Diagnosing appendicitis: evidence-based review of the diagnostic approach in 2014

Diagnostic reliability of pediatric appendicitis score, ultrasound and low-dose computed tomography scan in children with suspected acute appendicitis

Background

Diagnosis of appendicitis in children is clinically challenging. Computed tomography (CT) is the gold standard for diagnosis; however, radiation exposure early in life is a concern with this technique. Therefore, in this study, we aimed to evaluate the diagnostic reliability of low-dose CT, pediatric appendicitis score (PAS), and abdominal ultrasound (US) in children with acute appendicitis, to reach a safe diagnosis.

Patients and methods

This retrospective study was conducted on 140 children who were admitted with clinically suspected acute appendicitis (45 with positive appendicitis and 95 children with negative appendicitis). Low-dose CT was performed, and PAS was retrospectively calculated for all subjects. US was initially performed for 38 subjects. All results were compared with the final diagnosis reached by an operative, histopathological analysis and follow-up.

Results

Low-dose CT showed a sensitivity, specificity, and accuracy of 97.8%, 100%, and 99.3%, respectively. At a cutoff value ≥5, PAS showed a sensitivity, specificity, and accuracy of 95%, 84%, and 89%, respectively. Abdominal US examination showed sensitivity, specificity, and accuracy of 55.6%, 85%, and 71%, respectively. Implementing Poortman’s model resulted in higher accuracy (92%) of US. There was a significant difference in accuracy between a low-dose CT and PAS on one side and between Poortman’s model and US examination on the other side. A diagnostic scheme was suggested using PAS as the excluding tool (PAS ≤2 send home and ≥7 send directly to operation) followed by US examination and reserving low-dose CT for inconclusive cases. This scheme would eliminate the use of CT for at least 33.7% and in 7 cases who had initial US examination.

Conclusion

Although CT remains the most accurate and less operator-dependent diagnostic tool for pediatric appendicitis, the radiation hazards could however be minimized using PAS as an excluding tool and US as the primary imaging modality followed by low-dose CT for inconclusive cases only.

Laparoscopic Appendectomy Protocol Expedites Management of Uncomplicated Acute Appendicitis

Bed availability remains a constant struggle for tertiary care centers resulting in the use of management protocols to streamline patient care and reduce length of stay (LOS). A standardized perioperative management protocol for uncomplicated acute appendicitis (UA) was implemented in April 2014 to decrease both CT scan usage and LOS. Patients who underwent laparoscopic appendectomy for UA from April 2012 to May 2013 (PRE group) and April 2014 to May 2015 (POST group) were compared retrospectively. There were no differences in patient demographics or clinical findings between the groups. All patients in the PRE group had a CT scan for the diagnosis of appendicitis, whereas there was a 14 per cent decrease in the POST group (P = 0.002). There was a significant decrease in median LOS between the groups [PRE 1.3 vs POST 0.9 days; (P < 0.001)]. There was no difference in subsequent emergency department visits for complications [3 (4%) vs 4 (4%); P = 1.0] or 30-day readmission rate [1 (1%) vs 5 (5%); P = 0.22] between the groups. A standardized perioperative management protocol for UA patients significantly decreased CT scan utilization and LOS without compromising patient care.

Diagnostic Value and Effect of Bedside Ultrasound in Acute Appendicitis in the Emergency Department

OBJECTIVE

Early and accurate diagnosis of acute appendicitis (AA) with ultrasound (US) can minimize the morbidity and mortality of the patients. In this regard, US can help emergency physicians (EPs) in the diagnosing process and clinical decision making for AA. Therefore, we primarily aimed to evaluate the effectiveness of point-of-care US (POCUS) in clinical decision making of EPs for the diagnostic evaluation for AA in the emergency department (ED).

