were 86% and 90%, respectively, at a score of 1.5. The combined score demonstrated 98% sensitivity and 82% specificity at 6.5, and 95% sensitivity, and 87% specificity at a score of 7.5. Sensitivity and specificity were confirmed by bootstrap resampling for validation. Area under receiver operating characteristic (ROC) curves for our new US score were similar to the ROC curve for the Alvarado score (91.9 and 91.1, p = 0.8). The combined US and Alvarado score yielded an area under the ROC curve of 97.1, significantly better than either score alone (p = 0.017 and p < 0.001, respectively). Our scoring system based entirely on US findings was highly sensitive and specific for appendicitis, and it significantly improved when combined with the Alvarado score. After prospective evaluation, the combined US-Alvarado score might

Copious Irrigation Versus Suction Alone During Laparoscopic Appendectomy for Complicated Appendicitis in Adults.

PubMed

Sun, Fengbo; Wang, He; Zhang, Fengjuan; Zhang, Xinming; Xing, Zhiyuan; Zhang, Shenglin; Zhang, Haifeng; Wang, Ye

2017-05-09

The objective of this study was to determine whether copious irrigation of peritoneal cavity during laparoscopic appendectomy for complicated appendicitis effectively reduces the incidence of postoperative complications and improves the postoperative recovery in adults compared with suction alone. In this prospective randomized trial, adult patients with complicated appendicitis were randomized to "irrigation and suction"(IS) group or "suction only"(SO) group. All surgery was performed with a standardized 3-port laparoscopic approach. The IS group received peritoneal irrigation with a minimum of 2000 mL sterile normal saline. The study primary outcomes included wound infection and postoperative intra-abdominal abscess. The study secondary outcomes included duration of operation, first anal exsufflation time, duration of hospital stay and hospital charges. Chi-squared and t-tests were used to analyze the study data. Between January 2015 and June 2016, a total of 260 patients with complicated appendicitis were enrolled in the study. The peritoneal irrigation resulted in a longer operation time (51.6 ± 16.1 vs. 41.5 ± 15.2 min, p <0.001). There was no significant difference in the rate of wound infection between the two groups. However, the patients who received irrigation had a lower postoperative intra-abdominal abscess rate (3.1% vs. 9.2%, p = 0.039), earlier anal exsufflation (25.2 ± 16.5 vs. 30.7 ± 18.1 hr, p = 0.011), shorter hospital stay (10.2 ± 2.5 vs. 12.5 ± 2.8 days, p <0.001) and lower hospital charges (¥14,592 ± 2,251 vs. 16,674 ± 2,163, p <0.001) compared to those received suction alone. The study findings revealed that copious irrigation of peritoneal cavity during laparoscopic appendectomy could decrease the incidence of postoperative intra-abdominal abscess in adult patients with complicated appendicitis. These patients also had faster postoperative recovery and lower hospital charges.

Novel solutions for an old disease: diagnosis of acute appendicitis with random forest, support vector machines, and artificial neural networks.

PubMed

Hsieh, Chung-Ho; Lu, Ruey-Hwa; Lee, Nai-Hsin; Chiu, Wen-Ta; Hsu, Min-Huei; Li, Yu-Chuan Jack

2011-01-01

Diagnosing acute appendicitis clinically is still difficult. We developed random forests, support vector machines, and artificial neural network models to diagnose acute appendicitis. Between January 2006 and December 2008, patients who had a consultation session with surgeons for suspected acute appendicitis were enrolled. Seventy-five percent of the data set was used to construct models including random forest, support vector machines, artificial neural networks, and logistic regression. Twenty-five percent of the data set was withheld to evaluate model performance. The area under the receiver operating characteristic curve (AUC) was used to evaluate performance, which was compared with that of the Alvarado score. Data from a total of 180 patients were collected, 135 used for training and 45 for testing. The mean age of patients was 39.4 years (range, 16-85). Final diagnosis revealed 115 patients with and 65 without appendicitis. The AUC of random forest, support vector machines, artificial neural networks, logistic regression, and Alvarado was 0.98, 0.96, 0.91, 0.87, and 0.77, respectively. The sensitivity, specificity, positive, and negative predictive values of random forest were 94%, 100%, 100%, and 87%, respectively. Random forest performed better than artificial neural networks, logistic regression, and Alvarado. We demonstrated that random forest can predict acute appendicitis with good accuracy and, deployed appropriately, can be an effective tool in clinical decision making. Copyright © 2011 Mosby, Inc. All rights reserved.

Appendectomy versus non-operative treatment for acute uncomplicated appendicitis in children: study protocol for a multicentre, open-label, non-inferiority, randomised controlled trial

PubMed Central

Eaton, Simon; Abbo, Olivier; Arnaud, Alexis P; Beaudin, Marianne; Brindle, Mary; Bütter, Andreana; Davies, Dafydd; Jancelewicz, Tim; Johnson, Kathy; Keijzer, Richard; Lapidus-Krol, Eveline; Offringa, Martin; Piché, Nelson; Rintala, Risto; Skarsgard, Erik; Svensson, Jan F; Ungar, Wendy J; Wester, Tomas; Willan, Andrew R; Zani, Augusto; St Peter, Shawn D; Pierro, Agostino

2017-01-01

Background Appendectomy is considered the gold standard treatment for acute appendicitis. Recently the need for surgery has been challenged in both adults and children. In children there is growing clinician, patient and parental interest in non-operative treatment of acute appendicitis with antibiotics as opposed to surgery. To date no multicentre randomised controlled trials that are appropriately powered to determine efficacy of non-operative treatment (antibiotics) for acute appendicitis in children compared with surgery (appendectomy) have been performed. Methods Multicentre, international, randomised controlled trial with a non-inferiority design. Children (age 5–16 years) with a clinical and/or radiological diagnosis of acute uncomplicated appendicitis will be randomised (1:1 ratio) to receive either laparoscopic appendectomy or treatment with intravenous (minimum 12 hours) followed by oral antibiotics (total course 10 days). Allocation to groups will be stratified by gender, duration of symptoms (> or <48 hours) and centre. Children in both treatment groups will follow a standardised treatment pathway. Primary outcome is treatment failure defined as additional intervention related to appendicitis requiring general anaesthesia within 1 year of randomisation (including recurrent appendicitis) or negative appendectomy. Important secondary outcomes will be reported and a cost-effectiveness analysis will be performed. The primary outcome will be analysed on a non-inferiority basis using a 20% non-inferiority margin. Planned sample size is 978 children. Discussion The APPY trial will be the first multicentre randomised trial comparing non-operative treatment with appendectomy for acute uncomplicated appendicitis in children. The results of this trial have the potential to revolutionise the treatment of this common gastrointestinal emergency. The randomised design will limit the effect of bias on outcomes seen in other studies. Trial registration number

Systemic classification for a new diagnostic approach to acute abdominal pain in children.

PubMed

Kim, Ji Hoi; Kang, Hyun Sik; Han, Kyung Hee; Kim, Seung Hyo; Shin, Kyung-Sue; Lee, Mu Suk; Jeong, In Ho; Kim, Young Sil; Kang, Ki-Soo

2014-12-01

With previous methods based on only age and location, there are many difficulties in identifying the etiology of acute abdominal pain in children. We sought to develop a new systematic classification of acute abdominal pain and to give some helps to physicians encountering difficulties in diagnoses. From March 2005 to May 2010, clinical data were collected retrospectively from 442 children hospitalized due to acute abdominal pain with no apparent underlying disease. According to the final diagnoses, diseases that caused acute abdominal pain were classified into nine groups. The nine groups were group I "catastrophic surgical abdomen" (7 patients, 1.6%), group II "acute appendicitis and mesenteric lymphadenitis" (56 patients, 12.7%), group III "intestinal obstruction" (57 patients, 12.9%), group IV "viral and bacterial acute gastroenteritis" (90 patients, 20.4%), group V "peptic ulcer and gastroduodenitis" (66 patients, 14.9%), group VI "hepatobiliary and pancreatic disease" (14 patients, 3.2%), group VII "febrile viral illness and extraintestinal infection" (69 patients, 15.6%), group VIII "functional gastrointestinal disorder (acute manifestation)" (20 patients, 4.5%), and group IX "unclassified acute abdominal pain" (63 patients, 14.3%). Four patients were enrolled in two disease groups each. Patients were distributed unevenly across the nine groups of acute abdominal pain. In particular, the "unclassified abdominal pain" only group was not uncommon. Considering a systemic classification for acute abdominal pain may be helpful in the diagnostic approach in children.

Systemic Classification for a New Diagnostic Approach to Acute Abdominal Pain in Children

PubMed Central

Kim, Ji Hoi; Kang, Hyun Sik; Han, Kyung Hee; Kim, Seung Hyo; Shin, Kyung-Sue; Lee, Mu Suk; Jeong, In Ho; Kim, Young Sil

2014-01-01

Purpose With previous methods based on only age and location, there are many difficulties in identifying the etiology of acute abdominal pain in children. We sought to develop a new systematic classification of acute abdominal pain and to give some helps to physicians encountering difficulties in diagnoses. Methods From March 2005 to May 2010, clinical data were collected retrospectively from 442 children hospitalized due to acute abdominal pain with no apparent underlying disease. According to the final diagnoses, diseases that caused acute abdominal pain were classified into nine groups. Results The nine groups were group I "catastrophic surgical abdomen" (7 patients, 1.6%), group II "acute appendicitis and mesenteric lymphadenitis" (56 patients, 12.7%), group III "intestinal obstruction" (57 patients, 12.9%), group IV "viral and bacterial acute gastroenteritis" (90 patients, 20.4%), group V "peptic ulcer and gastroduodenitis" (66 patients, 14.9%), group VI "hepatobiliary and pancreatic disease" (14 patients, 3.2%), group VII "febrile viral illness and extraintestinal infection" (69 patients, 15.6%), group VIII "functional gastrointestinal disorder (acute manifestation)" (20 patients, 4.5%), and group IX "unclassified acute abdominal pain" (63 patients, 14.3%). Four patients were enrolled in two disease groups each. Conclusion Patients were distributed unevenly across the nine groups of acute abdominal pain. In particular, the "unclassified abdominal pain" only group was not uncommon. Considering a systemic classification for acute abdominal pain may be helpful in the diagnostic approach in children. PMID:25587522

Inflammatory arthritis mimicking Complex Regional Pain Syndrome (CRPS) in a child: A case report.

PubMed

Egilmez, Zeliha; Turgut, Selin Turan; Icagasioglu, Afitap; Bicakci, Irem

2016-01-01

Joint complaints in childhood are seen frequently and differential diagnosis can be difficult. Juvenile idiopathic arthritis (JIA) is the most common rheumatological disease of childhood. It involves peripheral joint arthritis, chronic synovitis, and extra-articular manifestations. Accurate diagnosis can take a long time and sometimes multiple diagnoses are used while following the patient until a final diagnosis can be reached. Arthritis may be triggered by trauma and confused with other diseases like complex regional pain syndrome (CRPS), in which trauma plays a role in the etiology. In the present case, ankle pain in an 8-year-old girl was misdiagnosed as CRPS.

Three-step sequential positioning algorithm during sonographic evaluation for appendicitis increases appendiceal visualization rate and reduces CT use.

PubMed

Chang, Stephanie T; Jeffrey, R Brooke; Olcott, Eric W

2014-11-01

The purpose of this article is to examine the rates of appendiceal visualization by sonography, imaging-based diagnoses of appendicitis, and CT use after appendiceal sonography, before and after the introduction of a sonographic algorithm involving sequential changes in patient positioning. We used a search engine to retrospectively identify patients who underwent graded-compression sonography for suspected appendicitis during 6-month periods before (period 1; 419 patients) and after (period 2; 486 patients) implementation of a new three-step positional sonographic algorithm. The new algorithm included initial conventional supine scanning and, as long as the appendix remained nonvisualized, left posterior oblique scanning and then "second-look" supine scanning. Abdominal CT within 7 days after sonography was recorded. Between periods 1 and 2, appendiceal visualization on sonography increased from 31.0% to 52.5% (p < 0.001), postsonography CT use decreased from 31.3% to 17.7% (p < 0.001), and the proportion of imaging-based diagnoses of appendicitis made by sonography increased from 63.8% to 85.7% (p = 0.002). The incidence of appendicitis diagnosed by imaging (either sonography or CT) remained similar at 16.5% and 17.3%, respectively (p = 0.790). Sensitivity and overall accuracy were 57.8% (95% CI, 44.8-70.1%) and 93.0% (95% CI, 90.1-95.3%), respectively, in period 1 and 76.5% (95% CI, 65.8-85.2%) and 95.4% (95% CI, 93.1-97.1%), respectively, in period 2. Similar findings were observed for adults and children. Implementation of an ultrasound algorithm with sequential positioning significantly improved the appendiceal visualization rate and the proportion of imaging-based diagnoses of appendicitis made by ultrasound, enabling a concomitant decrease in abdominal CT use in both children and adults.

The cost-effectiveness of nonoperative management versus laparoscopic appendectomy for the treatment of acute, uncomplicated appendicitis in children.

PubMed

Wu, James X; Sacks, Greg D; Dawes, Aaron J; DeUgarte, Daniel; Lee, Steven L

2017-07-01

Several studies have demonstrated the safety and short-term success of nonoperative management in children with acute, uncomplicated appendicitis. Nonoperative management spares the patients and their family the upfront cost and discomfort of surgery, but also risks recurrent appendicitis. Using decision-tree software, we evaluated the cost-effectiveness of nonoperative management versus routine laparoscopic appendectomy. Model variables were abstracted from a review of the literature, Healthcare Cost and Utilization Project, and Medicare Physician Fee schedule. Model uncertainty was assessed using both one-way and probabilistic sensitivity analyses. We used a $100,000 per quality adjusted life year (QALY) threshold for cost-effectiveness. Operative management cost $11,119 and yielded 23.56 quality-adjusted life months (QALMs). Nonoperative management cost $2277 less than operative management, but yielded 0.03 fewer QALMs. The incremental cost-to-effectiveness ratio of routine laparoscopic appendectomy was $910,800 per QALY gained. This greatly exceeds the $100,000/QALY threshold and was not cost-effective. One-way sensitivity analysis found that operative management would become cost-effective if the 1-year recurrence rate of acute appendicitis exceeded 39.8%. Probabilistic sensitivity analysis indicated that nonoperative management was cost-effective in 92% of simulations. Based on our model, nonoperative management is more cost-effective than routine laparoscopic appendectomy for children with acute, uncomplicated appendicitis. Cost-Effectiveness Study: Level II. Published by Elsevier Inc.

A large epidermoid cyst of breast mimicking carcinoma: A case report and review of literature

PubMed Central

Debnath, Debasish; Taribagil, Savita; Al-Janabi, Khalid J.S.; Inwang, Reggie

2012-01-01

INTRODUCTION Triple assessment of a suspicious breast lesion may not always provide a definite diagnosis. We report a case of epidermoid cyst of breast, which caused diagnostic dilemma in spite of a thorough triple assessment and entailed mastectomy. PRESENTATION OF CASE A 69-year-old woman presented with a large painful retroareolar left breast mass. Clinical examination, ultrasound and mammography were highly suspicious of malignancy. However, core biopsy suggested a benign lesion. Due to size of the lesion and diagnostic uncertainty, various options were discussed with the patient. She opted for a simple mastectomy. The histology confirmed a large epidermoid cyst. DISCUSSION It is rare for an epidermoid cyst to present as such an advanced lesion, mimicking carcinoma. Excision of such a large retroareolar ‘benign’ lesion, however, may sometime entail mastectomy. This is the first reported case of an epidermoid cyst of breast necessitating mastectomy. CONCLUSION Diagnostic dilemma while dealing with a suspected breast cancer is not rare. Involvement of multidisciplinary team as well as patient is important in the decision-making. The report illustrates a rare presentation of a deep seated large epidermoid cyst of breast, which mimicked carcinoma, caused diagnostic confusion and entailed mastectomy. We strongly advocate the option of breast reconstruction in such cases. PMID:22705938

An implemented MRI program to eliminate radiation from the evaluation of pediatric appendicitis.

PubMed

Kulaylat, Afif N; Moore, Michael M; Engbrecht, Brett W; Brian, James M; Khaku, Aliasgher; Hollenbeak, Christopher S; Rocourt, Dorothy V; Hulse, Michael A; Olympia, Robert P; Santos, Mary C; Methratta, Sosamma T; Dillon, Peter W; Cilley, Robert E

2015-08-01

Recent efforts have been directed at reducing ionizing radiation delivered by CT scans to children in the evaluation of appendicitis. MRI has emerged as an alternative diagnostic modality. The clinical outcomes associated with MRI in this setting are not well-described. Review of a 30-month institutional experience with MRI as the primary diagnostic evaluation for suspected appendicitis (n=510). No intravenous contrast, oral contrast, or sedation was administered. Radiologic and clinical outcomes were abstracted. MRI diagnostic characteristics were: sensitivity 96.8% (95% CI: 92.1%-99.1%), specificity 97.4% (95% CI: 95.3-98.7), positive predictive value 92.4% (95% CI: 86.5-96.3), and negative predictive value 98.9% (95% CI: 97.3%-99.7%). Radiologic time parameters included: median time from request to scan, 71 minutes (IQR: 51-102), imaging duration, 11 minutes (IQR: 8-17), and request to interpretation, 2.0 hours (IQR: 1.6-2.6). Clinical time parameters included: median time from initial assessment to admit order, 4.1 hours (IQR: 3.1-5.1), assessment to antibiotic administration 4.7 hours (IQR: 3.9-6.7), and assessment to operating room 9.1 hours (IQR: 5.8-12.7). Median length of stay was 1.2 days (range: 0.2-19.5). Given the diagnostic accuracy and favorable clinical outcomes, without the potential risks of ionizing radiation, MRI may supplant the role of CT scans in pediatric appendicitis imaging. Copyright © 2015 Elsevier Inc. All rights reserved.

Single daily dosing ceftriaxone and metronidazole vs standard triple antibiotic regimen for perforated appendicitis in children: a prospective randomized trial.

PubMed

St Peter, Shawn D; Tsao, Kuojen; Spilde, Troy L; Holcomb, George W; Sharp, Susan W; Murphy, J Patrick; Snyder, Charles L; Sharp, Ronald J; Andrews, Walter S; Ostlie, Daniel J

2008-06-01

Appendicitis is the most common emergency condition in children. Historically, a 3-drug regimen consisting of ampicillin, gentamicin, and clindamycin (AGC) has been used postoperatively for perforated appendicitis. A retrospective review at our institution has found single day dosing of ceftriaxone and metronidazole (CM) to be a more simple and cost-effective antibiotic strategy. Therefore, we performed a prospective, randomized trial to compare efficacy and cost-effectiveness of these 2 regimens. After internal review board approval (IRB no. 04 12-149), children found to have perforated appendicitis at appendectomy were randomized to either once daily dosing of CM (2 total doses per day) or standard dosing of AGC (11 total doses per day). Perforation was defined as an identifiable hole in the appendix. The operative approach (laparoscopic), length of antibiotic use, and criteria for discharge were standardized for the groups. Based on our retrospective analysis using length of postoperative hospitalization as a primary end point, a sample size of 100 patients was calculated for an alpha of .5 and a power of 0.82. One hundred patients underwent laparoscopic appendectomy for perforated appendicitis. On presentation, there were no differences in sex distribution, days of symptoms, temperature, or leukocyte count. There was no difference in abscess rate or wound infections between groups. The CM group resulted in significantly less antibiotic charges then the AGC group. Once daily dosing with the 2-drug regimen (CM) offers a more efficient, cost-effective antibiotic management in children with perforated appendicitis without compromising infection control when compared to a traditional 3-drug regimen.

Economic evaluation of antibiotic therapy versus appendicectomy for the treatment of uncomplicated acute appendicitis from the APPAC randomized clinical trial.

PubMed

Sippola, S; Grönroos, J; Tuominen, R; Paajanen, H; Rautio, T; Nordström, P; Aarnio, M; Rantanen, T; Hurme, S; Salminen, P

2017-09-01

An increasing amount of evidence supports antibiotic therapy for treating uncomplicated acute appendicitis. The objective of this study was to compare the costs of antibiotics alone versus appendicectomy in treating uncomplicated acute appendicitis within the randomized controlled APPAC (APPendicitis ACuta) trial. The APPAC multicentre, non-inferiority RCT was conducted on patients with CT-confirmed uncomplicated acute appendicitis. Patients were assigned randomly to appendicectomy or antibiotic treatment. All costs were recorded, whether generated by the initial visit and subsequent treatment or possible recurrent appendicitis during the 1-year follow-up. The cost estimates were based on cost levels for the year 2012. Some 273 patients were assigned to the appendicectomy group and 257 to antibiotic treatment. Most patients randomized to antibiotic treatment did not require appendicectomy during the 1-year follow-up. In the operative group, overall societal costs (€5989·2, 95 per cent c.i. 5787·3 to 6191·1) were 1·6 times higher (€2244·8, 1940·5 to 2549·1) than those in the antibiotic group (€3744·4, 3514·6 to 3974·2). In both groups, productivity losses represented a slightly higher proportion of overall societal costs than all treatment costs together, with diagnostics and medicines having a minor role. Those in the operative group were prescribed significantly more sick leave than those in the antibiotic group (mean(s.d.) 17·0(8·3) (95 per cent c.i. 16·0 to 18·0) versus 9·2(6·9) (8·3 to 10·0) days respectively; P < 0·001). When the age and sex of the patient as well as the hospital were controlled for simultaneously, the operative treatment generated significantly more costs in all models. Patients receiving antibiotic therapy for uncomplicated appendicitis incurred lower costs than those who had surgery. © 2017 BJS Society Ltd Published by John Wiley & Sons Ltd.

Indices of diagnostic abdominal ultrasonography in acute appendicitis: influence of gender and physical constitution, time evolution of the disease and experience of radiologist.

PubMed

Peixoto, Rodrigo de Oliveira; Nunes, Tarcizo Afonso; Gomes, Carlos Augusto

2011-01-01

To assess the value of abdominal ultrasonography in the diagnosis of acute appendicitis and the influence of gender, physical constitution, experience of the radiologist and the time evolution of the disease on the results of diagnostic indices. We prospectively evaluated 156 patients with clinical diagnosis of acute appendicitis who underwent laparoscopic appendectomy and abdominal ultrasonography, together with pathology of the excised appendices. Patients were allocated in relation to BMI in both groups (below or above 25 kg/m²) and radiologists, in three groups according to their professional experience (less than five years, between five and 10 years and more than 10 years). The survey also assessed the influence of gender and time of disease progression using the median of 36 hours. The sensitivity and specificity of abdominal ultrasonography for diagnosing appendicitis were 64.9 and 72% respectively. Gender, body mass index, length of experience of the radiologists in the three groups and time of onset of symptoms showed no significant differences in the establishment of sonographic diagnosis of acute appendicitis. The abdominal ultrasonography showed low sensitivity and specificity and little contribution to the diagnosis of acute appendicitis. Gender, physical constitution, the experience of the radiologist and time of onset of symptoms did not affect the outcome of the sonography.

