The Alvarado score for predicting acute appendicitis: a systematic review

Schistosomal appendicitis: a case report

BACKGROUND

Schistosomiasis is one of the endemic parasitic diseases in many developing countries. Despite this, appendicitis secondary to schistosomiasis is an uncommon condition even in some endemic areas. Schistosomal appendicitis, an incidentally discovered appendicitis associated with schistosomiasis histological findings, affects young males predominantly. Timely diagnosis and treatment, including appendectomy and anti-helminthic therapy, are crucial.

CASE REPORT

A 24-year-old Sudanese male patient presented with abdominal pain. Diagnosed with acute appendicitis, he underwent appendectomy, revealing appendix inflammation with Schistosoma ova in histopathology. Abdominal ultrasound detected no complications. Weakly positive Schistosoma serology was noted, but stool and urine analysis showed no infection evidence. Prescribed praziquantel, patient had 3-year post-op follow-up without complications.

CONCLUSIONS

This case report underscores the significance of including schistosomiasis in the differential diagnosis of appendicitis, particularly in regions where the disease is endemic. It underscores the necessity of histopathological evaluations for accurate diagnosis, emphasizing the potential implications for clinical practice in similar settings.

Observation Safely Reduces the Use of the Computerized Tomography in Medium-to-Low-Risk Patients with Suspected Acute Appendicitis: Results of a Randomized Controlled Trial

Objectives-The objective was to compare the effectiveness of observation in standard-of-care computed tomography (CT) in adult patients with suspected acute appendicitis (AA). Methods-Patients with clinically suspected AA and inconclusive diagnosis after primary clinical examination, laboratory examination, and transabdominal ultrasound (TUS) were eligible for the study, and they were randomized (1:1) to parallel groups: observation-group patients were observed for 8-12 h and then, repeated clinical and laboratory examinations and TUS were performed; CT group (control group) patients underwent abdominopelvic CT scan. The study utilized Statistical Analysis System 9.2 for data analysis, including tests, logistic regression, ROC analysis, and significance evaluation. Patients were enrolled in the study at Vilnius University Hospital Santaros Klinikos in Lithuania between December 2018 and June 2021. Results-A total of 160 patients (59 men, 101 women), with a mean age of 33.7 ± 14.71, were included, with 80 patients in each group. Observation resulted in a reduced likelihood of a CT scan compared with the CT group (36.3% vs. 100% p < 0.05). One diagnostic laparoscopy was performed in the observation group; there were no cases of negative appendectomy (NA) in the CT group. Both conditional CT and observation pathways resulted in high sensitivity and specificity (97.7% and 94.6% vs. 96.7% and 95.8%). Conclusions-Observation including the repeated evaluation of laboratory results and TUS significantly reduces the number of CT scans without increasing NA numbers or the number of complicated cases.

RAMA-WeRA Risk Score in Predicting the Ruptured Appendicitis in Emergency Department; a Multicenter Study for External Validation

Introduction

Distinguishing between ruptured and non-ruptured acute appendicitis presents a significant challenge. This study aimed to validate the accuracy of RAMA-WeRA Risk Score in predicting ruptured appendicitis (RA) in emergency department.

Methods

This study was a multicenter diagnostic accuracy study conducted across six hospitals in Thailand from February 1, 2022, to January 20, 2023. The eligibility criteria included individuals aged >15 years suspected of acute appendicitis, presenting to the ED, and having an available pathology report following appendectomy or intraoperative diagnosis by the surgeon. We assessed the screening performance characteristics of RAMA-WeRA Risk Score, in detecting the ruptured appendicitis (RA) cases.

Results

860 patients met the study criteria. 168 (19.38%) had RA and 692 (80.62%) patients had non-RA. The area under the receiver operating characteristic curve (AuROC) of RAMA-WeRA Risk Score was 75.11% (95% CI: 71.10, 79.11). The RAMA-WeRA Risk Score > 6 points (high-risk group) demonstrated a positive likelihood ratio (LR) of 3.22 in detecting the ruptured cases. The sensitivity and specificity of score in > 6 cutoff point was 43.8% (95%CI: 36.2, 51.6) and 86.4% (95%CI: 83.6, 88.9), respectively.

Conclusions

The RAMA-WeRA Risk Score can predict rupture in patients presenting with suspected acute appendicitis in the emergency department with total accuracy of 75% for high-risk cases.

AI in the ED: Assessing the efficacy of GPT models vs. physicians in medical score calculation

BACKGROUND AND AIMS

Artificial Intelligence (AI) models like GPT-3.5 and GPT-4 have shown promise across various domains but remain underexplored in healthcare. Emergency Departments (ED) rely on established scoring systems, such as NIHSS and HEART score, to guide clinical decision-making. This study aims to evaluate the proficiency of GPT-3.5 and GPT-4 against experienced ED physicians in calculating five commonly used medical scores.

METHODS

This retrospective study analyzed data from 150 patients who visited the ED over one week. Both AI models and two human physicians were tasked with calculating scores for NIH Stroke Scale, Canadian Syncope Risk Score, Alvarado Score for Acute Appendicitis, Canadian CT Head Rule, and HEART Score. Cohen's Kappa statistic and AUC values were used to assess inter-rater agreement and predictive performance, respectively.

RESULTS

The highest level of agreement was observed between the human physicians (Kappa = 0.681), while GPT-4 also showed moderate to substantial agreement with them (Kappa values of 0.473 and 0.576). GPT-3.5 had the lowest agreement with human scorers. These results highlight the superior predictive performance of human expertise over the currently available automated systems for this specific medical outcome. Human physicians achieved a higher ROC-AUC on 3 of the 5 scores, but none of the differences were statistically significant.

CONCLUSIONS

While AI models demonstrated some level of concordance with human expertise, they fell short in emulating the complex clinical judgments that physicians make. The study suggests that current AI models may serve as supplementary tools but are not ready to replace human expertise in high-stakes settings like the ED. Further research is needed to explore the capabilities and limitations of AI in emergency medicine.

Gene Expression Profiling in Pediatric Appendicitis

Importance

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

Objective

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

Design, Setting, and Participants

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

Exposure

SA, PA, or nonappendicitis abdominal pain.

Main Outcomes and Measures

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

Results

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

Conclusions

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

A case report on appendicular diverticulitis: Eluding traditional diagnosis

INTRODUCTION AND IMPORTANCE

Diverticula of the vermiform appendix are rare entities. Although the pathogenesis and natural course of appendiceal diverticulitis (AD) are different from acute appendicitis, AD is treated like acute appendicitis because of similar clinical manifestations and low incidence.

CASE PRESENTATION

We describe cases of two male patients of different ages who respectively underwent elective laparoscopic appendectomy and an emergent laparoscopic appendectomy in a multi-speciality hospital in Kerala, India. Both of them had acute appendicitis, as confirmed by imaging and laboratory testing. Subsequent histopathological examination revealed AD.

CLINICAL DISCUSSION

AD is an uncommon but potentially more serious form of appendiceal disease that can mimic acute appendicitis or malignancy. The first patient mimicked a malignancy with the mass presentation, while the second case presented like appendicitis. Unlike colonic diverticula, AD diverticula are typically not detectable by imaging or colonoscopy, which poses a diagnostic challenge.

CONCLUSION

In patients who present with lower abdominal pain or who may have appendicitis, AD should be considered as a differential diagnosis.

Complication analysis in acute appendicitis, results from an international multicenter study

PURPOSE

Acute appendicitis (AA) is frequent, its diagnosis is challenging, and the surgical intervention is not risk free. An accurate diagnosis will reduce unnecessary surgeries and associated risks. This study aimed to analyze the rate of appendectomies' postoperative complications.

METHODS

Multicenter, prospective, observational study conducted at three large hospitals (Pisa University Hospital, Italy; Henri Mondor University Hospital, Paris, France; and Valencia University Hospital, Spain).

RESULTS

A total of 3070 patients with a median age of 28 years (IQR 20-43) were enrolled. 1403 (45.7%) were females. Eight hundred ninety patients (29%) did not undergo preoperative imaging. Ultrasound and CT scans were performed in 1465 (47.7%) and 715 (23.3%) patients. Patients requiring CT scan were older [median 38 (IQR 26-53) vs. no imaging median 24 (IQR 16-35), Ultrasound median 28 (IQR 20-41); p < 0.0001]. Laparoscopic appendectomy was performed in 58.6%. Complications developed in 1279 (41.7%) patients: Clavien-Dindo grades I-II in 1126 (33.9%); Clavien-Dindo grades III-IV in 146 (5.2%). Overall mortality was 0.2%. Following resection of a normal appendix, 15% experienced major complications (Clavien-Dindo grades IIIb and above). Multivariable analysis revealed that age, Charlson comorbidity index, histopathology, and Alvarado score over 7 were associated with a higher risk of Clavien-Dindo complication grades IIIa and higher.

