Unusual presentation of a familiar pathology: chronic appendicitis.

PubMed

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

2016-02-11

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

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

PubMed Central

Hatipoglu, Sinan; Hatipoglu, Filiz; Abdullayev, Ruslan

2014-01-01

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

Diagnostic performance of a biomarker panel as a negative predictor for acute appendicitis in adult ED patients with abdominal pain.

PubMed

Huckins, David S; Copeland, Karen; Self, Wesley; Vance, Cheryl; Hendry, Phyllis; Borg, Keith; Gogain, Joseph

2017-03-01

Evaluate the diagnostic accuracy of the APPY1TM biomarker panel, previously described for use in pediatric patients, for identifying adult ED patients with abdominal pain who are at low risk of acute appendicitis. This study prospectively enrolled subjects >18years of age presenting to seven U.S. emergency departments with <72hours of abdominal pain suggesting possible acute appendicitis. The APPY1 panel was performed on blood samples drawn from each patient at the time of initial evaluation and results were correlated with the final diagnosis either positive or negative for acute appendicitis. 431 patients were enrolled with 422 completing all aspects of the study. The APPY1 biomarker panel exhibited a sensitivity of 97.5% (95% CI, 91.3-99.3%), a negative predictive value of 98.4% (95% CI, 94.4-99.6%), a negative likelihood ratio of 0.07 (95% CI, 0.02-0.27), with a specificity of 36.5% (95% CI, 31.6-41.8%) for acute appendicitis. The panel correctly identified 125 of 342 (36.6%) patients who did not have appendicitis with 2 (2.5%) false negatives. The CT utilization rate in this population was 72.7% (307/422). Of 307 CT scans, 232 were done for patients who did not have appendicitis and 79 (34%) of these patients were correctly identified as negative with "low risk" biomarker panel results, representing 26% (79/307) of all CT scans performed. This biomarker panel exhibited high sensitivity and negative predictive value for acute appendicitis in this prospective adult cohort, thereby potentially reducing the dependence on CT for the evaluation of possible acute appendicitis. Copyright © 2016 Elsevier Inc. All rights reserved.

Appendicitis following blunt abdominal trauma.

PubMed

Cobb, Travis

2017-09-01

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.

Vacation appendicitis.

PubMed

Redan, Jay A; Tempel, Michael B; Harrison, Shannon; Zhu, Xiang

2013-01-01

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.

Appendectomy - series (image)

MedlinePlus

... to the entire abdominal space. Symptoms of acute appendicitis include pain in the lower right side of ... be performed. There is no test to confirm appendicitis and the symptoms may be caused by other ...

Vacation Appendicitis

PubMed Central

Tempel, Michael B.; Harrison, Shannon; Zhu, Xiang

2013-01-01

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

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

PubMed

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

2014-01-01

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

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

PubMed

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

2013-11-01

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

Risk Factors for Complications in Acute Appendicitis among Paediatric Population.

PubMed

Poudel, R; Bhandari, T R

2017-01-01

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

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

PubMed

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

2017-02-01

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

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

PubMed Central

2018-01-01

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

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

PubMed

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

2014-01-01

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

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

PubMed

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

2017-11-01

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

Enterobius vermicularis: A Cause of Abdominal Pain Mimicking Acute Appendicitis in Children. A Retrospective Cohort Study.

PubMed

Zouari, Mohamed; Louati, Hamid; Abid, Imen; Trabelsi, Fatma; Ben Dhaou, Mahdi; Jallouli, Mohamed; Mhiri, Riadh

2018-02-01

Enterobius vermicularis (EV) is the most common helminthic infection in the world. This small parasite is predominant in the pediatric population. The presence of EV in the appendix can cause or mimick appendicitis. The aim of our study was to compare patients with EV infection and those without EV infection, and to identify predictive factors that may help the diagnosis of EV infection in patients presenting with right iliac fossa pain and avoid negative appendectomy. A retrospective analysis of all the appendices removed between January 2012 and December 2016 was conducted at the department of pediatric surgery, Hedi Chaker Hospital, Sfax, Tunisia. According to the final histopathological diagnosis, patients with EV infection were compared to those without EV infection. Data including age, sex, white blood cell (WBC) count, neutrophil count, eosinophil count, C-reactive protein, and ultrasound results for both groups were analyzed and compared. The study protocol was approved by the local hospital ethics committee. Statistical analysis was performed using IBM SPSS, version 20. Descriptive analysis in the form of mean and standard deviation was performed on demographic information. Differences between groups were assessed using the student t-test for continuous variables and the χ2 test and Fisher exact test where appropriate for categorical variables. In total, 540 pediatric appendectomies were performed. Overall, 63.5% of patients were male and 36.5% were female. Mean age was 9.28 ± 2.77 years. 22.2% of procedures were completed laparoscopically, 76.5% were open and 1.3% were converted. The negative appendectomy rate was 11.1%. EV was present in 9.8% of cases. Comparison of clinical, biological, and ultrasound findings between two groups of patients with EV (EV+) and those without EV (EV-) shows a statistical significance for pruritus ani (P < 0.001), WBC count (P < 0.001), neutrophil count (P < 0.001), C-reactive protein (CRP) (P = 0.001), positive ultrasound (P < 0.001), perforation rate (P = 0.009), and negative appendectomy rate (P < 0.001). No significant difference between the two groups was seen when comparing gender (P = 0.271), vomiting (P = 0.130), eosinophil count (P = 0.915), and procedure (P = 0.536). EV was seen in 9.8% of pediatric appendectomies in our study. Pruritus ani, normal WBC count, normal neutrophil count, and normal CRP level at presentation could predict EV infection in children who present with right iliac fossa pain. © 2018 The Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Appendicitis by Enterobius vermicularis presenting with recurrent abdominal pain and eosinophilia A case report.

PubMed

Risio, Domenico; Rendine, Anna; Napolitano, Luca; Schiavone, Cosima

2016-02-29

Enterobius vermicularis (EV) is the most common parasitic infection in developed countries. Enterobius vermicularis infestation of the appendix can cause symptoms of appendiceal pain, independent of microscopic evidence of acute inflammation. The diagnosis of a parasitic infestation is generally achieved only after the pathologic examination of the resected appendices. We present a case of a 23 year old female with enterobiasis of appendix presented with clinical features of acute appendicitis. The appendix was surgically removed and the specimen was pathologically. We highlight that the symptoms of appendicitis can be due to Enterobius vermicularis infestation also without any histological evidence of acute inflammation. High index of suspicion and including parasitic origin in differential diagnosis of abdominal disturbances might hopefully Appencitis, Elminth, Enterobius vermicularis (EV).

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

PubMed

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

2017-12-01

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

Laparoscopic treatment of perforated appendicitis

PubMed Central

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

2014-01-01

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

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

PubMed

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

2017-06-01

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

Enterobius vermicularis: a rare cause of appendicitis.

PubMed

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

2012-01-01

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

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

PubMed

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

2005-01-01

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

Necrotizing fasciitis caused by perforated appendicitis: a case report.

PubMed

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

2015-01-01

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

Total antioxidant capacity in children with acute appendicitis.

PubMed

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

2006-02-01

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

Streptococcal Pharyngitis and Appendicitis in Children.

PubMed

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

2018-01-01

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

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

PubMed

Dinu, C A; Moraru, D

2011-01-01

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

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

PubMed

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

2006-11-01

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

Missed appendicitis after self-induced abortion.

PubMed

Punguyire, Damien; Iserson, Victor Kenneth

2011-01-01

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

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

PubMed

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

2017-01-01

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

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

PubMed

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

2000-11-01

To test the hypothesis that physician errors (failure to diagnose appendicitis at initial evaluation) correlate with adverse outcome. The authors also postulated that physician errors would correlate with delays in surgery, delays in surgery would correlate with adverse outcomes, and physician errors would occur on patients with atypical presentations. This was a retrospective two-arm observational cohort study at 12 acute care hospitals: 1) consecutive patients who had an appendectomy for appendicitis and 2) consecutive emergency department abdominal pain patients. Outcome measures were adverse events (perforation, abscess) and physician diagnostic performance (false-positive decisions, false-negative decisions). The appendectomy arm of the study included 1, 026 patients with 110 (10.5%) false-positive decisions (range by hospital 4.7% to 19.5%). Of the 916 patients with appendicitis, 170 (18.6%) false-negative decisions were made (range by hospital 10.6% to 27.8%). Patients who had false-negative decisions had increased risks of perforation (r = 0.59, p = 0.058) and of abscess formation (r = 0.81, p = 0.002). For admitted patients, when the inhospital delay before surgery was >20 hours, the risk of perforation was increased [2.9 odds ratio (OR) 95% CI = 1.8 to 4.8]. The amount of delay from initial physician evaluation until surgery varied with physician diagnostic performance: 7.0 hours (95% CI = 6.7 to 7.4) if the initial physician made the diagnosis, 72.4 hours (95% CI = 51.2 to 93.7) if the initial office physician missed the diagnosis, and 63.1 hours (95% CI = 47.9 to 78.4) if the initial emergency physician missed the diagnosis. Patients whose diagnosis was initially missed by the physician had fewer signs and symptoms of appendicitis than patients whose diagnosis was made initially [appendicitis score 2.0 (95% CI = 1.6 to 2.3) vs 6.5 (95% CI = 6.4 to 6.7)]. Older patients (>41 years old) had more false-negative decisions and a higher risk of perforation or abscess (3.5 OR 95% CI = 2.4 to 5.1). False-positive decisions were made for patients who had signs and symptoms similar to those of appendicitis patients [appendicitis score 5.7 (95% CI = 5.2 to 6.1) vs 6.5 (95% CI = 6.4 to 6.7)]. Female patients had an increased risk of false-positive surgery (2.3 OR 95% CI = 1.5 to 3.4). The abdominal pain arm of the study included 1,118 consecutive patients submitted by eight hospitals, with 44 patients having appendicitis. Hospitals with observation units compared with hospitals without observation units had a higher "rule out appendicitis" evaluation rate [33.7% (95% CI = 27 to 38) vs 24.7% (95% CI = 23 to 27)] and a similar hospital admission rate (27.6% vs 24.7%, p = NS). There was a lower miss-diagnosis rate (15.1% vs 19.4%, p = NS power 0.02), lower perforation rate (19.0% vs 20.6%, p = NS power 0.05), and lower abscess rate (5.6% vs 6.9%, p = NS power 0.06), but these did not reach statistical significance. Errors in physician diagnostic decisions correlated with patient clinical findings, i.e., the missed diagnoses were on appendicitis patients with few clinical findings and unnecessary surgeries were on non-appendicitis patients with clinical findings similar to those of patients with appendicitis. Adverse events (perforation, abscess formation) correlated with physician false-negative decisions.

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

PubMed

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

2012-03-27

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

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

PubMed Central

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

2012-01-01

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

Spontaneous Extraperitoneal Bladder Rupture Because of Chronic Appendicitis

PubMed Central

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

2013-01-01

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

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

PubMed

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

2012-06-28

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

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

PubMed

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

2009-11-01

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

Nonspecific abdominal pain is a safe diagnosis.

PubMed

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

2014-11-01

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

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

PubMed

Biçer, Şenol; Çelik, Ali

2015-08-27

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

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

PubMed

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

2013-12-01

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

Predictors of Nondiagnostic Ultrasound for Appendicitis.

PubMed

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

2017-03-01

Ionizing radiation and cost make ultrasound (US), when available, the first imaging study for the diagnosis of suspected pediatric appendicitis. US is less sensitive and specific than computed tomography (CT) or magnetic resonance imaging (MRI) scans, which are often performed after nondiagnostic US. We sought to determine predictors of nondiagnostic US in order to guide efficient ordering of imaging studies. A prospective cohort study of consecutive patients 4 to 30 years of age with suspected appendicitis took place at an emergency department with access to 24/7 US, MRI, and CT capabilities. Patients with US as their initial study were identified. Clinical (i.e., duration of illness, highest fever, and right lower quadrant pain) and demographic (i.e., age and sex) variables were collected. Body mass index (BMI) was calculated based on Centers for Disease Control and Prevention criteria; BMI >85th percentile was categorized as overweight. Patients were followed until day 7. Univariate and stepwise multivariate logistic regression analysis was performed. Over 3 months, 106 patients had US first for suspected appendicitis; 52 (49%) had nondiagnostic US results. Eighteen patients had appendicitis, and there were no missed cases after discharge. On univariate analysis, male sex, a yearly increase in age, and overweight BMI were associated with nondiagnostic US (p < 0.05). In the multivariate model, only BMI (odds ratio 4.9 [95% CI 2.0-12.2]) and age (odds ratio 1.1 [95% CI 1.02-1.20]) were predictors. Sixty-eight percent of nondiagnostic US results occurred in overweight patients. Overweight and older patients are more likely to have a nondiagnostic US or appendicitis, and it may be more efficient to consider alternatives to US first for these patients. Also, this information about the accuracy of US to diagnose suspected appendicitis may be useful to clinicians who wish to engage in shared decision-making with the parents or guardians of children regarding imaging options for children with acute abdominal pain. Copyright © 2016 Elsevier Inc. All rights reserved.

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

PubMed

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

2017-12-01

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

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

PubMed

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

2018-05-01

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

Evaluation of acute pelvic pain in women.

PubMed

Kruszka, Paul S; Kruszka, Stephen J

2010-07-15

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

Barium appendicitis after upper gastrointestinal imaging.

PubMed

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

2010-02-01

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

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

PubMed

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

2015-11-28

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

Massive ovarian edema, due to adjacent appendicitis.

PubMed

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

2017-04-01

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

Perforated Appendicitis After Colonoscopy

PubMed Central

Johnston, Paul

2008-01-01

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

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

PubMed Central

Gandhi, Jamish; Tan, Jeffrey

2015-01-01

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

Appendiceal diverticulum associated with chronic appendicitis

PubMed Central

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

2014-01-01

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

First Aid: Stomachaches (For Parents)

MedlinePlus

... on this topic for: Parents Kids Teens Constipation Food Poisoning Helicobacter pylori Campylobacter Infections Vomiting Appendicitis "Stomach Flu" Belly Pain Indigestion Stress When Tests Make You Nervous Word! Gastroenteritis Food ...

ABDX A Decision Support System for the Management of Acute Abdominal Pain. Version 3.0. Programmer’s Manual

DTIC Science & Technology

1989-10-31

appendicitis." The presence of diverticular disease does not preclude development of acute appendicitis concomitantly. The initial medical treatment...and creates this file. The format of the file is a random access file with a record length of seven (i.e., the number of diseases considered) bytes...of record equals the total number of responses in ABDX. X is seven, the number of diseases considered by the database; however, dyspepsia is combined

Diagnostic laparoscopy

MedlinePlus

... from inside the uterus grow in other areas ( endometriosis ) Inflammation of the gallbladder (cholecystitis) Ovarian cysts or ... team. Abdominal Pain Read more Appendicitis Read more Endometriosis Read more A.D.A.M., Inc. is ...

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

PubMed

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

2018-01-01

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

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

PubMed

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

2016-11-01

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

A Clinical Score to Predict Appendicitis in Older Male Children.

PubMed

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

2017-04-01

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

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

PubMed Central

Gonzalez, Adolfo; Corpron, Cynthia

2011-01-01

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

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

PubMed

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

2017-10-01

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

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

PubMed

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

2016-01-01

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

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

PubMed

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

2017-01-01

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

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

PubMed

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

2016-01-01

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

Comparison of post operative morbidity between laparoscopic and open appendectomy in children.

PubMed

Saha, N; Saha, D K; Rahman, M A; Islam, M K; Aziz, M A

2010-07-01

This prospective comparative study was conducted in the department of Pediatric Surgery, Dhaka Shishu (children) Hospital during the period of June 2007 to September 2008 with the children of <12 years, diagnosed as acute Appendicitis. Patient selection was done by simple random technique by means of lottery. For open Appendectomy (OA) conventional method & for Laparoscopic Appendectomy (LA) 3 trocher technique was applied. Data was analyzed with the help of SPSS version 10. In this study 60 cases with acute Appendicitis including both gender were studied by two groups, group-A include 30 cases for laparoscopic and group-B include 30 cases for open appendectomy. Postoperative pain was assessed in both groups by using FLACC scale and compared at 1st 6-hours, 24 hours, 72 hours, 96 hours & at day 7. At 1st 6-hours, most of the children 24(80%) of group A had moderate pain whereas 17(56.7%) children of group B had severe pain (p<0.001). At 24 hours most of the patient 17(56.7%) of group A had mild pain compared to 27 (90%) patients of group B had moderate pain (p<0.0001). At 48 hours in group A most of the children 23(76.7%) had mild pain compared to moderate pain in 18(60%) children of group B (p<0.0001). Subsequently at 72 hours and at 96 hours most of the patients of LA group were free of pain compared to OA group. At final follow-up on day 7, 29(96.7%) children of group A had no pain compared to 26(86.7%) of group B. Regarding analgesics requirement both qualitative & quantitative requirements of analgesics were less in LA group than OA group. About post operative wound infection in group A only 1(3.3%) case had developed post operative wound infection whereas in group B 7(23.3 %) cases had. The mean (+/-SD) of post operative length of hospital stay was 52.00+/-11.62 (range 48-96) hours for group A and 76.00+/-12.74 (range 48-96) hours for group B children (p<0.001). Laparoscopic Appendectomy is more effective, preferable & superior procedure than that of open Appendectomy to reduce the post operative morbidity in children undergone appendectomy for acute appendicitis.

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

PubMed

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

2015-11-01

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

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

PubMed

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

2017-11-01

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

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

PubMed

Giri, Subha; Nixdorf, Donald

2007-03-01

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

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

PubMed

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

2016-12-01

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

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

PubMed Central

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

2004-01-01

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

Incidence of acute appendicitis in Kumasi, Ghana.

PubMed

Ohene-Yeboah, M; Abantanga, F A

2009-03-01

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

Pattern of acute appendicitis in Mekelle, Ethiopia.

PubMed

Hagos, Mekonnen

2014-07-01

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

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

PubMed

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

2016-07-01

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

Appendectomy and Risk of Subsequent Diverticular Disease Requiring Hospitalization: A Population-Based Case-Control Study.

PubMed

Sköldberg, Filip; Olén, Ola; Ekbom, Anders; Schmidt, Peter T

2018-07-01

Appendicitis and acute diverticulitis share clinical features and are both influenced by genetic and environmental factors. Appendectomy has been positively associated with diverticular disease in hospital-based case-control studies. The aim of the present study was to investigate, in a population-based setting, whether appendectomy, with or without appendicitis, is associated with an altered risk of hospitalization with diverticular disease. This was a population-based case-control study. The study was based on national healthcare and population registers. We studied 41,988 individuals hospitalized between 2000 and 2010 with a first-time diagnosis of colonic diverticular disease and 413,115 matched control subjects. The association between appendectomy with or without appendicitis and diverticular disease was investigated by conditional logistic regression, including a model adjusting for hospital use. A total of 2813 cases (6.7%) and 19,037 controls (4.6%) had a previous record of appendectomy (appendectomy with acute appendicitis: adjusted OR = 1.31 (95% CI, 1.24-1.39); without appendicitis: adjusted OR = 1.30 (95% CI, 1.23-1.38)). Appendectomy was most strongly associated with an increased risk of diverticular disease within 1 year (with appendicitis: adjusted OR = 2.26 (95% CI, 1.61-3.16); without appendicitis: adjusted OR = 3.98 (95% CI, 2.71-5.83)), but the association was still present ≥20 years after appendectomy (with appendicitis: adjusted OR = 1.22 (95% CI, 1.12-1.32); without appendicitis: adjusted OR = 1.19 (95% CI, 1.10-1.28)). Detailed clinical information on the cases was not available. There were unmeasured potential confounders, such as smoking and dietary factors. The findings are consistent with a hypothesis of appendectomy causing an increased risk of diverticular disease, for example, by affecting the mucosal immune system or the gut microbiome. However, several other mechanisms may contribute to, or account for, the positive association, including a propensity for abdominal pain increasing the risk of both the exposure and the outcome. See Video Abstract at http://links.lww.com/DCR/A604.

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

PubMed

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

2016-01-01

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

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

PubMed

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

2006-02-01

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

Race and acute abdominal pain in a pediatric emergency department.

PubMed

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

2013-06-01

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

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

PubMed

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

2017-09-01

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

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

PubMed

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

2015-06-01

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

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

PubMed Central

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

2011-01-01

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

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

PubMed

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

2017-10-01

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

Hyperbilirubinemia as a Diagnostic Tool for the Prediction of Appendicular Perforation: A Prospective Study.

PubMed

Saxena, Divish; Tandon, Mrinal; Shah, Yunus; Gedam, B S

2015-01-01

The certainty of diagnosing acute appendicitis in patients presenting with right iliac fossa pain still remains a mystery though acute appendicitis being the commonest surgical procedure done in emergency. In acute appendicitis, serum bilirubin levels are raised due to hepatocellular damage as a result of direct insult caused by Gram-negative bacterial endotoxemia. The need for the study is to conclude whether the serum bilirubin can be considered as a new laboratory marker to aid in the diagnosis of acute appendicitis and if so, does it have the predictive capacity to warn us about appendicular perforation. This is a prospective study carried out at rural tertiary healthcare center and includes 213 patients clinically diagnosed as acute appendicitis. Out of 213 patients, raised serum bilirubin ≥1.2 mg/dl was present in 195 (91.5%) patients, out of which 194 (99.4%) patients had histopathologically inflamed appendix and this difference was statistically highly significant with p-value < 0.0001. In this study, 32 patients had perforated appendix. Out of those, 30 patients had bilirubin ≥ 4 mg/dl and 2 patients had bilirubin level between 1.2 and < 4 mg/dl. Raised serum bilirubin (≥4 mg/dl) was present in 35 (17.9%) patients, out of which 30 (87.7%) patients had perforated appendix. Saxena D, Tandon M, Shah Y, Gedam BS. Hyperbilirubinemia as a Diagnostic Tool for the Prediction of Appendicular Perforation: A Prospective Study. Euroasian J Hepato-Gastroenterol 2015;5(2):87-89.

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

PubMed

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

2016-12-01

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

WSES Jerusalem guidelines for diagnosis and treatment of acute appendicitis.

PubMed

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

2016-01-01

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

Presenting features of Enterobius vermicularis in the vermiform appendix.

PubMed

Sodergren, Mikael H; Jethwa, Paras; Wilkinson, Simon; Kerwat, Rajab

2009-01-01

Enterobius vermicularis (pinworm) infestation can present with symptoms resembling acute appendicitis, although current evidence suggests that it does not necessarily cause acute appendicitis. The purpose of this study was to characterize the clinical presentation of patients with pinworms in the vermiform appendix and to establish features suggestive of this condition. A retrospective analysis of all patients undergoing appendicectomy with appendicular pinworms between 1998 and 2003 was undertaken. Patients were compared against 54 controls with confirmed acute suppurative appendicitis from the same time period. Presenting features, vital signs and modified Alvarado scores were obtained from the patients' records. Eighteen out of 1150 patients (1.5%) undergoing appendicectomy were proven to have pinworms (age range 8-37 years, 12 F, 6 M). Two of 18 appendices containing pinworms showed evidence of inflammation. Patients with pinworms had significantly lower white cell counts (WCCs) than the control group (median 8.9 versus 14.7, p=0.045), lower total Alvarado scores (median 5.5 versus 7, p=0.01) and were more likely to have had recurrent episodes of right iliac fossa (RIF) pain and previous hospital admissions (p<0.001). E. vermicularis infestation of the appendix should be considered in the differential diagnosis of patients who present with recurrent RIF pain but do not have a significantly raised WCCs, or high Alvarado scores. These patients should be investigated with early fecal sampling and night-time application of cellophane tape, and they may benefit from empirical antiparasitic treatment.

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

PubMed

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

Urgent appendectomy has long been the standard of care for acute appendicitis. Six randomized trials have demonstrated that antibiotics can safely treat appendicitis, but approximately 1 in 4 of these patients eventually requires appendectomy. Overall treatment success may be limited by complex disease including perforation. Patients׳ success on antibiotic therapy may depend on preoperative identification of complex disease on imaging. However, the effectiveness of computed tomography (CT) in differentiating complex disease including perforated from nonperforated appendicitis remains to be determined. The purpose of this study was to assess the preoperative diagnostic accuracy of CT in determining appendiceal perforation in patients operated for acute appendicitis. We performed a retrospective review of pathology and radiology reports from consecutive patients who presented to the emergency department with suspicion for acute appendicitis between January 2012 and May 2015. CT scans were re-reviewed by abdominal imaging fellowship-trained radiologists using standardized criteria, and the radiologists were blinded to pathology and surgical findings. Radiologists specifically noted presence or absence of periappendiceal gas, abscess, appendicolith, fat stranding, and bowel wall thickening. The overall radiologic impression as well as these specific imaging findings was compared to results of pathology and operative reports. Pathology reports were considered the standard for diagnostic accuracy. Eighty-nine patients (65% male, average age of 34 years) presenting with right lower quadrant pain underwent CT imaging and prompt appendectomy. Final pathology reported perforation in 48% (n = 43) of cases. Radiologic diagnosis of perforation was reported in 9% (n = 8), correctly identifying perforation in 37.5% (n = 3), and incorrectly reporting perforation in 62.5% of nonperforated cases per pathology. Radiology missed 93% (n = 40) of perforations postoperatively diagnosed by pathology. There was no secondary finding (fat stranding, diameter >13mm, abscess, cecal wall thickening, periappendiceal gas, simple fluid collection, appendicolith, and phlegmon) with a clinically reliable sensitivity or specificity to predict perforated appendicitis. Surgeon׳s report of perforation was consistent with the pathology report of perforation in only 28% of cases. The usefulness of a CT for determining perforation in acute appendicitis is limited, and methods to improve precision in identifying patients with complicated appendicitis should be explored as this may help for improving risk prediction for failure of treatment with antibiotic therapy and help guide patients and providers in shared decision-making for treatment options. Copyright © 2017 Elsevier Inc. All rights reserved.

Abdominal pain in children with sickle cell disease.

PubMed

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

2014-02-01

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

Gangrenous Appendicitis in a Boy with Mobile Caecum.

PubMed

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

2015-04-01

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

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

PubMed

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

2012-11-01

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

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

PubMed

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

2016-04-01

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

Differential diagnosis of jaw pain using informatics technology.

PubMed

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

2018-05-21

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

Unusual causes of abdominal pain: sickle cell anemia.

PubMed

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

2005-04-01

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

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

PubMed

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

2010-11-28

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

The value of laparoscopy in acute pelvic pain.

PubMed Central

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

1975-01-01

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

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

PubMed

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

2017-03-01

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

Omental infarction: preoperative diagnosis and laparoscopic management in children.

PubMed

Gosain, Ankush; Blakely, Martin; Boulden, Thomas; Uffman, John K; Seetharamaiah, Rupa; Huang, Eunice; Langham, Max; Eubanks, James W

2010-11-01

Omental infarction (OI) is an unusual, poorly characterized cause of abdominal pain in children and is often mistaken for appendicitis preoperatively. We present our experience with this disease process over a 5-year period to identify preoperative factors to aid in timely diagnosis and treatment. We retrospectively reviewed the medical records of all children that had OI and underwent laparoscopic omentectomy from November 2004 to June 2009. Ten patients with the diagnosis of OI were identified. OI occurred in 9 boys and 1 girl, with a median age at presentation of 8.5 years (range, 7-11). Median body mass index at presentation was 23.7 (range, 17-29), with 1 child categorized as healthy weight for age, 1 child as overweight for age, and 5 children as obese for age, based on Centers for Disease Control and Prevention criteria. All patients complained of right-sided abdominal pain; 4 patients complained of predominantly right-upper quadrant (RUQ) pain, 3 patients of right-lower quadrant (RLQ) pain, and 3 of combined RUQ/RLQ pain. On examination, 6 patients had RUQ tenderness and 4 patients had RLQ tenderness. The median duration of symptoms prior to seeking medical attention was 3 days (range, 2-7). All patients underwent computed tomography and the preoperative diagnosis of OI was established in 9 of 10 cases. Operative time was 48 ± 14 minutes. All patients underwent resection of the infarcted omentum; 2 patients underwent concurrent appendectomy. Median length of stay was 2 days (range, 2-4). OI occurs predominantly, but not exclusively, in obese preadolescent males. OI can be reliably distinguished from appendicitis on preoperative history, physical examination, laboratory analysis, and imaging. Laparoscopic omentectomy results in prompt resolution of symptoms and discharge.

Single-incision versus conventional laparoscopic appendectomy in 688 patients: a retrospective comparative analysis

PubMed Central

Liang, Hung-Hua; Hung, Chin-Sheng; Wang, Weu; Tam, Ka-Wai; Chang, Chun-Chao; Liu, Hui-Hsiung; Yen, Ko-Li; Wei, Po-Li

2014-01-01

Background Laparoscopic surgery has become the standard for treating appendicitis. The cosmetic benefits of using single-incision laparoscopy are well known, but its duration, complications and time to recovery have not been well documented. We compared 2 laparoscopic approaches for treating appendicitis and evaluated postoperative pain, complications and time to full recovery. Methods We retrospectively reviewed the cases of consecutive patients with appendicitis and compared those who underwent conventional laparoscopic appendectomy (CLA) performed using 3 incisions and those who underwent single-incision laparoscopic appendectomy (SILA). During SILA, the single port was prepared to increase visibility of the operative site. Results Our analysis included 688 consecutive patients: 618 who underwent CLA and 70 who underwent SILA. Postsurgical complications occurred more frequently in the CLA than the SILA group (18.1% v. 7.1%, p = 0.018). Patients who underwent SILA returned to oral feeding sooner than those who underwent CLA (median 12 h v. 22 h, p < 0.001). These between-group differences remained significant after controlling for other factors. Direct comparison of only nonperforated cases, which was determined by pathological examination, revealed that SILA was significantly longer than CLA (60 min v. 50 min, p < 0.001). Patients who underwent SILA had longer in-hospital stays than those who underwent CLA (72 v. 55 h, p < 0.001); however, they had significantly fewer complications (3.0% v. 14.4%, p = 0.006). Conclusion In addition to its cosmetic advantages, SILA led to rapid recovery and no increase in postsurgical pain or complications. PMID:24869622

Acute pancreatitis during sickle cell vaso-occlusive painful crisis.

PubMed

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

2003-07-01

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

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

PubMed Central

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

2015-01-01

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

Lassa fever presenting as acute abdomen: a case series.

PubMed

Dongo, Andrew E; Kesieme, Emeka B; Iyamu, Christopher E; Okokhere, Peter O; Akhuemokhan, Odigie C; Akpede, George O

2013-04-19

Lassa fever, an endemic zoonotic viral infection in West Africa, presents with varied symptoms including fever, vomiting, retrosternal pain, abdominal pain, sore-throat, mucosal bleeding, seizures and coma. When fever and abdominal pain are the main presenting symptoms, and a diagnosis of acute abdomen is entertained, Lassa fever is rarely considered in the differential diagnosis, even in endemic areas. Rather the diagnosis of Lassa fever is suspected only after surgical intervention. Therefore, such patients often undergo unnecessary surgery with resultant delay in the commencement of ribavirin therapy. This increases morbidity and mortality and the risk of nosocomial transmission to hospital staff. We report 7 patients aged between 17 months and 40 years who had operative intervention for suspected appendicitis, perforated typhoid ileitis, intussuception and ruptured ectopic pregnancy after routine investigations. All seven were post-operatively confirmed as Lassa fever cases. Four patients died postoperatively, most before commencement of ribavirin, while the other three patients eventually recovered with appropriate antibiotic treatment including intravenous ribavirin. Surgeons working in West Africa should include Lassa fever in the differential diagnosis of acute abdomen, especially appendicitis. The presence of high grade fever, proteinuria and thrombocytopenia in patients with acute abdomen should heighten the suspicion of Lassa fever. Prolonged intra-operative bleeding should not only raise suspicion of the disease but also serve to initiate precautions to prevent nosocomial transmission.

Lassa fever presenting as acute abdomen: a case series

PubMed Central

2013-01-01

Lassa fever, an endemic zoonotic viral infection in West Africa, presents with varied symptoms including fever, vomiting, retrosternal pain, abdominal pain, sore-throat, mucosal bleeding, seizures and coma. When fever and abdominal pain are the main presenting symptoms, and a diagnosis of acute abdomen is entertained, Lassa fever is rarely considered in the differential diagnosis, even in endemic areas. Rather the diagnosis of Lassa fever is suspected only after surgical intervention. Therefore, such patients often undergo unnecessary surgery with resultant delay in the commencement of ribavirin therapy. This increases morbidity and mortality and the risk of nosocomial transmission to hospital staff. We report 7 patients aged between 17 months and 40 years who had operative intervention for suspected appendicitis, perforated typhoid ileitis, intussuception and ruptured ectopic pregnancy after routine investigations. All seven were post-operatively confirmed as Lassa fever cases. Four patients died postoperatively, most before commencement of ribavirin, while the other three patients eventually recovered with appropriate antibiotic treatment including intravenous ribavirin. Surgeons working in West Africa should include Lassa fever in the differential diagnosis of acute abdomen, especially appendicitis. The presence of high grade fever, proteinuria and thrombocytopenia in patients with acute abdomen should heighten the suspicion of Lassa fever. Prolonged intra-operative bleeding should not only raise suspicion of the disease but also serve to initiate precautions to prevent nosocomial transmission. PMID:23597024

The connection between acute otitis media and the acute abdomen.

PubMed

Masood, Imran; Hendriksz, Tami

2017-06-22

A female aged 9 years with a recent episode of acute otitis media (AOM) presented to her primary care physician with complaints of severe abdominal pain with right lower quadrant rebound tenderness, suggestive of an acute surgical abdomen. Neurological examination was normal on presentation. She was transferred to the local children's hospital for workup of appendicitis, during which she began exhibiting ataxia and slurred speech. Further evaluation revealed mastoiditis, venous sinus thrombosis and subdural empyema. Appendicitis was ruled out. We describe the first documented case of neurological complications of AOM presenting as an acute surgical abdomen without initial neurological findings. © BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Post-appendectomy visits to the emergency department within the global period: a target for cost containment.

PubMed

Aiello, Francesco A; Gross, Erica R; Krajewski, Aleksandra; Fuller, Robert; Morgan, Anthony; Duffy, Andrew; Longo, Walter; Kozol, Robert; Chandawarkar, Rajiv

2010-09-01

Postoperative visits to the emergency department (ED) instead of the surgeon's office consume enormous cost. Postoperative ED visits can be avoided. Fully accredited, single-institution, 617-bed hospital affiliated with the University of Connecticut School of Medicine. Retrospective analysis of 597 consecutive patients with appendectomies over a 4-year period. Demographic and medical data, at initial presentation, surgery, and ED visit were recorded as categorical variables and statistically analyzed (Pearson chi(2) test, Fisher exact test, and linear-by-linear). Costs were calculated from the hospital's billing department. Forty-six patients returned to the ED within the global period with pain (n = 22, 48%), wound-related issues (n = 6, 13%), weakness (n = 4, 9%), fever (13%), and nausea and vomiting (n = 3, 6%). Thirteen patients (28%) required readmission. Predictive factors for ED visit postoperatively were perforated appendicitis (2-fold increase over uncomplicated appendicitis) and comorbidities (cardiovascular or diabetes). The cost of investigations during ED visits was $55,000 plus physician services. ED visits during the postoperative global period are avoidable by identifying patients who may need additional care; improving patient education, optimizing pain control, and improving patient office access. 2010 Elsevier Inc. All rights reserved.

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

PubMed

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

2017-07-01

Randomized trials suggest that nonoperative treatment of uncomplicated appendicitis with antibiotics-first is safe. No trial has evaluated outpatient treatment and no US randomized trial has been conducted, to our knowledge. This pilot study assessed feasibility of a multicenter US study comparing antibiotics-first, including outpatient management, with appendectomy. Patients aged 5 years or older with uncomplicated appendicitis at 1 US hospital were randomized to appendectomy or intravenous ertapenem greater than or equal to 48 hours and oral cefdinir and metronidazole. Stable antibiotics-first-treated participants older than 13 years could be discharged after greater than or equal to 6-hour emergency department (ED) observation with next-day follow-up. Outcomes included 1-month major complication rate (primary) and hospital duration, pain, disability, quality of life, and hospital charges, and antibiotics-first appendectomy rate. Of 48 eligible patients, 30 (62.5%) consented, of whom 16 (53.3%) were randomized to antibiotics-first and 14 (46.7%) to appendectomy. Median age was 33 years (range 9 to 73 years), median WBC count was 15,000/μL (range 6,200 to 23,100/μL), and median computed tomography appendiceal diameter was 10 mm (range 7 to 18 mm). Of 15 antibiotic-treated adults, 14 (93.3%) were discharged from the ED and all had symptom resolution. At 1 month, major complications occurred in 2 appendectomy participants (14.3%; 95% confidence interval [CI] 1.8% to 42.8%) and 1 antibiotics-first participant (6.3%; 95% CI 0.2% to 30.2%). Antibiotics-first participants had less total hospital time than appendectomy participants, 16.2 versus 42.1 hours, respectively. Antibiotics-first-treated participants had less pain and disability. During median 12-month follow-up, 2 of 15 antibiotics-first-treated participants (13.3%; 95% CI 3.7% to 37.9%) developed appendicitis and 1 was treated successfully with antibiotics; 1 had appendectomy. No more major complications occurred in either group. A multicenter US trial comparing antibiotics-first to appendectomy, including outpatient management, is feasible to evaluate efficacy and safety. Copyright © 2016 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

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

PubMed

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

2004-07-01

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

Co-existence of idiopathic cecal ulcer and incidental appendix carcinoid tumor

PubMed Central

İnce, Volkan; Barut, Bora; Karakaş, Serdar

2016-01-01

Idiopathic cecal ulcer or solitary cecal ulcer is a rare entity that can only be diagnosed by histopathological evaluation. Generally, it is diagnosed by histolopathological evaluation of biopsy specimens obtained by colonoscopy that is performed for lower gastrointestinal bleeding. It can also be diagnosed after surgical resection performed for acute abdomen or cecal mass mimicking malignancy. Cecal carcinoid tumor is a rare cause of this condition; however, coexistence of cecal ulcer and appendix carcinoid tumor has not been previously reported. In this case, we present a 73-year-old woman who clinically presented as acute appendicitis with cecal wall thickening, underwent right hemicolectomy and was subsequently diagnosed with cecal ulcer, serosal abscess and coexisting appendix carcinoid tumor. PMID:28149127

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

PubMed

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

2018-05-07

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

A case of De Garengeot hernia requiring early surgery

PubMed Central

Pan, Chao-Wen; Tsao, Min-Jen; Su, Ming-Shan

2015-01-01

De Garengeot hernia is a rare clinical entity defined as the presence of a vermiform appendix within a femoral hernia sac. A 50-year-old woman presented to the emergency department with a painful lump over her right groin region. A bedside ultrasound was performed and soft tissue lesion was suspected. CT was performed and revealed a swollen tubular structure with fat stranding within the mass. De Garengeot hernia with acute appendicitis was diagnosed preoperatively, and an emergency appendectomy and hernioplasty were performed. Although it is usually an incidental finding during hernioplasty, De Garengeot hernia should be considered in the differential diagnosis of patients with an incarcerated femoral hernia. Mesh repair can be performed depending on the clinical situation. We report a rare case of incarcerated femoral hernia with acute appendicitis that required early surgical management to avoid associated complications. PMID:26199302

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

PubMed

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

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

Postpolypectomy Electrocoagulation Syndrome: A Mimicker of Colonic Perforation

PubMed Central

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

2013-01-01

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

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

PubMed

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

2015-01-01

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

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

PubMed

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

2017-04-01

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

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

PubMed

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

2017-04-01

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

Inflammatory Myofibroblastic Tumor Mimicking Apical Periodontitis.

