Appendicitis Acute [keywords]
- The diagnostic performance of ultrasound for acute appendicitis in pregnant and young nonpregnant women: a case-control study. [JOURNAL ARTICLE]
- Int J Surg 2016 Aug 20.
Ultrasonography is frequently used to diagnose acute appendicitis in women of reproductive age, but its diagnostic value in pregnant patients remains unclear. This study sought to compare the diagnostic performance of ultrasound in pregnant and young nonpregnant women with suspected acute appendicitis.The database of a single tertiary medical center was reviewed for all women of reproductive age who underwent appendectomy either during pregnancy (2000-2014) or in the nonpregnant state (2004-2007) following ultrasound evaluation. The performance of ultrasound in terms of predicting the final pathologic diagnosis was compared between the pregnant and non pregnant groups using receiver operating characteristic curve analysis.Of 586 young women treated for appendicitis during the study periods (92 pregnant, 494 non-pregnant), 200 underwent preoperative ultrasound [67 pregnant, and 133 nonpregnant young women]. The pregnant and nonpregnant groups were comparable in age and presenting symptoms. There was no significant difference in the predictive performance of ultrasound between the two groups (AUC 0.76 and 0.73 respectively, p=0.78) or within the pregnant group, by trimester [first (n=23), AUC 0.73; second (n=32), AUC 0.67; third (n=12), AUC 0.86; p=0.4]. Ultrasound had a positive predictive value of 0.94 in the pregnant group and 0.91 in the nonpregnant group; corresponding negative predictive values were 0.40 and 0.43.There appears to be no difference in the ability of ultrasound to predict the diagnosis of acute appendicitis between pregnant women and nonpregnant women of reproductive age. Therefore, similar preoperative imaging algorithms may be used in both patient populations.
- Risk Stratification to Decrease Unnecessary Diagnostic Imaging for Acute Appendicitis. [JOURNAL ARTICLE]
- Pediatrics 2016 Aug 23.
There has been an increase in the use of imaging modalities to diagnose appendicitis despite evidence that can help identify children at especially high or low risk of appendicitis who may not benefit. We hypothesized that the passive diffusion of a standardized care pathway (including diagnostic imaging recommendations) would improve the diagnostic workup of appendicitis by safely decreasing the use of unnecessary imaging when compared with historical controls and that an electronic, real-time decision support tool would decrease unnecessary imaging.We used an interrupted time series trial to compare proportions of patients who underwent diagnostic imaging (computed tomography [CT] and ultrasound) between 3 time periods: baseline historical controls, after passive diffusion of a diagnostic workup clinical pathway, and after introduction of an electronic medical record-embedded clinical decision support tool that provides point-of-care imaging recommendations (active intervention).The moderate- and high-risk groups showed lower proportions of CT in the passive and active intervention time periods compared with the historical control group. Proportions of patients undergoing ultrasound in all 3 risk groups showed an increase from the historical baseline. Time series analysis confirmed that time trends within any individual time period were not significant; thus, incidental secular trends over time did not appear to explain the decreased use of CT.Passive and active decision support tools minimized unnecessary CT imaging; long-term effects remain an important area of study.
- Deciduosis of the appendix: diagnostic dilemma continues despite MRI evidence. [JOURNAL ARTICLE]
- Ann R Coll Surg Engl 2016 Aug 23.:e1-e3.
Deciduosis (ectopic or extrauterine decidua) is a phenomenon seen in the ovary and cervix and on serosal surfaces of abdominal and pelvic organs. It is thought to be the result of progesterone effects on extrauterine mesenchymal cells during pregnancy. Although deposits are typically asymptomatic and incidentally found in surgically removed tissues on microscopy, deciduosis has also been known to cause pain and intraperitoneal haemorrhage. We sourced all cases of appendiceal deciduosis that have occurred in Sir Charles Gairdner Hospital and Bunbury Hospital between the years 2006 and 2014. Clinical information was obtained from patients' medical records. Four cases of ectopic decidua of the appendix, all of which were incidentally found in pregnant patients presenting with features highly suggestive of appendicitis, were reviewed. These patients underwent appendicectomy and subsequent histopathology findings showed deciduosis with no evidence of appendicitis. Deciduosis of the appendix can mimic acute appendicitis in pregnancy. At present, it is difficult to confidently differentiate one from the other either by way of clinical presentation or with current imaging modalities.
