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Ahmed A, Feroz SH, Dominic JL, Muralidharan A, Thirunavukarasu P. Is Emergency Appendicectomy Better Than Elective Appendicectomy for the Treatment of Appendiceal Phlegmon?: A Review. Cureus 2020; 12:e12045. [PMID: 33447475 PMCID: PMC7802400 DOI: 10.7759/cureus.12045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Appendiceal phlegmon is considered to be sequelae to acute appendicitis which presents as an appendiceal mass composed of the inflamed appendix, the adjacent bowel loops, and the greater omentum. The definitive diagnosis can be obtained by a CT scan of the abdomen. Though conservative management was the most practiced approach, recent studies have shifted the trends towards immediate appendicectomy for the management of appendiceal phlegmon. Thus, the management of appendiceal phlegmon has been debatable. Evidence to support this review was gathered via the PubMed database as this database uses the Medline, PubMed Central, and NLM databases and also offers a quick diverse search with up-to-date citations and numerous open-access free articles focused on Medicine. We did not include other databases like Google Scholar, Embase, and Scopus due to its limited access to free articles, recent articles, and citation information. Search terms used were combinations of "Appendicitis," "Appendiceal phlegmon", "Appendiceal phlegmon (AND) appendicectomy ". The resultant studies were reviewed and cross‐referenced for additional reports. Emergency appendicectomy is defined as appendicectomy carried out during the same, initial admission. An elective or interval appendicectomy is an appendicectomy carried out four to six weeks after the initial episode at a later admission. The interval is bridged by antibiotics and conservative management. Emergency appendicectomy is considered to have a higher rate of complications when compared to conservative management for appendiceal phlegmon. However, interval appendicectomy requires multiple re-admissions, leads to delayed diagnosis of any underlying pathology, and an increased risk of recurrent appendicitis. In our review, we aimed to compare and contrast the effectiveness of the different treatment modalities available for appendiceal phlegmon. Though the meta-analyses showed an increased association of complications with emergency appendicectomy, they included studies conducted before the laparoscopic era. Emergency appendicectomy decreases the financial burden, re-admission rate, and aids in the early diagnosis of any underlying pathology. In the laparoscopic era, we can consider the shifting trends towards emergency appendicectomy for the management of appendiceal phlegmon.
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Affiliation(s)
- Asma Ahmed
- General Surgery, Ramaiah Medical College and Hospital, Bangalore, IND
| | - Shah Huzaifa Feroz
- General Surgery, Jawaharlal Nehru Medical College, Aligarh, IND.,General Surgery, Larkin Community Hospital, Miami, USA
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2
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Lee HJ, Woo JY, Byun J. Right hydronephrosis as a sign of complicated appendicitis. Eur J Radiol 2020; 131:109241. [PMID: 32916410 DOI: 10.1016/j.ejrad.2020.109241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 07/09/2020] [Accepted: 08/10/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Acute appendicitis is known for one of the most common cause of acute abdomen. However, it is still challenging to clearly distinguish complicated from uncomplicated appendicitis preoperatively. We investigated the association between right hydronephrosis and complicated appendicitis compared with other computed tomography (CT) findings of acute appendicitis. MATERIALS AND METHODS 1275 patients who pathologically diagnosed with acute appendicitis were included. They were classified into the complicated appendicitis and uncomplicated appendicitis groups based on their histopathological results. We reviewed their CT findings, including right hydronephrosis, appendiceal wall defect, periappendiceal abscess, extraluminal or intraluminal free air, appendicolith, appendiceal dilatation, appendiceal wall thickening, periappendiceal infiltration, periappendiceal fluid collection, and ascites. Comparison between the two groups was performed and the diagnostic performance of each CT finding was evaluated. The location of appendix and periureteral extension of periappendiceal infiltration were evaluated in patients with right hydronephrosis. RESULTS Out of 1275 patients, 29 (2.3 %) patients showed right hydronephrosis. Right hydronephrosis was significantly related to complicated appendicitis with the odds ratio of 4.90 (95 % confidence interval, 1.62-14.83; P = 0.005). Right hydronephrosis yielded specificity of 99.3 %. All patients with right hydronephrosis accompanied with periappendiceal infiltration and 28 (96.6 %) patients showed periureteral extension. Subcecal and pelvic areas are the most common locations, with 11 (37.9 %) patients each. CONCLUSION The presence of right hydronephrosis was specific finding for complicated appendicitis and it could be considered as one of indirect sign of complicated appendicitis.
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Affiliation(s)
- Hyung Ju Lee
- Department of Radiology, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Ji Young Woo
- Department of Radiology, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea.
| | - Jieun Byun
- Department of Radiology, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
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3
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Tames AC, Yamauchi FI, Castro ADAE, Amoedo CDDM, Cardoso EF, Baroni RH, Tachibana A. Morphologic criteria of vermiform appendix on computed tomography and a possible risk of developing acute appendicitis. Radiol Bras 2019; 52:217-221. [PMID: 31435081 PMCID: PMC6696745 DOI: 10.1590/0100-3984.2018.0118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective To evaluate the correlation of morphological criteria of the cecal appendix
using computed tomography (CT) and the possible risk of developing acute
appendicitis. Materials and Methods Cases were defined as patients with surgically confirmed acute appendicitis
who had undergone CT at least twice: at diagnosis and at least one month
prior. Controls were defined as emergency patients with abdominal pain who
had undergone abdominal CT that excluded acute appendicitis and had also
undergone CT at least one month before. Results 100 cases and 100 controls were selected for inclusion in the final analysis.
