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Background & Objectives: Differentiation of histologic subtypes of appendiceal mucoceles may prove to be difficult on computed tomography (CT). The main objective of this study was to identify the CT features of mucocele of the appendix and correlate the imaging findings with histopathology in inflammatory, benign, and malignant neoplastic lesions, and whether these entities can be accurately differentiated on CT imaging., Materials and Methods: CT scans of 31 patients with diagnosis of appendiceal mucocele were retrospectively reviewed and compared with histopathology. The appendix was evaluated for maximal luminal diameter, cystic dilatation, luminal attenuation, appendicolith, mural calcification and enhancement, periappendiceal fat stranding and fluid. CT findings were compared by use of Mann-Whitney U and Fisher's exact tests. Receiver operating characteristics analysis was performed to assess the diagnostic utility of appendiceal luminal diameter in differentiating different types of mucoceles., Results: Patients were classified into three groups: those with inflammatory mucoceles (n = 10), benign mucoceles (simple mucocele, mucosal hyperplasia and low-grade appendiceal mucinous neoplasm (n = 17), and those with malignant mucinous adenocarcinoma (n = 4). The mean diameter was found to be significantly different in the three groups with the largest diameter in the benign subgroup. Soft tissue thickening (p-value 0.01), mural calcification (p-value < 0.01), internal septation (p-value 0.02) and fat stranding (p-value 0.05) was found to be of statistical significance among the various groups. The best cut-off diameter for diagnosis of inflammatory mucoceles to be ≤ 2.3 cm with a sensitivity of 71% and specificity of 90%., Conclusion: Our study suggests that CT findings such as appendiceal diameter less than 2.3 cm, absence of soft tissue thickening, mural calcification and internal septation may be useful in preoperative diagnosis of inflammatory appendiceal mucocele., Competing Interests: Declarations. Ethical approval and consent to participate: Ethical approval for this study was taken from Aga Khan University ethical review committee board (Approval # 2019-2050-5597). The study was performed according to the ethical guidelines of the Declaration of Helsinki. Informed consent was obtained from all study participants. Consent for publication: Written informed consent for publication of clinical details and/or clinical images was obtained from the patient/participants. A copy of the consent form is available for review by the Editor of this journal. Competing interests: The authors declare no competing interests. Disclaimer: Preliminary findings presented as a poster presentation (C-04208) at the European Congress of Radiology, 2020. https://doi.org/10.26044/ecr2020/C-04208 ., (© 2025. The Author(s).)

Ultrasound is a first-line and often preferred imaging modality in the diagnosis of acute appendicitis. When the appendix is not visualised during a dedicated appendix ultrasound study, patients may require a CT study, which uses ionising radiation, or undergo conservative clinical observation with the inherent risk of clinical deterioration, perforation and sepsis. Median baseline data, at our hospital imaging department, revealed a rate of combined normal and abnormal appendix visualisation of 34.5% which is below the reported visualisation rates in the North American literature and well below the rates reported in the global literature. We embarked on a formal quality improvement (QI) project to improve the rates of appendix visualisation in our hospital ultrasound department. Using the Model of Improvement framework and a team approach, we generated and trialled multiple plan-do-study-act interventions over a project term of 12 months. In the second half of the project term, we saw a sustained rise in appendix visualisation exceeding our original stretch goal of 75% visualisation which was sustained 6 months after the formal project end (p<0.001). This rise was accompanied by a commensurate increase in sonographer confidence in appendix visualisation. In our case, the Model of Improvement methodology proved successful in solving our complex problem of sonographic appendix under-visualisation. The learnings of this QI project have been widely shared and spread according to the ethos of QI., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2025. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ Group.)

Amyand hernias are unusual inguinal hernias that contain the vermiform appendix. Rarely, an Amyand hernia can be complicated by acute appendicitis and present a diagnostic dilemma. Herein, we present the case of a complicated Amyand hernia that was initially diagnosed as an incarcerated inguinal hernia. However, imaging later clinched the diagnosis of an Amyand hernia complicated by acute appendicitis., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2025. No commercial re-use. See rights and permissions. Published by BMJ Group.)

Introduction: Amyand's hernia, an uncommon condition characterized by the presence of the appendix within an inguinal hernial sac (< 1% incidence), poses diagnostic and therapeutic challenges. Often it is an intraoperative finding, with almost no clinical symptoms., Case Presentation: This is a case of an Indian male in his early 80 years, diagnosed with bilateral direct inguinal hernias, one of which contained a noninflamed appendix. Given the thinned out abdominal wall, dense adhesions, and no demarcation between layers, the decision to proceed with a modified Bassini's with Lichtenstein mesh repair without appendectomy, guided by intraoperative findings and the Losanoff-Basson Classification, reflecting the complex interplay between individual patient factors and intraoperative considerations. The patient did well during his postoperative stay and was in good health on a 45 day follow-up, with no complaints suggestive of recurrence or obstruction., Conclusion: This case underscores the importance of tailored management strategies and highlights, especially in cases where recurrence and postoperative wall integrity are in question, the ongoing need for research to refine treatment guidelines for Amyand's hernia, especially in cases of appendicitis not diagnosed preoperatively., Competing Interests: Declarations. Ethics approval and consent to participate: Not applicable. Consent for publication: Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal. Competing interests: No competing interests to disclose., (© 2025. The Author(s).)

