Ong, Eugene Mun Wai; Venkatesh, Sudhakar Kundapur
Acute appendicitis is a common surgical condition that is usually managed with early surgery, and is associated with low morbidity and mortality. However, some patients may have atypical symptoms and physical findings that may lead to a delay in diagnosis and increased complications. Atypical presentation may be related to the position of the appendix. Ascending retrocecal appendicitis presenting with right upper abdominal pain may be clinically indistinguishable from acute pathology in the gallbladder, liver, biliary tree, right kidney and right urinary tract. We report a series of four patients with retrocecal appendicitis who presented with acute right upper abdominal pain. The clinical diagnoses at presentation were acute cholecystitis in two patients, pyelonephritis in one, and ureteric colic in one. Ultrasound examination of the abdomen at presentation showed subhepatic collections in two patients and normal findings in the other two. Computed tomography (CT) identified correctly retrocecal appendicitis and inflammation in the retroperitoneum in all cases. In addition, abscesses in the retrocecal space (n = 2) and subhepatic collections (n = 2) were also demonstrated. Emergency appendectomy was performed in two patients, interval appendectomy in one, and hemicolectomy in another. Surgical findings confirmed the presence of appendicitis and its retroperitoneal extensions. Our case series illustrates the usefulness of CT in diagnosing ascending retrocecal appendicitis and its extension, and excluding other inflammatory conditions that mimic appendicitis. PMID:19630119
Hsieh, Chi-Hsun; Wang, Yu-Chun; Yang, Horng-Ren; Chung, Ping-Kuei; Jeng, Long-Bin; Chen, Ray-Jade
As a disease commonly encountered in daily practice, acute appendicitis is usually diagnosed and managed easily with a low mortality and morbidity rate. However, acute appendicitis may occasionally become extraordinarily complicated and life threatening. A 56-year-old man, healthy prior to this admission, was brought to the hospital due to spiking high fever, poor appetite, dysuria, progressive right flank and painful swelling of the thigh for 3 d. Significant inflammatory change of soft tissue was noted, involving the entire right trunk from the subcostal margin to the knee joint. Painful disability of the right lower extremity and apparent signs of peritonitis at the right lower abdomen were disclosed. Laboratory results revealed leukocytosis and an elevated C-reactive protein level. Abdominal CT revealed several communicated gas-containing abscesses at the right retroperitoneal region with mass effect, pushing the duodenum and the pancreatic head upward, compressing and encasing inferior vena cava, destroying psoas muscle and dissecting downward into the right thigh. Laparotomy and right thigh exploration were performed immediately and about 500 mL of frank pus was drained. A ruptured retrocecal appendix was the cause of the abscess. The patient fully recovered at the end of the third post-operation week. This case reminds us that acute appendicitis should be treated carefully on an emergency basis to avoid serious complications. CT scan is the diagnostic tool of choice, with rapid evaluation followed by adequate drainage as the key to the survival of the patient.
... 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 ...
Evrimler, Sehnaz; Okumuser, Irfan; Unal, Nermin
Summary Background Acute appendicitis is an emergent surgically treated disease generally represented by right lower abdominal pain. The most common location of the appendix is descending intraperitoneal. However, it can also show atypical locations such as inguinal canal, femoral canal, subhepatic, retrocecal, intraperitoneal abdominal midline and left side in situs inversus or intestinal malrotation patients. Atypical location can lead to atypical clinical presentations. Ultrasonography is the first choice modality for imaging. However, it can be insufficient for demonstration of the appendix. Therefore, computed tomography (CT) is needed for further examination. We aim to review the CT findings of atypically located acute appendicitis with cases and remind the clinicians and radiologists the importance of the prompt diagnosis. Case Report We presented five atypically-located appendix cases, including four with acute appendicitis that presented to our emergency department with acute abdominal pain. Two of the acute appendicitis cases had normal, the other two had elevated white blood cell count, but all of them had elevated CRP. Ultrasonography imaging was performed as a first-line imaging modality. Because of the inconclusive results of both clinical-laboratory findings and ultrasonography, CT imaging was performed. Abdominal CT demonstrated all of the atypically localised appendices successfully, which were left-sided in a malrotated patient, retrocecal, subhepatic, retrocecal ascending, intraperitoneal abdominal midline localised. Conclusıons Atypically located acute appendicitis can show atypical presentation and result in misdiagnosis. If ultrasonograpgy is inconclusive, we suggest abdominal CT in such confusing, complicated cases, because misdiagnosis or delay in the right diagnosis can result in complications and increased morbidity and mortality rates. PMID:28058072
... be removed? What Is Appendicitis? Your appendix (say: uh-PEN-dix) is a small, finger-shaped pouch ... inflamed, or swells up, it's called appendicitis (say: uh-pen-di-SYE-tis). Both kids and adults ...
... of the appendix, a finger-shaped pouch that projects from your colon on the lower right side of your abdomen. The appendix doesn't seem to have a specific purpose. Appendicitis causes pain in your lower right abdomen. ...
Herzig, Maximilian L.
1. Symptoms referable to compression of the spermatic cord and incarceration of right testicle, obscure the underlying pathologic changes occurring in the vermiform appendix. 2. Testicular underdevelopment and resulting subnormal cerebration. 3. Operative technique: (a) Pre-operative diagnosis: Incarceration of right testicle and possible perforative appendicitis. (b) Descent of right incarcerated testicle. Bassini closure. (c) Exploratory laparotomy: Intramuscular gridiron incision. 4. Operative findings: (a) Strangulation and incarceration of undescended right testicle and spermatic cord in inguinal canal. (b) Copious pus, free in peritoneal cavity. An adherent, sloughing, perforative, retrocecal appendix identified, left undisturbed and free drainage established. 5. Progress: (a) Eventful recovery from acute suppurative appendicitis following drainage of appendical focus. (b) Marked development following the operative descent of an incarcerated testicle in a backward boy, age twelve, who had a bilateral cryptorchism. PMID:18739377
Rentea, Rebecca M; St Peter, Shawn D
Appendicitis is one of the most common surgical pathologies in children. It can present with right lower quadrant pain. Scoring systems in combination with selective imaging and surgical examination will diagnose most children with appendicitis. Clinical pathways should be used. Most surgical interventions for appendicitis are now almost exclusively laparoscopic, with trials demonstrating better outcomes for children who undergo index hospitalization appendectomies when perforated. Nonoperative management has a role in the treatment of both uncomplicated and complicated appendicitis. This article discusses the workup and management, modes of treatment, and continued areas of controversy in pediatric appendicitis.
Redan, Jay A; Tempel, Michael B; Harrison, Shannon; Zhu, Xiang
When someone plans a vacation, one of the last things taken into consideration is the possibility of contracting an illness while away. Unfortunately, if people develop abdominal pain while planning for a vacation, they usually proceed with the vacation and do not consider getting medical attention for their pain. The purpose of this study was to examine the effect of being on vacation and its association with ruptured appendicitis. From January 1, 2007 to December 31, 2008, the incidence of ruptured appendicitis cases at Florida Hospital-Celebration Health, located 5 miles from Walt Disney World, was compared with that of Florida Hospital-Orlando, approximately 30 miles away from Walt Disney World. We evaluated whether patients "on vacation" versus residents of Orlando have an increased incidence of ruptured appendicitis. Of patients treated for presumed appendicitis, 60.59% at Florida Hospital-Celebration Health had ruptured appendicitis during this time versus 20.42% at Florida Hospital-Orlando. Of those 266 patients seen at Florida Hospital-Celebration Health, 155 were on vacation versus only 21 at Florida Hospital-Orlando. Although there is not a direct cause and effect, it is clear that there is a higher incidence of ruptured appendicitis in patients on vacation versus in the regular community in the Orlando, Florida area.
Tempel, Michael B.; Harrison, Shannon; Zhu, Xiang
Objective: When someone plans a vacation, one of the last things taken into consideration is the possibility of contracting an illness while away. Unfortunately, if people develop abdominal pain while planning for a vacation, they usually proceed with the vacation and do not consider getting medical attention for their pain. The purpose of this study was to examine the effect of being on vacation and its association with ruptured appendicitis. Methods: From January 1, 2007 to December 31, 2008, the incidence of ruptured appendicitis cases at Florida Hospital–Celebration Health, located 5 miles from Walt Disney World, was compared with that of Florida Hospital–Orlando, approximately 30 miles away from Walt Disney World. We evaluated whether patients “on vacation” versus residents of Orlando have an increased incidence of ruptured appendicitis. Results: Of patients treated for presumed appendicitis, 60.59% at Florida Hospital–Celebration Health had ruptured appendicitis during this time versus 20.42% at Florida Hospital–Orlando. Of those 266 patients seen at Florida Hospital–Celebration Health, 155 were on vacation versus only 21 at Florida Hospital–Orlando. Conclusion: Although there is not a direct cause and effect, it is clear that there is a higher incidence of ruptured appendicitis in patients on vacation versus in the regular community in the Orlando, Florida area. PMID:23743367
Goldman, J A; Peleg, D; Feldberg, D; Dicker, D; Samuel, N
A case of uterine perforation by an IUD with acute and chronic irritation of the appendix is presented. The patient, a 30-year old gravida 4, para 4, was admitted to the hospital with severe abdominal pain, fever, and diarrhea. A Lippes loop IUD had been inserted 3 years previously. The device could not be visualized at laparoscopy. At laparotomy the IUD was palpable within a large inflammatory mass in the right lower abdomen . Dissection of the adhesions revealed the IUD twisted around the appendix, and appendectomy was performed. This is the 1st reported case of a perforated, nonmedicated IUD causing appendicitis. The 2 cases of IUD appendicitis previously described in the literature involved Copper-7 devices, which have been shown to cause considerable tissue response when placed in the peritoneal cavity. Abdominal signs and symptoms associated with a missing IUD string should alert physicians to the possibility of IUD appendicitis.
Debnath, Jyotindu; Kumar, Rajesh; Mathur, Ankit; Sharma, Pawan; Kumar, Nikhilesh; Shridhar, Nagaraj; Shukla, Ashwani; Khanna, Shiv Pankaj
The purposes of this study were to revisit the utility of ultrasonography (USG) as a primary imaging modality in acute appendicitis (AA) and to establish the role of CT scan as a second-line/problem-solving modality. All cases of suspected AA were referred for urgent USG. USG was done with standard protocol for appendicitis. Limited computed tomographic (CT) scan [NCCT ± CECT (IV contrast only)] was done for the lower abdomen and pelvis where sonographic findings were equivocal. One hundred and twenty-one patients were referred for USG for suspected appendicitis. Eight-four patients underwent surgery for AA based on clinical as well as imaging findings, of whom 76 had appendicitis confirmed at histopathology. Three patients were misdiagnosed (3.6 %) on USG as appendicitis. Of 76 patients of appendicitis confirmed histopathologically, 63 (82.8 %) had features of appendicitis on USG and did not require any additional imaging modality. Of 121 patients, 12 (10 %) needed CT scan because of atypical features on USG. Of these 12 patients, seven had retrocecal appendicitis, and three high-up paracolic appendicitis. USG alone had sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of 81, 88, 92.6, 71.6, and 83 %, respectively. When combined with CT scan in select cases, the sensitivity, specificity, PPV, NPV, and accuracy of combined USG + CT scan were 96 % (P = 0.0014), 89 %, 93 %, 93.5 % (P = 0.0001), and 93 % (P = 0.0484), respectively. Twenty-eight (23 %) patients were given alternative diagnosis on USG. Dedicated appendiceal USG should be used as a primary imaging modality in diagnosing or excluding AA. Appendiceal CT can serve as a problem-solving modality.
Watchorn, Richard E.; Poder, Liina; Wang, Zhen J.; Yeh, Benjamin M.; Webb, Emily M.; Coakley, Fergus V.
The primary computed tomography (CT) signs of appendicitis can also be seen with other inflammatory or neoplastic processes. We report on two cases in which appendiceal dilatation and peri-appendiceal fluid or stranding were the dominant imaging manifestations of colorectal carcinoma in the ascending colon. This study highlights the need to closely examine the ascending colon in patients with a suspected CT diagnosis of acute appendicitis, since these findings may be secondary to an inconspicuous colorectal carcinoma. PMID:19857802
... Supplements Videos & Tools You Are Here: Home → Multiple Languages → All Health Topics → Appendicitis URL of this page: https://medlineplus.gov/languages/appendicitis.html Other topics A-Z Expand Section ...
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
Palter, Steven F.; Rodas, Edgar B.; Prosst, Ruediger L.; Rosser, Ludie E.
The timely diagnosis of intra-abdominal pathology continues to be an elusive problem. Delays in diagnosis and therapeutic decision making are continuing dilemmas in patients who are females of childbearing age, elderly, obese or immunosuppressed. Minilaparoscopy without general anesthesia potentially can provide an accurate, cost-effective method to assist in the evaluation of patients with acute abdominal pain. Laparoscopy without general anesthesia is not a new technique, but with the combination of two emerging factors— 1) the introduction of new technology with the development of improved, smaller laparoscopes and instruments, and 2) the shifting of emphasis on healthcare to a more cost-effective managed care environment--its value and widespread utilization is being reconsidered. We report the case of a 22 year old female with an acute onset of increasing abdominal and pelvic pain. Despite evaluation by general surgery, gynecology, emergency room staff, as well as, non-invasive testing, a clear diagnosis could not be made. In view of this, minilaparoscopy without general anesthesia was performed and revealed an acute, retrocecal appendicitis. The diagnosis was made with the assistance from the conscious patient. The utilization of this technique greatly expedited the treatment of this patient. Full-sized laparoscopic equipment was then used to minimally invasively remove the diseased appendix under general anesthesia. Both procedures were well tolerated by the patient. PMID:9876717
Waseem, Muhammad; Simha, Shruti
Acute appendicitis is the most common acute surgical condition in children. Parasitic infestations are ubiquitous on a worldwide basis and are seen in the United States because of increasing international travel and emigration from developing countries. These infestations may produce symptoms of acute appendicitis, although the role of parasitic infestation in relation to appendicitis is controversial. Intestinal parasites may cause significant morbidity and mortality. We report a patient with symptoms of acute appendicitis in whom intramural parasites were found during laparoscopic surgery. Histology of the appendix specimen revealed a normal appendix. The pertinent literature is also reviewed.
... of the abdomen and chest, ultrasound, or a CAT scan. If the doctor suspects appendicitis, you may ... TOPIC Appendectomy Preparing Your Child for Surgery Abscess CAT Scan: Abdomen Ultrasound: Abdomen X-Ray Exam: Abdomen ...
Kim, David; Butterworth, Sonia A; Goldman, Ran D
While the diagnosis of acute appendicitis is relatively straightforward, chronic appendicitis is an entity that can be controversial and is often misdiagnosed. How and when should clinicians be investigating chronic appendicitis as a cause of chronic and recurrent abdominal pain in the pediatric population? Chronic appendicitis is a long-standing inflammation or fibrosis of the appendix that presents clinically as prolonged or intermittent abdominal pain. It is often a challenging diagnosis and might result in complications such as intra-abdominal infections or bowel obstruction or perforation. Clinical presentation, along with imaging studies, can help the clinician rule out other conditions, and among those who are diagnosed, for many children, appendectomy results in partial or complete resolution of pain symptoms. Copyright© the College of Family Physicians of Canada.
Ichikawa, Hitoshi; Imai, Jin; Mizukami, Hajime; Uda, Shuji; Yamamoto, Soichiro; Nomura, Eiji; Tajiri, Takuma; Watanabe, Norihito; Makuuchi, Hiroyasu
We report a case of amoebic appendicitis without colitis symptoms. Acute appendicitis is commonly encountered by gastroenterologists in their daily practice. The number of cases of amoebiasis increases annually in Japan, and is thought to be associated with an increase in sexually transmitted disease or travel to endemic areas. However, acute amoebic appendicitis is rare and the prognosis is very poor compared to nonamoebic appendicitis. In our case, appendectomy was performed immediately after onset, and the patient was discharged without complications. It is difficult to differentiate between amoebic and nonamoebic appendicitis preoperatively, and the possibility of amoebic appendicitis should be kept in mind.
Silva Guisasola, Jacobo; Alvarez-Cabo, Rubén; Hernández-Vaquero, Daniel; Méndez, Rocío Díaz
Ascending aorta reinterventions present a challenge for surgeons as the technical difficulties of the procedure and the complex strategic approach can complicate successful treatment. These patients should be treated by surgical teams with ample experience in aortic diseases as they can be at high risk of mortality. The number of interventions on the ascending aorta and aortic arch and the use of biological conducts (lung autograft, homograft, etc.) have increased in recent years; therefore, the number of reinterventions can also be expected to increase, representing 10% of aortic surgical procedures. This article reviews the current status of ascending aorta reinterventions, analyzing the principal aspects of indication and surgical strategy, as well as the results published in the largest studies.
ABSTRACT ii FRANCE 1940 3 BATTLEFIELD DOMINANCE 6 FORCE XXI AND ARMY AFTER NEXT 9 CONCLUSION 15 END NOTES 19 BIBLIOGRAPHY 23 VI The...the greatest probability for decisive action in the 21st Century. 17 18 End Notes 1 Glenn K. Otis [General, US Army (Ret.)] "The Ascendancy of
Brender, Jean D.; And Others
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)
Brender, Jean D.; And Others
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)
Figueiredo, Jacinta; Santos, Ângela; Clemente, Horácio; Lourenço, Augusto; Costa, Sandra; Grácio, Maria Amélia; Belo, Silvana
Acute appendicitis associated to Schistosoma haematobium and S. mansoni infection has been found in patients submitted to urgent appendectomy at the Hospital Américo Boavida in Luanda. Due to the high prevalence and morbidity caused by schistosomiasis (or bilharziasis) in the country, we suspect that the involvement of Schistosoma infection on appendicular pathology could be very frequent, in particular for those individuals more exposed to the parasite transmission. We report two clinical cases of acute appendicitis whose surgical specimens of the appendix revealed S. haematobium and S. mansoni eggs in histological samples. The reported patients live in endemic areas and have been exposed to schistosome during childhood, which may explain the infection's chronicity. Information of these clinical cases could be relevant, particularly for surgery specialists and clinical pathologists, due to the possibility of finding more patients with concurrent appendicitis and schistosomiasis.
Beh, Joey Chan Yiing; Uppaluri, Anandswaroop Srinivas; Koh, Beatrice Fang Ju; Cheow, Peng-Chung
Ingested foreign bodies tend to pass through the gastrointestinal tract without incidence, and vast majority of cases do not need intervention. Rarely, these foreign bodies drop into the appendix and not likely to re-enter the normal digestive tract. We describe a case of a 72-year-old male patient who presented with right iliac fossa pain of 3-day duration. Clinical examination suggested classic acute appendicitis. Blood test results revealed leukocytosis. Computed tomography of the abdomen and pelvis showed evidence of acute appendicitis and a linear hyperdensity (foreign body) perforating the appendix. The patient was managed successfully with prompt laparoscopic appendectomy and removal of the foreign body which was confirmed to be a fish bone measuring about 10mm. While imaging diagnosis of fishbone in the appendix has been published, reports are few. To the best of the author's knowledge, fishbone induced perforated appendicitis has been described only in 2 cases (including this case) in the literature.
Stănescu, D; Sternberg, D; Chirilă, R; Teleguţă, L; Tănase, M; Copelovici, Y
Investigations were conducted on groups of subjects hospitalized in surgery services with a clinical diagnosis of acute or chronic appendicitis, to detect the presence of inframicrobial antibodies and antigens, as well as that of the C reactive protein in these patients as compared with a control group. The results of serological tests and of the examination of pieces of appendix are also presented. The obtained data are used as arguments for the theory of an inframicrobial infection part in some acute and chronic forms of appendicitis.
St Peter, Shawn D; Snyder, Charles L
Appendectomy has been the standard of care for appendicitis since the late 1800s, and remains one of the most common operations performed in children. The advent of data-driven medicine has led to questions about every aspect of the operation-whether appendectomy is even necessary, when it should be performed (timing), how the procedure is done (laparoscopic variants versus open and irrigation versus no irrigation), length of hospital stay, and antibiotic duration. The goal of this analysis is to review the current status of, and available data regarding, the surgical management of appendicitis in children. Copyright © 2016 Elsevier Inc. All rights reserved.
... breath, can exacerbate the pain. Don’t offer water, food, laxatives, aspirin or a heating pad. How Appendicitis ... lots of water (at least eight cups of water or other liquid every day). Keep physically active. Chew food slowly and thoroughly before swallowing. Use aspirin and ...
Shen, Zhanlong; Ye, Yingjiang; Yin, Mujun; Wang, Shan
The advantage or disadvantage of laparoscopic appendectomy for acute appendicitis remains unclear. Data were collected prospectively from 129 consecutive patients with appendicitis between June 2008 and December 2009. The clinical outcomes of acute appendicitis after laparoscopic and open operation were compared. Furthermore, the outcomes of laparoscopic procedure for acute and chronic appendicitis were compared. The length of hospitalization and incidence of intra-abdominal abscess were significantly decreased in patients with laparoscopic group after operation as compared to open operation. The mean operation time, the time of first anal exsufflation, and oral intake after operation were longer for acute appendicitis patients than for chronic appendicitis in laparoscopic group. The incidence of postoperative intestinal obstruction in patients with acute appendicitis was higher after laparoscopic surgery than after open procedure. Laparoscopic appendectomy for acute appendicitis is feasible and safe. However, laparoscopic appendectomy for acute appendicitis might cause more postoperative complications including intra-abdominal abscess and small intestinal obstruction compared to laparoscopic appendectomy for chronic appendicitis. These complications could potentially be avoided by improving techniques in operation.
Bonfante Ramírez, E; Estrada Altamirano, A; Bolaños Ancona, R; Juárez Garcia, L; Castelazo Morales, E
Acute appendicitis es the most common cause of lapparotomy during pregnancy. The differential diagnosis in the pregnant woman becomes a challenge due to the anatomic changes that take place during the maternal adjustment to pregnancy. We have done a retrospective study between january 1989 and december 1994, at Instituto Nacional de Perinatologia. We found in that period of time 35,080 deliveries reported and 4 cases of acute appendicitis during pregnancy. The maternal age was between 16 and 42 years old, 26 years in average. Three patients were in the 3 trimester at the time of diagnosis, and the most important clinical sign was found to be diffuse abdominal pain. In 3 cases diagnosis was attributed to obstetric pathology rather than appendicitis in first place. Laparotomy and appendicectomy was done to all patients, with on block hysterectomy in only one case, having this particular patient an abscess as a postquirurgical complication. Just one case reported a healthy newborn delivered at term. It is obvious that early diagnosis and quirurgical treatment are important factors for the mother and the fetus prognosis. Appendicectomy as well as cholecystectomy are the two most common causes of laparotomy during pregnancy.
Teixeira, Pedro G R; Demetriades, Demetrios
Neoplasms are an uncommon finding after appendectomy, with malignant tumors occurring in less than 1% of the surgical specimens, and carcinoid being the most frequent malignancy. A negative or inconclusive ultrasound is not adequate to rule out appendicitis and should be followed by CT scan. For pregnant patients, MRI is a reasonable alternative to CT scan. Nonoperative treatment with antibiotics is safe as an initial treatment of uncomplicated appendicitis, with a significant decrease in complications but a high failure rate. Open and laparoscopic appendectomies for appendicitis provide similar results overall, although the laparoscopic technique may be advantageous for obese and elderly patients but may be associated with a higher incidence of intraabdominal abscess. Preoperative diagnostic accuracy is of utmost importance during pregnancy because a negative appendectomy is associated with a significant incidence of fetal loss. The increased morbidity associated with appendectomy delay suggests that prompt surgical intervention remains the safest approach. Routine incidental appendectomy should not be performed except in selected cases. Interval appendectomy is not indicated because of considerable risks of complications and lack of any clinical benefit. Patients older than 40 years with an appendiceal mass or abscess treated nonoperatively should routinely have a colonoscopy as part of their follow-up to rule out cancer or alternative diagnosis.
Beh, Joey Chan Yiing; Uppaluri, Anandswaroop Srinivas; Koh, Beatrice Fang Ju; Cheow, Peng-Chung
Ingested foreign bodies tend to pass through the gastrointestinal tract without incidence, and vast majority of cases do not need intervention. Rarely, these foreign bodies drop into the appendix and not likely to re-enter the normal digestive tract. We describe a case of a 72-year-old male patient who presented with right iliac fossa pain of 3-day duration. Clinical examination suggested classic acute appendicitis. Blood test results revealed leukocytosis. Computed tomography of the abdomen and pelvis showed evidence of acute appendicitis and a linear hyperdensity (foreign body) perforating the appendix. The patient was managed successfully with prompt laparoscopic appendectomy and removal of the foreign body which was confirmed to be a fish bone measuring about 10mm. While imaging diagnosis of fishbone in the appendix has been published, reports are few. To the best of the author’s knowledge, fishbone induced perforated appendicitis has been described only in 2 cases (including this case) in the literature. PMID:27761185
Appendicitis is a frequently encountered surgical problem in the Emergency Department (ED). Appendicitis typically results from obstruction of the appendiceal lumen, although trauma has been reported as an infrequent cause of acute appendicitis. Intestinal injury and hollow viscus injury following blunt abdominal trauma are well reported in the literature but traumatic appendicitis is much less common. The pathophysiology is uncertain but likely results from several mechanisms, either in isolation or combination. These include direct compression/crush injury, shearing injury, or from indirect obstruction of the appendiceal lumen by an ileocecal hematoma or traumatic impaction of stool into the appendix. Presentation typically mirrors that of non-traumatic appendicitis with nausea, anorexia, fever, and right lower quadrant abdominal tenderness and/or peritonitis. Evaluation for traumatic appendicitis requires a careful history and physical exam. Imaging with ultrasound or computed tomography is recommended if the history and physical do not reveal an acute surgical indication. Treatment includes intravenous antibiotics and surgical consultation for appendectomy. This case highlights a patient who developed acute appendicitis following blunt trauma to the abdomen sustained during a motor vehicle accident. Appendicitis must be considered as part of the differential diagnosis in any patient who presents to the ED with abdominal pain, including those whose pain begins after sustaining blunt trauma to the abdomen. Because appendicitis following trauma is uncommon, timely diagnosis requires a high index of suspicion. Copyright © 2017 Elsevier Inc. All rights reserved.
Sazhin, A V; Mosin, S V; Kodzhoglian, A A; Mirzoian, A T; Laĭpanov, B K
915 diagnostic laparoscopies for the suspicion on the acute appendicitis were analyzed. Frequency of the acute surgical disease' absence in patients with right iliac pain was defined. The frequency of the chronic appendicitis was defined, basing on the morphologic investigation of the 321 resected appendixes, ectomized on the reason of the acute appendicitis. Literature and personal experience were reviewed to set the frequency of the recurrence secondary chronic appendicitis. Clinical and morphological correlations between chronic noninflammation changes of the appendix and right iliac pain were followed.
Brender, J D; Weiss, N S; Koepsell, T D; Marcuse, E K
Parents of 135 children with appendicitis and of 212 comparison children were interviewed about their children's diet. Children in the upper two quartiles of fiber intake were estimated to have a 30 per cent lower risk of appendicitis than children in the lowest quartile. Estimated risk of appendicitis decreased as monthly intake of whole-grain foods increased. Children 7 to 18 years of age who had an intake of whole-grain foods in the upper fiftieth percentile were estimated to have a 50 per cent lower risk of appendicitis. This reduction in risk was not observed in the group of children less than 7 years of age. PMID:2983577
Salö, Martin; Roth, Bodil; Stenström, Pernilla; Arnbjörnsson, Einar; Ohlsson, Bodil
The diagnosis of pediatric appendicitis is still a challenge, resulting in perforation and negative appendectomies. The aim of this study was to evaluate novel biomarkers in urine and to use the most promising biomarkers in conjunction with the Pediatric Appendicitis Score (PAS), to see whether this could improve the accuracy of diagnosing appendicitis. A prospective study of children with suspected appendicitis was conducted with assessment of PAS, routine blood tests, and measurements of four novel urinary biomarkers: leucine-rich α-2-glycoprotein (LRG), calprotectin, interleukin 6 (IL-6), and substance P. The biomarkers were blindly determined with commercial ELISAs. Urine creatinine was used to adjust for dehydration. The diagnosis of appendicitis was based on histopathological analysis. Forty-four children with suspected appendicitis were included, of which twenty-two (50 %) had confirmed appendicitis. LRG in urine was elevated in children with appendicitis compared to children without (p < 0.001), and was higher in children with gangrenous and perforated appendicitis compared to those with phlegmonous appendicitis (p = 0.003). No statistical significances between groups were found for calprotectin, IL-6 or substance P. LRG had a receiver operating characteristic area under the curve of 0.86 (95 % CI 0.79-0.99), and a better diagnostic performance than all routine blood tests. LRG in conjunction with PAS showed 95 % sensitivity, 90 % specificity, 91 % positive predictive value, and 95 % negative predictive value. LRG, adjusted for dehydration, is a promising novel urinary biomarker for appendicitis in children. LRG in combination with PAS has a high diagnostic performance.
Bababekov, Yanik J; Stanelle, Eric J; Abujudeh, Hani H; Kaafarani, Haytham M A
We review the literature and describe a case of fishbone-induced appendicitis. A 63-year-old man presented with abdominal pain. Work up including a focused history and imaging revealed fishbone-induced perforated appendicitis. The patient was managed safely and successfully with laparoscopic removal of the foreign body and appendectomy.
Montiel-Jarquín, Alvaro José; Gómez-Conde, Eduardo; Reyes-Páramo, Pedro; Romero-Briones, Carlos; Mendoza-García, Aurelio Valentín; García-Ramírez, Ulises Noel
The term chronic appendicitis has been used to describe any type of chronic pain that originates in the appendix, with or without inflammation. This broad category can be divided more specifically into: chronic or recurrent appendicitis and appendiceal colic pain. a 41-year-old female, suffering intestinal chronic constipation, abdominal pain, nausea, hiporexia and febricula, treated with antibiotics, vermifuges, analgesics and antispasmodics, showing a slight and partial improvement. She was suffering chronic pain in lower abdomen, mostly on the right side along a year. With these symptoms, she underwent an exploratory laparotomy, that showed chronic appendicitis. Appendix had been removed. The histopathological report corresponded to chronic appendicitis. the histopathological characteristics and the clinical manifestations of the chronic appendicitis are different from those of acute appendicitis. Criteria for chronic appendicitis include: symptoms lasting longer than 4 weeks, confirmation of chronic swelling through histopathological examination, improvement of symptoms after appendectomy. The ultrasonic images, the barium enema and the computerized helicoidal tomography could be suggestive for its diagnosis.
Badmos, K B; Komolafe, A O; Rotimi, O
Schistosomiasis is a chronic granulomatous inflammation that affects many systems in the body including the gastrointestinal tract. This study was carried out by reviewing all cases of schistosomal appendicitis, and documents any association with acute appendicitis. To review all cases of schistosomal appendicitis and document any possible asspciation with acute appendicitis. A retrospective study. Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria, 1991 to 2004. Eight hundred and forty three specimen of appendicectomy were reviewed. Thirty five of them were diagnosed as schistosomal appendicitis. The involvement of the vermiform appendix by schistosomiasis found in 35/843 (4.2%) cases of all the appendicectomy specimen received in our histopathology laboratory between 1991 and 2004 shows that 23 of the cases (65.7%) had histologically proven acute appendicitis while the remaining 12 cases (34.3%) were schistosomiasis without active inflammation. The appendiceal wall oviposition is associated with submucosal fibrosis, narrowing of the lumen and subsequent acute suppurative inflammation in 17 cases while there were active granulomas with tissue eosinophilia in six cases. This finding has demonstrated that though the frequency of appendix involvement is low considering the endemicity of schistosomiasis in our environment, however acute appendicitis may be caused by schistosomiasis.
Starker, Lee F.; Duffy, Andrew J.; Bell, Robert L.; Bokhari, Jamal
Background: Stump appendicitis is defined by the recurrent inflammation of the residual appendix after the appendix has been only partially removed during an appendectomy for appendicitis. Forty-eight cases of stump appendicitis were identified in the English literature. Database: The institutional CPT codes were evaluated for multiple hits of the appendectomy code, yielding a total of 3 patients. After appropriate approval from an internal review board, a retrospective chart review was completed and all available data extracted. All 3 patients were diagnosed with stump appendicitis, ranging from 2 months to 20 years after the initial procedure. Two patients underwent a laparoscopic and the one an open completion appendectomy. All patients did well and were discharged home in good condition. Conclusion: Surgeons need a heightened awareness of the possibility of stump appendicitis. Correct identification and removal of the appendiceal base without leaving an appendiceal stump minimizes the risk of stump appendicitis. If a CT scan has been obtained, it enables exquisite delineation of the surrounding anatomy, including the length of the appendiceal remnant. Thus, we propose that unless there are other mitigating circumstances, the completion appendectomy in cases of stump appendicitis should also be performed laparoscopically guided by the CT findings. PMID:21985727
Hydronephrosis is a rare complication of acute appendicitis. We present a case of missed appendicitis in a 52-year-old female which presented as a right-sided hydronephrosis. 2 days after admission to the Department of Urology CT revealed acute appendicitis for what open appendectomy was performed. Acute appendicitis can lead to obstructive uropathy by periappendiceal inflammation due to adjacency. Urologists, surgeons, and emergency physicians should be aware of this rare complication of atypical acute appendicitis. PMID:27818827
Berry, J; Malt, R A
In an analysis of the first 72 cases treated after the formulation of the appendicitis syndrome in 1886 compared with the experience from 1929-1959 and with 307 randomly selected recent cases, the major therapeutic trend has been an emphasis on appendectomy before perforation and abscess formation occur. The rate of infection nonetheless remains approximately 17%. Although the overall mortality rate has declined from 26% overall (40% for surgery) to 0.8%, the current rate of perforation is 28%, with a diagnostic accuracy of 82%. Among 13,848 patients from several reports the perforation rate increases linearly with diagnostic accuracy; therefore, a balance must be sought. Delay awaiting a diagnosis is a major determinant of perforation, but diagnostic aids are of limited help. Clinical acuity and prudent decisiveness are the keys to proper action. Images FIGS. 1A and B. FIG. 2. PMID:6385879
Lin, Heng-Fu; Lai, Hong-Shiee; Lai, I-Rue
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
Groth, D; Henderson, S O
Necrotizing fasciitis, although rare, is one of the more serious, life-threatening complications of missed acute appendicitis. Patients who are predisposed to developing necrotizing fasciitis, regardless of the cause, are typically immunocompromised. We present a case of a 49-year-old immunocompetent female whose diagnosis of acute appendicitis was missed and who subsequently developed necrotizing fasciitis of the abdominal wall and flank. She recovered 1 month after admission due to aggressive surgical and medical therapy.
Appendicitis, a common disease, has different presentations. This has made its diagnosis difficult. This paper aims to present two cases of missed appendicitis with completely urologic presentation and the way that helped us to reach the correct diagnosis. The first case with symptoms fully related to kidney and the second mimicking epididymorchitis hindered prompt diagnosis. Right site of the pain, relapsing fever, frequent physical examination, and resistance to medical treatment were main clues which help us to make correct diagnosis. PMID:23326748
Ito, Daisuke; Hata, Shojirou; Seiichiro, Shimizu; Kobayashi, Kaoru; Teruya, Masanori; Kaminishi, Michio
INTRODUCTION Outside of these high-risk regions, acute amebic appendicitis is considerably rarer and the mortality rate is much higher than with non-amebic appendicitis. PRESENTATION OF CASE A 31-year-old woman presented with fever and right lower abdominal pain with no history of traveling abroad or sexual infection. Computed tomography revealed a dilated appendix and thickened cecal and ascending colon walls. She underwent an appendectomy for appendicitis. Owing to a lack of symptom resolution, we performed a pathologic examination of the appendix again that revealed multiple Entamoeba histolytica trophozoites; the serum amebic antibody was positive. She was treated postoperatively with metronidazole for amebiasis and discharged on postoperative day 12. DISCUSSION The mortality rate and frequency of severe postoperative intraabdominal complications were higher in the Japanese literature (1995–2013) (25% and 33%, respectively) than in other developed countries (3.3% and 19.4%, respectively). Japan is a low-risk area for amebiasis; many physicians fail to consider amebiasis in the differential diagnosis of acute abdomen. It is important to conduct further examinations, including those for amebiasis, when appendectomy does not resolve acute appendicitis. CONCLUSION We report a case of acute amebic appendicitis in a 31-year-old woman and review the ages at presentation, causative factors, treatments, and outcomes of 11 cases reported in Japan between 1995 and 2013. PMID:25460473
Ito, Daisuke; Hata, Shojirou; Seiichiro, Shimizu; Kobayashi, Kaoru; Teruya, Masanori; Kaminishi, Michio
Outside of these high-risk regions, acute amebic appendicitis is considerably rarer and the mortality rate is much higher than with non-amebic appendicitis. A 31-year-old woman presented with fever and right lower abdominal pain with no history of traveling abroad or sexual infection. Computed tomography revealed a dilated appendix and thickened cecal and ascending colon walls. She underwent an appendectomy for appendicitis. Owing to a lack of symptom resolution, we performed a pathologic examination of the appendix again that revealed multiple Entamoeba histolytica trophozoites; the serum amebic antibody was positive. She was treated postoperatively with metronidazole for amebiasis and discharged on postoperative day 12. The mortality rate and frequency of severe postoperative intraabdominal complications were higher in the Japanese literature (1995-2013) (25% and 33%, respectively) than in other developed countries (3.3% and 19.4%, respectively). Japan is a low-risk area for amebiasis; many physicians fail to consider amebiasis in the differential diagnosis of acute abdomen. It is important to conduct further examinations, including those for amebiasis, when appendectomy does not resolve acute appendicitis. We report a case of acute amebic appendicitis in a 31-year-old woman and review the ages at presentation, causative factors, treatments, and outcomes of 11 cases reported in Japan between 1995 and 2013. Copyright © 2014 The Authors. Published by Elsevier Ltd.. All rights reserved.
Baek, Seong Kyu; Kim, Mi Sun; Kim, Yong Hoon; Chung, Woo Jin; Kwon, Jung Hyeok
Stump appendicitis is an acute inflammation of the residual appendix and a rare complication after an appendectomy. Although the signs and symptoms do not differ from acute appendicitis, the diagnosis is often not considered because of the past surgical history. Only a small number of stump appendicitis cases have been reported, but there has been no report of stump appendicitis in Korea. Herein, we report a case of stump appendicitis. A 28-year-old female was admitted to our hospital due to right lower quadrant abdominal pain. Fifteen months ago, the patient had a laparoscopic appendectomy under the diagnosis of an acute appendicitis, but she subsequently suffered from intermittent abdominal pain and fever. Abdominal ultrasonography and CT scan showed an inflamed appendiceal stump. Laparoscopic stump appendectomy was done and the biopsy revealed stump appendicitis.
Danys, Donatas; Poskus, Tomas; Mikalauskas, Saulius; Poskus, Eligijus; Jotautas, Valdemaras; Beisa, Virgilijus; Strupas, Kestutis
Abstract Objective The optimal diagnostics and treatment of acute appendicitis continues to be a challenge. A false positive diagnosis of appendicitis may lead to an unnecessary operation, which has been appropriately termed negative appendectomy. The aim of our study was to identify the effectiveness of preoperative investigations in preventing negative appendectomy. Methods A retrospective study was performed on adult patients who underwent operation for suspected acute appendicitis from 2008 to 2013 at Vilnius University Hospital Santariskiu Klinikos. Patients were divided into two groups: group A underwent an operation, where appendix was found to be normal (non-inflamed); group B underwent an appendectomy for inflamed appendix. Groups were compared for preoperative data, investigations, treatment results and pathology findings. Results 554 patients were included in the study. Preoperative laboratory tests results of hemoglobin, hematocrit concentrations and white blood cell count were significantly higher in group B (p<0.001). Ultrasonography was performed for 78 % of patients in group A and 74 % in group B and did not provide any statistically significant results. Comparing Alvarado score results, there were more patients with Alvarado score less than 7 in group A than in group B. In our large series we could find only four independent risk factors, and they could only account for 24 % of cases. Conclusions In summary, acute appendicitis is still often misdiagnosed and the ratio of negative appendectomies remains rather high. Additional investigations such as observation and computed tomography should be used to prevent this.
Mak, Grace Zee; Loeff, Deborah S
Acute appendicitis is the most common cause of emergent surgery in children. Historically, surgical dogma dictated emergent appendectomy due to concern for impending perforation. Recently, however, there has been a paradigm shift in both the understanding of its pathophysiology as well as its treatment to more nonoperative management. No longer is it considered a spectrum from uncomplicated appendicitis inevitably progressing to complicated appendicitis over time. Rather, uncomplicated and complicated appendicitis are now considered two distinct pathophysiologic entities. This change requires not only educating the patients and their families but also the general practitioners who will be managing treatment expectations and caring for patients long term. In this article, we review the pathophysiology of appendicitis, including the differentiation between uncomplicated and complicated appendicitis, as well as the new treatment paradigms. [Pediatr Ann. 2016;45(7):e235-e240.].
Golledge, J.; Toms, A. P.; Franklin, I. J.; Scriven, M. W.; Galland, R. B.
The aim of this study was to evaluate the accuracy of different methods of demonstrating right iliac fossa peritonism in appendicitis. The methods used were cat's eye symptom (pain on going over a bump in the road), cough sign, right iliac fossa tenderness, percussion tenderness, rebound tenderness and guarding. A series of 100 consecutive patients with a median age of 25 years (range 4-81 years), presenting with right iliac fossa pain were studied prospectively; the male:female ratio was 39:61. In all, 58 patients underwent operation, 44 had appendicitis confirmed on histology. Fourteen patients had a normal appendix removed; 11 were women aged between 16 and 45 years. Cat's eye symptom and cough sign were sensitive indicators of appendicitis (sensitivity 0.80 and 0.82, respectively), but were not specific (specificity 0.52 and 0.50, respectively) and therefore inaccurate (accuracy 64%). Percussion tenderness was less sensitive (sensitivity 0.57) but more specific (specificity 0.86). Rebound tenderness proved to be sensitive (sensitivity 0.82), specific (specificity 0.89) and accurate (accuracy 86%). Thus, rebound tenderness had a positive predictive value of 86% compared with 56% and 57% for cough sign and cat's eye symptom, respectively. In the difficult diagnostic group of young women, the positive predictive value of rebound tenderness was 88% compared with 58% and 56% for cat's eye symptom and cough sign. Appendicitis remains a difficult diagnosis, particularly in young women. Rebound tenderness still has an important role to play in clinical assessment. PMID:8659965
Wake, Sarah; Abhyankar, Aruna; Hutton, Kim
A cystic lymphangioma arising within the abdomen is a rare entity in children. It may present with an abdominal mass and symptoms of abdominal pain, vomiting, and anorexia. These nonspecific clinical symptoms are often attributed to more common acute pediatric conditions. In this report, we describe two pediatric cases of intra-abdominal cystic lymphangioma that were initially diagnosed and treated as appendicitis. True diagnosis was only achieved on surgical excision and pathological investigation of cystic material.
Meinke, Alan K
To review the clinical presentation, outcome and causes of acute appendicitis presenting within a groin hernia. A comprehensive review of the past 70 years of English language surgical literature was conducted pertaining to acute appendicitis presenting within an inguinal or femoral hernia. Thirty-four reports describing 45 patients were reviewed to determine age, position, gender, pathologic stage at presentation, causal suppositions, and clinical outcomes. Hernial appendicitis presented as an inguinal abscess or a tender inguinal mass, often in the femoral position, and most commonly at the extremes of age. It was almost never recognized preoperatively, and, because of the sequestered nature of the inflammatory process, presented with few classic systemic signs or symptoms suggestive of acute appendicitis. Advanced pathologic stage and death correlated with the patient's age, delay in presentation, and delay in recognition. Evaluation of an inguinal abscess or a nonreducible tender groin hernia presenting in a patient at the extremes of age, should include computed tomography to rule out an occult acute appendicitis within the hernia, as systemic signs and symptoms of appendicitis are rarely evident. The condition appears to be caused by inflammatory adhesions caused by appendicitis occurring within an enlarged hernial orifice rather than appendicitis caused by external compression of the appendix base. Early recognition of this unique presentation of appendicitis allows trans-hernial appendectomy and immediate herniorraphy. Delayed diagnosis requires drainage of abscess with appendectomy and interval hernia repair.
Pham, Xuan-Binh D; Sullins, Veronica F; Kim, Dennis Y; Range, Blake; Kaji, Amy H; de Virgilio, Christian M; Lee, Steven L
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
Rao, P M; Rhea, J T; Novelline, R A
To determine the appearance of appendicitis in the distal part of the organ (distal appendicitis) on computed tomographic (CT) scans and to evaluate the accuracy of diagnosis based on CT findings. CT scans and medical records in 180 consecutive patients with proved appendicitis were reviewed. Fourteen had distal appendicitis with at least a 3-cm length of normal proximal appendix. Appendiceal CT scans and initial reports were reviewed retrospectively. The proximal appendix was collapsed (n = 6) or was filled with contrast material (n = 6) or air (n = 2). Inflamed distal appendices averaged 13.2 mm in diameter and were associated with periappendiceal fat stranding (n = 14), adenopathy (n = 6), appendolith(s) (n = 4), or fluid (n = 2). Transition points consisted of a progressively narrowed appendiceal lumen and thickened wall (n = 5) or appendiceal diameter enlargement (n = 9). No cecal apical changes were seen. Scans in all 14 patients were prospectively interpreted as indicative of appendicitis, including 12 (86%) interpreted as indicative of distal appendicitis. CT findings are useful for the accurate diagnosis of distal appendicitis. Visualization of the proximal appendix alone is insufficient to exclude distal appendicitis.
Kaushik, Rajni; Gulati, Anchana; Vedant, Deepak; Kaushal, Vijay
Xanthogranulomatous reaction can occur in any organ but the most common sites are kidney and gallbladder. Xanthogranulomatous appendicitis (XA) is a rare clinical entity. There are a few case reports of XA diagnosed on histopathology but none on cytology. Here we report a case of a 47-year-old lady who presented with acute abdomen and was found to have a mass lesion in the right iliac fossa. She was diagnosed with XA intraoperatively on imprint cytology that was subsequently confirmed on histopathological examination. Due to the rarity of XA itself and the use of imprint cytology for intraoperative diagnosis the case is being presented. PMID:28182060
Udgiri, Navalkishor; Curras, Ernesto; Kella, Venkata K; Nagpal, Kamal; Cosgrove, John
Prompt appendectomy has always been a standard of care because of the risk of progression in pathology. This time honored practice has been recently challenged by studies, suggesting that appendicitis can be operated on electively. The aim of this study is to examine whether delayed intervention in acute appendicitis is safe by correlating the interval from presentation to operation with the operative and postoperative complications. Retrospective review of patients who underwent appendectomy for acute appendicitis in 2009 was done. The following parameters were recorded: demographics, duration from presentation to evaluation by emergency room attending, performing CT scan, surgical consult, and operation. The pathology, post operative complications, and length of stay were also recorded. Patients were divided into two groups: incision time < 10 hours (early group) and incision time > 10 hours (delayed group). The end points chosen for comparison were: 1) laparoscopic to open conversion rate, 2) complications, 3) readmissions, and 4) length of stay. Number of cases totaled 201, with 76 in the < 10 hours group and 125 in the > 10 hours group. The male to female ratio for the < 10 hours group was 54:22 and for the > 10 hours group was 59:66 (P < 0.001). Length of stay for the early group was 75.52 hours and for the delayed group, 89.15 hours (P = 0.04). There was one intra-abdominal abscess in the early group and 10 in the delayed group (P = 0.04). The early group had 0.2 (2.6%) open conversions, and the delayed group had five (4.1%) conversions (P = 0.58). There were six (4.8%) readmissions in the delayed group and none in the early group (P = 0.05). Our study reveals that the complication rate, length of stay, and readmissions are more in the delayed group. Conversion rate was more in the delayed group, but the difference was not significant. We conclude that early surgical intervention is beneficial in acute appendicitis.
Sullins, Veronica F; Rouch, Joshua D; Lee, Steven L
Appendicitis is one of the most common diagnoses in children and is frequently the focus of alleged malpractice. Causes for medical malpractice claims and outcomes of disputes in pediatric patients with appendicitis are currently unknown. A retrospective database review of all medical malpractice claims concerning the diagnosis of appendicitis from 1984 to 2013 in pediatric patients was performed. Alleged claims, causes of malpractice, and outcomes were recorded and analyzed. Of the 203 included cases, failure or delays in diagnosing appendicitis are the most common causes of malpractice lawsuits and account for the majority of the largest payments to plaintiffs outcomes. Cases that ultimately went to trial resulted in defense verdicts in 67.5%. Mortality occurred in 19.9% of included cases. Timely diagnosis of appendicitis in children should be the focus of physicians across all specialties to improve patient safety and potentially reduce medicolegal liability.
Menclová, K; Traboulsi, E; Nikov, A; Hána, L; Rousek, M; Ryska, M
Acute appendicitis is the most common cause of intra-abdominal emergency surgery worldwide. The approach to its treatment keeps changing. The number of acute appendectomies has been decreasing. Many patients are treated conservatively with success. Our study compares conservative and surgical treatment of acute appendicitis, including its complications in our department. We retrospectively analyzed the group of 117 patients hospitalized with the clinical diagnosis of acute appendicitis. We distinguished patients with complicated and uncomplicated appendicitis, and patients operated and treated conservatively. We evaluated complication rates and recurrences of the disease, respectively, in 1-year follow-up. The Student t test and Fishers exact test were used for the statistical analysis. In 2012 we hospitalized 117 patients with acute appendicitis: 83 patients (71%) for uncomplicated and 34 (29%) for complicated appendicitis. 41% of patients with complicated and 13% with uncomplicated appendicitis (p=0.02) were treated conservatively. Conservative treatment or laparoscopic surgery, respectively, were used more often in women ( p0.001). There was no failure of conservative treatment. Perioperative morbidity was 13%. No patient died. 6 patients (24%) of the conservatively treated group were hospitalized in the subsequent year for recurrent problems. 4 (16%) were reoperated. The rate of negative appendectomy (negative pathological findings) was 11%. The hospitalization time was shorter in patients treated conservatively or using laparoscopy, respectively, compared to the group of patients undergoing appendectomy. In the modern era of available complementary examinations and a broad spectrum of antibiotics the conservative approach is favoured as a treatment of complicated appendicitis. Conservative treatment of uncomplicated appendicitis is an option, but not the method of choice. Routine elective appendectomy after successful conservative treatment is groundless
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
Gialamas, Eleftherios; Papavramidis, Theodossis; Michalopoulos, Nick; Karayannopoulou, Georgia; Cheva, Angeliki; Vasilaki, Olga; Kesisoglou, Isaak; Papavramidis, Spiros
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.
Leardi, S; Delmonaco, S; Ventura, T; Chiominto, A; De Rubeis, G; Simi, M
Chronic appendicitis may be the cause of recurrent abdominal pain. This hypothesis is the subject of controversy. The aim is to clarify the possible existence of a chronic inflammation of the appendix by a clinical and histopathologic study. The case history and the preoperative symptoms and serum findings of 269 patients with appendectomy have been studied. All the appendices have been histologically examined. Chronic appendicitis was diagnosed when at least two typical histological factors of chronic inflammation were present. The histological findings of the appendices have been correlated with preoperative clinical and serum findings of the patients. 14-46 months after the appendectomy, the patients have been examined. Histological examination revealed 187 cases (69.5%) with acute appendicitis, 44 cases (16.3%) with non disease of appendix and 38 cases (14.2%) with chronic appendicitis. Recurrent abdominal pain and normal leukocyte count were closely correlated (chi 2 = 18.3, p < 0.001; chi 2 = 21.3, p < 0.001 respectively) with diagnosis of chronic appendicitis. 81.8% of 33 patients with chronic appendicitis who underwent follow-up had relief of all the symptoms after appendectomy. Therefore, the study seems to confirm the existence of a clinico-pathological condition that can be defined as chronic appendicitis, resolvable with appendectomy.
Cheong, Li Hsia Alicia; Emil, Sherif
Outcomes of appendicitis may be influenced by access to healthcare. We investigated the determinants of pediatric appendicitis outcomes in the single-payer Canadian healthcare system. Children coded for urgent appendectomy by the Canadian Institute of Health Information during the period 2004-2010 were analyzed. Misdiagnosis rate, perforated appendicitis rate, and hospital stay were the outcomes studied. Analyzed variables included age, gender, domicile, socioeconomic status, surgeon's specialty, hospital type, region, and operative approach. Logistic regression analysis was used to examine associations, and a quintile regression model examined the effect on median hospital stay. 41,702 patients were studied. A higher rate of perforated appendicitis was associated with lower age [OR 2.66], male gender [OR 1.18], pediatric surgeon [OR 1.25], and treatment outside the Maritimes. A higher rate of misdiagnosis was associated with lower age [OR 1.53], female gender [OR 2.29], non-children's hospital [OR 1.33], and western Canada [OR 1.22]. A significantly longer hospital stay was associated with open appendectomy, pediatric surgeon, and the Territories for simple appendicitis, and open appendectomy, pediatric surgeon, children's hospital, and the Maritimes for perforated appendicitis. In Canada, outcomes of pediatric appendicitis are associated with regional and treatment-level factors. Rural domicile and socioeconomic status do not affect outcomes. Copyright © 2014 Elsevier Inc. All rights reserved.
Poole, G V
Gangrene or perforation of the appendix is often caused by failure to make an early diagnosis of appendicitis. Variability in the anatomic location of the appendix can be responsible for atypical manifestations of appendicitis and diagnostic errors. Over a 52-month period, 125 appendectomies were done for suspected appendicitis at a military hospital. After excluding cases in which the location of the appendix was not provided, 106 cases were available for review. Fifteen patients (14%) did not have appendicitis. The appendix was found in the true pelvis, was behind the ileum or ileocolic mesentery, or was both retrocolic and retroperitoneal in 11 of 16 patients (69%) with gangrenous or perforative appendicitis. In contrast, the appendix was in one of these three sites in only four of 75 patients (5%) with simple appendicitis (P less than .001). Both physicians and patients were responsible for diagnostic delays, but the paucity of symptoms and signs in patients with a "hidden" appendix was the most likely cause of failure to diagnose appendicitis before perforation.
Singh, Naorem Gopendro; Mannan, A A S Rifat; Kahvic, Mirza
Acute appendicitis of amebic origin is considered a rare cause of acute appendicitis. We report a case of amebic appendicitis presenting with fever, severe pain in the right lower quadrant of the abdomen and rebound tenderness. Lab investigations revealed neutrophilic leukocytosis. The patient underwent appendectomy. Histopathological examination revealed numerous Entameba histolytica trophozoites in the mucosa of the appendix. Acute appendicitis of amebic origin does not appear frequently. Appendicular amebiasis can give the clinical features of acute appendicitis and should be treated accordingly.
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Rao, P M; Rhea, J T; Novelline, R A
The clinical diagnosis of appendicitis and diverticulitis remains challenging. Clinical diagnosis alone can lead to unnecessary hospitalizations and surgeries, prolonged periods of hospital observation, and delays prior to necessary medical or surgical treatment. Helical CT combined with recently reported techniques for imaging appendicitis and diverticulitis offers rapid and accurate confirmation or exclusion of these entities as well as identification of alternative conditions that can clinically mimic them. More routine use of helical CT holds great promise for improving patient care and lowering hospital resource use in patients with clinically suspected appendicitis and diverticulitis.
Lisanti, Francesco; Scarano, Enrico
Renal infarction is a rare cause of referral to the emergency department, with very low estimated incidence (0.004%–0.007%). Usually, it manifests in patients aged 60–70 with risk factors for thromboembolism, mostly related to heart disease, atrial fibrillation in particular. We report a case of idiopathic segmental renal infarction in a 38-year-old patient, presenting with acute abdominal pain with no previous known history or risk factors for thromboembolic diseases. Because of its aspecific clinical presentation, this condition can mimic more frequent pathologies including pyelonephritis, nephrolithiasis, or as in our case appendicitis. Here we highlight the extremely ambiguous presentation of renal infarct and the importance for clinicians to be aware of this condition, particularly in patients without clear risk factors, as it usually has a good prognosis after appropriate anticoagulant therapy. PMID:28203466
Hunjan, Tia; Chaudery, Muzzafer; Zaidi, Ahsan; Beggs, Andrew D
Appendicular sarcoidosis is a very rare cause of acute abdominal pain, with only seven cases reported previously in the literature. A 45-year-old woman, known to have sarcoidosis, presented to the emergency department with a 1-week history of epigastric and right iliac fossa abdominal pain. At diagnostic laparoscopy, an acutely inflamed appendix was found and removed as well as an omental mass which was biopsied. Subsequent histopathological examination of the appendix demonstrated appendicular sarcoidosis without acute appendicitis and chronic inflammatory changes in the omental biopsy. The patients’ symptoms completely resolved postoperatively. It is important to undertake urgent operative intervention in patients with sarcoidosis who present with right iliac fossa pain, owing to the high risk of perforation. PMID:23162022
Hunjan, Tia; Chaudery, Muzzafer; Zaidi, Ahsan; Beggs, Andrew D
Appendicular sarcoidosis is a very rare cause of acute abdominal pain, with only seven cases reported previously in the literature. A 45-year-old woman, known to have sarcoidosis, presented to the emergency department with a 1-week history of epigastric and right iliac fossa abdominal pain. At diagnostic laparoscopy, an acutely inflamed appendix was found and removed as well as an omental mass which was biopsied. Subsequent histopathological examination of the appendix demonstrated appendicular sarcoidosis without acute appendicitis and chronic inflammatory changes in the omental biopsy. The patients' symptoms completely resolved postoperatively. It is important to undertake urgent operative intervention in patients with sarcoidosis who present with right iliac fossa pain, owing to the high risk of perforation.
