Are acute exacerbations of chronic inflammatory appendicitis triggered by coprostasis and/or coproliths？

AIM- To examine the role of coprostasis and coproliths in recurrent appendicitis. METHODS： We evaluated four hundred and twenty seven consecutive pathology reports of all appendectomy specimens from January 2003 to December 2004. Findings were categorised as showing acute appendicitis, acute recurrent appendicitis, subacute recurrent appendicitis, chronic appendicitis, or appendices without inflammation. All patients had presented with acute right lower quadrant pain, In 94 instances, there was a history of recurrent similar episodes in the past. RESULTS： Of the 427 histology reports, 294 were inter- preted as showing acute appendicitis, 56 acute recurrent appendicitis, 34 subacute recurrent appen-dicitis, 28 chronic appendicitis, and 15 non-inflamed appendices. Coprostasis was observed in 58 patients （13.58%） and the presence of coprolith in 6 （1.4%）. Coprostasis, and age, were among the predictors in the final model. CONCLUSION： Coprostasis but not coproliths seems to be a contributing factor to acute exacerbations of chronic inflammatory appendicitis.     

Acute chylous ascites mimicking acute appendicitis in a patient with pancreatitis

We report a case of acute chylous peritonitis mimicking acute appendicitis in a man with acute on chronic pancreatitis. Pancreatitis, both acute and chronic, causing the development of acute chylous ascites and peritonitis has rarely been reported in the English literature. This is the fourth published case of acute chylous ascites mimicking acute appendicitis in the literature.     

Asymptomatic early acute appendicitis initiated and diagnosed during colonoscopy： A case report

Colonoscopic diagnosis of asymptomatic early acute appendicitis is exceedingly rare. Although obstruction of the lumen due to various causes is believed to be the most common physiologic mechanism of acute appendicitis, all of the previously documented cases in the literature have only shown a patent appendiceal lumen with pus flowing into the cecum. We present the case of a patient undergoing colonoscopy for colorectal cancer evaluation with no abdominal symptoms. An obstructed, swollen appendix was seen. The process was probably initiated during the colonoscopy, documenting perhaps the earliest stage of acute appendicitis for the first time. Endoscopic, CT and microscopic documentation of the case is also presented.     

Ascending retrocecal appendicitis presenting with right upper abdominal pain： Utility of computed tomography

Acute appendicitis is a common surgical condition that is usually managed with early surgery, and is associated with low morbidity and mortality. However, some patients may have atypical symptoms and physical findings that may lead to a delay in diagnosis and increased complications. Atypical presentation may be related to the position of the appendix. Ascending retrocecal appendicitis presenting with right upper abdominal pain may be clinically indistinguishable from acute pathology in the gallbladder, liver, biliaw tree, right kidney and right urinary tract. We report a series of four patients with retrocecal appendicitis who presented with acute right upper abdominal pain. The clinical diagnoses at presentation were acute cholecystitis in two patients, pyelonephritis in one, and ureteric colic in one. Ultrasound examination of the abdomen at presentation showed subhepatic collections in two patients and normal findings in the other two. Computed tomography （CT） identified correctly retrocecal appendicitis and inflammation in the retroperitoneum in all cases. In addition, abscesses in the retrocecal space （n = 2） and subhepatic collections （n = 2） were also demonstrated. Emergency appendectomy was performed in two patients, interval appendectomy in one, and hemicolectomy in another. Surgical findings confirmed the presence of appendicitis and its retroperitoneal extensions. Our case series illustrates the usefulness of CT in diagnosing ascending retrocecal appendicitis and its extension, and excluding other in- fiammatory conditions that mimic appendicitis.     

Diagnostic value of maximal-outer-diameter and maximalmural-thickness in use of ultrasound for acute appendicitis in children

