Major Variation in the Incidence of Appendicitis Before, During and After Pregnancy: A Population-Based Cohort Study

What you need to know: Current management of acute appendicitis in adults

ABSTRACT

Acute appendicitis is one of the most common acute surgical diseases in the world today. Acute appendicitis can present with a well-recognized clinical presentation with abdominal pain which localize in the right lower quadrant. This presentation is more typical in men than in women of child baring age. Several clinical and laboratory calculations can be used to increase the likelihood of making a correct diagnosis. Various imaging modalities can be used to make the diagnosis which include ultrasound, computer tomography, and magnetic resonance imaging. Each study has well known sensitivity/specificity of positive predictive value of making the diagnosis of appendicitis. The management of acute appendicitis is based on the presentation of the patient and dividing it into uncomplicated and complicated disease. Each requires management with antibiotics and followed with timely appendectomy. Recent studies have demonstrated nonoperative management of uncomplicated appendicitis without no fecalith that can be managed with antibiotics alone. Complicated acute appendicitis should undergo timely surgical intervention. Patients presenting with a large appendiceal abscess or phlegmon should undergo percutaneous drainage and antibiotic management. There are certain patient populations that should be considered for surgical intervention. Pregnant patients as well as immunosuppressed patients should undergo timely surgical intervention to decrease the risk of complications. This review outlines the current principles of the diagnosis, imaging, and treatment of acute appendicitis based on the best available evidence of acute appendicitis in adults.

LEVEL OF EVIDENCE

Original Review Article, Level III.

Validation of the Appendicitis Inflammatory Response (AIR) score during pregnancy: A nested case-control study

OBJECTIVES

Appendicitis poses diagnostic challenges. A correct diagnosis is important during pregnancy to avoid unnecessary surgery on the one hand and delayed surgery on the other hand, as both may negatively affect pregnancy outcomes. Clinical scores for risk-stratified management of suspected appendicitis are well established in adults but have not been validated during pregnancy. This nested case-control study evaluated the diagnostic accuracy of the Appendicitis Inflammatory Response (AIR) score and imaging during pregnancy.

METHODS

By cross-linking national Swedish health registries from a defined geographical area, we identified a cohort of 154 women who underwent appendectomy for suspected appendicitis during pregnancy and a matched cohort of 232 pregnant women admitted for acute abdominal pain and suspected appendicitis but with a discharge diagnosis of nonspecific abdominal pain (NSAP). All variables were extracted from medical records. The diagnostic value of AIR score and imaging was estimated for patients with a final diagnosis of appendicitis compared with patients with negative appendectomy and NSAP patients.

RESULTS

The final diagnoses for the operated patients were uncomplicated and complicated appendicitis in 49.4% and 26.6%, respectively, and negative appendectomy in 24.0%. Nearly half of all the patients underwent diagnostic imaging (41%), mainly by ultrasonography. The sensitivity and specificity of diagnostic imaging were 44.9% (95% CI 32.9%-57.4%) and 42.2% (95% CI 31.9%-53.1%), respectively. The area under the receiver operating characteristic curve of AIR score was 0.88 (95% CI 0.84-0.92) for all appendicitis and 0.90 (95% CI 0.84-0.95) for complicated appendicitis. The sensitivity for complicated appendicitis was 100% at a score of ≥4. The specificity for all appendicitis was 97% at a score of ≥9.

CONCLUSIONS

The results of this study suggest that the AIR score may be a suitable diagnostic tool for risk stratification of pregnant women with abdominal pain and suspected appendicitis but further validation among pregnant women is needed.

SAGES guidelines for the use of laparoscopy during pregnancy

BACKGROUND

When pregnant patients present with nonobstetric pathology, the physicians caring for them may be uncertain about the optimal management strategy. The aim of this guideline is to develop evidence-based recommendations for pregnant patients presenting with common surgical pathologies including appendicitis, biliary disease, and inflammatory bowel disease (IBD).

METHODS

The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Guidelines Committee convened a working group to address these issues. The group generated five key questions and completed a systematic review and meta-analysis of the literature. An expert panel then met to form evidence-based recommendations according to the Grading of Recommendations Assessment, Development, and Evaluation approach. Expert opinion was utilized when the available evidence was deemed insufficient.

RESULTS

The expert panel agreed on ten recommendations addressing the management of appendicitis, biliary disease, and IBD during pregnancy.