Diagnostic accuracy at several reduced radiation dose levels for CT imaging in the diagnosis of appendicitis

NASA Astrophysics Data System (ADS)

Zhang, Di; Khatonabadi, Maryam; Kim, Hyun; Jude, Matilda; Zaragoza, Edward; Lee, Margaret; Patel, Maitraya; Poon, Cheryce; Douek, Michael; Andrews-Tang, Denise; Doepke, Laura; McNitt-Gray, Shawn; Cagnon, Chris; DeMarco, John; McNitt-Gray, Michael

2012-03-01

Purpose: While several studies have investigated the tradeoffs between radiation dose and image quality (noise) in CT imaging, the purpose of this study was to take this analysis a step further by investigating the tradeoffs between patient radiation dose (including organ dose) and diagnostic accuracy in diagnosis of appendicitis using CT. Methods: This study was IRB approved and utilized data from 20 patients who underwent clinical CT exams for indications of appendicitis. Medical record review established true diagnosis of appendicitis, with 10 positives and 10 negatives. A validated software tool used raw projection data from each scan to create simulated images at lower dose levels (70%, 50%, 30%, 20% of original). An observer study was performed with 6 radiologists reviewing each case at each dose level in random order over several sessions. Readers assessed image quality and provided confidence in their diagnosis of appendicitis, each on a 5 point scale. Liver doses at each case and each dose level were estimated using Monte Carlo simulation based methods. Results: Overall diagnostic accuracy varies across dose levels: 92%, 93%, 91%, 90% and 90% across the 100%, 70%, 50%, 30% and 20% dose levels respectively. And it is 93%, 95%, 88%, 90% and 90% across the 13.5-22mGy, 9.6-13.5mGy, 6.4-9.6mGy, 4-6.4mGy, and 2-4mGy liver dose ranges respectively. Only 4 out of 600 observations were rated "unacceptable" for image quality. Conclusion: The results from this pilot study indicate that the diagnostic accuracy does not change dramatically even at significantly reduced radiation dose.

Heparin-Mimicking Polymers: Synthesis and Biological Applications

PubMed Central

2016-01-01

Heparin is a naturally occurring, highly sulfated polysaccharide that plays a critical role in a range of different biological processes. Therapeutically, it is mostly commonly used as an injectable solution as an anticoagulant for a variety of indications, although it has also been employed in other forms such as coatings on various biomedical devices. Due to the diverse functions of this polysaccharide in the body, including anticoagulation, tissue regeneration, anti-inflammation, and protein stabilization, and drawbacks of its use, analogous heparin-mimicking materials are also widely studied for therapeutic applications. This review focuses on one type of these materials, namely, synthetic heparin-mimicking polymers. Utilization of these polymers provides significant benefits compared to heparin, including enhancing therapeutic efficacy and reducing side effects as a result of fine-tuning heparin-binding motifs and other molecular characteristics. The major types of the various polymers are summarized, as well as their applications. Because development of a broader range of heparin-mimicking materials would further expand the impact of these polymers in the treatment of various diseases, future directions are also discussed. PMID:27739666

Heparin-Mimicking Polymers: Synthesis and Biological Applications.

PubMed

Paluck, Samantha J; Nguyen, Thi H; Maynard, Heather D

2016-11-14

Heparin is a naturally occurring, highly sulfated polysaccharide that plays a critical role in a range of different biological processes. Therapeutically, it is mostly commonly used as an injectable solution as an anticoagulant for a variety of indications, although it has also been employed in other forms such as coatings on various biomedical devices. Due to the diverse functions of this polysaccharide in the body, including anticoagulation, tissue regeneration, anti-inflammation, and protein stabilization, and drawbacks of its use, analogous heparin-mimicking materials are also widely studied for therapeutic applications. This review focuses on one type of these materials, namely, synthetic heparin-mimicking polymers. Utilization of these polymers provides significant benefits compared to heparin, including enhancing therapeutic efficacy and reducing side effects as a result of fine-tuning heparin-binding motifs and other molecular characteristics. The major types of the various polymers are summarized, as well as their applications. Because development of a broader range of heparin-mimicking materials would further expand the impact of these polymers in the treatment of various diseases, future directions are also discussed.

Performance of CT examinations in children with suspected acute appendicitis in the community setting: a need for more education.

PubMed

Kim, Michael E; Orth, Robert C; Fallon, Sara C; Lopez, Monica E; Brandt, Mary L; Zhang, Wei; Bisset, George S

2015-04-01

Despite a recent focus on the preferential use of ultrasound over CT for pediatric appendicitis, most children transferred from community hospitals still undergo diagnostic CT scans. The purpose of this study was to evaluate CT techniques performed for children with acute appendicitis at nonpediatric treatment centers. All patients treated for acute appendicitis at our tertiary-care pediatric hospital from July 1, 2011, through June 30, 2012, were identified. Patient demographics, imaging modality used to diagnoses appendicitis (CT or ultrasound), location (home or referral institution), and CT technique parameters were collected. The estimated mean organ radiation dose, number of imaging phases, and use of contrast media were evaluated at home and referral institutions. During the study period, 1215 patients underwent appendectomies after imaging, with 442 (36.4%) imaged at referral facilities. Most referral patients received a diagnosis by CT (n=384, 87%), compared with 73 of 773 (9.4%) who received a diagnosis by CT at the home institution. The estimated mean (±SD) organ radiation dose was not statistically significantly different between home and referral institutions (13.5±7.3 vs 12.9±6.4 mGy; p=0.58) for single-phase examinations. Of 384 referral patients, 344 had images available for review. In total, 40% (138/344) of patients from referral centers were imaged with suboptimal CT techniques: 50 delayed phase only, 52 dual phase (eight of which were imaged twice in delayed phase), eight triple phase, and 36 without IV contrast agent. CT parameters and radiation doses from single-phase examinations in children with appendicitis were similar at nonpediatric treatment centers and a tertiary care children's hospital. Future educational outreach should focus on optimizing other technical parameters.

Diagnostic Accuracy of History, Physical Examination, Laboratory Tests, and Point-of-care Ultrasound for Pediatric Acute Appendicitis in the Emergency Department: A Systematic Review and Meta-analysis.

PubMed

Benabbas, Roshanak; Hanna, Mark; Shah, Jay; Sinert, Richard

2017-05-01

Acute appendicitis (AA) is the most common surgical emergency in children. Accurate and timely diagnosis is crucial but challenging due to atypical presentations and the inherent difficulty of obtaining a reliable history and physical examination in younger children. The aim of this study was to determine the utility of history, physical examination, laboratory tests, Pediatric Appendicitis Score (PAS) and Emergency Department Point-of-Care Ultrasound (ED-POCUS) in the diagnosis of AA in ED pediatric patients. We performed a systematic review and meta-analysis and used a test-treatment threshold model to identify diagnostic findings that could rule in/out AA and obviate the need for further imaging studies, specifically computed tomography (CT) scan, magnetic resonance imaging (MRI), and radiology department ultrasound (RUS). We searched PubMed, EMBASE, and SCOPUS up to October 2016 for studies on ED pediatric patients with abdominal pain. Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS-2) was used to evaluate the quality and applicability of included studies. Positive and negative likelihood ratios (LR+ and LR-) for diagnostic modalities were calculated and when appropriate data was pooled using Meta-DiSc. Based on the available literature on the test characteristics of different imaging modalities and applying the Pauker-Kassirer method we developed a test-treatment threshold model. Twenty-one studies were included encompassing 8,605 patients with weighted AA prevalence of 39.2%. Studies had variable quality using the QUADAS-2 tool with most studies at high risk of partial verification bias. We divided studies based on their inclusion criteria into two groups of "undifferentiated abdominal pain" and abdominal pain "suspected of AA." In patients with undifferentiated abdominal pain, history of "pain migration to right lower quadrant (RLQ)" (LR+ = 4.81, 95% confidence interval [CI] = 3.59-6.44) and presence of "cough/hop pain" in the physical

Calvarial sarcoid mimicking metastatic disease.

PubMed

Bodie, B F; Kheir, S M; Omura, E F

1980-10-01

A 61-year-old white woman presented with localized cutaneous Boeck's sarcoid and multiple lytic skull lesions mimicking metastatic carcinoma. Complete workup revealed no neoplastic process; biopsy of the skull lesions showed noncaseating granulomas consistent with sarcoid. Although rare, calvarial sarcoid can occur.

Bad bacteria in acute appendicitis: rare but relevant.

PubMed

Reinisch, Alexander; Malkomes, Patrizia; Habbe, Nils; Bechstein, Wolf Otto; Liese, Juliane

2017-09-01

Bacterial infections are a factor for morbidity in patients with acute appendicitis (AA). The spreading of multidrug-resistant (MDR) bacteria is a significant problem in surgery, and the most relevant MDR pathogens are summarized as Enterobacteriaceae, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterococci (ESKAPE) bacteria. Data regarding the species and distribution of bacteria in AA are available, but information about the resistances and their relevance is deficient. In this retrospective study, we analyzed microbiological swabs of patients with AA. The outcome parameters of patients after laparoscopic appendectomy were analyzed against microbiological results, including antibiotic resistance testing. Positive swabs were compared with bacteria cultivated after alternative abdominal emergency surgery (AES). In total, 584 patients with AA were included and had a mean age of 35.5 years. In 216 patients (36.9%), a swab was taken, and in 128 (59.3%) swabs, bacteria could be cultivated. The most frequent organisms were Escherichia coli, Bacteroides species, and Pseudomonas. In 9.4% of the positive AA swabs, MDR germs were cultivated, and all of them were ESKAPE pathogens. Patients with MDR bacteria in AA suffered more infectious complications (p = 0.006) and needed longer hospitalizations (p < 0.009). In AES, aside from appendicitis, a different spectrum containing more MDR bacteria was cultivated (5.9 vs. 20.9%; p < 0.0001). Although they occur less frequently in appendectomy compared to emergency surgeries for other abdominal diseases, MDR bacteria are traceable in this common disease and contribute to additional morbidity.

Acute appendicitis with unusual dual pathology.

PubMed

Riddiough, Georgina E; Bhatti, Imran; Ratliff, David A

2012-01-01

Meckel's diverticulum is a rare congenital abnormality arising due to the persistence of the vitelline duct in 1-3% of the population. Clinical presentation is varied and includes rectal bleeding, intestinal obstruction, diverticulitis and ulceration; therefore diagnosis can be difficult. We report a case of acute appendicitis complicated by persistent post operative small bowel obstruction. Further surgical examination of the bowel revealed an non-inflamed, inverted Meckel's diverticulum causing intussusception. Intestinal obstruction in patients with Meckel's diverticulum may be caused by volvulus, intussusception or incarceration of the diverticulum into a hernia. Obstruction secondary to intussusception is relatively uncommon and frequently leads to a confusing and complicated clinical picture. Consideration of Meckel's diverticulum although a rare diagnosis is imperative and this case raises the question "should surgeons routinely examine the bowel for Meckel's diverticulum at laparoscopy?"

Clear cell carcinoma of the ovary mimicking struma ovarii and carcinoid tumor.

PubMed

Alduaij, Ahmad; Quddus, M Ruhul

2011-04-01

Clear cell carcinomas are considered as high-grade tumor often with poor prognosis. We describe 2 cases of clear cell carcinomas of the ovary mimicking benign or less aggressive tumors encountered in the female genital track. The first case is mimicking a benign monodermal teratoma, the so-called struma ovarii, and the second mimicking a carcinoid tumor. Copyright © 2011 Elsevier Inc. All rights reserved.

Accuracy and reliability of tablet computer as an imaging console for detection of radiological signs of acute appendicitis using PACS workstation as reference standard.

PubMed

Awais, Muhammad; Khan, Dawar Burhan; Barakzai, Muhammad Danish; Rehman, Abdul; Baloch, Noor Ul-Ain; Nadeem, Naila

2018-05-01

To ascertain the accuracy and reliability of tablet as an imaging console for detection of radiological signs of acute appendicitis [on focused appendiceal computed tomography (FACT)] using Picture Archiving and Communication System (PACS) workstation as reference standard. From January, 2014 to June, 2015, 225 patients underwent FACT at our institution. These scans were blindly re-interpreted by an independent consultant radiologist, first on PACS workstation and, two weeks later, on tablet. Scans were interpreted for the presence of radiological signs of acute appendicitis. Accuracy of tablet was calculated using PACS as reference standard. Kappa (κ) statistics were calculated as a measure of reliability. Of 225 patients, 99 had radiological evidence of acute appendicitis on PACS workstation. Tablet was 100% accurate in detecting radiological signs of acute appendicitis. Appendicoliths, free fluid, lymphadenopathy, phlegmon/abscess, and perforation were identified on PACS in 90, 43, 39, 10, and 12 scans, respectively. There was excellent agreement between tablet and PACS for detection of appendicolith (к = 0.924), phlegmon/abscess (к = 0.904), free fluid (к = 0.863), lymphadenopathy (к = 0.879), and perforation (к = 0.904). Tablet computer, as an imaging console, was highly reliable and was as accurate as PACS workstation for the radiological diagnosis of acute appendicitis.

Utility of CT after sonography for suspected appendicitis in children: integration of a clinical scoring system with a staged imaging protocol.

PubMed

Srinivasan, Abhay; Servaes, Sabah; Peña, Andrès; Darge, Kassa

2015-02-01

To improve diagnosis of pediatric appendicitis, many institutions have implemented a staged imaging protocol utilizing ultrasonography (US) first and then computed tomography (CT). A substantial number of children with suspected appendicitis undergo CT after US, and the efficient and accurate diagnosis of pediatric appendicitis continues to be challenging. The objective of the study is to characterize the utility of CT following US for diagnosis of pediatric appendicitis, in conjunction with a clinical appendicitis score (AS). Imaging studies of children with suspected appendicitis who underwent CT after US in an imaging protocol were retrospectively reviewed by three radiologists in consensus. Chart review derived the AS (range 0-10) and obtained the patient diagnosis and disposition, and an AS was applied to each patient. Clinical and radiologic data were analyzed to assess the yield of CT after US. Studies of 211 children (mean age 11.3 years) were included. The positive threshold for AS was determined to be 6 out of 10. When AS and US were concordant (N = 140), the sensitivity and specificity of US were similar to CT. When AS and US were discordant (N = 71) and also when AS ≥ 6 (N = 84), subsequent CT showed superior sensitivity and specificity to US alone. In the subset where US showed neither the appendix nor inflammatory change in the right lower quadrant (126/211, 60 % of scans), when AS < 6 (N = 83), the negative predictive value (NPV) of US was 0.98. However, when AS ≥ 6 (N = 43), NPV of US was 0.58, and the positive predictive value of subsequent CT was 1. There was a significant decrease in depiction of the appendix on US with patient weight-to-age ratio of >6 (kg/year, P < 0.001) and after-hours (1700 -0730 hours) performance of US (P < 0.001). Results suggest that the appendicitis score has utility in guiding an imaging protocol and support the contention that non-visualization of the appendix on US is not

Non-harmful insertion of data mimicking computer network attacks

DOE Office of Scientific and Technical Information (OSTI.GOV)

Neil, Joshua Charles; Kent, Alexander; Hash, Jr, Curtis Lee

Non-harmful data mimicking computer network attacks may be inserted in a computer network. Anomalous real network connections may be generated between a plurality of computing systems in the network. Data mimicking an attack may also be generated. The generated data may be transmitted between the plurality of computing systems using the real network connections and measured to determine whether an attack is detected.

Polymerization of a divalent/tetravalent metal-storing atom-mimicking dendrimer.

PubMed

Albrecht, Ken; Hirabayashi, Yuki; Otake, Masaya; Mendori, Shin; Tobari, Yuta; Azuma, Yasuo; Majima, Yutaka; Yamamoto, Kimihisa

2016-12-01

The phenylazomethine dendrimer (DPA) has a layer-by-layer electron density gradient that is an analog of the Bohr atom (atom mimicry). In combination with electron pair mimicry, the polymerization of this atom-mimicking dendrimer was achieved. The valency of the mimicked atom was controlled by changing the chemical structure of the dendrimer. By mimicking a divalent atom, a one-dimensional (1D) polymer was obtained, and by using a planar tetravalent atom mimic, a 2D polymer was obtained. These poly(dendrimer) polymers could store Lewis acids (SnCl 2 ) in their unoccupied orbitals, thus indicating that these poly(dendrimer) polymers consist of a series of nanocontainers.

A history of the treatment of appendicitis in children: lessons learned.

PubMed

Hamill, James K; Hill, Andrew G

2016-10-01

During the latter half of the 19th century, surgeons increasingly reported performing appendicectomies. Fitz from Harvard, Groves from Canada and Tait from Britain all recorded successful removal of the appendix. McBurney described the point of maximal tenderness in classic appendicitis and also the muscle-splitting incision centred on this point. Priority is given to McArthur in describing the lateral muscle-splitting incision. The direction of the cutaneous incision was later modified by Elliott and Lanz. Incisions that healed well were essential to recovery. Appendicectomy became a 'fashionable' operation after the London surgeon, Treves, removed the appendix of King Edward VII. Through the 20th century, the mortality from appendicitis fell notably with the advent of sulphonamide and penicillin, improvements in fluid therapy and safer anaesthesia. By 1990, diagnostic delay was the main cause of death. Semm performed the first laparoscopic appendicectomy in 1990, roundly criticized at the time for what is now a routine procedure. We view contemporary debates on the indications for appendicectomy, the best approach and how to optimize recovery in the light of the history of this intriguing disease. © 2016 Royal Australasian College of Surgeons.

Variation in the Diagnosis and Management of Appendicitis at Canadian Pediatric Hospitals.

PubMed

Thompson, Graham C; Schuh, Suzanne; Gravel, Jocelyn; Reid, Sarah; Fitzpatrick, Eleanor; Turner, Troy; Bhatt, Maala; Beer, Darcy; Blair, Geoffrey; Eccles, Robin; Jones, Sarah; Kilgar, Jennifer; Liston, Natalia; Martin, John; Hagel, Brent; Nettel-Aguirre, Alberto

2015-07-01

The objective was to characterize the variations in practice in the diagnosis and management of children admitted to hospitals from Canadian pediatric emergency departments (EDs) with suspected appendicitis, specifically the timing of surgical intervention, ED investigations, and management strategies. Twelve sites participated in this retrospective health record review. Children aged 3 to 17 years admitted to the hospital with suspected appendicitis were eligible. Site-specific demographics, investigations, and interventions performed were recorded and compared. Factors associated with after-hours surgery were determined using generalized estimating equations logistic regression. Of the 619 children meeting eligibility criteria, surgical intervention was performed in 547 (88%). After-hours surgery occurred in 76 of the 547 children, with significant variation across sites (13.9%, 95% confidence interval = 7.1% to 21.6%, p < 0.001). The overall perforation rate was 17.4% (95 of 547), and the negative appendectomy rate was 6.8% (37 of 547), varying across sites (p = 0.004 and p = 0.036, respectively). Use of inflammatory markers (p < 0.001), blood cultures (p < 0.001), ultrasound (p = 0.001), and computed tomography (p = 0.001) also varied by site. ED administration of narcotic analgesia and antibiotics varied across sites (p < 0.001 and p = 0.001, respectively), as did the type of surgical approach (p < 0.001). After-hours triage had a significant inverse association with after-hours surgery (p = 0.014). Across Canadian pediatric EDs, there exists significant variation in the diagnosis and management of children with suspected appendicitis. These results indicate that the best diagnostic and management strategies remain unclear and support the need for future prospective, multicenter studies to identify strategies associated with optimal patient outcomes. © 2015 by the Society for Academic Emergency Medicine.

Protective pathways against colitis mediated by appendicitis and appendectomy

PubMed Central

Cheluvappa, R; Luo, A S; Palmer, C; Grimm, M C

2011-01-01

Appendicitis followed by appendectomy (AA) at a young age protects against inflammatory bowel disease (IBD). Using a novel murine appendicitis model, we showed that AA protected against subsequent experimental colitis. To delineate genes/pathways involved in this protection, AA was performed and samples harvested from the most distal colon. RNA was extracted from four individual colonic samples per group (AA group and double-laparotomy control group) and each sample microarray analysed followed by gene-set enrichment analysis (GSEA). The gene-expression study was validated by quantitative reverse transcription–polymerase chain reaction (RT–PCR) of 14 selected genes across the immunological spectrum. Distal colonic expression of 266 gene-sets was up-regulated significantly in AA group samples (false discovery rates < 1%; P-value < 0·001). Time–course RT–PCR experiments involving the 14 genes displayed down-regulation over 28 days. The IBD-associated genes tnfsf10, SLC22A5, C3, ccr5, irgm, ptger4 and ccl20 were modulated in AA mice 3 days after surgery. Many key immunological and cellular function-associated gene-sets involved in the protective effect of AA in experimental colitis were identified. The down-regulation of 14 selected genes over 28 days after surgery indicates activation, repression or de-repression of these genes leading to downstream AA-conferred anti-colitis protection. Further analysis of these genes, profiles and biological pathways may assist in developing better therapeutic strategies in the management of intractable IBD. PMID:21707591

Comparison of colonic transit between polyethylene glycol and water as oral contrast vehicles in the CT evaluation of acute appendicitis.

PubMed

Hebert, Jeffrey J; Taylor, Andrew J; Winter, Thomas C

2006-11-01

The objective of our study was to assess the efficacy of a new positive oral contrast agent's ability to reach the colon during CT evaluation of acute appendicitis. Eighty adult emergency department patients who underwent abdominal CT to evaluate for appendicitis were studied. Forty patients received the department's standard dose of 1,600 mL of a water-iodinated contrast mixture (ratio of 2 mL of iodinated contrast material to 100 mL of water) with a standard delay time of 2-2.5 hours from the beginning of contrast medium ingestion. Forty patients were given a new oral contrast mixture of 1,000 mL of polyethylene glycol (PEG) mixed with 30 mL of iodinated contrast agent, and the examination was conducted only 1 hour from inception of contrast administration. Examinations were reviewed for the presence of contrast medium in the cecum and the presence of appendicitis or other abdominal abnormality. Thirty-eight of 40 patients in the PEG group had contrast medium in the colon at 1 hour after contrast administration, 20 of whom had surgically confirmed cases of appendicitis. In five other patients in that group, another cause to explain the patient's complaints was identified on imaging. Only 18 of the 40 patients who received the standard oral preparation had contrast material present in the cecum. Eleven patients in that group had confirmed appendicitis, and four others had another abnormal finding detected at CT. There was a significant difference in the success of contrast medium transit to the colon with these two agents (p < 0.0001). The use of an oral contrast agent composed of PEG and iodinated contrast material provided a marked improvement in oral agent transit to the colon even in patients with intraabdominal inflammation.

