Acute appendicitis in pregnancy: literature review

Using MRI appendicitis scale and DWI for the diagnosis of acute appendicitis in pregnant women

OBJECTIVES

To assess the performance of MRI scale for the diagnosis of acute appendicitis in pregnant women and to determine the added diagnostic value of diffusion-weighted imaging (DWI).

METHODS

From January 2018 to December 2020, 80 patients were included. All MRI were performed with a 1.5-Tesla scanner with anterior array body coil. This analysis included (1) T2-weighted imaging (T2WI), (2) fat-saturated T2WI, and (3) DWI. Two radiologists blinded to the diagnosis recorded their assessment of four findings: appendiceal diameter, appendiceal wall thickness, luminal mucus, and periappendiceal inflammation. The MRI scale of acute appendicitis which ranged from 0 to 4 was determined from these factors. An additional one point was added to the MRI appendicitis scale in those patients with evidence of appendiceal restricted diffusion on DWI. The diagnostic values and predictive factors were computed.

RESULTS

Multivariate analysis demonstrated that the calculated MRI appendicitis scale was a significant independent predictor of acute appendicitis with a sensitivity of 96.6%, specificity of 90.2%, and PPV of 84.8%. The odds ratio of appendicitis is increased by 22.3 times for every increase in one point on the MRI appendicitis scale. Therefore, the addition of one point for restricted diffusion in the appendix on DWI imaging can add substantial value, both positive and negative predictive value, towards making an accurate diagnosis of acute appendicitis.

CONCLUSIONS

MRI appendicitis scale is an objective and significant independent predictive factor for acute appendicitis in pregnant women. Incorporation of diffusion weighted imaging to MRI can improve diagnosis of acute appendicitis.

CLINICAL RELEVANCE STATEMENT

MRI appendicitis scale is an objective and significant independent predictor of acute appendicitis in pregnant women. Incorporation of DWI/ADC map to MRI examinations can improve diagnosis of acute appendicitis in pregnant women.

KEY POINTS

• MRI appendicitis scale is an objective and significant independent predictive factor for acute appendicitis in pregnant women. • The odds ratio of appendicitis can be increased by 22.3 times for every increase of one unit in MRI scale. • Incorporation of diffusion-weighted imaging to MRI examinations can add value to the scale (4.2 ± 0.7 vs. 0.7 ± 1.1; p < 0.001) among pregnant women with appendicitis versus pregnant women without appendicitis.

Findings on emergent magnetic resonance imaging in pregnant patients with suspected appendicitis: A single center perspective

This study's aim is to describe the imaging findings in pregnant patients undergoing emergent MRI for suspected acute appendicitis, and the various alternative diagnoses seen on those MRI scans. This is a single center retrospective analysis in which we assessed the imaging, clinical and pathological data for all consecutive pregnant patients who underwent emergent MRI for suspected acute appendicitis between April 2013 and June 2021. Out of 167 patients, 35 patients (20.9%) were diagnosed with acute appendicitis on MRI. Thirty patients (18%) were diagnosed with an alternative diagnosis on MRI: 17/30 (56.7%) patients had a gynecological source of abdominal pain (e.g. ectopic pregnancy, red degeneration of a leiomyoma); 8 patients (26.7%) had urological findings such as pyelonephritis; and 6 patients (20%) had gastrointestinal diagnoses (e.g. abdominal wall hernia or inflammatory bowel disease). Our conclusions are that MRI is a good diagnostic tool in the pregnant patient, not only in diagnosing acute appendicitis, but also in providing information on alternative diagnoses to acute abdominal pain. Our findings show the various differential diagnoses on emergent MRI in pregnant patients with suspected acute appendicitis, which may assist clinicians and radiologists is patient assessment and imaging utilization.

Predicting Acute Appendicitis in Pregnant Patients Using the Neutrophil-to-Lymphocyte Ratio: A Meta-Analysis

Background: To determine whether the neutrophil-to-lymphocyte ratio (NLR) can serve as a predictive indicator for acute appendicitis among pregnant females. Patients and Methods: A comprehensive search was conducted across multiple databases including PubMed, Embase, and Web of Science seeking to gather pertinent research on the NLR concerning pregnant individuals either suspected of or diagnosed with acute appendicitis. The NLR value and receiver operating characteristic (ROC) curve were utilized to assess the predictive value of the NLR in predicting acute appendicitis among pregnant patients. Results: Seven studies and 410 patients were included in the meta-analysis. The area under the curve (AUC) for identifying acute appendicitis in pregnant patients using the NLR was found to be 0.856 (95% confidence interval [CI], 0.833-0.879). Additionally, the NLR values for pregnant patients with acute appendicitis were significantly elevated, showing a mean difference (MD) of 0.80 (95% CI, 0.58-1.03; p < 0.001). Conclusions: The NLR can be considered a valuable and effective diagnostic tool for anticipating acute appendicitis in pregnant patients.

Analysis of risk factors for complicated appendicitis during pregnancy and evaluation of clinical prediction model: A prospective cohort study

OBJECTIVE

To investigate the risk factors and the value of clinical prediction model for complicated appendicitis (CA) during pregnancy.

METHODS

Prospective analysis of pregnant patients who underwent appendectomy at a single tertiary care center between February 2020 and February 2023 and who ultimately had pathologically confirmed acute appendicitis (AA). According to intraoperative conditions and postoperative pathology, they were divided into the CA group and the uncomplicated appendicitis (UA) group. The two groups of patients were then compared in terms of demographic characteristics, disease features, ancillary tests and predictive models of acute appendicitis.

RESULTS

A total of 90 patients with AA in pregnancy were included, 21 of whom had CA in pregnancy and 69 had UA in pregnancy. Multivariate regression analysis showed that gestational week, neutrophil ratio and C-reactive protein (CRP) were independent risk factors for CA during pregnancy. Relative to the first trimester, the third trimesters had an increased risk of complicated appendicitis (OR = 12.48, 95% CI: 1.56-99.57, P = 0.017). Neutrophil ratio ≥85.30% (OR = 24.54, 95% CI: 2.59-232.72, P = 0.005) and CRP ≥34.26 mg/L (OR = 7.86, 95% CI: 2.18-28.38, P = 0.002) had a significantly increased risk of CA. The AIR and AAS score models were statistically different between the two groups, but with a lower sensitivity of 52.38% and 42.86%, respectively.

CONCLUSION

The third trimesters, neutrophil ratio ≥85.30% and CRP ≥34.26 mg/L may be key predictors of CA in pregnancy. The current scoring model is inadequate to identify complex appendicitis in pregnancy and further research is needed.

What is the margin of error of surgeons and radiological imaging in diagnosing acute appendicitis?

Background

Acute appendicitis is the most common emergency requiring surgical intervention in general surgery. Negative appendectomy is defined as the removal of a pathologically normal appendix.

Aim

In this study, we aimed to show our negative appendectomy rate.

Materials and Methods

This study was carried out among 2990 patients who were operated on for appendicitis between 2015-2020 at the Health Sciences University, İstanbul Kanuni Sultan Suleyman Training, and Research Hospital. Accrual and historical records of the patients were analyzed using NCSS (Number Cruncher Statistical System) 2007 Statistical Software (Utah, USA) package program. The results were evaluated at the significance level of P < 0.05.

Results

The mean age of all patients was 33. Of the patients, 1011 were women and 1979 were men. 27 of the women patients were pregnant. We requested a blood test (WBC count) and an abdominal ultrasound for all our patients who came with the complaint of abdominal pain in the right lower quadrant. Negative appendectomy was performed with ultrasonography in 622 patients with pathological diagnoses of lymphoid hyperplasia and fibrous obliteration (20.8%). We had abdominal computerized tomography (CT) for 285 patients and abdominal magnetic resonance imaging (MRI) for 16 of 27 pregnant women (59.25%) due to unclear clinical picture. Diagnostic laparoscopy was performed in 36 of the patients who underwent CT and 4 of the patients who underwent MRI since the diagnosis could not be made. We performed unnecessary appendectomy in 21.2% of the patients.