CONCLUSIONS

Conditional recommendations were made in favor of appendectomy over nonoperative treatment of appendicitis, laparoscopic appendectomy over open appendectomy, and laparoscopic cholecystectomy over nonoperative treatment of biliary disease and acute cholecystitis specifically. Based on expert opinion, the panel also suggested either operative or nonoperative treatment of biliary diseases other than acute cholecystitis in the third trimester, endoscopic retrograde cholangiopancreatography rather than common bile duct exploration for symptomatic choledocholithiasis, applying the same criteria for emergent surgical intervention in pregnant and non-pregnant IBD patients, utilizing an open rather than minimally invasive approach for pregnant patients requiring emergent surgical treatment of IBD, and managing pregnant patients with active IBD flares in a multidisciplinary fashion at centers with IBD expertise.

Exploring the role of an artificial intelligence chatbot on appendicitis management: an experimental study on ChatGPT

BACKGROUND

Appendicitis is a common surgical condition that requires urgent medical attention. Recent advancements in artificial intelligence and large language processing, such as ChatGPT, have demonstrated potential in supporting healthcare management and scientific research. This study aims to evaluate the accuracy and comprehensiveness of ChatGPT's knowledge on appendicitis management.

METHODS

Six questions related to appendicitis management were created by experienced RACS qualified general surgeons to assess ChatGPT's ability to provide accurate information. The criteria of ChatGPT answers' accuracy were compared with current healthcare guidelines for appendicitis and subjective evaluation by two RACS qualified General Surgeons. Additionally, ChatGPT was then asked to provide five high level evidence references to support its responses.

RESULTS

ChatGPT provided clinically relevant information on appendicitis management, however, was inconsistent in doing so and often provided superficial information. Further to this, ChatGPT encountered difficulties in generating relevant references, with some being either non-existent or incorrect.

CONCLUSION

ChatGPT has the potential to provide timely and comprehensible medical information on appendicitis management to laypersons. However, its issue of inaccuracy in information and production of non-existent or erroneous references presents a challenge for researchers and clinicians who may inadvertently employ such information in their research or healthcare. Therefore, clinicians should exercise caution when using ChatGPT for these purposes.

Associations between Th1-related cytokines and complicated pediatric appendicitis

The pathogenesis of appendicitis is not understood fully, and the diagnosis can be challenging. Previous research has suggested an association between a T helper (Th) 1-dependent immune response and complicated appendicitis. This prospective cohort study aimed to evaluate the association between serum concentrations of the Th1-associated cytokines interleukin (IL)-1α, IL-1β, IL-2, IL-6, IL-10, IL-17A and tumor necrosis factor beta (TNF-β) and the risk of complicated appendicitis in children. Appendicitis severity was determined through histopathological examination. A total of 137 children < 15 years with appendicitis were included with a median age of 10 years (IQR 8-12); 86 (63%) were boys, and 58 (42%) had complicated appendicitis. Children with complicated appendicitis had significantly higher concentrations of serum IL-6 and IL-10, and lower of TNF-β. After adjustment for age, symptom duration, and presence of appendicolith in a multivariable logistic regression, a higher concentration of IL-6 remained associated with an increased risk of complicated appendicitis (aOR 1.001 [95% CI 1.000-1.002], p = 0.02). Serum concentrations of IL-1α, IL-1β, IL-2, IL-10, IL-17A and TNF-β were not significantly associated with the risk of complicated appendicitis. In conclusion, our results suggests that the systemic inflammatory response in complicated appendicitis is complex and not solely Th1-dependent.

Appendectomy during pregnancy: rates, safety, and outcomes over a five-year period. A hospital-based follow-up study

INTRODUCTION

Appendicitis is the most common acute abdominal complication during pregnancy. If appendix perforation occurs there is an increasing risk of preterm delivery and other pregnancy complications.

OBJECTIVE

To assess the outcome of pregnancy after appendectomy, the mode of surgery used, appendectomy rates, and complications.

METHODS

A prospective cohort study of pregnant women with, or without, appendectomy at South Stockholm General Hospital, December 2015 to February 2021 in a setting where pregnant women are prioritized for surgery and laparoscopic surgery was standard of care in first half of pregnancy. Data on preoperative imaging, surgical method, intraoperative findings, microscopic findings, hospital stay, pregnancy, and 30-day complications were prospectively recorded in a local appendectomy register. A non-pregnant control group was gathered comprising women of fertile age in the same study interval.

RESULTS

During the study period 50 pregnant women, of whom 44 gave birth, underwent appendectomy of 38 199 women giving birth. There were no differences between women with or without appendectomy in proportion of preterm delivery (4.5% vs. 5.6%), small-for-gestational age (2.3% vs. 6.2%), or Cesarean delivery (18.2% vs. 20.4%). The rate of appendix perforation was 19% in non-pregnant control group compared to 12% among pregnancy. There was no case of perforated appendix in the second half of pregnancy. However, women with gestational age > 20 weeks more frequently had an unaffected appendix compared to those operated ≤ 20 gestational weeks (4/11 vs. 2/39, p = .005). Laparoscopic surgery was used in 97% of non-pregnant control group, 92% of appendectomies ≤ 20 weeks gestation, and in 27% >20 weeks. As compared to first half, the appendectomy rate was three times lower during the second half of pregnancy. Pregnant women had priority for surgery < 6 h compared to < 24 h among non-pregnant women, this resulted in a shorter time-to-surgery among pregnant women (p < .001).