PubMed

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

2015-12-01

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

Acute appendicitis in patients with sickle cell disease.

PubMed

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

2003-09-01

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

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

PubMed

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

2018-06-01

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

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

PubMed

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

2017-04-01

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

Laparoscopy In Unexplained Abdominal Pain: Surgeon's Perspective.

PubMed

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

2016-01-01

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

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

PubMed Central

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

2017-01-01

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

Removal of Retained Lead Shot Through Laparoscopic Appendectomy

PubMed Central

Lloyd, D. M.

2003-01-01

We describe a patient presenting with lead shot in his appendix. A plain radiograph of his lumbar spine was performed for back pain, and an incidental finding of lead shot retained within the appendix was seen. Lead shot in the appendix is associated with appendicitis, and 2 cases have been reported of lead intoxication. We suggest that an elective laparoscopic appendectomy should be offered to patients as a possible management option. PMID:12856854

Florid reactive lymphoid hyperplasia of terminal ileum.

PubMed

Kanakala, Venkatesh; Birch, Peter; Kasaraneni, Ramesh

2010-01-01

Florid lymphoid hyperplasia in the terminal ileum can present to surgeons as an acute abdominal pain. Only few cases were reported in the literature. Our case illustrates that a rare case of florid lymphoid hyperplasia can present to surgeons as acute appendicitis. During the operation the gross appearance may mimic Crohn's disease. A limited resection is sufficient to clinch the diagnosis of florid lymphoid hyperplasia / Crohn's disease. In florid lymphoid hyperplasia limited resection may be curative.

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

PubMed

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

2011-12-01

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

Lung Metastasis Mimicking Fingertip Infection

PubMed Central

Soylemez, Salih; Demiroglu, Murat; Yayla, Mehmet Ali; Ozkan, Korhan; Alpan, Bugra; Ozger, Harzem

2015-01-01

Metastasis fingers (acral metastasis) are finding a poor prognosis. Past medical history should be questioned and metastasis from primary tumor should be kept in mind in patients with pain, swelling, and hyperemia in fingers. Successful surgical treatment on acral metastasis does not extend the life expectancy; however, it reduces the patient's pain during his terminal period, saves the functions of the limb, and increases life comfort. PMID:26236517

Cost-effectiveness of routine imaging of suspected appendicitis.

PubMed

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

2018-01-01

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

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

PubMed

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

2017-01-01

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

[The acute (surgical) abdomen - epidemiology, diagnosis and general principles of management].

PubMed

Grundmann, R T; Petersen, M; Lippert, H; Meyer, F

2010-06-01

This review comments on epidemiology, diagnosis and general principles of surgical management in patients with acute abdomen. DEFINITION AND EPIDEMIOLOGY: The most common cause of acute abdominal pain is non-specific abdominal pain (24 - 44.3 % of the study populations), followed by acute appendicitis (15.9 - 28.1 %), acute biliary disease (2.9 - 9.7 %) and bowel obstruction or diverticulitits in elderly patients. Acute appendicitis represents the cause of surgical intervention in two-thirds of the children with acute abdomen. A standardised physical examination combined with ultrasonography (US) represents the initial investigation in patients with acute abdominal pain. Due to the risk associated with radiation and due to the costs, a selective use of CT imaging is recommended. The work-flow given in this paper restricts the use of CT imaging to less than 50 % of patients with acute abdominal pain. Diagnostic laparoscopy should be considered in patients without a specific diagnosis after appropriate imaging and as an alternative to active clinical observation which is the current practice in patients with non-specific abdominal pain. Acute small bowel obstruction has previously been considered as a relative contraindication for laparoscopic management, but it has been shown in the meantime that laparoscopic treatment is an elegant tool for the management of simple band small bowel obstruction. Bedside diagnostic laparoscopy is recommended in intensive care unit (ICU) patients with acute abdomen or sepsis of unknown origin, in suspicion of acute cholecystitis, diffuse gut hypoperfusion and mesenteric ischaemia or in refractory lactic acidosis, especially after cardiac surgery. Early administration of analgesia to patients with acute abdominal pain in the emergency department will reduce the patient's discomfort without impairing clinically important diagnostic accuracy and is recommended on the basis of some prospective randomised trials. However, the impact on diagnostic accuracy depends on dosage, kind of application and cause of acute abdominal pain. A practice of judicious provision of analgesia therefore appears safe. There are significant differences between the knowledge of the current literature and the routine practice of providing analgesia as a survey has shown demonstrating that less than 50 % of paediatric emergency physicians and paediatric surgeons are usually willing to provide analgesia before definitive diagnosis. Georg Thieme Verlag KG Stuttgart. New York.

Appendicitis

MedlinePlus

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

Florid reactive lymphoid hyperplasia of terminal ileum

PubMed Central

Kanakala, Venkatesh; Birch, Peter; Kasaraneni, Ramesh

2010-01-01

Florid lymphoid hyperplasia in the terminal ileum can present to surgeons as an acute abdominal pain. Only few cases were reported in the literature. Our case illustrates that a rare case of florid lymphoid hyperplasia can present to surgeons as acute appendicitis. During the operation the gross appearance may mimic Crohn’s disease. A limited resection is sufficient to clinch the diagnosis of florid lymphoid hyperplasia / Crohn’s disease. In florid lymphoid hyperplasia limited resection may be curative. PMID:22242075

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

PubMed Central

Onida, S; Lynes, K; Whitehouse, PA

2010-01-01

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

Perforated posterior cecal diverticulum: challenges in establishing an accurate preoperative diagnosis of a rare emergency.

PubMed

Salemis, Nikolaos S; Grapatsas, Konstantinos; Matzoukas, Ioannis; Lagoudianakis, Emmanuel

2015-03-01

Solitary cecal diverticulitis is a rare cause of abdominal pain in Western countries. The preoperative diagnosis is very difficult to establish and most patients are operated on with a presumptive diagnosis of acute appendicitis based on clinical grounds. We describe a very rare case of perforated posterior cecal diverticulum and discuss the challenges in establishing a correct preoperative diagnosis. We conclude that although very rare, the possibility of perforated posteriorcecal diverticulum should always be considered in the differential diagnosis of patients presenting with atypical clinical manifestations of acute appendicitis. A perforation of a posterior cecal diverticulum maybe associated with a mild clinical course without signs of peritonitis. Athorough preoperative evaluation including a computed tomography scan is essential in order to establish a correct preoperative diagnosis which is of utmost importance for treatment planning in the emergency setting. Simple diverticulectomy is an effective surgical treatment in the absence of extensive inflammatory changes and when a colonic tumor can be ruled out.

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

PubMed Central

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

2017-01-01

Introduction Based on epidemiological, immunological and pathology data, the idea that appendicitis is not necessarily a progressive disease is gaining ground. Two types are distinguished: simple and complicated appendicitis. Non-operative treatment (NOT) of children with simple appendicitis has been investigated in several small studies. So far, it is deemed safe. However, its effectiveness and effect on quality of life (QoL) have yet to be established in an adequately powered randomised trial. In this article, we provide the study protocol for the APAC (Antibiotics versus Primary Appendectomy in Children) trial. Methods and analysis This multicentre, non-inferiority, randomised controlled trial randomises children aged 7–17 years with imaging-confirmed simple appendicitis between appendectomy and NOT. Patients are recruited in 15 hospitals. The intended sample size, based on the primary outcome, rate of complications and a non-inferiority margin of 5%, is 334 patients. NOT consists of intravenous antibiotics for 48–72 hours, daily blood tests and ultrasound follow-up. If the patient meets the predefined discharge criteria, antibiotic treatment is continued orally at home. Primary outcome is the rate of complications at 1-year follow-up. An independent adjudication committee will assess all complications and their relation to the allocated treatment. Secondary outcomes include, but are not limited to, delayed appendectomies, QoL, pain and (in)direct costs. The primary outcome will be analysed both according to the intention-to-treat principle and the per-protocol principle, and is presented with a one-sided 97.5% CI. We will use multiple logistic and linear regression for binary and continuous outcomes, respectively, to adjust for stratification factors. Ethics and dissemination The protocol has been approved by the Medical Ethics Review Committee of the Academic Medical Center, Amsterdam. Data monitoring is performed by an independent institute and a Data Safety Monitoring Board has been assigned. Results will be presented in peer-reviewed academic journals and at (international) conferences. Trial registration number NCT02848820; NTR5977; Pre-results. PMID:29146647

The Introduction of Adult Appendicitis Score Reduced Negative Appendectomy Rate.

PubMed

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

2017-09-01

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

Fulminant amoebic colitis: a clinicopathological study of 30 cases.

PubMed

Chaturvedi, Rachana; Gupte, Prajakta A; Joshi, Amita S

2015-04-01

To review the clinical and pathological factors associated with fulminant amoebic colitis (FAC) requiring colonic resection and its outcome. We retrospectively identified adult patients admitted to our centre between June 2007 and December 2011 with FAC who underwent colonic resection and were diagnosed with amoebic colitis based on the presence of trophozoites on histological examination. The clinical details were extracted from the medical notes and correlated with the pathological findings. Thirty patients (18 men and 12 women) met the inclusion criteria. Their mean age was 50.1 years (range 21-89). The most frequent symptoms were abdominal pain, vomiting and fever. More than half the patients (16/30) had underlying conditions associated with immunosuppression including diabetes mellitus and tuberculosis. Pathological investigation of colonic resections showed predominantly right-sided involvement with geographic colonic ulcers covered with a creamy-white pseudomembrane, perforations, gangrenous changes, amoeboma and lesions mimicking inflammatory bowel disease. All showed basophilic dirty necrosis with abundant nuclear debris and amoebic trophozoites on histological examination. 21/30 patients (70%) had involvement beyond the caecum. 17/30 patients (57%) died. Those with involvement beyond the caecum were more likely to die (15/21, 71.4%) than those with less extensive disease. FAC presents as acute abdomen and can mimic appendicitis, ischaemic bowel disease, tuberculosis and malignancy. Comorbidities causing immunosuppression frequently associated. Mortality remains high despite surgery, so FAC should be suspected in every case of acute abdomen with colonic perforation if associated with typical gross and microscopic findings and a history of stay in an endemic area. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Hypereosinophilia Secondary to Disseminated Paracoccidioidomycosis

PubMed Central

Mejia-Zuluaga, Mateo; Rosas, Samuel; Vélez, Verónica Posada; Quintero, Pedro A.

2017-01-01

Patient: Male, 28 Final Diagnosis: Disseminated paracoccidioidomycosis Symptoms: Fever • rash Medication: — Clinical Procedure: — Specialty: Infectious Diseases Objective: Unusual clinical course Background: Paracoccidioidomycosis is an endemic mycosis in Central and South America caused by the thermally dimorphic fungus Paracoccidioides brasiliensis. Despite its self-limited course and usually asymptomatic infection, some patients may present with a systemic illness mimicking multiple conditions and thus question the general state of their immune system. Case Report: A 28-year-old male presented to the hospital with fever, dry cough, and non-pruritic rash with no characteristic distribution for the past 10 days. Past medical history revealed that the patient had worked as a farmer three years ago, had abused cocaine paste over the same period, and also had in the last month presented to the hospital for acute appendicitis. Initial laboratory tests revealed hypereosinophilia greater than 10,000 eosinophils/mL. Infection of P. brasiliensis was confirmed by lymph node, skin, and colonoscopy biopsies. After treatment with itraconazole, the patient’s eosinophil count returned to normal and his symptoms resolved. Conclusions: Paracoccidioidomycosis may present as a systemic illness with only marked eosinophilia on initial diagnostic tests. Furthermore, in our patient’s case, the high degree of eosinophilia may have contributed towards the patient’s appendicitis in the weeks preceding the subacute infection. It is possible that the patient’s history of working at a farm and abusing cocaine paste may have contributed to the initial colonization by the fungus. PMID:29042530

The computed tomography appearance of recurrent and chronic appendicitis.

PubMed

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

1998-01-01

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

Diagnostic Accuracy of History, Physical Examination, Laboratory Tests, and Point-of-care Ultrasound for Pediatric Acute Appendicitis in the Emergency Department: A Systematic Review and Meta-analysis.

PubMed

Benabbas, Roshanak; Hanna, Mark; Shah, Jay; Sinert, Richard

2017-05-01

Acute appendicitis (AA) is the most common surgical emergency in children. Accurate and timely diagnosis is crucial but challenging due to atypical presentations and the inherent difficulty of obtaining a reliable history and physical examination in younger children. The aim of this study was to determine the utility of history, physical examination, laboratory tests, Pediatric Appendicitis Score (PAS) and Emergency Department Point-of-Care Ultrasound (ED-POCUS) in the diagnosis of AA in ED pediatric patients. We performed a systematic review and meta-analysis and used a test-treatment threshold model to identify diagnostic findings that could rule in/out AA and obviate the need for further imaging studies, specifically computed tomography (CT) scan, magnetic resonance imaging (MRI), and radiology department ultrasound (RUS). We searched PubMed, EMBASE, and SCOPUS up to October 2016 for studies on ED pediatric patients with abdominal pain. Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS-2) was used to evaluate the quality and applicability of included studies. Positive and negative likelihood ratios (LR+ and LR-) for diagnostic modalities were calculated and when appropriate data was pooled using Meta-DiSc. Based on the available literature on the test characteristics of different imaging modalities and applying the Pauker-Kassirer method we developed a test-treatment threshold model. Twenty-one studies were included encompassing 8,605 patients with weighted AA prevalence of 39.2%. Studies had variable quality using the QUADAS-2 tool with most studies at high risk of partial verification bias. We divided studies based on their inclusion criteria into two groups of "undifferentiated abdominal pain" and abdominal pain "suspected of AA." In patients with undifferentiated abdominal pain, history of "pain migration to right lower quadrant (RLQ)" (LR+ = 4.81, 95% confidence interval [CI] = 3.59-6.44) and presence of "cough/hop pain" in the physical examination (LR+ = 7.64, 95% CI = 5.94-9.83) were most strongly associated with AA. In patients suspected of AA none of the history or laboratory findings were strongly associated with AA. Rovsing's sign was the physical examination finding most strongly associated with AA (LR+ = 3.52, 95% CI = 2.65-4.68). Among different PAS cutoff points, PAS ≥ 9 (LR+ = 5.26, 95% CI = 3.34-8.29) was most associated with AA. None of the history, physical examination, laboratory tests findings, or PAS alone could rule in or rule out AA in patients with undifferentiated abdominal pain or those suspected of AA. ED-POCUS had LR+ of 9.24 (95% CI = 6.24-13.28) and LR- of 0.17 (95% CI = 0.09-0.30). Using our test-treatment threshold model, positive ED-POCUS could rule in AA without the use of CT and MRI, but negative ED-POCUS could not rule out AA. Presence of AA is more likely in patients with undifferentiated abdominal pain migrating to the RLQ or when cough/hop pain is present in the physical examination. Once AA is suspected, no single history, physical examination, laboratory finding, or score attained on PAS can eliminate the need for imaging studies. Operating characteristics of ED-POCUS are similar to those reported for RUS in literature for diagnosis of AA. In ED patients suspected of AA, a positive ED-POCUS is diagnostic and obviates the need for CT or MRI while negative ED-POCUS is not enough to rule out AA. © 2017 by the Society for Academic Emergency Medicine.

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

PubMed

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

2004-04-01

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

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

PubMed

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

2018-06-01

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

Systemic classification for a new diagnostic approach to acute abdominal pain in children.

PubMed

Kim, Ji Hoi; Kang, Hyun Sik; Han, Kyung Hee; Kim, Seung Hyo; Shin, Kyung-Sue; Lee, Mu Suk; Jeong, In Ho; Kim, Young Sil; Kang, Ki-Soo

2014-12-01

With previous methods based on only age and location, there are many difficulties in identifying the etiology of acute abdominal pain in children. We sought to develop a new systematic classification of acute abdominal pain and to give some helps to physicians encountering difficulties in diagnoses. From March 2005 to May 2010, clinical data were collected retrospectively from 442 children hospitalized due to acute abdominal pain with no apparent underlying disease. According to the final diagnoses, diseases that caused acute abdominal pain were classified into nine groups. The nine groups were group I "catastrophic surgical abdomen" (7 patients, 1.6%), group II "acute appendicitis and mesenteric lymphadenitis" (56 patients, 12.7%), group III "intestinal obstruction" (57 patients, 12.9%), group IV "viral and bacterial acute gastroenteritis" (90 patients, 20.4%), group V "peptic ulcer and gastroduodenitis" (66 patients, 14.9%), group VI "hepatobiliary and pancreatic disease" (14 patients, 3.2%), group VII "febrile viral illness and extraintestinal infection" (69 patients, 15.6%), group VIII "functional gastrointestinal disorder (acute manifestation)" (20 patients, 4.5%), and group IX "unclassified acute abdominal pain" (63 patients, 14.3%). Four patients were enrolled in two disease groups each. Patients were distributed unevenly across the nine groups of acute abdominal pain. In particular, the "unclassified abdominal pain" only group was not uncommon. Considering a systemic classification for acute abdominal pain may be helpful in the diagnostic approach in children.

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

PubMed

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

2017-06-01

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

Ectopic Enterobius Vermicularis Infestation; An Extremely Rare Cause Of Mesenteric Lymphadenopathy Mimicking Tuberculous Lymphadenitis.

PubMed

Zafar, Summaiya; Tariq, Muhammad Usman; Ahmed, Zubair

2018-01-01

Enterobius vermicularis (EV) is a pinworm which commonly resides in the lumen of the intestinal tract and lays eggs on the perianal skin. However, rarely the worm can infest various other sites in the body and cases with infestation of such ectopic sites have been reported in literature. Rare cases of mesenteric lymph node involvement have also been reported. We report a case in a young male who presented with signs and symptoms of acute appendicitis. During surgery, enlarged mesenteric lymph nodes were identified. Histological examination revealed adult worm in the appendiceal lumen. Histological examination of mesenteric lymph node revealed degenerated worm surrounded by caseating chronic granulomatous inflammation. We conclude that EV infestation should be considered in the differential diagnosis of enlarged mesenteric lymph node with chronic granulomatous inflammation, especially in young patients and when accompanying bowel tissue also reveal the helminth.

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

PubMed Central

2014-01-01

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

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

PubMed

Kumar, A; Shah, J; Vaidya, P

2016-01-01

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

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

PubMed Central

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

2014-01-01

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

A Novel Reporting System to Improve Accuracy in Appendicitis Imaging

PubMed Central

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

2015-01-01

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

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

PubMed

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

2018-02-01

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

The Helminths Causing Surgical or Endoscopic Abdominal Intervention: A Review Article.

PubMed

Uysal, Erdal; Dokur, Mehmet

2017-01-01

Helminths sometimes require surgical or endoscopic intervention. Helminths may cause acute abdomen, mechanical intestinal obstruction, gastrointestinal hemorrhage, perforation, hepatitis, pancreatitis, and appendicitis. This study aimed to determine the surgical diseases that helminths cause and to gather, analyze the case reports, case series and original articles about this topic in literature. This study was designed as a retrospective observational study. In order to determine the studies published in literature, the search limits in Pub-Med database were set to 1 Jan 1957 and 31 Mar 2016 (59 yr), and the articles regarding Helminth-Surgery-Endoscopy were taken into examination. Among 521 articles scanned, 337 specific ones were involved in this study. The most common surgical pathology was found to be in Ascaris lumbricoides group. Enterobius vermicularis was found to be the parasite that caused highest amount of acute appendicitis. Anisakiasis was observed to seem mainly because of abdominal pain and mechanical intestinal obstruction. Strongyloides stercoraries causes duodenal pathologies such as duodenal obstruction and duodenitis. Taenia saginata comes into prominence with appendicitis and gastrointestinal perforations. Fasciola hepatica exhibits biliary tract involvement and causes common bile duct obstruction. Hookworms were observed to arise along with gastrointestinal hemorrhage and anemia. Trichuris trichiuria draws attention with gastrointestinal hemorrhage, mechanical intestinal obstruction. Helminths may lead to life-threatening clinic conditions such as acute abdomen, gastrointestinal perforation, intestinal obstruction, and hemorrhages. There is a relationship between surgery and helminths. It is very important for surgeons to consider and remember helminths in differential diagnoses during their daily routines.

The evolving management of the appendix mass in the era of laparoscopy and interventional radiology.

PubMed

Forsyth, James; Lasithiotakis, Konstantinos; Peter, Mark

2017-04-01

An appendix mass is the result of a walled-off perforation of the appendix which localises, resulting in a mass and it is encountered in up to 7% of patients presenting with acute appendicitis. However, its management is controversial due to the lack of high level evidence. This review article sets out a rationale diagnostic and therapeutic strategy for the appendix mass based upon up-to-date available evidence. A literature review of the investigation and management of appendix mass/complicated appendicitis was undertaken using PubMed, EMBASE and Google Scholar. No prospective studies were identified. The great majority of recent evidence supports a conservative management approach avoiding urgent appendicectomy because of the high risk of major complications and bowel resection. Appendix abscesses over 5 cm in diameter and persistent abscesses should be drained percutaneously along with antibiotics. Appendix phlegmon should be treated with antibiotics alone. Surgery is reserved for patients who fail conservative treatment. Routine interval appendicectomy is not recommended, but should be considered in the context of persistent faecolith, ongoing right iliac fossa pain, recurrent appendicitis and appendix mass persistent beyond 2 weeks. Clinicians should be particularly wary of patients with appendix mass aged over 40 and those with features suggesting malignancy. Copyright © 2016 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.

Torsion of the Vermiform Appendix: A Case Report and Review of Literature

PubMed Central

Hassan, Wan Amir Wan; Tay, Yeng Kwang; Ghadiri, Marjan

2018-01-01

Patient: Male, 30 Final Diagnosis: Torsion of appendix Symptoms: Abdominal pain • anorexia • nausea Medication: — Clinical Procedure: Laparoscopic appendicectomy Specialty: Surgery Objective: Rare disease Background: Torsion of the vermiform appendix is a rare condition that presents with symptoms analogous to those of common acute appendicitis; therefore, it is often diagnosed during surgery. It was first described by Payne et al. in 1918. Since then, there has been wide recognition of a primary and a secondary form of the condition, affecting both the pediatric and adult populations. We present a case of an adult patient and conducted a literature review in the adult demographic. Case Report: We report the case of a 30-year-old man who presented with clinically acute appendicitis. Laparoscopically, we diagnosed a torsion of the vermiform appendix secondary to a mucocele process. Histology confirmed a low-grade mucinous cystoadenoma, with a hemorrhagic necrosis of the wall, in keeping with torsion. Conclusions: Torsion of the vermiform appendix is a rare condition that presents similar to acute appendicitis, and therefore is often diagnosed intraoperatively. Since first described, 33 cases in adults were identified in the English literature, and recognition of a primary or secondary form has emerged. Preoperative radiological imaging is rarely useful in diagnosis. To the best of our knowledge, this is the eighth reported case in the English literature of a torsion of the vermiform appendix secondary to a mucinous cystoadenoma. PMID:29588439

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

PubMed Central

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

2016-01-01

Importance At the turn of the 21st century, studies evaluating the change in incidence of appendicitis over time have reported inconsistent findings. Objectives We compared the differences in the incidence of appendicitis derived from a pathology registry versus an administrative database in order to validate coding in administrative databases and establish temporal trends in the incidence of appendicitis. Design We conducted a population-based comparative cohort study to identify all individuals with appendicitis from 2000 to2008. Setting & Participants Two population-based data sources were used to identify cases of appendicitis: 1) a pathology registry (n = 8,822); and 2) a hospital discharge abstract database (n = 10,453). Intervention & Main Outcome The administrative database was compared to the pathology registry for the following a priori analyses: 1) to calculate the positive predictive value (PPV) of administrative codes; 2) to compare the annual incidence of appendicitis; and 3) to assess differences in temporal trends. Temporal trends were assessed using a generalized linear model that assumed a Poisson distribution and reported as an annual percent change (APC) with 95% confidence intervals (CI). Analyses were stratified by perforated and non-perforated appendicitis. Results The administrative database (PPV = 83.0%) overestimated the incidence of appendicitis (100.3 per 100,000) when compared to the pathology registry (84.2 per 100,000). Codes for perforated appendicitis were not reliable (PPV = 52.4%) leading to overestimation in the incidence of perforated appendicitis in the administrative database (34.8 per 100,000) as compared to the pathology registry (19.4 per 100,000). The incidence of appendicitis significantly increased over time in both the administrative database (APC = 2.1%; 95% CI: 1.3, 2.8) and pathology registry (APC = 4.1; 95% CI: 3.1, 5.0). Conclusion & Relevance The administrative database overestimated the incidence of appendicitis, particularly among perforated appendicitis. Therefore, studies utilizing administrative data to analyze perforated appendicitis should be interpreted cautiously. PMID:27820826

Hydronephrosis in Acute Uncomplicated Appendicitis.

PubMed

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

2015-01-01

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

Appendicitis

MedlinePlus

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

Hydronephrosis in acute uncomplicated appendicitis.

PubMed

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

2015-01-01

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

Acute corneal hydrops mimicking full thickness perforation.

PubMed

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

2012-05-11

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

Early Uncomplicated Appendicitis-Who Can We Treat Nonoperatively?

PubMed

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

2018-02-01

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

Appendicitis

MedlinePlus

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

Factors predictive of complicated appendicitis in children.

PubMed

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

2016-11-01

The ability to predict whether a child has complicated appendicitis at initial presentation may influence clinical management. However, whether complicated appendicitis is associated with prehospital or inhospital factors is not clear. We also investigate whether hyponatremia may be a novel prehospital factor associated with complicated appendicitis. A retrospective review of all pediatric patients (≤12 y) with appendicitis treated with appendectomy from 2000 to 2013 was performed. The main outcome measure was intraoperative confirmation of gangrenous or perforated appendicitis. A multivariable analysis was performed, and the main predictors of interest were age <5 y, symptom duration >24 h, leukocytosis (white blood cell count >12 × 10 3 /mL), hyponatremia (sodium ≤135 mEq/L), and time from admission to appendectomy. Of 392 patients, 179 (46%) had complicated appendicitis at the time of operation. Univariate analysis demonstrated that patients with complicated appendicitis were younger, had a longer duration of symptoms, higher white blood cell count, and lower sodium levels than patients with noncomplicated appendicitis. Multivariable analysis confirmed that symptom duration >24 h (odds ratio [OR] = 5.5, 95% confidence interval [CI] = 3.5-8.9, P < 0.01), hyponatremia (OR = 3.1, 95% CI = 2.0-4.9, P < 0.01), age <5 y (OR = 2.3, 95% CI = 1.3-4.0, P < 0.01), and leukocytosis (OR = 1.9, 95% CI = 1.0-3.5, P = 0.04) were independent predictors of complicated appendicitis. Increased time from admission to appendectomy was not a predictor of complicated appendicitis (OR = 0.8, 95% CI = 0.5-1.2, P = 0.2). Prehospital factors can predict complicated appendicitis in children with suspected appendicitis. Hyponatremia is a novel marker associated with complicated appendicitis. Delaying appendectomy does not increase the risk of complicated appendicitis once intravenous antibiotics are administered. This information may help guide resource/personnel allocation, timing of appendectomy, and decision for nonoperative management of appendicitis in children. Copyright © 2016 Elsevier Inc. All rights reserved.

Retroperitoneal abscess shortly after chemotherapy for lung cancer: A case report.

PubMed

Ohara, Gen; Kondo, Tadashi; Kagohashi, Katsunori; Watanabe, Hiroko; Kawaguchi, Mio; Kurishima, Koichi; Satoh, Hiroaki; Hizawa, Nobuyuki

2014-03-01

To the best of our knowledge, the formation of a retroperitoneal abscess due to acute appendicitis shortly after administration of chemotherapy for lung cancer has not been previously reported. This is the case report of a 59-year-old male who was admitted to the Mito Medical Center (Mito, Japan) and diagnosed with lung adenocarcinoma with pleuritis carcinomatosis. Although no distant metastasis was identified, combination chemotherapy with cisplatin and pemetrexed was administered. Nine days after initiating chemotherapy, the patient developed right lower quadrant abdominal pain and high fever. Computed tomography (CT) of the abdomen and pelvis revealed the collection of gas and fluid in the retroperitoneum adjacent to the cecum. The abscess was locally drained; however, the infection continued to spread, with subsequent development of a scrotal abscess. Consequently, appendectomy was performed. The patient recovered well and the lung adenocarcinoma was treated with additional courses of chemotherapy following the remission of the local inflammation. Retroperitoneal abscess due to acute appendicitis is an unusual finding; however, this rare complication should be considered during or shortly after chemotherapy in patients with lung cancer.

The status of patients with negative appendicectomies in Maiduguri.

PubMed

Eni, U E; Nggada, H A; Gali, B M

2005-12-01

This study was conducted to verify the status of patients with negative appendicectomies in our practice and thus assess possible ways of reducing it. Of a total of 554 appendicectomies done in UMTH from January 1997 to December 2001, 27 (4.9 %) of these appendices were reported at histology as normal. 21 (77.8 %) were females and 6 (22.2 %) were males giving a female to male ratio of 3.5 to 1. The age range of the female patients was between 18 and 47 years with a mean 28.8 (SD) of (8.2) years. The age range of the male patients was between 11 and 47 years with a mean 31.5 (SD) of (12.6) years. The diagnostic alternatives depict the common scenario: Gynaecological conditions, urinary problems, peptic ulcer disease and non specific abdominal pain which are some of the major known differential diagnosis of acute appendicitis. Therefore careful clinical assessment of the patient should be depended upon for the diagnosis of appendicitis especially in our environment where sophisticated aids to diagnosis remains scarce.

Medical Approach to Right Colon Diverticulitis with Perforation.

PubMed

Espinosa, James; Sharma, Rahul; Lucerna, Alan; Stranges, Doug

2017-01-01

We report a case of a 71-year-old female who presented with right lower quadrant (RLQ) abdominal pain and was diagnosed on CT scan with right-sided diverticulitis with perforation. She was admitted under the surgical service after consultation and received intravenous fluids, intravenous antibiotics, and pain medications as needed. The patient was discharged 2 days after admission in stable condition with follow-up with gastroenterology. The differential diagnosis of right lower quadrant abdominal pain is vast. Right-sided diverticulitis often presents in a manner similar to appendicitis. In the absence of peritonitis, conservative treatment may be possible. It is predictable that as the population ages, the incidence of right-sided diverticular disease will increase and will result in more presentations of acute right-sided diverticulitis to the emergency department (ED). The aim of this case report is to increase awareness of the incidence, pathophysiology, presentation, work-up (laboratory studies and imaging), and management (medical and surgical) of right-sided diverticulitis among emergency physicians.

Acoustic Neuroma Mimicking Orofacial Pain: A Unique Case Report

PubMed Central

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

2016-01-01

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

Inflammatory arthritis mimicking Complex Regional Pain Syndrome (CRPS) in a child: A case report.

PubMed

Egilmez, Zeliha; Turgut, Selin Turan; Icagasioglu, Afitap; Bicakci, Irem

2016-01-01

Joint complaints in childhood are seen frequently and differential diagnosis can be difficult. Juvenile idiopathic arthritis (JIA) is the most common rheumatological disease of childhood. It involves peripheral joint arthritis, chronic synovitis, and extra-articular manifestations. Accurate diagnosis can take a long time and sometimes multiple diagnoses are used while following the patient until a final diagnosis can be reached. Arthritis may be triggered by trauma and confused with other diseases like complex regional pain syndrome (CRPS), in which trauma plays a role in the etiology. In the present case, ankle pain in an 8-year-old girl was misdiagnosed as CRPS.

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

PubMed

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

2017-02-01

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

Can abdominal surgical emergencies be treated in an ambulatory setting?

PubMed

Genser, L; Vons, C

2015-12-01

The performance of emergency abdominal surgery in an outpatient setting is increasingly the order of the day in France. This review evaluates the feasibility and reliability of ambulatory surgical treatment of the most common abdominal emergencies: appendectomy for acute appendicitis and cholecystectomy for acute complications of gallstone disease (acute cholecystitis and gallstone pancreatitis). This study evaluates surgical procedures performed on an ambulatory basis according to the international definition (admission in the morning, discharge in the evening with a hospital stay of less than 12 hours). Just as for elective surgery, eligibility of patients for an ambulatory approach depends on the capacities of the surgical and anesthesia team: to manage the risks, particularly the risk of deferring surgery until the morning); to prevent or treat post-operative symptoms like pain, nausea, vomiting, re-ambulation in order to permit rapid post-operative discharge. Recent studies have shown that appendectomy for non-complicated acute appendicitis can be deferred for up to 12 hours without any increase in danger. Many other studies have shown that early discharge after appendectomy for acute non-complicated appendicitis is feasible and safe. Nonetheless, there is only one published series of truly ambulatory appendectomies. The results were excellent. Patients who presented in the afternoon were brought back for operation the following morning. The appropriate timing for performance of cholecystectomy in patients with acute calculous cholecystitis or gallstone pancreatitis has not been well defined, but is always somewhat delayed relative to the onset of symptoms. To minimize operative complications, cholecystectomy for acute calculous cholecystitis should probably be performed between 24 and 72 hours after diagnosis. Cholecystectomy for gallstone pancreatitis should probably not be delayed longer than a week; the need to keep the patient hospitalized during the interval has not been demonstrated. Early discharge after cholecystectomy was usually possible, even in series where acute cholecystitis was diagnosed intra-operatively. Cholecystectomy for acute cholecystitis and gallstone pancreatitis seems to be feasible but no reports specifically support this approach. Emergency abdominal surgery seems to be feasible on an ambulatory setting for non-complicated acute appendicitis, acute calculous cholecystitis and gallstone pancreatitis. Only a single French series on ambulatory appendectomy for acute appendicitis has been reported. Copyright © 2015. Published by Elsevier Masson SAS.

Three quantitative approaches to the diagnosis of abdominal pain in children: practical applications of decision theory.

PubMed

Klein, M D; Rabbani, A B; Rood, K D; Durham, T; Rosenberg, N M; Bahr, M J; Thomas, R L; Langenburg, S E; Kuhns, L R

2001-09-01

The authors compared 3 quantitative methods for assisting clinicians in the differential diagnosis of abdominal pain in children, where the most common important endpoint is whether the patient has appendicitis. Pretest probability in different age and sex groups were determined to perform Bayesian analysis, binary logistic regression was used to determine which variables were statistically significantly likely to contribute to a diagnosis, and recursive partitioning was used to build decision trees with quantitative endpoints. The records of all children (1,208) seen at a large urban emergency department (ED) with a chief complaint of abdominal pain were immediately reviewed retrospectively (24 to 72 hours after the encounter). Attempts were made to contact all the patients' families to determine an accurate final diagnosis. A total of 1,008 (83%) families were contacted. Data were analyzed by calculation of the posttest probability, recursive partitioning, and binary logistic regression. In all groups the most common diagnosis was abdominal pain (ICD-9 Code 789). After this, however, the order of the most common final diagnoses for abdominal pain varied significantly. The entire group had a pretest probability of appendicitis of 0.06. This varied with age and sex from 0.02 in boys 2 to 5 years old to 0.16 in boys older than 12 years. In boys age 5 to 12, recursive partitioning and binary logistic regression agreed on guarding and anorexia as important variables. Guarding and tenderness were important in girls age 5 to 12. In boys age greater than 12, both agreed on guarding and anorexia. Using sensitivities and specificities from the literature, computed tomography improved the posttest probability for the group from.06 to.33; ultrasound improved it from.06 to.48; and barium enema improved it from.06 to.58. Knowing the pretest probabilities in a specific population allows the physician to evaluate the likely diagnoses first. Other quantitative methods can help judge how much importance a certain criterion should have in the decision making and how much a particular test is likely to influence the probability of a correct diagnosis. It now should be possible to make these sophisticated quantitative methods readily available to clinicians via the computer. Copyright 2001 by W.B. Saunders Company.

Systemic Classification for a New Diagnostic Approach to Acute Abdominal Pain in Children

PubMed Central

Kim, Ji Hoi; Kang, Hyun Sik; Han, Kyung Hee; Kim, Seung Hyo; Shin, Kyung-Sue; Lee, Mu Suk; Jeong, In Ho; Kim, Young Sil

2014-01-01

Purpose With previous methods based on only age and location, there are many difficulties in identifying the etiology of acute abdominal pain in children. We sought to develop a new systematic classification of acute abdominal pain and to give some helps to physicians encountering difficulties in diagnoses. Methods From March 2005 to May 2010, clinical data were collected retrospectively from 442 children hospitalized due to acute abdominal pain with no apparent underlying disease. According to the final diagnoses, diseases that caused acute abdominal pain were classified into nine groups. Results The nine groups were group I "catastrophic surgical abdomen" (7 patients, 1.6%), group II "acute appendicitis and mesenteric lymphadenitis" (56 patients, 12.7%), group III "intestinal obstruction" (57 patients, 12.9%), group IV "viral and bacterial acute gastroenteritis" (90 patients, 20.4%), group V "peptic ulcer and gastroduodenitis" (66 patients, 14.9%), group VI "hepatobiliary and pancreatic disease" (14 patients, 3.2%), group VII "febrile viral illness and extraintestinal infection" (69 patients, 15.6%), group VIII "functional gastrointestinal disorder (acute manifestation)" (20 patients, 4.5%), and group IX "unclassified acute abdominal pain" (63 patients, 14.3%). Four patients were enrolled in two disease groups each. Conclusion Patients were distributed unevenly across the nine groups of acute abdominal pain. In particular, the "unclassified abdominal pain" only group was not uncommon. Considering a systemic classification for acute abdominal pain may be helpful in the diagnostic approach in children. PMID:25587522

Granulomatous mastitis caused by histoplasma and mimicking inflammatory breast carcinoma.

PubMed

Osborne, B M

1989-01-01

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

Cogan's syndrome mimicking acute Lyme arthritis.

PubMed

Schwegmann, J P; Enzenauer, R J

1995-05-01

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

Demographic characteristics and seasonal variations of acute appendicitis.

PubMed

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

2015-01-01

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

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

PubMed

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

2017-06-15

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

Water permeability is a measure of severity in acute appendicitis.

PubMed

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

2017-12-01

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

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

PubMed

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

2014-07-01

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

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

PubMed Central

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

2013-01-01

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

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

PubMed

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

2017-02-01

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

Spontaneous haemothorax in Osler-Weber-Rendu disease.

PubMed Central

Karnik, A. M.; Sughayer, A.; Fenech, F. F.

1983-01-01

A case of hereditary haemorrhagic telangiectasia (Osler-Weber-Rendu disease) is described who presented with severe, central chest pain mimicking acute myocardial infarction, a presentation which has not been described before. He was found to have developed spontaneous haemothorax which is a very rare complication of this disease. PMID:6622342

The sonographic features of neonatal appendicitis: A case report.

PubMed

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

2017-11-01

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

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

PubMed

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

2017-07-01

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

Two-incision laparoscopic appendectomy for a severe hemophilia A child patient with coagulation factor VII deficiency: Case report and review of literature.