MM： To evaluate the maximal-outer-diameter （MOD） and the maximal-mural-thickness （MMT） of the appendix in children with acute appendicitis and to determine their optimal cut-off values to diagnose acute appendicitis.
METHODS： In total, 164 appendixes from 160 children between 1 and 17 years old （84 males, 76 females; mean age, 7.38 years） were examined by high-resolution abdominal ultrasound for acute abdominal pain and the suspicion of acute appendicitis. We measured the MOD and the MMT at the thickest point of the appendix. Patients were categorized into two groups according to their medical records： patients who had surgery （surgical appendix group） and patients who did not have surgery （non-surgical appendix group）. Data were analyzed by MedCalc v.9.3. The rank sum test （Mann-Whitney test） was used to evaluate the difference in the MOD and the MMT between the two groups. ROC curve analysis was used to determine the optimal cut-off value of the MOD and the MMT on diagnosis of acute appendicitis.
RESULTS： There were 121 appendixes （73.8%） in the non-surgical appendix group and 43 appendixes （26.2%） in the surgical appendix group. The median MOD differed significantly between the two groups （0.37 cm vs 0.76 cm, P〈 0.0001）, and the median MMT also differed （0.15 cm vs 0.33 cm, P 〈 0.0001）. The optimal cut-off value of the MOD and the MMT for diagnosis of acute appendicitis in children was 〉 0.57 cm （sensitivity 95.4%, specificity 93.4%） and 〉 0.22 cm （sensitivity 90.7%, specificity 79.3%）, respectively.
CONCLUSION： The MOD and the MMT are reliable criteria to diagnose acute appendicitis in children. An MOD 〉 0.57 cm and an MMT 〉 0.22 cm are the optimal criteria.     

Abdominal pain among children re-evaluation of a diagnostic algorithm

AIM：To re-evaluate the algorithm that has been used for over 40years for diagnosis of acute abdominal pain among children.METHODS:Among the 937cases admitted to the surgical emergency ward in 2000,656cases of acute appendicitis were studied to evaluate the usefulness of the present algorithm ofr its calculated accuracy,false positive and false negative rates,the sensitivity and specificity in the instant diagnosis of various types of acute appendicitis in different age groups.The algorithm used was established in 1958and reised for this study in 1999,It includes a 3-step analysis of clinical presentations,i.e:firstly,a diagnosis of surgical pain by edfinite organic abdominal signs;then a diagnosis of the subgroup of surgical condition by special signs;and finally the diagnosis of the present disease by specific signs.A footnote describes a “comparative technique”of abdominal examination in non-cooperative children.RESULTS:The general accuracy of diagnosis was92.8%,overall mortality0.1% amon973cases of abdominal pai in2000,373attending surgeons and 241 residents including trainees joined the diagnosis and treatment with no temarkable difference in the results.The incidence of acute appendicitis,656in973cases,was67.4%representing the majority of abdominal pain.In the series of 656cases,the accuracy of diagnosis of acute appendicitis was 93.6%,false positive 6.4%,false negative0.9%,sensitivity at first visit82.7%,specificity for appendicitis98.0%,no death or documentary complication.CONCLUSION:The present algorithm used for diagnosis of acute abdominal pain is effective and preferable in reducing misdiagnosis and maltreatme nt at emergency,The use of some modern technology should be further explored.     

Alvarado,Eskelinen,Ohhmann and Raja Isteri Pengiran Anak Saleha Appendicitis scores for diagnosis of acute appendicitis

AIM:To assess the reliability and practical applicability of the widely used Alvarado,Eskelinen,Ohhmann and Raja Isteri Pengiran Anak Saleha Appendicitis(RIPASA)scoring systems in patients with suspected acute appendicitis.METHODS:Patients admitted to our tertiary center due to suspected acute appendicitis constituted the study group.Patients were divided into two groups.appendicitis group(Group A)consisted of patients who underwent appendectomy and were histopathologically diagnosed with acute appendicitis,and non-appendicitis group(Group N-A)consisted of patients who underwent negative appendectomy and were diagnosed with pathologies other than appendicitis and patients that were followed non-operatively.The operative findings for the patients,the additional analyses from follow up of the patients and the results of those analyses were recorded using the follow-up forms.RESULTS:One hundred and thirteen patients with suspected acute appendicitis were included in the study.Of the 113 patients(62 males,51 females),the mean age was 30.2±10.1(range 18-67)years.Of the 113patients,94 patients underwent surgery,while the rest were followed non-operatively.Of the 94 patients,77patients were histopathologically diagnosed with acute appendicitis.Our study showed a sensitivity level of81%for the Alvarado system when a cut-off value of 6.5was used,a sensitivity level of 83.1%for the Ohmann system when a cut-off value of 13.75 was used,a sensitivity level of 80.5%for the Eskelinen system when a cut-off value of 63.72 was used,and a sensitivity level of 83.1%for the RIPASA system when a cut-off value of 10.25 was used.CONCLUSION:The Ohmann and RIPASA scoring systems had the highest specificity for the diagnosis of acute appendicitis.     