METHODS

The study sample consisted of patients aged > 18 years who presented to the ED with abdominal pain and underwent diagnostic evaluation for AA. All patients were examined initially with POCUS by EPs and then with radiology-performed US (RADUS) by radiologists. Pre- and post-POCUS median diagnostic certainty values (MDCVs) for AA were determined with visual analog scale (VAS) scores (0 = not present, 100 = certainly present) by POCUS performers. Definitive diagnoses were determined by surgery, pathologic evaluation of appendectomy specimens, or clinical follow-up results. The sensitivity, specificity, positive likelihood ratio (PLR), and negative likelihood ratio (NLR) for POCUS and RADUS together with pre- and post-POCUS VAS scores for MDCVs were compared.

RESULTS

A total of 264 patients were included into the final analysis and 169 (64%) had a diagnosis of AA. The sensitivity, specificity, PLR, and NLR of US examinations were 92.3% (95% confidence interval [CI] = 87.2%-95.8%), 95.8% (89.5%-98.8%), 21.9 (8.4-57.2), and 0.08 (0.05-0.1) for POCUS and 76.9% (69.8-83%), 97.8% (84.9-99.7%), 36.4 (9.25-144.3), and 0.24 (0.18-0.31) for RADUS, respectively. Pre-POCUS and post-POCUS VAS scores for MDCVs were 60 (interquartile range [IQR] = 50-65) and 95 (IQR = 20-98), respectively (p = 0.000).

CONCLUSION

Point-of-care ultrasonography, when performed in ED for the diagnosis of AA, has high sensitivity and specificity and had a positive impact on the clinical decision making of EPs.

How to diagnose an acutely inflamed appendix; a systematic review of the latest evidence

Acute appendicitis is the most common condition that presents with an acute abdomen needing emergency surgery. Despite this common presentation, correctly diagnosing appendicitis remains a challenge as clinical signs or positive blood results can be absent in 55% of the patients. The reported proportion of missed diagnoses of appendicitis ranges between 20% and 40%. A delay or mis-diagnosis of appendicitis can result in severe complications such as perforation, abscess formation, sepsis, and intra-abdominal adhesions. Literature has shown that patients who had a negative appendectomy suffer post-op complications and infections secondary to hospital stays; there have even been reported cases of fatality. It is therefore crucial that timely and accurate diagnosis of appendicitis is achieved to avoid complications of both non-operating as well as unnecessary surgical intervention. The aim of this review is to systematically report and analyse the latest evidence on the different approaches used in diagnosing appendicitis. We include discussions of clinical scoring systems, laboratory tests, latest innovative bio-markers and radiological imaging.

Evaluation of Platelet Indices and Red Cell Distribution Width as New Biomarkers for the Diagnosis of Acute Appendicitis

BACKGROUND

Debate around the value of laboratory tests in establishing the diagnosis of acute appendicitis (AA) still continues. This prospective study aimed to investigate the changes in mean platelet volume (MPV), platelet distribution width (PDW), and red cell distribution width (RDW) with the diagnosis of acute appendicitis.

METHOD

200 patients who underwent emergency appendectomy were included. According to postoperative histology, patients were divided into three groups: acute non-complicated, acute complicated appendicitis (positive appendicectomy groups), and negative appendectomy group. White blood cell (WBC), neutrophil, lymphocyte count, neutrophil-to-lymphocyte ratio (NLR), platelets (PLT) count, MPV, PDW, RDW, and C-reactive protein (CRP) were compared among the groups.

RESULTS

One hundred twenty-five (62.5%) patients had non-complicated acute appendicitis, 20 (10%) had complicated acute appendicitis, while 55 (27.5%) had normal appendix. WBC (p <.001), neutrophil (p <.001), NLR (p <.001), PDW (p =.003), and CRP (p =.001) were higher, while lymphocyte (p <.001) and PLT counts (p =.020) were lower in positive appendectomy compared with negative appendectomy patients. MPV levels were insignificantly different across the groups. RDW level was significantly higher in complicated compared with non-complicated acute appendicitis (p =.006); however, no significant difference was found between positive and negative appendectomy groups. Using receiver operating characteristic analysis, sensitivity, specificity, and diagnostic accuracy respectively were 44.83, 100.0, and 72.415% for WBC count, 72.41, 81.82, and 77.115% for neutrophil count, 48.28, 90.91, and 69.595% for PDW, 89.66, 63.64, and 76.65% for CRP.