Conclusion

With the increasing clinical follow-up experience of surgeons and developing technology in radiology, our aim is to minimize the negative appendectomy rate as much as possible.

Development of a nomogram for the prediction of complicated appendicitis during pregnancy

BACKGROUND

Complicated appendicitis during pregnancy directly affects the clinical prognosis of both mother and fetus. However, accurate identification of complicated appendicitis in pregnancy is fraught with various challenges. The purpose of this study was to identify the risk factors and to develop a useful nomogram to predict complicated appendicitis during pregnancy.

METHODS

This retrospective study involved pregnant women who underwent appendectomy at the Maternal and Child Health Hospital of Hubei Provincial from May 2016 to May 2022 and who ultimately had histopathological confirmed acute appendicitis. Univariate and multivariate logistic regression were applied to analyze clinical parameters and imaging features as a way to identify risk factors. Then, nomogram and scoring systems predicting complicated appendicitis in pregnancy were constructed and evaluated. Finally, the potential non-linear association between risk factors and complicated appendicitis was analyzed using restricted cubic splines.

RESULTS

Three indicators were finally identified for the construction of the nomogram: gestational weeks, C-reactive protein (CRP), and neutrophil percentage (NEUT%). To improve the clinical utility, the gestational weeks were divided into three periods (first trimesters, second trimesters, and third trimesters), while the optimal cut-offs for CRP level and NEUT% were found to be 34.82 mg/L and 85.35%, respectively. Multivariate regression analysis showed that third trimesters (P = 0.013, OR = 16.81), CRP level ≥ 34.82 mg/L (P = 0.007, OR = 6.24) and NEUT% ≥85.35% (P = 0.011, OR = 18.05) were independent risk factors for complicated appendicitis. The area under the ROC curve (AUC) of the nomogram predicting complicated appendicitis in pregnancy was 0.872 (95% CI: 0.803-0.942). In addition, the model was shown to have excellent predictive performance by plotting calibration plots, Decision Curve Analysis (DCA), and clinical impact curves. When the optimal cut-off point of the scoring system was set at 12, the corresponding AUC, sensitivity, specificity, Positive Likelihood Ratio (PLR), Negative Likelihood Ratio (NLR), Positive Predictive Value (PPV), and Negative Predictive Value (NPV) values were AUC: 0.869(95% CI: 0.799-0.939),100%, 58.60%, 2.41, 0, 42%, and 100%, respectively. The restricted cubic splines revealed a linear relationship between these predictors and complicated appendicitis during pregnancy.

CONCLUSIONS

The nomogram utilizes a minimum number of variables to develop an optimal predictive model. Using this model, the risk of developing complicated appendicitis in individual patients can be determined so that reasonable treatment choices can be made.

Clinical Characteristics of Acute Appendicitis in Pregnancy: 10-Year Experience at a Single Institution in South Korea

BACKGROUND

Acute appendicitis is the most common cause of non-obstetric surgical disease in pregnant women. The diagnosis and treatment of appendicitis during pregnancy are very important because it can cause life-threatening morbidity to the fetus and mother. We evaluated the clinical characteristics of acute appendicitis in pregnant women.

METHODS

We retrospectively reviewed a medical database that included patients who underwent surgery for acute appendicitis at our hospital from January 2013 through December 2022. We compared non-pregnant women of reproductive age with pregnant women. We classified the pregnant women according to gestational age.

RESULT

A total of 828 patients were reproductive-aged women between 15 and 44 years old. There were 759 non-pregnant patients and 69 pregnant patients. ASA (American Society of Anesthesiologists) physical status classes were significantly higher and hospital stays were significantly longer in the pregnant group. There was no significant intergroup difference in terms of the proportions of complicated appendicitis, extended surgery, or complications. When the enrolled pregnant women were divided into three subgroups according to gestational age, the mean operation time was longest in the third-trimester subgroup. There were no differences among the subgroups in terms of the proportions of complicated appendicitis, extended surgery, or complications, nor were there differences among the subgroups in terms of laboratory findings. Preterm labor and stillbirth occurred in two pregnant women with complicated appendicitis in the second trimester.

CONCLUSION

Immediate surgical treatment should be strongly considered in pregnant women with appendicitis. Efforts for more accurate diagnosis are needed for pregnant women with appendicitis.

Typical and Atypical Presentations of Appendicitis and Their Implications for Diagnosis and Treatment: A Literature Review

Appendicitis, an acute inflammation of the appendix, affects all demographic groups and exhibits various incidences and clinical manifestations. While acute appendicitis typically presents with colicky periumbilical abdominal pain that localizes to the right lower quadrant, atypical presentations are more common in children, geriatric, and pregnant patient populations, leading to delays in diagnosis. Clinical evaluation, clinical scoring systems, and inflammatory markers are commonly used, but their limitations have led to the increased use of diagnostic imaging in patients suspected of appendicitis. Acute appendicitis is managed by non-operative and operative management, depending on whether it is uncomplicated or complicated. Developing diagnostic pathways to improve outcomes and reduce complications is crucial. Although medical advancements have been made, diagnosing and managing appendicitis can be challenging, mainly when patients are present atypically. This literature review aims to comprehensively review typical and atypical presentations of appendicitis and their current implications for diagnosis and treatment modalities in pediatric, adult, pregnant, and geriatric patient populations.

MRI remains highly accurate in the diagnosis of appendicitis in pregnancy when read by radiologists of mixed specialty training and experience

PURPOSE

To audit the accuracy of magnetic resonance imaging (MRI) abdominal studies performed in the diagnosis of appendicitis in pregnant patients when read by radiologists of mixed experience.

METHODS

MRI reports from 45 pregnant women presenting to our emergency department for the investigation of appendicitis between 2009 and 2020 were retrospectively reviewed. Where available, these reports were correlated with surgical and pathology reports as well as follow-up clinical information. Following a review of literature, accuracy targets were set. Statistical analyses including sensitivity, specificity, positive, and negative predictive values were calculated.

RESULTS

A total of 18 radiology consultants read 45 MRI abdominal studies in the assessment of appendicitis during pregnancy with 62% (n = 28) of these read by specialist radiologists and the remainder by general radiologists. This yielded an accuracy in diagnosis of 99.8%, sensitivity of 80% (95% CI: 49-94.3%), and specificity of 100% (95% CI: 90-100%). The calculated negative predictive value was 94.6% (95% CI: 82.3-98.5%), and positive predictive value was 100% (95% CI: 90-100%). The appendix was not identified in 19 patients (42%). A statistically significant relationship between the presence of right iliac fossa stranding of the fat OR free fluid was associated with appendicitis (p = 0.01). Alternate diagnoses were identified in 8% (n = 4) of cases.

CONCLUSION

MRI is a highly accurate imaging modality for the assessment of appendicitis in pregnancy. Even with variable reader MRI experience, MRI demonstrates an accuracy of 99.8% and a positive predictive value for acute appendicitis of 100%. Double reading and the possible inclusion of DWI may help further improve accuracy and minimise false-negative rates.

Diffusion-weighted imaging versus non-contrast magnetic resonance imaging in the diagnosis of acute appendicitis during pregnancy

OBJECTIVE

The aim of this study was to evaluate the diagnostic performance of diffusion-weighted imaging compared to non-contrast magnetic resonance imaging in the differential diagnosis of acute appendicitis in pregnant patients.

METHODS

A total of 72 pregnant patients with the suspicion of acute appendicitis who underwent magnetic resonance imaging combined with diffusion-weighted imaging examinations were enrolled in this retrospective study. Magnetic resonance imaging images (non-contrast and diffusion-weighted imaging sequences) were evaluated. Moreover, apparent diffusion coefficient ratios were estimated. The diagnostic performances of magnetic resonance imaging and diffusion-weighted imaging findings were statistically analyzed on the basis of surgical and follow-up results.

