Pelvic ectopic kidney with acute pyelonephritis: wolf in sheep's clothing

The differential diagnosis of right lower quadrate pain at the emergency department is quite perplexing. We describe a 38-year-old woman presenting with characteristic clinical and laboratory features of ruptured appendicitis with severe sepsis. However, contrast-enhanced computed tomography scan of the abdomen established the diagnosis of pelvic ectopic kidney with acute pyelonephritis. Antibiotic treatment eventually achieved satisfactory resolution without compromise of renal function. It is should be addressed that, even with the advent of modern imaging modalities, there can be a diagnostic pitfall in general practice when managing right lower quadrate pain in patients with typical presentations of acute appendicitis without sonographic evidence, as illustrated in this case. In conclusion, early recognition using exquisite imaging studies with raised awareness in the clinical setting and prompt antibiotic treatment can avoid unnecessary intervention, preserve renal function, and prevent a life-threatening catastrophe.     

MDCT of acute appendicitis: value of coronal reformations

Acute appendicitis is the most common cause of abdominal pain requiring urgent surgery in the United States. The clinical diagnosis can be difficult in patients with atypical presentations and, over the past several decades, computed tomography (CT) has been increasingly utilized to improve diagnostic accuracy. Helical CT has proven to be an excellent tool in the work-up of acute abdominal pain with a diagnostic accuracy for acute appendicitis of 93–99%. However, occasionally there are equivocal or false positive or negative cases, often due to non-visualization of the appendix. The development of multi-detector row CT and recent advancements in reconstruction software has allowed rapid, high-resolution imaging of the entire abdomen and pelvis resulting in multiplanar reformations (MPR) with a spatial resolution similar to that of the axial plane. This article reviews the utility of CT in suspected acute appendicitis and the potential added diagnostic value of coronal reformations in confirming or excluding the diagnosis.     

Imaging Acute Appendicitis

Acute appendicitis is the most common entity requiring emergent abdominal surgery. Early diagnosis is critical to proper management. Patients often present with a classic clinical picture and may not require imaging, although many patients have nonspecific signs and symptoms. It is in these cases that imaging plays a large role. Imaging options include computed tomography, ultrasound, and magnetic resonance. The following discussion addresses the different imaging modality options with regard to diagnostic performance, indications, and interpretation in patients with suspected acute appendicitis.     

Diagnosing appendicitis across the life span

Arriving at a definitive diagnosis of acute appendicitis (AA) requires an understanding of the various presenting signs and symptoms of all ages and genders across the life span. Primary care providers must also be aware of the pertinent laboratory tests and imaging procedures that will assist in providing useful information toward making an accurate diagnosis of AA. Utilizing an in-depth review of the literature, this article delineates the presenting signs and symptoms of AA from children to adults to elders. It also delineates which laboratory and imaging techniques should be used for each age group as effective adjuncts in diagnosing AA.     

Recognizing the various presentations of appendicitis.

Appendicitis is one of the most common causes of acute abdominal pain in the industrialized world. Appendicitis must be considered in the differential diagnosis of any patient presenting with abdominal pain. Workup may include blood tests, abdominal radiographs, abdominal ultrasound, and focused appendix computed tomography. Unfortunately, none of these provides definitive results. Although several signs and symptoms are associated with appendicitis, their inconsistent presentation, especially among the young and the elderly, can lead to an erroneous diagnosis. The classic sequence of symptoms includes the onset of vague epigastric or periumbilical pain; associated nausea, anorexia, or unsustained vomiting; and pain migrating to the right lower quadrant. In uncomplicated cases, the treatment of appendicitis is appendectomy. However, less definitive presentations merit further diagnostic testing and close follow-up.     

Imaging of acute appendicitis in children

Acute appendicitis is the most common acute abdominal condition that results in surgical intervention in childhood. The clinical diagnosis of acute appendicitis in children can be challenging. Approximately one-third of children with the condition have atypical clinical findings and are initially managed nonoperatively. Complications associated with delayed diagnosis of this condition include perforation, abscess formation, peritonitis, sepsis, bowel obstruction, infertility, and death. The use of cross sectional imaging has proven useful for the evaluation of suspected acute appendicitis in children. Both graded compression sonography and CT have been widely utilized in the imaging assessment of the condition. The principal advantages of sonography are its lower cost, lack of ionizing radiation, and ability to assess ovarian pathology that can often mimic acute appendicitis in female patients. The principal advantages of CT include less operator dependency than sonography as reflected by a higher diagnostic accuracy, and enhanced delineation of disease extent in perforated appendicitis.     