Work-related thumb pain in physiotherapists is associated with thumb alignment during performance of PA pressures.

PubMed

Wajon, Anne; Ada, Louise; Refshauge, Kathryn

2007-02-01

Pain is common in the thumbs of physiotherapists. The purpose of this observational study was to investigate whether there is an association between the alignment of the thumb during performance of postero-anterior (PA) pressures and the presence of thumb pain. One hundred and twenty-nine physiotherapists who attended the Musculoskeletal Physiotherapy Association Conference (2003) participated. After providing a history of any work-related thumb pain, participants applied a PA pressure mimicking the technique they would use on a cervical spine, while the position of their metacarpophalangeal (MP) and interphalangeal (IP) joints was photographed. There was an association (p<0.05) between work-related thumb pain and alignment of the thumb during performance of PA pressures: participants who were able to maintain their MP and IP joints in extension were less likely to report pain. These findings serve as a guide to the safe performance of mobilization techniques, both for beginning practitioners and for experienced therapists complaining of thumb pain.

Enzyme-mimicking polymer brush-functionalized surface for combating biomaterial-associated infections

NASA Astrophysics Data System (ADS)

Jiang, Rujian; Xin, Zhirong; Xu, Shiai; Shi, Hengchong; Yang, Huawei; Song, Lingjie; Yan, Shunjie; Luan, Shifang; Yin, Jinghua; Khan, Ather Farooq; Li, Yonggang

2017-11-01

Biomaterial-associated infections critically compromise the functionality and performance of the medical devices, and pose a serious threat to human healthcare. Recently, natural DNase enzyme has been recognized as a potent material to prevent bacterial adhesion and biofilm formation. However, the vulnerability of DNase dramatically limits its long-term performance in antibacterial applications. In this work, DNase-mimicking polymer brushes were constructed to mimic the DNA-cleavage activity as well as the macromolecular scaffold of the natural DNase. The bacteria repellent efficacy of DNase-mimicking polymer brush-functionalized surface was comparable to that of the DNase-functionalized surface. More importantly, due to their inherent stability, DNase-mimicking polymer brushes presented the much better performance in inhibiting bacterial biofilm development for prolonged periods of time, as compared to the natural DNase. The as-developed DNase-mimicking polymer brush-functionalized surface presents a promising approach to combat biomaterial-associated infections.

Appendectomy - series (image)

MedlinePlus

... to the entire abdominal space. Symptoms of acute appendicitis include pain in the lower right side of ... be performed. There is no test to confirm appendicitis and the symptoms may be caused by other ...

Progress in the Diagnosis of Appendicitis: A Report from Washington State’s Surgical Care and Outcomes Assessment Program (SCOAP)

PubMed Central

Drake, Frederick Thurston; Florence, Michael G.; Johnson, Morris G.; Jurkovich, Gregory J.; Kwon, Steve; Schmidt, Zeila; Thirlby, Richard C.; Flum, David R.

2012-01-01

BACKGROUND and OBJECTIVES Studies suggest that CT and US can effectively diagnose and rule-out appendicitis, safely reducing negative appendectomies (NA); however, some within the surgical community remain reluctant to add imaging to clinical evaluation of patients with suspected appendicitis. The Surgical Care and Outcomes Assessment Program (SCOAP) is a physician-led quality initiative that monitors performance by benchmarking processes of care and outcomes. Since 2006, accurate diagnosis of appendicitis has been a priority for SCOAP. The objective of this study was to evaluate the association between imaging and NA in the general community. METHODS Data were collected prospectively for consecutive appendectomy patients (age > 15) at nearly 60 hospitals. SCOAP data are obtained directly from clinical records, including radiology, operative, and pathology reports. Multivariate logistic regression models were used to examine the association between imaging and NA. Tests for trends over time were also conducted. RESULTS Among 19,327 patients (47.9% female) who underwent appendectomy, 5.4% had NA. Among patients who were imaged, frequency of NA was 4.5%, whereas among those who were not imaged, NA was 15.4% (p < 0.001). This association was consistent for males (3% vs. 10%, p < 0.001) and for reproductive-age females (6.9% vs. 24.7%, p < 0.001). In a multivariate model adjusted for age, sex, and WBC, odds of NA for patients not imaged were 3.7 times the odds for those who received imaging (95%CI 3.0 – 4.4). Among SCOAP hospitals, use of imaging increased and NA decreased significantly over time; frequency of perforation was unchanged. CONCLUSIONS Patients who were not imaged during work-up for suspected appendicitis had over three times the odds of NA as those who were imaged. Routine imaging in the evaluation of patients suspected to have appendicitis can safely reduce unnecessary operations. Programs such as SCOAP improve care through peer-led, benchmarked

A crown ether appended super gelator with multiple stimulus responsiveness.

PubMed

Dong, Shengyi; Zheng, Bo; Xu, Donghua; Yan, Xuzhou; Zhang, Mingming; Huang, Feihe

2012-06-26

A crown ether appended super gelator is designed and synthesized. It can gel a variety of organic solvents and shows excellent gelation properties with both low critical gelation concentration and short gelation time. Due to the introduction of the crown ether moiety and a secondary ammonium unit, the supramolecular gels show reversible gel-sol transitions. The supramolecular gels can also be molded into shape-persistent and free-standing objects. Copyright © 2012 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim.

Hospital readmission after management of appendicitis at freestanding children's hospitals: contemporary trends and financial implications.

PubMed

Rice-Townsend, Samuel; Hall, Matthew; Barnes, Jeff N; Baxter, Jessica K; Rangel, Shawn J

2012-06-01

The purpose of this study was to characterize epidemiologic trends and cost implications of hospital readmission after treatment of pediatric appendicitis. We conducted a 5-year retrospective cohort analysis of 30-day readmission rates for 52,054 patients admitted with appendicitis at 38 children's hospitals participating in the Pediatric Health Information System database. Patients were categorized as "uncomplicated" (postoperative length of stay [LOS] ≤ 2 days) or "complicated" (LOS ≥ 3 days and ≥ 4 consecutive days of antibiotics) and analyzed for demographic data, treatment received during the index admission, readmission rates, and excess LOS and hospital-related costs attributable to readmission encounters. The aggregate 30-day readmission rate was 8.7%, and this varied significantly by disease severity and management approach (uncomplicated appendectomy, 5.6%; complicated appendectomy, 12.8%; drainage, 22.6%; antibiotics only, 24.6%; P < .0001). The median hospital cost per case attributable to readmission was $3401 (reflecting a 44% relative increase in cumulative treatment-related cost), and this varied significantly by disease severity and management approach (uncomplicated appendectomy, $1946 [31% relative increase]; complicated appendectomy, $6524 [53% increase]; drainage, $6827 [48% increase]; antibiotics only, $5835 [58% increase]; P < .0001). In freestanding children's hospitals, readmission after treatment of pediatric appendicitis is a relatively common and costly occurrence. Collaborative efforts are needed to characterize patient, treatment, and hospital-related risk factors as a basis for developing preventative strategies. Copyright © 2012 Elsevier Inc. All rights reserved.

Abdominal Wall Endometriosis Mimicking Metastases.

PubMed

Nambiar, Rakul; Anoop, T M; Mony, Rari P

2018-06-01

Abdominal wall lesions can be broadly divided into nontumorous and tumorous conditions. Nontumorous lesions include congenital lesion, abdominal wall hernia, inflammation and infection, vascular lesions, and miscellaneous conditions like hematoma. Tumorous lesions include benign and malignant neoplasms. Here, we report an unusual case of abdominal wall endometriosis mimicking metastases in a patient with breast carcinoma.

Acute appendicitis with unusual dual pathology

PubMed Central

Riddiough, Georgina E.; Bhatti, Imran; Ratliff, David A.

2011-01-01

INTRODUCTION Meckel's diverticulum is a rare congenital abnormality arising due to the persistence of the vitelline duct in 1–3% of the population. Clinical presentation is varied and includes rectal bleeding, intestinal obstruction, diverticulitis and ulceration; therefore diagnosis can be difficult. PRESENTATION OF CASE We report a case of acute appendicitis complicated by persistent post operative small bowel obstruction. Further surgical examination of the bowel revealed an non-inflamed, inverted Meckel's diverticulum causing intussusception. DISCUSSION Intestinal obstruction in patients with Meckel's diverticulum may be caused by volvulus, intussusception or incarceration of the diverticulum into a hernia. Obstruction secondary to intussusception is relatively uncommon and frequently leads to a confusing and complicated clinical picture. CONCLUSION Consideration of Meckel's diverticulum although a rare diagnosis is imperative and this case raises the question “should surgeons routinely examine the bowel for Meckel's diverticulum at laparoscopy?” PMID:22288035

Tailoring the operative approach for appendicitis to the patient: a prediction model from national surgical quality improvement program data.

PubMed

Senekjian, Lara; Nirula, Raminder

2013-01-01

Laparoscopic appendectomy (LA) is increasingly being performed in the United States, despite controversy about differences in infectious complication rates compared with open appendectomy (OA). Subpopulations exist in which infectious complication rates, both surgical site and organ space, differ with respect to LA compared with OA. All appendectomies in the National Surgical Quality Improvement Program database were analyzed with respect to surgical site infection (SSI) and organ space infection (OSI). Multivariate logistic regression analysis identified independent predictors of SSI or OSI. Probabilities of SSI or OSI were determined for subpopulations to identify when LA was superior to OA. From 2005 to 2009, there were 61,830 appendectomies performed (77.5% LA), of which 9,998 (16.2%) were complicated (58.7% LA). The risk of SSI was considerably lower for LA in both noncomplicated and complicated appendicitis. Across all ages, body mass index, renal function, and WBCs, LA was associated with a lower probability of SSI. The risk of OSI was considerably greater for LA in both noncomplicated and complicated appendicitis. In complicated appendicitis, OA was associated with a lower probability of OSI in patients with WBC >12 cells × 10(3)/μL. In noncomplicated appendicitis, OA was associated with a lower probability of OSI in patients with a body mass index <37.5 when compared with LA. Subpopulations exist in which OA is superior to LA in terms of OSI, however, SSI is consistently lower in LA patients. Copyright © 2013 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

Protective pathways against colitis mediated by appendicitis and appendectomy.

PubMed

Cheluvappa, R; Luo, A S; Palmer, C; Grimm, M C

2011-09-01

Appendicitis followed by appendectomy (AA) at a young age protects against inflammatory bowel disease (IBD). Using a novel murine appendicitis model, we showed that AA protected against subsequent experimental colitis. To delineate genes/pathways involved in this protection, AA was performed and samples harvested from the most distal colon. RNA was extracted from four individual colonic samples per group (AA group and double-laparotomy control group) and each sample microarray analysed followed by gene-set enrichment analysis (GSEA). The gene-expression study was validated by quantitative reverse transcription-polymerase chain reaction (RT-PCR) of 14 selected genes across the immunological spectrum. Distal colonic expression of 266 gene-sets was up-regulated significantly in AA group samples (false discovery rates < 1%; P-value < 0·001). Time-course RT-PCR experiments involving the 14 genes displayed down-regulation over 28 days. The IBD-associated genes tnfsf10, SLC22A5, C3, ccr5, irgm, ptger4 and ccl20 were modulated in AA mice 3 days after surgery. Many key immunological and cellular function-associated gene-sets involved in the protective effect of AA in experimental colitis were identified. The down-regulation of 14 selected genes over 28 days after surgery indicates activation, repression or de-repression of these genes leading to downstream AA-conferred anti-colitis protection. Further analysis of these genes, profiles and biological pathways may assist in developing better therapeutic strategies in the management of intractable IBD. © 2011 The Authors. Clinical and Experimental Immunology © 2011 British Society for Immunology.

Added Value of Coronal Reformations for Duty Radiologists and for Referring Physicians or Surgeons in the CT Diagnosis of Acute Appendicitis

PubMed Central

Lee, Kyoung Ho; Hahn, Seokyung; Lee, Kyung Won; Lee, Hak Jong; Kim, Tae Jung; Kang, Sung-Bum; Shin, Joong Ho; Park, Byung Joo

2006-01-01

Objective To assess the added value of coronal reformation for radiologists and for referring physicians or surgeons in the CT diagnosis of acute appendicitis. Materials and Methods Contrast-enhanced CT was performed using 16-detector-row scanners in 110 patients, 46 of whom had appendicitis. Transverse (5-mm thickness, 4-mm increment), coronal (5-mm thickness, 4-mm increment), and combined transverse and coronal sections were interpreted by four radiologists, two surgeons and two emergency physicians. The area under the receiver operating characteristic curve (Az value), sensitivity, specificity (McNemar test), diagnostic confidence and appendiceal visualization (Wilcoxon signed rank test) were compared. Results For radiologists, the additional coronal sections tended to increase the Az value (0.972 vs. 0.986, p = 0.076) and pooled sensitivity (92% [95% CI: 88, 96] vs. 96% [93, 99]), and enhanced appendiceal visualization in true-positive cases (p = 0.031). For non-radiologists, no such enhancement was observed, and the confidence for excluding acute appendicitis declined (p = 0.013). Coronal sections alone were inferior to transverse sections for diagnostic confidence as well as appendiceal visualization for each reader group studied (p < 0.05). Conclusion The added value of coronal reformation is more apparent for radiologists compared to referring physicians or surgeons in the CT diagnosis of acute appendicitis. PMID:16799269

Histopathological study of Enterobius vermicularis among appendicitis patients in Gaza strip, Palestine.

PubMed

Hamdona, Shereen M; Lubbad, Abdel Monem; Al-Hindi, Adnan I

2016-03-01

Enterobius vermicularis is one of the most common intestinal parasite in human. The main objective of this study is to determine the role of E. vermicularis in appendicitis through histopathological examination. A cross sectional study included 200 patients who had appendectomy from three hospitals in Gaza strip. The inflamed appendix was the cause of attending the hospital. Histopathological examination for each appendix was carried out. A questionnaire was designed (interview with patients who underwent appendectomy), and information were obtained from patient and analyzed by using SPSS. The study showed that 30 (15.0 %) of 200 appendices had E. vermicularis in histopathological examination. It was found that ages of patients with histologically proven E. vermicularis in appendices less than 18 years old was found to be (18.2 %). Regarding sex, (16.5 %) of females, (14.0 %) of males patients had E. vermicularis in appendices. Patients who had the highest infection with E. vermicularis were students (17.3 %). In conclusion E. vermicularis occurs more frequently inflamed appendices than in normal. From these results we can conclude that E. vermicularis could be associated to cause of appendicitis in Gaza strip.

A long noncoding RNA contributes to neuropathic pain by silencing Kcna2 in primary afferent neurons

PubMed Central

Zhao, Xiuli; Tang, Zongxiang; Zhang, Hongkang; Atianjoh, Fidelis E.; Zhao, Jian-Yuan; Liang, Lingli; Wang, Wei; Guan, Xiaowei; Kao, Sheng-Chin; Tiwari, Vinod; Gao, Yong-Jing; Hoffman, Paul N.; Cui, Hengmi; Li, Min; Dong, Xinzhong; Tao, Yuan-Xiang

2013-01-01

Neuropathic pain is a refractory disease characterized by maladaptive changes in gene transcription and translation within the sensory pathway. Long noncoding RNAs (lncRNAs) are emerging as new players in gene regulation, but how lncRNAs operate in the development of neuropathic pain is unclear. Here we identify a conserved lncRNA for Kcna2 (named Kcna2 antisense RNA) in first-order sensory neurons of rat dorsal root ganglion (DRG). Peripheral nerve injury increases Kcna2 antisense RNA expression in injured DRG through activation of myeloid zinc finger protein 1, a transcription factor that binds to Kcna2 antisense RNA gene promoter. Mimicking this increase downregulates Kcna2, reduces total Kv current, increases excitability in DRG neurons, and produces neuropathic pain symptoms. Blocking this increase reverses nerve injury-induced downregulation of DRG Kcna2 and attenuates development and maintenance of neuropathic pain. These findings suggest native Kcna2 antisense RNA as a new therapeutic target for the treatment of neuropathic pain. PMID:23792947

Three quantitative approaches to the diagnosis of abdominal pain in children: practical applications of decision theory.

PubMed

Klein, M D; Rabbani, A B; Rood, K D; Durham, T; Rosenberg, N M; Bahr, M J; Thomas, R L; Langenburg, S E; Kuhns, L R

2001-09-01

The authors compared 3 quantitative methods for assisting clinicians in the differential diagnosis of abdominal pain in children, where the most common important endpoint is whether the patient has appendicitis. Pretest probability in different age and sex groups were determined to perform Bayesian analysis, binary logistic regression was used to determine which variables were statistically significantly likely to contribute to a diagnosis, and recursive partitioning was used to build decision trees with quantitative endpoints. The records of all children (1,208) seen at a large urban emergency department (ED) with a chief complaint of abdominal pain were immediately reviewed retrospectively (24 to 72 hours after the encounter). Attempts were made to contact all the patients' families to determine an accurate final diagnosis. A total of 1,008 (83%) families were contacted. Data were analyzed by calculation of the posttest probability, recursive partitioning, and binary logistic regression. In all groups the most common diagnosis was abdominal pain (ICD-9 Code 789). After this, however, the order of the most common final diagnoses for abdominal pain varied significantly. The entire group had a pretest probability of appendicitis of 0.06. This varied with age and sex from 0.02 in boys 2 to 5 years old to 0.16 in boys older than 12 years. In boys age 5 to 12, recursive partitioning and binary logistic regression agreed on guarding and anorexia as important variables. Guarding and tenderness were important in girls age 5 to 12. In boys age greater than 12, both agreed on guarding and anorexia. Using sensitivities and specificities from the literature, computed tomography improved the posttest probability for the group from.06 to.33; ultrasound improved it from.06 to.48; and barium enema improved it from.06 to.58. Knowing the pretest probabilities in a specific population allows the physician to evaluate the likely diagnoses first. Other quantitative methods can help

[Appendicitis and acquired immunodeficiency syndrome. Apropos of 19 cases].

PubMed

Johanet, H; Marmuse, J P; Benhamou, G; Charleux, H

1991-01-01

Appendectomy is the most current digestive surgical procedure in France. Ascending prevalence of infection by HIV, invites us to report 19 documented cases of appendicular syndroma in a population infected by HIV, within 13 cases who required criteria for AIDS. In 31.5% of cases, operation discovered infection by HIV or AIDS. 10 patients had an abscess or gangrenous appendicitis. Furthermore, a tumoral, inflammatory of infectious associated disease which required a treatment was found in 5 others patients. 2 patients died. In all cases, histologic, bacteriologic, virologic and parasitologic samps are warranted to discover current associated diseases.

Microbiologic Analysis of Complicated and Uncomplicated Acute Appendicitis.

PubMed

García-Marín, Andrés; Pérez-López, Mercedes; Martínez-Guerrero, Elena; Rodríguez-Cazalla, Lorena; Compañ-Rosique, Antonio

2018-01-01

Microbiologic studies suggest that complicated (CAA) and uncomplicated (UAA) acute appendicitis are different entities. Routine peritoneal fluid cultures continue to be controversially related to a low positive rate, found mainly in UAA; to isolation of typical micro-organisms with expected susceptibilities; and to a community-acquired intra-abdominal infection. The aim of this study was to describe microbiologic isolates in CAA and UAA and the usefulness of peritoneal fluid cultures to determine the susceptibilities to our antibiotic therapy guidelines. This study was a retrospective review of a prospective database collected at University San Juan Hospital (Spain) between June 2014 and June 2017. Complicated acute appendicitis was defined as gangrenous or perforated, whereas UAA was defined as phegmonous or suppurative. Our antibiotic recommendations are amoxicillin-clavulanic acid and in patients with β-lactam allergies, metronidazole plus aztreonam, and an aminoglycoside (gentamicin or tobramycin). Microbiologic cultures were performed in 264 patients, 157 with a CAA and 107 with a UAA. The positive culture rate was significantly higher in CAA (59%) than in UAA (24.3%). Gram-positive cocci (51.6% CAA; 23.1% UAA), including Streptococcus constellatus (29% CAA; 3.8% UAA), and anaerobes (67.7% CAA; 42.3% UAA) were significantly more common in CAA. The rates of antibiotic resistance were amoxicillin-clavulanic acid 14% (17.2% CAA; 3.8% UAA), gentamicin or tobramycin 8.4% (9.7% CAA; 3.8% UAA), ciprofloxacin 5.9% (6.5% CAA; 3.8% UAA), and ertapenem 10.9% (14% CAA; 0 UAA). The culture-positive rate was higher in CAA, with different isolates and susceptibilities than in UAA, identifying a higher frequency of gram-positive cocci (including S. constellatus) and anaerobes. We recommend obtaining peritoneal fluid cultures in CAA, which frequently will lead to a change in the antimicrobial drug therapy guidelines, creating specific recommendations in AA.

Increased anatomic severity in appendicitis is associated with outcomes in a South African population.

PubMed

Hernandez, Matthew C; Kong, Victor Y; Aho, Johnathon M; Bruce, John L; Polites, Stephanie F; Laing, Grant L; Zielinski, Martin D; Clarke, Damian L

2017-07-01

Severity of emergency general surgery (EGS) diseases has not been standardized until recently. The American Association for the Surgery of Trauma (AAST) proposed an anatomic severity grading system for EGS diseases to facilitate communication and quality comparisons between providers and hospitals. Previous work has demonstrated validity of the system for appendicitis in the United States. To demonstrate generalizability, we aim to externally validate this grading system in South African patients with appendicitis. Patients with acute appendicitis during 2010 to 2016 were identified at multi-institutional sites within South Africa. Baseline demographics and procedure types were recorded, and AAST grades were assigned based on intraoperative findings. Outcomes included duration of stay, mortality, and Clavien-Dindo complications. Summary statistical univariate and nominal logistic regression analyses were performed to compare AAST grade and outcomes. A total of 1,415 patients with a median (interquartile range) age of 19 years (14-28 years) were included (55% men). One hundred percent underwent appendectomy: 63.5% completed via midline laparotomy, 36.5% via limited incision (31.8% via McBurney incision and 4.7% via laparoscopy). Overall, 30-day mortality rate was 1.4% with an overall complication rate of 44%. Most common complications included surgical site infection (n = 147, 10.4%), pneumonia (n = 105, 7.4%), and renal failure (n = 64, 4.5%). Distribution of AAST grade is as follows: Grade 0 (10, 0.7%), Grade 1 (247, 17.4%), Grade 2 (280, 19.8%), Grade 3 (158, 11.3%), Grade 4 (179, 12.6%), and Grade 5 (541, 38.2%). Increased median (interquartile range) AAST grades were recorded in patients with complications, 5 (3-5) compared with those without (2 [1-3], p = 0.001). Duration of stay was increased for patients with higher AAST grades: 4 and 5 (10.6 ± 5.9 days) versus I and II (3.6 ± 4.3 days; p = 0.001). Area under the receiver operating characteristic analysis

The diagnostic performance of ultrasound for acute appendicitis in pregnant and young nonpregnant women: A case-control study.