Objectives: To assess the accuracy of diagnosing complicated appendicitis by examining changes in the involved fasciae on CT imaging., Methods: From January 1, 2020, to December 31, 2023, 273 patients (median age 50 years; range 14-80 years) with surgically and pathologically confirmed appendicitis were analyzed. Of these, 96 had complicated appendicitis and 177 had uncomplicated appendicitis. Fascial involvement score was assessed along with other CT findings and clinical data. Univariate and multivariate logistic regression analyses were conducted to identify potential predictors of complicated appendicitis., Results: Univariate analysis identified several features significantly associated with complicated appendicitis: age (P < 0.001), gender (P = 0.006), time from symptom onset to diagnosis (P = 0.015), CRP level (P < 0.001), fascial involvement score (P < 0.001), appendiceal diameter (P < 0.001), and the presence of extraluminal air (P < 0.001). Multivariate analysis revealed that the fascial involvement score (odds ratio 2.252; P < 0.001) and appendiceal diameter (odds ratio 1.263; P < 0.001) were independent risk factors for complicated appendicitis. The fascial involvement score demonstrated an area under the receiver operating characteristic curve of 0.896, with a cutoff value of 2.5., Conclusion: Both the fascial involvement score and an appendiceal diameter of 14.5 mm or greater are independent predictors of complicated appendicitis., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Purpose: Diagnosis of acute appendicitis is more difficult in children aged 0-4 years due to atypical clinical presentation, leading to delay in diagnosis and higher incidence of complications. Nonvisualization of the appendix on ultrasound increases diagnostic challenge. We examined the utility of standardized reporting of sonographic secondary signs of appendicitis in children younger than 5 years with nonvisualization of the appendix., Methods: A retrospective cohort study of children younger than 5 years who underwent appendectomy following nonvisualization of the appendix on ultrasound from 2016 to 2022 was performed. Primary outcome was comparison of ultrasound and intraoperative findings. Two-sample t test and Wilcoxon sum-rank test compared continuous variables, and Fisher exact test compared categorical variables. Univariate and multivariate logistic regression analyses were performed to assess risk factors for complicated appendicitis in those with category 3 ultrasounds., Results: Overall, 92 patients whose appendix was not visualized on ultrasound were included: 26 without secondary signs (category 2) and 66 with secondary signs (category 3). Significant differences in intraoperative findings between category 2 and category 3 patients existed ( P < 0.001). On intraoperative assessment of patients with ultrasound category 2, 3.8% had no appendicitis, 46.2% had simple appendicitis, 34.6% had complicated appendicitis, and 15.4% underwent interval appendectomy. Conversely, of category 3 patients, 0% had no appendicitis, 7.6% had simple appendicitis, 48.5% had complicated appendicitis, and 43.9% underwent interval appendectomy. On logistic regression, in children with category 3 ultrasounds, presence of both fluid collection and free fluid as secondary signs was associated with intraoperative findings of complicated appendicitis. However, number of secondary signs was not significantly associated with increased likelihood of complicated appendicitis intraoperatively., Conclusion: Presence of secondary signs without visualization of the appendix was shown to be indicative of appendicitis, with high suspicion for complicated appendicitis, in patients younger than 5 years. Further validation of the presence of secondary signs on right-lower-quadrant ultrasound may lead to more expedient diagnosis, reduction in cross-sectional imaging, and earlier treatment of complicated appendicitis., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Aim: To investigate the application of ultrasound along with clinical features for the differential diagnosis of low-grade appendiceal mucinous neoplasm (LAMN) and acute suppurative appendicitis (ASA)., Material and Methods: The ultrasound and clinical data of 76 patients with histopathologically confirmed LAMN (31 patients) and ASA (45 patients) were retrospectively analyzed. Univariate analysis and binary logistic regression analysis of the influencing factors were conducted to identify LAMN and ASA. The AUROC was calculated to analyze the diagnostic efficacy of these independent factors. A four-grid table was established to determine the diagnostic efficacy of the ultrasound marks for diagnosing LAMN., Results: Patient age and appendix short diameter in the LAMN group were found to be significantly higher than those in the ASA group. The neutrophil ratio and thickness of the appendix wall in the LAMN group were significantly lower than they were in the ASA group. Patient age (OR=1.112, p=0.015) and appendix short diameter (OR=1.476, p=0.008) were independent risk factors for LAMN. The AUROCs for age and short diameter were 0.898 [95% CI: 0.807, 0.956] and 0.953 [95% CI: 0.879, 0.988], respectively. The LAMN group tumors were characterized by the appearance of an "onion skin" sign or a purely cystic mark on sonograms, with specificities of 100% for both. Neutrophil ratio (OR<0.001, p=0.064) and thickness of the appendix wall (OR=0.776, p=0.414) were not independent risk factors for ASA., Conclusion: Employing ultrasonography with clinical features is useful for distinguishing LAMN from ASA. Patient age, short diameter of the appendix, and sonographic appearance of "onion skin" or purely cystic mark could be key factors in diagnosing LAMN.

An appendiceal mucocele is a rare clinical entity often mimicking that of acute appendicitis in a majority of cases leading to incidental intraoperative findings. Nevertheless, appropriate diagnosis is vital prior to surgery to prevent complications such as pseudomyxoma peritonei. This report details a case of a man in his 70s, who was admitted to the emergency department with right iliac fossa pain with imaging showing wall thickening of the caecum and the ascending colon. During surgery, a calcified appendix raised the suspicion of a neoplastic process leading to a right hemicolectomy. The histology revealed a low-grade appendiceal mucinous neoplasm., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Abdominal ultrasonography is widely used to evaluate suspected cases of appendicitis. Objective descriptions of the direct and indirect signs of appendicitis result in varied assessments of its likelihood. This study introduces the Appendix Imaging Reporting and Data System (APENDIC-RADS) to standardize the reporting of appendix ultrasound findings., Methods: This single-center retrospective study included consecutive patients of all ages who underwent abdominal ultrasonography for the investigation of acute appendicitis. The primary outcome was histopathological confirmation of acute appendicitis post-surgery. The imaging findings were classified into five categories: APENDIC-RADS 0, where the appendix cannot be visualized; APENDIC-RADS 1, indicating a normal appendix; APENDIC-RADS 2, describing an appendix that is likely normal but only partially visualized; APENDIC-RADS 3, appendicitis cannot be ruled out due to uncertain features and APENDIC-RADS 4, acute appendicitis., Results: A total of 747 patients were assessed for suspected acute appendicitis using ultrasonography. Of the diagnosed patients, 52% were male, primarily exhibiting symptoms such as nausea and/or vomiting (60%), right iliac fossa pain (54%), and sudden decompression in the right iliac fossa (24%). Stratification into APENDIC-RADS categories revealed a significant variation in the incidence of acute appendicitis, with incidence rates of 4.5% for category 0 and 0.7%, 2.2%, 11.5%, and 93.5% for categories 1 to 4, respectively (p<0.001). The APENDIC-RADS showed excellent discriminative ability, evidenced by an area under the receiver operating characteristic curve of 0.950 (95%CI=0.899-1)., Conclusion: APENDIC-RADS categorization demonstrated excellent performance in standardizing the ultrasound-determined probability of acute appendicitis. Its implementation could improve physician communication and standardization of patient management.

Competing Interests: The authors declare that they have no conflict of interest.

Abstract: Leukemia spread in the bone marrow typically is greater in the axial skeleton than in the appendicular skeleton. We report an unusual pattern of FDG-avid bone marrow infiltration that is more prominent in the appendicular skeleton than the axial skeleton in a pediatric patient with B-cell acute lymphoblastic leukemia., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: To determine whether superb microvascular imaging (SMI) provides a more precise delineation between reversible and irreversible stages of uncomplicated acute appendicitis managed non-operatively., Methods: This prospective clinical study examined pediatric patients with acute appendicitis initially treated non-operatively and evaluated using power Doppler (PD) and SMI. We determined case severity, monitor appendiceal blood flow (BF), and appendicitis reversibility. Complicated cases were excluded. Severity was classified using B-mode as well as PD, or SMI: Grade I, smooth wall/normal BF; Grade IIa, irregular wall/increased BF; Grade IIb, irregular wall/decreased BF; and Grade III, absence of wall/loss of BF., Results: This study examined a total of 100 patients with acute appendicitis, after excluding 29 patients. All 10 patients with normal BF on PD (Grade I) showed similar BF on SMI (Grade I). Among 29 patients with increased BF on PD (Grade IIa), corresponding increased BF was noted on SMI (Grade IIa), and all these patients showed full recovery. Of the 55 patients showing decreased BF on PD (Grade IIb), 52 showed increased BF on SMI (Grade IIa). The remaining three patients, identified with an impacted appendicolith, showed decreased BF on SMI (Grade IIb) and experienced treatment failure, subsequently developing abscesses. In all six patients with undetectable BF on PD (Grade III), SMI similarly could not detect appendiceal BF (Grade III), and non-operative management failed for these patients., Conclusions: SMI offers an objective and effective means of delineating the threshold between reversible and irreversible stages in uncomplicated acute appendicitis following non-operative management., (© 2024 American Institute of Ultrasound in Medicine.)

