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Background: Over the past decade, pediatric patients with ruptured appendicitis (RA) have been successfully treated with IV antibiotics and an interval appendectomy. Because the treatment of acute appendicitis (AA) and RA in children is now diverging, distinguishing between these two conditions preoperatively is critical. Study Design: A prospective cohort study was conducted. Clinical data were collected, and the attending surgeon''s preoperative diagnosis was recorded. Accuracy of the pediatric surgeon''s diagnosis was determined. Univariable and multivariable logistic regression were then used to determine independent clinical predictors of RA. Using the relative beta coefficients of these predictors, a scoring system was constructed to aid in the diagnosis of RA. Results: Two hundred forty-seven patients were evaluated: 98 AA (40%), 53 RA (21%), and 97 not appendicitis (39%). Median age was 10 years old. The overall accuracy of the pediatric surgeon''s preoperative diagnosis was 92%. Sensitivity and specificity for the diagnosis of RA were 96% and 83%, respectively. Multivariable regression analysis identified generalized tenderness on examination, duration of symptoms longer than 48 hours, WBC>19,400 cells/μL, abscess, and fecalith on CT scan as independent predictors for RA. A novel scoring system was developed with these variables, and, when applied to the study population, the specificity for the diagnosis of RA improved to 98%. Conclusions: Pediatric surgeons differentiate AA from RA and not appendicitis preoperatively with high accuracy and sensitivity, but the specificity for diagnosing ruptured appendicitis is lower. The scoring system improved the specificity of the preoperative diagnosis. The validity and utility of this scoring system should be examined in future studies in larger patient populations. [Copyright &y& Elsevier]

Abstract: The purpose of this study was to describe the CT appearance and determine the prevalence of thick-walled appendices in patients with an extraintestinal primary malignancy. This potential mimic of appendicitis may occur in up to 2% of cancer patients. Awareness of this pitfall is important to avoid unnecessary laparotomy in this patient population. [Copyright &y& Elsevier]

Acute appendicitis (AA) in elderly patients (60 years of age and older) is a challenging problem associated with significant morbidity and mortality when perforation is present. We hypothesized that laparoscopic appendectomy (LA) would enable an earlier correct diagnosis and have advantages in elderly patients. We performed a retrospective review of patients who underwent laparoscopic appendectomy for suspected AA. Data of elderly patients were compared to data of younger patients (18 to <60 years of age). Fifty-four LA were performed in elderly patients and 423 in younger patients. Patients over the age of 60 years had more co-morbidities and required more frequent use of anticoagulants. Preoperative imaging (ultrasound or computerized tomography) was significantly more frequent in elderly patients (36% versus 15%), and was associated with a higher rate of confirmation of acute appendicitis (78% versus 55%), which allowed a decrease in the rate of negative surgical explorations to 4.1% in elderly patients compared to 10.2% in younger patients. Complicated appendicitis and conversions were more frequent in the elderly patients. This resulted in prolonged operative time and longer hospital stay for this group. The overall complication rate was equivalent in the two groups, without differences in the occurrence either of infectious complications or of complications related to surgical site. There were no deaths following appendectomy in our series. Laparoscopic appendectomy is safe in the elderly population and is not associated with any increase in morbidity. The high incidence of complicated appendicitis in elderly patients affects operative time and length of hospital stay following laparoscopic appendectomy, and it can also lead to an increased rate of conversion to an open procedure. Use of preoperative abdominal computerized tomography scan is mandatory in elderly patients to provide an early diagnosis and to decrease unnecessary surgical exploration when acute appendicitis is suspected. [ABSTRACT FROM AUTHOR]

The timing, type, and technique of imaging evaluation of suspected appendicitis in children are all debated. This debate is both local and international. The fact is that choices in imaging evaluation will depend on both local and national influences, which are reasonable and to be expected. There still is a responsibility, though, for those involved with evaluation of patients with possible appendicitis to come to agreement about an appropriate diagnostic pathway that considers standards of care and available resources. [ABSTRACT FROM AUTHOR]

Background: Following an appendectomy, surgeons define appendicitis, for treatment and billing purposes, into one of four categories: normal appendix, acute appendicitis, gangrenous appendicitis, and perforated appendicitis. Treatment of appendicitis is predicated upon classification at the time of visual inspection. Further, this classification often plays a role in the assessment of hospital outcomes. The currently accepted classification system is based solely upon intraoperative surgeon opinion and not objective data. Inconsistent surgeon grading of the severity of appendicitis may have implications in both management and outcomes. Objective: The aim of this study was to assess the interobserver variation among surgeons in grading of the inflammatory severity of acute appendicitis as recognized on visual findings at operation. Methods: A cross-sectional study design. 110 surgeons, and surgical residents were randomly selected. Surgeons were shown images of intraoperative appendicitis and were asked to evaluate the severity of the appendicitis (i.e., normal, inflamed, gangrenous, and perforated). Demographic information regarding the type of practice, hospital setting, and the number of encounters with patients with acute appendicitis were assessed. An Intraclass Correlation Coefficient score, represented by R, was calculated to assess interobserver reliability in grading the inflammatory severity of acute appendicitis. The two-way analysis of variance procedure for multivariate analysis was used for this calculation. Results: The study group consisted of 100 surgeons, 62 practicing surgeons, and 48 surgical trainees. Overall, 79% of the surgeons treated predominately adults with appendicitis, 18% treated primarily children, and 3% treated both children and adults. Hospital practices included university hospitals (47%), community hospitals (33%), children's hospitals (14%), and others (6%). Overall, there was poor agreement among surgeons in assessing the severity of appendicitis. Among all attending surgeons, the agreement of defining an image as to whether it was perforated or not was 27% (R4 = 0.27). Completion of a general surgery residency did improve the interobserver agreement, when compared with trainees. Conclusion: There is poor agreement among surgeons in describing the severity of appendicitis. Treatment protocols based on more accurate assessment and categorization could potentially lead to more favorable, cost-effective outcomes. Further, studies determining efficacy in the diagnosis and treatment of appendicitis should consider observer variability. Future work must attempt to define critical objective assessment points, such as visible discontinuity of the appendix or fecal soilage, to assure a better correlation of findings with prognosis. [ABSTRACT FROM AUTHOR]

Objective. Enterobius vermicularis (pinworm) infestation can present with symptoms resembling acute appendicitis, although current evidence suggests that it does not necessarily cause acute appendicitis. The purpose of this study was to characterize the clinical presentation of patients with pinworms in the vermiform appendix and to establish features suggestive of this condition. Material and methods. A retrospective analysis of all patients undergoing appendicectomy with appendicular pinworms between 1998 and 2003 was undertaken. Patients were compared against 54 controls with confirmed acute suppurative appendicitis from the same time period. Presenting features, vital signs and modified Alvarado scores were obtained from the patients' records. Results. Eighteen out of 1150 patients (1.5%) undergoing appendicectomy were proven to have pinworms (age range 8-37 years, 12 F, 6 M). Two of 18 appendices containing pinworms showed evidence of inflammation. Patients with pinworms had significantly lower white cell counts (WCCs) than the control group (median 8.9 versus 14.7, p=0.045), lower total Alvarado scores (median 5.5 versus 7, p=0.01) and were more likely to have had recurrent episodes of right iliac fossa (RIF) pain and previous hospital admissions (p<0.001). Conclusions. E. vermicularis infestation of the appendix should be considered in the differential diagnosis of patients who present with recurrent RIF pain but do not have a significantly raised WCCs, or high Alvarado scores. These patients should be investigated with early fecal sampling and night-time application of cellophane tape, and they may benefit from empirical antiparasitic treatment. [ABSTRACT FROM AUTHOR]

