Treatment of Acute Appendicitis in Geriatric Patients - Literature Review.

The work is dedicated to the features of the clinic, diagnosis, and treatment of acute appendicitis (AA) in patients with the new coronavirus infection (COVID-19). An analysis of 73 cases of diagnosis and treatment of AA in patients with COVID-19 in an infectious diseases hospital was conducted. In patients with COVID-19, immunopathological reactions, disturbances of consciousness, and the administration of antibacterial and anti-inflammatory therapy complicated the diagnosis of concurrent AA, leading to a smoothing or complete absence of local pain symptoms, an inability to fully collect complaints and medical history, and the presence of leukopenia. In patients with severe COVID-19 with disturbances of consciousness according to the Glasgow Coma Scale up to 9–13 points, CT grade 4, and respiratory failure of the 3rd degree, the basis for targeted diagnostic search for acute surgical pathology of the abdominal cavity of an inflammatory nature was the progressive increase in leukocytosis in the complete blood count, refractory to the administered antibacterial and anti-inflammatory therapy, in combination with values of CRP and procalcitonin (PCT) exceeding their average values in the group of patients with COVID-19. With an increase in the severity of COVID-19, the final diagnosis of AA was possible only when using additional instrumental diagnostic methods and performing diagnostic laparotomies (laparoscopies). A direct correlation was found between the severity of COVID-19 and an increase in the frequency of gangrenous forms of AA and secondary AA. The number of postoperative complications in AA was directly correlated with the severity of COVID-19. Fatal outcomes occurred only in patients with severe COVID-19 due to the progression of multiorgan failure.

ackground/aim: Alvarado score can help diagnose acute appendicitis based on predictive clinical factors and reduce the number of radiological examinations. Correct diagnosis and early surgical intervention are the best treatment to reduce morbidity, mortality and complications, with appendicectomy as the gold standard of treatment. This study aims to determine the relationship between a high Alvarado score and the occurrence of complicated acute appendicitis in acute appendicitis patients who underwent appendicectomy surgery at Sanglah General Hospital. Methods: This study used a cross sectional design. Data observation was carried out retrospectively. The research sample in this study was selected sequentially (consecutive sampling) which involved 108 respondents who had met the inclusion criteria and there were no exclusion criteria. Data analysis in this study consisted of univariate analysis (descriptive statistics), bivariate analysis (Chi Square test) and multivariate analysis (logistic regression). Results: Alvarado score in the complicated group obtained with a mean of 7.4 (SD: 1.2) and the non-complicated group obtained with a mean of 6.7 (SD: 1.8) with p value = 0.049. Alvarado score 7 with the occurrence of complicated appendicitis as many as 45 respondents (41.7%) and 29 respondents non-complicated (26.9%), Alvarado score <7 with complicated appendicitis status as many as 9 respondents (8.3%) and non-complicated as many as 25 respondents (23.1%). Conclusion: There is a significant relationship between a high Alvarado score and the occurrence of complicated acute appendicitis in patients with acute appendicitis who underwent appendicectomy with a 4 times chance of complications if they have a high Alvarado score. Keywords: Appendicitis, Alvarado score, complications, clinical symptoms.

IntroductionStrategies to postpone elective surgeries were proposed to maintain the hospital capacity to cater for coronavirus disease 2019 (COVID-19) and emergency non-COVID cases. Non-operative management (NOM) was recommended when possible during the COVID-19 era. However, the optimal approach to acute appendicitis (AA) in patients with COVID-19 remains controversial.Presentation of caseA 25-year-old man who tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2) was referred to our institution with a diagnosis of AA with appendicolith. Chest computed tomography did not detect evidence of pneumonia. Laparoscopic appendectomy was performed after strict infection prevention measures were taken. The postoperative course was uneventful. No respiratory symptoms such as cough or sputum production occurred postoperatively. No signs of infection in medical staff or spread in the operating room and infectious disease ward were observed.DiscussionThe treatment policy should fully consider the risk of COVID-19 infection to medical staff and the risk of aggravation in patients who tested positive for SARS-Cov-2. Surgery was chosen over NOM for AA with appendicolith because the presence of appendicolith was thought to indicate a high probability of treatment failure in NOM and possible perforation; thus, case more difficult measures were required for SARS-Cov-2-positive cases.ConclusionCareful assessment of the patient's condition and consideration of the treatment method is important, rather than choosing NOM over operative management based solely on SARS-Cov-2-positive status. Laparoscopic appendectomy with adequate infection control measures can be safely performed in SARS-Cov-2-positive cases.