Competing Interests: The authors declare that they have no conflict of interest.

Background: Neonatal appendicitis is a rare but critical condition that presents diagnostic challenges due to its nonspecific symptoms and clinical manifestations. Early and accurate diagnosis is crucial for reducing the high mortality rates associated with this condition. Abdominal ultrasonography plays a pivotal role in identifying characteristic signs of appendicitis in neonates. This study aimed to investigate whether neonatal appendicitis can be diagnosed with abdominal ultrasonography by identifying its specific signs., Methods: This study reviewed 20 consecutive cases of neonatal appendicitis confirmed through surgery at a National Medical Center. Preoperative abdominal ultrasonography was analyzed for direct and indirect signs of appendicitis., Results: Our study included neonates with a mean age of 13.0 ± 7.1 days. The appendix was identifiable in 13 out of 20 cases (65%). The mean outer diameter of the appendix was 4.6 ± 1.8 mm. Eight cases had appendix diameter ≥ 4 mm. Fluid accumulation within the appendiceal cavity was noted in 6 (30%) patients, and peri-appendiceal fluid accumulation was detected in 5 (25%) patients. Ultrasonography revealed appendiceal perforation in 12 out of 16 cases (75%). The indirect signs of neonatal appendicitis included right lower quadrant (RLQ) abscess, pneumoperitoneum, and thickening of the intestinal wall and mesentery in the RLQ., Conclusion: Most cases of neonatal appendicitis may be diagnosed through abdominal ultrasonography by identifying both direct and indirect signs. Future studies with larger patient cohorts are needed to improve ultrasonographic diagnosis of neonatal appendicitis., Competing Interests: Declarations Ethics approval and consent to participate The study was approved by the Institutional Review Board of Beijing Children’s Hospital, and informed consent was waived due to the retrospective nature of the study. Informed consent was waived by the institutional review boards due to the retrospective study of deidentified data. Consent for publication Not applicable. Competing interests The authors have no competing interests to declare that are relevant to the content of this article. Clinical trial number Not applicable., (© 2024. The Author(s).)

A 54-year-old woman was referred to our hospital because of abnormal colonoscopic findings, including a submucosal protuberance at the appendiceal root. A biopsy showed no malignant findings. Computed tomography revealed a 20-mm cystic lesion with thick walls at the appendiceal root, suggestive of an appendiceal mucocele. Laparoscopic ileocecal resection was performed based on the preoperative diagnosis of a suspected mucinous appendiceal neoplasm. The resected specimen showed a closed appendiceal orifice surrounded by a mucus-containing submucosal tumor. Histopathologically, the appendiceal epithelium was circumferentially inverted in the appendiceal root, with hyperplasia of the submucosal connective tissue. No atypical epithelium was observed. We hypothesized that repeated partial invagination of the appendiceal root caused submucosal hyperplasia and drainage disturbance of the appendiceal content, leading to the development of a mucocele., Competing Interests: Human/animal rightsAll procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008(5).Informed consentInformed consent was obtained from the patient included in the study.Authors’ contributionsAll authors contributed to the study conception and design. Material preparation and data collection were performed by Shuhei Asai, Hideo Miyake, Asayo Kato, Norihiro Yuasa, Rio Takada, and Masahiko Fujino. The first draft of the manuscript was written by Shuhei Asai, and all authors read and approved the manuscript.Conflict of interestThe authors declare that they have no conflict of interest.Funding sourceThis work is supported by Japanese Red Cross Aichi Medical Center Nagoya Daiichi Hospital Research Grant to SK (NFRCH 23-0008). The funder had no role in study design, data collection, data analysis, decision to publish, or preparation of the manuscript.

Background: In many centers, pediatric radiology-performed ultrasound and/or POCUS fellowship training are not readily available., Objective: To present our experience using point of care ultrasound (POCUS) in a pediatric emergency medicine training program without POCUS fellowship-trained staff, and to demonstrate that POCUS of the appendix is feasible outside the context for POCUS fellowship training., Methods: We identified children diagnosed with appendicitis or periappendiceal abscess from June 2016 to June 2024. Variables reviewed include details of PED visit such as presenting symptoms, laboratory and imaging results, and PED treatment, as well as surgical report and pathology result. We evaluated the frequency and performance characteristics of POCUS over the study period., Results: 999 children were diagnosed with appendicitis. POCUS was performed in 360 of 845 cases (43%) of histology-confirmed appendicitis and in 19 of 69 cases (28%) in which histology was negative for appendicitis. Both the number of POCUS examinations for appendicitis and the percentage of examinations correctly identifying appendicitis steadily increased over the study period. Accuracy was highest in the 5-10-year age range and lowest for females from 10 to 15 years. In 96% of cases with a pathology result of appendicitis and a positive POCUS examination, POCUS correctly identified appendicitis. However, only 6 of 19 POCUS examinations in children without appendicitis on histology found no appendicitis. Performance of POCUS for appendicitis was significantly associated with increased opioid administration and a 20-min mean decrease in length of pediatric emergency department stay., Conclusions: POCUS for appendicitis within the context of PEM fellowship training is feasible and associated with decreased length of stay., (© 2024 Wiley Periodicals LLC.)

Objective: To evaluate the utility of laboratory ultrasonographic and Doppler ultrasonographic findings in the differentiation of simple and complicated appendicitis., Methods: A prospective study was conducted, including pediatric patients who underwent surgery with the diagnosis of appendicitis., Results: Fifty patients, who were found to have appendicitis on ultrasonographic examination, were included. The mean age was found to be 12.80 ± 3.67 years, with 30% female and 70% male. The patients were histopathologically divided into two groups: simple appendicitis (Group 1, 41 patients, 82%) and complicated appendicitis (Group 2, 9 patients, 18%). CRP (C-reactive protein) levels (p = 0.004) and periappendiceal fatty tissue thickness (PFI) (p < 0.005) were found to be statistically significantly higher in Group 2 compared to Group 1. The portal vein (PV) diameter and peak systolic velocity (PSV) values were significantly higher in the study group compared to the control group (p = 0.033, p = 0.001)., Conclusion: Doppler ultrasonographic examination did not significantly differentiate complicated from simple appendicitis. The CRP value is an independent risk factor in the diagnosis of complicated appendicitis, and the presence of a significant increase in mesenteric tissue thickness is one of the important criteria for differentiating complicated appendicitis from simple appendicitis., (© 2024 Wiley Periodicals LLC.)