Dajer-Fadel, Walid Leonardo; Pichardo-González, Martha; Estrada-Ramos, Sandra; Palafox, Damián; Navarro-Reynoso, Francisco Pascual; Argüero-Sánchez, Rubén
Mediastinal infections usually originate from postoperative complications or in a descending manner from a cervical infectious process; few reports have emerged describing an ascending trajectory. A 56-year-old woman with a Huang class 1 left emphysematous pyelonephritis was referred due to a progression of an ascending necrotizing mediastinitis. A left posterolateral thoracotomy was performed, drainage and thorough lavage were carried out with a successful outcome. We believe this is the first reported case of ascending necrotizing mediastinitis secondary to an emphysematous renal infection. © The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.
Spyridakis, Ioannis; Patoulias, Dimitrios; Tsioulas, Paschalis; Patoulias, Ioannis
Acute appendicitis is one of the most common surgical conditions that are diagnosed in children presenting with acute abdominal pain in the emergency department. An atypical presentation of symptoms is encountered in 30% of cases. Atypical localization of the appendix as in left sided appendicitis, although rare, has an increased risk of missed or delayed diagnosis. We present two consecutive cases of left sided appendicitis in order to describe how increased awareness in the second case helped us to avoid pitfalls in the management and diagnosis of this atypical and variant condition. Increased cautiousness and awareness of left sided appendicitis can assist emergency physicians to avoid pitfalls in the management and diagnosis of this atypical and variant condition. PMID:27042523
Hassan, Saidi; Chavda, S K; Magoha, G A
In recent years, several reports have underlined the possible existence of chronic appendicitis. Up to 38% of spontaneously resolving acute appendicitis may recur. We studied 41 patients operated on between July 2000 and June 2001 for chronic and recurrent appendicitis at a teaching hospital in the city of Nairobi. The patients comprised 17.8% of all patients undergoing surgery for appendicitis during the study period. The majority (65.9%) were females. The faecolith rate was 51.2%. About half of appendices removed for these symptoms were normal at histology. Nearly 70% of the normal appendices contained faecoliths. Symptoms resolved in 90% of faecolith-containing appendices and 87.5% of non-faecolith-containing appendices that were normal on histology.
Lamps, Laura W
The pathologic spectrum of the acutely inflamed appendix encompasses a wide range of infectious and noninfectious entities. The appendix suffers alone in some of these disorders, and in others may be involved through extension from other areas of the gastrointestinal tract. Although the appendix is the most commonly resected and examined intraabdominal organ, the pathogenesis and etiology of acute nonspecific appendicitis (the most common diagnosis made in this organ) remains enigmatic. This review encompasses the pathology, pathogenesis, and bacteriology of acute appendicitis, as well as controversial issues such as the diagnosis of chronic appendicitis and the significance of a morphologically unremarkable appendectomy specimen in the clinical context of appendicitis. In addition, the pathologic features, pertinent diagnostic techniques, and clinical significance of several specific bacterial, viral, fungal, and parasitic infections affecting the appendix are presented, including adenovirus, cytomegalovirus, Yersinia species, actinomycosis, Mycobacteria species, histoplasmosis, pinworms, schistosomiasis, and Strongyloides stercoralis.
Ait Ali Slimane, M; Montupet, P
The management of acute appendicitis in the pediatric patient has undergone radical rethinking in recent years. It has been shown that simple uncomplicated acute appendicitis can be successfully managed with antibiotic therapy and may not even require interval appendectomy. Appendicitis complicated by perforation, abscess, or inflammatory phlegmon can be successfully treated by initial antibiotic therapy (with or without percutaneous drainage) and delayed interval appendectomy. While the laparoscopic approach has proved to be well-adapted to many other pediatric surgical procedures, its utility in the treatment of uncomplicated acute appendicitis remains open to debate; compared to standard open appendectomy, it offers only minimal advantages with regard to post-operative care, length of hospital stay, and complications. Children can be managed either by general surgeons or pediatric surgeons depending on the organization of the emergency service; there may be a higher incidence of removal of a normal appendix in non-specialized services.
Kaselas, Christos; Spyridakis, Ioannis; Patoulias, Dimitrios; Tsioulas, Paschalis; Patoulias, Ioannis
Acute appendicitis is one of the most common surgical conditions that are diagnosed in children presenting with acute abdominal pain in the emergency department. An atypical presentation of symptoms is encountered in 30% of cases. Atypical localization of the appendix as in left sided appendicitis, although rare, has an increased risk of missed or delayed diagnosis. We present two consecutive cases of left sided appendicitis in order to describe how increased awareness in the second case helped us to avoid pitfalls in the management and diagnosis of this atypical and variant condition. Increased cautiousness and awareness of left sided appendicitis can assist emergency physicians to avoid pitfalls in the management and diagnosis of this atypical and variant condition.
Sartorelli, Alesso Cervantes; da Silva, Márcia Guimarães; Rodrigues, Maria Aparecida Marchesan; da Silva, Reinaldo José
A case of parasitic appendicitis caused by Taenia sp. in a 28-year-old woman from Brazil is reported. Histopathological data and a description of the helminthe found in the appendix lumen are presented.
VON-MÜHLEN, Bruno; FRANZON, Orli; BEDUSCHI, Murilo Gamba; KRUEL, Nicolau; LUPSELO, Daniel
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
Ekici, Mehmet Fatih; Bayhan, Zulfu; Zeren, Sezgin; Ucar, Bercis Imge; Korkmaz, Mehmet; Deger, Ayse Nur
Stump appendicitis is an acute inflammation of remnant appendix, a rare complication of incomplete appendectomy. It may present as acute abdomen with history of appendectomy, which may cause delay in diagnosis. Therefore, incomplete appendectomy should be considered as a differential diagnosis of acute abdomen in patients with medical history of appendectomy. The present case is one of stump appendicitis 6 months after appendectomy. Stump appendectomy was performed and the patient was discharged 7 days after the operation without any complication.
Himeno, Shinji; Yasuda, Seiei; Oida, Yasuhisa; Mukoyama, Sayuri; Nishi, Takayuki; Mukai, Masaya; Nakasaki, Hisao; Makuuchi, Hiroyasu
Acute appendicitis is usually encountered clinically as acute abdomen. Typical cases are easy to diagnose, but it can sometimes be very difficult to make a diagnosis in atypical cases. We retrospectively studied patients who underwent ultrasonography for right-sided lower abdominal pain suggesting acute appendicitis, and assessed the accuracy of ultrasonic diagnosis. The subjects were 202 patients (100 males and 102 females) aged 6-89 years (mean: 33.3 years). From the ultrasonic findings, appendicitis was classified as follows: 1) catarrhal: a clear layer structure of the appendiceal wall and mucosal edema; 2) phlegmonous: an ill-defined layer structure of the appendiceal wall, moderate enlargement of the apendix, and maximum transverse dimension of > or = 10 mm; and 3) gangrenous: unidentifiable layer structure of the appendiceal wall and marked enlargement to form a mass. The appendix was visualized in 142 of the 202 patients (70.3 %). When the appendix was detected, the sensitivity, specificity and accuracy of ultrasound for making a diagnosis of appendicitis were 97.6%, 82.0 %, 91.5 %, respectively. With regard to assessment of the severity of inflammation, ultrasonic and histologic findings were concordant in 61.2 % of the patients. However, ultrasound was shown to possibly underestimate the extent of inflammation. On the other hand, 11 of the 60 patients with an undetectable appendix (18.3 %) were clinically diagnosed as having appendicitis. The pathologic diagnosis was catarrhal appendicitis in 3 patients and phlegmonous appendicitis in 8 patients. In patients with an undetectable appendix, the possibility of catarrhal or phlegmonous appendicitis should be kept in mind.
Bachur, Richard G; Lipsett, Susan C; Monuteaux, Michael C
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.
Kordzadeh, Ali; Lorenzi, Bruno; Kalyan, Jiten P.; Hanif, Muhammad A.; Charalabopoulos, Alexandros
Paraumbilical hernia sac usually contains omentum, bowel loop and rarely appendicular epiploicae, metastatic deposits and vermiform appendix. Presentation of acute appendicitis in a paraumbilical hernia is rare and limited to few case reports in the literature. Herein, we would like to report a case of a successfully treated acute appendicitis presenting in a paraumbilical hernia in an 84-year-old lady with 6-month follow-up. PMID:28096326
Antal, András; Kocsis, Béla
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.
Adams, H L; Jaunoo, S S
The aim of this study is to evaluate the diagnostic value of pre-operative bilirubin levels in the diagnosis of acute appendicitis and appendiceal perforation. A retrospective analysis of 557 patients undergoing emergency appendicectomy over a 24-month period at a large teaching hospital. Hyperbilirubinaemia was defined as >25 µmol/L. Data were analysed using descriptive statistics. 484 of the 557 (86.9 %) operated cases were found histologically to be appendicitis. 116 cases of the 484 were perforated (24 %). Bilirubin levels were significantly higher in the group with appendicitis versus the group found to have a normal appendix at histology, [median (IQR) 12.0 µmol/L (9.00) vs. 8.0 µmol/L (7.00) respectively, p < 0.001], despite being within normal serum bilirubin range. Sensitivity of hyperbilirubinaemia for acute appendicitis was only 8 %, however specificity was 94 %. PPV was 85 % and NPV was 26 %. Whilst bilirubin was higher in patients with a perforated appendix versus acute appendicitis [median (IQR) 13.0 µmol/L (9.00) vs. 11.0 µmol/L (9.00), respectively], statistically, there was no significant difference in pre-operative bilirubin levels between the perforated appendicitis cases and the non-perforated appendicitis cases (p = 0.326). However, the specificity of hyperbilirubinaemia for perforated appendicitis was 93 %, sensitivity 9.4 %, PPV 24 % and NPV 82 %. Bilirubin levels may be high, but remain within normal range, in cases of appendicitis. Therefore, bilirubin levels may be a useful measurement when investigating a patient with suspected appendicitis. Hyperbilirubinaemia is highly specific with regards to perforation, a finding supported by other studies. However, possibly because of the few perforated cases in this study, we cannot recommend that hyperbilirubinaemia be used to predict perforation.
Meljnikov, Igor; Radojcić, Branka; Grebeldinger, Slobodan; Radojcić, Nikola
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.
Manzelli, Antonio; Coscarella, Giorgio; Pietrantuono, Maurizio; Jarzembowski, Tomasz Marek; Fisichella, Piero Marco; Gaspari, Achille Lucio
Background: Minilaparoscopic appendectomy for appendicitis is not a well-established procedure. This approach provides less abdominal wall trauma, fewer complications, and excellent cosmetic results. Our aim was to show the feasibility and safety of the minilaparoscopic approach. Methods: Minilaparoscopic appendectomy was performed in 37 patients. Two 2.2-mm trocars were used to manipulate a 2.2-mm, 0-degree laparoscope and for grasper access. A 5-mm trocar was used for the ultrasonic scalpel. Results: No deaths occurred. In 3 patients (8%), appendectomy was aborted due to pathology of the ovary. Conversion to the open approach occurred in 2.7% of patients. The average operating time was 34 minutes (range, 15 to 80), and the median length of hospital stay was 1.2 day (range, 1 to 5). Conclusions: The minilaparoscopic approach a) has the same advantages as the conventional laparoscopic approach in terms of better diagnostic accuracy and safety; b) a low incidence of complications; and c) yields excellent cosmetic results. PMID:16709358
Mussack, T; Schmidbauer, S; Nerlich, A; Schmidt, W; Hallfeldt, K K
Chronic appendicitis is not generally accepted as an independent clinical entity. The diagnosis is often made only after histological analysis when the patient has undergone appendectomy in a case of persistent or recurrent pain. The objectives of this prospective study were to analyse the incidence of chronic appendicitis among our patients, to compare demographic and clinical data with histological results and to evaluate long-term follow-up after appendectomy. Between November 1995 and February 1998, 322 patients underwent appendectomy due to typical symptoms of appendicitis. All appendices were analysed macroscopically by the surgeon and histologically by two independent pathologists. Furthermore, demographic data, standard blood results, Alvarado score, body mass index, operation time, complications, and length of hospital stay were evaluated. In April 2001, a long-term follow-up survey evaluated the present complaints of all operated patients. A total of 112 patients showed clinical signs of non-acute appendicitis. However, 26.8% of these appendices histologically revealed an acute inflammation. In the subgroup of histologically non-acute appendicitis, 4.9% of the appendices were inconspicuous, 42.0% chronically inflamed and 50.6% fibrotic. Compared to that, the macroscopic examination by the surgeon resulted in a 93.5% specificity and a 77.8% sensitivity. The preoperative period of pain was significantly longer (7 days) compared to patients with acute appendicitis (0.5 days). White blood count (8.700 versus 13.400) and preoperative Alvarado score (4 versus 7 points) were significantly lower, the hospital stay significantly shorter (3 versus 4 days). A specificity of 89.9% and a positive likelihood ratio of 4.64 were calculated for an optimal cut-off value of 7 days for preoperative pain. At a median of 50.2 months after the operation, 93.1% of the patients were asymptomatic, and five patients reported persistent pain in the right lower quadrant. Three
Moore, M M; Kulaylat, A N; Brian, J M; Khaku, A; Hulse, M A; Engbrecht, B W; Methratta, S T; Boal, D K B
As the utilization of MRI in the assessment for paediatric appendicitis increases in clinical practice, it is important to recognize alternative diagnoses as the cause of abdominal pain. The purpose of this review is to share our institution's experience using MRI in the evaluation of 510 paediatric patients presenting with suspected appendicitis over a 30 month interval (July 2011 to December 2013). An alternative diagnosis was documented in 98/510 (19.2%) patients; adnexal pathology (6.3%, n = 32), enteritis-colitis (6.3%, n = 32), and mesenteric adenitis (2.2%, n = 11) comprised the majority of cases. These common entities and other less frequent illustrative cases obtained during our overall institutional experience with MRI for suspected appendicitis are reviewed.
Milica, Berisavac; Biljan, Kastratović Kotlica; Tosić, V; Marković, N; Ljustina, S; Zizić, V; Maricić, Z
Acute appendicitis in puerperium is often diagnosed too late, because clinical signs can be unrelaible. Abdominal wall rigidity is rarely noticed in puerpeium because of weak abdominal wall muscles, laboratory parameters are not enough relaible and atip cal appendix presentation makes dificulties in diagnosis. Knowing clinical signs and symptoms of appendicitis, possible complications and their early detection, make a chanse for a good surgical outcome. Measuring of axillar and rectal temperature can take confusion in, and prolong time until surgical treatment. Leucocytosis in puerperium is not valid for diagnosis. We report a case of patient in puerperium with high laboratory infection parameters. Diagnosis of appendicitis is made based on clinical signs and symptoms, that is proved intraoperatively and histologicaly. Appendectomy without perforation carries less risks for mother and fetus.
Rentea, Rebecca M; Peter, Shawn D St; Snyder, Charles L
Appendicitis is a common cause of abdominal pain in children. The diagnosis and treatment of the disease have undergone major changes in the past two decades, primarily as a result of the application of an evidence-based approach. Data from several randomized controlled trials, large database studies, and meta-analyses have fundamentally affected patient care. The best diagnostic approach is a standardized clinical pathway with a scoring system and selective imaging. Non-operative management of simple appendicitis is a reasonable option in selected cases, with the caveat that data in children remain limited. A minimally invasive (laparoscopic) appendectomy is the current standard in US and European children's hospitals. This article reviews the current 'state of the art' in the evaluation and management of pediatric appendicitis.
Dewhurst, Catherine; Beddy, Peter; Pedrosa, Ivan
In recent years, magnetic resonance imaging (MRI) has become a valuable diagnostic tool for evaluation of acute abdominal pain in pregnancy. MRI offers an opportunity to identify the normal or inflamed appendix as well as a variety of other pathologic conditions that can masquerade clinically as acute appendicitis in pregnant women. Visualization of the normal appendix by MRI virtually excludes the diagnosis of acute appendicitis and may help reduce the negative laparotomy rate in this patient population. Here we discuss a comprehensive MRI protocol for evaluation of pregnant women with abdominal pain, focusing on the appearance and location of the normal and diseased appendix, and we describe an approach to diagnosing acute appendicitis and other conditions with MRI. Copyright © 2012 Wiley Periodicals, Inc.
Moore, Michael M; Brian, James M; Methratta, Sosamma T; Hulse, Michael A; Choudhary, Arabinda K; Eggli, Kathleen D; Boal, Danielle K B
As utilization of MRI for clinically suspected pediatric appendicitis becomes more common, there will be increased focus on case interpretation. The purpose of this pictorial essay is to share our institution's case interpretation experience. MRI findings of appendicitis include appendicoliths, tip appendicitis, intraluminal fluid-debris level, pitfalls of size measurements, and complications including abscesses. The normal appendix and inguinal appendix are also discussed.
Kadera, Samantha P; Mower, William R; Krishnadasan, Anusha; Talan, David A
Appendicitis has long been considered a progressive inflammatory condition best treated by prompt appendectomy. Recently, several trials comparing initial treatment with antibiotics alone to appendectomy suggest that antibiotic therapy may be a safe option in select patients. However, little is known about patients' understanding of appendicitis, prioritized outcomes, and treatment preferences. We conducted a prospective, observational survey at a Los Angeles County public hospital emergency department. Trained study coordinators recorded the following data on each subject: basic knowledge of appendicitis, past surgical and antibiotic history, and medical illness outcome priorities. Participants were then educated about appendicitis and were told that studies had demonstrated that appendicitis can be treated safely with antibiotics alone. Subjects were then surveyed as to their preference for urgent surgery or antibiotics alone in a hypothetical scenario of acute uncomplicated appendicitis. Of 129 subjects interviewed, 56 (43%) correctly defined appendicitis, and 69 (53%) identified the treatment for appendicitis as surgery. When presented with a hypothetical acute appendicitis scenario, 57% chose antibiotics over surgery. Persons with previous appendectomy and parents of minors more often chose antibiotics alone, 74% and 63%, respectively. Dying was the most frequently cited and highest-ranked concern about medical illness. Our results demonstrate that, among persons at one US public hospital, understanding of appendicitis is poor. Once presented with background information about appendicitis and being informed that antibiotics can safely treat appendicitis, many people would prefer an antibiotic approach over appendectomy. Death is the most prioritized concern. Copyright © 2016 Elsevier Inc. All rights reserved.
Frazee, Richard; Abernathy, Stephen; Davis, Matthew; Isbell, Travis; Regner, Justin; Smith, Randall
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.
Hearne, Christopher B.; Taboada, Jorge
Epiploic appendagitis (EA) is a rare cause of acute abdominal pain caused by inflammation of an epiploic appendage. It has a nonspecific clinical presentation that may mimic other acute abdominal pathologies on physical exam, such as appendicitis, diverticulitis, or cholecystitis. However, EA is usually benign and self-limiting and can be treated conservatively. We present the case of a patient with two episodes of EA, the first mimicking acute appendicitis and the second mimicking acute cholecystitis. Although recurrence of EA is rare, it should be part of the differential diagnosis of acute, localized abdominal pain. A correct diagnosis of EA will prevent unnecessary hospitalization, antibiotic use, and surgical procedures. PMID:28127129
Salö, Martin; Marungruang, Nittaya; Roth, Bodil; Sundberg, Tiia; Stenström, Pernilla; Arnbjörnsson, Einar; Fåk, Frida; Ohlsson, Bodil
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
Prada Arias, Marcos; Salgado Barreira, Angel; Montero Sánchez, Margarita; Fernández Eire, Pilar; García Saavedra, Silvia; Gómez Veiras, Javier; Fernández Lorenzo, José Ramón
Non-specific acute abdominal pain is the most common process requiring differential diagnosis with appendicitis in clinical practice. The aim of this study was to assess the Paediatric Appendicitis Score in differentiating between these two entities. All patients admitted due to suspicion of appendicitis were prospectively evaluated in our hospital over a two-year period. Cases of non-specific acute abdominal pain and appendicitis were enrolled in the study. Several variables were collected, including Score variables and C-reactive protein levels. Descriptive, univariate and multivariate analyses and diagnostic accuracy studies (ROC curves) were performed. A total of 275 patients were studied, in which there were 143 cases of non-specific acute abdominal pain and 132 cases of appendicitis. Temperature and right iliac fossa tenderness on palpation were the variables without statistically significant differences, and with no discrimination power between groups. Pain on coughing, hopping, and/or percussion tenderness in the right lower quadrant was the variable with greater association with appendicitis. The Score correctly stratified the patients into risk groups. Substitution of temperature for C-reactive protein in the Score increased diagnostic accuracy, although with no statistically significant differences. The Paediatric Appendicitis Score helps in differential diagnosis between appendicitis and non-specific acute abdominal pain. It would be advisable to replace the temperature in the Score, since it has no discrimination power between these groups. C-reactive protein at a cut-off value of 25.5mg/L value could be used instead. Copyright © 2017. Publicado por Elsevier España, S.L.U.
Gonzalez, Dani O; Deans, Katherine J; Minneci, Peter C
Appendectomy is currently considered the standard of care for children with acute appendicitis. Although commonly performed and considered a safe procedure, appendectomy is not without complications. Non-operative management has a role in the treatment of both uncomplicated and complicated appendicitis. In uncomplicated appendicitis, initial non-operative management appears to be safe, with an approximate 1-year success rate of 75%. Compared to surgery, non-operative management is associated with less disability and lower costs, with no increase in the rate of complicated appendicitis. In patients with complicated appendicitis, initial non-operative management with interval appendectomy has been shown to be safe with reported success rates between 66% and 95%. Several studies suggest that initial non-operative management with interval appendectomy may be beneficial in patients with perforated appendicitis with a well-formed abscess or inflammatory mass. Recent data suggest that interval appendectomy may not be necessary after initial non-operative management of complicated appendicitis.
Ahmed, Syed Tausif; Ranjan, Rajeev; Saha, Subhendu Bikas; Singh, Balbodh
Acute appendicitis is one of the most common emergencies handled by a surgeon. Various aetiologies of acute appendicitis have been proposed but none have been proved. Trauma too has been proposed as a cause of acute appendicitis. Here we present a case of blunt trauma abdomen which was explored to rule out a perforation of hollow viscous organ and haemoperitoneum, but at the time of exploration a perforated appendicitis was found. The chronological order of events points towards blunt trauma as the probable cause of this appendicitis. This case also highlights the fact that even if trauma was not the cause of acute appendicitis, acute appendicitis should still be kept in the differential diagnosis of a patient presenting with pain in the right lower abdomen and a history of trauma. PMID:24759158
Mazza, J F; Augenstein, J S; Kreis, D J
The mortality of acute appendicitis increases sixfold if perforation occurs. We have reported a case of perforated appendix complicated by necrotizing fasciitis of the abdominal wall and retroperitoneum. We believe this complication has not been previously described in the English literature.
Canterino, Joseph E; McCormack, Michael; Gurung, Ananta; Passarelli, James; Landry, Marie L; Golden, Marjorie
Cytomegalovirus (CMV) is a common viral pathogen. Asymptomatic infection or a mononucleosis syndrome are the most common manifestations in otherwise healthy individuals. End-organ disease is rare in immunocompetent individuals. Here, we describe a case of CMV appendicitis in a patient without an immune-compromising condition.
Bu-Ali, Omaima; Al-Bashir, Mohamed; Samir, Hashim A; Abu-Zidan, Fikri M
Stump appendicitis is a rare delayed complication of appendectomy. The delay in diagnosis is usually because of a prior history of appendectomy. We report a case of stump appendicitis diagnosed pre-operatively with a computerized tomography (CT) scan after laparoscopic appendectomy. An 18-year-old male presented with a one-week history of lower abdominal pain, nausea and vomiting. He had a history of laparoscopic appendectomy for acute appendicitis. Physical examination revealed tenderness and guarding in the lower abdomen. CT scan showed free pelvic fluid with a tubular structure of about 2.5 cm in length and 0.78 cm in diameter located posterior to the ileo-cecal junction. Laparoscopic exploration confirmed the findings. A residual appendiceal stump was found and dissected from the adhesion and removed. Histopathology showed a residual appendix with transmural neutrophilic infiltration associated with multifocal hemorrhagic necrosis. The postoperative period was uneventful. The diagnosis of stump appendicitis can be challenging. CT scan has proven to be a useful tool for the diagnosis of this rare condition.
Wilson, Dennis A; Wilson, Gerald A; Bryan, Charles S
A returning traveler presenting with fever accompanied by abdominal "pressure" and pain proved to have amebic appendicitis, amebic liver abscess, and probable recent amebic dysentery--a rare combination of findings amply illustrating the value of asking "Unde venis--from where do you come?"
Gilmore, Thomas; Jordan, Charlton; Edelstein, Elisabeth
Right-sided diverticulitis is a rare source of right lower quadrant pain in Western society; however, it is quite common in Asian societies. Right-sided diverticulitis presents very similarly to appendicitis, with right lower quadrant pain, fever, nausea, and laboratory abnormalities, and is often seen in young patients. In this report, we present a case of right-sided diverticulitis. We review right-sided diverticulitis' diagnosis and management. It is important to diagnose right-sided diverticulitis because it is a good mimic of appendicitis and ideally should be diagnosed before a patient has unnecessary surgery. A 26-year-old Asian woman presented for evaluation of right lower quadrant pain and fever. She was initially thought to have appendicitis clinically, but had right-sided diverticulitis diagnosed by computed tomography (CT) scan. She was admitted and received intravenous antibiotics and bowel rest. Her right-sided diverticulitis resolved in 3 days. Severe right lower quadrant pain in young patients of Asian descent can be right-sided diverticulitis. Right-sided diverticulitis is a benign condition managed medically that mimics appendicitis. CT imaging seems to be the best way to avoid unnecessary surgery. Copyright © 2013 Elsevier Inc. All rights reserved.
Zubieta-O’Farrill, Gregorio; Guerra-Mora, José Raúl; Gudiño-Chávez, Andrés; Gonzalez-Alvarado, Carlos; Cornejo-López, Gilberto Bernabe; Villanueva-Sáenz, Eduardo
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
Zubieta-O'Farrill, Gregorio; Guerra-Mora, José Raúl; Gudiño-Chávez, Andrés; Gonzalez-Alvarado, Carlos; Cornejo-López, Gilberto Bernabe; Villanueva-Sáenz, Eduardo
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. 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. 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. 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. Copyright © 2014 The Authors. Published by Elsevier Ltd.. All rights reserved.
Park, Sung Yun; Kim, Sung Min
Artificial neural networks is one of pattern analyzer method which are rapidly applied on a bio-medical field. The aim of this research was to propose an appendicitis diagnosis system using artificial neural networks (ANNs). Data from 801 patients of the university hospital in Dongguk were used to construct artificial neural networks for diagnosing appendicitis and acute appendicitis. A radial basis function neural network structure (RBF), a multilayer neural network structure (MLNN), and a probabilistic neural network structure (PNN) were used for artificial neural network models. The Alvarado clinical scoring system was used for comparison with the ANNs. The accuracy of the RBF, PNN, MLNN, and Alvarado was 99.80%, 99.41%, 97.84%, and 72.19%, respectively. The area under ROC (receiver operating characteristic) curve of RBF, PNN, MLNN, and Alvarado was 0.998, 0.993, 0.985, and 0.633, respectively. The proposed models using ANNs for diagnosing appendicitis showed good performances, and were significantly better than the Alvarado clinical scoring system (p < 0.001). With cooperation among facilities, the accuracy for diagnosing this serious health condition can be improved.
Coward, Stephanie; Kareemi, Hashim; Clement, Fiona; Zimmer, Scott; Dixon, Elijah; Ball, Chad G; Heitman, Steven J; Swain, Mark; Ghosh, Subrata; Kaplan, Gilaad G
At the turn of the 21st century, studies evaluating the change in incidence of appendicitis over time have reported inconsistent findings. 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. We conducted a population-based comparative cohort study to identify all individuals with appendicitis from 2000 to2008. 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). 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. 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). The administrative database overestimated the incidence of appendicitis, particularly among perforated appendicitis. Therefore, studies utilizing administrative data to analyze
Rao, P M; Rhea, J T; Novelline, R A; McCabe, C J
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.
Tsuji, M; Puri, P; Reen, D J
In this study we have characterised the local inflammatory response in acute suppurative appendicitis (S), focal appendicitis (F), and normal appendices (C). Enumeration of lymphocyte subpopulations, cells expressing IL-2 receptor, natural killer (NK) cells, monocytes and plasma cell isotypes and subclasses infiltrating the lamina propria was carried out on all specimens using immunoperoxidase staining procedures. Total T cells were significantly increased in both acute suppurative appendicitis and focal appendicitis compared with controls (p < 0.001). Cells infiltrating the lamina propria expressed IL-2 receptor in all appendiceal specimens but were significantly increased in both acute and focal appendicitis (p < 0.01). IgG and IgA plasma cell isotypes were significantly increased in all S and F appendiceal specimens (p < 0.001). Monocyte and NK cell numbers, however, were only increased in acute suppurative appendiceal specimens. The increased lymphocyte and plasma cell isotypes seen in focal appendicitis occurred throughout the entire organ even through the inflammatory focus was confined to only three to seven serial sections. These results clearly show a differential pattern of cellular infiltration in focal appendicitis from that seen in acute suppurative appendicitis. The selective lymphocyte and plasma cell nature of the cellular infiltrate in the lamina propria of focal appendicitis may reflect the presence of a specific immune response to an as yet unidentified luminal antigen as a possible cause of appendicitis.
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
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
Kharbanda, Anupam B.; Rai, Alex J.; Cosme, Yohaimi; Liu, Khin; Dayan, Peter S.
Objectives To describe the association between two novel biomarkers, calprotectin and leucine-rich alpha glycoprotein-1 (LRG), and appendicitis in children. Methods This was a prospective, cohort study of children 3 to 18 years old presenting to a pediatric emergency department with possible appendicitis. Blood and urine samples were assayed for calprotectin and LRG via enzyme-linked immunosorbent assay. Final diagnosis was determined by histopathology or telephone follow-up. Biomarker levels were compared for subjects with and without appendicitis. Recursive partitioning was used to identify thresholds that predicted appendicitis. Results Of 176 subjects, mean age was 11.6 years (SD ±4.0 years) and 52% were male. Fifty-eight patients (34%) were diagnosed with appendicitis. Median plasma calprotectin, serum LRG, and urine LRG levels were higher in appendicitis versus non-appendicitis (p < 0.008). When stratified by perforation status, median plasma calprotectin and serum LRG levels were higher in non-perforated appendicitis vs. non-appendicitis (p < 0.01). Median serum LRG, urine LRG, and plasma calprotectin levels were higher in perforated appendicitis as compared to non-perforated appendicitis (p < 0.05). Urine calprotectin did not differ among groups. A serum LRG < 40,150 ng/ml, a urine LRG < 42 ng/ml, and a plasma calprotectin < 159 ng/ml, each provided a sensitivity and negative predictive value of 100% to identify children at low risk for appendicitis, but with specificities ranging from 23% to 35%. The standard white blood cell (WBC) count achieved 100% sensitivity at a higher specificity than both novel biomarkers. Conclusions Plasma calprotectin and serum/urine LRG are elevated in pediatric appendicitis. No individual marker performed as well as the WBC. PMID:22221321
Fahed, R; Menassa-Moussa, L; Sader-Ghorra, C; Haddad-Zebouni, S
Intrathoracic appendicitis is an uncommon diagnosis. We report the case of a 6-year-old boy with elevated CRP and no fever, who complained of nonspecific abdominal pain. A diaphragmatic hernia was suspected on a chest X-ray and confirmed by an ultrasound examination. A multidetector CT scan revealed intrathoracic acute appendicitis associated with a right posterolateral Bochdalek hernia. Abdominal diseases associated with late-presenting congenital diaphragmatic hernia are often manifested by an atypical clinical presentation, which can be a source of delay or error in diagnosis. We recommend radiological exploration in the case of diaphragmatic hernia, even with subtle clinical findings in the search of associated gastrointestinal complications. Copyright © 2012 Elsevier Masson SAS. All rights reserved.
Kim, Ki Up; Kim, Jin Kyeung; Won, Jong Ho; Hong, Dae Sik; Park, Hee Sook; Park, Kyeung Kyu
The decision to operate for abdominal pain in patients with leukopenia can be exceedingly difficult. Surgical exploration may be the only effective way to differentiate acute appendicitis from other causes, but it involves considerable risk of infectious complications due to immunesuppression. Leukemic patients, who presented significant RLQ pain, had been indicated for operation, despite having advanced disease or having had received chemotherapy or steroids. Four adult leukemia patients, complicated by acute appendictis, were reviewed. Two patients were in induction chemotherapy, one receiving salvage chemotheapy due to relapse and the other was in conservative treatment. Two patients were acute myelocytic leukemia (AML), one had acute lymphocytic leukemia (ALL), and the other had aleukemic leukemia. All patients underwent appendectomy and recovered without complication. Our experience supports the theory that the surgical management of appendicitis in acute leukemia is the most effective way, in spite of leukopenia. PMID:8268146
Kim, Joo Heung; Lee, Dae Sup
Foreign bodies usually do not cause complications and pass through the gastrointestinal tract spontaneously. Usually endoscopic intervention is recommended within 24 hours. Cases of acute appendicitis caused by foreign bodies are very rare. In our case, we experienced successful endoscopic and surgical treatment of a patient with ingestion of razor blade and some unrecognizable foreign bodies. A 22-year-old soldier was admitted with a small quantity of hematemesis and epigastric pain. We performed emergent endoscopy and successfully removed several foreign bodies. After 17 days, we performed appendectomy to remove the remaining foreign body and to relieve the symptoms. There is no doubt that endoscopic intervention is definitely useful method to remove foreign bodies. If there is no spontaneous drainage of the foreign body from the appendix, an appendectomy must be considered to remove the foreign body and prevent surgical complications such as appendicitis, periappendiceal abscess, and perforation. PMID:26366386
Blanco, Felix C; Sandler, Anthony D; Nadler, Evan P
Based on their clinical impression, the authors hypothesized that children with obesity may more commonly present with perforated appendicitis. Therefore, the authors reviewed their experience from 2008 to 2010 to determine whether obesity affected the clinical presentation of appendicitis. Variables studied were height, weight, use of diagnostic imaging, and clinical findings of appendicitis at presentation. Outcomes assessed were length of stay and complication rate. The study identified 319 patients with appendicitis. Children with obesity were more likely (P = .026) to present with perforation (28/62, 45%) than nonobese patients (78/257, 30%). Neither length of stay nor complication rate was affected by the presence of obesity. The data suggest that children with obesity are more likely to present with perforated appendicitis. This finding suggests that the diagnosis of appendicitis may be more difficult in obese patients or their presentation may be delayed. Practitioners should have heightened awareness in children with obesity and symptoms of abdominal pain.
Tuberculosis (TB) is a common disease that ranks as the second leading cause of death from an infectious disease worldwide, after the human immunodeficiency virus (HIV). However, primary TB of the appendix is rare and may or may not be associated with specific clinical features. Thus, diagnosis is made only after histopathological examination. It suggests that all surgically removed appendices should be subjected to histopathological examination. This reported case is an uncommon case of chronic tubercular appendicitis.
Kager, Liesbeth M; Bemelman, Willem A; Bastiaansen, Barbara A
For two years, every 6 weeks a 23-year-old man presented with episodes of severe abdominal pain and fever. After an extensive diagnostic workup, showing only slightly increased infectious parameters during the pain attacks and infiltration around the terminal ileum, a diagnostic laparoscopy diagnosed 'chronic recurrent appendicitis'. A 40-year-old female had severe attacks of abdominal pain and fever every 4-6 weeks for 1.5 years. Some inflammation around the appendix was seen on colonoscopy, and a diagnostic laparoscopy finally confirmed the same diagnosis 'chronic recurrent appendicitis'. Patients with recurrent abdominal pain often are a diagnostic challenge for the clinician. The appendix is rarely recognized as the causative factor and the diagnosis 'chronic recurrent appendicitis' is not widely accepted. This disease entity often has an atypical presentation and well-defined criteria are lacking. In this article we plea for a broader acceptance of this diagnosis, which, in our opinion, deserves to be included in the differential diagnosis of longstanding or recurrent abdominal pain attacks.
Kruis, Wolfgang; Morgenstern, Julia; Schanz, Stefan
Appendicitis and diverticulitis are very common entities that show some similarities in diagnosis and course of disease. Both are widely believed to be simple clinical diagnoses, which is in contrast to scientific evidence. An accurate diagnosis has to describe not only the initial detection, but particularly the severity of the disease. It is based mainly on cross-sectional imaging by ultrasound (US) and computed tomography (CT). Appendectomy is the standard treatment for acute appendicitis and is mandatory in complicated cases. Antibiotic therapy is similarly effective in uncomplicated appendicitis, but long-term results are not sufficiently known. Treatment of diverticulitis is related to the disease status. Complications such as perforation and bleeding require intervention. Uncomplicated diverticulitis as graded by US or CT are subject to conservative management, in the form of outpatient or hospital care. It is an unresolved debate as to whether antibiotic treatment offers benefits. Mesalazine seems at least to improve pain. The real challenge is treatment of recurrent diverticulitis. Lifestyle measures such as nutritional habits and physical activity are found to influence diverticular disease. Besides immunosuppression, obesity is a significant risk factor for complicated diverticulitis. Whether any medication such as chronic antibiotics, probiotics or mesalazine offers benefits is unclear. The indication for sigmoid resection has changed; it is no longer given by the number of attacks, but rather by structural changes as depicted by cross-sectional imaging. Copyright © 2013 S. Karger AG, Basel.
Katagiri, Hideki; Lefor, Alan Kawarai; Kubota, Tadao; Mizokami, Ken
AIM To review clinical experience with barium appendicitis at a single institution. METHODS A retrospective review of patients admitted with a diagnosis of acute appendicitis, from January 1, 2013 to December 31, 2015 was performed. Age, gender, computed tomography (CT) scan findings if available, past history of barium studies, pathology, and the presence of perforation or the development of complications were reviewed. If the CT scan revealed high density material in the appendix, the maximum CT scan radiodensity of the material is measured in Hounsfield units (HU). Barium appendicitis is defined as: (1) patients diagnosed with acute appendicitis; (2) the patient has a history of a prior barium study; and (3) the CT scan shows high density material in the appendix. Patients who meet all three criteria are considered to have barium appendicitis. RESULTS In total, 396 patients were admitted with the diagnosis of acute appendicitis in the study period. Of these, 12 patients (3.0%) met the definition of barium appendicitis. Of these 12 patients, the median CT scan radiodensity of material in the appendix was 10000.8 HU, ranging from 3066 to 23423 HU (± 6288.2). In contrast, the median CT scan radiodensity of fecaliths in the appendix, excluding patients with barium appendicitis, was 393.1 HU, ranging from 98 to 2151 HU (± 382.0). The CT scan radiodensity of material in the appendices of patients with barium appendicitis was significantly higher than in patients with nonbarium fecaliths (P < 0.01). CONCLUSION Barium appendicitis is not rare in Japan. Measurement of the CT scan radiodensity of material in the appendix may differentiate barium appendicitis from routine appendicitis. PMID:27721929
Introduction The prevailing view on appendicitis is that the main aetiology is obstruction owing to faecoliths in adults and lymphoid hyperplasia in children. Faecoliths on imaging studies are believed to correlate well with appendicitis. Methods A retrospective chart review was conducted of 1,014 emergency appendicectomy patients between 2001 and 2011. Faecolith prevalence in adult and paediatric appendicectomy specimens with and without perforation was studied. The sensitivity and positive predictive value (PPV) of computed tomography (CT) for identifying faecoliths in the pathology specimen were examined. Results Overall, faecoliths were found in 18.1% (178/986) of appendicitis specimens and 28.6% (8/28) of negative appendicectomies. Faecolith prevalence for positive cases was 29.9% (79/264) in paediatric patients and 13.7% (99/722) in adults (p<0.05). Faecolith prevalence was 39.4% in perforated appendicitis but only 14.6% in non-perforated appendicitis (p<0.05). In adults, faecolith prevalence was 27.5% in perforated appendicitis and 12.0% in non-perforated appendicitis (p<0.05) while in paediatric patients, it was 56.1% in perforated appendicitis and 22.7% in non-perforated appendicitis (p=0.00). Sensitivity and PPV of preoperative CT in identifying faecoliths on pathology were 53.1% (86/162) and 44.8% (86/192) respectively. Conclusions Faecolith prevalence is too low to consider the faecolith the most common cause of non-perforated appendicitis. Faecoliths are more prevalent in paediatric appendicitis than in adult appendicitis. Preoperative CT is an unreliable predictor of faecoliths in pathology specimens. PMID:23317728
Ayoub, Barrak Hani; Al Omran, Yasser; Hassan, Aziz; Al Hindi, Saeed
The clinical presentation of cute appendicitis is rarely encountered in neonatology. When it does occur, it is thought to be due to prematurity or develops secondary to coexisting diseases. We present a case of appendicitis in a 10-day-old Middle-Eastern girl, who was born at term and who had no underlying conditions that are typically associated with neonatal appendicitis. This case highlights that certain causes and clinical signs are unreliable when coming to a working diagnosis of neonatal appendicitis, and that regardless of the cause, timely detection and management are necessary in achieving surgical success. 2014 BMJ Publishing Group Ltd.
Ayoub, Barrak Hani; Al Omran, Yasser; Hassan, Aziz; Al Hindi, Saeed
The clinical presentation of cute appendicitis is rarely encountered in neonatology. When it does occur, it is thought to be due to prematurity or develops secondary to coexisting diseases. We present a case of appendicitis in a 10-day-old Middle-Eastern girl, who was born at term and who had no underlying conditions that are typically associated with neonatal appendicitis. This case highlights that certain causes and clinical signs are unreliable when coming to a working diagnosis of neonatal appendicitis, and that regardless of the cause, timely detection and management are necessary in achieving surgical success. PMID:24855077
Gaetke-Udager, Kara; Maturen, Katherine E; Hammer, Suntrea G
While acute appendicitis is a common and important clinical problem, a variety of other disease processes can affect the appendix. Simple and perforated appendicitis, tip appendicitis, and stump appendicitis share a common clinical presentation including anorexia, right lower quadrant pain, and fever. By imaging, most cases of acute appendicitis exhibit luminal dilation, wall thickening, and periappendiceal inflammatory stranding. In tip appendicitis, these changes are isolated to the distal appendix, often with an obstructing appendicolith. Perforated appendicitis can exhibit mural discontinuity, periappendiceal abscess, and/or extraluminal appendicoliths. After appendectomy, the appendiceal remnant or "stump" can become inflamed, often necessitating repeat surgery. Inflammatory bowel disease can involve the terminal ileum, secondarily involving the appendix, or may primarily involve the appendix. Patient symptoms can be chronic in such cases, and mucosal hyperenhancement is a pronounced imaging feature. In asymptomatic patients without appendiceal inflammation, the appendix can be dilated by intraluminal material such as inspissated succus in cystic fibrosis or mucus from benign appendiceal mucocele. Finally, neoplasms such as typical appendiceal carcinoid tumor and mucinous adenocarcinoma can involve the appendix. Carcinoids are often small and incidentally discovered at pathologic examination, while malignant mucinous adenocarcinoma tends to present with advanced disease including pseudomyxoma peritonei. Cecal cancers can also obstruct the appendiceal lumen and cause acute appendicitis; an astute radiologist can recognize this prospectively and facilitate definitive resection (right hemicolectomy) at the time of surgery. Attention to mural features, cecal configuration, and periappendiceal inflammation is essential to the correct prospective diagnosis of complicated appendicitis and less common appendiceal pathologies.
Mountain, M. E.; Eluszkiewicz, J.; Nehrkorn, T.; Hegarty, J. D.; Aschbrenner, R.; Henderson, J.; Zaccheo, S.
Quantification of greenhouse gas fluxes at regional and local scales is required by the Kyoto protocol and potential follow-up agreements, and their accompanying implementation mechanisms (e.g., cap-and-trade schemes and treaty verification protocols). Dedicated satellite observations, such as those provided by the Greenhouse gases Observing Satellite (GOSAT), the upcoming Orbiting Carbon Observatory (OCO-2), and future active missions, particularly Active Sensing of CO2 Emissions over Nights, Days, and Seasons (ASCENDS) and Advanced Space Carbon and Climate Observation of Planet Earth (A-SCOPE), are poised to play a central role in this endeavor. In order to prepare for the ASCENDS mission, we are applying the Stochastic Time-Inverted Lagrangian Transport (STILT) model driven by meteorological fields from a customized version of the Weather Research and Forecasting (WRF) model to generate surface influence functions for ASCENDS observations. These "footprints" (or adjoint) express the sensitivity of observations to surface fluxes in the upwind source regions and thus enable the computation of a posteriori flux error reductions resulting from the inclusion of satellite observations (taking into account the vertical sensitivity and error characteristics of the latter). The overarching objective of this project is the specification of the measurement requirements for the ASCENDS mission, with a focus on policy-relevant regional scales. Several features make WRF-STILT an attractive tool for regional analysis of satellite observations: 1) WRF meteorology is available at higher resolution than for global models and is thus more realistic, 2) The Lagrangian approach minimizes numerical diffusion present in Eulerian models, 3) The WRF-STILT coupling has been specifically designed to achieve good mass conservation characteristics, and 4) The receptor-oriented approach offers a relatively straightforward way to compute the adjoint of the transport model. These aspects allow
Avanzini, Andrea; Battini, Davide
The biomechanical properties of ascending aortic aneurysms were investigated only in the last decade in a limited number of studies. Indeed, in recent years, there has been a growing interest in this field in order to identify new predictive parameters of risk of dissection, which may have clinical relevance. The researches performed so far have been conducted according to the methods used in the study of abdominal aortic aneurysms. In most cases, uniaxial or biaxial tensile tests were used, while in a smaller number of studies other methods, such as opening angle, bulge inflation, and inflation-extension tests, were used. However, parameters and protocols of these tests are at present very heterogeneous in the studies reported in the literature, and, therefore, the results are not comparable and are sometimes conflicting. The purpose of this review then thence to provide a comprehensive analysis of the experimental methodology for determination of biomechanical properties in the specific field of aneurysms of the ascending aorta to allow for better comparison and understanding of the results. PMID:24991568
Scott, A J; Mason, S E; Arunakirinathan, M; Reissis, Y; Kinross, J M; Smith, J J
Current management of suspected appendicitis is hampered by the overadmission of patients with non-specific abdominal pain and a significant negative exploration rate. The potential benefits of risk stratification by the Appendicitis Inflammatory Response (AIR) score to guide clinical decision-making were assessed. During this 50-week prospective observational study at one institution, the AIR score was calculated for all patients admitted with suspected appendicitis. Appendicitis was diagnosed by histological examination, and patients were classified as having non-appendicitis pain if histological findings were negative or surgery was not performed. The diagnostic performance of the AIR score and the potential for risk stratification to reduce admissions, optimize imaging and prevent unnecessary explorations were quantified. A total of 464 patients were included, of whom 210 (63·3 per cent) with non-appendicitis pain were correctly classified as low risk. However, 13 low-risk patients had appendicitis. Low-risk patients accounted for 48·1 per cent of admissions (223 of 464), 57 per cent of negative explorations (48 of 84) and 50·7 per cent of imaging requests (149 of 294). An AIR score of 5 or more (intermediate and high risk) had high sensitivity for all severities of appendicitis (90 per cent) and also for advanced appendicitis (98 per cent). An AIR score of 9 or more (high risk) was very specific (97 per cent) for appendicitis, and the majority of patients with appendicitis in the high-risk group (21 of 30, 70 per cent) had perforation or gangrene. Ultrasound imaging could not exclude appendicitis in low-risk patients (negative likelihood ratio (LR) 1·0) but could rule-in the diagnosis in intermediate-risk patients (positive LR 10·2). CT could exclude appendicitis in low-risk patients (negative LR 0·0) and rule-in appendicitis in the intermediate group (positive LR 10·9). Risk stratification of patients with suspected appendicitis by the AIR score could
Vos, Cornelis G; Mollema, Robbert; Richir, Milan C
We present a case of a 78-year-old female patient with an uncommon presentation of acute appendicitis. She was found to have a perforated appendicitis which developed in a femoral hernia sack. An appendix present in a femoral hernia is called a De Garengeot Hernia, which is a rare form of femoral hernia. Clinical presentation, diagnosis and management are discussed.
See, T C; Watson, C J E; Arends, M J; Ng, C S
Acute appendicitis is a diagnosis that can be made on clinical symptoms and signs but can often be extremely challenging. Difficulties arise particularly when the presentation is atypical, and this can lead to untoward sequelae. In this review, we present the range of presentations of atypical appendicitis, the variety of management options and the potential value of CT.
Castro, Ricardo; Fernandes, Teresa; Oliveira, Maria I; Castro, Miguel
Pylephlebitis is defined as septic thrombophlebitis of the portal vein. It is a rare but serious complication of an intraabdominal infection, more commonly diverticulitis and appendicitis. It has an unspecific clinical presentation and the diagnosis is difficult. The authors report a case of a 21-year-old man with acute appendicitis complicated by pylephlebitis. The diagnosis was made with contrast enhanced CT.
Rodriguez, Eduardo A.; Lopez, Marvin A.; Valluri, Kartik; Wang, Danlu; Fischer, Andrew; Perdomo, Tatiana
Patient: Female, 43 Final Diagnosis: Myeloid sarcoma appendicitis Symptoms: Abdominal pain • chills • fever Medication: — Clinical Procedure: Laparoscopic appendectomy, bone marrow biopsy Specialty: Gastroenterology and Hepatology Objective: Rare disease Background: The gastrointestinal tract is a rare site for extramedullary involvement in acute promyelocytic leukemia (APL). Case Report: A 43-year-old female with no past medical history presented complaining of mild abdominal pain, fever, and chills for the past day. On examination, she was tachycardic and febrile, with mild tenderness of her right lower quadrant and without signs of peritoneal irritation. Laboratory examination revealed pancytopenia and DIC, with a fibrinogen level of 290 mg/dL. CT of the abdomen showed a thickened and hyperemic appendix without perforation or abscess, compatible with acute appendicitis. The patient was given IV broad-spectrum antibiotics and was transfused with packed red blood cells and platelets. She underwent uncomplicated laparoscopic appendectomy and bone marrow biopsy, which revealed neo-plastic cells of 90% of the total bone marrow cellularity. Flow cytometry indicated presence of 92.4% of immature myeloid cells with t (15: 17) and q (22: 12) mutations, and FISH analysis for PML-RARA demonstrated a long-form fusion transcript, positive for APL. Appendix pathology described leukemic infiltration with co-expression of myeloperoxidase and CD68, consistent with myeloid sarcoma of the appendix. The patient completed a course of daunorubicin, cytarabine, and all trans-retinoic acid. Repeat bone marrow biopsy demonstrated complete remission. She will follow up with her primary care physician and hematologist/oncologist. Conclusions: Myeloid sarcoma of the appendix in the setting of APL is very rare and it might play a role in the development of acute appendicitis. Urgent management, including bone marrow biopsy for definitive diagnosis and urgent surgical intervention
Krska, Z; Sváb, J
Analysis of the literary findings and the clinical experiences of chronic appendicitis (CA) is presented. Analysis of the literary findings and study of our group of patients who were operated between years 2002 and 2004 is presented. The cohort includes 146 patients; 81% women, 19% men, aged between 14 to 72 years, average age 34 years, average age of men 46 years, women 29 years. The trend in the number of surgeries is decreasing in about 10% per year. Surgery findings: men--90% adhesions, atypical positions, findings of coprolites. Women--only 40% had macroscopical "findings". Medical history in the obscure cases (evaluable only in 50%), long-term hormonal contraception in 20%, 1-2 months after setting of hormonal contraception in 30%, intrauterine corpuscle in 10%, total negative in 40%. Effects of surgery in the group obscure surgery findings were practically always incomplete. Basic controversy in the diagnostic, in the range and in the appropriate time of surgical intervention is discussed. Surgeon also participates in the diagnostics, because the diagnosis of chronic appendicitis can come from some other medical specialists and the accuracy of indications can vary. Another aspect of the role of surgeon is the high evidence of laparoscopic methods for the diagnosis. Our results correspond with the literary sources. Chronic inflammation changes in the wall of the appendix bring about structural changes in the abdominal cavity. Clinical correlate exists only in the relation to the serious changes resulting from the inflammation of appendix for example: fixations, adhesions. That is why the chronic appendicitis as a clinical entity markedly receded. Problem is the restricted possibility, the range and level of investigation of right iliac region. From this point of view the rationality and professional opinion are essential in the indication to surgery.
Oumeiri, Bachar El; Eynden, Frédéric Vanden; Stefanidis, Constantin; Antoine, Martine; Nooten, Guido Van
We describe a patient with ascending aorta aneurysm and bovine aortic arch who initially presented with fever. A 65-year-old man with a 2-month history of intermittent fever was referred to our hospital and diagnosed as having a gonococcal ascending aorta aneurysm with penetrating ulcers. He was successfully treated by resection of the ascending aorta and ulcers, replacement of the aortic valve, and prolonged postoperative antibiotic therapy.
Woo, J Susie; Rabkin, David G; Mokadam, Nahush A; Rendi, Mara H; Aldea, Gabriel S
Neisseria gonorrhoeae is an uncommon pathogen causing bacterial aortitis. We describe a patient with a bicuspid aortic valve and known ascending aortic aneurysm who presented with fever and chest pain. Imaging demonstrated complex penetrating ulcers in the proximal ascending aorta. The patient underwent a modified Bentall procedure, resection of the ulcers, and ascending aortic reconstruction. Pathologic examination and culture of the aortic specimens revealed the infectious cause.
Roberts, J P
A quantitative bacteriological study of the appendix wall of 43 children admitted to this unit showed no significant differences between the flora of the histologically normal and acutely inflamed appendices. Bacteroides species, Escherichia coli, and streptococcal species were the commonest organisms isolated and were found in counts of 10(3) to 10(8) organisms per gram of tissue. Bacteroides species were most commonly the dominant flora in both normal and inflamed appendices. The lack of increased counts of organisms in acute inflammation of the appendix suggests an unfavourable environment to bacterial proliferation making primary bacterial infection an unlikely aetiological factor in the pathogenesis of appendicitis. PMID:3389871
Thongprayoon, C; Pasa-Arj, S
A 34-year-old woman, gravida 6 with 10 weeks of gestation was admitted because of abdominal pain and fainting. On physical examination she had hypotension, was pale with abdominal tenderness and guarding. Culdocentesis yielded unclotted blood. Immediate laparotomy was performed, because a diagnosis of ectopic pregnancy was made. About 2,500 ml of fresh blood was found in the abdominal cavity. Appendicular artery tear caused active arterial bleeding. The torn appendicular artery was observed to be the consequence of perforated appendicitis, which, in turn, was caused by a faecalith. Appendectomy was performed and she made a good recovery.
Sandell, Eva; Berg, Maria; Sandblom, Gabriel; Sundman, Joar; Fränneby, Ulf; Boström, Lennart; Andrén-Sandberg, Åke
Acute appendicitis is one of the most common acute abdominal conditions. Among other parameters, the decision to perform surgical exploration in suspected appendicitis involves diagnostic accuracy, patient age and co-morbidity, patient's own wishes, the surgeon's core medical values, expected natural course of non-operative treatment and priority considerations regarding the use of limited resources. Do objective clinical findings, such as radiology and laboratory results, have greater impact on decision-making than "soft" clinical variables? In this study we investigate the parameters that surgeons consider significant in decision-making in cases of suspected appendicitis; specifically we describe the process leading to surgical intervention in real settings. The purpose of the study was to explore the process behind the decision to undertake surgery on a patient with suspected appendicitis as a model for decision-making in surgery. All appendectomy procedures (n = 201) at the Department of Surgery at Karolinska University Hospital performed in 2009 were retrospectively evaluated. Every two consecutive patients seeking for abdominal pain after each case undergoing surgery were included as controls. Signs and symptoms documented in the medical records were registered according to a standardized protocol. The outcome of this retrospective review formed the basis of a prospective registration of patients undergoing appendectomy. During a three- month period in 2011, the surgeons who made the decision to perform acute appendectomy on 117 consecutive appendectomized patients at the Karolinska University Hospital, Huddinge, and Södersjukhuset, were asked to answer a questionnaire about symptoms, signs and diagnostic measures considered in their treatment decision. They were also asked which three symptoms, signs and diagnostic measures had the greatest impact on their decision to perform appendectomy. In the retrospective review, tenderness in the right fossa had the
DeLaney, A R; Raviola, C A; Weber, P N; McDonald, P T; Navarro, D A; Jasko, I
A prospective nonrandomized study investigating the accuracy and utility of autologous leukocyte scanning in the diagnosis of apendicitis was performed. One hundred patients in whom the clinical diagnosis of appendicitis was uncertain underwent indium 111 oxyquinoline labelling of autologous leukocytes and underwent scanning 2 hours following reinjection. Of 32 patients with proved appendicitis, three scans revealed normal results (false-negative rate, 0.09). Of 68 patients without appendicitis, three scans had positive results (false-positive rate, 0.03; sensitivity, 0.91; specificity, 0.97; predictive value of positive scan, 0.94; predictive value of negative scan, 0.96; and overall accuracy, 0.95). Scan results altered clinical decisions in 19 patients. In 13 cases, the scan produced images consistent with diagnoses other than appendicitis, expediting appropriate management. Early-imaging111 In oxyquinoline autologous leukocyte scanning is a practical and highly accurate adjunct for diagnosing appendicitis.
Dey, Subhajeet; Mohanta, Pradip K; Baruah, Anil K; Kharga, Bikram; Bhutia, Kincho L; Singh, Varun K
Acute appendicitis is a clinical diagnosis, so it's impossible to have a definitive diagnosis by gold standard (histopathology) pre operatively. The treatment being surgical, negative appendicectomy rates are high. Present study was conducted to evaluate Alvarado scoring system for diagnosis of acute appendicitis and its co relation by histopathology. Retrospective study of consecutive patients admitted with suspected acute appendicitis during the period March 2005 to March 2007. The Alvarado scoring system was computed from admission notes and records and correlated with the histopathology reports. Out of 155 patients, 92 underwent appendicectomy with the intention to treat appendicitis and diagnosis was confirmed in 80 patients. Reliability of scoring system was assessed by calculating negative appendicectomy rate and positive predictive value. The normal appendicectomy frequency was 13% and positive predictive value was 86%. Alvarado scoring system is easy, simple, cheap, useful tool in pre operative diagnosis of acute appendicitis and can work effectively in routine practice.
