White Cell Count and C-Reactive Protein Measurement in Patients with Possible Appendicitis

INTRODUCTION

Clinical assessment outweighs the use of investigations in the diagnosis of acute appendicitis. Nevertheless, white cell count (WCC) and C-reactive protein (CRP) are regularly measured in patients with suspected appendicitis. The aim of this study was to assess the utility of these markers in patients presenting with acute lower abdominal pain.

PATIENTS AND METHODS

WCC and CRP were measured prospectively in 98 patients presenting with lower abdominal pain, and the results were correlated with each patient''s outcome.

RESULTS

No patients with WCC and CRP both in the normal range had acute appendicitis. Raised WCC and CRP were poor positive predictors of appendicitis, both alone and in combination, and correlated poorly with the development of complications.

CONCLUSIONS

This result may have important clinical and economic implications. We suggest that patients experiencing lower abdominal pain, with normal WCC and CRP values, are unlikely to have acute appendicitis and can be safely sent home.     

The value of hyperbilirubinaemia in the diagnosis of acute appendicitis

INTRODUCTION

No reliably specific marker for acute appendicitis has been identified. Although recent studies have shown hyperbilirubinaemia to be a useful predictor of appendiceal perforation, they did not focus on the value of bilirubin as a marker for acute appendicitis. The aim of this study was to determine the value of hyperbilirubinaemia as a marker for acute appendicitis.

MATERIALS AND METHODS

A retrospective analysis of appendicectomies performed in two hospitals (n=472). Data collected included laboratory and histological results. Patients were grouped according to histology findings and comparisons were made between the groups.

RESULTS

The mean bilirubin levels were higher for patients with simple appendicitis compared to those with a non-inflamed appendix (p<0.001). More patients with simple appendicitis had hyperbilirubinaemia on admission (30% vs 12%) and the odds of these patients having appendicitis were over three times higher (odds ratio: 3.25, p<0.001). Hyperbilirubinaemia had a specificity of 88% and a positive predictive value of 91% for acute appendicitis. Patients with appendicitis who had a perforated or gangrenous appendix had higher mean bilirubin levels (p=0.01) and were more likely to have hyperbilirubinaemia (p<0.001). The specificity of hyperbilirubinaemia for perforation or gangrene was 70%. The specificities of white cell count and C-reactive protein were less than hyperbilirubinaemia for simple appendicitis (60% and 72%) and perforated or gangrenous appendicitis (19% and 36%).

CONCLUSIONS

Hyperbilirubinaemia is a valuable marker for acute appendicitis. Patients with hyperbilirubinaemia are also more likely to have appendiceal perforation or gangrene. Bilirubin should be included in the assessment of patients with suspected appendicitis.     

Diagnostic markers in acute appendicitis

Background

An adequate medical history combined with clinical examination is usually enough to make the diagnosis of acute appendicitis. The aim of this study was to determine the value of elevated white cell count (WCC), C-reactive protein (CRP), and bilirubin as diagnostic markers of acute appendicitis.

Methods

A retrospective analysis was carried out on consecutive patients who underwent appendicectomy over a 3-year period. All data including patients' age, sex, blood test results, and appendix histology were summarized. Sensitivities, specificities, positive, and negative predictive values of WCC, CRP, and bilirubin were calculated separately or in combination for all patients.

Results

A total of 447 patients were included. There is a significant difference in the results between patients with negative and positive appendicitis with regards to CRP (32 vs 73; P < .001), mean total WCC (10.9 vs 14.0; P < .001), and the mean levels of bilirubin (10.9 vs 17.2; P < .001).

Conclusions

The diagnosis of appendicitis remains multifactorial and blood tests may help to guide the surgeon in the decision making.     

72 h Is the Time Critical Point to Operate in Acute Appendicitis

Background and Aims

Delay of operative management of acute appendicitis may adversely affect post-operative outcomes and increase the likelihood of post-operative complications occurring. We aim to correlate the duration of symptoms with intra-operative findings to create a timeline of the pathological change in appendicitis.

Methods

Appendicectomies performed at a large teaching hospital between June 2015 and July 2016 were prospectively analysed. Time of onset of pain, operative findings, pre-operative C-reactive protein (CRP) and white cell count (WCC) were recorded. Intra-operative findings were categorised by the macroscopic appearance of the appendix, which was subdivided into erythematous, purulent, necrotic and perforated. These results were correlated with the symptom duration. Statistical analysis was completed using Mann-Whitney U and Chi-squared tests.