Septic thrombophlebitis of the porto-mesenteric veins as a complication of acute appendicitis

Pylephlebitis, a rare complication of acute appendicitis, is defined as thrombophlebitis of the portal venous system. Pylephlebitis usually occurs due to secondary infection in the region drained into the portal system. We report a case of pylephlebitis caused by acute appendicitis. The patient was transferred from a private clinic 1 wk after appendectomy with the chief complaints of high fever and abdominal pain. He was diagnosed with pylephlebitis of the portal vein and superior mesenteric vein by CT-scan. The patient was treated with antibiotics and anticoagulation therapy, and discharged on the 25th day and follow-up CT scan showed a cavernous transformation of portal thrombosis.     

Atresia of the appendix vermiformis:A rare case of developmental abnormality

Acute appendicitis,which requires immediate surgical intervention,is an important diagnosis in patients with acute abdomen.However,developmental abnormalities may interfere with the preoperative diagnosis and surgical treatment in some cases.Agenesis and atresia of the cecal vermiform appendix is an extremely rare clinical diagnosis.In addition,preoperative diagnosis may be difficult in some cases.Thus,diagnosis of the congenital absence of the vermiform appendix requires a thorough exploration of the retrocecal and ileocecal regions.A 59-year-old male was admitted from the emergency services with right lower abdominal pain.A celiotomy was performed with the suspicion of acute appendicitis.However,an atresia of the vermiform appendix was observed.The patient’s appendix was thus removed.Pathological examination confirmed suppurative appendicitis.This case underlines the importance of the clinical entity for surgeons who may deal with a similar case.     

A case of stump appendicitis after appendectomy]

Stump appendicitis is an acute inflammation of the residual appendix and a rare complication after an appendectomy. Although the signs and symptoms do not differ from acute appendicitis, the diagnosis is often not considered because of the past surgical history. Only a small number of stump appendicitis cases have been reported, but there has been no report of stump appendicitis in Korea. Herein, we report a case of stump appendicitis. A 28-year-old female was admitted to our hospital due to right lower quadrant abdominal pain. Fifteen months ago, the patient had a laparoscopic appendectomy under the diagnosis of an acute appendicitis, but she subsequently suffered from intermittent abdominal pain and fever. Abdominal ultrasonography and CT scan showed an inflamed appendiceal stump. Laparoscopic stump appendectomy was done and the biopsy revealed stump appendicitis.     

Stump appendicitis and chorioamnionitis due to incomplete appendectomy: a case report

Acute appendicitis represents the most common non-obstetric indication for surgical intervention in pregnant women, with a reported incidence of 1 in 1440 pregnancies. Stump appendicitis is a rare clinical situation when there is incomplete appendectomy. A rare case occurred of stump appendicitis and chorioamnionitis complicating after incomplete appendectomy. In this way the literature review suggests that only a few cases have been reported so far. We report a case of stump appendicitis and chorioamnionitis occurring three weeks after an appendectomy performed in another medical center. This will involve the discussion of clinical presentation, diagnosis, surgical management and literature review.     

Stump appendicitis and generalized peritonitis due to incomplete appendectomy

Abstract. Stump appendicitis is a rare clinical situation when there is incomplete appendectomy. A wide spectrum of diseases in the differential diagnosis of right lower quadrant pain of the abdomen and presence of appendectomy operation in a patients history delay the diagnosis. We report such a case of perforated stump appendicitis and generalized peritonitis occurring eight months after appendectomy.     

Simple way to improve accuracy in diagnosis of quadrant inflammatory disease: how to avoid adverse laparotomy by using plain CT

BACKGROUND/AIMS: It has been reported that contrast computed tomography (CT) provides a rapid and accurate diagnosis of acute appendicitis, and could potentially prevent adverse appendectomy. In the present study, we evaluated the diagnostic value of precontrast CT combined with that of serum C reactive protein (CRP) concentration for right lower quadrant inflammatory diseases. METHODOLOGY: One hundred consecutive patients who had rebound tenderness and muscular rigidity or guarding on right lower quadrant underwent an emergency abdominal CT without contrast medium and laboratory tests. Based on the CT findings, 10 patients with peritonitis and 41 patients with definite acute appendicitis underwent emergency operations. Of 19 patients with negative CT findings, 11 patients who had positive CRP levels also underwent emergency appendectomies. The remaining patients, of whom 8 had negative CRP levels and 30 had CT findings of other inflammatory diseases, underwent conservative therapy and were examined again later on. RESULTS: The final diagnosis was acute appendicitis in 58 cases, other intestinal diseases in 21, gynecological disease in 6, urolithiasis in 1, and unknown in 14. Among 86 patients who underwent emergency operations and had a pathological diagnosis, CT had a sensitivity of 81% for the diagnosis of appendicitis, with a specificity of 89%, and an accuracy of 84%. CT combined with serum CRP concentration yielded a sensitivity of 100%, an accuracy of 97%, and a specificity of 89%. The adverse appendectomy rate was 3%. None of the patients underwent a delayed appendectomy. CT differentiated other inflammatory diseases from acute appendicitis in 23 patients. CONCLUSIONS: It may be concluded that precontrast CT scan combined with serum CRP can provide a rapid and accurate diagnosis of acute appendicitis and other right lower quadrant inflammatory diseases.     