RESULTS

Of 72 pregnant patients, 10 (14%) had acute appendicitis on magnetic resonance imaging and diffusion-weighted imaging. Among 10 patients with acute appendicitis, three (3/10) had perforation. diffusion-weighted imaging findings had higher sensitivity (90 versus 60%), negative predictive value (98.41 versus 93.94%), and accuracy (98.61 versus 94.44%) ratios compared to non-contrast magnetic resonance imaging in the diagnosis of acute appendicitis. There was one false-negative result on diffusion-weighted imaging. Diffusion restriction facilitated the detection of appendicitis. The apparent diffusion coefficient ratios were lower in acute appendicitis than in the normal appendix (0.70±0.19 versus 0.96±0.16) (p<0.05).

CONCLUSION

With a shorter scan time and higher diagnostic accuracy, diffusion-weighted imaging can be useful for the early diagnosis of acute appendicitis and for planning appropriate management.

[Laparoscopic appendectomy for acute appendicitis in pregnancy]

The review is devoted to the role of laparoscopic appendectomy in surgical management of acute appendicitis in pregnancy. We analyzed reviews, prospective and retrospective studies in the PubMed, Google, the Springer Link online library, the Cochrane Systematic Review databases. The results of laparoscopic and traditional treatment of acute appendicitis in pregnant women were assessed. We analyzed clinical, epidemiological features in these patients, differential diagnosis of acute appendicitis in pregnant women, indications and contraindications for endoscopic treatment, features of laparoscopic procedures. Comparative assessment of laparoscopic and open surgeries for acute appendicitis in pregnant women was carried out. We also estimated the influence of surgical treatment of acute appendicitis on subsequent course of pregnancy.

Accuracy of Point-of-care Ultrasound in Diagnosing Acute Appendicitis During Pregnancy

Introduction: Acute appendicitis is the most common non-obstetrical surgical emergency in pregnancy. Ultrasound is the imaging tool of choice, but its use is complicated due to anatomical changes during pregnancy and depends on the clinician’s expertise. In this study, our aim was to investigate the diagnostic accuracy of point-of-care ultrasound (POCUS) in suspected appendicitis in pregnant women. Methods: We conducted a retrospective analysis of all pregnant women undergoing POCUS for suspected appendicitis between June 2010–June 2020 in a tertiary emergency department. The primary outcome was to establish sensitivity, specificity, and likelihood ratios of POCUS in diagnosing acute appendicitis, overall and for each trimester. We used histology of the appendix as the reference standard in case of surgery. If appendectomy was not performed, the clinical course until childbirth was used to rule out appendicitis. If the patients underwent magnetic resonance imaging (MRI), we compared readings to POCUS. Results: A total of 61 women were included in the study, of whom 34 (55.7%) underwent appendectomy and in 30 (49.2%) an acute appendicitis was histopathologically confirmed. Sensitivity of POCUS was 66.7% (confidence interval [CI] 95% 47.1-82.7), specificity 96.8% (CI 95% 83.3-99.9), and positive likelihood ratio 20.7. Performance of POCUS was comparable in all trimesters, with highest sensitivity in the first trimester (72.7%). The MRI reading showed a sensitivity of 84.6% and a specificity of 100%. In the four negative appendectomies a MRI was not performed. Conclusion: Point-of-care ultrasound showed a high specificity and positive likelihood ratio in diagnosing acute appendicitis in pregnant women in all trimesters with suspected appendicitis. In negative (or inconclusive) cases further imaging as MRI could be helpful to avoid negative appendectomy.

Acute appendicitis in pregnant women: A Tunisian center experience

Acute appendicitis is the most common surgical pathology during pregnancy. It occurs in about 1 in 500 to 1 in 635 pregnancies per year,[1] and appendectomy is the gold standard in the treatment approach.[2] However, its diagnosis represents a challenge to both surgeons and obstetrician-gynecologists. In addition, the role of laparoscopy remains controversial. This study discusses the diagnostic approach and reviews the appropriate surgical approach while evaluating the part of laparoscopy. This is a retrospective descriptive analysis reviewing 36 patients who underwent surgery for acute appendicitis during pregnancy at the "Surgery Department of Jendouba Hospital from January 1, 2005 to December 31, 2019. Data include age, comorbidities, previous abdominal surgery, symptoms, physical examination findings, complementary exams results, operative treatment details, the emergency status of the procedure, associated medical treatment, antibiotics and tocolysis, the pathology reports, and follow-up. The mean age of patients was 27 years. Twenty-one patients (58, 33%) were in the second trimester of pregnancy, 6 patients (16, 66 %) were in the first trimester, and 9 (25%) in the third one. The physical examination reported a right iliac fossa tenderness in 27 patients (75%). The abdominal ultrasound was performed in all cases and guided the diagnosis in 24 cases (66, 66%). 18 patients (50%) underwent laparoscopy, 12 patients (33, 33%) underwent laparotomy. The remaining 6 patients (16, 66%) required a conversion from laparoscopic to open surgery. The clinical presentation of appendicitis in pregnancy is often misguiding. Therefore, an abdominal ultrasound should be performed for all pregnant patients having abdominal pain. The difficulty of operating under laparoscopy increases with the pregnancy term, leading to a higher risk of conversion, which increases the operating time and the doses of anesthetics, causing a maternal and fetal risk.

Differential diagnoses of right lower quadrant pain in late pregnancy

We present two patients with right lower quadrant pain during the 36th week of pregnancy. In both cases, the challenges in diagnosing acute appendicitis in late pregnancy is underlined by misleading imaging results, revealing fluid in the lower abdomen, suggesting an appendicitis. Surgery was performed. Pre- and intraoperative gynecological examinations showed no signs of fetal distress. In patient 1, surgery revealed a torsion and necrosis of the right ovary and a 7-cm cyst of the fallopian tube. Open ovariectomy and appendectomy were performed. In patient 2, we saw a perforated appendicitis and cloudy ascites. Histology after appendectomy showed spots of endometriosis and serositis infiltrating into the appendix with signs of perforation at the tip. Patient 1 recovered after a short period of bowel paralysis. Patient 2 needed Caesarean section due to severe deceleration in the cardiotocograph and irregular uterine contractions. The newborn was kept in the neonatal ICU for 10 days.

Physical Examination and Appendiceal Signs During Pregnancy

The clinical diagnosis of acute appendicitis is challenging as patients present with an array of objective and subjective symptoms early or late in the disease course. Ultrasound is routinely performed in all patients with suspected acute appendicitis. Equivocal test results frequently require further assessments using other imaging techniques that are limited in scope during pregnancy because of issues involving safety, availability, and accessibility. Physical examination diagnostic signs in acute appendicitis during pregnancy have not been well studied. Studies failed to describe, standardize, or correlate the technique used to the pathologic disease process. Therefore, gaps remain in current knowledge regarding the usefulness and application of these tests during the physical examination. Improvement in diagnostic acumen is critically important, particularly in cases where there remains diagnostic uncertainty because of equivocal imaging results. This article reviews signs used to diagnose patients with acute appendicitis using a pathophysiologic approach based on visceral and cerebrospinal nerve pathways to explain the mechanism for a positive test result. It also suggests a framework to study them further to better understand their role, if any, in clinical practice.

Significance of laboratory parameters in diagnosing acute appendicitis during pregnancy

BACKGROUND

Acute appendicitis (AA) is the most frequently seen surgical emergency in pregnant women and the most frequently encountered cause of non-obstetric acute abdomen. Due to the physiological and anatomical changes that occur during pregnancy and the limited use of radiological methods, it is difficult to diagnose AA during pregnancy. These conditions increase the risk of morbidity and mortality; therefore, it is crucial to identify ideal laboratory markers that can be utilized to diagnose disease.

METHODS

One hundred and ten pregnancies that fulfilled the inclusion criteria for AA diagnosis were retrospectively analysed between 2010 and 2021. Markers with high diagnostic values were discussed.

