Acute appendicitis: epidemiology, diagnostic accuracy, and complications

Diagnostic Accuracy Rates of Appendicitis Scoring Systems for the Stratified Age Groups

BACKGROUND

Many scoring systems have been developed for acute appendicitis, which is the most common emergent disorder in surgical practice. Considering the physiological changes and chronic diseases occurring with advancing age, an applied scoring system may not produce the same score in similar patients in all age groups.

OBJECTIVES

We aimed to compare the predictive values of scoring systems in different age groups.

METHODS

In this prospective study, the patients operated on in our clinic with a prediagnosis of acute appendicitis between March 2020 and March 2021 were included. We divided them into three age groups as 18-45 years (group 1), 46-65 years (group 2), and >65 years (group 3). We compared the scores of the nine acute appendicitis scoring systems most commonly used in the literature for these age groups.

RESULTS

A total of 203 patients were included in our study. The Alvarado scoring system yielded the most accurate results for group 1, whereas the Fenyo-Linberg scoring system was the most accurate system for group 2 and the Eskelinen scoring system for group 3.

CONCLUSION

Age should be considered as a major parameter during the selection of the scoring system to be applied for patients with prediagnosis of acute appendicitis. Our study revealed the Alvarado and the Fenyo-Lindberg scoring systems as the most accurate systems for the differential diagnosis of appendicitis in the 18-45 and 46-65 years age groups, respectively. Although we found the Eskelinen scoring system as the most accurate one in the >65 years age group, the confidence intervals indicated that it may not be appropriate for use alone in this group.

Evidence-based appendicitis: the initial work-up

In this article we provide an evidence-based review of appendicitis, which is one of the most challenging conditions to diagnose in patients presenting with abdominal pain. Almost all clinicians are faced with the diagnostic work-up of these patients, and missing the diagnosis can result in patient decompensation. We review the literature from the initial description of McBurney's point to the clinical presentation, as well as the most appropriate imaging testing. Additionally, we review the usefulness of specific diagnostic laboratory tests. The use of computed tomography scans has reduced negative appendectomy rates when combined with a physical examination, and assists in ruling out appendicitis. Computed tomography scans with no contrast or just rectal contrast are becoming the standard in many institutions. It is essential that when the diagnosis of abdominal pain of unclear etiology is suspected, the clinician's discussion with the patient is well documented on the patient's chart.

Laparoscopic appendectomy for perforated appendicitis: a comparison with open appendectomy

BACKGROUND

The role of laparoscopic appendectomy for perforated appendicitis remains controversial. This study aimed to compare laparoscopic and open appendectomy outcomes for children with perforated appendicitis.

METHODS

Over a 36-month period, 111 children with perforated appendicitis were analyzed in a retrospective review. These children were treated with either laparoscopic (n = 59) or open appendectomy. The primary outcome measures were operative time, length of hospital stay, time to adequate oral intake, wound infection, intraabdominal abscess formation, and bowel obstruction.

RESULTS

The demographic data, presenting symptoms, preoperative laboratory values, and operative times (laparoscopic group, 61 +/- 3 min; open group, 57 +/- 3 were similar for the two groups (p = 0.3). The time to adequate oral intake was 104 +/- 7 h for the laparoscopic group and 127 +/- 12 h for the open group (p = 0.08). The hospitalization time was 189 +/- 14 h for the laparoscopic group, as compared with 210 +/- 15 h for the open group (p = 0.3). The wound infection rate was 6.8% for the laparoscopic group and 23% for the open group (p < 0.05). The wounds of another 29% of the patients were left open at the time of surgery. The postoperative intraabdominal abscess formation rate was 13.6% for the laparoscopic group and 15.4% for the open group. One patient in each group experienced bowel obstruction.

CONCLUSIONS

Laparoscopic appendectomy for the children with perforated appendicitis in this study was associated with a significant decrease in the rate of wound infection. Furthermore, on the average, the children who underwent laparoscopic appendectomy tolerated enteral feedings and were discharged from the hospital approximately 24 h earlier than those who had open appendectomy.

[Comparative incidence of acute appendicitis in a mixed population, related to skin color]

BACKGROUND

Acute appendicitis is a very common surgical emergency, but its etiology and pathology remain incompletely understood.

OBJECTIVE

To elucidate epidemiological aspects of acute appendicitis related to skin color, gender and age.

METHODS

Five-hundred patients operated on for acute appendicitis, and other 500 patients treated for different diseases and considered as a control group were studied at "Hospital das Clinicas", Federal University of Minas Gerais, Belo Horizonte, MG, Brazil. Gender, age and skin color were investigated. The results were compared by chi-square test.

RESULTS

There was no prevalence related to gender. A significant prevalence of white patients (73.8%) was verified in this series. The number of white men with appendicitis was significantly higher than white men in the control group. The incidence of black patients with appendicitis was significantly lower than black patients of the control group. The mean age was 23.2 years old for the white patients with appendicitis and 32.3 years old for the black patients.

CONCLUSIONS

The present paper shows an evident relation between appendicitis and white skin color.