Results

One hundred and ninety patients had histologically confirmed appendicitis during the study period. Median time to operation from symptom onset was 49 h. Median time for the appearances of erythematous, purulent, necrotic and perforated appendicitis to develop was 36.5, 41, 55.5 and 86 h, respectively (p value < 0.0001). Median CRP of the non-perforated and perforated appendicitis groups was 22 and 161 mg/L, respectively (p value < 0.0001). Our data demonstrated that after 72 h of symptoms, the likelihood of a perforated appendicitis increased significantly (p value < 0.0001) when compared to 60–72 h.

Conclusions

A significant increase in the likelihood of a perforated appendicitis occurs after 72 h of symptoms, when compared to 60–72 h. We can therefore argue that it may be reasonable to prioritise patients approaching 72 h of symptoms for operative management.

     

Role of the faecolith in modern-day appendicitis

Introduction

The prevailing view on appendicitis is that the main aetiology is obstruction owing to faecoliths in adults and lymphoid hyperplasia in children. Faecoliths on imaging studies are believed to correlate well with appendicitis.

Methods

A retrospective chart review was conducted of 1,014 emergency appendicectomy patients between 2001 and 2011. Faecolith prevalence in adult and paediatric appendicectomy specimens with and without perforation was studied. The sensitivity and positive predictive value (PPV) of computed tomography (CT) for identifying faecoliths in the pathology specimen were examined.

Results

Overall, faecoliths were found in 18.1% (178/986) of appendicitis specimens and 28.6% (8/28) of negative appendicectomies. Faecolith prevalence for positive cases was 29.9% (79/264) in paediatric patients and 13.7% (99/722) in adults (p<0.05). Faecolith prevalence was 39.4% in perforated appendicitis but only 14.6% in non-perforated appendicitis (p<0.05). In adults, faecolith prevalence was 27.5% in perforated appendicitis and 12.0% in non-perforated appendicitis (p<0.05) while in paediatric patients, it was 56.1% in perforated appendicitis and 22.7% in non-perforated appendicitis (p=0.00). Sensitivity and PPV of preoperative CT in identifying faecoliths on pathology were 53.1% (86/162) and 44.8% (86/192) respectively.

Conclusions

Faecolith prevalence is too low to consider the faecolith the most common cause of non-perforated appendicitis. Faecoliths are more prevalent in paediatric appendicitis than in adult appendicitis. Preoperative CT is an unreliable predictor of faecoliths in pathology specimens.     

Factors predicting significant pathology on ultrasonography in women presenting with non-specific lower abdominal pain

INTRODUCTION

Ultrasonography is used frequently to exclude significant pathology in young women presenting with nonspecific lower abdominal pain (NSLAP). This study examined parameters that predicted the likelihood of significant findings on ultrasonography. These results could be used to select patients for priority imaging or identify those who could be managed with no ultrasonography.

METHODS

A total of 65 women with NSLAP were identified from 283 admissions. Group 1 (n=42) consisted of patients with normal imaging. Group 2 (n=23) included patients with ‘positive’ scans requiring treatment. White cell count (WCC), C-reactive protein (CRP) levels, platelet count, age, duration of pain and length of stay in hospital were compared between the groups.

RESULTS

The median WCC and CRP were greater in Group 2 than in Group 1: 15 x 10⁹/l and 123mg/l versus 11 x 1071 and 72mg/l respectively (p=0.01 and p=0.05). CRP was a weak predictor of positive pathology on ultrasonography (area under curve [AUC]=0.66, p=0.027) and WCC was a strong predictor of abnormal pathology on ultrasonography (AUC=0.7, p=0.005). A WCC of >12.8 x 10⁹/l was 65% sensitive and 71% specific in predicting subsequent pathology on ultrasonography. The median wait for ultrasonography was 24 hours (range: 1-96 hours).

CONCLUSIONS

This study failed to define any criteria that could select patients not requiring ultrasonography. Since ultrasonography is a relatively cheap and safe investigation, its continued use to screen women with NSLAP is justified. WCC should be used to prioritise imaging.     

Ultrasonography aids decision-making in children with abdominal pain

INTRODUCTION

Although regular clinical assessment of the acute abdomen is considered best practice, ultrasonography confirming the presence of appendicitis will add to the decision-making process. The aim of this study was to assess the accuracy of ultrasonography and its usefulness in diagnosing acute appendicitis in a regional paediatric surgical institution.

METHODS

Retrospectively and in this order, radiology, theatre and histopathology databases were searched for patients who had presented with acute abdominal pain, patients who had undergone an appendicectomy and all appendix specimens over a two-year period. The databases were cross-referenced against each other.