CONCLUSIONS

Increased PDW combined with elevated WBC and neutrophil counts maybe used as diagnostic tests in the cases of acute appendicitis, while MPV and RDW levels were not useful diagnostic markers.

Stimulation of Erythrocyte Cell Membrane Scrambling by C-Reactive Protein

Background: Eryptosis, the suicidal erythrocyte death characterized by cell shrinkage and phosphatidylserine-translocation, is triggered by fever and inflammation. Signaling includes increased cytosolic Ca2+-activity ([Ca2+]i), caspase activation, and ceramide. Inflammation is associated with increased plasma concentration of C-reactive protein (CRP). The present study explored whether CRP triggers eryptosis. Methods: Phosphatidylserine abundance at the cell surface was estimated from annexin-V-binding, cell volume from forward scatter, [Ca2+]i from Fluo3-fluorescence, ceramide abundance and caspase-3-activity utilizing FITC-conjugated antibodies. Moreover, blood was drawn from patients with acute appendicitis (9♀,11♂) and healthy volunteers (10♀,10♂) for determination of CRP, blood count and phosphatidylserine. Results: A 48h CRP treatment significantly increased the percentage of annexin-V-binding cells (≥5µg/ml), [Ca2+]i (≥5µg/ml), ceramide (20µg/ml) and caspase-activity (20µg/ml). Annexin-V-binding was significantly blunted by caspase inhibitor zVAD (10µM). The percentage of phosphatidylserine-exposing erythrocytes in freshly drawn blood was significantly higher in appendicitis patients (1.83±0.21%) than healthy volunteers (0.81±0.09%), and significantly higher following a 24h incubation of erythrocytes from healthy volunteers to patient plasma than to plasma from healthy volunteers. The percentage of phosphatidylserine-exposing erythrocytes correlated with CRP plasma concentration. Conclusion: C-reactive protein triggers eryptosis, an effect at least partially due to increase of [Ca2+]i, increase of ceramide abundance and caspase activation.

Pediatric Abdominal Pain: An Emergency Medicine Perspective

Abdominal pain is a common complaint that leads to pediatric patients seeking emergency care. The emergency care provider has the arduous task of determining which child likely has a benign cause and not missing the devastating condition that needs emergent attention. This article reviews common benign causes of abdominal pain as well as some of the cannot-miss emergent causes.

Clinical utility of abdominal and pelvic ultrasound in the evaluation of right iliac fossa pain in females

BACKGROUND

Ultrasound (US) is often the imaging modality of choice in women with acute right iliac fossa (RIF) pain, identifying the appendix in up to 99% of patients. The literature, however, lacks clear guidelines on how ultrasonography should be performed to maximise sensitivity and specificity in such patients. Many centres perform untargeted abdomino-pelvic scans, including organs such as the liver and spleen, which unlikely contribute to the presenting complaint.

AIMS

We aimed to evaluate the clinical utility of unfocussed abdominal and pelvic US in women of reproductive age with acute RIF pain.

METHODS

This multicentre study describes 501 women between the ages of 12 and 50, over a 3-year period from three institutions, presenting acutely with RIF pain and investigated with US abdomen and pelvis.

RESULTS

5.9% of cases confirmed appendicitis sonographically. A normal appendix was visualised in 0.2%. Over 10% identified gynaecological pathology, 41% relating to the right ovary. 10.4% incidental extra-pelvic findings were unrelated to the acute clinical presentation. 0.8% of patients had extra-pelvic findings meriting further clinical assessment.

CONCLUSION

The results herein reflect findings from high volume emergency surgical departments, demonstrating that unfocussed abdominal and pelvic ultrasounds are not an appropriate use of resources in reproductive women with RIF pain. Clinically relevant extra-pelvic US findings account for less than 1%, rarely contributing to the acute presentation. The appendix was only visualised in 6% of patients, suggesting that a focussed appendiceal and pelvic US would better assist diagnosis with a higher yield and increased sensitivity and specificity.

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

BACKGROUND

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.