Comparisons between the cases and controls revealed the following: mean
transverse diameter of 0.6 cm (range, 0.4-1.0 cm) versus 0.6 cm (range,
0.6-0.8 cm; p = 0.37); mean length of 6.6 cm (range,
3.5-9.7 cm) versus 6.6 cm (range, 4.5-8.3 cm; p = 0.87);
mean angle of 100° (range, 23-178°) versus 86° (range, 43-160°;
p = 0.01); vertical descending orientation in 56%
versus 45% (p = 0.2); absence of gas in 69% versus 77%
(p = 0.34); and presence of an appendicolith in 17%
versus 8% (p = 0.08). Conclusion Hypothetical risk factors for obstruction of the vermiform appendix detected
on CT were not associated with acute appendicitis. That suggests that
factors other than those related to mechanical obstruction are implicated in
the pathogenesis of acute appendicitis.
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Affiliation(s)
- Amanda Chambi Tames
- Radiology and Diagnostic Imaging, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - Fernando Ide Yamauchi
- Radiology and Diagnostic Imaging, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.,Instituto de Radiologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InRad/HC-FMUSP), São Paulo, SP, Brazil
| | - Adham do Amaral E Castro
- Radiology and Diagnostic Imaging, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.,Department of Diagnostic Imaging, Escola Paulista de Medicina da Universidade Federal de São Paulo (EPM-Unifesp), São Paulo, SP, Brazil
| | | | - Ellison Fernando Cardoso
- Radiology and Diagnostic Imaging, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.,Instituto de Radiologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InRad/HC-FMUSP), São Paulo, SP, Brazil
| | - Ronaldo Hueb Baroni
- Radiology and Diagnostic Imaging, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - Adriano Tachibana
- Radiology and Diagnostic Imaging, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
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Khan MS, Siddiqui MTH, Shahzad N, Haider A, Chaudhry MBH, Alvi R. Factors Associated with Complicated Appendicitis: View from a Low-middle Income Country. Cureus 2019; 11:e4765. [PMID: 31363446 PMCID: PMC6663039 DOI: 10.7759/cureus.4765] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Introduction Factors associated with complicated appendicitis have been inconsistently identified. Moreover, studies are lacking from low and low-middle countries where access to surgical care is limited. Our objective was to identify factors predicting complicated appendicitis as diagnosed intraoperatively in a low-middle income country hospital. Methodology Retrospective case-control study of patients who underwent laparoscopic appendectomy from 01/2008 to 12/2015 was completed. Based on intraoperative diagnosis of complicated appendicitis, patients were divided into two groups; those with complicated appendicitis (CA) and those who had non-complicated appendicitis (NCA). CT scans were further reviewed to identify presence of appendicolith. Result Of the 442 patients included, 88 (20%) patients were in the CA group while 354 (80%) patients were in the NCA group. Patients in the CA group were older [CA vs. NCA: 34.6 ± 14 vs. 30.4 ± 11.5; p-value < 0.001], had symptoms for longer duration [CA vs. NCA: 2 ± 1.2 vs. 1.5 ± 0.8; p-value: 0.001] and had a greater proportion of patients with appendicoliths [CA vs. NCA: 37 (42%) vs. 84 (23.7%); p-value: 0.001]. On multivariable regression analysis, patients with complicated appendicitis had greater odds of having appendicoliths (OR: 2.4, 95% CI: 1.4-4.07; p-value < 0.001) and symptoms for a longer duration (OR: 1.57, 95% CI: 1.25-1.97; p-value < 0.001). Conclusion Patients with complicated appendicitis had greater odds of having appendicoliths and symptoms for a longer duration. Further studies are warranted in low and low-middle income countries to gauge the impact delay in presentation and intervention has on appendicitis and its outcomes.
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Affiliation(s)
| | | | - Noman Shahzad
- General Surgery, East Kent Hospitals University National Health Service Foundation Trust, Margate, GBR
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5
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Ali M, Iqbal J, Sayani R. Accuracy of Computed Tomography in Differentiating Perforated from Nonperforated Appendicitis, Taking Histopathology as the Gold Standard. Cureus 2018; 10:e3735. [PMID: 30800545 PMCID: PMC6384046 DOI: 10.7759/cureus.3735] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Accepted: 12/14/2018] [Indexed: 01/11/2023] Open
Abstract
Introduction Acute appendicitis is one of the more common causes of acute abdominal pain. It occurs when the lumen of the appendix is obstructed, leading to inflammation and finally perforation. The preoperative differentiation of perforated from nonperforated appendicitis is important and helpful to define prognosis and determine an adequate therapeutic approach, including consideration for nonsurgical treatment. This study recommends computed tomography (CT), a noninvasive method of investigation, be used frequently in clinically suspected cases of perforated appendicitis in the Pakistani population for better patient outcomes. Objective To determine the diagnostic accuracy of CT in differentiating perforated from nonperforated appendicitis by using histopathology as the gold standard. Material and methods A total of 236 patients with a clinical suspicion of appendicitis were included in this study. CT was performed in Liaquat National Hospital and Medical College. At the time of scanning, intravenous contrast was administered. Histopathology was used as the diagnostic gold standard. CT findings were documented using a proforma. The patient was returned to the referring department and followed after surgery for histopathology. Results Sensitivity, specificity, and positive and negative predictive values, as well as the accuracy of CT in the detection of perforated appendicitis, was 71.4%, 90.7%, 62.5%, 93.6%, and 87.3%, respectively. Conclusion CT findings can be used to select patients with perforated appendicitis for initial nonoperative management.