PubMed

He, Jin Peng; Feng, Jie Xiong

2017-10-01

The main complication of patients with severe hemophilia is recurrent bleeding events that usually affected musculoskeletal contractures. And replacement therapy methods were continuously improved to minimize adverse impacts brought by those complications. However, only several cases reported about the appendectomy for hemophilia A. We report a case of acute appendicitis treated by two-incision laparoscopy in a boy with hemophilia A and coagulation factor VII deficiency for the first time. An 8y7m-old Chinese boy presented with half a day of right sided abdominal pain, fever, nausea, and vomiting. He received a computed tomography (CT) scan which revealed an enlarged appendix, thickened wall and appendiceal fecalith, and had received a conservative anti-bacterial treatment for his acute appendicitis but failed. He was diagnosed with hemophilia A and coagulation factor VII deficiency. Two-incision laparoscopic appendectomy was made in success with a careful management of perioperative period. We monitored the clotting factor FVIII level and gave him a replacement therapy. The patient had an uneventful recovery. It is important to exclude intraabdominal or retroperitoneal hemorrhage in patients suffering from hemophilia and acute abdominal pain. Pre-operative evaluation of validity of the FVIII replacement therapy is another effective strategy to assess the safety and feasibility of applying an operation procedure. The two-incision laparoscopic appendectomy is an effective treatment for this kind of patients for its minimal trauma and fast recovery characteristics. Our report shows that laparoscopic appendectomy is feasible in a child suffering from hemophilia after adequate blood clotting factor replacement treatment.

The Helminths Causing Surgical or Endoscopic Abdominal Intervention: A Review Article

PubMed Central

UYSAL, Erdal; DOKUR, Mehmet

2017-01-01

Background: Helminths sometimes require surgical or endoscopic intervention. Helminths may cause acute abdomen, mechanical intestinal obstruction, gastrointestinal hemorrhage, perforation, hepatitis, pancreatitis, and appendicitis. This study aimed to determine the surgical diseases that helminths cause and to gather, analyze the case reports, case series and original articles about this topic in literature. Methods: This study was designed as a retrospective observational study. In order to determine the studies published in literature, the search limits in Pub-Med database were set to 1 Jan 1957 and 31 Mar 2016 (59 yr), and the articles regarding Helminth-Surgery-Endoscopy were taken into examination. Among 521 articles scanned, 337 specific ones were involved in this study. Results: The most common surgical pathology was found to be in Ascaris lumbricoides group. Enterobius vermicularis was found to be the parasite that caused highest amount of acute appendicitis. Anisakiasis was observed to seem mainly because of abdominal pain and mechanical intestinal obstruction. Strongyloides stercoraries causes duodenal pathologies such as duodenal obstruction and duodenitis. Taenia saginata comes into prominence with appendicitis and gastrointestinal perforations. Fasciola hepatica exhibits biliary tract involvement and causes common bile duct obstruction. Hookworms were observed to arise along with gastrointestinal hemorrhage and anemia. Trichuris trichiuria draws attention with gastrointestinal hemorrhage, mechanical intestinal obstruction. Conclusion: Helminths may lead to life-threatening clinic conditions such as acute abdomen, gastrointestinal perforation, intestinal obstruction, and hemorrhages. There is a relationship between surgery and helminths. It is very important for surgeons to consider and remember helminths in differential diagnoses during their daily routines. PMID:28761475

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

PubMed Central

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

2017-01-01

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

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

PubMed

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

2016-11-01

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

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

PubMed

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

2016-12-01

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

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

PubMed

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

2017-08-01

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

Work-related thumb pain in physiotherapists is associated with thumb alignment during performance of PA pressures.

PubMed

Wajon, Anne; Ada, Louise; Refshauge, Kathryn

2007-02-01

Pain is common in the thumbs of physiotherapists. The purpose of this observational study was to investigate whether there is an association between the alignment of the thumb during performance of postero-anterior (PA) pressures and the presence of thumb pain. One hundred and twenty-nine physiotherapists who attended the Musculoskeletal Physiotherapy Association Conference (2003) participated. After providing a history of any work-related thumb pain, participants applied a PA pressure mimicking the technique they would use on a cervical spine, while the position of their metacarpophalangeal (MP) and interphalangeal (IP) joints was photographed. There was an association (p<0.05) between work-related thumb pain and alignment of the thumb during performance of PA pressures: participants who were able to maintain their MP and IP joints in extension were less likely to report pain. These findings serve as a guide to the safe performance of mobilization techniques, both for beginning practitioners and for experienced therapists complaining of thumb pain.

Therapeutic touch and postoperative pain: a Rogerian research study.

PubMed

Meehan, T C

1993-01-01

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

Does the Intestinal Parasite Enterobius vermicularis Cause Acute Appendicitis?

PubMed

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

2017-06-01

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

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

PubMed Central

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

2014-01-01

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

The pathology of acute appendicitis.

PubMed

Carr, N J

2000-02-01

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

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

PubMed

Akgun, C

2012-01-01

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

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

PubMed

Chen, Bo-Nien

2016-11-01

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

Differential diagnosis and treatment of periodontitis-mimicking actinomycosis.

PubMed

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

2012-12-01

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

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

PubMed

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

2001-01-01

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

Enterobius Vermicularis as a Cause of Intestinal Occlusion: How To Avoid Unnecessary Surgery.

PubMed

Adorisio, Ottavio; De Peppo, Francesco; Rivosecchi, Massimo; Silveri, Massimiliano

2016-04-01

Enterobius vermicularis may cause infections of the gastrointestinal tract and occurs approximately in 4% to 28% of children worldwide. It is most common in children aged 5 to 14 years.The most commonly reported symptoms are pruritus in the perianal region, abdominal pain, urinary tract infection, insomnia, irritability, salpingitis, and appendicitis, whereas intestinal obstruction is a very rare but would be considered to perform the right instrumental examination avoiding unnecessary surgical exploration.We report a case of an 8-year-old boy with an intestinal occlusion due to a colonic intussusception by Enterobius vermicularis managed conservatively.

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

PubMed Central

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

2010-01-01

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

std::string Append

DTIC Science & Technology

2015-10-01

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

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

PubMed

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

2017-09-12

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

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

PubMed

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

2017-08-01

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

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

PubMed Central

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

2016-01-01

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

Utility of Immature Granulocyte Percentage in Pediatric Appendicitis

PubMed Central

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

2014-01-01

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

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

PubMed

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

2015-02-13

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

Appendicitis

MedlinePlus

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

A long noncoding RNA contributes to neuropathic pain by silencing Kcna2 in primary afferent neurons

PubMed Central

Zhao, Xiuli; Tang, Zongxiang; Zhang, Hongkang; Atianjoh, Fidelis E.; Zhao, Jian-Yuan; Liang, Lingli; Wang, Wei; Guan, Xiaowei; Kao, Sheng-Chin; Tiwari, Vinod; Gao, Yong-Jing; Hoffman, Paul N.; Cui, Hengmi; Li, Min; Dong, Xinzhong; Tao, Yuan-Xiang

2013-01-01

Neuropathic pain is a refractory disease characterized by maladaptive changes in gene transcription and translation within the sensory pathway. Long noncoding RNAs (lncRNAs) are emerging as new players in gene regulation, but how lncRNAs operate in the development of neuropathic pain is unclear. Here we identify a conserved lncRNA for Kcna2 (named Kcna2 antisense RNA) in first-order sensory neurons of rat dorsal root ganglion (DRG). Peripheral nerve injury increases Kcna2 antisense RNA expression in injured DRG through activation of myeloid zinc finger protein 1, a transcription factor that binds to Kcna2 antisense RNA gene promoter. Mimicking this increase downregulates Kcna2, reduces total Kv current, increases excitability in DRG neurons, and produces neuropathic pain symptoms. Blocking this increase reverses nerve injury-induced downregulation of DRG Kcna2 and attenuates development and maintenance of neuropathic pain. These findings suggest native Kcna2 antisense RNA as a new therapeutic target for the treatment of neuropathic pain. PMID:23792947

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

PubMed

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

2017-01-01

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

Ovarian torsion in a three-year-old girl.

PubMed

Ochsner, Todd Justin; Roos, Joel A; Johnson, Andrew S; Henderson, Janet L

2010-05-01

Ovarian torsion is the fifth most encountered gynecological emergency requiring surgery. Representing only 2.7% of surgical emergencies, it is an entity that is worth being familiar with in the emergency department (ED). Untreated ovarian torsion may result in loss of ovarian function, tissue necrosis, and death from thromboembolism or sepsis. Presenting with vague symptoms and abdominal pain, diagnosing ovarian torsion can be difficult, especially in children. The objective of this article is to present a case of pediatric ovarian torsion and to review its epidemiology, diagnosis, and treatment. A 3-year-old girl presented to the ED with vomiting, fever, anorexia, and abdominal pain. Initially diagnosed with appendicitis by physical examination and computed tomography scan, this patient was taken to the operating room for surgical exploration. The patient was subsequently found to have ovarian torsion, which was treated appropriately. Although a rare phenomenon, this case serves to increase awareness of the clinical presentation of ovarian torsion in the pediatric patient. Abdominal pain in the female child represents a challenging differential diagnosis, for which a physician must consider ovarian torsion. Copyright (c) 2010. Published by Elsevier Inc.

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

PubMed Central

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

2016-01-01

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

Parasitic Appendicitis From Past to Present in Turkey

PubMed Central

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

2010-01-01

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

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

PubMed

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

2017-07-01

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

A 3-Year Study of Predictive Factors for Positive and Negative Appendicectomies.

PubMed

Chang, Dwayne T S; Maluda, Melissa; Lee, Lisa; Premaratne, Chandrasiri; Khamhing, Srisongham

2018-03-06

Early and accurate identification or exclusion of acute appendicitis is the key to avoid the morbidity of delayed treatment for true appendicitis or unnecessary appendicectomy, respectively. We aim (i) to identify potential predictive factors for positive and negative appendicectomies; and (ii) to analyse the use of ultrasound scans (US) and computed tomography (CT) scans for acute appendicitis. All appendicectomies that took place at our hospital from the 1st of January 2013 to the 31st of December 2015 were retrospectively recorded. Test results of potential predictive factors of acute appendicitis were recorded. Statistical analysis was performed using Fisher exact test, logistic regression analysis, sensitivity, specificity, and positive and negative predictive values calculation. 208 patients were included in this study. 184 patients had histologically proven acute appendicitis. The other 24 patients had either nonappendicitis pathology or normal appendix. Logistic regression analysis showed statistically significant associations between appendicitis and white cell count, neutrophil count, C-reactive protein, and bilirubin. Neutrophil count was the test with the highest sensitivity and negative predictive values, whereas bilirubin was the test with the highest specificity and positive predictive values (PPV). US and CT scans had high sensitivity and PPV for diagnosing appendicitis. No single test was sufficient to diagnose or exclude acute appendicitis by itself. Combining tests with high sensitivity (abnormal neutrophil count, and US and CT scans) and high specificity (raised bilirubin) may predict acute appendicitis more accurately.

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

PubMed

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

2015-01-01

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

Metastatic melanoma misdiagnosed as a temporomandibular disorder: a case report and review of the literature.

PubMed

Singh, Samir; Desai, Bhavik; Laskin, Daniel

2014-10-01

Malignancies in the head and neck region are difficult to diagnose because of their deep location and presence of symptoms mimicking those of temporomandibular disorders or other orofacial pain disorders. A 75-year-old woman reported experiencing right-sided jaw pain, temporal discomfort and paresthesia. She had undergone conservative therapy for temporomandibular joint disorder, which was unsuccessful. A magnetic resonance image of the midface revealed a mass on the base of the tongue along with possible metastatic lesions to the brain. Further investigation of the lesions revealed them to be metastatic melanoma. Patients with atypical symptoms of facial pain, including neurological signs, should undergo further investigation with advanced imaging to determine the source of the symptoms, which could include neoplasms.

Two-incision laparoscopic appendectomy for a severe hemophilia A child patient with coagulation factor VII deficiency

PubMed Central

He, Jin Peng; Feng, Jie Xiong

2017-01-01

Abstract Rationale: The main complication of patients with severe hemophilia is recurrent bleeding events that usually affected musculoskeletal contractures. And replacement therapy methods were continuously improved to minimize adverse impacts brought by those complications. However, only several cases reported about the appendectomy for hemophilia A. We report a case of acute appendicitis treated by two-incision laparoscopy in a boy with hemophilia A and coagulation factor VII deficiency for the first time. Patient concerns: An 8y7m-old Chinese boy presented with half a day of right sided abdominal pain, fever, nausea, and vomiting. Diagnoses: He received a computed tomography (CT) scan which revealed an enlarged appendix, thickened wall and appendiceal fecalith, and had received a conservative anti-bacterial treatment for his acute appendicitis but failed. He was diagnosed with hemophilia A and coagulation factor VII deficiency. Interventions: Two-incision laparoscopic appendectomy was made in success with a careful management of perioperative period. We monitored the clotting factor FVIII level and gave him a replacement therapy. Outcomes: The patient had an uneventful recovery. Lessons: It is important to exclude intraabdominal or retroperitoneal hemorrhage in patients suffering from hemophilia and acute abdominal pain. Pre-operative evaluation of validity of the FVIII replacement therapy is another effective strategy to assess the safety and feasibility of applying an operation procedure. The two-incision laparoscopic appendectomy is an effective treatment for this kind of patients for its minimal trauma and fast recovery characteristics. Our report shows that laparoscopic appendectomy is feasible in a child suffering from hemophilia after adequate blood clotting factor replacement treatment. PMID:29019885

Pneumomediastinum and Mediastinal Hematoma Secondary to Right Brachiocephalic Vein Thrombectomy Mimicking STEMI

PubMed Central

Shukla, Prem; Nivera, Noel

2017-01-01

A 50-year-old male with a history of hemodialysis dependent chronic kidney disease presented to our emergency department with acute midsternal crushing chest pain. Patient was diagnosed with acute anterolateral wall Myocardial Infraction due to the presence of corresponding ST segment elevations in EKG and underwent emergent cardiac catheterization which revealed normal patent coronaries without any disease. He continued to have chest pain for which CT of the chest was done which revealed pneumomediastinum with mediastinal hematoma, due to the recent attempted thrombectomy for thrombus in his right brachiocephalic vein. PMID:28804656

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

PubMed Central

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

2014-01-01

Introduction Appendicitis is a common condition presenting to the emergency department (ED). Increasingly emergency physicians (EP) are using bedside ultrasound (BUS) as an adjunct diagnostic tool. Our objective is to investigate the test characteristics of BUS for the diagnosis of appendicitis and identify components of routine ED workup and BUS associated with the presence of appendicitis. Methods Patients four years of age and older presenting to the ED with suspected appendicitis were eligible for enrollment. After informed consent was obtained, BUS was performed on the subjects by trained EPs who had undergone a minimum of one-hour didactic training on the use of BUS to diagnose appendicitis. They then recorded elements of clinical history, physical examination, white blood cell count (WBC) with polymophonuclear percentage (PMN), and BUS findings on a data form. We ascertained subject outcomes by a combination of medical record review and telephone follow-up. Results A total of 125 subjects consented for the study, and 116 had adequate image data for final analysis. Prevalence of appendicitis was 40%. Mean age of the subjects was 20.2 years, and 51% were male. BUS was 100% sensitive (95% CI 87–100%) and 32% specific (95% CI 14–57%) for detection of appendicitis, with a positive predictive value of 72% (95% CI 56–84%), and a negative predictive value of 100% (95% CI 52–100%). Assuming all non-diagnostic studies were negative would yield a sensitivity of 72% and specificity of 81%. Subjects with appendicitis had a significantly higher occurrence of anorexia, nausea, vomiting, and a higher WBC and PMN count when compared to those without appendicitis. Their BUS studies were significantly more likely to result in visualization of the appendix, appendix diameter >6mm, appendix wall thickness >2mm, periappendiceal fluid, visualization of the appendix tip, and sonographic Mcburney’s sign (p<0.05). In subjects with diagnostic BUS studies, WBC, PMN, visualization of appendix, appendix diameter >6mm, appendix wall thickness >2mm, periappendiceal fluid were found to be predictors of appendicitis on logistic regression. Conclusion BUS is moderately useful for appendicitis diagnosis. We also identified several components in routine ED workup and BUS that are associated with appendicitis generating hypothesis for future studies. PMID:25493122

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

PubMed Central

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

2014-01-01

Introduction Acute appendicitis is the most common abdominal emergency requiring emergency surgery. However, the diagnosis is often challenging and the decision to operate, observe or further work-up a patient is often unclear. The utility of clinical scoring systems (namely the Alvarado score), laboratory markers, and the development of novel markers in the diagnosis of appendicitis remains controversial. This article presents an update on the diagnostic approach to appendicitis through an evidence-based review. Methods We performed a broad Medline search of radiological imaging, the Alvarado score, common laboratory markers, and novel markers in patients with suspected appendicitis. Results Computed tomography (CT) is the most accurate mode of imaging for suspected cases of appendicitis, but the associated increase in radiation exposure is problematic. The Alvarado score is a clinical scoring system that is used to predict the likelihood of appendicitis based on signs, symptoms and laboratory data. It can help risk stratify patients with suspected appendicitis and potentially decrease the use of CT imaging in patients with certain Alvarado scores. White blood cell (WBC), C-reactive protein (CRP), granulocyte count and proportion of polymorphonuclear (PMN) cells are frequently elevated in patients with appendicitis, but are insufficient on their own as a diagnostic modality. When multiple markers are used in combination their diagnostic utility is greatly increased. Several novel markers have been proposed to aid in the diagnosis of appendicitis; however, while promising, most are only in the preliminary stages of being studied. Conclusion While CT is the most accurate mode of imaging in suspected appendicitis, the accompanying radiation is a concern. Ultrasound may help in the diagnosis while decreasing the need for CT in certain circumstances. The Alvarado Score has good diagnostic utility at specific cutoff points. Laboratory markers have very limited diagnostic utility on their own but show promise when used in combination. Further studies are warranted for laboratory markers in combination and to validate potential novel markers. PMID:25493136

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

PubMed

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

2018-02-11

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

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

PubMed

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

2017-11-01

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

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

PubMed

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

2016-12-01

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

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

PubMed

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

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

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

PubMed

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

2013-01-01

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

Stratified computed tomography findings improve diagnostic accuracy for appendicitis

PubMed Central

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

2014-01-01

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

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

PubMed

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

2016-05-01

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

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

PubMed Central

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

2016-01-01

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

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

PubMed

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

2018-01-01

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

Fiber Intake and Childhood Appendicitis.

ERIC Educational Resources Information Center

Brender, Jean D.; And Others

1985-01-01

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

A Case of Painful Hashimoto Thyroiditis that Mimicked Subacute Thyroiditis

PubMed Central

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

2012-01-01

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

Chlamydia trachomatis-induced Fitz-Hugh-Curtis syndrome: a case report.

PubMed

Ekabe, Cyril Jabea; Kehbila, Jules; Njim, Tsi; Kadia, Benjamin Momo; Tendonge, Celestine Ntemlefack; Monekosso, Gottlieb Lobe

2017-01-03

Fitz-Hugh-Curtis syndrome is defined as perihepatitis associated with pelvic inflammatory disease. Chlamydia trachomatis is one of its most common aetiologies. This syndrome usually presents with right upper quadrant abdominal pain mimicking other hepatobiliary and gastrointestinal pathologies, hence, posing a diagnostic dilemma in settings with limited diagnostic tools. A 32 year old African female presented with acute right upper quadrant abdominal pain and vaginal discharge, for which she had previously received treatment in another health center with no improvement. Clinical and laboratory findings were suggestive of Fitz-Hugh-Curtis syndrome. Five days after treatment with oral doxycycline, the patient showed marked clinical improvement. Fitz-Hugh-Curtis syndrome is a common cause of right upper quadrant pain which is often under diagnosed in poor communities. Hence, it should be included as a differential diagnosis in patients presenting with right upper quadrant pain, especially in females of reproductive age.

[Spontaneous bile duct perforation: a rare cause of acute abdominal pain during childhood].

PubMed

Ozdemir, Tunç; Akgül, Ahsen Karagözlü; Arpaz, Yağmur; Arikan, Ahmet

2008-07-01

Spontaneous perforation of the bile duct (SPBD) is a rare cause of acute abdominal pain during childhood. Pancreatico-biliary malfunction has been postulated to contribute to its etiology. Factors related to diagnosis and treatment and difference from the other common causes of acute abdominal pain are emphasized. Five patients (3 boys, 2 girls, mean age 4.6) were admitted with peritonitis and operated with initial diagnosis of perforated appendicitis. During laparotomy, SPBD was detected. Presentation, laboratory findings and operative technique of the patients were evaluated retrospectively. Common complaints were abdominal pain and bilious vomiting. Abdominal distention was present in all patients. Leukocytosis and mild hyperbilirubinemia were detected in 5, elevated serum transaminase levels in 4, hyperglycemia in 1 and constipation in 1 patient(s). Abdominal ultrasonography showed a large amount of free fluid. During laparotomy, sterile bile peritonitis was detected initially. After exploration, SPBD was seen. T-tube drainage of the bile duct was carried out. Patients were discharged after removal of the T-tubes. Pancreatico-biliary malfunction was detected in 4 of 5 patients. In patients with generalized peritonitis, elevated transaminase levels and hyperbilirubinemia, SPBD must be considered. Even though the T-tube drainage is the treatment of choice, Roux-en-Y hepatico-portoenterostomy may be mandatory in certain patients.

DNA methyltransferase DNMT3a contributes to neuropathic pain by repressing Kcna2 in primary afferent neurons

PubMed Central

Zhao, Jian-Yuan; Liang, Lingli; Gu, Xiyao; Li, Zhisong; Wu, Shaogen; Sun, Linlin; Atianjoh, Fidelis E.; Feng, Jian; Mo, Kai; Jia, Shushan; Lutz, Brianna Marie; Bekker, Alex; Nestler, Eric J.; Tao, Yuan-Xiang

2017-01-01

Nerve injury induces changes in gene transcription in dorsal root ganglion (DRG) neurons, which may contribute to nerve injury-induced neuropathic pain. DNA methylation represses gene expression. Here, we report that peripheral nerve injury increases expression of the DNA methyltransferase DNMT3a in the injured DRG neurons via the activation of the transcription factor octamer transcription factor 1. Blocking this increase prevents nerve injury-induced methylation of the voltage-dependent potassium (Kv) channel subunit Kcna2 promoter region and rescues Kcna2 expression in the injured DRG and attenuates neuropathic pain. Conversely, in the absence of nerve injury, mimicking this increase reduces the Kcna2 promoter activity, diminishes Kcna2 expression, decreases Kv current, increases excitability in DRG neurons and leads to spinal cord central sensitization and neuropathic pain symptoms. These findings suggest that DNMT3a may contribute to neuropathic pain by repressing Kcna2 expression in the DRG. PMID:28270689

Fracture through a geode in the proximal ulna.

PubMed

Wordsworth, B P; Mowat, A G; Watson, N A

1984-05-01

Chronic joint pain in rheumatoid arthritis may mask that from other causes. Stress fractures, particularly in osteoporotic lower limb bones of such patients, are well described but can still cause diagnostic difficulty. These difficulties were highlighted by a case in which an unusual fracture occurred through a geode in the proximal ulna mimicking an exacerbation of synovitis in the elbow joint.

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

PubMed Central

Varadhan, Krishna K; Neal, Keith R

2012-01-01

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

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

PubMed

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

2017-01-01

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

Appendicular bleeding: an excepcional cause of lower hemorrhage.

PubMed

Magaz Martínez, Marta; Martín López, Javier; De la Revilla Negro, Juan; González Partida, Irene; de Las Heras, Tania; Sánchez Yuste, María Rosario; Ríos Garcés, Roberto; Salas Antón, Clara; Abreu García, Luis Esteban

2016-07-01

Chronic complications of acute appendicitis managed in a conservative manner are not frequent. We present a case of acute lower gastrointestinal hemorrhage in a young patient with a previous acute appendicitis without surgical intervention. The colonoscopy detected an appendicular bleeding which was surgically treated. The anatomopathological diagnosis was granulomatous appendicitis. The clinical evolution of the patient was favorable without bleeding recurrence. Appendicular hemorrhage can be an unusual complication-however potentially severe-of acute appendicitis not treated surgically.

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

PubMed

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

2003-03-01

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

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

PubMed

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

2010-01-01

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

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

PubMed

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

2017-11-01

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

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

PubMed

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

2017-03-01

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

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

PubMed Central

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

2017-01-01

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

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

PubMed

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

2016-12-01

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

"Surgical" abdomen in a patient with chronic lymphocytic leukemia: a case of acquired angioedema.

PubMed

Jung, Moonjung; Rice, Lawrence

2011-12-01

Acquired angioedema (AAE), an acquired deficiency of C1esterase inhibitor, is a medically treatable condition which can cause severe abdominal pain mimicking an acute surgical abdomen. This disorder is strongly associated with chronic lymphocytic leukemia (CLL) and other indolent lymphoplasmacytic disorders. We describe a patient with known CLL who developed incapacitating, recurrent severe abdominal pains, culminating in partial bowel resection. Signs, symptoms, laboratory and pathologic findings demonstrated AAE. Wider appreciation of the possibility of AAE, particularly in patients with lymphoproliferative disorders, could lead to preventive therapy and spare unnecessary surgery. This is more important now that more effective medical therapies are available.

Hyperbilirubinaemia: its utility in non-perforated appendicitis.

PubMed

Sandstrom, Anna; Grieve, David A

2017-07-01

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

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

PubMed

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

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

Outcomes of Nonoperative Management of Uncomplicated Appendicitis.

PubMed

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

2017-07-01

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

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

PubMed

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

2017-01-01

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

Enterobius vermicularis causing symptoms of appendicitis in Nepal.

PubMed

Sah, Shatrughan Prasad; Bhadani, Punam Prasad

2006-07-01

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

Ruptured superficial dorsal vein of the penis masquerading as a penile fracture: case report.

PubMed

Perlmutter, Adam E; Roberts, Lawrence; Farivar-Mohseni, Hesam; Zaslau, Stanley

2007-08-01

Acute onset of pain, swelling, and ecchymosis of the penis during sexual intercourse indicate a penile fracture until proven otherwise. However, there have been few case reports of isolated injuries to the dorsal penile artery or dorsal vein mimicking a penile fracture. Presented herein is a rare case of a patient who ruptured his superficial dorsal vein during intercourse.

An adult case of giant bronchogenic cyst mimicking tension pneumothorax.

PubMed

Yalcinkaya, Serhat; Vural, A Hakan; Ozal, Hasan

2010-10-01

Bronchogenic cysts are usually discovered only incidentally in the adult. A giant bronchogenic cyst in a 19-year-old woman presenting with pain and shortness of breath was mistaken for tension pneumothorax and initially treated with tube thoracostomy. Giant bullae were diagnosed by computed tomography. Bullae resection was undertaken, but the remaining lung tissue required pneumonectomy. Pathologic examination of the specimen confirmed bronchogenic cyst.

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

PubMed

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

1992-07-25

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

Acute appendicitis in children: not only surgical treatment.

PubMed

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

2017-03-01

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

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

PubMed

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

2017-01-01

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

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

PubMed Central

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

2017-01-01

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

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

PubMed Central

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

1985-01-01

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

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

PubMed

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

2015-09-01

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

Differences in disease features between childhood-onset and adult-onset systemic lupus erythematosus patients presenting with acute abdominal pain.

PubMed

Tu, Yu-Ling; Yeh, Kuo-Wei; Chen, Li-Chen; Yao, Tsung-Chieh; Ou, Liang-Shiou; Lee, Wen-I; Huang, Jing-Long

2011-04-01

Abdominal pain in systemic lupus erythematosus (SLE) patients has rarely been analyzed in pediatric populations. We planned to investigate the potential differences between childhood-onset and adult-onset SLE patients who were hospitalized because of acute abdominal pain. A retrospective study including 23 childhood-onset SLE patients with 38 admissions and 88 adult-onset SLE patients with 108 admissions from 1999 to 2008 were conducted in our hospital. All of them had the chief complaint of diffuse abdominal pain. The etiologies of acute abdominal pain in adult-onset SLE patients were more diverse than childhood-onset SLE patients. The most common cause of acute abdominal pain in SLE patients was lupus mesenteric vasculitis (LMV) (18.5%), followed by acute gastroenteritis (14.4%), pancreatitis (10.3%), appendicitis (7.5%), and cholecystitis (6.2%). Compared with adults, children were admitted more often due to LMV (31.6% versus 13.9%; P = 0.016), had more frequently recurrent episodes (39.1% versus 14.8%; P = 0.009), and were more often treated with immunosuppressive agents (31.6% versus 7.4%; P < 0.001) at the time of admission. The overall case fatality rate of acute abdomen in SLE patients was 9.4%. The extra-gastrointestinal symptoms, laboratory evaluation, disease activity, and organ damage measured by the SLE Disease Activity Index and outcomes were comparable between children and adults. Various etiologies of acute abdominal pain should be considered in SLE patients. LMV is the most common cause of acute abdomen in childhood-onset SLE patients with low mortality and morbidity provided by prompt diagnosis and timely administration of high-dose intravenous corticosteroids after excluding real surgical abdomen. Crown Copyright © 2011. Published by Elsevier Inc. All rights reserved.

Reported provision of analgesia to patients with acute abdominal pain in Canadian paediatric emergency departments.

PubMed

Poonai, Naveen; Cowie, Allyson; Davidson, Chloe; Benidir, Andréanne; Thompson, Graham C; Boisclair, Philippe; Harman, Stuart; Miller, Michael; Butter, Andreana; Lim, Rod; Ali, Samina

2016-09-01

Evidence exists that analgesics are underutilized, delayed, and insufficiently dosed for emergency department (ED) patients with acute abdominal pain. For physicians practicing in a Canadian paediatric ED setting, we (1) explored theoretical practice variation in the provision of analgesia to children with acute abdominal pain; (2) identified reasons for withholding analgesia; and (3) evaluated the relationship between providing analgesia and surgical consultation. Physician members of Paediatric Emergency Research Canada (PERC) were prospectively surveyed and presented with three scenarios of undifferentiated acute abdominal pain to assess management. A modified Dillman's Tailored Design method was used to distribute the survey from June to July 2014. Overall response rate was 74.5% (149/200); 51.7% of respondents were female and mean age was 44 (SD 8.4) years. The reported rates of providing analgesia for case scenarios representative of renal colic, appendicitis, and intussusception, were 100%, 92.1%, and 83.4%, respectively, while rates of providing intravenous opioids were 85.2%, 58.6%, and 12.4%, respectively. In all 60 responses where the respondent indicated they would obtain a surgical consultation, analgesia would be provided. In the 35 responses where analgesia would be withheld, 21 (60%) believed pain was not severe enough, while 5 (14.3%) indicated it would obscure a surgical condition. Pediatric emergency physicians self-reported rates of providing analgesia for acute abdominal pain scenarios were higher than previously reported, and appeared unrelated to request for surgical consultation. However, an unwillingness to provide opioid analgesia, belief that analgesia can obscure a surgical condition, and failure to take self-reported pain at face value remain, suggesting that the need exists for further knowledge translation efforts.

A preliminary study on how hypohydration affects pain perception.

PubMed

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

2016-05-01

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

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

PubMed

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

2018-06-01

The pediatric perforated appendix rate is a quality metric measured by the Agency for Healthcare Research and Quality (AHRQ) that reflects access to care. The association of health care utilization prior to presentation with appendicitis is unknown. To determine whether increased health care utilization prior to presentation with appendicitis is associated with lower perforated appendicitis rates in children. Retrospective cohort study of privately insured children drawn from large employer and insurance company administrative data found in the Truven MarketScan national insurance claims database. Cases of appendicitis were identified among 38 348 children 18 years or younger from January 1, 2010, through December 31, 2013, with corresponding primary health care encounters from January 1, 2009, through December 31, 2012. In all, 19 109 eligible children were identified using International Classification of Diseases, Ninth Revision (ICD-9) diagnosis codes for appendicitis after excluding those patients who did not have continuous insurance coverage during the study period. Statistical analysis was performed from September 1, 2016, to October 15, 2017. Health care utilization was determined by the number of outpatient clinic encounters for each patient in the 1 to 12 months before presentation with appendicitis. Perforated appendicitis was defined according to the AHRQ by using ICD-9 codes for perforation and hospital length of stay of 3 or more days. Logistic regression models were used for perforated appendicitis after adjustment for age, sex, income, gastrointestinal comorbidities, geographic region, and insurance type. We identified 38 348 children 18 years or younger with ICD-9 diagnosis codes for appendicitis, and 19 109 children remained for analysis after applying exclusion criteria. Of these, 11 422 were boys (59.8%); the mean (SD) age was 12.4 (3.9) years. Of the 19 109 children identified who underwent appendectomy, 5509 (28.8%) presented with perforated appendicitis. Children with perforation had lower outpatient health care utilization in the year before presentation compared with those diagnosed with acute appendicitis (4554 of 5509 children [82.7%] vs 11 937 of 13 600 [87.8%]; P < .001). In the adjusted model, outpatient health care utilization before presentation was associated with lower odds of perforated appendicitis (odds ratio [OR], 0.63; 95% CI, 0.58-0.69; P < .001). This association increased with visit frequency in the year before presentation (OR, 0.86; 95% CI, 0.77-0.95 for 1-2 visits, P = .003; OR, 0.61; 95% CI, 0.55-0.67 for 3-6 visits, P < .001; and OR, 0.43; 95% CI, 0.38-0.48 for ≥7 visits [5-18 years], P < .001). Covariates associated with perforation included younger age, geographic region, family income, and higher out-of-pocket insurance plans. Among insured children 18 years or younger, increased health care utilization was associated with lower rates of perforated appendicitis. Primary health care relationships may facilitate timely presentation or serve as a marker for health-related self-efficacy, thereby contributing to outcomes for acute surgical conditions.

[Acute abdomen secondary to appendiceal intussusception].

PubMed

Betancourth-Alvarenga, J E; Vázquez-Rueda, F; Murcia-Pascual, F J; Ayala-Montoro, J

2015-01-01

Appendiceal intussusception is a rare condition that can occur at any age. Only a few cases have been reported, and most are found during surgery. The therapeutic approach is usually surgical, ranging from an appendectomy to a hemicolectomy, primarily for biopsy and to rule out possible malignancy. Three cases of children under 14 years who underwent surgery for acute abdominal pain located in the right iliac fossa are presented; one with preoperative diagnosis by ultrasound, and the other two with positive intraoperative findings of intussusception of the cecal appendix, with acute appendicitis being histologically confirmed. Copyright © 2013 Asociación Española de Pediatría. Published by Elsevier Espana. All rights reserved.

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

PubMed

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

2015-01-01

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

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

PubMed

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

2018-04-01

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

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

PubMed

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

2018-05-01

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

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

PubMed

Amalesh, T; Shankar, M; Shankar, R

2004-01-01

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

Improved training of house officers in a rheumatology consult service.

PubMed

Mazzuca, S A; Brandt, K D; Katz, B P

1993-06-01

This study examined whether the clinical environment could be used to increase internal medicine house officers' adoption of care recommendations taught in a didactic conference. Subjects were 11 internal medicine house officers who served 6-week rheumatology elective rotations. At the start of each of four rotation periods, house officers attended a 1-hour conference in which periarticular rheumatic disorders associated with knee pain (anserine bursitis, pseudothrombophlebitis) and shoulder pain (bicipital tendinitis) were discussed. All house officers also practiced physical examination techniques on anatomic models simulating the disorders. During alternate rotation periods, reminder sheets were appended to the records of arthritis patients with histories of chronic knee or shoulder pain. The frequency with which house officers followed conference recommendations was documented by direct observation (6 house officers in 17 encounters with reminders, 5 house officers in 30 encounters without reminders). Specific questioning about a recent history of knee or shoulder pain and the performance of four of five recommended physical examination maneuvers were increased significantly by reminder sheets in patients' charts (P < 0.05 for all). Although rheumatology faculty often have limited options available to increase the number of house officer trainees or to intensify clinical activity, qualitative improvements within existing logistic parameters are feasible by assuring that the clinical environment (e.g., patient records) contains salient cues that will prompt desired actions.

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

PubMed

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

2013-01-01

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

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

PubMed

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

2015-07-29

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

Evaluation of the microbiome in children's appendicitis.

PubMed

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

2017-01-01

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

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

PubMed

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

2017-10-01

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

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

PubMed

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

2018-03-01

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

A Comparative Study of Routine Laparoscopic Versus Open Appendectomy

PubMed Central

Yong, Jamy L.; Lam, Chi Ming

2006-01-01

Objective: We evaluated the outcomes of routine laparoscopy and laparoscopic appendectomy (LA) in patients with suspected appendicitis. This is a retrospective study of the outcomes of patients undergoing laparoscopic appendectomy compared with outcomes for patients undergoing open appendectomy (OA) during the time that LA came into use. Method: Results of patients managed with routine laparoscopy and LA for suspected acute appendicitis were reviewed and analyzed. The preoperative and intraoperative findings were recorded. The clinical outcomes were compared with those of patients undergoing OA in the preceding 10 months. Results: During the LA study period, 97 patients (47 men) with the median age of 34 years (range, 18 to 79) presented with clinical features of acute appendicitis. With the exclusion of 5 patients with open operations and 10 patients with other pathologies, 82 patients underwent laparoscopic appendectomy (Group A) for appendicitis. Thirty-one (37.8%) patients had complicated appendicitis (perforated or gangrenous appendicitis). Conversions were required in 6 patients (7.3%). During the OA period, 125 patients (57 men) with the median age of 42 (range, 19 to 79) years were operated on. With the exclusion of 6 patients with other pathologies, 119 underwent OA for acute appendicitis (Group B). Fifty-one (42.9%) had either perforated or gangrenous appendicitis. The median durations of surgery in Group A and Group B were 80 minutes (range, 40 to 195) and 60 minutes (range, 25 to 260), respectively (P<0.005). Postoperative complication rates were comparable between the 2 groups (13.4% in Group A versus 15.8% in Group B). The median hospital stay for patients in Group A and Group B were 3.0 days (range, 1 to 47) and 4.0 days (range, 1 to 47), respectively (P=0.037). Conclusions: We conclude that routine laparoscopy and LA for suspected acute appendicitis is safe and is associated with a significantly shorter hospital stay. Other intra-abdominal pathologies can also be diagnosed more accurately with the laparoscopic approach. PMID:16882418

Brucella pelvic tubo-ovarian abscess mimicking a pelvic malignancy.

PubMed

Seoud, Muhiedine A F; Kanj, Suha S; Habli, Munira; Araj, George F; Khalil, Ali M

2003-01-01

A 57-y-old woman presented with recurrent abdominal and pelvic pain of 6 months' duration with low-grade fever. A computed tomographic scan indicated an ovarian tumor. Laparotomy revealed a pelvic abscess. Her symptoms resolved following surgery and antibiotic therapy. Pathology revealed an extensive inflammatory process. Tissue culture grew Brucella sp. The diagnosis and management of this previously undescribed pelvic tubo-ovarian abscess present a particular challenge.

Extradural hemangioma mimicking a dumbbell nerve sheath tumor in the thoracolumbar spine: Case report.