AIM

To investigate the diagnostic value of ERAT for acute appendicitis by the combination of colonoscopy and endoscopic retrograde appendicography (ERA).

METHODS

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.

RESULTS

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.

CONCLUSION

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.

Neutrophil to Lymphocyte Ratio on Appendectomy of Geriatric and Nongeriatric Patients

PURPOSE

Acute appendicitis is the most frequent emergency procedure that requires acute surgical intervention. The mortality risk is higher in geriatric patients. There is not a single parameter to diagnose it easily and negative appendectomy is traditionally accepted however the operation itself can cause morbidity and mortality especially in elderly patients. The neutrophil-to-lymphocyte ratio is a predictor of acute inflammation and was recently studied for the diagnosis of AA. The aim of this study is to analyze the diagnostic value of NLR on positive appendectomy rates amongst geriatric and nongeriatric patients.

MATERIALS AND METHODS

755 patients admitted to the emergency department, with abdominal pain who underwent urgent laparotomy after diagnosed as acute appendicitis. Patients' ages, genders, laboratory results, and intraoperative findings were collected. Geriatric patients were analyzed in group one, and nongeriatric patients were in group 2. Groups then sorted into subgroups by means of positive and negative appendectomies.

RESULTS

Although NLR was higher in positive appendectomy subgroup in group 1 it was not statistically significant. NLR could not independently predict positive appendectomy in geriatric patients. In group 2, male gender was significantly higher in the positive appendectomy group (p < 0.001). NLR was also significantly higher in the positive appendectomy group (p < 0.001). In group 2 NLR could independently predict positive appendectomy (p < 0.001).

CONCLUSION

NLR could not predict positive appendectomy rates in the geriatric population but could in the nongeriatric patient group. To find the optimal NLR levels, prospective randomized studies are needed.

The use of platelet indices, plateletcrit, mean platelet volume and platelet distribution width in emergency non-traumatic abdominal surgery: a systematic review

Platelet indices (PI) -- plateletcrit, mean platelet volume (MPV) and platelet distribution width (PDW) -- are a group of derived platelet parameters obtained as a part of the automatic complete blood count. Emerging evidence suggests that PIs may have diagnostic and prognostic value in certain diseases. This study aimed to summarize the current scientific knowledge on the potential role of PIs as a diagnostic and prognostic marker in patients having emergency, non-traumatic abdominal surgery. In December 2015, we searched Medline/PubMed, Scopus and Google Scholar to identify all articles on PIs. Overall, considerable evidence suggests that PIs are altered with acute appendicitis. Although the role of PI in the differential diagnosis of acute abdomen remains uncertain, low MPV might be useful in acute appendicitis and acute mesenteric ischemia, with high MPV predicting poor prognosis in acute mesenteric ischemia. The current lack of consistency and technical standards in studies involving PIs should be regarded as a serious limitation to comparing these studies. Further large, multicentre prospective studies concurrently collecting data from different ethnicities and genders are needed before they can be used in routine clinical practice.

Contrast-enhanced ultrasound improves accurate identification of appendiceal mucinous adenocarcinoma in an old patient: A case report

BACKGROUND

Adenocarcinoma of appendiceal origin is far rarer than other colorectal carcinomas and its preoperative diagnosis is challenging. To our knowledge, utility of contrast-enhanced ultrasound (CEUS) to diagnose it is much less.

METHOD

A 61-year-old man presented with abdominal pain in the right lower quadrant for 20 days. In order to fulfill an accurately preoperative diagnosis, he received laboratory and imaging tests such as carcinoembryonic antigen (CEA), computer tomography (CT), CEUS and endoscope.

DIAGNOSIS AND INTERVENTION

He was initially suspected of suffering appendicitis, while his white blood cell count was normal and carcinoembryonic antigen (CEA) in serum was remarkably increased. Both routine ultrasound and computer tomography (CT) examinations supported suppurative appendicitis. The overall data, however, failed to excluded neoplastic pathology thoroughly. Therefore, CEUS was carried out and showed an inhomogeneous enhancement intra the lesion located in the body of the appendix, which made our consideration of neoplasm. The result of the follow-up biopsy guided by endoscope was consistent with appendiceal tumor. The patient received laparoscopic right hemicolectomy. Histopathology confirmed as well differentiated mucinous adenocarcinoma of appendix origin. His postoperative course was uneventful, and he had a regular diet again without any complaint.