RESULTS

The patients were divided into three groups as follows; Group I: negative appendectomy (n = 19); Group IIa: uncomplicated appendicitis (n = 59); Group IIb: complicated appendicitis (n = 32). There was no statistically significant difference in mean age or gestational week (P > 0.05). Group IIb had a higher rate of complications and a longer length of hospital stay (P < 0.05). There were significant differences between the groups in terms of white blood cell (WBC), neutrophil, neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), C-reactive protein, lymphocyte-to- C-reactive protein ratio, total, direct, and indirect bilirubin values (P < 0.05). While platelet and lactate dehydrogenase (LDH) values did not differ substantially between groups, both were found to have a high diagnostic value.

CONCLUSION

It was concluded that WBC, neutrophil, NLR, PLR, total, direct and indirect bilirubin levels could be utilized to diagnose AA. Moreover, levels of WBC, neutrophil, NLR, platelet, PLR, LDH, total, direct and indirect bilirubin can be utilized to diagnose complicated appendicitis.

Analysis of 190 Female Patients after Appendectomy

This study is a retrospective cohort review carried out at a single, private tertiary center. We included 190 female patients who underwent surgery for acute appendicitis between January 2016 and December 2018. Two groups of patients were analyzed based on the pregnancy. The main outcome measures were complication rate and risk of abortion during or after surgery. Out of 190 female patients, eight of them were pregnant (4.2%). The pregnant group more significantly underwent ultrasound investigation compared to the nonpregnant group. Complicated appendicitis present in two pregnant patients at advanced gestational age was not statistically significant from nonpregnant. Laparoscopic appendectomy was performed in 6/8 (75%) of pregnant compared to 158/182 (87%) in nonpregnant (p = 0.415). Compared to the nonpregnant, the pregnant group has a more fecolith, positive peritoneal fluid culture, and wound infection, with E. coli more frequently isolated in 25%. None of the pregnant patients had an abortion, preterm labor, or mortality during or after surgery. In conclusion, laparoscopic appendectomy is a low-risk operation for pregnant with acute appendicitis.

The diagnostic role of hemogram parameters in pregnant appendicitis

Background: Acute appendicitis is the most frequently encountered non-obstetric disease requiring surgical intervention during pregnancy. Early diagnosis reduces maternal and fetal morbidity / mortality rates. Aim: This study aims to investigate hemogram parameters in the diagnosis of acute appendicitis in pregnant women. Material and Methods: A retrospective case-controlled study was conducted in three groups. Thirty-nine pregnant patients with acute appendicitis (Group A), 39 fertile nonpregnant patients with acute appendicitis (Group B), and 39 healthy pregnant women (Group C) were included in the study. WBC, neutrophil count, lymphocyte count, NLR, PLR, MPV and RDW values were compared. Results: The mean NLR values in group A, group B and group C were 7.39 (1.58–46.6), 5.66 (1–20) and 4.23 (1.54–10.77) respectively, and there was a significant difference in NLR values between the groups (P= 0.002). The mean PLR values in group A, group B and group C were 159.09 (69.1–574), 134.28 (21.5-360) and 120 (68.7–334) and difference was statistically significant (P= 0.019). Cutoff points for WBC count was 14155 106/μL (51,3% sensitivity, 82,1% specificity), for neutrophil count is 10955 106/μL (53,8% sensitivity, 84,6% specificity), for NLR is 9.23 (46,2% sensitivity, 92,3% specificity) and PLR is 157,6 (51,3% sensitivity and 82,1% specificity) NLR had largest area under the curve with 0.667 NLR. Conclusion: Neutrophil count, WBC and PLR were found to be the most valuable inflammatory parameters however, RDW, Lymphocyte count, and MPV levels are not found valuable markers in terms of sensitivity and specificity in the diagnosis of acute appendicitis in pregnant patients by this study.

Acute Appendicitis During Pregnancy: A Case Series of 42 Pregnant Women

Introduction It is difficult to diagnose the symptoms of acute appendicitis in pregnant women due to its similarities with pregnancy physiology. In this study, we examined the diagnostic value of laboratory parameters in the diagnosis of acute appendicitis in pregnant women. Material and methods Forty-two patients who underwent appendectomy during pregnancy were evaluated. The demographic characteristics, laboratory parameters and imaging methods of the patients were examined. According to the pathology results, the patients were evaluated in two groups as normal appendix and acute appendicitis. In addition, a non-pregnant control group was formed to compare the results between the pregnant and control groups. Results The mean age of the 42 patients was 30±6 years, and the pathology results were evaluated as normal in 16 (38.1%) of the patients. As imaging methods, ultrasonography was undertaken in all patients, with MRI being additionally performed in two patients. When the normal appendix and acute appendicitis groups were compared, no significant difference was observed in terms of laboratory parameters (neutrophil, lymphocyte, white blood cell and platelet counts, neutrophil-lymphocyte ratio, platelet-lymphocyte ratio, mean thrombocyte volume, red cell distribution width, and pregnancy trimesters (P>0.05). The group that had undergone appendectomy had a significantly higher rate of negative appendectomy compared to the control group (P=0.001). Conclusion Laboratory parameters alone cannot be sufficient for the diagnosis of acute appendicitis in pregnant patients. If clinical examination, laboratory parameters and USG are not sufficient for diagnosis, MRI is the imaging method that should be considered to reduce negative appendectomy rate.

Laparoscopic Versus Open Appendectomy for Appendicitis in Pregnancy: Systematic Review and Meta-Analysis

OBJECTIVES

The clinical safety, efficacy and feasibility of laparoscopic appendectomy (LA) compared with open appendectomy (OA) in pregnancy are still controversial. Herein, we are aiming to compare the clinical outcomes of LA and OA in patients with acute appendicitis during their pregnancy.

MATERIALS AND METHODS

This was a systematic review and meta-analysis of studies comparing laparoscopic and OA in pregnancy identifying using PubMed, Web of science, Embase, The Cochrane Library, Ovid and Scopus. Two independent reviewers extracted data on surgical complication, fetal loss, preterm delivery, hospital stay, Apgar score in both groups.

RESULTS

Twenty-seven studies with total of 6497 patients (4464 in open and 2031 in laparoscopic group) were included. LA was associated with lower rate of wound infection [odds risk (OR)=3.13, 95% confidence interval (CI): 1.77-5.56, P<0.0001] overall complications (OR=2.15, 95% CI: 1.47-3.14, P<0.0001) and shorter hospitalization (mean difference=0.72, 95% CI: 0.43-1.02, P<0.00001) compared with open group. LA was in a lower risk for 5-minute Apgar score (mean difference=0.09, 95% CI: 0.02-0.17, P=0.01) group than open group. No difference was found regarding preterm delivery between 2 groups. LA was associated with higher fetal loss (OR=0.57, 95% CI: 0.41-0.79, P=0.0007) compared with open surgery. However, laparoscopy was not associated with increased fetal loss after 2010 (OR=0.74, 95% CI: 0.44-1.24, P=0.26) compared with open group.

CONCLUSIONS

LA in pregnancy seems to be feasible with acceptable outcome, especially in patients with early and mid-trimester period, with sophisticated hands and experienced centers.

The effect of acute complicated appendicitis on liver function test

Objectives

To determine the diagnostic role of hyperbilirubinemia in acute appendicitis like suppurative and gangrenous appendicitis.

Methods

This observational study was conducted at Ward-3, Jinnah Postgraduate Medical Center (JPMC), Karachi from 1^st June 2019 to 1^st June 2020. Males and females above 12 years of age were included. Serum liver function tests and leukocyte counts were carried out. Appendectomies were done, the operative findings and histopathology reports were noted. Hyperbilirubinemia was related with the stages of appendicitis. Results were analyzed by SPSS version 25.