PubMed

Segev, Lior; Segev, Yakir; Rayman, Shlomi; Nissan, Aviram; Sadot, Eran

2016-10-01

Ultrasonography is frequently used to diagnose acute appendicitis in women of reproductive age, but its diagnostic value in pregnant patients remains unclear. This study sought to compare the diagnostic performance of ultrasound in pregnant and young nonpregnant women with suspected acute appendicitis. The database of a single tertiary medical center was reviewed for all women of reproductive age who underwent appendectomy either during pregnancy (2000-2014) or in the nonpregnant state (2004-2007) following ultrasound evaluation. The performance of ultrasound in terms of predicting the final pathologic diagnosis was compared between the pregnant and non pregnant groups using receiver operating characteristic curve analysis. Of 586 young women treated for appendicitis during the study periods (92 pregnant, 494 non-pregnant), 200 underwent preoperative ultrasound [67 pregnant, and 133 nonpregnant young women]. The pregnant and nonpregnant groups were comparable in age and presenting symptoms. There was no significant difference in the predictive performance of ultrasound between the two groups (AUC 0.76 and 0.73 respectively, p = 0.78) or within the pregnant group, by trimester [first (n = 23), AUC 0.73; second (n = 32), AUC 0.67; third (n = 12), AUC 0.86; p = 0.4]. Ultrasound had a positive predictive value of 0.94 in the pregnant group and 0.91 in the nonpregnant group; corresponding negative predictive values were 0.40 and 0.43. There appears to be no difference in the ability of ultrasound to predict the diagnosis of acute appendicitis between pregnant women and nonpregnant women of reproductive age. Therefore, similar preoperative imaging algorithms may be used in both patient populations. Copyright © 2016 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.

Acute appendicitis--a clear-cut case in men, a guessing game in young women. A prospective study on the role of laparoscopy.

PubMed

Borgstein, P J; Gordijn, R V; Eijsbouts, Q A; Cuesta, M A

1997-09-01

The aggressive surgical approach to patients suspected of having acute appendicitis for fear of perforation, and the inaccuracy of available diagnostic methods lead to an unacceptably high negative appendicectomy rate, especially in young women, in whom gynecological disorders frequently mimic appendicitis. Our objectives were to determine the value of diagnostic laparoscopy in women of child-bearing age to reduce the number of negative laparotomies and establish the correct diagnosis to allow prompt and appropriate treatment. 161 consecutive adult female patients under 50 years of age with a clinical diagnosis of acute appendicitis underwent diagnostic laparoscopy prior to the planned appendicectomy. If an inflamed appendix was found, appendicectomy was usually done through a muscle-splitting McBurney incision. Other diagnoses were treated accordingly. A normal appendix was not removed. Results were compared to a group of 42 similar patients in whom the laparoscopy was omitted for various reasons, to 23 postmenopausal women, and to all 137 male adults, directly operated by the McBurney approach. After laparoscopy, 55% of the patients required appendicectomy for appendicitis while in 23% a gynecological diagnosis was made in spite of previous examination by a gynecologist. Fourteen percent had a negative laparoscopy. There were no false-negative results. The negative appendicectomy rate after laparoscopy was 5% due to two false positives and eight laparoscopy failures. In the group of fertile females who escaped laparoscopy the negative appendicectomy rate was 38%. The respective rates for postmenopausal women and men were 4% and 8%. All women of child-bearing age suspected of having acute appendicitis should undergo diagnostic laparoscopy prior to the planned appendicectomy, regardless of the certainty of the preoperative diagnosis. This is currently the only way to reduce the negative appendicectomy rate and establish a correct diagnosis allowing prompt and

Concentration of UHCL1 in the Serum of Children with Acute Appendicitis, Before and After Surgery, and Its Correlation with CRP and Prealbumin.

PubMed

Matuszczak, Ewa; Tylicka, Marzena; Dębek, Wojciech; Tokarzewicz, Anna; Gorodkiewicz, Ewa; Hermanowicz, Adam

2018-04-01

Ubiquitin-mediated protein degradation plays a crucial role in various cellular processes, including signal transduction, cell differentiation, and stress response. Ubiquitin C-terminal hydrolase 1 (UCHL1) is a unique deubiquitinating enzyme that has both hydrolase and ligase activities. The aim of this study was the determination of UCHL1 concentration in serum of children with appendicitis, before and after the surgery. 42 children with acute appendicitis, who were managed at the Pediatric Surgery Department, between 2013 and 2014, were randomly included into the study (age 9 months up to 14 years, mean age 2.5 + 1 years). There were 15 girls and 27 boys. 18 healthy, age-matched subjects, admitted for planned surgeries served as controls. Exclusion criteria were: severe preexisting infections, immunological or cardiovascular diseases that required long-term medication, and complicated cases of appendicitis with perforation of appendix and/or peritonitis. The UCHL1 concentrations in the blood plasma of patients with acute appendicitis, were highest before the surgery, and were above the range of concentrations measured in controls, the difference was statistically significant. The UCHL1 concentration measured 24 and 72 h after the operation, slowly decreased over time, and still did not reach the normal range, when compared with the concentration measured in controls (p < 0.05). UCHL1 concentration may reflect the metabolic response to acute state inflammation, and the process of gradual ebbing of the inflammation. The method of operation-classic open appendectomy, or laparoscopic appendectomy, does not influence the general trend in UCHL1 concentration in children with appendicitis. There is strong negative correlation between prealbumin and UCHL1 concentrations.

Immunoproteasome in the blood plasma of children with acute appendicitis, and its correlation with proteasome and UCHL1 measured by SPR imaging biosensors.

PubMed

Matuszczak, E; Sankiewicz, A; Debek, W; Gorodkiewicz, E; Milewski, R; Hermanowicz, A

2018-01-01

The aim of this study was to determinate the immunoproteasome concentration in the blood plasma of children with appendicitis, and its correlation with circulating proteasome and ubiquitin carboxyl-terminal hydrolase L1 (UCHL1). Twenty-seven children with acute appendicitis, managed at the Paediatric Surgery Department, were included randomly into the study (age 2 years 9 months up to 14 years, mean age 9·5 ± 1 years). There were 10 girls and 17 boys; 18 healthy, age-matched subjects, admitted for planned surgeries served as controls. Mean concentrations of immunoproteasome, 20S proteasome and UCHL1 in the blood plasma of children with appendicitis before surgery 24 h and 72 h after the appendectomy were higher than in the control group. The immunoproteasome, 20S proteasome and UCHL1 concentrations in the blood plasma of patients with acute appendicitis were highest before surgery. The immunoproteasome, 20S proteasome and UCHL1 concentration measured 24 and 72 h after the operation decreased slowly over time and still did not reach the normal range (P < 0·05). There was no statistical difference between immunoproteasome, 20S proteasome and UCHL1 concentrations in children operated on laparoscopically and children after classic appendectomy. The immunoproteasome concentration may reflect the metabolic response to acute state inflammation, and the process of gradual ebbing of the inflammation may thus be helpful in the assessment of the efficacy of treatment. The method of operation - classic open appendectomy or laparoscopic appendectomy - does not influence the general trend in immunoproteasome concentration in children with appendicitis. © 2017 British Society for Immunology.

Beyond perforation: Influence of peritoneal contamination on clinical severity and resource utilization in children with perforated appendicitis.

PubMed

Feng, Christina; Anandalwar, Seema; Sidhwa, Feroze; Glass, Charity; Karki, Mahima; Zurakowski, David; Rangel, Shawn J

2016-11-01

The purpose of the study was to explore the relationship between the degree of peritoneal contamination and postoperative resource utilization in children with complicated appendicitis. Intraoperative findings were collected prospectively at a single children's hospital from 2012 to 2014. The degree of peritoneal contamination was categorized as either "localized" (confined to the right lower quadrant and pelvis) or "extensive" (extending to the liver). Imaging utilization, postoperative length of stay (pLOS), hospital cost, and readmission rates were compared between groups. Of 88 patients with complicated appendicitis, 38% had extensive contamination. Preoperative characteristics were similar between groups. Patients with extensive contamination had higher rates of postoperative imaging (58.8% vs 27.7%, P<0.01), a 50% longer median pLOS (6days [IQR 4-9] vs 4days [IQR 2-5], P=0.003), a 30% higher median hospital cost ($17,663 [IQR $12,564-$23,697] vs $13,516 [IQR $10,546-$16,686], P=0.004), and a nearly four-fold higher readmission rate (20.6% vs 5.6%, P=0.04) compared to children with localized contamination. Extensive peritoneal contamination is associated with significantly higher resource utilization compared to localized contamination in children with complicated appendicitis. These findings may have important severity-adjustment implications for reimbursement and readmission rate reporting for hospitals that serve populations where late presentation is common. Copyright © 2016 Elsevier Inc. All rights reserved.

Adrenal cortical oncocytoma mimicking pheochromocytoma.

PubMed

Kiriakopoulos, Andreas; Papaioannou, Dimitrios; Linos, Dimitrios

2011-01-01

Adrenal tumors present with clinical features and signs unique to their specific hormonal hypersecretion. However, there have been cases in which the clinical expression has been in conflict with the histologic features of the tumor. In this communication we report an unusual clinical presentation of an adrenal cortical tumor with histologic features of an oncocytoma that clinically mimicked a pheochromocytoma. A 49-year old man was referred to our Unit due to type B aortic dissection and a mass of the left adrenal gland. Computed tomography and magnetic resonance imaging confirmed the presence of aortic dissection extending from the left subclavian artery to both iliac arteries and also revealed a 6 cm tumor on the left adrenal gland. Preoperative endocrine evaluation showed a near tenfold increase of urinary vanillylmandelic acid (VMA) and metanephrine values. Transperitoneal laparoscopic adrenalectomy was successfully performed. The adrenal tumor proved to be an adrenal cortical neoplasm with histologic features of oncocytoma. Although the case of an adrenal cortical adenoma clinically mimicking a pheochromocytoma has been described in the literature, to the best of our knowledge, there has been no previous report of an adrenal cortical neoplasm with predominant features of oncocytoma.

[Spontaneous bile duct perforation: a rare cause of acute abdominal pain during childhood].

PubMed

Ozdemir, Tunç; Akgül, Ahsen Karagözlü; Arpaz, Yağmur; Arikan, Ahmet

2008-07-01

Spontaneous perforation of the bile duct (SPBD) is a rare cause of acute abdominal pain during childhood. Pancreatico-biliary malfunction has been postulated to contribute to its etiology. Factors related to diagnosis and treatment and difference from the other common causes of acute abdominal pain are emphasized. Five patients (3 boys, 2 girls, mean age 4.6) were admitted with peritonitis and operated with initial diagnosis of perforated appendicitis. During laparotomy, SPBD was detected. Presentation, laboratory findings and operative technique of the patients were evaluated retrospectively. Common complaints were abdominal pain and bilious vomiting. Abdominal distention was present in all patients. Leukocytosis and mild hyperbilirubinemia were detected in 5, elevated serum transaminase levels in 4, hyperglycemia in 1 and constipation in 1 patient(s). Abdominal ultrasonography showed a large amount of free fluid. During laparotomy, sterile bile peritonitis was detected initially. After exploration, SPBD was seen. T-tube drainage of the bile duct was carried out. Patients were discharged after removal of the T-tubes. Pancreatico-biliary malfunction was detected in 4 of 5 patients. In patients with generalized peritonitis, elevated transaminase levels and hyperbilirubinemia, SPBD must be considered. Even though the T-tube drainage is the treatment of choice, Roux-en-Y hepatico-portoenterostomy may be mandatory in certain patients.

Malignant mesenchymal neoplasms of the dermis and subcutis mimicking benign lesions: a case-based review.

PubMed

Mentzel, Thomas; Brenn, Thomas

2017-11-01

In this short review, malignant mesenchymal neoplasms of the dermis and subcutis mimicking benign lesions and their differential diagnoses are discussed. These include plaque-like dermatofibrosarcoma protuberans, superficial low-grade fibromyxoid sarcoma, low-grade superficial malignant peripheral nerve sheath tumour, epithelioid sarcoma, pseudomyogenic haemangioendothelioma, Kaposi sarcoma mimicking cavernous haemangioma and benign lymphangioendothelioma, and rare forms of angiosarcoma mimicking a benign vascular lesion.

Surgical Treatment for Chronic Pelvic Pain

PubMed Central

1998-01-01

The source of chronic pelvic pain may be reproductive organ, urological, musculoskeletal - neurological, gastrointestinal, or myofascial. A psychological component almost always is a factor, whether as an antecedent event or presenting as depression as result of the pain. Surgical interventions for chronic pelvic pain include: 1) resection or vaporization of vulvar/vestibular tissue for human papillion virus (HPV) induced or chronic vulvodynia/vestibulitis; 2) cervical dilation for cervix stenosis; 3) hysteroscopic resection for intracavitary or submucous myomas or intracavitary polyps; 4) myomectomy or myolysis for symptomatic intramural, subserosal or pedunculated myomas; 5) adhesiolysis for peritubular and periovarian adhesions, and enterolysis for bowel adhesions, adhesiolysis for all thick adhesions in areas of pain as well as thin ahesions affecting critical structures such as ovaries and tubes; 6) salpingectomy or neosalpingostomy for symptomatic hydrosalpinx; 7) ovarian treatment for symptomatic ovarian pain; 8) uterosacral nerve vaporization for dysmenorrhea; 9) presacral neurectomy for disabling central pain primarily of uterine but also of bladder origin; 10) resection of endometriosis from all surfaces including removal from bladder and bowel as well as from the rectovaginal septal space. Complete resection of all disease in a debulking operation is essential; 11) appendectomy for symptoms of chronic appendicitis, and chronic right lower quadrant pain; 12) uterine suspension for symptoms of collision dyspareunia, pelvic congestion, severe dysmenorrhea, cul-desac endometriosis; 13) repair of all hernia defects whether sciatic, inguinal, femoral, Spigelian, ventral or incisional; 14) hysterectomy if relief has not been achieved by organ-preserving surgery such as resection of all endometriosis and presacral neurectomy, or the central pain continues to be disabling. Before such a radical step is taken, MRI of the uterus to confirm presence of adenomyosis

Does catastrophic thinking enhance oesophageal pain sensitivity? An experimental investigation.

PubMed

Martel, M O; Olesen, A E; Jørgensen, D; Nielsen, L M; Brock, C; Edwards, R R; Drewes, A M

2016-09-01

Gastro-oesophageal reflux disease (GORD) is a major health problem that is frequently accompanied by debilitating oesophageal pain symptoms. The first objective of the study was to examine the association between catastrophizing and oesophageal pain sensitivity. The second objective was to examine whether catastrophizing was associated with the magnitude of acid-induced oesophageal sensitization. Twenty-five healthy volunteers (median age: 24.0 years; range: 22-31) were recruited and were asked to complete the Pain Catastrophizing Scale (PCS). During two subsequent study visits, mechanical, thermal, and electrical pain sensitivity in the oesophagus was assessed before and after inducing oesophageal sensitization using a 30-min intraluminal oesophageal acid perfusion procedure. Analyses were conducted based on data averaged across the two study visits. At baseline, catastrophizing was significantly associated with mechanical (r = -0.42, p < 0.05) and electrical (r = -0.60, p < 0.01) pain thresholds. After acid perfusion, catastrophizing was also significantly associated with mechanical (r = -0.58, p < 0.01) and electrical (r = -0.50, p < 0.05) pain thresholds. Catastrophizing was not significantly associated with thermal pain thresholds. Subsequent analyses revealed that catastrophizing was not significantly associated with the magnitude of acid-induced oesophageal sensitization. Taken together, findings from the present study suggest that catastrophic thinking exerts an influence on oesophageal pain sensitivity, but not necessarily on the magnitude of acid-induced oesophageal sensitization. WHAT DOES THIS STUDY ADD?: Catastrophizing is associated with heightened pain sensitivity in the oesophagus. This was substantiated by assessing responses to noxious stimulation of the oesophagus using an experimental paradigm mimicking features and symptoms experienced by patients with gastro-oesophageal reflux disease (GORD). © 2016 European Pain Federation

Evaluation of the Effect of Reflexology on Pain Control and Analgesic Consumption After Appendectomy.

PubMed

Khorsand, Ali; Tadayonfar, Moosa Al-Reza; Badiee, Shapour; Aghaee, Monavar Afzal; Azizi, Hoda; Baghani, Sara

2015-12-01

Appendicitis is the most common cause of severe abdominal pain in the world, and the associated postsurgical pain, as occurs with other surgical procedures, is one of the most common problems. Today, there is a growing tendency toward nondrug methods and alternative medicine to reduce the adverse effects of drugs. Reflexology involves applying pressure on certain areas of the palms, feet, and ears in order to reduce stress and pain in certain areas of the body. The aim of this study was to determine the effect of reflexology massage on pain relief after appendectomy. This clinical trial was conducted at the surgical emergency unit of Imam Reza Hospital of Mashhad, Iran, in 2013. Pain intensity and analgesic consumption were compared between 105 patients before and immediately, 1 hour, 6 hours, and 24 hours after the intervention in three groups of intervention, control, and placebo. Patients in all three groups received analgesics, as required. The experimental group received pressure on a defined area of the right foot for about 10 minutes and the Shen Men point of the ear for 1 minute. This pressure in the placebo group was applied on the left foot and the left earlobe. Patients in the control group received routine care only. The results were evaluated at a 95% confidence level, and data were analyzed using SPSS software version 12 (SPSS, Inc., Chicago, IL). At the beginning of the study, the mean pain intensity in different groups according to analysis of variance was not significantly different (p = 0.439); however, there was a notable difference in pain intensity between the intervention and other groups after reflexology therapy. In addition, methadone consumption was significantly lower in the reflexology group than in the other two groups (p ≤ 0.001). Reflexology is effective for reducing pain after appendectomy surgery.

A prospective randomized controlled multicenter trial comparing antibiotic therapy with appendectomy in the treatment of uncomplicated acute appendicitis (APPAC trial).

PubMed

Paajanen, Hannu; Grönroos, Juha M; Rautio, Tero; Nordström, Pia; Aarnio, Markku; Rantanen, Tuomo; Hurme, Saija; Dean, Kirsti; Jartti, Airi; Mecklin, Jukka-Pekka; Sand, Juhani; Salminen, Paulina

2013-02-08

Although the standard treatment of acute appendicitis (AA) consists of an early appendectomy, there has recently been both an interest and an increase in the use of antibiotic therapy as the primary treatment for uncomplicated AA. However, the use of antibiotic therapy in the treatment of uncomplicated AA is still controversial. The APPAC trial is a randomized prospective controlled, open label, non-inferiority multicenter trial designed to compare antibiotic therapy (ertapenem) with emergency appendectomy in the treatment of uncomplicated AA. The primary endpoint of the study is the success of the randomized treatment. In the antibiotic treatment arm successful treatment is defined as being discharged from the hospital without the need for surgical intervention and no recurrent appendicitis during a minimum follow-up of one-year (treatment efficacy). Treatment efficacy in the operative treatment arm is defined as successful appendectomy evaluated to be 100%. Secondary endpoints are post-intervention complications, overall morbidity and mortality, the length of hospital stay and sick leave, treatment costs and pain scores (VAS, visual analoque scale). A maximum of 610 adult patients (aged 18-60 years) with a CT scan confirmed uncomplicated AA will be enrolled from six hospitals and randomized by a closed envelope method in a 1:1 ratio either to undergo emergency appendectomy or to receive ertapenem (1 g per day) for three days continued by oral levofloxacin (500 mg per day) plus metronidazole (1.5 g per day) for seven days. Follow-up by a telephone interview will be at 1 week, 2 months and 1, 3, 5 and 10 years; the primary and secondary endpoints of the trial will be evaluated at each time point. The APPAC trial aims to provide level I evidence to support the hypothesis that approximately 75-85% of patients with uncomplicated AA can be treated with effective antibiotic therapy avoiding unnecessary appendectomies and the related operative morbidity, also resulting

Extended Versus Narrow-spectrum Antibiotics in the Management of Uncomplicated Appendicitis in Children: A Propensity-matched Comparative Effectiveness Study.

PubMed

Cameron, Danielle B; Melvin, Patrice; Graham, Dionne A; Glass, Charity C; Serres, Stephanie K; Kronman, Matthew P; Saito, Jacqueline M; Rangel, Shawn J

2018-07-01

The aim of this study was to compare the effectiveness of extended versus narrow spectrum antibiotics in preventing surgical site infections (SSIs) and hospital revisits in children with uncomplicated appendicitis. There is a paucity of high-quality evidence in the pediatric literature comparing the effectiveness of extended versus narrow-spectrum antibiotics in the prevention of SSIs associated with uncomplicated appendicitis. Clinical data from the ACS NSQIP-Pediatric Appendectomy Pilot Project were merged with antibiotic utilization data from the Pediatric Health Information System database for patients undergoing appendectomy for uncomplicated appendicitis at 17 hospitals from January 1, 2013 to June 30, 2015. Patients who received piperacillin/tazobactam (extended spectrum) were compared with those who received either cefoxitin or ceftriaxone with metronidazole (narrow spectrum) after propensity matching on demographic and severity characteristics. Study outcomes were 30-day SSI and hospital revisit rates. Of the 1389 patients included, 39.1% received piperacillin/tazobactam (range by hospital: 0% to 100%), and the remainder received narrow-spectrum agents. No differences in demographics or severity characteristics were found between groups following matching. In the matched analysis, the rates of SSI were similar between groups [extended spectrum: 2.4% vs narrow spectrum 1.8% (odds ratio, OR: 1.05, 95% confidence interval, 95% CI 0.34-3.26)], as was the rate of revisits [extended spectrum: 7.9% vs narrow spectrum 5.1% (OR: 1.46, 95% CI 0.75-2.87)]. Use of extended-spectrum antibiotics was not associated with lower rates of SSI or hospital revisits when compared with narrow-spectrum antibiotics in children with uncomplicated appendicitis. Our results challenge the routine use of extended-spectrum antibiotics observed at many hospitals, particularly given the increasing incidence of antibiotic-resistant organisms.

Diagnostic confounders of chronic widespread pain: not always fibromyalgia

PubMed Central

Häuser, Winfried; Perrot, Serge; Sommer, Claudia; Shir, Yoram; Fitzcharles, Mary-Ann

2017-01-01

Abstract Introduction: Chronic widespread pain (CWP) is the defining feature of fibromyalgia (FM), a worldwide prevalent condition. Chronic widespread pain is, however, not pathognomonic of FM, and other conditions may present similarly with CWP, requiring consideration of a differential diagnosis. Objectives: To conduct a literature search to identify medical conditions that may mimic FM and have highlighted features that may differentiate these various conditions from FM. Methods: A comprehensive literature search from 1990 through September 2016 was conducted to identify conditions characterized by CWP. Results: Conditions that may mimic FM may be categorized as musculoskeletal, neurological, endocrine/metabolic, psychiatric/psychological, and medication related. Characteristics pertaining to the most commonly identified confounding diagnoses within each category are discussed; clues to enable clinical differentiation from FM are presented; and steps towards a diagnostic algorithm for mimicking conditions are presented. Conclusion: Although the most likely reason for a complaint of CWP is FM, this pain complaint can be a harbinger of illness other than FM, prompting consideration of a differential diagnosis. This review should sensitize physicians to a broad spectrum of conditions that can mimic FM. PMID:29392213

The efficacy of combined therapy with metronidazole and broad-spectrum antibiotics on postoperative outcomes for pediatric patients with perforated appendicitis.