RESULT

Serum CEA was remarkably increased (12.00 ng/mL). Both routine ultrasound and CT examinations supported suppurative appendicitis. However, CEUS examination showed an inhomogeneous enhancement intra the lesion located in the body of the appendix, which made our consideration of neoplasm. The follow-up biopsy guided by endoscope and surgical specimens confirmed as well differentiated mucinous adenocarcinoma of appendix origin.

CONCLUSION

Most mucinous adenocarcinoma mimicking appendicitis results in difficult diagnosis preoperatively. Clinician and radiologist should be aware of it when old patient presented with appendicitis especially along with high level of CEA.

Pyosalpinx causing acute appendicitis in a 32-year-old Cameroonian female: a case report

Background

Pyosalpinx as a cause of acute appendicitis is very rare. We report the first case of a right pyosalpinx causing an extrinsic compression of the appendiceal lumen and consequently an acute appendicitis following an obstruction.

Case presentation

A 32 year old female from the North west region of Cameroon, presented with an acute exacerbation of a mild chronic right iliac fossa pain over a 2 day duration. She underwent exploratory laparotomy and intraoperative findings were a bilateral pyosalpinx, with the right fallopian tube adhering to the caecum and the terminal ileum, and obstructing the lumen of an inflammed appendix. A classical appendectomy and a right salpingectomy were done. The post-operative period was uneventful and she returned after 2 weeks for a follow-up visit with no further complaints.

Conclusion

We describe to the best of our knowledge, the first case of an acute appendicitis caused by an extrinsic obstruction of the appendiceal lumen by a pyosalpinx. The close proximity of the caecum to the right fallopian tube most likely accounted for this occurrence. Although a rare entity, physicians should always keep in mind very rare causes of an acute appendicitis to guide management. This case highlights the shortcomings of pelvic ultrasonography in the diagnosis this condition. A pelvic computed tomography scanning should therefore be sought in case of a doubtful pelvic ultrasonography result. Finally, there is an urgent need to improve the awareness on sexually transmitted infections in our setting.

Paradigm Shifts in the Treatment of Appendicitis

Acute appendicitis is the most common cause of emergent surgery in children. Historically, surgical dogma dictated emergent appendectomy due to concern for impending perforation. Recently, however, there has been a paradigm shift in both the understanding of its pathophysiology as well as its treatment to more nonoperative management. No longer is it considered a spectrum from uncomplicated appendicitis inevitably progressing to complicated appendicitis over time. Rather, uncomplicated and complicated appendicitis are now considered two distinct pathophysiologic entities. This change requires not only educating the patients and their families but also the general practitioners who will be managing treatment expectations and caring for patients long term. In this article, we review the pathophysiology of appendicitis, including the differentiation between uncomplicated and complicated appendicitis, as well as the new treatment paradigms. [Pediatr Ann. 2016;45(7):e235-e240.].

Lower Abdominal Pain

Although most frequently presenting with lower abdominal pain, appendicitis, colitis, and diverticulitis can cause pain throughout the abdomen and can cause peritoneal and retroperitoneal symptoms. Evaluation and management of lower intestinal disease requires a nuanced approach by the emergency physician, sometimes requiring computed tomography, ultrasonography, MRI, layered imaging, shared decision making, serial examination, and/or close follow-up. Once a presumed or confirmed diagnosis is made, appropriate treatment is initiated, and may include surgery, antibiotics, and/or steroids. Appendicitis patients should be admitted. Diverticulitis and inflammatory bowel disease can frequently be managed on an outpatient basis, but may require admission and surgical consultation.