RESULTS

A total of 273 non-incidental appendicectomies were performed over the study period. The negative appendicectomy rate was 16.5% and the perforation rate 23.7%. Thirty-nine per cent of children undergoing an appendicectomy had at least one pre-operative ultrasound scan. Ultrasonography as a diagnostic tool for acute appendicitis in children had a sensitivity of 83.3%, a specificity of 97.4 %, a positive predictive value of 92.1% and a negative predictive value of 94.0%.

CONCLUSIONS

Ultrasonography is used liberally to aid in the decision making process of equivocal and complicated cases of acute appendicitis and it achieves good measures of accuracy. As a diagnostic tool it is unique in its ability to positively predict as well as exclude. A high negative predictive value suggests that more patients could be managed on an outpatient basis following a negative scan.     

Predictive value of white blood cell count and C-reactive protein in children with appendicitis

Background/Purpose

Few studies have addressed the predictive value of white blood cells (WBCs) and C-reactive protein (CRP) at different cutoff values in appendicitis. Our purpose was to determine the cutoff values for WBC and CRP at different periods during clinical evolution of appendicitis and to establish their use for the diagnosis of appendicitis and differentiation of simple from perforated appendicitis.

Methods

We studied 198 patients operated on for appendicitis, which were further divided into 4 subgroups according to the time from the onset of symptoms to diagnosis. Receiver operating characteristic curves were constructed for CRP and WBC; the best cutoff points were used to calculate the sensitivity and specificity to discriminate patients with and without appendicitis and patients with simple and perforated appendicitis.

Results

White blood cell and CRP individually and together had a high sensitivity to differentiate patients with and without appendicitis. The specificity of WBC and CRP taken individually and together to differentiate patients with simple and perforated appendicitis was high, but the sensitivity was low.

Conclusions

White blood cell and CRP could be used to support the clinical diagnosis of appendicitis, and, depending on the time from the onset of symptoms to diagnosis, to differentiate patients with and without appendicitis and discriminate simple from perforated appendicitis.     

Endoloop versus endostapler closure of the appendiceal stump in pediatric laparoscopic appendectomy

Background

There is little information available to inform choice of technique for appendiceal stump control in pediatric laparoscopic appendectomy (LA). We compared complications (stump leak, intra-abdominal abscess formation [IAA], surgical site infection [SSI]) in children undergoing LA for perforated (PA) and nonperforated appendicitis (NPA) by technique of appendiceal stump control.

Methods

All children who underwent LA for confirmed acute appendicitis between 2006 and 2009 were reviewed. Choice of stump control (endoloop [EL] or endostapler [ES]) was determined by surgeon preference. Interactions between stump closure techniques and other potential confounders (intra-abdominal drain, irrigation, different antibiotic regimens) were explored using a logistic regression model.

Results

Of 242 patients undergoing LA, 57 (23.6%) had PA. In the PA group the appendiceal stump was closed with EL in 47 (82.5%) patients, while in the NPA group EL was used in 161 (87%) patients. Among PA patients, IAA was more common in the ES than the EL group (5 of 10 [50%] v. 6 of 47 [12.7%]). There was no significant difference in rates of SSI. Among NPA patients, there were no differences in rates of IAA or SSI. There were no stump leaks in either group. Logistic regression analysis confirmed the predictive effect of ES use on IAA formation in PA (adjusted odds ratio 7.09; 95% confidence interval 1.08–46.13; p = 0.042).

Conclusion

Our data suggest that in most cases of PA, the appendiceal stump can be safely controlled with EL. Within the PA group, the higher rates of IAA seen in ES patients may be attributable to the quality of the appendiceal stump rather than the technique of closure.     

A Comparison of Laparoscopic and Open Appendectomy

Background and Objectives:

To compare laparoscopic appendectomy with traditional open appendectomy.

Methods:

Seventy-one patients requiring operative intervention for suspected acute appendicitis were prospectively compared. Thirty-seven patients underwent laparoscopic appendectomy, and 34 had open appendectomy through a right lower quadrant incision. Length of surgery, postoperative morbidity and length of postoperative stay (LOS) were recorded. Both groups were similar with regard to age, gender, height, weight, fever, leukocytosis, and incidence of normal vs. gangrenous or perforated appendix.

Results:

Mean LOS was significantly shorter for patients with acute suppurative appendicitis who underwent laparoscopic appendectomy (2.5 days vs. 4.0 days, p<0.01). Mean LOS was no different when patients classified as having gangrenous or perforated appendicitis were included in the analysis (3.7 days vs. 4.1 days, P=0.11). The laparoscopy group had significantly longer surgery times (72 min vs. 58 min, p<0.001). There was no significant difference in the incidence of postoperative morbidity.