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Affiliation(s)
| | - Jawaid Iqbal
- Radiology, Liaquat National Hospital, Karachi, PAK
| | - Raza Sayani
- Radiology, Aga Khan University, Karachi, PAK
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6
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Kim HY, Park JH, Lee YJ, Lee SS, Jeon JJ, Lee KH. Systematic Review and Meta-Analysis of CT Features for Differentiating Complicated and Uncomplicated Appendicitis. Radiology 2017; 287:104-115. [PMID: 29173071 DOI: 10.1148/radiol.2017171260] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Purpose To perform a systematic review and meta-analysis to identify computed tomographic (CT) features for differentiating complicated appendicitis in patients suspected of having appendicitis and to summarize their diagnostic accuracy. Materials and Methods Studies on diagnostic accuracy of CT features for differentiating complicated appendicitis (perforated or gangrenous appendicitis) in patients suspected of having appendicitis were searched in Ovid-MEDLINE, EMBASE, and the Cochrane Library. Overlapping descriptors used in different studies to denote the same image finding were subsumed under a single CT feature. Pooled diagnostic accuracy of the CT features was calculated by using a bivariate random effects model. CT features with pooled diagnostic odds ratios with 95% confidence intervals not including 1 were considered as informative. Results Twenty-three studies were included, and 184 overlapping descriptors for various CT findings were subsumed under 14 features. Of these, 10 features were informative for complicated appendicitis. There was a general tendency for these features to show relatively high specificity but low sensitivity. Extraluminal appendicolith, abscess, appendiceal wall enhancement defect, extraluminal air, ileus, periappendiceal fluid collection, ascites, intraluminal air, and intraluminal appendicolith showed pooled specificity greater than 70% (range, 74%-100%), but sensitivity was limited (range, 14%-59%). Periappendiceal fat stranding was the only feature that showed high sensitivity (94%; 95% confidence interval: 86%, 98%) but low specificity (40%; 95% confidence interval, 23%, 60%). Conclusion Ten informative CT features for differentiating complicated appendicitis were identified in this study, nine of which showed high specificity, but low sensitivity. © RSNA, 2017 Online supplemental material is available for this article.
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Affiliation(s)
- Hae Young Kim
- From the Department of Radiology, Seoul National University Bundang Hospital, 82 Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620 Seongnam, Korea (H.Y.K., J.H.P., Y.J.L., S.S.L., K.H.L.); and Department of Statistics, University of Seoul, Seoul, Korea (J.J.J.)
| | - Ji Hoon Park
- From the Department of Radiology, Seoul National University Bundang Hospital, 82 Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620 Seongnam, Korea (H.Y.K., J.H.P., Y.J.L., S.S.L., K.H.L.); and Department of Statistics, University of Seoul, Seoul, Korea (J.J.J.)
| | - Yoon Jin Lee
- From the Department of Radiology, Seoul National University Bundang Hospital, 82 Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620 Seongnam, Korea (H.Y.K., J.H.P., Y.J.L., S.S.L., K.H.L.); and Department of Statistics, University of Seoul, Seoul, Korea (J.J.J.)
| | - Sung Soo Lee
- From the Department of Radiology, Seoul National University Bundang Hospital, 82 Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620 Seongnam, Korea (H.Y.K., J.H.P., Y.J.L., S.S.L., K.H.L.); and Department of Statistics, University of Seoul, Seoul, Korea (J.J.J.)
| | - Jong-June Jeon
- From the Department of Radiology, Seoul National University Bundang Hospital, 82 Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620 Seongnam, Korea (H.Y.K., J.H.P., Y.J.L., S.S.L., K.H.L.); and Department of Statistics, University of Seoul, Seoul, Korea (J.J.J.)
| | - Kyoung Ho Lee
- From the Department of Radiology, Seoul National University Bundang Hospital, 82 Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620 Seongnam, Korea (H.Y.K., J.H.P., Y.J.L., S.S.L., K.H.L.); and Department of Statistics, University of Seoul, Seoul, Korea (J.J.J.)
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7
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Vaghela K, Shah B. Diagnosis of Acute Appendicitis Using Clinical Alvarado Scoring System and Computed Tomography (CT) Criteria in Patients Attending Gujarat Adani Institute of Medical Science - A Retrospective Study. Pol J Radiol 2017; 82:726-730. [PMID: 29662595 PMCID: PMC5894019 DOI: 10.12659/pjr.902246] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Accepted: 01/20/2017] [Indexed: 12/14/2022] Open
Abstract
Background The aim was to evaluate the clinical Alvarado scoring system and computed tomography (CT) criteria for the diagnosis of acute appendicitis. Material/Methods The study was carried out retrospectively in patients who were referred to the Institute between March 2014 and January 2015. One hundred seventeen patients with acute abdominal pain who underwent abdominal CT were enrolled in this retrospective study. Patient demographics, clinical Alvarado scoring, CT images, and pathologic results of the patients were evaluated. Results Thirty nine of the 53 patients who were operated on had pathologically proven acute appendicitis. CT criteria of appendiceal diameter, presence of periappendiceal inflammation, fluid, appendicoliths, and white blood cell count (WBC) were significantly correlated with the inflammation of the appendix. The optimal cut-off value of the appendiceal diameter was 6.5 mm. The correlation between appendiceal diameter and WBC was 80% (P=0.01 <0.05). The correlation between appendiceal diameter and Alvarado score was 78.7% (P=0.01 <0.05). Conclusions Presence of appendiceal diameter above 6.5 mm on CT, periappendiceal inflammation, fluid, and appendicoliths should prompt the diagnosis of acute appendicitis. Since patients with acute appendicitis may not always show the typical signs and symptoms, CT is a helpful imaging modality for patients with relatively low Alvarado scores and leukocytosis, when physical examination is confusing.