Sex-specific diagnostic scores for acute appendicitis

The role of clinical and computer-based decisions in the diagnosis of acute appendicitis was studied in connection with the survey of acute abdominal pain by the Research Committee of the World Organization of Gastroenterology (OMGE). One thousand three hundred and thirty-three patients presenting with acute abdominal pain were included in the study. Twenty-two preoperative clinical history variables, 14 clinical signs, and 3 tests were evaluated in a multivariate analysis to find the best combination of independent predictors of acute appendicitis for males and females. Independent predictors of acute appendicitis in males were tenderness, previous abdominal surgery, rebound, rigidity, location of pain at diagnosis, guarding, and body temperature. To sum up the contributions of the most significant diagnostic factors, a diagnostic score (DS) was built. When the male patients with a DS value between -2.00 and -0.48 were considered nondefined (n = 75, follow-up required before deciding to operate), the sensitivity of the computer-aided diagnosis in detecting acute appendicitis in males was 0.95, with a specificity of 0.89 and an efficiency of 0.91. In males whose leucocyte count was available (n = 476), previous abdominal surgery, leucocytosis, location of pain at diagnosis, tenderness, rigidity, rebound, guarding, rectal digital tenderness, and body temperature predicted significantly acute appendicitis. The DS reached a sensitivity of 0.94 (the cut-off level was -1.74), with a specificity of 0.80 and an efficiency of 0.84. (ABSTRACT TRUNCATED AT 250 WORDS)

Correlation of peritoneal aspiration cytology with acute appendicitis

Fifty-one patients in whom a clinical diagnosis of acute appendicitis had been made underwent peritoneal aspiration cytology (PAC). Thirty-six had a positive result, 11 had a negative result and aspiration failed in four cases. All patients had an appendicectomy and the histological findings were correlated with the PAC results. Thirty-five of the 36 patients with a positive PAC had histologically proven appendicitis. Seven of the 11 patients with a negative result had normal appendices. The sensitivity of PAC for acute appendicitis was 85% and the specificity was 70%. The positive predictive value was found to be 97% and the negative predictive value 60%. Peritoneal aspiration cytology is a useful aid in the diagnosis of acute appendicitis however, a negative result does not exclude this diagnosis.

Role of sequential leucocyte counts and C-reactive protein measurements in acute appendicitis

The accurate clinical diagnosis of acute appendicitis is difficult, and many techniques have been suggested to improve diagnostic accuracy such as laparoscopy, ultrasonography and barium enema examination. In this study serial total leucocyte counts and serial C-reactive protein (CRP) concentrations in acute appendicitis were measured. The sensitivity and specificity of serial leucocyte counts in acute appendicitis were 92 and 100 per cent, and for CRP concentrations 69 and 75 per cent, respectively. The sensitivity and specificity of serial total leucocyte counts fulfilled the criteria for a diagnostic test. It is suggested that in patients with equivocal clinical findings, clinical observation combined with serial leucocyte counts may improve decision making.

The value of laboratory tests in patients suspected of acute appendicitis

The clinical usefulness of laboratory tests was examined in 258 patients admitted to the emergency room with the general practitioner's tentative diagnosis, acute appendicitis. Acute appendectomy was performed on 91 patients. Histological examination of the appendix confirmed the diagnosis in 69 cases (acute appendicitis 20, phlegmonous appendicitis 36, perforation 13). Seven patients with appendicular infiltrate were not subjected to operation but the diagnosis was clear from clinical examination. On close examination/operation by the surgical team, 96 admitted patients were excluded from the primary diagnosis, acute appendicitis, and served as a control group. Receiver Operation Characteristic curves (ROC-curves) showed that the sensitivity and specificity and hence diagnostic efficiency for total white blood cell count, number of segmented leukocytes and C-reactive protein concentration for the detection of acute appendicitis were higher than for erythrocyte sedimentation rate, alpha 1-antiproteinase concentration and body temperature. We observed that when all three parameters, C-reactive protein, white blood cell count and segmented leukocytes, are within the normal range the diagnosis, acute appendicitis is highly unlikely. The diagnostic value of the different laboratory parameters appears, moreover, to be highly dependent on the degree of inflammation/perforation and the development of appendicular infiltration. However, diagnostic efficiency can be improved, and unnecessary surgery prevented, by performance of an appropriately selected combination of laboratory tests combined with evaluation of clinical symptoms.

Aids in the diagnosis of acute appendicitis

Methods used to improve the accuracy of diagnosis of acute appendicitis are reviewed. Laparoscopy, barium enema, ultrasonography and computer assistance have all been shown to improve accuracy, but no one method is of proven superiority. Such diagnostic aids or intensive in-hospital observation must be used to reduce the 15-30 per cent negative laparotomy rate when acute appendicitis is suspected, without increasing the incidence of appendiceal perforation.

Appendicitis near its centenary

In an analysis of the first 72 cases treated after the formulation of the appendicitis syndrome in 1886 compared with the experience from 1929-1959 and with 307 randomly selected recent cases, the major therapeutic trend has been an emphasis on appendectomy before perforation and abscess formation occur. The rate of infection nonetheless remains approximately 17%. Although the overall mortality rate has declined from 26% overall (40% for surgery) to 0.8%, the current rate of perforation is 28%, with a diagnostic accuracy of 82%. Among 13,848 patients from several reports the perforation rate increases linearly with diagnostic accuracy; therefore, a balance must be sought. Delay awaiting a diagnosis is a major determinant of perforation, but diagnostic aids are of limited help. Clinical acuity and prudent decisiveness are the keys to proper action.