Tandberg-Hanssen, E.; Hansen, R. T.; Riddle, A. C.
Cinematographic observations of solar prominences made at Mauna Loa, Hawaii, during the past few years suggest that there is a well-defined subclass of ascending prominences characterized by closed-system transference of chromospheric material along an arch or loop (up one leg and down the other). While this occurs, the entire prominence envelope steadily rises upward and expands through the corona. These prominences are denoted as 'fountains'. Several examples are described. Fountains appear to be well contained by coronal magnetic fields. Their total kinetic energy is of the order of 10 to the 30th power erg, but dissipation is typically quite slow (over time periods of 100 min or so), so that the correlative disturbances (radio bursts, coronal transients, chromospheric brightenings) are generally not spectacular or nonexistent.
Mathews, Eleanor K.; Griffin, Russell L.; Mortellaro, Vincent; Beierle, Elizabeth A.; Harmon, Carroll M.; Chen, Mike K.; Russell, Robert T.
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
Clement, Fiona; Zimmer, Scott; Dixon, Elijah; Ball, Chad G.; Heitman, Steven J.; Swain, Mark; Ghosh, Subrata
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
Levens, Afra M A; Schurink, Maarten; Koetse, Harma A; van Baren, Robertine
Gastrointestinal infestation with the parasite Enterobius vermicularis is common in humans and is usually harmless. Anal pruritus is the most characteristic symptom, but the parasites can cause severe abdominal pain mimicking appendicitis. Early recognition can prevent an unnecessary appendectomy. A six-year-old girl reported to the accident and emergency department with pain in the lower right abdominal region. She was admitted and treated for suspected perforated appendix, following physical examination supplemented with an abdominal CT scan. After antibiotic treatment the symptoms disappeared as did the abscess, apart from a minor amount of residual infiltrate. She was then readmitted twice with recurrent abdominal pain without radiological evidence of an abdominal focus. We decided to conduct a diagnostic laparoscopy and an elective appendectomy à froid. During this procedure living worms were found in the appendix. Treatment with the anthelminthicum mebendazol was effective. Gastro-intestinal infestation with E. vermicularis is very common, especially in young children. This infestation is usually harmless, but can mimic appendicitis. This infestation is easily treatable with mebendazol.
Nägeli, J; Zünd, M; Lange, J
Since introduction of laparoscopic appendectomy we have the possibility to examine the whole abdominal cavity and not only the ileocaecal region and right adnex. The aim of the study is to find out if there is an advantage in laparoscopic diagnostics compared to conventional laparotomy for suspected acute appendicities. We compared prospectively all patients who underwent laparoscopy for acute right lower abdominal pain between August 1991 and March 1993 with a comparable group retrospectively analyzed who underwent conventional appendectomy in 1989. In both groups 20% of patients had a normal appendix. In 1% of the laparoscopically operated patients we couldn't find any pathological findings, in 12% of the conventionally operated group we couldn't find an accurate diagnosis. The average operation time of laparoscopically operated patients without acute appendicities was 20 minutes shorter compared to conventionally operated patients. We found identically results for the duration of hospital stay. The median hospital stay for conventionally operated patients was 6.6 days, for laparoscopically operated patients 4.7 days. The complications were in both groups 1-2%. We conclude that in laparoscopy the diagnostics are more reliable, and with a diagnostic accuracy of almost 100% the unnecessary appendectomy with a higher morbidity would not be necessary in 12% of patients.
Macco, Sven; Vrouenraets, Bart C; de Castro, Steve M M
Acute appendicitis can be difficult to diagnose, especially in children. Appendicitis scoring systems have been developed as a diagnostic tool to improve the decision-making process in patients with suspected acute appendicitis. This study evaluates the Appendicitis Inflammatory Response score, Alvarado score, and Pediatric Appendicitis Score in children suspected of acute appendicitis. Data were collected retrospectively. All children younger than 18 years suspected of acute appendicitis who presented to the emergency department between January 2006 and June 2014 were included in this study. Variables were registered to evaluate 3 different appendicitis scoring systems. The diagnostic performance of the 3 scores was analyzed using the area under the receiver-operating curve and by calculating the diagnostic performances at different cut-off points. The present study included 747 consecutive children. There were 399 boys (53%) and 348 girls (47%) with a mean age of 11 years (range, 1-17 years). In total, 269 children (36%) were diagnosed with acute appendicitis. The area under the receiver-operating curve of the Appendicitis Inflammatory Response score was 0.90, the Alvarado score was 0.87, and the Pediatric Appendicitis Score was 0.82 (P < .05, respectively). The specificity and positive predictive value of the Appendicitis Inflammatory Response score were better at predicting an acute appendicitis than that of the Alvarado score and Pediatric Appendicitis Score. In children with a low-risk acute appendicitis, false negative rates of 14% for the Appendicitis Inflammatory Response, 7% for the Alvarado, and 18% for the Pediatric Appendicitis Score were measured. In this study, the Appendicitis Inflammatory Response score had the highest discriminating power and outperformed the Alvarado score and Pediatric Appendicitis Score in predicting acute appendicitis in children. Excluding acute appendicitis safely in children with the scoring systems still remains
Li, Yingchao; Mi, Chen; Li, Weizhi; She, Junjun
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.
Sgourakis, George; Sotiropoulos, Georgios C; Molmenti, Ernesto P; Eibl, Charis; Bonticous, Stylianous; Moege, Jurgen; Berchtold, Christoph
To examine the role of coprostasis and coproliths in recurrent appendicitis. We evaluated four hundred and twenty seven consecutive pathology reports of all appendectomy specimens from January 2003 to December 2004. Findings were categorised as showing acute appendicitis, acute recurrent appendicitis, subacute recurrent appendicitis, chronic appendicitis, or appendices without inflammation. All patients had presented with acute right lower quadrant pain. In 94 instances, there was a history of recurrent similar episodes in the past. Of the 427 histology reports, 294 were inter-preted as showing acute appendicitis, 56 acute recurrent appendicitis, 34 subacute recurrent appen-dicitis, 28 chronic appendicitis, and 15 non-inflamed appendices. Coprostasis was observed in 58 patients (13.58%) and the presence of coprolith in 6 (1.4%). Coprostasis, and age, were among the predictors in the final model. Coprostasis but not coproliths seems to be a contributing factor to acute exacerbations of chronic inflammatory appendicitis.
Ceresa, F; Sansone, F; Zagarella, G; Patanè, F
Giant ascending aorta aneurysms (AAA), which are larger than 10 cm, are rarely been reported (1-7). We hereby present the case of a giant AAA of about 11 cm in a very old women who was successfully operated on for ascending aorta and aortic arch replacement under deep hypothermic circulatory arrest.
Barik, Ramachandra; Patnaik, Amar Narayana; Kumar, Ravintula Venkata; Mohapatra, Rudra Prasad; Medep, Vikas; Nemani, Lalita
Pseudoaneurysm of ascending aorta after cardiac surgery is rare in children. We report a case of successful surgical exclusion of ascending aortic pseudoaneurysm in a 15-year-old boy. The neck of the aneurysm was in close proximity to the right coronary artery (RCA). PMID:24987261
Burcu, Busra; Ekinci, Ozgur; Atak, Tuba; Orhun, Kivilcim; Eren, Turgut Tunc; Alimoglu, Orhan
OBJECTIVE: Acute appendicitis is one of the most common acute surgical pathology we encountered. In this study we investigated our pregnant cases of appendicitis, and reviewed literature. METHODS: A total of 21 pregnant women who underwent appendectomy with the initial diagnosis of acute appendicitis in Istanbul Medeniyet University Clinics of General Surgery between January 2012, and December 2014 were retrospectively analyzed. The patients’s ages, trimesters, complaints, abdominal examination, laboratory, and ultrasonographic findings, surgical techniques, complications and hospital stay were noted. RESULTS: The patients were in their first (n=12; 57.1%), second (n=5; 23.8%), and third trimesters (n=4; 19.0%) of their pregnancies Median age was 23.9 years. All of the patients had abdominal pain. Median value of WBC count was 13.297/mm³. Ultrasound was positive in 12 patients (57.1%). In 14 (66.6%) patients McBurney incision, and in 6 (28.6%) cases right paramedian incision were used. One patient (4.8%) underwent laparoscopic appendectomy. Nineteen cases were acute appendicitis (90.5%), and two cases were perforated appendicitis (9.5%). Average hospital stay was 3.8 days. Two cases with perforated acute appendicitis developed wound infection and treated conservatively. There were no fetomaternal mortality. CONCLUSION: Physiologically anatomic and biochemical changes occurring during pregnancy can delay the diagnosis of acute appendicitis threaten the lives of both the mother and the fetus Therefore, rapid diagnosis and appropriate treatment convey importance. PMID:28058387
Burcu, Busra; Ekinci, Ozgur; Atak, Tuba; Orhun, Kivilcim; Eren, Turgut Tunc; Alimoglu, Orhan
Acute appendicitis is one of the most common acute surgical pathology we encountered. In this study we investigated our pregnant cases of appendicitis, and reviewed literature. A total of 21 pregnant women who underwent appendectomy with the initial diagnosis of acute appendicitis in Istanbul Medeniyet University Clinics of General Surgery between January 2012, and December 2014 were retrospectively analyzed. The patients's ages, trimesters, complaints, abdominal examination, laboratory, and ultrasonographic findings, surgical techniques, complications and hospital stay were noted. The patients were in their first (n=12; 57.1%), second (n=5; 23.8%), and third trimesters (n=4; 19.0%) of their pregnancies Median age was 23.9 years. All of the patients had abdominal pain. Median value of WBC count was 13.297/mm³. Ultrasound was positive in 12 patients (57.1%). In 14 (66.6%) patients McBurney incision, and in 6 (28.6%) cases right paramedian incision were used. One patient (4.8%) underwent laparoscopic appendectomy. Nineteen cases were acute appendicitis (90.5%), and two cases were perforated appendicitis (9.5%). Average hospital stay was 3.8 days. Two cases with perforated acute appendicitis developed wound infection and treated conservatively. There were no fetomaternal mortality. Physiologically anatomic and biochemical changes occurring during pregnancy can delay the diagnosis of acute appendicitis threaten the lives of both the mother and the fetus Therefore, rapid diagnosis and appropriate treatment convey importance.
Malik, Ajaz Ahmad; Wani, Mohd Lateef; Wani, Shadab Nabi; Parray, Fazl Qadir; Nayeem-Ul-Hassan; Irshad, Ifat
Background: Interval appendectomy after acute appendicitis with lump formation (phlegmon) remains controversial. We conducted this study to determine the risk of recurrent appendicitis following initial non-operative treatment for appendicitis, and evaluate factors associated with recurrence. Secondarily, we evaluate the efficacy of interval appendectomy versus no appendectomy. Materials and Methods: Patients who received conservative treatment for appendicitis with lump formation were prospectively studied from June 2006 to June 2008. These patients were followed for recurrence of appendicitis. Results: Of 763 patients with acute appendicitis some 220 patients had lump formation (28.8%). Median age was 28 years. Conservative treatment was successful in 213 (96.8%) patients. The rate of recurrence was 13.1%, all occurring within six months after the index admission. Mean follow-up was 26±18 months. Conclusion: Conservative treatment of appendicitis with lump formation is efficient and the recurrence rate is low. Routine interval appendectomy after initial conservative treatment for lump formation is not a cost-effective intervention and not recommended. PMID:22416152
Hansen, Laura W; Dolgin, Stephen E
• On the basis of class B evidence and consensus, acute appendicitis in children can often be diagnosed clinically with only selective use of imaging. (13)(14)(15)(16) • On the basis of class B evidence and consensus, ultrasonography is the test of choice when acute appendicitis is suspected but is unclear based on history, physical examination, and laboratory results. (17)(18)(19) • On the basis of class B evidence and consensus, the use of computed tomography scan should be limited to cases of suspected complex appendicitis with abscess or when there is clinical suspicion for acute appendicitis but ultrasonography results are not helpful. (16) • On the basis of class C evidence and consensus, children with possible appendicitis ideally should be treated in medical centers that have skilled sonographic personnel. (21) • On the basis of class B evidence and consensus, simple appendicitis should be treated by appendectomy during normal operating hours. Preoperative treatment with intravenous antibiotics and fluids during the overnight hours halts disease progression and allows for the safest surgery with the benefit of a full and rested staff. (24)(25)(26) • On the basis of class B evidence and consensus, complex appendicitis with a well-defined abscess can be treated nonoperatively initially, with the option of an interval appendectomy after recovery from the acute infection. (29)(30) (31)(32)(33)
Rao, P M; Wittenberg, J; McDowell, R K; Rhea, J T; Novelline, R A
To determine the frequency of collection of a contrast medium in the upper portion of the cecum, which the authors call the arrowhead sign, on computed tomographic (CT) scans of the lower abdomen and to assess the sensitivity and specificity of this sign for appendicitis. One hundred consecutive patients clinically suspected of having appendicitis prospectively underwent helical CT limited to the lower abdomen. Contrast media were administered orally and by means of an enema. Each scan was reviewed for the arrowhead sign, and the findings were correlated with surgical and pathologic results or clinical follow-up findings. The arrowhead sign was present in 17 of 56 cases (30%) of appendicitis and in no case of excluded appendicitis. It allowed the unequivocal diagnosis of appendicitis in four cases (7%) of otherwise non-specific right lower-quadrant inflammation and in one case (2%) of subtle appendicitis seen at CT. The arrowhead sign is an often present, highly specific sign of appendicitis that can add specificity to the diagnosis of right lower-quadrant inflammatory processes at CT.
Pirhan, Yavuz; Özen, Fatma Zeynep; Kılınç, Çetin; Güçkan, Rıdvan
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.
Engin, O; Calik, S; Calik, B; Yildirim, M; Coskun, G
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
Emil, Sherif G S; Taylor, Michael B
Pediatric appendicitis is treated by both pediatric and general surgeons. We investigated whether specialty-dependent differences existed in patients' characteristics and outcomes. A retrospective chart review of 465 consecutive children treated for appendicitis at a university-affiliated children's hospital during a 28-month period was performed. Characteristics and outcomes of patients treated by pediatric surgeons were compared with those treated by general surgeons. Rates of misdiagnosis, postoperative readmission, wound infection, intraabdominal infection, and duration of hospital stay were considered primary outcomes and analyzed by chi-square, Fisher's exact test, or Student's t-test where appropriate. Hospital charges were considered secondary outcomes and analyzed by Wilcoxon rank sum test. Three hundred four children (65%) were treated by pediatric surgeons and 161 (35%) by general surgeons. Pediatric-surgeon patients were younger (8.3 +/- 3.6 versus 13.2 +/- 3.1 years, p < 0.001), and more likely to have gangrenous or perforated appendicitis (54% versus 33%, p < 0.001). There was no significant difference in the normal appendix rate (pediatric surgeon, 4.3% versus general surgeon, 5.6%, p = 0.53). In patients with simple and complicated appendicitis, there were no significant differences between pediatric and general surgeons in readmissions, postoperative complications, or hospital stay. Median hospital charges were not significantly different for complicated appendicitis, but were lower for pediatric-surgeon patients with simple appendicitis (10,735 dollars versus 11,613 dollars, p = 0.005). Pediatric surgeons treat younger children with more severe appendicitis. There are no specialty-dependent differences in clinical outcomes for simple or complicated appendicitis. Hospital charges are lower for simple appendicitis treated by pediatric surgeons.
Checkoff, Jaime L; Wechsler, Richard J; Nazarian, Levon N
Acute appendicitis is commonly diagnosed on CT, but chronic appendiceal processes can mimic acute appendicitis. The purpose of this study was to identify the frequency of these alternative conditions and their findings on helical CT. Chronic inflammatory conditions other than acute appendicitis were found in 9% of patients who underwent surgery after CT findings were interpreted as suspicious for appendicitis. These inflammatory conditions were indistinguishable from acute appendicitis when we used either primary or secondary CT signs.
Lam, Michael; Singh, Ajay; Kaewlai, Rathachai; Novelline, Robert A
Acute appendicitis is the most common surgical abdominal emergency. Although the clinical diagnosis can be made accurately in typical cases, imaging plays an important role in improving diagnostic accuracy of this condition, especially when the clinical diagnosis is uncertain. Magnetic resonance imaging is an emerging promising technique for the diagnosis of acute appendicitis, especially in patients with nondiagnostic ultrasound and in patients where radiation is a clinical concern. In the following review, the role of magnetic resonance in the diagnosis of appendicitis will be discussed.
Chuang, Tsung-Ju; Chen, Chun-Wen; Lin, Hsin-Yuan; Hsu, Wen-Hsiu; Wang, Shou-Cheng; Tu, Chuan-Chou
Appendicitis is the most common abdominal disease that requires surgery in the emergency ward. It usually presents as right lower quadrant pain, but may rarely present as left upper quadrant (LUQ) pain due to congenital anatomical abnormalities of the intestine. We report a patient who complained of persistent LUQ abdominal pain and was finally diagnosed by computed tomography (CT) as congenital intestinal malrotation complicated with acute appendicitis. It is important to include acute appendicitis in the differential diagnosis of patients who complain of LUQ abdominal pain. Abdominal CT can provide significant information that is useful in preoperative diagnosis and determination of proper treatment. PMID:24348602
Aydin, O U; Soylu, L; Dandin, O; Uysal Aydin, E; Karademir, S
The purpose of the study was that monitoring, which is used in diagnosis of acute appendicitis, and laboratory values, were evaluated for verifying diagnosis of complicated appendicitis and these parameters revealed cut-off values in complicated acute/non-complicated appendicitis. 195 patients, who had had an operation for acute appendicitis between January 2012 and March 2015 and who were proved to have acute complicated/non-complicated appendicitis from the results of histopathology consideration, were included in this study. Patients' age, preoperative serum, WBC, CRP, NLR and BT with USG results were evaluated. RESULTS: Among the groups, there were no meaningful differences in the sense of age. Meaningful difference was obtained in between (p > 0.05), WBC, NLR, CRP and appendix diameter values.Serum in WBC >13800 (AUC = 0.614, p = 0.006, %95 GA: 0.541-0.682), in NLR > 4.87 (AUC = 0.641, p = 0.001, %95 GA: 0.569-0.708), in CRP > 5.98 (AUC = 0.651, p 11 mm (AUC = 0.630, p = 0.002, %95 GA: 0.558-0.698) values were obtained. The values that were obtained, were confirmed to be descriptive in analysis of complicated appendicitis and non-complicated appendicitis.According to the obtained cut-off values, serum WBC, diameter of appendicitis, NLR and CRP values', (OR) ratios were calculated for complicated appendicitis by being classified (odds ratio respectively; 3.103 (1.713-5.621), 2.765 (1.496-5.109), 3.025 (1.665-5.494), 2.313 (1.295-4.130)). It is important that treatment options are evaluated to be able to discriminate complicated appendicitis fast and with a high accuracy. In the case that serum WBC is higher than 13800. CRP is higher than 5.98, NLR is higher than 4.87 and appendicitis diameter is longer than 11mm, inflammation of appendicitis is complex with gangrene, perforation and abscess and it emphasizes the suggestion of surgical treatment option to patients (Tab. 4, Fig. 1, Ref. 28).
Limberg, Jessica; Ginsburg, Howard; Lala, Shailee; Tomita, Sandra
The effect of perforated appendicitis on the adnexa is an issue of concern and controversy. Long-term fertility studies have been conflicting. We present the case of a patient with chronic pelvic infections, salpingitis, and hydrosalpinx after perforated appendicitis. Magnetic resonance imaging was helpful in diagnosing a chronically obstructed fallopian tube, likely secondary to the dense adhesions from her previously treated perforated appendicitis. Salpingectomy relieved her symptoms of chronic pain and recurrent infections. Copyright © 2015 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.
Glass, Charity C; Rangel, Shawn J
Appendicitis represents the most common abdominal surgical emergency in the pediatric age group. Despite being a relatively common condition, the diagnosis of appendicitis in children can prove to be challenging in many cases. The goal of this article is to review the predictive utility for presenting signs and symptoms, laboratory tests, and imaging studies in the diagnostic work-up of appendicitis. Furthermore, we sought to explore the predictive utility of composite measures based on multiple sources of diagnostic information, as well as the utility of clinical pathways as a means to streamline the diagnostic process.
Kingston, R D; Shah, K J; Dawson-Edwards, P
Ascending uretero-pyelography has been carried out over a period of 13 years in 97 consecutive patients with undiagnosed renal failure. Sixty-nine were in a non-obstructive uropathy group while 26 had ureteric obstructions. There were two failures. Over 60% of examinations were performed under local anaesthesia, each examination taking an average of 20 min. There has been no mortality and two anaesthetic complications have been the only significant morbidity. Ureteric injury, urinary infection and renal function have all been investigated and recorded. Five per cent of patients developed urinary infection following AUP but without any major consequences. No significant ureteric injury occurred and no late sequelae were noted. Neither any reaction to contrast medium nor any further deterioration in renal function was observed; AUP was diagnostic in 46% of patients. In the remainder it ruled out obstructive uropathy and gave useful information about the kidneys, ureters and bladder. In experienced hands and with proper facilities AUP is safe and can be helpful in the diagnosis and management of patients in renal failure.
Quick, Lynnae C.; Marsh, Bruce D.
Jupiter's moon Europa has a relatively young surface (60-90 Myr on average), which may be due in part to cryovolcanic processes. Current models for both effusive and explosive cryovolcanism on Europa may be expanded and enhanced by linking the potential for cryovolcanism at the surface to subsurface cryomagmatism. The success of cryomagma transport through Europa's crust depends critically on the rate of ascent relative to the rate of solidification. The final transport distance of cryomagma is thus governed by initial melt volume, ascent rate, overall ascent distance, transport mechanism (i.e., diapirism, diking, or ascent in cylindrical conduits), and melt temperature and composition. The last two factors are especially critical in determining the budget of expendable energy before complete solidification. Here we use these factors as constraints to explore conditions under which cryomagma may arrive at Europa's surface to facilitate cryovolcanism. We find that 1-5 km radius warm ice diapirs ascending from the base of a 10 km thick stagnant lid can reach the shallow subsurface in a partially molten state. Cryomagma transport may be further facilitated if diapirs travel along pre-heated ascent paths. Under certain conditions, cryolava transported from 10 km depths in tabular dikes or pipe-like conduits may reach the surface at temperatures exceeding 250 K. Ascent rates for these geometries may be high enough that isothermal transport is approached. Cryomagmas containing significant amounts of low eutectic impurities can also be delivered to Europa's surface by propagating dikes or pipe-like conduits.
Callen, Andrew L; Illangasekare, Tushani; Poder, Liina
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.
Punguyire, Damien; Iserson, Victor Kenneth
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.
Hayashi, Yasunari; Ito, Toshiaki; Maekawa, Atsuo; Sawaki, Sadanari; Fujii, Genyo; Hoshino, Satoshi; Tokoro, Masayoshi; Yanagisawa, Junji
Replacement of the asceding aorta is indicated in patients undergoing aortic valve replacement( AVR), if the diameter of the ascending aorta is greater than 5.0 cm. If the diameter of the asceding aorta is from 4.0 to 5.0 cm, it was arguable whether replacement of the ascending aorta should be performed. Nine patients who underwent reoperative ascending aorta replacement after AVR were reviewed retrospectively. Reoperation on the asending aorta replacement was performed 11.8±7.2 years (range 1y5m~23y3m) after AVR. Mean patient age was 69.9±6.3 (range 60~81). In 2 cases, reoperations were performed early year after AVR. Although ascending aorta was dilated at the 1st operation, replacement wasn't performed for the age and minimally invasive cardiac surgery (MICS). In 3 cases, reoperations were performed more than 10 years later. On these cases, ascending aorta aneurysm and dissection occurred with no pain and were pointed out by computed tomography(CT) or ultrasonic cardiogram(UCG). We think that patients with dilatation of the ascending aorta should undergo AVR and aorta replacement at the 1st operation regardness of age. It is important that patients who underwent AVR should undergo a regular checkup on the ascending aorta.
Nakatani, Hajime; Hamada, Shinichi; Okanoue, Toyotake; Kawamura, Akihiro; Inoue, Yuichiro; Yamamoto, Shinya; Chikai, Takashi; Hiroi, Makoto; Hanazaki, Kazuhiro
Acute appendicitis often presents as right lower quadrant (RLQ) pain, severe tenderness at the point of McBurny or Lanz, and Blumberg's sign. Scrotal events with appendicitis are very rare. In our case, a 63-year-old Japanese man presented with severe RLQ pain and high fever. Physical examination revealed severe tenderness (including both points of McBurny and Lanz) and Blumberg's sign. The scrotum was slightly swollen and showed local heat with severe testicular pain. Abdominal computed tomography revealed ascites in a pelvic space and the right side of the spermatic cord was swollen. Emergency operation was performed and the final diagnosis was catarrhal appendicitis and acute epididymitis. This is the first report of acute appendicitis concomitant with acute epididymitis.
Malanga, Milo; Darcsi, Andras; Balint, Mihaly; Benkovics, Gabor; Sohajda, Tamas; Beni, Szabolcs
Xanthene dyes can be appended to cyclodextrins via an ester or amide bridge in order to switch the fluorescence on or off. This is made possible through the formation of nonfluorescent lactones or lactams as the fluorophore can reversibly cyclize. In this context we report a green approach for the synthesis of switchable xanthene-dye-appended cyclodextrins based on the coupling agent 4-(4,6-dimethoxy-1,3,5-triazin-2-yl)-4-methylmorpholinium chloride (DMT-MM). By using 6-monoamino-β-cyclodextrin and commercially available inexpensive dyes, we prepared rhodamine- and fluorescein-appended cyclodextrins. The compounds were characterized by NMR and IR spectroscopy and MS spectrometry, their UV-vis spectra were recorded at various pH, and their purity was determined by capillary electrophoresis. Two potential models for the supramolecular assembly of the xanthene-dye-appended cyclodextrins were developed based on the set of data collected by the extensive NMR characterization.
Cağlayan, Fatma; Cakmak, Murat; Cağlayan, Osman; Cavuşoglu, Turgut
We investigated the possible use of D-lactate as a predictor in the diagnosis of appendicitis. C-reactive protein level (CRP) and leukocyte counts were also evaluated. Venous blood D-lactate, CRP, and leukocyte counts were measured preoperatively in 53 patients undergoing surgery for appendicitis, as well as in 20 healthy subjects. Levels of all three parameters in the surgical patients were significantly higher than in the control group (p <.05). Previous studies have shown that venous D-lactate is more specific to the intestine than CPR or leukocyte count. Based on our data, venous D-lactate, which had the lowest false-negative rate among these laboratory parameters, may be a useful diagnostic marker for appendicitis. None of these parameters were helpful in identifying the type of the appendicitis.
Kobayashi, Taiichiro; Yano, Hideaki; Murata, Yukinori; Igari, Toru; Nakada-Tsukui, Kumiko; Yagita, Kenji; Nozaki, Tomoyoshi; Kaku, Mitsuo; Tsukada, Kunihisa; Gatanaga, Hiroyuki; Kikuchi, Yoshimi; Oka, Shinichi
ABSTRACT 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. PMID:27847377
Park, Geon; Lee, Sang Chul; Choi, Byung-Jo; Kim, Say-June
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
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
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.
Ruffolo, Cesare; Fiorot, Alain; Pagura, Giulia; Antoniutti, Michele; Massani, Marco; Caratozzolo, Ezio; Bonariol, Luca; Calia di Pinto, Francesco; Bassi, Nicolò
McBurney’s procedure represented the gold-standard for acute appendicitis until 1981, but nowadays the number of laparoscopic appendectomies has progressively increased since it has been demonstrated to be a safe procedure, with excellent cosmetic results and it also allows a shorter hospitalization, a quicker and less painful postoperative recovery. The aim of this editorial was to perform a review of the literature in order to address controversial issues in the treatment of acute appendicitis. PMID:24379603
Shaoul, Ron; Rimar, Yosi; Toubi, Aurora; Mogilner, Jorge; Polak, Reuven; Jaffe, Michael
The clinical diagnosis of classic Crohn's disease (CD) of the small bowel is based on a typical history, tender right lower quadrant fullness or mass, and characteristic radiographic findings of the terminal ileum. Appendicitis may as well present with chronic or recurrent symptoms and this presentation may be confused with CD. We herein describe the case of a young teenage girl with a presumptive diagnosis of CD, who was ultimately diagnosed as having chronic nongranulomatous appendicitis. The literature on the subject is reviewed.
Pilgrim, Ashley; Russo, Rachel; Moulin, Aimee
This case outlines the emergency department and surgical course of a 63-year-old male presenting with acute onset abdominal pain. Appendicitis was high on the differential for the treating physician, but after the computed tomography and laboratory evaluation were unremarkable, the patient was discharged only to return the next day. What ensued was one of the rarest cases of missed appendicitis documented in the medical literature. PMID:25493134
Rao, P M; Feltmate, C M; Rhea, J T; Schulick, A H; Novelline, R A
To determine the accuracy and effect of helical computed tomography (CT) in women clinically suspected of having either appendicitis or an acute gynecologic condition. One hundred consecutive nonpregnant women suspected of having appendicitis or an acute gynecologic condition prospectively had helical CT. Interpretations were correlated with surgical and pathologic findings (41 cases) and clinical follow-up for at least 2 months (59 cases). The accuracy for confirming or excluding both appendicitis and acute gynecologic conditions was determined. The effect on patient care was determined by comparing pre-CT plans with actual treatment. Thirty-two women had appendicitis, 15 had acute gynecologic conditions, 27 had other specific diagnoses, and 26 had nonspecific abdominal pain. For diagnosing appendicitis or acute gynecologic conditions, CT had 100% and 87% sensitivity, 97% and 100% specificity, 94% and 100% positive predictive value, 100% and 98% negative predictive value, and 98% and 98% accuracy, respectively. After CT was done, 36 planned hospital admissions, 25 planned hospital observations, and six planned appendectomies were deferred; six women had alternative surgical procedures on the basis of CT results. One patient had an unnecessary appendectomy on the basis of CT findings. Helical CT is an excellent imaging option for differentiating appendicitis from most acute gynecologic conditions.
Caruso, Anna Maria; Pane, Alessandro; Garau, Roberto; Atzori, Pietro; Podda, Marcello; Casuccio, Alessandra; Mascia, Luigi
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.
Coşkun, Kağan; Menteş, Oner; Atak, Ayşegül; Aral, Arzu; Eryılmaz, Mehmet; Onguru, Onder; Balkan, Müjdat; Kozak, Orhan; Cetiner, Sadettin
The diagnosis of acute appendicitis, even for experienced surgeons, can sometimes be complex. A delay in diagnosis increases the complication rate. This experimental study aimed to investigate the suitability and significance of neopterin as a marker for acute appendicitis. The levels of neopterin were measured using an acute appendicitis animal model in 35 New Zealand male rabbits. They were divided into 5 groups as Group 1= control; Group 2= sham; and Groups 3 (12-hour); 4 (24-hour); and 5 (48-hour) (based on the elapsed time period before their appendectomies). The neopterin levels of each group were measured by neopterin enzyme immunoassay kit in blood samples (taken before the appendectomies in Groups 3, 4 and 5). For the diagnosis of acute appendicitis, the optimal cut-off point was 34.475 nmol/L. The probability of acute appendicitis was found to be 4.667 times higher when the neopterin level was greater than 34.475 nmol/L. This study was an experimental animal study; however, it provides valuable clues useful in clinical assessment. Neopterin seems to have great potential as a new diagnostic marker for the diagnosis of acute appendicitis.
Kuga, T; Taniguchi, S; Inoue, T; Zempo, N; Esato, K
This study was conducted to determine the immunologic cellular composition in human appendicitis and its association with the development of perforated appendicitis. Appendiceal specimens from 27 patients with acute appendicitis were immunostained to detect lymphocyte surface markers. Moreover, the lymphocyte surface markers of peripheral blood were analyzed by laser flow cytometry in 12 patients. Helper T lymphocytes (CD4) were present in all the patients, while B lymphocytes (CD19), natural killer (NK) cells (CD56), and cytotoxic T lymphocytes (CD8) were present in 7 (70%), 10 (100%), and 9 patients (90%) with perforated appendicitis, and in 12 (63.2%), 10 (58.8%), and 6 (54.5%) patients without perforation, respectively. There were significant differences between the patients with a perforated appendix and those without perforation, in the positivity rate for CD8 and CD56 cells (P < 0.05). The number of cells positive for CD56, being NK cells, in the blood from the patients with perforation was significantly lower than that in the blood from those without perforation (P < 0.05). The infiltration of a greater number of cytotoxic T lymphocytes and NK cells was observed in the appendices from patients with perforated appendicitis than in those from patients with nonperforated appendicitis.
Albu, E; Miller, B M; Choi, Y; Lakhanpal, S; Murthy, R N; Gerst, P H
Serum C-reactive protein was measured in 56 patients hospitalized with a suspected diagnosis of acute appendicitis. Based on these determinations, four groups of patients were defined: Group A = 26 patients with acute appendicitis who had a C-reactive protein level higher than 2.5 mg/dl. Group B = 4 patients with a C-reactive protein level lower than 2.5 mg/dl who, after surgery based on a presumed diagnosis of acute appendicitis, were found to have a normal appendix. Group C = 22 patients with nonspecific abdominal pain, 18 (72 percent) of whom had an elevated C-reactive protein level, although in only 4 (7.1 percent) were these levels higher than 2.5 percent mg/dl. Group D = 4 patients who had diseases other than acute appendicitis. It is concluded that an increase in C-reactive protein levels to more than 2.5 mg/dl is not a definite indicator of acute appendicitis. However, if the C-reactive protein level in blood drawn 12 hours after the onset of symptoms is less than 2.5 mg/dl, acute appendicitis can be excluded.
Akkapulu, N; Abdullazade, S
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.
Radu, Narcis Costin; Gervais, Marianne; Michineau, Stéphanie; Blanc, Raphaël; Fifre, Alexandre; Kirsch, Ernst Wilhelm Matthias; Allaire, Eric
The singularity of the ascending aorta regarding mechanisms driving aneurysm formation requires the development of specific animal models. We investigated if adventitial elastase application results in ascending aorta aneurysms in rats. Adult Lewis rats (n = 26) were anesthetized, their ascending aortas measured by transthoracic ultrasound, and exposed via median sternotomy. Elastase or saline was applied on the ascending aortic adventitia. Ascending aorta diameters were monitored by ultrasound at 10 and 30 days, when the animals were killed. Wall area was measured on orcein stained sections. Matrix metalloproteinase-2 and matrix metalloproteinase-9 levels were quantified on gelatin zymography. Following elastase application, ascending aortic diameter increased at 10 and 30 days follow-up by 38% and 44%, respectively (P = .004). Despite thinning of the media secondary to vascular dilation, standardized medial area was not different between elastase-treated aortas and controls. Standardized total wall area had a significant increase in treated aortas compared with controls. Active matrix metalloproteinase-2 was significantly increased at 30 days in treated aortas, whereas active matrix metalloproteinase-9 was no different from controls. Elastase application on rat ascending aortic adventitia produced aneurysms, creating a reproducible model. Aortic wall remodeling evolved toward an increase in total wall area, reproducing the main structural features of this disease in human beings. Copyright © 2013 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.
Jansen, Peter L M; Ghallab, Ahmed; Vartak, Nachiket; Reif, Raymond; Schaap, Frank G; Hampe, Jochen; Hengstler, Jan G
In this review we develop the argument that cholestatic liver diseases, particularly primary biliary cholangitis and primary sclerosing cholangitis (PSC), evolve over time with anatomically an ascending course of the disease process. The first and early lesions are in "downstream" bile ducts. This eventually leads to cholestasis, and this causes bile salt (BS)-mediated toxic injury of the "upstream" liver parenchyma. BS are toxic in high concentration. These concentrations are present in the canalicular network, bile ducts, and gallbladder. Leakage of bile from this network and ducts could be an important driver of toxicity. The liver has a great capacity to adapt to cholestasis, and this may contribute to a variable symptom-poor interval that is often observed. Current trials with drugs that target BS toxicity are effective in only about 50%-60% of primary biliary cholangitis patients, with no effective therapy in PSC. This motivated us to develop and propose a new view on the pathophysiology of primary biliary cholangitis and PSC in the hope that these new drugs can be used more effectively. These views may lead to better stratification of these diseases and to recommendations on a more "tailored" use of the new therapeutic agents that are currently tested in clinical trials. Apical sodium-dependent BS transporter inhibitors that reduce intestinal BS absorption lower the BS load and are best used in cholestatic patients. The effectiveness of BS synthesis-suppressing drugs, such as farnesoid X receptor agonists, is greatest when optimal adaptation is not yet established. By the time cytochrome P450 7A1 expression is reduced these drugs may be less effective. Anti-inflammatory agents are probably most effective in early disease, while drugs that antagonize BS toxicity, such as ursodeoxycholic acid and nor-ursodeoxycholic acid, may be effective at all disease stages. Endoscopic stenting in PSC should be reserved for situations of intercurrent cholestasis and
Deplano, Valérie; Boufi, Mourad; Boiron, Olivier; Guivier-Curien, Carine; Alimi, Yves; Bertrand, Eric
One of the aims of this work is to develop an original custom built biaxial set-up to assess mechanical behavior of soft tissues. Stretch controlled biaxial tensile tests are performed and stereoscopic digital image correlation (SDIC) is implemented to measure the 3D components of the generated displacements. Using this experimental device, the main goal is to investigate the mechanical behavior of porcine ascending aorta in the more general context of human ascending aorta pathologies. The results highlight that (i) SDIC arrangement allows accurate assessment of displacements and so stress strain curves, (ii) porcine ascending aorta has a nearly linear and anisotropic mechanical behavior until 30% of strain, (iii) porcine ascending aorta is stiffer in the circumferential direction than in the longitudinal one, (iv) the material coefficient representing the interaction between the two loading directions is thickness dependent, (v) taking into account the variability of the samples the stress values are independent of the stretch rate in the range of values from 10(-3) to 10(-1)s(-1) and finally, (vi) unlike other segments of the aorta, 4-month-old pigs ascending aorta is definitely not a relevant model to investigate the mechanical behavior of the human ascending aorta. Copyright © 2016 Elsevier Ltd. All rights reserved.
Obland, M. D.; Antill, C.; Browell, E. V.; Campbell, J. F.; CHEN, S.; Cleckner, C.; Dijoseph, M. S.; Harrison, F. W.; Ismail, S.; Lin, B.; Meadows, B. L.; Mills, C.; Nehrir, A. R.; Notari, A.; Prasad, N. S.; Kooi, S. A.; Vitullo, N.; Dobler, J. T.; Bender, J.; Blume, N.; Braun, M.; Horney, S.; McGregor, D.; Neal, M.; Shure, M.; Zaccheo, T.; Moore, B.; Crowell, S.; Rayner, P. J.; Welch, W.
The ASCENDS CarbonHawk Experiment Simulator (ACES) is a NASA Langley Research Center project funded by NASA's Earth Science Technology Office that seeks to advance technologies critical to measuring atmospheric column carbon dioxide (CO2) mixing ratios in support of the NASA Active Sensing of CO2 Emissions over Nights, Days, and Seasons (ASCENDS) mission. The technologies being advanced are: (1) multiple transmitter and telescope-aperture operations, (2) high-efficiency CO2 laser transmitters, (3) a high bandwidth detector and transimpedance amplifier (TIA), and (4) advanced algorithms for cloud and aerosol discrimination. The instrument architecture is being developed for ACES to operate on a high-altitude aircraft, and it will be directly scalable to meet the ASCENDS mission requirements. The above technologies are critical for developing an airborne simulator and spaceborne instrument with lower platform consumption of size, mass, and power, and with improved performance. This design employs several laser transmitters and telescope-apertures to demonstrate column CO2 retrievals with alignment of multiple laser beams in the far-field. ACES will transmit five laser beams: three from commercial lasers operating near 1.57-microns, and two from the Exelis atmospheric oxygen (O2) fiber laser amplifier system operating near 1.26-microns. The Master Oscillator Power Amplifier at 1.57-microns measures CO2 column concentrations using an Integrated-Path Differential Absorption (IPDA) lidar approach. O2 column amounts needed for calculating the CO2 mixing ratio will be retrieved using the Exelis laser system with a similar IPDA approach. The three aperture telescope design was built to meet the constraints of the Global Hawk high-altitude unmanned aerial vehicle (UAV). This assembly integrates fiber-coupled transmit collimators for all of the laser transmitters and fiber-coupled optical signals from the three telescopes to the aft optics and detector package. The detector
O'Malley, Martin E; Alharbi, Fawaz; Chawla, Tanya P; Moshonov, Hadas
To determine superior-inferior anatomic borders for CT following inconclusive/nondiagnostic US for possible appendicitis. Ninety-nine patients with possible appendicitis and inconclusive/nondiagnostic US followed by CT were included in this retrospective study. Two radiologists reviewed CT images and determined superior-inferior anatomic borders required to diagnose or exclude appendicitis and diagnose alternative causes. This "targeted" coverage was used to estimate potential reduction in anatomic coverage compared to standard abdominal/pelvic CT. The study group included 83 women and 16 men; mean age 32 (median, 29; range 18-73) years. Final diagnoses were: nonspecific abdominal pain 50/99 (51%), appendicitis 26/99 (26%), gynaecological 12/99 (12%), gastrointestinal 9/99 (10%), and musculoskeletal 2/99 (2%). Median dose-length product for standard CT was 890.0 (range, 306.3 - 2493.9) mGy.cm. To confidently diagnose/exclude appendicitis or identify alternative diagnoses, maximum superior-inferior anatomic CT coverage was the superior border of L2-superior border of pubic symphysis, for both reviewers. Targeted CT would reduce anatomic coverage by 30-55% (mean 39%, median 40%) compared to standard CT. When CT is performed for appendicitis following inconclusive/nondiagnostic US, targeted CT from the superior border of L2-superior border of pubic symphysis can be used resulting in significant reduction in exposure to ionizing radiation compared to standard CT. • When CT is used following inconclusive/ nondiagnostic ultrasound, anatomic coverage can be reduced. • CT from L2 to pubic symphysis can be used to diagnose/exclude appendicitis. • Reduced anatomic coverage for CT results in reduced exposure to ionizing radiation.
Jørgensen, Anders Bech; Amirian, Ilda; Watt, Sara Kehlet; Boel, Thomas; Gögenur, Ismail
To examine if there were circadian variations in surgeons' ability to diagnose acute appendicitis. Retrospective database study of all patients admitted to an acute surgical procedure under the potential diagnosis of acute appendicitis in a 4-year period. The day was divided into 2 time intervals, day to evening hours (08:00-23:59) and night hours (00:00-07:59). Relevant data regarding the admission and surgical procedures were categorized into these 2 time intervals. Department of Surgery at a Danish university hospital in Copenhagen. A total of 2366 patients were included. There were no age limitations or selection in sex. There was no significant difference in the ability to diagnose appendicitis in day-evening hours vs night hours (p = 0.391), nor was any significant difference found on weekdays (Monday-Thursday) vs weekends (Friday-Sunday) (p = 0.278). There were no differences in duration of the procedures, rate of conversion, or severity of postoperative surgical complications between the 2 groups. More patients underwent diagnostic imaging during day to evening hours compared with night hours (308 vs 46; p = 0.014). The use of imaging had no effect on the ability to diagnose appendicitis. Male sex showed a higher probability of the diagnosis being appendicitis compared with other or no pathology (odds ratio: 3.094; p < 0.001). Age between 40 and 80 years was significantly associated with a higher probability of the diagnosis being appendicitis compared with other or no pathology. The negative appendectomy rate was 10.5%. We found no difference in the surgeons' ability to diagnose acute appendicitis during night hours compared with day to evening hours. Copyright © 2015 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.
Boomer, Laura; Freeman, Jennifer; Landrito, Earl; Feliz, Alexander
Significant racial and socioeconomic disparities have been found in the diagnosis and treatment of acute appendicitis in children. There has been little focus on the outcomes of Latino children with appendicitis. This study evaluates whether ethnicity or insurance status are associated with differences in presentation and outcomes of children with acute appendicitis. A retrospective analysis was performed for all children between the ages of 2 and 18 y with acute appendicitis between July 1, 2005 and December 31, 2008 at the only teaching hospital in the region. χ(2) and regression analyses were used to evaluate the impact of ethnicity and insurance status on perforation rates and outcomes. A total of 410 children with acute appendicitis were identified, of whom 259 (63.2%) were Latino. Latino children were on public insurance in greater proportion (34.8% versus 19.9%) compared with non-Latino children (P = 0.001). The perforation rate for the entire sample was 29.6%. There were no significant differences in perforation rates with respect to ethnicity, insurance status (private, public, none), or age. Once within the medical system, there were no significant differences in radiologic studies performed, types of operations received, length of stay, or number of complications between ethnic groups. There have been multiple reports showing disparities in the rates of perforated appendicitis in children. At our institution, we observed no differences in the presentation and care of children with acute appendicitis with respect to ethnicity and insurance status. Copyright © 2010 Elsevier Inc. All rights reserved.
Iwańczak, Barbara; Stawarski, Andrzej; Czernik, Jerzy; Bronowickip, Krzysztof; Iwańczak, Franciszek; Pytrus, Tomasz; Klempous, Jan; Godziński, Jan
Pediatric abdominal pain is one of the most common symptom of children brought to attention of primary care physicians and pediatric surgeons. In many children clinical symptoms may be uncharacteristic and may lead to diagnostic difficulties. Clinical analysis of children with right lower quadrant abdominal pain suspected of appendicitis or children with periappendicular mass. The histories of 14 children aged from 18 months to 17 years treated in Pediatric Clinic were analysed. All children were operated because of right lower quadrant abdominal pain or abdominal mass before admission to the Pediatric Clinic or during hospitalization in Pediatric Clinic. Intraoperatively in all children pathologies other than appendicitis were the cause of symptoms. The most often Crohn's disease were recognized (9 children), in 2 cases with concomitant other pathologies (fecal tumor of appendix in one case and with peritoneal abscess after perforation of intestinal wall). Sporadically the inflammation of the mesenterial lymph nodes caused by Yersinia infection suggested appendicitis. In one boy with ulcerative colitis, during exacerbation of the disease appendicitis complicated by rupture and peritonitis was observed. In 18-month old child with right lower quadrant abdominal mass invagination complicated by perforation of the ileum was recognized. In the case of 14-years old boy 6 months after appendectomy we observed mechanical intestinal obstruction complicated by perforation and peritonitis. Carcinoid of the appendix was the cause of abdominal pain in one child. 1. Appendicitis is the most frequent surgical etiology of the right lower quadrant pediatric abdominal pain. 2. Despite new diagnostic imagines there are no definite criteria to recognize appendicitis, in most cases physical examination and very carefull evaluation of abdominal pain are the most important. 3. All children with periappendipected of Crohn's disease. 4. All children with equivocal presentations of
Swischuk, Leonard E; Chung, Dai H; Hawkins, Hal K; Jadhav, Siddharth P; Radhakrishnan, Ravi
This study aims to document the imaging and pathology findings in non-fecalith-induced appendicitis. We reviewed the imaging and pathologic findings in 40 patients with histologically proven purulent appendicitis seen over a 2-year period. Findings documented were (1) total appendiceal involvement, (2) predominant appendiceal tip involvement, (3) presence of a fecalith, and (4) presence of lymphoid hyperplasia. There were a total of 40 patients, 28 males and 12 females. The age range was 2-18 years with a mean of 11.5 years. Twenty-two (55 %) patients demonstrated classic purulent appendicitis of the whole appendix, 20 (91 %) of these appendices had a fecalith. Eighteen (45 %) patients demonstrated purulent appendicitis confined to or predominately involving the tip of the appendix, and all 18 (100 %) patients demonstrated marked lymphoid hyperplasia. Only two (11 %) of these appendices had a fecalith. Overall, a fecalith was found in only 55 % of our cases, while 45 % demonstrated no fecalith, but rather marked lymphoid hyperplasia. Lymphoid hyperplasia appeared to be the underlying predisposing cause of purulent appendicitis in these cases.
Löfvenberg, Fanny; Salö, Martin
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.
Zakaria, Ossama M.; Zakaria, Hazem M.; Daoud, Mohamed Yasser; Al Wadaani, Hamed; Al Buali, Waleed; Al-Mohammed, Hamdan; Al Mulhim, Abdulrahman S.; Zaki, Wafaa
Objective The relationship between parasites and pediatric appendicitis is a highly debatable issue. This study aims to investigate the role of parasitic infestation in the etiology of acute pediatric appendicitis. Methods A retrospective study including 1600 pediatric and adolescent patients who had undergone surgical therapy for a diagnosis of acute appendicitis over a period of ten years from Jan 2001 to Dec 2010. Demographic data were retrieved including the patient's age, sex, clinical data, clinical presentations, laboratory investigations, operative data and pathological findings to identify the presence and type of parasites. Patients were divided into two groups according to the presence or absence of parasites in the appendix lumen. In group I (n: 88), parasitic infestation was observed, whereas in group II (n: 1502), no parasitic infestation was present. Results Parasites were present in 5.5% (88 patients), and of those 88 parasitic infestations, 45 (51.1%) were Enterobaisis, 8 (9.1%) were Schistosomiasis, 23 (26.1%) were Ascariasis, 7 (8%) Trichuriasis, and 5 (5.7%) were Teania Saginata. The percentage of patients with suppurative, gangrenous or perforated appendicitis was similar in both groups with no statistical significance, irrespective of the presence or absence of parasitic infestation. Conclusion The low prevalence of parasites among the appendectomy specimens did not support the notion that parasites were a major cause of appendicitis in pediatric patients. PMID:23599875
McFarlane, M E C; Plummer, J M; Leake, P A; Powell, L; Chand, V; Chung, S; Tulloch, K
Dengue fever is an acute viral disease, which usually presents as a mild febrile illness. Patients with severe disease present with dengue haemorrhagic fever or dengue toxic shock syndrome. Rarely, it presents with abdominal symptoms mimicking acute appendicitis. We present a case of a male patient presenting with right iliac fossa pain and suspected acute appendicitis that was later diagnosed with dengue fever following a negative appendicectomy. A 13-year old male patient presented with fever, localized right-sided abdominal pain and vomiting. Abdominal ultrasound was not helpful and appendicectomy was performed due to worsening abdominal signs and an elevated temperature. A normal appendix with enlarged mesenteric nodes was found at surgery. Complete blood count showed thrombocytopenia with leucopenia. Dengue fever was now suspected and confirmed by IgM enzyme-linked immunosorbent assay against dengue virus. This unusual presentation of dengue fever mimicking acute appendicitis should be suspected during viral outbreaks and in patients with atypical symptoms and cytopenias on blood evaluation in order to prevent unnecessary surgery. This case highlights the occurrence of abdominal symptoms and complications that may accompany dengue fever. Early recognition of dengue fever mimicking acute appendicitis will avoid non-therapeutic operation and the diagnosis may be aided by blood investigations indicating a leucopenia, which is uncommon in patients with suppurative acute appendicitis. Copyright © 2013 The Authors. Published by Elsevier Ltd.. All rights reserved.
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
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.
Souza-Gallardo, Luis Manuel; Martínez-Ordaz, José Luis
Appendicitis represents a common disease for the surgeon with a relative risk between 7-8%. It was thought that if more time passed between diagnosis and treatment, the risk for complications, such as perforation or abscess formation, was higher; nevertheless; the evolution is variable, making necessary the development of different strategies such as antibiotic use only, interval surgery or endoscopic treatment. The purpose of this study is to make a revision in the management of appendicitis comparing conservative and surgical treatment. It is known that traditional management of appendicitis is appendectomy with a complication rate of 2.5% to 48%. Nowadays, laparoscopy is the approach of choice by many surgeons and there have proposed new invasive techniques such as endoscopic treatment with the use of prosthesis and ambulatory surgery. Antibiotic use is essential in the management of appendicitis. Its use as the only strategy to treat this disease has the purpose of lowering costs and diminishing complications related to surgery or the resection of the organ. We conclude that the ideal management of appendicitis remains controversial and it will depend of the clinical characteristics of each patient and the resources available.
Sah, Shatrughan Prasad; Bhadani, Punam Prasad
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.
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
Pinto Leite, Nuno; Pereira, José M; Cunha, Rui; Pinto, Pedro; Sirlin, Claude
This article reviews various CT protocols for appendicitis, identifies key CT findings for diagnosing appendicitis, discusses unusual manifestations such as chronic and recurrent appendicitis, and profiles imaging features that differentiate appendicitis from other inflammatory and neoplastic ileocecal conditions. Patients were studied with helical CT. CT is a highly accurate, noninvasive test for appendicitis, but the optimal CT technique is controversial. Major complications of appendicitis (perforation, abscess formation, peritonitis, bowel obstruction, septic seeding of mesenteric vessels, gangrenous appendicitis) and their management are discussed. Abdominal CT is a well-established technique in the study of acute abdominal pain and has shown high sensitivity and specificity for diagnosing and differentiating appendicitis, providing an accurate diagnosis in the early stages of disease.
Chloptsios, C; Stamatiou, K; Kavouras, N; Moustakis, E; Ilias, G; Lebrun, F
Acute appendicitis is the most common surgical problem in pregnancy. Antibiotic treatment does not always improve the outcome and emergency intervention is required. We present a case of appendicitis complicated by a plastron formation occurring during pregnancy and the outcome.
More Appropriate than CT? presented at/published to Should Non-Contrast Rapid MRE Evaluation of Clinically Suspected Pediatric Appendicitis Trump ...Appendicitis Trump CT after Equivocal Ultrasound? 6. TITLE OF MA TE RIAL TO BE PUBLISHED OR PRESENTED: Electronic Poster: Diagnosis of Pediatric Appendicitis...MRI Evaluation o f C:Iinically Suspected Pediatric Appendicitis Trump CT after Equivocal Ultrasound? (Ng 181 11c. POSTER (To be demonstrated at
Tanaka, Yujiro; Uchida, Hiroo; Kawashima, Hiroshi; Fujiogi, Michimasa; Suzuki, Keisuke; Takazawa, Shinya; Deie, Kyoichi; Amano, Hizuru; Iwanaka, Tadashi
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 Â© 2016 Elsevier Inc. All rights reserved.
Zia Ullah, Qazi
Appendicitis and trauma both present in emergency department commonly but their presentation together in the same patient is unusual. We present a case of a middle-aged man brought by emergency medical services (EMS) to the emergency department with complaints of abdominal pain after he was involved in motor vehicle collision. He was perfectly fine before the accident. His primary survey was normal. Secondary survey revealed tenderness in right iliac fossa with seat belt mark overlying it. Computerized tomography (CT) of the abdomen and pelvis was performed which showed 8 mm thickening of appendix with minimal adjacent fat stranding. There is also subcutaneous fat stranding of anterior lower abdominal wall possibly due to bruising. Impression of posttraumatic seat belt compression appendicitis was made. Laparoscopic appendectomy was done and patient recovered uneventfully. Histopathology showed inflamed appendix, proving it to be a case of seat belt compression appendicitis. PMID:28337350
Sazhin, A V; Mosin, S V; Kodzhoglian, A A; Mirzoian, A T; Laĭpanov, B K; Iuldoshev, A R
Treatment results of 101 patients, operated on with the diagnosis of the chronic appendicitis, were analyzed. Of them, 55 had periodic right iliac pain syndrome, the rest 46 had a history of appendicular abscess or infiltrate. 58 patients were operated on laparoscopically, the rest had traditional open appendectomy. The use of ultrasound and roentgen diagnostics proved to be non-effective. The reliable laparoscopic symptoms of chronic appendicitis were singled out. The laparoscopy provided the correct diagnosis in 93.3% of patients and allowed avoiding the groundless appendectomy in 31.2%. The intraoperative ultrasound is helpful in questionable cases. The diagnostic and treatment algorithm for chronic appendicitis, based on laparoscopic methods, was worked out.
Efimenko, N A; Chursin, V V; Stepanov, A A; Balalykin, A S
The article presents the results of analyze of diagnostic laparoscopy on the example of 1028 patients with clinical characters of appendicitis, diagnosis of 682 patients (66.3%) is conformed. 667 patients (99.3%) had transformation of laparoscopy from diagnostic to medicinal. Postoperative prearranged sanitational laparoscopy was conducted with 28 patients (4.5%), including 1 time--21 patients, 2 times--6 patients, 3 times--patient. 24 patients had different complications (intraperitoneal hemorrhage, commissural and paralytic terminal ileuses, abscesses and infiltrates of abdominal cavity, infiltrates of anterior abdominal wall, subcutaneous eventration of small intestinal loop). There were no lethal outcomes. Average day in a hospital in conditions of acute appendicitis is 4.2 day, in conditions of chronic appendicitis--3.1 day.
Nowzaradan, Y; Barnes, J P; Westmoreland, J; Hojabri, M
Results and complications in 100 patients treated over a 3-year period with the laparoscopic approach for clinically diagnosed acute appendicitis are evaluated. They are compared with results and complications in 100 patients with the same diagnosis who had been treated with the open technique performed by the same surgeon during the same 3 years. The results suggest that laparoscopy provides excellent exposure of the appendix regardless of its position. In the absence of pathology of the appendix, laparoscopy allows for a thorough examination of the entire abdomen and pelvis and good exposure and definitive treatment of most surgical conditions encountered. In the event of appendicitis, regardless of its severity, laparoscopic appendectomy results in less postoperative pain, shorter hospital stays, faster return to normal activities, fewer postoperative complications, and superior cosmetic results. Our experience suggests that the laparoscopic approach is the best approach to diagnosis and treatment of the conditions encountered in patients with suspected appendicitis.