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Affiliation(s)
- Krishnkant Vaghela
- Department of Radiology, Gujarat Adani Institute of Medical Science, Bhuj, Kutch, Gujarat
| | - Bhaven Shah
- Department of Radiology, Gujarat Adani Institute of Medical Science, Bhuj, Kutch, Gujarat
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8
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Talan DA, Saltzman DJ, Mower WR, Krishnadasan A, Jude CM, Amii R, DeUgarte DA, Wu JX, Pathmarajah K, Morim A, Moran GJ. Antibiotics-First Versus Surgery for Appendicitis: A US Pilot Randomized Controlled Trial Allowing Outpatient Antibiotic Management. Ann Emerg Med 2016; 70:1-11.e9. [PMID: 27974169 DOI: 10.1016/j.annemergmed.2016.08.446] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 08/13/2016] [Accepted: 08/22/2016] [Indexed: 12/17/2022]
Abstract
STUDY OBJECTIVE Randomized trials suggest that nonoperative treatment of uncomplicated appendicitis with antibiotics-first is safe. No trial has evaluated outpatient treatment and no US randomized trial has been conducted, to our knowledge. This pilot study assessed feasibility of a multicenter US study comparing antibiotics-first, including outpatient management, with appendectomy. METHODS Patients aged 5 years or older with uncomplicated appendicitis at 1 US hospital were randomized to appendectomy or intravenous ertapenem greater than or equal to 48 hours and oral cefdinir and metronidazole. Stable antibiotics-first-treated participants older than 13 years could be discharged after greater than or equal to 6-hour emergency department (ED) observation with next-day follow-up. Outcomes included 1-month major complication rate (primary) and hospital duration, pain, disability, quality of life, and hospital charges, and antibiotics-first appendectomy rate. RESULTS Of 48 eligible patients, 30 (62.5%) consented, of whom 16 (53.3%) were randomized to antibiotics-first and 14 (46.7%) to appendectomy. Median age was 33 years (range 9 to 73 years), median WBC count was 15,000/μL (range 6,200 to 23,100/μL), and median computed tomography appendiceal diameter was 10 mm (range 7 to 18 mm). Of 15 antibiotic-treated adults, 14 (93.3%) were discharged from the ED and all had symptom resolution. At 1 month, major complications occurred in 2 appendectomy participants (14.3%; 95% confidence interval [CI] 1.8% to 42.8%) and 1 antibiotics-first participant (6.3%; 95% CI 0.2% to 30.2%). Antibiotics-first participants had less total hospital time than appendectomy participants, 16.2 versus 42.1 hours, respectively. Antibiotics-first-treated participants had less pain and disability. During median 12-month follow-up, 2 of 15 antibiotics-first-treated participants (13.3%; 95% CI 3.7% to 37.9%) developed appendicitis and 1 was treated successfully with antibiotics; 1 had appendectomy. No more major complications occurred in either group. CONCLUSION A multicenter US trial comparing antibiotics-first to appendectomy, including outpatient management, is feasible to evaluate efficacy and safety.
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Affiliation(s)
- David A Talan
- Department of Emergency Medicine, Olive View-UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Medicine, Division of Infectious Diseases, Olive View-UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA.
| | - Darin J Saltzman
- Department of Surgery, Olive View-UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - William R Mower
- Department of Emergency Medicine, Ronald Reagan Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Anusha Krishnadasan
- Department of Emergency Medicine, Olive View-UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Cecilia M Jude
- Department of Radiology, Olive View-UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Ricky Amii
- Department of Emergency Medicine, Olive View-UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Daniel A DeUgarte
- Division of Pediatric Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - James X Wu
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Kavitha Pathmarajah
- Department of Emergency Medicine, Olive View-UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Ashkan Morim
- Department of Emergency Medicine, Olive View-UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Gregory J Moran
- Department of Emergency Medicine, Olive View-UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Medicine, Division of Infectious Diseases, Olive View-UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA
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9
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Gaskill CE, Simianu VV, Carnell J, Hippe DS, Bhargava P, Flum DR, Davidson GH. Use of Computed Tomography to Determine Perforation in Patients With Acute Appendicitis. Curr Probl Diagn Radiol 2016; 47:6-9. [PMID: 28162864 DOI: 10.1067/j.cpradiol.2016.12.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Revised: 11/30/2016] [Accepted: 12/03/2016] [Indexed: 12/22/2022]
Abstract
PURPOSE Urgent appendectomy has long been the standard of care for acute appendicitis. Six randomized trials have demonstrated that antibiotics can safely treat appendicitis, but approximately 1 in 4 of these patients eventually requires appendectomy. Overall treatment success may be limited by complex disease including perforation. Patients׳ success on antibiotic therapy may depend on preoperative identification of complex disease on imaging. However, the effectiveness of computed tomography (CT) in differentiating complex disease including perforated from nonperforated appendicitis remains to be determined. The purpose of this study was to assess the preoperative diagnostic accuracy of CT in determining appendiceal perforation in patients operated for acute appendicitis. METHODS We performed a retrospective review of pathology and radiology reports from consecutive patients who presented to the emergency department with suspicion for acute appendicitis between January 2012 and May 2015. CT scans were re-reviewed by abdominal imaging fellowship-trained radiologists using standardized criteria, and the radiologists were blinded to pathology and surgical findings. Radiologists specifically noted presence or absence of periappendiceal gas, abscess, appendicolith, fat stranding, and bowel wall thickening. The overall radiologic impression as well as these specific imaging findings was compared to results of pathology and operative reports. Pathology reports were considered the standard for diagnostic accuracy. RESULTS Eighty-nine patients (65% male, average age of 34 years) presenting with right lower quadrant pain underwent CT imaging and prompt appendectomy. Final pathology reported perforation in 48% (n = 43) of cases. Radiologic diagnosis of perforation was reported in 9% (n = 8), correctly identifying perforation in 37.5% (n = 3), and incorrectly reporting perforation in 62.5% of nonperforated cases per pathology. Radiology missed 93% (n = 40) of perforations postoperatively diagnosed by pathology. There was no secondary finding (fat stranding, diameter >13mm, abscess, cecal wall thickening, periappendiceal gas, simple fluid collection, appendicolith, and phlegmon) with a clinically reliable sensitivity or specificity to predict perforated appendicitis. Surgeon׳s report of perforation was consistent with the pathology report of perforation in only 28% of cases. CONCLUSIONS The usefulness of a CT for determining perforation in acute appendicitis is limited, and methods to improve precision in identifying patients with complicated appendicitis should be explored as this may help for improving risk prediction for failure of treatment with antibiotic therapy and help guide patients and providers in shared decision-making for treatment options.
