Pitfalls in Appendicitis

Gene Expression Profiling in Pediatric Appendicitis

Importance

Appendicitis is the most common indication for urgent surgery in the pediatric population, presenting across a range of severity and with variable complications. Differentiating simple appendicitis (SA) and perforated appendicitis (PA) on presentation may help direct further diagnostic workup and appropriate therapy selection, including antibiotic choice and timing of surgery.

Objective

To provide a mechanistic understanding of the differences in disease severity of appendicitis with the objective of developing improved diagnostics and treatments, specifically for the pediatric population.

Design, Setting, and Participants

The Gene Expression Profiling of Pediatric Appendicitis (GEPPA) study was a single-center prospective exploratory diagnostic study with transcriptomic profiling of peripheral blood collected from a cohort of children aged 5 to 17 years with abdominal pain and suspected appendicitis between November 2016 and April 2017 at the Alberta Children's Hospital in Calgary, Alberta, Canada, with data analysis reported in August 2023. There was no patient follow-up in this study.

Exposure

SA, PA, or nonappendicitis abdominal pain.

Main Outcomes and Measures

Blood transcriptomics was used to develop a hypothesis of underlying mechanistic differences between SA and PA to build mechanistic hypotheses and blood-based diagnostics.

Results

Seventy-one children (mean [SD] age, 11.8 [3.0] years; 48 [67.6%] male) presenting to the emergency department with abdominal pain and suspected appendicitis were investigated using whole-blood transcriptomics. A central role for immune system pathways was revealed in PA, including a dampening of major innate interferon responses. Gene expression changes in patients with PA were consistent with downregulation of immune response and inflammation pathways and shared similarities with gene expression signatures derived from patients with sepsis, including the most severe sepsis endotypes. Despite the challenges in identifying early biomarkers of severe appendicitis, a 4-gene signature that was predictive of PA compared to SA, with an accuracy of 85.7% (95% CI, 72.8-94.1) was identified.

Conclusions

This study found that PA was complicated by a dysregulated immune response. This finding should inform improved diagnostics of severity, early management strategies, and prevention of further postsurgical complications.

Does the length matter in acute appendicitis for the perforation risk?: A retrospective cohort study

It has been hypothesized that short appendices increase intraluminal pressure more rapidly and perforate more frequently than long appendices. Two hundred seventy-seven adult patients were retrospectively analyzed and underwent an appendectomy between January 2015 and August 2021. Data extracted from patient records included sex, age, time from admission to operation (hospital interval), weekday or weekend operation time, and operative and pathological findings. Operation was performed on 273 patients, of whom 178 (65.2%) were male and 95 (34.8%) female. The mean age of the male patients was 31.7 ± 08 (range 18-67), and that of the female patients was 38.9 ± 1.4 (range 18-78). Perforation was observed in 57 (20.9%) patients. Sex was not a factor in the development of perforation (P = .95). The mean age of the patients with and without perforation was 40.1 ± 2.2 and 32.7 ± 0.7, respectively. The perforation rate increased with age (P = .003). Appendix lengths were similar in both groups, and length was not a factor in the development of perforation (P = .83). This study found that the development of perforated appendicitis is not related to the length of the appendix. The risk of perforation increased with age.

Factors associated with delayed diagnosis of appendicitis in adults: A single-center, retrospective, observational study

Appendicitis is one of the most common causes of acute abdominal pain; yet the risk of delayed diagnosis remains despite recent advances in abdominal imaging. Understanding the factors associated with delayed diagnosis can lower the risk of diagnostic errors for acute appendicitis. These factors, including physicians’ specialty as a generalist or non-generalist, were evaluated through a retrospective, observational study of adult acute appendicitis cases at a single center, between April 1, 2014, and March 31, 2021. The main outcome was timely diagnosis, defined as "diagnosis at the first visit if the facility had computed tomography (CT) capability" or "referral to an appropriate medical institution promptly after the first visit for a facility without CT capability," with all other cases defined as delayed diagnosis. The frequency of delayed diagnosis was calculated and associated factors evaluated through multivariate and exploratory analyses. The overall rate of delayed diagnosis was 26.2% (200/763 cases). Multivariate analysis showed that tenderness in the right lower abdominal region, absence of diarrhea, a consultation of ≤6 h after symptom onset, and consultation with a generalist were associated with a decreased risk of delayed diagnosis of acute appendicitis. Exploratory analysis found that generalists performed more physical findings related to acute appendicitis, suggesting that this diagnostic approach may be associated with timely diagnosis. Future studies should adjust for other potential confounding factors, including patient complexity, consultation environment, number of physicians, diagnostic modality, and physician specialties.

