INTRODUCTION:

The clinical outcomes from suspected appendicitis depend on balancing the rate of negative appendicectomy (NA) with perforated appendicitis (PA). An Acute Surgical Model (ASM) was introduced at Geelong Hospital (GH) in 2011 involving a dedicated emergency general surgery theatre list every business day giving greater access to theatre for general surgeons. The aim of this study was to evaluate the effect of the ASM at GH on the management of appendicitis, in particular the NA and PA rates.

METHODS:

Data for 357 patients undergoing emergency appendicectomy was collected prospectively over 1 year (2011) and compared with a historical control group of 351 patients (2010). The data was analysed for patient demographics, preoperative diagnostic radiology and outcomes including NA and PA rates and complications. The negative appendicectomy rates were compared with contemporary studies.

RESULTS:

There was no difference between the two groups in rates of negative appendicectomy 21% (ASM; 73/357) versus 21% (Control; 73/351) P = 0.98, or perforated appendicitis 17% (ASM; 61/357) versus 13% (Control; 47/351) P = 0.18. The introduction of the ASM corresponded to a significantly lower proportion of emergency appendicectomies overnight (4% [16/357] versus 12% [44/351] P = 0.005). There was no significant difference in the use of preoperative diagnostic radiology or complications. Matched contemporary studies had a NA rate of 26%.

CONCLUSION:

The introduction of the ASM at GH has not significantly altered the rate of NA or PA. The NA rate at GH is comparable to other published UK and Australian series.

OBJECTIVE:

To investigate the demographic and clinical factors of children who present to the pediatric emergency department (ED) with abdominal pain and their outcomes.

METHODS:

A review of the electronic medical record of patients 1 to 18 years old, who presented to the Children's Hospital of Pittsburgh ED with a complaint of abdominal pain over the course of 2 years, was conducted. Demographic and clinical characteristics, as well as visit outcomes, were reviewed. Subjects were grouped by age, race, and gender. Results of evaluation, treatment, and clinical outcomes were compared between groups by using multivariate analysis and recursive partitioning.

RESULTS:

There were 9424 patient visits during the study period that met inclusion and exclusion criteria. Female gender comprised 61% of African American children compared with 52% of white children. Insurance was characterized as private for 75% of white and 37% of African American children. A diagnosis of appendicitis was present in 1.9% of African American children and 5.1% of white children. Older children were more likely to be admitted and have an operation associated with their ED visit. Appendicitis was uncommon in younger children. Constipation was commonly diagnosed. Multivariate analysis by diagnosis as well as recursive partitioning analysis did not reflect any racial differences in evaluation, treatment, or outcome.

CONCLUSIONS:

Constipation is the most common diagnosis in children presenting with abdominal pain. Our data demonstrate that no racial differences exist in the evaluation, treatment, and disposition of children with abdominal pain.

Meckel's diverticulum is a congenital anomaly found in approximately 2% of the general population. The complications caused by Meckel's diverticulum include intussusception, volvulus in adolescents and acute bleeding in adults 3. This is an interesting and unusual case of spontaneous perforation of Meckel's diverticulum, in a Caucasian woman.A 46-year-old Caucasian woman was admitted because of severe abdominal pain and diarrhoea. A CT (Fig. 1) scan of the abdomen and pelvis was obtained, which demonstrated free air and a moderate amount of free fluid in the pelvis tracking up the gutters. The patient was consented and taken to theatre for diagnostic laparoscopy. A normal appendix was identified during laparoscopic examination of the abdomen. An inflammatory mass was seen with turbid fluid collection in the pelvic area on laparoscopy. The inflammatory mass turned out to be a perforated Meckel's diverticulum (Fig. 2). Wedge resection of the perforated Meckel's diverticulum was performed with endoGIA stapler fired at the base of diverticulum. Histopathology showed heterotopic gastric mucosa within the diverticulum and evidence of acute inflammation with perforation. The patient was followed up for two years and is symptom-free.The total lifetime rate of complications is widely accepted at 4%, with a male-to female ratio ranging from 1.8:1 to 3:1 4,5. Hemorrhage is the most common presentation in children and is reported in over 50% of cases 10. In adults, hemorrhage occurs often but only in 11.8% is present 5. 90% of bleeding diverticula contain heterotropic mucosa, most often gastric mucosa 13. In one study, 11% of children with complicated Meckel's diverticulum (MD) were initially diagnosed with appendicitis.8The diagnosis of ruptured MD was ultimately made by laparoscopy. This case demonstrates that a healthy degree of suspicion for complicated MD should be present when dealing with a questionable diagnosis of appendicitis. Laparoscopy has a definite role in patients with symptomatic Meckel's diverticulum, especially when the diagnosis is in doubt and it has proved definitive in facilitating diagnosis. KEY WORDS: Gastric mucosa, Heterotropic mucosa, Merkel's diverticulum.

