Improvement in the diagnosis of appendicitis. Adv Surg. 2013;47:299-328. [PMID: 24298858 DOI: 10.1016/j.yasu.2013.03.003]

A Novel Deep Learning Approach for the Automatic Diagnosis of Acute Appendicitis

Background: Acute appendicitis (AA) is a major cause of acute abdominal pain requiring surgical intervention. Approximately 20% of AA cases are diagnosed neither early nor accurately, leading to an increased risk of appendiceal perforation and postoperative sequelae. AA can be identified with good accuracy using computed tomography (CT). However, some studies have found that a false-negative AA diagnosis made using CT can cause surgical therapy to be delayed. Deep learning experiments are aimed at minimizing false-negative diagnoses. However, the success rates reported in these studies are far from 100%. In addition, the methods used to divide patients into groups do not adequately reflect situations in which accurate radiological diagnosis is difficult. Therefore, in this study, we propose a novel deep-learning approach for the automatic diagnosis of AA using CT based on establishing a new strategy for classification according to the difficulties encountered in radiological diagnosis. Methods: A total of 266 patients with a pathological diagnosis of AA who underwent appendectomy were divided into two groups based on CT images and radiology reports. A deep learning analysis was performed on the CT images and clinical and laboratory parameters that contributed to the diagnosis of both the patient and age- and sex-adjusted control groups. Results: The deep learning diagnosis success rate was 96% for the group with advanced radiological findings and 83.3% for the group with radiologically suspicious findings that could be considered normal. Conclusions: Using deep learning, successful results can be achieved in cases in which the appendix diameter has not increased significantly and there is no significant edema effect.

Value of ultrasound and computed tomography in the diagnosis of acute appendicitis with histopathology as gold standard

BACKGROUND

To evaluate the value of ultrasound (US), computed tomography (CT) and laboratory testing in diagnosing acute appendicitis and to evaluate the impact on the treatment of acute appendicitis, keeping histopathology as the gold standard. Retrospective evaluation of all patients treated surgically for appendicitis from 1 January 2016 to 31 December 2018 at Sint-Andries Hospital, Tielt, Belgium.

METHODS

For each patient, we recorded: age, sex, duration of hospitalization, type of radiological investigation, fever (>37.3 °C), C-reactive protein (CRP), leukocyte particle count (LPC), Alvarado score and the type of surgery. For US and CT sensitivity, specificity and negative appendectomy rate were evaluated.

RESULTS

Over a period of 3 years, 304 appendectomies were performed. The overall prevalence of appendicitis was 95.1%. Mean age was 31 years. All patients underwent radiological examination. US was performed in 35.9% (109), CT in 50.3% (153) and CT after US in 13.8% (42) of all cases. The sensitivity and specificity of CT were 99.4% and 80.0%, respectively. For US, the respective figures were 74.8 and 62.5%. CRP and LPC were significantly higher in the appendicitis group, compared to the non-appendicitis group. The negative appendectomy rate was slightly higher in the CT after US group i.e. 7.1% (3/42) compared to 4.67% (5/107) in the US group and 4.50% (7/155) in the CT group.

CONCLUSIONS

The diagnostic value of US and CT are both very high. The diagnostic value of clinical features and biochemistry alone is quite low. By combining radiological examination, clinical examination and laboratory values, low negative appendectomy rates can be achieved.

Demonstration of a new entity of non-perforated appendicitis through studying cluster of appendicitis

Differential diagnosis and management for perforated appendicitis and non-perforated appendicitis are current hot topics. The aim of this study is to demonstrate a new entity of non-perforated appendicitis, “acute hemorrhagic appendicitis” through studying cluster of acute appendicitis among Tibetan students at a high school in central China. Over the 11-year period, there were 120 patients with more female patients (102 of 499, 20.4%) than male patients (18 of 474, 3.8%) among 973 Tibetan students. 117 patients’ clinical data were available. Clinical manifestations were identical to classic appendicitis. However, axilla temperature, white blood cell counts and neutrophil level were elevated mildly in 12 (10.3%), 19 (16.2%) and 12 (10.3%) patients respectively. Pathologically, the resected appendices exhibited focal or diffuse hemorrhages in mucosa and/or submucosa, and infiltration by eosinophil and by lymphocytes. No patients had perforated appendicitis. The median time from the onset to surgery was 3 days (IQR, 2–4). All patients were discharged with full recovery. In conclusion, “acute hemorrhagic appendicitis” represented a new entity of non-perforated appendicitis with unique cause and pathogenesis, which might be treated with antibiotics alone or self-limited. Studying the cluster is a reliable method to find new entity of appendicitis.

Case series: Treatment outcome of late presentation of acute appendicitis

INTRODUCTION AND IMPORTANCE

Late presentation of Acute Appendicitis (AA) is associated with a high risk of perforation-related complications and morbidity. Even though AA is a well-known disease, late presented AA is not uncommon. This study aims to report the treatment outcome of several cases of late presented AA, treated at a government public hospital at Mojokerto, a small town in East Java, Indonesia, where no previous report were known.

CASE PRESENTATION

Eleven patients experienced surgical removal of the appendix during one year period (January 2021 until December 2021). Those patients are treated by one surgeon at Dr. Wahidin Sudiro Husodo Kota Mojokerto Hospital. Furthermore, they were divided into 3 groups, (A: presented within 2 days after onset of abdominal pain; B: presented within 2-5 days after onset of abdominal pain; C: presented more than 5 days after onset of abdominal pain). The morbidities for all patients were studied, which they all followed up until the surgery wound healed completely.