Results

There were one hundred twenty patients. Thirty-eight (31.66%) were females and eighty-two (68.33%) were males. Age range was 13 to 60 years. Ten patients (8.33%) were between 13 - 20 years, sixty five (54.16%) were 21 to 30 years, thirty (25%) were 31 - 40 years, ten (8.33%) were 41 - 50 years and five patients (4.17%) were above 50 years of age. Sixty-two (51.66%) patients had simple appendicitis and fifty-four (45%) had complicated appendicitis like suppurative (26.66%) and (16.66%) gangrenous appendicitis. Negative appendectomy was found in four (3.33%). Hyperbilirubinemia was found (100%) in gangrenous, (94.12%) in suppurative and (12.3%) in catarrhal appendicitis. Enzymes like Alanine transaminase and Aspartate transaminase were raised (50%) in gangrenous, (50%) in suppurative and (9.67%) in catarrhal appendicitis. TLC was raised in 112 (96.55%) out of 116 patients and total leukocyte count was normal in negative appendectomies.

Conclusions

It is concluded that hyperbilirubinemia is strong diagnostic predictor for complicated appendicitis.

Surgery in pregnancy: Identifying factors contributing to variation and delay in diagnosis and management of appendicitis in pregnancy

BACKGROUND

Suspected appendicitis is the most common indication for surgery for non-obstetric conditions during pregnancy. Delay in management increases the risk of appendiceal perforation and pregnancy loss. Stand-alone specialty obstetric hospitals often don't have surgical teams on site. It has been suspected that this may be a factor that leads to delayed diagnosis and management of non-obstetric surgical conditions in pregnancy.

AIMS

To assess the differences in time to diagnosis, imaging, surgical management and outcomes between a stand-alone tertiary obstetric hospital and a tertiary general hospital for pregnant patients presenting with suspected appendicitis who underwent an appendicectomy.

MATERIALS AND METHODS

A retrospective study of all women who underwent appendicectomy in pregnancy for suspected appendicitis over a four-year period.

RESULTS

Women who attended the specialist hospital were later in gestation (medians 29 weeks vs 18 weeks, P = 0.004) and less likely to have imaging (84% vs 56%, P = 0.047) with no difference in the rates of confirmation of diagnosis of appendicitis using imaging. Women who presented to the specialist hospital were more likely to be managed with a laparotomy, admitted to high dependency unit, have a longer hospital stay and tended to be later in gestation. There was no difference in rates of positive appendicectomies, appendiceal perforation or management in under the recommended 24 h.

CONCLUSIONS

The specialty obstetric hospital has a much higher rate of laparotomy and longer length of stay. The majority of patients presenting to both hospitals did not undergo surgery within 24 h and delay in imaging was a major contributor.

Concurrent ruptured spontaneous heterotopic pregnancy and ruptured appendix with delayed presentation in the first trimester: a case report

Acute appendicitis is the commonest non-gynaecological surgical emergency in pregnancy. However, the concurrent occurrence of acute appendicitis with a heterotopic pregnancy is a rare event and presents diagnostic challenges to unsuspecting clinicians and sonographers. We present a case of a woman who had a heterotopic pregnancy and was noted to have a gangrenous appendicitis at laparotomy, illustrating how a diagnosis of acute appendicitis could easily be missed in pregnancy. We report the case of a 34-year-old woman in the first trimester of pregnancy who had a missed diagnosis of acute appendicitis after she had complained of vague abdominal symptoms for three weeks. She presented to a gynaecologist with vaginal bleeding for three days and was noted to have a heterotopic pregnancy on ultrasound scan. At laparotomy, she was noted to have a gangrenous appendicitis with pyoperitoneum concurrent with a ruptured left fimbrial ectopic pregnancy. Left salpingectomy and saline lavage were done and she had uneventful post-operative recovery. Unsuspecting clinicians, in patients without risk factors, can miss both heterotopic pregnancy and acute appendicitis. As assisted reproductive techniques become widespread, the possibility of heterotopic pregnancies must always be considered and any patient who presents with vague abdominal symptoms must be suspected to have the possibility of acute appendicitis. Because of the unreliability of laboratory investigations and clinical predictive scores in pregnancy, sonographers must be specifically asked to scan for heterotopic pregnancy and appendicitis in suspected cases.

Ultrasound features and the diagnostic strategy of subhepatic appendicitis

Background

This study aimed to compare the differences of ultrasound findings between subhepatic appendicitis and appendicitis at a normal position, then discuss the diagnostic strategies and improve the accuracy of diagnosis.

Methods

A retrospective analysis was performed in our hospital. One thousand five hundred ninety-one patients with appendicitis were diagnosed from January 2014 to January 2018. Eighteen patients with subhepatic appendicitis and 25 patients with appendicitis with regular positions were selected randomly as the control group. The difference in ultrasound features between the two groups was studied. Comparisons between the two groups showed statistically significant differences in the frequencies of the fishbone sign, enlarged appendix, appendicoliths, and hyperechoic omental cap (P<0.05).

Results

Statistical significance was not observed with the difference in the frequency of whether there was lymphadenectasis (P>0.05) in the abdominal cavity between the two groups. The Pareto chart was drawn to look for the main factors associated. The results of interpretation on the critical points of diagnosis for subhepatic appendicitis: (I) the fishbone sign of a dilated ileum in the right lower abdomen; and (II) the fishbone sign of a dilated ileum in the right lower abdomen + presence of an enlarged appendix in the right upper abdomen.

Conclusions

An abnormally dilated ileum in the right lower abdomen – the fishbone sign, is a vital sign leading to the diagnosis of subhepatic appendicitis. The fishbone sign of a dilated ileum in the right lower abdomen + whether there is a vermiform structure is an important diagnostic indicator for subhepatic appendicitis.

Discordant outcomes of laparoscopic versus open appendectomy for suspected appendicitis during pregnancy in published meta-analyses: an overview of systematic reviews

OBJECTIVES

Our study aimed to explore the discrepancy of results between overlapping systematic reviews (SRs) of laparoscopic appendectomy (LA) versus open appendectomy (OA) for suspected appendicitis during pregnancy.

METHODS

MEDLINE, Embase, and Cochrane Database of Systematic Reviews (CDSR) were searched for SRs published from January 1, 2017 to September 10, 2019. SRs and meta-analyses (MA) that compared outcomes of LA versus OA during pregnancy were used. Data regarding the methodology of SR/MA, included studies, efficacy and safety outcomes were extracted. SR quality was analysed with AMSTAR 2.

RESULTS

Four SRs were found, published between April 2018 and April 2019. These reviews included a variety of primary studies, ranging from 17 to 22, and number of included patients varied from 4694 to 6276. A total of 13 outcomes were analyzed. Nine outcomes were included in more than one review; among them, discrepancies between summary effect sizes in meta-analyses were found in four outcomes: preterm birth, Apgar score at 5 min, length of stay in hospital, and wound infection rates. One primary study, which included more than half of the total number of patients in analyzed reviews, showed a predominant effect on the outcome for fetal loss. All four SRs had critically low methodological quality.

CONCLUSIONS

The outcomes of LA versus OA for suspected appendicitis in pregnancy represented in four recent SRs do not provide consistent results. Such uncertainties require new, high-quality primary and secondary evidence on this topic.

Reasons for Undesirable Pregnancy Outcomes among Women with Appendicitis: The Experience of a Tertiary Center

Background

Although laparoscopic appendectomy increases its popularity today, the answer to the question of whether to perform open or laparoscopic appendectomy during pregnancy is appropriate in many studies, and the choice of surgery depends on the surgeon. Herein, we aimed to evaluate the variables that affect undesirable pregnancy outcomes that occur as a result of appendicitis during pregnancy.

Methods

Seventy-eight pregnant patients with acute appendicitis who underwent laparoscopic or open technique intervention enrolled in this retrospective study. In addition to the demographic structure of the patients, surgical technique, the number of pregnancies, multiple pregnancy status, surgical pathologies, laboratory values, radiological imaging methods, and length of hospital stay were evaluated. The severity of appendicitis was classified according to the pathology results. The patients were divided into two groups according to the outcomes of their pregnancy. Preterm delivery and abortion involved in the study as a single complication section.