- Clinical mimics of acute appendicitis: Is there any role of imaging? [Journal Article]
- Med J Armed Forces India 2016 Jul; 72(3):285-92.
Acute appendicitis (AA) is a common surgical emergency. Accurate and timely diagnosis of AA is essential for successful outcome. Imaging plays an important role in the diagnosis, exclusion of AA as well as diagnosing alternative clinical conditions which can closely simulate AA. A correct alterative diagnosis may obviate the need of unnecessary appendectomy or may even change the treatment regime altogether. This pictorial essay illustrates various clinical conditions which mimicked AA clinically during our day to day practice.
- Management of Uncomplicated Acute Appendicitis as Day Case Surgery: Feasibility and a Critical Analysis of Exclusion Criteria and Treatment Failure. [JOURNAL ARTICLE]
- J Am Coll Surg 2016 Aug 17.
Day case surgery (DCS) for uncomplicated acute appendicitis (NCAA) is under evaluation. The objective of this prospective, single-center, descriptive, non-randomized, intention-to-treat (ITT) cohort study was to assess the feasibility of DCS for NCAA with a critical analysis of the reasons for exclusion and treatment failures and a focus on patients discharged to home and admitted for DCS on the following day.From April 2013 to December 2015, NCAA patients meeting the inclusion criteria were included in the study. The primary endpoint was the success rate for DCS (length of stay <12 hours) in the ITT population (all NCAA) and in the per-protocol (PP) population (no pre/peroperative exclusion criteria). The secondary endpoints were morbidity, DCS quality criteria, predictive factors for successful DCS, patient satisfaction, quality of life and reasons for pre/peroperative exclusion. A subgroup of patients discharged to home the day before surgery was also analyzed.A total of 240 patients were included. The success rate of DCS was 31.5% in the ITT population and 91.5% in the PP population. The rate of unplanned consultations, hospitalization and reoperation were 13%, 4% and 1% respectively. An analysis of the reasons for DCS exclusion showed that 73% could have been modified. For the 68 patients discharged to home on the day before surgery, the DCS success rate was 91%.DCS is feasible in NCAA. A critical analysis of the reasons for exclusion from DCS showed that it should be possible to dramatically increase the eligible population.
- A Pain in the Psoas: Groin Injury in a Collegiate Football Athlete. [JOURNAL ARTICLE]
- Sports Health 2016 Aug 19.
General medical conditions are an important part of the differential diagnosis in athletes presenting with pain or injury. A psoas abscess is a collection of pus in the iliopsoas muscle compartment and is a rare cause of hip, low back, or groin pain. Psoas abscesses may have significant morbidity and mortality, as 20% progress to septic shock. Presenting symptoms are generally nonspecific and the onset may be subacute. Clinical presentation may have features suggestive of other diagnoses, including septic hip arthritis, iliopsoas bursitis, and retrocecal appendicitis. Proper diagnosis and management is critical to prevent complications of septic shock and death. In this unique case, a 19-year-old Division 1 collegiate football player presented to the emergency department 4 days following injury to his right groin during football practice. He complained of severe right groin pain accompanied by fatigue, fevers, nausea, and diarrhea. He later developed septic shock with multisystem organ dysfunction, requiring advanced life support. Imaging revealed an abscess located in the right iliopsoas compartment. After proper treatment, the athlete eventually made a complete recovery, returning to collegiate football 4 months postinjury. A literature review found no described cases of psoas abscess related to athletes with acute hip flexor strain. This athlete had no known risk factors for psoas abscess. This case highlights the importance of maintaining a broad differential in an athlete presenting with pain after injury. Making the diagnosis of psoas abscess often requires a high degree of suspicion and timely acquisition of imaging studies. In this particular case, imaging was key to making a proper diagnosis and tailoring treatment not only to return him to sport but also to save his life.
- Acute Appendicitis: A Weak Concordance Between Perioperative Diagnosis, Pathology and Peritoneal Fluid Cultivation. [JOURNAL ARTICLE]
- World J Surg 2016 Aug 19.