CONCLUSION

Routine laparoscopic surgery and time priority for pregnant surgery is associated with a low risk of perforation, preterm birth and other complications. However, a low threshold for surgery may increase the risk of a negative exploration.

MRI remains highly accurate in the diagnosis of appendicitis in pregnancy when read by radiologists of mixed specialty training and experience

PURPOSE

To audit the accuracy of magnetic resonance imaging (MRI) abdominal studies performed in the diagnosis of appendicitis in pregnant patients when read by radiologists of mixed experience.

METHODS

MRI reports from 45 pregnant women presenting to our emergency department for the investigation of appendicitis between 2009 and 2020 were retrospectively reviewed. Where available, these reports were correlated with surgical and pathology reports as well as follow-up clinical information. Following a review of literature, accuracy targets were set. Statistical analyses including sensitivity, specificity, positive, and negative predictive values were calculated.

RESULTS

A total of 18 radiology consultants read 45 MRI abdominal studies in the assessment of appendicitis during pregnancy with 62% (n = 28) of these read by specialist radiologists and the remainder by general radiologists. This yielded an accuracy in diagnosis of 99.8%, sensitivity of 80% (95% CI: 49-94.3%), and specificity of 100% (95% CI: 90-100%). The calculated negative predictive value was 94.6% (95% CI: 82.3-98.5%), and positive predictive value was 100% (95% CI: 90-100%). The appendix was not identified in 19 patients (42%). A statistically significant relationship between the presence of right iliac fossa stranding of the fat OR free fluid was associated with appendicitis (p = 0.01). Alternate diagnoses were identified in 8% (n = 4) of cases.

CONCLUSION

MRI is a highly accurate imaging modality for the assessment of appendicitis in pregnancy. Even with variable reader MRI experience, MRI demonstrates an accuracy of 99.8% and a positive predictive value for acute appendicitis of 100%. Double reading and the possible inclusion of DWI may help further improve accuracy and minimise false-negative rates.

Clinical and pathologic characteristics of appendiceal neuroendocrine neoplasms diagnosed during pregnancy

INTRODUCTION

Although appendicitis occurs in approximately 1:1000 pregnancies, appendiceal neuroendocrine neoplasm (ANEN) diagnosis during pregnancy is very rare. Data on presentation, treatment and prognosis is scarce.

AIM

To describe ANEN cases diagnosed during pregnancy.

MATERIALS AND METHODS

A retrospective appraisal of 7 consecutive ANEN patients diagnosed during pregnancy from four Israeli tertiary medical centers and comparison with 17 cases described in the literature from 1965-2021.

RESULTS

Age at ANEN diagnosis was 26.4 ± 3.5 years (range 21-33). Patients were diagnosed between gestational weeks 6-40, most frequently in the third trimester (53%). The most common presenting symptom was abdominal pain. Tumor size was 14.3 ± 8.9mm (range 3-45mm). In patients from our series appendiceal base involvement was reported in 2/7; mesoappendiceal invasion in 5/7; lympho-vascular invasion in 2/7. Ki67 staining was reported in 6/7 cases and ranged from 1-10%. Pathology details were lacking in most of the previously published cases. All 7 pregnancies in our series resulted in term delivery with no complications, whereas in historical cases there were one first trimester abortion, one ectopic pregnancy, and one stillbirth. Right hemicolectomy was performed in 5/7 patients in our series and reported in 2/17 historical cases. All hemicolectomies were performed after delivery, 3-16 months after appendectomy. Local metastases were reported in two cases. Follow-up duration was 7-98 months for our patients and 3-48 months in 5 historical cases. No disease recurrence, distant metastases or mortality were noted.

CONCLUSIONS

To the best of our knowledge, this is the largest series describing the extremely rare diagnosis of ANEN during pregnancy. Although pathologic characteristics varied, pregnancy outcomes were usually favorable and long-term prognosis was excellent. This data may suggest that a conservative approach to patients with ANEN diagnosis during pregnancy can be considered.

Are Cesarean Section and Appendectomy in Pregnancy and Puerperium Interrelated? A Cohort Study

Introduction

It is not known whether appendectomy for acute appendicitis (AA) increases the Cesarean section (CS) rate and whether CS increases the likelihood of AA and appendectomy in the early puerperium. In this study, delivery type and delivery outcomes and appendectomy during pregnancy and puerperium were analyzed.