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Affiliation(s)
- Cameron E Gaskill
- Department of Surgery, University of Washington, Seattle, WA; Surgical Outcomes Research Center, University of Washington, Seattle, WA.
| | - Vlad V Simianu
- Department of Surgery, University of Washington, Seattle, WA; Surgical Outcomes Research Center, University of Washington, Seattle, WA
| | | | - Daniel S Hippe
- Department of Radiology, University of Washington, Seattle, WA
| | - Puneet Bhargava
- Department of Radiology, University of Washington, Seattle, WA
| | - David R Flum
- Department of Surgery, University of Washington, Seattle, WA; Surgical Outcomes Research Center, University of Washington, Seattle, WA
| | - Giana H Davidson
- Department of Surgery, University of Washington, Seattle, WA; Surgical Outcomes Research Center, University of Washington, Seattle, WA
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Acute appendicitis with a neuroendocrine tumor G1 (carcinoid): pitfalls of conservative treatment. Clin J Gastroenterol 2016; 9:203-7. [PMID: 27311320 DOI: 10.1007/s12328-016-0660-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 05/31/2016] [Indexed: 12/26/2022]
Abstract
A man in his early thirties presented to our clinic with right lower abdominal pain. Computed tomography (CT) and ultrasonography (US) revealed a swollen appendix and an appendicolith. Abscess formation was not observed but ongoing appendiceal rupture was not ruled out. Three months after successful conservative therapy, the lumen of the apical portion was kept dilated and laparoscopic interval appendectomy was performed. No tumorous findings were observed macroscopically. However, histology revealed many tiny nests infiltrating the submucosa, muscular layer, and subserosa at the root of the appendix. An appendiceal neuroendocrine tumor G1 (NET G1; carcinoid) was diagnosed immunohistologically. Neither CT nor US visualized the tumor because of its non-tumor-forming but infiltrative growth. In conclusion, after successful conservative treatment, interval appendectomy should be considered to uncover a possible appendiceal NET G1 (carcinoid), particularly when dilatation of the distal lumen is kept under observation.
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11
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Evaluation of Clinical Alvarado Scoring System and CT Criteria in the Diagnosis of Acute Appendicitis. Radiol Res Pract 2016; 2016:9739385. [PMID: 27242926 PMCID: PMC4868911 DOI: 10.1155/2016/9739385] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 04/04/2016] [Indexed: 12/14/2022] Open
Abstract
Aim. The aim was to evaluate the clinical Alvarado scoring system and computed tomography (CT) criteria for the diagnosis of acute appendicitis. Material and Methods. 117 patients with acute abdominal pain who underwent abdominal CT were enrolled in this retrospective study. Patient demographics, clinical Alvarado scoring, CT images, and pathologic results of the patients were evaluated. Results. 39 of the 53 patients who were operated on had pathologically proven acute appendicitis. CT criteria of appendiceal diameter, presence of periappendiceal inflammation, fluid, appendicolith, and white blood cell (WBC) count were significantly correlated with the inflammation of the appendix. The best cut-off value for appendiceal diameter was 6.5 mm. The correlation between appendiceal diameter and WBC count was 80% (P = 0.01 < 0.05). The correlation between appendiceal diameter and Alvarado score was 78.7% (P = 0.01 < 0.05). Conclusion. Presence of CT criteria of appendiceal diameter above 6.5 mm, periappendiceal inflammation, fluid, and appendicolith should prompt the diagnosis of acute appendicitis. Since patients with acute appendicitis may not always show the typical signs and symptoms, CT is a helpful imaging modality for patients with relatively low Alvarado score and leukocytosis and when physical examination is confusing.
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Del Gaizo AJ, Lall C, Allen BC, Leyendecker JR. From esophagus to rectum: a comprehensive review of alimentary tract perforations at computed tomography. ACTA ACUST UNITED AC 2016; 39:802-23. [PMID: 24584681 DOI: 10.1007/s00261-014-0110-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Gastrointestinal (GI) tract perforation is a life-threatening condition that can occur at any site along the alimentary tract. Early perforation detection and intervention significantly improves patient outcome. With a high sensitivity for pneumoperitoneum, computed tomography (CT) is widely accepted as the diagnostic modality of choice when a perforated hollow viscus is suspected. While confirming the presence of a perforation is critical, clinical management and surgical technique also depend on localizing the perforation site. CT is accurate in detecting the site of perforation, with segmental bowel wall thickening, focal bowel wall defect, or bubbles of extraluminal gas concentrated in close proximity to the bowel wall shown to be the most specific findings. In this article, we will present the causes for perforation at each site throughout the GI tract and review the patterns that can lead to prospective diagnosis and perforation site localization utilizing CT images of surgically proven cases.
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Affiliation(s)
- Andrew J Del Gaizo
- Department of Radiology, Wake Forest University Baptist Medical Center, Medical Center Blvd, Winston-Salem, NC, 27157, USA,
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Atema JJ, van Rossem CC, Leeuwenburgh MM, Stoker J, Boermeester MA. Scoring system to distinguish uncomplicated from complicated acute appendicitis. Br J Surg 2015; 102:979-90. [PMID: 25963411 DOI: 10.1002/bjs.9835] [Citation(s) in RCA: 117] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Revised: 02/04/2015] [Accepted: 03/24/2015] [Indexed: 12/11/2022]
Abstract
Abstract
Background
Non-operative management may be an alternative for uncomplicated appendicitis, but preoperative distinction between uncomplicated and complicated disease is challenging. This study aimed to develop a scoring system based on clinical and imaging features to distinguish uncomplicated from complicated appendicitis.
Methods
Patients with suspected acute appendicitis based on clinical evaluation and imaging were selected from two prospective multicentre diagnostic accuracy studies (OPTIMA and OPTIMAP). Features associated with complicated appendicitis were included in multivariable logistic regression analyses. Separate models were developed for CT and ultrasound imaging, internally validated and transformed into scoring systems.