Challenging Obstetrical Management in Generalized Peritonitis during Pregnancy

Acute abdomen in pregnancy represents a diagnostic and therapeutic challenge, despite the current advances in modern medicine, since the typical symptoms and altered laboratory parameters mimic normal pregnancy. Acute appendicitis is the most common nonobstetric surgical emergency during pregnancy, with an incidence of 1 per 500-2000 pregnancies. Delayed diagnosis and reluctance to operate on a pregnant woman predispose to adverse maternal and fetal outcomes. The elective termination of pregnancy or interventions to prolong it in the presence of appendicitis is controversial. We present a case of a 38-year-old Caucasian woman, G2P0, admitted to the Obstetric Emergency Department at 13 4/7 weeks of gestation with a primary complaint of severe nausea and vomiting associated with progressive diffuse abdominal pain which had started 7 days before. After the difficulty of inherent differential diagnosis, she was diagnosed with generalized peritonitis due to acute perforated appendicitis. Prompt exploratory laparotomy with appendectomy and drainage of multiple abscesses were performed. Conservative obstetrical management was assumed, with subsequent periodic monitoring of the fetal focus. Due to abdominal compartment syndrome, the abdomen was left open for 4 days. After 7 days in the intensive care unit, recovery was favorable, pregnancy remained uneventful, and a healthy full-term baby was born 27 weeks later. This case represents a successful example of how the cooperation of the obstetrics and general surgery teams and the decision of conservative obstetrical management in the surgical environment contributed to optimizing maternal health, achieving the best obstetrical outcome.

Can Neutrophil-Lymphocyte Ratio in Complete Blood Count Help in the Differential Diagnosis Between Acute Appendicitis and Right Ureteral Stones in Pediatric Age Groups?

Background and objective

Abdominal pain is one of the most common problems in children presenting to the pediatric emergency departments and is often a diagnostic challenge for the physician. Clinical studies have been carried out on adult patients to differentiate between ureteral stones and acute appendicitis (AA) in which neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) were analyzed in the complete blood count, and it was found that NLR and PLR could help in the differential diagnosis. In this study, we investigated whether complete blood count parameters in pediatric patients could be helpful in the differential diagnosis between AA and right ureteral stones.

Methods

The files of pediatric patients who were followed up and treated for AA and right ureteral stones between January 2019 and March 2021 were reviewed retrospectively. The demographic characteristics of the patients and their WBC, NLR, PLR, and red cell distribution width (RDW) values were evaluated to determine whether there was a difference between the two groups.

Results

In this study, 77 patients with AA and 48 patients with right ureteral stones were included. Univariate regression analysis revealed that age, gender, WBC, PLR, and NLR were factors likely responsible for AA. As per multivariate linear regression analysis, NLR level (odds ratio: 0.407; 95% CI: 0.293-0.566; p<0.001) was an independent predictor of AA.

Conclusion

Based on our findings, NLR can help in establishing the diagnosis in pediatric patients who present to the emergency department with right lower quadrant pain, and in whom physical examination, routine laboratory tests, and imaging methods cannot help distinguish between AA and ureteral stones.

Metabolomics and Inflammatory Mediator Profiling for the Differentiation of Life-Threatening and Non-Severe Appendicitis in the Pediatric Population

While children with appendicitis often have excellent clinical outcomes, some develop life-threatening complications including sepsis and organ dysfunction requiring pediatric intensive care unit (PICU) support. Our study applied a metabolomics and inflammatory protein mediator (IPM) profiling approach to determine the bio-profiles of children who developed severe appendicitis compared with those that did not. We performed a prospective case-control study of children aged 0-17 years with a diagnosis of appendicitis. Cases had severe disease resulting in PICU admission. Primary controls had moderate appendicitis (perforation without PICU); secondary controls had mild appendicitis (non-perforated). Serum samples were analyzed using Proton Nuclear Magnetic Resonance (¹H NMR) Spectroscopy and Gas Chromatography-Mass Spectrometry (GC-MS); IPM analysis was performed using plasma bead-based multiplex profiling. Comparisons were made using multivariate data statistical analysis. Fifty-three children were included (15 severe, 38 non-severe). Separation between severe and moderate appendicitis demonstrated excellent sensitivity and specificity (100%, 88%; 14 compounds), separation between severe and mild appendicitis also showed excellent sensitivity and specificity (91%, 90%; 16 compounds). Biomarker patterns derived from metabolomics and IPM profiling are capable of distinguishing children with severe appendicitis from those with less severe disease. These findings provide an important first step towards developing non-invasive diagnostic tools for clinicians in early identification of children who are at a high risk of developing severe appendicitis.