CONCLUSION

Appendectomy may be associated with serious postoperative complications. Complications were associated with older age, Charlson comorbidity index, histopathology, and high Alvarado scores. The definition of accurate diagnostic and therapeutic pathways may improve results. The association between clinical scores and radiology is recommended.

Pediatric Ultrasound Appendicitis Score for the Diagnosis of Acute Appendicitis to Reduce Computed Tomography Scan Utilization

BACKGROUND

Acute appendicitis is one of the most common reasons for pediatric surgical consultation in the emergency room. Although acute appendicitis is a clinical diagnosis, the use of imaging in the emergency department to assist with the diagnosis is very common. Ultrasound is frequently utilized in pediatrics because of the radiation risks associated with computed tomography (CT) scan. The risks of radiation in the pediatric population are much more significant than in adults. Reasons for this include smaller size so there is a relative higher radiation dose than for larger adults, radiosensitive organs such as thyroid, bone marrow, and gonads, and radiation exposure earlier in life allows for more time that a radiation induced cancer could develop. The risks of radiation from imaging are increased with cumulative dosing.

METHODS

The purpose of this study was to incorporate the pediatric appendicitis score (PAS) and standardized ultrasound scoring system to provide a combined score that would assist with the clinical diagnosis of acute appendicitis and avoid the need for a CT scan.

RESULTS

The presented data shows that for scores of 7 or more, the specificity and sensitivity is 90% and 90.2%, respectively for the diagnosis of acute appendicitis.

DISCUSSION

This study validates the combined score, shows the specific cutoffs, and initiates the discussion that CT scan may not always be required for diagnosing acute appendicitis if this scoring system is used.

Emergent Applications of Machine Learning for Diagnosing and Managing Appendicitis: A State-of-the-Art Review

Background: Appendicitis is an inflammatory condition that requires timely and effective intervention. Despite being one of the most common surgically treated diseases, the condition is difficult to diagnose because of atypical presentations. Ultrasound and computed tomography (CT) imaging improve the sensitivity and specificity of diagnoses, yet these tools bear the drawbacks of high operator dependency and radiation exposure, respectively. However, new artificial intelligence tools (such as machine learning) may be able to address these shortcomings. Methods: We conducted a state-of-the-art review to delineate the various use cases of emerging machine learning algorithms for diagnosing and managing appendicitis in recent literature. The query ("Appendectomy" OR "Appendicitis") AND ("Machine Learning" OR "Artificial Intelligence") was searched across three databases for publications ranging from 2012 to 2022. Upon filtering for duplicates and based on our predefined inclusion criteria, 39 relevant studies were identified. Results: The algorithms used in these studies performed with an average accuracy of 86% (18/39), a sensitivity of 81% (16/39), a specificity of 75% (16/39), and area under the receiver operating characteristic curves (AUROCs) of 0.82 (15/39) where reported. Based on accuracy alone, the optimal model was logistic regression in 18% of studies, an artificial neural network in 15%, a random forest in 13%, and a support vector machine in 10%. Conclusions: The identified studies suggest that machine learning may provide a novel solution for diagnosing appendicitis and preparing for patient-specific post-operative complications. However, further studies are warranted to assess the feasibility and advisability of implementing machine learning-based tools in clinical practice.

The Alvarado Score Is the Most Impactful Diagnostic Tool for Appendicitis: A Bibliometric Analysis

INTRODUCTION

The objective of this bibliometric analysis was to investigate the citation pattern of studies that have developed a diagnostic tool to diagnose appendicitis.

METHODS

We investigated characteristics of citations, publication frequency, evolution of citations, and fluctuation of previously highly cited studies. We analyzed which studies had been cited in the method section and identified impactful studies in this research field by a network visualization. We analyzed the differences in citations between diagnostic tools requiring a doctor to be present against the diagnostic tools not requiring doctors to be present, English language studies against non-English studies, and identified diagnostic tools targeting children.

RESULTS

There was an upward trend in publications in this research field, and between 1999-2021 the Alvarado score has been cited the most. In general, there was a high fluctuation, and 40 studies had been cited in the methods sections. There were significant differences in studies regarding diagnostic tools written in English compared to non-English studies, with more citations in the English-language studies. Furthermore, 22 studies had children as the target population.

CONCLUSIONS

The Alvarado score was the highest cited study since 1999, with 1086 citations, making it the most impactful study in this research field of diagnostic tools to diagnose appendicitis. Due to the diversity of target populations and settings for which diagnostic tools are developed, there is a need to expand research on diagnostic tools for appendicitis.

What is important to the GP in recognizing acute appendicitis in children: a delphi study

BACKGROUND

For diagnostic research on appendicitis in registration data, insight is needed in the way GPs generate medical records. We aimed to reach a consensus on the features that GPs consider important in the consultation and medical records when evaluating a child with suspected appendicitis.

METHODS

We performed a three-round Delphi study among Dutch GPs selected by purposive sampling. An initial feature list was created based on a literature search and features in the relevant Dutch guideline. Finally, using a vignette describing a child who needed later reassessment, we asked participants to complete an online questionnaire about which consultation features should be addressed and recorded.

RESULTS

A literature review and Dutch guideline yielded 95 consultation features. All three rounds were completed by 22 GPs, with the final consensus list containing 26 symptoms, 29 physical assessments and signs, 2 additional tests, and 8 further actions (including safety-netting, i.e., informing the patient about when to contact the GP again). Of these, participants reached consensus that 37 should be actively addressed and that 20 need to be recorded if findings are negative.

CONCLUSIONS

GPs agreed that negative findings do not need to be recorded for most features and that records should include the prognostic and safety-netting advice given. The results have implications in three main domains: for research, that negative findings are likely to be missing; for medicolegal purposes, that documentation cannot be expected to be complete; and for clinical practice, that safety-netting advice should be given and documented.

A Comparison of the Modified Alvarado Score and the Raja Isteri Pengiran Anak Saleha Appendicitis (Ripasa) Score in a Southeast Asian Population With Histopathology as the Gold Standard

Background The diagnosis of acute appendicitis has remained difficult despite it being one of the most common surgical emergencies in the world. One of the most frequently used scoring systems is the Modified Alvarado Score (MAS). However, the MAS has been known to be less efficient in Asian populations. To overcome this issue, the Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) score has been specifically developed to improve the diagnosis of acute appendicitis in Asian populations. This study aimed to evaluate the accuracy of the RIPASA score compared to the MAS for the diagnosis of acute appendicitis in a Southeast Asian population keeping histopathology as the gold standard. Methodology The study group comprised 150 patients. Data were collected from each patient using a simple proforma to ascertain both the MAS and the RIPASA score for each patient at the time of presentation. The patients then underwent open appendectomy and histopathology was used as the gold standard to determine the presence or absence of acute appendicitis in the excised specimens. Results The RIPASA score had a sensitivity and specificity of 89.83% and 59.38%, respectively, compared to 64.41% and 53.12%, respectively, for the MAS. Diagnostic accuracy was similarly higher for the RIPASA score at 83.33% versus 62.00% for the MAS. Conclusions The RIPASA score is superior to the MAS for the diagnosis of acute appendicitis. Using the RIPASA score instead of the MAS in Southeast Asian populations can lead to a more accurate and timely clinical diagnosis of patients with suspected acute appendicitis and help improve patient outcomes.

Retro-psoas appendicitis

The vermiform appendix (VA) is known to exhibit a wide range of anatomic variability, with clinical presentation correlating with certain known anatomic positioning. To the best of our knowledge, we describe the second known case of a retro-psoas muscle VA variant and the first known case of appendicitis in such a location. Retroperitoneal access was obtained, and the appendix was freed from the intermuscular recess between the psoas and iliacus. The peritoneal defect was primarily repaired, and the patient was discharged on postoperative day 1 in good condition.