Background/Aim: Acute appendicitis is one of the most common acute intraabdominal affections seen in surgical departments, which can be treated easily if an accurate diagnosis is made in time. Otherwise, delay in diagnosis and treatment can lead to diffuse peritonitis. Materials and Methods: A study was conducted on 110 patients who were operated for acute appendicitis to determine the role and predictive value of the total leucocyte count (TLC), C-reactive protein (CRP) and percentage of neutrophil count in the diagnosis of acute appendicitis. Preoperative TLC, CRP and percentage of neutrophil count were determined and were compared with the results of the histopathology of the removed appendix. Results: Of all the patients studied, 92 had histopathologically positive appendicitis. The TLC was found to be significantly high in 90 patients who proved to have acute appendicitis, whereas CRP was high in only 88 patients and neutrophil percentage was raised in 91; four had a normal CRP level. Thus, TLC had a sensitivity, specificity and positive predictive value of 97.82%, 55.55% and 91.8%, respectively. CRP had a sensitivity, specificity and positive predictive value of 95.6%, 77.77% and 95.6% respectively. Percentage of neutrophil count had a sensitivity, specificity and positive predictive value of 98.9%, 38.88% and 89.21%, respectively. When used in combination, there was a marked improvement in the specificity and the positive predictive value to 88.04% and 98.7%, respectively. Conclusion: The inflammatory markers, i.e., TLC, CRP and neutrophil count can be helpful in the diagnosis when measured together as this increases their specificity and positive predictive value. [ABSTRACT FROM AUTHOR]

Suspected appendicitis is the most common indication for emergent abdominal surgery in children. The clinical diagnosis of appendicitis can be challenging, and CT is playing an increasing role in the evaluation of right lower quadrant pain. Occasionally, alternative diagnoses to appendicitis can be suggested on CT. The appreciation of a fat-containing lesion in the right lower quadrant will often allow a specific diagnosis. Importantly, many of these lesions are self-limited and treated nonoperatively. The purpose of this pictorial essay is to illustrate the spectrum of fat-containing lesions that can present as alternative diagnoses to appendicitis on CT scans performed for the evaluation of right lower quadrant pain in children. [ABSTRACT FROM AUTHOR]

Appendicitis usually afflicts the young, but there is a large tail in the distribution of onset age. The genetics of this disease are still not well understood. A heritability analysis and genome wide linkage analysis of a large twin dataset was undertaken. Treating age of onset of appendicitis as a censored survival trait revealed a heritability of 0.21, and found evidence of linkage to Chromosome 1p37.3. [ABSTRACT FROM AUTHOR]

Abstract  Risk factors for progression to advanced appendicitis have not been clarified. The purpose of this study was to investigate whether the presence of appendicolith on computed tomography (CT) is related to progression of pathologic grade. We performed a retrospective review of 46 consecutive patients who underwent appendectomy and who had an inflamed appendix on CT scan. Patients were divided into two groups: group A underwent CT scan within 10 h of onset of symptoms, and group B was scanned after more than 10 h of symptoms. The presence or absence of appendicolith on CT as well as pathologic inflammatory grade was recorded. We analyzed correlation between the presence of appendicolith and ultimate pathologic grade in each group. Appendicoliths were detected on CT in 17 (17/36) of group B. The presence of appendicolith on CT in group B was significantly correlated with pathologic severity (p = 0.006). Retained appendicolith that is identified in an inflamed appendix on CT more than 10 h after onset of symptoms may be useful as a predictor of pathologic inflammatory grade of appendicitis. [ABSTRACT FROM AUTHOR]

The reported negative appendicectomy rate for young women remains high. This high rate of unnecessary appendicectomies has morbidity and high cost. Consensus European Association of Endoscopic Surgeons (EAES) guidelines have emphasised the value of routine laparoscopy as a diagnostic tool in young women. The objective of this study is to investigate the role of routine laparoscopy in the diagnosis of suspected appendicitis in young women. The details of young female patients who have had an appendicectomy with or without laparoscopy between 1980 and 2005 were obtained. The histopathological reports pertaining to the episode of appendicectomy were manually searched. Three periods were identified for comparison. The first period was between 1980 and 1990 when diagnostic laparoscopy was not practised in the emergency setting. The second period was between 1991 and 1999 when diagnostic laparoscopy was used selectively. The third period was between 2000 and 2005 when diagnostic laparoscopy was used routinely to investigate female patients presenting with acute right iliac fossa pain. Selective laparoscopy reduced the rate of negative appendicectomy rate from 37% to 31% (ns). By contrast, routine laparoscopy reduced the negative appendicectomy rate to 5% ( p < 0.005). Additionally, considering the ratios of all appendectomies to normal appendices, an average of one in three appendices excised was normal before the era of laparoscopy. The selective use of laparoscopy did not significantly alter this ratio (ns). By contrast routine use of laparoscopy has altered the ratio to 1 in 20 appendices removed to be normal ( p < 0.001). In young females, diagnostic laparoscopy used selectively reduces the rate of negative appendicectomy but not significantly. However, when used routinely, laparoscopy significantly reduces the rate of negative appendicectomy. Diagnostic laparoscopy should be used routinely for all young females presenting with right iliac fossa pain sufficiently severe to warrant surgical exploration. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this study was to determine whether the admission and active observation of children where the diagnosis of acute appendicitis is uncertain is a safe and effective way to improve the diagnostic accuracy of appendicitis and safely reduce the incidence of negative laparotomies without increasing complications.Methods: We performed a retrospective cohort study of children who presented with a complaint of right lower quadrant pain and were hospitalized with a diagnosis of appendicitis or suspected appendicitis from 1 January to 31 December 2007.Results: A total of 569 patients were included in the study. The mean age was 9.5 +/- 3.2 (range 1.1-17) years. The number of patients directly operated on with a diagnosis of appendicitis was 186 (32%) from the total of 575 while 389 patients (68%) were observed in the surgical ward as the examination and/or investigation findings were equivocal. Of the 383 patients admitted for observation, 173 (45%) were operated on with a suspicion of appendicitis after 14.4 +/- 6.7 h while 210 (55%) were discharged after 1.1 +/- 1.2 days as there seemed to have no surgical problem. Our total negative appendectomy rate was 4% (14/350) and total perforation rate was 37.4% (131/350). The patients operated on directly and those operated on after observation were similar, and there was no difference for the preoperative duration of symptom, histopathological diagnosis, postoperative complication rate, postoperative inpatient days and hospital charges. Total hospitalization duration was significantly longer and the hospital charges significantly higher in the negative appendectomy group.Conclusion: Both the features and results and the complication rates and costs of the group operated on after observation were the same as the directly operated on group. However, patients undergoing a negative appendectomy stayed as inpatients longer than only observation patients with higher treatment charges. We could therefore decrease the negative appendectomy rate, the associated cost and duration of hospitalization without causing extra complications if we observe and investigate patients with right lower quadrant pain with a doubtful diagnosis and did not operate on them directly. [ABSTRACT FROM AUTHOR]