Novel molecular biomarkers and diagnosis of acute appendicitis in children

Reliable and efficient diagnosis of pediatric appendicitis is essential for the establishment of a clinical management plan and improvement of patient outcomes. Current strategies used to diagnose a child presenting with a suspected appendicitis include laboratory studies, clinical scores and diagnostic imaging. Although these modalities work in conjunction with each other, one optimal diagnostic strategy has yet to be agreed upon. The recent introduction of precision medicine techniques such as genomics, transcriptomics, proteomics and metabolomics has increased both the diagnostic sensitivity and specificity of appendicitis. Using these novel strategies, the integration of precision medicine into clinical practice via point-of-care technologies is a plausible future. These technologies would assist in the screening, diagnosis and prognosis of pediatric appendicitis.

Comparison of leucine-rich alpha-2-glycoprotein-1 (LRG-1) plasma levels between patients with and without appendicitis, a case-controlled study

Acute appendicitis (AA) is the first cause of emergency surgery. Leucine-Rich Alpha-2-Glycoprotein 1 (LRG1) has been shown to be a potential biomarker in cases of AA in children, but there are conflicting results for its use in adults. The objective of this study is to compare the median plasma values of LRG1 in patients with acute abdomen with and without appendicitis. This case–control study was conducted prospectively at the emergency room (ER) of a tertiary teaching hospital, between March 1st, 2011 and December 31st, 2012. Patients with recent abdominal pain, aged 18–70 years who attended at the ER were included in the study. Blood samples were drawn at the first presentation. Those who were submitted to surgery and had a pathology report of AA were considered as cases. Those without a need for surgery and treated for other conditions, e.g., pelvic inflammatory disease, were considered as controls. Follow-up in controls was made up to 30 days. LRG1 plasma median values were measured using an ELISA kit and compared between groups. A total of 28 participants, 14 cases with acute appendicitis and 14 controls, were included. The median (range) values of leucine-rich alpha-2-glycoprotein-1 level in the group with appendicitis and control group were 8.8 ng/ml (5.5–31) and 11 (4.6–108) ng/ml, respectively (Mann–Whitney test P = 0.26). Median plasma leucine-rich alpha-2-glycoprotein-1 levels were not useful in diagnosing Acute Appendicitis in patients with acute abdominal pain.

Near miss abdominal pain

An 18-year-old adolescent with intermittent colicky abdominal pain for 4 months was admitted to a Medical Emergency Assessment Unit for further investigation of possible colitis, after being reviewed by a surgeon in Accident and Emergency. Initially he was treated for a urinary tract infection, however a CT of the abdomen revealed appendicular perforation with pelvic abscess formation. The patient required an urgent laparoscopy and was discharged without complications. Typically, appendicitis is an acute surgical problem whereas chronic abdominal pain is routinely considered a medical problem. This case demonstrates the importance of maintaining acute causes as part of the differentials list in young patients with unexplained recurrent abdominal pain as well as justifying the early use of CT when there is ambiguity surrounding a diagnosis.

Diagnostic accuracy of combined WBC, ANC and CRP in adult emergency department patients suspected of acute appendicitis

OBJECTIVES

To assess the sensitivity, specificity, and negative predictive value (NPV) of normal total white blood cell count (WBC) and normal absolute neutrophil count (ANC) combined with a normal proprietary C-reactive protein (pCRP) level in adult emergency department (ED) patients with abdominal pain suspected of possible acute appendicitis.

METHODS

We prospectively enrolled patients ≥18 years of age at seven U.S. emergency departments with ≤72 h of abdominal pain and other signs and symptoms suggesting possible acute appendicitis. Sensitivity, specificity, and NPV for normal WBC and ANC combined with normal pCRP were correlated with the final diagnosis of acute appendicitis.

RESULTS

We enrolled 422 patients with a prevalence of acute appendicitis of 19.1%. The combination of normal WBC and pCRP exhibited a sensitivity of 97.5% (95% CI, 91.3-99.3%), an NPV of 98.8% (95% CI, 95.9-99.7%) and a specificity of 50.0% (95% CI, 44.7-55.3%) for acute appendicitis. Normal ANC and pCRP resulted in a sensitivity of 100% (95% CI, 95.4-100%), a negative predictive value of 100% (95% CI, 97.5-100%) and a specificity of 44.4% (95% CI, 39.2-49.7%) for acute appendicitis. Normal WBC and pCRP correctly identified 171 of 342 (50.0%) patients who did not have appendicitis with 2 (2.5%) false negatives, while normal ANC and pCRP identified 150 of 338 (44.3%) of patients without appendicitis with no false negatives.