Comparison of Pediatric Acute Appendicitis Before and During the COVID-19 Pandemic in New York City

Background: Acute appendicitis (AA) is the most common abdominal surgical emergency in children and adolescents. In the year immediately following the declaration of the coronavirus disease 2019 (COVID-19) pandemic by the World Health Organization (WHO), there was a precipitous decline in emergency department (ED) visits especially for surgical conditions and infectious diseases. Fear of exposure to severe acute respiratory coronavirus 2 infection resulted in delay in presentation and time to surgery, and a shift toward more conservative management. Objective: Our goal was to compare the incidence and severity of AA before and during the COVID-19 pandemic. Methods: Patients aged 2-18 years admitted with the diagnosis of AA to Flushing Hospital Medical Center or Jamaica Hospital Medical Center in Queens, New York, were selected for chart review. Data extracted from electronic health records included demographics, clinical findings, imaging studies, and operative and pathological findings. We calculated the Alvarado score (AS) for incidence and the American Association for the Surgery of Trauma (AAST) grade for severity. We compared patients admitted between March 1, 2018-February 29, 2020 (pre-pandemic) to patients admitted between March 1, 2020-February 28, 2021 (pandemic). We then compared pre-pandemic and pandemic groups to determine differences in pediatric AA incidence and severity. Results: Of 239 patients diagnosed with AA, 184 (77%) were in the pre-pandemic group and 55 (23%) in the pandemic group. Incidence (number per year) of AA declined by 40%. The pandemic group had significantly greater overall AS of ≥7, indicating increased likelihood to require surgery, (P = 0.04) and higher AAST grade demonstrating increased severity (P = 0.02). Conclusion: There was a decline in the number of AA cases seen in our pediatric EDs and admitted during the first year of the pandemic. Clinicians need to be aware of increased severity of AA at time of presentation during public health emergencies such as a pandemic, possibly due to modified patient behavior.

Validation of the modified Alvarado score on patients attending A&E units with suspected appendicitis

INTRODUCTION

The aim of our prospective study was to confirm validity and diagnostic accuracy of the modified Alvarado score, which was developed at the Department of Surgery, University of Szeged, on patients presenting with symptoms suggestive of acute appendicitis (right lower quadrant complaints) at the A&E department.

PATIENT POPULATION, METHODS

138 patients were included in our study between 01.01.2019 and 01.01.2020. For patients attending A&E, the first medic calculated and recorded the modified Alvarado score before surgical consultation. The consulting surgeon decided on further treatment without knowing the score. Validation of the score was based on the pathology report of the removed appendix (whether the operation was warranted, and if the score also supported indication for surgery), if there was readmission or surgery due to worsening symptoms after discharge from A&E. We also examined if there was any connection between the value of the Alvarado score and the severity of inflammation. Our aim was to prove that using modified Alvarado score at the A&E Units helps to reduce patient's waiting time and avoid unnecessary surgical consultations. Furthermore our study included measuring the diagnostic accuracy of the ultrasound examination (specificity, sensitivity).

RESULTS

Based on the results, patients presenting at A&E had a mean modified Alvarado score of 6.5. Comparing the score to histological results showed that the specificity of the modified Alvarado score was 100%, and its sensitivity was 80.7%. Based on Spearman's rank correlation (0.796) and ROC analysis (AUC 0.968), the modified Alvarado score has an excellent predictive value in diagnosing acute appendicitis. When comparing the patients' waiting times with the use of modified Alvarado score and without it we found that there was a significant difference in group also in group under 4 points and in group over 7 points when using modified Alvarado score, so the diagnostic and therapeutic algorithm should be much quicker with the help of the score. We found a correlation between the severity of inflammation based on the Fisher's exact test. Rank correlation of the same question also showed a significant connection. All patients had an US examination during their diagnostic course, its sensitivity was 82.6%, specificity was 87%. Based on this, we can conclude that the predictive value of the imaging method is good.

CONCLUSIONS

We can conclude according to our results that the predictive value of the modified score is excellent, and it can be safely applied by non-surgeons in urgent care in the differential diagnosis of acute appendicitis. The new score incorporates the results of an easily obtainable, ionising radiation free imaging method, the ultrasound, which was not included in previous scores. With the help of the new score, the number of unnecessary surgical referrals and waiting times for patients are reduced, excess examinations will become avoidable.

Appendicitis in Children

The management of pediatric appendicitis continues to advance with the development of evidence-based treatment algorithms and a recent shift toward patient-centered treatment approaches. Further research should focus on development of standardized institution-specific diagnostic algorithms to minimize rates of missed diagnosis and appendiceal perforation and refinement of evidence-based clinical treatment pathways that reduce complication rates and minimize health care resource utilization.

Adult appendicitis score versus Alvarado score: A comparative study in the diagnosis of acute appendicitis

Background

Acute Appendicitis (AA) is the most common abdominal surgical emergency. It requires proper management to decrease mortality and morbidity. Clinical scoring systems for diagnosing AA aimed to decrease the use of radiological scans and the rate of negative appendectomies (NA). We aim to assess the adult appendicitis score (AAS) in the diagnosis prediction of AA.

Method

A retrospective study with 1303 cases of AA is performed. We compared the correlation of AAS and Alvarado scores to postoperative histopathology. Specificity, sensitivity, Positive Predictive Value (PPV), and Negative Predictive Value (NPV) were assessed. ROC was used.

Results

AAS risk stratification was applied to the study population. Group I for a low probability, and groups II and III for an intermediate and high probability of AA. We found that 159 patients were matched in group I, 505, and 639 were in groups II and III of AAS, respectively. The correlation between Alvarado and AAS with HP was significant. AAS ≥ 16 presented sensitivity and specificity of 50 % and 75.47 %, respectively, with PPV of 97.96 % and NPV of 6.02 %, with an accuracy of 51.04 %. Regarding AAS ≥ 11, the sensitivity was 88.96 %, specificity was 39.62 %, PPV was 97.2 %, NPV was 13.21 %, and accuracy was 86.95 %.

Conclusion

AAS is relatively more accurate than Alvarado's score, especially in selecting a safe candidate for discharge from an emergency. In addition, AAS is found to decrease the need for radiological images and NA rate more than Alvarado.

Referrals for Pediatric Appendicitis to a Tertiary Care Children's Hospital

OBJECTIVES

This study aimed to analyze pediatric referrals for definite or possible appendicitis, to compare clinical predictors and laboratory values between patients with and without a final diagnosis of appendicitis, and to determine the accuracy of prereferral diagnostic interpretations of computed tomography scans, ultrasound, and magnetic resonance imaging modalities.

METHODS

We conducted a retrospective analysis of pediatric patients referred from 2015 to 2019 to a tertiary care children's emergency department with definitive or possible appendicitis. Data abstracted included patient demographics, clinical symptoms, physical examination findings, laboratory results, and diagnostic imaging findings (by the referring center and the pediatric radiologist at the accepting center). An Alvarado and Appendicitis Inflammatory Response (AIR) score was calculated for each patient.

RESULTS

Analysis was performed on 381 patients; 226 (59%) had a final diagnosis of appendicitis. Patients with appendicitis were more likely to have symptoms of nausea ( P < 0.0001) and vomiting ( P < 0.0001), have a higher mean temperature ( P = 0.025), right lower quadrant abdominal pain to palpation ( P = <0.0001), rebound tenderness ( P < 0.0001), a higher mean Alvarado score [5.35 vs 3.45 ( P < 0.0001)], and a higher mean AIR score [4.02 vs 2.17 ( P < 0.0001)]. Of the 97 diagnostic images initially interpreted as appendicitis by the referring center, 10 (10.3%) were read as no evidence of appendicitis. Of the 62 diagnostic images initially interpreted as "possible appendicitis" by the referring center, 34 (54.8%) were read as no evidence of appendicitis. Of those diagnostic images initially interpreted as "appendicitis" or "possible appendicitis" by the referring center, 24/89 (27.0%) of computed tomography scans, 17/62 (27.4%) of ultrasounds, and 3/8 (37.5%) of magnetic resonance imaging results were read as no evidence of appendicitis.

CONCLUSIONS

Usage of established scoring algorithms, such as Alvarado and AIR, may decrease the unnecessary cost of diagnostic imaging and transfer to tertiary care. Virtual radiology consultations may be 1 potential solution to improve the referral process for pediatric appendicitis if initial interpretation is uncertain.

Implementation of ultrasound and fast magnetic resonance imaging pathway reduces computed tomography utilization in children with suspected appendicitis

PURPOSE

Computed tomography (CT) is still used in the imaging diagnosis of acute appendicitis in children at many hospitals. We implemented an ultrasound (US) and fast magnetic resonance imaging (MRI) pathway for suspected appendicitis at our institution with the goal of reducing radiation exposure in children.

METHODS

All children (< 18 years old) who underwent appendectomy between January 2011 and July 2021 were reviewed. Data were collected on all imaging studies performed. In December 2015, we initiated an imaging pathway for suspected acute appendicitis. US was the initial imaging study, and a rapid protocol MRI was performed if US was equivocal. Those could not tolerate MRI underwent CT. We evaluated the difference in percentage of patients who underwent CT before and after pathway initiation.

RESULTS

554 patients who underwent appendectomy did not have prior imaging studies on presentation to our hospital and were included in analysis. After initiating the pathway, the use of abdominal US increased from 87% (220 of 254) to 97% (291 of 300, p < 0.0001) and the use of MRI increased by 100% (0 MRIs pre-protocol, 90 of 300 patients post-protocol, p < 0.0001). CT utilization decreased significantly from 32% (82 of 254) to 2% (6 of 300, p < 0.0001).