CLINICAL DISCUSSION

The perforation of the appendix occurred in 7 patients consisting of 2 in Group A, 2 in Group B, and 3 in Group C. Furthermore, the two patients who experienced extension of surgical resection were all from Group C and this group has 10.67 days of highest Length of Stay (LOS). The two patients with perforated AA, 1 from group A and 1 from group C, developed surgical site infection. The main reason for the late presentation of AA was non-operative treatment due to equivocal clinical findings.

CONCLUSION

The late presentation of AA causes perforation-associated morbidities, including a possible extension of surgical resection, long hospitalization period, and surgical site infection. Some late presented AA does not develop into perforation since perforated and non-perforated AA may represents two different entities.

Hospitalization Trends for Acute Appendicitis in Spain, 1998 to 2017

The incidence of acute appendicitis decreased in Western countries from 1930 to at least the early 1990s, when epidemiological data started becoming scarcer. This study aimed to assess the trend in annual hospitalizations for acute appendicitis in all people Spain for a 20-year period between 1998 and 2017. This observational study analyzing direct age-standardized hospital admission rates by gender and age group (0–14 years, 15–34 years, 35–44 years, 45–64 years, and ≥65 years). Joinpoint regression models were fitted to evaluate changes in trends. There were 789,533 emergency hospital admissions for acute appendicitis between 1998 and 2017: 58.9% in boys and men and 41.1% in girls and women. Overall, there was a significant increase in admissions for this cause from 1998 to 2009, with an annual percent change (APC) of 0.6%. Following the peak in 2009, admission rates decreased by around 1.0% annually until 2017. The length of hospital stay gradually decreased from 4.5 days in 1998 to 3.4 days in 2017. The trends in hospital admissions for acute appendicitis in Spain changed over the study period, decreasing from 2009, especially in people younger than 35 years.

Conditional CT Strategy-An Effective Tool to Reduce Negative Appendectomy Rate and the Overuse of the CT

(1) Background: Diagnosis of acute appendicitis (AA) remains challenging; either computed tomography (CT) is universally used or negative appendectomy rates of up to 30% are reported. Transabdominal ultrasound (TUS) as the first-choice imaging modality might be useful in adult patients to reduce the need for CT scans while maintaining low negative appendectomy (NA) rates. The aim of this study was to report the results of the conditional CT strategy for the diagnosis of acute appendicitis. (2) Methods: All patients suspected of acute appendicitis were prospectively registered from 1 January 2016 to 31 December 2018. Data on their clinical, radiological and surgical outcomes are presented. (3) Results: A total of 1855 patients were enrolled in our study: 1206 (65.0%) were women, 649 (35.0%) were men, and the median age was 34 years (IQR, 24.5–51). TUS was performed in 1851 (99.8%) patients, and CT in 463 (25.0%) patients. Appendices were not visualized on TUS in 1320 patients (71.3%). Furthermore, 172 (37.1%) of 463 CTs were diagnosed with AA, 42 (9.1%) CTs revealed alternative emergency diagnosis and 249 (53.8%) CTs were normal. Overall, 519 (28.0%) patients were diagnosed with AA: 464 appendectomies and 27 diagnostic laparoscopies were performed. The NA rate was 4.2%. The sensitivity and specificity for TUS and CT are as follows: 71.4% and 96.2%; 93.8% and 93.6%. (4) Conclusion: A conditional CT strategy is effective in reducing NA rates and avoids unnecessary CT in a large proportion of patients. Observation and repeated TUS might be useful in unclear cases.

Xanthogranulomatous appendicitis: A comprehensive literature review

BACKGROUND

Xanthogranulomatous inflammation is characterized histologically by a collection of lipid-laden macrophages admixed with lymphocytes, plasma cells, neutrophils, and often multinucleated giant cells with or without cholesterol clefts.

AIM

To review the medical literature on xanthogranulomatous appendicitis (XGA).

METHODS

We present a patient with XGA and review published articles on XGA accessed via the PubMed, MEDLINE, Google Scholar, and Google databases. Keywords used were “appendix vermiformis,” “appendectomy,” “acute appendicitis,” and “XGA.” The search included articles published before May 2020, and the publication language was not restricted. The search included letters to the editor, case reports, review articles, original articles, and meeting presentations. Articles or abstracts containing adequate information about age, sex, clinical presentation, white blood cells, initial diagnosis, surgical approach, histopathological and immunohistochemical features of appendectomy specimens were included in the study.

RESULTS

A total of 29 articles involving 38 patients with XGA, were retrospectively analyzed. Twenty (52.6%) of the 38 patients, aged 3 to 78 years (median: 34; IQR: 31) were female, and the remaining 18 (47.4%) were male. Twenty-five patients were diagnosed with acute appendicitis, ruptured appendicitis, or subacute appendicitis, and the remaining 13 patients underwent surgery for tumoral lesions of the ileocecal region. Twenty-two of the patients underwent urgent or semi-urgent surgery, and the remaining 16 patients underwent interval appendectomy.

CONCLUSION

Xanthogranulomatous inflammation rarely affects the appendix vermiformis. It is associated with significant diagnostic and therapeutic dilemmas due to its variable presentation. It is often associated with interval appendectomies, and a significant number of patients require bowel resection due to the common presentation of a tumoral lesion. XGA is usually identified retrospectively on surgical pathology and has no unique features in preoperative diagnostic studies.