Introduction Appendicitis in pregnancy (AIP) is the most common nonobstetric cause of an acute abdomen requiring surgical intervention. Diagnostic difficulties arising from gestational symptoms compound the risk of foetal loss after negative appendicectomy and exponentially increase the risk to mother and foetus with delay in genuine cases. In this article, we investigate the symptoms and signs of AIP and attempt to identify consistent clinical features and review the role of imaging in diagnosis. Method MEDLINE and PubMed were searched for case–control studies recording preoperative symptoms/signs suggestive of AIP, as well as appendiceal pathology. Combined likelihood and odds ratios (OR) were created for clinical features across homogenous papers. Papers examining the use of laparoscopy, ultrasound (US), computerized tomography (CT) and magnetic resonance imaging (MRI) were assessed qualitatively. Results Seven papers met the inclusion criteria for the analysis of consistent clinical features (450 patients). The only symptoms or signs significantly associated with a diagnosis of appendicitis were nausea (OR: 2.21, 95%CI: 1.34–3.66), vomiting (OR: 0.82–15.6 range) and peritonism (OR: 1.80, 95%CI: 1.06–3.04). US, CT and MRI have all been used to successfully diagnose AIP. Laparoscopic appendicectomy has been safely undertaken in pregnancy. Conclusion Appendicitis will continue to challenge the diagnostic acumen of surgeons. Whilst useful, consensus regarding the safety of laparoscopy, CT and MRI in pregnancy is yet to be achieved. [ABSTRACT FROM AUTHOR]

BACKGROUND AND AIMS: The interstitial cells of Cajal (ICC) have not yet been investigated in the vermiform appendix. They are important for the peristalsis of the gastrointestinal tract and have been found to be altered in various motility disorders. Motor disturbance has been suggested as a possible contributor in the unclear etiology of appendicitis. We wanted to examine the distribution of the ICC in the vermiform appendix. Furthermore we investigated whether ICC are altered in persons with appendicitis. METHODS: We investigated the ICC distribution in 28 appendices of children using immunohistochemistry and anti-c-kit antibodies. Cells and processes were quantified in normal, acute and chronic inflamed appendices. RESULTS: IC(C)-CM and IC(C)-LM were found in the circular and longitudinal muscle layers, respectively. IC(C)-LM, however, were scarce and inhomogeneous in contrast to the IC(C)-CM. The functionally important subgroups of the colon, the IC(C)-SM and IC(C)-MP, however, could not be detected in the appendix with the used antibody. There was no difference in the distribution of detected ICC between normal and inflamed appendices. CONCLUSION: IC(C)-LM are altered and IC(C)-SM and IC(C)-MP are lost in the vermiform appendix with no differences between healthy and inflamed tissue and without a correlation to appendicitis. Thus, other factors must be considered in the etiology of appendicitis. [ABSTRACT FROM AUTHOR]

Appendicitis can be a difficult clinical diagnosis to make. A negative appendicectomy rate of 20% has traditionally been accepted as the consequences of appendiceal perforation can be grave. Cross-sectional imaging is increasingly being employed in the investigation of adults with suspected appendicitis. This review will demonstrate the appearance of the normal appendix on computed tomography (CT) and its appearance in a range of inflammatory and neoplastic processes including appendicitis, Crohn''s disease, infections, and benign and malignant tumours. [Copyright &y& Elsevier]

Abstract: Background: Appendectomy is the treatment of choice in acute appendicitis in children. Delayed diagnosis of acute appendicitis in children can lead to complications like perforation. Studies on the diagnostic value of WBC and CRP in establishing the diagnosis of appendicitis have contradictory results. Our study evaluates the role of CRP in diagnosing appendicitis in a pediatric population. Methods: A retrospective chart study on 130 patients aged less than 19 years who had an appendectomy at Sparrow hospital during years 2002–2006 formed the basis for this report. Based on histology appendicitis was classified as simple or perforated (complicated). Results: Patients (75 boys, 55 girls) were 6–18 years of age (median 14 years). The appendix was normal in 9/130 cases. Appendicitis was simple in 58/130 cases and perforated in 63/130 cases. Overall WBC count had the highest sensitivity in the prediction of (diagnosis) appendicitis at 88% whereas CRP was 69% and, WBC and CRP combined was 60%. PPV of WBC was highest at 0.81 (47/58) for simple appendicitis and 0.93 (59/63) for perforated appendicitis, when compared to CRP at 0.57 (33/58) and 0.81 (51/63); and CRP and WBC combined at 0.45 (26/58) and 0.75 (47/63). Conclusion: The sensitivity and PPV of WBC were better than CRP alone, or in combination with WBC. We conclude that CRP does not aid in the diagnosis of appendicitis. Simple appendicitis was seen in spite of normal WBC and CRP. [Copyright &y& Elsevier]

Abstract: Objective: The aim of the study was to determine the microbiological profile of acute appendicitis in children. Study design: Prospective descriptive study including children hospitalized for acute appendicitis. Methods: A specimen of the appendice and the peritoneal exudates (if exists) was performed intraoperatively for aerobe bacteriological examination. Anaerobic incubation was not possible in our study. Results: Eighty children were included. The specimen culture isolated aerobic bacteria in 56patients (70%). Polymicrobial infection was found in 14 children. Gram-negative bacilli were the most frequently isolated microorganisms (64/70). Escherichia coli was found in 48 children. The resistance rate to amoxicilline-clavulanic acid and to cefazolin was 35%. Pseudomonas aeruginosa susceptible to ticarcillin was detected in seven patients. Conclusion: In our study, the specimen culture found aerobic bacteria in 70% of cases, especially Gram-negative bacilli. Empiric antibiotherapy in acute complicated appendicitis in children should be efficient against these microorganisms. [Copyright &y& Elsevier]

Background: Laparoscopic appendicectomy is increasingly used in children. This national retrospective study compared outcomes of paediatric open and laparoscopic appendicectomy.Methods: Length of stay, readmission rates and mortality in children undergoing open and laparoscopic appendicectomy in English NHS Trusts between 1 April 1996 and 31 March 2006 were compared. Procedures coded as emergency excision of appendix (OPCS-4 H01) on the Hospital Episode Statistics (HES) database in patients less than 15 years of age were included. Multivariate analysis was used to identify independent predictors of length of hospital stay and mortality.Results: Eighty-nine thousand, four-hundred and ninety-seven (89,497) appendicectomies were studied; of which, 2,689 (3%) were performed laparoscopically. The percentage of laparoscopic cases rose from 0.6 to 8.4% between 1996 and 2006 (Pearson's r = 0.954, P < 0.001). Length of stay (median 3, interquartile range 2 days, P = 0.068) and 28-day readmission rates were similar (6.3 vs. 7.2%, respectively; P = 0.072) between groups. No independent hospital stay advantage for laparoscopy was observed (P = 0.121). No difference in 30-day mortality (P = 0.986) or 365-day mortality (P = 0.598) was demonstrated.Conclusion: Hospital stay, readmission rates and mortality are similar following laparoscopic and open appendicectomy in children. [ABSTRACT FROM AUTHOR]