Sonography of acute appendicitis

Graded compression sonography is an established imaging modality in the clinical setting of acute right lower quadrant pain or to diagnose acute appendicitis because of its easy assessability, noninvasiveness, real-time imaging. However, the ability to accurately diagnose appendicitis can be affected by several factors including operator dependence, deeper-located appendix, and obesity or muscularity of the patient. However, adjuvant techniques utilizing advanced equipment and accumulated operator's experience to conventional graded compression sonography will yield more frequent detection of the vermiform appendix and more accurate results of acute appendicitis on sonography. This article introduces adjuvant techniques and various know-how of real field in the detection of the vermiform appendix and diagnosis of acute appendicitis.     

A prospective clinical trial evaluating urinary 5-hydroxyindoleacetic acid levels in the diagnosis of acute appendicitis

Background

To improve the diagnostic accuracy of identifying acute appendicitis, imaging modalities, such as ultrasound and the computed tomography scan, are used in combination with the history and physical examination. There is no reliable single laboratory marker to assist with this diagnosis. During inflammation, enterochromaffin cells in the appendix secrete serotonin, and 5-hydroxyindoleacetic acid (5-HIAA), a serotonin metabolite excreted in urine, has been found to be elevated in patients presenting with acute appendicitis.

Objective

The aim of this study was to measure the urinary 5-HIAA concentrations of patients presenting with symptoms of acute appendicitis to determine the sensitivity and specificity of urinary 5-HIAA levels for diagnosing acute appendicitis.

Methods

5-HIAA was quantitatively measured by high-performance liquid chromatography in the spot urine of 100 healthy individuals, aged 18 to 70 years, who presented to the emergency medicine department with a clinical picture of acute appendicitis. Urine concentration results were correlated to the gold standard of histopathologic reports of removed appendices. The sensitivity, specificity, and their 95% confidence intervals were derived.

Results

Of the 100 patients presenting with symptoms consistent with acute appendicitis, 72 had appendectomies and 2 had cholecystectomies. The remaining 26 patients were discharged after hospital observation. A total of 64 patients were found to have appendicitis: 52 had acute appendicitis, whereas 12 had perforated and/or gangrenous (nonacute) appendices. The acute appendicitis group had a mean urinary 5-HIAA level of 19.31 μmol/L, slightly lower than the 23.10 μmol/L of the patients with gangrenous/perforated appendicitis. The group without appendicitis had a urinary 5-HIAA value of 17.27 μmol/L. Using the lowest of previously reported cutoffs, we calculated the sensitivity and specificity of this test for acute appendicitis as 63% and 33%, respectively.

Conclusion

Urinary 5-HIAA level is not a good diagnostic tool for determining acute appendicitis.     

基波、自然谐波和彩色多普勒超声对急性阑尾炎的诊断价值

目的探讨二维基波和自然谐波条件下,结合彩色多普勒超声在急性阑尾炎检查中的实用价值。方法对166例因腹部疼痛或可疑阑尾炎的患者,分别在二维基波、自然组织谐波和彩色多普勒超声条件下,使用7.0～10.0MHz高频和3.5～4.0MHz普通腹部探头做超声检查,分析阑尾区的图像特点,对比不同频率的探头对于阑尾显示的效果。结果全部病例经手术、病理或治疗后随访观察证实。166例病例中,超声确诊急性阑尾炎136例(81.9%),急性阑尾炎合并周围脓肿或炎性包块30例(18.1%),急性阑尾炎的彩色血流信号显示率62.0%。结论高频超声在显示肿大阑尾结构上更具有特异性,能明显提高肿大阑尾的显示率。彩色多普勒血流有助于急性阑尾炎的诊断。二维基波、自然谐波和彩色多普勒超声检查可作为临床诊断急性阑尾炎的重要依据。     

Targeted helical CT of the acute abdomen: Appendicitis, diverticulitis, and small bowel obstruction

CT, especially helical CT, provides a fast and reliable modality for evaluation of the patient presenting with acute abdominal pain. Helical CT can provide an accurate diagnosis in the majority of patients and has found great utility in the evaluation of acute gastrointestinal emergencies, including acute appendicitis, diverticulitis, and small bowel obstruction. This article reviews proper helical CT technique, diagnostic imaging findings, and pitfalls of interpretation in evaluation of these acute abdominal disorders.     