Kafetzis, D A; Velissariou, I M; Nikolaides, P; Sklavos, M; Maktabi, M; Spyridis, G; Kafetzis, D D; Androulakakis, E
The aim of this study was to assess the diagnostic value of procalcitonin (PCT) in 212 children with appendicitis and compare it with that of the standard diagnostic modalities, C-reactive protein (CRP) level, leukocyte count, and abdominal ultrasound findings, in relation to the surgical and histological findings of the appendix. A PCT value of >0.5 ng/ml was found to be indicative of perforation or gangrene with 73.4% sensitivity and 94.6% specificity, a CRP level of >50 mg/l and a leukocyte count of >10(4)/mm3 were useful diagnostic markers for perforation, while abdominal ultrasonography had a sensitivity of 82.8% and a specificity of 91.2% for detecting appendicitis with imaging findings. PCT measurement seems to be a useful adjunctive tool for diagnosing acute necrotizing appendicitis or perforation, and surgical exploration will probably be required in patients with PCT values >0.5 ng/ml.
Ramezani, Mohammad Arash; Dehghani, Mahmoud Reza
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).
Vidrine, Steven R; Cortina, Chandler; Black, Marissa; Vidrine, Steven B
Acute appendicitis is a common cause for pediatric surgery, with an increasing incidence as this population ages. Pseudomembranous colitis (PMC) from Clostridum difficle is being seen more frequently in pediatric patients, especially after treatment with antibiotics and in those with Hirschsprung's disease. Only three prior cases of appendicitis associated with PMC have been described in the literature, and all of them occurred in adult patients. Here, we describe the first documented pediatric case: a 16-year-old female who developed acute appendicitis while concomitantly being treated for suspected pseudomembranous colitis. We concur with previous authors that there may be an association between these two pathologies; furthermore, this association may not always be clinically apparent and may be both under-diagnosed and under-reported.
Khilji, Muhammad Faisal; Zia Ullah, Qazi
Appendicitis and trauma both present in emergency department commonly but their presentation together in the same patient is unusual. We present a case of a middle-aged man brought by emergency medical services (EMS) to the emergency department with complaints of abdominal pain after he was involved in motor vehicle collision. He was perfectly fine before the accident. His primary survey was normal. Secondary survey revealed tenderness in right iliac fossa with seat belt mark overlying it. Computerized tomography (CT) of the abdomen and pelvis was performed which showed 8 mm thickening of appendix with minimal adjacent fat stranding. There is also subcutaneous fat stranding of anterior lower abdominal wall possibly due to bruising. Impression of posttraumatic seat belt compression appendicitis was made. Laparoscopic appendectomy was done and patient recovered uneventfully. Histopathology showed inflamed appendix, proving it to be a case of seat belt compression appendicitis.
Köksal, Hande; Kurban, Sevil; Doğru, Osman
The aim of this study was to investigate the levels of oxidative stress including total oxidant status, total antioxidant status, and paraoxonase activity in patients with a diagnosis of acute appendicitis. Seventy-three patients who underwent surgery with a preoperative diagnosis of acute appendicitis (Group I) were included into the study. The control group (Group II) consisted of thirty otherwise healthy subjects. After histopathologic examination, the patients were categorized as follows: 1) Acute focal appendicitis, 2) Acute advanced appendicitis including acute suppurative, phlegmonous and gangrenous appendicitis, 3) Acute perforated appendicitis, 4) Sub-acute appendicitis, and 5) Negative exploration. Blood samples for paraoxonase activities, and total oxidant and antioxidant status levels were obtained preoperatively. Total oxidant and antioxidant status of the patients in the acute appendicitis group were higher than those of the control group. When paraoxonase activities of Group I was compared with Group II, no significant difference was determined. Both total oxidant and antioxidant status levels of acute perforated appendicitis were higher than those of both acute focal appendicitis and acute advanced appendicitis. The increase in the oxidative status (total oxidant and antioxidant status) was related with the progression of inflammation to the perforation in acute appendicitis.
Erginel, Basak; Soysal, Feryal Gun; Celik, Alaaddin; Salman, Tansu
Appendicitis in newborns is uncommon and difficult to diagnose. Reports on neonatal appendicitis subsequent to inguinal hernia incarceration are exceptionally rare. We present the case of a 26-day-old infant with perforated appendicitis due to incarceration of a right inguinal hernia, mimicking right testicular torsion. © 2017 Japan Pediatric Society.
Chien, Ming; Habis, Arie; Glynn, Loretto; O'Connor, Ann; Smith, Tracie L; Prendergast, Francis
Despite significant radiation exposure involved with computed tomography (CT) in evaluation of pediatric appendicitis, its use is still widespread. The goal of this study was to assess the effect of a staged imaging pathway for appendicitis to significantly decrease CT use while maintaining diagnostic accuracy. Chart review was performed for patients evaluated for appendicitis over a 12-month period prior to and after pathway implementation. There was a significant decrease in CT use as initial imaging after implementation of the pathway; 87.1-13.4 % for evaluations positive for appendicitis (decrease 84.6 %, p < 0.0001) and 82.6-9.2 % for evaluations negative for appendicitis (decrease 88.9 %, p < 0.0001). Use of CT during any point in the evaluation decreased from 91.7 to 25.1 % (decrease 72.6 %, p < 0.0001). The negative appendectomy rate was similar; 5.4 % prior, 4.9 % post (p = 0.955). The missed appendicitis rate did not statistically change; 1.1 % prior, 3.7 % post (p = 0.523). The perforation rate was not statistically altered; 6.5 % prior; 9.8 % post (p = 0.421). 350 less patients underwent CT during the year following the pathway. The staged imaging pathway resulted in a marked decrease in children exposed to CT without compromising diagnostic accuracy.
Chao, Pei-Wen; Ou, Shuo-Ming; Chen, Yung-Tai; Lee, Yi-Jung; Wang, Feng-Ming; Liu, Chia-Jen; Yang, Wu-Chang; Chen, Tzeng-Ji; Chen, Tzen-Wen; Li, Szu-Yuan
Acute appendicitis in patients with end-stage renal disease (ESRD) poses a diagnostic challenge. Delayed surgery can contribute to higher morbidity and mortality rates. However, few studies have evaluated this disease among ESRD patients. Our study focused on the lack of data on the incidence and risk factors of acute appendicitis among ESRD patients and compared the outcomes in patients who underwent different dialysis modalities. This national survey was conducted between 1997 and 2005 and included ESRD patients identified from the Taiwan National Health Insurance database. The incidence rate of acute appendicitis in ESRD patients was compared with that in randomly selected age-, sex-, and Charlson comorbidity score-matched non-dialysis controls. A Cox regression hazard model was used to identify risk factors. Among 59,781 incident ESRD patients, matched one-to-one with controls, there were 328 events of acute appendicitis. The incidence rate of 16.9 per 10,000 person-years in the ESRD cohort was higher than that in the control cohort (p = 0.003). The independent risk factors were atrial fibrillation (hazard ratio [HR], 2.08), severe liver disease (HR, 1.74), diabetes mellitus (HR, 1.58), and hemodialysis (HR, 1.74). Compared with the control cohort, subsequent perforation and mortality rates of acute appendicitis were also higher in the ESRD cohorts. There was no effect of dialysis modality on the patient outcomes. ESRD patients had a higher risk for acute appendicitis and poorer outcomes than non-dialysis populations. A careful examination of ESRD patients presenting with atypical abdominal pain to avoid misdiagnosis is extremely important to prevent delayed surgery.
Alfraih, Yasser; Postuma, Ray; Keijzer, Richard
Considerable variability exists in the diagnostic approach to acute appendicitis (in children), affecting both quality and costs of care. Interestingly, an international evaluation of what is commonly practiced today has not been performed. We aimed to document current practice patterns in the diagnosis of appendicitis in children and to determine whether a consensus exists in the workup of these patients among Canadian, Dutch, and Saudi Arabian pediatric surgeons. We performed a cross-sectional survey using a pre-designed, self-administered, 14-item survey. We sent the survey to participants via electronic mail. In total, 83 responses were received and analyzed, yielding a response rate of 42%. The majority of respondents practiced at pediatric surgery centers with over 50 beds (58% of Canadian surgeons, 81% of Dutch surgeons, 93% of Saudi Arabian surgeons). The majority of Dutch surgeons had a preference for physical examination and radiological imaging as opposed to Canadian and Saudi Arabian surgeons who favored history and physical examination. Interestingly, only one of the surgeons surveyed used an appendicitis scoring system. Regarding history and physical examination, most respondents deemed migratory abdominal pain and localized RLQ tenderness to be most suggestive of appendicitis. Ultrasound was the most preferable imaging modality in acute appendicitis across all three countries. This study demonstrates that international pediatric surgeons vary substantially in the diagnostic workup of patients with appendicitis. Furthermore, there is a variability between common practice and the current evidence. We recommend that pediatric surgeons develop clinical practice guidelines that are based on consensus information (expert opinion) and the best available literature. Copyright © 2013 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
Piskun, G; Kozik, D; Rajpal, S; Shaftan, G; Fogler, R
Perforated appendicitis is associated with a significant risk of postoperative abdominal and wound infection. Only a few controversial studies evaluate the role of laparoscopy in perforated appendicitis. The significance of conversion from laparoscopy to open appendectomy for perforated appendicitis is not well defined. Statistical analysis was performed using Student's t-test. Data on 52 patients with perforated appendicitis were prospectively collected and retrospectively reviewed. Among these patients, 18 had laparoscopic appendectomies (LA); 24 had open appendectomies (OA); and 10 had converted appendectomies (CA). The indications for either method were based on the attending surgeons's philosophy. Laparoscopic appendectomy was performed using a retrograde stapler technique. Operative time, hospital stay, ability to tolerate a liquid diet, and postoperative infectious complications were documented. No statistically significant difference in the operative time in minutes was found between the LA (114 +/- 29.3), CA (120.0 +/- 32.2), and OA (105.8 +/- 64.1) groups (p = NS). There was no statistically significance difference in length of stay (days) between the LA (9.2 +/- 4.1), OA (10.5 +/- 3.3), and CA (10.0 +/- 1.8) groups. The wound infection rate was less frequent in the LA group (0%) than in 0A (14%) and CA (10%) groups. The rate of intra-abdominal abscess infections (IAAs) and ileus were 22% and 28%, respectively, in LA group, 38% and 29%, respectively, in OA group, and 60% and 50%, respectively, in CA group. No difference in the rate of postoperative intra-abdominal abscesses exists between laparoscopic and open appendectomy for perforated appendicitis. Wound infections and ileus complicate the postoperative course of patients after laparoscopic appendectomy less frequently than after open appendectomy. The conversion of laparoscopic to open appendectomy for perforated appendicitis is associated with increased postoperative morbidity.
Varzgalis, Manvydas; Bowden, Dermot J; Mc Donald, Ciaran K; Kerin, Michael J
Acute appendicitis is one of the most commonly encountered emergency surgical conditions. An understanding of the most highly cited research works in this field is key to good evidence based clinical practice. To perform a bibliometric analysis on the 100 most frequently cited articles in the field of acute appendicitis. The database of the Institute for Scientific Information (ISI) Web of Science Expanded citation index was searched to identify the 100 most frequently cited articles in the field of acute appendicitis. The web of science expanded citation index tracks article citations made since 1946. The top 100 most frequently cited articles were selected for analysis in this series. The most frequently cited article was cited 649 times and the least cited three article 93 times. The average number of citations per article was 167.74. The top 100 cited articles originated from 17 countries. Over half of the papers originated from the USA. Fifty-one of the papers concentrated on diagnostics of acute appendicitis. Thirty-six papers looked at the treatment of acute appendicitis with 30 of these dealing with the surgical management of the disease. There were 6 studies at level 1a, 20 studies at level 1b and 43,5,17 and 9 studies at levels 2, 3, 4 and 5 respectively. Bibliometric analysis of the citation classics in a given field can provide interesting insights into the relationship between the quality of research outputs and clinical practice. The study of acute appendicitis remains an active field of research with a growing body of higher quality evidence underpinning our clinical practice.
Bromberg, Rudy; Goldman, Ran D.
QUESTION Can analgesia be given safely to patients with suspected appendicitis prior to surgical evaluation without masking physical signs and symptoms? ANSWER Withholding analgesia from patients with acute abdominal pain and suspected appendicitis is common. This practice, however, is not supported by published literature. Although a few trials have noted some changes in abdominal examination with analgesia, this has not been associated with any changes in patient outcome. If patients are in pain, analgesia is warranted. Larger multicentre trials are needed to establish practice guidelines. PMID:17872606
Sran, Harkiran; Sebastian, Joseph; Doughan, Samer
Idiopathic ulcer of the caecum is a rare condition of unknown aetiology. Its clinical presentation may mimic various pathologies, including appendicitis, inflammatory bowel disease and caecal malignancy. A definitive diagnosis is rarely established preoperatively, and is usually only confirmed histologically following surgical resection. We report a case of a young patient with caecal ulceration presenting with symptoms and signs of appendicitis, in whom laparoscopic anterior 'sleeve' caecectomy was performed to excise an inflammatory-looking mass involving the caecum. Histological examination demonstrated a deep mucosal ulcer and subsequent colonoscopy did not reveal any further pathology.
Sierakowski, Kyra; Pattichis, Andrew; Russell, Patrick; Wattchow, David
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.
Altay, Canan; Yavuz, Esra; Egeli, Tufan; Canda, Emre Aras; Sarioglu, Sulen; Secil, Mustafa
Xanthogranulomatous inflammation (XGI) is a rare chronic inflammatory condition most commonly involving the kidneys and gallbladder. The condition is histopathologically characterized by the presence of foamy histiocytes, lymphocytes, and plasma cells. A few reports describing appendicitis caused by XGI have appeared in the English-language literature. However, no study has yet focused on the imaging features of xanthogranulomatous appendicitis (XGA). We present a pathologically confirmed case of XGA with an endometrial abscess; the patient underwent ultrasonography, computed tomography, and magnetic resonance imaging. To the best of our knowledge, this is the first case of XGA with uterine and right adnexal involvement presenting as a complicated pelvic abscess on radiological imaging.
Pepper, Victoria K; Stanfill, Amy B; Pearl, Richard H
Three of the most common causes of surgical abdominal pain in pediatric patients include appendicitis, Meckel diverticulum, and intussusception. All 3 can present with right lower quadrant pain, and can lead to significant morbidity and even mortality. Although ultrasound is the preferred method of diagnosis with appendicitis and intussusception, considerable variety exists in the modalities needed in the diagnosis of Meckel diverticulum. This article discusses the pathways to diagnosis, the modes of treatment, and the continued areas of controversy. Copyright © 2012 Elsevier Inc. All rights reserved.
Choi, Jea Yeon; Jo, Jeong Hyun; Hann, Tchah; Kim, Seong Min
Purpose This study examined the risk factors of a delayed diagnosis of acute appendicitis in children undergoing an appendectomy. Methods This retrospective study involved children aged below 18 years, who underwent an appendectomy. After dividing them into a delayed diagnosis group and nondelayed diagnosis group according to the time interval between the initial hospital visit and final diagnosis, the risk factors of delayed diagnosis were identified using logistic regression analysis. Results Among 712 patients, 105 patients (14.7%) were classified in the delayed diagnosis group; 92 patients (12.9%) were diagnosed using ultrasonography (US), and both US and computed tomography were performed in 38 patients (5.3%). More patients in the delayed diagnosis group underwent US (P=0.03). Spring season and prior local clinic visit were significantly associated with a delayed diagnosis. Fever and diarrhea were more common in the delayed diagnosis group (fever: odds ratio [OR], 1.37; 95% confidence interval [CI], 1.05–1.81; diarrhea: OR, 1.94; 95% CI, 1.08–3.46; P<0.05). These patients showed symptoms for a longer duration (OR, 2.59; 95% CI, 1.78–3.78; P<0.05), and the admission course (OR, 1.26; 95% CI, 1.11–1.44; P<0.05) and C-reactive protein (CRP) levels (OR, 1.47; 95% CI, 1.19–1.82; P<0.05) were associated with the delayed diagnosis. Conclusion To decrease the rate of delayed diagnoses of acute appendicitis, symptoms such as fever and diarrhea, seasonal variations, admission course, and CRP levels should be considered and children with a longer duration of symptoms should be closely monitored. PMID:27721841
Gray, Bruce H; Langan, Eugene M; Manos, Ginger; Bair, Leah; Lysak, Steven Z
We present two cases of ascending aortic pseudoaneurysm exclusion with off-the-shelf aortic stent grafts. The right common carotid artery was used for access to facilitate graft delivery. Control of graft deployment was aided using a compliant right atrial occlusion balloon to lower cardiac output at the time of deployment. Transesophageal echocardiography facilitated the sizing and positioning of the right atrial balloon and was used to survey the heart and ascending aorta on successful exclusion of the pseudoaneurysm. These simple maneuvers made an uncommon procedure straight forward, predictable, and successful. Copyright © 2012 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.
Bozlu, Gulcin; Taskinlar, Hakan; Unal, Selma; Alakaya, Mehmet; Nayci, Ali; Kuyucu, Necdet
The aim of this study was to evaluate the diagnostic value of red blood cell distribution width (RDW) in children with acute appendicitis. In this retrospective study, a total of 344 children aged ≤18 years with clinically suspected acute appendicitis who underwent appendectomy between January 2007 and January 2014 were reviewed, and 200 healthy controls of the same age group were included. Based on histopathology, the patients were classified as having normal appendix, simple or perforated appendicitis, and preoperative white blood cell count (WBC), C-reactive protein (CRP) and RDW were compared. Compared with the controls, mean WBC, CRP and RDW were significantly higher in the appendectomy group (P <0.001). The children with simple or perforated appendicitis had significantly higher WBC, CRP and RDW than did those with normal appendix (P <0.001). Mean WBC and CRP were significantly higher in the children with perforated appendicitis (P <0.001), but no statistically significant difference was found in RDW between the simple and perforated appendicitis groups (P = 0.081). Children with histologically proven acute appendicitis have higher RDW than children without appendicitis, but the diagnostic value of RDW was not superior to WBC or CRP in children with acute appendicitis. Although higher RDW may be valuable for aiding the diagnosis of acute appendicitis in children, it is not a useful marker for predicting perforated appendicitis. © 2015 Japan Pediatric Society.
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
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.
Darcsi, Andras; Balint, Mihaly; Benkovics, Gabor; Sohajda, Tamas; Beni, Szabolcs
Summary Xanthene dyes can be appended to cyclodextrins via an ester or amide bridge in order to switch the fluorescence on or off. This is made possible through the formation of nonfluorescent lactones or lactams as the fluorophore can reversibly cyclize. In this context we report a green approach for the synthesis of switchable xanthene-dye-appended cyclodextrins based on the coupling agent 4-(4,6-dimethoxy-1,3,5-triazin-2-yl)-4-methylmorpholinium chloride (DMT-MM). By using 6-monoamino-β-cyclodextrin and commercially available inexpensive dyes, we prepared rhodamine- and fluorescein-appended cyclodextrins. The compounds were characterized by NMR and IR spectroscopy and MS spectrometry, their UV–vis spectra were recorded at various pH, and their purity was determined by capillary electrophoresis. Two potential models for the supramolecular assembly of the xanthene-dye-appended cyclodextrins were developed based on the set of data collected by the extensive NMR characterization. PMID:27340446
Boehnert, Markus U; Zimmermann, Heinz; Exadaktylos, Aristomenis K
Much effort goes into developing and publishing guidelines which physicians fail to implement. We feel that major discrepancies still exist between theory and reality and that the translational approach to this aspect of medical care has not yet established itself. We therefore decided to investigate in an exemplary audit how liberally inappropriate imaging is used in our emergency department (ED) to rule out acute appendicitis. Our electronic medical record ED database 'Qualicare' (http://www.qualidoc.ch) was searched using the 'appendicitis' sub data base. The frequency and accuracy of abdominal imaging was determined in patients with clinically suspected appendicitis on admission over a 5-year period at a university hospital emergency unit. In total, 272 (41.2%) of the 577 patients were male and 305 (46.3%) were female. The attending physicians ordered abdominal X-rays in 133 patients, abdominal ultrasounds in 319, and abdominal computerized tomography (CT) scans in 93 patients. 125 patients underwent more than one imaging procedure. In all, 85/125 patients received a combination of X-rays, ultrasound and CT scanning! Physicians are often insecure about indications for surgery and therefore order useless imaging procedures. The reliability of such procedures in excluding acute appendicitis is limited, which was confirmed by our results. Although evidence-based medicine guidelines exist, they are neglected for many reasons. Future academic efforts should therefore focus more on knowledge translation and the implementation of existing knowledge by heightening awareness, rather than on simply creating new guidelines.
Nemoto, Yukako; Tokuhisa, Junya; Shimada, Nagasato; Gomi, Tatsuya; Maetani, Iruru
Endoscopic mucosal resection (EMR) allows the removal of flat or sessile lesions, laterally spreading tumors, and carcinoma of the colon or the rectum limited to the mucosa or the superficial submucosa. Acute appendicitis is the most common abdominal emergency requiring emergency surgery, and it is also a rare complication of diagnostic colonoscopy and therapeutic endoscopy, including EMR. In the case presented here, a 53-year-old female underwent colonoscopy due to a positive fecal occult blood test and was diagnosed with cecal adenoma. She was referred to our hospital and admitted for treatment. The patient had no other symptoms. EMR was performed, and 7 h after the surgery, the patient experienced right -lower abdominal pain. Laboratory tests performed the following day revealed a WBC count of 16000/mm(3), a neutrophil count of 14144/mm(3), and a C-reactive protein level of 2.20 mg/dL, indicating an inflammatory response. Computed tomography also revealed appendiceal wall thickening and swelling, so acute appendicitis following EMR was diagnosed. Antibiotics were initiated leading to total resolution of the symptoms, and the patient was discharged on the sixth post-operative day. Pathological analysis revealed a high-grade cecal tubular adenoma. Such acute appendicitis following EMR is extremely rare, and EMR of the cecum may be a rare cause of acute appendicitis.
Hua, Jie; Yao, Le; He, Zhi-Gang; Xu, Bin; Song, Zhen-Shun
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.
Rogers, William; Hoffman, Jerome; Noori, Naudereh
In this brief analysis we compare the risks and benefits of performing a CT scan to confirm appendicitis prior to surgery instead of operating based on the surgeon's clinical diagnosis. We conclude that the benefit of universal imaging is to avoid 12 unnecessary appendectomies but the cost of those 12 avoided surgeries is one cancer death due to the imaging.
Brunner, Stefan M; Comman, Andreas; Gaetzschmann, Peter; Kipf, Bianca; Behrend, Matthias
The intrauterine contraceptive device (IUD) is a common form of reversible birth control. One of the rare, but serious, complications is uterine perforation. In this paper, we report a case of a patient who underwent laparoscopy for presumed chronic appendicitis. Intraoperatively, uterine perforation by the IUD was found. The IUD was removed laparoscopically. The postoperative course was uneventful.
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
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.
Neufeld, David; Vainrib, Michael; Buklan, Genady; Gutermacher, Michael; Paran, Haim; Werner, Myriam; Rathause, Valeria; Zissin, Rivka; Lazar, Ludwig; Erez, Ilan
The pre-operative diagnosis of acute appendicitis (AA) has markedly changed during the last couple of decades due to the advent of modern imaging technology. Nowadays, the use of imaging has dramatically changed the way we approach children admitted to emergency room for abdominal pain with suspected AA. This change is mainly manifested in our diagnostic strategy.
Jayakumar, Karthika; Sahu, Priyadarshi Soumyaranjan; R, Vinoth
Background: The appendix is a vestigial organ which is infiltrated by faecal material, microbes and parasites. The most important aetio-pathology of appendicitis is obstruction of its lumen, by a faecolith. This results from accumulation and inspissation of faecal matter around vegetable fibres. The cause for appendicitis is numerous and one among them is parasitic infestation. Aims: To analyze the faecolith present in the appendectomy specimen for parasites and to compare the results in fresh and preserved specimens. Materials and Methods: Patients with acute/chronic appendicitis were subjected for surgery and the appendectomy specimens were collected in saline and formalin suspensions, for preservation purposes. The lumen was washed with normal saline and contents were collected and wet mount preparations were examined under low and high power microscopy. Results: Among 100 specimens 48 faecolith analyses proved to be positive for parasitic association, giving 48% positivity, which is quite high. The commonest isolate was followed by mixed infection. In our study we observed that saline preparations were easy for handling and we were also able to demonstrate the undistorted morphology of parasite better than formalin preserved specimens. Conclusion: This study reveals the importance of analyzing the appendectomy specimen for understanding the etiopathogenisis of appendicitis in spite of having a negative stool microscopy. A post surgical analysis of appendectomy specimen may surprise you with different etiological agents as confirmed by our study. PMID:24995176
Jada, Sunil Kumar; Jayakumar, Karthika; Sahu, Priyadarshi Soumyaranjan; R, Vinoth
The appendix is a vestigial organ which is infiltrated by faecal material, microbes and parasites. The most important aetio-pathology of appendicitis is obstruction of its lumen, by a faecolith. This results from accumulation and inspissation of faecal matter around vegetable fibres. The cause for appendicitis is numerous and one among them is parasitic infestation. To analyze the faecolith present in the appendectomy specimen for parasites and to compare the results in fresh and preserved specimens. Patients with acute/chronic appendicitis were subjected for surgery and the appendectomy specimens were collected in saline and formalin suspensions, for preservation purposes. The lumen was washed with normal saline and contents were collected and wet mount preparations were examined under low and high power microscopy. Among 100 specimens 48 faecolith analyses proved to be positive for parasitic association, giving 48% positivity, which is quite high. The commonest isolate was followed by mixed infection. In our study we observed that saline preparations were easy for handling and we were also able to demonstrate the undistorted morphology of parasite better than formalin preserved specimens. This study reveals the importance of analyzing the appendectomy specimen for understanding the etiopathogenisis of appendicitis in spite of having a negative stool microscopy. A post surgical analysis of appendectomy specimen may surprise you with different etiological agents as confirmed by our study.
Rodrigues, H.; de Pinho, M. O.; Portes, D., Jr.; Santiago, A.
In continuation of a previous work, we present an analytic study of ascending vertical motion of a rocket subjected to a quadratic drag for the case where the mass-variation law is a linear function of time. We discuss the detailed analytical solution of the model differential equations in closed form. Examples of application are presented and…
Cipani, Ennio; And Others
The study was designed to modify the stair climbing behavior of two profoundly retarded residents through backward shaping with graduated guidance, edible rewards, a correction procedure, and a 30 second timeout. Both residents showed an increase in the number of correct steps used while ascending the stairs.
Ozbek, C; Kestelli, M; Emrecan, B; Ozsöyler, I; Bayatli, K; Yaşa, H; Lafci, B; Gürbüz, A
Lower limb arterial occlusion with no patent distal artery suitable for revascularisation is a common problem. The aim of this study was to assess the role of revascularisation to distal veins (ascending venous arterialization) in patients not reconstructable by conventional bypass. Ascending venous arterialization is a distal arteriovenous fistula. Reversed great saphenous vein grafts, from above the knee, were anastomosed to the common femoral artery, superficial femoral artery or popliteal artery and distally to the saphenous vein at the level of medial malleolus. No intervention was done to destroy the venous valves. The great saphenous vein was ligated below the knee. In this way, oxygenated blood could reach to dorsal venous arch and the tissues below the knee in an ascending fashion through the great saphenous vein, which was not removed. All of the patients recovered immediately after the operation. The lesions on the feet and on the toes of the patients improved in a short time. Intermittent claudication of the patients disappeared. Strong pulses were detected on the dorsal venous arch with manual Doppler in 3 weeks. The below knee tissues were perfused with the applied technique. Ascending venous arterialization can be applied for limb salvage to the patients who do not have a suitable arterial bed to revascularize with conventional techniques.
Rodrigues, H.; de Pinho, M. O.; Portes, D., Jr.; Santiago, A.
In continuation of a previous work, we present an analytic study of ascending vertical motion of a rocket subjected to a quadratic drag for the case where the mass-variation law is a linear function of time. We discuss the detailed analytical solution of the model differential equations in closed form. Examples of application are presented and…
Saleh, Sherif; He, Weiliang
This paper describes a comprehensive simulation for high altitude zero pressure balloon trajectories. A mathematical model was established to simulate the ascending process which considers the atmospheric conditions and thermodynamic variations. Influences of launch parameters on ascending performance were analyzed. The necessary quantity of initial lift gas was estimated and optimized, so that ensures no ballast consuming during the ascending process. The climbing rate was a governing parameter to evaluate the ascending performance. Based on the simulation, results revealed the apparent different effect on climbing rate at troposphere and stratosphere layers. Change in launch time and site mainly affect the climbing rate at the stratosphere and have no significant effect at the troposphere and tropopause altitudes. Meanwhile, change in launch date has a negligible effect on both layers. Due to the earth's declination angle, the influence of the same launch latitude and the same launch longitude is not identical within a year. Also, results showed that the optimum lift gas quantity improved the climbing rate stability to obtain an accurate simulation.
New York City Board of Education, Brooklyn, NY. Center for Career and Occupational Education.
Project ASCEND (A Systematic Career Education Network for Dissemination) of the Center for Career and Occupational Education (CCOE) in New York City developed (1) a sustained communication network in career education and (2) a kit for the dissemination of career education concepts, strategies, and materials into this network. Surveys of the…
van Rossem, Charles C; Schreinemacher, Marc H F; van Geloven, Anna A W; Bemelman, Willem A
Optimal duration of antibiotic treatment to reduce infectious complications after an appendectomy for acute complicated appendicitis remains unclear. To investigate the effect of antibiotic duration on infectious complications after laparoscopic appendectomy for acute complicated appendicitis. National multicenter prospective, observational, surgical resident-led cohort study conducted in June and July 2014. This study involved academic teaching hospitals (n = 8), community teaching hospitals (n = 38), and community nonteaching hospitals (n = 16), and all consecutive patients (n = 1975) who underwent surgery for suspected acute appendicitis. Patients treated laparoscopically for whom the antibiotic regimens were prolonged postoperatively because of complicated appendicitis. Receiving either 3 or 5 days of antibiotic treatment as planned and additional variables were explored as risk factors for infectious complications using regression analyses. A total of 1975 patients were included in 62 participating Dutch hospitals; 1901 (96.3%) of these underwent an appendectomy for acute appendicitis and laparoscopy was used in 74.4% of these patients (n = 1415). In 415 laparoscopically treated patients, antibiotic treatment was continued for more than 24 hours because of acute complicated appendicitis (29.3%). The prescribed antibiotic duration varied between 2 and 6 days in all of these patients. In 123 patients (29.6%), the length of treatment was adjusted. A shorter duration of antibiotic treatment (3 days instead of 5) had no significant effect on any infectious complication (odds ratio [OR], 0.93; 95% CI, 0.38-2.32; P = .88) or on intra-abdominal abscess development (OR, 0.89; 95% CI, 0.34-2.35; P = .81). Perforation of the appendix was the only independent risk factor for the development of an infectious complication (OR, 4.90; 95% CI, 1.41-17.06; P = .01) and intra-abdominal abscess (OR, 7.46; 95% CI, 1.65-33.66; P = .009) in multivariable regression analysis
Kaplan, Gilaad G.; Dixon, Elijah; Panaccione, Remo; Fong, Andrew; Chen, Li; Szyszkowicz, Mieczyslaw; Wheeler, Amanda; MacLean, Anthony; Buie, W. Donald; Leung, Terry; Heitman, Steven J.; Villeneuve, Paul J.
Background The pathogenesis of appendicitis is unclear. We evaluated whether exposure to air pollution was associated with an increased incidence of appendicitis. Methods We identified 5191 adults who had been admitted to hospital with appendicitis between Apr. 1, 1999, and Dec. 31, 2006. The air pollutants studied were ozone, nitrogen dioxide, sulfur dioxide, carbon monoxide, and suspended particulate matter of less than 10 μ and less than 2.5 μ in diameter. We estimated the odds of appendicitis relative to short-term increases in concentrations of selected pollutants, alone and in combination, after controlling for temperature and relative humidity as well as the effects of age, sex and season. Results An increase in the interquartile range of the 5-day average of ozone was associated with appendicitis (odds ratio [OR] 1.14, 95% confidence interval [CI] 1.03–1.25). In summer (July–August), the effects were most pronounced for ozone (OR 1.32, 95% CI 1.10–1.57), sulfur dioxide (OR 1.30, 95% CI 1.03–1.63), nitrogen dioxide (OR 1.76, 95% CI 1.20–2.58), carbon monoxide (OR 1.35, 95% CI 1.01–1.80) and particulate matter less than 10 μ in diameter (OR 1.20, 95% CI 1.05–1.38). We observed a significant effect of the air pollutants in the summer months among men but not among women (e.g., OR for increase in the 5-day average of nitrogen dioxide 2.05, 95% CI 1.21–3.47, among men and 1.48, 95% CI 0.85–2.59, among women). The double-pollutant model of exposure to ozone and nitrogen dioxide in the summer months was associated with attenuation of the effects of ozone (OR 1.22, 95% CI 1.01–1.48) and nitrogen dioxide (OR 1.48, 95% CI 0.97–2.24). Interpretation Our findings suggest that some cases of appendicitis may be triggered by short-term exposure to air pollution. If these findings are confirmed, measures to improve air quality may help to decrease rates of appendicitis. PMID:19805497
Sato, Yasuto; Kojimahara, Noriko; Kiyohara, Kosuke; Endo, Motoki; Yamaguchi, Naohito
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.
Background The Alvarado score can be used to stratify patients with symptoms of suspected appendicitis; the validity of the score in certain patient groups and at different cut points is still unclear. The aim of this study was to assess the discrimination (diagnostic accuracy) and calibration performance of the Alvarado score. Methods A systematic search of validation studies in Medline, Embase, DARE and The Cochrane library was performed up to April 2011. We assessed the diagnostic accuracy of the score at the two cut-off points: score of 5 (1 to 4 vs. 5 to 10) and score of 7 (1 to 6 vs. 7 to 10). Calibration was analysed across low (1 to 4), intermediate (5 to 6) and high (7 to 10) risk strata. The analysis focused on three sub-groups: men, women and children. Results Forty-two studies were included in the review. In terms of diagnostic accuracy, the cut-point of 5 was good at 'ruling out' admission for appendicitis (sensitivity 99% overall, 96% men, 99% woman, 99% children). At the cut-point of 7, recommended for 'ruling in' appendicitis and progression to surgery, the score performed poorly in each subgroup (specificity overall 81%, men 57%, woman 73%, children 76%). The Alvarado score is well calibrated in men across all risk strata (low RR 1.06, 95% CI 0.87 to 1.28; intermediate 1.09, 0.86 to 1.37 and high 1.02, 0.97 to 1.08). The score over-predicts the probability of appendicitis in children in the intermediate and high risk groups and in women across all risk strata. Conclusions The Alvarado score is a useful diagnostic 'rule out' score at a cut point of 5 for all patient groups. The score is well calibrated in men, inconsistent in children and over-predicts the probability of appendicitis in women across all strata of risk. PMID:22204638
Malnati, R; Capasso, G; Stagni, S; Bua, L; Albisetti, A; Erenbourg, L; Paesano, P L
Acute appendicitis is the first cause of emergency surgery in children. Actually, emergency abdominal sonography has evolved in differential diagnosis of acute appendicitis in children to differentiate it from other causes of acute abdomen as mesenteric lymphoadenitis, acute right pyelonephritis, acute diverticulitis in Meckel's diverticulum, intestinal intussusception, regional enterits, primary peritonitis, anaphylactoid purpura of Henoch-Schonlein. The aim of this study is the evaluation of the usefulness of abdominal sonography in diagnosing acute appendicitis in our current series of pediatric patients. We have operated 102 patients afflicted by appendicitis admitted to the pediatric department of Ospedale San Raffaele, Milano in a period of 5 years and operated on for appendectomy. In the last 2 years 36 patients were evaluated with abdominal sonography. This diagnostic tool showed in 34 (94.4%) a liquid effusion, sometimes thick of the right iliac fossa. In 2 patients the appendix had thickened layers, was edematous and the lumen was clearly filled with debris. Abdominal sonography has given a clear cut picture of the acute inflammatory process of the appendix. None of these patients has suffered from septic or obstructive complications. Mean duration of hospital stay was 6.35 days (3-15 days). Differential diagnosis of acute appendicitis can be extremely variable, from simple, paradigmatic situations to the most intriguing ones. This concept is well emphasized by William Silen when he says that "differential diagnosis of acute appendicits is an encyclopedic compendium of every abdominal disease that causes pain" in the 11th edition of Harrison's Principles of Internal Medicine.(ABSTRACT TRUNCATED AT 250 WORDS)
Bulanova, A A; Akhanzaripov, Z A
The immune status was studied during the development of the disease in 182 children who were operated on for acute appendicitis. T lymphocytes and their subpopulations circulating in the blood, as well as B lymphocytes, immunoglobulins A, M, G, and immune complexes were determined. The character of changes of these values before the operation and in various postoperative periods were determined. The effect of complex treatment, including T-activin, on the clinical and immunological parameters in children with acute appendicitis was appraised. Analysis of the results showed that a transitory immunodepressive state forms in children with the disease, which is more marked in the destructive form, with normalization of the main values of cell-mediated and humoral immunity by the 7th day after appendectomy. In a complicated course of acute appendicitis the state of immunodeficiency is torpid in character and does not return to normal values even after clinical recovery, i.e. before discharge from the clinic. Inclusion of the immunostimulating agent T-activin into the complex treatment of patients with appendicitis ensures a more rapid involution of the main clinical manifestations of the disease. The therapeutic effect was most pronounced in destructive appendicitis: after 3 days of treatment the pain syndrome was encountered twice less frequently and intestinal paresis more than twice less frequently in these patients, and the term of hospital stay (8.8 +/- 0.4 days) was less shorter than for children of the control group (12.2 +/- 1.9 days) who did not receive T-activin in the therapeutic complex.
Dalpiaz, Amanda; Gandhi, Jason; Smith, Noel L.; Dagur, Gautam; Schwamb, Richard; Weissbart, Steven J.; Khan, Sardar Ali
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
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
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.
Petroianu, Andy; Alberti, Luiz Ronaldo; Zac, Renata Indelicato
AIM: Although the radiological features of acute appendicitis have been well documented, the value of plain radiography has not been fully appreciated. The aim of this study was to determine the frequency of the association of acute appendicitis with images of fecal loading in the cecum. METHODS: Plain abdominal radiographs of 400 patients operated upon for acute appendicitis (n = 100), acute cholecystitis (n = 100), right acute pelvic inflammatory disease (n = 100) and right nephrolithiasis (n = 100) were assessed. The presence of fecal loading was recorded and the sensitivity and specificity of this sign for acute appendicitis were calculated. RESULTS: The presence of fecal loading in the cecum occurred in 97 patients with acute appendicitis, 13 patients with acute cholecystitis, 12 patients with acute inflammatory pelvic disease and 19 patients with nephrolithiasis. The sensitivity of this sign for appendicitis was 97% and its specificity to this disease was 85.3%. Its positive predictive value for appendicitis was 68.7%; however, its negative predictive value for appendicitis was 98.8%. CONCLUSION: The present study suggests that the presence of radiological images of fecal loading in the cecum may be a useful sign of acute appendicitis, and the absence of this sign probably excludes this disease. This is the first description of fecal loading as a radiological sign for acute appendicitis. PMID:16015695
Prada-Arias, Marcos; Vázquez, José Luis; Salgado-Barreira, Ángel; Gómez-Veiras, Javier; Montero-Sánchez, Margarita; Fernández-Lorenzo, José Ramón
The aim of this study was to assess the diagnostic accuracy of the biomarker fibrinogen (FB), along with the more traditional markers white blood cell count (WBC), absolute neutrophil count (ANC), and C-reactive protein (CRP), to discriminate appendicitis from nonspecific abdominal pain (NSAP) in children. We prospectively evaluated all children aged 5 to 15 years admitted for suspected appendicitis at an academic pediatric emergency department during 2 years. Diagnostic accuracy of FB (prothrombin time-derived method), WBC, ANC, and CRP was assessed by the area under the curve (AUC) of the receiver operating characteristic curve. A total of 275 patients were enrolled in the study (143 NSAP, 100 uncomplicated appendicitis, and 32 complicated appendicitis). WBC and ANC had a moderate diagnostic accuracy for appendicitis vs NSAP (WBC: AUC 0.79, ANC: AUC 0.79). FB and CPR had a poor diagnostic accuracy for appendicitis vs NSAP (FB: AUC 0.63, CRP: AUC 0.64) and a good diagnostic accuracy for complicated vs uncomplicated appendicitis (FB: AUC 0.86, CRP: AUC 0.90). All inflammatory markers had a good diagnostic accuracy for complicated appendicitis vs NSAP. WBC and ANC are useful inflammatory markers to discriminate appendicitis from NSAP. FB and CRP are not very useful to discriminate appendicitis from NSAP, but they discriminate properly complicated from uncomplicated appendicitis and NSAP, with a similar diagnostic accuracy. In a child with suspected appendicitis, a plasma FB level (prothrombin time-derived method) >520 mg/dL is associated to an increased likelihood of complicated appendicitis. Copyright © 2016 Elsevier Inc. All rights reserved.
Stengel, Joseph W; Webb, Emily M; Poder, Liina; Yeh, Benjamin M; Smith-Bindman, Rebecca; Coakley, Fergus V
To investigate the clinical outcome in patients with a diagnosis of appendicitis at computed tomography (CT) in whom treatment is deemed unnecessary after clinical evaluation. After institutional review board approval, 2283 patients (856 men, 1427 women; mean age, 46 years; age range, 18-99 years) who underwent CT because they were suspected of having appendicitis between 2002 and 2007 were retrospectively identified. CT reports were reviewed, and the likelihood of appendicitis was assigned a score on a five-point scale: score 1, definitely absent; score 2, nonvisualized appendix with no secondary signs of inflammation; score 3, equivocal; score 4, probable; and score 5, definitely present. Diagnosis of appendicitis at CT was considered a false-positive result if the CT report was classified as probable or definite appendicitis but the patient was not treated within 4 days. Cases with false-positive results were reviewed by two readers blinded to patient outcome, supporting clinical data, and prospective scan interpretation, and a grade was assigned by using the same scale. Medical records were reviewed to determine outcomes. Descriptional statistics were used. Overall, 516 (23%) of 2283 patients had CT findings of probable or definite appendicitis. Thirteen (3%) of 516 patients did not receive immediate treatment for appendicitis. Of these, five (38%; 95% confidence interval: 18%, 65%) underwent later appendectomy with proved appendicitis after a mean interval of 118 days (range, 5-443 days). Seven (54%) of 13 patients never developed appendicitis across a mean follow-up of 583 days (range, 14-1460 days). One (8%) of 13 had a normal appendix at eventual surgery. Five of 13 patients with CT findings of appendicitis and reassuring clinical evaluation results in whom immediate treatment was deferred ultimately returned with appendicitis. In patients with CT results positive for appendicitis and benign or atypical clinical findings, a diagnosis of chronic or recurrent
Clyburn, Virginia L; Smith, Jacob E; Rumboldt, Tihana; Matheus, Maria G; Day, Terry A
A plunging ranula is a rare phenomenon that represents mucous extravasation extending through or behind the mylohyoid. The mucous dissects the tissue planes inferiorly and usually manifests as a swelling in the submental or submandibular regions. Some plunging ranulas are believed to result from disruption of excretory ducts that originate from the sublingual gland. The currently accepted definitive treatment of a plunging ranula is resection of the ipsilateral sublingual gland and evacuation of the cyst with removal of the pseudocapsule. There have been no reported cases of "ascending" ranulas into the parapharyngeal or pterygomaxillary space. The following represents the first known case that involved an extensive ascending and plunging ranula in a pediatric patient, which recurred despite complete excision of the ranula and sublingual gland. IRB approval was not required per institutional policy on retrospective case reports.
Uspenskiy, Vladimir; Lavreshin, Alexei; Osadchii, Alexei; Gordeev, Michael
Ascending aortic false aneurysm is a rare but serious complication of pericardial mesothelioma. We report a case of ascending aortic pseudoaneurysm due to spindle cell pericardial mesothelioma. In this case, the first symptoms of the disease appeared 18 months before surgery. The final diagnosis was determined only when severe late complications occurred. Palliative tumour excision, aortoplasty and aortic valve prosthesis were performed with subsequent adjuvant chemotherapy. Over 10 months after surgery, the patient is alive and a significant reduction of the tumour mass has been achieved. This case demonstrates that timely lifetime diagnosis of malignant pericardial tumour remains very difficult and effective adjuvant chemotherapy is needed to improve the results of surgery. PMID:22593561
Pang, Philip Y K; Nathan, Viswa B
A mobile thrombus in an otherwise normal ascending aorta is rare, but it should be thoroughly searched for in patients with unexplained cerebral or peripheral embolism. We report the case of a 49-year-old man admitted for right lower quadrant abdominal pain secondary to embolic renal infarction. Echocardiography and computed tomography of the chest revealed a 2.5 cm × 1.5 cm hypermobile mass at the distal ascending aorta, which was otherwise normal. No hypercoagulable condition could be identified. The mass was successfully removed with the patient under deep hypothermic circulatory arrest and was confirmed to be a thrombus. The cause of this thrombus remains unknown.
Mineta, Sho; Shimanuki, Kimiyoshi; Sugiura, Atsushi; Tsuchiya, Yoshikazu; Kaneko, Masahiro; Sugiyama, Yoshihiko; Akimaru, Koho; Tajiri, Takashi
Chronic anisakiasis of the colon is rare and difficult to diagnose. We report a case of chronic anisakiasis associated with advanced colonic carcinoma. A 69-year-old man was admitted for abdominal pain, diarrhea, and urticaria. Right hemicolectomy was performed because of an obstruction of the ascending colon and a palpable tumor of the right lower abdomen. The lesion was thought to be located in the deeper layers of the ascending colon. Preoperative examinations failed to detect the coexistence of anisakiasis and carcinoma of the colon. The anisakis was identified morphologically in the intestinal wall of the resected specimen and by an elevated titer of an IgE antibody specific to the parasite. Seventy-five cases of colonic and rectal anisakiasis, including the present case, have been reported in Japan. This is the only reported case of anisakiasis to appear in association with colonic carcinoma.
Smith, Craig R; Stamou, Sotiris C; Boeve, Theodore J; Hooker, Robert C
Penetrating ascending aortic ulcers are rarely encountered, yet they present significant risk of hemorrhage and aortic dissection. Expedient recognition and repair is of vital importance. The current management of penetrating ulcer of the ascending aorta includes replacement of the ascending aorta with a prosthetic graft. We describe our technique of repairing a penetrating ulcer of the ascending aorta with localized ulcer resection and extracellular matrix patch aortoplasty.
Marcaggi, X; Courant, N; Soubrier, M; Kemeny, J L; Camilleri, L; Lusson, J R; Cassagnes, J
The authors report the histological discovery of a case of Takayasu syndrome affecting the ascending aorta. This involvement appearing to concern only the aorta, with no symptomatic complaints nor any laboratory abnormalities indicative of an inflammatory syndrome, corticosteroids were not prescribed. Management consisted of biennial monitoring by transthoracic and transesophageal ultrasonography of the aorta and the supra-aortic main vessels together with monitoring of laboratory parameters.
Ebbesson, S O; Goodman, D C
Ascending spinal projections in the caiman (Caiman crocodilus) were demonstrated with Nauta and Fink-Heimer methods following hemisections of the third spinal segment in a series of twelve animals. These results were compared with earlier data in the literature obtained from a turtle, a snake, and a lizard using the same experimental and histological procedures. The results show remarkable similarities considering that each species represents a different reptilian order with different evolutionary history and habitat. However, the caiman displays several important peculiarities. Although the dorsal funiculus of the caiman contains the largest number of ascending spinal projections of the four species examined, this funiculus has not differentiated into cuneate and gracile fasciculi as is the case in the tegu lizard. The ventro-lateral ascending spinal projections follow a fundamentally similar general morphologic pattern in the four species with only minor variations. The anatomical arrangement in the caiman and tegu lizard appears most similar in the high cervical and the medullary regions; however, this is not the case in midbrain and thalamic regions where considerably more extensive projections are seen in the caiman. In the caiman an extensive spinal connection to the ventro-lateral nucleus of the dorsal thalamus is present; this connection is reminiscent of the mammalian spinal projection to the ventro-basal complex. The caiman has in common with the other three reptilian species a small projection to another dorsal thalamic region that is apparently homologous to the mammalian intralaminar nuclei, which are the destination of the mammalian paleospinothalamic tract.
Matsumoto, Kazuhisa; Hisashi, Yosuke; Imoto, Yutaka
A totally calcified ascending aorta prevents aortic crossclamping and aortotomy during aortic valve replacement, and replacement of the ascending aorta is a valid option in these cases. We describe a simple technique for calcified ascending aorta replacement using the Cavitron Ultrasonic Surgical Aspirator. This can be used in aortic endarterectomy for removal of the calcified plaque in the anastomotic part.
Maurice, Andrew Phillip; Ibrahim, Hany; Franz, Robert; Iswariah, Harish
A 31-year-old healthy man presented with right lower quadrant pain and tenderness, mild neutrophilia and clinical presentation consistent with appendicitis, despite undergoing a laparoscopic appendicectomy 5 years prior. CT scan demonstrated a caecal phlegmon, in the expected region of the appendiceal stump. The patient was taken for laparoscopy and a 2 cm inflamed appendiceal stump was encountered. A distal caecectomy was performed and the patient made an unremarkable recovery. Histological examination was consistent with acute inflammation of the appendiceal stump. Only a small number of case reports of stump appendicitis have been published so far. Correct identification and ligation of the appendiceal stump is crucial to prevent this complication. Although normally it is treated with completion appendicectomy, the optimal treatment approach for this condition has not been well established.
Chong, Hock Chin; Balakrishnan, Dhayal; Asilah, Siti Mohd Desa; Adila, Irene Nur Ibrahim; Syibrah, Khuzaimah Zahid
Subhepatically located caecum and appendix is a very rare entity. It occurs due to the anomaly in fetal gut rotation that results in an incomplete rotation and fixation of the intestine. Appendicitis, which is a common surgical emergency, in combination with the abnormal subhepatic location, presents a great challenge in its diagnosis and management. Here, we describe a 42-year-old male with chronic dyspepsia who presented with sepsis and severe pain at his right hypochondriac and epigastric region. The final diagnosis was acute appendicitis of the subhepatic appendix. Our discussion focuses on the diagnostic approach and clinical and surgical management. We hope that our report will increase the awareness among the clinicians and hasten the management of such rare condition to avoid complications. PMID:27648337
Vanwinter, Jo T; Beyer, Derek A
Recurrent right lower quadrant pain in young women can be a diagnostic dilemma. Chronic appendicitis is often mistakenly excluded from the differential diagnosis. In the present case, pelvic inflammatory disease was diagnosed in a 19-year-old woman with bilateral lower abdominal pain (greater on the right than the left), fever, and elevated white blood cell count. She was treated with intravenous antibiotics until resolution of symptoms. The pain recurred 1 month later, and the patient presented to our emergency department. At that time, she was afebrile and all laboratory results were normal or negative, aside from an elevated white blood cell count. Computed tomography suggested a right ovarian dermoid. At laparoscopy, however, the right tube and ovary were normal, and chronic appendicitis was confirmed. Although computed tomography is often accurate for delineating the cause of pelvic abnormality, it also may be misleading.
Steiner, Zvi; Buklan, Genady; Stackievicz, Rodica; Gutermacher, Michael; Litmanovitz, Ita; Golani, Guy; Arnon, Shmuel
The success rate of conservative treatment for children with uncomplicated appendicitis was prospectively evaluated among 197 children. All who received intravenous antibiotics for 3-5 days, and if symptoms resolved, were discharged home on oral antibiotics for 5 days. Failure rate, symptoms, laboratory signs, and sonographic findings were evaluated for prognostic markers of treatment failure. Children were followed for 18 months. The success rate of conservative treatment was 87%, with shorter hospital stays compared to children who eventually needed surgery (72 [60-84] vs. 84 h [72-126], P = 0.001). Vomiting and/or nausea and intraluminal fluid on sonography were the only prognostic signs of failed treatment (P = 0.028 and P = 0.0001, respectively). After multi-regression analysis, intraluminal fluid was the only prognostic sign for failed treatment (odds ratio = 10.2; 95% CI 3.3-31.8, P = 0.001). Patients who failed conservative treatment were successfully operated without significant morbidity. Pathology findings were compatible with acute or subacute inflammation in 94% of operated AA, with no perforated appendices. When applying rigorous criteria for children with uncomplicated appendicitis, a high success rate can be achieved with conservative treatment. Those who fail conservative treatment have a benign medical course without serious complications. Intraluminal fluid may increase risk for conservative treatment failure. What is Known: • Conservative treatment in uncomplicated acute appendicitis is a reasonable alternative to appendectomy. What is New: • Using rigorous criteria for conservative treatment in uncomplicated acute appendicitis is safe and feasible. • Intraluminal fluid should be considered a contraindication to conservative treatment.
Eren, T; Tombalak, E; Ozemir, I A; Leblebici, M; Ziyade, S; Ekinci, O; Alimoglu, O
Our aim was to establish the role of hyperbilirubinemia as a predictive parameter for the prediction of either acute, or gangrenous/perforated appendicitis as well as to compare other parameters in a similar role. Medical files of the patients who underwent appendectomies between September 2013 and September 2014 were evaluated. Age, gender, preoperative white blood cell count (WBC), neutrophil count (NEU), neutrophil percentage (NEU%), C-reactive protein (CRP), total/direct/indirect bilirubin levels, and the postoperative histopathological findings were recorded. The Fisher's exact, Pearson's χ (2), ANOVA, and Kruskal-Wallis tests while logistic regression for multivariate analysis was performed. p < 0.05 was accepted as statistically significant. The study group of 162 patients consisted of 97 (60 %) men and 65 (40 %) women with a median age of 36 (18-90). Histopathological examinations revealed normal appendix in 21 (13 %) patients, non-complicated acute appendicitis in 100 (62 %), and appendiceal gangrene/perforation in 41 (25 %) patients. WBC, NEU, NEU%, and CRP levels were significantly higher in cases of acute and gangrenous/perforated appendicitis (p < 0.01). Total and direct bilirubin levels were also significantly elevated in patients with acute and gangrenous/perforated appendicitis (p < 0.01). According to multivariate analysis, elevated CRP levels were associated with 14 times, elevated total bilirubin levels were associated with five times, and elevated direct bilirubin levels were associated with 36 times greater risk for appendiceal gangrene/perforation (p < 0.01, p < 0.05, p < 0.01, respectively). Hyperbilirubinemia, especially with elevated direct bilirubin levels, may be considered as an important marker for the prediction of appendiceal gangrene/perforation.
Sulkowski, Jason P.; Asti, Lindsey; Cooper, Jennifer N.; Kenney, Brian D.; Raval, Mehul V.; Rangel, Shawn J.; Deans, Katherine J.; Minneci, Peter C.
Background The purpose of this study was to compare postoperative outcomes of pediatric patients with complicated appendicitis managed with or without a peripherally inserted central catheter (PICC). Methods Patients ≤18 years old in the Pediatric Health Information System database with complicated appendicitis that underwent appendectomy during their index admission in 2000–2012 were grouped by whether they had a PICC placed using relevant procedure and billing codes. Rates of subsequent encounters within 30 days of discharge along with associated diagnoses and procedures were determined. A propensity score matched (PSM) analysis was performed to account for differences in baseline exposures and severity of illness. Results We included 33,482 patients with complicated appendicitis, of whom 6,620 (19.8%) received a PICC and 26,862 (80.2%) did not. The PICC group had a longer post-operative length of stay (median 7 vs. 5 days, p<0.001), and were more likely to undergo intra-abdominal abscess drainage during the index admission (14.4% vs. 2.1%, p<0.001), and have a re-encounter (17.5% vs. 11.4%, p<0.001) within 30 days of discharge. However, in the PSM cohort (n=4,428 in each group), outcomes did not differ between treatment groups, although the PICC group did have increased odds for development of other post-operative complications (odds ratio=3.95, 95% confidence interval: 1.45, 10.71). Conclusions After accounting for differences in severity of illness by propensity score matching, patients managed with PICCs had a similar risk for nearly all post-operative complications, including re-encounters. Post-operative management of pediatric complicated appendicitis with a PICC is not clearly associated with improved outcomes. PMID:24721604
Johnston, Jennifer; Myers, Daniel T; Williams, Todd R
Stump appendicitis, also known as remnant appendicitis, is an uncommon entity with little radiologic literature. It is the result of unintentional incomplete appendectomy with subsequent inflammatory changes in the appendiceal remnant. A retrospective review of the radiology and pathology archives at our institution over an 8-year period yielded six surgically/pathologically confirmed cases. Imaging findings at presentation were evaluated, including appendiceal stump length, appendiceal stump diameter, presence or absence of surrounding stranding in the periappendiceal fat, and presence or absence of complication (perforation or abscess). The CT findings of the six cases had an average surgical specimen appendiceal stump length of 3.5 cm (range 2.0-5 cm) and an average appendiceal diameter of 12.3 mm (range 10-16 mm). All six cases demonstrated the presence of periappendiceal inflammatory fat stranding on the CT scan. Range of imaging presentation is reviewed with pictorial examples as well as examples of potential false-positive cases (mimics) including Crohn's disease, residual surgical drain tract, and epiploic appendagitis. Familiarity with stump appendicitis as well as its imaging mimics may lead to earlier diagnosis and treatment and prevent unnecessary complications.
Montiel-Jarquín, Álvaro José; Ramírez-Sánchez, Celso; García-Cano, Eugenio; González-Hernández, Nicolás; Rodríguez-Pérez, Fabiola; Alvarado-Ortega, Ivan
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.