PubMed

Shang, Qingjuan; Geng, Qiankun; Zhang, Xuebing; Guo, Chunbao

2017-11-01

The aim of this study was to evaluate the efficacy of combined therapy with metronidazole and broad-spectrum antibiotics for patients with perforated appendicitis who underwent surgical intervention.Broad-spectrum antibiotic therapy is warranted in the treatment of perforated appendicitis. Metronidazole has been used as anaerobic antimicrobial therapy. However, few studies about the use of metronidazole in perforated appendicitis have been reported.The medical records of 249 patients treated with metronidazole combined with broad-spectrum antibiotics following perforated appendicitis surgery were reviewed retrospectively and compared with the medical records of 149 patients treated only with broad-spectrum antibiotics. Propensity score matching was performed to adjust for selected baseline variables. Clinical outcomes, including postoperative complications and length of hospital stay, were compared between the 2 groups.No differences were found between the use of combined therapy with metronidazole and the use of solely broad-spectrum antibiotic agents with regard to postoperative duration of intravenous antibiotic treatment (6.8 ± 1.3 vs 7.9 ± 2.1 days, respectively, P = .18), inflammation variables at POD 5 (white blood cell [WBC] [risk ratio [RR], 1.06; 95% confidence interval [CI], 0.67-1.93, P = .15] and C-reactive protein [CRP] [RR, 1.18; 95% CI, 0.73-2.25, P = .36]) (Table 2), and the mean postoperative length of hospital stay (LOS) (RR, 0.68, 95% CI, 0.41-0.94, P = .41). There were also no differences in the incidence of postoperative complications, including the intra-abdominal or pelvic abscess rate (7[7.1%] vs 9[9.2%], respectively, P = .40), the incidence of wound infection (14[14.3%] vs 15[15.3%], respectively, P = .50), and the 30-day readmission rate (9[9.2%] vs 12[12.2%], respectively, P = .32).Regarding overall postoperative outcomes and complications, our study demonstrated no beneficial clinical effects of

The efficacy of combined therapy with metronidazole and broad-spectrum antibiotics on postoperative outcomes for pediatric patients with perforated appendicitis

PubMed Central

Shang, Qingjuan; Geng, Qiankun; Zhang, Xuebing; Guo, Chunbao

2017-01-01

Abstract The aim of this study was to evaluate the efficacy of combined therapy with metronidazole and broad-spectrum antibiotics for patients with perforated appendicitis who underwent surgical intervention. Broad-spectrum antibiotic therapy is warranted in the treatment of perforated appendicitis. Metronidazole has been used as anaerobic antimicrobial therapy. However, few studies about the use of metronidazole in perforated appendicitis have been reported. The medical records of 249 patients treated with metronidazole combined with broad-spectrum antibiotics following perforated appendicitis surgery were reviewed retrospectively and compared with the medical records of 149 patients treated only with broad-spectrum antibiotics. Propensity score matching was performed to adjust for selected baseline variables. Clinical outcomes, including postoperative complications and length of hospital stay, were compared between the 2 groups. No differences were found between the use of combined therapy with metronidazole and the use of solely broad-spectrum antibiotic agents with regard to postoperative duration of intravenous antibiotic treatment (6.8 ± 1.3 vs 7.9 ± 2.1 days, respectively, P = .18), inflammation variables at POD 5 (white blood cell [WBC] [risk ratio [RR], 1.06; 95% confidence interval [CI], 0.67–1.93, P = .15] and C-reactive protein [CRP] [RR, 1.18; 95% CI, 0.73–2.25, P = .36]) (Table 2), and the mean postoperative length of hospital stay (LOS) (RR, 0.68, 95% CI, 0.41–0.94, P = .41). There were also no differences in the incidence of postoperative complications, including the intra-abdominal or pelvic abscess rate (7[7.1%] vs 9[9.2%], respectively, P = .40), the incidence of wound infection (14[14.3%] vs 15[15.3%], respectively, P = .50), and the 30-day readmission rate (9[9.2%] vs 12[12.2%], respectively, P = .32). Regarding overall postoperative outcomes and complications, our study demonstrated no beneficial

Mesalamine treatment mimicking relapse in a child with ulcerative colitis.

PubMed

Hojsak, Iva; Pavić, Ana M; Kolaček, Sanja

2014-11-01

There are reports on mesalamine-induced bloody diarrhea mimicking ulcerative colitis (UC) relapse, mostly in adults. Herein we present a case of a child with UC who developed relapse of hemorrhagic colitis related to mesalamine. A 10-year-old girl developed severe symptoms mimicking UC relapse 3 weeks after introduction of mesalamine therapy. After mesalamine was withdrawn, her symptoms improved, but deteriorated again during the challenge of mesalamine despite concomitant use of corticosteroids. This is the first case report on such a young child during the concomitant use of corticosteroids.

DNA methyltransferase DNMT3a contributes to neuropathic pain by repressing Kcna2 in primary afferent neurons

PubMed Central

Zhao, Jian-Yuan; Liang, Lingli; Gu, Xiyao; Li, Zhisong; Wu, Shaogen; Sun, Linlin; Atianjoh, Fidelis E.; Feng, Jian; Mo, Kai; Jia, Shushan; Lutz, Brianna Marie; Bekker, Alex; Nestler, Eric J.; Tao, Yuan-Xiang

2017-01-01

Nerve injury induces changes in gene transcription in dorsal root ganglion (DRG) neurons, which may contribute to nerve injury-induced neuropathic pain. DNA methylation represses gene expression. Here, we report that peripheral nerve injury increases expression of the DNA methyltransferase DNMT3a in the injured DRG neurons via the activation of the transcription factor octamer transcription factor 1. Blocking this increase prevents nerve injury-induced methylation of the voltage-dependent potassium (Kv) channel subunit Kcna2 promoter region and rescues Kcna2 expression in the injured DRG and attenuates neuropathic pain. Conversely, in the absence of nerve injury, mimicking this increase reduces the Kcna2 promoter activity, diminishes Kcna2 expression, decreases Kv current, increases excitability in DRG neurons and leads to spinal cord central sensitization and neuropathic pain symptoms. These findings suggest that DNMT3a may contribute to neuropathic pain by repressing Kcna2 expression in the DRG. PMID:28270689

Comparison of Outcomes of antibiotic Drugs and Appendectomy (CODA) trial: a protocol for the pragmatic randomised study of appendicitis treatment

PubMed Central

Davidson, Giana H; Flum, David R; Talan, David A; Kessler, Larry G; Lavallee, Danielle C; Bizzell, Bonnie J; Farjah, Farhood; Stewart, Skye D; Krishnadasan, Anusha; Carney, Erin E; Wolff, Erika M; Comstock, Bryan A; Monsell, Sarah E; Heagerty, Patrick J; Ehlers, Annie P; DeUgarte, Daniel A; Kaji, Amy H; Evans, Heather L; Yu, Julianna T; Mandell, Katherine A; Doten, Ian C; Clive, Kevin S; McGrane, Karen M; Tudor, Brandon C; Foster, Careen S; Saltzman, Darin J; Thirlby, Richard C; Lange, Erin O; Sabbatini, Amber K; Moran, Gregory J

2017-01-01

Introduction Several European studies suggest that some patients with appendicitis can be treated safely with antibiotics. A portion of patients eventually undergo appendectomy within a year, with 10%–15% failing to respond in the initial period and a similar additional proportion with suspected recurrent episodes requiring appendectomy. Nearly all patients with appendicitis in the USA are still treated with surgery. A rigorous comparative effectiveness trial in the USA that is sufficiently large and pragmatic to incorporate usual variations in care and measures the patient experience is needed to determine whether antibiotics are as good as appendectomy. Objectives The Comparing Outcomes of Antibiotic Drugs and Appendectomy (CODA) trial for acute appendicitis aims to determine whether the antibiotic treatment strategy is non-inferior to appendectomy. Methods/Analysis CODA is a randomised, pragmatic non-inferiority trial that aims to recruit 1552 English-speaking and Spanish-speaking adults with imaging-confirmed appendicitis. Participants are randomised to appendectomy or 10 days of antibiotics (including an option for complete outpatient therapy). A total of 500 patients who decline randomisation but consent to follow-up will be included in a parallel observational cohort. The primary analytic outcome is quality of life (measured by the EuroQol five dimension index) at 4 weeks. Clinical adverse events, rate of eventual appendectomy, decisional regret, return to work/school, work productivity and healthcare utilisation will be compared. Planned exploratory analyses will identify subpopulations that may have a differential risk of eventual appendectomy in the antibiotic treatment arm. Ethics and dissemination This trial was approved by the University of Washington’s Human Subjects Division. Results from this trial will be presented in international conferences and published in peer-reviewed journals. Trial registration number NCT02800785. PMID:29146633

Incidence of right-sided colonic tumors (non-appendiceal) in patient's ≥40 years of age presenting with features of acute appendicitis.

PubMed

Khan, Suhail Aslam; Khokhar, Haseeb Anwar; Nasr, A R H; Carton, Eleanor

2013-01-01

Non-appendiceal tumors can mimic and present with clinical features of acute appendicitis in patients of age 40 years or above. The aim of this prospective study is to investigate the incidence of right-sided (non-appendiceal) colonic tumors in patients presenting with clinical features of acute appendicitis. A prospective data analysis of 1662 patients using appendectomy database was performed from 2005 to 2011. Patients above age 40 years or older were included. Patients were compared for demographic data, clinical presentation, radiological findings, operative technique & findings, histo-pathological findings and postoperative complications. The primary outcome was incidence of right-sided colonic (non-appendiceal) tumors presenting with features of acute appendicitis. Secondary outcomes measured were, role of diagnostic radiology, negative appendectomy rate, length of stay and changing trends in operative techniques. From 1662 patients initially reviewed, only 179 patients (10.77%) age 40 years or above mean (56 ± 11.75), median 54 (40-89), with clinical features of acute appendicitis were included in the final analysis. F:M ratio was (1:1.06). CT scan showed in only 1 patient (1.25%, OR = 0.806, p = 0.695), suspicion of cecal tumor and underwent right hemicolectomy. Histological examination of specimen showed, 2 patients (1.11%, OR = 1.10, p = 0.47) had primary appendiceal tumors, in which one patient was histologically reported as appendiceal mucocele (mucinous cystadenoma with low-grade dysplasia), while the other one had appendeceal carcinoid (Goblet cell carcinoid). In the other tumor group one patient had metastatic involvement of appendix from ovarian tumor. The time to appendectomy in radiological group was delayed by (9.2 ± 3.7 h). 131 (73.1%) had laparoscopic while 48 (26.81%) underwent open appendectomy. The negative appendectomy rate was (1.12%) and 30 days complication rate was (11.73%, p = 0.27). Mean length of stay was 3.54�

Appending Limited Clinical Data to an Administrative Database for Acute Myocardial Infarction Patients: The Impact on the Assessment of Hospital Quality.

PubMed

Hannan, Edward L; Samadashvili, Zaza; Cozzens, Kimberly; Jacobs, Alice K; Venditti, Ferdinand J; Holmes, David R; Berger, Peter B; Stamato, Nicholas J; Hughes, Suzanne; Walford, Gary

2016-05-01

Hospitals' risk-standardized mortality rates and outlier status (significantly higher/lower rates) are reported by the Centers for Medicare and Medicaid Services (CMS) for acute myocardial infarction (AMI) patients using Medicare claims data. New York now has AMI claims data with blood pressure and heart rate added. The objective of this study was to see whether the appended database yields different hospital assessments than standard claims data. New York State clinically appended claims data for AMI were used to create 2 different risk models based on CMS methods: 1 with and 1 without the added clinical data. Model discrimination was compared, and differences between the models in hospital outlier status and tertile status were examined. Mean arterial pressure and heart rate were both significant predictors of mortality in the clinically appended model. The C statistic for the model with the clinical variables added was significantly higher (0.803 vs. 0.773, P<0.001). The model without clinical variables identified 10 low outliers and all of them were percutaneous coronary intervention hospitals. When clinical variables were included in the model, only 6 of those 10 hospitals were low outliers, but there were 2 new low outliers. The model without clinical variables had only 3 high outliers, and the model with clinical variables included identified 2 new high outliers. Appending even a small number of clinical data elements to administrative data resulted in a difference in the assessment of hospital mortality outliers for AMI. The strategy of adding limited but important clinical data elements to administrative datasets should be considered when evaluating hospital quality for procedures and other medical conditions.

Financial impact of surgical technique in the treatment of acute appendicitis in children.

PubMed

Litz, Cristen; Danielson, Paul D; Gould, Jay; Chandler, Nicole M

2013-09-01

Appendicitis is the most common emergent problem encountered by pediatric surgeons. Driven by improved cosmetic outcomes, many surgeons are offering pediatric patients single-incision laparoscopic appendectomy. We sought to investigate the financial impact of different surgical approaches to appendectomy. A retrospective study of patients with acute appendicitis undergoing appendectomy from February 2010 to September 2011 was conducted. Based on surgeon preference, patients underwent open appendectomy (OA), laparoscopic appendectomy (LA), or single-incision laparoscopic appendectomy (SILA). Demographic information, surgical outcomes, surgical supply costs, and total direct costs were recorded. A total of 465 patients underwent appendectomy during the study. The mean age of all patients was 11.2 years (range, 1 to 18 years). There were no conversions in the LA or SILA groups. There was a significant difference among surgical technique in regard to surgical supply costs (OA $159 vs. LA $650 vs. SILA $814, P < 0.01) and total direct costs (OA $2129 vs. LA $2624 vs. SILA $2991, P < 0.01). In our institution, both multiport laparoscopic and SILA carry higher costs when compared with OA, largely as a result of the cost of disposable instrumentation. Cost efficiency should be considered by surgeons when undertaking a minimally invasive approach to appendectomy.

Tongue metastasis mimicking an abscess.

PubMed

Mavili, Ertuğrul; Oztürk, Mustafa; Yücel, Tuba; Yüce, Imdat; Cağli, Sedat

2010-03-01

Primary tumors metastasizing to the oral cavity are extremely rare. Lung is one of the most common primary sources of metastases to the tongue. Although the incidence of lung cancer is increasing, tongue metastasis as the initial presentation of the tumor remains uncommon. Due to the rarity of tongue metastasis, little is known about its imaging findings. Herein we report the magnetic resonance imaging and clinical findings of a lingual metastasis, mimicking an abscess, from a primary lung cancer.

Improving ultrasound quality to reduce computed tomography use in pediatric appendicitis: the Safe and Sound campaign.

PubMed

Kotagal, Meera; Richards, Morgan K; Chapman, Teresa; Finch, Lisa; McCann, Bessie; Ormazabal, Amaya; Rush, Robert J; Goldin, Adam B

2015-05-01

Safety concerns about the use of radiation-based imaging such as computed tomography (CT) in children have resulted in national recommendations to use ultrasound (US) for the diagnosis of appendicitis when possible. We evaluated the trends in CT and US use in a statewide sample and the accuracy of these modalities. Patients less than or equal to 18 years undergoing appendectomy in Washington State from 2008 to 2013 were evaluated for preoperative US/CT use, as well as imaging/pathology concordance using data from the Surgical Care and Outcomes Assessment Program. Among 3,353 children, 98.3% underwent preoperative imaging. There was a significant increase in the use of US first over the study period (P < .001). The use of CT at any time during the evaluation decreased. Despite this, in 2013, over 40% of the children still underwent CT imaging. Concordance between US imaging and pathology varied between 40% and 75% at hospitals performing greater than or equal to 10 appendectomies in 2013. Over one third (34.9%) of CT scans performed in the evaluation of children with appendicitis were performed after an indeterminate US. Although the use of US as the first imaging modality to diagnose pediatric appendicitis has increased over the past 5 years, over 40% of children still undergo a CT scan during their preoperative evaluation. Causality for this persistence of CT use is unclear, but could include variability in US accuracy, lack of training, and lack of awareness of the risks of radiation-based imaging. Developing a campaign to focus on continued reduction in CT and increased use of high-quality US should be pursued. Copyright © 2015 Elsevier Inc. All rights reserved.

A Feasibility Study of Smartphone-Based Telesonography for Evaluating Cardiac Dynamic Function and Diagnosing Acute Appendicitis with Control of the Image Quality of the Transmitted Videos.

PubMed

Kim, Changsun; Cha, Hyunmin; Kang, Bo Seung; Choi, Hyuk Joong; Lim, Tae Ho; Oh, Jaehoon

2016-06-01

Our aim was to prove the feasibility of the remote interpretation of real-time transmitted ultrasound videos of dynamic and static organs using a smartphone with control of the image quality given a limited internet connection speed. For this study, 100 cases of echocardiography videos (dynamic organ)-50 with an ejection fraction (EF) of ≥50 s and 50 with EF <50 %-and 100 cases of suspected pediatric appendicitis (static organ)-50 with signs of acute appendicitis and 50 with no findings of appendicitis-were consecutively selected. Twelve reviewers reviewed the original videos using the liquid crystal display (LCD) monitor of an ultrasound machine and using a smartphone, to which the images were transmitted from the ultrasound machine. The resolution of the transmitted echocardiography videos was reduced by approximately 20 % to increase the frame rate of transmission given the limited internet speed. The differences in diagnostic performance between the two devices when evaluating left ventricular (LV) systolic function by measuring the EF and when evaluating the presence of acute appendicitis were investigated using a five-point Likert scale. The average areas under the receiver operating characteristic curves for each reviewer's interpretations using the LCD monitor and smartphone were respectively 0.968 (0.949-0.986) and 0.963 (0.945-0.982) (P = 0.548) for echocardiography and 0.972 (0.954-0.989) and 0.966 (0.947-0.984) (P = 0.175) for abdominal ultrasonography. We confirmed the feasibility of remotely interpreting ultrasound images using smartphones, specifically for evaluating LV function and diagnosing pediatric acute appendicitis; the images were transferred from the ultrasound machine using image quality-controlled telesonography.

Off-site smartphone reading of CT images for patients with inconclusive diagnoses of appendicitis from on-call radiologists.

PubMed

Seong, Nak Jong; Kim, Bohyoung; Lee, Sungmin; Park, Hee Sun; Kim, Hyuk Jung; Woo, Hyunsik; Kang, Heung-Sik; Lee, Kyoung Ho

2014-07-01

The purpose of this study was to simulate a mobile consultation in patients with inconclusive diagnosis of appendicitis made by on-call radiologists, as well as to measure the diagnostic confidence and performance of the mobile consultation. Two off-site abdominal radiologists interpreted the CT images from 68 patients (including 29 patients with confirmed appendicitis) on a smart-phone for whom the preliminary CT reports by 25 in-house on-call radiologists were inconclusive. The smartphone readings were compared with the preliminary reports by on-call radiologists and with the original final reports by in-house abdominal radiologists. Heat maps, kappa statistics, Wilcoxon signed-rank tests, and ROC curves were used for data analysis. The heat maps and kappa statistics showed that the smartphone readings were more similar to the final reports than to the preliminary reports. In diagnosing or ruling out appendicitis, the smartphone readings were more confident than the preliminary reports (p ≤ 0.01) and did not significantly differ in diagnostic confidence from the final reports (p ≥ 0.19). The AUCs of the smartphone readings (0.91 and 0.92) did not differ significantly from those of the preliminary (0.85) or final (0.97) reports (p ≥ 0.09). With the given study sample, the diagnostic performance of the off-site smartphone readings did not differ significantly from that of the in-house preliminary reports. However, the smartphone readings provided higher diagnostic confidence than the preliminary reports.

Pneumopyopericardium mimicking an inferior ST elevation myocardial infarction with regional electrocardiogram changes: a case report.

PubMed

Ratnayake, Eranda Chamara; Premaratne, Sandamali; Lokunarangoda, Niroshan; Fernando, Sanduni; Fernando, Nilanthi; Ponnamperuma, Chandrike; Santharaj, W Samuel

2015-04-30

Pneumopyopericardium is a rare disease with poor prognosis. The usual presentation is with fever, shortness of breath and haemodynamic compromise. The Electrocardiogram changes associated with this disease entity would be similar to pericarditis such as concave shaped ST elevations in all leads with PR sagging. Pneumopyopericardium mimicking an acute ST Elevation Myocardial Infarction, with regional Electrocardiogram changes has hitherto not been described in world literature. We describe the case of a 48 year old native Sri Lankan man, presenting with chest pain and Electrocardiogram changes compatible with an Acute ST Elevation Myocardial Infarction, subsequently found to have Pneumopyopericardium secondary to an oesophageal tear. Retrospective history revealed repetitive vomiting due to heavy alcohol consumption, prior to presentation. It unfortunately led to a fatal outcome. Pneumopyopericardium may mimic an acute ST elevation myocardial infarction with associated regional Electrocardiogram changes. A high degree of suspicion should be maintained and an adequate history should always be obtained prior to any intervention in all ST Elevation Myocardial Infarction patients.

Reported provision of analgesia to patients with acute abdominal pain in Canadian paediatric emergency departments.

PubMed

Poonai, Naveen; Cowie, Allyson; Davidson, Chloe; Benidir, Andréanne; Thompson, Graham C; Boisclair, Philippe; Harman, Stuart; Miller, Michael; Butter, Andreana; Lim, Rod; Ali, Samina

2016-09-01

Evidence exists that analgesics are underutilized, delayed, and insufficiently dosed for emergency department (ED) patients with acute abdominal pain. For physicians practicing in a Canadian paediatric ED setting, we (1) explored theoretical practice variation in the provision of analgesia to children with acute abdominal pain; (2) identified reasons for withholding analgesia; and (3) evaluated the relationship between providing analgesia and surgical consultation. Physician members of Paediatric Emergency Research Canada (PERC) were prospectively surveyed and presented with three scenarios of undifferentiated acute abdominal pain to assess management. A modified Dillman's Tailored Design method was used to distribute the survey from June to July 2014. Overall response rate was 74.5% (149/200); 51.7% of respondents were female and mean age was 44 (SD 8.4) years. The reported rates of providing analgesia for case scenarios representative of renal colic, appendicitis, and intussusception, were 100%, 92.1%, and 83.4%, respectively, while rates of providing intravenous opioids were 85.2%, 58.6%, and 12.4%, respectively. In all 60 responses where the respondent indicated they would obtain a surgical consultation, analgesia would be provided. In the 35 responses where analgesia would be withheld, 21 (60%) believed pain was not severe enough, while 5 (14.3%) indicated it would obscure a surgical condition. Pediatric emergency physicians self-reported rates of providing analgesia for acute abdominal pain scenarios were higher than previously reported, and appeared unrelated to request for surgical consultation. However, an unwillingness to provide opioid analgesia, belief that analgesia can obscure a surgical condition, and failure to take self-reported pain at face value remain, suggesting that the need exists for further knowledge translation efforts.