The effect of blunt abdominal trauma on appendix vermiformis

Objectives: Trauma and appendicitis are the most common conditions of childhood for which surgical consultation is sought in emergency departments. Occasionally, appendicitis and trauma exist together, which causes an interesting debate whether trauma has led to appendicitis. We aimed to evaluate our patients with traumatic appendicitis and to discuss their properties in the light of the literature. Methods: We retrospectively reviewed the charts of children of blunt abdominal trauma accompanied by appendicitis. Results: Of 29 cases of blunt abdominal trauma that had required surgical exploration, five were found to have gross findings of acute appendicitis and underwent appendicectomy. Appendicitis was confirmed histopathologically. Conclusion: It should be kept in mind that children managed for severe blunt abdominal trauma may develop appendicitis. If clinical outlook suggests appendicitis in cases conservatively managed for blunt abdominal trauma, physical examinations, abdominal ultrasonography and/or abdominal computed tomography should be repeated for diagnosis of traumatic appendicitis. This approach will help to protect the patients against the complications of appendicitis that are likely to develop.     

Artificial neural networks in the diagnosis of acute appendicitis

The aim of the study was to assess the role of artificial neural networks in the diagnosis of acute appendicitis in patients presenting with right lower abdominal pain. Data from 156 patients presenting with suspected appendicitis over a 12-month period to a rural hospital were collected prospectively. The sensitivity, specificity, and positive and negative predictive values of the artificial neural network were 100%, 97.2%, 96.0%, and 100% respectively. Artificial neural networks can be an effective tool for accurately diagnosing acute appendicitis and may reduce unnecessary appendectomies.     

Imaging of acute pelvic pain

Determining the cause of acute pelvic pain in the female patient is often a clinical challenge. Diagnostic imaging can be invaluable in this situation. Ectopic pregnancy, pelvic inflammatory disease, and hemorrhagic ovarian cysts are the most commonly diagnosed gynecologic conditions presenting with acute pelvic pain. Ovarian torsion and degenerating fibroids occur less frequently. Other causes to consider include endometriosis, and postpartum causes such as endometritis, or ovarian vein thrombosis. Finally, nongynecologic conditions may overlap in their presentation of acute pelvic pain and should also be considered. The most important of these is acute appendicitis.     

Clinical Confounder: An Incarcerated Appendix Masquerading as Epididymitis

Background: Acute appendicitis can have various unusual presentations. Detection of this entity is often confounded by its presence in the company of symptoms consistent with distinctly different etiologies. Objectives: This article highlights an extremely rare presentation of appendicitis. Case Report: The case of a man presenting to an urban Emergency Department complaining of scrotal swelling and pain is discussed. On surgical exploration, the patient's symptomatology was diagnosed as acute appendicitis within an Amyand hernia. Conclusion: Appendicitis can sometimes be a challenging diagnosis. Thorough examination and maintenance of a wide differential diagnosis with common complaints can assist the emergency physician in reaching the correct diagnosis.     

Nongynecologic findings on pelvic ultrasound: focus on gastrointestinal diseases

Ultrasound (US) is considered the first-line imaging modality of choice in women presenting with pelvic complaints. Although imaging is focused on detecting abnormalities of the uterus and adnexa, occasionally nongynecologic findings are detected, which may or may not explain the patient's symptoms. Many of these findings are related to the gastrointestinal (GI) tract. Although most of these GI abnormalities are better diagnosed with computed tomography (CT), symptoms are often nonspecific and US may be the first imaging modality requested by referring clinicians. Sonographers should be aware of the possibility of nongynecologic diseases in patients with pelvic symptoms, particularly if US evaluation of the female reproductive tract does not provide an answer to the clinical question. Careful attention to the bowel when performing a pelvic US may allow the sonographer to diagnose GI pelvic diseases such as appendicitis, diverticulitis, colitis, bowel obstruction, mesenteric adenitis, epiploic appendagitis, Crohn disease, and even GI malignancy. As concerns grow regarding the radiation dose of pelvic CT, the use of iodinated contrast material, and imaging costs, US examination may be increasingly requested as an initial imaging study in patients in whom GI diseases is primarily suspected in the pelvis, and familiarity with the various sonographic manifestations will aid considerably in establishing the correct diagnosis.     

The use of the clinical scoring system by Alvarado in the decision to perform computed tomography for acute appendicitis in the ED

Study Objective

Appendicitis is part of the differential of an acute abdomen and can be a difficult diagnosis to make. Strategies to suggest which patients presenting to the emergency department (ED) should undergo computed tomography (CT) scan to confirm appendicitis have not been addressed. We develop guidelines for CT scanning based on Alvarado clinical scores for patients with suspected and confirmed cases of appendicitis.

Methods

A retrospective review of 150 charts of patients aged 7 and older who presented with abdominal pain to the ED of a 392-bed acute care facility over a 6-month period were evaluated by ED physicians and underwent CT to rule out appendicitis. Patient demographics, presenting signs, and symptoms were documented. Using the scoring system for appendicitis, developed by Alvarado, each chart was retrospectively scored. The Alvarado scores were correlated with positive pathology findings, as well as Alvarado scores with a negative CT scan. Equivocal scores, having neither high sensitivity nor specificity for appendicitis were calculated.