The classification of acute appendicitis (AA) into various grades is not consistent, partly because it is not clear whether the perioperative or the histological findings should be the foundation of the classification. When comparing results from the literature on the frequency and treatment of AA it is important that the classifications are consistent. Furthermore, in the clinical settings, incorrect classification might lead to over diagnosing and a prolonged antibiotic treatment. The aim of our study was to investigate the concordance between perioperative diagnosis made by the surgeon and the histological findings of the removed appendix and furthermore compare this to the results from cultivation of peritoneal fluid aspirated perioperatively.A prospective observational cohort study including patients (≥15 years of age) undergoing appendectomy.A total of 131 patients were included. In 116 (89 %) of these cases, appendicitis was confirmed histological. There was low concordance between the perioperative and histological diagnoses, varying from 16 to 76 % depending on grade of AA. Only 44 % of the patients receiving antibiotics postoperatively had a positive peritoneal fluid cultivation.There was a low concordance in clinical and histopathological diagnoses of the different grades of appendicitis. Perioperative cultivation of the peritoneal fluid as a standard should be further examined. The potential could be a reduced postoperative antibiotic use. CLINICALTRIALS.GOV: Registration no.: NCT02304653.
- Valentino's Syndrome: Perforated Peptic Ulcer Mimicking Acute Appendicitis Managed Through Rutherford Morrison Incision. [Journal Article]
- J Coll Physicians Surg Pak 2016 Aug; 26(8):727-8.
- Pregnancy outcome following non-obstetric abdominal surgery in Jos University Teaching Hospital: A 5-year retrospective study. [Journal Article]
- Niger J Clin Pract 2016 Sep-Oct; 19(5):591-4.
The need for nonobstetric abdominal surgical interventions in pregnant females arises periodically in practice and can be a source for concern for both the patient and the surgeon because of the risk of adverse outcome.To determine the indications for, and assess maternal and fetal outcome following nonobstetric abdominal surgeries in Jos University Teaching Hospital.This was a retrospective cross-sectional study analyzing clinical records of pregnant women, who had nonobstetric abdominal surgeries in Jos University Teaching Hospital between January 2007 and December 2011.Fifty patients had nonobstetric abdominal surgery during the study period (January 2007 to December 2011). The ages of the women ranged 15-49 years with a mean of 29 ± 8.13 years. Intraoperative findings in the patients were consistent with acute appendicitis in 43 (86%) patients, two patients (4%) had ruptured spleen while one patient each (2.0%) had a transverse colon injury, postoperative adhesion bands, ruptured uterus and urinary bladder, and mesenteric injury. One (2.0%) mother died after surgery. 38 (76%) had spontaneous deliveries, and there were 11 miscarriages (22%) and 1 perinatal death. The perinatal mortality rate was 0.093/1000 deliveries. The mean hospital stay was 5.52 days.Nonobstetric abdominal surgeries in pregnant women are an infrequent occurrence at Jos University Teaching Hospital but when they do occur, they are indicated by acute appendicitis in pregnancy.
- Mortality Related to Appendectomy; a Population Based Analysis over Two Decades in Finland. [JOURNAL ARTICLE]
- World J Surg 2016 Aug 17.
To define the mortality rate of appendectomy patients and appendectomy-related risk factors.Appendectomy has been considered as a safe operation and negative appendectomies acceptable in order to avoid perforations. There are few publications on appendectomy-related mortality. Removal of a normal appendix has been suggested to be related to a higher mortality rate versus removal of an inflamed appendix.Data on all appendectomy patients between 1990 and 2010 in Finland were retrieved from the Discharge Register of the National Institute for Health and Welfare and combined with data from the Death Certificate Register of Statistics Finland. Thirty-day mortality was identified and compared with overall mortality. Detailed information from death certificates of patients dying within 30-day post-surgery was collected and analyzed.Over the study period, the thirty-day post-appendectomy mortality rate was 2.1/1000. Increased mortality was found in patients over 60 years of age. Negative appendectomy and complicated appendicitis were related to mortality. The negative appendectomy rate was higher in patients older than 40 years of age. During the study period, both mortality and the rate of negative appendectomies decreased, while the rate of laparoscopic appendectomies increased.Post-appendectomy mortality is related to both negative appendectomies and complicated appendicitis. Diagnostic accuracy is fundamental in the care of patients with acute appendicitis, especially in the elderly. Improved diagnostic accuracy may have reduced mortality over the last two decades in Finland.