Methods

This cross-sectional retrospective study was performed on 11,513 women, delivered during 2015–2020. Inclusion criteria were patients undergoing appendectomy for AA during pregnancy and the first 6 weeks after delivery. Evaluating parameters were age, parity, gestational week at birth, delivery type, and babies' birth weight.

Results

Thirty-two patients underwent appendectomy: 12 during pregnancy (2 in the first trimester, 6 in the second trimester, 4 in the third trimester) and 20 women during puerperium. 58.2% of pregnant women and 65% of puerperal women were submitted to CS.

Discussion

Half of the women who underwent appendectomy for AA during pregnancy may require urgent CS. The cause of acute abdomen in the postpartum period, especially in the first week, could be AA, especially in women delivered by CS.

An Evaluation of Serum IgE and Th2-Associated Interleukins in Children With Uncomplicated and Complicated Appendicitis

BACKGROUND

The pathogenesis of appendicitis is not understood completely and establishing a correct diagnosis can be clinically challenging. Previous investigations have shown an association between a T helper cell (Th)2-mediated inflammatory response, for example immunoglobulin E (IgE)-mediated allergy, and a decreased risk of complicated appendicitis. The present study aimed to evaluate differences in serum concentrations of IgE and Th2-associated interleukins (IL) in children with uncomplicated and complicated appendicitis.

METHOD

A prospective study including children <15 years with appendicitis. Blood samples were collected preoperatively at the time of clinical assessment at the Pediatric Emergency Department and analyzed for concentrations of serum total IgE and IL-4, IL-9, and IL-13. Associations with complicated appendicitis were evaluated through logistic regression adjusting for age, appendicolith, and symptom duration.

RESULTS

138 children with confirmed appendicitis were included. The median age was 10 (IQR 8-12) years, 87 (63%) were boys and 58 (42%) had complicated appendicitis. Children with complicated appendicitis had significantly higher concentrations of IL-9 and IL-13 compared to children with uncomplicated appendicitis. In the univariate logistic regression, high concentrations of IL-13 were associated with an increased risk of complicated appendicitis [OR 1.02 (95% CI 1.01-1.04) p = 0.005], which remained in the multivariate analysis [aOR 1.02 (95% CI 1.01-1.04), p = 0.01]. Serum concentrations of IgE, IL-4, and IL-9 did not significantly affect the risk of complicated appendicitis.

CONCLUSION

High levels of IL-13 seem to be associated with an increased risk of complicated appendicitis. This is incongruent with the hypothesis of an Th1/Th17-driven inflammation in this type of appendicitis.

Nationwide paediatric cohort study of a protective association between allergy and complicated appendicitis

BACKGROUND

In a nationwide cohort the potentially protective association between allergy and complicated appendicitis was analysed, and the influence of seasonal antigens, antihistamine treatment, and timing of allergy onset assessed.

METHODS

Some 1 112 571 children born between 2000 and 2010 were followed from birth until the end of 2014. A cross-sectional analysis of appendicitis cases, with comparison of allergic versus non-allergic children for absolute risk and odds of complicated appendicitis was first undertaken. This was followed by a longitudinal analysis of children with allergy and matched controls who had never had an allergy, for incidence rate and hazard of subsequent complicated or simple appendicitis.

RESULTS

Of all children, 20.4 per cent developed allergy and 0.6 per cent had appendicitis during follow-up. Among children with appendicitis, complicated appendicitis was more common among non-allergic children (18.9 per cent, 948 of 5016) than allergic children (12.8 per cent, 173 of 1351) (P < 0.001), and allergic children had a lower adjusted odds of complicated appendicitis (adjusted odds ratio (OR) 0.80, 95 per cent c.i. 0.67 to 0.96; P = 0.021). The risk of complicated appendicitis among children with manifest allergy was reduced by one-third in the longitudinal analysis (incidence rate 0.13 versus 0.20 per 1000 person-years; hazard ratio (HR) 0.68, 95 per cent c.i. 0.58 to 0.81; P < 0.001), whereas the risk of simple appendicitis remained unchanged (incidence rate 0.91 versus 0.91; HR 1.00, 0.94 to 1.07; P = 0.932). Seasonal antigen exposure was a protective factor (adjusted OR 0.82, 0.71 to 0.94; P = 0.004) and ongoing antihistamine medication a risk factor (adjusted OR 2.28, 1.21 to 4.28; P = 0.012).

CONCLUSION

Children with allergy have a lower risk of complicated appendicitis, but the same overall risk of simple appendicitis. Seasonal antigen exposure reduced, and antihistamine treatment increased, the risk of complicated disease.