Results
A total of 395 patients with suspected acute appendicitis based on clinical evaluation and imaging were identified, of whom 110 (27·8 per cent) had complicated appendicitis, 239 (60·5 per cent) had uncomplicated appendicitis and 46 (11·6 per cent) had an alternative disease. CT was positive for appendicitis in 284 patients, and ultrasound imaging in 312. Based on clinical and CT features, a model was created including age, body temperature, duration of symptoms, white blood cell count, C-reactive protein level, and presence of extraluminal free air, periappendiceal fluid and appendicolith. A scoring system was constructed, with a maximum possible score of 22 points. Of the 284 patients, 150 had a score of 6 points or less, of whom eight (5·3 per cent) had complicated appendicitis, giving a negative predictive value (NPV) of 94·7 per cent. The model based on ultrasound imaging included the same predictors except for extraluminal free air. The ultrasound score (maximum 19 points) was calculated for 312 patients; 105 had a score of 5 or less, of whom three (2·9 per cent) had complicated appendicitis, giving a NPV of 97·1 per cent.
Conclusion
With use of novel scoring systems combining clinical and imaging features, 95 per cent of the patients deemed to have uncomplicated appendicitis were correctly identified as such. The score can aid in selection for non-operative management in clinical trials.
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Affiliation(s)
- J J Atema
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - C C van Rossem
- Department of Surgery, Tergooi Hospital, Hilversum, The Netherlands
| | - M M Leeuwenburgh
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - J Stoker
- Department of Radiology, Academic Medical Centre, Amsterdam, The Netherlands
| | - M A Boermeester
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
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Kim MS, Park HW, Park JY, Park HJ, Lee SY, Hong HP, Kwag HJ, Kwon HJ. Differentiation of early perforated from nonperforated appendicitis: MDCT findings, MDCT diagnostic performance, and clinical outcome. ACTA ACUST UNITED AC 2015; 39:459-66. [PMID: 24633221 DOI: 10.1007/s00261-014-0117-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
To determine the CT findings and assess their diagnostic performance in differentiating early perforated appendicitis from nonperforated appendicitis, and to compare therapeutic approaches and clinical outcomes between two types of appendicitis. Our retrospective study was approved by our institutional review board and informed consent was waived. From July 2012 to July 2013, 339 patients [mean age 40.8 years; age range 19-80 years; 183 male (mean age 40.5 years; age range 19-79 years) and 156 female (mean age 41.2 years; age range 19-80 years)] who underwent appendectomy with preoperative CT examination for suspected acute appendicitis were included, with exclusion of 37 patients with specific CT findings for advanced perforated appendicitis. And they were categorized into nonperforated and early perforated appendicitis groups according to surgical and pathologic reports. The following CT findings were evaluated by two radiologists blinded to pathologic and surgical findings: transverse diameter of the appendix, thickness of the appendiceal wall, the depth of intraluminal appendiceal fluid, appendiceal wall enhancement, presence or absence of focal defect in the appendiceal wall, intraluminal appendiceal air, appendicolith/fecalith, periappendiceal changes, cecal wall thickening, and free fluid. The type of surgical procedures, performance of surgical drainage, and the length of hospital stay were recorded. Univariate and multivariate logistic regression analysis were used to determine the CT findings for differentiating early perforated appendicitis from nonperforated appendicitis, a total of 75 (22%) of the 339 patients was diagnosed with early perforated appendicitis. Focal wall defect [adjusted odds ratio (aOR), 23.40; p < 0.001], circumferential periappendiceal changes (aOR, 5.63; p < 0.001), appendicoliths/fecaliths (aOR, 2.47; p = 0.015), and transverse diameter of the appendix (aOR, 1.22; p = 0.003) were independently differentiating variables for early perforated appendicitis. The transverse diameter of the appendix (≥11 mm) had the highest sensitivity (62.7%) and focal wall defect in the appendiceal wall showed the highest specificity (98.8%). The prevalence of surgical drainage was higher (p = 0.001) and the mean hospital stay was approximately one day longer (p < 0.001) in the early perforated group than nonperforated group. CT can be helpful in differentiating early perforated appendicitis from nonperforated appendicitis, although the sensitivity of the evaluated findings was somewhat limited.
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Affiliation(s)
- Mi Sung Kim
- Department of Radiology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, 108 Pyung dong, Jongno-gu, Seoul, 110-746, Korea
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Willekens I, Peeters E, De Maeseneer M, de Mey J. The normal appendix on CT: does size matter? PLoS One 2014; 9:e96476. [PMID: 24802879 PMCID: PMC4011757 DOI: 10.1371/journal.pone.0096476] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Accepted: 04/08/2014] [Indexed: 12/29/2022] Open
Abstract
PURPOSE (1) To evaluate the frequency of visualisation and measurements of the normal appendix. (2) To correlate Body Mass Index (BMI) and gender with visualisation of the normal appendix. (3) To correlate age, gender and body length with appendiceal length. MATERIALS AND METHODS A retrospective review of 186 patients undergoing abdominal CT without suspicion of acute appendicitis was done. Frequency of visualisation and measurements (including maximal outer diameter, wall thickness, length, content, location of base and tip) of normal appendices were recorded. RESULTS Prevalence of appendectomy was 34.4%. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of visualisation of the normal appendix were 76%, 94%, 96%, 67%, and 82% respectively. The mean maximal diameter of the appendix was 8.19 mm±1.6 (SD) (range, 4.2-12.8 mm). The mean length of the appendix was 81.11 mm±28.44 (SD) (range, 7.2-158.8 mm). The mean wall thickness of the appendix was 2.22 mm±0.56 (SD) (range, 1.15-3.85 mm). The most common location of the appendiceal tip was pelvic in 66% appendices. The most common location of the appendiceal base was inferior, medial, and posterior in 37%. The normal appendix contained high-density material in 2.2%. There was a significant correlation between gender and appendiceal length, with men having longer appendices than women. CONCLUSION Most normal appendices are seen at multislice CT using i.v. contrast. The maximal outer diameter of the normal appendix overlaps with values currently used to diagnose appendicitis on CT.