Alemayehu, Hanna; Desai, Amita A; Thomas, Priscilla; Sharp, Susan W; St Peter, Shawn D
Ceftriaxone has been associated with development of pseudolithiasis. In our institution, it is used for treatment of perforated appendicitis in children. This study evaluated the occurrence of ceftriaxone-related pseudolithiasis in this population. After obtaining IRB approval, we performed a retrospective chart review over 51 months. We included patients undergoing laparoscopic appendectomy for perforated appendicitis. All patients were treated with ceftriaxone post-operatively. Patients without initial or post-treatment gallbladder imaging available for review were excluded. There were 71 patients who met inclusion criteria with a mean (±SD) age of 10.8 ± 3.8 years. Of these, 14 % (n = 10) developed stones or sludge in the gallbladder. The mean duration of ceftriaxone therapy was 8.7 ± 3.8 days. The average time to post-antibiotic imaging was 11.5 ± 10.3 days from initiation of antibiotics. There was no significant difference in duration of ceftriaxone therapy in the children that developed pseudolithiasis or sludge (10.0 ± 4.9 days) compared to those that did not (8.5 ± 3.6, p = 0.26). One child (10 %) with pseudolithiasis went on to become symptomatic, requiring a laparoscopic cholecystectomy. In our experience, ceftriaxone use for perforated appendicitis is associated with a significant incidence of biliary pseudolithiasis, and is unrelated to duration of ceftriaxone therapy.
Cundy, Thomas P; Gent, Roger; Frauenfelder, Claire; Lukic, Laura; Linke, Rebecca J; Goh, Day Way
This study appraises the diagnostic quality of ultrasound for acute appendicitis in children and consequently challenges the perception of inferior accuracy and suitability compared to computed tomography (CT). Radiologist reports for consecutive "query appendicitis" ultrasound studies were retrieved from a hospital database for the study period 2009-2014. Children who subsequently underwent appendicectomy were identified. Corresponding operative and histopathology findings were evaluated. Diagnostic accuracy of ultrasound was determined by analyzing overall accuracy, sensitivity, specificity, predictivity, and likelihood ratios. A total of 3799 ultrasound examinations were evaluated. Mean age was 11.5±3.8years. The proportion of patients investigated with preoperative ultrasound was 59.9% (1103/1840). Appendix visualization rate was 91.7%. Overall diagnostic accuracy was 95.5%. Sensitivity and specificity values were 97.1% (95.9-98.1; 95% CI) and 94.8% (93.9-95.6; 95% CI), respectively. Separate analysis of only ultrasound positive and negative examinations (i.e., excluding nondiagnostic examinations) confirmed sensitivity and specificity values of 98.8% and 98.3%. In this largest reported single institution series of ultrasound examinations for appendicitis, we report benchmark standard quality of diagnostic accuracy and visualization rates. Given the radiation and cost implications of CT, there is a strong argument to recommend ultrasound as the primary imaging modality. Diagnostic Study-Level II. Copyright Â© 2016 Elsevier Inc. All rights reserved.
Carditello, A; Bartolotta, M; Bonavita, G; Lentini, B; Sturniolo, G
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.
Louis, Martine A.; Lin, Elizabeth; Baek, Ji Yoon; Andoni, Alda; Wang, Xiao Hui
General surgeons are often asked to evaluate acute abdominal pain which has an expanded differential diagnosis in women of childbearing age. Acute appendicitis accounts for many surgical emergencies as a common cause of nongynecologic pelvic pain. In some rare instances, acute appendicitis has been shown to occur simultaneously with a variety of gynecologic diseases. We report a case of concurrent acute appendicitis and ruptured ovarian endometrioma. PMID:28097032
Sanchez, Thomas Ray; Corwin, Michael T; Davoodian, Andrew; Stein-Wexler, Rebecca
Abdominal pain is very common in the pediatric population (<18 years of age). Sonography is a safe modality that can often differentiate the frequently encountered causes of abdominal pain in children. This pictorial essay will discuss the sonographic findings of acute appendicitis, including the imaging appearance of a perforated appendicitis. It will also present the sonographic features of the relatively common mimics of appendicitis, such as mesenteric adenitis/gastroenteritis, intussusception, Meckel diverticulum, and ovarian torsion.
Kaminski, Anna; Liu, In-Lu Amy; Applebaum, Harry; Lee, Steven L; Haigh, Philip I
The role of interval appendectomy (IA) after an episode of acute appendicitis is debated. Patients treated nonoperatively for acute appendicitis do not require routine IA. Retrospective cohort study using discharge abstract data. Twelve regional Kaiser Permanente hospitals in Southern California. A total of 32 938 patients were hospitalized with acute appendicitis. Appendectomy or nonoperative treatment with or without abscess drainage. Hospitalization for recurrent appendicitis or IA. The type of appendicitis was abscess in 7% of patients, peritonitis in 18%, and no peritonitis or abscess in 75%. Emergency appendectomy was performed in 31 926 (97%) patients. Nonoperative treatment was used initially in 1012 patients (3%). Of these, 148 (15%) had an IA and the remaining 864 (85%) did not. Thirty-nine patients (5%) recurred after a median follow-up of 4 years. Using Cox regression, sex had a slight influence on recurrent appendicitis (hazard ratio males vs females = 0.52, 95% CI, 0.27-0.99, P = .05). Age, Charlson comorbidity index, type of appendicitis, or percutaneous abscess drainage had no influence on recurrence. Median length of hospital stay was 4 days for the admission for recurrent appendicitis compared with 6 days for the IA admission (P = .006). Most patients with acute appendicitis undergo appendectomy initially. For those treated nonoperatively, the recurrence rate is low. Routine IA after initial successful nonoperative treatment is not justified and should be abandoned.
Laméris, W.; van Es, H. W.; ten Hove, W.; Bouma, W. H.; van Leeuwen, M. S.; van Keulen, E. M.; van der Hulst, V. P. M.; Henneman, O. D.; Bossuyt, P. M.; Boermeester, M. A.; Stoker, J.
Objectives To identify and evaluate profiles of US and CT features associated with acute appendicitis. Methods Consecutive patients presenting with acute abdominal pain at the emergency department were invited to participate in this study. All patients underwent US and CT. Imaging features known to be associated with appendicitis, and an imaging diagnosis were prospectively recorded by two independent radiologists. A final diagnosis was assigned after 6 months. Associations between appendiceal imaging features and a final diagnosis of appendicitis were evaluated with logistic regression analysis. Results Appendicitis was assigned to 284 of 942 evaluated patients (30%). All evaluated features were associated with appendicitis. Imaging profiles were created after multivariable logistic regression analysis. Of 147 patients with a thickened appendix, local transducer tenderness and peri-appendiceal fat infiltration on US, 139 (95%) had appendicitis. On CT, 119 patients in whom the appendix was completely visualised, thickened, with peri-appendiceal fat infiltration and appendiceal enhancement, 114 had a final diagnosis of appendicitis (96%). When at least two of these essential features were present on US or CT, sensitivity was 92% (95% CI 89–96%) and 96% (95% CI 93–98%), respectively. Conclusion Most patients with appendicitis can be categorised within a few imaging profiles on US and CT. When two of the essential features are present the diagnosis of appendicitis can be made accurately. PMID:20119730
Uludag, Mehmet; Isgor, Adnan; Basak, Muzaffer
Stump appendicitis is an acute inflammation of the residual appendix and one of the rare complications after appendectomy. Paying attention to the possibility of stump appendicitis in patients with right lower abdominal pain after appendectomy can prevent the delay of diagnosis and treatment. In patients with stump appendicitis, CT scan not only assists in making an accurate preoperative diagnosis but also excludes other etiologies. We report a 47-year old man with preoperatively diagnosed stump appendicitis by CT, who underwent an open appendectomy 20 years ago.
Santillanes, Genevieve; Simms, Sonia; Gausche-Hill, Marianne; Diament, Michael; Putnam, Brant; Renslo, Richard; Lee, Jumie; Tinger, Elga; Lewis, Roger J.
Objectives The objective was to assess the performance of a clinical practice guideline for evaluation of possible appendicitis in children. The guideline incorporated risk stratification, staged imaging, and early surgical involvement in high-risk cases. Methods The authors prospectively evaluated the clinical guideline in one pediatric emergency department (ED) in a general teaching hospital. Patients were risk-stratified based on history, physical examination findings, and laboratory results. Imaging was ordered selectively based on risk category, with ultrasound (US) as the initial imaging modality. Computed tomography (CT) was ordered if the US was negative or indeterminate. Surgery was consulted before imaging in high-risk patients. Results A total of 475 patients were enrolled. Of those, 193 (41%) had appendicitis. No low-risk patient had appendicitis. Medium-risk patients had a 19% rate of appendicitis, and 83% of high-risk patients had appendicitis. Factors associated with an increased likelihood of appendicitis included decreased bowel sounds; rebound tenderness; and presence of psoas, obturator, or Rovsing’s signs. Of the 475 patients, 276 (58%) were managed without a CT scan. Seventy-one of the 193 (37%) patients with appendicitis went to the operating room without any imaging. The rate of missed appendicitis was 2%, and the rate of negative appendectomy was 1%. Conclusions The clinical practice guideline performed well in a general teaching hospital. Rates of negative appendectomy and missed appendicitis were low and 58% of patients were managed without a CT scan. PMID:22849662
Battaglia, Luigi; Belli, Filiberto; Vannelli, Alberto; Bonfanti, Giuliano; Gallino, Gianfrancesco; Poiasina, Elia; Rampa, Mario; Vitellaro, Marco; Leo, Ermanno
Idiopathic segmental infarction of the greater omentum is an uncommon cause of acute abdomen. The etiology is still unclear and the symptoms mimic acute appendicitis. Its presentation simultaneously with acute appendicitis is still more infrequent. We present a case of a 47-year old woman without significant previous medical history, admitted with an acute abdomen, in which the clinical diagnosis was acute appendicitis and in whom an infarcted segment of right side of the greater omentum was also found at laparotomy. As the etiology is unknown, we highlighted some of the possible theories, and emphasize the importance of omental infarction even in the presence of acute appendicitis as a coincident intraperitoneal pathological condition.
Chen, Fang; Wu, Hui; Wu, Yun; Mao, Ren; Zhang, Shenghong; Feng, Ting; Tang, Ruihan; Chen, Baili; Zeng, Zhirong; Chen, Minhu; He, Yao
To analyze the clinical manifestations and identify independent diagnostic predictive factors for Crohn's disease (CD) initially diagnosed as appenicitis and treated by surgery. The medical records of patients diagnosed as acute appendicitis upon admission and treated by surgical operation in the First Affiliated Hospital of Sun Yat-sen University from January 2000 to December 2014 were retrospectively analyzed. Based on postoperative pathological examination and clinical examination results, 28 CD patients were identified (CD group), and for each CD case, 3 controls with confirmed diagnosis of appendicitis were included (appendicitis group, n=84). Clinical manifestations and laboratory examination results of the two groups were analyzed with multivariable Logistic regression to determine independent diagnostic predictive factors for CD initially misdiagnosed as appendicitis. Altogether 112 patients were enrolled, with a male-to-female ratio of 1.04:1 (57:55), and a median age of 36 years. No significant differences were found in gender, age, and body temperature between the CD group and appendicitis group (all P>0.05). In the appendicitis and CD groups, median duration (Q1-Q3) of abdominal pain was 24 (14-48) hours vs 216 (96-384) hours, proportion of patients with lower right abdominal pain was 98.8% (83/84) vs 75.0% (21/28), proportion of patients with shifting lower right abdominal pain was 98.8% (83/84) vs 7.1% (2/28), proportion of patients with local lower right peritonitis was 95.2% (80/84) vs 53.6% (15/28), proportion of patients with change of bowel emptying habit or stool consistency was 7.1% (6/84) vs 46.4% (13/28), proportion of patients with history of chronic abdominal pain or diarrhea was 10.7% (9/84) vs 75.0% (21/28), preoperative white blood cell count was (14.08±4.13)×10(9)/L vs (8.00±3.42)×10(9)/L, preoperative neutrophil count was (11.34±4.10)×10(9)/L vs (5.58±3.22)×10(9)/L, preoperative hemoglobin was (139.52±19.90) g/L vs (107.65±21
Xu, Yingding; Jeffrey, R Brooke; Chang, Stephanie T; DiMaio, Michael A; Olcott, Eric W
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.
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
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.
Ceylan, Bahadır; Aslan, Turan; Çınar, Ahmet; Ruhkar Kurt, Ayşe; Akkoyunlu, Yasemin
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.
Lee, Jung Hun; Park, Young Sun; Choi, Joong Sub
Background Appendicitis is one of the most frequent acute surgical conditions of the abdomen, and appendectomy is one of the most commonly performed operations in the world. However, epidemiological data on appendicitis have not been reported for South Korean or East Asian populations. Methods We analyzed the epidemiological features and lifetime risk of appendicitis and appendectomy in South Korea using data collected for the national health insurance database from 2005 through 2007. Results Appendectomy was performed in 59.70% of inpatients diagnosed with appendicitis. The overall incidences of appendicitis, total appendectomy, and perforated appendectomy were 22.71, 13.56, and 2.91 per 10 000 population per year, respectively. The incidence of appendicitis and appendectomy showed clear seasonality, with a peak in summer. The standardized lifetime risks of appendicitis and appendectomy were constant from 2005 through 2007. A life table model suggests that the lifetime risk of appendicitis is 16.33% for males and 16.34% for females, and that the lifetime risk of appendectomy is 9.89% for males and 9.61% for females. Conclusions As compared to results obtained in research on Western populations, appendicitis and appendectomy had a similar perforation rate and seasonality, but a higher overall incidence, in South Koreans. Between 2005 and 2007, the incidence of appendicitis and appendectomy was constant. Overall, an estimated 15 incidental appendectomies are performed to prevent 1 inpatient with suspected appendicitis, and 26 incidental appendectomies are performed to prevent 1 appendectomy. Incidental appendectomy may have greater preventive value in Koreans. PMID:20023368
Chen, Ko-Chin; Arad, Alon; Chen, Ko-Chien; Storrar, Jonathan; Christy, Andrew G
To explore the diagnostic accuracy of acute appendicitis among different patient groups and evaluate the statistical diagnostic values of common pathology and imaging tests for the diagnosis of acute appendicitis. Proportions of histology-proven appendicitis in different patient groups. Statistical parameters including sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (+LR), negative likelihood ratio (-LR) and diagnostic odds ratio (DOR) between the histology-proven appendicitis and abnormal results of U/S, CT, WCC, CRP, bilirubin, pancreatic, and combined test results of WCC and CRP. Our data showed that up to 25.7% of patients underwent appendectomy has normal appendix. Appendicitis is often accurately diagnosed among male patients, up to 90.3% of the time, while misdiagnosis of appendicitis among young females (<40 years old) is significantly high, up to 30.9%. CT has high diagnostic performance index for appendicitis, sensitivity > 90%, and no individual pathology test out of those examined can rival the sensitivity of CT. Nevertheless, by examining the combined results of WCC and CRP, we found that abnormal results in one or both these yields sensitivity similar to CT scans in detecting acute appendicitis, up to 95%. Young female patients have highest risk of being falsely diagnosed with acute appendicitis and hence unnecessary surgery. Bilirubin and lipase exhibit no correlations with acute appendicitis. Combined interpretation of WCC or CRP abnormal results yields competitive sensitivity as CT. Hencewe would suggest that, under the appropriate clinical context, one can use both WCC and CRP as a simple tool to support the diagnosis of appendicitis. If both tests show normal results, we would highly recommend considering alternative diagnosis. 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/
Duda, Jeremy B; Lynch, Miranda L; Bhatt, Shweta; Dogra, Vikram S
Imaging and pathology findings are used to analyze the capability of computed tomography (CT) to distinguish between acute appendicitis and radiological mimickers. A retrospective review of 5861 patients undergoing abdominopelvic CT from 2000 to 2008 for suspicion of acute appendicitis was performed. Appendix diameter, surrounding inflammation, appendicolith, and location were assessed. Only those cases were included where patients underwent surgery for acute appendicitis on CT findings. Pathology specimens were examined and those indicative of acute appendicitis were identified. Statistical analysis was performed to correlate pathology and CT signs. A total of 969 of the 5681 patients were included in the study. Acute appendicitis was verified in 870/969 (89%) cases, while 99/969 (11%) demonstrated either chronic findings (i.e., fibrosis [32%], granulomatous disease [16%], lymphoid hyperplasia [11%]) or no abnormality. In regression models, appendiceal diameter >7 mm (odds ratio [OR] = 3.98, P < 0.0001) and mesenteric fat stranding (OR = 6.04, P < 0.0001) were associated with acute appendicitis. Nearly 87% (754/870) of acute appendicitis cases showed both signs on CT, compared with 53% (52/99) of those with other pathologic finding (P < 0.0001). In cases with non-appendicitis findings, 39% (39/99) had only one of these signs compared with 13% (112/870) of those with acute appendicitis (P < 0.0001). Diseases of the appendix other than acute appendicitis may manifest with isolated radiological findings and should be considered as part of the differential diagnosis in cases of borderline acute appendicitis.
Lakhotia, Siddharth; Prakash, Shashi; Singh, Dinesh Kumar; Kumar, Ashok; Panigrahi, Debasish
Penetrating injuries of the aorta are rare and highly lethal; very few patients are able to reach the hospital alive. We report a case of penetrating injury into the ascending aorta with the arrow still in situ, shot by a bow in a tribal region of India. The wound of entry into the aorta was sealed by the arrow itself. The patient came to us walking and supporting the arrow with his left hand. He was operated on, and the arrow was successfully removed from the aorta. Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.
Yao, Justin D.; Bremen, Peter
Stream segregation enables a listener to disentangle multiple competing sequences of sounds. A recent study from our laboratory demonstrated that cortical neurons in anesthetized cats exhibit spatial stream segregation (SSS) by synchronizing preferentially to one of two sequences of noise bursts that alternate between two source locations. Here, we examine the emergence of SSS along the ascending auditory pathway. Extracellular recordings were made in anesthetized rats from the inferior colliculus (IC), the nucleus of the brachium of the IC (BIN), the medial geniculate body (MGB), and the primary auditory cortex (A1). Stimuli consisted of interleaved sequences of broadband noise bursts that alternated between two source locations. At stimulus presentation rates of 5 and 10 bursts per second, at which human listeners report robust SSS, neural SSS is weak in the central nucleus of the IC (ICC), it appears in the nucleus of the brachium of the IC (BIN) and in approximately two-thirds of neurons in the ventral MGB (MGBv), and is prominent throughout A1. The enhancement of SSS at the cortical level reflects both increased spatial sensitivity and increased forward suppression. We demonstrate that forward suppression in A1 does not result from synaptic inhibition at the cortical level. Instead, forward suppression might reflect synaptic depression in the thalamocortical projection. Together, our findings indicate that auditory streams are increasingly segregated along the ascending auditory pathway as distinct mutually synchronized neural populations. SIGNIFICANCE STATEMENT Listeners are capable of disentangling multiple competing sequences of sounds that originate from distinct sources. This stream segregation is aided by differences in spatial location between the sources. A possible substrate of spatial stream segregation (SSS) has been described in the auditory cortex, but the mechanisms leading to those cortical responses are unknown. Here, we investigated SSS in
Di Benedetto, Giuseppe; Citro, Rodolfo; Longobardi, Antonio; Mastrogiovanni, Generoso; Panza, Antonio; Iesu, Severino; Bossone, Eduardo
We report the case of a 46-year-old male hospitalized for abdominal pain and fever with history of a David procedure followed by an aortic valve replacement due to severe aortic regurgitation. Transesophageal echocardiography (TEE) and computed tomography showed a large mass floating in the aorta. After surgical excision of the vegetation, attached to the Dacron prosthesis, histological examination revealed Candida hyphae and spores confirming the diagnosis of a mycetoma in an ascending aorta tubular graft. At six-month follow-up, the patient was in good clinical condition without recurrence of the fungal mass on TEE. © 2013 Wiley Periodicals, Inc.
Hijikawa, Takeshi; Yoshida, Ryo; Yamada, Masanori; Nakatani, Kazuyoshi; Tokuhara, Katsuji; Kitade, Hiroaki; Shikata, Nobuaki; Yoshioka, Kazuhiko; Kon, Masanori
We report a case of adenosquamous carcinoma of the colon. A 70-year-old woman underwent a colonoscopic examination because of a positive fecal occult blood test. Colonoscopy demonstrated a type 2 tumor of the ascending colon, and a biopsy specimen showed poorly-moderately differentiated tubular adenocarcinoma. We performed a right hemicolectomy with D2 lymphadenectomy. The histopathology of the tumor demonstrated adenosquamous adenocarcinoma. Primary adenosquamous carcinoma of the colon is relatively rare and has a poor prognosis. Therefore, adenosquamous carcinoma of the colon may require strict follow-up.
Campbell, Jessica; Huang, Yumeng; Liu, Yuanjun; Schenken, Robert; Arulanandam, Bernard; Zhong, Guangming
Chlamydial pathogenicity in the upper genital tract relies on chlamydial ascending from the lower genital tract. To monitor chlamydial ascension, we engineered a luciferase-expressing C. muridarum. In cells infected with the luciferase-expressing C. muridarum, luciferase gene expression and enzymatic activity (measured as bioluminescence intensity) correlated well along the infection course, suggesting that bioluminescence can be used for monitoring chlamydial replication. Following an intravaginal inoculation with the luciferase-expressing C. muridarum, 8 of 10 mice displayed bioluminescence signal in the lower with 4 also in the upper genital tracts on day 3 after infection. By day 7, all 10 mice developed bioluminescence signal in the upper genital tracts. The bioluminescence signal was maintained in the upper genital tract in 6 and 2 mice by days 14 and 21, respectively. The bioluminescence signal was no longer detectable in any of the mice by day 28. The whole body imaging approach also revealed an unexpected airway infection following the intravaginal inoculation. Although the concomitant airway infection was transient and did not significantly alter the genital tract infection time courses, caution should be taken during data interpretation. The above observations have demonstrated that C. muridarum can not only achieve rapid ascending infection in the genital tract but also cause airway infection following a genital tract inoculation. These findings have laid a foundation for further optimizing the C. muridarum intravaginal infection murine model for understanding chlamydial pathogenic mechanisms.
Campbell, Jessica; Huang, Yumeng; Liu, Yuanjun; Schenken, Robert; Arulanandam, Bernard; Zhong, Guangming
Chlamydial pathogenicity in the upper genital tract relies on chlamydial ascending from the lower genital tract. To monitor chlamydial ascension, we engineered a luciferase-expressing C. muridarum. In cells infected with the luciferase-expressing C. muridarum, luciferase gene expression and enzymatic activity (measured as bioluminescence intensity) correlated well along the infection course, suggesting that bioluminescence can be used for monitoring chlamydial replication. Following an intravaginal inoculation with the luciferase-expressing C. muridarum, 8 of 10 mice displayed bioluminescence signal in the lower with 4 also in the upper genital tracts on day 3 after infection. By day 7, all 10 mice developed bioluminescence signal in the upper genital tracts. The bioluminescence signal was maintained in the upper genital tract in 6 and 2 mice by days 14 and 21, respectively. The bioluminescence signal was no longer detectable in any of the mice by day 28. The whole body imaging approach also revealed an unexpected airway infection following the intravaginal inoculation. Although the concomitant airway infection was transient and did not significantly alter the genital tract infection time courses, caution should be taken during data interpretation. The above observations have demonstrated that C. muridarum can not only achieve rapid ascending infection in the genital tract but also cause airway infection following a genital tract inoculation. These findings have laid a foundation for further optimizing the C. muridarum intravaginal infection murine model for understanding chlamydial pathogenic mechanisms. PMID:24983626
Lohman, A H; van Woerden-Verkley, I
The ascending connections to the striatum and the cortex of the Tegu lizard, Tupinambis nigropunctatus, were studied by means of anterograde fiber degeneration and retrograde axonal transport. The striatum receives projections by way of the dorsal peduncle of the lateral forebrain bundle from four dorsal thalamic nuclei: nucleus rotundus, nucleus reuniens, the posterior part of the dorsal lateral geniculate nucleus and nucleus dorsomedialis. The former three nuclei project to circumscribed areas of the dorsal striatum, whereas nucleus dorsomedialis has a distribution to the whole dorsal striatum. Other sources of origin to the striatum are the mesencephalic reticular formation, substantia nigra and nucleus cerebelli lateralis. With the exception of the latter afferentation all these projections are ipsilateral. The ascending connections to the pallium originate for the major part from nucleus dorsolateralis anterior of the dorsal thalamus. The fibers course in both the medial forebrain bundle and the dorsal peduncle of the lateral forebrain bundle and terminate ipsilaterally in the middle of the molecular layer of the small-celled part of the mediodorsal cortex and bilaterally above the intermediate region of the dorsal cortex. The latter area is reached also by fibers from the septal area. The large-celled part of the mediodorsal cortex receives projections from nucleus raphes superior and the corpus mammillare.
Susak, Stamenko; Redzek, Aleksandar; Torbica, Vladimir; Rajić, Jovan; Todić, Mirko
Intramural hematoma of the aorta presents potentially fatal condition developing as a result of a vasa vasorum rupture. It is a major risk factor for developing a frank aortic dissection. A 65-year-old woman was admitted to our clinic for the second time, after her symptoms of chest pain and vertigo (with no electrocardiographic signs of myocardial infarction) hadn't disappeared after several months of medicament treatment (indicated in the first hospitalization). Computed tomography arteriography of the aorta showed no sign of acute aortic dissection, but revealed a contrast depo in the aortic wall of 8 x 14 mm dimensions, with no extravasation of contrast. Also, massive pericardial effusion was observed (10-30 mm in thickness). Transesophageal echocardiography confirmed these findings completely. The patient underwent surgery, in which plaque exulceration was detected on the convex side of the ascending aorta, 3 cm above the aortic valve, 1 cm in diameter, with no signs of intimal tear. A resection of the ascending aorta was performed, and the aorta was reconstructed with a 30 mm Dacron tube graft. The patient was discharged on the 14th postoperative day with satisfactory results. Intramural hematoma is not a common event, but it is potentially a fatal one. Open surgery in patients with an intramural hematoma is an effective treatment strategy, although percutaneous endovascular treatment options are being described.
McKinley, David P.
Significant error has been observed in the long term prediction of the Mean Local Time of the Ascending Node on the Aqua spacecraft. This error of approximately 90 seconds over a two year prediction is a complication in planning and timing of maneuvers for all members of the Earth Observing System Afternoon Constellation, which use Aqua's MLTAN as the reference for their inclination maneuvers. It was determined that the source of the prediction error was the lack of a solid Earth tide model in the operational force models. The Love Model of the solid Earth tide potential was used to derive analytic corrections to the inclination and right ascension of the ascending node of Aqua's Sun-synchronous orbit. Additionally, it was determined that the resonance between the Sun and orbit plane of the Sun-synchronous orbit is the primary driver of this error. The analytic corrections have been added to the operational force models for the Aqua spacecraft reducing the two-year 90-second error to less than 7 seconds.
Bonnier, Franck; Rubin, Sylvain; Debelle, Laurent; Ventéo, Lydie; Pluot, Michel; Baehrel, Bernard; Manfait, Michel; Sockalingum, Ganesh D
The advent of moderate dilatations in ascending aortas is often accompanied by structural modifications of the main components of the aortic tissue, elastin and collagen. In this study, we have undertaken an approach based on FTIR microscopy coupled to a curve-fitting procedure to analyze secondary structure modifications in these proteins in human normal and pathological aortic tissues. We found that the outcome of the aortic pathology is strongly influenced by these proteins, which are abundant in the media of the aortic wall, and that the advent of an aortic dilatation is generally accompanied by a decrease of parallel beta-sheet structures. Elastin, essentially composed of beta-sheet structures, seems to be directly related to these changes and therefore indicative of the elastic alteration of the aortic wall. Conventional microscopy and confocal fluorescence microscopy were used to compare FTIR microscopy results with the organization of the elastic fibers present in the tissues. This in-vitro study on 6 patients (three normal and three pathologic), suggests that such a spectroscopic marker, specific to aneurismal tissue characterization, could be important information for surgeons who face the dilemma of moderate aortic tissue dilatation of the ascending aortas.
Li, Yingjie; Li, Mingshan; Li, Xiaoxia; Sang, Haiquan
Abstract Rationale: Metastasis of cancer cells involves shedding from the primary tumor through various means to distant tissues and organs with continued growth and formation of new metastatic tumors of the same cancer type as the original tumor. The common sites for colon cancer metastases include the pelvis, retroperitoneal lymph nodes, liver, and lungs; Colon cancer metastases to the appendix are rare, as reported in this case. Patient concerns and diagnoses: A 45-year-old man was admitted to our department with a 24-hour history of abdominal distension and incomplete obstruction. Colonoscopy showed an elevated lesion in the ascending colon and the pathologic diagnosis was adenocarcinoma. Interventions and outcomes: This patient underwent a radical right hemi-colectomy. The post-operative pathologic examination revealed metastatic adenocarcinoma in all layers of the appendix, especially the muscularis mucosae. The diagnosis was adenocarcinoma of the ascending colon (pT4bN2bM0 stage IIIC) with metastatic adenocarcinoma of the appendix. Lessons: An absent right colic artery with lymph node fusion might increase the risk of appendiceal cancer metastasis. PMID:28296772
Burcu, Busra; Ekinci, Ozgur; Inan, Ibrahim; Ozyalvac, Ferman Tevfik; Eren, Turgut Tunc; Alimoglu, Orhan
Epiploic appendices, first described in 1543 by Vesalius, are fatty structures which are attached through the length of the colon and consisted of visceral peritoneum. Epiploic appendicitis is an uncommon and self-limiting disease. In this report, we aimed to present two patients with epiploic appendicitis. PMID:28058362
Kılıç, Murat Özgür; Güldoğan, Cem Emir; Balamir, İlhan; Tez, Mesut
The early prediction of gangrenous/perforated appendicitis is of great importance for the surgical planning, further treatments, and predicting the course of disease. Ischemia-modified albumin (IMA) was previously reported as a biomarker of various ischemia-based diseases. Our aim is to determine the predictive value of serum IMA in the severity of acute appendicitis. Sixty-two patients who underwent urgent appendectomy were included in the study. Plasma level of IMA was measured after diagnosis and before treatment. All patients were classified as noncomplicated (acute) appendicitis and complicated (gangrenous/perforated) appendicitis according to histopathological findings, and comparisons were made between the groups. The data of 62 patients with a mean age of 30.1 years were statistically evaluated. The pathological diagnoses were acute appendicitis in 33 (53.2%), and gangrenous/perforated appendicitis in 29 (46.8%) patients. There were significant differences in computed tomography (CT) findings (P = .031) and IMA (P = .012) levels between the groups. A strong positive correlation between IMA levels and CT findings was also found (Spearman ρ = +0.688, P = .003). The IMA can be considered as a novel and useful marker to distinguish gangrenous/perforated appendicitis from noncomplicated appendicitis. The correlation of IMA with CT findings also enhances the predictive value of IMA. Copyright © 2016 Elsevier Inc. All rights reserved.
Partain, Kristin N; Patel, Adarsh; Travers, Curtis; McCracken, Courtney E; Loewen, Jonathan; Braithwaite, Kiery; Heiss, Kurt F; Raval, Mehul V
Ultrasound (US) is the preferred imaging modality for evaluating appendicitis. Our purpose was to determine if including secondary signs (SS) improve diagnostic accuracy in equivocal US studies. 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. 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. Use of SS in RLQ US assists in the diagnostic accuracy of appendicitis. SS may guide clinicians and reduce unnecessary CT and admissions. Copyright © 2016 Elsevier Inc. All rights reserved.
Tsai, Ming-Chieh; Lin, Herng-Ching; Lee, Cha-Ze
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.
Smith, Emily K; Ek, Edmund; Croagh, Daniel; Spain, Lavinia A; Farrell, Stephen
We report a case of acute chylous peritonitis mimicking acute appendicitis in a man with acute on chronic pancreatitis. Pancreatitis, both acute and chronic, causing the development of acute chylous ascites and peritonitis has rarely been reported in the English literature. This is the fourth published case of acute chylous ascites mimicking acute appendicitis in the literature.
Blevrakis, Evangelos; Tampakaki, Zoi; Dimopoulou, Anastasia; Bakantaki, Anna; Blevrakis, Emmanouil; Sakellaris, George
We report an unusual case of a 3-year-old child with appendicitis complicated by ileoileal intussusception. Although acute complicated appendicitis and concurrent ileoileal intussusception represent a possible cause of an acute abdomen, very few cases have been reported in the literature.
Osuna-Ramos, Juan Fidel; Silva-Gracia, Carlos; Maya-Vacio, Gerardo Joel; Romero-Utrilla, Alejandra; Ríos-Burgueño, Efrén Rafael; Velarde-Félix, Jesús Salvador
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.
Aguiló, Javier; Peiró, Salvador; Muñoz, Carmen; García del Caño, Julián; Garay, Miguel; Viciano, Vicente; Ferri, Ramón; García-Botella, Miguel; Medrano, José; Torró, José
To describe adverse outcomes after appendectomy for acute appendicitis and to analyze the association between these outcomes and specific characteristics of the patient and hospital admission. We studied a cohort of 792 patients who underwent appendectomy for acute appendicitis. Postoperative complications, reoperations and deaths were prospectively studied and all readmissions were retrospectively identified. Logistic regression was used to evaluate the relationship between complications and patient characteristics, as well as hospital admission. Postsurgical complications developed in 9.8% of the patients. These complications mainly consisted of surgical wound infection (4.2%) and intra-abdominal complications (2.1%). A total of 0.7% of patients underwent reoperation during admission, 0.5% were admitted to the intensive care unit and five patients (0.6%) died in hospital. The rate of operation-related readmissions in the following year was 3.2%. Length of hospital stay was longer in patients with complications than in those without complications (9.6 and 3.5 days, respectively). Postoperative complications were associated with older age (45-65 years, OR 3.62, p < 0.001; more than 65 years OR 8.68, p < 0.001) and acute appendicitis complicated with peritonitis or perforation (OR 3.69, p < 0.005). Readmissions related to previous surgery were associated only with complications during the first admission (OR 18.79, p < 0.001). In appendectomy, the most frequent adverse outcomes are surgical wound infection and intra-abdominal complications, which are associated with older patients and perforations. This subgroup of patients at high risk requires closer surveillance.
Xu, Feng-feng; Xiao, Long-bin; Wu, Wen-hui; Zhang, Xing-wei; Long, Shuo; Tan, Jin-fu; Tan, Min
To compare the advantages and disadvantages of laparoscopic versus open appendectomy in patients with chronic appendicitis. Two hundred twenty- four patients were divided into laparoscopic group (n=98) and open appendectomy group (n=126) according to individual willing. Prospective non- randomized study was performed to compare the operative time, operative bleeding, hospitalization time, the discovery and management concerned in operation. Abdominal pain in these chronic appendicitis cases was followed up. The operative time was (54.8+/-21.8) min in open group and (51.8+/-18.0) min in laparoscopic group (t=0.80,P > 0.05). The operative bleeding was (18.6+/-23.3) ml in open group and (9.8+/-4.7) ml in laparoscopic group (t=3.13, P < 0.05). The hospitalization time was (8.9+/-5.3) d in open group and (6.8+/-3.0) d in laparoscopic group (t=2.66,P < 0.05). Twenty- five cases had abdominal adhesion in laparoscopic group, including 9 cases of adhesion around appendix, 6 cases of adhesion between ileocecum and anterior or lateral abdominal wall, 4 cases of adhesion between epiploon and abdominal wall or intestines, 6 cases of adhesion around colon and others. All adhesion had been dissected. Fourteen cases adhesion around appendix had been discovered in 126 cases of open group and dissected (chi(2) =7.95,P < 0.05). In follow- up research, 24 cases still had chronic abdominal pain in 98 case of open group, and 9 cases had chronic abdominal pain in 87 of laparoscopic group, the difference was significant (chi(2)=6.29,P < 0.05). The laparoscopic appendectomy possesses more advantages in treating chronic appendicitis and can decrease the incidence of chronic abdominal pain after operation.
Dinc, Bulent; Oskay, Alten; Dinc, Selcan Enver; Bas, Bilge; Tekin, Sabri
AIM: To investigate the diagnostic accuracy of the mean platelet volume and platelet distribution width in acute appendicitis. METHODS: This retrospective, case-controlled study compared 295 patients with acute appendicitis (Group I), 100 patients with other intra-abdominal infections (Group II), and 100 healthy individuals (Group III) between January 2012 and January 2013. The age, gender, and white blood cell count, neutrophil percentage, mean platelet volume, and platelet distribution width values from blood samples were compared among the groups. Statistical analyses were performed using SPSS for Windows 21.0 software. In addition, the sensitivity, specificity, positive and negative predictive values and likelihood ratios, and diagnostic accuracy were calculated. RESULTS: The mean ages of patients were 29.9 ± 12.0 years for Group I, 31.5 ± 14.0 years for Group II, and 30.4 ± 13.0 years for Group III. Demographic features such as age and gender were not significantly different among the groups. White blood cell count, neutrophil percentage and platelet distribution width were significantly higher in Group I compared to groups II and III (P < 0.05). Diagnostically, the sensitivity, specificity and diagnostic accuracy were 73.1%, 94.0%, and 78% for white blood cell count, 70.0%, 96.0%, and 76.0% for neutrophil percentage, 29.5%, 49.0%, and 34.0% for mean platelet volume, and 97.1%, 93.0%, and 96.0% for platelet distribution width, respectively. The highest diagnostic accuracy detected was for platelet distribution width between Group I and Group III (P < 0.01). CONCLUSION: Platelet distribution width analysis can be used for diagnosis of acute appendicitis without requiring additional tests, thus reducing the cost and loss of time. PMID:25684947
Sarda, Samir; Short, Heather L; Hockenberry, Jason M; McCarthy, Ian; Raval, Mehul V
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.
Kawa, S. R.; Baker, D. F.; Schuh, A. E.; Crowell, S.; Rayner, P. J.; Hammerling, D.; Michalak, A. M.; Wang, J. S.; Eluszkiewicz, J.; Ott, L.; Zaccheo, T.; Abshire, J. B.; Browell, E. V.; Moore, B.; Crisp, D.
The measurement of atmospheric CO2 from space using active (lidar) sensing techniques has several potentially significant advantages in comparison to current and planned passive CO2 instruments. Application of this new technology aims to advance CO2 measurement capability and carbon cycle science into the next decade. The NASA Active Sensing of Carbon Emissions, Nights, Days, and Seasons (ASCENDS) mission has been recommended by the US National Academy of Sciences Decadal Survey for the next generation of space-based CO2 observing systems. ASCENDS is currently planned for launch in 2022. Several possible lidar instrument approaches have been demonstrated in airborne campaigns and the results indicate that such sensors are quite feasible. Studies are now underway to evaluate performance requirements for space mission implementation. Satellite CO2 observations must be highly precise and unbiased in order to accurately infer global carbon source/sink fluxes. Measurement demands are likely to further increase in the wake of GOSAT, OCO-2, and enhanced ground-based in situ and remote sensing CO2 data. The objective of our work is to quantitatively and consistently evaluate the measurement capabilities and requirements for ASCENDS in the context of advancing our knowledge of carbon flux distributions and their dependence on underlying physical processes. Considerations include requirements for precision, relative accuracy, spatial/temporal coverage and resolution, vertical information content, interferences, and possibly the tradeoffs among these parameters, while at the same time framing a mission that can be implemented within a constrained budget. Here, we attempt to synthesize the results of observing system simulation studies, commissioned by the ASCENDS Science Requirements Definition Team, into a coherent set of mission performance guidelines. A variety of forward and inverse model frameworks are employed to reduce the potential dependence of the results on model
DeFilippis, Ersilia M; Callahan, Lisa M
A 15-year-old female cheerleader presented to a sports medicine physician for evaluation of a suspected hip flexor injury. Five weeks before presentation, the patient developed acute right lower quadrant (RLQ) pain. She was seen in a local emergency room where her vital signs, abdominal computed tomography, and ultrasound were normal. No definitive diagnosis was made. Her initial symptoms resolved. The patient then attended cheerleading camp where her RLQ pain recurred and she was referred to sports medicine for further evaluation. Her examination was significant for exquisite tenderness at McBurney point. She was referred for surgical evaluation for probable appendicitis.
Peyvasteh, Mehran; Askarpour, Shahnam; Javaherizadeh, Hazhir; Besharati, Sepideh
Appendicitis is one of the most common abdominal emergency. Some predictive scoring systems are recommended to decrease the rate of negative appendectomy. To evaluate sensitivity, specificity, positive predictive value, and negative predictive value of modified Alvarado score in children who underwent appendectomy. Four hundred children with initial diagnosis of appendicitis were randomly selected from patients who underwent appendectomy. Modified Alvarado score was used for evaluation of the appendicitis, that was confirmed using histology. Of modified Alvarado score components, anorexia; nausea and vomiting and rebound tenderness were significantly more common in children with positive appendectomy in contrast to patients with negative appendectomy. Sensitivity, specificity, positive predictive value, and negative predictive value for modified Alvarado score were: 91.3%; 38.4%; 87.7%; and 51.2% respectively. Alvarado score has high sensitivity but low specificity for diagnosis of acute appendicitis in children. A apendicite é uma das emergências abdominais mais comuns. Alguns sistemas de pontuação preditivos são recomendados para diminuir a taxa de apendicectomia negativa. Avaliar a sensibilidade, especificidade, valor preditivo positivo e valor preditivo negativo do escore de Alvarado modificado em crianças submetidas à apendicectomia. Quatrocentos crianças com diagnóstico inicial de apendicite foram selecionadas aleatoriamente de pacientes submetidos à apendicectomia. A pontuação de Alvarado modificada foi utilizada para avaliação do quadro, que foi confirmado por meio de histologia. Anorexia; náuseas, vômitos e desconforto abdominal foram significativamente mais comuns em crianças com apendicectomia positiva, em contraste com casos negativos pelo escore de Alvarado modificado. A sensibilidade, especificidade, valor preditivo positivo e valor preditivo negativo para o escore de Alvarado modificado foram: 91,3%; 38,4%; 87,7%; e 51
Morganstern, Bradley A; Viviano, Robert; Elsamra, Sammy
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.
Pandza, Haris; Custović, Samir; Cović, Ranko; Delibegovic, Samir
The appendicitis is one of the most common entities that could be met at surgical department. Chronic pelvic pain of right iliac fossa is common and it causes disability and distress and results in significant costs to health services. Often, investigation by laparoscopy reveals no obvious cause for pain. There are several possible explanations for chronic pelvic pain including undetected irritable bowel syndrome, the vascular hypothesis where pain is thought to arise from dilated pelvic veins in which blood flow is markedly reduced and altered spinal cord and brain processing of stimuli in women with chronic pelvic pain. As the pathophysiology of chronic pelvic pain is not well understood, its treatment is often unsatisfactory and limited to symptom relief. We aimed to identify and review treatments for chronic pelvic pain related to appendicitis. Frequently ultrasound and CT scan cannot confirm the diagnosis of chronic appendicitis due to non significant swelling of vermiform appendix. The study excludes patients with a diagnosis of pelvic congestion syndrome, those with pain known to be caused by gynecological disorders or irritable bowel syndrome. Detailed history, clinical examination, and serological and radiological investigations failed to reveal the cause of the pain in all cases. We presumed that pain is caused by chronic appendicitis with appendicolithiasis and that removal of appendix will result in symptom relief. We performed study with 75 patients treated by laparoscopic appendectomy. Duration of symptoms ranged from 3 to 48 months, with a mean of 13.1 months. All patients included in this study had right iliac fossa pain lasting more than three months. We performed radiological contrast studies to verify appendicolithiasis of irregularity of appendicular wall. Patient with mild symptoms were excluded, only patients that have symptoms that cause disability were operated. We compared pain according to localization, duration and character. We evaluated
Handra-Luca, Adriana; Bisseret, Damien; Dragoescu, Ema
Appendiceal pneumatosis is rare, reported either in the context of acute appendicitis or enterocolitis. Here, we report the case of an elderly adult in whom the acute appendicitis was associated with pneumatosis and occurred in the context of a malformed appendix with pathogenic organism remnants. A 72-year-old man presented with abdominal pain 3 weeks after posttraumatic dorsolumbar surgery. The computed tomography scan showed acute appendicitis and 2 diverticula. On microscopy, the appendix showed acute appendicitis along with a Cave-Wallbridge type A duplication. In addition, several optically clear spaces were observed in the entire appendiceal wall consistent with pneumatosis of the appendix. Focally, calcified structures suggesting pathogenic organisms such as Schistosoma were noted as well. In conclusion, we report a case of appendiceal pneumatosis occurring in the context of acute appendicitis in a duplicated appendix, with presence of calcified structures suggestive of pathogenic organisms.
Subramanian, Anuradha; Liang, Mike K
Stump appendicitis is an underreported and poorly defined condition. It is the development of obstruction and inflammation of the residual appendix after appendectomy. This is a review of the basic clinical, pathological, and surgical significance of stump appendicitis, and the "critical view" required for prevention. PubMed MEDLINE search was performed using terms "stump appendicitis" and "retained appendix" to obtain reported cases of stump appendicitis. Sixty-one cases were identified. Each case was charted based on 14 variables. Data were analyzed. Stump appendicitis warrants early detection. Patients can present with abdominal pain, nausea, and vomiting. A prior history of appendectomy can delay the diagnosis. A diagnosis can be made with an abdominal ultrasound or computed tomography scan. If treated early, laparoscopic or open completion appendectomy can be performed. If diagnosis is delayed and perforation is found, extensive resection is often required. A "critical view," as described in this article, is key for prevention. Published by Elsevier Inc.
Xu, Yingding; Jeffrey, R Brooke; DiMaio, Michael A; Olcott, Eric W
The objective of this study was to test the hypothesis that thickening of the lamina propria, a finding produced by lymphoid hyperplasia, is significantly associated with false-positive sonographic diagnoses of appendicitis in 6- to 8-mm noncompressible appendixes. Sonograms of 119 consecutive patients with suspected appendicitis and 6- to 8-mm noncompressible appendixes were retrospectively blindly evaluated for thickening of the lamina propria (short axis thickness ≥ 1 mm). The reference standard for appendicitis was pathologic analysis of resected specimens. Results were compared with the two-tailed Fisher exact test. Thirty-one patients (26.1%) had a thickened lamina propria and 88 (73.9%) did not. Of the 27 pediatric patients with a thickened lamina propria, five (18.5%) had true-positive and 22 (81.5%) had false-positive sonograms for appendicitis; among the 55 pediatric patients without a thickened lamina propria, 27 (49.1%) had true-positive and 28 (50.9%) had false-positive sonograms for appendicitis (p = 0.009). Similar differences in adult patients were not statistically significant. All five pediatric patients with appendicitis and thickened lamina propria also showed two or more findings of periappendiceal fluid, hyperechoic periappendiceal fat, or mural hyperemia on color Doppler examination, compared with two of 22 similar pediatric patients without appendicitis (p < 0.001). Lymphoid hyperplasia may result in a noncompressible appendix 6-8 mm in diameter and may be misdiagnosed as appendicitis in pediatric patients. True-positive diagnoses of appendicitis can be accurately identified by the presence of at least two additional findings from the group of periappendiceal fluid, hyperechoic periappendiceal fat, and mural hyperemia. Identifying the characteristic sonographic appearance of lymphoid hyperplasia may help prevent false-positive misdiagnoses of appendicitis.
Gjeorgjievski, Mihajlo; Amin, Mitual B; Cappell, Mitchell S
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
Gjeorgjievski, Mihajlo; Amin, Mitual B; Cappell, Mitchell S
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
Kharbanda, Anupam B; Fishman, Steven J; Bachur, Richard G
To compare the interexaminer reliability and ability to predict appendicitis between pediatric emergency physicians (EPs) and senior surgical residents. The authors conducted a prospective cohort study of children aged 3 to 18 years of age with signs and symptoms suspicious for appendicitis. Patients were initially examined by a pediatric EP attending and then by a consulting senior surgical resident. Physicians reported the presence or absence of specific historical and physical exam findings and predicted the likelihood the patient had appendicitis. Interexaminer reliability of historical and physical exam findings was compared (kappa statistic). Distributions and median probabilities of appendicitis were calculated for pediatric EP and surgeon predictions. The authors evaluated 350 patients with acute abdominal pain. Historical questions revealed slight to very good agreement (kappa statistic range 0.33-0.82) between physician types, whereas physical examination findings exhibited poor to fair agreement (range 0.14-0.48). Physicians predicted similar median probabilities of appendicitis for patients who were ultimately diagnosed with appendicitis (75% vs. 70%; p = 0.73) and patients without appendicitis (25% vs. 30%; p = 0.59). For a subset of patients given a > or = 90% predicted probability of appendicitis, pediatric EPs and senior surgical residents had similar accuracy (80% vs. 79%; p = 0.92). Similarly, among patients with < or = 10% predicted probability, pediatric EPs were correct in 95% and senior surgical residents correct in 94% of patients (p = 0.63). Pediatric EPs and senior surgical residents elicit historical findings from patients with suspected appendicitis with a greater degree of similarity than physical examination findings, which exhibit a wide degree of variability. Pediatric EPs and senior surgical residents do not differ in their ability to clinically predict appendicitis. These findings may be helpful in developing institutional
Yilmaz, Mehmet; Akbulut, Sami; Kutluturk, Koray; Sahin, Nurhan; Arabaci, Ebru; Ara, Cengiz; Yilmaz, Sezai
AIM: To investigate the prevalence and implications of unusual histopathological findings in appendectomy specimens from patients with suspected acute appendicitis. METHODS: The demographic and histopathological data of 1621 patients (≥ 16 years-old) who underwent appendectomy to treat an initial diagnosis of acute appendicitis between January 1999 and November 2011 were retrospectively assessed. Microscopic findings were used to classify the patients under six categories: appendix vermiformis, phlegmonous appendicitis, gangrenous appendicitis, perforated appendicitis, supurative appendicitis, and unusual histopathologic findings. The demographic and clinicopathologic characteristics of patients with unusual histopathologic findings were evaluated in detail, and re-analysis of archived resected appendix specimens was carried out. RESULTS: A total of 912 males and 709 females, from 16 to 94 years old, were included in the study and comprised 789 cases of suppurative appendicitis, 370 cases of appendix vermiformis, 243 cases of perforated gangrenous appendicitis, 53 cases of flegmaneous appendicitis, 32 cases of gangrenous appendicitis, and 134 (8.3%) cases of unusual histopathological findings. The unusual histopathological findings included fibrous obliteration (n = 62), enterobius vermicularis (n = 31), eosinophilic infiltration (n = 10), mucinous cystadenoma (n = 8), carcinoid tumor (n = 6), granulomatous inflammation (n = 5), adenocarcinoma (n = 4; one of them mucinous), and mucocele (n = 3), adenomatous polyp (n = 1), taenia sup (n = 1), ascaris lumbricoides (n = 1), appendiceal diverticula (n = 1), and B cell non-hodgkin lymphoma (n = 1). None of the 11 patients with subsequent diagnosis of tumor were suspected of cancer prior to the appendectomy. CONCLUSION: Even when the macroscopic appearance of appendectomy specimens is normal, histopathological assessment will allow early diagnosis of many unusual diseases. PMID:23840147
Nyboe Andersen, Nynne; Gørtz, Sanne; Frisch, Morten; Jess, Tine
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/.
Shogilev, Daniel J.; Duus, Nicolaj; Odom, Stephen R.; Shapiro, Nathan I.
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
Abshire, J. B.; Browell, E. V.; Menzies, R. T.; Lin, B.; Spiers, G. D.; Ismail, S.
The objectives of NASA's ASCENDS mission are to improve the knowledge of global CO2 sources and sinks by precisely measuring the tropospheric column abundance of atmospheric CO2 and O2. The mission will use a continuously operating nadir-pointed integrated path differential absorption (IPDA) lidar in a polar orbit. The lidar offers a number of important new capabilities and will measure atmospheric CO2 globally over a wide range of challenging conditions, including at night, at high latitudes, through hazy and thin cloud conditions, and to cloud tops. The laser source enables a measurement of range, so that the absorption path length to the scattering surface will be always accurately known. The lidar approach also measures consistently in a nadir-zenith path and the narrow laser linewidth allows weighting the measurement to the lower troposphere. Using these measurements with atmospheric and flux models will allow improved estimates of CO2 fluxes and hence better understanding of the processes that exchange CO2 between the surface and atmosphere. The ASCENDS formulation team has developed a preliminary set of requirements for the lidar measurements. These were developed based on experience gained from the numerous ASCENDS airborne campaigns that have used different candidate lidar measurement techniques. They also take into account the complexity of making precise measurement of atmospheric gas columns when viewing the Earth from space. Some of the complicating factors are the widely varying reflectance and topographic heights of the Earth's land and ocean surfaces, the variety of cloud types, and the degree of cloud and aerosol absorption and scattering in the atmosphere. The requirements address the precision and bias in the measured column mixing ratio, the dynamic range of the expected surface reflected signal, the along-track sampling resolution, measurements made through thin clouds, measurements to forested and slope surfaces, range precision, measurements
Attaran, Saina; Felderhoff, Jeremy; Westwood, Mark A; Awad, Wael I
A 38-year-old man with a history of uncontrolled hypertension was investigated for atypical chest pains and found to have an aneurysm of the ascending aorta and a coexisting coarctation of the aorta. The timing and sequence of surgical repair of these 2 pathologies are controversial. We report an elective single-stage operation in which the ascending aorta was replaced and an extracardiac bypass from the ascending to the descending aorta was performed with excellent results.
Dennett, Kate V; Tracy, Sarah; Fisher, Sharon; Charron, Gisele; Zurakowski, David; Calvert, Catherine E; Chen, Catherine
We compared direct hospital costs and indirect costs to the family associated with immediate appendectomy or initial nonoperative management for perforated appendicitis in children. From June 2009 through May 2010, 61 prospectively identified families completed a cost diary, documenting the numbers of missed school days for the child and missed employment days for the adult caregiver(s) over the treatment course. Hospital costs were obtained from hospital financial databases. Mann-Whitney U tests and Fisher exact tests were used to compare outcome measures for each treatment strategy. Patients treated by initial nonoperative management had a significantly longer median length of stay (9 days vs 7 days, P = .02) and a significantly greater median total hospital cost per patient ($31,349 vs $21,323, P = .01) when compared with those treated by immediate appendectomy. There was no significant difference in median number of missed school days (9 days vs 10 days, P = .23) or missed employment days for adult caregiver(s) (5 days vs 7 days, P = .18) between treatment strategies. Patients with perforated appendicitis treated by initial nonoperative management had a greater length of stay and a significantly greater total hospital cost but were not burdened by significantly greater indirect costs compared with those treated by immediate appendectomy. Copyright © 2012 Elsevier Inc. All rights reserved.
Mancini, Gregory J; Mancini, Matthew L; Nelson, Henry S
Laparoscopic appendectomy (LA) is safe and effective in cases of peritonitis, perforation, and abscess. We investigated our conversion rate and clinical outcomes in this patient population, as well as preoperative factors that predict operative conversion. A retrospective nonrandomized cohort of 92 patients underwent LA for acute appendicitis with peritonitis, perforation, or abscess at our institution between 1997 and 2002. Thirty-six of the 92 were converted to open appendectomy (OA), yielding a conversion rate of 39 per cent. The presence of phlegmon (42%), nonvisualized appendix (44%), technical failures (8%), and bleeding (6%) were reasons for conversion. Preoperative data had no predictive value for conversion. CT scan findings of free fluid, phlegmon, and abscess did not correlate with findings at the time of surgery. Total complication rates were 8.9 per cent in the LA group as compared to 50 per cent in the converted cohort. Postoperative data showed LA patients stayed 3.2 days versus 6.9 days for converted patients (P = 0.01). LA patients had less pneumonia (P = 0.02), intra-abdominal abscess (P = 0.01), ileus (P = 0.01), and readmissions (P = 0.01). LA is safe and effective in patients with appendicitis with peritonitis, perforation, and abscess, resulting in shorter hospital stays and less complication.
Piyarom, Patwadee; Kaewlai, Rathachai
The objective was to describe nature and factors associated with false-negative ultrasound (US) for adult appendicitis. Patients with pathologically proven appendicitis and pre-operative US from January 2011 to May 2013 were included in this retrospective case-control study. They were divided into true-positive and false-negative groups, matched by age and gender. There were 112 patients (40 men, mean age = 40 y, 56 true positives) included. Two factors were found differ significantly: abdominal wall thickness and pain score. Greater abdominal wall thickness (18.6 mm vs. 14.9 mm, p = 0.001) and lower pain score (6.6 vs. 7.5, p = 0.018) were statistically associated with false negativity. The two groups did not differ significantly in terms of weight, height, body mass index, symptom duration, Alvarado score, US examination time, appendix position/size, perforation rate and operator. In conclusion, lower pain score and increased abdominal wall thickness are associated with false negativity in US examinations. Copyright © 2014 World Federation for Ultrasound in Medicine & Biology. Published by Elsevier Inc. All rights reserved.
Ghelase, F; Georgescu, I; St Ghelase, M; Baleanu, V; Cioara, Fl; Georgescu, E; Traila, H; Siloşi, C
diagnostic improvement in complicated acute appendicitis (AA) by implementing the new sepsis concepts and modern imaging procedures; optimization of treatment with decreasing postoperation morbidity and mortality and improving the cost-efficiency indicator. 1495 cases of AA admitted between 2000 and 2004 have been assessed retrospectively and among them 306 (20.46%) had complications. On admission 80.43% patients were diagnosed with AA, 17.50% with acute abdominal syndrome and 2.07% with chronic appendicitis. On discharge there were 1158 (77.45%) cases of inflammatory AA and 306 (20.46%) cases of complicated AA (perforation, gangrene, peritonitis, plastron abscess). 98.26% of patients under-went operation and 1.73% did not. standard appendicectomy in 1407 (95.77%) cases; laparoscopic appendicectomy in 30 (2.04%) cases; extraperitoneal approach in 15 (1.02%) cases; associated with surgical interventions on other organs in 75 (5.10%) cases. POST-OPERATORY MORBIDITY:128 (41.08%) cases out of 306; septic parietal complications in 102 (33.33%) cases; intraperitoneal complications in 26 (8.49%) cases. POST-OPERATORY MORTALITY: 6 deaths in patients aged over 68. 4 days for uncomplicated AA and 14.6 days for complicated ones. Perioperative septic complications are the result of evolution of late diagnosed disease, unjustified postponing of operation, surgical technique, patient health condition.
