Differentiating acute appendicitis from pelvic inflammatory disease in women of childbearing age

Pelvic inflammatory disease in the adolescent and young adult: An update

Pelvic inflammatory disease (PID) is an infection of the female upper genital tract that is typically polymicrobial with classic core involvement of Neisseria gonorrhoeae and/or Chlamydia trachomatis, though other endogenous flora from the vagino-cervical areas can be involved as well. It is often a sexually transmitted disease but other etiologic routes are also noted. A variety of risk factors have been identified including adolescence, young adulthood, adolescent cervical ectropion, multiple sexual partners, immature immune system, history of previous PID, risky contraceptive practices and others. An early diagnosis and prompt treatment are necessary to reduce risks of PID complications such as chronic pelvic pain, ectopic pregnancy and infertility. Current management principles of PID are also reviewed. It is important for clinicians to screen sexually active females for common sexually transmitted infections such as Chlamydia trachomatis and provide safer sex education to their adolescent and young adult patients. Clinicians should provide comprehensive management to persons with PID and utilize established guidelines such as those from the US Centers for Disease Control and Prevention (CDC).

How to differentiate acute pelvic inflammatory disease from acute appendicitis ? A decision tree based on CT findings

PURPOSE

To construct a decision tree based on CT findings to differentiate acute pelvic inflammatory disease (PID) from acute appendicitis (AA) in women with lower abdominal pain and inflammatory syndrome.

MATERIALS AND METHODS

This retrospective study was approved by our institutional review board and informed consent was waived. Contrast-enhanced CT studies of 109 women with acute PID and 218 age-matched women with AA were retrospectively and independently reviewed by two radiologists to identify CT findings predictive of PID or AA. Surgical and laboratory data were used for the PID and AA reference standard. Appropriate tests were performed to compare PID and AA and a CT decision tree using the classification and regression tree (CART) algorithm was generated.

RESULTS

The median patient age was 28 years (interquartile range, 22-39 years). According to the decision tree, an appendiceal diameter ≥ 7 mm was the most discriminating criterion for differentiating acute PID and AA, followed by a left tubal diameter ≥ 10 mm, with a global accuracy of 98.2 % (95 % CI: 96-99.4).

CONCLUSION

Appendiceal diameter and left tubal thickening are the most discriminating CT criteria for differentiating acute PID from AA.

KEY POINTS

• Appendiceal diameter and marked left tubal thickening allow differentiating PID from AA. • PID should be considered if appendiceal diameter is < 7 mm. • Marked left tubal diameter indicates PID rather than AA when enlarged appendix. • No pathological CT findings were identified in 5 % of PID patients.

Managing acute abdominal pain in pediatric patients: current perspectives

Acute abdominal pain in pediatric patients has been a challenge for providers because of the nonspecific nature of symptoms and difficulty in the assessment and physical examination in children. Although most children with acute abdominal pain have self-limited benign conditions, pain may be a manifestation of an urgent surgical or medical condition where the biggest challenge is making a timely diagnosis so that appropriate treatment can be initiated without any diagnostic delays that increase morbidity. This is weighed against the need to decrease radiation exposure and avoid unnecessary operations. Across all age groups, there are numerous conditions that present with abdominal pain ranging from a very simple viral illness to a life-threatening surgical condition. It is proposed that the history, physical examination, laboratory tests, and imaging studies should initially be directed at differentiating surgical versus nonsurgical conditions both categorized as urgent versus nonurgent. The features of the history including patient’s age, physical examination focused toward serious conditions, and appropriate tests are highlighted in the context of making these differentiations. Initial testing and management is also discussed with an emphasis on making use of surgeon and radiologist consultation and the need for adequate follow-up and reevaluation of the patient.

Abdominal Pain in the Female Patient: A Case of Concurrent Acute Appendicitis and Ruptured Endometrioma

General surgeons are often asked to evaluate acute abdominal pain which has an expanded differential diagnosis in women of childbearing age. Acute appendicitis accounts for many surgical emergencies as a common cause of nongynecologic pelvic pain. In some rare instances, acute appendicitis has been shown to occur simultaneously with a variety of gynecologic diseases. We report a case of concurrent acute appendicitis and ruptured ovarian endometrioma.