Results

Computed tomography scans with Alvarado scores of 3 or lower were performed in 37% (55/150) of patients to rule out appendicitis. The sensitivity of Alvarado scores 3 or lower for not having appendicitis was 96.2% (53/55), and the specificity 67% (2/3). Patients with Alvarado scores 7 or higher had an incidence of acute appendicitis of 77.7% (28/36). The sensitivity of Alvarado scores 7 or higher for appendicitis was 77% (28/36), and the specificity 100% (8/8). The sensitivity of equivocal Alvarado scores, defined as scores of 4 to 6, for acute appendicitis was 35.6% (21/59), and the specificity 94% (36/38). The sensitivity and specificity of CT scans in patients with equivocal Alvarado scores remained high, at 90.4% and 95%, respectively.

Conclusions

In the equivocal clinical presentation of appendicitis as defined by Alvarado scores of 4 to 6, adjunctive CT is recommended to confirm the diagnosis in the ED setting. If clinical presentation suggests acute appendicitis by an Alvarado score of 7 or higher, surgical consultation is recommended. Computed tomography is not indicated in patients with Alvarado scores of 3 or lower to diagnose acute appendicitis.     

Perforated Meckel’s diverticulitis on the mesenteric side: MDCT findings

Meckel’s diverticulum (MD) is the most common congenital anomaly of the gastro-intestinal tract (approximately 2% of population), and arises from improper closure and absorption of the omphalomesenteric duct. Very few cases of Meckel’s diverticulitis on the mesenteric side have been reported in the surgical literature, and no reported cases have been documented on preoperative imaging. We report a 65-year-old woman presenting symptoms and signs of acute abdomen with an initial suspicion of acute appendicitis. MDCT imaging revealed a mesenteric abscess in the right lower quadrant at the level of the distal ileum as a complication of Meckel’s diverticulitis on the mesenteric side. The patient recovered after a diverticulectomy without the need for a small bowel resection. This case demonstrates that MDCT is a fast imaging technique that may be helpful in the emergency setting for the preoperative diagnosis of an unusual complicated MD on the mesenteric side.     

Necrotizing fasciitis due to acute perforated appendicitis: case report

Acute appendicitis is one of the most common surgical emergencies. Accurate diagnosis is often hindered due to various presentations that differ from the typical signs of appendicitis, especially the position of the appendix. A delay in treatment increases the likelihood of complications such as perforation, which is associated with an increase in morbidity and mortality rates. We herein present the case of a 76-year-old woman presenting with necrotizing fasciitis of the abdominal wall and right flank regions due to a perforated appendix. Such complication is extremely rare but life-threatening. It may be confused with cellulitis, causing a delay in aggressive treatment. This case represents an unusual complication of a common disease. Also, acute appendicitis or intra-abdominal pathologies should be taken into consideration in determining the cause of necrotizing fasciitis presenting over abdominal, flank, or perineal regions.     

Acute recurrent appendicitis with appendicolith

Appendiceal disease can be acute, acute recurrent, or chronic. Acute appendicitis is the most common form. Acute recurrent appendicitis is more common than chronic appendicitis. In children the clinical manifestations of appendicitis are variable. Patients who have an appendicolith usually develop appendicitis, often with perforation. A case is presented of 3-year follow-up of a patient with an appendicolith and acute recurrent appendicitis. The literature about appendicoliths is reviewed. In the appropriate clinical setting, a history of prior episodes of similar right lower quadrant pain does not preclude the diagnosis of appendiceal disease. Awareness of the less common forms of appendicitis is important so that appropriate treatment is not delayed.     

特殊人群急性阑尾炎影像学检查及治疗新进展

急性阑尾炎是一种常见病和多发病,结合临床表现、实验室检查诊断典型阑尾炎并不困难,但是对于一些临床表现不典型,阑尾位置变异又高度怀疑阑尾炎的患者,尤其是对于儿童、孕妇及老年患者的诊断显得较为困难。此时,结合影像学检查对于诊断具有重要意义,检查手段包括超声、CT、磁共振影像、钡剂灌肠X线、结肠镜等。诊断明确后,开腹手术作为急性阑尾炎的经典手术方案曾经在临床上被广泛使用,而腹腔镜阑尾切除术作为一种新的微创手术已被人们接受。近年来,内镜下逆行阑尾炎治疗作为一种创新性手术引起国内外学界的广泛关注,在未来可能成为治疗急性阑尾炎的一种新模式。本文就急性阑尾炎,尤其特殊人群急性阑尾炎的诊断及治疗进展做一综述。