Nowzaradan, Y; Westmoreland, J; McCarver, C T; Harris, R J
Laparoscopic evaluation was performed in 43 consecutive patients with right lower abdominal pain and preoperative diagnosis of possible appendicitis. Patients with generalized peritonitis and evidence of perforation of the appendix were not considered for laparoscopy. Visualization was sufficient for making a diagnosis in 97.7% of the cases. In 95%, laparoscopic findings were compatible with the pathology report. Thirty-five patients underwent successful laparoscopic appendectomy with neither intraoperative nor postoperative complications. No further surgery was required; slightly elevated temperatures in 6 patients responded to treatment with antibiotics, and there were no wound infections. Laparoscopic appendectomy is minimally invasive and results in less postoperative pain and morbidity and fewer adhesions and other long-term sequelae than conventional laparotomy. It is associated with superior cosmetic results, a shorter hospital stay, and faster return to normal activities. This experience suggests that if there is no evidence that the appendix is perforated or that generalized peritonitis exists and if qualified physicians and adequate facilities are available, patients presenting with right lower quadrant abdominal pain and possible appendicitis are best evaluated and treated with laparoscopic technique.
Lan, Tianwei; Zhang, Hongwei; Li, Sheng; Han, Jun; Song, Weihua; Batugin, A C; Tang, Guoshui
Coal seams ascending mining technology is very significant, since it influences the safety production and the liberation of dull coal, speeds up the construction of energy, improves the stability of stope, and reduces or avoids deep hard rock mining induced mine disaster. Combined with the Xiaoming ascending mining mine 4-1, by numerical calculation, the paper analyses ascending mining 4-1 factors, determines the feasibility of ascending mining 4-1 coalbed, and proposes roadway layout program about working face, which has broad economic and social benefits.
Tianwei, Lan; Hongwei, Zhang; Sheng, Li; Weihua, Song; Batugin, A. C.; Guoshui, Tang
Coal seams ascending mining technology is very significant, since it influences the safety production and the liberation of dull coal, speeds up the construction of energy, improves the stability of stope, and reduces or avoids deep hard rock mining induced mine disaster. Combined with the Xiaoming ascending mining mine 4-1, by numerical calculation, the paper analyses ascending mining 4-1 factors, determines the feasibility of ascending mining 4-1 coalbed, and proposes roadway layout program about working face, which has broad economic and social benefits. PMID:25866840
Bakoto, N; Corman, V; Legros, J J
Cardiovascular and endocrine complications in male or sexually-ambiguous patients carrying a 45,X/46,XY mosaicism are rarely discussed in the medical literature. However, young female patients with a diagnosis of Turner's disease usually benefit from regular cardiologic and endocrine follow-up, in accordance with current international guidelines. We report the case of a male patient, aged 23 years, with an ambiguous phenotype known to harbor a mixed gonadic 45,X/46,XY type dysgenesis. The patient was admitted to the cardiology ward for investigation and management of cardiac failure secondary to both a biscupid aortic valve and ascending aorta aneurysm. This case report, and the few others, which have been previously reported in the literature, emphasizes the importance of cardiologic and endocrine follow-up in male carriers of 45,X/46,XY mosaicism.
Bodur, Derya; Demiralp, Metin
In this work we have focused on a very recently developed method called as Separate Node Ascending Derivatives Expansion (SNADE). SNADE can be considered as an infinite interpolation like Taylor Series Expansion. A Taylor Series is an infinite sum representation whose terms are calculated from the values of the functions derivatives at a single point. This newly proposed method involves denumerable infinitely many nodes in contrast to Taylor Series Expansion. SNADE is based on derivative integration formula for a univariate function. Integral of derivative identity is not only required to be used for the target function but repetitiously for its all derivatives. It may not be required to be used in the same interval. In addition to all these, each derivative value becomes evaluated at a different independent variable value. This work is designed to emphasize on the methods interpolatory nature. For this purpose certain implementation results are given and compared with well-known interpolation methods.
Mismar, Ayman; Yousef, Mohammad; Badran, Darwish; Younes, Nidal
Bone and soft tissue infection in the foot of diabetic patients is a well-described issue in the literature. A sound anatomical knowledge of the foot anatomy and compartments is mandatory to understand the mechanisms of infection spread. We describe four cases of diabetic foot infection complicated by long ascending infection. All did not respond initially to antibiotic treatment and the usual surgical debridement and were cured only after excision of the infected tendons. We highlight a rare but serious complication of the diabetic foot disease not commonly seen by the surgical community. We hope that this report raises the awareness of this condition so that a prompt diagnosis is made and appropriate treatment started, thereby reducing the risk of major lower limb amputations.
Pratto, Felicia; Saguy, Tamar; Stewart, Andrew L; Morselli, Davide; Foels, Rob; Aiello, Antonio; Aranda, María; Cidam, Atilla; Chryssochoou, Xenia; Durrheim, Kevin; Eicher, Veronique; Licata, Laurent; Liu, James H; Liu, Li; Meyer, Ines; Muldoon, Orla; Papastamou, Stamos; Petrovic, Nebojsa; Prati, Francesca; Prodomitis, Gerasimos; Sweetman, Joseph
Arab nations are decades behind many other previously colonized nations in developing stronger economies, more democratic institutions, and more autonomy and self-government, in part as a result of external interference. The year 2011 brought the potential for greater Arab autonomy through popular uprisings against autocratic governments in Tunisia, Egypt, and Yemen, and through the Palestinian request for state recognition by the United Nations. We examined the psychology of support for Arab ascendancy among adults in 14 nations in the Balkans, the Middle East, Asia, Oceania, Europe, and North America. We predicted and found that people low on social dominance orientation endorsed forming an independent Palestinian state and desired that the Arab uprisings succeed. Rejection of ideologies that legitimize outside interference with Arabs mediated this support. Measures and model results were robust across world regions. We discuss theoretical implications regarding the advent of new ideologies and extending social dominance theory to address international relations.
Toyoda, Tetsutaka; Nishimura, Yoji; Yatsuoka, Toshimasa; Yokoyama, Yasuyuki; Shimada, Ryu; Ishikawa, Hideki; Fukuda, Takashi; Amikura, Katsumi; Kawashima, Yoshiyuki; Sakamoto, Hirohiko; Tanaka, Yoichi; Nishimura, Yu
A 6 8-year-old man was admitted to our hospital with lower abdominal pain. Lower gastrointestinal endoscopy showed type 2 advanced cancer in the ascending colon. Histopathological examination after endoscopical biopsy revealed both moderately differentiated adenocarcinoma and well-differentiated squamous carcinoma. Subsequently, right hemicolectomy was performed. The tumor was 55 × 40 mm in size and was diagnosed as an adenosquamous carcinoma A, type 2, pSS, pN0, sH0, sP0, sM0, fStageII. Adenosquamous carcinoma is extremely rare, represents about 0.1% of all colorectal cancer, and usually has a poor prognosis. Thirty-one months after surgery, the patient is still in good health and displays no signs of recurrence.
Fuller, Patrick M.; Sherman, David; Pedersen, Nigel P.; Saper, Clifford B.; Lu, Jun
The “ascending reticular activating system” theory proposed that neurons in the upper brainstem reticular formation projected to forebrain targets that promoted wakefulness. More recent formulations have emphasized that most neurons at the pontomesencepahlic junction that participate in these pathways are actually in monoaminergic and cholinergic cell groups. However, cell-specific lesions of these cell groups have never been able to reproduce the deep coma seen after acute paramedian midbrain lesions that transect ascending axons at the caudal midbrain level. To determine whether the cortical afferents from the thalamus or the basal forebrain were more important in maintaining arousal, we first place large cell-body specific lesions in these targets. Surprisingly, extensive thalamic lesions had little effect on EEG or behavioral measures of wakefulness or on c-Fos expression by cortical neurons during wakefulness. In contrast, animals with large basal forebrain lesions were behaviorally unresponsive, had a monotonous sub-1 Hz EEG, and little cortical c-Fos expression during continuous gentle handling. We then retrogradely labeled inputs to the basal forebrain from the upper brainstem, and found a substantial input from glutamatergic neurons in the parabrachial nucleus and adjacent pre-coeruleus area. Cell specific lesions of the parabrachial-precoeruleus complex produced behavioral unresponsiveness, a monotonous sub-1Hz cortical EEG, and loss of cortical c-Fos expression during gentle handling. These experiments indicate that in rats the reticulo-thalamo-cortical pathway may play a very limited role in behavioral or electrocortical arousal, while the projection from the parabrachial nucleus and precoeruleus region, relayed by the basal forebrain to the cerebral cortex, may be critical for this process. PMID:21280045
Hammerling, D.; Michalak, A. M.; Kawa, S. R.; Doney, S. C.; Schaefer, K. M.
Emerging satellite observations of carbon dioxide (CO2) offer novel and distinctive opportunities for quantifying the carbon cycle, which is an important scientific and societal challenge with anthropogenic CO2 emissions and accumulation rates in the atmosphere still on the rise. One mission in the planning stage is the Active Sensing of CO2 Emissions over Nights, Days, and Seasons (ASCENDS) mission, which is a laser CO2 sensing mission with an anticipated launch date around 2022. Notable features of this mission include the ability to sample at night and at high latitudes, which passive missions cannot do because of their reliance on reflected sunlight. In this work we present findings from signal detection studies, i.e. experiments that investigate if perturbations in carbon fluxes can be detected in the ASCENDS observations of atmospheric CO2 concentrations. The experiments employ a realistic synthetic-data setup using the PCTM/GEOS-5/CASA GFED CO2 flux and transport model in combination with CALIPSO and MODIS measurements. The signal detection approach applied uses a geostatistical mapping methodology that can leverage the information content of nearby observations, thereby potentially facilitating enhanced signal detection. The specific perturbation scenarios investigated are: carbon release from the melting of permafrost in the high Northern latitudes, the shifting of fossil fuel emissions from Europe to P.R. China, and natural variability in the CO2 fluxes in the Southern Ocean. Results indicate that the permafrost carbon release is comparatively easy to detect, while the Southern Ocean change is more challenging. The ability to detect a shift in fossil fuel emissions strongly depends on its magnitude: a 50% decrease in Europe is easily detectible, while a 20% decrease is only marginally so. A key conclusion is that the optimal signal detection strategy is intrinsically linked to how the carbon flux perturbations translate into atmospheric CO2 concentrations
Benedik, Jaroslav; Pilarczyk, Kevin; Wendt, Daniel; Indruch, Jiri; Flek, Radek; Tsagakis, Konstantinos; Alaeddine, Savvas; Jakob, Heinz
Objectives. Bicuspid aortic valve (AV) represents the most common form of congenital AV malformation, which is frequently associated with pathologies of the ascending aorta. We compared the mechanical properties of the aortic wall between patients with bicuspid and tricuspid AV using a new custom-made device mimicking transversal aortic wall shear stress. Methods. Between 03/2010 and 07/2011, 190 consecutive patients undergoing open aortic valve replacement at our institution were prospectively enrolled, presenting either with a bicuspid (group 1, n = 44) or a tricuspid (group 2, n = 146) AV. Aortic wall specimen were examined with the "dissectometer" resulting in nine specific aortic-wall parameters derived from tensile strength curves (TSC). Results. Patients with a bicuspid AV showed significantly more calcified valves (43.2% versus 15.8%, P < 0.001), and a significantly thinner aortic wall (2.04 ± 0.42 mm versus 2.24 ± 0.41 mm, P = 0.008). Transesophageal echocardiography diameters (annulus, aortic sinuses, and sinotubular junction) were significantly larger in the bicuspid group (P = 0.003, P = 0.02, P = 0.01). We found no difference in the aortic wall cohesion between both groups as revealed by shear stress testing (P = 0.72, P = 0.40, P = 0.41). Conclusion. We observed no differences of TSC in patients presenting with tricuspid or bicuspid AVs. These results may allow us to assume that the morphology of the AV and the pathology of the ascending aorta are independent.
Background When ascending to the high altitude, people living in low altitude areas will suffer from acute mountain sickness. The aim of this study is to test the hypothesis that whether an oxygen concentration membrane can be made and used to construct a new portable oxygen enrichment device for individuals in acute exposure to the high altitude. Methods The membrane was fabricated using vinylsiloxane rubber, polyphenylene oxide hydrogen silicone polymers, chloroplatinic acid and isopropyl alcohol. The membrane was assembled in a frame and the performance was tested in terms of concentration of oxygen, flow rate of oxygen enriched air, pressure ratio across the membrane and ambient temperature. Furthermore, the oxygen concentration device was constructed using the membrane, a DC fan, vacuum pump and gas buffer. A nonrandomized preliminary field test was conducted, in which eight healthy male subjects were flown to Tibet (Lhasa, 3,700 m). First, subjects wore the oxygen enrichment device and performed an incremental exercise on cycle ergometer. The test included heart rate (HR), saturation of peripheral oxygen (SpO2) and physical work capacity (PWC). Then, after a rest period of 4 hours, the experimental protocol was repeated without oxygen enrichment device. Results The testing showed that the membrane could increase the oxygen concentration by up to 30%. Simulation test indicated that although the performance of the oxygen enrichment device decreased with altitudes, the oxygen concentration could still maintain 28% with flow rate of enriched air 110 cm3/s at 5000 m. The field test showed that higher SpO2, lower HR, and better PWC (measured by the PWC-170) were observed from all the subjects using oxygen enrichment device compared with non-using (P < 0.01). Conclusions We concluded that the new portable oxygen enrichment device would be effective in improving exercise performance when ascending to the high altitude. PMID:24103365
Campbell, Joel; lin, bing; nehrir, amin; harrison, fenton; obland, michael
Global atmospheric carbon dioxide (CO2) measurements for the NASA Active Sensing of CO2 Emissions over Nights, Days, and Seasons (ASCENDS) space mission are critical for improving our understanding of global CO2 sources and sinks. Advanced Intensity-Modulated Continuous-Wave (IM-CW) lidar techniques are investigated as a means of facilitating CO2 measurements from space to meet the ASCENDS measurement requirements. In recent numerical, laboratory and flight experiments we have successfully used the Binary Phase Shift Keying (BPSK) modulation technique to uniquely discriminate surface lidar returns from intermediate aerosol and cloud contamination. We demonstrate the utility of BPSK to eliminate sidelobes in the range profile as a means of making Integrated Path Differential Absorption (IPDA) column CO2 measurements in the presence of optically thin clouds, thereby eliminating the need to correct for sidelobe bias errors caused by the clouds. Furthermore, high accuracy and precision ranging to the surface as well as to the top of intermediate cloud layers, which is a requirement for the inversion of column CO2 number density measurements to column CO2 mixing ratios, has been demonstrated using new hyperfine interpolation techniques that takes advantage of the periodicity of the modulation waveforms. This approach works well for both BPSK and linear swept-frequency modulation techniques. The BPSK technique under investigation has excellent auto-correlation properties while possessing a finite bandwidth. A comparison of BPSK and linear swept-frequency is also discussed in this paper. These results are extended to include Richardson-Lucy deconvolution techniques to extend the resolution of the lidar beyond that implied by limit of the bandwidth of the modulation.
Gorter, Ramon R; van den Boom, Anne Loes; Heij, Hugo A; Kneepkens, C M Frank; Hulsker, Caroline C; Tenhagen, Mark; Dawson, Imro; van der Lee, Johanna H
It appears that two forms of appendicitis exist. Preoperative distinction between the two is essential to optimize treatment outcome. This study aimed to develop a scoring system to accurately determine the severity of appendicitis in children. Historical cohort study of pediatric patients (aged 0-17 y old) with appendicitis treated between January 2010 and December 2012. Division into simple, complex appendicitis, or another condition based on preset criteria. Multiple logistic regression analysis was used to build the prediction model with subsequent validation. There were 64 patients with simple and 66 with complex appendicitis. Five variables explained 64% of the variation. Independent validation of the derived prediction model in a second cohort (55 simple and 10 complex appendicitis patients) demonstrated 90% sensitivity (54-99), 91% specificity (79-97), a positive predictive value of 64% (36-86), and an negative predictive value of 98% (88-100). The likelihood ratio+ was 10 (4.19-23.42), and likelihood ratio- was 0.11 (0.02-0.71). Diagnostic accuracy was 91% (84-98). Our scoring system consisting of five variables can be used to exclude complex appendicitis in clinical practice if the score is <4. Copyright © 2016 Elsevier Inc. All rights reserved.
Kao, Li-Ting; Tsai, Ming-Chieh; Lin, Herng-Ching; Lee, Cha-Ze
Appendicitis and gastroesophageal reflux disease (GERD) are both prevalent diseases and might share similar pathological mechanisms. The aim of this study was to investigate the association between GERD and appendicitis using a large population-based dataset. This study used administrative claims data from the Taiwan Longitudinal Health Insurance Database 2005. We identified 7113 patients with appendicitis as cases, and 28452 matched patients without appendicitis as controls. This study revealed that GERD was found in 359 (5.05%) cases and 728 (2.56%) controls (p < 0.001). Conditional logistic regression shows that the adjusted odds ratio (OR) of GERD for cases was 2.05 (95% confidence interval (CI): 1.08~2.33) compared to controls. The adjusted ORs of prior GERD for patients aged 18~39, 40~59, and ≥60 years with appendicitis were 1.96 (95% CI: 1.56~2.47), 2.36 (95% CI: 1.94~2.88), and 1.71 (95% CI: 1.31~2.22) than controls, respectively. We concluded that patients with appendicitis had higher odds of prior GERD than those without appendicitis regardless of age group.
Wei, Po-Li; Lin, Herng-Ching; Kao, Li-Ting; Chen, Yi-Hua; Lee, Cha-Ze
The purpose of this study was to investigate the relationship between perforated appendicitis and patient with diabetes using a population-based data set. This study used data from the Longitudinal Health Insurance Database 2005 in Taiwan. We identified 4,806 patients hospitalized with acute appendicitis. The independent variable was whether a patient had ever received a diagnosis of diabetes before the index hospitalization. We performed a conditional logistic regression model to explore the odds ratio and its corresponding 95% confidence interval of perforated appendicitis. Rates of perforated appendicitis for patients with and those without diabetes were 46.2% and 28.3%, respectively. A chi-square test revealed that there was a significant difference in rates of perforated appendicitis between patients with and those without diabetes (P < .001). The conditional logistic regression model revealed that the adjusted odds ratio of perforated appendicitis for patients with diabetes was 1.35 (95% confidence interval = 1.11 to 1.65) compared with patients without diabetes. Our study demonstrated that a history of diabetes is an important factor with regard to the rate of perforated appendicitis. Copyright © 2016 Elsevier Inc. All rights reserved.
Patel, Darshan; Fingard, Jordan; Winters, Sean; Low, Gavin
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.
Kao, Li-Ting; Tsai, Ming-Chieh; Lin, Herng-Ching; Lee, Cha-Ze
Appendicitis and gastroesophageal reflux disease (GERD) are both prevalent diseases and might share similar pathological mechanisms. The aim of this study was to investigate the association between GERD and appendicitis using a large population-based dataset. This study used administrative claims data from the Taiwan Longitudinal Health Insurance Database 2005. We identified 7113 patients with appendicitis as cases, and 28452 matched patients without appendicitis as controls. This study revealed that GERD was found in 359 (5.05%) cases and 728 (2.56%) controls (p < 0.001). Conditional logistic regression shows that the adjusted odds ratio (OR) of GERD for cases was 2.05 (95% confidence interval (CI): 1.08~2.33) compared to controls. The adjusted ORs of prior GERD for patients aged 18~39, 40~59, and ≥60 years with appendicitis were 1.96 (95% CI: 1.56~2.47), 2.36 (95% CI: 1.94~2.88), and 1.71 (95% CI: 1.31~2.22) than controls, respectively. We concluded that patients with appendicitis had higher odds of prior GERD than those without appendicitis regardless of age group. PMID:26932391
Sack, Ulrich; Biereder, Birgit; Elouahidi, Tino; Bauer, Katrin; Keller, Thomas; Tröbs, Ralf-Bodo
Background Acute appendicitis (AA) is a common surgical problem that is associated with an acute-phase reaction. Previous studies have shown that cytokines and acute-phase proteins are activated and may serve as indicators for the severity of appendicitis. The aim of this study was to compare diagnostic value of different serum inflammatory markers in detection of phlegmonous or perforated appendicitis in children. Methods Data were collected prospectively on 211 consecutive children. Laparotomy was performed for suspected AA for 189 patients. Patients were subdivided into groups: nonsurgical abdominal pain, early appendicitis, phlegmonous or gangrenous appendicitis, perforated appendicitis. White blood cell count (WBC), serum C-reactive protein (CRP), interleukin-6 (IL-6), tumor necrosis factor α (TNF-α), acid α1-glycoprotein (α1GP), endotoxin, and erythrocyte sedimentation reaction (ESR) were estimated ad the time of admission. The diagnostic performance was analyzed using receiver operating characteristic (ROC) curves. Results WBC count, CRP and IL-6 correlated significantly with the severity of appendiceal inflammation. Identification of children with severe appendicitis was supported by IL-6 or CRP but not WBC. Between IL-6 and CRP, there were no significant differences in diagnostic use. Conclusion Laboratory results should be considered to be integrated within the clinical assessment. If used critically, CRP and IL-6 equally provide surgeons with complementary information in discerning the necessity for urgent operation. PMID:17132173
Demircan, Mehmet; Cetin, Selma; Uguralp, Sema; Sezgin, Nurzen; Karaman, Abdurrahman; Gozukara, Engin M
Early diagnosis of perforated appendicitis is important for reducing morbidity rates. The aim of this study was to determine the value and utility of plasma D-lactic acid levels in identifying the type of appendicitis. In this clinical study, plasma D-lactic acid levels were assessed in 44 consecutive paediatric patients (23 with acute appendicitis, 21 with perforated appendicitis) before laparotomy. D-lactic acid levels were determined by an enzymatic spectrophotometric technique using a D-lactic acid dehydrogenase kit. Patients with perforated appendicitis had higher D-lactic acid levels (3.970 +/- 0.687 mg/dL) than patients in the control group (0.478 +/- 0.149 mg/dL) and patients with acute appendicitis (1.409 +/- 0.324 mg/dL; p < 0.05). For a plasma D-lactic acid level greater than 2.5 mg/dL, the sensitivity and specificity of the D-lactic acid assay were 96% and 87%, respectively. The positive predictive value was 87%, the negative predictive value was 96%, and the diagnostic value was 91%. These results suggest that the measurement of plasma D-lactic acid levels may be a useful adjunct to clinical and radiological findings in distinguishing perforated from acute non-perforated appendicitis in children.
Bat, Orhan; Kaya, Hakan; Çelik, Hamit Kafkas; Şahbaz, Nuri Alper
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
Liang, Tsung-Jung; Liu, Shiuh-Inn; Tsai, Chung-Yu; Kang, Chi-Hsiang; Huang, Wei-Chun; Chang, Hong-Tai; Chen, I-Shu
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.
Liang, Tsung-Jung; Liu, Shiuh-Inn; Tsai, Chung-Yu; Kang, Chi-Hsiang; Huang, Wei-Chun; Chang, Hong-Tai; Chen, I-Shu
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
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
Tseng, Peggy; Berdahl, Carl; Kearl, Y Liza; Behar, Solomon; Cooper, John; Dollbaum, Ryan; Hardasmalani, Madhu; Hardiman, Kevin; Rose, Emily; Santillanes, Genevieve; Lam, ChunNok; Claudius, Ilene
Acute appendicitis is the most common cause of acute abdomen in pediatric emergency department (ED) visits, and right lower quadrant abdominal ultrasound (RLQUS) is a valuable diagnostic tool in the clinical approach. The utility of ultrasound in predicting perforation has not been well-defined. We sought to determine the sensitivity of RLQUS to identify perforation in pediatric patients with appendicitis. A chart review of all patients 3 to 21 years of age who received a radiographic work-up and who were ultimately diagnosed with perforated appendicitis between 2010 and 2013 at a pediatric ED was conducted. The final read for ultrasonography was compared to either the operative diagnosis, surgical pathology diagnosis, or further imaging results (if the patient was managed nonoperatively). Test characteristics were calculated for the identification of appendicitis and identification of perforation. Of the 539 patients evaluated for appendicitis, 144 (26.7%) patients had appendicitis, and 40 of these (27.8%) were perforated. Thirty-nine had RLQUS performed as part of their evaluation. Of these, 28 had positive findings for appendicitis, and 9 were read as definite or possible perforated appendicitis. The sensitivity of RLQUS for the diagnosis of appendicitis in the group with perforation was 77.1% (95% confidence interval [CI], 59.4-89%) and the sensitivity for diagnosing a perforation was 23.1% (95% CI, 11.1-39.3%). There was a low rate of detection of perforation by RLQUS in our pediatric population. If larger studies confirm this, additional imaging should be recommended in patients with a high suspicion of perforation and in whom a diagnosis of perforation would change management. Copyright © 2016 Elsevier Inc. All rights reserved.
Telesmanich, Morgan E; Orth, Robert C; Zhang, Wei; Lopez, Monica E; Carpenter, Jennifer L; Mahmood, Nadia; Jadhav, Siddharth P; Guillerman, R Paul
Ultrasound (US) is the preferred imaging modality for evaluating suspected pediatric appendicitis. However, borderline appendiceal enlargement or questionable inflammatory changes can confound interpretation and lead to equivocal exams. The purpose of this study was to determine which findings on equivocal US exams are most predictive of appendicitis. All US exams performed for suspected pediatric appendicitis from July 1, 2013, through July 9, 2014, were initially interpreted using a risk-stratified scoring system. Two blinded pediatric radiologists independently reviewed US exams designated as equivocal and recorded the following findings: increased wall thickness, loss of mural stratification, peri-appendiceal fat inflammation, peri-appendiceal fluid, appendicolith and maximum appendiceal diameter. A third pediatric radiologist resolved discrepancies. US features were correlated with the final diagnosis via multivariate analysis. During the study period, 162/3,750 (4.3%) children had US exams initially interpreted as equivocal (mean age 9.8 +/- 3.8 years). Five outpatients were lost to follow-up. Forty-eight of the remaining 157 (30.6%) children had an operative diagnosis of appendicitis. Findings significantly associated with appendicitis were loss of mural stratification (odds ratio [OR] = 6.7, P=0.035), peri-appendiceal fat inflammation (OR = 10.0, P<0.0001) and appendicolith (OR = 15.8, P=0.025). While appendiceal diameter tended to be larger in patients with appendicitis, the difference was not statistically significant. Loss of mural stratification, peri-appendiceal fat inflammation and an appendicolith are significant predictors of appendicitis in children with otherwise equivocal US exams. While maximum appendiceal diameter is not statistically associated with appendicitis in our study, mean appendiceal diameter of 6.7 mm in those without appendicitis suggests that the customary upper normal limit of 6 mm is too sensitive.
Lin, K-H; Leung, W-S; Wang, C-P; Chen, W-K
CT scanning of the abdomen is a highly accurate diagnostic tool for acute appendicitis. However, it is still relatively expensive in Taiwan, especially in hospitals which have adopted a global budgeting scheme. The purpose of this study was to analyse the cost of the management of this disease with and without CT scanning. A retrospective observational study was undertaken from 1 January to 30 June 2005. Patients with a working diagnosis of "acute appendicitis", "acute appendicitis should be ruled out" and "differential diagnosis including acute appendicitis" were enrolled in the study. Patient demographic data, chief complaints, working diagnoses, laboratory data, CT reports, surgical findings and costs in the emergency department (ED) and ward were collected. A total of 266 patients were admitted to an ED with symptoms suggesting acute appendicitis. Of these, 207 underwent an emergency appendectomy. An abdominal CT scan was performed in 71% of patients with a diagnosis of "differential diagnosis including acute appendicitis", which was higher than in the other two diagnostic groups (18% and 60%). Patient age, high sensitivity C-reactive protein (hsCRP) concentration, ED stay, ED expenses and hospital stay were lower in the group that did not have a CT scan than in those who did. The net cost per patient with acute appendicitis in the group who underwent CT scanning was New Taiwan dollar (NT$)40,728, which was nearly equal to the net cost per patient in the group without CT scanning (NT$39,192). Routine CT scanning in patients with possible appendicitis is not necessary. History taking and physical examination combined with laboratory tests are still useful and cost-effective methods of diagnosing acute appendicitis.
Kentsis, Alex; Lin, Yin Yin; Kurek, Kyle; Calicchio, Monica; Wang, Yan Yan; Monigatti, Flavio; Campagne, Fabien; Lee, Richard; Horwitz, Bruce; Steen, Hanno; Bachur, Richard
Study Objective Molecular definition of disease has been changing all aspects of medical practice, from diagnosis and screening to understanding and treatment. Acute appendicitis is among many human conditions that are complicated by the heterogeneity of clinical presentation and shortage of diagnostic markers. Here, we sought to profile the urine of patients with appendicitis with the goal of identifying new diagnostic markers. Methods Candidate markers were identified from the urine of children with histologically proven appendicitis by using high accuracy mass spectrometry proteome profiling. These systemic and local markers were used to assess the probability of appendicitis in a blinded, prospective study of children being evaluated for acute abdominal pain in our emergency department. Tests of performance of the markers were evaluated against the pathologic diagnosis and histologic grade of appendicitis. Results Test performance of 57 identified candidate markers was studied in 67 patients, with median age of 11 years, 37% of whom had appendicitis. Several exhibited favorable diagnostic performance, including calgranulin A (S100-A8), α-1-acid glycoprotein 1 (orosomucoid), and leucine-rich α-2-glycoprotein (LRG), with the ROC AUC and values of 0.84 (95 % CI 0.72-0.95), 0.84 (0.72-0.95), and 0.97 (0.93-1.0), respectively. LRG was enriched in diseased appendices and its abundance correlated with severity of appendicitis. Conclusions High accuracy mass spectrometry urine proteome profiling allowed identification of diagnostic markers of acute appendicitis. Usage of LRG and other identified biomarkers may improve the diagnostic accuracy of clinical evaluations of appendicitis. PMID:19556024
Lourenco, Pedro; Brown, Jacquie; Leipsic, Jonathan; Hague, Cameron
The purpose of this study is to evaluate the current performance of ultrasound in the diagnosis of acute appendicitis. Retrospectively, patients who presented to a single institution between 2011 and 2012 were included. Diagnostic accuracy was calculated, with surgery considered gold-standard. Our data demonstrates that US relative to surgery-confirmed appendicitis has a sensitivity and specificity of 48.4% and 97.9%, respectively. The diagnostic accuracy was further increased when there was a low pre-test probability, with a NPV of up to 96.6%. Ultrasound has a strong PPV in the diagnosis of acute appendicitis, and in equivocal cases, the NPV is reliable.
Bakker, Olaf J; Go, Peter M N Y H; Puylaert, Julien B C M; Kazemier, Geert; Heij, Hugo A
Every year, over 2500 unnecessary appendectomies are carried out in the Netherlands. At the initiative of the Dutch College of Surgeons, the evidence-based guideline on the diagnosis and treatment of acute appendicitis was developed. This guideline recommends that appendectomy should not be carried out without prior imaging. Ultrasonography is the recommended imaging technique in patients with suspected appendicitis. After negative or inconclusive ultrasonography, a CT scan can be carried out. Appendectomy is the standard treatment for acute appendicitis; this can be done either by open or laparoscopic surgery. The first choice treatment of appendicular infiltrate is conservative treatment.
Moraga, Felipe; Ahumada, Vanessa; Crovari, Fernando
Acute appendicitis is a common cause of acute abdominal pain and the most frequent cause of emergency abdominal surgery. In the last two decades, growing evidence has been published about the use of antibiotics as the exclusive treatment for acute appendicitis. Searching in Epistemonikos database, which is maintained by screening 30 databases, we identified only one systematic review including one pertinent randomized trial. We generated a summary of findings following the GRADE approach. We concluded the use of antibiotics to treat acute uncomplicated appendicitis may be less effective than appendectomy and probably increases major complications compared with appendectomy.
Khaavel', A A; Birkenfeldt, R R
The authors analyzed 2009 appendicitis case records for the period from 1964 to 1973. In a sea climate region an evident season distribution of the apendicitis morbidity was found, with the rise of the incidence rate in January, March and April. The rise of the appendicitis incidence rate during the periods of vast fluctuations of air temperature, increase of air humidity and decrease of actual duration of sun radiance was established. The rise of the incidence of acute appendicitis was also noted during the months of a great and extremely great magnetic storms.
Petro, Michelle; Minocha, Anil
Colonoscopic diagnosis of asymptomatic early acute appendicitis is exceedingly rare. Although obstruction of the lumen due to various causes is believed to be the most common physiologic mechanism of acute appendicitis, all of the previously documented cases in the literature have only shown a patent appendiceal lumen with pus flowing into the cecum. We present the case of a patient undergoing colonoscopy for colorectal cancer evaluation with no abdominal symptoms. An obstructed, swollen appendix was seen. The process was probably initiated during the colonoscopy, documenting perhaps the earliest stage of acute appendicitis for the first time. Endoscopic, CT and microscopic documentation of the case is also presented. PMID:16149156
Horuz, F; Sleeboom, C; Bouts, A H; Davin, J C; Groothoff, J W
Peritonitis as a result of a perorated appendicitis is a rare but life-threatening situation in a patient on peritoneal dialysis (PD). As far as we are aware, the combination of clear dialysate effluent and phlegmonous appendicitis in a patient on PD has not previously been described. We report a 16-year-old girl with acute onset of abdominal pain and vomiting who turned out to have phlegmonous appendicitis, despite having a clear dialysate effluent with normal cell count, and who subsequently developed E coli peritonitis after surgery.
Leung Wai Sang, Stephane; Bavaria, Joseph E; Giri, Jay S; Wickramasinghe, Rasi; Desai, Nimesh
The presence of thoracic aortic aneurysms, particularly in the ascending aorta and arch, presents a challenge to transcatheter aortic valve replacement. We present a case of TAVR in the presence of a chronic ascending aortic aneurysm. doi: 10.1111/jocs.12724 (J Card Surg 2016;31:318-320).
Obland, M. D.; Prasad, N. S.; Harrison, F. W.; Browell, E. V.; Ismail, S.; Dobler, J. T.; Moore, B.; Zaccheo, T.; Campbell, J.; Chen, S.; Cleckner, C. S.; DiJoseph, M.; Little, A.; Notari, A.; Refaat, T. F.; Rosenbaum, D.; Vanek, M. D.; Bender, J.; Braun, M.; Chavez-Pirson, A.; Neal, M.; Rayner, P. J.; Rosiewicz, A.; Shure, M.; Welch, W.
The ASCENDS CarbonHawk Experiment Simulator (ACES) is a NASA Langley Research Center project funded by NASA's Earth Science Technology Office (ESTO) Instrument Incubator Program (IIP) that seeks to advance technologies critical to measuring atmospheric column carbon dioxide (CO2) mixing ratios in support of the NASA Active Sensing of CO2 Emissions over Nights, Days, and Seasons (ASCENDS) mission. The technologies being advanced are: (1) a high bandwidth detector, (2) a multi-aperture telescope assembly, (3) advanced algorithms for cloud and aerosol discrimination, and (4) high-efficiency, multiple-amplifier CO2 and O2 laser transmitters. The instrument architecture will be developed to operate on a high-altitude aircraft and will be directly scalable to meet the ASCENDS mission requirements. These technologies are viewed as critical towards developing an airborne simulator and eventual spaceborne instrument with lower size, mass, and power consumption, and improved performance. The detector effort will improve the existing detector subsystem by increasing its bandwidth to a goal of 5 MHz, reducing its overall mass from 18 lbs to <10 lbs, and stretching the duration of autonomous, service-free operation periods from 4 hrs to >24 hrs. The development goals are to permit higher laser modulation rates, which provides greater flexibility for implementing thin-cloud discrimination algorithms as well as improving range resolution and error reduction, and to enable long flights on a high-altitude unmanned aerial vehicle (UAV). The telescope development consists of a three-telescope design built for the constraints of the Global Hawk aircraft. This task addresses the ability of multiple smaller telescopes to provide equal or greater collection efficiency compared with a single larger telescope with a reduced impact on launch mass and cost. The telescope assembly also integrates fiber-coupled transmit collimators for all of the laser transmitters and fiber-coupled optical
West, R R; Carey, M J
In a study designed to investigate the variations in rates of admission to hospital for appendicitis in Wales Hospital Activity Analysis listings were analysed according to the sex and age of the patients and the month and day of the week of admission. The incidence of hospitalisation was greatest among boys aged 10-14 and girls aged 15-19. The number of admissions was higher on weekdays than at weekends, but there were no seasonal variations. Durations of stay differed between the 17 health districts. We conclude that admission rates vary mainly because of differing hospital admission policies. Admission is not wholly governed by the sudden onset of abdominal pain; other factors include the threshold of consultation of each patient, the referral habits of general practitioners, the availability of hospital beds, and the degree to which doctors and patients expect admission. PMID:656866
Lin, B.; Browell, E. V.; Campbell, J. F.; Choi, Y.; Dobler, J. T.; Fan, T. F.; Harrison, F. W.; Kooi, S. A.; Liu, Z.; Meadows, B.; Nehrir, A. R.; Obland, M. D.; Plant, J.; Yang, M. M.
Accurate observations of atmospheric CO2 with a space-based lidar system, such as for the NASA ASCENDS mission, will improve knowledge of global CO2 distribution and variability and increase the confidence in predictions of future climate changes. To prepare for the ASCENDS mission, the NASA Langley Research Center and Exelis Inc. (now part of Harris Corp.) have been collaborating in the development and evaluation of an Intensity-Modulated Continuous-Wave (IM-CW) lidar approach for measuring atmospheric CO2 from space. Two airborne IM-CW lidars operating in the 1.57-mm CO2 absorption band have been developed and flight tested to demonstrate precise atmospheric CO2 column measurements. A total of 14 flight campaigns have been conducted with the two lidar and in-situ CO2 measurement systems. Significant atmospheric CO2 variations on various spatiotemporal scales were observed during these campaigns. For example, around 10-ppm CO2 changes were found within free troposphere in a region of about 200×300 km2 over Iowa during a summer 2014 flight. Even over extended forests, about 2-ppm CO2 column variability was measured within about 500-km distance. For winter times, especially over snow covered ground, relatively less horizontal CO2 variability was observed, likely owing to minimal interactions between the atmosphere and land surface. Inter-annual variations of CO2 drawdown over cornfields in the Mid-West were found to be larger than 5 ppm due to slight differences in the corn growing phase and meteorological conditions even in the same time period of a year. Furthermore, considerable differences in atmospheric CO2 profiles were found during winter and summer campaigns. In the winter CO2 was found to decrease from about 400 ppm in the atmospheric boundary layer (ABL) to about 392 ppm above 10 km, while in the summer CO2 increased from 386 ppm in the ABL to about 396 ppm in free troposphere. These and other CO2 observations are discussed in this presentation.
Padrón-Arredondo, Guillermo; de Atocha Rosado-Montero, Manuel
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.
Reinisch, Alexander; Malkomes, Patrizia; Habbe, Nils; Bechstein, Wolf Otto; Liese, Juliane
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.
Cheluvappa, R; Luo, A S; Palmer, C; Grimm, M C
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
Camp, Melissa; Chang, David C; Zhang, Yiyi; Arnold, Meghan; Sharpe, Leilani; Gabre-Kidan, Alodia; Bathurst, Melinda A; Abdullah, Fizan
To examine whether density of providers or health care facility factors have a significant effect on the rates of perforated appendicitis in the pediatric population. A retrospective database analysis. Data were linked to the Area Resource File to determine if there was an association between perforated appendicitis and density of provider and facility factors. The National Inpatient Sample database and the Kids' Inpatient Database from 1988 to 2005. All patients included had an age at admission of younger than 18 years and were selected by International Classification of Diseases, Ninth Revision code as having perforated appendicitis (540.0 or 540.1) or acute appendicitis (540.9). Main Outcome Measure Odds ratio of perforated appendicitis to acute appendicitis by county-level density of provider and health care facility factors. The odds ratio of perforated appendicitis to acute appendicitis when stratified by quartiles of increasing density of providers and facility-level factors was statistically significant only for the highest-density quartile of pediatricians (odds ratio = 0.88; 95% confidence interval = 0.78-0.99). Increasing geographic density of pediatricians was associated with a decreasing trend in the odds ratio of perforated appendicitis, with a statistically significant protective effect observed in the highest-density quartile of pediatricians. The density of all other provider and health care facility factors analyzed did not demonstrate a significant association with the rates of perforated appendicitis.
Dumlu, Ersin Gürkan; Tokaç, Mehmet; Bozkurt, Birkan; Yildirim, Murat Baki; Ergin, Merve; Yalçin, Abdussamed; Kiliç, Mehmet
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
Significant atmospheric CO2 variations on various spatiotemporal scales were observed during ASCENDS flight campaigns. For example, around 10-ppm CO2 changes were found within free troposphere in a region of about 200x300 sq km over Iowa during a summer 2014 flight. Even over extended forests, about 2-ppm CO2 column variability was measured within about 500-km distance. For winter times, especially over snow covered ground, relatively less horizontal CO2 variability was observed, likely owing to minimal interactions between the atmosphere and land surface. Inter-annual variations of CO2 drawdown over cornfields in the Mid-West were found to be larger than 5 ppm due to slight differences in the corn growing phase and meteorological conditions even in the same time period of a year. Furthermore, considerable differences in atmospheric CO2 profiles were found during winter and summer campaigns. In the winter CO2 was found to decrease from about 400 ppm in the atmospheric boundary layer (ABL) to about 392 ppm above 10 km, while in the summer CO2 increased from 386 ppm in the ABL to about 396 ppm in free troposphere. These and other CO2 observations are discussed in this presentation.
Davis, Frances M; Luo, Yuanming; Avril, Stéphane; Duprey, Ambroise; Lu, Jia
Ascending thoracic aortic aneurysms (ATAAs) are focal, asymmetric dilatations of the aortic wall which are prone to rupture. To identify potential rupture locations in advance, it is necessary to consider the inhomogeneity of the ATAA at the millimeter scale. Towards this end, we have developed a combined experimental and computational approach using bulge inflation tests, digital image correlation (DIC), and an inverse membrane approach to characterize the pointwise stress, strain, and hyperelastic properties of the ATAA. Using this approach, the pointwise hyperelastic material properties were identified on 10 human ATAA samples collected from patients undergoing elective surgery to replace their ATAAs with a graft. Our method was able to capture the varying levels of heterogeneity in the ATAA from regional to local. It was shown for the first time that the material properties in the ATAA are unmistakably heterogeneous at length scales between 1mm and 1cm, which are length scales where vascular tissue is typically treated as homogeneous. The distributions of the material properties for each patient were also examined to study the inter- and intra-patient variability. Large inter-subject variability was observed in the elastic properties.
Martin, Caitlin; Elefteriades, John
Catastrophic ascending aorta aneurysm (AsAA) dissection and rupture can be prevented by elective surgical repair, but identifying individuals at risk remains a challenge. Typically the decision to operate is based primarily on the overall aneurysm size, which may not be a reliable indicator of risk. In this study, AsAA inflation and rupture was simulated in 27 patient-specific finite element models constructed from clinical CT imaging data and tissue mechanical testing data from matching patients. These patients included n = 8 with concomitant bicuspid aortic valve (BAV), n = 10 with bovine aortic arch (BAA), and n = 10 with neither BAV nor BAA. AsAA rupture risk was found to increase with elevated systolic wall stress and tissue stiffness. The aortic size index was sufficient for identifying the patients with the lowest risk of rupture, but unsuitable for delineating between patients at moderate and high risk. There was no correlation between BAV or BAA and AsAA rupture risk; however, the AsAA morphology was different among these patients. These results support the use of mechanical parameters such as vessel wall stress and tissue stiffness for AsAA presurgical evaluation. PMID:25770248
Yuan, Fei; Necas, Martin
Purpose: To assess the ultrasound performance on patients presenting to Waikato hospital ultrasound department with a clinical suspicion of appendicitis. Method: This was a retrospective audit of 309 patients presenting to our department within business hours with clinical suspicion of appendicitis between September 2012 and March 2014. The patients were evaluated by operators of mixed experience. The scan reports, surgical reports, histology and discharge summaries were reviewed. Results: The overall sensitivity of ultrasound on detecting appendicitis was 50%, the specificity was 98.5%. The positive predictive value and the negative predictive value were 84% and 92.6% respectively. The appendix was visualised in 14% of the true positive cases. When the appendix was visualised, the sensitivity and specificity of ultrasound was 95.2% and 69.2% respectively. Conclusion: The sensitivity of ultrasound to appendicitis was lower than that commonly reported in the literature, but on a par with a recent audit from another tertiary hospital in New Zealand.
Rusanova, Julia; Pilkington, Melanie; Decurtins, Silvio
The synthetic route to a new fully conjugated phenanthroline appended phthalocyanine is described. This compound has been fully characterised by elemental analysis, UV-VIS, IR, MS and 1H NMR spectroscopy.
Vleeschouwers, W; Hofman, Ph; Gillardin, J P; Meert, V; Van Slycke, S
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.
López de Cenarruzabeitia, I.; Landolfi, S.; Armengol Carrasco, M.
Intestinal schistosomiasis as unusual aetiology for acute appendicitis, nowadays a rising disease in western countries. Recent changes in global migration has led to an immigration growth in our scenario, upsurging people coming from endemic areas of schistosomiasis. Schistosomal appendicitis, seldom reported in developed countries, is now an expected incrising entity in our hospitals during the near future. Due to this circumstances, we believe that schistosomiasis should be consider as a rising source for acute appendicitis in western countries. In order to illustrate this point, we present a case of a 45-years-old black man, from Africa, was admitted via A&E because of acute abdominal pain, located in right lower quadrant. Acute appendicitis was suspected, and he underwent laparotomy and appendectomy. Pathological study by microscope revealed a gangrenous appendix with abscesses and parasitic ova into the submucosal layer of the appendix, suggesting Schistosomiasis. PMID:22792502
Cakar, E; Bayrak, S; Bektaş, H; Colak, Ș; Guneyi, A; Sevinc, M Mahsuni; Bag, M
Acute appendicitis is the most common cause of acute abdomen. Carcinoid tumor of the appendix is a rare incidental finding that can present with the clinical picture of acute appendicitis. During open surgery for acute appendicitis, a 3 cm solid mass, not noticed externally, was palpated at the base of the appendix. The mass and the appendix were excised by en-bloc wedge resection. The histopathological examination of the lesion revealed carcinoid tumor. The aim of this presentation is to remind that neoplasms of the appendix may, although rarely, present the clinical picture of acute appendicitis, and to highlight that they, particularly those located at the base of the appendix and in cecum, may be overlooked during laparoscopy. The importance of preoperative computerized tomography ins uch cases has to be underlined. Celsius.
Battaglia, Luigi; Belli, Filiberto; Vannelli, Alberto; Bonfanti, Giuliano; Gallino, Gianfrancesco; Poiasina, Elia; Rampa, Mario; Vitellaro, Marco; Leo, Ermanno
Idiopathic segmental infarction of the greater omentum is an uncommon cause of acute abdomen. The etiology is still unclear and the symptoms mimic acute appendicitis. Its presentation simultaneously with acute appendicitis is still more infrequent. We present a case of a 47-year old woman without significant previous medical history, admitted with an acute abdomen, in which the clinical diagnosis was acute appendicitis and in whom an infarcted segment of right side of the greater omentum was also found at laparotomy. As the etiology is unknown, we highlighted some of the possible theories, and emphasize the importance of omental infarction even in the presence of acute appendicitis as a coincident intraperitoneal pathological condition. PMID:18959804
Domingues-Ferreira, Maurício; Saddi-Rosa, Pedro; dos Santos, André Luis
The general consensus is that appendicitis is basically provoked by fecaliths or lymphoid hyperplasic obstruction. Several studies based on histological diagnosis have not confirmed this hypothesis. On the contrary, obstruction has been proved in only a minority of cases. Diverse infections by parasites, bacteria, fungus, and noninfective agents have been associated with appendicitis in the medical literature. We describe a firefighter, who ingested a small quantity of leachate from decomposing corpses while working and developed enteritis a few hours later, which lasted several days and evolved to appendicitis. This case raises the possibility that the high quantity of bacteria concentration present in the leachate could have provoked enteritis and the subsequent appendicitis due to a direct effect of the bacteria on the appendix. PMID:21541232
Singla, Anand; Singla, Satpaul; Singh, Mohinder; Singla, Deeksha
Acute appendicitis is a common but elusive surgical condition and remains a diagnostic dilemma. It has many clinical mimickers and diagnosis is primarily made on clinical grounds, leading to the evolution of clinical scoring systems for pin pointing the right diagnosis. The modified Alvarado and RIPASA scoring systems are two important scoring systems, for diagnosis of acute appendicitis. We prospectively compared the two scoring systems for diagnosing acute appendicitis in 50 patients presenting with right iliac fossa pain. The RIPASA score correctly classified 88 % of patients with histologically confirmed acute appendicitis compared with 48.0 % with modified Alvarado score, indicating that RIPASA score is more superior to Modified Alvarado score in our clinical settings.
Athans, Brett S; Depinet, Holly E; Towbin, Alexander J; Zhang, Yue; Zhang, Bin; Trout, Andrew T
Purpose To determine the incremental value of clinical data in patients with ultrasonographic (US) examinations that were interpreted as being equivocal for acute appendicitis. Materials and Methods Institutional review board approval, with a waiver of informed consent, was obtained for this analysis of clinical and imaging data in patients younger than 18 years old who were evaluated for acute appendicitis. Findings from US examinations were reported in a structured fashion, including two possible equivocal impressions. Clinical data were captured as Pediatric Appendicitis (PAS) or Alvarado scores and considered as categoric (high, intermediate, or low likelihood) and continuous variables to simulate stratification of equivocal US examinations to predict appendicitis. Receiver operating characteristic curves were used to define score cutoffs, and logistic regression was used to assess individual clinical variables as predictors of appendicitis. Results The study population was made up of 776 patients (mean age, 11.7 years ± 3.7), with 429 (55.2%) girls. A total of 203 (26%) patients had appendicitis. US had a negative predictive value of 96.2% and a positive predictive value of 93.3% for depicting appendicitis, with 89 of 782 (11.4%) equivocal examinations. Categoric PAS and Alvarado scores were equivocal for 59.5% (53 of 89) and 50.6% (45 of 89) of equivocal US examinations, respectively. Categoric low- and high-likelihood PAS and Alvarado scores correctly predicted the presence of appendicitis in 61.1% (22 of 36) and 77.3% (34 of 44) of equivocal US examinations, respectively. As continuous variables, a PAS or Alvarado score of 5 or lower could be used to exclude appendicitis, with a 80.8% (21 of 26) and 90% (18 of 20) negative predictive value, respectively. Conclusion The study confirms the excellent performance of US for depicting pediatric appendicitis. In the subset of equivocal US examinations, a low clinical score (≤5) may be used to identify patients
Miano, Danielle I.; Silvis, Renee M.; Popp, Jill M.; Culbertson, Marvin C.; Campbell, Brendan; Smith, Sharon R.
Introduction Acute appendicitis in children is a clinical diagnosis, which often requires preoperative confirmation with either ultrasound (US) or computed tomography (CT) studies. CTs expose children to radiation, which may increase the lifetime risk of developing malignancy. US in the pediatric population with appropriate clinical follow up and serial exam may be an effective diagnostic modality for many children without incurring the risk of radiation. The objective of the study was to compare the rate of appendiceal rupture and negative appendectomies between children with and without abdominal CTs; and to evaluate the same outcomes for children with and without USs to determine if there were any associations between imaging modalities and outcomes. Methods We conducted a retrospective chart review including emergency department (ED) and inpatient records from 1/1/2009–2/31/2010 and included patients with suspected acute appendicitis. Results 1,493 children, aged less than one year to 20 years, were identified in the ED with suspected appendicitis. These patients presented with abdominal pain who had either a surgical consult or an abdominal imaging study to evaluate for appendicitis, or were transferred from an outside hospital or primary care physician office with the stated suspicion of acute appendicitis. Of these patients, 739 were sent home following evaluation in the ED and did not return within the subsequent two weeks and were therefore presumed not to have appendicitis. A total of 754 were admitted and form the study population, of which 20% received a CT, 53% US, and 8% received both. Of these 57%, 95% CI [53.5,60.5] had pathology-proven appendicitis. Appendicitis rates were similar for children with a CT (57%, 95% CI [49.6,64.4]) compared to those without (57%, 95% CI [52.9,61.0]). Children with perforation were similar between those with a CT (18%, 95% CI [12.3,23.7]) and those without (13%, 95% CI [10.3,15.7]). The proportion of children with a
Jaremko, Jacob L; Crockett, Ann; Rucker, Diana; Magnus, Kenneth G
Frustratingly, sonography to assess for appendicitis in children often leads to an inconclusive report (eg, "suspicious for appendicitis") or nonvisualization of the appendix. To aid in planning who to image and how to interpret the results, we investigated whether these 2 results were more frequent in teenagers than preteens and the prevalence of appendicitis associated with each result. We retrospectively reviewed sonographic and surgical findings in patients <18 years (n = 189) referred with clinical suspicion of appendicitis over a 12-month period. Children (≤12.0 years old; n = 86) and teens (>12.0 years old; n = 103) were compared. Prevalence of appendicitis was 34% in each group, similar to other centres; 0% for those with negative ultrasound reports (0/35), 10% for nonvisualized appendix (8/84), 68% for inconclusive report (15/22), and 85% for positive ultrasound (41/48). Teens were significantly more likely to have an inconclusive ultrasound. Inconclusive reports were because of borderline findings (eg, appendix size near 6 mm; 9/22), body habitus, bowel gas, or unusual findings due in retrospect to perforation. The rate of nonvisualization of the appendix did not vary significantly with age (42% vs 47%). An inconclusive result of ultrasound for appendicitis was significantly more frequent in teens than in preteens and carried a high (68%) likelihood of appendicitis. Conversely, a nonvisualized appendix was equally frequent in teens and preteens, and had a low likelihood of appendicitis (only 10% positive). These findings encourage the use of ultrasound in preteens in particular and can assist interpretation of these common results. Copyright © 2011 Canadian Association of Radiologists. Published by Elsevier Inc. All rights reserved.
Chang, Patricia T; Schooler, Gary R; Lee, Edward Y
Right lower quadrant pain in children can result from various underlying conditions other than acute appendicitis. The common mimics of acute appendicitis are related to acute gastrointestinal and genitourinary diseases. Diagnosis of right lower quadrant pain in the pediatric population can be challenging, especially when the symptoms are often nonspecific. This article reviews the currently available imaging techniques for evaluating a child with right lower quadrant pain and the spectrum of differential diagnoses with a focus on imaging clues to a specific diagnosis.
Sand, M.; Trullen, X.V.; Bechara, F.G.; Pala, X.F.; Sand, D.; Landgrafe, G.; Mann, B.
Background Procalcitonin (PCT) is an established laboratory marker for disease severity in patients with infection and sepsis. In addition, PCT has been shown to be an effective marker for a limited number of localized infections. However, whether or not PCT has any diagnostic value for acute appendicitis, still remains unclear. The purpose of this prospective bicenter study was, therefore, to determine whether or not the PCT levels in the serum of patients with acute appendicitis have any diagnostic value. Methods This prospective study included 103 patients who received an appendectomy, based on the clinical diagnosis of acute appendicitis, in a surgical department of an academic teaching hospital in Germany or in a county hospital in Spain. White blood cell count (WBC), C-reactive protein (CRP) and procalcitonin (PCT) values were determined preoperatively. All appendectomy specimens were sent for routine histopathological evaluation. Based on this information, the patients were assigned to 1 of 5 groups that reflected the severity of the appendicitis. Results Of the 103 patients who were included in the study, 98 had appendicitis. Fourteen (14.3%) showed an increase in PCT values. Of those 14, 4 had a serum PCT >0.5 ng/ml, 9 had a PCT value >2–10 ng/ml and 1 had a PCT value >10 ng/ml. The sensitivity of PCT was calculated to be 0.14. The mean WBC value was 13.0/nl (± 5.2, 3.4–31), and for CRP it was 8.8 mg/dl (± 13, 0–60.2). The values of CRP, WBC and PCT increased with the severity of the appendicitis. Conclusions PCT is potentially increased in rare cases of severe inflammation and, in particular, after appendiceal perforation or gangrenous appendicitis. However, its remarkably low sensitivity prohibits its routine use for the diagnosis of appendicitis. PMID:19672084
Rajkumar, Janavikula Sankaran; Ganesh, Deepa; Rajkumar, Anirudh
Perforated appendicitis leading to inflammatory stricture of the right ureter is a rarity. We present this fairly uncommon case of a patient who developed a stricture of the right ureter secondary to an ongoing inflammatory process in the peritoneum and retroperitoneum. A perforated appendicitis was operated upon, and on follow-up the mild hydronephrosis had worsened. Stenting of the right ureter completely solved the problem. PMID:27251819
Li, Hao-Ming; Yeh, Lee-Ren; Huang, Ying-Kai; Lin, Cheng-Li; Kao, Chia-Hung
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.