Factors Associated With Potentially Missed Diagnosis of Appendicitis in the Emergency Department

IMPORTANCE

Appendicitis may be missed during initial emergency department (ED) presentation.

OBJECTIVE

To compare patients with a potentially missed diagnosis of appendicitis (ie, patients with symptoms associated with appendicitis, including abdominal pain, constipation, nausea and/or vomiting, fever, and diarrhea diagnosed within 1-30 days after initial ED presentation) with patients diagnosed with appendicitis on the same day of ED presentation to identify factors associated with potentially missed appendicitis.

DESIGN, SETTING, AND PARTICIPANTS

In this cohort study, a retrospective analysis of commercially insured claims data was conducted from January 1 to December 15, 2019. Patients who presented to the ED with undifferentiated symptoms associated with appendicitis between January 1, 2010, and December 31, 2017, were identified using the Clinformatics Data Mart administrative database (Optum Insights). The study sample comprised eligible adults (aged ≥18 years) and children (aged <18 years) who had previous ED visits within 30 days of an appendicitis diagnosis.

MAIN OUTCOMES AND MEASURES

Potentially missed diagnosis of appendicitis. Adjusted odds ratios (AORs) for abdominal pain and its combinations with other symptoms associated with appendicitis were compared between patients with a same-day diagnosis of appendicitis and patients with a potentially missed diagnosis of appendicitis.

RESULTS

Of 187 461 patients with a diagnosis of appendicitis, a total of 123 711 (66%; 101 375 adults [81.9%] and 22 336 children [18.1%]) were eligible for analysis. Among adults, 51 923 (51.2%) were women, with a mean (SD) age of 44.3 (18.2) years; among children, 9631 (43.1%) were girls, with a mean (SD) age of 12.2 (18.2) years. The frequency of potentially missed appendicitis was 6060 of 101 375 adults (6.0%) and 973 of 22 336 children (4.4%). Patients with isolated abdominal pain (adults, AOR, 0.65; 95% CI, 0.62-0.69; P < .001; children, AOR, 0.79; 95% CI, 0.69-0.90; P < .001) or with abdominal pain and nausea and/or vomiting (adults, AOR, 0.90; 95% CI, 0.84-0.97; P = .003; children, AOR, 0.84; 95% CI, 0.71-0.98; P = .03) were less likely to have missed appendicitis. Patients with abdominal pain and constipation (adults, AOR, 1.51; 95% CI, 1.31-1.75; P < .001; children, AOR, 2.43; 95% CI, 1.86-3.17; P < .001) were more likely to have missed appendicitis. Stratified by the presence of undifferentiated symptoms, women (abdominal pain, AOR, 1.68; 95% CI, 1.58-1.78; nausea and/or vomiting, AOR, 1.68; 95% CI, 1.52-1.85; fever, AOR, 1.32; 95% CI, 1.10-1.59; diarrhea, AOR, 1.19; 95% CI, 1.01-1.40; and constipation, AOR, 1.50; 95% CI, 1.24-1.82) and girls (abdominal pain, AOR, 1.64; 95% CI, 1.43-1.88; nausea and/or vomiting, AOR, 1.74; 95% CI, 1.42-2.13; fever, AOR, 1.55; 95% CI, 1.14-2.11; diarrhea, AOR, 1.80; 95% CI, 1.19-2.74; and constipation, AOR, 1.25; 95% CI, 0.88-1.78) as well as patients with a comorbidity index of 2 or greater (adults, abdominal pain, AOR, 3.33; 95% CI, 3.09-3.60; nausea and/or vomiting, AOR, 3.66; 95% CI, 3.23-4.14; fever, AOR, 5.00; 95% CI, 3.79-6.60; diarrhea, AOR, 4.27; 95% CI, 3.39-5.38; and constipation, AOR, 4.17; 95% CI, 3.08-5.65; children, abdominal pain, AOR, 2.42; 95% CI, 1.93-3.05; nausea and/or vomiting, AOR, 2.55; 95% CI, 1.89-3.45; fever, AOR, 4.12; 95% CI, 2.71-6.25; diarrhea, AOR, 2.17; 95% CI, 1.18-3.97; and constipation, AOR, 2.19; 95% CI, 1.30-3.70) were more likely to have missed appendicitis. Adult patients who received computed tomographic scans at the initial ED visit (abdominal pain, AOR, 0.58; 95% CI, 0.52-0.65; nausea and/or vomiting, AOR, 0.63; 95% CI, 0.52-0.75; fever, AOR, 0.41; 95% CI, 0.29-0.58; diarrhea, AOR, 0.83; 95% CI, 0.58-1.20; and constipation, AOR, 0.60; 95% CI, 0.39-0.94) were less likely to have missed appendicitis.

CONCLUSIONS AND RELEVANCE

Regardless of age, a missed diagnosis of appendicitis was more likely to occur in women, patients with comorbidities, and patients who experienced abdominal pain accompanied by constipation. Population-based estimates of the rates of potentially missed appendicitis reveal opportunities for improvement and identify factors that may mitigate the risk of a missed diagnosis.