The appendix is lined by a mucosa which has many neuroendocrine cells containing serotonin. Local release of serotonin can act as a mediator of inflammation. In this study we explored the serotonin content of the neuroendocrine cells of the appendixes removed for clinical diagnosis of appendicitis. Appendix specimens were divided into three groups: Acute appendicitis (AA), non-appendicitis (NA), and follicular hyperplasia (FH). Normal appendix specimens from patients undergoing elective abdominal surgery were used as the control group (NL). All sections were exposed to proteinase K, incubated with anti-serotonin, chromogranin A, and synaptophysin antibodies, and treated with the LSAB kit. Polygonal cells were seen within the crypt epithelium (enterochromaffin cell, EC) and within the lamina propria (subepithelial neuroendocrine cell, SNC). In AA, only 16 cases (64%) showed serotonin staining in non-destructed glands. There was a significant reduction in the number of ECs in AA compared to the FH (96%), NA (100%) and NL (100%) groups (P<0.001). Chromogranin and synaptophysin immunostaining also showed a significant reduction in the number of ECs in AA compared with the other three groups (P<0.001). SNC serotonin reactivity was lower in the AA group compared with the other groups (p<0.001). The inflamed appendix is markedly depleted of serotonin in the epithelium and lamina propria. Local serotonin release from ECs and SNCs in the appendix may act as an inflammatory mediator in appendicitis and is likely to be the source of raised blood serotonin in AA. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to elucidate the natural history of appendicitis. Methods: Data was collected prospectively from consecutive patients admitted to hospital for acute abdominal pain. The degree of appendiceal inflammation in relation to preoperative duration of pain was analysed. Results: The study comprised 253 patients operated on for acute appendicitis that could recall the onset of abdominal pain. There was a longer duration of pre-hospital pain in patients, irrespective of age, with perforated appendicitis compared to patients with phlegmonous or gangrenous appendicitis (p < 0.001). In the multivariate analysis, patient age and preoperative duration of pain were independent risk factors for perforation. Conclusion: Patient delay in presentation is the predominant factor determining the incidence of complicated appendicitis, and this delay is not influenced by age or gender. Copyright © 2008 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

The highest degrees of accuracy have been demonstrated for CT scans using rectal contrast in diagnosing appendicitis. However, the administration of rectal contrast is associated with patient discomfort and rarely, rectosigmoid perforation (0.04%). Additionally, the commonly accepted negative appendectomy rate is around 16 per cent. We performed a retrospective review of radiology, operative, and pathology reports of consecutive patients undergoing appendectomy or CT examination for appendicitis during 2006. CT scans were performed without rectal contrast. The accuracy of each type of inpatient CT examination and negative appendectomy rates were determined. Two hundred and thirty-eight patients underwent appendectomy. One hundred and thirty-four appendectomy patients (56%) received a preoperative CT scan. The negative appendectomy rates were 6.3 per cent overall, 8.7 per cent without CT examination and 4.5 per cent with CT (P = 0.3). Two hundred and forty-five inpatient CT scans were performed for suspected appendicitis with a sensitivity of 90 per cent, specificity of 98 per cent, accuracy of 94 per cent, positive predictive value of 98 per cent, and negative predictive value of 91 per cent. CT scanning without rectal contrast is effective for the diagnosis of acute appendicitis making rectal contrast, with its attendant morbidity, unnecessary. The previously acceptable published negative appendectomy rate is higher than that found in current surgical practice likely due to preoperative CT scanning. [ABSTRACT FROM AUTHOR]

This publication focuses on abdominal pain in older people. it is noted that majority of the elderly going to emergency departments complain about abdominal pain. There are many conditions associated with abdominal pain, they include, billiary tract disease, appendicitis, bowel obstruction and cholecystitis.

The article reports on the diagnosis of appendicitis. Appendicitis can be caused by several factors including foreign bodies, tumors, and fecaliths. Diagnosing the condition is difficult due to the variations in symptoms and location of the appendix. Methods in diagnosis include physical examination, radiological tools, and laboratory tests. An overview of the diagnosis of appendicitis is provided.

ABSTRACTBackground:Appendectomy for acute appendicitis is an effective, universally accepted procedure performed more than 300,000 times annually in the United States. It is generally believed that appendicitis progresses invariably from early inflammation to later gangrene and perforation, and that appendectomy is required for surgical source control. Although non-operative management with antibiotics of uncomplicated diverticulitis, salpingitis, and neonatal enterocolitis is now established, the non-operative management of appendicitis remains largely unexplored.Methods:Systematic review of published literature and derived expert opinion.Results:Clinical, epidemiologic, radiologic, and pathologic evidence is presented for spontaneous resolution of uncomplicated acute appendicitis. The pathogenesis of appendicitis is reviewed with specific consideration of the role of bacterial infection in the pathogenesis. Evidence is also provided documenting the clinical success of non-operative management.Conclusions:Appendectomy may not be necessary for the majority of patients with acute uncomplicated appendicitis, as many patients resolve spontaneously and others may be treatable with antibiotics alone. However, the supporting documentation is scant and of poor quality. A randomized, prospective trial of non-operative management versus early appendectomy of acute uncomplicated appendicitis corroborated by radiologic imaging is called for. [ABSTRACT FROM AUTHOR]

Aim: Depth of appendiceal metastasis in patients with epithelial ovarian carcinoma (EOC) has not been previously analyzed for a possible relationship with clinico-pathological variables. Methods: Sixty-nine patients with EOC treated at Hacettepe University were retrospectively analyzed. All of the patients had appendiceal metastasis. Pathological slides were re-reviewed by the same pathologist. Appendiceal metastases were defined as serosal (if tumoral spread involved only serosa of the appendix) or sero-mucosal (if tumoral spread also involved either muscular or mucosal surfaces of the appendix). Univariate and multivariate analysis did not reveal a significant difference with respect to the prognostic variables between the groups. Results: Thirty-nine patients had serosal appendiceal metastasis (56.5%), while the remaining 30 patients (43.5%) had appendiceal metastasis extending toward the muscular layer (seromucosal metastasis: 16 within muscularis mucosa, 14 within the mucosa of the appendix). The mean age at the time of diagnosis was 54.58 years (range, 26-88 years), with no significant difference between the groups ( P = 0.9). Comparison of the survival rates between the two groups did not reveal a significant difference. Three-year survival rates were 23.3% in the serosal metastasis and 27.9% in the seromucosal metastasis group ( P = 0.9). This figure was 25% for patients with only muscular metastasis and 41.6% for patients with appendiceal metastasis extending to the mucosal layer ( P = 0.2). Conclusion: This is the first report to analyze the metastatic pattern of EOC on the appendix with respect to depth of invasion which could not reveal a significant difference. [ABSTRACT FROM AUTHOR]