The diagnostic performance of reduced-dose CT for suspected appendicitis in paediatric and adult patients: A systematic review and diagnostic meta-analysis.

PubMed

Yoon, Hee Mang; Suh, Chong Hyun; Cho, Young Ah; Kim, Jeong Rye; Lee, Jin Seong; Jung, Ah Young; Kim, Jung Heon; Lee, Jeong-Yong; Kim, So Yeon

2018-06-01

To evaluate the diagnostic performance of reduced-dose CT for suspected appendicitis. A systematic search of the MEDLINE and EMBASE databases was carried out through to 10 January 2017. Studies evaluating the diagnostic performance of reduced-dose CT for suspected appendicitis in paediatric and adult patients were selected. Pooled summary estimates of sensitivity and specificity were calculated using hierarchical logistic regression modelling. Meta-regression was performed. Fourteen original articles with a total of 3,262 patients were included. For all studies using reduced-dose CT, the summary sensitivity was 96 % (95 % CI 93-98) with a summary specificity of 94 % (95 % CI 92-95). For the 11 studies providing a head-to-head comparison between reduced-dose CT and standard-dose CT, reduced-dose CT demonstrated a comparable summary sensitivity of 96 % (95 % CI 91-98) and specificity of 94 % (95 % CI 93-96) without any significant differences (p=.41). In meta-regression, there were no significant factors affecting the heterogeneity. The median effective radiation dose of the reduced-dose CT was 1.8 mSv (1.46-4.16 mSv), which was a 78 % reduction in effective radiation dose compared to the standard-dose CT. Reduced-dose CT shows excellent diagnostic performance for suspected appendicitis. • Reduced-dose CT shows excellent diagnostic performance for evaluating suspected appendicitis. • Reduced-dose CT has a comparable diagnostic performance to standard-dose CT. • Median effective radiation dose of reduced-dose CT was 1.8 mSv (1.46-4.16). • Reduced-dose CT achieved a 78 % dose reduction compared to standard-dose CT.

Deep Granuloma Annulare Mimicking Inflamed Cysts in a Teenager.

PubMed

Guo, Emily L; Degesys, Catherine A; Jahan-Tigh, Richard; Chan, Audrey

2017-07-01

We describe deep granuloma annulare (DGA) of the forehead mimicking inflamed cysts. Reactive inflammation and sterile purulent drainage may be an underrecognized feature of DGA. © 2017 Wiley Periodicals, Inc.

Lyme disease presenting with facial palsy and myocarditis mimicking myocardial infarction.

PubMed

Gilson, Julieta; Khalighi, Koroush; Elmi, Farhad; Krishnamurthy, Mahesh; Talebian, Amirsina; Toor, Rubinder S

2017-01-01

A 45-year-old woman presented with a sudden episode of typical chest pain, radiating to her neck. The patient denied premature coronary artery disease in the family. Initial EKG showed normal sinus rhythm with a 1 mm ST-elevation involving lead II and lead aVF and a 1 mm ST-depression in lead V1 with associated T-wave inversion. Initial Troponin I (normal <0.4 ng/mL) and CK-MB (normal <7.7 ng/mL) were elevated at 7.82 ng/mL and 55.2 ng/mL, respectively. Six hours later, Troponin I increased to 13.44 ng/mL and CK-MB to 75.7 ng/mL. The patient underwent cardiac catheterization which did not show any significant obstructive coronary artery disease. Two days later the patient developed right-sided facial palsy. Diagnosis of Lyme disease was confirmed by ELISA with positive IgM and IgG antibodies. Treatment with intravenous ceftriaxone and oral steroids was started. Eventually resolution of symptoms and, normalization of cardiac markers and EKG changes, were achieved. This is a rare case of Lyme myocarditis associated with markedly elevated Troponin I, normal left ventricle function, and an absence of conduction abnormalities. To the best of our knowledge, Lyme myocarditis mimicking acute coronary syndrome with such high levels of Troponin I and neurologic compromise has not been previously described. Lyme myocarditis may be a challenging diagnosis in endemic areas especially in patients with coronary artery disease risk factors, presenting with typical chest pain, EKG changes and positive cardiac biomarkers. Therefore, it should be considered a differential diagnosis in patients presenting with clinical symptoms suggestive of acute coronary syndrome. Abbreviations AV: Atrioventricular; CK-MB: Creatinine Kinase-MB; EKG: Electrocardiogram; ELISA: Enzyme-Linked Immunosorbent Assay; IgG: Immunoglobulin G; IgM: Immunoglobulin M.

Multi-modality gellan gum-based tissue-mimicking phantom with targeted mechanical, electrical, and thermal properties.

PubMed

Chen, Roland K; Shih, A J

2013-08-21

This study develops a new class of gellan gum-based tissue-mimicking phantom material and a model to predict and control the elastic modulus, thermal conductivity, and electrical conductivity by adjusting the mass fractions of gellan gum, propylene glycol, and sodium chloride, respectively. One of the advantages of gellan gum is its gelling efficiency allowing highly regulable mechanical properties (elastic modulus, toughness, etc). An experiment was performed on 16 gellan gum-based tissue-mimicking phantoms and a regression model was fit to quantitatively predict three material properties (elastic modulus, thermal conductivity, and electrical conductivity) based on the phantom material's composition. Based on these material properties and the regression model developed, tissue-mimicking phantoms of porcine spinal cord and liver were formulated. These gellan gum tissue-mimicking phantoms have the mechanical, thermal, and electrical properties approximately equivalent to those of the spinal cord and the liver.

The Effects of Focused/Unfocused Audio-Appended Reading Tasks on Intermediate Female EFL Learners' Written Accuracy

ERIC Educational Resources Information Center

Alavinia, Parviz; Shafaei, Ali; Salimi, Asghar

2018-01-01

The current research study was conducted to examine the impacts of focused and unfocused audio-appended reading tasks on female EFL learners' acquisition of a rule-bound structure (passive voice) and a non-rule-bound structure (prepositions). The participants of this study involved ninety intermediate female English learners. They were assigned…

Rare extraskeletal Ewing's sarcoma mimicking as adenocarcinoma of the sigmoid.

PubMed

Mertens, Michelle; Haenen, Filip W N; Siozopoulou, Vasiliki; Van Cleemput, Marc

2017-06-01

Extraskeletal Ewing's sarcoma (EES) is a rare finding in comparison with Ewing's sarcoma of bone and usually manifests in young patients. However, even in older patients, one must consider the diagnosis. In this case, we describe a 52-year-old woman diagnosed with EES, mimicking as adenocarcinoma of the sigmoid. The tumor was not visualized by a multi-slice spiral computed tomography of the abdomen and pelvis with intravenous contrast, and eventually the diagnosis was made by positive immunohistochemical staining for CD99 and by molecular testing for EWSR1 translocation. This combination of the patient's age and the localization of the tumor mimicking an adenocarcinoma of the sigmoid has never been described before.

Tension pneumocephalus mimicking septic shock: a case report.

PubMed

Miranda, Caroline; Mahta, Ali; Wheeler, Lee Adam; Tsiouris, A John; Kamel, Hooman

2018-02-01

Tension pneumocephalus can lead to rapid neurologic deterioration. We report for the first time its association with aseptic systemic inflammatory response syndrome mimicking septic shock and the efficacy of prompt neurosurgical intervention and critical care support in treating this condition. A 64-year-old man underwent 2-stage olfactory groove meningioma resection. The patient developed altered mental status and gait instability on postoperative day 6. Imaging showed significant pneumocephalus. The patient subsequently developed worsening mental status, respiratory failure, and profound shock requiring multiple vasopressors. Bedside needle decompression, identification and repair of the cranial fossa defect, and critical care support led to improved mental status and reversal of shock and multiorgan dysfunction. Thorough evaluation revealed no evidence of an underlying infection. In this case, tension pneumocephalus incited an aseptic systemic inflammatory response syndrome mimicking septic shock. Prompt neurosurgical correction of pneumocephalus and critical care support not only improved neurologic status, but also reversed shock. Such a complication indicates the importance of close monitoring of patients with progressive pneumocephalus.

Cerebello-cortical network fingerprints differ between essential, Parkinson's and mimicked tremors.

PubMed

Muthuraman, Muthuraman; Raethjen, Jan; Koirala, Nabin; Anwar, Abdul Rauf; Mideksa, Kidist G; Elble, Rodger; Groppa, Sergiu; Deuschl, Günter

2018-06-01

Cerebello-thalamo-cortical loops play a major role in the emergence of pathological tremors and voluntary rhythmic movements. It is unclear whether these loops differ anatomically or functionally in different types of tremor. We compared age- and sex-matched groups of patients with Parkinson's disease or essential tremor and healthy controls (n = 34 per group). High-density 256-channel EEG and multi-channel EMG from extensor and flexor muscles of both wrists were recorded simultaneously while extending the hands against gravity with the forearms supported. Tremor was thereby recorded from patients, and voluntarily mimicked tremor was recorded from healthy controls. Tomographic maps of EEG-EMG coherence were constructed using a beamformer algorithm coherent source analysis. The direction and strength of information flow between different coherent sources were estimated using time-resolved partial-directed coherence analyses. Tremor severity and motor performance measures were correlated with connection strengths between coherent sources. The topography of oscillatory coherent sources in the cerebellum differed significantly among the three groups, but the cortical sources in the primary sensorimotor region and premotor cortex were not significantly different. The cerebellar and cortical source combinations matched well with known cerebello-thalamo-cortical connections derived from functional MRI resting state analyses according to the Buckner-atlas. The cerebellar sources for Parkinson's tremor and essential tremor mapped primarily to primary sensorimotor cortex, but the cerebellar source for mimicked tremor mapped primarily to premotor cortex. Time-resolved partial-directed coherence analyses revealed activity flow mainly from cerebellum to sensorimotor cortex in Parkinson's tremor and essential tremor and mainly from cerebral cortex to cerebellum in mimicked tremor. EMG oscillation flowed mainly to the cerebellum in mimicked tremor, but oscillation flowed mainly

IL-18 Contributes to Bone Cancer Pain by Regulating Glia Cells and Neuron Interaction.

PubMed

Liu, Su; Liu, Yue-Peng; Lv, You; Yao, Jun-Li; Yue, Dong-Mei; Zhang, Mao-Yin; Qi, Dun-Yi; Liu, Gong-Jian

2018-02-01

Glial cell hyperactivity has been proposed to be responsible for chronic pain, however, the mechanisms remain unclear. Interleukin (IL)-18, released from glial cells, has been reported to be involved in neuropathic pain. In this study, we investigated the role of IL-18 in bone cancer pain. Bone cancer pain was mimicked by injecting Walker-256 mammary gland carcinoma cells into the intramedullary space of the tibia in rats. Expression and location of IL-18 and the IL-18 receptor were tested. To investigate the contribution of IL-18 signaling to bone cancer pain, IL-18 binding protein and recombinant IL-18 were used. To investigate the mechanisms of glial cells effects, MK801, N-methyl-D-aspartate (NMDA) receptor inhibitor, and Src kinase-specific inhibitor PP1 were used. Tumor cell implantation (TCI) treatment increased expression of IL-18 and IL-18 receptor in spinal cord. The time course of IL-18 upregulation was correlated with TCI-induced pain behaviors. Blocking the IL-18 signaling pathway prevented and reversed bone cancer-related pain behaviors. Meanwhile, blocking IL-18 signaling also suppressed TCI-induced glial cell hyperactivity, as well as activation of GluN2B and subsequent Ca 2+ -dependent signaling. Spinal administration of recombinant IL-18 in naive rat induced significant mechanical allodynia, as well as GluN2B activation. However, intrathecal injection of MK801 failed to suppress recombinant IL-18-induced GluN2B phosphorylation, whereas Src kinase inhibitor PP1 significantly inhibited IL-18-induced GluN2B activation. IL-18-mediated glial-glia and glial-neuron interaction may facilitate bone cancer pain. Blocking IL-18 signaling may effectively prevent and/or suppress bone cancer pain. IL-18 signaling may be a new target for cancer pain therapy. Copyright © 2017 The American Pain Society. Published by Elsevier Inc. All rights reserved.

Electrocardiogram artifact caused by rigors mimicking narrow complex tachycardia: a case report.

PubMed

Matthias, Anne Thushara; Indrakumar, Jegarajah

2014-02-04

The electrocardiogram (ECG) is useful in the diagnosis of cardiac and non-cardiac conditions. Rigors due to shivering can cause electrocardiogram artifacts mimicking various cardiac rhythm abnormalities. We describe an 80-year-old Sri Lankan man with an abnormal electrocardiogram mimicking narrow complex tachycardia during the immediate post-operative period. Electrocardiogram changes caused by muscle tremor during rigors could mimic a narrow complex tachycardia. Identification of muscle tremor as a cause of electrocardiogram artifact can avoid unnecessary pharmacological and non-pharmacological intervention to prevent arrhythmias.

Irrigation of Abdomen With Imipenem Solution Decreases Surgical Site Infections in Patients With Perforated Appendicitis: A Randomized Clinical Trial

PubMed Central

Hesami, Mohammad Ali; Alipour, Hamid; Nikoupour Daylami, Hamed; Alipour, Bijan; Bazargan-Hejazi, Shahrzad; Ahmadi, Alireza

2014-01-01

Background: Perforated appendicitis is one of the most common causes of acute abdomen requiring emergent surgery for immediate appendectomy and peritoneal cavity irrigation; however, the efficacy of irrigation with antibiotic solutions is controversial. Objectives: The aim of this study was to assess the efficacy of imipenem solution irrigation on post-operative surgical site infections (SSIs), hospital length of stay, and hospital costs. We hypothesized that there would be lower rate of SSIs, a shorter hospital stay, and lower hospital cost in patients with perforated appendicitis who received peritoneal cavity irrigation with imipenem solution in comparison to their counterparts who received irrigation with normal saline. Patients and Methods: In this randomized single-blind parallel-group clinical trial, we enrolled 90 patients with perforated appendicitis with 12-50 years of age and randomly allocated them into experimental group (n = 45) and control group (n = 45). The control group received peritoneal irrigation with normal saline (0.9%) and experimental group underwent peritoneal irrigation with imipenem solution (1 mg/mL). All surgical procedures were performed in Imam Reza Hospital of Kermanshah University of Medical Sciences. The study primary outcome was surgical site infections (including wound infection and abdominal abscess) and the secondary outcomes were length of hospital stay and hospital cost. Chi-squared and t-tests were used to analyze the study data. Results: Imipenem solution irrigation was associated with significant clinical improvement at one-month follow-up. The experimental group presented with significantly lower rate of SSIs and shorter length of hospital stay. The experimental group had lower rate of SSIs compared to the control group (4.4% vs. 22.2%, respectively) (p= 0.013). The duration of hospital stay was nearly one day longer in control group (5.84 ± 2.58 days) vs. experimental group (4.91 ± 1.29 days) (P = 0.034), and

Peptide-Appended Permethylated β-Cyclodextrins with Hydrophilic and Hydrophobic Spacers

PubMed Central

2017-01-01

A novel synthetic methodology, employing a combination of the strain-promoted azide–alkyne cycloaddition and maleimide–thiol reactions, for the preparation of permethylated β-cyclodextrin-linker-peptidyl conjugates is reported. Two different bifunctional maleimide cross-linking probes, the polyethylene glycol containing hydrophilic linker bicyclo[6.1.0] nonyne-maleimide and the hydrophobic 5′-dibenzoazacyclooctyne-maleimide, were attached to azide-appended permethylated β-cyclodextrin. The successfully introduced maleimide function was exploited to covalently graft a cysteine-containing peptide (Ac-Tyr-Arg-Cys-Amide) to produce the target conjugates. The final target compounds were isolated in high purity after purification by isocratic preparative reverse-phase high-performance liquid chromatography. This novel synthetic approach is expected to give access to many different cyclodextrin–linker peptides. PMID:28697600

An unusual case of uterine tube cancer (transitional cell carcinoma) co-existing with appendicitis: a case report.

PubMed

Surmacki, Piotr; Sporny, Stanisław; Tosiak, Arkadiusz; Lasota, Janusz

2005-12-01

The authors present an exceptional case of a transitional cell carcinoma of the uterine tube in a 59-year-old female patient, co-existing with appendicitis. Originally, the patient was assigned to surgery due to an inflamed tumour of the right adnexa. A mid-surgery diagnose revealed appendicitis by chance, but in the course of an examination of the right uterine tube, performed on the spot, no progressive carcinoid process was univocally diagnosed. Therefore, the treatments applied were a bilateral salpingectomy and appendectomy. In the course of the final pathomorphological examination, using an immunohistochemical technique, a primary cancer of the uterine tube composed of transitional epithelium cells (transitional cell carcinoma G-2, pT1a) was diagnosed. At the time of the second surgery, a radical hysterectomy, bilateral oophorectomy and omentectomy were performed and afterwards, the patient was treated with a post-operational radiotherapy. The authors support the thesis that a primary cancer of the uterine tube may, as it looks, suggest a different ailment and present diagnostic problems.

Imaging findings of mimickers of hepatocellular carcinoma

PubMed Central

Lee, Eunchae; Jang, Hyun-Jung

2015-01-01

Radiological imaging plays a crucial role in the diagnosis of hepatocellular carcinoma (HCC) as the noninvasive diagnosis of HCC in high-risk patients by typical imaging findings alone is widely adopted in major practice guidelines for HCC. While imaging techniques have markedly improved in detecting small liver lesions, they often detect incidental benign liver lesions and non-hepatocellular malignancy that can be misdiagnosed as HCC. The most common mimicker of HCC in cirrhotic liver is nontumorous arterioportal shunts that are seen as focal hypervascular liver lesions on dynamic contrast-enhanced cross-sectional imaging. Rapidly enhancing hemangiomas can be easily misdiagnosed as HCC especially on MR imaging with liver-specific contrast agent. Focal inflammatory liver lesions mimic HCC by demonstrating arterial-phase hypervascularity and subsequent washout on dynamic contrast-enhanced imaging. It is important to recognize the suggestive imaging findings for intrahepatic cholangiocarcinoma (CC) as the management of CC is largely different from that of HCC. There are other benign mimickers of HCC such as angiomyolipomas and focal nodular hyperplasia-like nodules. Recognition of their typical imaging findings can reduce false-positive HCC diagnosis. PMID:26770920

Dedifferentiated Liposarcoma Mimicking a Primary Colon Mass.

PubMed

Hollowoa, Blake; Lamps, Laura W; Mizell, Jason S; English, George W; Bridge, Julia A; Ram, Roopa; Gardner, Jerad M

2018-04-01

Dedifferentiated liposarcoma is typically a nonlipogenic high-grade sarcoma that arises from well-differentiated liposarcoma. It most commonly presents as a large mass in the retroperitoneum. Significant involvement of the gastrointestinal tract by dedifferentiated liposarcoma is uncommon. We present a unique case of dedifferentiated liposarcoma radiographically mimicking a primary colon mass with resulting intussusception; stranding of the adjacent adipose tissue was presumed to be a secondary reactive change. On histopathologic analysis of the hemicolectomy specimen, a high-grade sarcoma was seen growing through the colonic wall, and the majority of the surrounding pericolonic adipose tissue was actually composed of well-differentiated liposarcoma with characteristic fibrous bands rather than benign fat with reactive fibrosis. This case raises awareness that well-differentiated liposarcoma and dedifferentiated liposarcoma can rarely present as a primary intestinal mass mimicking colon cancer or other more common entities. When radiographic examination shows a perigastrointestinal or retroperitoneal fatty mass and/or stranding of the fat adjacent to a solid gastrointestinal mass, this unusual scenario should be considered in the radiologic differential diagnosis. Pathologists should keep dedifferentiated liposarcoma in the initial histologic differential diagnosis for any high-grade spindle cell tumor of the retroperitoneum or intra-abdominal visceral organs.

Effect of a Standardized Protocol of Antibiotic Therapy on Surgical Site Infection after Laparoscopic Surgery for Complicated Appendicitis.

PubMed

Park, Hyoung-Chul; Kim, Min Jeong; Lee, Bong Hwa

Although it is accepted that complicated appendicitis requires antibiotic therapy to prevent post-operative surgical infections, consensus protocols on the duration and regimens of treatment are not well established. This study aimed to compare the outcome of post-operative infectious complications in patients receiving old non-standardized and new standard antibiotic protocols, involving either 5 or 10 days of treatment, respectively. We enrolled 1,343 patients who underwent laparoscopic surgery for complicated appendicitis between January 2009 and December 2014. At the beginning of the new protocol, the patients were divided into two groups; 10 days of various antibiotic regimens (between January 2009 and June 2012, called the non-standardized protocol; n = 730) and five days of cefuroxime and metronidazole regimen (between July 2012 and December 2014; standardized protocol; n = 613). We compared the clinical outcomes, including surgical site infection (SSI) (superficial and deep organ/space infections) in the two groups. The standardized protocol group had a slightly shorter operative time (67 vs. 69 min), a shorter hospital stay (5 vs. 5.4 d), and lower medical cost (US$1,564 vs. US$1,654). Otherwise, there was no difference between the groups. No differences were found in the non-standardized and standard protocol groups with regard to the rate of superficial infection (10.3% vs. 12.7%; p = 0.488) or deep organ/space infection (2.3% vs. 2.1%; p = 0.797). In patients undergoing laparoscopic surgery for complicated appendicitis, five days of cefuroxime and metronidazole did not lead to more SSIs, and it decreased the medical costs compared with non-standardized antibiotic regimens.

Radiation exposure - how do CT scans for appendicitis compare between a free standing children's hospital and non-dedicated pediatric facilities?

PubMed

Sharp, Nicole E; Raghavan, Maneesha U; Svetanoff, Wendy J; Thomas, Priscilla T; Sharp, Susan W; Brown, James C; Rivard, Douglas C; St Peter, Shawn D; Holcomb, George W

2014-06-01

We compare the amount of radiation children receive from CT scans performed at non-dedicated pediatric facilities (OH) versus those at a dedicated children's hospital (CH). Using a retrospective chart review, all children undergoing CT scanning for appendicitis at an OH were compared to children undergoing CT imaging for appendicitis at a CH between January 2011 and November 2012. One hundred sixty-three children underwent CT scans at 42 different OH. Body mass index was similar between the two groups (21.00±6.49kg/m(2), 19.58±5.18kg/m(2), P=0.07). Dose length product (DLP) was 620±540.3 at OH and 253.78±211.08 at CH (P < 0.001). OH CT scans accurately diagnosed appendicitis in 81%, while CT scans at CH were accurate in 95% (P=0.026). CTDIvol was recorded in 65 patients with subset analysis showing CTDIvol of 16.98±15.58 and 4.89±2.64, a DLP of 586.25±521.59 and 143.54±41.19, and size-specific dose estimate (SSDE) of 26.71±23.1 and 3.81±2.02 at OH and CH, respectively (P<0.001). Using SSDE as a marker for radiation exposure, children received 86% less radiation and had improved diagnostic accuracy when CT scans are performed at a CH. Copyright © 2014 Elsevier Inc. All rights reserved.