A five-year longitudinal observational study in morbidity and mortality of negative appendectomy in Sulaimani teaching Hospital/Kurdistan Region/Iraq

The most common surgical emergency is suspected acute appendicitis, the lifetime risk of acute appendicitis is estimated to be 8.6% for men and 6.7% for women, with a male to female ratio of 1.4:1; correct diagnosis can be made in 70–80% of patients after the operations about 32% of appendectomies revealed normal appendices and meanwhile appendectomy has a considerable morbidity and mortality. The aim is to explore potential morbidity and mortality associated with negative appendectomy. Prospective case series study, including 5847 patients, who were suspected to have acute appendicitis over a period of five years from 1st December 2013 to 30th November 2018, in emergency department of Sulaimani Teaching Hospital. All the collected data were collected, organized then analyzed by Statistical Package for the Social Sciences version 21. Morbidity in the patients with negative appendectomies occurred in patients in the form of 90 (01.91%) wound infection, 48 (01.02%) intestinal obstruction and last 15 (00.32%) patients developed septicemia. While mortality in negative appendectomy patients was 21, (00.45%). Negative appendectomies have high rates of morbidity and mortality, knowing real rates may help in considering various policies and may be helpful to elude avoidable complications and potential mortality.

The impact of hospital grade, hospital-volume, and surgeon-volume on outcomes for adults undergoing appendicectomy

INTRODUCTION

Acute Appendicitis and appendicectomy are common surgical emergencies worldwide. However, there is a lack of published data on the impact of hospital grade, surgeon- and hospital-volumes on patient outcomes following appendicectomy.

AIM

To establish if hospital grade, hospital-volume, or surgeon-volume impacted patient outcomes following appendicectomy.

METHODS

Using the National Quality Assurance and Improvement System (NQAIS) data for all appendicectomies performed in Ireland between January 2014 and November 2017 were examined. Data relating to patient demographics, type of surgery (open/laparoscopic/laparoscopic converted to open), length of stay (LOS), mortality, admission to critical care and re-admission rates were collected and analysed.

RESULTS

During the study period, 15,896 adult appendicectomies were performed, 14,521 were laparoscopic procedures. Patients treated in district general hospitals (DGHs) had lower LOS (2.96 v 3.37 days, p < 0.0001) than patients treated in tertiary referral hospitals (TRHs), had lower rates of laparoscopic procedures (87.38% v 95.56% p < 0.0001) and higher admission rates to critical care (1.91% v 0.75% p < 0.0001). No significant outcome difference was seen between those treated by high-volume (>62 cases/year) or low volume surgeons (<20 cases/year). Patients treated in high-volume hospitals (>260 cases/year) had higher rates of laparoscopic procedures (94.9% v 83.5%, p < 0.0001), lower rates of admission to critical care (0.85% v 2.25%, p < 0.0001) and lower 7-day re-admission rates (2.54% v 3.55%, p = 0.02) than those operated in low-volume hospitals (<161 cases/year).

CONCLUSION

Patients operated on in high-volume hospitals benefit from higher rates of laparoscopic surgery and fewer critical care admissions. No significant difference in outcome was noted in those patients operated upon by high- or low-volume surgeons or based on hospital grade.

Cost Comparison of Ultrasound Versus MRI to Diagnose Adolescent Female Patients Presenting with Acute Abdominal/Pelvic Pain Using Time-Driven Activity-Based Costing

RATIONALE AND OBJECTIVES

To compare the cost of ultrasound (US) versus magnetic resonance imaging (MRI) using time-driven activity-based costing in adolescent female patients with suspected appendicitis.

MATERIALS AND METHODS

Process maps were created using data from electronic medical record review and patient shadowing for adolescent female patients undergoing US or noncontrast MRI exams of the abdomen and pelvis for suspected appendicitis. Capacity cost rates for all personnel, equipment, facilities, and supplies in each exam pathway were established from institutional accounting data. The cost of each process step was determined by multiplying step-specific capacity cost rates by the mean time required to complete the step. Total pathway costs for US and MRI were computed by summing the costs of all steps through each pathway, and a direct cost comparison was made between the two modalities.

RESULTS

Process maps for US and MRI pathways were generated from 231 and 52 patient encounters, respectively. Patients undergoing US exams followed one of six pathways depending on exam order (abdomen versus pelvis performed first) and whether additional time was needed for bladder filling. Mean total US pathway time was 91 minutes longer than for MRI (US = 166 minutes; MRI = 75 minutes). Total MRI pathway cost was $209.97 compared to a mean US cost of $258.33 (range = $163.21-$293.24).

CONCLUSION

MRI can be a faster and less costly alternative to US for evaluating suspected appendicitis in adolescent female patients. While precise costs will vary by institution, MRI may be a viable and at times preferable alternative to US in this patient population.

[Acute abdomen : What the clinician wants to know from the radiologist]

CLINICAL ISSUE

Acute abdominal pain is a prevalent problem in the emergency department. The work-up has to include a broad spectrum of differential diagnoses, which should be narrowed down with respect to frequent diagnoses without overlooking rare but potentially even more severe pathologies.

STANDARD RADIOLOGICAL METHODS

The radiological method of choice for the initial work-up after sonography is computed tomography, which has demonstrated the highest sensitivity and specificity for most findings. Plain film radiographs of the abdomen rarely contribute to the final diagnosis. Magnetic resonance imaging is reserved for selected cases, which are described in this article.

ASSESSMENT

The clinical decision trees and recommendations, which need to be in the report depending on the diagnosis, are of relevance for every radiologist who deals with patients with acute abdominal presentations.

PRACTICAL RECOMMENDATIONS

Knowledge of the clinical diagnostic approach in patients with acute abdomen is an unavoidable prerequisite for optimal cooperation between clinicians and radiologists in acute situations.