Results

The mean age of the pregnant patients was 28.6 ± 5. Of the 78 pregnant women with appendicitis, 47.4% had their first pregnancy, 37.2% had their second pregnancy, and 15.4% had 3 or more pregnancies. The preterm delivery and abortus were 19.5% in the open appendectomy (OA) group and 16.2% in the laparoscopic appendectomy (LA) group. No statistically significant difference was detected in this group in terms of appendicitis pathology triggering preterm delivery or abortion (p 0.075). When white blood count (WBC) and C-reactive protein (CRP) were evaluated by laboratory findings, CRP was found to be statistically significantly higher in patients with preterm birth (p 0.042).

Conclusion

Consequently, acute appendicitis may cause serious intra-abdominal infection and inflammation in addition to the complexity of the diagnosis due to the nature of pregnancy, as well as undesired pregnancy outcomes with the surgical technique, or independently with other variables.

Body mass index as an indicator of the likelihood of ultrasound visualization of the appendix in pregnant women with suspicion of appendicitis

PURPOSE

To determine if clinical characteristics of pregnant women are associated with the likelihood of ultrasound (US) visualization of the appendix in cases where there is a clinical suspicion of appendicitis.

MATERIALS AND METHODS

A retrospective study of 471 pregnant patients with suspicion of appendicitis from 2009 to 2018 were studied. Patients underwent sonography of the appendix as their initial imaging study. The association of body mass index (BMI) and gestational age with sonographic visualization of the appendix was analyzed using logistic regression. Cut-off values were determined for BMI to predict visualization of the appendix.

RESULTS

The rate of visualization of the appendix on US was 16% (95% CI 12% to 19%). When stratified by trimester of pregnancy, rebound pain on compression US examination in the 1st trimester and BMI in the 2nd and 3rd trimesters were identified as predictors of US visualization. Applying BMI cut-off values rounded to the nearest whole number, 36, 30, and 26 in the 1st, 2nd, and 3rd trimesters, non-visualization rates would be reduced by 16% (95% CI 10% to 25%), 35% (95% CI 29% to 42%), and 67% (95% CI 58% to 74%). Using BMI index cut-off values would reduce the number of primary US examinations by 35% (95% CI 30% to 39%) and increase the rate of visualization by 6% (95% CI 0.02% to 12%, P = 0.04).

CONCLUSION

Using BMI cut-off values for determining the efficaciousness of US visualization of the appendix in pregnant women with suspicion of appendicitis could significantly reduce the non-visualization rate.

Which appendicitis scoring system is most suitable for pregnant patients? A comparison of nine different systems

BACKGROUND

Acute appendicitis is the most common non-gynecological emergency during pregnancy. The diagnosis of appendicitis during pregnancy is challenging due to changes in both physiological and laboratory variables. Guidelines suggest patients with suspected acute appendicitis should be stratified based on clinical scoring systems, to optimize the use of diagnostic imaging and prevent unnecessary surgery. Surgeons require additional information beyond that provided by imaging studies before deciding upon exploratory laparoscopy in patients with a high suspicion of appendicitis. Various scoring methods have been evaluated for the diagnosis of acute appendicitis. However, there is no consensus on a method to use during pregnancy, and a detailed comparison of existing scoring methods for this purpose has not yet been conducted. The purpose of this study was to evaluate the efficacy of the most popular scoring systems applied to diagnose acute appendicitis during pregnancy.

METHODS

This single-center retrospective study included 79 pregnant patients who were admitted to the emergency department with abdominal pain between May 2014 and May 2019. The patients were diagnosed with acute appendicitis and underwent an appendectomy. As a control group, the study also included 79 non-pregnant patients who underwent appendectomy within the last 1.5 years. To ensure that the groups were similar, women in the case group were stratified according to age, and the proportions of women in the strata were determined. The women in the control group were similarly stratified. Women were randomly selected from the strata to prevent bias. Both laboratory and examination findings required for each scoring method were obtained and assessed separately for each patient. Negative appendectomy rates were evaluated according to pathology results. Categorical variables were compared using the chi-square test. A p value < 0.05 was considered to indicate significance. Receiver operator characteristic curve analysis was used to identify the best threshold value and to assess the performance of the test scores in terms of diagnosing appendicitis.

RESULTS

Among all scoring systems, the Tzanakis score was most efficacious at predicting appendicitis in non-pregnant women. The positive predictive value (PPV) of the Tzanakis score was 90.6%, whereas the negative predictive value (NPV) was 46.7%. The RIPASA score performed the best among the scoring systems in pregnant women. It was associated with a PPV of 94.40%, NPV of 44%, and sensitivity and specificity of 78.46% and 78.57%, respectively.

CONCLUSION

Although the RIPASA score can be used to efficaciously diagnose acute appendicitis in pregnant women, a specific scoring system is needed for diagnosis during the gestation period.

[Magnetic resonance imaging for diagnosis of acute appendicitisin pregnant women in multi-field hospital]

OBJECTIVE

Tooptimize MRI protocol in pregnant women with suspected acute appendicitis.

MATERIAL AND METHODS

There were 44pregnant women (gestation period 11 - 36 weeks)with suspected appendicitis.

RESULTS

Fat-suppressed T2-weighted and diffusion-weighted imaging (DWI) was the most valuable to diagnose inflammation of appendix and surrounding tissues. Sensitivity, specificity and accuracy were 100, 90 and 97.8%.

CONCLUSION

MRI was useful to assess appendix and differentiate appendicitis with biliary and urinary diseases.

Delaying laparoscopic surgery in pregnant patients with an equivocal acute appendicitis: a step-wise approach does not affect maternal or fetal safety

BACKGROUND

Accurate and timely diagnoses of acute appendicitis (AA) during pregnancy avoids maternal and fetal morbidity and mortality. We present our experience of using an initial transabdominal ultrasound (US) performed at presentation to diagnose AA in pregnant patients as well as the value of a delayed repeat study in those who remain equivocal. We explore the sensitivity and specificity of this algorithm as well as the maternal and fetal safety of this approach.

METHODS

Of the 225 patients identified within the study period who underwent laparoscopic appendectomy, 216 met the inclusion criteria and were retrospectively analyzed. If the US performed on presentation revealed AA, surgery was performed. Patients with a non-diagnostic US were admitted with surgery performed if there was clinical and/or biochemical deterioration. Patients who remained equivocal underwent a repeat delayed study. The results of the initial versus delayed studies were compared. Maternal and fetal complications were recorded and contrasted.

RESULTS

Of the 216 patients included, 164 (75.9%) had AA, 14 (6.5%) had complicated AA and 38 (17.6%) had a normal appendix. Initial US was diagnostic for 125/216 (57.9%) of patients and 19/34 (55.8%) of patients who underwent a delayed repeat study. The remaining patients underwent empirical surgery. The pooled sensitivity and specificity of US for the cohort was 79.2% and 92.1%, respectively. There was no difference in proxies of maternal or fetal safety between the groups.

CONCLUSION

US is a useful tool for diagnosing AA in pregnancy. In this cohort, performing a delayed repeat US during a period of observation in those patients who remained otherwise equivocal increased the diagnostic yield of the US. Delaying surgery in this specific group of patients does not affect maternal or fetal safety.

Location of appendix in pregnancy: does it change?

Objectives

This study aimed to determine the change in anatomical location of appendix in full-term pregnancy.

Study design

This was a descriptive cross-sectional study.

Place and duration of study

Liaquat National University Hospital, Karachi, Pakistan, Department of General Surgery, January 01 to July 31, 2010.

Patients and methods

Full-term pregnant women undergoing caesarean section were enrolled. The anatomical position of the appendix was noted by visual inspection with reference to the transtubercular plane (TTP). SPSS-10 was used for analysis.

Results

Seventy-seven full-term pregnant female patients who underwent caesarean section were included in the study. Their mean age was 29 years, the mean height was 5.3 feet, and mean gestational age was 38 weeks. Appendix was found at the normal anatomical location in 63 out of 77 patients (81.8%), while it was located above the TTP in 14 patients (18.2%).