A National Evaluation of the Conservative Management of Uncomplicated Acute Appendicitis: How Common Is This and What Are the Issues.

PubMed

Kelly, Michael E; Khan, Asif; Ur Rehman, Jameel; Waldron, Ronan M; Khan, Waqar; Barry, Kevin; Khan, Iqbal Z

2015-01-01

The management approach for acute appendicitis has been challenged in recent years, with numerous randomized controlled trials demonstrating that antibiotics/conservative management is an efficacious treatment, with lower complication rates. A national survey of all consultant general surgeons evaluating their practices was performed. Reasons for changed practices, choice of antibiotics and follow-up investigations were evaluated. In addition, the role of interval appendicectomy and conservative management in the pediatric population was also assessed. The response rate for this survey was 74.7% (n = 74/99). Over one-fifth (n = 17, 22.9%) routinely treat acute appendicitis conservatively, while another 14.8% (n = 11) consider this approach in selected cases. Main reasons for modified practices included the presence of inflammatory phlegmon (75%), delayed presentation (64%), and recent evidence-based medicine developments (46%). Co-amoxiclav/clavulanic acid was the most popular antibiotic for conservative management (53%). Alternatively, combinations of antibiotics were also utilized. One-third felt interval appendicectomy was warranted, while one-fifth supported conservative management in the paediatric setting. The overwhelming majority (>95%) advocate follow-up colonoscopy ± computed tomography in any patient aged >40 years managed conservatively. Considerable variation in management of uncomplicated appendicitis remains in Ireland despite growing evidence suggesting that the non-operative approach is safe. Reasons for adopting a conservative management practice have been identified and reflect the expanding literature on this subject. © 2015 S. Karger AG, Basel.

Peroxidase-Mimicking Nanozyme with Enhanced Activity and High Stability Based on Metal-Support Interactions.

PubMed

Li, Zhihao; Yang, Xiangdong; Yang, Yanbing; Tan, Yaning; He, Yue; Liu, Meng; Liu, Xinwen; Yuan, Quan

2018-01-09

Peroxidase-mimicking nanozymes offer unique advantages in terms of high stability and low cost over natural peroxidase for applications in bioanalysis, biomedicine, and the treatment of pollution. However, the design of high-efficiency peroxidase-mimicking nanozymes remains a great challenge. In this study, we adopted a structural-design approach through hybridization of cube-CeO 2 and Pt nanoparticles to create a new peroxidase-mimicking nanozyme with high efficiency and excellent stability. Relative to pure cube-CeO 2 and Pt nanoparticles, the as-hybridized Pt/cube-CeO 2 nanocomposites display much improved activities because of the strong metal-support interaction. Meanwhile, the nanocomposites also maintain high catalytic activity after long-term storage and multiple recycling. Based on their excellent properties, Pt/cube-CeO 2 nanocomposites were used to construct high-performance colorimetric biosensors for the sensitive detection of metabolites, including H 2 O 2 and glucose. Our findings highlight opportunities for the development of high-efficiency peroxidase-mimicking nanozymes with potential applications such as diagnostics, biomedicine, and the treatment of pollution. © 2018 Wiley-VCH Verlag GmbH & Co. KGaA, Weinheim.

SU-F-I-36: In-Utero Dose Measurements Within Postmortem Subjects for Estimating Fetal Doses in Pregnant Patients Examined with Pulmonary Embolism, Trauma, and Appendicitis CT

DOE Office of Scientific and Technical Information (OSTI.GOV)

Lipnharski, I; Quails, N; Carranza, C

Purpose: The imaging of pregnant patients is medically necessary in certain clinical situations. The purpose of this work was to directly measure uterine doses in a cadaver scanned with CT protocols commonly performed on pregnant patients in order to estimate fetal dose and assess potential risk. Method: One postmortem subject was scanned on a 320-slice CT scanner with standard pulmonary embolism, trauma, and appendicitis protocols. All protocols were performed with the scan parameters and ranges currently used in clinical practice. Exams were performed both with and without iterative reconstruction to highlight the dose savings potential. Optically stimulated luminescent dosimeters (OSLDs)more » were inserted into the uterus in order to approximate fetal doses. Results: In the pulmonary embolism CT protocol, the uterus is outside of the primary beam, and the dose to the uterus was under 1 mGy. In the trauma and appendicitis protocols, the uterus is in the primary beam, the fetal dose estimates were 30.5 mGy for the trauma protocol, and 20.6 mGy for the appendicitis protocol. Iterative reconstruction reduced fetal doses by 30%, with uterine doses at 21.3 for the trauma and 14.3 mGy for the appendicitis protocol. Conclusion: Fetal doses were under 1 mGy when exposed to scatter radiation, and under 50 mGy when exposed to primary radiation with the trauma and appendicitis protocols. Consistent with the National Council on Radiation Protection & Measurements (NCRP) and the International Commission on Radiological Protection (ICRP), these doses exhibit a negligible risk to the fetus, with only a small increased risk of cancer. Still, CT scans are not recommended during pregnancy unless the benefits of the exam clearly outweigh the potential risk. Furthermore, when possible, pregnant patients should be examined on CT scanners equipped with iterative reconstruction in order to keep patient doses as low as reasonable achievable.« less

[Costs of appendicitis treatment by diagnosis-related groups in a third-level pediatric hospital].

PubMed

Tlacuilo-Parra, Alberto; Hernández-Hernández, Araceli; Venegas-Dávalos, Martha; Gutiérrez-Hermosillo, Violeta; Guevara-Gutiérrez, Elizabeth; Ambriz-González, Gabriela

2014-01-01

Diagnosis-related groups (DRGs) are widely used in Europe. They allow performing comparisons in hospitals and incurrent hospital payment systems, defining the payment categories. We undertook this study to classify children who underwent appendectomy according to DRGs. Cross-sectional study. Comorbidities, length of hospitalization, histopathologic classification, and DRG classifications were analyzed. We included 313 patients, 62% males, with an average age of 8 ± 3 years; 91% were referred by another hospital and 67% were treated at night. Average length of hospitalization was 4 ± 3 days. There were comorbidities in 8% and surgical complications in 11%. According to histopathology, appendicitis was edematous (11%), suppurative (36%), gangrenous (22%), perforated (29%), and abscessed (2%). At discharge, 97% of the patients were healthy. Total cost for DRG 343 was $10,470,173.00 (Mexican pesos), DRG 342 was $1,227,592.00 and DRG 340 was $511,521.00. The global amount was $12,209,286.00 (Mexican pesos). The unitary cost for treatment of appendectomy for DRG 343 was $37,935.00, for DRG 342 was $49,103.00 and for DRG 340 was $42,626.00 (Mexican pesos). Because 88% of the cases of appendicitis were uncomplicated, this amount of money could be spent to treat these patients in a second-level hospital, using reimbursement 343 without generating additional expenses.

A Novel Oxidative Stress Mediator in Acute Appendicitis: Thiol/Disulphide Homeostasis

PubMed Central

Turan, Umit; Kuvvetli, Adnan; Kilavuz, Huseyin; Karakaya, Burak; Ozaltun, Pınar; Alısık, Murat; Erel, Ozcan

2016-01-01

Aim. To investigate the role of a novel oxidative stress marker, thiol/disulphide homeostasis, in patients diagnosed with acute appendicitis (AA). Methods. In this study, seventy-one (43 male and 28 female) patients diagnosed with AA and 71 (30 male and 41 female) healthy volunteers were included. Age, gender, body mass index (BMI), haemoglobin (Hb), white blood cell (WBC), c-reactive protein (CRP), and thiol/disulphide homeostasis parameters (native thiol, total thiol, disulphide, disulphide/native thiol, native thiol/total thiol, and disulphide/total thiol ratios) were compared between the groups. Thiol/disulphide homeostasis was determined by a newly developed method by Erel and Neselioglu. Results. The native thiol, total thiol, and the native thiol/total thiol ratio levels were statistically significantly decreased in the AA compared with the control group (p < 0.001). Disulphide level and the ratios of disulphide/native thiol and disulphide/total thiol were higher in the AA group than in the control group (p < 0.001). There was a negative correlation of CRP with native thiol, total thiol, and native thiol/total thiol ratio while there was a positive correlation of CRP with disulphide/native thiol and disulphide/total thiol in the AA group. In the stepwise regression model, risk factors as disulphide/native thiol (OR = 1.368; p = 0.018) and CRP (OR = 1.635; p = 0.003) were determined as predictors of perforated appendicitis compared to the nonperforated group. Conclusion. This is the first study examining the thiol/disulphide homeostasis as a diagnostic aid in AA and establishing thiol/disulphide homeostatis balance shifted towards the disulphide formation due to thiol oxidation. Further studies are needed to optimize the use of this novel oxidative stress marker in AA. PMID:27642237

Management of necrotising appendicitis associated with widespread necrotising enterocolitis of the small and large bowel and perforated duodenal ulcer.

PubMed

Gupta, Vaibhav; Zani, Augusto; Jackson, Paul; Singh, Shailinder

2015-06-08

A 7-year-old boy presented in septic shock secondary to appendicitis with generalised peritonitis. Following crystalloid resuscitation, he underwent surgery. Faecopurulent contamination and free air were found. This was secondary to a perforated and gangrenous appendix, multiple large and small bowel segments with perforations, patches of necrosis, interspersed with healthy bowel and segments of questionable viability. There was also a perforated duodenal ulcer. Necrotic segments were resected using a 'clip-and-drop' technique to shorten operative duration and guide resection to preserve bowel length. After six laparotomies and multiple bowel resections, the child was discharged home with an ileostomy that was subsequently reversed. He is currently on a normal diet and pursuing all activities appropriate for his age. Perforated appendicitis can be associated with widespread bowel necrosis and multiple perforations. A conservative damage limitation approach using the 'clip-and-drop' technique and relook laparotomies is useful in the management of extensive bowel necrosis in children. 2015 BMJ Publishing Group Ltd.

Appendicitis with appendicular atresia: a rare presentation

PubMed Central

Masood, Irfan; Majid, Zain; Rafiq, Ali; Fatima, Saba; Siddiqui, Osama Bin Zia

2015-01-01

Acute appendicitis is the most common acute surgical condition; making appendectomy the most commonly performed emergency surgical procedure in the world. Anomalies of the appendix are relatively uncommon. However, their presence may alter the course of pre-operative diagnosis and the surgical treatment provided, leading to medico-legal issues in certain cases as well. We hereby present the case of a 17 year-old female who had the suggestive signs, symptoms and investigations of appendicular lump. She was managed according to the Ochsner-Sherren regimen and then underwent interval open appendectomy 6 weeks later. During the procedure, the findings of a 5 cm long appendix were noted. The base of the appendix was attached to the caecum, however there was complete mucosal discontinuity between the base and the remaining portion of the appendix. A fibrous strand connected the two blind ending parts together. After thorough literature search, the authors concluded that this is only the fourth reported case of appendicular atresia ever to have been reported. Considering the rarity of this finding we feel this could be of valuable interest to surgeons and readers alike PMID:26090015

Evaluating the risk of appendiceal perforation when using ultrasound as the initial diagnostic imaging modality in children with suspected appendicitis.

PubMed

Alerhand, Stephen; Meltzer, James; Tay, Ee Tein

2017-08-01

Ultrasound scan has gained attention for diagnosing appendicitis due to its avoidance of ionizing radiation. However, studies show that ultrasound scan carries inferior sensitivity to computed tomography scan. A non-diagnostic ultrasound scan could increase the time to diagnosis and appendicectomy, particularly if follow-up computed tomography scan is needed. Some studies suggest that delaying appendicectomy increases the risk of perforation. To investigate the risk of appendiceal perforation when using ultrasound scan as the initial diagnostic imaging modality in children with suspected appendicitis. We retrospectively reviewed 1411 charts of children ≤17 years old diagnosed with appendicitis at two urban academic medical centers. Patients who underwent ultrasound scan first were compared to those who underwent computed tomography scan first. In the sub-group analysis, patients who only received ultrasound scan were compared to those who received initial ultrasound scan followed by computed tomography scan. Main outcome measures were appendiceal perforation rate and time from triage to appendicectomy. In 720 children eligible for analysis, there was no significant difference in perforation rate between those who had initial ultrasound scan and those who had initial computed tomography scan (7.3% vs. 8.9%, p = 0.44), nor in those who had ultrasound scan only and those who had initial ultrasound scan followed by computed tomography scan (8.0% vs. 5.6%, p = 0.42). Those patients who had ultrasound scan first had a shorter triage-to-incision time than those who had computed tomography scan first (9.2 (IQR: 5.9, 14.0) vs. 10.2 (IQR: 7.3, 14.3) hours, p = 0.03), whereas those who had ultrasound scan followed by computed tomography scan took longer than those who had ultrasound scan only (7.8 (IQR: 5.3, 11.6) vs. 15.1 (IQR: 10.6, 20.6), p < 0.001). Children < 12 years old receiving ultrasound scan first had lower perforation rate (p = 0.01) and

Cystic Benign Metastasizing Leiomyoma of the Lung Mimicking Hydatid Cyst.

PubMed

Alimi, Faouzi; El Hadj Sidi, Chighali; Ghannouchi, Chams

2016-12-01

A 60-year-old woman, with history of a resected uterine benign leiomyoma, is operated for a cystic lesion in the left lung, mimicking an hydatid cyst, and confirmed histologically as Cystic Benign Metastasizing Leiomyoma.

Rational Design of Pathogen-Mimicking Amphiphilic Materials as Nanoadjuvants

NASA Astrophysics Data System (ADS)

Ulery, Bret D.; Petersen, Latrisha K.; Phanse, Yashdeep; Kong, Chang Sun; Broderick, Scott R.; Kumar, Devender; Ramer-Tait, Amanda E.; Carrillo-Conde, Brenda; Rajan, Krishna; Wannemuehler, Michael J.; Bellaire, Bryan H.; Metzger, Dennis W.; Narasimhan, Balaji

2011-12-01

An opportunity exists today for cross-cutting research utilizing advances in materials science, immunology, microbial pathogenesis, and computational analysis to effectively design the next generation of adjuvants and vaccines. This study integrates these advances into a bottom-up approach for the molecular design of nanoadjuvants capable of mimicking the immune response induced by a natural infection but without the toxic side effects. Biodegradable amphiphilic polyanhydrides possess the unique ability to mimic pathogens and pathogen associated molecular patterns with respect to persisting within and activating immune cells, respectively. The molecular properties responsible for the pathogen-mimicking abilities of these materials have been identified. The value of using polyanhydride nanovaccines was demonstrated by the induction of long-lived protection against a lethal challenge of Yersinia pestis following a single administration ten months earlier. This approach has the tantalizing potential to catalyze the development of next generation vaccines against diseases caused by emerging and re-emerging pathogens.

Epidermal cyst mimicking incision line metastasis.

PubMed

Gündoğdu, Ramazan; Ayhan, Erhan; Çolak, Tahsin

2017-01-01

Epidermal cysts are cystic tumors lined with keratinized squamous layer and filled with keratin debris. Epidermal cysts may develop by implantation of surface epidermal layer into the dermis or subcutaneous tissue after trauma or surgical procedures. Cervix cancer spreads either directly or via the vascular and lymphatic systems. Distant skin metastasis of endometrium or cervix cancer is very rare. In this case report, a patient who had a history of cervix cancer operation 11 years ago and presented with a mass that mimicked incision line metastasis and was histopathologically diagnosed with epidermal cyst is presented.

Impact of outpatient management following appendectomy for acute appendicitis: An ACS NSQIP-P analysis.

PubMed

Litz, Cristen N; Stone, Laurie; Alessi, Roberta; Walford, Nebbie E; Danielson, Paul D; Chandler, Nicole M

2018-04-01

In 2012, a same-day discharge protocol following appendectomy for acute appendicitis was initiated. Our objective was to determine the success of the protocol by reviewing the National Surgical Quality Improvement Program-Pediatric (NSQIP-P) outcomes following protocol development. The 2015 NSQIP-P Participant Use Data File was queried to identify patients with acute appendicitis who underwent appendectomy. Outcomes were compared to institutional outcomes. There were 154 institutional patients and 4973 from NSQIP-P centers. Institutional rate of outpatient management was higher compared to NSQIP-P (84% vs 48%, p<0.0001). Surgical length of stay was shorter compared to national rates (0.3±0.7 vs 1.1±1.9days, p<0.0001). There was no significant difference in the incidence of superficial (1.9% vs 1.0%, p=0.2), deep (0.6% vs 0.1%, p=0.17) or organ/space surgical site infections (1.3% vs 0.7%, p=0.31). The incidences of other complications (1.3% vs 0.6%, p=0.26) and 30-day readmissions (3.2% vs 2.6%, p=0.61) were similar. Outpatient management following appendectomy in children is possible with low morbidity and readmission rates. Comparison with other NSQIP-Pediatric centers suggests an opportunity to generalize this practice with considerable savings to the health care system. Prognosis study, level II. Copyright © 2017 Elsevier Inc. All rights reserved.

Subependymal Heterotopia Mimicking Mass in Conventional Magnetic Resonance Imaging: Demonstration With 3T Advanced Neuroimages.

PubMed

Aktas, Filiz; Ogul, Hayri

2017-10-01

The authors reported a rare patient with large subependymal heterotopia mimicking cerebral neoplasia. A 22-year-old female was admitted with a history of right-sided paresthesia accompanied by progressive headache. Cerebral magnetic resonance (MR) imaging showed a large solid lesion in the left frontal lobe. Advanced MR images proved that the lesion was compatible with subependymal heterotopia. Large subependymal heterotopia may mimick cerebral neoplasia.

Friedreich's ataxia mimicking hereditary motor and sensory neuropathy.

PubMed

Panas, Marios; Kalfakis, Nikolaos; Karadima, Georgia; Davaki, Panagiota; Vassilopoulos, Demetris

2002-11-01

Four patients from three unrelated families, with clinical and electrophysiological findings compatible with the diagnosis of hereditary motor and sensory neuropathy, are presented. The molecular analysis showed that the affected individuals were homozygous for the mutation in the X25 gene, characteristic of Friedreich's ataxia. These patients seem to represent a form of Friedreich's ataxia mimicking Charcot-Marie-Tooth disease.

Central nervous system borreliosis mimicking a pontine tumour.

PubMed

Latsch, Kirsten; Tappe, Dennis; Warmuth-Metz, Monika; Hebestreit, Helge

2006-11-01

In childhood, facial nerve palsy and headache are typical symptoms of second and third stage neuroborreliosis. While focal demyelination is occasionally observed on MRI scans, the appearance of a tumorous lesion is extremely rare. The case of a 10-year-old girl with neuroborreliosis mimicking a space-occupying lesion in the brainstem, without any previously recognized manifestations of borreliosis, is reported.

Autoimmunity to Tropomyosin-Specific Peptides Induced by Mycobacterium leprae in Leprosy Patients: Identification of Mimicking Proteins.

PubMed

Singh, Itu; Yadav, Asha Ram; Mohanty, Keshar Kunja; Katoch, Kiran; Sharma, Prashant; Pathak, Vinay Kumar; Bisht, Deepa; Gupta, Umesh D; Sengupta, Utpal

2018-01-01

It has been shown earlier that there is a rise in the levels of autoantibodies and T cell response to cytoskeletal proteins in leprosy. Our group recently demonstrated a rise in both T and B cell responses to keratin and myelin basic protein in all types of leprosy patients and their associations in type 1 reaction (T1R) group of leprosy. In this study, we investigated the association of levels of autoantibodies and lymphoproliferation against myosin in leprosy patients across the spectrum and tried to find out the mimicking proteins or epitopes between host protein and protein/s of Mycobacterium leprae . One hundred and sixty-nine leprosy patients and 55 healthy controls (HC) were enrolled in the present study. Levels of anti-myosin antibodies and T-cell responses against myosin were measured by ELISA and lymphoproliferation assay, respectively. Using 2-D gel electrophoresis, western blot and MALDI-TOF/TOF antibody-reactive spots were identified. Three-dimensional structure of mimicking proteins was modeled by online server. B cell epitopes of the proteins were predicted by BCPREDS server 1.0 followed by identification of mimicking epitopes. Mice of inbred BALB/c strain were hyperimmunized with M. leprae soluble antigen (MLSA) and splenocytes and lymph node cells of these animals were adoptively transferred to naïve mice. Highest level of anti-myosin antibodies was noted in sera of T1R leprosy patients. We observed significantly higher levels of lymphoproliferative response ( p  < 0.05) with myosin in all types of leprosy patients compared to HC. Further, hyperimmunization of inbred BALB/c strain of female mice and rabbit with MLSA revealed that both hyperimmunized rabbit and mice evoked heightened levels of antibodies against myosin and this autoimmune response could be adoptively transferred from hyperimmunized to naïve mice. Tropomyosin was found to be mimicking with ATP-dependent Clp protease ATP-binding subunit of M. leprae . We found four mimicking

Wound infection prophylaxis in pediatric acute appendicitis: a 26-year prospective study.

PubMed

Ein, Sigmund H; Sandler, Anthony

2006-03-01

The purpose of this study was to determine the best wound infection prophylaxis in pediatric acute appendicitis. From 1969 to 1995 inclusive, 453 consecutive pediatric patients at the same children's hospital had an appendix with acute inflammation (acute appendicitis) removed by the same staff surgeon and his resident. The stump was not inverted, and chromic catgut was used throughout. No intraperitoneal antibiotics, irrigation, or drains were used, and the skin closure was with silk sutures initially and then with staples since 1986. The infants and children were divided into 6 consecutive groups of 52 to 96 patients, with each group lasting 2 to 5 years. The wound treatment groups were as follows: no treatment, drain or pack, drain or pack plus antibiotic powder, antibiotic powder, preoperative intravenous antibiotic plus antibiotic powder, and preoperative intravenous antibiotic. The wound Penrose drain, one half-inch gauze pack, and/or antibiotic powder (ampicillin, 1977-1981; cefoxitin, 1982-1995) were all placed in the subcutaneous space. There were a total of 50 (11%) wound infections (pus) that occurred between 4 and 40 days when no antibiotic powder was used and 2 to 14 days with antibiotic powder. In all 6 groups of patients, no organism was grown in most (80%) infections and Escherichia coli was the second commonest (12%). The serous ooze, which occurred only with the use of antibiotic powder (8%), was seen between 6 and 18 days, and no organism was ever cultured. The patients with preoperative (or intraoperative) intravenous antibiotics (cefoxitin) plus wound antibiotic powder (cefoxitin) had the lowest infection rate (2.5%). When this group was compared with the baseline group 1 (no treatment), it was the only group in which wound treatment made a significant difference (P = .003).