PubMed

Chachan, Sourabh; Bin Abd Razak, H R; Loo, W Lim; Tan, C Sheng; Dinesh, S K

2017-01-01

Extradural hemangiomas are rare, have varied and challenging clinical presentations, and require special considerations from the management point of view. A 70-year-old female presented with back pain that was ultimately attributed to a thoracolumbar extra-dural "dumbbell" hemangioma. Following surgical resection, the patient did well. Extradural hemangiomas may present as spinal extradural soft tissue masses that must be differentiated from dumbbell neurofibroma.

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

PubMed Central

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

2015-01-01

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

Lumbar Gout Tophus Mimicking Epidural Abscess with Magnetic Resonance Imaging, Bone, and Gallium Scans

PubMed Central

Vicente, Justo Serrano; Gómez, Alejandro Lorente; Moreno, Rafael Lorente; Torre, Jose Rafael Infante; Bernardo, Lucía García; Madrid, Juan Ignacio Rayo

2018-01-01

Gout is a common metabolic disorder, typically diagnosed in peripheral joints. Tophaceous deposits in lumbar spine are a very rare condition with very few cases reported in literature. The following is a case report of a 52-year-old patient with low back pain, left leg pain, and numbness. Serum uric acid level was in normal range. magnetic resonance imaging, bone scan, and gallium-67 images suggested an inflammatory-infectious process focus at L4. After a decompressive laminectomy at L4–L5 level, histological examination showed a chalky material with extensive deposition of amorphous gouty material surrounded by macrophages and foreign-body giant cells (tophaceous deposits). PMID:29643682

Lumbar Gout Tophus Mimicking Epidural Abscess with Magnetic Resonance Imaging, Bone, and Gallium Scans.

PubMed

Vicente, Justo Serrano; Gómez, Alejandro Lorente; Moreno, Rafael Lorente; Torre, Jose Rafael Infante; Bernardo, Lucía García; Madrid, Juan Ignacio Rayo

2018-01-01

Gout is a common metabolic disorder, typically diagnosed in peripheral joints. Tophaceous deposits in lumbar spine are a very rare condition with very few cases reported in literature. The following is a case report of a 52-year-old patient with low back pain, left leg pain, and numbness. Serum uric acid level was in normal range. magnetic resonance imaging, bone scan, and gallium-67 images suggested an inflammatory-infectious process focus at L4. After a decompressive laminectomy at L4-L5 level, histological examination showed a chalky material with extensive deposition of amorphous gouty material surrounded by macrophages and foreign-body giant cells (tophaceous deposits).

Is Enterobius vermicularis infestation associated with acute appendicitis?

PubMed

Akkapulu, N; Abdullazade, S

2016-08-01

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

Ultrasound Accuracy in Diagnosing Appendicitis in Obese Pediatric Patients.

PubMed

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

2017-10-01

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

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

PubMed

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

2017-08-01

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

A prospective randomized controlled multicenter trial comparing antibiotic therapy with appendectomy in the treatment of uncomplicated acute appendicitis (APPAC trial).

PubMed

Paajanen, Hannu; Grönroos, Juha M; Rautio, Tero; Nordström, Pia; Aarnio, Markku; Rantanen, Tuomo; Hurme, Saija; Dean, Kirsti; Jartti, Airi; Mecklin, Jukka-Pekka; Sand, Juhani; Salminen, Paulina

2013-02-08

Although the standard treatment of acute appendicitis (AA) consists of an early appendectomy, there has recently been both an interest and an increase in the use of antibiotic therapy as the primary treatment for uncomplicated AA. However, the use of antibiotic therapy in the treatment of uncomplicated AA is still controversial. The APPAC trial is a randomized prospective controlled, open label, non-inferiority multicenter trial designed to compare antibiotic therapy (ertapenem) with emergency appendectomy in the treatment of uncomplicated AA. The primary endpoint of the study is the success of the randomized treatment. In the antibiotic treatment arm successful treatment is defined as being discharged from the hospital without the need for surgical intervention and no recurrent appendicitis during a minimum follow-up of one-year (treatment efficacy). Treatment efficacy in the operative treatment arm is defined as successful appendectomy evaluated to be 100%. Secondary endpoints are post-intervention complications, overall morbidity and mortality, the length of hospital stay and sick leave, treatment costs and pain scores (VAS, visual analoque scale). A maximum of 610 adult patients (aged 18-60 years) with a CT scan confirmed uncomplicated AA will be enrolled from six hospitals and randomized by a closed envelope method in a 1:1 ratio either to undergo emergency appendectomy or to receive ertapenem (1 g per day) for three days continued by oral levofloxacin (500 mg per day) plus metronidazole (1.5 g per day) for seven days. Follow-up by a telephone interview will be at 1 week, 2 months and 1, 3, 5 and 10 years; the primary and secondary endpoints of the trial will be evaluated at each time point. The APPAC trial aims to provide level I evidence to support the hypothesis that approximately 75-85% of patients with uncomplicated AA can be treated with effective antibiotic therapy avoiding unnecessary appendectomies and the related operative morbidity, also resulting in major cost savings.

Misdiagnosis trends in patients with hereditary angioedema from the real-world clinical setting.

PubMed

Zanichelli, Andrea; Longhurst, Hilary J; Maurer, Marcus; Bouillet, Laurence; Aberer, Werner; Fabien, Vincent; Andresen, Irmgard; Caballero, Teresa

2016-10-01

Hereditary angioedema due to C1 inhibitor deficiency (C1-INH-HAE) causes swelling in the skin and upper airways and pain in the abdomen because of mucosal swelling. C1-INH-HAE is frequently misdiagnosed, leading to delays in diagnosis, inadequate treatment, and unnecessary procedures. To evaluate the history of misdiagnosis in patients participating in the Icatibant Outcome Survey (IOS). The IOS is an observational study in which safety and effectiveness of icatibant have been evaluated since 2009. As part of the IOS, patients record any misdiagnoses received before being diagnosed as having C1-INH-HAE. In January 2016, a total of 418 of 633 IOS patients with C1-INH-HAE type I or II had provided misdiagnosis data. Of these, 185 of 418 (44.3%) received 1 or more prior misdiagnoses. The most common misdiagnoses were allergic angioedema (103 of 185) and appendicitis (50 of 185). A variety of other misdiagnoses were reported, including a substantial number of gastrointestinal disorders (excluding appendicitis). Misdiagnosis rates were similar between males (41.1%) and females (46.5%) and between C1-INH-HAE type I (43.7%) and type II (51.6%). Patients with family members diagnosed as having C1-INH-HAE were significantly less likely to be misdiagnosed than patients without a family history (140 of 366 [41.7%] vs 38 of 58 [65.5%], respectively; P = .001). Patients with a prior misdiagnosis had longer median delay to C1-INH-HAE diagnosis (13.3 years) than patients without (1.7 years; P < .001). From this large database, approximately 50% of patients with C1-INH-HAE type I or II have previously had their conditions misdiagnosed, most commonly as allergic angioedema or appendicitis. Misdiagnosis results in marked delays in receiving the correct diagnosis, during which time patients cannot access effective, lifesaving treatment. ClinicalTrials.gov: NCT01034969. Copyright © 2016 The Authors. Published by Elsevier Inc. All rights reserved.

Evaluation of the Effect of Reflexology on Pain Control and Analgesic Consumption After Appendectomy.

PubMed

Khorsand, Ali; Tadayonfar, Moosa Al-Reza; Badiee, Shapour; Aghaee, Monavar Afzal; Azizi, Hoda; Baghani, Sara

2015-12-01

Appendicitis is the most common cause of severe abdominal pain in the world, and the associated postsurgical pain, as occurs with other surgical procedures, is one of the most common problems. Today, there is a growing tendency toward nondrug methods and alternative medicine to reduce the adverse effects of drugs. Reflexology involves applying pressure on certain areas of the palms, feet, and ears in order to reduce stress and pain in certain areas of the body. The aim of this study was to determine the effect of reflexology massage on pain relief after appendectomy. This clinical trial was conducted at the surgical emergency unit of Imam Reza Hospital of Mashhad, Iran, in 2013. Pain intensity and analgesic consumption were compared between 105 patients before and immediately, 1 hour, 6 hours, and 24 hours after the intervention in three groups of intervention, control, and placebo. Patients in all three groups received analgesics, as required. The experimental group received pressure on a defined area of the right foot for about 10 minutes and the Shen Men point of the ear for 1 minute. This pressure in the placebo group was applied on the left foot and the left earlobe. Patients in the control group received routine care only. The results were evaluated at a 95% confidence level, and data were analyzed using SPSS software version 12 (SPSS, Inc., Chicago, IL). At the beginning of the study, the mean pain intensity in different groups according to analysis of variance was not significantly different (p = 0.439); however, there was a notable difference in pain intensity between the intervention and other groups after reflexology therapy. In addition, methadone consumption was significantly lower in the reflexology group than in the other two groups (p ≤ 0.001). Reflexology is effective for reducing pain after appendectomy surgery.

Clinical and Histologic Mimickers of Celiac Disease.

PubMed

Kamboj, Amrit K; Oxentenko, Amy S

2017-08-17

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

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

PubMed

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

2017-12-01

Purpose To test the hypothesis that appendiceal spectral Doppler waveforms can distinguish patients with and patients without appendicitis. Materials and Methods In this retrospective study, Doppler waveforms were obtained from intramural appendiceal arteries identified with color Doppler imaging in 60% (93 of 155) of consecutive patients whose appendices were visualized at graded compression ultrasonography (US) performed for suspected appendicitis (53 male and 40 female; age, 1-56 years; mean, 14.5 years) over the 5-month period from November 2015 through March 2016. Point, non-angle-corrected peak systolic velocity (PSV) and resistive index (RI) values were compared between patients with and patients without appendicitis by utilizing histopathologically proven appendicitis and 6-week clinical follow-up as diagnostic reference standards. Data were assessed by using the Student t test, exact binomial distribution, two-sample test of proportions, and receiver operating characteristic analysis. Results Among the 93 patients, 36 (38.7%) had proven appendicitis (mean PSV, 19.7 cm/sec; mean RI, 0.69) and 57 patients (61.2%) did not (mean PSV, 7.1 cm/sec, P < .0001; mean RI, 0.50, P < .0001). The area under the receiver operating characteristic curve for the diagnosis of appendicitis was 0.97 (95% confidence interval [CI]: 0.95, 1.00) for PSV and 0.86 (95% CI: 0.78, 0.95; P = .011) for RI. Chosen discriminatory criteria of PSV greater than 10 cm/sec and RI greater than 0.65 yielded specificity for appendicitis of 94.7% and 96.5% with sensitivity of 88.9% and 63.9% (P = .013) and negative predictive value of 93.1% and 80.9% (P = .045), respectively. Original clinical graded compression US interpretations based on established US findings demonstrated specificity of 96.2% and sensitivity of 100.0%. Considering the subset of 20 patients whose maximum outer diameter measured 6-8 mm, the discriminatory criteria of PSV greater than 10 cm/sec and RI greater than 0.65 yielded specificity for appendicitis of 88.9% each, with sensitivity of 100.0% and 63.6% and negative predictive value of 100.0% and 66.6%, respectively. Conclusion In patients with visualized appendices at US, those with appendicitis exhibit significantly higher point PSV and point RI values than do patients without appendicitis and are distinguishable with high specificity by using a PSV greater than 10 cm/sec and an RI greater than 0.65 as diagnostic criteria. © RSNA, 2017.

Prospective evaluation of the Sunshine Appendicitis Grading System score.

PubMed

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

2017-05-01

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

[History of surgical treatment of appendicitis].

PubMed

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

2009-01-01

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

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

PubMed

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

2017-10-06

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

AIR SCORE ASSESSMENT FOR ACUTE APPENDICITIS

PubMed Central

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

2015-01-01

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

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

PubMed

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

2010-08-01

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

Teaching single-incision laparoscopic appendectomy in pediatric patients.

PubMed

Burjonrappa, Sathyaprasad C; Nerkar, Hrishikesh

2012-01-01

Laparoscopic appendectomy is accepted as the gold standard technique for the treatment of acute appendicitis. Recently single-incision laparoscopic surgery (SILS) was tried in the pediatric population and was shown to be both feasible and safe. We describe our early experience in teaching the SILS procedure for appendicitis in a large community hospital center surgical residency program. SILS appendectomy was performed in 40 consecutive patients with acute appendicitis who were admitted by a single surgeon from May 2011 to August 2011. All patients over the age of 4 y presenting with noncomplicated and complicated appendicitis (perforated) were offered SILS appendectomy. Execution of the technical aspects of 20 SILS operations done by 3 PGY III residents was evaluated. The average age of the patient was 11.1 y (range, 7 to 15). SILS was performed successfully in 19 out of 20 patients. Nineteen patients underwent emergent or urgent appendectomy, while 1 patient underwent an interval procedure. Nine patients were found to have perforated appendicitis, while the other 11 had noncomplicated acute appendicitis. One patient was converted to conventional 3-port laparoscopy due to difficulties during the procedure. The mean operative time was 73 min (range, 47 to 112). A significant learning curve to successfully execute the critical steps of the SILS procedure was noted in all residents evaluated. SILS technology appears promising for the treatment of acute appendicitis. However, its successful incorporation into surgical training programs will depend on the development of innovative simulation strategies.

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

PubMed

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

2016-12-01

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

Fast track pathway for perforated appendicitis.

PubMed

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

2017-04-01

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

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

PubMed

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

2017-08-01

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

Electroacupuncture for postoperative pain and gastrointestinal motility after laparoscopic appendectomy (AcuLap): study protocol for a randomized controlled trial.

PubMed

Kim, Gangmi

2015-10-14

Acupuncture is a widely serviced complementary medicine. Although acupuncture is suggested for managing postoperative ileus and pain, supporting evidence is weak. The AcuLap trial is designed to provide high-level evidence regarding whether or not electroacupuncture is effective in promoting gastrointestinal motility and controlling pain after laparoscopic surgery. This study is a prospective randomized controlled trial with a three-arm, parallel-group structure evaluating the efficacy of electroacupuncture for gastrointestinal motility and postoperative pain after laparoscopic appendectomy. Patients with appendicitis undergoing laparoscopic surgery are included and randomized into three groups: 1) electroacupuncture group, 2) sham acupuncture group, and 3) control group. Patients receive 1) acupuncture with electrostimulation or 2) fake electroacupuncture with sham device twice a day or 3) no acupuncture after laparoscopic appendectomy. The primary outcome is time to first passing flatus after operation. Secondary outcomes include postoperative pain, analgesics, nausea/vomiting, bowel motility, time to tolerable diet, complications, hospital stay, readmission rates, time to recovery, quality of life, medical costs, and protocol failure rate. Patients and hospital staff (physicians and nurses) are blinded to which group the patient is assigned, electroacupuncture or sham acupuncture. Data analysis personnel are blinded to group assignment among all three groups. Estimated sample size to detect a minimum difference of time to first flatus with 80 % power, 5 % significance, and 10 % drop rate is 29 × 3 groups = 87 patients. Analysis will be performed according to the intention-to-treat principle. The AcuLap trial will provide evidence on the merits and/or demerits of electroacupuncture for bowel motility recovery and pain relief after laparoscopic appendectomy. The trial was registered in Clinical Research Information Service (CRiS), Republic of Korea ( KCT0001486 ) on 14 May 2015.

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

PubMed

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

2015-06-16

An increasing amount of evidence supports the use of antibiotics instead of surgery for treating patients with uncomplicated acute appendicitis. To compare antibiotic therapy with appendectomy in the treatment of uncomplicated acute appendicitis confirmed by computed tomography (CT). The Appendicitis Acuta (APPAC) multicenter, open-label, noninferiority randomized clinical trial was conducted from November 2009 until June 2012 in Finland. The trial enrolled 530 patients aged 18 to 60 years with uncomplicated acute appendicitis confirmed by a CT scan. Patients were randomly assigned to early appendectomy or antibiotic treatment with a 1-year follow-up period. Patients randomized to antibiotic therapy received intravenous ertapenem (1 g/d) for 3 days followed by 7 days of oral levofloxacin (500 mg once daily) and metronidazole (500 mg 3 times per day). Patients randomized to the surgical treatment group were assigned to undergo standard open appendectomy. The primary end point for the surgical intervention was the successful completion of an appendectomy. The primary end point for antibiotic-treated patients was discharge from the hospital without the need for surgery and no recurrent appendicitis during a 1-year follow-up period. There were 273 patients in the surgical group and 257 in the antibiotic group. Of 273 patients in the surgical group, all but 1 underwent successful appendectomy, resulting in a success rate of 99.6% (95% CI, 98.0% to 100.0%). In the antibiotic group, 70 patients (27.3%; 95% CI, 22.0% to 33.2%) underwent appendectomy within 1 year of initial presentation for appendicitis. Of the 256 patients available for follow-up in the antibiotic group, 186 (72.7%; 95% CI, 66.8% to 78.0%) did not require surgery. The intention-to-treat analysis yielded a difference in treatment efficacy between groups of -27.0% (95% CI, -31.6% to ∞) (P = .89). Given the prespecified noninferiority margin of 24%, we were unable to demonstrate noninferiority of antibiotic treatment relative to surgery. Of the 70 patients randomized to antibiotic treatment who subsequently underwent appendectomy, 58 (82.9%; 95% CI, 72.0% to 90.8%) had uncomplicated appendicitis, 7 (10.0%; 95% CI, 4.1% to 19.5%) had complicated acute appendicitis, and 5 (7.1%; 95% CI, 2.4% to 15.9%) did not have appendicitis but received appendectomy for suspected recurrence. There were no intra-abdominal abscesses or other major complications associated with delayed appendectomy in patients randomized to antibiotic treatment. Among patients with CT-proven, uncomplicated appendicitis, antibiotic treatment did not meet the prespecified criterion for noninferiority compared with appendectomy. Most patients randomized to antibiotic treatment for uncomplicated appendicitis did not require appendectomy during the 1-year follow-up period, and those who required appendectomy did not experience significant complications. clinicaltrials.gov Identifier: NCT01022567.

Non-Hodgkin's lymphoma of the breast presenting as breast abscess during pregnancy.

PubMed

Sultan, Naheed; Khalid, Mahvesh; Khan, Sarah Rafi; Khan, Fahadullah

2012-10-01

Primary non-Hodgkin's lymphoma of the breast is an uncommon disease. In all patients with breast lump, primary lymphoma of breast should be considered as it is one of the most easily missed pathology. We report a case of a 22 years old lactating mother who presented with the complaint of a painful swelling in the right breast, noticed during the last trimester of her pregnancy, mimicking breast abscess.

Comparison of transumbilical laparoscopic-assisted appendectomy versus single incision laparoscopic appendectomy in children: which is the better surgical option?

PubMed

Boo, Yoon Jung; Lee, Yoon; Lee, Ji Sung

2016-08-01

Transumbilical laparoscopic-assisted appendectomy (TULA) is a single incision technique that exteriorizes the appendix through the umbilicus. The aim of this study was to compare the surgical outcomes of TULA with SILA in pediatric appendicitis. A retrospective review of medical records between April 2011 and April 2015 identified 250 pediatric patients who underwent single incision laparoscopic appendectomy. Of these, 137 patients underwent TULA and 113 patients underwent SILA. Measured outcomes included patients' demographics, clinical characteristics, operative time, length of stay, pain, and postoperative complications. TULA group had a shorter operative time than SILA group (28.93 vs. 49.19min, p<0.001). The use of rescue analgesics was more frequent in the SILA group (six cases (6.5%) vs. 19 cases (23.4%), p<0.001). There was no significant difference in cosmetic outcome between the two groups. However, TULA was associated with a lower complication rate (2/137, 1.5%) than SILA (11/113, 9.8%) (p=0.0035). In multiple logistic regression analysis, TULA was significantly associated with a lower complication rate (p=0.049). TULA is preferable to SILA for treating pediatric acute appendicitis because it is technically easier, results in better surgical outcomes, and provides the same excellent cosmetic results. Copyright © 2016 Elsevier Inc. All rights reserved.

Emergency management of acute abdomen in children.

PubMed

Balachandran, Binesh; Singhi, Sunit; Lal, Sadhna

2013-03-01

Acute abdomen can be defined as a medical emergency in which there is sudden and severe pain in abdomen with accompanying signs and symptoms that focus on an abdominal involvement. It accounts for about 8 % of all children attending the emergency department. The goal of emergency management is to identify and treat any life-threatening medical or surgical disease condition and relief from pain. In mild cases often the cause is gastritis or gastroenteritis, colic, constipation, pharyngo-tonsilitis, viral syndromes or acute febrile illnesses. The common surgical causes are malrotation and Volvulus (in early infancy), intussusception, acute appendicitis, and typhoid and ischemic enteritis with perforation. Lower lobe pneumonia, diabetic ketoacidosis and acute porphyria should be considered in patients with moderate-severe pain with little localizing findings in abdomen. The approach to management in ED should include, in order of priority, a rapid cardiopulmonary assessment to ensure hemodynamic stability, focused history and examination, surgical consult and radiologic examination to exclude life threatening surgical conditions, pain relief and specific diagnosis. In a sick patient the initial steps include rapid IV access and normal saline 20 ml/kg (in the presence of shock/hypovolemia), adequate analgesia, nothing per oral/IV fluids, Ryle's tube aspiration and surgical consultation. An ultrasound abdomen is the first investigation in almost all cases with moderate and severe pain with localizing abdominal findings. In patients with significant abdominal trauma or features of pancreatitis, a Contrast enhanced computerized tomography (CECT) abdomen will be a better initial modality. Continuous monitoring and repeated physical examinations should be done in all cases. Specific management varies according to the specific etiology.

[Enterobius vermicularis causing symptoms of acute appendicitis].

PubMed

Antal, András; Kocsis, Béla

2008-08-01

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

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

PubMed

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

2017-08-01

Management of appendicitis as an urgent rather than emergency procedure has become an increasingly common practice in children. Controversy remains as to whether this practice is associated with increased risk of complicated appendicitis and adverse events. To examine the association between time to appendectomy (TTA) and risk of complicated appendicitis and postoperative complications. In this retrospective cohort study using the Pediatric National Surgical Quality Improvement Program appendectomy pilot database, 2429 children younger than 18 years who underwent appendectomy within 24 hours of presentation at 23 children's hospitals from January 1, 2013, through December 31, 2014, were studied. The main exposure was TTA, defined as the time from emergency department presentation to appendectomy. Patients were further categorized into early and late TTA groups based on whether their TTA was shorter or longer than their hospital's median TTA. Exposures were defined in this manner to compare rates of complicated appendicitis within a time frame sensitive to each hospital's existing infrastructure and diagnostic practices. The primary outcome was complicated appendicitis documented at operation. The association between treatment delay and complicated appendicitis was examined across all hospitals by using TTA as a continuous variable and at the level of individual hospitals by using TTA as a categorical variable comparing outcomes between late and early TTA groups. Secondary outcomes included length of stay (LOS) and postoperative complications (incisional and organ space infections, percutaneous drainage procedures, unplanned reoperation, and hospital revisits). Of the 6767 patients who met the inclusion criteria, 2429 were included in the analysis (median age, 10 years; interquartile range, 8-13 years; 1467 [60.4%] male). Median hospital TTA was 7.4 hours (range, 5.0-19.2 hours), and 574 patients (23.6%) were diagnosed with complicated appendicitis (range, 5.2%-51.1% across hospitals). In multivariable analyses, increasing TTA was not associated with risk of complicated appendicitis (odds ratio per 1-hour increase in TTA, 0.99; 95% CI, 0.97-1.02). The odds ratios of complicated appendicitis for late vs early TTA across hospitals ranged from 0.39 to 9.63, and only 1 of the 23 hospitals had a statistically significant increase in their late TTA group (odds ratio, 9.63; 95% CI, 1.08-86.17; P = .03). Increasing TTA was associated with longer LOS (increase in mean LOS for each additional hour of TTA, 0.06 days; 95% CI, 0.03-0.08 days; P < .001) but was not associated with increased risk of any of the other secondary outcomes. Delay of appendectomy within 24 hours of presentation was not associated with increased risk of complicated appendicitis or adverse outcomes. These results support the premise that appendectomy can be safely performed as an urgent rather than emergency procedure.

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

PubMed

Daskalakis, K; Juhlin, C; Påhlman, L

2014-03-01

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

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

PubMed

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

2014-12-01

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

Ultrasound for Appendicitis: Performance and Integration with Clinical Parameters

PubMed Central

Löfvenberg, Fanny

2016-01-01

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

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

PubMed

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

2017-11-01

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

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

PubMed

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

2017-06-01

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

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

PubMed

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

2017-01-01

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

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

PubMed

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

2017-01-01

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

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

PubMed

Lotti, Marco

2017-06-01

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

Can common serum biomarkers predict complicated appendicitis in children?

PubMed

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

2017-07-01

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

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

PubMed

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

2005-12-01

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

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

PubMed Central

Eaton, Simon; Abbo, Olivier; Arnaud, Alexis P; Beaudin, Marianne; Brindle, Mary; Bütter, Andreana; Davies, Dafydd; Jancelewicz, Tim; Johnson, Kathy; Keijzer, Richard; Lapidus-Krol, Eveline; Offringa, Martin; Piché, Nelson; Rintala, Risto; Skarsgard, Erik; Svensson, Jan F; Ungar, Wendy J; Wester, Tomas; Willan, Andrew R; Zani, Augusto; St Peter, Shawn D; Pierro, Agostino

2017-01-01

Background Appendectomy is considered the gold standard treatment for acute appendicitis. Recently the need for surgery has been challenged in both adults and children. In children there is growing clinician, patient and parental interest in non-operative treatment of acute appendicitis with antibiotics as opposed to surgery. To date no multicentre randomised controlled trials that are appropriately powered to determine efficacy of non-operative treatment (antibiotics) for acute appendicitis in children compared with surgery (appendectomy) have been performed. Methods Multicentre, international, randomised controlled trial with a non-inferiority design. Children (age 5–16 years) with a clinical and/or radiological diagnosis of acute uncomplicated appendicitis will be randomised (1:1 ratio) to receive either laparoscopic appendectomy or treatment with intravenous (minimum 12 hours) followed by oral antibiotics (total course 10 days). Allocation to groups will be stratified by gender, duration of symptoms (> or <48 hours) and centre. Children in both treatment groups will follow a standardised treatment pathway. Primary outcome is treatment failure defined as additional intervention related to appendicitis requiring general anaesthesia within 1 year of randomisation (including recurrent appendicitis) or negative appendectomy. Important secondary outcomes will be reported and a cost-effectiveness analysis will be performed. The primary outcome will be analysed on a non-inferiority basis using a 20% non-inferiority margin. Planned sample size is 978 children. Discussion The APPY trial will be the first multicentre randomised trial comparing non-operative treatment with appendectomy for acute uncomplicated appendicitis in children. The results of this trial have the potential to revolutionise the treatment of this common gastrointestinal emergency. The randomised design will limit the effect of bias on outcomes seen in other studies. Trial registration number clinicaltrials.gov: NCT02687464. Registered on Jan 13th 2016. PMID:29637088

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

PubMed

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

2017-12-01

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

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

PubMed Central

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

2016-01-01

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

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

PubMed

Corson-Knowles, Daniel; Russell, Frances M

2018-05-01

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

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

PubMed

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

2016-05-01

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

Torsion of Meckel's Diverticulum in a Child

PubMed Central

Nose, Satoko; Okuyama, Hiroomi; Sasaki, Takashi; Nishimura, Mika

2013-01-01

Meckel's diverticulum (MD) is a common congenital anomaly of the gastrointestinal tract, the majority of cases of which are clinically silent. Patients with asymptomatic MD can unexpectedly develop acute abdominal pain. Making a diagnosis of MD is often difficult due to the lack of specific symptoms caused by this condition. Diagnostic laparotomy can be useful for making an accurate and prompt diagnosis of complicated MD. We herein describe a pediatric case of torsion of a MD in whom we performed laparoscopic-assisted emergency surgery. The patient was an 11-year-old male who developed sudden severe right lower abdominal pain. Clinical and laboratory findings were suggestive of appendicitis, however computed tomography scans showed a large cystic mass in the pelvis. Exploratory laparoscopy led to a diagnosis of torsion of a MD, and wedge resection of the gangrenous MD was performed through an umbilical port incision. The patient's postoperative course was uneventful. We conclude that diagnostic laparoscopy followed by laparoscopy-assisted Meckel's diverticulectomy via an umbilical incision is useful in the treatment of acute abdomen caused by MD. PMID:23466748

Single Incision Laparoscopic Assisted Appendectomy: Experience of 82 Cases

PubMed Central

Sinha, Anant Narayan; Deepak, Desh; Pandey, NK; Nandani

2016-01-01

Introduction Single Incision Laparoscopic Surgery (SILS) is one of the most recent developments which have been made in the field of minimal assesses surgery. It has potential advantages of less postoperative pain and better cosmesis, but at the same time, this procedure is time consuming and it increases the cost of surgery. Aim In this study, we evaluated the feasibility, safety and potential advantages of single incision laparoscopic assisted appendectomy. Materials and Methods Single incision laparoscopic assisted appendectomy was done in 82 patients who were diagnosed with acute or chronic appendicitis. A single 10mm incision made over right lower quadrant was used for placing two 5mm trocars and appendisectomy was done as in open surgery, after delivering out the appendix from the incision. Results Mean operative time was 32.56 ± 15.5 minutes. Mean post-operative pain scores as per visual analogue scalewere 6.5, 4.2 and 1.2 on 12 hours day 1 and day 2 after surgery respectively. Mean length of hospital stay was 1.4 ± 1.2 days. Conclusion Single incision laparoscopic appendectomy is safe and feasible. PMID:27437295

Clinical features of abdominopelvic actinomycosis: report of twenty cases and literature review.

PubMed

Choi, Myung-Min; Baek, Jeong Heum; Beak, Jeong Heum; Lee, Jung Nam; Park, Sanghui; Lee, Won-Suk

2009-08-31

Intrabdominal actinomycosis is difficult to diagnose preoperatively. This chronic infection has a propensity to mimic many other diseases and may present with a wide variety of symptoms. The aim of this study was to evaluate the characteristic clinical features with review of the literature. We retrospectively analyzed 22 patients with intrabdominal actinomycosis between January 2000 and January 2006. There were two men and 20 women with a mean age of 42.8 years (range, 24-69). Twelve patients presented with masses or abdominal pain, whereas 3 patients presented with acute appendicitis. The rate of performing an emergency surgery was 50% due to symptoms of peritonitis. The mean size of tumor was 5.5 cm (range, 2.5-11.0). Sixty percent (n = 12) of female patients had intrauterine device (IUD). The average time to definite diagnosis was 10.6 days. Intrabdominal abdominal actinomycosis must first be suspected in any women with a history of current or recent IUD use who presents abdominal pain. If recognized preoperatively, a limited surgical procedure, may spare the patient from an extensive operation.

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

PubMed

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

2016-01-01

Patient-centered outcomes research (PCOR) aims to give patients a better understanding of the treatment options to enable optimal decision-making. As nonoperative alternatives are now being evaluated in children for acute appendicitis, we surveyed patients and their families regarding their knowledge of appendicitis and evaluated whether providing basic medical information would affect their perception of the disease and allow them to more rationally consider the treatment alternatives. Families of children aged 5-18 presenting to the Emergency Department with suspected appendicitis were recruited for a tablet-based interactive educational survey. One hundred subjects (caregivers and patients ≥ 15 years) were questioned before and after an education session about their understanding of appendicitis, including questions on three hypothetical treatment options: urgent appendectomy, antibiotics alone, or initial antibiotics followed by elective appendectomy. Subjects were clearly informed that urgent appendectomy is currently the standard of care. Only 14% of respondents correctly identified the mortality rate of appendicitis (17 deaths/year according to the 2010 US census) when compared with other extremely rare causes of death. Fifty-four and 31% thought it was more common than death from lightning (40/year) and hunting-associated deaths (44/year), respectively. Eighty-two percent of respondents believed it "likely" or "very likely" that the appendix would rupture if operation was at all delayed, and 81% believed that rupture of the appendix would rapidly lead to severe complications and death. In univariate analysis, this perception was significantly more prevalent for mothers (odds ratio, (OR) 5.19, confidence interval (CI) 1.33-21.15), and subjects who knew at least one friend or relative who had a negative experience with appendicitis (OR 5.53, CI 1.40-25.47). Following education, these perceptions changed significantly (53% still believed that immediate operation was necessary, and 47% believed perforation led to great morbidity and potential mortality, P<0.001). In a survey of potential appendicitis treatment options, urgent appendectomy was considered a "good" or "very good" option by 74% of subjects, compared with 68% for antibiotics only without appendectomy and 49% for initial antibiotic therapy followed by elective outpatient appendectomy. There was a striking knowledge gap in the participant perception of appendicitis. Appropriate education can correct anecdotally supported misconceptions. Adequate education may empower patients to make better-informed decisions about their medical care and may be important for future studies in alternative treatments for appendicitis in children. Copyright © 2016 Elsevier Inc. All rights reserved.

PULMONARY MUCORMYCOSIS MIMICKING AS PULMONARY TUBERCULOSIS: A CASE REPORT

PubMed Central

Garg, Rajiv; Marak, Rungmei SK; Verma, Sanjay Kumar; Singh, Jagdeep; Sanjay; Prasad, Rajendra

2008-01-01

Pulmonary Mucormycosis is an uncommon disease caused by fungi of class Zygomycetes. It occurs predminantly in an immunodeficient host most common risk factor being diabetes mellitus. The lesions are localized in the lungs or the mediastinum. We are reporting a case of 70 years old male, having cough, haemoptysis, fever and chest pain. He was on antituberculosis treatment (RHEZ) for last 10 days and was later found to have Pulmonary Mucormycosis on further evaluation. PMID:20165666

Diagnostic confounders of chronic widespread pain: not always fibromyalgia

PubMed Central

Häuser, Winfried; Perrot, Serge; Sommer, Claudia; Shir, Yoram; Fitzcharles, Mary-Ann

2017-01-01

Abstract Introduction: Chronic widespread pain (CWP) is the defining feature of fibromyalgia (FM), a worldwide prevalent condition. Chronic widespread pain is, however, not pathognomonic of FM, and other conditions may present similarly with CWP, requiring consideration of a differential diagnosis. Objectives: To conduct a literature search to identify medical conditions that may mimic FM and have highlighted features that may differentiate these various conditions from FM. Methods: A comprehensive literature search from 1990 through September 2016 was conducted to identify conditions characterized by CWP. Results: Conditions that may mimic FM may be categorized as musculoskeletal, neurological, endocrine/metabolic, psychiatric/psychological, and medication related. Characteristics pertaining to the most commonly identified confounding diagnoses within each category are discussed; clues to enable clinical differentiation from FM are presented; and steps towards a diagnostic algorithm for mimicking conditions are presented. Conclusion: Although the most likely reason for a complaint of CWP is FM, this pain complaint can be a harbinger of illness other than FM, prompting consideration of a differential diagnosis. This review should sensitize physicians to a broad spectrum of conditions that can mimic FM. PMID:29392213

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

PubMed

Raahave, Dennis

2015-03-01

The present studies explored whether faecal retention in the colon is a causative factor in functional bowel disease, appendicitis, and haemorrhoids. Faecal retention was characterized by colon transit time (CTT) after radio-opaque marker ingestion and estimation of faecal loading on abdominal radiographs at 48 h and 96 h. Specific hypotheses were tested in patients (n = 251 plus 281) and in healthy random controls (n = 44). A questionnaire was completed for each patient, covering abdominal and anorectal symptoms and without a priori grouping. Patients with functional bowel disorders, predominantly women, had a significantly increased CTT and faecal load compared to controls. The CTT was significantly and positively correlated with segmental and total faecal loading. The faecal load was equal at 48 h and 96 h, mirroring the presence of permanent faecal reservoirs. In these first clinical studies to correlate bowel symptoms with CTT and colon faecal loading, abdominal bloating was significantly correlated with faecal loading in the right colon, total faecal load, and CTT. Abdominal pain was significantly and positively correlated to distal faecal loading and significantly associated with bloating. A new phenomenon with a high faecal load and a normal CTT was observed in a subset of patients (n = 90), proving faecal retention as hidden constipation. The CTT and faecal load were significantly higher in the right-side compared to the left and distal segments. Within the control group of healthy persons, the right-sided faecal load was significantly greater than the left and distal load. The CTT and faecal load significantly positively correlated with a palpable mass in the left iliac fossa and meteorism. Cluster analysis revealed that CTT and faecal load positively correlated with a symptom factor consisting of bloating, proctalgia and infrequent defecation of solid faeces. On the other hand, CTT and faecal load negatively correlated with a symptom factor comprising frequent easy defecations, repetitiveness, and incompleteness with solid or liquid faeces. The majority of patients with a heavy faecal load but normal CTT had repetitive daily defecation, mostly with ease and with altering faecal consistence. Flue-like episodes co-existed in symptom factors with abdominal pain and meteorism, and these symptoms together with a palpable right iliac fossa mass and tenderness, and in other factors with seldom and difficult defecation, and with epigastric discomfort and halitosis. Patients with seldom and difficult defecation of solid faeces experienced abdominal pain significantly more often and presented a palpable mass in the right iliac fossa with tenderness and meteorism. The CTT was significantly prolonged and faecal load significantly increased. In patients with a normal CTT and increased faecal load, only patients with abdominal pain had a significant correlation between faecal loading and bloating. CTT and faecal load were shown for the first time to increase significantly with the number of colonic redundancies (colon length), which also resulted in significantly increased bloating and pain. Intervention with a bowel stimulation regimen combining a fibre-rich diet, fluid, physical activity, and a prokinetic drug was essential to proving that abdominal symptoms and defecation disorders are caused by faecal retention, with or without a prolonged CTT. The CTT was significantly reduced, as was faecal load. Bloating and pain were reduced significantly. The defecation became easy with solid faeces, towards one per day and with significant reductions in incompleteness and repetitiveness. Proctalgia and flue-like episodes were significantly reduced. The intervention significantly reduced the presence of a tender palpable mass in the right fossa and rectal constipation. In patients with a normal CTT but increased faecal load, the intervention did not significantly change the CTT or load, but bloating and pain were significantly reduced, just as defecation improved overall. The novel knowledge of faecal retention in the patients does not explain why faecal retention occurs. However, it may be inferred from the present results that a constipated or irritable bowel may belong to the same underlying disease dimension, where faecal retention is a common factor. Thus, measuring CTT and faecal load is suggested as a guide to a positive functional diagnosis of bowel disorders compared to the constellation of symptoms alone. Thirty-five patients underwent surgery after being refractory to the conservative treatment for constipation. They had a significantly prolonged CTT and heavy faecal loading, which was responsible for the aggravated abdominal and defaecatory symptoms. The operated patients presented with a redundant colon (dolichocolon) significantly more often. These patients also had an extremely high rate of previous appendectomy. Twenty-one patients underwent hemicolectomy, and 11 patients had a subtotal colectomy with an ileosigmoidal anastomosis; three patients received a stoma. However, some patients had to have the initial segmental colectomy converted to a final subtotal colectomy because of persisting symptoms. Six more subtotal colectomies have been performed and the leakage rate of all colectomies is then 4.9 % (one patient died). After a mean follow-up of 5 years, the vast majority of patients were without abdominal pain and bloating, having two to four defecations daily with control and their quality of life had increased considerably. A faecalith is often located in the appendix, the occlusion of which is responsible for many cases of acute appendicitis, which is infrequent in all except white populations. An effort to trace the origin of the faecalith to faecal retention in the colon was made in a case control study (56 patients and 44 random controls). The CTT was longer and faecal load greater in patients with appendicitis compared to controls, though the difference was not significant. Power calculations showed that more patients were needed to reach statistical significance for these parameters. The presence of a faecalith was most often associated with a gangrenous or perforated appendix. No significant differences were found between the CTT and faecal load of patients who had or did not have a faecalith. However, the right-sided faecal load was significantly higher than the left and distal load. Haemorrhoids are often a consequence of constipation and defaecatory disorders and were found in every second patient with functional bowel disorders. The present studies are the first Danish reports of a novel operation to cure this disease, stapled haemorrhoidopexy (n = 40 and 258 patients). The majority of patients had prolapsed haemorrhoids, and the durability of procedure was confirmed with a follow-up of up to 5 years, meaning a normal anus. The operation time was short, post-operative pain was low, and recovery was rapid. No incontinence was observed, and patient satisfaction was high and significantly correlated with the appearance of a normal anus without prolapse. The cumulative risk of re-operation was greatest in the first 2 years after the stapled haemorrhoidopexy. Patients with persisting haemorrhoidal prolapse had the procedure repeated with results as good as those obtained in the rest of the patients. It was shown in a statistical model that the preoperative severity of haemorrhoidal disease and the immediate postoperative result contributed significantly to predicting the outcome that is the durability of the operation. The most frequent post-operative complication was bleeding requiring surgical haemostasis. One serious complication occurred after an anastomotic leak from a highly placed anastomosis, resulting in retro rectal, retro- and intra-peritoneal, and mediastinal gas. The patient recovered after conservative treatment and without surgical intervention. The stapling technique now used has revolutionized the surgical treatment of prolapsing haemorrhoids. Finally, a common cause may be suspected for diseases constantly associated with one another. Epidemiological evidence has recognized that constipation, diverticulosis and IBS increase the risk of colon cancer (and adenomas), diseases exceedingly rare in communities exempt from appendicitis. Haemorrhoids are a colonic co-morbidity as well. Notably, the patients with a functional bowel disorder had a much higher rate of a previous appendectomy than the background population. In addition, the patients who had previously had an appendectomy had a significantly longer CTT compared to patients, who had not. The data points to the involvement of faecal retention in the origin of faecaliths and, thus, acute appendicitis. Faecal reservoirs were shown in the right and left colon segments in both patients and controls, which are the same areas bearing the highest incidences of adenomateous polyps and malignancies. Familial colorectal cancer occurred significantly more often in patients who had a higher faecal load than the controls. Four malignancies and 25 adenomas were identified. An increased faecal load in the colon with or without delayed transit will increase bacterial counts and create a chronic inflammation of the colonic mucosa, which is a risk factor for cancer onset. A functional bowel disorder is then likely to occur with gradually transition from a primary functional disease into specific organic diseases. A diet rich in fibre and regular physical activity have a therapeutic and preventive effect on colorectal diseases associated with faecal retention. A “common cause” was earlier proposed for constipation, colon diverticula, cancer, appendicitis, and haemorrhoids. The actual results of the present studies support this unifying theory for these diet-related diseases, in which the functional retention of faeces maybe the common cause.