Background: This study aimed to elucidate the diagnostic significance of changes in periappendiceal fat density observed on computed tomography (CT) in patients with acute appendicitis (AA)., Methods: Patients who underwent surgery with a diagnosis of AA based on CT findings from January 1, 2020 to December 31, 2020 were included in the study. Patients were divided into three grades. In Grade 1, the periappendiceal tissue appears hypoechoic, indicative of normal tissue. In Grade 2, the periappendiceal tissue is slightly hyperechoic but confined to the periappendiceal area. In Grade 3, dense hyperechoic areas are present not only in the periappendiceal tissue but also extend into surrounding organs and deeper tissues. The groups were compared in terms of clinical, laboratory, and pathological outcomes., Results: A total of 195 patients-131 males and 64 females-were included in the study. A correlation was identified between grade and several factors: appendix diameter, appendix wall thickness, incidence of lymphadenopathy, and duration of symptoms onset (p<0.001). Conditions such as appendicolitis, free air, and intra-abdominal abscesses were more frequently observed in Grade 3 patients compared to Grade 1 and Grade 2 patients (p=0.002, p<0.001). Both operative time and length of hospital stay were highest in Grade 3 patients (p<0.001). The rate of patients found to have a normal appendix upon pathological examination was significantly higher in Grade 1 than in Grade 2 (p=0.03)., Conclusion: In cases where the diagnosis is uncertain, the hyperechogenicity in periappendiceal tissue observed on CT strengthens the diagnosis of AA. Additionally, cases of AA become increasingly complex as echogenicity in periappendiceal tissue increases.

Background: Unlike acute appendicitis, chronic appendicitis is characterized by nonspecific abdominal pain and intermittent course. This may lead to late diagnosis or misdiagnosis, with the possibility of serious complications., Case Report: A male patient of Arab origin aged 55 years had a 2-year history of recurrent episodes of mild pain in the right lower quadrant of the abdomen. The episodes were associated with nausea, chills, and abdominal bloating but no vomiting, rectal bleeding, or weight loss. On examination, the patient showed soft and lax abdomen with mild tenderness in the right lower quadrant, with no organomegaly or abdominal masses. Laboratory findings showed normal complete blood count and C-reactive protein. The patient underwent colonoscopy to rule out malignancy, which showed appendiceal orifice polyp that required resection. The computed tomography scan showed an enlarged appendix with multiple intraluminal dense appendicoliths. The largest stone at the appendiceal orifice measured 1.5 cm × 0.9 cm and was partially protruding within the cecal lumen. The diagnosis of chronic appendicitis was confirmed. The patient underwent appendectomy and was asymptomatic a few days after discharge., Conclusions: We are reporting a patient with chronic appendicitis presented with multiple appendicoliths. The patient was initially misdiagnosed as periappendiceal orifice polyp. The current finding highlights the importance of imaging, especially computed tomography in confirming the diagnosis in patients with atypical appendicitis presentation., (© 2024. The Author(s).)

Appendicitis, an infection and inflammation of the appendix is a prevalent condition in children that requires immediate treatment. Rupture of the appendix may lead to several complications, such as peritonitis and sepsis. Appendicitis is medically diagnosed using urine, blood, and imaging tests. In recent times, Artificial Intelligence and machine learning have been a boon for medicine. Hence, several supervised learning techniques have been utilized in this research to diagnose appendicitis in pediatric patients. Six heterogeneous searching techniques have been used to perform hyperparameter tuning and optimize predictions. These are Bayesian Optimization, Hybrid Bat Algorithm, Hybrid Self-adaptive Bat Algorithm, Firefly Algorithm, Grid Search, and Randomized Search. Further, nine classification metrics were utilized in this study. The Hybrid Bat Algorithm technique performed the best among the above algorithms, with an accuracy of 94% for the customized APPSTACK model. Five explainable artificial intelligence techniques have been tested to interpret the results made by the classifiers. According to the explainers, length of stay, means vermiform appendix detected on ultrasonography, white blood cells, and appendix diameter were the most crucial markers in detecting appendicitis. The proposed system can be used in hospitals for an early/quick diagnosis and to validate the results obtained by other diagnostic modalities., (© 2024. The Author(s).)

Background: Gangrene and perforation are severe complications of acute appendicitis, associated with a higher mortality rate compared to uncomplicated appendicitis. Accurate preoperative identification of Gangrenous or perforated appendicitis (GPA) is crucial for timely surgical intervention., Methods: This retrospective multicenter study includes 796 patients who underwent appendectomy. Univariate and multivariate logistic regression analyses are used to develop a nomogram model for predicting GPA based on laboratory tests and computed tomography (CT) findings. The model is validated using an external dataset., Results: Seven independent predictors were included in the nomogram: white blood cell count, lymphocyte count, D-dimer, serum glucose, albumin, maximum outer diameter of the appendix, and presence of appendiceal fecalith. The nomogram achieved good discrimination and calibration in both the training and testing sets. In the training set, the AUC was 0.806 (95%CI: 0.763-0.849), and the sensitivity and specificity were 82.1% and 66.9%, respectively. The Hosmer-Lemeshow test showed good calibration (P = 0.7378). In the testing set, the AUC was 0.799 (95%CI: 0.741-0.856), and the sensitivity and specificity were 70.5% and 75.3%, respectively. Decision curve analysis (DCA) confirmed the clinical utility of the nomogram., Conclusion: The laboratory test-CT nomogram model can effectively identify GPA patients, aiding in surgical decision-making and improving patient outcomes., (© 2024. The Author(s).)

Objective: To determine the diagnostic and therapeutic value of contrast-enhanced ultrasound-guided endoscopic retrograde appendicitis treatment (ERAT) in patients with uncomplicated appendicitis., Methods: A retrospective analysis was performed on clinical and ultrasound data collected from 105 pediatric patients with uncomplicated appendicitis between January 2020 and December 2023. The ultrasound findings before and after treatment, as well as postoperative follow-up and recurrence rates, were summarized and analyzed., Results: Successful intubation was achieved in 96 patients (91.4%). The conventional ultrasound appendix visualization rate was 39.6% (38/105), while the appendix visualization rate after contrast-enhanced ultrasound-guidance was 75% (72/105). Contrast-enhanced ultrasound revealed various appendiceal morphologic changes in 89 patients, such as twisting, tortuosity, stiffness, rough inner wall, dilated diameter, and narrowing of the lumen. Additionally, local filling defects, which indicated the presence of fecal stones or debris deposition, were noted in 68 patients. No leakage of the contrast agent occurred. Post-treatment evaluation showed improvement in appendiceal diameter, lumen, and filling defects (P < .01). The follow-up rate was 82 of 89 patients (92.1%), all of whom recovered well without a recurrence. The recurrence rate was 7.9% (7/89). Among the patients with recurrences, five patients resolved after medical treatment and two patients recovered after surgical treatment., Conclusion: Contrast-enhanced ultrasound-guided ERAT for uncomplicated appendicitis is safe and effective. Specifically, the appendix is increased, which facilitates an evaluation of therapeutic effectiveness. ERAT serves as a valuable supplementary modality to determine the need for surgical treatment of acute appendicitis, which is of significant clinical value., (© 2024 American Institute of Ultrasound in Medicine.)