CONCLUSION

Embracing a new US and rapid MRI pathway to evaluate pediatric patients with suspected acute appendicitis resulted in significant reduction in CT utilization and therefore radiation exposure.

Diagnosis of Acute Appendicitis: A Cross-sectional Study on Alvarado's Score from a Low Income Country

Background

Alvarado score is the most widely used scoring system for diagnosing acute appendicitis, globally. There have been concerns regarding the diagnostic accuracy of this score as it was shown to have lower sensitivity in certain populations like Blacks and Asians. Despite its wide clinical use in the Ethiopian set up, the diagnostic accuracy of this score remained largely unexamined in this population.

Methodology

A prospective cross-sectional study was conducted and all adult patients who presented with right lower quadrant abdominal pain and evaluated with a clinical impression of acute appendicitis were enrolled in the study. Data was collected by trained surgical residents over a period of six months (August 2019- January 2020) and analysed using SPSS version 25.

Results

A total of 235 patients were enrolled in this study among whom two thirds were males. The majority of the study participants (61.7%) had an Alvarado score of ≥7 while almost a quarter of them had a score of <4. The mean Alvarado score in this study was 7 ± 1.8 whereas the median and the mode were 7 and 9 respectively. The overall sensitivity, specificity, positive predictive value and negative predictive value of Alvarado score were 99.1%, 55.6%, 98.2% and 62.5% respectively. The sensitivity and specificity of this score was superior in males compared to females (99.3% vs 97.6% and 80% vs 25%). A score of ≥5 was found to have a sensitivity of 98.4%.

Conclusion

Alvarado score was found to have good sensitivity and positive predictive value in this study. A score of ≥5 can be used to "rule in" the diagnosis of acute appendicitis. Hence, the use of Alvarado score's in the Ethiopian setup is to be encouraged.

Accuracy of emergency physician bedside ultrasonography compared with private teleradiologist for acute appendicitis diagnosis

BACKGROUND

Acute appendicitis (AA) is a common cause of abdominal pain resulting in admission to the emergency room. Imaging methods such as ultrasonography and CT are usually used for diagnosing acute appendicitis. Reports regarding CT scans conducted during night shifts are prepared by private teleradiologists.

AIMS

The aim of this study was to compare the accuracy of point-of-care ultrasound performed by an emergency medicine specialist and private teleradiologists in the diagnosis of AA.

METHODS

This study was conducted prospectively and in a single center in the emergency department of a tertiary hospital. Patients who were admitted to the study between 15.09.2020 and 15.09.2021 and were diagnosed with AA who met the study criteria were included. A total of 134 patients diagnosed with AA, who met the inclusion criteria, out of 158 operated patients were included in the study.

RESULTS

In the study, 77 were male and 57 were female. The mean age of patients with histopathologically positive AA was 31 and 31.5 in negative patients. The sensitivity and specificity of POCUS performed by the emergency physician and private teleradiology for the diagnosis of AA were 78.4% and 59.3% and 58.8% and 53.1%, respectively.

CONCLUSIONS

POCUS performed by an emergency medicine specialist showed a higher sensitivity for the diagnosis of AA compared with private teleradiology. Hence, POCUS is more successful in diagnosing AA than private teleradiology. In conclusion, we recommend the concurrent use of AS and POCUS in emergency departments rather than private teleradiology for the diagnosis of AA.

An Ovarian Teratoma Mimicking Complicated Acute Appendicitis: A Case Report and Literature Review

Acute appendicitis is one of the most common causes of right iliac fossa (RIF) pain in the younger population. However, multiple other pathologies presenting with RIF pain can mimic acute appendicitis. In the female gender, the differentials for RIF pain are broader. Multiple pathologies can present with similar symptomatology that can mimic acute appendicitis, leading to an incorrect diagnosis, unnecessary surgical interventions, and complications. In females of reproductive age, gynaecological causes can present similarly. Here, we present a case of an ovarian teratoma mimicking acute complicated appendicitis. A female of reproductive age presented to our hospital with RIF pain of six days, associated with fever, nausea, vomiting, and anorexia. A clinical diagnosis of acute complicated appendicitis was suspected, and further imaging was arranged to confirm the diagnosis. Imaging showed a normal appendix with a right adnexal mass separated from the ovary, representing a teratoma. She underwent elective surgery for the excision of teratoma after further investigations. Ovarian teratomas are not a common mimicker of appendicitis. One should consider possible gynaecological causes as a differential for RIF pain. Due to the wide variety of differentials, when in doubt, especially in the female gender, further imaging should be considered for confirmation of diagnosis.

An Occlusive Form of Acute Gangrenous Appendicitis With Periappendicular Abscess in an Elderly Patient: A Case Report and Literature Review

Acute appendicitis represents one of the common causes of admission to the emergency department. In rare cases, patients with appendicitis can suffer complications such as intestinal obstruction. These particular cases of occlusive appendicitis with a periappendicular abscess usually occur in elderly patients and can develop in an aggressive form, nonetheless with a favorable evolution. We present a case of an 80-year-old male patient, reporting symptoms similar to an occlusive digestive pathology: abdominal pain, intestinal transit disorders, and fecal vomiting. A computerized tomography scan suggested a mechanical bowel obstruction. The patient had an exploratory laparotomy indication to find the cause of the obstruction. The peritoneal cavity inspection revealed an occlusive form of acute gangrenous appendicitis with a periappendicular abscess. An appendectomy was performed. In conclusion, as surgeons, we must always take into consideration that acute appendicitis can represent a cause of intestinal obstruction, especially in elderly patients.

Pediatric Appendicitis Transfers From Adult Centers: Can Alvarado Scores Help Determine Which Patients Need a CT?

BACKGROUND

Acute appendicitis is possible for any pediatric patient with abdominal pain. At our tertiary care center, patients are transferred for surgical management with unnecessary or excessive imaging. We hypothesize that using the Alvarado score (AS) to clinically stage patients will identify patient groups that could be transferred prior to imaging.

METHODS

Retrospective review of pediatric patients transferred to our hospital for suspected appendicitis between 11/2020 and 3/2022 was performed. Variables collected included AS, imaging, and pathology. Alvarado score was calculated for each patient, and patients were grouped into low score, intermediate score, and high score groups. Positive predictive values (PPVs) were calculated for patients who underwent CT.

RESULTS

196 patients (age 2-17, 58% male) were transferred with suspected appendicitis. CT was obtained in 67% of patients and was not significantly different between groups. The low-score group (n=35) had a rate of appendicitis of 14% and the PPV of CT was 33%. The intermediate-score group (n = 74) had a rate of appendicitis of 62% and the PPV of CT was 88%. In the high-score group (n = 87), the rate of appendicitis was 92% and PPV of CT was 98%.

DISCUSSION

Our data show that patients with low, intermediate, and high AS undergo CT at similar rates. We suggest that patients in the low score and high score groups may not benefit from reflexive CT given the likelihood of appendicitis based on the Alvarado score. We propose that CT in these groups be performed at the discretion of the pediatric center in order to expedite transfer and spare children excess radiation.

A systematic review and meta-regression for validation of the Alvarado score as a tool for predicting acute appendicitis

The Alvarado score (AS) has not been widely used for diagnosing acute appendicitis although it has shown to be a good predictor for diagnosing appendicitis. The aim was to perform a systematic review of the available literature and synthesize the evidence.

Methods

A systematic review was performed as per the PRISMA guidelines using search engines like Ovid, PubMed, and Google Scholar with predefined, strict inclusion and exclusion criteria. The quality assessment of included studies was performed using the QUADAS 2 tool. Summary statistics were performed for all variables. A linear regression model was performed between dependent and independent variables using STATA software. Heterogeneity testing showed significant heterogeneity within the included studies; hence, a forest plot with pooled estimates could not be constructed, and therefore a meta-regression was performed.

Results

Seventeen full-text articles met inclusion and exclusion criteria. Ten of which were identified as low-risk studies. Five studies were included in final data pooling with total patients being 2239 and mean age of 31.9 years. (1) Linear regression demonstrated an association between 'histological appendicitis' and 'AS 7-0' with patients receiving intervention, with a significant P value of less than 0.005. (2) Meta-regression demonstrated a positive coefficient (0.298), a positive Z score of 2.20 with a significant P value of 0.028 for patients with 'high AS' who received interventions that were significantly proven to be 'histologically appendicitis', indicating a cause-and-effect relationship.

Conclusion

High AS (7 and above) is a significant predictor of acute appendicitis. The authors recommend further prospective randomized clinical trials to establish a cause-and-effect relationship.