Conclusions:

Laparoscopic appendectomy reduces LOS as compared with the traditional open technique in patients with acute suppurative appendicitis. The longer operative time for the laparoscopic approach in our study is likely related to the learning curve associated with the procedure and did not increase morbidity.     

Admission inflammatory markers and isolation of a causative organism in patients with spontaneous spinal infection

Introduction

The purpose of this study was to investigate the significance of the inflammatory markers on admission in the isolation of a causative pathogen in patients with spinal infection. Spinal infection is treated frequently at spinal units and can encompass a broad range of clinical entities. Its diagnosis is often delayed because of the difficulty of identifying the responsible pathogen.

Methods

Patients with spinal infection treated in our institution over a period of eight years were identified and their notes studied retrospectively. Admission C-reactive protein (CRP), white cell count (WCC) as well as co-morbidities and mode of pathogen identification were recorded. Overall, 96 patients were included in the study.

Results

The CRP levels on admission were correlated significantly with the overall potential for isolation of a pathogen (p<0.0001) and positive biopsy cultures (p=0.0016). Admission WCC levels were associated significantly with the overall potential for isolation of a pathogen (p=0.0003) and positive biopsy cultures (p=0.0023). Both CRP and WCC levels were significantly negatively correlated with the duration of the preceding symptoms (p=0.0003 and p<0.0001 respectively). Delay in presentation was significantly negatively correlated with organism isolation (p=0.0001). Multivariate analyses identified the delay in presentation as the strongest independent variable for organism isolation (p=0.014) in cases of spontaneous spinal infection when compared with the admission CRP level (p=0.031) and WCC (p=0.056).

Conclusions

In spontaneous spinal infection, delay in presentation is the strongest independent variable for organism isolation. High inflammatory marker levels on admission are a useful prognostic marker for the overall potential of isolating a causative organism either by blood cultures or by biopsy in patients with negative blood cultures. Furthermore, the admission inflammatory marker levels allow for treating surgeons to counsel their patients of the likelihood of achieving a positive microbiological yield from biopsy.     

Association between the appendix and the fecalith in adults

Background

We sought to determine the association between the presence of a fecalith and acute/nonperforated appendicitis, gangrenous/perforated appendicitis and the healthy appendix.

Methods

We retrospectively analyzed appendectomies performed between October 2003 and February 2012. We collected data on age, sex, appendix histology and the presence of a fecalith.

Results

During the study period, 1357 appendectomies were performed. Fecaliths were present in 186 patients (13.7%). There were 94 male (50.5%) and 92 female patients, and the mean age was 32 (range of 10–76) years. The fecalith rate was 13%–16% and was nonexistant after age 80 years. The main groups with fecaliths were those with acute/nonperforated appendicitis (n = 121, 65.1%, p = 0.041) and those with a healthy appendix (n = 65, 34.9%, p = 0.003). The presence of fecaliths in the gangrenous/perforated appendicitis group was not significant (n = 19, 10.2%, p = 0.93). There were no fecaliths in patients with serositis, carcinoid or carcinoma.

Conclusion

Our data confirm the theory of a statistical association between the presence of a fecalith and acute (nonperforated) appendicitis in adults. There was also a significant association between the healthy appendix and asymptomatic fecaliths. There was no correlation between a gangrenous/perforated appendix and the presence of a fecalith. The fecalith is an incidental finding and not always the primary cause of acute (nonperforated) appendictis or gangrenous (perforated) appendicitis. Further research on the topic is recommended.     

The influence of age on the severity of peritonitis

Objective

To evaluate the influence of age on the evolution and severity of peritonitis.

Design

A chart review.

Setting

An adult university hospital.

Patients

One hundred and twenty-two patients with acute appendicitis and 100 patients with acute colonic diverticulitis requiring operation or percutaneous drainage.

Main Outcome Measures

Patient age and sex, presence of perforation or gangrene (appendicitis), extent of peritonitis (diverticulitis); duration of symptoms prior to admission; admission leukocyte count; duration of hospitalization before surgery; length of hospital stay; and death rate.

Results

Patients with acute appendicitis who were aged 65 years or older were three times more likely than younger patients to have a gangrenous or perforated appendix (odds ratio 3.1, 95% confidence interval 1.1 to 8.4, p < 0.05); older patients with perforated diverticulitis were three times more likely than younger patients to have generalized peritonitis than localized (pericolic or pelvic) peritonitis (odds ratio 2.9, 95% confidence interval 1.2 to 7.5, p < 0.05).

Conclusion

These findings are consistent with the hypothesis that the biologic features of peritonitis differ in the elderly, who are more likely to present with an advanced or severe process than young patients.     