Appendix (image)

MedlinePlus

... become infected. Although most people are familiar with appendicitis, it is a relatively rare disease. It is ... of the appendix (appendectomy). Recovery time for uncomplicated appendicitis is usually just three days.

A large epidermoid cyst of breast mimicking carcinoma: A case report and review of literature

PubMed Central

Debnath, Debasish; Taribagil, Savita; Al-Janabi, Khalid J.S.; Inwang, Reggie

2012-01-01

INTRODUCTION Triple assessment of a suspicious breast lesion may not always provide a definite diagnosis. We report a case of epidermoid cyst of breast, which caused diagnostic dilemma in spite of a thorough triple assessment and entailed mastectomy. PRESENTATION OF CASE A 69-year-old woman presented with a large painful retroareolar left breast mass. Clinical examination, ultrasound and mammography were highly suspicious of malignancy. However, core biopsy suggested a benign lesion. Due to size of the lesion and diagnostic uncertainty, various options were discussed with the patient. She opted for a simple mastectomy. The histology confirmed a large epidermoid cyst. DISCUSSION It is rare for an epidermoid cyst to present as such an advanced lesion, mimicking carcinoma. Excision of such a large retroareolar ‘benign’ lesion, however, may sometime entail mastectomy. This is the first reported case of an epidermoid cyst of breast necessitating mastectomy. CONCLUSION Diagnostic dilemma while dealing with a suspected breast cancer is not rare. Involvement of multidisciplinary team as well as patient is important in the decision-making. The report illustrates a rare presentation of a deep seated large epidermoid cyst of breast, which mimicked carcinoma, caused diagnostic confusion and entailed mastectomy. We strongly advocate the option of breast reconstruction in such cases. PMID:22705938

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

PubMed

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

2018-03-02

Currently, the routine treatment for acute appendicitis in the United Kingdom is an appendicectomy. However, there is increasing scientific interest and research into non-operative treatment of appendicitis in adults and children. While a number of studies have investigated non-operative treatment of appendicitis in adults, this research cannot be applied to the paediatric population. Ultimately, we aim to perform a UK-based multicentre randomised controlled trial (RCT) to test the clinical and cost effectiveness of non-operative treatment of acute uncomplicated appendicitis in children, as compared with appendicectomy. First, we will undertake a feasibility study to assess the feasibility of performing such a trial. The study involves a feasibility RCT with a nested qualitative research to optimise recruitment as well as a health economic substudy. Children (aged 4-15 years inclusive) diagnosed with acute uncomplicated appendicitis that would normally be treated with an appendicectomy are eligible for the RCT. Exclusion criteria include clinical/radiological suspicion of perforated appendicitis, appendix mass or previous non-operative treatment of appendicitis. Participants will be randomised into one of two arms. Participants in the intervention arm are treated with antibiotics and regular clinical assessment to ensure clinical improvement. Participants in the control arm will receive appendicectomy. Randomisation will be minimised by age, sex, duration of symptoms and centre. Children and families who are approached for the RCT will be invited to participate in the embedded qualitative substudy, which includes recording of recruitment consultants and subsequent interviews with participants and non-participants and their families and recruiters. Analyses of these will inform interventions to optimise recruitment. The main study outcomes include recruitment rate (primary outcome), identification of strategies to optimise recruitment, performance of trial treatment pathways, clinical outcomes and safety of non-operative treatment. We have involved children, young people and parents in study design and delivery. In this study we will explore the feasibility of performing a full efficacy RCT comparing non-operative treatment with appendicectomy in children with acute uncomplicated appendicitis. Factors determining success of the present study include recruitment rate, safety of non-operative treatment and adequate interest in the future RCT. Ultimately this feasibility study will form the foundation of the main RCT and reinforce its design. ISRCTN15830435 . Registered on 8 February 2017.

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

PubMed

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

2017-09-01

The use of ultrasonography (US) to diagnose appendicitis is well established. More recently, point-of-care ultrasonography (POCUS) has also been studied for the diagnosis of appendicitis, which may also prove a valuable diagnostic tool. The purpose of this study was through systematic review and meta-analysis to identify the test characteristics of POCUS, specifically US performed by a nonradiologist physician, in accurately diagnosing acute appendicitis in patients of any age. We conducted a thorough and systematic literature search of English language articles published on point-of-care, physician-performed transabdominal US used for the diagnosis of acute appendicitis from 1980 to May, 2015 using OVID MEDLINE In-Process & Other Non-indexed Citations and Scopus. Studies were selected and subsequently independently abstracted by two trained reviewers. A random-effects pooled analysis was used to construct a hierarchical summary receiver operator characteristic curve, and a meta-regression was performed. Quality of studies was assessed using the QUADAS-2 tool. Our search yielded 5,792 unique studies and we included 21 of these in our final review. Prevalence of disease in this study was 29.8%, (range = 6.4%-75.4%). The sensitivity and specificity for POCUS in diagnosing appendicitis were 91% (95% confidence interval [CI] = 83%-96%) and 97% (95% CI = 91%-99%), respectively. The positive and negative predictive values were 91 and 94%, respectively. Studies performed by emergency physicians had slightly lower test characteristics (sensitivity = 80%, specificity = 92%). There was significant heterogeneity between studies (I 2 = 99%, 95% CI = 99%-100%) and the quality of the reported studies was moderate, mostly due to unclear reporting of blinding of physicians and timing of scanning and patient enrollment. Several of the studies were performed by a single operator, and the education and training of the operators were variably reported. Point-of-care US has relatively high sensitivity and specificity for diagnosing acute appendicitis, although the data presented are limited by the quality of the original studies and large CIs. In the hands of an experienced operator, POCUS is an appropriate initial imaging modality for diagnosing appendicitis. Based on our results, it is premature to utilize POCUS as a stand-alone test or to rule out appendicitis. © 2017 by the Society for Academic Emergency Medicine.

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

PubMed

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

2011-07-25

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

Risk of appendicitis in patients with incidentally discovered appendicoliths.

PubMed

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

2018-01-01

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

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

PubMed

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

2017-01-01

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

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

PubMed

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

2015-08-01

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

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

PubMed

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

2012-09-01

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

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

PubMed

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

2017-07-01

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

Indices of diagnostic abdominal ultrasonography in acute appendicitis: influence of gender and physical constitution, time evolution of the disease and experience of radiologist.

PubMed

Peixoto, Rodrigo de Oliveira; Nunes, Tarcizo Afonso; Gomes, Carlos Augusto

2011-01-01

To assess the value of abdominal ultrasonography in the diagnosis of acute appendicitis and the influence of gender, physical constitution, experience of the radiologist and the time evolution of the disease on the results of diagnostic indices. We prospectively evaluated 156 patients with clinical diagnosis of acute appendicitis who underwent laparoscopic appendectomy and abdominal ultrasonography, together with pathology of the excised appendices. Patients were allocated in relation to BMI in both groups (below or above 25 kg/m²) and radiologists, in three groups according to their professional experience (less than five years, between five and 10 years and more than 10 years). The survey also assessed the influence of gender and time of disease progression using the median of 36 hours. The sensitivity and specificity of abdominal ultrasonography for diagnosing appendicitis were 64.9 and 72% respectively. Gender, body mass index, length of experience of the radiologists in the three groups and time of onset of symptoms showed no significant differences in the establishment of sonographic diagnosis of acute appendicitis. The abdominal ultrasonography showed low sensitivity and specificity and little contribution to the diagnosis of acute appendicitis. Gender, physical constitution, the experience of the radiologist and time of onset of symptoms did not affect the outcome of the sonography.

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

PubMed

Ali, Kishwar; Latif, Humera; Ahmad, Sajjad

2015-01-01

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

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

PubMed

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

2017-09-01

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

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

PubMed

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

2017-11-01

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

Accuracy and reliability of tablet computer as an imaging console for detection of radiological signs of acute appendicitis using PACS workstation as reference standard.

PubMed

Awais, Muhammad; Khan, Dawar Burhan; Barakzai, Muhammad Danish; Rehman, Abdul; Baloch, Noor Ul-Ain; Nadeem, Naila

2018-05-01

To ascertain the accuracy and reliability of tablet as an imaging console for detection of radiological signs of acute appendicitis [on focused appendiceal computed tomography (FACT)] using Picture Archiving and Communication System (PACS) workstation as reference standard. From January, 2014 to June, 2015, 225 patients underwent FACT at our institution. These scans were blindly re-interpreted by an independent consultant radiologist, first on PACS workstation and, two weeks later, on tablet. Scans were interpreted for the presence of radiological signs of acute appendicitis. Accuracy of tablet was calculated using PACS as reference standard. Kappa (κ) statistics were calculated as a measure of reliability. Of 225 patients, 99 had radiological evidence of acute appendicitis on PACS workstation. Tablet was 100% accurate in detecting radiological signs of acute appendicitis. Appendicoliths, free fluid, lymphadenopathy, phlegmon/abscess, and perforation were identified on PACS in 90, 43, 39, 10, and 12 scans, respectively. There was excellent agreement between tablet and PACS for detection of appendicolith (к = 0.924), phlegmon/abscess (к = 0.904), free fluid (к = 0.863), lymphadenopathy (к = 0.879), and perforation (к = 0.904). Tablet computer, as an imaging console, was highly reliable and was as accurate as PACS workstation for the radiological diagnosis of acute appendicitis.

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

PubMed Central

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

2011-01-01

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

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

PubMed

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

2014-01-01

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

Comparison of Alvarado Score Evaluation and Clinical Judgment in Acute Appendicitis

PubMed Central

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

2014-01-01

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

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

PubMed

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

2011-10-01

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

Non-operative management of appendicitis in children.

PubMed

Hall, Nigel J; Eaton, Simon

2018-05-01

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

Stress antagonizes morphine-induced analgesia in rats

NASA Technical Reports Server (NTRS)

Vernikos, J.; Shannon, L.; Heybach, J. P.

1981-01-01

Exposure to restraint stress resulted in antagonism of the analgesic effect of administered morphine in adult male rats. This antagonism of morphine-induced analgesia by restraint stress was not affected by adrenalectomy one day prior to testing, suggesting that stress-induced secretion of corticosteroids is not critical to this antagonism. In addition, parenteral administration of exogenous adrenocorticotropin (ACTH) mimicked the effect of stress in antagonizing morphine's analgesic efficacy. The hypothesis that ACTH is an endogenous opiate antagonist involved in modulating pain sensitivity is supported.

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

PubMed

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

2017-10-01

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

Intermittent intussusception caused by colonic lipoma.

PubMed

Chan, K C; Lin, N H; Lien, H C; Chan, S L; Yu, S C

1998-01-01

Colonic lipomas are rare, usually small, and occur most often in the right colon, particularly in the cecum. They are most common in elderly women. Intermittent episodes of intussusception are not uncommon in patients with colonic lipoma, but they are usually caused by larger pedunculated lipomas. We report a 43-year-old woman with a large colonic submucosal lipoma that induced intermittent colocolic intussusception. The patient presented with symptoms of peptic ulcer, including intractable upper abdominal pain, which did not resolve with treatment. Abdominal sonography showed typical findings of intussusception caused by a lipoma, but the manifestations on barium enema and computed tomography mimicked a malignant colonic tumor. The patient's abdominal pain disappeared after right hemicolectomy and the tumor was demonstrated to be a lipoma. The postoperative course was uneventful; there was no evidence of recurrence at follow-up 6 months later. Physicians should be aware that surrounding organs should also be evaluated in cases of chronic peptic ulcer with intractable upper abdominal pain.

Anisakiasis.

PubMed Central

Sakanari, J A; McKerrow, J H

1989-01-01

Anisakiasis is a zoonotic disease caused by the ingestion of larval nematodes in raw seafood dishes such as sushi, sashimi, ceviche, and pickled herring. Symptoms of anisakiasis include abdominal pain, nausea, vomiting, and diarrhea. Because symptoms are vague, this disease is often misdiagnosed as appendicitis, acute abdomen, stomach ulcers, or ileitis. Endoscopic examination with biopsy forceps has facilitated the diagnosis of gastric anisakiasis. Worms can be removed and identified, and a definitive diagnosis can be made. Patients generally recover with no further evidence of disease. Worms can become invasive, however, and migrate beyond the stomach, penetrating the intestine, omentum, liver, pancreas, and probably the lungs. Surgery is often necessary for treatment of invasive anisakiasis. With the increase in popularity of eating lightly cooked or raw fish dishes, the number of cases of anisakiasis may be expected to increase. Images PMID:2670191

Alvarado score in the diagnostic of pain in the right lower quadrant.

PubMed

Lada, Paul Eduardo

2017-09-08

Acute appendicitis neither suspected nor diagnosed could develop a perforation or otherwise it would take to removing of a normal appendix. Utilization of a clinical score system for aided diagnosis of this pathology and can reduce a negative appendicitis. National Clinicas Hospital. Córdoba. Argentina. Prospective and protocolized study. 594 patients were studied between October 2002 and December 2013. 312 males and 282 females their age average was 26.2 years. Alvarado score was realized in all patients when they entered. According clinic and second valoration with the score surgical exploration was decided in 574 patients. The remaining 20 were excluded due to other pathology. The diagnosis in acute appendicitis was confirmed by surgical finding and histopathologic studies. In surgical finding we showed 594 patients (91,28 %) had acute appendicitis. There was no operative mortality. Respects morbidity there was 1,74 % of medical and 13,93 % of surgical complications. The anatomo-pathologic report showed a normal cecal appendix in 50. The incidence of negative appendicectomy was about 8.71 %. The utilization of score related to the surgical and anatomo-pathologic finding confirmed it was appreciable from 6 points to acute appendicitis diagnosis.   RESUMENAntecedentes: La apendicitis aguda no sospechada y diagnosticada puede evolucionar hacia la perforación, ó por el contrario conduce a la remoción de un apéndice normal. Objetivo: La utilización de un  sistema  de Score, desde un  punto de vista clínico, para el diagnóstico de esta patología y lograr disminuir las apendicetomías negativas.Lugar de Aplicación: Hospital Nacional de Clínicas. Córdoba. (Argentina)Diseño: Estudio prospectivo y protocolizado.Material y Métodos: Comprende a 594 pacientes estudiados entre octubre de 2002 y diciembre del 2013. De ellos, 312 eran del sexo masculino y 282 del femenino, con una edad promedio de 26,2 años de edad. A todos los pacientes se les realizo al ingreso el Score de Alvarado. En base a la clínica y a una segunda valoración con el Score se decidió la exploración quirúrgica en 574 pacientes. De los 20 restantes, fueron excluidos por otra patología. El diagnóstico de apendicitis aguda fue confirmado por los hallazgos quirúrgicos y la  anatomía patológica.Resultados: En los hallazgos operatorios se encontró en 524 pacientes (91,28%) que tenían una apendicitis aguda. No hubo mortalidad postoperatoria. En relación a la morbilidad hubo un 1,74 % de complicaciones médicas y un 13,93 % de las quirúrgicas. El informe anatomopatológico mostró en 50 pacientes un apéndice cecal normal. Por lo tanto la incidencia de las apendicetomías negativas fue del 8,71%. Conclusiones: La utilización del Score en relación a los hallazgos quirúrgicos y anatomopatológicos confirma que fue sensible a partir de 6 puntos para el diagnóstico de apendicitis aguda.

Does catastrophic thinking enhance oesophageal pain sensitivity? An experimental investigation.

PubMed

Martel, M O; Olesen, A E; Jørgensen, D; Nielsen, L M; Brock, C; Edwards, R R; Drewes, A M

2016-09-01

Gastro-oesophageal reflux disease (GORD) is a major health problem that is frequently accompanied by debilitating oesophageal pain symptoms. The first objective of the study was to examine the association between catastrophizing and oesophageal pain sensitivity. The second objective was to examine whether catastrophizing was associated with the magnitude of acid-induced oesophageal sensitization. Twenty-five healthy volunteers (median age: 24.0 years; range: 22-31) were recruited and were asked to complete the Pain Catastrophizing Scale (PCS). During two subsequent study visits, mechanical, thermal, and electrical pain sensitivity in the oesophagus was assessed before and after inducing oesophageal sensitization using a 30-min intraluminal oesophageal acid perfusion procedure. Analyses were conducted based on data averaged across the two study visits. At baseline, catastrophizing was significantly associated with mechanical (r = -0.42, p < 0.05) and electrical (r = -0.60, p < 0.01) pain thresholds. After acid perfusion, catastrophizing was also significantly associated with mechanical (r = -0.58, p < 0.01) and electrical (r = -0.50, p < 0.05) pain thresholds. Catastrophizing was not significantly associated with thermal pain thresholds. Subsequent analyses revealed that catastrophizing was not significantly associated with the magnitude of acid-induced oesophageal sensitization. Taken together, findings from the present study suggest that catastrophic thinking exerts an influence on oesophageal pain sensitivity, but not necessarily on the magnitude of acid-induced oesophageal sensitization. WHAT DOES THIS STUDY ADD?: Catastrophizing is associated with heightened pain sensitivity in the oesophagus. This was substantiated by assessing responses to noxious stimulation of the oesophagus using an experimental paradigm mimicking features and symptoms experienced by patients with gastro-oesophageal reflux disease (GORD). © 2016 European Pain Federation - EFIC®

National Patient Safety Foundation

MedlinePlus

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Appendicitis in Teens

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

Lead poisoning in a 16-year-old girl: a case report and a review of the literature (CARE compliant).

PubMed

Mărginean, Cristina Oana; Meliţ, Lorena Elena; Moldovan, Horaţiu; Lupu, Vasile Valeriu; Mărginean, Maria Oana

2016-09-01

Lead is a toxic element of the environment which leads to major complications once it enters the blood stream, affecting multiple organs and systems of the body. We present the case of a 16-year-old girl, diagnosed with lead poisoning after occupational exposure due to the fact that the girl was actively involved in the family's pottery business.History revealed that the girl participated in the process of pottery, her father was also diagnosed with lead poisoning 2 years before. The patient's personal history underlined that approximately 1 year ago she presented with severe abdominal pain, being diagnosed with acute appendicitis and she underwent appendectomy, but the pain persisted, thus due to family history of lead poisoning, the suspicion of saturnine colic rose, and she was diagnosed with lead poisoning. The main symptoms and signs were severe abdominal pain, vomiting, and arterial hypertension. The clinical evolution was favorable under symptomatic treatment and chelation therapy. Lead toxicity is a life-threatening condition because of its severe acute and chronic complications. In children, there is no safe blood lead level, prevention methods are, therefore, very important in order to avoid toxic multiorganic effects of this metal. Even though the diagnosis of lead poisoning remains difficult in children, it must also be taken into consideration by the clinician facing a child with gastrointestinal or neurological involvement.

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

PubMed

Blackmore, C Craig; Terasawa, Teruhiko

2006-02-01

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

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

PubMed

Yang, Estin; Cook, Colin; Kahn, Delawir

2015-07-01

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

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

PubMed

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

2016-03-01

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

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

PubMed

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

2017-08-01

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

Diagnosing perforated appendicitis in pediatric patients: a new model.

PubMed

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

2016-03-01

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

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

PubMed

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

2011-01-01

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

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

PubMed Central

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

2014-01-01

Purpose The function of the appendix is largely unknown, but its microbiota likely contributes to function. Alterations in microbiota may contribute to appendicitis, but conventional culture studies have not yielded conclusive information. We conducted a pilot, culture-independent 16S rRNA-based microbiota study of paired appendix and rectal samples. Methods We collected appendix and rectal swabs from 21 children undergoing appendectomy, six with normal appendices and fifteen with appendicitis (nine perforated). After DNA extraction, we amplified and sequenced 16S rRNA genes and analyzed sequences using CLoVR. We identified organisms differing in relative abundance using ANOVA (p<0.05) by location (appendix vs. rectum), disease (appendicitis vs. normal), and disease severity (perforated vs. non-perforated). Results We identified 290 taxa in the study's samples. Three taxa were significantly increased in normal appendices vs. normal rectal samples: Fusibacter (p = 0.009), Selenomonas (p = 0.026), and Peptostreptococcus (p = 0.049). Five taxa were increased in abundance in normal vs. diseased appendices: Paenibacillaceae (p = 0.005), Acidobacteriaceae GP4 (p = 0.019), Pseudonocardinae (p = 0.019), Bergeyella (p = 0.019) and Rhizobium (p = 0.045). Twelve taxa were increased in the appendices of appendicitis patients vs. normal appendix: Peptostreptococcus (p = 0.0003), Bilophila (p = 0.0004), Bulleidia (p = 0.012), Fusobacterium (p = 0.018), Parvimonas (p = 0.003), Mogibacterium (p = 0.012), Aminobacterium (p = 0.019), Proteus (p = 0.028), Actinomycineae (p = 0.028), Anaerovorax (p = 0.041), Anaerofilum (p = 0.045), Porphyromonas (p = 0.010). Five taxa were increased in appendices in patients with perforated vs. nonperforated appendicitis: Bulleidia (p = 0.004), Fusibacter (p = 0.005), Prevotella (p = 0.021), Porphyromonas (p = 0.030), Dialister (p = 0.035). Three taxa were increased in rectum samples of patients with appendicitis compared to the normal patients: Bulleidia (p = 0.034), Dialister (p = 0.003), and Porphyromonas (p = 0.026). Conclusion Specific taxa are more abundant in normal appendices compared to the rectum, suggesting that a distinctive appendix microbiota exists. Taxa with altered abundance in diseased and severely diseased (perforated) samples may contribute to appendicitis pathogenesis, and may provide microbial signatures in the rectum useful for guiding both treatment and diagnosis of appendicitis. PMID:24759879

Oral desmoplastic melanoma mimicking inflammatory hyperplasia.

PubMed

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

2012-06-01

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

Retroperitoneal Pseudoaneurysm Mimicking Ureteral Calculus: Pitfalls in Diagnosis.

PubMed

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

2017-10-08

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

Retroperitoneal Pseudoaneurysm Mimicking Ureteral Calculus: Pitfalls in Diagnosis

PubMed Central

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

2017-01-01

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

Pneumopyopericardium mimicking an inferior ST elevation myocardial infarction with regional electrocardiogram changes: a case report.

PubMed

Ratnayake, Eranda Chamara; Premaratne, Sandamali; Lokunarangoda, Niroshan; Fernando, Sanduni; Fernando, Nilanthi; Ponnamperuma, Chandrike; Santharaj, W Samuel

2015-04-30

Pneumopyopericardium is a rare disease with poor prognosis. The usual presentation is with fever, shortness of breath and haemodynamic compromise. The Electrocardiogram changes associated with this disease entity would be similar to pericarditis such as concave shaped ST elevations in all leads with PR sagging. Pneumopyopericardium mimicking an acute ST Elevation Myocardial Infarction, with regional Electrocardiogram changes has hitherto not been described in world literature. We describe the case of a 48 year old native Sri Lankan man, presenting with chest pain and Electrocardiogram changes compatible with an Acute ST Elevation Myocardial Infarction, subsequently found to have Pneumopyopericardium secondary to an oesophageal tear. Retrospective history revealed repetitive vomiting due to heavy alcohol consumption, prior to presentation. It unfortunately led to a fatal outcome. Pneumopyopericardium may mimic an acute ST elevation myocardial infarction with associated regional Electrocardiogram changes. A high degree of suspicion should be maintained and an adequate history should always be obtained prior to any intervention in all ST Elevation Myocardial Infarction patients.

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

PubMed

Nitoń, Tomasz; Górecka-Nitoń, Aleksandra

2014-01-01

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

Laparoscopic Appendectomy in Children: Preliminary Study in Pediatric Hospital Albert Royer, Dakar

PubMed Central

Fall, Mbaye; Wellé, Ibrahima Bocar; Lo, Faty Balla; Sagna, Aloise; Diop, Marie; Fall, Ibrahima

2015-01-01

Appendiceal pathology's management has benefited in recent years from the advent of laparoscopic surgery. This study is to make a preliminary assessment of laparoscopic management of acute and complicated appendicitis in children after a few months of practice at the University Hospital Albert Royer, Dakar. This is a retrospective study of 22 cases of patients, all operated on by the same surgeon. The parameters studied were age, sex, clinical data and laboratory features, radiological data, and results of surgical treatment. The mean age of patients was 9.5 years with a male predominance. The series includes 14 cases of acute appendicitis and 8 complicated cases. Appendectomy anterograde is practiced in 81% of cases. Appendectomy was associated with peritoneal wash in 17 patients including 9 cases of acute appendicitis. Drainage of Douglas pouch is performed in 2 patients with complicated appendicitis; the average production was 300 cc of turbid liquids and any complications were not founded. An abscess of Douglas pouch is noted in 2 patients with complicated appendicitis undrained. These Douglas abscesses were treated medically. No conversion of laparotomy was performed in the series. After an average of 8 months no other problems were noted. PMID:26448743

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

PubMed

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

2018-01-01

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

Relationship between Enterobius vermicularis and the incidence of acute appendicitis.

PubMed

Ramezani, Mohammad Arash; Dehghani, Mahmoud Reza

2007-01-01

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

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

PubMed

Salemis, Nikolaos S

2009-10-01

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

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

PubMed

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

2017-03-01

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

Single daily dosing ceftriaxone and metronidazole vs standard triple antibiotic regimen for perforated appendicitis in children: a prospective randomized trial.

PubMed

St Peter, Shawn D; Tsao, Kuojen; Spilde, Troy L; Holcomb, George W; Sharp, Susan W; Murphy, J Patrick; Snyder, Charles L; Sharp, Ronald J; Andrews, Walter S; Ostlie, Daniel J

2008-06-01

Appendicitis is the most common emergency condition in children. Historically, a 3-drug regimen consisting of ampicillin, gentamicin, and clindamycin (AGC) has been used postoperatively for perforated appendicitis. A retrospective review at our institution has found single day dosing of ceftriaxone and metronidazole (CM) to be a more simple and cost-effective antibiotic strategy. Therefore, we performed a prospective, randomized trial to compare efficacy and cost-effectiveness of these 2 regimens. After internal review board approval (IRB no. 04 12-149), children found to have perforated appendicitis at appendectomy were randomized to either once daily dosing of CM (2 total doses per day) or standard dosing of AGC (11 total doses per day). Perforation was defined as an identifiable hole in the appendix. The operative approach (laparoscopic), length of antibiotic use, and criteria for discharge were standardized for the groups. Based on our retrospective analysis using length of postoperative hospitalization as a primary end point, a sample size of 100 patients was calculated for an alpha of .5 and a power of 0.82. One hundred patients underwent laparoscopic appendectomy for perforated appendicitis. On presentation, there were no differences in sex distribution, days of symptoms, temperature, or leukocyte count. There was no difference in abscess rate or wound infections between groups. The CM group resulted in significantly less antibiotic charges then the AGC group. Once daily dosing with the 2-drug regimen (CM) offers a more efficient, cost-effective antibiotic management in children with perforated appendicitis without compromising infection control when compared to a traditional 3-drug regimen.

Twelve years' experience of computer-aided diagnosis in a district general hospital.

PubMed Central

McAdam, W. A.; Brock, B. M.; Armitage, T.; Davenport, P.; Chan, M.; de Dombal, F. T.

1990-01-01

This paper describes experience in a modern district general hospital with a small desktop system for computer-aided diagnosis of acute abdominal pain, over a 12-year period involving 5512 cases. When compared with a baseline year (1973) in which unaided performance was monitored, during an initial study period (1974-76) the diagnostic accuracy of junior staff rose by between 10 and 15%. This higher performance level was then maintained for a decade (1976-86) despite changes in staff. The perforation rate among appendicitis cases fell from 27% to 12.5%, accompanied by a smaller fall in negative laparotomy rates. The saving in surgical bednights devoted to acute abdominal pain was approximately 15%, and the notional cost of resources saved during the first 6 years of operation was 120,000 pounds. Other hospitals have shown--in the short term--benefits similar to those obtained at Airedale District General Hospital. The long-term benefits of the system at Airedale reinforce the conclusions of the earlier short-term trials that a comparable system should probably be offered to all DGHs in the UK, not as an exercise in 'artificial intelligence' but as an effective continuing stimulus to good clinical practice. PMID:2185682

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

PubMed

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

2017-05-01

Antibiotic therapy for acute uncomplicated appendicitis is effective in adult patients, but its application in pediatric patients remains controversial. To compare the safety and efficacy of antibiotic treatment vs appendectomy as the primary therapy for acute uncomplicated appendicitis in pediatric patients. The PubMed, MEDLINE, EMBASE, and Cochrane Library databases and the Cochrane Controlled Trials Register for randomized clinical trials were searched through April 17, 2016. The search was limited to studies published in English. Search terms included appendicitis, antibiotics, appendectomy, randomized controlled trial, controlled clinical trial, randomized, placebo, drug therapy, randomly, and trial. Randomized clinical trials and prospective clinical controlled trials comparing antibiotic therapy with appendectomy for acute uncomplicated appendicitis in pediatric patients (aged 5-18 years) were included in the meta-analysis. The outcomes included at least 2 of the following terms: success rate of antibiotic treatment and appendectomy, complications, readmissions, length of stay, total cost, and disability days. Data were independently extracted by 2 reviewers. The quality of the included studies was examined in accordance with the Cochrane guidelines and the Newcastle-Ottawa criteria. Data were pooled using a logistic fixed-effects model, and the subgroup pooled risk ratio with or without appendicolith was estimated. The primary outcome was the success rate of treatment. The hypothesis was formulated before data collection. A total of 527 articles were screened. In 5 unique studies, 404 unique patients with uncomplicated appendicitis (aged 5-15 years) were enrolled. Nonoperative treatment was successful in 152 of 168 patients (90.5%), with a Mantel-Haenszel fixed-effects risk ratio of 8.92 (95% CI, 2.67-29.79; heterogeneity, P = .99; I2 = 0%). Subgroup analysis showed that the risk for treatment failure in patients with appendicolith increased, with a Mantel-Haenszel fixed-effects risk ratio of 10.43 (95% CI, 1.46-74.26; heterogeneity, P = .91; I2 = 0%). This meta-analysis shows that antibiotics as the initial treatment for pediatric patients with uncomplicated appendicitis may be feasible and effective without increasing the risk for complications. However, the failure rate, mainly caused by the presence of appendicolith, is higher than for appendectomy. Surgery is preferably suggested for uncomplicated appendicitis with appendicolith.

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

PubMed Central

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

2017-01-01

Importance Antibiotic therapy for acute uncomplicated appendicitis is effective in adult patients, but its application in pediatric patients remains controversial. Objective To compare the safety and efficacy of antibiotic treatment vs appendectomy as the primary therapy for acute uncomplicated appendicitis in pediatric patients. Data Sources The PubMed, MEDLINE, EMBASE, and Cochrane Library databases and the Cochrane Controlled Trials Register for randomized clinical trials were searched through April 17, 2016. The search was limited to studies published in English. Search terms included appendicitis, antibiotics, appendectomy, randomized controlled trial, controlled clinical trial, randomized, placebo, drug therapy, randomly, and trial. Study Selection Randomized clinical trials and prospective clinical controlled trials comparing antibiotic therapy with appendectomy for acute uncomplicated appendicitis in pediatric patients (aged 5-18 years) were included in the meta-analysis. The outcomes included at least 2 of the following terms: success rate of antibiotic treatment and appendectomy, complications, readmissions, length of stay, total cost, and disability days. Data Extraction and Synthesis Data were independently extracted by 2 reviewers. The quality of the included studies was examined in accordance with the Cochrane guidelines and the Newcastle-Ottawa criteria. Data were pooled using a logistic fixed-effects model, and the subgroup pooled risk ratio with or without appendicolith was estimated. Main Outcomes and Measures The primary outcome was the success rate of treatment. The hypothesis was formulated before data collection. Results A total of 527 articles were screened. In 5 unique studies, 404 unique patients with uncomplicated appendicitis (aged 5-15 years) were enrolled. Nonoperative treatment was successful in 152 of 168 patients (90.5%), with a Mantel-Haenszel fixed-effects risk ratio of 8.92 (95% CI, 2.67-29.79; heterogeneity, P = .99; I2 = 0%). Subgroup analysis showed that the risk for treatment failure in patients with appendicolith increased, with a Mantel-Haenszel fixed-effects risk ratio of 10.43 (95% CI, 1.46-74.26; heterogeneity, P = .91; I2 = 0%). Conclusions and Relevance This meta-analysis shows that antibiotics as the initial treatment for pediatric patients with uncomplicated appendicitis may be feasible and effective without increasing the risk for complications. However, the failure rate, mainly caused by the presence of appendicolith, is higher than for appendectomy. Surgery is preferably suggested for uncomplicated appendicitis with appendicolith. PMID:28346589

[Lombosacral epidural capillary hemangioma mimicking a dumbbell-shaped neurinoma: A case report and review of the literature].

PubMed

Egu, K; Kinata-Bambino, S; Mounadi, M; Rachid El Maaqili, M; El Abbadi, N

2016-04-01

Capillary hemangiomas are benign endothelial cell neoplasms that are believed to be hamartomatous proliferations of vascular endothelial cells. The occurrence of spinal epidural capillary hemangiomas is exceedingly rare. Only 8 epidurally located cases of capillary hemangiomas in the spinal canal have been reported in the literature. We report for the first time, to our knowledge, a case of lumbosacral epidural capillary hemangioma revealed by S1 back pain and radicular pain in a 60-year-old patient, caused by an L5-S1 epidural capillary hemangioma. The neurological symptoms of the patient improved after surgery. Spinal epidural capillary hemangioma is exceedingly rare. These lesions are benign and can mimic dumbbell-shaped neurinoma. Total removal by surgery is curative. Copyright © 2015 Elsevier Masson SAS. All rights reserved.

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

PubMed

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

2018-04-01

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

Systematic review of nonoperative versus operative treatment of uncomplicated appendicitis.

PubMed

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

2017-08-01

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

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

PubMed

Blumfield, Einat; Yang, Daniel; Grossman, Joshua

2017-10-01

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

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

PubMed

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

2017-10-01

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

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

PubMed

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

2016-10-01

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

Endometrioid Adenocarcinoma of Caecum Causing Intussusception

PubMed Central

Verma, Rashmi; Osborn, Sally; Horgan, Kieran

2013-01-01

Malignant transformation of endometriosis is rare and is usually seen in ovarian endometriosis. The colon and rectum are the most common sites for extragonadal endometriosis, and although serosal involvement is commonly seen, mucosal involvement is rare. Malignant transformation of endometriosis is a rare but a well-known complication of endometriosis. We report an unusual presentation of endometrioid adenocarcinoma with lymph node metastasis, arising from endometriosis in the caecal wall and causing ileocaecal intussusception. The patient presented with sudden onset of abdominal pain with features suggestive of acute appendicitis. Diagnostic laparoscopy revealed an ileocaecal intussusception. Conversion to open surgery confirmed a caecal mass causing ileocaecal intussusception, and a radical right hemicolectomy was performed. Histology revealed endometrioid adenocarcinoma arising in a focus of endometriosis in the muscularis propria and involving the mucosa, with one regional metastatic lymph node. PMID:23710407

A Mimicker of Gallbladder Carcinoma: Cystic Gastric Heterotopia with Intestinal Metaplasia.

PubMed

Özgün, Gonca; Adim, Şaduman Balaban; Uğraş, Nesrin; Kiliçturgay, Sadık

2017-01-01

Heterotopic gastric mucosa in the gallbladder is an unusual entity and is usually clinically silent. We report a 75-year-old female patient who presented with intermittent upper abdomial pain radiating to the back. Abdominal imaging studies showed a sessile polypoid lesion and a gallstone in the gallbladder. Gallbladder carcinoma was suspected and cholecystectomy performed. Intraoperative frozen section examination suggested mucinous tumor, suspicious for malignancy. However, the permanent sections revealed aberrant gastric tissue consisted of gastric pyloric and fundic glands of heterotopic gastric mucosa with intestinal metaplasia in the gallbladder.

Generalized Appended Product Indicator Procedure for Nonlinear Structural Equation Analysis.

ERIC Educational Resources Information Center

Wall, Melanie M.; Amemiya, Yasuo

2001-01-01

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

IL-18 Contributes to Bone Cancer Pain by Regulating Glia Cells and Neuron Interaction.