Focused CT for the evaluation of suspected appendicitis

PURPOSE

To determine the diagnostic accuracy of focused appendiceal CT as a feasible alternative to the standard CT of the abdomen and pelvis (CT-AP) in patients with suspected acute appendicitis.

METHODS

Retrospective review of 200 adults with suspected acute appendicitis between January and October 2016 were included in this study. Each patient underwent CT-AP with oral and intravenous (IV) contrast. A subset of axial images starting at the top of L4 vertebral body to the roof of the acetabula were obtained from each study which served as the focused appendiceal CT. After review of the focused CTs, the non-focused CT-AP scans were reviewed, each patient acting as their own control. Images were assessed for ability to identify the appendix, assess for appendicitis, or identify alternative diagnoses that could account for the presenting symptoms.

RESULTS

Of 200 cases, the appendix was visualized in the focused CT in 191 patients. In nine studies, the appendix was not visualized in focused or standard CT-AP. Using focused CT, 42 cases were positive for acute appendicitis. This result was identical when reviewing standard CT-AP. Alternative diagnoses were present in 38 patients. Using focused CT, 14 of these were not fully covered but the readers were able to make the diagnoses confidently on the focused CTs. Only one patient had acute non-appendiceal pathology mostly outside of the field of view.

CONCLUSIONS

Focused appendiceal CT with IV and oral contrast in the setting of clinically suspected appendicitis is a suitable alternative to conventional CT-AP.

Does time of surgery influence the rate of false-negative appendectomies? A retrospective observational study of 274 patients

Background

Multiple disciplines have described an “after-hours effect” relating to worsened mortality and morbidity outside regular working hours. This retrospective observational study aimed to evaluate whether diagnostic accuracy of a common surgical condition worsened after regular hours.

Methods

Electronic operative records for all non-infant patients (age > 4 years) operated on at a single centre for presumed acute appendicitis were retrospectively reviewed over a 56-month period (06/17/2012–02/01/2017). The primary outcome measure of unknown diagnosis was compared between those performed in regular hours (08:00–17:00) or off hours (17:01–07:59). Pre-clinical biochemistry and pre-morbid status were recorded to determine case heterogeneity between the two groups, along with secondary outcomes of length of stay and complication rate.

Results

Out of 289 procedures, 274 cases were deemed eligible for inclusion. Of the 133 performed in regular hours, 79% were appendicitis, compared to 74% of the 141 procedures performed off hours. The percentage of patients with an unknown diagnosis was 6% in regular hours compared to 15% off hours (RR 2.48; 95% CI 1.14–5.39). This was accompanied by increased numbers of registrars (residents in training) leading procedures off hours (37% compared to 24% in regular hours). Pre-morbid status, biochemistry, length of stay and post-operative complication rate showed no significant difference.

Conclusions

This retrospective study suggests that the rate of unknown diagnoses for acute appendicitis increases overnight, potentially reflecting increased numbers of unnecessary procedures being performed off hours due to poorer diagnostic accuracy. Reduced levels of staffing, availability of diagnostic modalities and changes to workforce training may explain this, but further prospective work is required. Potential solutions may include protocolizing the management of common acute surgical conditions and making more use of non-resident on call senior colleagues.

Negative Appendectomy Rate and Risk Factors That Influence Improper Diagnosis at King Abdulaziz University Hospital

INTRODUCTION

Acute Appendicitis is the most common emergent abdominal surgery worldwide. diagnosis based on clinical assessment, laboratory and radiological investigations and appendectomy is the treatment of choice. Removing a normal appendix is a relatively common surgical issue, defined as negative appendectomy (NA). Multiple risk factors contribute to NA; female gender, normal WBC, normal CRP count, and CT scan unavailability. However, recently NA is decreasing in incidence after CT scan and Alvarado scoring.

AIM

We aimed to estimate the rate of negative appendectomy, and determine possible risk factors among King Abdulaziz University Hospital.

PATIENTS AND METHODS

Article has a retrospective character and included non-incidental 441 patients who undergo an appendectomy, during period 2008 to 2018.

RESULTS

Negative Appendectomy incidence (9.5%) was higher among females at (64.3%). Gynecological complaints were seen in (22.2%) of cases with a sign for Negative Appendectomy. Surgery reports documented (29.6%) of female ovarian cyst diseases. Alvarado scoring at presentation was less than 7 in (69%) of cases with statistical significance value. Normal WBC count (50%), for automated neutrophil (45.2%) was high, and same number were recorded with the normal neutrophil count, all of them have statically significant relation with NA.

CONCLUSION

Proper clinical evaluation involves documenting Alvarado score, using CRP, efficient radiological utilization. Also, considering more referrals to gynecological specialists of similar presentation especially females at reproductive age. Investing in time and equipment for proper clinical assessment can avoid the unnecessary burden and save our resources for better use.

Retrospective Multivariate Analysis of Data from Children with Suspected Appendicitis: A New Tool for Diagnosis

BACKGROUND

Decision-making for management may sometimes be difficult in acute appendicitis (AA). Various diagnostic scoring systems exist, but their sensitivity and specificity rates are far from ideal. In this study, the determination of the predictors and the effect of radiological data and developing a new scoring system were aimed.