Para-iliac actinomycetoma presenting as sarcoma,a late complication of appendicitis: A case report

INTRODUCTION

Actinomycosis is known to mimic several types of neoplasms, leading to morbid surgical interventions.

PRESENTATION OF CASE

We report the particular case of an extensive right para-iliac actinomycetoma presenting as a sarcoma, which to our knowledge has not yet been described in the literature, in a patient with previous ruptured appendicitis. Thanks to the collaborative work between the orthopedic and general surgeons, pathologist and microbiologist, the diagnosis of actinomycosis was made pre-operatively, saving this 15-year-old patient from a tumor resection protocol.

DISCUSSION

Actinomycetomas have often been reported to present in the same way as several abdominal and gynecological neoplasms, and on rare occasions been described as mimicking other soft-tissue sarcomas, leading to unnecessary morbid tumor resection protocols. The most common cause of abdominal actinomycosis is perforated appendicitis, and may present several years later.

CONCLUSION

While faced with a soft tissue mass transgressing tissue planes and possibly extending to the region of the right lower quadrant, especially with a history of previous perforated appendicitis, one should consider the possibility of an abscess caused by pathogens of intestinal origin, including the gram positive anaerobe Actinomycosis israelii. Failure to actively search for this pathogen, which is not detectable with routine staining techniques and may take up to 1–2 weeks to isolate, may lead to unnecessary morbid surgical procedures.     

Single-incision laparoscopic appendectomy for treating appendicitis in a patient with gastrointestinal malrotation

INTRODUCTION

Intestinal malrotation is a rare congenital anomaly, and acute appendicitis associated with intestinal malrotation is extremely rare.PRESENTATION OF CASE We report a rare case of a 47-year-old Japanese woman diagnosed with barium-related perforated appendicitis associated with intestinal malrotation. We used a transumbilical single-incision laparoscopic approach to resect the appendix, and the procedure was completed successfully without perioperative complications.

DISCUSSION

To our knowledge, single-incision laparoscopic surgery for appendicitis associated with intestinal malrotation has not been reported yet. In cases with mobile cecum such as this one, mobilization from inflammatory adhesion of the surrounding structures is easy.

CONCLUSION

We conclude that transumbilical single-incision laparoscopic appendectomy is a simple and less invasive method for treating appendicitis associated with intestinal malrotation.     

Bladder injuries in emergency/expedited laparoscopic surgery in the absence of previous surgery: a case series

INTRODUCTION

The use of laparoscopy as a diagnostic and therapeutic tool is being used increasingly in the emergency setting with many of these procedures being performed by trainees. While the incidence of iatrogenic injuries is reported to be low, we present six emergency or expedited cases in which the bladder was perforated by the suprapubic trocar.

CASES

Three cases were related to the management of appendicitis, two to negative diagnostic laparoscopies for lower abdominal pain and one to an ectopic pregnancy. Management of the bladder injuries varied from a urinary catheter alone to laparotomy with debridement of the abdominal wall due to sepsis and later reconstruction. Four of the six cases were performed by registrars.

CONCLUSIONS

Although the incidence of bladder injury is low, its importance is highlighted by the large number of laparoscopies being performed. In addition to catheterisation of the patient, care must be taken with the insertion of low suprapubic ports and consideration should be made regarding alternative sites. Adequate laparoscopic supervision and training in port site planning is required for surgical trainees.     

Urachal Adenocarcinoma: Incidental Finding at the Time of Surgery for Ruptured Appendicitis

Background:

The urachus is a vestigial structure between the dome of the bladder and the umbilicus. Tumors may develop from the remnants, most of which are well-differentiated, mucinous adenocarcinomas. Urachal adenocarcinoma is an exceedingly rare type of tumor.

Methods:

We present a case of a 51-year-old female presenting to our institution with complaints of abdominal pain for 36 hours. The patient was taken to the operating room for an acute appendicitis. Laparoscopy was performed, and gross purulence and appendiceal perforation were noted as well as a mass on the anterior abdominal wall. Based on the location of the mass, we converted to an open midline laparotomy to treat both the perforated appendicitis and to remove the mass.

Results:

Pathology confirmed the diagnosis of perforated appendicitis and a mucinous-producing urachal adeno-carcinoma.

Discussion:

Data support both open and laparoscopic approaches for appendicitis. This case, although rare, highlights the importance of laparoscopy in a complete and thorough examination of the abdominal cavity. A standard right lower quadrant incision for an open technique would likely have resulted in omission of this lesion, and the patient would have presented at a more typical late stage of her cancer development with significantly more morbidity.