Mercury Toxicity Following Unauthorized Siddha Medicine Intake - A Mimicker of Acquired Neuromyotonia - Report of 32 Cases.

PubMed

Gnanashanmugam, G; Balakrishnan, R; Somasundaram, S P; Parimalam, N; Rajmohan, P; Pranesh, M B

2018-01-01

Mercury is used extensively in the preparation of Siddha medicines, after purification. In this study, we present 32 patients of mercury toxicity following unauthorized Siddha medicine intake who mimicked neuromyotonia clinically. We analyzed the clinical features of these patients, the role of autoimmunity in etiopathology, and compared it with acquired neuromyotonia. This is a retrospective study to analyze inpatients in a tertiary care center, admitted with mercury toxicity following Siddha medicine intake from August 2012 to October 2016. We analyzed the clinical features, laboratory data including mercury, arsenic and lead levels in blood, and serum voltage-gated potassium channels (VGKC)-CASPR2 Ab in selected patients. Thirty-two patients who had high blood mercury levels following Siddha medicine intake were included in the study. All patients (100%) had severe intractable neuropathic pain predominantly involving lower limbs. Twenty-six (81.25%) patients had fasciculations and myokymia. Fifteen patients (46.86%) had autonomic dysfunction (postural hypotension and resting tachycardia). Nine (28.12%) patients had encephalopathic features such as dullness, apathy, drowsiness, or delirium. Anti-VGKC Ab was positive in 12 patients with myokymia. All the patients in the study consumed Siddha medicines obtained from unauthorized dealers. Mercury toxicity following Siddha medicine intake closely mimics acquired neuromyotonia; severe intolerable neuropathic pain is the hallmark feature; Positive VGKC-CASPR2 antibody in some patients must be due to triggered autoimmunity secondary to mercury toxicity due to Siddha medicine intake. The government should establish licensing system to prevent distribution of unauthorized Siddha medicines.

Construction of supramolecular helical nanofibers using renewable biomaterials: self-assembly of a cytidylic acid-appended bolaamphiphile in lemon juice.

PubMed

Iwaura, Rika; Ohnishi-Kameyama, Mayumi

2012-07-07

We performed the self-assembly of a 1,18-cytidylic acid-appended bolaamphiphile (C18C) in lemon juice, which contained citric acid, and succeeded in forming left-handed helical nanofibers with diameters, lengths, and pitches of ca. 6-7 nm, several hundred nm to 5 μm, and ca. 30-40 nm, respectively.

Antinociceptive and pronociceptive effect of levetiracetam in tonic pain model.

PubMed

Cortes-Altamirano, José Luis; Reyes-Long, Samuel; Olmos-Hernández, Adriana; Bonilla-Jaime, Herlinda; Carrillo-Mora, Paul; Bandala, Cindy; Alfaro-Rodriguez, Alfonso

2018-04-01

Levetiracetam (LEV) is a novel anticonvulsant with proven antinociceptive properties. However, the antinociceptive and pronociceptive effect of this drug has not yet been fully elucidated in a tonic pain model. Thirty-six male rats (Wistar) were randomized into six groups and underwent the formalin test as follows: rats in the control group were administered 50μL of 1% formalin in the paw; sham-group rats were administered 50μL of saline in the paw to mimick the application of formalin; the four experimental groups were administered LEV intragastrically (ig) (50, 100, 200 and 300mg/kg), and 40min later 50μL of 1% formalin was injected in the paw. LEV exhibited antinociceptive effect in the 300mg/kg LEV group (p<0.05) and a pronociceptive effect in the 100mg/kg LEV group (p<0.05) and in the 50mg/kg LEV group (p<0.001). The antinociceptive and pronociceptive effect of LEV in a tonic pain model is dose-dependent. Copyright © 2017 Institute of Pharmacology, Polish Academy of Sciences. Published by Elsevier B.V. All rights reserved.

Epidermal cyst mimicking incision line metastasis

PubMed Central

Gündoğdu, Ramazan; Ayhan, Erhan; Çolak, Tahsin

2017-01-01

Epidermal cysts are cystic tumors lined with keratinized squamous layer and filled with keratin debris. Epidermal cysts may develop by implantation of surface epidermal layer into the dermis or subcutaneous tissue after trauma or surgical procedures. Cervix cancer spreads either directly or via the vascular and lymphatic systems. Distant skin metastasis of endometrium or cervix cancer is very rare. In this case report, a patient who had a history of cervix cancer operation 11 years ago and presented with a mass that mimicked incision line metastasis and was histopathologically diagnosed with epidermal cyst is presented. PMID:28740968

Differences in disease features between childhood-onset and adult-onset systemic lupus erythematosus patients presenting with acute abdominal pain.

PubMed

Tu, Yu-Ling; Yeh, Kuo-Wei; Chen, Li-Chen; Yao, Tsung-Chieh; Ou, Liang-Shiou; Lee, Wen-I; Huang, Jing-Long

2011-04-01

Abdominal pain in systemic lupus erythematosus (SLE) patients has rarely been analyzed in pediatric populations. We planned to investigate the potential differences between childhood-onset and adult-onset SLE patients who were hospitalized because of acute abdominal pain. A retrospective study including 23 childhood-onset SLE patients with 38 admissions and 88 adult-onset SLE patients with 108 admissions from 1999 to 2008 were conducted in our hospital. All of them had the chief complaint of diffuse abdominal pain. The etiologies of acute abdominal pain in adult-onset SLE patients were more diverse than childhood-onset SLE patients. The most common cause of acute abdominal pain in SLE patients was lupus mesenteric vasculitis (LMV) (18.5%), followed by acute gastroenteritis (14.4%), pancreatitis (10.3%), appendicitis (7.5%), and cholecystitis (6.2%). Compared with adults, children were admitted more often due to LMV (31.6% versus 13.9%; P = 0.016), had more frequently recurrent episodes (39.1% versus 14.8%; P = 0.009), and were more often treated with immunosuppressive agents (31.6% versus 7.4%; P < 0.001) at the time of admission. The overall case fatality rate of acute abdomen in SLE patients was 9.4%. The extra-gastrointestinal symptoms, laboratory evaluation, disease activity, and organ damage measured by the SLE Disease Activity Index and outcomes were comparable between children and adults. Various etiologies of acute abdominal pain should be considered in SLE patients. LMV is the most common cause of acute abdomen in childhood-onset SLE patients with low mortality and morbidity provided by prompt diagnosis and timely administration of high-dose intravenous corticosteroids after excluding real surgical abdomen. Crown Copyright © 2011. Published by Elsevier Inc. All rights reserved.

Adefovir-Induced Hypophosphatemic Osteomalacia Mimicking Bone Metastases From Primary Hepatocarcinoma.

PubMed

Wei, Wei-Jun; Sun, Zhen-Kui; Shen, Chen-Tian; Qiu, Zhong-Ling; Luo, Quan-Yong

2017-09-01

Adefovir-induced hypophosphatemic osteomalacia in the context of hepatocarcinoma is rare and needs to be differentiated from metastatic hepatocarcinoma. We here report a case of severe osteomalacia whose focal uptakes of radiotracer on the Tc-MDP SPECT/CT images mimicked that of metastatic hepatocarcinoma.

Demons-meigs pseudosyndrome mimicking the symptoms of pregnancy: a case report.

PubMed

Nohuz, Erdogan; Alaboud, Maher; El-Drayi, Bilal; Tamburro, Stefano; Kachkach, Said; Varga, Janos

2014-10-01

The Demons-Meigs syndrome should usually be evoked in case of presence of a typical triad: abdominopelvic mass, ascites and hydrothorax. Its diagnosis appears crucial to prevent the realization of unnecessary surgical procedures. A 32-year-old woman presented in April 2012 to the emergency department of our maternity unit (General Hospital, Thiers, France) with an abdominal distension mimicking the symptoms of a pregnancy at term. Physical examination revealed a voluminous painful abdominopelvic mass, extended from the pelvis to the upper abdomen with a large right pleural effusion. Ultrasound and computed tomography showed it was a tumor measuring more than 300 mm in diameter with a right hydrothorax. Serum CA-125 level was 289 U/ml. Cytologic analysis of the pleural effusion didn't show any malignant cells. In this study, Demons-Meigs syndrome was recognized. A laparoscopico-laparotomic management permitted an aspiration of 23 liters of a brownish liquid and an unilateral adnexectomy after pleural paracentesis was performed. Frozen section demonstrated benign mucinous cystadenoma. The final histologic findings objectified intracystic intestinal type ovarian mucinous borderline tumor. After multidisciplinary consultation, the patient was re-operated one month later. The exploration didn't reveal any suspected lesions and appendectomy and omentectomy were performed. The postoperative course was uneventful. Serum CA-125 level was normal at the time of the reoperation and 24 months after the initial surgery. The preoperative recognition of a Demons-Meigs syndrome or a Demons' pseudosyndrome is essential to avoid useless surgical procedures.

SU-F-T-433: Evaluation of a New Dose Mimicking Application for Clinical Flexibility and Reliability

DOE Office of Scientific and Technical Information (OSTI.GOV)

Hoffman, D; Nair, C Kumaran; Wright, C

2016-06-15

Purpose: Clinical workflow and machine down time occasionally require patients to be temporarily treated on a system other than the initial treatment machine. A new commercial dose mimicking application provides automated cross-platform treatment planning to expedite this clinical flexibility. The aim of this work is to evaluate the feasibility of automatic plan creation and establish a robust clinical workflow for prostate and pelvis patients. Methods: Five prostate and five pelvis patients treated with helical plans were selected for re-planning with the dose mimicking application, covering both simple and complex scenarios. Two-arc VMAT and 7- and 9-field IMRT plans were generatedmore » for each case, with the objective function of achieving similar dose volume histogram from the initial helical plans. Dosimetric comparisons include target volumes and organs at risk (OARs) (rectum, bladder, small bowel, femoral heads, etc.). Dose mimicked plans were evaluated by a radiation oncologist, and patient-specific QAs were performed to validate delivery. Results: Overall plan generation and transfer required around 30 minutes of dosimetrist’s time once the dose-mimicking protocol is setup for each site. The resulting VMAT and 7- and 9-field IMRT plans achieved equivalent PTV coverage and homogeneity (D99/DRx = 97.3%, 97.2%, 97.2% and HI = 6.0, 5.8, and 5.9, respectively), compared to helical plans (97.6% and 4.6). The OAR dose discrepancies were up to 6% in rectum Dmean, but generally lower in bladder, femoral heads, bowel and penile bulb. In the context of 1–5 fractions, the radiation oncologist evaluated the dosimetric changes as not clinically significant. All delivery QAs achieved >90% pass with a 3%/3mm gamma criteria. Conclusion: The automated dose-mimicking workflow offers a strategy to avoid missing treatment fractions due to machine down time with non-clinically significant changes in dosimetry. Future work will further optimize dose mimicking plans and

Acute Fulminant Uremic Neuropathy Following Coronary Angiography Mimicking Guillain-Barre Syndrome.

PubMed

Priti, Kumari; Ranwa, Bhanwar

2017-01-01

A 55-year-old diabetic woman suffered a posterior wall ST-elevation myocardial infarction. She developed contrast-induced nephropathy following coronary angiography. Acute fulminant uremic neuropathy was precipitated which initially mimicked Guillan-Barre Syndrome, hence reported.

Variation in practice and resource utilization associated with the diagnosis and management of appendicitis at freestanding children's hospitals: implications for value-based comparative analysis.

PubMed

Rice-Townsend, Samuel; Barnes, Jeff N; Hall, Matthew; Baxter, Jessica L; Rangel, Shawn J

2014-06-01

To characterize the scope and magnitude of practice variation associated with the diagnosis and treatment of appendicitis at freestanding children's hospitals. Variation in care has been associated with poor outcomes and is believed to be a key driver of excess health care spending. Retrospective cohort study of 13,328 patients treated with appendicitis at 34 children's hospitals (9/2010-9/2011). Patients were divided into complicated and uncomplicated cohorts and examined for interhospital variation in the use of diagnostic imaging (computed tomography or ultrasonography), laboratory tests, parenteral nutrition (PN), peripherally inserted central catheters (PICC), and hospital cost. The number and distribution of statistical outliers were calculated for all measures. Significant variation was found for all measures, including a 3.5-fold difference in preoperative imaging (aggregate rate: 49.0%, range across hospitals: 21.2%-73.5%, P < 0.001) and a 5-fold difference in preoperative laboratory utilization (aggregate median: 2 tests/encounter, range: 1-5 tests/encounter, P < 0.001). For patients with complicated appendicitis, we characterized a 12-fold difference in postoperative imaging (aggregate rate: 19.4%, range: 4.9%-61.6%, P < 0.001), a 48-fold difference in PICC lines (aggregate rate: 18.9%, range: 1.7%-81.8%, P < 0.001), and a 100-fold difference in PN utilization (aggregate rate: 9.3%, range: 0.4%-42.0%, P < 0.001). Median hospital cost differed 4-fold for patients with uncomplicated disease (aggregate median: $6804, range: $4200-$16,796, P < 0.001) and 4.6-fold for patients with complicated disease (aggregate median: $13,138, range: $5419-$24,779, P < 0.001). Statistical outliers on the basis of high and low utilization were identified for all measures. Significant variation exists in practice, resource utilization, and treatment-related cost associated with the management of appendicitis at freestanding children's hospitals. Value-based measures are

Heparin-mimicking multilayer coating on polymeric membrane via LbL assembly of cyclodextrin-based supramolecules.

PubMed

Deng, Jie; Liu, Xinyue; Ma, Lang; Cheng, Chong; Shi, Wenbin; Nie, Chuanxiong; Zhao, Changsheng

2014-12-10

In this study, multifunctional and heparin-mimicking star-shaped supramolecules-deposited 3D porous multilayer films with improved biocompatibility were fabricated via a layer-by-layer (LbL) self-assembly method on polymeric membrane substrates. Star-shaped heparin-mimicking polyanions (including poly(styrenesulfonate-co-sodium acrylate; Star-PSS-AANa) and poly(styrenesulfonate-co-poly(ethylene glycol)methyl ether methacrylate; Star-PSS-EGMA)) and polycations (poly(methyl chloride-quaternized 2-(dimethylamino)ethyl methacrylate; Star-PMeDMA) were first synthesized by atom transfer radical polymerization (ATRP) from β-cyclodextrin (β-CD) based cores. Then assembly of 3D porous multilayers onto polymeric membrane surfaces was carried out by alternating deposition of the polyanions and polycations via electrostatic interaction. The surface morphology and composition, water contact angle, blood activation, and thrombotic potential as well as cell viability for the coated heparin-mimicking films were systematically investigated. The results of surface ATR-FTIR spectra and XPS spectra verified successful deposition of the star-shaped supramolecules onto the biomedical membrane surfaces; scanning electron microscopy (SEM) and atomic force microscopy (AFM) observations revealed that the modified substrate had 3D porous surface morphology, which might have a great biological influence on the biointerface. Furthermore, systematic in vitro investigation of protein adsorption, platelet adhesion, human platelet factor 4 (PF4, indicates platelet activation), activate partial thromboplastin time (APTT), thrombin time (TT), coagulation activation (thrombin-antithrombin III complex (TAT, indicates blood coagulant)), and blood-related complement activation (C3a and C5a, indicates inflammation potential) confirmed that the heparin-mimicking multilayer coated membranes exhibited ultralow blood component activations and excellent hemocompatibility. Meanwhile, after surface coating

Neglected foreign body aspiration mimicking bronchial carcinoma.

PubMed

Afghani, Reza; Khandashpour Ghomi, Mahmoud; Khandoozi, Seyed Reza; Yari, Behrouz

2016-07-01

Foreign body aspiration can occur in any age group, but it is more commonly seen in children. In adults, there is usually a predisposing condition that poses a risk of aspiration. If aspiration occurs, prompt diagnosis and extraction of the foreign body is needed to prevent early and late complications. We report a rare case of neglected foreign body aspiration in a 45-year-old schizophrenic opium addicted patient, which resulted in an occlusive lesion in the bronchus, mimicking bronchial carcinoma. © The Author(s) 2016.

Reticulated acanthoma with sebaceous differentiation mimicking melanoma

PubMed Central

Ribeiro, Felipe; Leocadia, Elizabeth; Macarenco, Ricardo S.; Lapins, Jan; Huet, Pascale; Akay, Bengu Nisa; Steiner, Denise

2017-01-01

Reticulated acanthoma with sebaceous differentiation (RASD) is a rare, benign cutaneous tumor with peculiar histopathologic characteristics [1]. RASD had been described under various synonyms such as superficial epithelioma with sebaceous differentiation, sebocrine adenoma, poroma with sebaceous differentiation, and seborrheic keratosis with sebaceous differentiation [2]. Clinical differential diagnosis of RASD includes cutaneous superficial epithelial neoplasia such as Bowen’s disease, superficial basal cell carcinoma (BCC) and intraepidermal eccrine poroma [1]. We report the first case of RASD mimicking both clinically and dermoscopically a melanoma. PMID:29085717

Demodex folliculitis mimicking acute graft-vs-host disease.

PubMed

Cotliar, Jonathan; Frankfurt, Olga

2013-12-01

Acute graft-vs-host disease (GVHD) typically requires high-dose systemic steroids as first-line treatment. Like drug eruptions, viral exanthema, and toxic erythema of chemotherapy, Demodex folliculitis is a clinical mimicker of acute GVHD and requires nonimmunosuppressive therapy. This case of Demodex folliculitis mimicking acute GVHD highlights the need for skin biopsy in patients who have undergone a stem cell transplant with eruptions on the head and neck. A 46-year-old white woman with a history of Fms-like tyrosine kinase 3 acute myeloid leukemia presented to the dermatology clinic with a 5-day history of a nonpruritic eruption on her face and neck 28 days after undergoing a double umbilical cord blood hematopoietic stem cell transplant (HSCT). Findings from the skin biopsy demonstrated a deep dermal lymphocytic infiltrate adjacent to follicular units along with an abundance of Demodex mites noted within the hair follicles consistent with Demodex folliculitis. Oral ivermectin, 12 mg, was given, and the eruption cleared within 24 hours. To our knowledge, this is only the fifth reported case of Demodex folliculitis following HSCT, but the first ever reported to be successfully treated with oral ivermectin. Demodex folliculitis should be added to the differential diagnosis of skin eruptions that arise after HSCT.

Acute Fulminant Uremic Neuropathy Following Coronary Angiography Mimicking Guillain–Barre Syndrome

PubMed Central

Priti, Kumari; Ranwa, Bhanwar

2017-01-01

A 55-year-old diabetic woman suffered a posterior wall ST-elevation myocardial infarction. She developed contrast-induced nephropathy following coronary angiography. Acute fulminant uremic neuropathy was precipitated which initially mimicked Guillan–Barre Syndrome, hence reported. PMID:28706599

Subdural Hematoma Mimickers: A Systematic Review.

PubMed

Catana, Dragos; Koziarz, Alex; Cenic, Aleksa; Nath, Siddharth; Singh, Sheila; Almenawer, Saleh A; Kachur, Edward

2016-09-01

A variety of subdural pathologies that may mimic hematomas are reported in the literature. We aimed to identify the atypical clinical and radiologic presentations of subdural masses that may mimic subdural hematomas. A systematic review of MEDLINE and Embase was conducted independently by 2 reviewers to identify articles describing subdural hematoma mimickers. We also present a patient from our institution with a subdural pathology mimicking a subdural hematoma. We analyzed patient clinical presentations, underlying pathologies, radiologic findings, and clinical outcomes. We included 43 articles totaling 48 patients. The mean ± SD patient age was 55.7 ± 16.8 years. Of the 45 cases describing patient history, 13 patients (27%) had a history of trauma. The underlying pathologies of the 48 subdural collections were 10 metastasis (21%), 14 lymphoma (29%), 7 sarcoma (15%), 4 infectious (8%), 4 autoimmune (8%), and 9 miscellaneous (19%). Findings on computed tomography (CT) scan were 18 hyperdense (41%), 11 hypodense (25%), 9 isodense (20%), 3 isodense/hyperdense (7%), and 3 hypodense/isodense (7%). Thirty-four patients (71%) were treated surgically; among these patients, 65% had symptom resolution. Neither the pathology (P = 0.337) nor the management strategy (P = 0.671) was correlated with improved functional outcomes. Identification of atypical history and radiologic features should prompt further diagnostic tests, including magnetic resonance imaging (MRI), to elucidate the proper diagnosis, given that certain pathologies may be managed nonsurgically. A subdural collection that is hyperdense on CT scan and hyperintense on T2-weighted MRI, along with a history of progressive headache with no trauma, may raise the suspicion of an atypical subdural pathology. Copyright © 2016 Elsevier Inc. All rights reserved.

Mercury Toxicity Following Unauthorized Siddha Medicine Intake – A Mimicker of Acquired Neuromyotonia - Report of 32 Cases

PubMed Central

Gnanashanmugam, G.; Balakrishnan, R.; Somasundaram, S. P.; Parimalam, N.; Rajmohan, P.; Pranesh, M. B.

2018-01-01

Context: Mercury is used extensively in the preparation of Siddha medicines, after purification. In this study, we present 32 patients of mercury toxicity following unauthorized Siddha medicine intake who mimicked neuromyotonia clinically. We analyzed the clinical features of these patients, the role of autoimmunity in etiopathology, and compared it with acquired neuromyotonia. Subjects and Methods: This is a retrospective study to analyze inpatients in a tertiary care center, admitted with mercury toxicity following Siddha medicine intake from August 2012 to October 2016. We analyzed the clinical features, laboratory data including mercury, arsenic and lead levels in blood, and serum voltage-gated potassium channels (VGKC)-CASPR2 Ab in selected patients. Results: Thirty-two patients who had high blood mercury levels following Siddha medicine intake were included in the study. All patients (100%) had severe intractable neuropathic pain predominantly involving lower limbs. Twenty-six (81.25%) patients had fasciculations and myokymia. Fifteen patients (46.86%) had autonomic dysfunction (postural hypotension and resting tachycardia). Nine (28.12%) patients had encephalopathic features such as dullness, apathy, drowsiness, or delirium. Anti-VGKC Ab was positive in 12 patients with myokymia. All the patients in the study consumed Siddha medicines obtained from unauthorized dealers. Conclusions: Mercury toxicity following Siddha medicine intake closely mimics acquired neuromyotonia; severe intolerable neuropathic pain is the hallmark feature; Positive VGKC-CASPR2 antibody in some patients must be due to triggered autoimmunity secondary to mercury toxicity due to Siddha medicine intake. The government should establish licensing system to prevent distribution of unauthorized Siddha medicines. PMID:29720798