Background: Acute appendicitis is a common cause of acute abdominal pain necessitating surgical intervention. While the traditional treatment has been urgent appendectomy, recent studies suggest that an antibiotics-first approach can be safe for uncomplicated cases. Classifying appendicitis into uncomplicated and complicated categories is crucial for guiding treatment decisions and predicting patient outcomes. This study aims to evaluate the distinct imaging findings associated with uncomplicated appendicitis and its complicated subtypes-phlegmonous, gangrenous, and perforated appendicitis-to aid in differential diagnosis., Methods: This retrospective observational study was conducted from January 2014 to December 2023 and included 1,250 patients (492 women, 758 men) who underwent an appendectomy with available pathology results. After excluding 56 patients with normal pathology, 52 with non-appendicitis pathologies, and 48 with inaccessible computed tomography (CT) images, 1,094 patients were analyzed. CT images were evaluated for appendiceal diameter, wall thickness, cecal wall thickness, periappendiceal fat stranding, effusion, lymphadenopathy, intraluminal and free periappendiceal air, mucosal hyperenhancement, and the presence of appendicolith., Results: The diameter of the appendix, along with the presence of periappendiceal air, effusion, and intraluminal appendicolith, were significantly higher in the perforated appendicitis group compared to other groups (p<0.05). Periappendiceal fat stranding, evaluated as a binary variable, did not show significant differences among the groups. Appendiceal wall thickness was higher in the perforated group and lower in the non-perforated gangrenous group compared to the uncomplicated group (p<0.05). No significant correlation was found for mucosal hyperenhancement between the appendicitis subgroups. Intraluminal air, though normal in a healthy appendix, was a specific predictor of complicated appendicitis when combined with other findings., Conclusion: This study provides a detailed analysis of distinct imaging findings associated with uncomplicated and complicated appendicitis. Key differentiators such as appendiceal diameter, periappendiceal air, effusion, and intraluminal appendicolith are crucial for accurate diagnosis. The findings highlight the importance of these parameters in distinguishing various types of appendicitis, offering valuable insights for clinical practice. Future prospective studies and advanced imaging techniques are needed to validate these findings and enhance the diagnosis and management of acute appendicitis and its complications.

Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Background: Intestinal duplication cyst is an infrequent congenital malformation that can involve all the segments of the gastrointestinal tract. The cases of intestinal duplication cyst involving the colon, appendix, and ileum in children are particularly uncommon. The symptoms of abdominal pain are similar to other acute abdominal diseases in children, such as appendicitis, intussusception, and intestinal obstruction, so sometimes its diagnosis is challenging and leads to misdiagnosis., Case Presentation: We report a 4-year-old Asian boy who presented to the pediatric emergency department with abdominal pain and vomiting but no fever, peritonitis, or mass. No abdominal abnormality was found via radiology and ultrasonography. After 2 days' anti-inflammatory therapy, the patient was discharged with pain relief. A total of 9 months later, he was readmitted to the pediatric emergency department for the same complaint as the first admission. Abdominal physical examination and ultrasound examination were still negative. Barium examination found a large mass in the colon. Colonoscopy was performed before operation to confirm the rare co-cavity intestinal duplication cyst involving the colon, appendix, and ileum. After resection of intestinal duplication and ileocolonic anastomosis, the patient's abdominal pain and vomiting has not recurred for 5 years postoperatively., Conclusions: The diagnosis of intestinal duplication cyst in children is difficult, especially the rare co-cavity and long segmental intestinal duplication, which is easily misdiagnosed. Colonoscopy may be an effective auxiliary diagnostic method, especially for diseases that are difficult to diagnosed clinically, such as recurrent abdominal pain., (© 2024. The Author(s).)

Background: The diagnosis and management of fever of unknown origin pose significant challenges in the field of infectious diseases, as it is influenced by various factors. Infectious diseases have long been recognized as the primary etiology of fever of unknown origin. However, not all infectious diseases can definitively identify the causative pathogen and infection sites., Case Presentation: we present a case report of an individual with fever, nausea, and anorexia but did not report any abdominal pain. Physical examination revealed no signs of abdominal tenderness. Repeated imaging studies including enhanced CT and color US of the appendix, only one color US suggested the possibility of appendicitis. Despite effective anti-infective treatment, the patient continued to experience low-grade fever, leading to the decision for laparoscopic exploration and subsequent appendectomy. Pathological findings confirmed the presence of appendicitis. After the surgical procedure, the patient's temperature and infectious markers returned to within normal range, ultimately leading to a diagnosis of appendicitis., Conclusions: The atypical symptoms and signs, along with the negative imaging results, contribute to the under diagnosis of appendicitis and the progression of fever of unknown origin, thereby exacerbating the physical, mental, and economic burden on patients. Consequently, there are valuable insights to be gained regarding the management of both appendicitis and fever of unknown origin., (© 2024. The Author(s).)

A 71-year-old woman was found to have submucosal tumor-like lesion on colonoscopy (CS) before gastric surgery, and computed tomography (CT) showed a 12-mm structure at the base of the appendix. The lesion could not be clearly detected on CT nine months later, but it had enlarged again on CT one year later; therefore, CS and endoscopic ultrasound (EUS) were performed. The lesion was determined to be cystic with viscous contents, and laparoscopic appendicectomy was performed. This is the first report of low-grade appendiceal mucinous neoplasm (LAMN) diagnosed by a histopathologic examination of a resected specimen showing shrinkage and re-expansion of the appendix.

Background: Antibiotics have been reported as an efficient and safe treatment option for uncomplicated acute appendicitis without an appendicolith diagnosed using computed tomography (CT). The aim of this study was to assess the association of a CT-diagnosed appendicolith and its characteristics with appendicitis severity., Methods: A large prospective patient cohort with suspected acute appendicitis enrolled between April 2017 and November 2018 was retrospectively reviewed. The initial analysis evaluated the association of a CT-diagnosed appendicolith with complicated acute appendicitis; then, based on the availability of CT images, a subset of patients was analysed for the correlation of appendicolith characteristics with appendicitis severity. The final appendicitis assessment (uncomplicated or complicated-including perforation, gangrene, an abscess, or a tumour) was determined for all patients., Results: Out of 3512 eligible patients, 3085 patients with appendicitis were selected and 380 patients with an appendicolith and with a CT image available for reassessment were included. Out of the 3085 patients with CT-diagnosed acute appendicitis, 1101 (35.7%) patients presented with both acute appendicitis and an appendicolith and, out of these, 519 (47.1%) had complicated acute appendicitis. In the patients without an appendicolith (1984 patients), 426 (21.5%) had complicated appendicitis (P < 0.001). Re-evaluation of CT images for 380 patients showed that a larger appendicolith diameter (OR = 1.15 (95% c.i. 1.06 to 1.25); P < 0.001), appendicolith location at the base of the appendix (55.1% versus 44.9%; P = 0.008), and heterogeneous appendiceal wall enhancement around the appendicolith (68.4% versus 31.6%; P < 0.001) were associated with an increased risk of complicated acute appendicitis., Conclusion: The presence of an appendicolith in patients with acute appendicitis is correlated with the risk of complicated appendicitis. This risk is further increased by a larger appendicolith diameter or appendicolith location at the base of the appendix., (© The Author(s) 2024. Published by Oxford University Press on behalf of BJS Foundation Ltd.)