The clinical diagnosis of appendicitis is a subjective synthesis of information from variables with ill-defined diagnostic value. This process could be improved by using a scoring system that includes objective variables that reflect the inflammatory response. This study describes the construction and evaluation of a new clinical appendicitis score. Data were collected prospectively from 545 patients admitted for suspected appendicitis at four hospitals. The score was constructed from eight variables with independent diagnostic value (right-lower-quadrant pain, rebound tenderness, muscular defense, WBC count, proportion neutrophils, CRP, body temperature, and vomiting) in 316 randomly selected patients and evaluated on the remaining 229 patients. Ordered logistic regression was used to obtain a high discriminating power with focus on advanced appendicitis. Diagnostic performance was compared with the Alvarado score. The ROC area of the new score was 0.97 for advanced appendicitis and 0.93 for all appendicitis compared with 0.92 ( p = 0.0027) and 0.88 ( p = 0.0007), respectively, for the Alvarado score. Sixty-three percent of the patients were classified into the low- or high-probability group with an accuracy of 97.2%, leaving 37% for further investigation. Seventy-three percent of the nonappendicitis patients, 67% of the advanced appendicitis, and 37% of all appendicitis patients were correctly classified into the low- and high-probability zone, respectively. This simple clinical score can correctly classify the majority of patients with suspected appendicitis, leaving the need for diagnostic imaging or diagnostic laparoscopy to the smaller group of patients with an indeterminate scoring result. [ABSTRACT FROM AUTHOR]

Abstract: Background: Acute appendicitis is the most common non-obstetric indication for surgical intervention in pregnant women. The benefits of a laparoscopic over an open approach to appendicectomy are well established in the non-pregnant population. Data on the optimal surgical approach to acute appendicitis in pregnant women are conflicting. Methods: A systematic review of reported cases of laparoscopic appendicectomy (LA) in pregnancy over the period 1990 to 2007. Twenty-eight articles documenting 637 cases of LA in pregnancy were included. Data on pregnancy outcome, patient characteristics, operative technique and peri-operative complications were analysed. Results: The rate of fetal loss following LA in pregnancy approaches 6% and is significantly higher than that following open appendicectomy. Fetal loss was highest in cases of complicated appendicitis. Incidence of preterm delivery appears lower in the LA group although this complication is likely to be under-reported in a significant proportion of cases. Trimester at the time of LA does not appear to influence complication rates. The negative appendicectomy rate in this series was 27%, which is higher than in the non-pregnant population. Complication rates following LA with negative appendicitis are as high as with simple appendicitis. Rates of entry-related complications were 2.8% in the Veress needle group and 0% in the Hasson open entry group. The overall rate of conversion to laparotomy was 1%. No difference was found in the preterm delivery rate between women who received prophylactic tocolysis and those who were not tocolysed. Conclusions: Laparoscopic appendicectomy in pregnancy is associated with a low rate of intra-operative complications in all trimesters. However, LA in pregnancy is associated with a significantly higher rate of fetal loss compared to open appendicectomy. Rates of preterm delivery appear similar or slightly better following a laparoscopic approach. Open appendicectomy would appear to be the safer option for pregnant women for whom surgical intervention is indicated. [Copyright &y& Elsevier]

Background/Aim: Acute appendicitis during pregnancy is the most common problem encountered in general surgery. However, limited data are available regarding acute appendicitis in pregnant sickle cell disease (SCD) patients. We aimed to study was the clinical presentation, management, and outcome in SCD patients who underwent appendectomy for suspected acute appendicitis during pregnancy. Materials and Methods: Between January 1998 and December 2006, 65 pregnant patients with clinically suspected appendicitis underwent surgery at our hospital of whom 11 were SCD patients. Data collected retrospectively included age, gestational stage, clinical signs and symptoms, operative findings, and complications. Results: Eleven out of 65 (16.9%) were SCD patients. The mean age in the SCD group was 22.5 years while the mean gravida and parity values were 2.0 and 1.1, respectively. The mean HbS, HbF, and HbA2 values were 71.1, 26.2, and 2.6%, respectively. Abdominal pain and vomiting were the most common presenting symptoms regardless of the gestational age. Abdominal and rebound tenderness were the most common physical signs. The mean operative time was 49 min (range: 35-125 min) and the average length of postoperative hospital stay was 4.7 days (2-8 days). There was no maternal death but one patient had spontaneous abortion during the first trimester, two days after the operation. Two patients had premature, postoperative delivery at 30 and 31 weeks of gestation. Conclusion: The clinical manifestations and diagnosis of appendicitis in sickler pregnant patients are similar to those in nonsickler pregnant patients. [ABSTRACT FROM AUTHOR]

Background Limited studies have suggested increased incidence rates and unusual clinical presentations of appendicitis among HIV-infected patients during the pre-highly active antiretroviral therapy (HAART) era. Data in the HAART era are sparse, and no study has evaluated potential HIV-related risk factors for the development of appendicitis. Methods We retrospectively studied 449 HIV-infected patients receiving care at a US Naval hospital involving 4750 person-years (PY) of follow-up. We also evaluated the rates of appendicitis among HIV-negative persons at our medical facility. We compared demographics, HIV-specific data, and HAART use in HIV-infected patients with and without appendicitis. Results Sixteen (3.6%) of 449 patients developed appendicitis after HIV seroconversion. The incidence rate was 337 cases/100 000 PY, more than fourfold higher than among HIV-negative persons. Eighty-eight per cent of cases among HIV-infected patients had an elevated white blood count at presentation, 39% were complicated, and 64% required hospitalization. HIV-infected patients with appendicitis compared with those who did not develop appendicitis were less likely to be receiving HAART (25 vs. 71%, P<0.001), had higher viral loads (3.5 vs. 1.7 log10 HIV-1 RNA copies/mL, P=0.005), and were younger (median age of 30 vs. 41 years, P<0.002). In the multivariate model, receipt of HAART remained protective [odds ratio (OR) 0.21, P=0.012] for appendicitis, while younger age was positively associated (OR 1.08, P=0.048) with appendicitis. Conclusion Acute appendicitis occurs at higher incidence rates among HIV-infected patients compared with the general population. Our study demonstrates that the lack of HAART may be a risk factor for appendicitis among HIV-infected patients; further studies are needed. [ABSTRACT FROM AUTHOR]