CONCLUSION

The combination of normal WBC and ANC with normal pCRP levels exhibited high sensitivity and negative predictive value for acute appendicitis in this prospective adult patient cohort. Confirmation and validation of these findings with further study using commercially available CRP assays is needed.

Acute Appendicitis: Clinical Clues and Conundrums Related to the Greatest Misses

Introduction

In the United States (US), appendicitis is the most common acute abdominal emergency requiring surgery. Patients with appendicitis continue to display a complex and atypical range of clinical manifestations, providing a subsequent high risk for emergency physicians to miss acute abdominal pathology on a patient’s initial visits. Due to the risk of potential perforation, the proper and timely clinical identification of acute appendicitis is vital. The current study aims to identify clinical characteristics that could be useful in identifying patients at risk for having acute appendicitis that was misdiagnosed on their initial visits.

Methods

Medical charts consisting of patients between the ages of 19 and 55 years on their second visit were flagged and reviewed by the emergency department quality assurance (EDQA) committee. The retrospective chart review included patients who presented to the emergency department (ED) with the chief complaint of an abdominal-related complaint, were discharged, returned within 72 hours, and were diagnosed with a pathologically confirmed appendicitis. All patients were managed operatively, with pathology results reviewed for evidence of acute appendicitis. Those with confirmed pathologic appendicitis upon return were considered to have a “misdiagnosis.” Any patients managed nonoperatively and those with negative pathology were excluded from the study and considered not to have appendicitis.

Results

Fifty-five patients were identified through the EDQA committee from May 2011 to January 2014. After exclusion criteria were applied, 18 patients met the inclusion criteria for this study (7 males, 11 females). The mean age was 36.2 (range: 19-55). The most common presenting complaint on the initial visit was pain in the epigastric region of the abdomen (50%, n = 9). Twenty-two percent (n = 4) of patients had pain in the right lower quadrant documented in the physician’s note on the initial visit and 83% (n = 15) had right lower quadrant pain documented on the second visit. Two patients (11%) did not have right lower quadrant tenderness on either visit. The most common discharge diagnosis on the initial visit was undifferentiated abdominal pain (50%), followed by gastritis (28%). Opioid pain medication was administered or prescribed to 39% (n = 7) of the patients. The average return time was 23.9 hours.

Conclusion

The administration of opioid pain medication is associated with many of the return visits to the emergency department for missed appendicitis. Finally, discharge diagnosis and planning are imperative, as detailed early appendicitis instructions or extended ED observation can include more cases and decrease litigation risk.

Meta-analysis of unplanned readmission to hospital post-appendectomy: an opportunity for a new benchmark

BACKGROUND

Appendicitis is the most common cause of acute abdominal pain requiring surgical intervention. While many studies report readmission, a meta-analysis of readmission post-appendectomy has not been published. This meta-analysis was undertaken to determine rates and predictors of hospital readmission following appendectomy and to potentially provide a metric benchmark.

METHODS

An ethically approved PROSPERO-registered (ID CRD42017069040) meta-analysis following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, using databases PubMed and Scopus, was undertaken for studies published between January 2012 and June 2017. Articles relating to outcomes and readmissions after appendectomy were identified. Those scoring >15 for comparative studies and >10 for non-comparative studies, using Methodological Index for Non-Randomized Studies criteria were included in the final analysis. The odds ratios (OR) using random-effects, Mantel-Haenszel method with 95% confidence intervals (CI), were computed for each risk factor with RevMan5.

RESULTS

A total of 1757 articles reviewed were reduced to 45 qualifying studies for a final analysis of 836 921 appendectomies. 4.3% (range 0.0-14.4%) of patients were readmitted within 30 days. Significant preoperative patient factors for increased readmission were diabetes mellitus (OR 1.93, CI 1.63-2.28, P < 0.00001), complicated appendicitis (OR 3.6, CI 2.43-5.34, P < 0.00001) and open surgical technique (OR 1.39, CI 1.08-1.79, P < 0.00001). Increased readmission was not associated with gender, obesity or paediatric versus general surgeons or centres.