Appendicitis: the impact of computed tomography imaging on negative appendectomy and perforation rates

Objective: The purposes of this study were to investigate the use of computed tomography (CT) imaging in patients with suspected acute appendicitis and to evaluate the impact of CT on negative appendectomy and perforation rates. In patients clinically diagnosed of acute appendicitis the reported overall negative appendectomy rate is about 15–20%; 10% in men and 25–45% in women of childbearing age. This is associated with a perforation rate of 21–23%.
Methods: This is a retrospective analysis of 146 consecutive patients presenting with clinical symptoms suspicious of appendicitis over a 2-yr period in whom CT examinations were performed before therapy was instituted. The overall negative appendectomy and perforation rates were calculated for the entire group, as well as for the 54 women aged 15–50 yr in the childbearing cohort.
Results: The negative appendectomy rate was 4% in 122 patients operated on and the perforation rate was 22%. Among 36 women 15–50 yr of age operated on, the negative appendectomy rate was 8.3% and the perforation rate was 19%. Surgery was avoided in 24 patients, 18 of whom were women of childbearing age.
Conclusions: The judicious use of CT imaging in patients with equivocal clinical presentation suspected of having appendicitis led to a significant improvement in the preoperative diagnosis. It resulted in a substantial decrease in the negative appendectomy rate compared to previously published reports, without incurring an increase in the perforation rate.     

Clinical and imaging characteristics relating to surgical outcomes of perforated appendicitis

BACKGROUND/AIMS: To study the characteristics of clinical findings and CT imaging of perforated appendicitis for predicting the outcome of patients who received immediate appendectomy for perforated appendicitis. METHODOLOGY: Thirty-eight patients with perforated appendicitis who received immediate appendectomy were retrospectively reviewed. During a median follow-up period of 1091 days, 13 patients had to be re-hospitalized owing to occurrence of complications relating to the immediate appendectomy. Accordingly, the patients were divided into two groups as either complication or non-complication group. The clinical characteristics and CT imaging of these two groups were compared. RESULTS: Those patients who delayed seeking medical advice were more prone to develop surgical complications after immediate appendectomy. CT imaging showing either fat stranding with remarkable fluid content or abscess indicates the presence of severe inflammation and is related to adverse surgical outcomes. Moreover, extraluminal appendicolith was more frequently found in the CT imaging of complication group. CONCLUSIONS: Patients with perforated appendicitis differ in their severity. Patients who seek medical advice late or have signs of severe inflammation or extraluminal appendicolith on their CT imaging are associated with more severe diseases and are prone to develop complications of surgery at this time and should be better treated conservatively.     

The role of colonoscopy in the diagnosis of appendicitis in patients with atypical presentations

BACKGROUND: Acute appendicitis is one of the most common causes of acute abdomen. Despite recent advances in radiologic imaging, the diagnosis of acute appendicitis may be difficult on occasion. The aims of this study were to describe the colonoscopic features of appendicitis and to determine whether colonoscopy can be used as an adjunct for the diagnosis of appendicitis in patients with atypical presentations. METHODS: The colonoscopic findings in 21 patients (14 men, 7 women; average age 55 years) with a colonoscopic or histopathologic diagnosis of appendicitis were analyzed retrospectively. Colonoscopy was performed because diagnoses suggested by CT were other than acute appendicitis (11 patients), and/or the presenting clinical features were atypical for acute appendicitis with the duration of symptoms being 10 days or longer (17 patients). RESULTS: The colonoscopic diagnosis was acute appendicitis for all 21 patients. Seventeen underwent appendectomy, the diagnosis being verified in all cases. Of the 4 patients whose symptoms improved without appendectomy, 3 were considered to have acute appendicitis because pus was seen to drain from the appendiceal orifice at colonoscopy. A definite diagnosis could not be made in the remaining 1 patient. Therefore, the diagnosis of appendicitis was considered confirmed in 20 of 21 patients. Colonoscopic findings in these 20 patients included hyperemia (15) and bulging (18) at the appendiceal orifice area with surrounding mucosal edema (19), and drainage of pus from the appendiceal orifice (7). CONCLUSION: Colonoscopy may be useful in the diagnosis of appendicitis when the clinical presentation is atypical for appendicitis and/or imaging studies are nondiagnostic.     