PubMed

Liu, Su; Liu, Yue-Peng; Lv, You; Yao, Jun-Li; Yue, Dong-Mei; Zhang, Mao-Yin; Qi, Dun-Yi; Liu, Gong-Jian

2018-02-01

Glial cell hyperactivity has been proposed to be responsible for chronic pain, however, the mechanisms remain unclear. Interleukin (IL)-18, released from glial cells, has been reported to be involved in neuropathic pain. In this study, we investigated the role of IL-18 in bone cancer pain. Bone cancer pain was mimicked by injecting Walker-256 mammary gland carcinoma cells into the intramedullary space of the tibia in rats. Expression and location of IL-18 and the IL-18 receptor were tested. To investigate the contribution of IL-18 signaling to bone cancer pain, IL-18 binding protein and recombinant IL-18 were used. To investigate the mechanisms of glial cells effects, MK801, N-methyl-D-aspartate (NMDA) receptor inhibitor, and Src kinase-specific inhibitor PP1 were used. Tumor cell implantation (TCI) treatment increased expression of IL-18 and IL-18 receptor in spinal cord. The time course of IL-18 upregulation was correlated with TCI-induced pain behaviors. Blocking the IL-18 signaling pathway prevented and reversed bone cancer-related pain behaviors. Meanwhile, blocking IL-18 signaling also suppressed TCI-induced glial cell hyperactivity, as well as activation of GluN2B and subsequent Ca 2+ -dependent signaling. Spinal administration of recombinant IL-18 in naive rat induced significant mechanical allodynia, as well as GluN2B activation. However, intrathecal injection of MK801 failed to suppress recombinant IL-18-induced GluN2B phosphorylation, whereas Src kinase inhibitor PP1 significantly inhibited IL-18-induced GluN2B activation. IL-18-mediated glial-glia and glial-neuron interaction may facilitate bone cancer pain. Blocking IL-18 signaling may effectively prevent and/or suppress bone cancer pain. IL-18 signaling may be a new target for cancer pain therapy. Copyright © 2017 The American Pain Society. Published by Elsevier Inc. All rights reserved.

Concentration of UHCL1 in the Serum of Children with Acute Appendicitis, Before and After Surgery, and Its Correlation with CRP and Prealbumin.

PubMed

Matuszczak, Ewa; Tylicka, Marzena; Dębek, Wojciech; Tokarzewicz, Anna; Gorodkiewicz, Ewa; Hermanowicz, Adam

2018-04-01

Ubiquitin-mediated protein degradation plays a crucial role in various cellular processes, including signal transduction, cell differentiation, and stress response. Ubiquitin C-terminal hydrolase 1 (UCHL1) is a unique deubiquitinating enzyme that has both hydrolase and ligase activities. The aim of this study was the determination of UCHL1 concentration in serum of children with appendicitis, before and after the surgery. 42 children with acute appendicitis, who were managed at the Pediatric Surgery Department, between 2013 and 2014, were randomly included into the study (age 9 months up to 14 years, mean age 2.5 + 1 years). There were 15 girls and 27 boys. 18 healthy, age-matched subjects, admitted for planned surgeries served as controls. Exclusion criteria were: severe preexisting infections, immunological or cardiovascular diseases that required long-term medication, and complicated cases of appendicitis with perforation of appendix and/or peritonitis. The UCHL1 concentrations in the blood plasma of patients with acute appendicitis, were highest before the surgery, and were above the range of concentrations measured in controls, the difference was statistically significant. The UCHL1 concentration measured 24 and 72 h after the operation, slowly decreased over time, and still did not reach the normal range, when compared with the concentration measured in controls (p < 0.05). UCHL1 concentration may reflect the metabolic response to acute state inflammation, and the process of gradual ebbing of the inflammation. The method of operation-classic open appendectomy, or laparoscopic appendectomy, does not influence the general trend in UCHL1 concentration in children with appendicitis. There is strong negative correlation between prealbumin and UCHL1 concentrations.

Lessons Learned With Laparoscopic Management of Complicated Grades of Acute Appendicitis

PubMed Central

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

2014-01-01

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

Performance of CT examinations in children with suspected acute appendicitis in the community setting: a need for more education.

PubMed

Kim, Michael E; Orth, Robert C; Fallon, Sara C; Lopez, Monica E; Brandt, Mary L; Zhang, Wei; Bisset, George S

2015-04-01

Despite a recent focus on the preferential use of ultrasound over CT for pediatric appendicitis, most children transferred from community hospitals still undergo diagnostic CT scans. The purpose of this study was to evaluate CT techniques performed for children with acute appendicitis at nonpediatric treatment centers. All patients treated for acute appendicitis at our tertiary-care pediatric hospital from July 1, 2011, through June 30, 2012, were identified. Patient demographics, imaging modality used to diagnoses appendicitis (CT or ultrasound), location (home or referral institution), and CT technique parameters were collected. The estimated mean organ radiation dose, number of imaging phases, and use of contrast media were evaluated at home and referral institutions. During the study period, 1215 patients underwent appendectomies after imaging, with 442 (36.4%) imaged at referral facilities. Most referral patients received a diagnosis by CT (n=384, 87%), compared with 73 of 773 (9.4%) who received a diagnosis by CT at the home institution. The estimated mean (±SD) organ radiation dose was not statistically significantly different between home and referral institutions (13.5±7.3 vs 12.9±6.4 mGy; p=0.58) for single-phase examinations. Of 384 referral patients, 344 had images available for review. In total, 40% (138/344) of patients from referral centers were imaged with suboptimal CT techniques: 50 delayed phase only, 52 dual phase (eight of which were imaged twice in delayed phase), eight triple phase, and 36 without IV contrast agent. CT parameters and radiation doses from single-phase examinations in children with appendicitis were similar at nonpediatric treatment centers and a tertiary care children's hospital. Future educational outreach should focus on optimizing other technical parameters.

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

PubMed

Jablonski, Kathleen A; Guagliardo, Mark F

2005-05-04

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

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

PubMed

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

2017-12-01

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

Immunoproteasome in the blood plasma of children with acute appendicitis, and its correlation with proteasome and UCHL1 measured by SPR imaging biosensors.

PubMed

Matuszczak, E; Sankiewicz, A; Debek, W; Gorodkiewicz, E; Milewski, R; Hermanowicz, A

2018-01-01

The aim of this study was to determinate the immunoproteasome concentration in the blood plasma of children with appendicitis, and its correlation with circulating proteasome and ubiquitin carboxyl-terminal hydrolase L1 (UCHL1). Twenty-seven children with acute appendicitis, managed at the Paediatric Surgery Department, were included randomly into the study (age 2 years 9 months up to 14 years, mean age 9·5 ± 1 years). There were 10 girls and 17 boys; 18 healthy, age-matched subjects, admitted for planned surgeries served as controls. Mean concentrations of immunoproteasome, 20S proteasome and UCHL1 in the blood plasma of children with appendicitis before surgery 24 h and 72 h after the appendectomy were higher than in the control group. The immunoproteasome, 20S proteasome and UCHL1 concentrations in the blood plasma of patients with acute appendicitis were highest before surgery. The immunoproteasome, 20S proteasome and UCHL1 concentration measured 24 and 72 h after the operation decreased slowly over time and still did not reach the normal range (P < 0·05). There was no statistical difference between immunoproteasome, 20S proteasome and UCHL1 concentrations in children operated on laparoscopically and children after classic appendectomy. The immunoproteasome concentration may reflect the metabolic response to acute state inflammation, and the process of gradual ebbing of the inflammation may thus be helpful in the assessment of the efficacy of treatment. The method of operation - classic open appendectomy or laparoscopic appendectomy - does not influence the general trend in immunoproteasome concentration in children with appendicitis. © 2017 British Society for Immunology.

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

PubMed

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

2017-09-01

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

Early appendectomy reduces costs in children with perforated appendicitis.

PubMed

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

2017-12-01

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

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

PubMed

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

2017-08-01

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

Association between climatic elements and acute appendicitis in Japan.

PubMed

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

2017-05-01

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

Cost analysis of nonoperative management of acute appendicitis in children.

PubMed

Mudri, Martina; Coriolano, Kamary; Bütter, Andreana

2017-05-01

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

A Feasibility Study of Smartphone-Based Telesonography for Evaluating Cardiac Dynamic Function and Diagnosing Acute Appendicitis with Control of the Image Quality of the Transmitted Videos.

PubMed

Kim, Changsun; Cha, Hyunmin; Kang, Bo Seung; Choi, Hyuk Joong; Lim, Tae Ho; Oh, Jaehoon

2016-06-01

Our aim was to prove the feasibility of the remote interpretation of real-time transmitted ultrasound videos of dynamic and static organs using a smartphone with control of the image quality given a limited internet connection speed. For this study, 100 cases of echocardiography videos (dynamic organ)-50 with an ejection fraction (EF) of ≥50 s and 50 with EF <50 %-and 100 cases of suspected pediatric appendicitis (static organ)-50 with signs of acute appendicitis and 50 with no findings of appendicitis-were consecutively selected. Twelve reviewers reviewed the original videos using the liquid crystal display (LCD) monitor of an ultrasound machine and using a smartphone, to which the images were transmitted from the ultrasound machine. The resolution of the transmitted echocardiography videos was reduced by approximately 20 % to increase the frame rate of transmission given the limited internet speed. The differences in diagnostic performance between the two devices when evaluating left ventricular (LV) systolic function by measuring the EF and when evaluating the presence of acute appendicitis were investigated using a five-point Likert scale. The average areas under the receiver operating characteristic curves for each reviewer's interpretations using the LCD monitor and smartphone were respectively 0.968 (0.949-0.986) and 0.963 (0.945-0.982) (P = 0.548) for echocardiography and 0.972 (0.954-0.989) and 0.966 (0.947-0.984) (P = 0.175) for abdominal ultrasonography. We confirmed the feasibility of remotely interpreting ultrasound images using smartphones, specifically for evaluating LV function and diagnosing pediatric acute appendicitis; the images were transferred from the ultrasound machine using image quality-controlled telesonography.

Three-step sequential positioning algorithm during sonographic evaluation for appendicitis increases appendiceal visualization rate and reduces CT use.

PubMed

Chang, Stephanie T; Jeffrey, R Brooke; Olcott, Eric W

2014-11-01

The purpose of this article is to examine the rates of appendiceal visualization by sonography, imaging-based diagnoses of appendicitis, and CT use after appendiceal sonography, before and after the introduction of a sonographic algorithm involving sequential changes in patient positioning. We used a search engine to retrospectively identify patients who underwent graded-compression sonography for suspected appendicitis during 6-month periods before (period 1; 419 patients) and after (period 2; 486 patients) implementation of a new three-step positional sonographic algorithm. The new algorithm included initial conventional supine scanning and, as long as the appendix remained nonvisualized, left posterior oblique scanning and then "second-look" supine scanning. Abdominal CT within 7 days after sonography was recorded. Between periods 1 and 2, appendiceal visualization on sonography increased from 31.0% to 52.5% (p < 0.001), postsonography CT use decreased from 31.3% to 17.7% (p < 0.001), and the proportion of imaging-based diagnoses of appendicitis made by sonography increased from 63.8% to 85.7% (p = 0.002). The incidence of appendicitis diagnosed by imaging (either sonography or CT) remained similar at 16.5% and 17.3%, respectively (p = 0.790). Sensitivity and overall accuracy were 57.8% (95% CI, 44.8-70.1%) and 93.0% (95% CI, 90.1-95.3%), respectively, in period 1 and 76.5% (95% CI, 65.8-85.2%) and 95.4% (95% CI, 93.1-97.1%), respectively, in period 2. Similar findings were observed for adults and children. Implementation of an ultrasound algorithm with sequential positioning significantly improved the appendiceal visualization rate and the proportion of imaging-based diagnoses of appendicitis made by ultrasound, enabling a concomitant decrease in abdominal CT use in both children and adults.

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

PubMed

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

2015-11-01

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

Undigested Pills in Stool Mimicking Parasitic Infection.

PubMed

Mir, Fazia; Achakzai, Ilyas; Ibdah, Jamal A; Tahan, Veysel

2017-01-01

Background . Orally ingested medications now come in both immediate release and controlled release preparations. Controlled release preparations were developed by pharmaceutical companies to improve compliance and decrease frequency of pill ingestion. Case Report . A 67-year-old obese male patient presented to our clinic with focal abdominal pain that had been present 3 inches below umbilicus for the last three years. This pain was not associated with any trauma or recent heavy lifting. Upon presentation, the patient reported that for the last two months he started to notice pearly oval structures in his stool accompanying his chronic abdominal pain. This had coincided with initiation of his nifedipine pills for his hypertension. He reported seeing these undigested pills daily in his stool. Conclusion . The undigested pills may pose a cause of concern for both patients and physicians alike, as demonstrated in this case report, because they can mimic a parasitic infection. This can result in unnecessary extensive work-up. It is important to review the medication list for extended release formulations and note that the outer shell can be excreted whole in the stool.

Antinociceptive and pronociceptive effect of levetiracetam in tonic pain model.

PubMed

Cortes-Altamirano, José Luis; Reyes-Long, Samuel; Olmos-Hernández, Adriana; Bonilla-Jaime, Herlinda; Carrillo-Mora, Paul; Bandala, Cindy; Alfaro-Rodriguez, Alfonso

2018-04-01

Levetiracetam (LEV) is a novel anticonvulsant with proven antinociceptive properties. However, the antinociceptive and pronociceptive effect of this drug has not yet been fully elucidated in a tonic pain model. Thirty-six male rats (Wistar) were randomized into six groups and underwent the formalin test as follows: rats in the control group were administered 50μL of 1% formalin in the paw; sham-group rats were administered 50μL of saline in the paw to mimick the application of formalin; the four experimental groups were administered LEV intragastrically (ig) (50, 100, 200 and 300mg/kg), and 40min later 50μL of 1% formalin was injected in the paw. LEV exhibited antinociceptive effect in the 300mg/kg LEV group (p<0.05) and a pronociceptive effect in the 100mg/kg LEV group (p<0.05) and in the 50mg/kg LEV group (p<0.001). The antinociceptive and pronociceptive effect of LEV in a tonic pain model is dose-dependent. Copyright © 2017 Institute of Pharmacology, Polish Academy of Sciences. Published by Elsevier B.V. All rights reserved.

Acid mediates a prolonged antinociception via substance P signaling in acid-induced chronic widespread pain.

PubMed

Chen, Wei-Nan; Chen, Chih-Cheng

2014-05-21

Substance P is an important neuropeptide released from nociceptors to mediate pain signals. We recently revealed antinociceptive signaling by substance P in acid-sensing ion channel 3 (ASIC3)-expressing muscle nociceptors in a mouse model of acid-induced chronic widespread pain. However, methods to specifically trigger the substance P antinociception were still lacking. Here we show that acid could induce antinociceptive signaling via substance P release in muscle. We prevented the intramuscular acid-induced hyperalgesia by pharmacological inhibition of ASIC3 and transient receptor potential V1 (TRPV1). The antinociceptive effect of non-ASIC3, non-TRPV1 acid signaling lasted for 2 days. The non-ASIC3, non-TRPV1 acid antinociception was largely abolished in mice lacking substance P. Moreover, pretreatment with substance P in muscle mimicked the acid antinociceptive effect and prevented the hyperalgesia induced by next-day acid injection. Acid could mediate a prolonged antinociceptive signaling via the release of substance P from muscle afferent neurons in a non-ASIC3, non-TRPV1 manner.

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

PubMed

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

2013-06-01

Acute appendicitis is a common medical condition, whose effective, timely diagnosis can be difficult. A missed diagnosis not only puts the patient in danger but also requires additional resources for corrective treatments. An acute appendicitis diagnosis constitutes a classification problem, for which a further fundamental challenge pertains to the skewed outcome class distribution of instances in the training sample. A preclustering-based ensemble learning (PEL) technique aims to address the associated imbalanced sample learning problems and thereby support the timely, accurate diagnosis of acute appendicitis. The proposed PEL technique employs undersampling to reduce the number of majority-class instances in a training sample, uses preclustering to group similar majority-class instances into multiple groups, and selects from each group representative instances to create more balanced samples. The PEL technique thereby reduces potential information loss from random undersampling. It also takes advantage of ensemble learning to improve performance. We empirically evaluate this proposed technique with 574 clinical cases obtained from a comprehensive tertiary hospital in southern Taiwan, using several prevalent techniques and a salient scoring system as benchmarks. The comparative results show that PEL is more effective and less biased than any benchmarks. The proposed PEL technique seems more sensitive to identifying positive acute appendicitis than the commonly used Alvarado scoring system and exhibits higher specificity in identifying negative acute appendicitis. In addition, the sensitivity and specificity values of PEL appear higher than those of the investigated benchmarks that follow the resampling approach. Our analysis suggests PEL benefits from the more representative majority-class instances in the training sample. According to our overall evaluation results, PEL records the best overall performance, and its area under the curve measure reaches 0.619. The PEL technique is capable of addressing imbalanced sample learning associated with acute appendicitis diagnosis. Our evaluation results suggest PEL is less biased toward a positive or negative class than the investigated benchmark techniques. In addition, our results indicate the overall effectiveness of the proposed technique, compared with prevalent scoring systems or salient classification techniques that follow the resampling approach. Copyright © 2013 Elsevier B.V. All rights reserved.

Economic evaluation of antibiotic therapy versus appendicectomy for the treatment of uncomplicated acute appendicitis from the APPAC randomized clinical trial.

PubMed

Sippola, S; Grönroos, J; Tuominen, R; Paajanen, H; Rautio, T; Nordström, P; Aarnio, M; Rantanen, T; Hurme, S; Salminen, P

2017-09-01

An increasing amount of evidence supports antibiotic therapy for treating uncomplicated acute appendicitis. The objective of this study was to compare the costs of antibiotics alone versus appendicectomy in treating uncomplicated acute appendicitis within the randomized controlled APPAC (APPendicitis ACuta) trial. The APPAC multicentre, non-inferiority RCT was conducted on patients with CT-confirmed uncomplicated acute appendicitis. Patients were assigned randomly to appendicectomy or antibiotic treatment. All costs were recorded, whether generated by the initial visit and subsequent treatment or possible recurrent appendicitis during the 1-year follow-up. The cost estimates were based on cost levels for the year 2012. Some 273 patients were assigned to the appendicectomy group and 257 to antibiotic treatment. Most patients randomized to antibiotic treatment did not require appendicectomy during the 1-year follow-up. In the operative group, overall societal costs (€5989·2, 95 per cent c.i. 5787·3 to 6191·1) were 1·6 times higher (€2244·8, 1940·5 to 2549·1) than those in the antibiotic group (€3744·4, 3514·6 to 3974·2). In both groups, productivity losses represented a slightly higher proportion of overall societal costs than all treatment costs together, with diagnostics and medicines having a minor role. Those in the operative group were prescribed significantly more sick leave than those in the antibiotic group (mean(s.d.) 17·0(8·3) (95 per cent c.i. 16·0 to 18·0) versus 9·2(6·9) (8·3 to 10·0) days respectively; P < 0·001). When the age and sex of the patient as well as the hospital were controlled for simultaneously, the operative treatment generated significantly more costs in all models. Patients receiving antibiotic therapy for uncomplicated appendicitis incurred lower costs than those who had surgery. © 2017 BJS Society Ltd Published by John Wiley & Sons Ltd.

Peripheral Nerve Injury Leads to Working Memory Deficits and Dysfunction of the Hippocampus by Upregulation of TNF-α in Rodents

PubMed Central

Ren, Wen-Jie; Liu, Yong; Zhou, Li-Jun; Li, Wei; Zhong, Yi; Pang, Rui-Ping; Xin, Wen-Jun; Wei, Xu-Hong; Wang, Jun; Zhu, He-Quan; Wu, Chang-You; Qin, Zhi-Hai; Liu, Guosong; Liu, Xian-Guo

2011-01-01

Patients with chronic pain usually suffer from working memory deficits, which may decrease their intellectual ability significantly. Despite intensive clinical studies, the mechanism underlying this form of memory impairment remains elusive. In this study, we investigated this issue in the spared nerve injury (SNI) model of neuropathic pain, a most common form of chronic pain. We found that SNI impaired working memory and short-term memory in rats and mice. To explore the potential mechanisms, we studied synaptic transmission/plasticity in hippocampus, a brain region critically involved in memory function. We found that frequency facilitation, a presynaptic form of short-term plasticity, and long-term potentiation at CA3–CA1 synapses were impaired after SNI. Structurally, density of presynaptic boutons in hippocampal CA1 synapses was reduced significantly. At the molecular level, we found that tumor necrosis factor-α (TNF-α) increased in cerebrospinal fluid, in hippocampal tissue and in plasma after SNI. Intracerebroventricular or intrahippocampal injection of recombinant rat TNF mimicked the effects of SNI in naive rats, whereas inhibition of TNF-α or genetic deletion of TNF receptor 1 prevented both memory deficits and synaptic dysfunction induced by SNI. As TNF-α is critical for development of neuropathic pain, we suggested that the over-production of TNF-α following peripheral nerve injury might lead to neuropathic pain and memory deficits, simultaneously. PMID:21289602

The transcription factor C/EBPβ in the dorsal root ganglion contributes to peripheral nerve trauma–induced nociceptive hypersensitivity

PubMed Central

Li, Zhisong; Mao, Yuanyuan; Liang, Lingli; Wu, Shaogen; Yuan, Jingjing; Mo, Kai; Cai, Weihua; Mao, Qingxiang; Cao, Jing; Bekker, Alex; Zhang, Wei; Tao, Yuan-Xiang

2017-01-01

Changes in gene transcription in the dorsal root ganglion (DRG) after nerve trauma contribute to the genesis of neuropathic pain. We report that peripheral nerve trauma caused by chronic constriction injury (CCI) increased the abundance of the transcription factor C/EBPβ (CCAAT/enhancer binding protein β) in the DRG. Blocking this increase mitigated the development and maintenance of CCI-induced mechanical, thermal, and cold pain hypersensitivities without affecting basal responses to acute pain and locomotor activity. Conversely, mimicking this increase produced hypersensitivity to mechanical, thermal, or cold pain. In the ipsilateral DRG, C/EBPβ promoted a decrease in the abundance of the voltage-gated potassium channel subunit Kv1.2 and µ opioid receptor (MOR) at the mRNA and protein levels, which would be predicted to increase excitability in the ipsilateral DRG neurons and reduce the efficacy of morphine analgesia. These effects required C/EPBβ-mediated transcriptional activation of Ehmt2 (euchromatic histonelysine N-methyltransferase 2), which encodes G9a, an epigenetic silencer of the genes encoding Kv1.2 and MOR. Blocking the increase in C/EBPβ in the DRG improved morphine analgesia after CCI. These results suggest that C/EBPβ is an endogenous initiator of neuropathic pain and could be a potential target for the prevention and treatment of this disorder. PMID:28698219

Accumulation of methylglyoxal increases the advanced glycation end-product levels in DRG and contributes to lumbar disk herniation-induced persistent pain.

PubMed

Liu, Cui-Cui; Zhang, Xin-Sheng; Ruan, Yu-Ting; Huang, Zhu-Xi; Zhang, Su-Bo; Liu, Meng; Luo, Hai-Jie; Wu, Shao-Ling; Ma, Chao

2017-08-01

Lumbar disk herniation (LDH) with discogenic low back pain and sciatica is a common and complicated musculoskeletal disorder. The underlying mechanisms are poorly understood, and there are no effective therapies for LDH-induced pain. In the present study, we found that the patients who suffered from LDH-induced pain had elevated plasma methylglyoxal (MG) levels. In rats, implantation of autologous nucleus pulposus (NP) to the left lumbar 5 spinal nerve root, which mimicked LDH, induced mechanical allodynia, increased MG level in plasma and dorsal root ganglion (DRG), and enhanced the excitability of small DRG neurons (<30 μm in diameter). Intrathecal injection of MG also induced mechanical allodynia, and its application to DRG neurons ex vivo increased the number of action potentials evoked by depolarizing current pulses. Furthermore, inhibition of MG accumulation by aminoguanidine attenuated the enhanced excitability of small DRG neurons and the mechanical allodynia induced by NP implantation. In addition, NP implantation increased levels of advanced glycation end products (AGEs) in DRG, and intrathecal injection of MG-derived AGEs induced the mechanical allodynia and DRG neuronal hyperactivity. Intrathecal injection of MG also significantly increased the expression of AGEs in DRG. Importantly, scavenging of MG by aminoguanidine also attenuated the increase in AGEs induced by NP implantation. These results suggested that LDH-induced MG accumulation contributed to persistent pain by increasing AGE levels. Thus generation of AGEs from MG may represent a target for treatment of LDH-induced pain. NEW & NOTEWORTHY Our study demonstrates that methylglyoxal accumulation via increasing advanced glycation end-product levels in dorsal root ganglion contributes to the persistent pain induced by lumbar disk herniation, which proposed potential targets for the treatment of lumbar disk herniation-induced persistent pain. Copyright © 2017 the American Physiological Society.

Utility of CT after sonography for suspected appendicitis in children: integration of a clinical scoring system with a staged imaging protocol.

PubMed

Srinivasan, Abhay; Servaes, Sabah; Peña, Andrès; Darge, Kassa

2015-02-01

To improve diagnosis of pediatric appendicitis, many institutions have implemented a staged imaging protocol utilizing ultrasonography (US) first and then computed tomography (CT). A substantial number of children with suspected appendicitis undergo CT after US, and the efficient and accurate diagnosis of pediatric appendicitis continues to be challenging. The objective of the study is to characterize the utility of CT following US for diagnosis of pediatric appendicitis, in conjunction with a clinical appendicitis score (AS). Imaging studies of children with suspected appendicitis who underwent CT after US in an imaging protocol were retrospectively reviewed by three radiologists in consensus. Chart review derived the AS (range 0-10) and obtained the patient diagnosis and disposition, and an AS was applied to each patient. Clinical and radiologic data were analyzed to assess the yield of CT after US. Studies of 211 children (mean age 11.3 years) were included. The positive threshold for AS was determined to be 6 out of 10. When AS and US were concordant (N = 140), the sensitivity and specificity of US were similar to CT. When AS and US were discordant (N = 71) and also when AS ≥ 6 (N = 84), subsequent CT showed superior sensitivity and specificity to US alone. In the subset where US showed neither the appendix nor inflammatory change in the right lower quadrant (126/211, 60 % of scans), when AS < 6 (N = 83), the negative predictive value (NPV) of US was 0.98. However, when AS ≥ 6 (N = 43), NPV of US was 0.58, and the positive predictive value of subsequent CT was 1. There was a significant decrease in depiction of the appendix on US with patient weight-to-age ratio of >6 (kg/year, P < 0.001) and after-hours (1700 -0730 hours) performance of US (P < 0.001). Results suggest that the appendicitis score has utility in guiding an imaging protocol and support the contention that non-visualization of the appendix on US is not intrinsically non-diagnostic. There was little benefit to additional CT when AS < 6 and US did not show the appendix or evidence of inflammation; this would have avoided CT in 140/211 (66 %) patients. CT demonstrated benefit when AS ≥ 6, suggesting that cases with AS ≥ 6 and features that limit depiction of the appendix on US may be triaged to CT.

The cost-effectiveness of nonoperative management versus laparoscopic appendectomy for the treatment of acute, uncomplicated appendicitis in children.

PubMed

Wu, James X; Sacks, Greg D; Dawes, Aaron J; DeUgarte, Daniel; Lee, Steven L

2017-07-01

Several studies have demonstrated the safety and short-term success of nonoperative management in children with acute, uncomplicated appendicitis. Nonoperative management spares the patients and their family the upfront cost and discomfort of surgery, but also risks recurrent appendicitis. Using decision-tree software, we evaluated the cost-effectiveness of nonoperative management versus routine laparoscopic appendectomy. Model variables were abstracted from a review of the literature, Healthcare Cost and Utilization Project, and Medicare Physician Fee schedule. Model uncertainty was assessed using both one-way and probabilistic sensitivity analyses. We used a $100,000 per quality adjusted life year (QALY) threshold for cost-effectiveness. Operative management cost $11,119 and yielded 23.56 quality-adjusted life months (QALMs). Nonoperative management cost $2277 less than operative management, but yielded 0.03 fewer QALMs. The incremental cost-to-effectiveness ratio of routine laparoscopic appendectomy was $910,800 per QALY gained. This greatly exceeds the $100,000/QALY threshold and was not cost-effective. One-way sensitivity analysis found that operative management would become cost-effective if the 1-year recurrence rate of acute appendicitis exceeded 39.8%. Probabilistic sensitivity analysis indicated that nonoperative management was cost-effective in 92% of simulations. Based on our model, nonoperative management is more cost-effective than routine laparoscopic appendectomy for children with acute, uncomplicated appendicitis. Cost-Effectiveness Study: Level II. Published by Elsevier Inc.

Sarcopenia in children with perforated appendicitis.

PubMed

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

2017-12-01

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

Added Value of Coronal Reformations for Duty Radiologists and for Referring Physicians or Surgeons in the CT Diagnosis of Acute Appendicitis

PubMed Central

Lee, Kyoung Ho; Hahn, Seokyung; Lee, Kyung Won; Lee, Hak Jong; Kim, Tae Jung; Kang, Sung-Bum; Shin, Joong Ho; Park, Byung Joo

2006-01-01

Objective To assess the added value of coronal reformation for radiologists and for referring physicians or surgeons in the CT diagnosis of acute appendicitis. Materials and Methods Contrast-enhanced CT was performed using 16-detector-row scanners in 110 patients, 46 of whom had appendicitis. Transverse (5-mm thickness, 4-mm increment), coronal (5-mm thickness, 4-mm increment), and combined transverse and coronal sections were interpreted by four radiologists, two surgeons and two emergency physicians. The area under the receiver operating characteristic curve (Az value), sensitivity, specificity (McNemar test), diagnostic confidence and appendiceal visualization (Wilcoxon signed rank test) were compared. Results For radiologists, the additional coronal sections tended to increase the Az value (0.972 vs. 0.986, p = 0.076) and pooled sensitivity (92% [95% CI: 88, 96] vs. 96% [93, 99]), and enhanced appendiceal visualization in true-positive cases (p = 0.031). For non-radiologists, no such enhancement was observed, and the confidence for excluding acute appendicitis declined (p = 0.013). Coronal sections alone were inferior to transverse sections for diagnostic confidence as well as appendiceal visualization for each reader group studied (p < 0.05). Conclusion The added value of coronal reformation is more apparent for radiologists compared to referring physicians or surgeons in the CT diagnosis of acute appendicitis. PMID:16799269

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

PubMed

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

2016-01-01

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

Mercury Toxicity Following Unauthorized Siddha Medicine Intake – A Mimicker of Acquired Neuromyotonia - Report of 32 Cases

PubMed Central

Gnanashanmugam, G.; Balakrishnan, R.; Somasundaram, S. P.; Parimalam, N.; Rajmohan, P.; Pranesh, M. B.

2018-01-01

Context: Mercury is used extensively in the preparation of Siddha medicines, after purification. In this study, we present 32 patients of mercury toxicity following unauthorized Siddha medicine intake who mimicked neuromyotonia clinically. We analyzed the clinical features of these patients, the role of autoimmunity in etiopathology, and compared it with acquired neuromyotonia. Subjects and Methods: This is a retrospective study to analyze inpatients in a tertiary care center, admitted with mercury toxicity following Siddha medicine intake from August 2012 to October 2016. We analyzed the clinical features, laboratory data including mercury, arsenic and lead levels in blood, and serum voltage-gated potassium channels (VGKC)-CASPR2 Ab in selected patients. Results: Thirty-two patients who had high blood mercury levels following Siddha medicine intake were included in the study. All patients (100%) had severe intractable neuropathic pain predominantly involving lower limbs. Twenty-six (81.25%) patients had fasciculations and myokymia. Fifteen patients (46.86%) had autonomic dysfunction (postural hypotension and resting tachycardia). Nine (28.12%) patients had encephalopathic features such as dullness, apathy, drowsiness, or delirium. Anti-VGKC Ab was positive in 12 patients with myokymia. All the patients in the study consumed Siddha medicines obtained from unauthorized dealers. Conclusions: Mercury toxicity following Siddha medicine intake closely mimics acquired neuromyotonia; severe intolerable neuropathic pain is the hallmark feature; Positive VGKC-CASPR2 antibody in some patients must be due to triggered autoimmunity secondary to mercury toxicity due to Siddha medicine intake. The government should establish licensing system to prevent distribution of unauthorized Siddha medicines. PMID:29720798

Mercury Toxicity Following Unauthorized Siddha Medicine Intake - A Mimicker of Acquired Neuromyotonia - Report of 32 Cases.

PubMed

Gnanashanmugam, G; Balakrishnan, R; Somasundaram, S P; Parimalam, N; Rajmohan, P; Pranesh, M B

2018-01-01

Mercury is used extensively in the preparation of Siddha medicines, after purification. In this study, we present 32 patients of mercury toxicity following unauthorized Siddha medicine intake who mimicked neuromyotonia clinically. We analyzed the clinical features of these patients, the role of autoimmunity in etiopathology, and compared it with acquired neuromyotonia. This is a retrospective study to analyze inpatients in a tertiary care center, admitted with mercury toxicity following Siddha medicine intake from August 2012 to October 2016. We analyzed the clinical features, laboratory data including mercury, arsenic and lead levels in blood, and serum voltage-gated potassium channels (VGKC)-CASPR2 Ab in selected patients. Thirty-two patients who had high blood mercury levels following Siddha medicine intake were included in the study. All patients (100%) had severe intractable neuropathic pain predominantly involving lower limbs. Twenty-six (81.25%) patients had fasciculations and myokymia. Fifteen patients (46.86%) had autonomic dysfunction (postural hypotension and resting tachycardia). Nine (28.12%) patients had encephalopathic features such as dullness, apathy, drowsiness, or delirium. Anti-VGKC Ab was positive in 12 patients with myokymia. All the patients in the study consumed Siddha medicines obtained from unauthorized dealers. Mercury toxicity following Siddha medicine intake closely mimics acquired neuromyotonia; severe intolerable neuropathic pain is the hallmark feature; Positive VGKC-CASPR2 antibody in some patients must be due to triggered autoimmunity secondary to mercury toxicity due to Siddha medicine intake. The government should establish licensing system to prevent distribution of unauthorized Siddha medicines.

Endometriosis of umbilical cicatrix: case report and review of the literature.

PubMed

Rosina, Paolo; Pugliarello, Silvia; Colato, Chiara; Girolomoni, Giampiero

2008-01-01

Umbilical endometriosis has an estimated incidence of 0.5%-1% of all patients with endometrial ectopia. It is a very rare disease, but should be considered on the differential diagnosis of umbilical lesions. We report on a case of spontaneous umbilical endometriosis in a 38-year-old woman, with a dark brown nodule periodically bleeding, associated with severe abdominal pain. There was no history of endometriosis and she had not been pregnant before. Laparoscopic visualization of pelvic cavity showed bilateral ovarian endometrioma (it was removed while sparing the ovaries). Surgical treatment proved effective. Cutaneous endometriosis could be a sign of internal endometriosis. Presentations may be atypical and pose diagnostic difficulty, mimicking other acute diseases, e.g., skin neoplasm, folliculitis, etc., but it should be suspected in any female presenting with a painful or bleeding mass close to the umbilicus or abdominal surgical scar.

Incidence of three presentations of acute myocarditis in young men in military service. A 20-year experience.

PubMed

Karjalainen, J; Heikkilä, J

1999-08-01

The incidence of myocarditis is uncertain as diagnostic criteria have been vague. We evaluated the incidence of myocarditis presenting in three well defined forms (mimicking myocardial infarction, presenting as dilated cardiomyopathy, and as a cause of sudden death) in young men in military service over a 20-year period. The study population consisted of 672 672 Finnish men at a mean age of 20 years conscripted from 1977-1996. All those suspected of having myocardial disease were studied prospectively in the same institution. A clinical diagnosis of myocarditis mimicking myocardial infarction required ECG signs (ST-segment elevation followed by T-wave inversion) and a simultaneous detection of serum markers of acute myocardial injury (CK-MB and/or troponin T) in an infectious patient with chest pain. This form of myocarditis was diagnosed in 98 men, the incidence being 0.17 (95% CI 0.14-0.21). 1000 man-years(-1). Causative microbes were those commonly infecting the conscripts, but Coxsackievirus aetiology could be confirmed in only 4% of the cases. Nine patients presented with dilated cardiomyopathy of recent origin (incidence 0.02. 1000 man-years(-1)). None had histopathological evidence of myocarditis. Myocarditis caused one of the 10 sudden unexpected deaths (incidence 0.002. 1000 man-years(-1)). The usual presentation of acute myocarditis in young men mimicks alterations evoked by myocardial infarction but not those of dilated cardiomyopathy. Copyright 1999 The European Society of Cardiology.

Effect of MELT method on thoracolumbar connective tissue: The full study.

PubMed

Sanjana, Faria; Chaudhry, Hans; Findley, Thomas

2017-01-01

Altered connective tissue structure has been identified in adults with chronic low back pain (LBP). A self-care treatment for managing LBP is the MELT method. The MELT method is a hands-off, self-treatment that is said to alleviate chronic pain, release tension and restore mobility, utilizing specialized soft treatments balls, soft body roller and techniques mimicking manual therapy. The objective of this study was to determine whether thickness of thoracolumbar connective tissue and biomechanical and viscoelastic properties of myofascial tissue in the low back region change in subjects with chronic LBP as a result of MELT. This study was designed using a quasi experimental pre-post- design that analyzed data from subjects who performed MELT. Using ultrasound imaging and an algorithm developed in MATLAB, thickness of thoracolumbar connective tissue was analyzed in 22 subjects. A hand-held digital palpation device, called the MyotonPRO, was used to assess biomechanical properties such as stiffness, elasticity, tone and mechanical stress relaxation time of the thoracolumbar myofascial tissue. A forward bending test assessing flexibility and pain scale was added to see if MELT affected subjects with chronic LBP. A significant decrease in connective tissue thickness and pain was observed in participants. Significant increase in flexibility was also recorded. Copyright © 2016 Elsevier Ltd. All rights reserved.

Electroacupuncture to alleviate postoperative pain after a laparoscopic appendectomy: study protocol for a three-arm, randomised, controlled trial.

PubMed

Lee, Seunghoon; Nam, Dongwoo; Kwon, Minsoo; Park, Won Seo; Park, Sun Jin

2017-08-04

The purpose of this study is to evaluate the efficacy and safety of electroacupuncture (EA) for postoperative pain after laparoscopic appendectomy compared with sham electroacupuncture (SEA) and no acupuncture treatment. This study is a protocol for a three-arm, randomised, patient-assessor-blinded (to the type of acupuncture treatment), controlled, parallel trial. 138 participants diagnosed with appendicitis and scheduled for laparoscopic appendectomy will be randomly assigned to the EA group (n=46), SEA group (n=46) or control group (n=46). The EA group will receive acupuncture treatment at both regional and distal acupuncture points with electrostimulation. The SEA group will receive sham acupuncture treatment with mock electrostimulation. Both EA and SEA groups will receive a total of four treatments 1 hour preoperative, 1 hour postoperative and during the morning and afternoon the day after surgery with the same routine postoperative pain control. The control group will receive only routine postoperative pain control. The primary outcome is the 11-point Pain Intensity Numerical Rating Scale (PI-NRS) at 24 hours after surgery. The secondary outcomes are the PI-NRS, analgesic consumption, opioid-related side effects, time to first passing flatus, quality of life and adverse events evaluated 6, 12, 24 and 36 hours and 7 days after surgery. The study was planned in accordance with the Helsinki Declaration and the Korean Good Clinical Practice Guidelines to protect the participants and was approved by the institutional review board (IRB) of Kyung Hee University Medical Center (KMC IRB-1427-02). The results will be disseminated in peer-reviewed journals and presented at international conferences. Clinical Research Information Service (KCT0001328). © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Point Cloud Storage and Access on a Global Scale

DTIC Science & Technology

2015-01-01

coordinates. These Geodetic values are appended to the list of parameters and are re-projected into WGS84 Geocentric (ECEF X,Y,Z), replacing the original...Append Lon,Lat,Alt to point parameters Re-project point with Proj.4 from Geodetic (Lon,Lat,Alt) -> Geocentric (X,Y,Z) Insert point into

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

PubMed

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

2013-01-14

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

N-heterocyclic carbene gold(I) and silver(I) complexes bearing functional groups for bio-conjugation

PubMed Central

Garner, Mary E.; Niu, Weijia; Chen, Xigao; Ghiviriga, Ion; Tan, Weihong; Veige, Adam S.