CONCLUSION

This meta-analysis identified that readmission is not uncommon post-appendectomy, occurring in one in 25 cases. The mean readmission rate of 4.3% may act as a quality benchmark for improving emergency surgical care. Targeting high-risk groups with diabetes or complicated appendicitis and increasing use of laparoscopic technique may help reduce readmission rates.

Metabolomic and inflammatory mediator based biomarker profiling as a potential novel method to aid pediatric appendicitis identification

Various limitations hinder the timely and accurate diagnosis of appendicitis in pediatric patients. The present study aims to investigate the potential of metabolomics and cytokine profiling for improving the diagnosis of pediatric appendicitis. Serum and plasma samples were collected from pediatric patients for metabolic and inflammatory mediator analyses respectively. Targeted metabolic profiling was performed using Proton Nuclear Magnetic Resonance Spectroscopy and Flow Injection Analysis Mass Spectrometry/Mass Spectrometry and targeted cytokine/chemokine profiling was completed using a multiplex platform to compare children with and without appendicitis. Twenty-three children with appendicitis and 35 control children without appendicitis from the Alberta Sepsis Network pediatric cohorts were included. Metabolomic profiling revealed clear separation between the two groups with very good sensitivity (80%), specificity (97%), and AUROC (0.93 ± 0.05) values. Inflammatory mediator analysis also distinguished the two groups with high sensitivity (82%), specificity (100%), and AUROC (0.97 ± 0.02) values. A biopattern comprised of 9 metabolites and 7 inflammatory compounds was detected to be significant for the separation between appendicitis and control groups. Integration of these 16 significant compounds resulted in a combined metabolic and cytokine profile that also demonstrated strong separation between the two groups with 81% sensitivity, 100% specificity and AUROC value of 0.96 ± 0.03. The study demonstrated that metabolomics and cytokine mediator profiling is capable of distinguishing children with appendicitis from those without. These results suggest a potential new approach for improving the identification of appendicitis in children.

The Use of Metabolomics and Inflammatory Mediator Profiling Provides a Novel Approach to Identifying Pediatric Appendicitis in the Emergency Department

Multiplexed profiling approaches including various ‘omics’ platforms are becoming a new standard of biomarker development for disease diagnosis and prognosis. The present study applied an integrated metabolomics and cytokine profiling approach as a potential aid to the identification of pediatric appendicitis. Metabolic analysis using serum (n = 121) and urine (n = 102) samples, and cytokine analysis using plasma (n = 121) samples from children presenting to the Emergency Department with abdominal pain were performed. Comparisons between children with appendicitis vs. non-appendicitis abdominal pain, and with perforated vs. non-perforated appendicitis were made using multivariate statistics. Serum and urine biomarker patterns were statistically significantly different between groups. The combined serum metabolomics and inflammatory mediator model revealed clear separation between appendicitis and non-appendicitis abdominal pain (AUROC: 0.92 ± 0.03) as well as for perforated and non-perforated appendicitis (AUROC: 0.88 ± 0.05). Urine metabolic analysis also demonstrated distinction between the groups appendicitis and non-appendicitis abdominal pain (AUROC: 0.85 ± 0.04), and perforated and non-perforated appendicitis (AUROC: 0.98 ± 0.02). In children presenting to the Emergency Department with abdominal pain, metabolomics and inflammatory mediator profiling are capable of distinguishing children with appendicitis from those without. The approach also differentiates between severities of disease. These results provide an important first step towards a potential aid for improving appendicitis identification.

The Diagnostic Accuracy of Sonography, With Graded Compression to Image Acute Appendicitis Compared to Histopathologic Results

Acute appendicitis is the most common surgical abdominal emergency. Its clinical diagnosis remains a challenge to surgeons, so different imaging options were introduced to improve diagnostic accuracy. Among these imaging modality choices, diagnostic medical sonography (DMS) is a simple, easily available, and cost effective clinical tool. The purpose of this study was to assess the accuracy of DMS, in the diagnosis of acute appendicitis compared to the histopathology report, as a gold standard. Between May 2015 and May 2016, 215 patients with suspected appendicitis were examined with DMS. The DMS findings were recorded as positive and negative for acute appendicitis and compared with the histopathological results, as a gold standard. In all, 173 patients were correctly diagnosed as having acute appendicitis by DMS out of 200 cases, with a final histopathologic result. Similarly, DMS revealed 13 normal appendices out of 15 nonappendicitis patients. This demonstrated that DMS has a sensitivity of 86.5%, specificity of 86.6%, positive predictive value of 99.8%, negative predictive value of 32.5%, and overall accuracy of 86.5%. These results suggest that DMS may be an accurate, sensitive, and specific tool for diagnosing acute appendicitis and reducing unnecessary appendectomies. DMS should be considered as a credible imaging modality for diagnosing acute appendicitis.