Background: The normal treatment based on acute appendicitis is appendectomy. Traditional appendectomy procedures have been open appendectomy (OA), but laparoscopic appendectomy (LA) has the benefits of minimally invasive surgery. Aim: To compare laparoscopic and open appendectomy in the treatment of acute appendicitis in patients about safety and efficacy. Methodology: A comparative observational study was conducted involving 80 patients (40 with local anesthesia and 40 with overall anesthesia) in the Department of General Surgery at Bhagwan Mahavir Institute of Medical Sciences, Pawapuri, Nalanda, Bihar, India. Included in the patients were those over 10 years who were diagnosed with acute appendicitis. The variables analyzed included operative time, postoperative recovery, complications, hospital stay and return to normal activity. Results: OA had a shorter operating time (31.4 vs. 54.9 min, p<0.0001). LA patients experienced earlier bowel movements and diet tolerance (92.5% vs. 70% and 85% vs. 62.5%; p<0.001), lower analgesic requirements, shorter hospital stays (1.4 vs. 2.7 days; p=0.015), and faster return to normal activity (11.5 vs. 16.1 days; p<0.001). Wound-related complications were significantly lower in LA (infection: 10% vs. 82.5%; dehiscence: 0% vs. 32.5%; p<0.001). Major intra-abdominal complications were comparable. Conclusion: Laparoscopic appendectomy, despite longer operative time, offers superior postoperative recovery, fewer wound complications, and earlier return to normal activities, making it the preferred approach for uncomplicated acute appendicitis when feasible.

This retrospective cohort study used the nationwide database of Taiwan’s National Health Insurance to investigate whether metformin would reduce the risk of acute appendicitis in patients with type 2 diabetes mellitus. We first identified 423,949 patients newly diagnosed of diabetes from 1999 to 2005. After excluding patients having type 1 diabetes mellitus, missing data, previous history of acute appendicitis, aged < 15 years, aged > 80 years and followed up for < 6 months, 338,172 ever users and 21,861 never users of metformin were followed up from January 1, 2006 until December 31, 2011. Incidence of acute appendicitis was estimated for never users, ever users and subgroups (divided by median, tertiles and quartiles, respectively) of dose–response indicators including cumulative duration (months), cumulative dose (mg) and average daily dose (mg/day) of metformin therapy. We used Cox regression incorporated with the inverse probability of treatment weighting using propensity score to estimate the overall hazard ratio for ever versus never users, and the hazard ratios for subgroups of dose–response indicators versus never users. Results showed that new-onset acute appendicitis was diagnosed in 1558 ever users and 179 never users during follow-up. The incidence was 98.15 per 100,000 person-years in ever users and was 189.48 per 100,000 person-years in never users. The overall hazard ratio (95% confidence interval) of 0.514 (0.441–0.600) suggested a lower risk of acute appendicitis associated with metformin use. A dose–response pattern was consistently observed in the analyses of different subgroups of dose–response indicators and the reduced risk associated with metformin use was consistently observed in various sensitivity analyses. An average daily dose of 1000–1500 mg/day can significantly reduce the risk by > 50%. The benefit did not differ between different formulations of metformin, and the estimated hazard ratio for conventional/immediate-release metformin versus never users was 0.516 (0.441–0.603) and was 0.509 (0.421–0.615) for prolonged/slow-release metformin versus never users. It is concluded that metformin use is associated with a reduced risk of acute appendicitis in patients with type 2 diabetes mellitus.

Peritonitis is the most common complication in patients undergoing peritoneal dialysis (PD). However, its persistence despite appropriate antibiotic therapy should prompt consideration of alternative diagnoses, particularly acute appendicitis. We report the case of a 39-year-old PD patient who presented with culture-negative peritonitis unresponsive to treatment, ultimately resulting in a diagnosis of latero-cecal acute appendicitis. Diagnosis was confirmed by abdominal CT scan and exploratory laparoscopy, leading to surgical management with appendectomy and peritoneal lavage, while the catheter was preserved. Clinical improvement was achieved with targeted antibiotic therapy, and PD was resumed with low-volume exchanges without switching to hemodialysis. This case highlights the diagnostic challenge of acute appendicitis in PD patients, where clinical signs can be masked by frequent peritoneal lavage and intraperitoneal antibiotics. Prompt imaging and early surgical intervention are crucial to prevent complications.