Background: Trauma services are increasingly providing emergency surgery care by creating “acute care surgery” teams. We compared two periods at a Level I trauma center to determine if trauma service coverage would negatively impact timely management of acute appendicitis. Study Design: All patients admitted through the emergency department of a Level I trauma center who underwent appendectomies between March 2005 and May 2006 (Trauma period) were identified. During this period, the trauma service covered most surgical emergencies. Comparison was made with the earlier 15-month period (Pretrauma). Emergency department to operating room (OR) time, procedure length, and negative appendectomy rates were obtained. Results: In the Pretrauma period, 273 patients underwent appendectomy, compared with 279 in the Trauma period. Two-thirds (66%) of appendectomies in the Trauma period were performed by trauma surgeons. There was no difference in both periods with regard to mean emergency department to OR time (10.5 hours versus 9.9 hours; p = 0.4509), perforation rates (12% Pretrauma versus 7.5% Trauma; p = 0.1134), or negative appendectomy rates (17.9% Pretrauma versus 18.2% Trauma; p = 1.0). In the Trauma period, more appendectomies were completed laparoscopically (84.6% Trauma versus 66.6% Pretrauma; p < 0.0001), and mean OR time was shorter (57.4 minutes versus 67 minutes; p = 0.0006). Conclusions: In comparing two periods with and without the trauma service coverage of surgical emergencies, no difference was found in emergency department to OR time, perforation rates, or negative appendectomy rates in the management of acute appendicitis. There was a decrease in operative time and an increase in the proportion of laparoscopic appendectomies in the Trauma period. Trauma services can effectively incorporate emergency surgical coverage of procedures, such as appendectomies, without compromising timely intervention. [Copyright &y& Elsevier]

Abstract: Abdominal pain is a ubiquitous experience during childhood and a common presenting complaint to secondary health care facilities. Amongst the large caseload are a number of serious and / or life-threatening conditions. In this article an approach to history and examination, initial management, diagnostic categories, modes of investigation, and treatment are discussed. Common and serious causes of abdominal pain in children are discussed. The clinical skills required to differentiate between them should not be underestimated. [Copyright &y& Elsevier]

Background/Purpose: The treatment options for complicated appendicitis in children continue to evolve. Optimal management of complicated appendicitis relies on an accurate preoperative diagnosis. We examined the accuracy of our preoperative diagnosis including computed tomography (CT) and the influence on the management of children with perforated and nonperforated appendicitis. Methods: Following IRB approval, a 6-year review of all patients that underwent an appendectomy for suspected appendicitis was performed. Treatments included immediate operations and initial nonoperative management (antibiotic therapy ± percutaneous drainage of abscess). Appendicitis was confirmed by histological examination. Results: One thousand seventy-eight patients underwent appendectomy for suspected appendicitis. Preoperative CT scans were performed in 697 (64.7%) patients: 615 (88.2%) positive for appendicitis; 42 (6.0%) negative; and 40 (5.7%) equivocal. One hundred seventy-three (28.1%) positive CT scans further suggested perforation. Initial nonoperative management was initiated in 39 (22.5%) cases of suspected perforated appendicitis with abscess. The positive-predictive value (PPV) for suspected acute appendicitis based on history and physical examination alone was 90.8%. The PPV for positive CT scan for acute appendicitis was 96.4% with a PPV of 91.9% for positive CT scan for perforated appendicitis. Conclusions: The correct preoperative diagnosis of appendicitis appears statistically more accurate with CT scan compared to history and physical examination alone (PPV 96.4% versus 90.8%, P = 0.045). For those with clinically suspicious complicated appendicitis, CT evaluation may direct therapy toward initial nonoperative management. The efficacy of this regimen warrants further investigation. [Copyright &y& Elsevier]

The article presents a case study of a 37-year-old man with a 6-month history of recurrent small bowel obstruction with abdominal pain, nausea and vomiting. The patient's medical history is also positive for acute appendicitis at 18 years of age. Abdominal radiographs and contrast enhanced computed tomography were acquired, which identified pseudomyxoma Peritonei (PMP). PMP is a rare condition marked by the progressive accumulation of mucinous tissue in the peritoneal cavity.

Matrix metalloproteinases (MMPs) and the tissue inhibitors of MMPs (TIMPs) have been demonstrated to be involved in inflammatory conditions in the intestine. The purpose of this study was to investigate whether the alterations of the MMP/TIMP balance might reflect the course of the inflammatory process in acute appendicitis and if the expression and localisation of MMPs and TIMP is variable in the various clinical manifestations of appendicitis. The study comprises 40 patients (26 men and 14 women) having emergency appendectomy and a control group constituting of 10 patients (5 men and 5 women) having a hemicolectomy for other reasons. MMP and TIMP expressions were assessed and compared in tissue specimens from phlegmonous ( n = 15), gangrenous ( n = 7), perforated appendicitis ( n = 11) and controls with noninflamed appendices ( n = 10) by means of enzyme-linked immunosorbent assay technique. Localisation of the enzymes was performed by immunohistochemistry. MMP-1 was significantly higher in gangrenous and perforated appendicitis compared with phlegmonous appendicitis and controls ( p < 0.05) while MMP-2 was significantly lower in gangrenous appendicitis compared with phlegmonous appendicitis and controls. MMP-2 was also lower in perforated appendicitis when compared with controls ( p < 0.01). Elevated expression of MMP-9 was demonstrated in all groups of appendicitis compared with the controls ( p < 0.001). MMP-9 is the most abundantly expressed MMP of those investigated in inflamed appendix. We postulate that a local imbalance between MMP-9 and TIMP-1 may trigger a perforation. These results suggest that MMPs might be useful as biomarkers of appendices prone to perforation. [ABSTRACT FROM AUTHOR]

To compare and evaluate diagnostic accuracy of modified Alvarado score and ultrasonography in co-relation to histopathology report for diagnosis of acute appendicitis. A prospective study of the patients who underwent appendectomy for suspected acute appendicitis at K.L.E.S. Hospital and M.R.C. Belgaum. The clinical, radiological and ultrasonogrpahic data of 60 patients with suspected appendicits was collected. These patients were evaluated by modified Alvarado here and ultrasonographically, which was correlated with histopatholocial finding. Out of 60 patients, 38.33% had acute appendicitis. 40% had modified Alvarado score ≥ 7 and 38.33% patients were ultrasonographically positive. In the present study, modified Alvarado score has sensitivity of 78.26%, specificity 83.78%, positive predictive value 75.00%, negative predictive value 86.11%, diagnostic accuracy 81.00% false positive error rate 16.22% and false negative error rate 21.74%. Ultrasonography had sensitivity of 82.61%, specificity of 89.19%, positive predictive value of 82.61, negative predictive value of 89.19.Diagnostic accuracy of 86.67%, false positive error rate of 10.81%, false negative error rate of 17.39%. When modified Alvarado score and ultrasonography were positive, 17 true positive cases and no false positive cases. The false negative cases in modified Alvarado score were five. When it was combined with ultrasonography the false negative cases reduced to two that is 60% reduction in false negative cases. Modified Alvarado score is useful tool in clinical decision making. When compared with ultrasonography neither one is advantageous. However, additional information provided by ultrasonography improves diagnostic accuracy. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the correlation between appendiceal size measured by contrast-enhanced CT of the abdomen and pelvis and the size of surgically removed appendixes on gross pathological examination. Materials and methods: The initial database consisted of the cases of 301 children, collected over 2 years, of which 56 met inclusion criteria. Both the radiology and surgical pathology reports of these patients were reviewed. Results: The mean size of appendixes meeting the CT size criteria of appendicitis was 10.3 mm, and that of the surgical pathology specimens was 10.4 mm. The pathological diagnosis of acute appendicitis was con- firmed in 54 of 56 cases, yielding a positive predictive value of 96.4%. The Pearson product-moment correlation coefficient was calculated to be 0.5443 (95% Cl 0.329 to 0.706). The slope of the linear correlation was 0.5788. The mean absolute difference in CT size versus pathological size was 2.2 mm. Conclusion: The data reveal a strong correlation in ability of CT to predict the presence of acute appendicitis, with moderate correlation in the size estimate of acutely inflamed appendixes, as imaged on CT, and the pathological specimen status after appendectomy. [ABSTRACT FROM AUTHOR]