Appendectomy Skin Closure Technique, Randomized Controlled Trial: Changing Paradigms (ASC)

BACKGROUND

Appendectomy is the most frequent and urgent gastrointestinal surgery. Overtime, the surgical techniques have been improved upon, in order to reduce complications, get better cosmetic results, and limit the discomfort associated with this procedure, by its high impact in the surgery departments. The traditional skin closure is associated with a poor cosmetic result and it requires stitches removal, alongside the pain associated with this procedure, and no benefits were demonstrated in the literature regarding separated stitches over intradermic stitch. This is a randomized controlled trial, and our objective is to compare two different skin closure techniques in open appendectomy.

METHODS

A prospective randomized trial method was used, with a total number of 208 patients participating in the study, after acute appendicitis diagnosis in the emergency department. They were randomized into two groups: patients who would receive skin closure with a unique absorbable intradermic stitch (Group A) and another group that would receive the traditional closure technique, consistent in non-absorbable separated stitches (Group B). General characteristics like gender, age, Body Mass Index (BMI), comorbidities, and allergies were registered. Days of Evolution (DOE) until surgery, previous use of antibiotics, complicated or uncomplicated appendicitis, surgical time, and wound complications like skin infection, dehiscence, seroma or abscess were also registered in each case.

RESULTS

8 patients were excluded due to negative appendicitis during surgery and lack of follow-up. Two groups, each containing 100 patients, were formed. General characteristics and parity were compared, and no statistically significant differences were observed. Difference in the surgical time (Group A: 47.35 min vs Group B: 54.13 min, p < .001) and cases with complicated appendicitis (Group A: 58 and Group B:38, p = .005) were found to be statistically significant. Four wound complications were reported, and the incidence of seroma (Group A:0 and Group B:5, p = .02) and abscess (Group A:2 and Group B:8, p = .05) were found to have some statistical significant difference. In a multivariate analysis, a relationship was observed between BMI > 25 kg/m² and seroma (p = .006), BMI > 25 kg/m² and abscess (p = .02), surgical time >50 min and seroma (p < .001), >2 DOE and abscess (p = .001), and complicated appendicitis with seroma development (p = .03).

CONCLUSION

Open appendectomy skin closure with a unique absorbable intradermic stitch is safe, with a reduced seroma and abscess incidence, compared to traditional closure, and an equivalent dehiscence and superficial infection incidence, allowing a lower hospital attention cost and length of hospital stay for treatment of complications. The relative risk of complications with traditional skin closure is 2.91 higher, compared to this new technique.

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

OBJECTIVES

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.

METHODS

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.

RESULTS

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.

CONCLUSION

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.

Predictive value of C-reactive protein, ultrasound and Alvarado score in acute appendicitis: a prospective pediatric cohort

PURPOSE

To evaluate whether C-reactive protein (CRP) level and ultrasound (US) results on admission could aid the diagnostic accuracy of Alvarado score.

METHODS

A prospective study was performed on children <14 years admitted for suspected acute appendicitis. Patients were categorized into three groups based on the Alvarado score: group I: score 7-10, group II: score 5-6, group III: score 0-4.

RESULTS

The difference between predictive values of Alvarado score alone and Alvarado score with CRP was not statically significant. The PPV increased from 74.29% (Alvarado score and CRP) to 93.75% (Alvarado score and US) in group 1 (P = .001) and the NPV increased from 64.86 and 79.69% (Alvarado score and CRP) to 82.6 and 88.2% (Alvarado score and US) in group 2 (P = .01) and group 3 (P = .001), respectively.

CONCLUSIONS

Alvarado score and ultrasound taken together improve the predictive value of diagnosing acute appendicitis in children.

Diagnostic Imaging of Appendicitis With Supplementation by Transabdominal and Transvaginal Sonography

Acute appendicitis is a condition that can affect any member of the population. Without timely treatment there is a high likelihood of rupture leading to peritonitis, and early diagnosis is imperative to obtaining treatment. Sonography can be used without fear of radiation exposure to the patient and with relatively little discomfort, ideal for pediatric patients. It can also be used with little patient preparation, with the possibility of a more rapid diagnosis than other imaging modalities. For patients presenting with atypical symptoms, sonography may be used to increase diagnostic accuracy, which will lead to a drop in the surgical removal rate of a healthy appendix. When diagnostic criteria are met, sonography results can be correlated with the patient’s blood test and clinical symptoms to make a positive diagnosis. The addition of the transvaginal approach for female patients has further increased the rate of success of diagnosing acute appendicitis, so that appropriate emergent surgery can be done.