Background and objectivesThe 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...

The aims of this study were to compare outcomes of appendectomy between acquired immunodeficiency syndrome (AIDS) and nonAIDS patients and laparoscopic appendectomy (LA) versus open appendectomy (OA) in AIDS patients. Using the Nationwide Inpatient Sample database, from 2006 to 2008, clinical data of patients with AIDS who underwent LA and OA were evaluated. A total of 800 patients with AIDS underwent appendectomy during these years. Patients with AIDS had a significantly higher postoperative complication rate (22.56% vs 10.36%), longer length of stay [(LOS) 4.9 vs 2.9 days], and higher mortality (0.61% vs 0.16%) compared with non-AIDS patients. In nonperforated cases in patients with AIDS, LA was associated with a significantly lower complication rate (11.25% vs 21.61%), lower mortality (0.0% vs 2.78%), and shorter mean LOS (3.22 days vs 4.82 days) compared with OA. In perforated cases in patients with AIDS, LA had a significantly lower complication rate (27.52% vs 57.50%), and shorter mean LOS (5.92 days vs 9.67 days) compared with OA. No mortality was reported in either group. In patients with AIDS, LA has a lower morbidity, lower mortality, and shorter LOS compared with OA. Laparoscopic appendectomy should be considered as a preferred operative option for acute appendicitis in patients with AIDS.

Acute Appendicitis in Patients with End-Stage Renal Disease

Abdominal surgery on patients with previous organ transplantation, especially in the early postoperative period, is a challenging problem. Due to high risk of complications in transplant patients, we usually tend to treat such patients more conservatively rather compared to the more aggressive attitude in diagnosis and surgery of non-transplant patients. Delayed diagnosis, delayed surgery, and high morbidity and mortality are more common in transplant patients with GI disease. While appendicitis is one of the most common surgical diseases, with an estimated lifetime risk of 8.6% for males and 6.7% for females, there are relatively few reports of appendicitis in solid organ transplant recipients, and the condition has rarely been reported after liver transplantation. We have performed surgery on 2 cases of presumed acute appendicitis among 75 cases of kidney and liver transplantation in our series in the last 10 years. Laparoscopic technique was used for exploration of presumed acute appendicitis with atypical clinical and image presentation in a deceased donor liver transplantation (DDLT) and a deceased donor kidney transplantation (DDKT). Acute appendicitis in both patients was highly suspected preoperatively in computed tomography, and early exploration with laparoscopic technique prompted early diagnosis and treatment, with excellent surgical outcomes.

Laboratory parameters have important diagnostic value in the evaluation of acute appendicitis. This study aimed to evaluate the efficacy of bilirubin values in predicting acute and complicated appendicitis in patients with leukocyte values in the normal reference range. This study included 200 patients aged 18 and over who underwent appendectomy with leukocyte values within the normal reference range. The demographic characteristics, total and direct bilirubin and C-reactive protein values of the patients were examined. According to the pathology results, the patients were divided into two groups as a normal appendix and acute appendicitis. Acute appendicitis was further classified as simple and complicated. Of the 200 patients included in this study, 110 (55%) were female and 90 (45%) were male, and the mean age was 37±16 years. The pathology results were reported as normal in 45 (22.5%) and acute appendicitis in the remainder of the sample. Of those diagnosed with acute appendicitis, 141 (91%) had simple appendicitis and 14 (9%) had complicated appendicitis. When the normal appendix and acute appendicitis groups were compared, the total and direct bilirubin levels were higher in the patients diagnosed with acute appendicitis. According to the receiver operator characteristic curve analysis, the area under the curve values of total bilirubin and direct bilirubin for the prediction of acute appendicitis were 0.597 and 0.625, respectively. In patients with normal leukocyte values, high bilirubin levels may be useful in predicting the diagnosis of acute appendicitis.

The Association Between Ventriculo-Peritoneal Shunt and Acute Appendicitis in Patients with Traumatic Brain Injury: A 14-Year, Population-Based Study.