Alvarado or RIPASA? Which one do you use to diagnose acute appendicitis?: A cross-sectional study

Background and Aims

Acute appendicitis is one of the most common causes of lower abdominal pain, which is considered a general surgical emergency worldwide. The present study aimed to compare the diagnostic value of Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) and Alvarado score systems in diagnosing acute appendicitis.

Methods

A prospective cross-sectional study was conducted at Shahid Sadoughi and Shahid Rahnemoon Hospitals in Yazd between September 2020 and February 2020. The statistical population consisted of all of the patients referred to the Accident and Emergency department with right iliac fossa (RIF) pain. All patients were scored using Alvarado and RIPASA scoring system. sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were computed by using SPSS statistical software. An receiver operating characteristic curve were plotted.

Results

In present study, one hundred suspected patients with appendicitis who underwent appendectomy were evaluated. The mean age of our study population was 25.2 ± 12.1 years, and the gender distribution was 57% males and 43% females. The sensitivity, specificity, PPV and NPV of RIPASA were 86.6%, 66.7%, 92.2%, and 52.2%, respectively. The sensitivity, specificity, PPV and NPV of Alvarado score were 67.1%, 72.2%, 91.7%, 32.5%, respectively. The diagnostic accuracy was 68% for Alvarado score and 83% for RIPASA. The area under the curve for RIPASA (0.87) was more than that for Alvarado score (0.77).

Conclusion

The RIPASA score system had higher sensitivity, PPV, NPV, and accuracy than the Alvarado one. It is recommended for the physician and surgeon to evaluate patients with RIF pain using the RIPASA score.

A novel Appendicitis TriMOdal prediction Score (ATMOS) for acute appendicitis in pregnancy: a retrospective observational study

Several scoring systems exist for the management of acute appendicitis (AA) during pregnancy. However, the systems are based on the nonpregnant adult population. The aim of this study was to create a highly accurate scoring system that can be applied to pregnant women and to compare it to the most commonly used scores in general population and pregnant women. The creation and subsequent implementation of a highly accurate score system could shorten the diagnostic period and minimize the use of (ionizing) diagnostic imaging allowing the selection of the best treatment approach in pregnant patients with acute appendicitis. A single-center, retrospective cohort observational study was conducted at the University Hospital Centre Zagreb, Zagreb, Croatia. Data were extracted from medical records of pregnant patients with suspected AA from January 2010 to December 2020. A total of 59 pregnant patients diagnosed with AA during pregnancy were identified, 41 were treated surgically, and 18 had non-surgical management. The main objective of our study was the detection of predictive factors of AA during pregnancy. Anorexia, pain migration to the right lower quadrant, rebound pain, axillary temperature over 37.3 °C, CRP/platelet ratio > 0.0422, neutrophil/lymphocyte ratio > 7.182, and ultrasonic signs of AA were scored. Scoring in Appendicitis TriMOdal Score (ATMOS) consists of positive clinical parameter, each bringing 1 point and other parameters mentioned above that bring 2 points each. The score ranges from 0 to 10. Our model of ATMOS yields a high area under the receiver-operating characteristic curve of 0.963. The positive likelihood ratio is 9.97 (95% CI 2.64-38.00), and the negative likelihood ratio is 0.1 (95% CI 0.03-0.31), meaning that 94% of cases with ATMOS > 4 have AA, while less than 13% with an ATMOS ≤ 4 have the diagnosis of AA. The potential of ATMOS differentiating AA during pregnancy was demonstrated. Future prospective, randomized trials are needed to evaluate its accuracy and whether it should be used instead of Alvarado or Tzanakis scores in clinical decision-making.Trial registration number ClinicalTrials.gov-NCT05202483. Date of registration: January 21, 2022.

Negative appendectomy rate in patients diagnosed with acute appendicitis

BACKGROUND

Acute appendicitis is the most common cause of acute lower abdominal pain leading patients to the emergency department. This study aims to find the negative appendectomy rate in patients diagnosed with acute appendicitis from 2015 to 2019.

METHODS

This study was a retrospective cohort study in the patients preoperatively diagnosed with acute appendicitis and underwent appendectomy from January 2015 to December 2019. Negative appendectomy is defined as the final pathologic results confirmed normal, congestion or peri-appendicitis.

RESULTS

The study population was 892 patients which was 54.3% female. The five-year negative appendectomy rate was 8.6% (n = 77) and 70% in female (n = 54). The factors associated with increasing the negative appendectomy rate were female (OR 2.23, P = 0.003), age ≤ 40 years old (OR 2.35, P = 0.003), and no history of diarrhea (OR 2.42, P = 0.017). Whereas the factors related to decline in the negative appendectomy rate were white blood cell count (WBC) [Formula: see text] 10,000 (OR 0.39, P = 0.016), neutrophil (N) [Formula: see text] 75% (OR 0.28, P < 0.001), and positive appendicitis from ultrasonography of abdomen (OR 0.04, P < 0.001) or computed tomography of abdomen (OR 0.07, P < 0.001).

CONCLUSION

The negative appendectomy rate was less than 10% in this study. Female, age 40 ≤ years old and history of diarrhea were related to increase in negative appendectomy. The factors that related to decline in negative appendectomy were leukocytosis with cells shift to the left, positive acute appendicitis from abdominal ultrasonography and CT scan. However, to request the further imaging studies to diagnose patients with suspected acute appendicitis depends on the risk and benefit to each patient and the choice of investigation.

Valentino's syndrome: A rare and lethal differential diagnosis for acute appendicitis

Due to the rarity of the condition, Valentino’s syndrome is an underrated differential diagnosis for acute appendicitis. We describe a patient with Valentino’s syndrome in whom preoperative and intraoperative diagnoses were challenging due to misleading clinical, investigative, and morphological findings. A 31-year-old woman who was on methylprednisolone for sensory radiculopathy presented to the emergency department with acute right lower quadrant pain. The clinical diagnosis of acute appendicitis was supported by the elevated inflammatory markers and ultrasonographic findings. An appendicectomy and an ovarian cystectomy were performed due to the findings of mild appendicitis and right ovarian endometrioma, respectively. Postoperatively, she developed peritonitis with a purulent bile-stained discharge from the surgical site and per vagina. Contrast-enhanced computed tomography of the abdomen showed a retroperitoneal collection at the second lumbar vertebral level extending along the right paracolic gutter to the pelvis and intraperitoneal fluid collections in right lower quadrant and pelvis. An emergency exploratory laparotomy confirmed a perforation at the posterior aspect of the duodenum which was repaired with an omental patch. Unfortunately, relaparotomy and end ileostomy were required due to colonic perforation with the eroded drain tube. She made an uneventful recovery with intensive care and underwent ileostomy reversal after 12 weeks. We emphasize the clues to have a high degree of suspicion during preoperative and intraoperative evaluation to recognize this lethal mimicker of acute appendicitis.

Impact of the coronavirus disease 2019 (COVID-19) pandemic on the presentation of paediatric acute appendicitis: an observational study

Aim

To determine whether there were differences in the clinical presentation of patients imaged to evaluate for acute appendicitis in 2020 compared to 2019 with the hope that this information might better identify patients who should undergo imaging work-up and those who should not.

Materials and methods

This retrospective observational study included patients <18 years who were evaluated for appendicitis between 1 March and 31 May 2019 and 2020. A total of 465 patients were stratified by final diagnosis (appendicitis versus not appendicitis) and compared based on presenting symptoms, physical examination findings, vital signs, and laboratory test results.

Results

Symptoms and physical examination findings that were significant in the positive cohort in both years included right lower quadrant pain, pain with movement, migration of pain, right lower quadrant tenderness, and peritoneal findings. Reporting upper respiratory symptoms was an independent predictor of negative results among all patients and in 2019. Both negative cohorts were more likely to have negative physical examinations. Anorexia and nausea/vomiting were more likely among positive cases in 2019 whereas diarrhoea was more likely among positive cases in 2020.

Conclusions

The COVID-19 pandemic did not significantly change the presenting features of acute appendicitis. The results of the present study emphasise the importance of the physical examination. The ambiguity of symptoms that mimic gastroenteritis justifies imaging in these patients.

Diagnostic accuracy of Alvarado scoring system relative to histopathological diagnosis for acute appendicitis: A retrospective cohort study

Background

Acute appendicitis (AA) is a surgical emergency that requires prompt diagnosis and suitable management. It may lead to complications resulting in mortality. To evaluate the diagnostic accuracy of the Alvarado scoring system (ASS) for acute appendicitis concerning histopathological data.

Methodology

About 120 patients were selected for this study consisting of 96 males and 24 females age between 20 and 60. Alvarado scoring system is calculated for each patient after collecting data about demographics, laboratory findings, and clinical examination. Then, we compared it with histopathological diagnosis taking it as a gold standard. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. SPSS version 20 was used for analyzing the data.