Tumors of the appendix are rare entities, and the majority of them are discovered accidentally during an investigation for other conditions. Laparoscopic surgery for appendiceal goblet-cell carcinoid (GCC) has only been reported once before. Our patient was incidentally discovered to have an appendiceal tumor and was referred to us for laparoscopy. The tumor involved the body of the appendix and was adherent to the cecum. A laparoscopic hemicolectomy was successfully performed for the patient. Postoperative recovery was uneventful. Histopathology confirmed an appendiceal goblet-cell carcinoid. Immunohistochemistry was negative for the neuroendocrine markers, CK20 and CK7. GCC is a rare tumor of the appendix. Hemicolectomy is indicated in specific situations, such as local involvement or tumor size >2 cm. In our patient, the tumor was adherent to the cecum and tumor size was 5 cm. Therefore, a laparoscopic right hemicolectomy was performed primarily. There are several reports in the literature supporting both the laparoscopic and open approaches. Laparoscopic surgery for appendiceal tumors is safe, feasible, and even may be beneficial. [ABSTRACT FROM AUTHOR]

Abstract: We report a diabetic renal transplant recipient who presented with fever and right lower quadrant abdominal pain. Acute appendicitis was considered initially and she underwent emergent appendectomy. However, persistent symptoms postoperatively made us perform an imaging study to identify the problems. Abdominal and pelvic computed tomography disclosed several focal wedge-shaped lesions of low attenuation in the renal allograft. Acute lobar nephronia was successfully managed with parenteral antibiotics. The patient recovered without any sequela. A renal allograft in the right iliac fossa complicates the diagnosis among acute renal infection, malignancy, acute rejection, and even acute appendicitis. Biopsy of the renal allograft is sometimes needed due to clinically ambiguous imaging results. In this report, we not only detail the clinical course of such a rare case, but also review the previous 3 cases of acute lobar nephronia in renal allografts in the literature. [Copyright &y& Elsevier]

Abstract: Introduction: Appendicitis is the most common emergency condition in children. Historically, a 3-drug regimen consisting of ampicillin, gentamicin, and clindamycin (AGC) has been used postoperatively for perforated appendicitis. A retrospective review at our institution has found single day dosing of ceftriaxone and metronidazole (CM) to be a more simple and cost-effective antibiotic strategy. Therefore, we performed a prospective, randomized trial to compare efficacy and cost-effectiveness of these 2 regimens. Methods: After internal review board approval (IRB no. 04 12-149), children found to have perforated appendicitis at appendectomy were randomized to either once daily dosing of CM (2 total doses per day) or standard dosing of AGC (11 total doses per day). Perforation was defined as an identifiable hole in the appendix. The operative approach (laparoscopic), length of antibiotic use, and criteria for discharge were standardized for the groups. Based on our retrospective analysis using length of postoperative hospitalization as a primary end point, a sample size of 100 patients was calculated for an α of .5 and a power of 0.82. Results: One hundred patients underwent laparoscopic appendectomy for perforated appendicitis. On presentation, there were no differences in sex distribution, days of symptoms, temperature, or leukocyte count. There was no difference in abscess rate or wound infections between groups. The CM group resulted in significantly less antibiotic charges then the AGC group. Conclusions: Once daily dosing with the 2-drug regimen (CM) offers a more efficient, cost-effective antibiotic management in children with perforated appendicitis without compromising infection control when compared to a traditional 3-drug regimen. [Copyright &y& Elsevier]

Abstract: Objective: Given the perceived technical demands of laparoscopic appendectomy and the expected postoperative morbidity in patients with a well-defined abscess, initial percutaneous drainage has become an attractive option in this patient population. This strategy allows for a laparoscopic appendectomy to be performed in an elective manner at the convenience of the surgeon. However, the medical burden on the patient and on the quality of patient outcomes has not been described in the literature. Therefore, we audited our experience with initial percutaneous drainage followed by laparoscopic interval appendectomy to evaluate the need for a prospective trial. Methods: After institutional review board approval, a retrospective chart review was performed on all children who presented with perforated appendicitis and a well-defined abscess and were treated by initial percutaneous aspiration/drainage followed by interval appendectomy between January 2000 and September 2006. Continuous variables are listed with standard deviation. Results: There were 52 patients with a mean age of 9.0 ± 3.9 years and weight of 34.4 ± 18.8 kg. The mean duration of symptoms at presentation was 8.4 ± 7.6 days. Percutaneous aspiration only was performed in 2 patients. The mean volume of fluid on initial aspiration/drain placement was 76.3 ± 81.1 mL. The mean time to appendectomy was 61.9 ± 25.2 days. The laparoscopic approach was used in 49 patients (94.2%), of which one was converted to an open operation. The mean length of hospitalization after interval appendectomy was 1.4 ± 1.4 days. A recurrent abscess developed in 17.3% of the patients. Six patients (11.5%) required another drainage procedure. The mean total charge to the patients was $40,414.02. There were 4 significant drain complications (ileal perforation, colon perforation, bladder perforation, and buttock/thigh necrotizing abscess). The child with the ileal perforation after drain placement is the only patient who failed initial nonoperative therapy. Conclusions: The use of initial percutaneous aspiration/drainage of periappendiceal abscess followed by interval appendectomy is an effective approach. However, this management poses complication risks and uses considerable resources. Therefore, this strategy should be compared with early operation in a prospective trial. [Copyright &y& Elsevier]

Abstract: Background: Controversies regarding the diagnosis and treatment of appendicitis remain. Practices and outcomes at a community center including imaging, timing of surgery, and surgical technique are reported. Methods: From January to July 2006, 134 patients undergoing appendectomy in Victoria, British Columbia, were reviewed. Accuracy of preoperative imaging, time from the emergency room to the operating room, length of stay, and early complications were analyzed. Patients with and without perforation were compared using sample t tests. Results: Preoperative computed tomography was obtained for 101 patients (75%) with a negative appendectomy rate of 3% versus 10% for patients without imaging. Imaging did not prolong the time to surgery (11.8 vs 10.9 h, P = .48). Patients with perforation stayed in the hospital significantly longer and had more complications. Conclusions: The liberal use of computed tomography resulted in fewer negative appendectomies without a significant delay to surgery. Patients with perforation had increased complications and longer hospitalizations. Efforts should be made to identify and treat early appendicitis. [Copyright &y& Elsevier]