METHODS

Medical records of patients who were hospitalized for AA between February 2012 and October 2016 were retrospectively reviewed. All data were compared between patients with and without appendicitis. The multivariate analysis was performed to define significant variables and to examine the sensitivity and specificity of each group of predictors including radiological data. A new scoring system (NSS) was formed and was compared with two existing scoring systems: pediatric appendicitis score (PAS) and Alvarado scoring system (ASS) by using reclassification method.

RESULTS

Negative appendectomy rate was 11.3%. Statistical analysis identified 21 independently significant variables. The heel drop test had the highest odds ratio. Sensitivity and specificity rates of clinical predictors were 84.6% and 94.8%, respectively. Radiological predictors increased the sensitivity rate to 86.9%. Sensitivity and specificity rates for PAS, ASS, and NSS were 86.8% and 83.9%, 84.7% and 81.6%, and 96.8% and 95.6%, respectively. The "re-assessed negative appendectomy rate" was 6.2% and false positive results were remarkably more common in patients with duration of symptoms less than 24 hours.

CONCLUSION

Radiological data improves the accuracy of diagnosis. Containing detailed clinical and radiological data, NSS performs superiorly to PAS and ASS, regarding sensitivity and specificity without any age limitation. The efficiency of NSS may be enhanced by determining different predictors for different phases of the inflammatory process.

Comprehensive review of typical and atypical pathology of the appendix on CT: cases with clinical implications

Acute appendicitis is the most common abdominal surgical emergency in the United States with approximately 250,000 cases annually. Computed Tomography (CT) has emerged as the most accurate diagnostic test to triage these patients for emergent surgery. Although the radiology search pattern is prioritized to detect an inflamed appendix, not all appearances equate to a typical surgical appendicitis. There are a select set of atypical pathologies involving the appendix that have subtle differences on CT, but can have catastrophic complications if treated with emergent appendectomy. This paper will review the spectrum of CT appearances and clinical management for typical and atypical appendiceal pathologies.

Sonography of the Cecum: Gateway to the Right Lower Quadrant

Sonography of the cecum has come of age largely as a consequence of the successful evolution of appendiceal sonography as a useful tool in the evaluation of patients with right lower-quadrant pain. At some medical centers, graded-compression sonography (GCS) has become the initial imaging study of choice in the assessment of these individuals. The cecum serves as a helpful anatomic landmark for localization of the appendix in these examinations-providing a sonographic starting point in the search for the appendix. During GCS, primary pathology within the cecum itself can become evident, including a variety of processes, such as infectious, inflammatory, or neoplastic disorders, whose presentations commonly mimic that of appendicitis. The accurate diagnosis of cecal abnormalities and their differentiation from acute appendicitis play valuable roles in the management of affected patients because the options for further workup and subsequent treatment vary greatly according to the diagnosis at hand. Additionally, the compressed cecum often becomes an acoustic window into the right lower quadrant, revealing pathology apart from the appendix within the right iliac fossa. The purpose of this pictorial essay is to highlight the importance and value of performing a careful evaluation of the cecum during GCS of patients with suspected appendicitis and to review the differential diagnosis and imaging findings of primary cecal abnormalities whose clinical presentations can mimic that of acute appendicitis.

CT guided appendicectomy incision: A prospective case series

OBJECTIVE

Several radiological studies have suggested that the base of the Appendix often does not correspond with Mc Burney's point. The aim of our study is to assess the value of using CT localization of the appendicocaecal junction to guide placement of the appendicectomy incision.

DESIGN & METHOD

32 consecutive patients, booked for open appendicectomy were prospectively included in this study. Coronal and axial CT scans with IV contrast were studied to assess site of the appendicocaecal junction. This information was used to guide placement of the incision.

RESULTS

28 out of 32 patients studied, the appendicocaecal junctions were accurately identified. It was noted that the final incision sites were cephalad to Mc Burney's point in 8, at the point in 3 and caudal in 17. In 1 patient, it was necessary to extend the incision medially by 2cm to retrieve the distal Appendix which had been detached through the site of rupture.

CONCLUSION

Mc Burney's point often does not correspond to the base of the appendix. We propose that using CT imaging to guide the appendicectomy incision is safe, facilitates locating the Appendix at surgery, minimizes incision size and decreases the need to extend it.

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.

Emergency appendicectomy in Australia: findings from a multicentre, prospective study

BACKGROUND

Emergency appendicectomy is the most common emergency surgical procedure performed in Australia. Despite this frequency, there is a relative paucity of contemporary, broad-based, local data that examine how emergency appendicectomies are currently performed and what are the outcomes from these operations.

METHODS

A multicentre, prospective, observational study was performed. Patients were recruited by local investigators for a period of 2 months with 30-day follow-up. Patients were eligible for study inclusion if they underwent an emergency appendicectomy for suspected acute appendicitis. The primary outcome of the study was the negative appendicectomy rate (NAR), with secondary outcomes including 30-day complication rates, method of operation and conversion rates.

RESULTS

A total of 1189 patients were recruited across 27 centres. The NAR across all centres was 19.0%. 98.2% of appendicectomies were performed with a laparoscopic-first approach. The rate of conversion from laparoscopy to open operation was 2.4%. 9.4% of patients were recorded as having one or more of the following complications: readmission (6.6%), surgical site infection (1.9%), intra-abdominal abscess (2.7%) or further intervention (1.5%). Patients who had an open operation had higher rates of readmission and surgical site infection.

CONCLUSION

The NAR found in this study is within the traditional measures of acceptance; however, this rate is high when measured against modern international benchmarks.