Results

About 120 patients were included in our study. The male to female ratio was 3:1. Sensitivity and specificity were 83.3% and 41% respectively. While PPV and NPV were 85% and 41% respectively. The negative appendectomy rate was 21%. The area under the curve for receiving operating characteristics is 0.628.

Conclusion

ASS is a useful diagnostic tool regarding sensitivity and positive predictive value, especially in developing countries. It is cheap, reliable, and can be easily applied.

•

We evaluated the diagnostic accuracy of the Alvarado scoring system (ASS) for acute appendicitis.

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Sensitivity and specificity were 83.3% and 41%.

•

While PPV and NPV were 85% and 41% respectively.

Clinical, Radiological and Pathological Appraisal of Acute Appendicitis in Al Qassim, Saudi Arabia: A Single-Center Retrospective Analysis

Background

Acute appendicitis can occur at any age but is rare among people of extreme age; it is more common in teenagers and young adults. Traditionally diagnosis is made on clinical grounds. In recent times imaging techniques have been deployed to improve diagnosis and reduce negative appendicectomy rates. The aim of the study was to describe the common clinical features of acute appendicitis among our patients, highlight the role of medical imaging, and compare all these with the histological report of the excised appendix.

Methods

A 24-months retrospective review of all patients who underwent appendicectomy (July 1, 2019-June 30, 2021) for suspected acute appendicitis was performed. Medical records numbers of patients who had appendicectomies were retrieved from the operating room register. These numbers were used to access the hospital's electronic medical records database for the patients' records. These records were reviewed for biodata, clinical features, laboratory, medical imaging findings, and histological reports.

Result

In this hospital, 354 appendicectomies were performed. Only 336 had complete data set suitable for further review. There were more males (N=257; 76.5%) than females (N=79, 23.5%), yielding a male to female ratio of 4:1. There were also more Saudi citizens (n=266, 79.2%), with the predominant age group being 11-30 years. Abdominal pain was the predominant symptom (100%) and was localized to the right iliac region in 331 (98.7%) of patients. Other symptoms recorded were anorexia (n=247, 73.5%), vomiting (n=190, 56.5%), and nausea (n=93, 27.7%). Atypical symptoms included diarrhoea (n=27, 8%) and constipation (n=12, 3.6%). Acute appendicitis, complicated appendicitis, and no appendicitis were the reported histological disposition in 174 (51.8%), 124 (36.9%), and 38 (11.3%) cases respectively. Abdominal CT scan had a higher sensitivity (98.6% vs 70.5%), higher diagnostic odd ratio (2.5 vs 1.4) and a lower miss (false negative) rate (1.4% vs 29.5%) compared to ultrasonography. However, the CT scan, from this study, has a rather low specificity (3.4%) and high false positive rates (96.5%). Open (n=205; 61%) and laparoscopic (n=131;39%) approaches were used for the appendicectomies. In our study, 44 patients were diagnosed with the decision to operate based on clinical grounds; and of this, 42 (95.4%; n=44) had confirmatory histology reports of appendicitis. Also, 38 patients had negative appendicectomy; giving a negative appendicectomy rate of 11.3%. This high rate may be due to the lower specificity and high false positive rate observed in this study. The post-operative complication rate was 21.4%, and this was solely due to surgical site infection, and this was more common with the open approach (p=0.001).

Conclusion

Suspected acute appendicitis was the sole indication for our appendicectomies. A computerized tomography scan was a more reliable diagnostic tool than ultrasonography. Despite the fact that acute appendicitis is majorly a clinical diagnosis, and good clinical acumen is an excellent skill in the management of patients, we observed an overreliance on medical imaging for diagnosis. Open appendicectomies were more common, and surgical site infection was the sole complication of surgery. There was a relatively high negative appendicectomy rate for an image-assisted diagnosis.

The Role of Alvarado Score in Predicting Acute Appendicitis and Its Severity in Correlation to Histopathology: A Retrospective Study in a Qatar Population

Background/objective

Acute appendicitis (AA) is one of the most common surgical emergencies that require a proper diagnosis to avoid a negative outcome in the case of missed or delayed diagnosis. Our study aims to assess the diagnostic power of the Alvarado score and the prediction of the severity of acute appendicitis in correlation to intraoperative findings and the final histopathology (HP) result.

Methods

This retrospective study was applied to 1,303 patients with clinically proven acute appendicitis (AA) and available HP results. We correlated Alvarado score to the gold standard HP and intraoperative findings. We selected the cutoff point of Alvarado at 5 and 7 as they were the most frequent cutoff value mentioned in the literature and based on the ROC curve in this study to assess sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV).

Results

The mean age of the study cohort is 33.3 ± 9.5 years, with a male predominance (75.8%). The negative appendectomy (NA) rate was 4%. The operative complication rate was 1.2%, and we recorded one mortality case (0.1%). The diagnostic evidence of AA was in 95.9% of cases. Alvarado score ≥ 7 presented sensitivity and specificity of 66.4% and 69.8%, respectively, with PPV of 98.1% and NPV of 8.1%, with an accuracy of 66.5%. For Alvarado score ≥ 5, the sensitivity was 91.2%, specificity was 22.6%, PPV was 96.5%, NPV was 9.8%, and accuracy was 88.4%. In addition, we demonstrated statistical significance between Alvarado risk stratification with HP and intraoperative grades (p = 0.001 each).

Conclusion

The Alvarado scoring system alone is not enough to diagnose AA with unsatisfactory sensitivity and specificity. However, it is a good indicator of the severity of AA that we can depend on to prioritize those patients waiting for surgery.

Comparison of Appendicitis Inflammatory Response (AIR) and Lintula scoring systems in diagnosing acute appendicitis among children

Appendectomy is still the best treatment for acute appendicitis in pediatric patients. Given the problems of early and immediate diagnosis of acute appendicitis, defining the best diagnostic protocol for this condition is of utmost importance. Different diagnostic methods, such as Lintula and appendicitis inflammatory response (AIR) scoring systems, are used for this purpose. This study aims to compare Lintula and AIR scoring systems among children with suspicion of acute appendicitis regarding their postoperative outcomes. During two years, a prospective multicentric study was carried out in the selected hospitals of Iran. Pediatric patients admitted with the diagnosis of acute appendicitis were enrolled in the study. Before decision making, each patient's score was calculated according to two appendicitis scoring systems of Lintula and AIR. The clinical outcomes and diagnosis of patients were then compared to the results of each scoring system. For those patients who were a candidate to undergo surgery, the final diagnosis of acute appendicitis was made by histopathology. Patients were divided into high and low-risk groups according to scoring systems outcomes. Among the patients with lower scoring for appendicitis, the AIR scoring system had a sensitivity and specificity of 95%, which was more promising than that of the Lintula system (19%); however, the specificity was comparable between the two models (74% vs. 83%). For patients at higher risk of acute appendicitis, although the AIR scoring systems did not provide reliable results (sen: 45% and spe: 25%), the Lintula scoring showed remarkable sensitivity (87%), accompanied by a high diagnostic accuracy (87%). AIR and Lintula scoring systems are not accurate models to predict the risk of acute appendicitis among children; therefore, they can serve as an adjacent modality for other diagnostic methods.

Performance optimization of support vector machine with oppositional grasshopper optimization for acute appendicitis diagnosis

Preoperative differentiation of complicated and uncomplicated appendicitis is challenging. The research goal was to construct a new intelligent diagnostic rule that is accurate, fast, noninvasive, and cost-effective, distinguishing between complicated and uncomplicated appendicitis. Overall, 298 patients with acute appendicitis from the Wenzhou Central Hospital were recruited, and information on their demographic characteristics, clinical findings, and laboratory data was retrospectively reviewed and applied in this study. First, the most significant variables, including C-reactive protein (CRP), heart rate, body temperature, and neutrophils discriminating complicated from uncomplicated appendicitis, were identified using random forest analysis. Second, an improved grasshopper optimization algorithm-based support vector machine was used to construct the diagnostic model to discriminate complicated appendicitis (CAP) from uncomplicated appendicitis (UAP). The resultant optimal model can produce an average of 83.56% accuracy, 81.71% sensitivity, 85.33% specificity, and 0.6732 Matthews correlation coefficients. Based on existing routinely available markers, the proposed intelligent diagnosis model is highly reliable. Thus, the model can potentially be used to assist doctors in making correct clinical decisions.

Heart Rate Variability May Predict the Severity of Appendicitis: A Cross-Sectional Study

OBJECTIVE

To evaluate the role of heart rate variability (HRV) in predicting pre-operative severity of appendicitis.