Objectives: To describe a systematic scanning approach using anatomical landmarks followed by an assessment of radiology trainees' ability to identify the normal appendix in healthy children., Methods: Uncontrolled pre and post study assessing radiology residents' sonographic skills in detecting the normal appendix in healthy children. Initial questionnaire for the trainees' demographics, perceptions and experiences in detecting the appendix with ultrasound in children followed by a precourse test on healthy volunteers. Hands-on training was conducted by describing a systematic sonographic approach to identify the appendix using anatomical landmarks, and then a postcourse test was carried out. The primary outcome was unprompted ability to identify the appendix. Subjective self-scoring of confidence was also recorded., Results: A three-hour hands-on workshop was conducted. Sixteen radiology trainees participated and were randomly distributed to four stations, each with different ultrasound machines and healthy volunteers. Fifteen had a precourse assessment, and 12 completed the postcourse assessment. Before the course, 3/15 (20%) identified the appendix, while 10/12 (83%) identified the appendix afterward. After the course, participants perceived finding the appendix easier than before. There was no statistically significant difference in the participants' perceived confidence in detecting the appendix., Conclusions: With the described scanning technique, most of the participants were able to identify the normal appendix after receiving short hands-on training. This highlights the importance of targeted training of radiology trainees and nonradiologists., (© 2024 Wiley Periodicals LLC.)

Objective: Appendicoliths are associated with a more complicated course of acute appendicitis and failure of non-operative treatment. We aimed to update the appendicolith classification originally described in 1966 and to assess the association of appendicolith characteristics with appendicitis severity., Design: This prospective predefined MAPPAC-trial (ClinicalTrials.gov NCT03257423) substudy included patients with CT diagnosed appendicitis presenting with an appendicolith. CT visible appendicoliths were harvested at surgery, measured and characterised by morphological examination complemented with micro-CT and micro-X-ray fluorescence spectroscopy. Patients were categorised into two groups: appendicolith appendicitis without other complications and appendicolith appendicitis with complications (appendiceal gangrene, perforation and/or abscess). The association of appendicolith classification and characteristics with appendicitis severity was evaluated., Results: Of 78 patients with a CT appendicolith, 41 appendicoliths were collected and classified based on the degree of hardness into three classes. The hardest appendicoliths (class 3) were less common (19.5%) presenting with a stone-hard outer layer and concentrically layered inner structure around a core. The layered inner structure was also observed in class 2 appendicoliths, but was absent in soft, class 1 appendicoliths. Appendicolith hardness or measures (maximum length, diameter and weight) were not associated with appendicitis severity. The spatial distribution of the main inorganic elements of calcium and phosphorus varied within most appendicoliths., Conclusion: This updated classification confirms categorisation of CT visible appendicoliths into three classes based on their physical and chemical characteristics. The data on clinical and aetiopathological characteristics of appendicoliths is scarce and using this systematic classification would add to this understanding., Competing Interests: Competing interests: EMu is currently working as full-time Medical Advisor for Biocodex Nordics. PS reports receiving personal fees for lectures form Merck and Orion Pharma. AJH reports receiving personal fees for lectures from BioCodex, Merck and Pfizer. All other authors declare no competing interests., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Conservative treatment of acute appendicitis is gaining popularity, and identifying patients with a higher risk of recurrence is becoming increasingly important. Previous studies have suggested that older age, male sex, diabetes, appendicolith and abscess formation may be contributing factors, however, results from the adult population are inconsistent., Aim: This study aims to identify predictive factors for recurrent appendicitis after conservative treatment., Methods: This retrospective study included patients with conservatively treated acute appendicitis at Skåne University Hospital, Sweden during 2012-2019. Information on patient demographics at index admission and follow-up data were retrieved from medical charts and radiologic images. Uni -and multivariable logistic regression analysis were performed using Stata Statistical Software., Results: In total, 379 patients with conservatively treated acute appendicitis were identified, of which 78 (20.6%) had recurrence. All patients were followed-up for a minimum of 41 months after the first diagnosis of acute appendicitis unless appendectomy after successful conservative treatment or death occurred during follow-up. The median time to recurrence was 6.5 (1-17.8) months. After multivariable logistic regression analysis, external appendix diameter >10 mm [OR 2.4 (CI 1.37-4.21), p  = .002] and intra-abdominal abscess [OR 2.05 (CI 1.18-3.56), p  = .011] on computed tomography were significant independent risk factors for recurrent appendicitis. Appendicolith was not associated with an increased risk of recurrence., Conclusion: This study suggests abscess formation and appendix distension of >10 mm to be potential risk factors for recurrent acute appendicitis after initial successful conservative treatment.

Acute appendicitis is a common surgical emergency. It is commonly caused by obstruction of the appendiceal lumen due to fecaliths, tumors, or lymphoid hyperplasia. For over a century, appendectomy has been the primary treatment for acute appendicitis. Abraham Groves performed the first open appendectomy in 1883. In 1983, Kurt Semm completed the first laparoscopic appendectomy, heralding a new era in appendectomy. However, appendectomy is associated with certain complications and a rate of negative appendectomies. Studies have suggested controversy over the impact of appendectomy on the development of inflammatory bowel disease and Parkinson's disease, but an increasing number of studies indicate a possible positive correlation between appendectomy and colorectal cancer, gallstones, and cardiovascular disease. With the recognition that the appendix is not a vestigial organ and the advancement of endoscopic te-chnology, Liu proposed the endoscopic retrograde appendicitis therapy. It is an effective minimally invasive alternative for treating uncomplicated acute appendicitis. Our team has developed an appendoscope with a disposable digital imaging system operated through the biopsy channel of a colonoscope and successfully applied it in the treatment of appendicitis. This article provides an overview of the progress in endoscopic treatment for acute appendicitis and offers a new perspective on the future direction of appendiceal disease treatment., Competing Interests: Conflict-of-interest statement: The authors declare that they have no competing interests., (©The Author(s) 2024. Published by Baishideng Publishing Group Inc. All rights reserved.)