Conclusion

Appendix does not migrate up with increasing gestational age in the majority of pregnant women. In most full-term pregnant female patients, appendix is located at the normal anatomical position.

Acute appendicitis complicating pregnancy: a 33 case series, diagnosis and management, features, maternal and neonatal outcomes

The occurrence of acute appendicitis during pregnancy may pose diagnostic and therapeutic difficulties. In fact pregnancy can make the clinical diagnosis delicate and the use of morphological examinations is still subject to controversy. The debates concerning the ideal surgical approach during pregnancy continue. On the other hand, in some cases the occurrence of acute appendicitis, especially in its complicated form, which is frequent in pregnant women, exposes to obstetrical complications and an increased risk of premature delivery We aims to describe the clinical and management features of acute appendicitis in pregnant women and the maternal and neonatal outcomes and carry out a review of the literature on this topic. It is a retrospective analysis of a series of 33 cases of appendicitis in pregnant women who were diagnosed and managed, in collaboration between the departments of General and digestive surgery, Gynecology and Obstetrics and Anaesthesia at Farhat Hached Universitary Hospital Sousse Tunisia between January 2005 and December 2015. The average age of the patients was 29 (20-40). Fourteen patients were in the first trimester, twelve in the 2^nd and seven in the third trimester. The main symptom was pain in the right iliac fossa. The mean delay between consultation and surgery was 2.7 days. Twenty five patients had a preoperative ultrasound. Eight of the 33 pregnant patients presented complicated appendicitis with localized or generalized peritonitis. Thirty patients underwent laparotomic appendectomy: 28 with a Mc Burney incision and 2 with a midline incision and only three patients underwent laparoscopy. Preventive tocolysis was given to 14 patients, maternal mortality was null. Twenty four pregnancies were followed until delivery: one case of premature birth and one case of preterm labor were observed. Pregnancy makes it difficult to diagnose appendicitis, which explains the high rate of complicated acute appendicitis in our series. An early treatment improves maternal and fetal outcome.

Accuracy of ultrasonography in diagnosing acute appendicitis during pregnancy based on surgical findings

Background: Acute appendicitis is the most common nonobstetric surgical problem in pregnancy. Common signs and symptoms of appendicitis are less reliable during pregnancy due to physiological changes; thus, the role of imaging becomes prominent. Thus, in the present study, we aimed at assessing the accuracy of sonography in diagnosing acute appendicitis during pregnancy. Methods: In this prospective analytic study, among 1000 patients diagnosed and treated as acute appendicitis, clinical and sonographic findings of 58 consecutive pregnant patients, who underwent appendectomy, were recorded and analyzed. All surgically resected samples were evaluated and confirmed through histological evaluation. Sonographic criteria were utilized to judge the results for appendicitis. Diagnostic test performance characteristics (sensitivity, specificity, predictive values, and likelihood ratios) were calculated. Results: The mean age of the patients was 27.1±4.9 years, and the most common clinical symptom was right lower quadrant pain. There was no significant difference in the mean leukocyte count between the appendicitis group and normal appendix group (p=0.768). Left shift was also unrelated with the appendix pathology (p= 0.549). The sensitivity, specificity, predictive values (positive and negative), and likelihood ratios (positive and negative) were 80%, 75%, 91.4%, 52.9%, 3.2, and 0.26, respectively during all trimesters of pregnancy. Conclusion: Ultrasonography is the initially preferred imaging modality in pregnant women suspected of having acute appendicitis with an acceptable sensitivity; however, application of other imaging modalities such as CT scan or MRI is recommended after inconclusive ultrasonography results.

Differential diagnoses of magnetic resonance imaging for suspected acute appendicitis in pregnant patients

BACKGROUND

Accurate and timely diagnosis of acute surgical disease in pregnant patient is challenging. Although magnetic resonance imaging (MRI) is the most accurate modality to diagnose acute appendicitis in pregnant patients, it is often used as a last resort because of high cost and long scan time. We performed this study to analyze differential diagnoses of appendix MRI and to investigate if there are any blood tests that can predict surgical condition in pregnant patients.

METHODS

A retrospective, cross-sectional study was conducted on 46 pregnant patients who underwent non-enhanced appendix MRI in suspicion of acute appendicitis from 2010 to 2016. Differential diagnoses of appendix MRI were analyzed and blood tests were compared between those who had surgical and non-surgical disease.

RESULTS

Appendix MRI differentiated two surgical disease; acute appendicitis and ovarian torsion; and various non-surgical conditions such as uterine myoma, hydronephrosis, ureterolithiasis and diverticulitis among clinically suspected acute appendicitis in pregnancy. The diagnostic accuracy of MRI for acute appendicitis in this study was 93.5%. Patients who had surgical disease showed significantly higher WBC count (≥11,000/mm³), proportion of neutrophils in the WBC (≥79.9%), neutrophil-to-lymphocyte ratio (NLR≥6.4), levels of C-reactive protein (CRP≥1.82 mg/dL) and bilirubin (≥0.66 mg/dL) than those who had non-surgical disease.

CONCLUSION

MRI can reliably differentiate surgical conditions and several blood tests (WBC, proportion of neutrophils in the WBC, NLR, CRP, bilirubin) can help anticipate acute surgical condition among pregnant patients suspected to have acute appendicitis.

The Role of Conventional Ultrasonography in the Evaluation of Antrum Wall Thickness in Obese Patients

BACKGROUND

The objective of this study is to evaluate the utility of conventional ultrasonography (USG) in the evaluation of the stomach antrum and distal corpus lesions.

METHODS

A prospective evaluation was made of 69 patients who underwent sleeve gastrectomy. Preoperative USG was applied to the patients and measurements were taken and recorded of the stomach antrum full layer wall thickness (USGFT) and of mucosal thickness (USGMT). Postoperatively, same parameters were again measured histopathologically and the pathological full thickness (PFT) and pathological mucosal thickness (PMT) values were compared.

RESULTS

When evaluation was made in respect of USG and pathological measurements, the USGFT was 8.51 ± 3.07 (range 4.5-15.8) and USGMT was 5.80 ± 2.15 (range 2.36-10.5). The PFT was determined as 8.13 ± 2.24 (range 4-14) and PMT as 5.53 ± 1.86 (range 2-10.5). In the histopathological examination, gastritis was seen in 53 (76.8 %) patients and Helicobacter pylori (HP) positivity was determined in 32 (46.4 %) patients. When the patients were grouped as obese (BMI ≤ 49.9 kg/m²) (group 1, n = 50) and super obese (BMI ≥ 50 kg/m²) (group 2, n = 19), no difference was determined between the groups ultrasonographically or histopathologically (p > 0.05). The antrum wall thickness was seen to be significantly greater in the patients with gastritis and HP positivity compared to the patients who were negative. In ROC analysis, cutoff values were calculated for USGFT (5.86 mm) and USGMT (4.49 mm). In gastritis diagnosis, the USGFT cutoff value was found to have 796 % sensitivity and 68.7 % specificity.

CONCLUSION

USG was seen to be an extremely effective method in visualising the antrum wall and gastritis diagnosis can be made comfortably from the wall thickness measurement.

Acute Appendicitis During Pregnancy: Different from the Nonpregnant State?

BACKGROUND

Acute appendicitis is the most common nonobstetric indication for surgical intervention during pregnancy. However, the current literature is scarce and composed of relatively small case series. We aimed to compare the presentation, management, and surgical outcomes of presumed acute appendicitis between a contemporary cohort of pregnant women and nonpregnant women of reproductive age.

METHODS

The study group included 92 pregnant patients who underwent appendectomy for presumed acute appendicitis at a single tertiary medical center in 2000-2014. Preoperative, operative, and postoperative clinical data were derived from medical records and compared to data for 494 nonpregnant patients of reproductive age who underwent appendectomy in 2004-2007 at the same institution.