Intestinal Infarction Caused by Thrombophlebitis of the Portomesenteric Veins as a Complication of Acute Gangrenous Appendicitis After Appendectomy: A Case Report

The clinical symptoms of pylephlebitis caused by acute appendicitis are varied and atypical, which leads to delayed diagnosis and poor outcomes. Here, we report a case of intestinal necrosis caused by thrombophlebitis of the portomesenteric veins as a complication of acute appendicitis after appendectomy.The patient had acute abdominal pain with tenderness and melena on the 3rd day after appendectomy for the treatment of gangrenous appendicitis. He was diagnosed with intestinal infarction caused by thrombophlebitis of the portomesenteric veins based on enhanced CT and diagnostic abdominal paracentesis. The patient was treated by bowel excision anastomosis and thrombectomy. After postoperative antibiotic and anticoagulation treatments, the patient recovered well and was discharged 22 days after the 2nd operation. A follow-up CT scan showed no recurrence of portomesenteric veins thrombosis 3 months later.Thrombophlebitis of the portomesenteric veins is a rare but fatal complication of acute appendicitis. For all the cases with acute abdominal pain, the possibility of thrombophlebitis should be considered as a differential diagnosis. Once pylephlebitis is suspected, enhanced CT scan is helpful for early diagnosis, and sufficient control of inflammation as well as anticoagulant therapy should be performed.     

Metal endoclips for the closure of the appendiceal stump in laparoscopic appendectomy

Closure of the appendiceal stump in laparoscopic appendectomy is the most crucial part of the procedure. In this retrospective clinical study, we describe a technique for laparoscopic appendectomy, in which the appendiceal stump is secured by metal endoclips. Medical data of the patients who underwent laparoscopic appendectomy for acute appendicitis between January 2005 and January 2011 at our institution were reviewed. The patients who had their appendiceal stump secured by metal endoclips were recruited for the study. The outcome measures were the rate of intraoperative and postoperative complications, operative time, and the length of hospital stay. A total of 233 patients were included to the study. The rate of intraoperative and postoperative complications, the mean operative time, and median length of hospital stay were 3 and 4%, 31.1 (15–75) min, and 18 (8–96) h, respectively. The closure of the appendiceal stump with metal endoclips in laparoscopic appendectomy is simple, quick, and safe with outcomes comparable to those of other methods.     

Diagnosis underlying appendectomy and coeliac disease risk

BACKGROUND: Earlier studies suggest that appendectomy is associated with a substantially reduced risk of certain types of bowel inflammation such as ulcerative colitis, particularly where the underlying diagnosis is acute appendicitis. Previous research on appendectomy and coeliac disease is inconsistent, based on small numbers with retrospective data collection, and has not differentiated between different diagnoses underlying appendectomy. OBJECTIVE: To investigate the association of diagnosis underlying appendectomy with coeliac disease. METHODS: We used Cox regression to study the risk of later appendectomy in more than 14,000 individuals with coeliac disease and 68,000 referents without coeliac disease, identified through the Swedish National Registers 1964-2003, and conditional logistic regression to study the risk of coeliac disease associated with a history of prior appendectomy. Appendectomy was categorised according to the underlying diagnosis: perforated appendicitis, non-perforated appendicitis, and appendectomy without appendicitis. RESULTS: Overall, coeliac disease was negatively associated with perforated appendicitis (hazard ratio=0.78, 95% confidence interval=0.60-1.01), not associated with non-perforated appendicitis (hazard ratio=1.11, 95% confidence interval=0.99-1.25), but positively associated with appendectomy without appendicitis (hazard ratio=1.58, 95% confidence interval=1.32-1.89). The magnitudes of the relative risks were similar irrespective of whether coeliac disease occurred prior to or after appendectomy. CONCLUSION: Coeliac disease and perforated appendicitis are negatively associated irrespective of the timing of the conditions. Not surprisingly, CD increases the risk for appendectomy without appendicitis.