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

PURPOSE

Computed tomography (CT) is a fast and ubiquitous tool to evaluate intra-abdominal organs and diagnose appendicitis. However, traditional CT reporting does not necessarily capture the degree of uncertainty and indeterminate findings are still common. The purpose of this study was to evaluate the reproducibility of a standardized CT reporting system for appendicitis across a large population and the system's impact on radiologists' certainty in diagnosing appendicitis.

METHODS

Using a previously described standardized reporting system, eight radiologists retrospectively evaluated CT scans, blinded to all clinical information, in a stratified random sample of 237 patients from a larger cohort of patients imaged for possible appendicitis (2010-2014). Receiver operating characteristic (ROC) curves and the area under the ROC curve (AUC) were used to evaluate the diagnostic performance of readers for identifying appendicitis. Two-thirds of these scans were randomly selected to be independently read by a second reader, using the original CT reports to balance the number of positive, negative and indeterminate exams across all readers. Inter-reader agreement was evaluated.

RESULTS

There were 113 patients with appendicitis (mean age 38, 67% male). Using the standardized report, radiologists were highly accurate at identifying appendicitis (AUC=0.968, 95%CI confidence interval: 0.95, 0.99. Inter-reader agreement was >80% for most objective findings, and certainty in diagnosing appendicitis was high and reproducible (AUC=0.955 and AUC=0.936 for the first and second readers, respectively).

CONCLUSIONS

Using a standardized reporting system resulted in high reproducibility of objective CT findings for appendicitis and achieved high diagnostic accuracy in an at-risk population. Predictive tools based on this reporting system may further improve communication about certainty in diagnosis and guide patient management, especially when CT findings are indeterminate.

Derivation and validation of the APPEND score: an acute appendicitis clinical prediction rule

BACKGROUND

Although many clinical prediction rules (CPRs) for appendicitis exist, none have been developed for a New Zealand population presenting with right iliac fossa (RIF) pain. The aim of this study was to derive and validate an appendicitis CPR for our population.

METHOD

This is a retrospective review of all patients from December 2010 to February 2012 of at least 15 years of age presenting to the general surgery service with RIF pain. Patient data were divided into derivation and validation groups. Univariate and multiple regression analyses identified significant predictors of appendicitis which were used to construct a CPR. A retrospective validation study was then performed and the CPR was refined accordingly. Finally, the accuracy of the CPR was tested.

RESULTS

The final components of the new CPR, the APPEND score, were Anorexia, migratory Pain, local Peritonism, Elevated C-reactive protein, Neutrophilia and male gender (Dude). This CPR has an area under the receiver operating characteristic curve of 0.84. The CPR can stratify patients into low, intermediate and high-risk groups which may standardize patient care and reduce the negative appendicectomy rate.

CONCLUSION

A new CPR for predicting appendicitis, in patients presenting with RIF pain, has been derived and validated for use in our population. A prospective study to further evaluate its performance is required.

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.

Acute appendicitis in children: not only surgical treatment

PURPOSE

An accurate diagnosis of acute appendicitis is important to avoid severe outcome or unnecessary surgery but management is controversial. The aim of study was to evaluate, in younger and older children, the efficacy of conservative management for uncomplicated appendicitis and the outcome of complicated forms underwent early surgery.

METHODS

Children with acute appendicitis were investigated by clinical, laboratory variables and abdominal ultrasound and divided in two groups: complicated and uncomplicated. Complicated appendicitis underwent early surgery; uncomplicated appendicitis started conservative treatment with antibiotic. If in the next 24-48h it was worsening, the conservative approach failed and patients underwent late surgery.

RESULTS

A total of 362 pediatric patients were included. One hundred sixty-five underwent early appendectomy; 197 patients were at first treated conservatively: of these, 82 were operated within 24-48h for failure. The total percentage of operated patients was 68.2%. An elevated association was found between surgery and ultrasound.

CONCLUSIONS

Conservative treatment for uncomplicated appendicitis had high percentage of success (58%). Complications in operated patients were infrequent. Our protocol was effective in order to decide which patients treat early surgically and which conservatively; specific red flags (age and onset) can identified patients at most risk of complications or conservative failure.

TYPE OF STUDY

treatment study.

LEVEL OF EVIDENCE

II.

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.

Time-of-day and appendicitis: Impact on management and outcomes

BACKGROUND

Observational research has shown that delayed presentation is associated with perforation in appendicitis. Many factors that affect the ability to present for evaluation are influenced by time of day (eg, child care, work, transportation, and office hours of primary care settings). Our objective was to evaluate for an association between care processes or clinical outcomes and presentation time of day.

METHODS

The study evaluated a prospective cohort of 7,548 adults undergoing appendectomy at 56 hospitals across Washington State. Relative to presentation time, patient characteristics, time to operation, imaging use, negative appendectomy, and perforation were compared using univariate and multivariate methodologies.

RESULTS

Overall, 63% of patients presented between noon and midnight. More men presented in the morning; however, race, insurance status, comorbid conditions, and white blood cell count did not differ by presentation time. Daytime presenters (6 am to 6 pm) were less likely to undergo imaging (94% vs 98%, P < .05) and had a nearly 50% decrease in median preoperative time (6.0 h vs 8.7 h, P < .001). Perforation significantly differed by time-of-day. Patients who presented during the workday (9 am to 3 pm) had a 30% increase in odds of perforation compared with patients presenting in the early morning/late night (adjusted odds ratio 1.29, 95% confidence interval, 1.05-1.59). Negative appendectomy did not vary by time-of-day.