2015-01-01

This work describes several synthetic approaches to append organic functional groups to gold and silver N-heterocyclic carbene (NHC) complexes suitable for applications in biomolecule conjugation. Carboxylate appended NHC ligands (3) lead to unstable AuI complexes that convert into bis-NHC species (4). A benzyl protected carboxylate NHC-AuI complex 2 was synthesized but deprotection to produce the carboxylic acid functionality could not be achieved. A small library of new alkyne functionalized NHC proligands were synthesized and used for subsequent silver and gold metalation reactions. The alkyne appended NHC gold complex 13 readily react with benzyl azide in a copper catalyzed azide-alkyne cycloaddition reaction to form the triazole appended NHC gold complex 14. Cell cytotoxicity studies were performed on DLD-1 (colorectal adenocarcinoma), Hep-G2 (hepatocellular carcinoma), MCF-7 (breast adenocarcinoma), CCRF-CEM (human T-Cell leukemia), and HEK (human embryonic kidney). Complete spectroscopic characterization of the ligands and complexes was achieved using 1H and 13C NMR, gHMBC, ESI-MS, and combustion analysis. PMID:25490699

Unusual Presentation of Duodenal Ulcer Presenting with Duodenal Intussusception.

PubMed

Lingala, Shilpa; Moore, Andrew; Kadire, Siri; Shankar, Sridhar; Das, Kanak; Howden, Colin W

2018-01-01

We present a unique case of duodeno-duodenal intussusception from a duodenal bulb ulcer. A 38-year-old man presented with nausea, vomiting, and abdominal pain. Computed tomography showed duodenal intussusception. Esophagogastroduodenoscopy (EGD) showed a linear gastric ulcer and a duodenal bulb ulcer with an overlying blood clot. Helicobacter pylori status was positive. Intussusception resolved spontaneously without intervention. He completed treatment for H. pylori infection, and repeat EGD showed ulcer healing. Duodenal intussusception is rarely reported; intussusception from an edematous duodenal ulcer with an overlying blood clot mimicking a mass lesion acting as lead point has never been reported to our knowledge.

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

PubMed

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

2016-07-01

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

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

PubMed

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

2011-12-01

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

[Perforated neonatal appendicitis in a preterm newborn].

PubMed

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

2014-01-01

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

Randomized clinical trial of antibiotic therapy for uncomplicated appendicitis.

PubMed

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

2017-12-01

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

SU-F-I-36: In-Utero Dose Measurements Within Postmortem Subjects for Estimating Fetal Doses in Pregnant Patients Examined with Pulmonary Embolism, Trauma, and Appendicitis CT

DOE Office of Scientific and Technical Information (OSTI.GOV)

Lipnharski, I; Quails, N; Carranza, C

Purpose: The imaging of pregnant patients is medically necessary in certain clinical situations. The purpose of this work was to directly measure uterine doses in a cadaver scanned with CT protocols commonly performed on pregnant patients in order to estimate fetal dose and assess potential risk. Method: One postmortem subject was scanned on a 320-slice CT scanner with standard pulmonary embolism, trauma, and appendicitis protocols. All protocols were performed with the scan parameters and ranges currently used in clinical practice. Exams were performed both with and without iterative reconstruction to highlight the dose savings potential. Optically stimulated luminescent dosimeters (OSLDs)more » were inserted into the uterus in order to approximate fetal doses. Results: In the pulmonary embolism CT protocol, the uterus is outside of the primary beam, and the dose to the uterus was under 1 mGy. In the trauma and appendicitis protocols, the uterus is in the primary beam, the fetal dose estimates were 30.5 mGy for the trauma protocol, and 20.6 mGy for the appendicitis protocol. Iterative reconstruction reduced fetal doses by 30%, with uterine doses at 21.3 for the trauma and 14.3 mGy for the appendicitis protocol. Conclusion: Fetal doses were under 1 mGy when exposed to scatter radiation, and under 50 mGy when exposed to primary radiation with the trauma and appendicitis protocols. Consistent with the National Council on Radiation Protection & Measurements (NCRP) and the International Commission on Radiological Protection (ICRP), these doses exhibit a negligible risk to the fetus, with only a small increased risk of cancer. Still, CT scans are not recommended during pregnancy unless the benefits of the exam clearly outweigh the potential risk. Furthermore, when possible, pregnant patients should be examined on CT scanners equipped with iterative reconstruction in order to keep patient doses as low as reasonable achievable.« less

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

PubMed

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

2018-04-20

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

Acute appendicitis--a clear-cut case in men, a guessing game in young women. A prospective study on the role of laparoscopy.

PubMed

Borgstein, P J; Gordijn, R V; Eijsbouts, Q A; Cuesta, M A

1997-09-01

The aggressive surgical approach to patients suspected of having acute appendicitis for fear of perforation, and the inaccuracy of available diagnostic methods lead to an unacceptably high negative appendicectomy rate, especially in young women, in whom gynecological disorders frequently mimic appendicitis. Our objectives were to determine the value of diagnostic laparoscopy in women of child-bearing age to reduce the number of negative laparotomies and establish the correct diagnosis to allow prompt and appropriate treatment. 161 consecutive adult female patients under 50 years of age with a clinical diagnosis of acute appendicitis underwent diagnostic laparoscopy prior to the planned appendicectomy. If an inflamed appendix was found, appendicectomy was usually done through a muscle-splitting McBurney incision. Other diagnoses were treated accordingly. A normal appendix was not removed. Results were compared to a group of 42 similar patients in whom the laparoscopy was omitted for various reasons, to 23 postmenopausal women, and to all 137 male adults, directly operated by the McBurney approach. After laparoscopy, 55% of the patients required appendicectomy for appendicitis while in 23% a gynecological diagnosis was made in spite of previous examination by a gynecologist. Fourteen percent had a negative laparoscopy. There were no false-negative results. The negative appendicectomy rate after laparoscopy was 5% due to two false positives and eight laparoscopy failures. In the group of fertile females who escaped laparoscopy the negative appendicectomy rate was 38%. The respective rates for postmenopausal women and men were 4% and 8%. All women of child-bearing age suspected of having acute appendicitis should undergo diagnostic laparoscopy prior to the planned appendicectomy, regardless of the certainty of the preoperative diagnosis. This is currently the only way to reduce the negative appendicectomy rate and establish a correct diagnosis allowing prompt and appropriate treatment. In male patients and postmenopausal women one may proceed directly to emergency appendicectomy.

Comparison of colonic transit between polyethylene glycol and water as oral contrast vehicles in the CT evaluation of acute appendicitis.

PubMed

Hebert, Jeffrey J; Taylor, Andrew J; Winter, Thomas C

2006-11-01

The objective of our study was to assess the efficacy of a new positive oral contrast agent's ability to reach the colon during CT evaluation of acute appendicitis. Eighty adult emergency department patients who underwent abdominal CT to evaluate for appendicitis were studied. Forty patients received the department's standard dose of 1,600 mL of a water-iodinated contrast mixture (ratio of 2 mL of iodinated contrast material to 100 mL of water) with a standard delay time of 2-2.5 hours from the beginning of contrast medium ingestion. Forty patients were given a new oral contrast mixture of 1,000 mL of polyethylene glycol (PEG) mixed with 30 mL of iodinated contrast agent, and the examination was conducted only 1 hour from inception of contrast administration. Examinations were reviewed for the presence of contrast medium in the cecum and the presence of appendicitis or other abdominal abnormality. Thirty-eight of 40 patients in the PEG group had contrast medium in the colon at 1 hour after contrast administration, 20 of whom had surgically confirmed cases of appendicitis. In five other patients in that group, another cause to explain the patient's complaints was identified on imaging. Only 18 of the 40 patients who received the standard oral preparation had contrast material present in the cecum. Eleven patients in that group had confirmed appendicitis, and four others had another abnormal finding detected at CT. There was a significant difference in the success of contrast medium transit to the colon with these two agents (p < 0.0001). The use of an oral contrast agent composed of PEG and iodinated contrast material provided a marked improvement in oral agent transit to the colon even in patients with intraabdominal inflammation.

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

PubMed

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

2017-09-01

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

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

PubMed

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

2016-12-01

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

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

PubMed

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

2017-10-01

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

Progress in the Diagnosis of Appendicitis: A Report from Washington State’s Surgical Care and Outcomes Assessment Program (SCOAP)

PubMed Central

Drake, Frederick Thurston; Florence, Michael G.; Johnson, Morris G.; Jurkovich, Gregory J.; Kwon, Steve; Schmidt, Zeila; Thirlby, Richard C.; Flum, David R.

2012-01-01

BACKGROUND and OBJECTIVES Studies suggest that CT and US can effectively diagnose and rule-out appendicitis, safely reducing negative appendectomies (NA); however, some within the surgical community remain reluctant to add imaging to clinical evaluation of patients with suspected appendicitis. The Surgical Care and Outcomes Assessment Program (SCOAP) is a physician-led quality initiative that monitors performance by benchmarking processes of care and outcomes. Since 2006, accurate diagnosis of appendicitis has been a priority for SCOAP. The objective of this study was to evaluate the association between imaging and NA in the general community. METHODS Data were collected prospectively for consecutive appendectomy patients (age > 15) at nearly 60 hospitals. SCOAP data are obtained directly from clinical records, including radiology, operative, and pathology reports. Multivariate logistic regression models were used to examine the association between imaging and NA. Tests for trends over time were also conducted. RESULTS Among 19,327 patients (47.9% female) who underwent appendectomy, 5.4% had NA. Among patients who were imaged, frequency of NA was 4.5%, whereas among those who were not imaged, NA was 15.4% (p < 0.001). This association was consistent for males (3% vs. 10%, p < 0.001) and for reproductive-age females (6.9% vs. 24.7%, p < 0.001). In a multivariate model adjusted for age, sex, and WBC, odds of NA for patients not imaged were 3.7 times the odds for those who received imaging (95%CI 3.0 – 4.4). Among SCOAP hospitals, use of imaging increased and NA decreased significantly over time; frequency of perforation was unchanged. CONCLUSIONS Patients who were not imaged during work-up for suspected appendicitis had over three times the odds of NA as those who were imaged. Routine imaging in the evaluation of patients suspected to have appendicitis can safely reduce unnecessary operations. Programs such as SCOAP improve care through peer-led, benchmarked practice change. PMID:22964731

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

PubMed

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

2007-12-01

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

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

PubMed Central

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

2014-01-01

Purpose To compare life expectancy (LE) losses attributable to three imaging strategies for appendicitis in adults—computed tomography (CT), ultrasonography (US) followed by CT for negative or indeterminate US results, and magnetic resonance (MR) imaging—by using a decision-analytic model. Materials and Methods In this model, for each imaging strategy, LE losses for 20-, 40-, and 65-year-old men and women were computed as a function of five key variables: baseline cohort LE, test performance, surgical mortality, risk of death from delayed diagnosis (missed appendicitis), and LE loss attributable to radiation-induced cancer death. Appendicitis prevalence, test performance, mortality rates from surgery and missed appendicitis, and radiation doses from CT were elicited from the published literature and institutional data. LE loss attributable to radiation exposure was projected by using a separate organ-specific model that accounted for anatomic coverage during a typical abdominopelvic CT examination. One- and two-way sensitivity analyses were performed to evaluate effects of model input variability on results. Results Outcomes across imaging strategies differed minimally—for example, for 20-year-old men, corresponding LE losses were 5.8 days (MR imaging), 6.8 days (combined US and CT), and 8.2 days (CT). This order was sensitive to differences in test performance but was insensitive to variation in radiation-induced cancer deaths. For example, in the same cohort, MR imaging sensitivity had to be 91% at minimum (if specificity were 100%), and MR imaging specificity had to be 62% at minimum (if sensitivity were 100%) to incur the least LE loss. Conversely, LE loss attributable to radiation exposure would need to decrease by 74-fold for combined US and CT, instead of MR imaging, to incur the least LE loss. Conclusion The specific imaging strategy used to diagnose appendicitis minimally affects outcomes. Paradigm shifts to MR imaging owing to concerns over radiation should be considered only if MR imaging test performance is very high. © RSNA, 2014 PMID:24988435

Effectiveness and safety of dydrogesterone in regularization of menstrual cycle: a post-marketing study.

PubMed

Trivedi, Nilesh; Chauhan, Naveen; Vaidya, Vishal

2016-08-01

Oral administration of dydrogesterone during second half of menstrual cycle has been shown to reduce menstrual irregularities. This prospective, observational study aimed to determine continued effectiveness of dydrogesterone (prescribed between 1 and 6 cycles or longer) in menstrual cycle regularization in Indian women aged ≥18 years with irregular menstrual cycle for at least 3 months. Those achieving regular cycles (21 to 35 days, inclusive) during treatment were followed up for 6 months after cessation of dydrogesterone treatment. Of the 910 women completing dydrogesterone treatment, 880 (96.7%) achieved cycle regularization (p<0.0001 for 90% success rate) at end of treatment (EOT). Of the 788 subjects available for follow up at 6 months, 747 (94.8%) reported cycle regularity (p<0.0001 for 90% success rate). At EOT, the mean cycle duration reduced by 16.14 (±24.04) days and mean amount of menstrual bleeding decreased by 0.45 (±1.20) pads/day. While five subjects reported worst pain at baseline, none experienced it at EOT. One serious adverse event (appendicitis) and three non-serious adverse events were reported. Dydrogesterone regularizes and improves the duration of the menstrual cycle, reduces the amount of bleeding, relieves menstrual pain and prevents relapse of irregular cycles at six months after discontinuation of treatment.

Research priorities for the influence of gender on diagnostic imaging choices in the emergency department setting.

PubMed

Ashurst, John V; Cherney, Alan R; Evans, Elizabeth M; Kennedy Hall, Michael; Hess, Erik P; Kline, Jeffrey A; Mitchell, Alice M; Mills, Angela M; Weigner, Michael B; Moore, Christopher L

2014-12-01

Diagnostic imaging is a cornerstone of patient evaluation in the acute care setting, but little effort has been devoted to understanding the appropriate influence of sex and gender on imaging choices. This article provides background on this issue and a description of the working group and consensus findings reached during the diagnostic imaging breakout session at the 2014 Academic Emergency Medicine consensus conference "Gender-specific Research in Emergency Care: Investigate, Understand, and Translate How Gender Affects Patient Outcomes." Our goal was to determine research priorities for how sex and gender may (or should) affect imaging choices in the acute care setting. Prior to the conference, the working group identified five areas for discussion regarding the research agenda in sex- and gender-based imaging using literature review and expert consensus. The nominal group technique was used to identify areas for discussion for common presenting complaints to the emergency department where ionizing radiation is often used for diagnosis: suspected pulmonary embolism, suspected kidney stone, lower abdominal pain with a concern for appendicitis, and chest pain concerning for coronary artery disease. The role of sex- and gender-based shared decision-making in diagnostic imaging decisions is also raised. © 2014 by the Society for Academic Emergency Medicine.

Role of MicroRNA-143 in Nerve Injury-Induced Upregulation of Dnmt3a Expression in Primary Sensory Neurons

PubMed Central

Xu, Bo; Cao, Jing; Zhang, Jun; Jia, Shushan; Wu, Shaogen; Mo, Kai; Wei, Guihua; Liang, Lingli; Miao, Xuerong; Bekker, Alex; Tao, Yuan-Xiang

2017-01-01

Peripheral nerve injury increased the expression of the DNA methyltransferase 3A (Dnmt3a) mRNA and its encoding Dnmt3a protein in injured dorsal root ganglia (DRG). This increase is considered as an endogenous instigator in neuropathic pain genesis through epigenetic silencing of pain-associated genes (such as Oprm1) in injured DRG. However, how DRG DNMT3a is increased following peripheral nerve injury is still elusive. We reported here that peripheral nerve injury caused by the fifth spinal nerve ligation (SNL) downregulated microRNA (miR)-143 expression in injured DRG. This downregulation was required for SNL-induced DRG Dnmt3a increase as rescuing miR-143 downregulation through microinjection of miR-143 mimics into injured DRG blocked the SNL-induced increase in Dnmt3a and restored the SNL-induced decreases in Oprm1 mRNA and its encoding mu opioid receptor (MOR) in injured DRG, impaired spinal cord central sensitization and neuropathic pain, and improved morphine analgesic effects following SNL. Mimicking SNL-induced DRG miR-143 downregulation through DRG microinjection of miR143 inhibitors in naive rats increased the expression of Dnmt3a and reduced the expression of Oprm1 mRNA and MOR in injected DRG and produced neuropathic pain-like symptoms. These findings suggest that miR-143 is a negative regulator in Dnmt3a expression in the DRG under neuropathic pain conditions and may be a potential target for therapeutic management of neuropathic pain. PMID:29170626

A Review and Annotated Bibliography of Armor Gunnery Training Device Effectiveness Literature

DTIC Science & Technology

1993-11-01

training effectiveness (skill acquisition, skill reten-tion, performance prediction, transfer of training) and (b) research limitations (sample size...standalone, tank-appended, subcaliber, and laser) and four areas of training effectiveness (skill acquisition, skill retention, performance prediction, and...standalone, tank-appended, subcaliber, laser) and areas of training effectiveness (skill acquisition, skill retention, performance prediction, transfer of

Left-sided incarcerated Amyand's hernia with cecum and terminal ileum: a case report.

PubMed

Bekele, Kebebe; Markos, Desalegn

2017-01-01

Amyand's hernia, which is the presence of a normal or pathological appendix as a part of an inguinal hernia, is a rare clinical entity. We are reporting a very rare case of left-sided incarcerated Amyand's hernia with cecum and terminal ileum involvement. A 4-year-old male child with left inguinal swelling of 2-year duration presented to Goba Referral Hospital. Two days before the patient visited our hospital, the swelling had become irreducible and caused severe groin pain. He had abdominal cramps, bilious vomiting, and mild abdominal distention, but passed feces. With the diagnosis of left-sided incarcerated inguinal hernia, the patient was investigated and prepared for surgical management. During the operative procedure, we identified the presence of appendix, cecum, and terminal ileum in the scrotum as the herniated component. After the sack was dissected, since there was also appendicitis, an appendectomy was performed. Then, high ligation of sack was done after cecum and ileum were reduced. After 3 uneventful postoperative days in the hospital, the patient was discharged. The patient was followed-up for 6 months, and he did not develop any complications. Left-sided incarcerated Amyand's hernia with cecum and terminal ileum involvement is a rare clinical entity. Even though it is not common, appendicitis is one of the comorbidities that can be seen in patients with left-sided incarcerated Amyand's hernia with cecum and terminal ileum. Surgeons should have a high index of clinical suspicion and be aware of the potential involvement of appendix, cecum, and ileum as part of an incarcerated hernia during surgery, even in the left inguinal region. In this case, left-sided incarcerated inguinal hernia which involved inflamed appendix, cecum, and terminal ileum was successfully managed using an inguinal approach.

Interleukin-1β overproduction is a common cause for neuropathic pain, memory deficit, and depression following peripheral nerve injury in rodents.

PubMed

Gui, Wen-Shan; Wei, Xiao; Mai, Chun-Lin; Murugan, Madhuvika; Wu, Long-Jun; Xin, Wen-Jun; Zhou, Li-Jun; Liu, Xian-Guo

2016-01-01

Chronic pain is often accompanied by short-term memory deficit and depression. Currently, it is believed that short-term memory deficit and depression are consequences of chronic pain. Here, we test the hypothesis that the symptoms might be caused by overproduction of interleukin-1beta (IL-1β) in the injured nerve independent of neuropathic pain following spared nerve injury in rats and mice. Mechanical allodynia, a behavioral sign of neuropathic pain, was not correlated with short-term memory deficit and depressive behavior in spared nerve injury rats. Spared nerve injury upregulated IL-1β in the injured sciatic nerve, plasma, and the regions in central nervous system closely associated with pain, memory and emotion, including spinal dorsal horn, hippocampus, prefrontal cortex, nucleus accumbens, and amygdala. Importantly, the spared nerve injury-induced memory deficits, depressive, and pain behaviors were substantially prevented by peri-sciatic administration of IL-1β neutralizing antibody in rats or deletion of IL-1 receptor type 1 in mice. Furthermore, the behavioral abnormalities induced by spared nerve injury were mimicked in naïve rats by repetitive intravenous injection of re combinant rat IL-1β (rrIL-1β) at a pathological concentration as determined from spared nerve injury rats. In addition, microglia were activated by both spared nerve injury and intravenous injection of rrIL-1β and the effect of spared nerve injury was substantially reversed by peri-sciatic administration of anti-IL-1β. Neuropathic pain was not necessary for the development of cognitive and emotional disorders, while the overproduction of IL-1β in the injured sciatic nerve following peripheral nerve injury may be a common mechanism underlying the generation of neuropathic pain, memory deficit, and depression. © The Author(s) 2016.

ACR Appropriateness Criteria® acute onset flank pain--suspicion of stone disease.

PubMed

Coursey, Courtney A; Casalino, David D; Remer, Erick M; Arellano, Ronald S; Bishoff, Jay T; Dighe, Manjiri; Fulgham, Pat; Goldfarb, Stanley; Israel, Gary M; Lazarus, Elizabeth; Leyendecker, John R; Majd, Massoud; Nikolaidis, Paul; Papanicolaou, Nicholas; Prasad, Srinivasa; Ramchandani, Parvati; Sheth, Sheila; Vikram, Raghunandan

2012-09-01

Low dose (<3 mSv) noncontrast CT (NCCT) is the imaging study of choice for accurate evaluation of patients with acute onset of flank pain and suspicion of stone disease (sensitivity 97%, specificity 95%). NCCT can reliably characterize the location and size of an offending ureteral calculus, identify complications, and diagnose alternative etiologies of abdominal pain such as appendicitis. By comparison, the sensitivity of radiographs (59%) and ultrasound (24-57%) for the detection of renal and ureteral calculi is relatively poor. Ultrasound can accurately diagnose pelvicaliectasis and ureterectasis, but it may take several hours for these findings to develop. In the pregnant patient, however, ultrasound is a first line test as it does not expose the fetus to ionizing radiation. MR is an accurate test for the diagnosis of pelvicaliectasis and ureterectasis, but is less sensitive than CT for the diagnosis of renal and ureteral calculi. For patients with known stone disease whose stones are visible on radiographs, radiographs are a good tool for post-treatment follow-up.The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every two years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Pediatric negative appendectomy rate: trend, predictors, and differentials.

PubMed

Oyetunji, Tolulope A; Ong'uti, Sharon K; Bolorunduro, Oluwaseyi B; Cornwell, Edward E; Nwomeh, Benedict C

2012-03-01

Appendectomy is one of the most commonly performed emergency operations in children. The diagnosis of appendicitis can be quite challenging, particularly in children. We set out to determine the accuracy of diagnosis of appendicitis by analyzing the trends in the negative appendectomy rate (NAR) using a national database. Analysis of the Kids Inpatient Database (KID) was performed for the years 2000, 2003, and 2006 on children with appendectomy, excluding incidental appendectomies. Children (<18 y) without appendicitis but who underwent appendectomies were classified as negative appendectomies (NA), and those with appendicitis as positive appendectomies (PA). Comparisons were made between those with PA versus NA by demographic characteristics. The subset of patients with NA was then further analyzed. An estimated 250,783 appendectomies met the inclusion criteria. The NAR was 6.7%. Length of stay (LOS) was longer in NA versus PA (7 versus 3 d, P < 0.05). The NAR was increased in children under 5 y (21.1% versus 5.4% for among the 5-10 y versus 5.9% among the >10 y, P < 0.0001) and in females (9.3% versus 5.1%, P < 0.001). On multivariate analysis, increasing age was associated with lower odds of NA (OR = 0.92, P < 0.001). Females, rural hospitals, and Blacks were significantly more likely to experience NA. Younger age, female gender, Black ethnicity and rural hospitals are independent predictors of NA. These factors can be incorporated into diagnostic algorithms to improve the accuracy of diagnosis of appendicitis in children. Copyright © 2012 Elsevier Inc. All rights reserved.

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

PubMed

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

2016-11-01

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

Tailoring the operative approach for appendicitis to the patient: a prediction model from national surgical quality improvement program data.

PubMed

Senekjian, Lara; Nirula, Raminder

2013-01-01

Laparoscopic appendectomy (LA) is increasingly being performed in the United States, despite controversy about differences in infectious complication rates compared with open appendectomy (OA). Subpopulations exist in which infectious complication rates, both surgical site and organ space, differ with respect to LA compared with OA. All appendectomies in the National Surgical Quality Improvement Program database were analyzed with respect to surgical site infection (SSI) and organ space infection (OSI). Multivariate logistic regression analysis identified independent predictors of SSI or OSI. Probabilities of SSI or OSI were determined for subpopulations to identify when LA was superior to OA. From 2005 to 2009, there were 61,830 appendectomies performed (77.5% LA), of which 9,998 (16.2%) were complicated (58.7% LA). The risk of SSI was considerably lower for LA in both noncomplicated and complicated appendicitis. Across all ages, body mass index, renal function, and WBCs, LA was associated with a lower probability of SSI. The risk of OSI was considerably greater for LA in both noncomplicated and complicated appendicitis. In complicated appendicitis, OA was associated with a lower probability of OSI in patients with WBC >12 cells × 10(3)/μL. In noncomplicated appendicitis, OA was associated with a lower probability of OSI in patients with a body mass index <37.5 when compared with LA. Subpopulations exist in which OA is superior to LA in terms of OSI, however, SSI is consistently lower in LA patients. Copyright © 2013 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

The Effects of Focused/Unfocused Audio-Appended Reading Tasks on Intermediate Female EFL Learners' Written Accuracy

ERIC Educational Resources Information Center

Alavinia, Parviz; Shafaei, Ali; Salimi, Asghar

2018-01-01

The current research study was conducted to examine the impacts of focused and unfocused audio-appended reading tasks on female EFL learners' acquisition of a rule-bound structure (passive voice) and a non-rule-bound structure (prepositions). The participants of this study involved ninety intermediate female English learners. They were assigned…

NHEXAS PHASE I ARIZONA STUDY--STANDARD OPERATING PROCEDURE FOR INSTRUCTIONS FOR THE ADDITION OF INDIVIDUAL CLEANED NON SCANNED DATA BATCHES TO MASTER DATABASES (UA-D-27.0)

EPA Science Inventory

The purpose of this SOP is to define the procedures involved in appending cleaned individual data batches to the master databases. This procedure applies to the Arizona NHEXAS project and the "Border" study. Keywords: data; appending.

The National Human Exposure Assessment Sur...

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

PubMed

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

2015-02-24

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

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

PubMed

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

2015-04-01

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

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

PubMed Central

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

2015-01-01

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

Small constrained SP1-7 analogs bind to a unique site and promote anti-allodynic effects following systemic injection in mice.

PubMed

Jonsson, A; Fransson, R; Haramaki, Y; Skogh, A; Brolin, E; Watanabe, H; Nordvall, G; Hallberg, M; Sandström, A; Nyberg, F

2015-07-09

Previous results have shown that the substance P (SP) N-terminal fragment SP1-7 may attenuate hyperalgesia and produce anti-allodynia in animals using various experimental models for neuropathic pain. The heptapeptide was found to induce its effects through binding to and activating specific sites apart from any known neurokinin or opioid receptor. Furthermore, we have applied a medicinal chemistry program to develop lead compounds mimicking the effect of SP1-7. The present study was designed to evaluate the pharmacological effect of these compounds using the mouse spared nerve injury (SNI) model of chronic neuropathic pain. Also, as no comprehensive screen with the aim to identify the SP1-7 target has yet been performed we screened our lead compound H-Phe-Phe-NH2 toward a panel of drug targets. The extensive target screen, including 111 targets, did not reveal any hit for the binding site among a number of known receptors or enzymes involved in pain modulation. Our animal studies confirmed that SP1-7, but also synthetic analogs thereof, possesses anti-allodynic effects in the mouse SNI model of neuropathic pain. One of the lead compounds, a constrained H-Phe-Phe-NH2 analog, was shown to exhibit a significant anti-allodynic effect. Copyright © 2015 IBRO. Published by Elsevier Ltd. All rights reserved.

Depression of home cage wheel running: a reliable and clinically relevant method to assess migraine pain in rats.

PubMed

Kandasamy, Ram; Lee, Andrea T; Morgan, Michael M

2017-12-01

The development of new anti-migraine treatments is limited by the difficulty inassessing migraine pain in laboratory animals. Depression of activity is one of the few diagnostic criteria formigraine that can be mimicked in rats. The goal of the present study was to test the hypothesis thatdepression of home cage wheel running is a reliable and clinically relevant method to assess migraine painin rats. Adult female rats were implanted with a cannula to inject allyl isothiocyanate (AITC) onto the dura to induce migraine pain, as has been shown before. Rats recovered from implantation surgery for 8 days in cages containing a running wheel. Home cage wheel running was recorded 23 h a day. AITC and the migraine medication sumatriptan were administered in the hour prior to onset of the dark phase. Administration of AITC caused a concentration-dependent decrease in wheel running that lasted 3 h. The duration and magnitude of AITC-induced depression of wheel running was consistent following three repeated injections spaced 48 h apart. Administration of sumatriptan attenuated AITC-induced depressionof wheel running when a large dose (1 mg/kg) was administered immediately following AITC administration. Wheel running patterns did not change when sumatriptan was given to naïve rats. These data indicate that home cage wheel running is a sensitive, reliable, and clinically relevant method to assess migraine pain in the rat.

Copper-Hydroperoxo Mediated N-Debenzylation Chemistry Mimicking Aspects of Copper Monoxygenases

PubMed Central

Maiti, Debabrata; Narducci Sarjeant, Amy A.; Karlin, Kenneth D.

2008-01-01

Substantial oxidative N-debenzylation reaction along with PhCH=O formation occurs from a hydroperoxo copper(II) complex which has a dibenzylamino substrate (-N(CH2Ph)2 appended as a substituent on one pyridyl group of its tripodal tetradentate TMPA {≡ TPA ≡ tris(2-pyridylmethyl)amine)} ligand framework. During the course of the (LN(CH2Ph)2)CuII(−OOH) reactivity, formation of a substrate and −OOH (an oxygen atom) derived alkoxo CuII(−OR) complex occurs. The observation that the same CuII(−OR) species occurs from CuI/PhIO chemistry suggests the possibility that a copper-oxo (cupryl) reactive intermediate forms during alkoxo species formation, and new ESI-MS data obtained provides some further support for this high-valent intermediate. Net H-atom abstraction chemistry is proposed, based on kinetic isotope effect studies provided here and that previously published for a closely related CuII(−OOH) species incorporating dimethylamine (-N(CH3)2) as the internal substrate (J. Am. Chem. Soc. 2007, 129, 6720-6721); the CuI/PhIO reactivity, with similar isotope effect results, provides further support. The reactivity of these chemical systems closely resembles proposed oxidative N-dealkylation mechanisms effected by the copper-monooxygenases dopamine β-monooxygenase (DβM) or peptidylglycine-α-hydroxylating monooxygenase (PHM). PMID:18783212

Aspergillus thyroiditis in a renal transplant recipient mimicking subacute thyroiditis.

PubMed

Solak, Y; Atalay, H; Nar, A; Ozbek, O; Turkmen, K; Erekul, S; Turk, S

2011-04-01

Fungal pathogens are increasingly encountered after renal transplantation. Aspergillus causes significant morbidity and mortality in transplant patients. Fungal thyroiditis is a rare occurrence owing to unique features of the thyroid gland. Most cases are caused by Aspergillus species and have been described in immunocompromised patients. Presentation may be identical with that of subacute thyroiditis, in which hyperthyroidism features and painful thyroid are the prominent findings. Diagnosis can be ascertained by fine-needle aspiration of thyroid showing branching hyphae of Aspergillus. We describe a renal transplant patient who developed Aspergillus thyroiditis as part of a disseminated infection successfully treated with voriconazole. © 2010 John Wiley & Sons A/S.

Osteomalacia mimicking spondyloarthropathy: a case report.

PubMed

Garip, Y; Dedeoglu, M; Bodur, H

2014-07-01

Osteomalacia is a metabolic bone disorder characterized by impaired mineralization of bone matrix. Symptoms of osteomalacia can be confused with other conditions such as spondyloarthropathy, polymyalgia rheumatica, polymyositis, and fibromyalgia. In this case, we report a patient with axial osteomalacia who developed low back pain, morning stiffness, and "grade 3 sacroiliitis" in pelvis X-ray, leading to the misdiagnosis as seronegative spondyloarthropathy. Serum biochemical studies revealed low serum phosphorus, low 25-hydroxy vitamin D3, normal calcium, elevated parathyroid hormone, and alkaline phosphatase levels. Her symptoms were relieved with vitamin D and calcium therapy. The diagnosis of osteomalacia should be considered in case of sacroiliitis and spondylitis.

[Umbilical endometriosis mimicking a keloid in a young black woman: A case report].

PubMed

Kourouma, H-S; Ecra, E-J; Allou, A-S; Kouyaté, M; Kouassi, Y-I; Kaloga, M; Kouassi, K-A; Kassi, K; Kouamé, K; Ahogo, C; Gbery, I-P; Sangaré, A

2017-10-01

Most umbilical tumors are diagnosed as benign tumors, umbilical metastases of abdominal and pelvic tumors, or Sister Marie Joseph nodule. Herein, we report a case of cutaneous umbilical endometriosis mistaken for a keloid. A young black woman aged 26 consulted for a painful umbilical tumefaction. She had noted the appearance of a nodule of the umbilicus 10 months ago with bleeding during her menstrual periods. Skin examination revealed a firm and painful umbilical nodule 2.5cm in diameter. She was treated with corticosteroid injections for one month for umbilical keloid. Given that the symptoms recurred regularly at the time of menstruation, we suspected umbilical endometriosis. This diagnosis was finally confirmed by histopathological examination and hormone therapy was instituted on gynecological advice before scheduled surgical excision. In a setting of an umbilical tumor simulating a keloid associated with cyclical symptoms in a black woman, the diagnosis of umbilical endometriosis should not be overlooked by the dermatologist. Copyright © 2017 Elsevier Masson SAS. All rights reserved.

Construction of supramolecular helical nanofibers using renewable biomaterials: self-assembly of a cytidylic acid-appended bolaamphiphile in lemon juice.

PubMed

Iwaura, Rika; Ohnishi-Kameyama, Mayumi

2012-07-07

We performed the self-assembly of a 1,18-cytidylic acid-appended bolaamphiphile (C18C) in lemon juice, which contained citric acid, and succeeded in forming left-handed helical nanofibers with diameters, lengths, and pitches of ca. 6-7 nm, several hundred nm to 5 μm, and ca. 30-40 nm, respectively.

Imaging trends in suspected appendicitis-a Canadian perspective.

PubMed

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

2017-06-01

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

The diagnostic performance of reduced-dose CT for suspected appendicitis in paediatric and adult patients: A systematic review and diagnostic meta-analysis.

PubMed

Yoon, Hee Mang; Suh, Chong Hyun; Cho, Young Ah; Kim, Jeong Rye; Lee, Jin Seong; Jung, Ah Young; Kim, Jung Heon; Lee, Jeong-Yong; Kim, So Yeon

2018-06-01

To evaluate the diagnostic performance of reduced-dose CT for suspected appendicitis. A systematic search of the MEDLINE and EMBASE databases was carried out through to 10 January 2017. Studies evaluating the diagnostic performance of reduced-dose CT for suspected appendicitis in paediatric and adult patients were selected. Pooled summary estimates of sensitivity and specificity were calculated using hierarchical logistic regression modelling. Meta-regression was performed. Fourteen original articles with a total of 3,262 patients were included. For all studies using reduced-dose CT, the summary sensitivity was 96 % (95 % CI 93-98) with a summary specificity of 94 % (95 % CI 92-95). For the 11 studies providing a head-to-head comparison between reduced-dose CT and standard-dose CT, reduced-dose CT demonstrated a comparable summary sensitivity of 96 % (95 % CI 91-98) and specificity of 94 % (95 % CI 93-96) without any significant differences (p=.41). In meta-regression, there were no significant factors affecting the heterogeneity. The median effective radiation dose of the reduced-dose CT was 1.8 mSv (1.46-4.16 mSv), which was a 78 % reduction in effective radiation dose compared to the standard-dose CT. Reduced-dose CT shows excellent diagnostic performance for suspected appendicitis. • Reduced-dose CT shows excellent diagnostic performance for evaluating suspected appendicitis. • Reduced-dose CT has a comparable diagnostic performance to standard-dose CT. • Median effective radiation dose of reduced-dose CT was 1.8 mSv (1.46-4.16). • Reduced-dose CT achieved a 78 % dose reduction compared to standard-dose CT.

Extended Versus Narrow-spectrum Antibiotics in the Management of Uncomplicated Appendicitis in Children: A Propensity-matched Comparative Effectiveness Study.

PubMed

Cameron, Danielle B; Melvin, Patrice; Graham, Dionne A; Glass, Charity C; Serres, Stephanie K; Kronman, Matthew P; Saito, Jacqueline M; Rangel, Shawn J

2018-07-01

The aim of this study was to compare the effectiveness of extended versus narrow spectrum antibiotics in preventing surgical site infections (SSIs) and hospital revisits in children with uncomplicated appendicitis. There is a paucity of high-quality evidence in the pediatric literature comparing the effectiveness of extended versus narrow-spectrum antibiotics in the prevention of SSIs associated with uncomplicated appendicitis. Clinical data from the ACS NSQIP-Pediatric Appendectomy Pilot Project were merged with antibiotic utilization data from the Pediatric Health Information System database for patients undergoing appendectomy for uncomplicated appendicitis at 17 hospitals from January 1, 2013 to June 30, 2015. Patients who received piperacillin/tazobactam (extended spectrum) were compared with those who received either cefoxitin or ceftriaxone with metronidazole (narrow spectrum) after propensity matching on demographic and severity characteristics. Study outcomes were 30-day SSI and hospital revisit rates. Of the 1389 patients included, 39.1% received piperacillin/tazobactam (range by hospital: 0% to 100%), and the remainder received narrow-spectrum agents. No differences in demographics or severity characteristics were found between groups following matching. In the matched analysis, the rates of SSI were similar between groups [extended spectrum: 2.4% vs narrow spectrum 1.8% (odds ratio, OR: 1.05, 95% confidence interval, 95% CI 0.34-3.26)], as was the rate of revisits [extended spectrum: 7.9% vs narrow spectrum 5.1% (OR: 1.46, 95% CI 0.75-2.87)]. Use of extended-spectrum antibiotics was not associated with lower rates of SSI or hospital revisits when compared with narrow-spectrum antibiotics in children with uncomplicated appendicitis. Our results challenge the routine use of extended-spectrum antibiotics observed at many hospitals, particularly given the increasing incidence of antibiotic-resistant organisms.