Right Hydronephrosis as a Complication of Acute Appendicitis

Introduction. Acute appendicitis is the most common cause of acute abdomen, but atypical appendicitis may lead to delayed diagnosis and related complications. In this report, we present a very rare case of acute appendicitis causing right hydronephrosis. Case Report. A 54-year-old male patient who had been receiving antibiotic therapy due to the diagnosis of urinary tract infection for the last one week but had no clinical improvement was admitted to the emergency service. Abdominal computed tomography (CT) showed right hydronephrosis and a pelvic abscess. After appendectomy and abscess drainage had been performed, hydronephrosis was completely recovered. Discussion. The use of appendicitis scoring systems, abdominal ultrasonography (USG), abdominal CT, and diagnostic laparoscopy can be useful for the diagnostic process in patients presenting with acute abdomen. In our patient, we considered that the surgical treatment was delayed since the symptoms of acute appendicitis were suppressed by the antibiotic therapy that was being administered due to the complaints including symptoms of urinary tract infections. Conclusion. Atypical appendicitis may cause a delay in the diagnosis of acute appendicitis and thus may lead to serious complications such as right hydronephrosis, prolonged hospital stay, increased morbidity and mortality, and increased antibiotic resistance.

Evaluation of mediators of oxidative stress and inflammation in patients with acute appendicitis

CONTEXT

This study aims to explore the potential of new inflammatory markers for improving the challenging diagnosis of acute appendicitis (AA).

METHODS

Levels of IL-1, IL-6, IL-8, IL-10, CRP, INF-γ, and TNF-α in serum were measured in 73 patients with AA. Oxidative stress and antioxidant enzymes were analyzed.

RESULTS

Serum levels of interleukins, TNF-α, and INF-γ were significantly elevated in patients with appendicitis (p < 0.0001), except for IL-10, which presented decreased levels. There were no significant differences in SOD (p = 0.29), CAT (p = 0.19), or TBARS levels (p = 0.18), whereas protein carbonyls presented significant increase (p < 0.0001).

CONCLUSION

Evaluating these biomarkers could aid in diagnosing AA.

Diagnostic value of red blood cell distribution width in pediatric acute appendicitis

BACKGROUND

The aim of this study was to evaluate the diagnostic value of red blood cell distribution width (RDW) in children with acute appendicitis.

METHODS

In this retrospective study, a total of 344 children aged ≤18 years with clinically suspected acute appendicitis who underwent appendectomy between January 2007 and January 2014 were reviewed, and 200 healthy controls of the same age group were included. Based on histopathology, the patients were classified as having normal appendix, simple or perforated appendicitis, and preoperative white blood cell count (WBC), C-reactive protein (CRP) and RDW were compared.

RESULTS

Compared with the controls, mean WBC, CRP and RDW were significantly higher in the appendectomy group (P <0.001). The children with simple or perforated appendicitis had significantly higher WBC, CRP and RDW than did those with normal appendix (P <0.001). Mean WBC and CRP were significantly higher in the children with perforated appendicitis (P <0.001), but no statistically significant difference was found in RDW between the simple and perforated appendicitis groups (P = 0.081).

CONCLUSIONS

Children with histologically proven acute appendicitis have higher RDW than children without appendicitis, but the diagnostic value of RDW was not superior to WBC or CRP in children with acute appendicitis. Although higher RDW may be valuable for aiding the diagnosis of acute appendicitis in children, it is not a useful marker for predicting perforated appendicitis.

How to diagnose acute appendicitis: ultrasound first

Acute appendicitis (AA) is a common abdominal emergency with a lifetime prevalence of about 7 %. As the clinical diagnosis of AA remains a challenge to emergency physicians and surgeons, imaging modalities have gained major importance in the diagnostic work-up of patients with suspected AA in order to keep both the negative appendectomy rate and the perforation rate low. Introduced in 1986, graded-compression ultrasound (US) has well-established direct and indirect signs for diagnosing AA. In our opinion, US should be the first-line imaging modality, as graded-compression US has excellent specificity both in the paediatric and adult patient populations. As US sensitivity is limited, and non-diagnostic US examinations with non-visualization of the appendix are more a rule than an exception, diagnostic strategies and algorithms after non-diagnostic US should focus on clinical reassessment and complementary imaging with MRI/CT if indicated. Accordingly, both ionizing radiation to our patients and cost of pre-therapeutic diagnosis of AA will be low, with low negative appendectomy and perforation rates.