WSES Jerusalem guidelines for diagnosis and treatment of acute appendicitis

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.

CT differentiation between tubo-ovarian and appendiceal origin of right lower quadrant abscess: CT, clinical, and laboratory correlation

To investigate which clinical, laboratory, and CT findings potentially facilitate the differential diagnosis between tubo-ovarian abscess (TOA) and periappendicular abscess (PAA), we retrospectively reviewed abdominal CT examinations and medical records for all women who presented to our medical center with unilateral right pelvic abscess formation who underwent CT evaluation from 2004-2014. A wide spectrum of clinical data and imaging findings were recorded. CT diagnoses were made in consensus by two experienced body radiologists blinded to the final diagnosis. Findings associated with the infections were compared using the chi-square (χ(2)) or the Fisher exact test. Ninety-one patients were included; 58 with PAA (mean age 46 years) and 33 with TOA (mean age 37 years). Pain on cervical motion (67 %) and vaginal discharge (21 %) were significantly more common in TOA; other clinical signs were similar. The presence of right ovarian vein entering the mass on CT had 100 % specificity and 94 % sensitivity to TOA. Distended right fallopian tube (79 %), mass posterior to mesovarium (76 %), contralateral pelvic fat stranding (55 %), and thickening of sacrouterine ligaments (55 %) were significantly more common in TOA. Positive "arrowhead sign" (91 %), mesenteric lymphadenopathy (85 %), small bowel wall thickening (55 %), fluid in the right paracolic gutter (50 %), and cecal wall thickening (48 %) were significantly more common in PAA;internal gas was revealed only in PAA (33 %). Distinct CT features can increase diagnostic certainty regarding the origin of right lower quadrant abscess in women.

Mandatory imaging cuts costs and reduces the rate of unnecessary surgeries in the diagnostic work-up of patients suspected of having appendicitis

OBJECTIVE

To evaluate whether mandatory imaging is an effective strategy in suspected appendicitis for reducing unnecessary surgery and costs.

METHODS

In 2010, guidelines were implemented in The Netherlands recommending the mandatory use of preoperative imaging to confirm/refute clinically suspected appendicitis. This retrospective study included 1,556 consecutive patients with clinically suspected appendicitis in 2008-2009 (756 patients/group I) and 2011-2012 (800 patients/group II). Imaging use (none/US/CT and/or MRI) was recorded. Additional parameters were: complications, medical costs, surgical and histopathological findings. The primary study endpoint was the number of unnecessary surgeries before and after guideline implementation.

RESULTS

After clinical examination by a surgeon, 509/756 patients in group I and 540/800 patients in group II were still suspected of having appendicitis. In group I, 58.5% received preoperative imaging (42% US/12.8% CT/3.7% both), compared with 98.7% after the guidelines (61.6% US/4.4% CT/ 32.6% both). The percentage of unnecessary surgeries before the guidelines was 22.9%. After implementation, it dropped significantly to 6.2% (p<0.001). The surgical complication rate dropped from 19.9% to 14.2%. The average cost-per-patient decreased by 594 <euro> from 2,482 to 1,888 <euro> (CL:-1081; -143).

CONCLUSION

Increased use of imaging in the diagnostic work-up of patients with clinically suspected appendicitis reduced the rate of negative appendectomies, surgical complications and costs.

KEY POINTS

• The 2010 Dutch guidelines recommend mandatory imaging in the work-up of appendicitis. • This led to a considerable increase in the use of preoperative imaging. • Mandatory imaging led to reduction in unnecessary surgeries and surgical complications. • Use of mandatory imaging seems to reduce health care costs.

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

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSION

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.

Clinical prediction rule to distinguish pelvic inflammatory disease from acute appendicitis in women of childbearing age

OBJECTIVE

We aimed to develop a clinical prediction rule to distinguish pelvic inflammatory disease (PID) from acute appendicitis in women of childbearing age.