Diagnostic accuracy at several reduced radiation dose levels for CT imaging in the diagnosis of appendicitis

NASA Astrophysics Data System (ADS)

Zhang, Di; Khatonabadi, Maryam; Kim, Hyun; Jude, Matilda; Zaragoza, Edward; Lee, Margaret; Patel, Maitraya; Poon, Cheryce; Douek, Michael; Andrews-Tang, Denise; Doepke, Laura; McNitt-Gray, Shawn; Cagnon, Chris; DeMarco, John; McNitt-Gray, Michael

2012-03-01

Purpose: While several studies have investigated the tradeoffs between radiation dose and image quality (noise) in CT imaging, the purpose of this study was to take this analysis a step further by investigating the tradeoffs between patient radiation dose (including organ dose) and diagnostic accuracy in diagnosis of appendicitis using CT. Methods: This study was IRB approved and utilized data from 20 patients who underwent clinical CT exams for indications of appendicitis. Medical record review established true diagnosis of appendicitis, with 10 positives and 10 negatives. A validated software tool used raw projection data from each scan to create simulated images at lower dose levels (70%, 50%, 30%, 20% of original). An observer study was performed with 6 radiologists reviewing each case at each dose level in random order over several sessions. Readers assessed image quality and provided confidence in their diagnosis of appendicitis, each on a 5 point scale. Liver doses at each case and each dose level were estimated using Monte Carlo simulation based methods. Results: Overall diagnostic accuracy varies across dose levels: 92%, 93%, 91%, 90% and 90% across the 100%, 70%, 50%, 30% and 20% dose levels respectively. And it is 93%, 95%, 88%, 90% and 90% across the 13.5-22mGy, 9.6-13.5mGy, 6.4-9.6mGy, 4-6.4mGy, and 2-4mGy liver dose ranges respectively. Only 4 out of 600 observations were rated "unacceptable" for image quality. Conclusion: The results from this pilot study indicate that the diagnostic accuracy does not change dramatically even at significantly reduced radiation dose.

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

PubMed

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

2018-01-01

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

Accuracy of clinical coding from 1210 appendicectomies in a British district general hospital.

PubMed

Bhangu, Aneel; Nepogodiev, Dmitri; Taylor, Caroline; Durkin, Natalie; Patel, Rajan

2012-01-01

The primary aim of this study was to assess the accuracy of clinical coding in identifying negative appendicectomies. The secondary aim was to analyse trends over time in rates of simple, complex (gangrenous or perforated) and negative appendicectomies. Retrospective review of 1210 patients undergoing emergency appendicectomy during a five year period (2006-2010). Histopathology reports were taken as gold standard for diagnosis and compared to clinical coding lists. Clinical coding is the process by which non-medical administrators apply standardised diagnostic codes to patients, based upon clinical notes at discharge. These codes then contribute to national databases. Statistical analysis included correlation studies and regression analyses. Clinical coding had only moderate correlation with histopathology, with an overall kappa of 0.421. Annual kappa values varied between 0.378 and 0.500. Overall 14% of patients were incorrectly coded as having had appendicitis when in fact they had a histopathologically normal appendix (153/1107), whereas 4% were falsely coded as having received a negative appendicectomy when they had appendicitis (48/1107). There was an overall significant fall and then rise in the rate of simple appendicitis (B coefficient -0.239 (95% confidence interval -0.426, -0.051), p = 0.014) but no change in the rate of complex appendicitis (B coefficient 0.008 (-0.015, 0.031), p = 0.476). Clinical coding for negative appendicectomy was unreliable. Negative rates may be higher than suspected. This has implications for the validity of national database analyses. Using this form of data as a quality indictor for appendicitis should be reconsidered until its quality is improved. Copyright © 2012 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.

Comparison of Outcomes of antibiotic Drugs and Appendectomy (CODA) trial: a protocol for the pragmatic randomised study of appendicitis treatment

PubMed Central

Davidson, Giana H; Flum, David R; Talan, David A; Kessler, Larry G; Lavallee, Danielle C; Bizzell, Bonnie J; Farjah, Farhood; Stewart, Skye D; Krishnadasan, Anusha; Carney, Erin E; Wolff, Erika M; Comstock, Bryan A; Monsell, Sarah E; Heagerty, Patrick J; Ehlers, Annie P; DeUgarte, Daniel A; Kaji, Amy H; Evans, Heather L; Yu, Julianna T; Mandell, Katherine A; Doten, Ian C; Clive, Kevin S; McGrane, Karen M; Tudor, Brandon C; Foster, Careen S; Saltzman, Darin J; Thirlby, Richard C; Lange, Erin O; Sabbatini, Amber K; Moran, Gregory J

2017-01-01

Introduction Several European studies suggest that some patients with appendicitis can be treated safely with antibiotics. A portion of patients eventually undergo appendectomy within a year, with 10%–15% failing to respond in the initial period and a similar additional proportion with suspected recurrent episodes requiring appendectomy. Nearly all patients with appendicitis in the USA are still treated with surgery. A rigorous comparative effectiveness trial in the USA that is sufficiently large and pragmatic to incorporate usual variations in care and measures the patient experience is needed to determine whether antibiotics are as good as appendectomy. Objectives The Comparing Outcomes of Antibiotic Drugs and Appendectomy (CODA) trial for acute appendicitis aims to determine whether the antibiotic treatment strategy is non-inferior to appendectomy. Methods/Analysis CODA is a randomised, pragmatic non-inferiority trial that aims to recruit 1552 English-speaking and Spanish-speaking adults with imaging-confirmed appendicitis. Participants are randomised to appendectomy or 10 days of antibiotics (including an option for complete outpatient therapy). A total of 500 patients who decline randomisation but consent to follow-up will be included in a parallel observational cohort. The primary analytic outcome is quality of life (measured by the EuroQol five dimension index) at 4 weeks. Clinical adverse events, rate of eventual appendectomy, decisional regret, return to work/school, work productivity and healthcare utilisation will be compared. Planned exploratory analyses will identify subpopulations that may have a differential risk of eventual appendectomy in the antibiotic treatment arm. Ethics and dissemination This trial was approved by the University of Washington’s Human Subjects Division. Results from this trial will be presented in international conferences and published in peer-reviewed journals. Trial registration number NCT02800785. PMID:29146633

The diagnostic performance of ultrasound for acute appendicitis in pregnant and young nonpregnant women: A case-control study.

PubMed

Segev, Lior; Segev, Yakir; Rayman, Shlomi; Nissan, Aviram; Sadot, Eran

2016-10-01

Ultrasonography is frequently used to diagnose acute appendicitis in women of reproductive age, but its diagnostic value in pregnant patients remains unclear. This study sought to compare the diagnostic performance of ultrasound in pregnant and young nonpregnant women with suspected acute appendicitis. The database of a single tertiary medical center was reviewed for all women of reproductive age who underwent appendectomy either during pregnancy (2000-2014) or in the nonpregnant state (2004-2007) following ultrasound evaluation. The performance of ultrasound in terms of predicting the final pathologic diagnosis was compared between the pregnant and non pregnant groups using receiver operating characteristic curve analysis. Of 586 young women treated for appendicitis during the study periods (92 pregnant, 494 non-pregnant), 200 underwent preoperative ultrasound [67 pregnant, and 133 nonpregnant young women]. The pregnant and nonpregnant groups were comparable in age and presenting symptoms. There was no significant difference in the predictive performance of ultrasound between the two groups (AUC 0.76 and 0.73 respectively, p = 0.78) or within the pregnant group, by trimester [first (n = 23), AUC 0.73; second (n = 32), AUC 0.67; third (n = 12), AUC 0.86; p = 0.4]. Ultrasound had a positive predictive value of 0.94 in the pregnant group and 0.91 in the nonpregnant group; corresponding negative predictive values were 0.40 and 0.43. There appears to be no difference in the ability of ultrasound to predict the diagnosis of acute appendicitis between pregnant women and nonpregnant women of reproductive age. Therefore, similar preoperative imaging algorithms may be used in both patient populations. Copyright © 2016 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.

Standardized ultrasound templates for diagnosing appendicitis reduce annual imaging costs.

PubMed

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

2018-01-01

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

Appending Limited Clinical Data to an Administrative Database for Acute Myocardial Infarction Patients: The Impact on the Assessment of Hospital Quality.

PubMed

Hannan, Edward L; Samadashvili, Zaza; Cozzens, Kimberly; Jacobs, Alice K; Venditti, Ferdinand J; Holmes, David R; Berger, Peter B; Stamato, Nicholas J; Hughes, Suzanne; Walford, Gary

2016-05-01

Hospitals' risk-standardized mortality rates and outlier status (significantly higher/lower rates) are reported by the Centers for Medicare and Medicaid Services (CMS) for acute myocardial infarction (AMI) patients using Medicare claims data. New York now has AMI claims data with blood pressure and heart rate added. The objective of this study was to see whether the appended database yields different hospital assessments than standard claims data. New York State clinically appended claims data for AMI were used to create 2 different risk models based on CMS methods: 1 with and 1 without the added clinical data. Model discrimination was compared, and differences between the models in hospital outlier status and tertile status were examined. Mean arterial pressure and heart rate were both significant predictors of mortality in the clinically appended model. The C statistic for the model with the clinical variables added was significantly higher (0.803 vs. 0.773, P<0.001). The model without clinical variables identified 10 low outliers and all of them were percutaneous coronary intervention hospitals. When clinical variables were included in the model, only 6 of those 10 hospitals were low outliers, but there were 2 new low outliers. The model without clinical variables had only 3 high outliers, and the model with clinical variables included identified 2 new high outliers. Appending even a small number of clinical data elements to administrative data resulted in a difference in the assessment of hospital mortality outliers for AMI. The strategy of adding limited but important clinical data elements to administrative datasets should be considered when evaluating hospital quality for procedures and other medical conditions.

Anticipation of electric shocks modulates low beta power and event-related fields during memory encoding.

PubMed

Bauch, Eva M; Bunzeck, Nico

2015-09-01

In humans, the temporal and oscillatory dynamics of pain anticipation and its effects on long-term memory are largely unknown. Here, we investigated this open question by using a previously established behavioral paradigm in combination with magnetoencephalography (MEG). Healthy human subjects encoded a series of scene images, which was combined with cues predicting an aversive electric shock with different probabilities (0.2, 0.5 or 0.8). After encoding, memory for the studied images was tested using a remember/know recognition task. Behaviorally, pain anticipation did not modulate recollection-based recognition memory per se, but interacted with the perceived unpleasantness of the electric shock [visual analogue scale rating from 1 (not unpleasant) to 10 (highly unpleasant)]. More precisely, the relationship between pain anticipation and recollection followed an inverted u-shaped function the more unpleasant the shocks were rated by a subject. At the physiological level, this quadratic effect was mimicked in the event-related magnetic fields associated with successful memory formation ('DM-effect') ∼450ms after image onset at left frontal sensors. Importantly, across all subjects, shock anticipation modulated oscillatory power in the low beta frequency range (13-20Hz) in a linear fashion at left temporal sensors. Taken together, our findings indicate that beta oscillations provide a generic mechanism underlying pain anticipation; the effect on subsequent long-term memory, on the other hand, is much more variable and depends on the level of individual pain perception. As such, our findings give new and important insights into how aversive motivational states can drive memory formation. Copyright © 2015 Elsevier Inc. All rights reserved.

Surgical Treatment for Chronic Pelvic Pain

PubMed Central

1998-01-01

The source of chronic pelvic pain may be reproductive organ, urological, musculoskeletal - neurological, gastrointestinal, or myofascial. A psychological component almost always is a factor, whether as an antecedent event or presenting as depression as result of the pain. Surgical interventions for chronic pelvic pain include: 1) resection or vaporization of vulvar/vestibular tissue for human papillion virus (HPV) induced or chronic vulvodynia/vestibulitis; 2) cervical dilation for cervix stenosis; 3) hysteroscopic resection for intracavitary or submucous myomas or intracavitary polyps; 4) myomectomy or myolysis for symptomatic intramural, subserosal or pedunculated myomas; 5) adhesiolysis for peritubular and periovarian adhesions, and enterolysis for bowel adhesions, adhesiolysis for all thick adhesions in areas of pain as well as thin ahesions affecting critical structures such as ovaries and tubes; 6) salpingectomy or neosalpingostomy for symptomatic hydrosalpinx; 7) ovarian treatment for symptomatic ovarian pain; 8) uterosacral nerve vaporization for dysmenorrhea; 9) presacral neurectomy for disabling central pain primarily of uterine but also of bladder origin; 10) resection of endometriosis from all surfaces including removal from bladder and bowel as well as from the rectovaginal septal space. Complete resection of all disease in a debulking operation is essential; 11) appendectomy for symptoms of chronic appendicitis, and chronic right lower quadrant pain; 12) uterine suspension for symptoms of collision dyspareunia, pelvic congestion, severe dysmenorrhea, cul-desac endometriosis; 13) repair of all hernia defects whether sciatic, inguinal, femoral, Spigelian, ventral or incisional; 14) hysterectomy if relief has not been achieved by organ-preserving surgery such as resection of all endometriosis and presacral neurectomy, or the central pain continues to be disabling. Before such a radical step is taken, MRI of the uterus to confirm presence of adenomyosis may be helpful; 15) trigger point injection therapy for myofascial pain and dysfunction in pelvic and abdominal muscles. With application of all currently available laparoscopic modalities, 80% of women with chronic pelvic pain will report a decrease of pain to tolerable levels, a significant average reduction which is maintained in 3-year follow-up. Individual factors contributing to pain cannot be determined, although the frequency of endometriosis dictates that its complete treatment be attempted. The beneficial effect of uterosacral nerve ablation may be as much due to treatment of occult endometriosis in the uterosacral ligaments as to transection of the nerve fibers themselves. The benefit of the presacral neurectomy appears to be definite but strictly limited to midline pain. Appendectomy, herniorraphy, and even hysterectomy are all appropriate therapies for patients with chronic pelvic pain. Even with all laparoscopic procedures employed, fully 20% of patients experience unsatisfactory results. In addition, these patients are often depressed. Whether the pain contributes to the depression or the depression to the pain is irrelevant to them. Selected referrals to an integrated pain center with psychologic assistance together with judicious prescription of antidepressant drugs will likely benefit both women who respond to surgical intervention and those who do not. A maximum surgical effort must be expended to resect all endometriosis, restore normal pelvic anatomy, resect nerve fibers, and treat surgically accessible disease. In addition, it is important to provide patients with chronic pelvic pain sufficient psychologic support to overcome the effects of the condition, and to assist them with underlying psychologic disorders. PMID:9876726

Clinical outcomes of pediatric patients with acute abdominal pain and incidental findings of free intraperitoneal fluid on diagnostic imaging.

PubMed

Matz, Samantha; Connell, Mary; Sinha, Madhumita; Goettl, Christopher S; Patel, Palak C; Drachman, David

2013-09-01

The presence of free intraperitoneal fluid on diagnostic imaging (sonography or computed tomography [CT]) may indicate an acute inflammatory process in children with abdominal pain in a nontraumatic setting. Although clinical outcomes of pediatric trauma patients with free fluid on diagnostic examinations without evidence of solid-organ injury have been studied, similar studies in the absence of trauma are rare. Our objective was to study clinical outcomes of children with acute abdominal pain of nontraumatic etiology and free intraperitoneal fluid on diagnostic imaging (abdominal/pelvic sonography, CT, or both). We conducted a retrospective review of medical records of children aged 0 to 18 years presenting to a pediatric emergency department with acute abdominal pain (nontraumatic) between April 2008 and March 2009. Patients with intraperitoneal free fluid on imaging were divided into 2 groups: group I, imaging suggestive of an intra-abdominal surgical condition such as appendicitis; and group II, no evidence of an acute surgical condition on imaging, including patients with equivocal studies. Computed tomograms and sonograms were reviewed by a board-certified radiologist, and the free fluid volume was quantitated. Of 1613 patients who underwent diagnostic imaging, 407 were eligible for the study; 134 (33%) had free fluid detected on diagnostic imaging. In patients with both sonography and CT, there was a significant correlation in the free fluid volume (r = 0.79; P < .0005). A significantly greater number of male patients with free fluid had a surgical condition identified on imaging (57.4% versus 25%; P < .001). Children with free fluid and an associated condition on imaging were more likely to have surgery (94.4% versus 6.3%; P < .001). We found clinical outcomes (surgical versus nonsurgical) to be most correlated with a surgical diagnosis on diagnostic imaging and not with the amount of fluid present.

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Science.gov Websites

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Giant Appendicular Mucocele Due to Mucinous Cystadenoma.

PubMed

Sertkaya, Mehmet; Emre, Arif; Pircanoglu, Eyüp Mehmet; Peker, Onur; Cengiz, Emrah; Karaagaç, Mustafa

2016-01-01

Mucocele of the appendix is a rare clinicopathological entity simulating acute appendicitis. The most common form of the mucocele is cystadenoma, which is characterized by luminal dilatation producing large amounts of mucin. We present a new case of a giant mucocele of appendix with mucinous cystadenoma. A 61-year-old female was admitted with complaints of severe lower right quadrant pain. Ultrasonography and computed tomography (CT) suggested that it was a mucocele, but due to severity of pain, she underwent an emergency operation. Fortunately, without a perforation, it was a giant mucocele and the operation was terminated with an uneventful appendectomy with segmental cecal resection. The histopathological evaluation of the specimen reported to be a mucocele with mucinous cystadenoma with negative surgical margins. The patient was discharged postoperative 6th day, and a control colonoscopy and abdominal CT was planned for 6 months following surgery. Appendicular mucocele is rare and difficult to diagnose preoperatively, and sometimes it may be of large size which increases the risk of perforation. Pseudomyxoma peritonei (PP) is the most feared complication of mucocele perforation. Appendectomy with negative margins is a requirement for adequate treatment for most cases. Utmost care should be taken during surgery to avoid perforation of mucocele. Sertkaya M, Emre A, Pircanoglu EM, Peker O, Cengiz E, Karaagaç M. Giant Appendicular Mucocele Due to Mucinous Cystadenoma. Euroasian J Hepato-Gastroenterol 2016;6(2):186-189.

Elemental mercury in the appendix: an unusual complication of a Mexican-American folk remedy.

PubMed

McKinney, P E

1999-01-01

Ingestion of small amounts of elemental mercury is generally thought to be harmless. However, in 4 previously reported cases, ingested mercury became sequestered in the appendix, causing appendicitis in one. We present a case in which elemental mercury was administered as a Mexican-American folk remedy for abdominal pain and became sequestered in the appendix. A 10-year-old Hispanic male presented with 3 days of right-sided abdominal pain, diarrhea, fever, and malaise. On admission, his temperature was 41.5 degrees C and he had right abdominal tenderness. Urinalysis showed 3 WBCs, 9 RBCs, occasional bacteria, and 1+ protein. An abdominal CT scan suggested right focal pyelonephritis, but also showed multiple intraabdominal metallic densities. On further questioning, the family admitted giving him elemental mercury as a remedy for "empacho." He was treated with intravenous ampicillin/sulbactam and gentamicin for a focal pyelonephritis. Because of mercury remaining in the gastrointestinal tract, activated charcoal and sorbitol were given. By hospital day 3, mercury filled the appendix as shown by abdominal radiograph. He was placed in the left lateral decubitus position overnight, and by the next morning, the mercury partially emptied from the appendix. By hospital day 8, his symptoms had resolved and mercury was no longer seen in the appendix. There were only minimal increases in urine mercury levels (18 mg/L). At 5-month follow-up, he has remained asymptomatic.

[Successful treatment of hyperthyroidism simulating acute abdomen and psychosis].

PubMed

Kósa, D; Patakfalvi, A; Györi, L

1992-07-19

A 49 years old female patient entered the surgical department because of epigastric and ileocoecal pains with the symptoms of acute abdomen. A surgical intervention was performed because of supposed appendicitis, but it was not verified. During the surgical observation the patient was confused and negativistic so she was transferred to the psychiatric department. Because of loss of 20 kg weight, high blood sedimentation and anaemia she was sent to our department with the suspicion of an organic disease. A moderate exophthalmos, glittering eyes and Graefe's sign was noted, therefore hyperthyroidism was diagnosed, which was proved by Kocher's blood picture, low serum cholesterol, extremely high T3 and T4 level, and iodine storage diagram. The antithyreotic treatment resulted a dramatic improvement in the extremely serious moreover hopeless case and after a long-term treatment the patient became symptom-free without complaints. Later because of regression of hyperthyreoidism and the growing nodular goitre the patient was treated on two occasions with radioactive iodine. At present the patient is in remission.

Appendiceal Enterobius vermicularis infestation in adults.

PubMed

Isik, Burak; Yilmaz, Mehmet; Karadag, Nese; Kahraman, Latif; Sogutlu, Gokhan; Yilmaz, Sezai; Kirimlioglu, Vedat

2007-01-01

The objective of this study is to evaluate the incidence of Enterobius vermicularis in the appendices of the adult population and a possible relationship between E. vermicularis and acute appendicitis. E. vermicularis was identified in 18 (2%) of 890 patients. Six hundred sixty-five operations were performed for presumptive diagnosis of acute appendicitis, and E. vermicularis was found in 12 (2%) patients. The histopathological examination revealed acute inflammatory cells in four cases (33%). Three of these four specimens included luminal ova and one E. vermicularis. Histopathological examination of six cases revealed E. vermicularis in 225 incidental appendectomies with no evidence of either acute or chronic inflammatory cells. This study suggests a relationship between the presence of E. vermicularis ova and acute inflammation, but the presence of the pinworm in the lumen of the appendix is coincidental. On the other hand E. vermicularis in the appendix lumen can cause symptoms of acute appendicitis.

[Anaesthetic management of patients in the third trimester of pregnancy undergoing urgent laparoscopic surgery. Experience in a general hospital].

PubMed

López-Collada Estrada, María; Olvera Martínez, Rosalba

2016-01-01

Laparoscopic surgery is well accepted as a safe technique when performed on a third trimester pregnant woman. The aim is to describe the anaesthetic management of a group of patients undergoing this type of surgery. An analysis was made of records of 6 patients in their third trimester of pregnancy and who underwent urgent laparoscopic surgery from 2011 to 2013. The study included 6 patients, with a diagnosis of acute cholecystitis in 4 of them. The other 2 patients had acute appendicitis, both of who presented threatened preterm labour. The most frequent indications for laparoscopic surgery during the last trimester of birth were found to be acute cholecystitis and acute appendicitis. Acute appendicitis is related to an elevated risk of presenting threatened preterm labour. Copyright © 2015 Academia Mexicana de Cirugía A.C. Publicado por Masson Doyma México S.A. All rights reserved.

E-learning module on chronic low back pain in older adults: evidence of effect on medical student objective structured clinical examination performance.

PubMed

Weiner, Debra K; Morone, Natalia E; Spallek, Heiko; Karp, Jordan F; Schneider, Michael; Washburn, Carol; Dziabiak, Michael P; Hennon, John G; Elnicki, D Michael

2014-06-01

The Institute of Medicine has highlighted the urgent need to close undergraduate and graduate educational gaps in treating pain. Chronic low back pain (CLBP) is one of the most common pain conditions, and older adults are particularly vulnerable to potential morbidities associated with misinformed treatment. An e-learning case-based interactive module was developed at the University of Pittsburgh Center of Excellence in Pain Education, one of 12 National Institutes of Health-designated centers, to teach students important principles for evaluating and managing CLBP in older adults. A team of six experts in education, information technology, pain management, and geriatrics developed the module. Teaching focused on common errors, interactivity, and expert modeling and feedback. The module mimicked a patient encounter using a standardized patient (the older adult with CLBP) and a pain expert (the patient provider). Twenty-eight medical students were not exposed to the module (Group 1) and 27 were exposed (Group 2). Their clinical skills in evaluating CLBP were assessed using an objective structured clinical examination (OSCE). Mean scores were 62.0 ± 8.6 for Group 1 and 79.5 ± 10.4 for Group 2 (P < .001). Using an OSCE pass-fail cutoff score of 60%, 17 of 28 Group 1 students (60.7%) and 26 of 27 Group 2 students (96.3%) passed. The CLBP OSCE was one of 10 OSCE stations in which students were tested at the end of a Combined Ambulatory Medicine and Pediatrics Clerkship. There were no between-group differences in performance on eight of the other nine OSCE stations. This module significantly improved medical student clinical skills in evaluating CLBP. Additional research is needed to ascertain the effect of e-learning modules on more-advanced learners and on improving the care of older adults with CLBP. © 2014, Copyright the Authors Journal compilation © 2014, The American Geriatrics Society.

E-Learning Module on Chronic Low Back Pain in Older Adults: Evidence of Effect on Medical Student Objective Structured Clinical Examination Performance

PubMed Central

Weiner, Debra K.; Morone, Natalia E.; Spallek, Heiko; Karp, Jordan F.; Schneider, Michael; Washburn, Carol; Dziabiak, Michael P.; Hennon, John G.; Elnicki, D. Michael

2015-01-01

The Institute of Medicine has highlighted the urgent need to close undergraduate and graduate educational gaps in treating pain. Chronic low back pain (CLBP) is one of the most common pain conditions, and older adults are particularly vulnerable to potential morbidities associated with misinformed treatment. An e-learning case-based interactive module was developed at the University of Pittsburgh Center of Excellence in Pain Education, one of 12 National Institutes of Health–designated centers, to teach students important principles for evaluating and managing CLBP in older adults. A team of six experts in education, information technology, pain management, and geriatrics developed the module. Teaching focused on common errors, interactivity, and expert modeling and feedback. The module mimicked a patient encounter using a standardized patient (the older adult with CLBP) and a pain expert (the patient provider). Twenty-eight medical students were not exposed to the module (Group 1) and 27 were exposed (Group 2). Their clinical skills in evaluating CLBP were assessed using an objective structured clinical examination (OSCE). Mean scores were 62.0 ± 8.6 for Group 1 and 79.5 ± 10.4 for Group 2 (P < .001). Using an OSCE pass–fail cutoff score of 60%, 17 of 28 Group 1 students (60.7%) and 26 of 27 Group 2 students (96.3%) passed. The CLBP OSCE was one of 10 OSCE stations in which students were tested at the end of a Combined Ambulatory Medicine and Pediatrics Clerkship. There were no between-group differences in performance on eight of the other nine OSCE stations. This module significantly improved medical student clinical skills in evaluating CLBP. Additional research is needed to ascertain the effect of e-learning modules on more-advanced learners and on improving the care of older adults with CLBP. PMID:24833496

[A case of group G Streptococcus sepsis, chest wall abscess, and vertebral osteomyelitis mimicking a primary lung cancer with bone metastasis].

PubMed

Hayashi, Yumeko; Ishii, Yoshiki; Arai, Ryo; Obara, Kazuki; Kamada, Aya; Takizawa, Hidenori; Hase, Isano; Mashio, Kazuki; Yamada, Issei; Takemasa, Akihiro; Sugiyama, Kumiya; Fukushima, Yasutsugu; Fukuda, Takeshi

2007-01-01

A 73-year-old woman who had been followed in our department of gynecology because of ovarian cancer since 2002, was admitted with liver dysfunction and complaining of back pain and light precordial chest pain. The chest radiograph on admission revealed a tumor in her left upper lung field, and chest CT revealed a tumor adjacent to the chest wall and mediastinum. FDG-positron emission tomography (PET) showed abnormal uptake in the tumor and Th6/7, and the subaortic lymph nodes. On the basis of these findings, primary lung cancer with bone metastasis was suspected. She had a high grade fever on admission, and blood cultures were positive for group G streptococcus. The treatment with intravenous penicillin was started. Percutaneous biopsy of the tumor in her left chest showed an abscess wall in the chest wall, but no evidence of malignancy. Transbronchial lung biopsy and CT-guided biopsy also showed no malignant cells. Since the tumor decreased in size and back pain improved gradually by only antibiotic treatment, a diagnosis of sepsis of group G streptococcus, chest wall abscess, and vertebral osteomyelitis was made. She was treated with intravenous penicillin for 4 weeks and oral amoxicillin for another 4 weeks. After 60 days of antibiotic treatment, the tumor vanished.

The efficacy of combined therapy with metronidazole and broad-spectrum antibiotics on postoperative outcomes for pediatric patients with perforated appendicitis

PubMed Central

Shang, Qingjuan; Geng, Qiankun; Zhang, Xuebing; Guo, Chunbao

2017-01-01

Abstract The aim of this study was to evaluate the efficacy of combined therapy with metronidazole and broad-spectrum antibiotics for patients with perforated appendicitis who underwent surgical intervention. Broad-spectrum antibiotic therapy is warranted in the treatment of perforated appendicitis. Metronidazole has been used as anaerobic antimicrobial therapy. However, few studies about the use of metronidazole in perforated appendicitis have been reported. The medical records of 249 patients treated with metronidazole combined with broad-spectrum antibiotics following perforated appendicitis surgery were reviewed retrospectively and compared with the medical records of 149 patients treated only with broad-spectrum antibiotics. Propensity score matching was performed to adjust for selected baseline variables. Clinical outcomes, including postoperative complications and length of hospital stay, were compared between the 2 groups. No differences were found between the use of combined therapy with metronidazole and the use of solely broad-spectrum antibiotic agents with regard to postoperative duration of intravenous antibiotic treatment (6.8 ± 1.3 vs 7.9 ± 2.1 days, respectively, P = .18), inflammation variables at POD 5 (white blood cell [WBC] [risk ratio [RR], 1.06; 95% confidence interval [CI], 0.67–1.93, P = .15] and C-reactive protein [CRP] [RR, 1.18; 95% CI, 0.73–2.25, P = .36]) (Table 2), and the mean postoperative length of hospital stay (LOS) (RR, 0.68, 95% CI, 0.41–0.94, P = .41). There were also no differences in the incidence of postoperative complications, including the intra-abdominal or pelvic abscess rate (7[7.1%] vs 9[9.2%], respectively, P = .40), the incidence of wound infection (14[14.3%] vs 15[15.3%], respectively, P = .50), and the 30-day readmission rate (9[9.2%] vs 12[12.2%], respectively, P = .32). Regarding overall postoperative outcomes and complications, our study demonstrated no beneficial clinical effects of metronidazole administration in patients with perforated appendicitis who underwent surgical intervention. Therefore, metronidazole is not indicated when broad-spectrum antibiotics such as aminopenicillins with β-lactam inhibitors or carbapenems and select cephalosporins are used. PMID:29381994

The efficacy of combined therapy with metronidazole and broad-spectrum antibiotics on postoperative outcomes for pediatric patients with perforated appendicitis.

PubMed

Shang, Qingjuan; Geng, Qiankun; Zhang, Xuebing; Guo, Chunbao

2017-11-01

The aim of this study was to evaluate the efficacy of combined therapy with metronidazole and broad-spectrum antibiotics for patients with perforated appendicitis who underwent surgical intervention.Broad-spectrum antibiotic therapy is warranted in the treatment of perforated appendicitis. Metronidazole has been used as anaerobic antimicrobial therapy. However, few studies about the use of metronidazole in perforated appendicitis have been reported.The medical records of 249 patients treated with metronidazole combined with broad-spectrum antibiotics following perforated appendicitis surgery were reviewed retrospectively and compared with the medical records of 149 patients treated only with broad-spectrum antibiotics. Propensity score matching was performed to adjust for selected baseline variables. Clinical outcomes, including postoperative complications and length of hospital stay, were compared between the 2 groups.No differences were found between the use of combined therapy with metronidazole and the use of solely broad-spectrum antibiotic agents with regard to postoperative duration of intravenous antibiotic treatment (6.8 ± 1.3 vs 7.9 ± 2.1 days, respectively, P = .18), inflammation variables at POD 5 (white blood cell [WBC] [risk ratio [RR], 1.06; 95% confidence interval [CI], 0.67-1.93, P = .15] and C-reactive protein [CRP] [RR, 1.18; 95% CI, 0.73-2.25, P = .36]) (Table 2), and the mean postoperative length of hospital stay (LOS) (RR, 0.68, 95% CI, 0.41-0.94, P = .41). There were also no differences in the incidence of postoperative complications, including the intra-abdominal or pelvic abscess rate (7[7.1%] vs 9[9.2%], respectively, P = .40), the incidence of wound infection (14[14.3%] vs 15[15.3%], respectively, P = .50), and the 30-day readmission rate (9[9.2%] vs 12[12.2%], respectively, P = .32).Regarding overall postoperative outcomes and complications, our study demonstrated no beneficial clinical effects of metronidazole administration in patients with perforated appendicitis who underwent surgical intervention. Therefore, metronidazole is not indicated when broad-spectrum antibiotics such as aminopenicillins with β-lactam inhibitors or carbapenems and select cephalosporins are used. Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.

Incidence of right-sided colonic tumors (non-appendiceal) in patient's ≥40 years of age presenting with features of acute appendicitis.

PubMed

Khan, Suhail Aslam; Khokhar, Haseeb Anwar; Nasr, A R H; Carton, Eleanor

2013-01-01

Non-appendiceal tumors can mimic and present with clinical features of acute appendicitis in patients of age 40 years or above. The aim of this prospective study is to investigate the incidence of right-sided (non-appendiceal) colonic tumors in patients presenting with clinical features of acute appendicitis. A prospective data analysis of 1662 patients using appendectomy database was performed from 2005 to 2011. Patients above age 40 years or older were included. Patients were compared for demographic data, clinical presentation, radiological findings, operative technique & findings, histo-pathological findings and postoperative complications. The primary outcome was incidence of right-sided colonic (non-appendiceal) tumors presenting with features of acute appendicitis. Secondary outcomes measured were, role of diagnostic radiology, negative appendectomy rate, length of stay and changing trends in operative techniques. From 1662 patients initially reviewed, only 179 patients (10.77%) age 40 years or above mean (56 ± 11.75), median 54 (40-89), with clinical features of acute appendicitis were included in the final analysis. F:M ratio was (1:1.06). CT scan showed in only 1 patient (1.25%, OR = 0.806, p = 0.695), suspicion of cecal tumor and underwent right hemicolectomy. Histological examination of specimen showed, 2 patients (1.11%, OR = 1.10, p = 0.47) had primary appendiceal tumors, in which one patient was histologically reported as appendiceal mucocele (mucinous cystadenoma with low-grade dysplasia), while the other one had appendeceal carcinoid (Goblet cell carcinoid). In the other tumor group one patient had metastatic involvement of appendix from ovarian tumor. The time to appendectomy in radiological group was delayed by (9.2 ± 3.7 h). 131 (73.1%) had laparoscopic while 48 (26.81%) underwent open appendectomy. The negative appendectomy rate was (1.12%) and 30 days complication rate was (11.73%, p = 0.27). Mean length of stay was 3.54 ± 2.1 days. Right-sided colonic (cecal) tumors rarely present with features of acute appendicitis. Only those patients with atypical presentation and findings should have pre-operative radiological evaluation. Copyright © 2013 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.

Morel-Lavallee Lesion (MLL) Mimicking A Soft Tissue Neoplasm.

PubMed

Kumar, Sandeep; Hasan, Roumina; Kadavigere, Rajagopal; Maddukuri, Satish Babu; Puppala, Radha

2015-04-01

Morel-lavallee lesion (MLL) represents post traumatic subcutaneous cyst generally overlying bony prominences like greater trochanter, lower back, knee and scapula. A 51-year-old man presented with a swelling in left thigh since six years which was insidious in onset, gradually progressive in size and not associated with pain, fever or discharge. There was no history of trauma or any associated constitutional symptoms. Since there was no history of trauma recalled by the patient the clinical dilemma was between soft tissue sarcoma and cold abscess. We report a case of slow growing painless mass lesion of thigh, diagnosed on Magnetic Resonance Imaging (MRI) as morel lavallee lesion and describe its salient imaging features with treatment options.

Methamphetamine use can mimic testicular torsion.

PubMed

Doherty, Michael H; Gerscovich, Eugenio O; Corwin, Michael T; Wilkendorf, Stephen R

2013-09-01

We report the case of a patient presenting with the classic clinical appearance of testicular torsion. Ultrasound showed testicular ischemia supporting the clinical diagnosis, but the lack of visualization of spermatic cord torsion was of concern. An attempt of clinical detorsion was considered unsuccessful and the patient was explored. No torsion was found. On postoperative review of the patient's medical history, we found methamphetamine use, with a positive urine test at the time of his emergent consultation for the scrotal pain episode. The use of amphetamines has been previously reported as the cause of ischemia of multiple organs, but we could not find previous reports of involvement of the testis mimicking torsion. Copyright © 2013 Wiley Periodicals, Inc.

The Hip in Ice Hockey: A Current Concepts Review.

PubMed

Kuhn, Andrew W; Noonan, Benjamin C; Kelly, Bryan T; Larson, Christopher M; Bedi, Asheesh

2016-09-01

Ice hockey is a fast, physical sport with unique associated biomechanical demands often placing the hip in forced and repetitive supraphysiological ranges of motion. Ice hockey players commonly endure and are sidelined by nebulous groin injury or hip pain. Underlying causes can be chronic or acute and extra-articular, intra-articular, or "hip-mimicking." This article serves to review common hip-related injuries in ice hockey. For each, we define the particular condition; comment on risk factors and preventive strategies; discuss key historical, physical examination, and imaging findings; and finally, suggest nonoperative and/or operative treatment plans. Copyright © 2016 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.

Disseminated Pleural Siliconoma Mimicking Malignant Pleural Mesothelioma.

PubMed

Tanaka, Toshiki; Tao, Hiroyuki; Hayashi, Tatsuro; Yoshiyama, Koichi; Furukawa, Masashi; Yoshida, Kumiko; Okabe, Kazunori

2015-12-01

A 48-year-old woman with a 3-month history of back pain was admitted for further examination of multiple left pleural nodules. She had undergone bilateral breast augmentation with silicone implants 10 years previously. Nine years after the operation, both ruptured implants were removed, and autologous fat was injected. Computed tomography revealed multiple pleural nodules suggestive of malignant pleural mesothelioma. Thoracoscopic exploration revealed multiple pleural nodules with massive pleural adhesions. The nodules were filled with viscous liquid and were histologically determined to be siliconomas. Disseminated pleural siliconoma should be recognized as a late adverse event of silicone breast implantation. Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Human Dietary Fibre: A Review,

DTIC Science & Technology

1979-05-01

in 1)iets ( Dietary Fibre and Lipid Metabolism 7 Dietary Fibre and Colon Function 8 Epidemiology of Bowel Disease 8 Dietary Fibre and 1)iverticular... Disease 9 Dietary Fibre aiicl Colonic Cancer 10 Fibre and Appendicitis II 1 i1)re and Dental Caries 11 References 1)istr ibution List __________ Access...infective bowel diseases include hlaeiiiorm’hoidl s, appendicitis , di v ert i— cnlar disease , cam icer (If the colon , co litis audi Cu’ohn’s disease . 1 t is

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

PubMed

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

2017-06-01

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

Improving ultrasound for appendicitis through standardized reporting of secondary signs.

PubMed

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

2017-08-01

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

Prospective Observational Study on acute Appendicitis Worldwide (POSAW).

PubMed

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

2018-01-01

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

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

PubMed

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

1985-04-01

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