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Affiliation(s)
- Inneke Willekens
- In vivo Cellular and Molecular Imaging (ICMI) - Vrije Universiteit Brussel, Department of Radiology - UZ Brussel, Brussels, Belgium
| | - Els Peeters
- Department of Radiology, ASZ Aalst, Aalst, Belgium
| | | | - Johan de Mey
- Department of Radiology, UZ Brussel, Brussels, Belgium
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Leeuwenburgh MMN, Wiezer MJ, Wiarda BM, Bouma WH, Phoa SSKS, Stockmann HBAC, Jensch S, Bossuyt PMM, Boermeester MA, Stoker J. Accuracy of MRI compared with ultrasound imaging and selective use of CT to discriminate simple from perforated appendicitis. Br J Surg 2013; 101:e147-55. [PMID: 24272981 DOI: 10.1002/bjs.9350] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2013] [Indexed: 01/05/2023]
Abstract
BACKGROUND Discrimination between simple and perforated appendicitis in patients with suspected appendicitis may help to determine the therapy, timing of surgery and risk of complications. The aim of this study was to estimate the accuracy of magnetic resonance imaging (MRI) in distinguishing between simple and perforated appendicitis, and to compare MRI against ultrasound imaging with selected additional (conditional) use of computed tomography (CT). METHODS Patients with clinically suspected appendicitis were identified prospectively at the emergency department of six hospitals. Consenting patients underwent MRI, but were managed based on findings at ultrasonography and conditional CT. Radiologists who evaluated the MRI were blinded to the results of ultrasound imaging and CT. The presence of perforated appendicitis was recorded after each evaluation. The final diagnosis was assigned by an expert panel based on perioperative data, histopathology and clinical follow-up after 3 months. RESULTS MRI was performed in 223 of 230 included patients. Acute appendicitis was the final diagnosis in 118 of 230 patients, of whom 87 had simple and 31 perforated appendicitis. MRI correctly identified 17 of 30 patients with perforated appendicitis (sensitivity 57 (95 per cent confidence interval 39 to 73) per cent), whereas ultrasound imaging with conditional CT identified 15 of 31 (sensitivity 48 (32 to 65) per cent) (P = 0.517). All missed diagnoses of perforated appendicitis were identified as simple acute appendicitis with both imaging protocols. None of the MRI features for perforated appendicitis had a positive predictive value higher than 53 per cent. CONCLUSION MRI is comparable to ultrasonography with conditional use of CT in identifying perforated appendicitis. However, both strategies incorrectly classify up to half of all patients with perforated appendicitis as having simple appendicitis. Triage of appendicitis based on imaging for conservative treatment is inaccurate and may be considered unsafe for decision-making. Presented to a scientific meeting of the Association of Surgeons of the Netherlands, Veldhoven, The Netherlands, May 2012; published in abstract form as Br J Surg 2012; 99(Suppl 7): S6.
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Affiliation(s)
- M M N Leeuwenburgh
- Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands; Department of Radiology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
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Tannoury J, Abboud B. Treatment options of inflammatory appendiceal masses in adults. World J Gastroenterol 2013; 19:3942-3950. [PMID: 23840138 PMCID: PMC3703180 DOI: 10.3748/wjg.v19.i25.3942] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Revised: 03/22/2013] [Accepted: 04/28/2013] [Indexed: 02/06/2023] Open
Abstract
At present, the treatment of choice for uncomplicated acute appendicitis in adults continues to be surgical. The inflammation in acute appendicitis may sometimes be enclosed by the patient’s own defense mechanisms, by the formation of an inflammatory phlegmon or a circumscribed abscess. The management of these patients is controversial. Immediate appendectomy may be technically demanding. The exploration often ends up in an ileocecal resection or a right-sided hemicolectomy. Recently, the conditions for conservative management of these patients have changed due to the development of computed tomography and ultrasound, which has improved the diagnosis of enclosed inflammation and made drainage of intra-abdominal abscesses easier. New efficient antibiotics have also given new opportunities for nonsurgical treatment of complicated appendicitis. The traditional management of these patients is nonsurgical treatment followed by interval appendectomy to prevent recurrence. The need for interval appendectomy after successful nonsurgical treatment has recently been questioned because the risk of recurrence is relatively small. After successful nonsurgical treatment of an appendiceal mass, the true diagnosis is uncertain in some cases and an underlying diagnosis of cancer or Crohn’s disease may be delayed. This report aims at reviewing the treatment options of patients with enclosed appendiceal inflammation, with emphasis on the success rate of nonsurgical treatment, the need for drainage of abscesses, the risk of undetected serious disease, and the need for interval appendectomy to prevent recurrence.
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Significance of size and location of appendicoliths as exacerbating factor of acute appendicitis. Emerg Radiol 2012. [PMID: 23179506 DOI: 10.1007/s10140-012-1093-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The aim of the present study was to investigate the significance of appendicoliths as an exacerbating factor of acute appendicitis using multivariate analysis. A total of 254 patients with pathologically proved acute appendicitis were enrolled in this retrospective study (male, 51 %; mean age, 40.1 years; range, 15-91 years). Two radiologists performed a consensus evaluation of preoperative CT images for the presence of appendicoliths in consensus. When there were appendicoliths, they assessed the number and location of appendicoliths, and measured the longest diameter of the largest appendicolith. Pathological diagnosis was used for the reference standard. The relationships of appendicoliths to gangrenous appendicitis and to perforated appendicitis were each assessed with multiple logistic regression models, which were adjusted for demographic and clinical characteristics of patients. Significant relationships were identified between gangrenous appendicitis and the presence of appendicoliths (OR, 2.2; 95 % CI, 1.2-4.0), the largest appendicolith more than 5 mm in the longest (OR, 3.0; 95 % CI, 1.6-5.7), and location of an appendicolith at the root of the appendix (OR, 2.0; 95 % CI, 1.1-3.8). Among the CT characteristics, the location of an appendicolith at the root of the appendix only showed significant relationship with perforated appendicitis (OR, 4.5; 95 % CI, 1.4-15.4). Size of the largest appendicolith and location of appendicoliths at the root of the appendix are exacerbating factors of acute appendicitis.