Abstract: Purpose: A fecalith is a fecal concretion that can obstruct the appendix leading to acute appendicitis. We hypothesized that the presence of a fecalith would lead to an earlier appendiceal perforation. Methods: Between January 2001 and December 2005, the charts of all patients younger than 18 years old who underwent appendectomy at our institution were reviewed. Duration of symptoms and timing between presentation and operation were noted along with radiologic, operative, and pathologic findings. Results: There were 388 patients who met the study criteria. A fecalith was present in 31% of patients (n = 121). The appendix was perforated in 57% of patients who had a fecalith vs 36% in patients without a fecalith (P < .001). The overall rate of interval appendectomies was 12%. A fecalith was present on the initial radiologic studies of 36% of the patients who had interval appendectomies, and the appendix was perforated significantly sooner in these patients when compared to those without a fecalith (91 vs 150 hours; P = .036). Conclusion: The presence of fecalith is associated with earlier and higher rates of appendiceal perforation in pediatric patients with acute appendicitis. An expedient appendectomy should therefore be performed in the pediatric patient with a radiologic evidence of fecalith. [Copyright &y& Elsevier]

Acute appendicitis is a diagnosis that can be made on clinical symptoms and signs but can often be extremely challenging. Difficulties arise particularly when the presentation is atypical, and this can lead to untoward sequelae. In this review, we present the range of presentations of atypical appendicitis, the variety of management options and the potential value of CT. [ABSTRACT FROM AUTHOR]

Background: Therapeutic and diagnostic laparoscopy, a minimal invasive technique, has been used effectively and frequently for appendicitis by surgeons. There is still controversy about whether this technique should be applied to all patients or in the setting of a doubt of the diagnosis of appendicitis, especially for women. Based on these controversies, the aim of this study was to assess the safety and efficacy of diagnostic and therapeutic laparoscopy for patients with suspected peritonitis imitating acute appendicitis. Patients and Methods: Between May 2002 and September 2006, a consecutive series of 74 patients operated on for suspected acute lower quadrant peritonitis were studied retrospectively. Despite being unclear, the preoperative diagnoses were thought to be suspected peritonitis imitating acute appendicitis. Therefore, patients all had diagnostic and therapeutic laparoscopy. Results: Seventy-four patients included in this study were successfully operated on by laparoscopy. Thirty-five of these patients were diagnosed with appendicitis and had an appendectomy by laparoscopy. Six of the 35 patients were converted to a conventional open appendectomy because of retrocecal localization and perforated appendicitis. In the 29 of the remaining 39 patients, pelvic inflammatory disease, mesenteric lenfadenopathy, torsed omentum and ruptured hemorrhagic, and endometrial or simple ovarian cysts were revealed. So, these 29 patients' (39.1) appendices were left in place, and an unnecessary appendectomy was avoided, thereby reducing the negative appendectomy rate. In the remaining 10 patients, nothing was found to explain the clinical signs. After a mean follow-up period of 16 months, postoperative evaluations of the patients were satisfactory. Conclusion: Laparoscopy, a single procedure and an accurate modality for the diagnosis and treatment of patients with acute abdominal conditions, can be recommended in patients, especially fertile women, with suspected peritonitis imitating acute appendicitis when the diagnosis cannot be made by physical examination and noninvasive methods. [ABSTRACT FROM AUTHOR]

Abstract  The role of computed tomography (CT) scanning in a case of Yersinia enterocolitica (YE) enteritis mimicking acute appendicitis in a 34-year-old female patient with β-thalassemia major is presented. Although the abdominal CT findings on admittance were indicative of acute appendicitis (enlargement of the appendix and thickening of its wall), making appendectomy a likely treatment option, a second CT scan 3 days later was diagnostic for infectious colitis (bowel wall thickening, ulcerations of the colonic mucosa, and fat stranding), and an unnecessary appendectomy was thus avoided. The diagnosis of YE colitis was later confirmed by serology tests. [ABSTRACT FROM AUTHOR]

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ABSTRACTBackground: Cost of treatment is an important consideration in antimicrobial agent selection for intra-abdominal infection. We analyzed the relation between the total cost of inpatient stay and the initial selection of antimicrobial agent.Methods: Actual costs of inpatient care were calculated for 1,234 patients treated at 22 hospitals with one of five antimicrobial regimens: Ampicillin/sulbactam (n 428), ertapenem (n 143), ceftriaxone (n 101), levofloxacin (n 245), or piperacillin/tazobactam (n 317) for intra-abdominal infections. Length of stay (LOS), demographic data, diagnosis, disease severity index, intensive care unit (ICU) stay, and total and specific costs were obtained from a large hospital-based, service level, comparative database for five types of infection (appendicitis, cholecystitis, diverticulitis, pancreatitis, and postoperative infection).Results: The LOS was shorter for appendicitis (3.8 days) and cholecystitis (4.6 days) than for diverticulitis (11.4 days), pancreatitis (8.1 days), or postoperative infection (8.4 days). Length of stay and total cost were most closely related to severity index (p < 0.01) and ICU days (p < 0.01). When patient and hospital characteristics and correlations within hospitals were accounted for in the model, piperacillin/tazobactam was associated with significantly higher cost than ertapenem, ampicillin/sulbactam, and levofloxacin.Conclusions: In assessing pharmacoeconomic outcomes in the treatment of intra-abdominal infection, cost of treatment, although lower with certain antimicrobial agents, is dependent on severity-of-illness indicators. [ABSTRACT FROM AUTHOR]

ABSTRACTBackground: The Surgical Infection Society published their most recent recommendations for antimicrobial therapy in patients with intra-abdominal infections in 2002. These guidelines outlined several important considerations for the treatment of such infections, including which patients require antimicrobial agents, the appropriate duration of treatment, which antimicrobial regimens are appropriate, and the risk factors and indications for intensified regimens. However, the applicability of these recommendations to the pediatric population is not entirely clear.Methods: Systematic review of all literature regarding antimicrobial therapy in the most common intra-abdominal infection in children, appendicitis, with the goal of establishing guidelines for use.Results: Children with uncomplicated (acute or gangrenous), but not perforated, appendicitis can be treated with prophylactic antimicrobial agents for 24 h or less. Children with perforated appendicitis can be treated after appendectomy in the same manner as adults with established intra-abdominal infections; i.e., with therapeutic antibiotics until no clinical evidence of infection exists. This is true after both laparoscopic and open operations. Whereas triple antibiotic therapy has been the gold standard in pediatric patients, monotherapy with broad-spectrum agents is equally effective and possibly more cost-effective. The nonoperative management of perforated appendicitis with interval appendectomy represents a unique problem, and guidelines for therapy are less well established.Conclusions: The evidence supports using guidelines in the pediatric population similar to those suggested for the adult population for the management of acute appendicitis. [ABSTRACT FROM AUTHOR]

The article focuses on the study about catamenial appendicitis. Intricately, it examines three patients with peritoneal endometriosis and recurrent symptoms of acute appendicitis coincident with menses underwent resection of a noninflamed appendix with long-term symptom resolution. The study proposes that a mechanism of pathogenesis of right lower quadrant pain and nausea in patients with histologically confirmed endometriosis.