Main Messages

• Ultrasound (US) should be the first imaging modality for diagnosing acute appendicitis (AA).

• Primary US for AA diagnosis will decrease ionizing radiation and cost.

• Sensitivity of US to diagnose AA is lower than of CT/MRI.

• Non-visualization of the appendix should lead to clinical reassessment.

• Complementary MRI or CT may be performed if diagnosis remains unclear.

Ultrasonography-triggered diagnosis of putrid, ulcero-phlegmonous, hemorrhagic appendicitis and periappendicitis with an atypical symptom pattern: a case report

BACKGROUND

Asymptomatic and oligosymptomatic appendicitis are rare and challenging diagnoses that should not be missed.

CASE PRESENTATION

A young female patient presented with mild to moderate pain in the middle and lower abdomen, and the results of physical examination, including digital rectal examination, were otherwise non-contributory. Ultrasonography demonstrated a marked increase of the outer appendiceal diameter up to 12 mm and a trace of free liquid around the terminal ileum. Subsequent surgical exploration and histological examination allowed for a final diagnosis of putrid, ulcero-phlegmonous, hemorrhagic appendicitis and periappendicitis.

CONCLUSIONS

Ultrasonography is increasingly used for the diagnosis of appendiceal inflammation, particularly in military medical settings. Increases in the outer appendiceal diameter up to >6 mm under compression have recently been demonstrated to be indicative of acute appendicitis. At a minimum, in cases with doubtful physical examination results, ultrasonography should be considered as an element in the diagnosis of acute appendicitis.

A new 2-step risk-stratification clinical score for suspected appendicitis in children

AIM

The aim of this study was to develop a new Children's Appendicitis Score (CAS) by combining 3 inflammatory markers and a set of predictors for suspected appendicitis in children.

METHODS

374 children aged 4-16years with suspicion of appendicitis were prospectively enrolled for the derivation cohort. Demographic characteristics, clinical features, laboratory, and histology data were collected. The outcome measure was the histological presence or absence of appendicitis. Backward logistic regression was employed to select predictors for construction of a score. Diagnostic performance of CAS was compared with the Pediatric Appendicitis Score (PAS) on a separate validation cohort.

RESULTS

The combination of normal white blood cell count (WBC), neutrophil percentage, and C-reactive protein (CRP) had a 100% negative predictive value for appendicitis. We assigned 'coefficient A' as 'zero' when all triple markers were negative and 'one' when any one markers was positive. A second component of 6 predictors was identified for construction of the 'raw score': Localized right-lower-quadrant pain, generalized guarding, constant characteristic of pain, pain on percussion or coughing, WBC≥14000/L and CRP≥24g/L. CAS was generated by multiplying 'coefficient A' by 'raw score'.

CONCLUSION

CAS is superior to PAS in ruling out appendicitis. Risk stratification of equivocal patients could guide the need for further diagnostic imaging examination.

Perforated Appendicitis: Assessment With Multidetector Computed Tomography

Appendicitis is one of the most common abdominal surgical emergencies. In some cases, the correct diagnosis may be challenging, owing to different conditions that can mimic this pathology. In this context, abdominal computed tomography (CT) is the imaging modality of choice, leading to an accurate diagnosis and to a reduction in unnecessary laparotomies. The diagnosis of perforated appendix is crucial, but the detection of the perforation signs by CT may not be so simple in the early process. The aim of this article is to review the multiple detector CT signs of perforated appendicitis.

Missed appendicitis diagnosis: A case report

OBJECTIVE

The purpose of this case report is to highlight and emphasize the need for an appropriate and thorough list of differential diagnoses when managing patients, as it is insufficient to assume cases are mechanical, until proven non-mechanical. There are over 250,000 cases of appendicitis annually in the United States. Of these cases, <50% present with classic signs and symptoms of pain in the right lower quadrant, mild fever and nausea. It is standard for patients who present with appendicitis to be managed operatively with a laparoscopic appendectomy within 24 hours, otherwise the risk of complications such as rupture, infection, and even death increases dramatically.