Göya, Cemil; Hamidi, Cihad; Okur, Mehmet Hanifi; İçer, Mustafa; Oğuz, Abdullah; Hattapoğlu, Salih; Çetinçakmak, Mehmet Güli; Teke, Memik
PURPOSE The aim of this study was to investigate the feasibility of using acoustic radiation force impulse (ARFI) imaging to diagnose acute appendicitis. METHODS Abdominal ultrasonography (US) and ARFI imaging were performed in 53 patients that presented with right lower quadrant pain, and the results were compared with those obtained in 52 healthy subjects. Qualitative evaluation of the patients was conducted by Virtual Touch™ tissue imaging (VTI), while quantitative evaluation was performed by Virtual Touch™ tissue quantification (VTQ) measuring the shear wave velocity (SWV). The severity of appendix inflammation was observed and rated using ARFI imaging in patients diagnosed with acute appendicitis. Alvarado scores were determined for all patients presenting with right lower quadrant pain. All patients diagnosed with appendicitis received appendectomies. The sensitivity and specificity of ARFI imaging relative to US was determined upon confirming the diagnosis of acute appendicitis via histopathological analysis. RESULTS The Alvarado score had a sensitivity and specificity of 70.8% and 20%, respectively, in detecting acute appendicitis. Abdominal US had 83.3% sensitivity and 80% specificity, while ARFI imaging had 100% sensitivity and 98% specificity, in diagnosing acute appendicitis. The median SWV value was 1.11 m/s (range, 0.6–1.56 m/s) for healthy appendix and 3.07 m/s (range, 1.37–4.78 m/s) for acute appendicitis. CONCLUSION ARFI imaging may be useful in guiding the clinical management of acute appendicitis, by helping its diagnosis and determining the severity of appendix inflammation. PMID:25323836
Wei, Po-Li; Liu, Shih-Ping; Keller, Joseph J.; Lin, Herng-Ching
Background Although procedures like appendectomy have been studied extensively, the relative importance of each surgeon's surgical volume-to-ruptured appendicitis has not been explored. The purpose of this study was to investigate the rate of ruptured appendicitis by surgeon-volume groups as a measure of quality of care for appendicitis by using a nationwide population-based dataset. Methods We identified 65,339 first-time hospitalizations with a discharge diagnosis of acute appendicitis (International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) codes 540, 540.0, 540.1 and 540.9) between January 2007 and December 2009. We used “whether or not a patient had a perforated appendicitis” as the outcome measure. A conditional (fixed-effect) logistic regression model was performed to explore the odds of perforated appendicitis among surgeon case volume groups. Results Patients treated by low-volume surgeons had significantly higher morbidity rates than those treated by high-volume (28.1% vs. 26.15, p<0.001) and very-high-volume surgeons (28.1% vs. 21.4%, p<0.001). After adjusting for surgeon practice location, and teaching status of practice hospital, and patient age, gender, and Charlson Comorbidity Index, and hospital acute appendicitis volume, patients treated by low-volume surgeons had significantly higher rates of perforated appendicitis than those treated by medium-volume surgeons (OR = 1.09, p<0.001), high-volume surgeons (OR = 1.16, p<0.001), or very-high-volume surgeons (OR = 1.54, p<0.001). Conclusion Our study suggested that surgeon volume is an important factor with regard to the rate of ruptured appendicitis. PMID:23300703
Yan, Yan; Evashwick, Thomas W.; Warner, Brad W.; Tarr, Phillip I.
OBJECTIVE: Accurate, timely diagnosis of pediatric appendicitis minimizes unnecessary operations and treatment delays. Preoperative abdominal-pelvic computed tomography (CT) scan is sensitive and specific for appendicitis; however, concerns regarding radiation exposure in children obligate scrutiny of CT use. Here, we characterize recent preoperative imaging use and accuracy among pediatric appendectomy subjects. METHODS: We retrospectively reviewed children who underwent operations for presumed appendicitis at a single tertiary-care children’s hospital and examined preoperative CT and ultrasound use with subject characteristics. Preoperative imaging accuracy was compared with postoperative and histologic diagnosis as the reference standard. RESULTS: Most children (395/423, 93.4%) who underwent an operation for appendicitis during 2009–2010 had preoperative imaging. Final diagnoses included normal appendix (7.3%) and perforated appendicitis (23.6%). In multivariable analysis, initial evaluation at a community hospital versus the children’s hospital was associated with 4.4-fold higher odds of obtaining a preoperative CT scan (P = .002), whereas preoperative ultrasound was less likely (odds ratio 0.20; P = .003). Ultrasound and CT sensitivities for appendicitis were diminished for studies performed at community hospitals compared with the children’s hospital. Girls were 4.5-fold more likely to undergo both ultrasound and CT scans and were associated with lower ultrasound sensitivity for appendicitis. CONCLUSIONS: Widespread preoperative imaging did not eliminate unnecessary pediatric appendectomies. Controlling for factors potentially associated with referral bias, a CT scan was more likely to be performed in children initially evaluated at community hospitals compared with the children’s hospital. Broadly-applicable strategies to systematically maximize diagnostic accuracy for childhood appendicitis, while minimizing ionizing radiation exposure, are
Kinner, Sonja; Repplinger, Michael D.; Pickhardt, Perry J.; Reeder, Scott B.
OBJECTIVE The purpose of this article is to describe our approach to contrast-enhanced abdominal MRI in patients with nontraumatic abdominal pain and suspected appendicitis. We aim to share our experience on the advantages, pearls, and pitfalls of MRI in this clinical setting, in comparison with CT and ultrasound. CONCLUSION We present some typical cases of appendicitis and alternative diagnoses in patients presenting with acute nontraumatic abdominal pain. PMID:27065072
Whelan-Johnson, Sophie; Isaacs, John; Pullan, Rupert D
Appendicitis is a common cause of acute abdominal pain in children and is treated by an open or laparoscopic appendicectomy. Well documented post-operative complications include wound infection, intra-abdominal collection, and adhesional bowel obstruction. We present the rare case of right sacro-iliitis and iliac bone osteomyelitis in a 13 year old boy following an open appendicectomy for a perforated appendicitis.
of the axial Reynolds shear stress is shown in Figure 4 to illustrate this point. Analogous characteristics have also been observed in the near wake...APPENDED BODI ES Most of the theoretical and experimental investigations of flows around appended bodies were carried out in relation to the wing /fuselage...Navier-Stokes equationf;, a projection by Chapman 24 on a similar problem in aerodynamics is worthwhile mentioning. According to him the practical 3D
Oh, Joo Suk; Kim, Ki Wook
Situs inversus totalis is a rare inherent disease in which the thoracic and abdominal organs are transposed. Symptoms of appendicitis in situs inversus (SI) may appear in the left lower quadrant, and the diagnosis of appendicitis is very difficult. We report a case of left-sided appendicitis diagnosed preoperatively after dextrocardia that was detected by chest X-ray, although the chief complaint of the patient was left lower-quadrant pain. The patient underwent an emergent laparoscopic appendectomy under the diagnosis of appendicitis after abdominal computed tomography (CT). In patients with left lower quadrant pain, if the chest X-ray shows dextrocardia, one should suspect left-sided appendicitis. A strong suspicion of appendicitis and an emergency laparoscopic operation after confirmation of the diagnosis by imaging modalities including abdominal CT or sonography can reduce the likelihood of misdiagnosis and complications including perforation and abscess. Laparoscopic appendectomy in SI was technically more challenging because of the mirror nature of the anatomy. PMID:22977765
Platon, Alexandra; Jlassi, Helmi; Rutschmann, Olivier T; Becker, Christoph D; Verdun, Francis R; Gervaz, Pascal; Poletti, Pierre-Alexandre
The aim of this study was to evaluate a low-dose CT with oral contrast medium (LDCT) for the diagnosis of acute appendicitis and compare its performance with standard-dose i.v. contrast-enhanced CT (standard CT) according to patients' BMIs. Eighty-six consecutive patients admitted with suspicion of acute appendicitis underwent LDCT (30 mAs), followed by standard CT (180 mAs). Both examinations were reviewed by two experienced radiologists for direct and indirect signs of appendicitis. Clinical and surgical follow-up was considered as the reference standard. Appendicitis was confirmed by surgery in 37 (43%) of the 86 patients. Twenty-nine (34%) patients eventually had an alternative discharge diagnosis to explain their abdominal pain. Clinical and biological follow-up was uneventful in 20 (23%) patients. LDCT and standard CT had the same sensitivity (100%, 33/33) and specificity (98%, 45/46) to diagnose appendicitis in patients with a body mass index (BMI) >or= 18.5. In slim patients (BMI<18.5), sensitivity to diagnose appendicitis was 50% (2/4) for LDCT and 100% (4/4) for standard CT, while specificity was identical for both techniques (67%, 2/3). LDCT may play a role in the diagnostic workup of patients with a BMI >or= 18.5.
Sarsu, S B; Sahin, K; Kilincaslan, H; Mirapoglu, S L; Buyukpınarbasili, N; Duz, M E; Aydogdu, I
In this study, the diagnostic value of serum endothelin-1 (ET-1) levels and the therapeutic effects of bosentan have been investigated in an experimental appendicitis rat model. Twenty-one male Sprague-Dawley rats were chosen for the study. The rats were allocated into three groups as follows: Group 1 (control, n = 7), Group 2 (appendicitis, n = 7), and Group 3 (bosentan treatment, n = 7). At the 6th hour of the experiment, Groups 1 and 2 received 2 ml saline, and group 3 received 30 mg/kg bosentan intraperitoneally. At the 24th postoperative hour, all rats were sacrificed and evaluated histopathologically to score the severity of appendicitis. The plasma malondialdehyde, reduced and total glutathione levels, serum, and appendiceal tissue ET-1 levels were evaluated. In this study, we found that the ET-1 levels were significantly increased with appendicitis (p = 0.018). The administration of bosentan can statistically significantly both decrease the histopathologic injury in the inflamed appendix and increase the serum total glutathione levels (p = 0.002). The increase in plasma ET-1 levels may have a diagnostic value of acute appendicitis. We believe that manifestations that occur during the acute phase of appendicitis may be reduced with the administration of bosentan, which may also help prevent complications.
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.
Aly, Noha E; McAteer, Dympna; Aly, Emad H
Clinical diagnosis is accurate in only 80% of patients with suspected appendicitis with negative appendectomy rates of up to 21%. In the UK the use of standard-dose CT (SDCT) is conservative due to concerns over radiation exposure and resource implications. The use of low dose computer tomography (LDCT) instead of standard dose computer tomography (SDCT) may partially address these concerns. To compare LDCT and SDCT in the diagnosis of appendicitis. A literature search of the EMBASE and MEDLINE databases in July 2015 was conducted using the keywords 'low dose CT' and 'appendicitis'. Data were analysed and p values calculated using the Chi-square test. P values less than 0.05 were considered to be significant. LDCT (1.2-5.3 mSv) was not inferior to SDCT (5.2-10.2 mSv) in the diagnosis of acute appendicitis and proposing alternative diagnoses. SDCT was superior to LDCT in the negative predictive value of diagnosis of appendiceal perforation. There was no significant difference between LDCT and SDCT in negative appendectomy rate, appendiceal perforation rate and the need for additional imaging. LDCT is not inferior to SDCT in the diagnosis of acute appendicitis and proposing alternative diagnoses. Further studies are recommended to further assess the potential role of LDCT & its cost effectiveness. Its use may improve the current management of patients with suspected acute appendicitis. Copyright © 2016 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.
Giesen, Louis J.X.; van den Boom, Anne Loes; van Rossem, Charles C.; den Hoed, P.T.; Wijnhoven, Bas P.L.
Background Surgical site infections (SSI) are seen in up to 5% of patients after appendectomy for acute appendicitis. SSI are associated with prolonged hospital stay and increased costs. The aim of this multicenter study was to identify factors associated with SSI after appendectomy for acute appendicitis. Methods Patients who underwent appendectomy for acute appendicitis between June 2014 and January 2015 in 6 teaching hospitals in the southwest of the Netherlands were included. Patient, diagnostic, intra-operative and disease-related factors were collected from the patients' charts. Primary outcome was surgical site infection. Multivariable logistic regression was performed to identify independent risk factors for SSI. Results Some 637 patients were included. Forty-two patients developed a SSI. In univariable analysis body temperature >38°C, CRP>65 and complex appendicitis were associated with SSI. After multivariable logistic regression with stepwise backwards elimination, complex appendicitis was significantly associated with SSI (OR 4.09; 95% CI 2.04-8.20). Appendiceal stump closure with a stapler device was inversely correlated with SSI (OR 0.40; 95% CI 0.24-0.97) Conclusions Complex appendicitis is a risk factor for SSI and warrants close monitoring postoperatively. The use of a stapler device for appendiceal stump closure is associated with a reduced risk of SSI. PMID:27631081
Shin, Ilah; An, Chansik; Lim, Joon Seok; Kim, Myeong-Jin; Chung, Yong Eun
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.
Choudhri, Asim F; Carr, Thomas M; Ho, Christopher P; Stone, James R; Gay, Spencer B; Lambert, Drew L
Advances in handheld computing now allow review of DICOM datasets from remote locations. As the diagnostic ability of this tool is unproven, we evaluated the ability to diagnose acute appendicitis on abdominal CT using a mobile DICOM viewer. This HIPAA compliant study was IRB-approved. Twenty-five abdominal CT studies from patients with RLQ pain were interpreted on a handheld device (iPhone) using a DICOM viewer (OsiriX mobile) by five radiologists. All patients had surgical confirmation of acute appendicitis or follow-up confirming no acute appendicitis. Studies were evaluated for the ability to find the appendix, maximum appendiceal diameter, presence of an appendicolith, periappendiceal stranding and fluid, abscess, and an assessment of the diagnosis of acute appendicitis. Results were compared to PACS workstation. Fifteen cases of acute appendicitis were correctly identified on 98% of interpretations, with no false-positives. Eight appendicoliths were correctly identified on 88% of interpretations. Three abscesses were correctly identified by all readers. Handheld device measurement of appendiceal diameter had a mean 8.6% larger than PACS measurements (p = 0.035). Evaluation for acute appendicitis on abdominal CT studies using a portable device DICOM viewer can be performed with good concordance to reads performed on PACS workstations.
Khan, S A; Gafur, M A; Islam, A; Rahman, M S
Acute appendicitis is usually encountered clinically as acute abdomen. Typical cases are easy to diagnose, but sometimes it is very difficult to make a diagnosis in atypical cases. The objective of the study was to determine the diagnostic accuracy in patient of clinically diagnosed acute appendicitis. This prospective study conducted in Mymensingh medical college hospital on 1136 patients presented with acute abdomen and clinically diagnosed as acute appendicitis from July 2004 to June 2010. Emergency appendicectomy was done in all consecutive patients after relevant investigation. Intraoperative findings along with histopathological reports were compared with clinical diagnosis. On the basis of histopathological report, 85.65% were found to have acute appendicitis with misdiagnosis in rest of the subjects requiring unnecessary explorations. Negative exploration was more in emergency than office hour. This may be due to diagnostic inaccuracy and decision-making in the management of the acute appendicitis. Management errors can be significantly reduced by accurate preoperative diagnosis of acute appendicitis by improving clinical skill and appropriate investigations.
Boomer, Laura; Freeman, Jennifer; Landrito, Earl; Feliz, Alexander
Delay in presentation is associated with increased perforation rates in acute appendicitis. Perforation is linked to greater morbidity, and greater risk of complications. The purpose of this study is to evaluate whether ethnicity or insurance status is associated with differences in presentation and outcomes in adult patients with acute appendicitis. A retrospective analysis was performed for all patients 18 y of age and over with acute appendicitis between July 1, 2005 and December 31, 2008 at the only teaching hospital in the region. χ(2) and regression analyses were used to evaluate the impact of ethnicity and insurance status on perforation rates. A total of 1003 patients with acute appendicitis were identified, of which 239 (23.8%) were perforated. Those patients with public insurance were significantly more likely to have perforated disease (P < 0.001). Additionally, those patients in the older age groups (41-64 and ≥65) were also significantly more likely (P < 0.001) to have perforated appendicitis (35.8% and 38.24%, respectively, versus 19.2% for those 18-40). The patients who presented with perforation had a greater length of stay (2.71 ± 2.14 versus 6.04 ± 3.91 d, P < 0.001). In our population sample, ethnicity does not predict perforation rates in adult patients with acute appendicitis. Significant risks of perforation appear related to insurance status and age. Copyright © 2010 Elsevier Inc. All rights reserved.
Chiapponi, Costanza; Jannasch, Olof; Petersen, Manuela; Lessel, Wiebke; Bruns, Christiane; Meyer, Frank
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.
Rateri, Debra L.; Davis, Frank M.; Balakrishnan, Anju; Howatt, Deborah A.; Moorleghen, Jessica J.; O’Connor, William N.; Charnigo, Richard; Cassis, Lisa A.; Daugherty, Alan
Angiotensin II (Ang II) promotes development of ascending aortic aneurysms (AAs), but progression of this pathology is undefined. We evaluated factors potentially involved in progression, and determined the temporal sequence of tissue changes during development of Ang II–induced ascending AAs. Ang II infusion into C57BL/6J mice promoted rapid expansion of the ascending aorta, with significant increases within 5 days, as determined by both in vivo ultrasonography and ex vivo sequential acquisition of tissues. Rates of expansion were not significantly different in LDL receptor–null mice fed a saturated fat-enriched diet, demonstrating a lack of effect of hypercholesterolemia. Augmenting systolic blood pressure with norepinephrine infusion had no significant effect on ascending aortic expansion. Pathological changes observed within 5 days of Ang II infusion included increased medial thickness and intramural hemorrhage characterized by erythrocyte extravasation in outer lamellar layers of the media. Intramedial hemorrhage was not observed after prolonged Ang II infusion, although partial medial disruption was present. Elastin fragmentation and transmural medial breaks of the ascending aorta were observed with continued Ang II infusion, which were restricted to anterior aspects. CD45+ cells accumulated in adventitia but were minimal in media. Similar pathology was observed in tissues obtained from patients with ascending AAs. In conclusion, Ang II promotes ascending AAs through region-specific changes that are independent of hypercholesterolemia or systolic blood pressure. PMID:25038458
Cally, Paul; Erdélyi, Robert; Norton
A total solar eclipse is the most spectacular and awe-inspiring astronomical phenomenon most people will ever see in their lifetimes. Even hardened solar scientists draw inspiration from it. The eclipse with 2 minutes totality in the early morning of 14 November 2012 (local time) drew over 120 solar researchers (and untold thousands of the general public) to the small and picturesque resort town of Palm Cove just north of Cairns in tropical north Queensland, Australia, and they were rewarded when the clouds parted just before totality to reveal a stunning solar display. Eclipse photograph The eclipse was also the catalyst for an unusually broad and exciting conference held in Palm Cove over the week 12--16 November. Eclipse on the Coral Sea: Cycle 24 Ascending served as GONG 2012, LWS/SDO-5, and SOHO 27, indicating how widely it drew on the various sub-communities within solar physics. Indeed, as we neared the end of the ascending phase of the peculiar Solar Cycle 24, it was the perfect time to bring the whole community together to discuss our Sun's errant recent behaviour, especially as Cycle 24 is the first to be fully observed by the Solar Dynamics Observatory (SDO). The whole-Sun perspective was a driving theme of the conference, with the cycle probed from interior (helioseismology), to atmosphere (the various lines observed by the Atmospheric Imaging Assemble (AIA) aboard SDO, the several instruments on Hinode, and other modern observatories), and beyond (CMEs etc). The quality of the presentations was exceptional, and the many speakers are to be commended for pitching their talks to the broad community present. These proceedings draw from the invited and contributed oral presentations and the posters exhibited in Palm Cove. They give an (incomplete) snapshot of the meeting, illustrating its broad vistas. The published contributions are organized along the lines of the conference sessions, as set out in the Contents, leading off with a provocative view of
Taylor, J. A.; Halliwill, J. R.; Brown, T. E.; Hayano, J.; Eckberg, D. L.
1. The notion that small, 'non-hypotensive' reductions of effective blood volume alter neither arterial pressure nor arterial baroreceptor activity is pervasive in the experimental literature. We tested two hypotheses: (a) that minute arterial pressure and cardiac autonomic outflow changes during hypovolaemia induced by lower body suction in humans are masked by alterations in breathing, and (b) that evidence for arterial baroreflex engagement might be obtained from measurements of thoracic aorta dimensions. 2. In two studies, responses to graded lower body suction at 0 (control), 5, 10, 15, 20 and 40 mmHg were examined in twelve and ten healthy young men, respectively. In the first, arterial pressure (photoplethysmograph), R-R interval, and respiratory sinus arrhythmia amplitude (complex demodulation) were measured during uncontrolled and controlled breathing (constant breathing frequency and tidal volume). In the second, cross-sectional areas of the ascending thoracic aorta were calculated from nuclear magnetic resonance images. 3. Lower body suction with controlled breathing resulted in an increased arterial pulse pressure at mild levels (5-20 mmHg; ANOVA, P < 0.05) and a decreased arterial pulse pressure at moderate levels (40 mmHg; ANOVA, P < 0.05). Both R-R intervals and respiratory sinus arrhythmia were negatively related to lower body suction level, whether group averages (general linear regression, r > 0.92) or individual subjects (orthogonal polynomials, 12 of 12 subjects) were assessed. 4. Aortic pulse area decreased progressively and significantly during mild lower body suction, with 47% of the total decline occurring by 5 mmHg. 5. These results suggest that small reductions of effective blood volume reduce aortic baroreceptive areas and trigger haemodynamic adjustments which are so efficient that alterations in arterial pressure escape detection by conventional means.
Quevedo, Henry C.; Santiago-Trinidad, Ricardo; Castellanos, Jorge; Atianzar, Kimberly; Anwar, Asif; Rafeh, Nidal Abi
Background The safety and efficacy of endovascular therapies for ascending aortic pseudoaneurysms (AAPs) are still controversial. Methods We report an endovascular correction of an AAP in a high-risk surgical patient and present the results of a literature review focusing on AAP treatment strategies. A multilingual search of AAP therapy was performed with limiting dates of January 1980 to May 2014. The studies were classified by intervention. Results A 79-year-old male with a 9 × 10 × 7 cm AAP in the anterior mediastinum was considered too high risk for surgery. An endovascular closure with a 12 mm Amplatzer septal occluder device (St. Jude Medical) was performed, and computed tomography angiography at 3-month follow-up exhibited a thrombosed AAP with minimal residual shunt. In our literature search, we identified 355 cases of AAPs, mostly case reports (91.5%) and a few patient series (8.5%). Surgical correction accounted for 73.8% of the cases, 5% of the patients were conservatively treated or considered too critically ill for any intervention, and 21.2% were treated with endovascular techniques. The most commonly reported endovascular techniques were stent grafts (9.8%) and septal occluder devices (9.8%). Conclusion Although endovascular closure of AAPs with off-label devices is a reliable option for controlling the expansion and symptoms in high-risk surgical patients, solid data on survival are lacking. Efforts to promote discussion within the heart team to expand the application of endovascular techniques can provide groundbreaking evidence to support the use of endovascular techniques as guideline therapy when facing these complicated cases. PMID:25598723
Ovalle, Alfredo; Martínez, María Angélica; Fuentes, Ariel; Marques, Ximena; Vargas, Francisco; Vergara, Paula; Staig, Pablo; Marín, María Paz; Oda, Francisco; Kakarieka, Elena
Obesity in pregnancy is associated with significantly higher rates of infection. To compare the infectious morbidity in pregnant women with normal and altered body mass index (BMI). Cross sectional retrospective study of 6,150 patients who had delivery or second trimester abortion during 2012. The patients were classified according to BMI as underweight, normal weight, overweight and obese. We compared the frequency of pregnancy and perinatal complications related to ascending bacterial infection (ABI). The data was obtained from the hospitals databases. Obese patients had higher rates of pregnancy and perinatal complications related to ABI compared to patients with normal weight. The odds ratios (OR) and 95% confidence intervals (CI) for second trimester abortion were 3.45 (1.63-7.31) p < 0.01, for preterm delivery 2.42 (1.51-3.87) p < 0.01, for labor and puerperium infections 3.42 (2.06-5.68) p < 0.01 and for early neonatal infectious and perinatal mortality 4.46 (1.75-11.37) p < 0.01. A logistic regression analysis revealed that obesity is an independent risk factor for second trimester abortion related to ABI with an OR of 3.18 (CI 95% 1.46-6.91), premature delivery related to ABI with an OR of 2.51 (CI 95% 1.54-4.09) and for delivery and postpartum infections with an OR of 4.44 (CI 95% 2.62 to 7.51). Obese pregnant women had a 2.5 to 4.5 times increased risk of infectious morbidity compared to normal weight patients. Obesity is an independent risk factor for second trimester abortion and preterm delivery related to ABI and delivery and postpartum infectious.
Segadal, L; Matre, K
Mapping of blood velocities across the lumen of the ascending aorta was performed in eight patients during open-heart surgery. A Doppler ultrasound probe was constructed to measure velocities in 2 mm steps from the maximum convexity to the maximum concavity of aorta, 6 to 7 cm above the aortic valve. In five patients with angina and normal aortic valves, velocity profiles were very similar and showed the following main features: a skewed peak systolic velocity profile with the highest velocity along the left posterior wall, a bidirectional velocity profile in late systole and early diastole with retrograde velocities along the left posterior wall, and a sustained antegrade flow along the convexity well into diastole. The resultant mean velocity profile had the highest velocity at the convex side and a central minimum velocity. In patients with Medtronic-Hall tilting disc prostheses, where the larger opening was oriented backwards and to the right, mean flow velocity profile was skewed in the opposite direction of normal. Moreover, instant systolic velocity profiles were much more irregular and dependent on the exact orientation of the prosthesis. In one patient with aortic valvular disease, very irregular and different velocity profiles were found. Based on a symmetry assumption, overall mean velocity for the total cross section was computed, and the magnitude of error in estimation of total flow from measurement of velocities at different depths was calculated. To measure total flow in the aorta, i.e., cardiac output, by single-gated Doppler technique, the most representative sampling site was about one-third of the diameter from the convex wall.
Taylor, J. A.; Halliwill, J. R.; Brown, T. E.; Hayano, J.; Eckberg, D. L.
1. The notion that small, 'non-hypotensive' reductions of effective blood volume alter neither arterial pressure nor arterial baroreceptor activity is pervasive in the experimental literature. We tested two hypotheses: (a) that minute arterial pressure and cardiac autonomic outflow changes during hypovolaemia induced by lower body suction in humans are masked by alterations in breathing, and (b) that evidence for arterial baroreflex engagement might be obtained from measurements of thoracic aorta dimensions. 2. In two studies, responses to graded lower body suction at 0 (control), 5, 10, 15, 20 and 40 mmHg were examined in twelve and ten healthy young men, respectively. In the first, arterial pressure (photoplethysmograph), R-R interval, and respiratory sinus arrhythmia amplitude (complex demodulation) were measured during uncontrolled and controlled breathing (constant breathing frequency and tidal volume). In the second, cross-sectional areas of the ascending thoracic aorta were calculated from nuclear magnetic resonance images. 3. Lower body suction with controlled breathing resulted in an increased arterial pulse pressure at mild levels (5-20 mmHg; ANOVA, P < 0.05) and a decreased arterial pulse pressure at moderate levels (40 mmHg; ANOVA, P < 0.05). Both R-R intervals and respiratory sinus arrhythmia were negatively related to lower body suction level, whether group averages (general linear regression, r > 0.92) or individual subjects (orthogonal polynomials, 12 of 12 subjects) were assessed. 4. Aortic pulse area decreased progressively and significantly during mild lower body suction, with 47% of the total decline occurring by 5 mmHg. 5. These results suggest that small reductions of effective blood volume reduce aortic baroreceptive areas and trigger haemodynamic adjustments which are so efficient that alterations in arterial pressure escape detection by conventional means.
Martin, Caitlin; Sun, Wei; Primiano, Charles; McKay, Raymond; Elefteriades, John
Quantification of the age- and gender-specific in vivo mechanical characteristics of the ascending aorta (AA) will allow for identification of abnormalities aside from changes brought on by aging alone. Multiphase clinical CT scans of 45 male patients between the ages of 30 and 79 years were analyzed to assess age-dependent in vivo AA characteristics. The three-dimensional AA geometry for each patient was reconstructed from the CT scans for 9–10 phases throughout the cardiac cycle. The AA circumference was measured during each phase and was used to determine the corresponding diameter, circumferential strain, and wall tension at each phase. The pressure-strain modulus was also determined for each patient. The mean diastolic AA diameter was significantly smaller among young (42.6±5.2 years) at 29.9±2.8 mm than old patients (69.0±5.2 years) at 33.2±3.2 mm. The circumferential AA strain from end-diastole to peak-systole decreased from 0.092±0.03 in young to 0.056±0.03 in old patients. The pressure-strain modulus increased two-fold from 68.4±30.5 kPa in young to 162.0±93.5 kPa in old patients, and the systolic AA wall tension increased from 268.5±31.3 kPa in young to 304.9±49.2 kPa in old patients. The AA dilates and stiffens with aging which increases the vessel wall tension, likely predisposing aneurysm and dissection. PMID:23817767
Barajas, L.; Powers, K.V.
The overlap of accumulations of autoradiographic grains (AAGs) on profiles of the thick ascending limb of Henle (TALH) was measured in autoradiograms of sections from rat kidneys with monoaminergic nerves labeled by means of tritiated norepinephrine. The amount of AAG overlap was used as an indirect means of quantifying innervation along the TALHs of superficial, mid-cortical, and juxtamedullary nephrons. The density of innervation along the TALH showed nephron heterogeneity; the juxtamedullary nephrons with a high pre- and postjuxtaglomerular apparatus (JGA) TALH density of innervation and the upper and midcortical nephrons with high TALH innervation densities at the level of the JGA. The pre-JGA TALH of the juxtamedullary nephrons had a significantly higher (P less than 0.001) density of innervation than the midcortical or superficial nephrons. The TALHs of juxtamedullary nephrons were found to have substantially more innervation than the TALHs of the other nephrons. For all three populations of nephrons, the pre-JGA TALH had the greatest amount of innervation. Neural regulation of TALH function would occur mainly along the pre-JGA and level of the JGA TALH. This regulation would increase TALH NaCl reabsorption (decrease luminal NaCl concentration) and therefore influence 1) the urinary concentrating mechanism, and 2) renin secretion via the macula densa mechanism. The innervation of the TALH was predominantly associated with the vasculature of the TALH's own nephron. However, innervation associated with medullary ray capillary beds from deeper nephrons was observed on pre-JGA TALHs from superficial and midcortical nephrons.
Martin, Caitlin; Sun, Wei; Pham, Thuy; Elefteriades, John
Aortic aneurysm is a leading cause of death in adults, often taking lives without any premonitory signs or symptoms. Adverse clinical outcomes of aortic aneurysm are preventable by elective surgical repair; however, identifying at-risk individuals is difficult. The objective of this study was to perform a predictive biomechanical analysis of ascending aortic aneurysm (AsAA) tissue to assess rupture risk on a patient-specific level. AsAA tissues, obtained intra-operatively from 50 patients, were subjected to biaxial mechanical and uniaxial failure tests to obtain their passive elastic mechanical properties. A novel analytical method was developed to predict the AsAA pressure-diameter response as well as the aortic wall yield and failure responses. Our results indicated that the mean predicted AsAA diameter at rupture was 5.6 ± 0.7 cm, and the associated blood pressure to induce rupture was 579.4 ± 214.8 mmHg. Statistical analysis showed significant positive correlation between aneurysm tissue compliance and predicted risk of rupture, where patients with a pressure-strain modulus ≥100 kPa may be nearly twice as likely to experience rupture than patients with more compliant aortic tissue. The mechanical analysis of pre-dissection patient tissue properties established in this study could predict the “future” onset of yielding and rupture in AsAA patients. The analysis results implicate decreased tissue compliance as a risk factor for AsAA rupture. The presented methods may serve as a basis for the development of a pre-operative planning tool for AsAA evaluation, a tool currently unavailable. PMID:23948500
Allen, Keith B; Davis, J Russell; Cohen, David J
Thoracic endovascular aortic repair (TEVAR) of acute ascending aortic pathology is feasible; however, the unique features of this aortic segment in addition to access challenges restricts its use to a select, high-risk subset of patients. With the advent of TAVR, large device delivery using transapical access has become a well-defined technique. We report a patient with critical aortic stenosis and an acute ascending aortic penetrating ulcer with tamponade managed successfully utilizing transapical TAVR and TEVAR. To our knowledge, this is the first reported case of a hybrid single-stage TAVR and ascending aortic TEVAR using transapical access.
Karimi, Ebrahim; Aminianfar, Mohammad; Zarafshani, Keivan; Safaie, Arash
Introduction: Diagnostic values reported for ultrasonographic screening of acute appendicitis vary widely and are dependent on the operator’s skill, patient’s gender, weight, etc. The present study aimed to evaluate the effect of operator skill on the diagnostic accuracy of ultrasonography in detection of appendicitis by comparing the results of ultrasonography done by radiologists and emergency physicians. Methods: This prospective diagnostic accuracy was carried out on patients suspected to acute appendicitis presenting to EDs of 2 hospitals. After the initial clinical examinations, all the patients underwent ultrasonography for appendicitis by emergency physician and radiologist, respectively. The final diagnosis of appendicitis was based on either pathology report or 48-hour follow-up. Screening performance characteristics of appendix ultrasonography by emergency physician and radiologist were compared using STATA 11.0 software. Results: 108 patients with the mean age of 23.91 ± 7.46 years were studied (61.1% male). Appendicitis was confirmed for 37 (34.26%) cases. Cohen's kappa coefficient between ultrasonography by the radiologist and emergency physician in diagnosis of acute appendicitis was 0.51 (95% CI: 0.35 – 0.76). Area under the ROC curve of ultrasonography in appendicitis diagnosis was 0.78 (95% CI: 0.69 – 0.86) for emergency physician and 0.88 (95% CI: 0.81 – 0.94) for radiologist (p = 0.052). Sensitivity and specificity of ultrasonography by radiologist and emergency physician in appendicitis diagnosis were 83.87% (95% CI: 67.32 – 93.23), 91.5% (95% CI: 81.89 – 96.52), 72.97% (95% CI: 55.61 – 85.63), and 83.10% (95% CI: 71.94 – 90.59), respectively. Conclusion: Findings of the present study showed that the diagnostic accuracy of ultrasonography carried out by radiologist (89%) is a little better compared to that of emergency physician (80%) in diagnosis of appendicitis, but none are excellent. PMID:28286829
Drake, Frederick Thurston; Mottey, Neli E.; Farrokhi, Ellen T.; Florence, Michael G.; Johnson, Morris G.; Mock, Charles; Steele, Scott R.; Thirlby, Richard C.; Flum, David R.
IMPORTANCE In the traditional model of acute appendicitis, time is the major driver of disease progression; luminal obstruction leads inexorably to perforation without timely intervention. This perceived association has long guided clinical behavior related to the timing of appendectomy. OBJECTIVE To evaluate whether there is an association between time and perforation after patients present to the hospital. DESIGN, SETTING, AND PARTICIPANTS Using data from the Washington State Surgical Care and Outcomes Assessment Program (SCOAP), we evaluated patterns of perforation among patients (≥18 years) who underwent appendectomy from January 1, 2010, to December 31, 2011. Patients were treated at 52 diverse hospitals including urban tertiary centers, a university hospital, small community and rural hospitals, and hospitals within multi-institutional organizations. MAIN OUTCOMES AND MEASURES The main outcome of interest was perforation as diagnosed on final pathology reports. The main predictor of interest was elapsed time as measured between presentation to the hospital and operating room (OR) start time. The relationship between in-hospital time and perforation was adjusted for potential confounding using multivariate logistic regression. Additional predictors of interest included sex, age, number of comorbid conditions, race and/or ethnicity, insurance status, and hospital characteristics such as community type and appendectomy volume. RESULTS A total of 9048 adults underwent appendectomy (15.8% perforated). Mean time from presentation to OR was the same (8.6 hours) for patients with perforated and nonperforated appendicitis. In multivariate analysis, increasing time to OR was not a predictor of perforation, either as a continuous variable (odds ratio = 1.0 [95% CI, 0.99-1.01]) or when considered as a categorical variable (patients ordered by elapsed time and divided into deciles). Factors associated with perforation were male sex, increasing age, 3 or more comorbid
Bach, Lindsay; Donovan, Andrew; Loggins, Whitney; Thompson, Stephanie; Richmond, Bryan
Appendicitis is the most common surgical emergency encountered by the general surgeon. Literature has demonstrated that diabetics may manifest atypical signs of infection, often clouding the diagnostic picture. We conducted a 3-year retrospective analysis of adults with appendicitis to determine differences in presentation, diagnosis, treatment, and outcomes for diabetic versus nondiabetic patients. Demographics, symptoms, imaging, procedure(s), complications, and length of stay (LOS) were obtained via chart review. Factors were compared between patients with and without diabetes using chi-squared test, t test, or Mann-Whitney U test (significance at P ≤ 0.05). Multivariate regression analysis identified variables predicting longer LOS or perforation at diagnosis. Overall, 339 patients met inclusion criteria [303 were nondiabetic (ND), 36 were diabetic (D)]. On univariate analysis, diabetics were more likely to have other comorbid illnesses: obesity (P < 0.001), chronic kidney disease (P = 0.003), hypertension (P < 0.001), coronary artery disease (P < 0.001), peripheral vascular disease (PVD, P = 0.31), and chronic obstructive pulmonary disease (P = 0.002). Diabetics presented with lower white blood cell counts (mean 14.2 ND, 11.9 D, P = 0.02), and were more likely to present with perforation (18.5% ND, 38.9% D, P = 0.008). LOS was longer in diabetics (1.0 day for ND, 3.0 day for D, P < 0.001). Complications were more frequent in diabetics (19.4% D vs 8.6% ND), which trended toward but failed to reach significance (P = 0.066). On multivariate analysis, however, old age was the only characteristic associated with perforation [odds ratio: 1.05 (1.02-1.06), P < 0.001], whereas diabetes, chronic obstructive pulmonary disease, and older age predicted longer LOS (P ≤ 0.001). Diabetics present a more complicated clinical picture having significantly more comorbidities and a trend toward postoperative complications necessitating a higher index of suspicion to detection
Nyuwi, Kuotho T; Khumukcham, Sridartha; Rangaswamy, Raju; Ezung, Yibenthung S; Chittvolu, Sowdin Reddy; Sharma, A Barindra; Singh, H Manihar
Introduction Acute appendicitis is the most common indication for emergent surgery and affects a wide range of patients at any age group. However, inspite of the presence of various imaging modalities, biochemical markers, and scoring systems the negative appendectomy rate remain high. Serum fibrinogen, an acute inflammatory mediator is usually raised in any acute inflammatory condition and the same is expected to rise in acute appendicitis, which may be used as a new inflammatory marker in the diagnosis and more importantly in decision making of management of acute appendicitis. Aim To determine the relationship between the rise in the level of serum fibrinogen and acute appendicitis and its role in reducing the negative appendectomy rate. Materials and Methods A total of 82 patients with clinical signs and symptoms of acute appendicitis who underwent emergency appendectomy were included in the study, the serum fibrinogen level were measured just before the operation and the sensitivity and the specificity was calculated. The final diagnosis was based on the histopathological examination. Results In our study, the Mean±SD of serum fibrinogen in mg/dl in those patient proved to be having acute appendicitis by histopathology was 436.6±40.6 while those with normal appendix was 391.91±66.54. The area under the curve was 0.697 i.e., it has an accuracy of around 70% and this is statistically significant (p=0.018). On further sub-analysis when the cut off level of fibrinogen level was reduced to 397, it resulted in a sensitivity of 82% and specificity of 60% and if the level was further reduced to 375 it increased the sensitivity to 88% with a specificity of 55%. Conclusion In the diagnosis of acute appendicitis, use of fibrinogen blood level may be a new diagnostic acute-phase reactant with possible role in reducing negative appendectomy rate. PMID:28274001
Bosak Versic, Ana; Glavan, Nedeljka; Bukvic, Nado; Tomasic, Zlatko; Nikolic, Harry
Acute appendicitis is the most common abdominal surgical emergency in children, and appendectomy is the most frequent acute abdominal operation. Prompt diagnosis and surgical treatment are required to reduce the risk of perforation and prevent complications, especially in small children. Enterochromaffin cells that contain large amounts of serotonin are mostly located in the distal appendix. Serotonin metabolite 5-hydroxyindoleacetic acid (5-HIAA) could therefore be a marker for acute appendicitis. We tested urinary 5-HIAA concentrations in spot urine samples from children with acute appendicitis. We enrolled 93 patients who underwent surgery for suspicion of acute appendicitis. The diagnosis was made intraoperatively and confirmed histopathologically. Additionally, urine samples from 102 healthy children were collected as controls. Their 5-HIAA was measured using high-performance liquid chromatography. Acute appendicitis was diagnosed in 81 patients, whereas there were other explanations for abdominal pain in the remaining 12 patients in the non-appendicitis group. The control group comprised 102 healthy children. Considering the median of all measured 5-HIAA values as the cut-off, we analysed the proportions of patients with elevated values in all the groups. Our analysis showed that statistically there was no significant difference in the distribution of percentages among the groups. The area under the curve for 5-HIAA was 0.55 (95% CI 0.47 to 0.62) with sensitivity and specificity 60.4% and 48.9%, respectively. Urine 5-HIAA concentration measured in spot samples is not a reliable method for diagnosing acute appendicitis in children. 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/.
Kang, Byung Mo; Hwang, Ji Woong; Ryu, Byoung Yoon
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.
Wiersma, Fraukje; Bakker, Rutger F. R.; Merkus, Jos W. S.; Breslau, Paul J.; Hamming, Jaap F.
Background Acute appendicitis continues to be a challenging diagnosis. Preoperative radiological imaging using ultrasound (US) or computed tomography (CT) has gained popularity as it may offer a more accurate diagnosis than classic clinical evaluation. The optimal implementation of these diagnostic modalities has yet to be established. The aim of the present study was to investigate a diagnostic pathway that uses routine US, limited CT, and clinical re-evaluation for patients with acute appendicitis. Methods A prospective analysis was performed of all patients presenting with acute abdominal pain at the emergency department from June 2005 until July 2006 using a structured diagnosis and management flowchart. Daily practice was mimicked, while ensuring a valid assessment of clinical and radiological diagnostic accuracies and the effect they had on patient management. Results A total of 802 patients were included in this analysis. Additional radiological imaging was performed in 96.3% of patients with suspected appendicitis (n = 164). Use of CT was kept to a minimum (17.9%), with a US:CT ratio of approximately 6:1. Positive and negative predictive values for the clinical diagnosis of appendicitis were 63 and 98%, respectively; for US 94 and 97%, respectively; and for CT 100 and 100%, respectively. The negative appendicitis rate was 3.3%, the perforation rate was 23.5%, and the missed perforated appendicitis rate was 3.4%. No (diagnostic) laparoscopies were performed. Conclusions A diagnostic pathway using routine US, limited CT, and clinical re-evaluation for patients with acute abdominal pain can provide excellent results for the diagnosis and treatment of appendicitis. PMID:20582544
Kharbanda, Anupam B; Dudley, Nanette C; Bajaj, Lalit; Stevenson, Michelle D; Macias, Charles G; Mittal, Manoj K; Bachur, Richard G; Bennett, Jonathan E; Sinclair, Kelly; Huang, Craig; Dayan, Peter S
Objective To validate and refine a clinical prediction rule to identify which children with acute abdominal pain are at low risk for appendicitis (Low Risk Appendicitis Rule). Design Prospective, multi-center cross-sectional study. Setting Ten pediatric hospital emergency departments. Participants Children 3–18 years old who presented with suspected appendicitis from May 2009 – April 2010. Main Outcome Measures The test performance of the Low Risk Appendicitis Rule. Results Among 2625 patients enrolled, 1018 (38.8%; 95% confidence interval [CI] 36.9% – 40.7%) had appendicitis. Validation of the rule resulted in a sensitivity of 95.5% (95% CI 93.9 – 96.7%), specificity of 36.3% (33.9 – 38.9%) and negative predictive value (NPV) of 92.7% (90.1 – 94.6%). Theoretical application would have identified 573 (24%) as low risk, misclassifying 42 patients (4.5%; 95% CI 3.4% – 6.1%) with appendicitis. We refined the prediction rule, resulting in a model that identified patients at low risk if: a) absolute neutrophil count (ANC) ≤ 6.75 × 103/µL and no maximal tenderness in right lower quadrant (RLQ) or b) ANC ≤ 6.75 × 103/µL, maximal tenderness in the RLQ but no abdominal pain with walking/jumping or coughing. This refined rule had a sensitivity of 98.1% (97.0 – 98.9%), specificity of 23.7% (21.7 – 25.9%) and NPV of 95.3% (92.3 – 97.0%). Conclusions We have validated and refined a simple clinical prediction rule for pediatric appendicitis. For patients identified as low risk, clinicians should consider alternative strategies such as observation or ultrasound, rather than proceed to immediate imaging with CT. PMID:22869405
Bakal, Unal; Saraç, Mehmet; Ciftci, Harun; Tartar, Tugay; Kocdemir, Esra; Aydin, Suleyman; Kazez, Ahmet
Appendicitis is very commonly encountered in emergency clinics. There is an urgent need for early and accurate predictive biomarkers of appendicitis in order to save lives, because currently-available biomarkers are imprecise and their delayed response impairs the ability of emergency doctors and pediatric surgeons to provide timely and potentially effective therapies. This study was performed to determine whether changes in the blood levels of neutrophil gelatinase-associated lipocalin (NGAL) can help to diagnose acute appendicitis in children and distinguish acute appendicitis from abdominal pain. Sixty children were enrolled and divided into three groups, with 20 patients per group: Group 1 (patients with appendicitis), Group 2 (patients with abdominal pain) and Group 3 (control). Blood NGAL levels were determined by ELISA. The basal average serum NGAL levels were 8.2 ng/ml for Group 1, 3.9 ng/ml for Group 2, and 3.3 ng/ml for Group 3. Twenty-four and 72 h after surgery the levels were 5.1 and 2.8 ng/ml, respectively, in Group 1, 2.9 and 2.8 ng/ml in Group 2, and 2.6, 2.7 ng/ml in Group 3. Setting the cut-off point to 7 generated an area under the receiving operating curve (ROC) curve at 95 % confidence interval with 77.3 % sensitivity and 97.4 % specificity. These data indicate a significant difference in NGAL values between basal and postoperative measurements in appendicitis patients (p < 0.05). The ROC curve results showed that NGAL is a promising novel biomarker for the differential diagnosis of acute appendicitis from abdominal pain.
Fullerton, Katherine; Depinet, Holly; Iyer, Sujit; Hall, Matt; Herr, Sandra; Morton, Inge; Lee, Timothy; Melzer-Lange, Marlene
Abdominal pain and concern for appendicitis are common chief complaints in patients presenting to the pediatric emergency department (PED). Although many professional organizations recommend decreasing use of computed tomography (CT) and choosing ultrasound as first-line imaging for pediatric appendicitis, significant variability persists in imaging utilization. This study investigated practice variation across children's hospitals in the diagnostic imaging evaluation of appendicitis and determined hospital-level characteristics associated with the likelihood of ultrasound as the first imaging modality. This was a multicenter (seven children's hospitals) retrospective investigation. Data from chart review of 160 consecutive patients aged 3-18 years diagnosed with appendicitis from each site were compared with a survey of site medical directors regarding hospital resource availability, usual practices, and departmental-level demographics. In the diagnostic evaluation of 1,090 children with appendicitis, CT scan was performed first for 22.4% of patients, with a range across PEDs of 3.1% to 83.8%. Ultrasound was performed for 54.0% of patients with a range of 2.5% to 96.9%. The only hospital-level factor significantly associated with ultrasound as the first imaging modality was 24-hour availability of in-house ultrasound (odds ratio = 29.2, 95% confidence interval = 1.2-691.8). Across children's hospitals, significant practice variation exists regarding diagnostic imaging in the evaluation of patients with appendicitis. Variation in hospital-level resources may impact the diagnostic evaluation of patients with appendicitis. Availability of 24-hour in-house ultrasound significantly increases the likelihood of ultrasound as first imaging and decreases CT scans. Hospitals aiming to increase the use of ultrasound should consider adding 24-hour in-house coverage. © 2017 by the Society for Academic Emergency Medicine.
Kim, Oh Hyun; Cha, Yong Sung; Hwang, Sung Oh; Jang, Ji Young; Choi, Eun Hee; Kim, Hyung Il; Cha, KyoungChul; Kim, Hyun; Lee, Kang Hyun
Background In children with acute appendicitis, 30% to 75% present with a complication, such as perforation, and the early diagnosis of complications is known to improve outcomes. Serum delta neutrophil index (DNI) and myeloperoxidase index (MPXI) are new inflammatory markers, and thus, in the present study, the authors evaluated the predictive values of these two markers for the presence of a complication in children with acute appendicitis. Methods This retrospective observational study was conducted on 105 consecutive children (<12 years old) with acute appendicitis treated over a 31-month period. DNI, MPXI, C-reactive protein (CRP), and white blood cells (WBCs) were measured in an emergency department and investigated with respect to their abilities to predict the presence of acute complicated appendicitis. Results Twenty-nine of the 105 patients (median age, 9 years) were allocated to the complicated group (27.6%) and 76 to the non-complicated group (72.4%). Median serum DNI and CRP were significantly higher in the complicated group [0% vs. 2.2%, p<0.001 and 0.65 mg/dL vs. 8.0 mg/dL, p<0.001], but median MPXI was not (p = 0.316). Area under curve (AUC) for the ability of serum DNI and CRP to predict the presence of acute complicated appendicitis were 0.738 and 0.840, respectively. Multiple logistic regression analyses showed initial CRP [odds ratio 1.301, 95% confidence interval (1.092–1.549), p = 0.003] significantly predicted the presence of a complication. The optimal cutoff for serum CRP was 4.0 mg/dL (sensitivity 69%, specificity 83%, AUC 0.840). Conclusions Although serum DNI values were significantly higher in children with acute complicated appendicitis, no evidence was obtained to support the notion that serum DNI or serum MPXI aid the differentiation of acute complicated and non-complicated appendicitis in the ED setting. PMID:26859663
Turley, Andrew J; Dark, John; Adams, Philip C
Aortic syndromes are an increasing cause of morbidity and mortality. Ascending aortic dissection is a clinical emergency with most patients requiring open surgery to replace the ascending aorta. Detection through clinical suspicion, improved non-invasive imaging and refined surgical techniques have resulted in an improved survival rate. Acquired supravalvular aortic stenosis is an extremely rare complication of cardiac surgery. We present the case of a patient who, 15 years after undergoing elective replacement of the ascending aorta for aortic dissection, required repeat surgery for symptomatic supravalvular aortic stenosis. This case elegantly highlights the need for a detailed focused assessment in patients where the clinical presentation does not correlate with initial investigations. To our knowledge this is the first reported case of late symptomatic supravalvular aortic stenosis following replacement of the ascending aorta.
Morimoto, Hironobu; Tsuchiya, Koji; Nakajima, Masato; Akashi, Okihiko
False aneurysm of the thoracic aorta unrelated to trauma, or to previous aortic or cardiac surgery, is extremely rare. We encountered a case of ascending aortic false aneurysm formation associated with ruptured acute type A aortic dissection. The false aneurysm, which was contained by thin connective tissue surrounding the aortic wall, was located beside the false lumen of the dissected ascending aorta, expanding toward the transverse sinus. We immediately decided to perform an emergency operation. We noted the large entry site at the anterior wall of the dissected ascending aorta after resection of the flap. We identified the false aneurysm arising from a small tear of the false lumen. Graft replacement of the ascending aorta using a tube graft was performed. The postoperative course was satisfactory. This pathology was believed to be not only a consequence of hemostasis, but also a process of re-rupture of the dissected aorta.
Kubota, Hiroshi; Demura, Shinichi
Hand grip force adjustment errors to ascending and descending phases of a sinusoidal target force in a controlled force exertion (CFE) test were measured and the laterality of responses evaluated. 75 men (M age = 19.6 yr., SD = 1.6) performed the CFE test after one practice trial by matching handgrip force to target level (5-25% of maximal grip force). The CFE errors in ascending and descending phases of the target force were calculated as the absolute differences between actual force and target force in each phase. There were significantly smaller CFE errors in the ascending phase for both dominant and non-dominant hands, but CFE error for the dominant hand was significantly smaller in both phases. Therefore, error in force exertion in the ascending and descending phases of the target force differed, and laterality influenced error in both phases.
Kawahara, Yu; Inage, Yuichi; Masaki, Naoki; Toyama, Shuji; Fukasawa, Manabu
56-year-old male, who had undergone re-aortic valve replacement (AVR) 33 years ago, received preoperative study for pancreatic surgery. Computed tomography (CT) revealed a giant pseudoaneurysm (7 cm diameter) of the ascending aorta. The ascending aorta was not dilated. A midline skin incision was performed, followed by full sternotomy. A tight pericardial adhesion was carefully dissected. Cardiopulmonary bypass was established by femoral arterial and bicaval venous cannulation. The pseudoaneurysm was incised under the retrograde cardioplegic protection. A communication between ascending aorta and aneurysm was found 1 cm distal to the previous aortic suture line. This communication coincided with the cardioplegic root cannulation site. The aortic prosthetic valve was intact. The ascending aorta was replaced with 26 mm prosthetic graft. Postoperative course was uneventful. In this case, CT was useful to select the approach to the complicated postoperative surgical site.
Baba, Hironori; Umesue, Masayoshi; Matsui, Kanzi
Although a severely calcified ascending aorta is encountered infrequently, it presents formidable problems during cardiac surgery. We describe a case of severe aortic valve stenosis and coronary artery disease combined with a severely calcified ascending aorta. The patient was an 80-year-old man with a calcified ascending aorta. He successfully underwent an aortic valve replacement and a single coronary artery bypass graft (CABG) using a saphenous vein graft with the proximal end connected on a Dacron patch, which was used for aortoplasty of the calcified plate along the aortotomy. These procedures were performed under moderate hypothermia with aortic clamping. This patch aortoplasty can be a useful alternative in cases that require aortotomy and proximal anastomoses of a CABG on a calcified ascending aorta.
Elalouf, J M; Sari, D C; Roinel, N; de Rouffignac, C
Previous studies from this laboratory have demonstrated that vasopressin stimulates K, Mg, Ca, Cl, and Na reabsorption by the thick ascending limb of Henle's loop (TALH) of the rat kidney. Micropuncture of superficial nephrons and clearance experiments were performed to determine whether desensitization of the TALH to vasopressin may be demonstrated in vivo and whether such desensitization is specific for the effects of vasopressin (i.e., homologous) or also alters the response to the other hormones acting on the same pool of adenylate cyclase in this nephron segment. Brattleboro rats, with hereditary hypothalamic diabetes insipidus (DI), were given i.m. injections of 1-desamino-8-D-arginine-vasopressin (des-1-amino-[DArg8]VP (herein designated dDAVP); 2 micrograms/day) for 3 days. The effects of maximal physiological doses of arginine-8-vasopressin ([Arg8]VP (herein designated AVP); 20 pg/min per 100 g of body weight) were studied 2 days after the cessation of treatment, when the animals had returned to DI. The K, Mg, Ca, and, to a lesser extent, Cl and Na concentrations in the fluid leaving the TALH of superficial nephrons were higher in dDAVP-treated than in untreated rats given similar amounts of AVP during the experiments. A 50-60% desensitization of the TALH to AVP was still apparent 2 days after stopping the dDAVP injections. Desensitization is homologous, as judged from normal responses to physiological doses of glucagon and calcitonin, two hormones acting on the same cyclase pool as AVP in the rat TALH. The AVP-dependent increase of urine osmolality, however, indicated that its effects on the permeability to water of the collecting duct were scarcely affected in dDAVP-treated rats. It is concluded that (i) AVP induces homologous desensitization in the rat TALH and (ii) the TALH can be markedly desensitized to AVP when the collecting duct response to this hormone is poorly affected or even fully maintained. PMID:3353389
Burnweit, C; Bilik, R; Shandling, B
We studied the clinical course of 506 children consecutively admitted with appendicitis at The Hospital for Sick Children from 1985 to 1989. One hundred eighty-one children (35%), ranging in age from 1 to 17 years, presented with perforation verified by histological examination. Ninety-six of them (53%) had generalized peritonitis, 47 (26%) had localized peritonitis, and 38 (21%) had abscess formation. Usually, triple antibiotics were begun preoperatively if perforation was suspected; otherwise, cefoxitin was started. Triple antibiotics were used postoperatively for 5 to 7 days in almost all children in the perforated group. Neither abdominal nor subcutaneous drainage was routinely used even in cases of intraabdominal abscess. The skin was closed primarily with steri-strips (63%), staples (20%), subcutaneous Dexon (11%), or silk (4%). Postoperative wound infection arose in 20 children (11%). Wound infections were noted from 1 to 14 days postoperatively (mean, 5.9 days). Whereas 9 of these were treated with local therapy only, 11 delayed the child's discharge or necessitated readmission. No patient suffered major complications from wound infection in that there were no cases of necrotizing fasciitis, reoperation for debridement, sepsis, or death. The intraabdominal abscess rate in this group of 181 children was 6% (n = 11). The low rate of infective complications fully justifies the policy of primary closure in contaminated wounds. This policy eliminates the necessity for painful and time-consuming dressing changes, shortens hospitalization, and obviates the trauma of delayed suturing of wounds in children.
Bielawa, Richard L.
Analytic evaluations of four different passive aeroelastic devices appended to helicopter rotor blades are presented. The devices consist of a passive tuned tab, a control coupled tab, an all-flying tip and a harmonic dilational airfoil tip. Each device was conceived for improving either aerodynamic performance or reducing vibratory control loads or hub shears. The evaluation was performed using a comprehensive rotor aeroelastic analysis (the G400PA code with appropriate modifications), together with data for a realistic helicopter rotor blade (the UH-60A Blackhawk), in high speed flight (90 m/s, 175 kts). The results of this study show that significant performance (L/(D sub e)) gains can be achieved with the all-flying free tip. Results from the harmonic dilational airfoil tip show the potential for moderate improvements in L/(D sub e). Finally, the results for the passive tuned tab and the control coupled tab, as configured for this study, show these devices to be impractical. Sections are included which describe the operation of each device, the required G400PA modifications, and the detailed results obtained for each device.