Role of Drains in Laparoscopic Appendectomy for Complicated Appendicitis at a Busy County Hospital

Laparoscopic appendectomy (LA) has become the treatment of choice for acute appendicitis with equal or better outcomes than traditional open appendectomy (OA). LA in patients with a gangrenous or perforated appendicitis carries increased rate of pelvic abscess formation when compared with OA. We hypothesized routine placement of pelvic drains in gangrenous or perforated appendicitis decreases pelvic abscess formation after LA. Three hundred thirty-one patients undergoing LA between January 2007 and June 2011 were reviewed. Patients with perforated or gangrenous appendicitis were included. Group I had a Jackson-Pratt (JP) drain(s) placed and Group II had no JP drain. Data included patient demographics, emergency department laboratory values and vital signs, and computed axial tomography scan findings, intra-abdominal or pelvic abscess postoperatively, interventional radiology drainage, and length of stay. Clinic follow-up notes were reviewed. One hundred forty-eight patients were identified. Forty-three patients had placement of JP drains (Group I) and 105 patients had no JP drain (Group II). Three patients (three of 43 [6%]) in Group I developed pelvic abscess and 21 of 105 (20%) patients in Group II developed pelvic abscesses requiring subsequent drainage. This was statistically significant. Patient demographics, temperature, and mean white blood count before surgery were similar. Presurgery computed tomography (CT) with appendicolith and CT with abscess were more prevalent in Group I. The use of JP drainage in patients with perforated or gangrenous appendicitis during LA has decreased rates of pelvic abscess. This was demonstrated despite the drain group having appendicolith or abscess on preoperative CT.

Utility of immature granulocyte percentage in pediatric appendicitis

BACKGROUND

Acute appendicitis is the most common cause of abdominal surgery in children. Adjuncts are used 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 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-June 2013 by International Classification of Diseases-9 code. Charts were reviewed for relevant demographic, clinical, and outcome data, which were compared between acute and perforated appendicitis groups using Fisher exact and t-tests for categorical and continuous variables, respectively. We used an adjusted logistic regression model using clinical laboratory values to predict the odds of perforated appendicitis.

RESULTS

A total of 251 patients were included in the analysis. Those with perforated appendicitis had a higher white blood cell count (P=0.0063), C-reactive protein (CRP) (P<0.0001), and IG% (P=0.0299). In the adjusted model, only elevated CRP (odds ratio 3.46, 95% confidence interval 1.40-8.54) and presence of left shift (odds ratio 2.66, 95% confidence interval 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.

Accuracy of ultrasonography in the diagnosis of acute appendicitis in adult patients: review of the literature

Background

Ultrasound is a widely used technique in the diagnosis of acute appendicitis; nevertheless, its utilization still remains controversial.

Methods

The accuracy of the Ultrasound technique in the diagnosis of acute appendicitis in the adult patient, as shown in the literature, was searched for.

Results

The gold standard for the diagnosis of appendicitis still remains pathologic confirmation after appendectomy. In the published literature, graded-compression Ultrasound has shown an extremely variable diagnostic accuracy in the diagnosis of acute appendicitis (sensitivity range from 44% to 100%; specificity range from 47% to 99% ). This is due to many reasons, including lack of operator skill, increased bowel gas content, obesity, anatomic variants, and limitations to explore patients with previuos laparotomies.

Conclusions

Graded-compression Ultrasound still remains our first-line method in patients referred with clinically suspected acute appendicitis: nevertheless, due to variable diagnostic accuracy, individual skill is requested not only to perform a successful exam, but also in order to triage those equivocal cases that, subsequently, will have to undergo assessment by means of Computed Tomography.

Appendix not seen: the predictive value of secondary inflammatory sonographic signs

BACKGROUND

Acute appendicitis is the most prevalent emergency surgical diagnosis in children. Although traditionally a clinical diagnosis, the diagnosis of acute appendicitis is uncertain in approximately 30% of pediatric patients. In attempts to avoid a misdiagnosis and facilitate earlier definitive care, imaging modalities such as ultrasonography have become important tools. In many pediatric studies, the absence of a visualized appendix with no secondary sonographic features has been reported as a negative study result, and a study where the appendix is not seen but demonstrates secondary features is often deemed equivocal. With ultrasound appendiceal detection rates reported at 60% to 89%, the dilemma of the nonvisualized appendix or equivocal study is frequently faced by clinicians.