The acute appendicitis (AA) is an infection of the vermiform appendix and conservative antibiotic treatment is regularly mentioned since 50 years. Its success depends on the susceptibility of bacteria to empiric antibiotic therapy. The main bias of the studies comparing conservative antibiotic treatment versus appendectomy is that AA can not be proven histologically during medical treatment. However, after antibiotic conservative, 12-23% of patients are operated early after revaluation, and 11 to 15% in the first year for a total of 25% to 40% failure of conservative antibiotic treatment when proposed in first intention. In case of complicated appendicitis, severe infection and peritonitis, surgical treatment should be carried out urgently and remains the gold standard.

Since the development of the new imaging techniques, such as ultrasonography and computed tomography, the attitude over acute appendicitis syndrome has drastically evolved, and the rate of negative appendectomies has noticeably decreased. These techniques allow, not only to improve the performance of the diagnosis of appendicitis, but also to assess the severity and the complications prior to surgery. Furthermore they are useful for establishing alternative diagnoses of the many diseases that may mimic acute appendicitis.

Facing a child with suspected acute appendicitis it is important to remind that a child is not a smaller adult. The main risk is to over-diagnose acute appendicitis in elder children and to misdiagnose it in preschool children and infants because it is less frequent, with early complications, and/or confusing symptoms in these age groups. Careful anamnesis and examination of the whole child--not only the belly--are mandatory. Biological findings of bacterial infection and US findings suggesting acute appendicitis are helpful. In doubtful cases the best help is offered by observation of the patient, symptoms and signs worsening necessarily in case of an acute appendicitis.

Since the princeps description of the appendectomy by Mac Burney in 1891, the treatment of appendicitis is still based on the resection of the appendix. The better quality of the pre-operative imaging leads to a significant decreased of unnecessary appendectomies during the last 30 years. The laparoscopic approach did not make a real change and is not the gold standard except in obese patient or young female. The question of an exclusive medical treatment is still a matter of debate, but it remains not recommended.

BACKGROUND:

MicroRNAs are 20-22 nucleotide molecular structures with post-transcriptional activity that are involved in the immune response, as well as in the inflammatory pathways of different cells and tissues.

AIMS:

We present herein a prospective study in which serum microRNA-21 expression was determined in patients diagnosed with acute appendicitis as a model of bowel inflammation.

MATERIAL AND METHODS:

A prospective cohort study of patients diagnosed with acute appendicitis was conducted. Serum microRNA-21 was analyzed through the PCR of blood samples taken from the patients prior to surgery. MicroRNA-21 values were compared with the analytic variables (leukocytes, hemoglobin, hematocrit, platelets, prothrombin activity, glucose, urea, and creatinine) and the anatomopathologic variables (normal appendix, phlegmonous, gangrenous, and perforated acute appendicitis).

RESULTS:

A total of 60 patients with acute appendicitis diagnosis were consecutively included in the study from June to October 2009. Sixty-six percent of the patients were men (40 men and 20 women), with a mean age of 26.2±14.8 years. The mean absolute level of microRNA-21 was 24.8±0.93, whereas the mean microRNA-21 gene expression was 1.04±0.28. No correlation between the analytic and anatomopathologic parameters evaluated was observed (P=.47).

CONCLUSIONS:

It is necessary to continue to search for the most appropriate microRNAs, so that their determination in serum can lead to greater precision in establishing the diagnosis and outcome of inflammatory disorders of the bowel.