RESULTS

Median age was 28 years (range 25-33) in the study group and 26 years (range 20-34) in the control group (P = 0.1). There were no between-group differences in mean white blood cell count, patient interval, hospital interval, or operative time. Preoperative abdominal ultrasound was used in a significantly higher proportion of patients in the pregnant group than in the nonpregnant group (73 and 27 %, respectively, P < 0.001) and computed tomography, in a significantly lower proportion of patients (1 vs. 16 %, respectively, P < 0.001) . The two groups had similar rates of negative appendectomy (23 and 22 %, P = 0.9), complicated appendicitis (12 and 11 %, P = 0.9), and overall postoperative complications (15 and 12 %, P = 0.3).

CONCLUSIONS

The clinical presentation and outcome of presumed acute appendicitis are similar in pregnant women and nonpregnant women of reproductive age. Therefore, similar perioperative management algorithms may be applied in both patient populations.

Acute Appendicitis in Pregnancy and the Developing World

Background

Acute appendicitis is the commonest nonobstetric surgical emergency during pregnancy. The aim of the study was to compare perioperative outcomes of acute appendicitis in pregnant and nonpregnant patients.

Methods

A retrospective review of medical records of 56 pregnant patients between 2011 and 2016 who were compared with 164 nonpregnant women of reproductive age who underwent open appendectomy between 2014 and 2016 for acute appendicitis. The patient's demographics and perioperative data were analyzed.

Results

The median age of pregnant and nonpregnant patients observed was 26 years (range 19–37) and 26 years (range 18–43). There were no significant differences between the groups in negative appendectomy (21.4 and 21.3%, P = 0.52), perforated appendicitis (25 and 23.8%, P = 0.85), postoperative complications (28.6 and 26.8%, P = 0.80), and median length of hospital stay (5 and 4.5 days, P = 0.36). There were 3.6% preterm labour, no maternal mortality, and no fetal loss. In multivariate analysis, WBC >18000/mm³ and long patient time to surgery were independent risk factors for appendicular perforation and postoperative complication (P < 0.05).

Conclusion

Our results of appendectomy in pregnant patients are comparable with nonpregnant patients. Hence the same perioperative treatment protocol can be followed in pregnant and nonpregnant patients even in resource-poor setting.

Clinical use of MRI for the evaluation of acute appendicitis during pregnancy

PURPOSE

The purpose of this study was to determine the diagnostic accuracy of MRI for detecting acute appendicitis in pregnancy in a multi-institution study involving general body MR readers with no specific expertise in MR imaging of the pregnant patient.

METHODS

Retrospective review of MRI examinations on PACS in 42 pregnant patients was evaluated for acute right lower quadrant pain. Three fellowship-trained general body radiologists analyzed the MRI examinations in consensus and attempted to localize the appendix, assess for features of appendicitis, and exclude alternative etiologies for the right lower quadrant pain.

RESULTS

Of the 42 MRI examinations, the readers noted 6 cases of acute appendicitis, 16 cases of a normal appendix, and 20 cases involving non-visualization of the appendix but where there were no secondary features of acute appendicitis. Based on the surgical data and clinical follow-up, there were 3 true-positive cases, 3 false-positive cases, 34 true-negative cases, and 2 false-negative cases of acute appendicitis on MRI. This yielded an accuracy of 88.1%, sensitivity of 60%, specificity of 91.9%, positive predictive value of 50%, and negative predictive value of 94.4% for the detection of acute appendicitis in the pregnant patient on MRI. Alternative etiologies for the right lower quadrant pain on MRI included torsion of an ovarian dermoid in 1 case and pyelonephritis in 1 case.

CONCLUSION

MRI is an excellent modality for excluding acute appendicitis in pregnant patients presenting with right lower quadrant pain.

Efficacy of the Evaluation of Inflammatory Markers for the Reduction of Negative Appendectomy Rates

Unnecessary appendectomy can cause complications; ways of reducing negative appendectomy rates (NAR) using biochemical and imaging methods are desirable. We retrospectively examined 640 patients who underwent appendectomy for suspected AA. Patients with histologically confirmed appendicitis were designated the positive appendectomy group (n = 565), whereas those with unconfirmed appendicitis were designated the negative appendectomy group (n = 75). The positive appendectomy group was subdivided into the non-perforated (n = 511) and perforated (n = 54) appendectomy groups according to pathology reports. We compared the age, sex, lymphocyte count, neutrophil percentage, pathologic positivity or negativity for appendicitis, C-reactive protein (CRP) level, neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR) of the patients. When the perforated, non-perforated, and negative appendectomy groups were compared, the highest CRP level, NLR, and PLR were evident in the perforated appendectomy group (p = 0.001), whereas the lowest neutrophil percentage was found in the non-perforated appendectomy group (p = 0.001). Multiple logistic regression analysis identified neutrophil percentage, CRP value, and NLR as independent variables and demonstrated that AA could be diagnosed with 88.9 % accuracy using the cutoff values determined. In patients with suspected AA, particularly in rural areas with limited access to advanced imaging modalities, the evaluation of neutrophil percentage, CRP level, and NLR, in combination with the findings of a physical examination, may aid diagnosis and reduce NAR.

The diagnostic performance of ultrasound for acute appendicitis in pregnant and young nonpregnant women: A case-control study

BACKGROUND

Ultrasonography is frequently used to diagnose acute appendicitis in women of reproductive age, but its diagnostic value in pregnant patients remains unclear. This study sought to compare the diagnostic performance of ultrasound in pregnant and young nonpregnant women with suspected acute appendicitis.

METHODS

The database of a single tertiary medical center was reviewed for all women of reproductive age who underwent appendectomy either during pregnancy (2000-2014) or in the nonpregnant state (2004-2007) following ultrasound evaluation. The performance of ultrasound in terms of predicting the final pathologic diagnosis was compared between the pregnant and non pregnant groups using receiver operating characteristic curve analysis.

RESULTS

Of 586 young women treated for appendicitis during the study periods (92 pregnant, 494 non-pregnant), 200 underwent preoperative ultrasound [67 pregnant, and 133 nonpregnant young women]. The pregnant and nonpregnant groups were comparable in age and presenting symptoms. There was no significant difference in the predictive performance of ultrasound between the two groups (AUC 0.76 and 0.73 respectively, p = 0.78) or within the pregnant group, by trimester [first (n = 23), AUC 0.73; second (n = 32), AUC 0.67; third (n = 12), AUC 0.86; p = 0.4]. Ultrasound had a positive predictive value of 0.94 in the pregnant group and 0.91 in the nonpregnant group; corresponding negative predictive values were 0.40 and 0.43.

CONCLUSIONS

There appears to be no difference in the ability of ultrasound to predict the diagnosis of acute appendicitis between pregnant women and nonpregnant women of reproductive age. Therefore, similar preoperative imaging algorithms may be used in both patient populations.

Appendicitis in Diabetics: Predictors of Complications and Their Incidence

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

Predictive role of neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios for diagnosis of acute appendicitis during pregnancy

Acute appendicitis (AA) is not uncommon during pregnancy but can be difficult to diagnose. This study evaluated the neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) in addition to conventional diagnostic indicators of the disease to diagnose AA during pregnancy. Age, gestational age, white blood cell (WBC) count, Alvarado scores, C-reactive protein (CRP), lymphocyte count, NLR and PLR were compared among 28 pregnant women who underwent surgery for AA, 35 pregnant women wrongly suspected as having AA, 29 healthy pregnant women, and 30 nonpregnant healthy women. Mean WBC counts and CRP levels were higher in women with proven AA than in those of control groups (all p < 0.05). Among all the groups, the median NLR and PLR were significantly different in women with proven AA (all p < 0.05). Receiver operating characteristic analysis was used to determine cut-off values for WBC count, CRP, lymphocyte count, NLR and PLR, and multiple logistic regression analysis showed that NLR and PLR used with routine methods could diagnose AA with 90.5% accuracy. Used in addition to routine diagnostic methods, NLR and PLR increased the accuracy of the diagnosis of AA in pregnant women.