METHODS

We reviewed medical records over a 4-year period of female patients of childbearing age who had presented with abdominal pain at an urban emergency department and had either appendicitis (n = 109) or PID (n = 72). A prediction rule was developed by use of recursive partitioning based on significant factors for the discrimination.

RESULTS

The significant factors to favor PID over appendicitis were (1) no migration of pain (odds ratio [OR], 4.2; 95% confidence interval [CI], 1.5-11.5), (2) bilateral abdominal tenderness (OR, 16.7; 95% CI, 5.3-50.0), and (3) absence of nausea and vomiting (OR, 8.4; 95% CI, 2.8-24.8). The prediction rule could rule out appendicitis from PID with sensitivity of 99% (95% CI, 94-100%) when classified as a low-risk group by the following factors: (1) no migration of pain, (2) bilateral abdominal tenderness, and (3) no nausea and vomiting.

CONCLUSION

We developed a prediction rule for childbearing-aged women presenting with acute abdominal pain to distinguish acute appendicitis from PID based on 3 simple, clinical features: migration of pain, bilateral abdominal tenderness, and nausea and vomiting. Prospective validation is needed in other settings.

Leucocyte count and C-reactive protein in the diagnosis of acute appendicitis

BACKGROUND

The aim of the present work was to study the preoperative leucocyte counts and C-reactive protein (CRP) values in three groups of patients operated on for a clinical suspicion of acute appendicitis with different findings at appendicectomy: an uninflamed appendix, uncomplicated acute appendicitis or complicated acute appendicitis. In particular, patients with acute appendicitis but a normal leucocyte count and CRP level were sought.

METHODS

In this retrospective study, the mean preoperative leucocyte count and CRP value in 100 consecutive patients with an uninflamed appendix (group A), in 100 consecutive patients with uncomplicated acute appendicitis (group B) and in 100 consecutive patients with complicated acute appendicitis (group C) were calculated. The numbers of patients with (1) both values normal, (2) only leucocyte count raised, (3) only CRP level raised and (4) both values raised were calculated in each of the three groups.

RESULTS

The increase in leucocyte count was an early marker of appendiceal inflammation, whereas the CRP value increased markedly only after appendiceal perforation or abscess formation. Group A (uninflamed appendix) contained 24 patients in whom both values were normal. Neither group B (uncomplicated acute appendicitis) nor group C (complicated acute appendicitis) contained any patient with both values in the normal range.

CONCLUSION

Acute appendicitis is very unlikely when both the leucocyte count and CRP value are normal.

Appendicitis: the impact of computed tomography imaging on negative appendectomy and perforation rates

OBJECTIVES

The purposes of this study were to investigate the use of computed tomography (CT) imaging in patients with suspected acute appendicitis and to evaluate the impact of CT on negative appendectomy and perforation rates. In patients clinically diagnosed of acute appendicitis the reported overall negative appendectomy rate is about 15-20%; 10% in men and 25-45% in women of childbearing age. This is associated with a perforation rate of 21-23%.

METHODS

This is a retrospective analysis of 146 consecutive patients presenting with clinical symptoms suspicious of appendicitis over a 2-yr period in whom CT examinations were performed before therapy was instituted. The overall negative appendectomy and perforation rates were calculated for the entire group, as well as for the 54 women aged 15-50 yr in the childbearing cohort.

RESULTS

The negative appendectomy rate was 4% in 122 patients operated on and the perforation rate was 22%. Among 36 women 15-50 yr of age operated on, the negative appendectomy rate was 8.3% and the perforation rate was 19%. Surgery was avoided in 24 patients, 18 of whom were women of childbearing age.

CONCLUSIONS

The judicious use of CT imaging in patients with equivocal clinical presentation suspected of having appendicitis led to a significant improvement in the preoperative diagnosis. It resulted in a substantial decrease in the negative appendectomy rate compared to previously published reports, without incurring an increase in the perforation rate.