CONCLUSION

Most patients with appendicitis presented in the afternoon/evening. Socioeconomic characteristics did not vary with time-of-presentation. Patients who presented during the workday more often had perforated appendicitis compared with those who presented early morning or late night. Processes of care differed (both time-to-operation and imaging use). Time-of-day is associated with patient outcomes, process of care, and decisions to present for evaluation; this association has implications for the planning of the surgical workforce and efforts directed at quality improvement.

Appendicitis in Diabetics: Predictors of Complications and Their Incidence

Appendicitis is the most common surgical emergency encountered by the general surgeon. Literature has demonstrated that diabetics may manifest atypical signs of infection, often clouding the diagnostic picture. We conducted a 3-year retrospective analysis of adults with appendicitis to determine differences in presentation, diagnosis, treatment, and outcomes for diabetic versus nondiabetic patients. Demographics, symptoms, imaging, procedure(s), complications, and length of stay (LOS) were obtained via chart review. Factors were compared between patients with and without diabetes using chi-squared test, t test, or Mann-Whitney U test (significance at P ≤ 0.05). Multivariate regression analysis identified variables predicting longer LOS or perforation at diagnosis. Overall, 339 patients met inclusion criteria [303 were nondiabetic (ND), 36 were diabetic (D)]. On univariate analysis, diabetics were more likely to have other comorbid illnesses: obesity ( P < 0.001), chronic kidney disease ( P = 0.003), hypertension ( P < 0.001), coronary artery disease ( P < 0.001), peripheral vascular disease (PVD, P = 0.31), and chronic obstructive pulmonary disease ( P = 0.002). Diabetics presented with lower white blood cell counts (mean 14.2 ND, 11.9 D, P = 0.02), and were more likely to present with perforation (18.5% ND, 38.9% D, P = 0.008). LOS was longer in diabetics (1.0 day for ND, 3.0 day for D, P < 0.001). Complications were more frequent in diabetics (19.4% D vs 8.6% ND), which trended toward but failed to reach significance ( P = 0.066). On multivariate analysis, however, old age was the only characteristic associated with perforation [odds ratio: 1.05 (1.02–1.06), P < 0.001], whereas diabetes, chronic obstructive pulmonary disease, and older age predicted longer LOS ( P ≤ 0.001). Diabetics present a more complicated clinical picture having significantly more comorbidities and a trend toward postoperative complications necessitating a higher index of suspicion to detection complications. Further study is needed to evaluate the optimal diagnostic and management approach in this challenging population.

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.

Is there a need to standardize reporting terminology in appendicitis?

While computed tomography (CT) remains the most accurate and widely used modality for appendicitis imaging, ultrasound has developed its own niche role, especially in the pediatric population and in premenopausal women. Ultrasound is commonly used as the initial imaging test when available, with indeterminate or clinically equivocal cases proceeding to CT.To avoid the radiation and time and cost of CT, ultrasound needs to be improved. While previous studies have focused on improving the diagnostic accuracy of ultrasound through better patient selection and technique, relatively little attention has been brought to the ultrasound report, which often serves as the sole mode of communication between the radiologist and the clinician.Standardization of reporting and terminology has been found to improve patient outcomes and management in breast imaging. A standardized report for appendicitis has the potential to decrease confusion and increase accuracy. A potential format could include a standardized list of the presence or absence of imaging findings associated with appendicitis, with a final summary or score indicating the likelihood of appendicitis being present. Aggregation of data over time through use of a common format could help guide radiologist recommendations based on which imaging findings are present. Overall, a standardized report could help increase the value of ultrasound, leading to improved radiologist-clinician communication, better patient outcomes, and decreased costs.

A novel reporting system to improve accuracy in appendicitis imaging

OBJECTIVE

The purpose of this study was to ascertain if standardized radiologic reporting for appendicitis imaging increases diagnostic accuracy.

MATERIALS AND METHODS

We developed a standardized appendicitis reporting system that includes objective imaging findings common in appendicitis and a certainty score ranging from 1 (definitely not appendicitis) through 5 (definitely appendicitis). Four radiologists retrospectively reviewed the preoperative CT scans of 96 appendectomy patients using our reporting system. The presence of appendicitis-specific imaging findings and certainty scores were compared with final pathology. These comparisons were summarized using odds ratios (ORs) and the AUC.

RESULTS

The appendix was visualized on CT in 89 patients, of whom 71 (80%) had pathologically proven appendicitis. Imaging findings associated with appendicitis included appendiceal diameter (odds ratio [OR] = 14 [> 10 vs < 6 mm]; p = 0.002), periappendiceal fat stranding (OR = 8.9; p < 0.001), and appendiceal mucosal hyperenhancement (OR = 8.7; p < 0.001). Of 35 patients whose initial clinical findings were reported as indeterminate, 28 (80%) had appendicitis. In this initially indeterminate group, using the standardized reporting system, radiologists assigned higher certainty scores (4 or 5) in 21 of the 28 patients with appendicitis (75%) and lower scores (1 or 2) in five of the seven patients without appendicitis (71%) (AUC = 0.90; p = 0.001).

CONCLUSION

Standardized reporting and grading of objective imaging findings correlated well with postoperative pathology and may decrease the number of CT findings reported as indeterminate for appendicitis. Prospective evaluation of this reporting system on a cohort of patients with clinically suspected appendicitis is currently under way.