Background and Objectives: The ability to rule appendicitis in or out using ultrasound is limited by studies where the appendix is not visualised. We determined whether the absence of indirect ultrasound signs can rule out appendicitis in children undergoing a radiology-performed ultrasound in which the appendix is not visualised METHODS: This was a single-centre retrospective observational study of patients aged 3-13 with a clinical suspicion of acute appendicitis evaluated in a Paediatric Emergency Department in Spain from 1 January 2013 to 31 December 2019. For those patients who had formal ultrasound, direct and indirect findings of ultrasound were abstracted from the ultrasound report. The surgical pathology report was established as the gold standard in patients who underwent an appendectomy. In those who did not, appendicitis was considered not to be present if there was no evidence in their charts that they had undergone an appendectomy or conservative therapy for appendicitis during the episode. The main outcome variable was the diagnosis of acute appendicitis. For patients undergoing ultrasound, the independent association of each indirect ultrasound sign with the diagnosis of appendicitis in patients without a visualised appendix was analysed using logistic regression., Results: We included 1756 encounters from 1609 different episodes. Median age at the first visit of each episode was 10.1 years (IQR, 7.7-11.9) and 921 (57.2%) patients were men. There were 730 (41.6%) encounters with an Alvarado score ≤3, 695 (39.6%) with a score 4-6 and 331 (18.9%) with a score ≥7. Appendicitis was diagnosed in 293 (17.8%) episodes. Ultrasonography was performed in 1115 (61.6%) encounters, with a visualised appendix in 592 (53.1%).The ultrasound findings independently associated with appendicitis in patients without a visualised appendix were the presence of free intra-abdominal fluid in a small quantity (OR:5.0 (95% CI 1.7 to 14.6)) or in an abundant quantity (OR:30.9 (95% CI 3.8 to 252.7)) and inflammation of the peri-appendiceal fat (OR:7.2 (95% CI 1.4 to 38.0)). The absence of free fluid and inflammation of the peri-appendiceal fat ruled out acute appendicitis in patients with an Alvarado score <7 with a sensitivity of 84.6% (95% CI 57.8 to 95.7) and a negative predictive value of 99.4% (95% CI 97.8 to 99.8)., Conclusions: Patients with an Alvarado score <7 and without a visualised appendix on ultrasound but who lack free fluid and inflammation of the peri-appendiceal fat are at very low risk of acute appendicitis., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: To validate whether the introduction of the ratio of the cross diameters on the transverse section of the appendix (RATIO) ≤ 1.18 is useful for improving the ultrasound diagnosis of acute appendicitis (AA)., Methods: Data from 220 patients with AA and 110 patients with a normal appendix were retrospectively studied. The RATIO ≤ 1.18, maximal outer diameter (MOD) > 6 mm, and a combination of RATIO ≤ 1.18 and MOD > 6 mm were used for predicting AA. The area under the receiver operating characteristic curve (AUC), sensitivity, specificity, positive and negative predictive values (PPV and NPV) were calculated., Results: The RATIO ≤ 1.18, MOD > 6 mm, and a combination of RATIO ≤ 1.18 and MOD > 6 mm for predicting AA showed a sensitivity of 90, 100, and 90%; specificity of 79.1, 27.3, and 88.2%; and AUC of 0.845, 0.636, and 0.891, respectively. When comparing the outcomes between MOD > 6 mm and a combination of MOD > 6 mm and RATIO ≤ 1.18, the specificity and PPV increased from 27.3 to 88.2% and 73.3 to 93.8%, respectively (all P < 0.0001). The sensitivity and NPV decreased from 100 to 90% and 100 to 81.5%, respectively (all P < 0.0001). The AUC increased from 0.636 to 0.891 (P < 0.0001). When comparing the AUC of MOD > 6 mm, and a combination of RATIO ≤ 1.18 and MOD > 6 mm for predicting AA with the AUC in a previous study, there were no significant differences between each other (all P > 0.05)., Conclusion: Introducing the RATIO ≤ 1.18 for the evaluation of AA can improve the diagnostic performance and significantly increase specificity., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Appendicovesical fistula is a rare complication associated with appendicitis, Crohn's disease, or appendiceal tumors, posing significant diagnostic challenges. We reported a pediatric case of appendicovesical fistula that remained undiagnosed by non-contrast computed tomography, fluoroscopic voiding cystourethrography (VCUG). Although identified during cystoscopy, its connection to the fistula site could not be determined. However, the transvesical contrast-enhanced ultrasound clearly demonstrated the presence of fistula. Subsequently, laparoscopic appendectomy and bladder repair were performed successfully, leading to complete recovery in the patient. To our knowledge, this is the first reported diagnosis of appendicovesical fistula in children using contrast-enhanced ultrasound., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Visualization of the entire appendix, including the tip, is thought, but has not been demonstrated, to be important for exclusion of appendicitis by ultrasound., Objective: To determine if incomplete visualization of the appendix has negative clinical ramifications including missed appendicitis., Methods: Under IRB approval we retrospectively reviewed right lower quadrant ultrasound reports from January 2017 to December 2020 to identify examinations with impressions of full visualization of the normal appendix, non-visualization of the appendix with and without secondary findings of appendicitis, and partial visualization of the appendix. Electronic health records were reviewed for follow-up imaging within 48 h, and surgery with pathology reports (if available)., Results: 12,193 examinations were included. 4171 (34.2 %) had full visualization of a normal appendix, 5369 (44.0 %) had non-visualization with no secondary findings, and 234 (1.9 %) had non-visualization with secondary findings, The frequencies of appendicitis in these three groups were 34 (0.8 %), 283 (5.3 %), and 127 (54.3 %) respectively. The appendix was partially visualized in 338 (2.8 %) patients with secondary findings present in 53 (15.6 %). Partial visualization without secondary findings had a similar frequency (4.9 %, 14/285) of appendicitis to non-visualized appendix without secondary findings (p = 0.797) and a higher frequency than full visualization of a normal appendix (p < 0.0001). Partial visualization with secondary findings had similar rates (54.7 %, 29/53) to non-visualized appendix with secondary findings (p = 0.953)., Conclusion: Partial visualization of the appendix with ultrasound (with and without secondary findings) is associated with similar frequencies of appendicitis as non-visualization of appendix (with and without secondary findings)., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Schistosomiasis is one of the endemic parasitic diseases in many developing countries. Despite this, appendicitis secondary to schistosomiasis is an uncommon condition even in some endemic areas. Schistosomal appendicitis, an incidentally discovered appendicitis associated with schistosomiasis histological findings, affects young males predominantly. Timely diagnosis and treatment, including appendectomy and anti-helminthic therapy, are crucial., Case Report: A 24-year-old Sudanese male patient presented with abdominal pain. Diagnosed with acute appendicitis, he underwent appendectomy, revealing appendix inflammation with Schistosoma ova in histopathology. Abdominal ultrasound detected no complications. Weakly positive Schistosoma serology was noted, but stool and urine analysis showed no infection evidence. Prescribed praziquantel, patient had 3-year post-op follow-up without complications., Conclusions: This case report underscores the significance of including schistosomiasis in the differential diagnosis of appendicitis, particularly in regions where the disease is endemic. It underscores the necessity of histopathological evaluations for accurate diagnosis, emphasizing the potential implications for clinical practice in similar settings., (© 2024. The Author(s).)

Immunoglobulin G4-related disease (IgG4-RD) is a fibroinflammatory condition characterized by chronic activation of the immune system and a tendency to form tumorous lesions. IgG4-RD is frequently characterized by the presence of tumor-like masses affecting multiple organs and is easily mistaken for a malignant neoplasm. However, IgG4-RD affecting the appendix is extremely rare, with only seven cases reported previously. We report the case of a woman in her early 60s who presented with insidious abdominal pain and radiological findings mimicking appendiceal neoplasms. After diagnosing appendiceal neoplasms, surgery was performed. The patient had a serum IgG4 concentration of <1.35 g/L, which did not satisfy one of the three revised comprehensive diagnostic criteria for IgG4-RD. A pathological examination was conducted, and the patient was diagnosed with appendiceal IgG4-RD. To the best of our knowledge, there have been no previously reported cases of IgG4-RD affecting the appendix in patients with low serum IgG4 concentrations. This report may prove beneficial for the future understanding of IgG4-RD and for the revision of diagnostic and treatment strategies., Competing Interests: Declaration of conflicting interestThe authors declare that there is no conflict of interest.