BackgroundAcute appendicitis is a common surgical emergency, but its diagnosis can be challenging in patients with hematologic malignancies or chemotherapy-induced leukopenia due to an impaired inflammatory response. The clinical presentation of acute appendicitis in these patients is often atypical, leading to delayed or misdiagnosis. This study aims to evaluate the outcomes of appendectomy in patients with hematologic malignancies or chemotherapy-induced leukopenia and assess the applicability of clinical scoring systems for the diagnosis of an acute appendicitis.MethodsWe conducted a retrospective analysis of patients with hematologic malignancies or chemotherapy-related leukopenia who underwent appendectomy for suspected acute appendicitis between 2007 and 2023. Clinical presentation, laboratory findings, and imaging results were reviewed. The accuracy and relevance of clinical scoring systems for diagnosing acute appendicitis in these patients were also evaluated.ResultsOur study included 12 patients with hematologic malignancies or chemotherapy-induced leukopenia who underwent appendectomy. Atypical clinical presentations were common, with a lower frequency of fever, elevated leukocytes, and other typical inflammatory markers. Only one patient developed postoperative complications (acute kidney failure), and none of the patients died due to appendicitis. Clinical scoring systems demonstrated limited applicability in this patient population, often underestimating the likelihood of appendicitis.ConclusionDiagnosing acute appendicitis in patients with hematologic malignancies or chemotherapy-induced leukopenia poses significant challenges, as standard scoring systems prove unreliable. The presence of abdominal pain coupled with elevated C-reactive protein (CRP) levels should prompt a multidisciplinary evaluation and timely imaging. Surgical therapies, particularly laparoscopic approaches, appear safe and feasible in these patients. Ongoing research is essential to refine surgical strategies for the growing population of immunocompromised individuals.

The COVID-19 pandemic has generated uncertainty about the management of appendicitis. The aim of this study was to evaluate differences in the evolution and treatment of acute appendicitis in patients with COVID-19 infection compared to patients without the infection. A case-control study of adult patients hospitalized for acute appendicitis was performed, having as cases those who presented COVID-19. Data were extracted from the medical records. The logistic regression model was used to calculate crude (cOR) and adjusted odds ratios (aOR) with their respective 95% confidence intervals (95% CI). We evaluated 38 cases and 76 controls, the mean age of the patients was 38.2 years (± 16.8), of whom 55.3% were women. Multivariate analysis showed, in cases, a lower probability of intraoperative findings (aOR: 0.21; 95% CI: 0.05-0.90) and a surgery time of more than 60 min (aOR: 0.21; 95% CI: 0.06-0.80), while there was a greater probability of management by open surgery (aOR: 3.83; 95% CI: 1.42-10.32) and a hospitalization time of more than 3 days after surgery (aOR: 3.33; 95% CI: 1.34-8.26). Significant differences were observed in terms of intraoperative findings, type of surgery, intraoperative time, and hospitalization time in patients with acute appendicitis and COVID-19.

Whether to perform surgery or conservatively manage appendicitis in immunosuppressed patients is a concern for clinicians. This study aimed to compare the outcomes of these 2 treatment options for appendicitis in patients with cancer undergoing chemotherapy. This retrospective study included 206 patients with cancer who were diagnosed with acute appendicitis between August 2001 and December 2021. Among them, patients who received chemotherapy within 1 month were divided into surgical and conservative groups. We evaluated the outcomes, including treatment success within 1 year, 1-year recurrence, and the number of days from the diagnosis of appendicitis to chemotherapy restart, between the 2 groups. Among the 206 patients with cancer who were diagnosed with acute appendicitis, 78 received chemotherapy within 1 month. The patients were divided into surgery (n = 63) and conservative (n = 15) groups. In the surgery group, the duration of antibiotic therapy (7.0 days vs. 16.0 days, P < 0.001) and length of hospital stay (8.0 days vs. 27.5 days, P = 0.002) were significantly shorter than conservative groups. The duration from the diagnosis of appendicitis to the restart of chemotherapy was shorter in the surgery group (20.8 ± 15.1 days vs. 35.2 ± 28.2 days, P = 0.028). The treatment success rate within 1 year was higher in the surgery group (100% vs. 33.3%, P < 0.001). Surgical treatment showed a significantly higher success rate than conservative treatment for appendicitis in patients less than 1 month after chemotherapy. Further prospective studies will be needed to clinically determine treatment options.