OBJECTIVE

This study aimed to assess the value of the nonvisualized appendix on ultrasound and the association of secondary sonographic findings in pediatric patients with acute right lower quadrant pain undergoing ultrasound, in whom acute appendicitis was a diagnostic consideration.

METHODS

Retrospective case review of 662 consecutive children (age < 18 years) presenting to a pediatric emergency department with clinically suspected appendicitis, who had graded compression sonographic studies during the 24-month study period, was performed.

RESULTS

The appendix could not be visualized in 241 studies (37.7%). An alternate diagnosis was identified via sonography in 47 patients (19.5%). Twenty-five patients (12.9%) were taken for surgery where 17 (8.8%) had acute appendicitis confirmed via pathology. The specificity of moderate-to-large amounts of free fluid is 98%, phlegmon at 100%, pericecal inflammatory fat changes at 98%, and any free fluids with prominent lymph nodes at 81%. The odds ratio of appendicitis increases from 0.56 to 0.64 to 2.3 and 17.5, respectively, when there were 2 and 3 ultrasonographic inflammatory markers identified.

CONCLUSIONS

Although uncommonly seen, large amounts of free fluid, phlegmon, and pericecal inflammatory fat changes were very specific signs of acute appendicitis. In the absence of a distinctly visualized appendix, the presence of multiple secondary inflammatory changes provides increasing support of a diagnosis of acute appendicitis.

Nonobstetric abdominal pain and surgical emergencies in pregnancy

The focus of this article is the evaluation and management of pregnant patients with nonobstetric abdominal pain and surgical emergencies. The anatomic and physiologic changes that occur during pregnancy can cause difficulties in interpreting patients' signs and symptoms in emergency departments. This article reviews some of the common causes of nonobstetric abdominal pain and surgical emergencies that present to emergency departments and discusses some of the literature surrounding the use of imaging modalities during pregnancy. After a review of these changes and their causes, imaging modalities that can be used for the assessment are discussed.

Acute appendicitis presenting as acute gastritis in an adult patient with undiagnosed congenital gut malrotation: a case report

BACKGROUND

We report a case of an atypical presentation of acute appendicitis in an adult due to an undiagnosed congenital gut malrotation.

OBJECTIVE

The obvious benefit of observation with serial examinations followed by the use of computed tomography (CT) is discussed in aiding in the diagnosis for atypical presentations of appendicitis.

CASE REPORT

A 45-year-old man who presented with epigastric pain and vomiting was diagnosed with acute left-sided appendicitis on CT scan. The patient's appendix was located in the left lower quadrant of the abdomen due to undiagnosed congenital gut malrotation, thus resulting in an atypical presentation of a common illness.

CONCLUSION

Observation with serial examinations, followed by CT scanning if indicated, is an invaluable strategy to use in diagnosing atypical presentations of common pathology.

Ultrasound body applications in children

A major goal of imaging is to obtain the correct examination to answer the clinical questions with the lowest possible radiation exposure. While CT examination provides essential information in many cases, other modalities that do not entail ionizing radiation exposure may be appropriate substitutes either as an initial screening study or as an alternative to CT. US has become a valuable imaging tool in children encompassing many different clinical scenarios. This manuscript highlights some of the less well-accepted applications of US as the first imaging study in pediatric patients, especially in the emergency room environment. These include evaluation of suspected appendicitis, abdominal mass, pleural effusion/empyema, thymic abnormality vs. mediastinal mass and extremity soft-tissue mass or vessel patency. Adoption of US imaging as a problem-solving tool for issues such as these requires appropriate allocation of resources to ensure high-quality performance and interpretation of pediatric US studies around the clock.

Hip pain in a child: myositis or appendicitis?

Hip pain is a common presenting complaint in the pediatric emergency department, which can be attributed to many possible causes. It may be due to a benign "growing pain" or a potentially serious illness requiring urgent evaluation. At times, hip pain can be a manifestation of an underlying appendicitis in a child; thus, it can be confused with many other conditions. Children can be at particular risk for misdiagnosis or delayed diagnosis of appendicitis as it often can have an uncommon presentation with atypical signs and symptoms. Early identification, however, is important to prevent potential complications of delaying the diagnosis. We present a case that illustrates an atypical presentation of acute appendicitis. This report also highlights the diagnostic dilemma encountered during the evaluation of hip pain in children.