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Lai V, Chan WC, Lau HY, Yeung TW, Wong YC, Yuen MK. Diagnostic power of various computed tomography signs in diagnosing acute appendicitis. Clin Imaging 2012; 36:29-34. [DOI: 10.1016/j.clinimag.2011.04.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2011] [Accepted: 03/11/2011] [Indexed: 12/29/2022]
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Fraser JD, Aguayo P, Sharp SW, Snyder CL, Rivard DC, Cully BE, Sharp RJ, Ostlie DJ, St Peter SD. Accuracy of computed tomography in predicting appendiceal perforation. J Pediatr Surg 2010; 45:231-4; discussion 234-4. [PMID: 20105609 DOI: 10.1016/j.jpedsurg.2009.10.040] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2009] [Accepted: 10/06/2009] [Indexed: 12/11/2022]
Abstract
BACKGROUND Some surgeons use nonoperative management with or without interval appendectomy for patients who present with perforated appendicitis. These strategies depend on accurately delineating perforation by computed tomography (CT). Since 2005, our institution has used an evidence-based definition for perforation as a hole in the appendix or fecalith in the abdomen. This has been shown to clearly separate those with a high risk of abscess from those without. To quantify the ability of CT to identify which patients would meet these criteria for perforation, we tested 6 surgeons and 2 radiologists who evaluated blinded CT scans. METHODS A junior and senior surgical residents, 2 staff interventional radiologists, and 4 attending pediatric surgeons with 3 to 30 years of experience reviewed 200 CT scans of pediatric patients who had undergone a laparoscopic appendectomy. All CT scans were reviewed electronically, and the reviewers were blinded to the results, outcome, and intraoperative findings. None of the patients had a well-formed abscess on CT. The reviewers were asked to decide only on perforated or nonperforated appendicitis according to our intraoperative definition. Clinical admission data were reviewed and compared between groups. RESULTS In total, the reviewers were correct 72% of the time with an overall sensitivity of 62% and a specificity of 81%. The overall positive predictive value was 67%, and the negative predictive value was 77%. CONCLUSIONS This study shows that in the absence of a well-formed abscess, the triage of patient care based on a preoperative diagnosis of perforation from CT may be imprudent and subject a portion of the population to an unnecessarily prolonged course of care.
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Affiliation(s)
- Jason D Fraser
- Department of Surgery, The Children's Mercy Hospital, Kansas City, MO 64108, USA
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Wu CT, Lim KE. A retrospective study of CT findings in cases undergoing appendectomy at a single hospital. Clin Imaging 2007; 31:239-43. [PMID: 17599617 DOI: 10.1016/j.clinimag.2007.03.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2006] [Accepted: 03/17/2007] [Indexed: 12/29/2022]
Abstract
The purpose of this study was to determine which clinical information or computed tomography (CT) features can distinguish perforated from nonperforated appendicitis. We collected data from 102 patients (62 men, 40 women; mean age, 49.6 years; age range, 16-85 years) who presented to the emergency department with acute abdominal pain or suspicion of acute appendicitis and underwent appendectomy. In the clinical information, there was no significant factor to predict appendiceal perforation. As for CT features, significant imaging factors for predicting appendiceal perforation included abscess, phlegmon, and thickening of lateroconal fascia. The treatment strategy of acute appendicitis varies according to the integrity of the appendiceal wall. Besides clinical findings, CT features can distinguish perforated from nonperforated appendicitis, facilitating proper decision making in ER.
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Affiliation(s)
- Chen-Te Wu
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
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Bixby SD, Lucey BC, Soto JA, Theysohn JM, Theyson JM, Ozonoff A, Varghese JC. Perforated versus nonperforated acute appendicitis: accuracy of multidetector CT detection. Radiology 2007; 241:780-6. [PMID: 17114626 DOI: 10.1148/radiol.2413051896] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE To retrospectively evaluate the accuracy of multidetector computed tomography (CT) in the diagnosis of perforated acute appendicitis by using surgery and pathologic examination combined as the reference standard. MATERIALS AND METHODS The study was institutional review board approved and HIPAA compliant. Informed patient consent was waived. The authors retrospectively identified 244 patients (150 male, 94 female; mean age, 32.8 years; age range, 4-83 years) with pathologically proved acute appendicitis who underwent abdominopelvic multidetector CT. Two radiologists reviewed in consensus the multidetector CT images obtained in all patients for various findings that may be associated with appendiceal perforation. For continuous variables, a comparison of means between the perforated and nonperforated groups was performed by using the Wilcoxon rank sum test. For categorical variables, the sensitivity and specificity of each CT finding for the diagnosis of perforated appendicitis were determined. RESULTS The CT findings of abscess (99%), extraluminal gas (98%), and ileus (93%) had the highest specificities for appendiceal perforation; however, the sensitivities of these findings were low: 34%, 35%, and 53%, respectively. The appendix was larger in patients with perforated appendicitis: The mean diameter was 15.1 mm compared with a mean diameter of 11.7 mm in patients with nonperforated appendicitis (P < .001). Appendicolith, free fluid, enlarged abdominal lymph nodes, and enhancement defect in the appendiceal wall were neither highly sensitive nor highly specific for the detection of perforation. CONCLUSION Although certain multidetector CT findings are very specific for the diagnosis of perforated appendicitis, overall multidetector CT sensitivity is poor. Unless abscess or extraluminal gas is present, multidetector CT cannot enable the diagnosis of perforation.
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Affiliation(s)
- Sarah D Bixby
- Division of Body Imaging, Department of Radiology, Boston University Medical Center, Boston, MA 02115, USA.
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