METHODS

In this cross-sectional study, 171 cases of acute appendicitis who underwent appendectomy were enrolled. Pre-anesthetic pulse rate of included patients were documented while the severity of appendicitis was determined by intra-operative evidences reported by two independent surgeons. Demographic characteristics, laboratory variables, and Alvarado criteria were recorded.

RESULTS

The mean age of patients was 28.75±4.21 years; 54% were men. HRV negatively associated the severity of appendix inflammation. A positive association was found between HRV and omental wrapping and Alvarado score (p<0.01). The receiver operating characteristic (ROC) curve analysis demonstrated that HRV could differentiate simple and complicated appendicitis with a sensitivity of 78.5% and specificity of 97.2%.

CONCLUSION

The present findings revealed that HRV may predict the pre-operative severity of appendicitis and help differentiate simple and complicated appendicitis.

Effect of the Movement Control Order on the Incidence of Complicated Appendicitis During the COVID-19 Pandemic: A Cross-Sectional Study

Background

Appendicitis is common and delayed presentation results in complicated appendicitis with increased morbidity. This study investigates the effect of the Movement Control Order (MCO) during the COVID-19 pandemic on the presentation and severity of appendicitis.

Methods

A cross-sectional study including 193 patients diagnosed with appendicitis was conducted at four hospitals in Pahang, Malaysia. Those who presented between 1 February 2020 and 17 March 2020 were included in the pre-MCO group and those between 18 March 2020 and 30 April 2020 in the MCO group. The definitions of simple and complicated appendicitis were based on the Sunshine Appendicitis Grading Score. The primary outcome was the incidence of complicated appendicitis, and the secondary outcomes were length of stay, a composite of surgical morbidities and a composite of organ failure.

Results

A total of 105 patients in the pre-MCO group and 88 in the MCO group were analysed. The incidence of complicated appendicitis was 33% and it was higher in the MCO than in the pre-MCO group (44% versus 23%, P = 0.002). The MCO period was independently associated with complicated appendicitis in the logistic regression (P = 0.001). It was also associated with prolonged length of stay (3.5 days versus 2.4 days, P < 0.001) and higher overall surgical morbidity (19% versus 5%, P = 0.002).

Conclusion

The MCO imposed during the COVID-19 pandemic was associated with a higher incidence of complicated appendicitis and surgical morbidity.

Diagnostic Accuracy of Suspected Appendicitis: A Comparative Analysis of Misdiagnosed Appendicitis in Children

OBJECTIVE

When evaluating suspected appendicitis, limited data support quality benchmarks for negative appendectomy (NA); none exist for delayed diagnosis of appendicitis (DDA). The objectives of this study are the following: (1) to provide preliminary evidence supporting a quality benchmark for DDA and 2) to compare presenting features and diagnostic evaluations of children with NA and DDA with those with pathology-confirmed appendicitis (PCA) diagnosed during initial emergency department (ED) encounter.

METHODS

Secondary analysis of data from a QI project designed to reduce the use computed tomography when evaluating suspected appendicitis using a case-control design. Patients undergoing appendectomy in an academic tertiary care children's hospital system between January 1, 2015, and December 31, 2016 (n = 1,189) were eligible for inclusion in this case-control study. Negative appendectomy was defined as no pathologic change or findings consistent with a different diagnosis. Delayed diagnosis of appendicitis was defined as patients undergoing appendectomy within 7 days of a prior ED visit for a related complaint. Controls of PCA (n = 150) were randomly selected from all cases undergoing appendectomy.

RESULTS

There were 42 NA (3.5%) and 31 DDA (2.6%). Cases of PCA and NA exhibited similar histories, examination findings, and underwent comparable diagnostic evaluations. Cases of PCA more frequently demonstrated a white blood cell count greater than 10 × 103/μL (85% vs 67%; P = 0.01), a left-shift (77% vs 45%; P < 0.001), and an ultrasound interpretation with high probability for appendicitis (73% vs 54%; P = 0.03). Numerous significant differences in history, examination findings, and diagnostic tests performed existed between cases of PCA and DDA.

CONCLUSIONS

Children with PCA and NA present similarly and undergo comparable evaluations resulting in appendectomy. A 3% to 4% NA rate may be unavoidable given these similarities. Presenting features in DDA significantly differ from those of PCA. An irreducible proportion of appendicitis diagnoses may be delayed.

Sensitivity and specificity of the Alvarado Score for the timely differential diagnosis of acute appendicitis for a case series in Samoa

Background

Timely diagnosis of acute appendicitis (AA) is essential for optimal management of abdominal pain emergency presentations. Improved diagnostic procedures should minimise progression to complicated appendicitis, as well as reduce the number of unwanted surgical interventions. The Alvarado Score is an important tool to assist with the management of AA based on clinically predictive values. The aim of the present study was to evaluate the sensitivity and specificity of the Alvarado Score as an instrument for the diagnosis of AA in our low-resourced context of Samoa.

Materials and methods

The lead investigator performed a retrospective clinical data review design of all patients admitted to the Tupua Tamasese Meaole Hospital Surgical Unit for AA from January 2015 to December 2016. Exclusion criteria were appendiceal abscess and/or mass, and final diagnosis ‘not acute appendicitis’. Age, sex, village, Alvarado Score, Ultrasound Scan Result, surgical management, and histopathology result were the main variables entered into the SPSS statistical software package for analysis.

Results

Of the 225 patients (2–86 years) admitted for AA, 67.1% (N = 151) underwent appendicectomy, and the remaining 32.9% (N = 74) were treated with antibiotics. An Alvarado Score (≥5) showed 91.7% sensitivity and 50% specificity for AA. There was a significant relationship between the Alvarado Score and the Ultrasound Scan for AA (p < 0.05). Histology results showed complicated AA in 68.6% (N = 94) of cases. The negative appendicectomy rate was 2.6%.

Conclusions

The Alvarado Score is an effective tool for the timely differential diagnosis of AA in our Samoan context. The high rate of complicated acute appendicitis warrants investigation to further improve the management of AA in the Pacific Island setting.

•

Effective instrument required for the timely diagnosis of appendicitis in low-resource contexts

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Alvarado Score is an effective tool for the differential diagnosis of acute appendicitis

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High specificity demonstrated for use of Alvarado Score in the emergency department of Samoa

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Histology results showed high rate of complicated acute appendicitis in Samoa

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Surgical outcomes showed low negative appendicectomy rate

[Appendix somewhat different-Excerpts from the history, controversies of the present and view to the future]

If one could talk about a superstar in abdominal surgery, the appendix would definitely be qualified for this name. Much has already been said about the vermiform appendix. The potential to talk about the appendix is, however, by no means exhausted. In this article already published articles are selected and subsumed. Less known details on the discovery and research of the appendix as well as the diagnostics of appendicitis and establishment of appendectomy are also included.

Effect of Alvarado Score on the Negative Predictive Value of Nondiagnostic Ultrasound for Acute Appendicitis

Background:

The purposes of this study were to calculate the negative predictive value (NPV) of nondiagnostic ultrasound (US) in patients with suspected appendicitis and to identify the clinical factors that were associated with the nondiagnostic US.

Methods:

We conducted a retrospective review of 412 patients who had graded-compression appendiceal US performed during January 2017 and December 2017. The NPV of the nondiagnostic US in combination with clinical parameters was calculated. Multivariate regression analysis was used to determine the independent predictors for the nondiagnostic US.

Results:

The US exam was nondiagnostic in 64.8% of the patients, giving an NPV of 70.8%. The NPV of nondiagnostic US increased to 96.2% in patients who had an Alvarado score of <5. The patients who did not have migratory pain, did not have leukocytosis, and had a pain score of <7 were more likely to have a nondiagnostic US study (P < 0.001).

Conclusion:

Alvarado score had an inverse effect on the NPV of nondiagnostic appendiceal US. Patients who had nondiagnostic US and Alvarado score of <5 were very unlikely to have appendicitis. Active clinical observation or re-evaluation rather than immediate computed tomography may be a safe alternative approach in these low-risk patients. However, the Alvarado score itself was not a predictive factor of nondiagnostic US. The absence of migratory pain, absence of leukocytosis, and low pain score were the independent predictors of nondiagnostic appendiceal US.