CLINICAL FEATURES

This is a retrospective case report following a 27-year-old male with missed appendicitis, who presented to a chiropractor two-weeks after self-diagnosed food poisoning. On assessment, he was tender with resisted lumbar rotation. Psoas Sign, McBurney's Point, vascular exam, hip exam, were negative. A diagnosis of an abdominal strain was provided. Two weeks later, he returned to the chiropractor without an improvement of symptoms.

INTERVENTION & OUTCOME

The patient was sent to the hospital, where he was provided a diagnosis of missed appendicitis. He required a hemicolonectomy due to the associated phlegmonous mass.

SUMMARY

When a patient presents to a chiropractic clinic with symptoms of abdominal pain, having a comprehensive list of non-mechanical differential diagnoses as well as mechanical differentials is crucial. Appropriate assessment and management of abdominal cases decreases the risk to patients, as missed diagnoses often require more invasive interventions.

Acute appendicitis following endoscopic mucosal resection of cecal adenoma

Endoscopic mucosal resection (EMR) allows the removal of flat or sessile lesions, laterally spreading tumors, and carcinoma of the colon or the rectum limited to the mucosa or the superficial submucosa. Acute appendicitis is the most common abdominal emergency requiring emergency surgery, and it is also a rare complication of diagnostic colonoscopy and therapeutic endoscopy, including EMR. In the case presented here, a 53-year-old female underwent colonoscopy due to a positive fecal occult blood test and was diagnosed with cecal adenoma. She was referred to our hospital and admitted for treatment. The patient had no other symptoms. EMR was performed, and 7 h after the surgery, the patient experienced right -lower abdominal pain. Laboratory tests performed the following day revealed a WBC count of 16000/mm³, a neutrophil count of 14144/mm³, and a C-reactive protein level of 2.20 mg/dL, indicating an inflammatory response. Computed tomography also revealed appendiceal wall thickening and swelling, so acute appendicitis following EMR was diagnosed. Antibiotics were initiated leading to total resolution of the symptoms, and the patient was discharged on the sixth post-operative day. Pathological analysis revealed a high-grade cecal tubular adenoma. Such acute appendicitis following EMR is extremely rare, and EMR of the cecum may be a rare cause of acute appendicitis.

Caecal diverticulitis: Presentation and management

Introduction

While left sided colonic diverticular disease is common in Western countries, right sided colonic diverticular disease is rare. With increasing migration from Asia, many western countries including Australia, are now seeing more right sided diverticular disease, of which caecal diverticulitis is the commonest. This study aims to determine the incidence of caecal diverticulitis in patients presenting with colonic diverticulitis, as well as identify the symptoms and clinical features that may aid in making a pre-operative diagnosis.

Methods

Data was collected using the Queen Elizabeth II Hospital medical records database identifying patients diagnosed with colonic diverticulitis and, more specifically, those with caecal diverticulitis from January 2007 to December 2013. Only those patients who had confirmed caecal diverticulitis on imaging studies or at laparoscopy on their first admission were included in this study.

Results

A total of 632 patients with colonic diverticulitis were admitted to our institution over a seven-year period, of which 13 patients had caecal diverticulitis (2.06%). Of the 13 patients, twelve were of Asian background and ten were considered young (≤50 years of age). The main complaints were right sided abdominal pain (n = 11, 84.6%) and diarrhoea (n = 5, 38.5%). Nine were diagnosed using computed tomography (n = 9/10, 90%), three on laparoscopy and one using ultrasound (n = 1/2, 50%). Ten patients were treated successfully by conservative means.

Discussion

A high index of suspicion in Asian patients with atypical symptoms of appendicitis, especially diarrhoea, may provide the diagnosis of caecal diverticulitis.

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CD occurs mostly in young Asians, presenting with atypical symptoms of appendicitis.

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With increasing migration, more patients are presenting in Western countries with CD.

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If imaging confirms uncomplicated CD, conservative treatment is recommended.

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In our limited study, diagnosis of CD was superior with computed tomography.