Background: Although ultrasound is considered the gold standard for the evaluation of children with suspected appendicitis, there is still much debate about the most accurate ultrasound findings. The purpose of this study was to define the best ultrasound signs that could ultimately improve the diagnostic accuracy of ultrasound for diagnosing pediatric acute appendicitis, and to differentiate between simple appendicitis and complicated appendicitis. Patients and Methods: After approval by our Institutional Review Board, a prospective study was carried out from January 1, 2022, to July 31, 2023, in a pediatric emergency department. We included all patients aged under 14 years with suspected appendicitis and ultrasound-visualized appendix. Results: A total of 550 patients presented with suspected appendicitis during the study period. Of these children, 411 had an ultrasound-visualized appendix. Our patients' mean age was 9.4 years. The best positive predictive value of ultrasound was found for appendiceal diameter ≥7.5 mm. The combination of an appendiceal diameter <6 mm and the lack of peri-appendiceal free fluid on ultrasound rules out the diagnosis of appendicitis. The best diagnostic accuracy of ultrasound, which was 92%, was achieved for appendix diameters ≥6.5 mm. The sonographic sign giving the best ultrasound accuracy for diagnosing complicated appendicitis was an appendix diameter ≥9 mm. Conclusions: In conclusion, our present study demonstrated that appendiceal diameter ≥6.5 mm is the gold standard for diagnosing appendicitis in pediatric patients. The combination of an appendiceal diameter <6 mm and the lack of peri-appendiceal free fluid on ultrasound would rule out appendicitis.

Acute diverticulitis of the appendix (ADA), though uncommon, often presents similarly to acute appendicitis but carries a higher risk of complications such as perforation and malignancy. We report the case of a male patient in his 50s with acute right iliac fossa abdominal pain, diagnosed via CT scan with ADA. Urgent laparoscopic appendicectomy was performed, and the patient was discharged without further issues. This case highlights the importance of promptly identifying and managing such conditions to minimise complications and improve outcomes. Despite the overlap in symptoms between appendiceal diverticulitis and acute appendicitis, accurate diagnosis is crucial for appropriate treatment. Healthcare providers should maintain a high index of suspicion, particularly in older patients presenting with an acute appendicitis, like clinical picture to ensure timely intervention and optimal patient care., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: This study aims to evaluate the added value of duplex Doppler examination to the routinely graded compression grayscale ultrasound (US) for patients with suspected acute appendicitis (AA) in correlation with surgical management outcomes., Methods: The study lasted from January 2020 to March 2021. Throughout that period, patients who had suspected appendicitis were included with a visible appendix in the grayscale US. These patients were categorized clinically based on Alvarado's score. They underwent graded compression grayscale US of the appendix and duplex Doppler study. Subsequently, they were assigned for non-contrast multislice computed tomography (MSCT) according to Alvarado's score and underwent either emergency appendicectomy or conservative clinical management afterward. A Student's t-test was used to determine if there were significant differences in the mean values between the groups. The diagnostic performance of spectral Doppler US for the diagnosis of AA was depicted., Results: Eighty-four patients with visualized color flow in the appendicular Doppler US were enrolled, with 60 (71.4%) having AA, and 24 (28.6%) not having appendicitis. Spectral Doppler criterion of PSV greater than 8.6 cm/s demonstrated a high sensitivity of 91.67% and specificity of 77.78% for patients with Alvarado score ranging from 4 to 7, and appendiceal MOD ranging from 6 to 8 mm, while a discriminatory criterion of RI greater than 0.51 had a high sensitivity of 100% and a relatively lower specificity of 66.67%., Conclusion: The patients with AA have significantly higher point PSV and point RI values than those without AA and are especially useful in equivocal patients whose MODs and Alvarado scores are in the diagnostically equivocal ranges of 6-8 mm and 4-7, respectively, with the point PSV and RI demonstrating negative predictive value 87.5% and 100%., (© 2024. The Author(s), under exclusive licence to American Society of Emergency Radiology (ASER).)

Background: Duplex or vermiform appendix refers to the presence of an appendix beside the naturally occurring one. Although, duplex appendix emerges from the caecum most of the time, yet it is encountered in other parts of the colon. Inflammation of duplex appendix may represent not only a clinical, but also a surgical dilemma, and this would be confusing further among patients who already had prior appendectomy., Case Presentation: We present a case of 29-years old Egyptian male patient with history of appendectomy one and half year before presenting to the emergency department with recurrent acute abdominal pain that was linked to duplex appendicitis abnormally emerged from the mid-ascending colon. The first episode was treated conservatively considering atypical right colon diverticulitis as a potential differential diagnosis. Seven months later the patient was treated by laparoscopic appendectomy and experienced an uneventful pot-operative course., Conclusion: Duplex appendicitis, though rare, should be considered in the differential diagnosis of recurrent acute abdomen even after appendectomy., (© 2024. The Author(s).)

Objective: To evaluate the association between clinical and imaging with surgical and pathological findings in patients with suspected neuroendocrine tumor of appendix and/or appendix endometriosis., Methods: Retrospective descriptive study conducted at the Teaching and Research Institute of Hospital Israelita Albert Einstein , in which medical records and databases of patients with suspected neuroendocrine tumor of appendix and/or endometriosis of appendix were analyzed by imaging., Results: Twenty-eight patients were included, all of which had some type of appendix alteration on the ultrasound examination. The pathological outcome of the appendix found 25 (89.3%) lesions compatible with endometriosis and three (10.7%) neuroendocrine tumors. The clinical findings of imaging and surgery were compared with the result of pathological anatomy by means of relative frequency., Conclusion: It was possible to observe a higher prevalence of appendix endometriosis when the patient presented more intense pain symptoms. The image observed on ultrasound obtained a high positive predictive value for appendicular endometriosis., Competing Interests: Conflicts to interest: none to declare., (© 2024. Federação Brasileira de Ginecologia e Obstetrícia. All rights reserved.)

Introduction: Mucocoele of the appendix occurs in 0.2-0.7% of people in the world without any well-defined clinical symptoms. It occurs when there is an accumulation of mucous in the lumen of the appendix., Case Presentation: We present three cases: a 48-year-old male admitted to the emergency room with a one-day history of right iliac fossa pain. Abdominal examination was suggestive of acute appendicitis. The initial abdominal computerised tomography scan was reported as being unremarkable. At surgery, a firm tumour of the appendix was found, and a limited right hemicolectomy was done. Histopathology confirmed a mucocoele of the appendix with borderline mucinous histology.The second case is a 63-year-old man who presented with a one-year history of abdominal distension and weight loss. Previous abdominal ultrasound was suggestive of liver cirrhosis with significant ascitic fluid. Abdominal magnetic resonance imaging found an appendix mucocoele with infiltration of the omentum and scalloping of the liver surface suggestive of pseudomyxoma peritonei. A percutaneous biopsy of the omental mass confirmed metastatic mucinous adenocarcinoma of the appendix.The third case is a 68-year-old man who, during an annual medical check-up, had an incidental finding of a cystic right iliac fossa mass on ultrasound, confirmed on abdominopelvic computerised tomography scan to be an appendix mucocele. He had laparoscopic appendicectomy. The histopathological diagnosis confirmed a mucinous cystadenoma of the appendix., Conclusion: Preoperative diagnosis of appendiceal mucocoele is difficult and commonly discovered intraoperatively. The prognosis is good for the histologically benign type, but it is poor when malignant or peritoneal lesions are present., Funding: None declared., Competing Interests: Conflict of interest: None declared, (Copyright © The Author(s).)

Competing Interests: The authors declare that they have no conflict of interest.