Nandi, K.N.; Beal, J.A.; Knight, D.S. )
Although the neurogenic period for neurons in the lumbar spinal cord has been clearly established (Days 12 through 16 of gestation), it is not known when the neurogenesis of ascending tract neurons is completed within this period. The purpose of the present study was to determine the duration of the neurogenic period for projection neurons of the ascending tracts. To label neurons undergoing mitosis during this period, tritiated thymidine was administered to fetal rats on Embryonic (E) Days E13 through E16 of gestation. Ascending tract neurons of the lumbar cord were later (Postnatal Days 40-50) labeled in each animal with a retrograde tracer, Fluoro-Gold, applied at the site of a hemisection at spinal cord segment C3. Ascending tract neurons which were undergoing mitosis in the upper lumbar cord were double labeled, i.e., labeled with both tritiated thymidine and Fluoro-Gold. On Day E13, 89-92% of the ascending tract neurons were double labeled; on Day E14, 35-37%; and on Day E15, 1-4%. Results showed, then, that some ascending tract neurons were double labeled through Day E15 and were, therefore, proliferating in the final one-third of the neurogenic period. Ascending tract neurons proliferating on Day E15 were confined to laminae III, IV, V, and X and the nucleus dorsalis. Long tract neurons in the superficial dorsal horn (laminae I and II), on the other hand, were found to have completed neurogenesis on Day E14 of gestation. Results of the present study show that spinal neurogenesis of ascending projection neurons continues throughout most of the neurogenic period and does not completely follow the well-established ventral to dorsal gradient.
Gonzalez-Vicente, Agustin; Cabral, Pablo D.; Garvin, Jeffrey L.
The thick ascending limb of the loop of Henle reabsorbs 30% of the NaCl filtered through the glomerulus. Nitric oxide (NO) produced by NO synthase 3 (NOS3) inhibits NaCl absorption by this segment. Resveratrol, a polyphenol, has beneficial cardiovascular and renal effects, many of which are mediated by NO. Resveratrol increases intracellular Ca2+ (Cai) and AMP kinase (AMPK) and NAD-dependent deacetylase sirtuin1 (SIRT1) activities, all of which could activate NO production. We hypothesized that resveratrol stimulates NO production by thick ascending limbs via a Ca2+/calmodulin-dependent mechanism. To test this, the effect of resveratrol on NO bioavailability was measured in thick ascending limb suspensions. Cai was measured in single perfused thick ascending limbs. SIRT1 activity and expression were measured in thick ascending limb lysates. Resveratrol (100 µM) increased NO bioavailability in thick ascending limb suspensions by 1.3±0.2 AFU/mg/min (p<0.03). The NOS inhibitor L-NAME blunted resveratrol-stimulated NO bioavailability by 96±11% (p<0.03). The superoxide scavenger tempol had no effect. Resveratrol elevated Cai from 48±7 to 135±24 nM (p<0.01) in single tubules. In Ca2+-free media, the resveratrol-induced increase in NO was blunted by 60±20% (p<0.05) and the rise in Cai reduced by 80%. Calmodulin inhibition prevented the resveratrol-induced increase in NO (p<0.002). AMPK inhibition had no effect. Resveratrol did not increase SIRT1 activity. We conclude that resveratrol increases NO production in thick ascending limbs via a Ca2+/calmodulin dependent mechanism, and SIRT1 and AMPK do not participate. Resveratrol-stimulated NO production in thick ascending limbs may account for part of its beneficial effects. PMID:25314136
Gonzalez-Esparza, A.; Romero-Hernandez, E.
We combined observations from: Helios 1 and 2, IMP-8, Voyager 1 and 2, from November 1977 to February 1978 (ascending phase of solar cycle 21). We identified five Corotating Interaction Regions, five Interplanetary Coronal Mass Ejections, and produced maps of large-scale features unifying and summarizing the data. We discuss their characteristics to illuminate some aspects of the solar wind dynamics, based on this unique data set, during the ascending phase of the cycle.
Topcu, Ahmet Can; Ciloglu, Ufuk; Bolukcu, Ahmet; Dagsali, Sabri
Traumatic aortic rupture is rupture of all or part of the aortic wall, mostly resulting from blunt trauma to the chest. The most common site of rupture is the aortic isthmus. Traumatic rupture of the ascending aorta is rare. A 62-year-old man with a family history of ascending aortic aneurysm was referred to our hospital after a motor vehicle accident. He had symptoms of cardiogenic shock. A contrast-enhanced computed tomographic scan revealed rupture of the proximal ascending aorta and an ascending aortic aneurysm with a diameter of 55 mm at the level of the sinuses of Valsalva. Transthoracic echocardiography at the bedside revealed severe aortic valvular insufficiency. We performed a successful Bentall procedure. During postoperative recovery, the patient experienced a cerebrovascular accident. Transesophageal echocardiography did not reveal thrombosis of the mechanical prosthesis. The patient's symptoms resolved in time, and he was discharged from the hospital on postoperative day 47 without any sequelae. He has been symptom free during a 6-month follow-up period. We suggest that individuals who have experienced blunt trauma to the chest and have symptoms of traumatic aortic rupture and a known medical history of ascending aortic aneurysm should be evaluated for a rupture at the ascending aorta and the aortic isthmus.
Tanyingoh, Divine; Dixon, Elijah; Johnson, Markey; Wheeler, Amanda J.; Myers, Robert P.; Bertazzon, Stefania; Saini, Vineet; Madsen, Karen; Ghosh, Subrata; Villeneuve, Paul J.
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
Torbati, Sam S; Guss, David A
To assess the impact of an emergency department (ED) guideline employing selective use of helical computed tomography (CT) on clinical outcomes of female patients with suspected appendicitis. All patients presenting with suspected appendicitis were prospectively enrolled and managed in accordance with a guideline incorporating selective use of helical CT. Although not the objective of this investigation, male patients were included for purposes of comparison. Patients with clinically evident appendicitis were referred to the surgical service, and patients with equivocal presentations were studied with helical CT. Patients were followed to final surgical or clinical outcomes. Outcome measures included time from ED presentation to laparotomy and rate of appendiceal perforation. These measures were compared with those of a historical cohort of patients preceding the use of helical CT. A total of 310 consecutive patients with suspected appendicitis were enrolled; 92 had appendicitis. Sixty patients were referred to the surgical service without helical CT, and 41 had appendicitis (68%). Helical CT was performed on 250 patients; 51 had appendicitis (20%). For males, the mean interval from ED presentation to laparotomy was 559 minutes (95% CI = 444 to 674 minutes) during guideline use and 480 minutes (95% CI = 405 to 555 minutes) before. This interval for females was 433 minutes (95% CI = 326 to 540 minutes) during guideline use and 710 minutes (95% CI = 558 to 862 minutes) before. Appendiceal perforation rate for males was 0.25 (95% CI = 0.14 to 0.36) during guideline use and 0.38 (95% CI = 0.29 to 0.47) before; perforation rate for females was 0.06 (95% CI = -0.05 to 0.17) during guideline use and 0.23 (95% CI = 0.14 to 0.32) before. Helical CT had 92% sensitivity, 97% specificity, and 96% accuracy in diagnosing appendicitis. Helical CT is highly accurate in detecting appendicitis in patients with equivocal ED presentations. The use of a guideline employing selective
Carpenter, Jennifer L; Orth, Robert C; Zhang, Wei; Lopez, Monica E; Mangona, Kate L; Guillerman, R Paul
Purpose To prospectively evaluate the diagnostic performance of ultrasonography (US) for differentiating perforated from nonperforated pediatric appendicitis and to investigate the association between specific US findings and perforation. Materials and Methods This HIPAA-compliant study had institutional review board approval, and the need for informed consent was waived. All abdominal US studies performed for suspected pediatric appendicitis at one institution from July 1, 2013, to July 9, 2014, were examined prospectively. US studies were reported by using a risk-stratified scoring system (where a score of 1 indicated a normal appendix; a score of 2, an incompletely visualized normal appendix; a score of 3, a nonvisualized appendix; a score of 4, equivocal; a score of 5a, nonperforated appendicitis; and a score of 5b, perforated appendicitis). The diagnostic performance of US studies designated 5a and 5b was calculated. The following US findings were correlated with perforation at multivariate analysis: maximum appendiceal diameter, wall thickness, loss of mural stratification, hyperemia, periappendiceal fat inflammation, periappendiceal fluid, lumen contents, and appendicolith presence. The number of symptomatic days prior to presentation was recorded. Surgical diagnosis and clinical follow-up served as reference standards. Results A total of 577 patients with a diagnosis of appendicitis at US met the study criteria (468 with a score of 5a; 109 with a score of 5b). Appendicitis was correctly identified in 573 (99.3%) of 577 patients. US performance in the detection of perforated appendicitis (5b) was as follows: a sensitivity of 44.0% (80 of 182), a specificity of 93.1% (364 of 391), a positive predictive value of 74.8% (80 of 107), and a negative predictive value of 78.1% (364 of 466). Statistically significant associations with perforated appendicitis were longer duration of symptoms (odds ratio [OR] = 1.46, P < .0001), increased maximum diameter (OR = 1.29, P
Cheng, Yao; Zhou, Shiyi; Zhou, Rongxing; Lu, Jiong; Wu, Sijia; Xiong, Xianze; Ye, Hui; Lin, Yixin; Wu, Taixiang; Cheng, Nansheng
Appendectomy, the surgical removal of the appendix, is performed primarily for acute appendicitis. Patients who undergo appendectomy for complicated appendicitis, defined as gangrenous or perforated appendicitis, are more likely to suffer from postoperative complications. The routine use of abdominal drainage to reduce postoperative complications after appendectomy for complicated appendicitis is controversial. To assess the safety and efficacy of abdominal drainage to prevent intra-peritoneal abscess after open appendectomy for complicated appendicitis. We searched The Cochrane Library (Issue 1, 2014), MEDLINE (1950 to February 2014), EMBASE (1974 to February 2014), Science Citation Index Expanded (1900 to February 2014), and Chinese Biomedical Literature Database (CBM) (1978 to February 2014). We included all randomised controlled trials (RCTs) that compared abdominal drainage and no drainage in patients undergoing emergency open appendectomy for complicated appendicitis. Two review authors identified the trials for inclusion, collected the data, and assessed the risk of bias independently. We performed the meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes (or a Peto odds ratio for very rare outcomes), and the mean difference (MD) for continuous outcomes with 95% confidence intervals (CI). We included five trials involving 453 patients with complicated appendicitis who were randomised to the drainage group (n = 228) and the no drainage group (n = 225) after emergency open appendectomies. All of the trials were at a high risk of bias. There were no significant differences between the two groups in the rates of intra-peritoneal abscess or wound infection. The hospital stay was longer in the drainage group than in the no drainage group (MD 2.04 days; 95% CI 1.46 to 2.62) (34.4% increase of an 'average' hospital stay). The quality of the current evidence is very low. It is not clear whether routine abdominal drainage has
Chau, Danielle B; Ciullo, Sean S; Watson-Smith, Debra; Chun, Thomas H; Kurkchubasche, Arlet G; Luks, Francois I
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
Charalampopoulos, Anestis; Dimopoulos, Ioannis; Koliakos, Nikolaos; Kopanakis, Konstantinos; And, Theodoros Liakakos
Backround: Surgical treatment of appendicitis remains the standard treatment, but many cases respond conservatively. Our purpose was the clarification of the clinical, laboratory and imaging characteristics of uncomplicated cases undergoing successful conservative treatment without recurrence. Methods: 105 adult patients (66 female, 39 male) with non-complicated acute appendicitis. Symptom duration, clinical abdominal examination, body temperature, inflammatory markers, imaging studies results and in-hospital treatment were recorded. No patient had a previous episode of appendicitis. Results: Duration of symptoms was 2 hours-3 days. Abdominal examination was compatible with appendicitis and findings were localized in the lower right quadrat. The majority (85.7%) had no or low fever ( 37.4 C). All had leukocytosis (range: 10.000-22.900 WBC/L, mean 14.370'+-2.900 WBC/L), 3 patients 20.000 WBC/L. All had CRP 3.36 mg/L (mean 46.8'+-40.5 mg/L), and 3 150 mg/L. U/S was performed on 95 patients (combined with transvaginal U/S in 19 females) with positive findings of acute appendicitis in 91 (91/95, 95.7%). When faced with inconclusive findings, CT was performed (13 patients) and MRI on one pregnant. In-hospital conservative treatment lasted 1-10 days, overstay was 1-2 days following clinic-laboratory regression. Outpatient, antibiotic treatment followed discharge in 27 patients. Conclusions: Young patients with non-complicated acute appendicitis and short symptom duration, without rare etiologic pathologies, are candidates for conservative treatment. Diagnosis of non-complicated acute appendicitis is based on combining clinical signs, positive inflammatory markers and imaging studies, excluding complicated cases, generalized peritonitis and sepsis. The inflammation seems self-limited, while the role of anti-inflammatory drugs remains obscure. AA = Acute Appendicitis, un-AA = Uncomplicated AA, cAA = Complicated Acute Appendicitis, WBC = White Blood Cells, CRP = C
Bhatt, Maala; Joseph, Lawrence; Ducharme, Francine M; Dougherty, Geoffrey; McGillivray, David
Clinical scoring systems attempt to improve the diagnostic accuracy of pediatric appendicitis. The Pediatric Appendicitis Score (PAS) was the first score created specifically for children and showed excellent performance in the derivation study when administered by pediatric surgeons. The objective was to validate the score in a nonreferred population by emergency physicians (EPs). A convenience sample of children, 4-18 years old presenting to a pediatric emergency department (ED) with abdominal pain of less than 3 days' duration and in whom the treating physician suspected appendicitis, was prospectively evaluated. Children who were nonverbal, had a previous appendectomy, or had chronic abdominal pathology were excluded. Score components (right lower quadrant and hop tenderness, anorexia, pyrexia, emesis, pain migration, leukocytosis, and neutrophilia) were collected on standardized forms by EPs who were blinded to the scoring system. Interobserver assessments were completed when possible. Appendicitis was defined as appendectomy with positive histology. Outcomes were ascertained by review of the pathology reports from the surgery specimens for children undergoing surgery and by telephone follow-up for children who were discharged home. Sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) were calculated. The overall performance of the score was assessed by a receiver operator characteristic (ROC) curve. Of the enrolled children who met inclusion criteria (n = 246), 83 (34%) had pathology-proven appendicitis. Using the single cut-point suggested in the derivation study (PAS 5) resulted in an unacceptably high number of false positives (37.6%). The score's performance improved when two cut-points were used. When children with a PAS of
Epifanio, Matias; Antonio de Medeiros Lima, Marco; Corrêa, Patricia; Baldisserotto, Matteo
The objective of the present study is to evaluate a new diagnostic strategy using clinical findings followed by ultrasound (US) and, in selected cases, MRI. This study included 166 children presenting signs and symptoms suggesting acute appendicitis. Cases classified as suggesting appendicitis according to clinical exams had to be referred to surgery, whereas the other cases were discharged. Unclear cases were evaluated using US. If the US results were considered inconclusive, patients underwent MRI. Of the 166 patients, 78 (47%) had acute appendicitis and 88 (53%) had other diseases. The strategy under study had a sensitivity of 96 per cent, specificity of 100 per cent, positive predictive value of 100 per cent, negative predictive value of 97 per cent, and accuracy of 98 per cent. Eight patients remained undiagnosed and underwent MRI. After MRI two girls presented normal appendixes and were discharged. One girl had an enlarged appendix on MRI and appendicitis could have been confirmed by surgery. In the other five patients, no other sign of the disease was detected by MRI such as an inflammatory mass, free fluid or an abscess in the right iliac fossa. All of them were discharged after clinical observation. In the vast majority of cases the correct diagnosis was reached by clinical and US examinations. When clinical assessment and US findings were inconclusive, MRI was useful to detect normal and abnormal appendixes and valuable to rule out other abdominal pathologies that mimic appendicitis.
Mahida, Justin B; Lodwick, Daniel L; Nacion, Kristine M; Sulkowski, Jason P; Leonhart, Karen L; Cooper, Jennifer N; Ambeba, Erica J; Deans, Katherine J; Minneci, Peter C
The purpose of this study was to investigate the feasibility of nonoperative management of acute appendicitis in children with an appendicolith identified on preoperative imaging. We performed a prospective nonrandomized trial of nonoperative management of uncomplicated acute appendicitis with an appendicolith in children aged 7 to 17years. The primary outcome was the failure rate of nonoperative management, defined as having undergone an appendectomy. Early termination was set to occur if the lower limit of the 95% confidence interval of the failure rate was greater than 20% at 30days or 30% at 1year. Recruitment for this study was halted after enrollment of 14 patients (N=5 nonoperative; N=9 surgery). The failure rate of nonoperative management was 60% (3/5) at a median follow-up of 4.7months (IQR 1.0-7.6) with a 95% CI of 23%-88%. None of the three patients that failed nonoperative management had complicated appendicitis at the time of appendectomy, while six out of nine patients who chose surgery had complicated appendicitis (0/3 vs. 6/9, p=0.18). The trial was stopped for concerns over patient safety. Nonoperative management of acute appendicitis with an appendicolith in children resulted in an unacceptably high failure rate. Copyright © 2016 Elsevier Inc. All rights reserved.
Mullins, M E; Kircher, M F; Ryan, D P; Doody, D; Mullins, T C; Rhea, J T; Novelline, R A
Colonic contrast material evaluation of suspected appendicitis in pediatric patients is technically more challenging than in adults because less intraabdominal fat is present. To determine the accuracy and feasibility of focused CT for pediatric patients, we carried out this retrospective investigation. Between November 1995 and July 1999, 199 pediatric patients (1-18 years old; mean age, 12 years) were examined with focused CT in the emergency division for suspected appendicitis. The findings on CT were compared with the findings at surgery, pathology, and clinical follow-up. There were 64 true-positive CT scans, two false-negative, 128 true-negative, one false-positive, and four indeterminate. Seventy-four patients underwent appendectomy, with a negative appendectomy rate of 9%. One hundred twenty-five patients without appendicitis were treated nonoperatively. The true-positive rate was 32%, true-negative rate was 64%, sensitivity was 97%, specificity was 99%, positive predictive value was 98%, negative predictive value was 98%, and overall accuracy was 96%. Pediatric patients tolerated the procedure well. Colonic contrast material saved time and provided improved identification of the cecum and appendix. In 62 patients without appendicitis, focused CT provided alternative diagnoses. Focused CT appears to be nearly as accurate in pediatric patients as in adults. Focused CT provided alternative diagnoses in 48% of the patients for whom CT findings were negative for appendicitis.
Rao, P M; Rhea, J T; Novelline, R A; McCabe, C J; Lawrason, J N; Berger, D L; Sacknoff, R
To evaluate a focused, helical computed tomographic (CT) technique for imaging the appendix in patients suspected of having appendicitis. One hundred patients prospectively underwent appendix CT examination, with use of oral and colon contrast media and contiguous, thin-collimation, helical CT imaging of the right lower quadrant. Results were correlated with the results of surgery and pathologic examination from 61 patients or from clinical follow-up in 39 patients. CT scans were positive for appendicitis in 59 patients: true-positive in 56 patients on the basis of surgery and pathologic examination, and false-positive in two patients on the basis of clinical follow-up; in the case of the other positive scan, the clinical outcome was indeterminate. CT scans were negative for appendicitis in 41 patients: true-negative in five patients on the basis of surgery and pathologic examination, and true-negative in 36 patients on the basis of clinical follow-up. CT had a sensitivity of 100%, a specificity of 95%, a positive predictive value of 97%, a negative predictive value of 100%, and an accuracy of 98%. The normal appendix was always identified. CT helped establish alternative diagnoses in 33 of the 41 patients (80%) in whom the results of CT were negative for appendicitis. Appendix CT examination can help diagnose or exclude appendicitis and establish an alternative diagnosis.
Bonadio, William; Bruno, Santina; Attaway, David; Dharmar, Logesh; Tam, Derek; Homel, Peter
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.
Shine, Rebecca J; Zarifeh, Abigail; Frampton, Chris; Rossaak, Jeremy
Appendicitis in older adults may present as the first sign of underlying colorectal cancer. We aim to determine whether there was a difference in the rate of diagnosis of colorectal carcinoma for patients ≥45 years following a presentation with appendicitis, compared with New Zealand standardised rates. Retrospective study of patients ≥45 years with a confirmed diagnosis of appendicitis from 2003 to 2015 inclusive. The rate of colorectal carcinoma diagnosed during the 36-month follow-up period was calculated and compared to standardised rates, as per the New Zealand cancer registry. Six hundred and twenty-nine patients were included for analysis, 15 had a diagnosis of colorectal cancer in the follow-up period. Patients ≥45 years had a 6.3-fold (CI 3.6-10.2) increased risk of colorectal carcinoma than predicted given the population demographics. Those patients aged between 45-60 years had a 17-fold (95% CI 8-32.2) increased standardised risk ratio. This is the first study of its kind conducted in Australasia. This study found patients ≥45 years who present with appendicitis have significantly increased risk of underlying colorectal cancer. Until further research is conducted the authors recommend clinicians consider colonic investigation for older adults following a diagnosis of appendicitis.
Tsai, Ming-Chieh; Kao, Li-Ting; Lin, Herng-Ching; Chung, Shiu-Dong; Lee, Cha-Ze
Despite some studies having indicated a possible association between appendicitis and duodenal ulcers, this association was mainly based on regional samples or limited clinician experiences, and as such, did not permit unequivocal conclusions. In this case-control study, we examined the association of acute appendicitis with peptic ulcers using a population-based database. We included 3574 patients with acute appendicitis as cases and 3574 sex- and age-matched controls. A Chi-squared test showed that there was a significant difference in the prevalences of prior peptic ulcers between cases and controls (21.7% vs. 16.8%, p < 0.001). The adjusted odds ratio (OR) of prior peptic ulcers for cases was 1.40 (95% confidence interval [CI]: 1.24~1.54, p < 0.001) compared to controls. The results further revealed that younger groups demonstrated higher ORs for prior peptic ulcers among cases than controls. In particular, the adjusted OR for cases < 30 years old was as high as 1.65 (95% CI = 1.25~2.19; p < 0.001) compared to controls. However, we failed to observe an association of acute appendicitis with peptic ulcers in the ≥ 60-year age group (OR = 1.19, 95% CI = 0.93~1.52). We concluded that there is an association between acute appendicitis and a previous diagnosis of peptic ulcers. PMID:26643405
Ito, Daisuke; Miki, Kenji; Seiichiro, Shimizu; Hata, Shojiro; Kobayashi, Kaoru; Teruya, Masanori; Kaminishi, Michio
AIM: To study the clinical features and computed tomography (CT) findings of appendiceal diverticulitis vs acute appendicitis. METHODS: We retrospectively reviewed the records of 451 patients who had undergone appendectomy in our institution from January 2007 to September 2012. Patient demographics, clinical features, pathological findings, and surgical outcomes were analyzed. We also compared preoperative CT images of 25 patients with appendiceal diverticulitis with those of 25 patients with acute appendicitis. RESULTS: Among 451 patients, 44 (9.7%) were diagnosed to have appendiceal diverticulitis and 398 (86.9%) to have acute appendicitis. Patients with appendiceal diverticulitis were older (59 vs 37 years, P < 0.001) and had a longer duration of the illness (4.0 d vs 1.0 d, P < 0.001). Perforation rates in patients with appendiceal diverticulitis were higher (68% vs 27%, P < 0.001). The appendix could be visualized in only 13 patients (52%) among the appendiceal diverticulitis cases, but in all acute appendicitis cases. CT findings suggestive of appendiceal diverticulitis included the absence of fluid collection in the appendix (84% vs 12%, P < 0.001), absence of appendicolith (92% vs 52%, P = 0.005), and formation of abscess (68% vs 16%, P < 0.001). Appendiceal diverticula were identified in 6 patients (24%). CONCLUSION: Among patients who had undergone appendectomy, 9.7% had appendiceal diverticulitis. Patients with appendiceal diverticulitis had different clinical features and CT findings from patients with acute appendicitis. PMID:25852277
da Silva, Paulo Sérgio Lucas; de Aguiar, Vânia Euzébio; Waisberg, Jaques
The absence of pediatric surgeons in many centers results in restriction of patient access to pediatric subspecialty care. The aim of this study was to compare the outcomes of children treated for appendicitis by pediatric surgeons (PS) and by general surgeons (GS). This was a retrospective review of the charts of all consecutive patients <16 years old who underwent appendectomy during 2 years The primary outcome measure was the overall rate of complications. Secondary outcome measures included length of hospital stay (LOS), symptom duration, time from emergency department diagnosis to surgery, and readmission rate within 30 days. A total of 94 patients (PS group, n = 66; GS group, n = 28) were included. PS patients were younger. For patients with complicated appendicitis, complications were significantly more prevalent in the GS group (57% vs 15%; P = 0.0001). Median LOS was not significantly different between the two groups for complicated appendicitis, but patients with non-complicated appendicitis had a significant longer LOS when treated by PS (3.74 ± 1.5 vs 2.57 ± 1.21 days; P = 0.0041). Patients in the PS group had a prolonged use of antibiotics (2 vs 4 days; P = 0.001), and longer LOS (3 vs 4 days; P = 0.0018). Overall complication rates were similar between PS and GS. Complications were significantly more prevalent in patients with complicated appendicitis who were treated by GS. © 2013 The Authors. Pediatrics International © 2013 Japan Pediatric Society.
Erdem, Hasan; Aktimur, Recep; Cetinkunar, Suleyman; Reyhan, Enver; Gokler, Cihan; Irkorucu, Oktay; Sozen, Selim
Background: Diagnosis of acute appendicitis remains to be challenging with up to 30% negative exploration rates. In addition to careful clinical history and physical examination, we still need easily applicable, cheap and effective biomarker. Patients and methods: A retrospective case-controlled study was designed in two groups, both containing 100 patients, acute appendicitis and control. Leukocyte count, neutrophil percentage, platelet count and meal platelet volume (MPV) were compared. Results: MPV values for acute appendicitis and control groups were 7.4 ± 0.9 fL (5.6-10.6) and 9.1 ± 1.6 fL (5.1-13.1). For the diagnosis of acute appendicitis, ROC analysis revealed 74% sensitivity and 75% specificity for a cut-off value of 7.95 fL of MPV, however, the diagnostic value of leukocyte count and/or neutrophil ratio was superior. Conclusion: Our results suggest that, MPV value is an important parameter in the diagnosis of acute appendicitis, but in terms of sensitivity and specificity, leukocyte count and/or neutrophil percentage is superior. PMID:25785128
Pinto, Fabio; Pinto, Antonio; Russo, Anna; Coppolino, Francesco; Bracale, Renata; Fonio, Paolo; Macarini, Luca; Giganti, Melchiorre
Ultrasound is a widely used technique in the diagnosis of acute appendicitis; nevertheless, its utilization still remains controversial. The accuracy of the Ultrasound technique in the diagnosis of acute appendicitis in the adult patient, as shown in the literature, was searched for. The gold standard for the diagnosis of appendicitis still remains pathologic confirmation after appendectomy. In the published literature, graded-compression Ultrasound has shown an extremely variable diagnostic accuracy in the diagnosis of acute appendicitis (sensitivity range from 44% to 100%; specificity range from 47% to 99% ). This is due to many reasons, including lack of operator skill, increased bowel gas content, obesity, anatomic variants, and limitations to explore patients with previuos laparotomies. Graded-compression Ultrasound still remains our first-line method in patients referred with clinically suspected acute appendicitis: nevertheless, due to variable diagnostic accuracy, individual skill is requested not only to perform a successful exam, but also in order to triage those equivocal cases that, subsequently, will have to undergo assessment by means of Computed Tomography.
Background Ultrasound is a widely used technique in the diagnosis of acute appendicitis; nevertheless, its utilization still remains controversial. Methods The accuracy of the Ultrasound technique in the diagnosis of acute appendicitis in the adult patient, as shown in the literature, was searched for. Results The gold standard for the diagnosis of appendicitis still remains pathologic confirmation after appendectomy. In the published literature, graded-compression Ultrasound has shown an extremely variable diagnostic accuracy in the diagnosis of acute appendicitis (sensitivity range from 44% to 100%; specificity range from 47% to 99% ). This is due to many reasons, including lack of operator skill, increased bowel gas content, obesity, anatomic variants, and limitations to explore patients with previuos laparotomies. Conclusions Graded-compression Ultrasound still remains our first-line method in patients referred with clinically suspected acute appendicitis: nevertheless, due to variable diagnostic accuracy, individual skill is requested not only to perform a successful exam, but also in order to triage those equivocal cases that, subsequently, will have to undergo assessment by means of Computed Tomography. PMID:23902717
Wei, Chang Kuo; Chang, Chun Min; Lee, Cheng Hung; Chen, Jian Han; Yin, Wen Yao
Abdominal surgery on patients with previous organ transplantation, especially in the early postoperative period, is a challenging problem. Due to high risk of complications in transplant patients, we usually tend to treat such patients more conservatively rather compared to the more aggressive attitude in diagnosis and surgery of non-transplant patients. Delayed diagnosis, delayed surgery, and high morbidity and mortality are more common in transplant patients with GI disease. While appendicitis is one of the most common surgical diseases, with an estimated lifetime risk of 8.6% for males and 6.7% for females, there are relatively few reports of appendicitis in solid organ transplant recipients, and the condition has rarely been reported after liver transplantation. We have performed surgery on 2 cases of presumed acute appendicitis among 75 cases of kidney and liver transplantation in our series in the last 10 years. Laparoscopic technique was used for exploration of presumed acute appendicitis with atypical clinical and image presentation in a deceased donor liver transplantation (DDLT) and a deceased donor kidney transplantation (DDKT). Acute appendicitis in both patients was highly suspected preoperatively in computed tomography, and early exploration with laparoscopic technique prompted early diagnosis and treatment, with excellent surgical outcomes.
Miftaroski, Almir; Kessler, Ulf; Monnard, Etienne; Egger, Bernhard
Optimal management of perforated appendicitis with perityphlitic phlegmon or abscess formation is controversial. The aim of the study was to assess the outcome after a two-step procedure to treat patients with perityphlitic abscess formation. We retrospectively assessed prospectively collected data from a single-centre database that included adult patients who had appendicitis and perityphlitic abscess (>=3 cm) but no generalised peritonitis, and were treated in 2007-2015. Patients underwent a two-step procedure that comprised antibiotic treatment and drainage when technically feasible (step 1) followed by interval appendectomy (step 2). We evaluated treatment modalities, complications and outcomes. Out of a total of 1480 patients with appendicitis, 15 patients presented with perityphlitic abscess. In addition to antibiotic treatment, computed tomography-guided drainage was performed in 12 of these cases. Step 1 and 2 hospital stays were (median, range) 7 days (5–14 days) and 2 days (2–12 days), respectively. One patient’s abscess recurred after 2 months, associated with new onset appendicitis and perforation. Another patient underwent reoperation after interval appendectomy for suspected postoperative peritonitis. This two-step procedure for appendicitis with appendicular abscess was highly successful (100%) with a low rate of complications (13%). In the view of a potentially increased rate of appendicular neoplasm in combination with abscess formation, the role of interval appendectomy has to be evaluated in larger trials.
Yang, Estin; Cook, Colin; Kahn, Delawir
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.
In 1984, 24,794 appendectomies and abscess drainage procedures were performed for acute appendicitis in California hospitals. Analysis of hospital discharge abstracts revealed age- and sex-specific incidence rates and in-hospital case fatality rates for acute appendicitis lower than previously reported. In persons aged 60 years and older, the case fatality rate for nonperforating appendicitis with appendectomy was 0.7% and for perforating appendicitis and abscess 2.4%. Surgery was delayed beyond the day of admission in 21% of persons aged 40-59 years, 29% of persons aged 60-79 years, and 47% of persons aged 80 years and over. The proportion of cases with perforation increased from 22% to 75% between ages 20 and 80 years. The population incidence of perforating appendicitis changed little after age 20 years, while the incidence of nonperforating cases declined sharply. The high proportion of appendicitis cases with perforation among the elderly may be due to the decreased incidence of nonperforating appendicitis in the elderly and not to a greater propensity for perforation, as previously proposed. Most elderly in California receive timely surgery for appendicitis and tolerate it better than previously reported. Diminished tolerance for intra-abdominal infection may be the primary determinant of the increase in case fatality with age.
van den Boom, A L; Gorter, R R; van Haard, P M M; Doornebosch, P G; Heij, H A; Dawson, I
Although a national guideline has been implemented, the optimal approach for appendectomy in children remains subject of debate in the Netherlands. Opponents of laparoscopy raise their concerns regarding its use in complex appendicitis as it is reported to be associated with an increased incidence of intra-abdominal abscesses. The aim of this study was to evaluate the outcome of surgical approaches in both simple and complex appendicitis in paediatric patients. A 10-year retrospective cohort study was performed (2001-2010) in paediatric patients treated for suspected acute appendicitis. Patients were divided into either simple or complex appendicitis and into different age groups. Primary outcome parameters were complication rate (intra-abdominal abscess (IAA), superficial surgical site infection (SSI) and readmission) and hospital stay. In total, 878 patients have been treated (median age 12, range 0-17 years). Two-thirds of the patients younger than 6 years had complex appendicitis, compared to one quarter in the group aged 13-18. In the complex appendicitis group, LA was associated with more IAA and early readmissions. In the simple appendicitis group, the complication rate was comparable between the two approaches. Significantly more IAAs were seen after LA in the youngest age group. This study demonstrates the unfavourable outcome of LA in the youngest age group and in patients with complex appendicitis. Therefore, we advise to treat these patients with an open approach.
Munakata, Koji; Uemura, Mamoru; Shimizu, Junzo; Miyake, Masakazu; Hata, Taishi; Ikeda, Kimimasa; Dono, Keizo; Kitada, Masashi; Doki, Yuichiro; Mori, Masaki
Several reports have demonstrated the effectiveness and feasibility of single incisional transumbilical laparoscopic-assisted appendectomy (TULAA). We developed a modified TULAA technique, gasless-TULAA, which involves lifting the abdominal wall with a retractor, without pneumoperitoneum or another incision. We assessed the surgical outcomes of 257 patients treated for appendicitis in our hospital between 2005 and 2013. In a preoperative comprehensive evaluation, appendicitis without abscess was defined as mild appendicitis (mild appendicitis group: MAG), and appendicitis with abscess was defined as severe appendicitis (severe appendicitis group: SAG). The clinical outcomes were compared with those in other published reports. The cost-effectiveness of gasless-TULAA was compared with that of conventional multiport laparoscopic appendectomy (CMLA) in our hospital. In MAG (n = 228), the operation time and postoperative hospital stay were 46.9 ± 22.7 min and 2.6 ± 1.2 days, respectively. The gasless-TULAA was completed without trocars in 91.2 % of patients. The surgical outcomes of SAG were significantly worse than those of MAG (p < 0.001). The surgical cost of gasless-TULAA was significantly lower than that of CMLA (p < 0.001). Gasless-TULAA is a cost-effective, safe, and readily available surgical technique for mild appendicitis, which can obviate the need for specialized equipment.
Rogers, Andrew P.; Zens, Tiffany J.; Leys, Charles M.; Nichol, Peter F.; Ostlie, Daniel J.
Background Abscess rates have been reported as low as 1% and as high as 50% following perforated appendicitis (PA). This range may be due to lack of universal definition for PA. An evidence-based definition (EBD) is crucial for accurate wound classification, risk-stratification, and subsequent process optimization. ACS NSQIP – Pediatric guidelines do not specify adefinition of PA. We hypothesize reported post-operative abscess rates underrepresent true incidence, as they may include low-risk cases in final calculations. Methods Local institutional records of PA patients were reviewed to calculate the post-operative abscess rate. The ACS NSQIP – Pediatric participant use file (PUF) was used to determine cross-institutional post-operative abscess rates. A PubMed literature review was performed to identify trials reporting PA abscess rates, and definitions and rates were recorded. Results 20.9% of our patients with PA developed a postoperative abscess. The ACS NSQIP – Pediatric abscess rate was significantly lower (7.61%, p<0.001). In the eighteen published studies analyzed, average abscess rate (14.49%) was significantly higher than ACS NSQIP – Pediatric (p< 0.001). There was significantly more variation in trials that do not employ an EBD of perforation (Levene’s test F-value = 6.980, p = 0.018). Conclusions A standard EBD of perforation leads to lower variability in reported post-operative abscess rates following PA; nonstandard definitions may be significantly altering the aggregate rate of post-operative abscess formation. We advocate for adoption of a standard definition by all institutions participating in ACS NSQIP – Pediatric data submission. PMID:27884453
Ditsatham, Chagkrit; Somwangprasert, Areewan; Watcharachan, Kirati; Wongmaneerung, Phanchaporn
Objective Acute appendicitis and incarcerated hernia rarely present in the same episode. Our study reports patient presentation, diagnosis method, and treatment of an unusual case at the Chiang Mai University Hospital. Method Case report. Result A 20-year-old man visited the Chiang Mai University Hospital with right lower quadrant pain and a right groin mass which could not be reduced. The computerized tomography scan showed acute appendicitis and omentum in the hernia sac. Operative treatment was an appendectomy and herniorrhaphy. The treatment was successful, and the patient was discharged from our hospital without any complications. Conclusion Concurrent acute appendicitis and incarcerated hernia are very rare, but should be kept in mind if a patient presents with right lower quadrant pain and a right groin mass. Further investigation may be helpful if the diagnosis is uncertain. Operative priority treatment depends on each individual case. PMID:26834499
Swidsinski, Alexander; Dörffel, Yvonne; Loening-Baucke, Vera; Tertychnyy, Alexander; Biche-ool, Salbakay; Stonogin, Sergei; Guo, Yi; Sun, Ning-Dong
Background/Aim: To investigate the geographic occurrence of mucosa-invading Fusobacteria in acute appendicitis. Patients and Methods: Carnoy- and formalin-fixated appendices from Germany, Russia, and China were comparatively investigated. Bacteria were detected using fluorescent in situ hybridization. Cecal biopsies from patients with inflammatory bowel disease and other conditions were used as disease controls. Results: Fusobacteria represented mainly by Fusobacterium nucleatum were the major invasive component in bacterial infiltrates in acute appendicitis but were completely absent in controls. The occurrence of invasive Fusobacteria in Germany, Russia, and China was the same. The detection rate in Carnoy-fixated material was 70–71% and in formalin-fixated material was 30–36%. Conclusions: Acute appendicitis is a polymicrobial infectious disease in which F. nucleatum and other Fusobacteria play a key role. PMID:22249094
Acute primary haemorrhagic omental torsion is an atypical and deceptive cause of acute abdomen that could closely mimic a myriad of intra-abdominal catastrophes, especially perforated appendicitis. The author reports a 30 years man who had presented with gradually worsening right-sided abdominal pain of 2 days duration. Laboratory work-up and abdominal radiographs were inconclusive. Abdominal sonography detected presence of free fluid in the pelvic cul-de-sac. Based on clinical and sonographic findings, presumptive diagnosis of perforated appendicitis was made and the patient was explored through extended Rockey-Davis incision. About 500 - 700 ml of dark-coloured blood (haemoperitoneum) was present in the peritoneal cavity and the pelvis secondary to acute haemorrhagic omental torsion. The appendix was grossly normal. Omentectomy and prophylactic appendicectomy resulted in uneventful recovery of the patient. Acute primary omental torsion is an uncommon pathology that must be kept in mind during differential diagnosis of acute abdomen, especially acute or perforated appendicitis.
Cetinkaya, Ziya; Aydin, Suleyman; Cerrahoglu, Yusuf Z; Ayten, Refik; Erman, Fazilet; Aygen, Erhan
This study was designed to measure the levels of serum and saliva ghrelin concentrations before and after surgery in an attempt to clarify whether this hormone plays any significant roles in acute appendicitis and cholelithiasis patients when compared with healthy controls. Samples were obtained from 20 patients with appendicitis, 10 patients with cholelithiasis before and after operation, and 16 healthy controls. The levels of ghrelin (acylated) were measured by means of a RIA assay. The results revealed that preoperative levels of ghrelin in saliva and serum were significantly decreased with respect to post-op in patients undergoing appendectomy, and control levels. This was also the case when the preoperative ghrelin concentrations in patients with appendicitis were compared with those having choelithiasis. Taken together, decreased ghrelin concentration in preoperative appendicitis might be a causative factor for the "loss of appetite" observed in an acute inflammatory condition such as acute appendicitis. However, further studies are necessary to reveal the exact mechanisms behind this observation.
Thieme, Mai E; Leeuwenburgh, Marjolein M N; Valdehueza, Zaldy D; Bouman, Donald E; de Bruin, Ivar G J M; Schreurs, W Hermien; Houdijk, Alexander P J; Stoker, Jaap; Wiarda, Bart M
To compare magnetic resonance imaging (MRI) and ultrasound in children with suspected appendicitis. In a single-centre diagnostic accuracy study, children with suspected appendicitis were prospectively identified at the emergency department. All underwent abdominal ultrasound and MRI within 2 h, with the reader blinded to other imaging findings. An expert panel established the final diagnosis after 3 months. We evaluated the diagnostic accuracy of three imaging strategies: ultrasound only, conditional MRI after negative or inconclusive ultrasound, and MRI only. Significance between sensitivity and specificity was calculated using McNemar's test statistic. Between April and December 2009 we included 104 consecutive children (47 male, mean age 12). According to the expert panel, 58 patients had appendicitis. The sensitivity of MRI only and conditional MRI was 100% (95% confidence interval 92-100), that of ultrasound was significantly lower (76%; 63-85, P < 0.001). Specificity was comparable among the three investigated strategies; ultrasound only 89% (77-95), conditional MRI 80% (67-89), MRI only 89% (77-95) (P values 0.13, 0.13 and 1.00). In children with suspected appendicitis, strategies with MRI (MRI only, conditional MRI) had a higher sensitivity for appendicitis compared with a strategy with ultrasound only, while specificity was comparable. • In children, MRI has a higher sensitivity for appendicitis than ultrasound. • Ultrasound followed by MRI in negative or inconclusive findings is accurate. • The tolerance for ultrasound and MRI in children is comparable. • MRI can be performed in children in an emergency setting.
Yılmaz, Eyüp Murat; Kapçı, Mücahit; Çelik, Sebahattin; Manoğlu, Berke; Avcil, Mücahit; Karacan, Erkan
Acute appendicitis is one of the most common causes of abdominal pain seen in surgical clinics. Although it can be easily diagnosed, the picture may be confusing, particularly in premenopausal women and the elderly. The present study is an evaluation of 2 of the current scoring systems with respect to accurate diagnosis of the disease and indication of inflammation severity. A total of 105 patients diagnosed with acute appendicitis were included in the study. Subsequent to Alvarado and Ohmann scoring, ultrasonography image was obtained and appendectomy was performed. A unique intraoperative severity scoring system was used to measure severity of inflammation and to compare Alvarado and Ohmann scoring system results to assess accuracy of predictive value for acute appendicitis. Moderate positive correlation was found between Alvarado score and Ohmann score (r=0.508; p<0.001). Rate of Alvarado score successfully predicting diagnosis of acute appendicitis based on histopathological results was statistically significant (p=0.027), while rate of Ohmann score was not statistically significant (p=0.807). Correlation between both scores and grading of inflammation performed during the operation was weak, but statistical significance was observed between Alvarado scoring system and intraoperative severity scoring (r=0.30; p=0.002). No statistical difference was observed between Ohmann scoring and intraoperative severity scoring (r=0.09; p=0.384). Alvarado score is better able to predict acute appendicitis and provide an idea of severity of inflammation. Ohmann score is more useful to provide guidance and eliminate acute appendicitis from consideration when conditions are more uncertain and obscured.
Kutasy, Balazs; Laxamanadass, Ganapathy; Puri, Prem
The diagnosis of acute appendicitis by physical examination can sometimes be difficult in extremely obese children. C-reactive protein (CRP) is commonly used to support the clinical diagnosis of appendicitis. However, obesity has been widely recognized as a chronic inflammatory condition and associated with elevated inflammatory indicators including CRP. The aim of this study was to examine the association between obesity and CRP levels in extremely obese children presenting with suspected appendicitis. The hospital records of 947 consecutive patients, who underwent appendectomy for acute appendicitis between 2002 and 2008 were retrospectively analyzed. 164 children (17.3%) were extremely obese. Extreme obesity was defined, as greater than two standard deviations above the standardized mean weight for age. The diagnostic value of CRP level was compared between extremely obese and non-obese children. The incidence of histologically normal appendix was significantly higher in extremely obese children [42 out of 164 (25.6%)] compared to non-obese children [85 out of 783 (10.8%) (P < 0.001)]. The mean CRP levels were significantly higher in extremely obese children with histologically normal appendix compared to non-obese children with normal appendix (P < 0.001). The specificity and the positive predictive value were significantly lower in the extremely obese children group than in the non-obese group (P < 0.001). CRP is not a reliable marker of inflammation in extremely obese children presenting with suspected appendicitis. Our data highlight the importance of obesity when interpreting the significance of an elevated CRP level in children with suspected diagnosis of appendicitis.
Abbas, Paulette I; Zamora, Irving J; Elder, Simone C; Brandt, Mary L; Lopez, Monica E; Orth, Robert C; Bisset, George S; Cruz, Andrea T
Appendicitis is the most common surgical emergency encountered in the pediatric emergency department (ED). We analyzed the time course of children evaluated for suspected appendicitis in relation to implementation of a risk-stratified ultrasound scoring system and structured reporting template (Appy-Score). In July 2013, a 6-level ultrasound (US)-based appendicitis scoring system was developed and implemented. The records of children (age ≤18 years) who underwent limited abdominal US exams for suspected appendicitis at a large academic pediatric ED were reviewed retrospectively. Time periods evaluated were from January 1 to April 1, 2013 (before implementation of the US scoring system, "PRE") and July 1 to October 1, 2013 (after implementation of the US scoring system, "POST"). Times are presented as medians with interquartile range. A total of 926 children were included (median age, 9.5 years [range, 0.1-18 years]; 49% female). Four hundred eighty-one patients were evaluated PRE and 445 POST. When comparing the 2 groups, there were no differences in the PRE and POST periods with regard to time from US ordered to first read (102 vs 112 minutes, P = 0.30), US ordered to disposition (215 vs 208 minutes, P = 0.40) and operating room posting (121 vs 122 minutes, P = 0.59), and overall ED stay (329 vs 333 minutes, P = 0.39). The development of a radiographic appendicitis score, although allowing for a standardized reporting method, did not significantly alter the ED process flow for evaluation of appendicitis. This reflects the complexities in ED throughput and reveals the need for additional factors to change to improve patient flow.
Ho, T-L; Muo, C-H; Shen, W-C; Kao, C-H
We used the Taiwan National Health Insurance Database for analysis and statistics to investigate the role of computed tomography (CT) in diagnosing acute appendicitis. All 10 046 patients with acute appendicitis were selected and categorized into two groups based on those who did and did not receive CT 3 days before acute appendicitis diagnosis: non-CT and CT groups. A noteworthy outcome was the incidence of peritonitis within 90 days after diagnosis of acute appendicitis. The rate of using CT for patients with acute appendicitis increased considerably from 7.9% to 52.9% from 2000 to 2010. The peritonitis incidence rates were 3.54% and 10.7% in the non-CT and CT groups, respectively. Patients who received CT on the same day exhibited a 3.8-fold higher risk of peritonitis than did those in the non-CT group. Those who underwent CT before diagnosis of acute appendicitis exhibited no significant difference of peritonitis risk when compared with those in the non-CT group. The CT group patients were hospitalized 2.19 days longer than the non-CT group patients. Patients who received CT before and on the same day were hospitalized 1.31 and 2.43 days longer than those who did not undergo CT. Patients who underwent CT exhibited higher risks of peritonitis and longer hospital stays compared with those who did not. Moreover, patients who received CT on the same day of operation exhibited a higher risk of peritonitis than those who underwent CT 1 or 2 days before operation. © The Author 2015. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For Permissions, please email: email@example.com.
Noviello, Carmine; Romano, Mercedes; Martino, Ascanio; Cobellis, Giovanni
Transumbilical laparoscopic-assisted appendectomy (TULAA) is increasingly being performed worldwide. The authors report their experience in the treatment of acute uncomplicated appendicitis in children with TULAA. From January 2008 to December 2012 all types of acute appendicitis were divided, according to the clinical and ultrasonographic findings, into complicated (appendiceal mass/abscess, diffuse peritonitis) and uncomplicated. Complicated appendicitis was treated by open appendectomy (OA). All patients with the suspicion of uncomplicated appendicitis were offered TULAA by all surgeons of the team. Conversion to open or laparoscopic appendectomy (LA) was performed in case of impossibility to complete TULAA, depending on the choice of surgeon. The histopathologic examination of appendix was always performed. 444 children (252 males) with acute appendicitis were treated. The mean age was 9.2 years (range, 2 to 14 years). Primary OA was performed in 144 cases. In 300 patients a transumbilical laparoscopic-assisted approach was performed. TULAA was completed in 252 patients. Conversion to OA was performed in 45 patients and to LA in 3. Conversion was related to the impossibility to adequately expose the appendix in 47 patients and bleeding in 1. The mean operative time for TULAA was 42 minutes. Histopathologic examination of the appendix removed by TULAA showed a phlegmonous/gangrenous type in 92.8% of cases. Among the 252 TULAA there were 11 cases of umbilical wound infection. TULAA is a feasible and effective procedure for uncomplicated appendicitis in children. It combines the advantages of open and laparoscopic technique (low operative time, low complications rate, and excellent cosmetic results). PMID:26491433
Khiria, Lakshman S; Ardhnari, Ramesh; Mohan, Narshimhan; Kumar, Palaniappan; Nambiar, Rajesh
Although laparoscopic appendectomy has some advantages over open appendectomy, the literature suggests conflicting results regarding postoperative complications for complicated appendicitis. A retrospective review of patients with complicated appendicitis managed surgically at Meenakshi Mission Hospital and Research Center, Madurai, Tamilnadu, India was undertaken. A total of 497 patients were admitted with acute appendicitis and operated during the study period of 10 years from January 1999 to July 2009, out of which 119 (24%) patients had complicated appendicitis whereas 378 (76%) had uncomplicated acute appendicitis. The mean age of patients included in the study was 33.42 years (range, 4 to 80 y) with a male: female ratio of 2:1. Ninety-nine patients (83.19%) underwent laparoscopic appendicectomy and 1 patient underwent laparoscopic-assisted right hemicolectomy for suspected mass lesion of the cecum. Eleven patients (9.24%) underwent open appendicectomy because of preoperative clinical features of peritonitis in 10 patients and mass in 1 patient. Seven patients (5.88%) had conversion from laparoscopic to open procedure. The overall mean operating time was 68 minutes (25 to 180 min). For laparoscopic appendicectomy, 66 minutes (25 to 180 min), for open appendicectomy 76 minutes (50 to 110 min), for lap to open conversion 85 minutes (40 to 135 min), and for drainage procedure 67 minutes (60 to 75 min). A total of 28 patients developed complication in the form of wound infection (7), pneumonia (8), intra-abdominal abscess (11), and enterocutaneous fistula (2) after percutaneous drainage of intra-abdominal collection. All were managed conservatively and no mortality occurred. The morbidity rates, particularly for intra-abdominal abscesses and wound infection were less for laparoscopic appendectomy in complicated appendicitis than those reported in the literature for open appendectomy, whereas operating times and hospital stays were similar.
Karakuş, Osman Zeki; Ulusoy, Oktay; Ateş, Oğuz; Hakgüder, Gülce; Olguner, Mustafa; Akgür, Feza Miraç
BACKGROUND: Laparoscopic appendectomy (LA) is gradually gaining popularity among paediatric surgeons for complicated appendicitis. A retrospective study was conducted to compare conventional single port LA, multiport LA and open appendectomy (OA) for complicated appendicitis in children. PATIENTS AND METHODS: From January 1995 from December 2014, 1,408 patients (604 girls, 804 boys) underwent surgery for uncomplicated and complicated appendicitis. The patient characteristics, operation times, duration of hospitalization, operative costs, and postoperative complications were recorded. A 10-mm 0° scope with a parallel eye piece and an integrated 6 mm working channel were inserted through an 11-mm “conventional umbilical port” for single port LA. RESULTS: A total of 314 patients with complicated appendicitis (128 girls, 186 boys) underwent appendectomy. Among these, 102 patients (32.4%) underwent single port LA, 17 patients (5.4%) underwent multiport LA and 195 patients (62.1%) underwent OA. The hospital stay of the single port LA group was significantly less (3.88 ± 1.1) compared with multiport LA (5.41 ± 1.2) and OA groups (6.14 ± 1.1) (P < 0.001). Drain usage, wound infection and adhesive intestinal obstruction rates were significantly high in the OA group. There was no significant difference between the groups in postoperative intraabdominal abscess formation. Single-port LA performed for complicated appendicitis was cheaper compared with the other groups. CONCLUSIONS: The present study has shown that single-port LA for complicated appendicitis can be conducted in a reasonable operative time; it shortens the hospitalization period, markedly reduces postoperative wound infection and adhesive intestinal obstruction rates and does not increase the operative cost. PMID:26917914
Cruz, Dennis Baroni; Friedrisch, Bruno Kras; Fontanive Junior, Vilmar; da Rocha, Vívian Wünderlich
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
Silva, Danielle Fernandes da; Silva, Reinaldo José da; Silva, Márcia Guimarães da; Sartorelli, Alesso Cervantes; Takegawa, Bonifácio Katsunori; Rodrigues, Maria Aparecida Marchesan
From 1,600 surgically removed appendices, 24 (1.5%) were found to have helminths. Enterobius vermicularis was observed in 23 of the 24 specimens (95.8%) and Taenia sp was detected in only 1 (4.2%) case. Sixteen patients (66.7%) were less than 10 year-old; 15 patients were male and 9 female. Pathologic analysis disclosed acute neutrophilic inflammation in 12 cases and lymphoid hyperplasia in 10 of the 24 appendices. Gangrenous appendicitis was diagnosed in 3 cases and peritonitis was found in 11 of the 24 infested appendices. Parasitic infection of the appendix is an uncommon cause of acute appendicitis in children and adolescents.
Davenport, Katherine P.; Fraser, Claire M.; Sandler, Anthony D.; Zeichner, Steven L.
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
Nishimura, Miho; Kodama, Yuichi; Fukano, Reiji; Okamura, Jun; Ogaki, Kippei; Sakaguchi, Yoshihisa; Migita, Masahiro; Inagaki, Jiro
A 7-year-old girl with Philadelphia chromosome-positive acute lymphoblastic leukemia developed recurrent fever and meralgia paresthetica (MP) during chemotherapy, which resolved after administration of antibiotics. Five months after the onset of these symptoms, enhanced computed tomography showed a periappendiceal abscess extending into the psoas muscle. The cause of her fever and MP was thought to be appendicitis, which probably developed during induction chemotherapy but did not result in typical abdominal pain. Patients with recurrent fever and MP should be evaluated by imaging examinations including computed tomography to search for appendicitis.
Chang, Chih-Chen; Wong, Yon-Cheong; Wu, Cheng-Hsien; Chen, Huan-Wu; Wang, Li-Jen; Lee, Yu-Hsien; Wu, Patricia Wanping; Irama, Wiwan; Chen, Wei Yuan; Chang, Chee-Jen
Background Low-dose computed tomography (LDCT) techniques can reduce exposure to radiation. Several previous studies have shown that radiation dose reduction in LDCT does not decrease the diagnostic performance for appendicitis among attending radiologists. But, the LDCT diagnostic performance for acute appendicitis in radiology residents with variable training levels has not been well discussed. Objectives To compare inter-observer and intra-observer differences of diagnostic performance on non-enhanced LDCT (NE-LDCT) and contrast-enhanced standard dose CT (CE-SDCT) for acute appendicitis among attending and resident radiologists. Patients and Methods This retrospective study included 101 patients with suspected acute appendicitis who underwent NE-LDCT and CE-SDCT. The CT examinations were interpreted and recorded on a five-point scale independently by three attending radiologists and three residents with 4, 1 and 1 years of training. Diagnostic performance for acute appendicitis of all readers on both examinations was represented by area under receiver operating characteristic (ROC) curves. Inter-observer and intra-observer AUC values were compared using Jackknife FROC software on both modalities. The diagnostic accuracy of each reader on NE-LDCT was compared with body mass index (BMI) subgroups and noise using independent T test. Results Diagnostic performances for acute appendicitis were not statistically different for attending radiologists at both examinations. Better performance was noted on the CE-SDCT with a borderline significant difference (P = 0.05) for senior radiology resident. No statistical difference of AUC values was observed between attending radiologists and fourth year resident on both examinations. Statistically signiﬁcant differences of AUC values were observed between attending radiologists and first year residents (P = 0.001 ~ 0.018) on NE-LDCT. Diagnostic accuracies of acute appendicitis on NE-LDCT for each reader were not significantly
Cruz, Dennis Baroni; Friedrisch, Bruno Kras; Fontanive Junior, Vilmar; da Rocha, Vívian Wünderlich
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.
Saravi, Kasra H; Fakhar, Mahdi; Nematian, Javad; Ghasemi, Maryam
In this report, we describe an unusual case of verminous appendicitis due to Enterobius vermicularis and Taenia saginata in a 29-year-old woman from Iran. The histopathological examinations and parasitological descriptions of both worms found in the appendix lumen are discussed. The removed appendix exhibited the macroscopic and microscopic features of acute appendicitis. Antihelminthic therapy was initiated with single doses of praziquantel for the taeniasis and mebendazole for the enterobiasis, and the patient was discharged. Copyright © 2015 King Saud Bin Abdulaziz University for Health Sciences. Published by Elsevier Ltd. All rights reserved.
Cho, Hyun Suk; Woo, Ji Young; Lee, Yul; Yang, Ik; Hwang, Ji-Young; Kim, Han Myun; Kim, Jeong Won
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