The Dynamics of Inflammatory Markers in Patients with Suspected Acute Appendicitis

Background: Laboratory tests of inflammatory mediators are routinely used in the diagnosis of acute appendicitis (AA). The aim of this study was to evaluate the differences of dynamics of inflammatory markers of the blood in patients with suspected acute appendicitis between complicated AA (CAA), non-complicated AA (NAA), and when AA was excluded (No-AA). Methods: This was a retrospective analysis of prospectively collected data of patients presented to the Emergency Department (ER) of a tertiary hospital center during a three-year period. All patients suspected of acute appendicitis were prospectively registered from 1 January 2016 to 31 December 2018. The dynamics of inflammatory markers of the blood between different types of AA (No-AA, NAA or CAA) during different periods of time are presented. Results: A total of 453 patients were included in the study, with 297 patients in the No-AA group, 99 in the NAA group, and 57 in the CAA group. White blood cell (WBC) count in the No-AA decreased with time, with a statistically significant difference between the <8 h and 25–72 h group. The neutrophils (NEU) percentage decreased in the No-AA group and was statistically significantly different between the <8 h and 25–72 h and <8 h and >72 h groups. C-reactive protein (CRP) increased significantly in the No-AA group throughout all time intervals, and from the first 24 h to the 25–72 h in the NAA and CAA groups. There was a statistically significant difference between the WBC count between No-AA, NAA, and No-AA and CAA groups during the first 24 and 24–48 h. There was a statistically significant difference between NEU percentage and LYMP percentage and in the NEU/LYMP ratio between No-AA and CAA groups through all time periods. CRP was significantly higher in the first 24 h in the CAA than in the No-AA group, and in the 24–48 h in the CAA group than in the No-AA and NAA groups. The linear logistic regression model, involving inflammatory mediators and clinical characteristics, showed mediocre diagnostic accuracy for diagnosing AA with an AUC of 0.737 (0.671–0.802). Conclusions: Increasing concentrations of inflammatory markers are more characteristic in CAA patients than in No-AA during the first 48 h after onset of the disease. A combination of laboratory tests with clinical signs and symptoms has a mediocre diagnostic accuracy in suspecting AA.

Predictive values of Alvarado score, serum C-reactive protein, and white blood cell count in the diagnosis of acute appendicitis: a prospective study

Background

The diagnosis of acute appendicitis in children is quite challenging as the rate of negative appendectomy varies between 15 and 57%. Increased utilization of imaging diagnostic facilities in advanced countries seems to have reduced the incidence of operating on normal appendix to a single digit. In low- and middle-income countries, the incidence remains unacceptably high (double digits). Inflammatory markers and scoring systems may be a suitable adjunct to increase diagnostic yield in most third world countries. Thus, the aim of this study was to evaluate the diagnostic value of Alvarado score, white blood cell count, and serum C-reactive protein in children with acute appendicitis.

Results

The ages of patients ranged between 4 and 15 years with a mean of 11.2 ± 2.8 years. The male to female ratio was 1.4 to 1.0. Nineteen percent of patients had negative appendiceal findings on histological examination. The sensitivity and specificity of Alvarado score, C-reactive protein estimation, total white blood cell count in diagnosing acute appendicitis were 86.4% and 63.2%, 98.8% and 36.8%, and 51.9% and 89.5% respectively. Alvarado score has the highest area under ROC curve analysis 0.824, 95% CI of 0.724 to 0.924 compared with CRP, 0.769. 95% CI of = 0.647 to 0.891 and WBC count, 0.765, 95% CI of 0.643 to 0.887. Both CRP and WBC count showed higher discriminatory values between complicated and uncomplicated appendicitis, p < 0.001.

Conclusion

Alvarado score outperformed other tests in setting the diagnosis of acute appendicitis. However, none of the tests can be relied on wholly for operative decision. Clinical judgement remains the bedrock for diagnosis and operative management.

Acute appendicitis–advances and controversies

Being one of the most common causes of the acute abdomen, acute appendicitis (AA) forms the bread and butter of any general surgeon’s practice. With the recent advancements in AA’s management, much controversy in diagnostic algorithms, possible differential diagnoses, and weighing the management options has been generated, with no absolute consensus in the literature. Since Alvarado described his eponymous clinical scoring system in 1986 to stratify AA risk, there has been a burgeoning of additional scores for guiding downstream management and mortality assessment. Furthermore, advancing literature on the role of antibiotics, variations in appendicectomy, and its adjuncts have expanded the surgeon’s repertoire of management options. Owing to the varied presentation, diagnostic tools, and management of AA have also been proposed in special groups such as pregnant patients, the elderly, and the immunocompromised. This article seeks to raise the critical debates about what is currently known about the above aspects of AA and explore the latest controversies in the field. Considering the ever-evolving coronavirus disease 2019 situation worldwide, we also discuss the pandemic’s repercussions on patients and how surgeons’ practices have evolved in the context of AA.

Abbreviated MRI in patients with suspected acute appendicitis in emergency: a prospective study

PURPOSE

To determine the diagnostic performance of an abbreviated non-contrast MRI protocol in diagnosing acute appendicitis.

METHODS

Prospectively, a total of 67 consenting consecutive patients with clinical suspicion of acute appendicitis (Alvarado score ≥ 5) were evaluated with an abbreviated three-sequence non-contrast MRI protocol (axial T2WI, coronal T2WI, axial DWI) at a single tertiary care center. MRI was interpreted by two radiologists blinded to the clinical details, other investigations, and outcome of the patients. Diagnostic performance of MRI was determined using either histopathological examination (HPE) results as the reference standard in surgical cases (n = 39), or final clinical diagnosis at discharge and 3-months follow-up in non-operatively managed cases (n = 28).

RESULTS

Sixty-seven patients comprising 42 males, 25 females including 1 pregnant patient were enrolled (median age 24 years; age range 6-70 years). The median acquisition duration of the MRI protocol was 12.5 min. In the analysis of the complete cohort including both surgical and non-operatively managed cases (n = 67), MRI showed sensitivity of 93.3% (95% CI 81.7-98.6%), specificity of 86.4% (95% CI 65.1-97.1%), and diagnostic accuracy of 91.0% (95% CI 81.5-96.6%) (p < 0.001). In the subset of surgical cases with HPE as the reference standard (n = 39), MRI showed sensitivity of 97.1% (95% CI 84.7-99.9%), specificity of 100% (95% CI 47.8-100%), and diagnostic accuracy of 98% (95% CI 87.5-100%) (p < 0.001).

CONCLUSION

MRI may be performed to diagnose acute appendicitis or alternative causes of right iliac fossa pain. An abbreviated MRI protocol consisting of only three sequences without IV contrast, patient preparation, or antiperistaltic agents could shorten the examination duration while retaining diagnostic accuracy.

Clinical Decision Rules in the Evaluation and Management of Adult Gastrointestinal Emergencies

Although abdominal pain is a common chief complaint in the emergency department, only 1 in 6 patients with abdominal pain are diagnosed with a gastrointestinal (GI) emergency. These patients often undergo extensive testing as well as hospitalizations to rule out an acute GI emergency and there is evidence that not all patients benefit from such management. Several clinical decision rules (CDRs) have been developed for the diagnosis and management of patients with suspected acute appendicitis and upper GI bleeding to identify those patients who may safely forgo further testing or hospital admission. Further validation studies demonstrating the superiority of these CDRs over contemporary practice are needed.

Sonographic diagnosis of appendicitis: A pictorial essay and a new diagnostic maneuver

While many cases of appendicitis are easy to diagnose clinically, a significant number need further workup in the form of imaging. Ultrasound and CT are both used extensively to diagnose or exclude appendicitis, or arrive at an alternate diagnosis. Ultrasound has many advantages but can be a difficult modality to use due to, among other reasons, the anatomical variations in appendicial location. The true retrocolic appendix is particularly difficult to diagnose with ultrasound. This pictorial essay examines the ultrasound features of normal and diseased appendix and proposes a new examining station, the prone view, for visualizing true retrocolic appendicitis.

A comparison of intra-operative diagnosis to histopathological diagnosis of acute appendicitis in paediatric and adult cohorts: an analysis of over 1000 patients

BACKGROUND

Appendicitis is a common general surgical emergency. The role of removing a normal appendix is debated. However, this relies on accurate intra-operative diagnosis of a normal appendix by the operating surgeon. This study aimed to compare surgeon's intra-operative assessment to final histological result acute appendicitis in paediatric and adult patients.

METHODS

All patients who underwent appendicectomy over a 14-year period in a general surgical department were identified using the prospective Lothian Surgical Audit system and pathology reports retrieved to identify final histological diagnosis. Open appendicectomy was selected to examine, as the routine practise at our institution is to remove a normal appendix at open appendicectomy.

RESULTS

A total of 1035 open appendicectomies were performed for clinically suspected appendicitis. Sensitivity of intra-operative diagnosis of appendicitis with operating surgeon was high at 95.13% with no difference between trainee and consultant surgeon or between adult and paediatric cases. Specificity of intra-operative diagnosis was lower in the paediatric group (32.58%) than in the adult group (40.58%). Women had a higher rate of negative appendicectomy than men.

CONCLUSION

The results of this study highlight some discordance between histological evidence of acute appendicitis and intra-operative impression. Therefore other clinical variables and not just macroscopic appearance alone should be used when deciding to perform appendicectomy.