Advanced Appendicitis Research Articles

Total oxidant status, total antioxidant status, and paraoxonase activity in acute appendicitis.

The aim of this study was to investigate the levels of oxidative stress including total oxidant status, total antioxidant status, and paraoxonase activity in patients with a diagnosis of acute appendicitis. Seventy-three patients who underwent surgery with a preoperative diagnosis of acute appendicitis (Group I) were included into the study. The control group (Group II) consisted of thirty otherwise healthy subjects. After histopathologic examination, the patients were categorized as follows: 1) Acute focal appendicitis, 2) Acute advanced appendicitis including acute suppurative, phlegmonous and gangrenous appendicitis, 3) Acute perforated appendicitis, 4) Sub-acute appendicitis, and 5) Negative exploration. Blood samples for paraoxonase activities, and total oxidant and antioxidant status levels were obtained preoperatively. Total oxidant and antioxidant status of the patients in the acute appendicitis group were higher than those of the control group. When paraoxonase activities of Group I was compared with Group II, no significant difference was determined. Both total oxidant and antioxidant status levels of acute perforated appendicitis were higher than those of both acute focal appendicitis and acute advanced appendicitis. The increase in the oxidative status (total oxidant and antioxidant status) was related with the progression of inflammation to the perforation in acute appendicitis.

Die durch Diagnosefehler bedingte Verzögerung der operativen Behandlung der akuten Appendizitis – Erfahrungen der Norddeutschen Schlichtungsstelle für Arzthaftpflichtfragen

From 2000 to 2012, 447 panel proceedings concerning acute appendicitis were evaluated. 271 cases (57%) were related to alleged diagnostic malpractice. This was confirmed in 176 cases (67%). The following medical specialities were involved (m=quote of malpractice): general surgery 33%, m=51%; paediatric surgery 3%, m=44%; general practitioner and prehospital emergency services 24%, m=62%; internal medicine 19%, m=70%; paediatrics 13%, m=57%; gynaecology 3%, m=91%; urology 2%, m=17%. The most frequent misdiagnosis was gastroenteritis (43% in adults, 69% in children), obviously based on the concomitant symptom of diarrhoea. Surgery revealed all stages of advanced appendicitis up to peritoneal sepsis, organic failure and death (n=5). The evaluation of the files and the experts' reports of the 176 cases of diagnostic malpractice allowed to define the following basic failures, which led to unjustified delay of operation: careless history-taking, no or incomplete physical examination, no follow-up investigations, incorrect interpretation of the patient's complaints and clinical findings, no or incomplete documentation. Conducting a thorough investigation is essential to avoiding diagnostic malpractice. Internal analysis of failures or near failures may contribute to reducing the number of future cases of malpractice.

Can new inflammatory markers improve the diagnosis of acute appendicitis?

The diagnosis of appendicitis is difficult and resource consuming. New inflammatory markers have been proposed for the diagnosis of appendicitis, but their utility in combination with traditional diagnostic variables has not been tested. Our objective is to explore the potential of new inflammatory markers for improving the diagnosis of appendicitis. The diagnostic properties of the six most promising out of 21 new inflammatory markers (interleukin [IL]-6, chemokine ligand [CXCL]-8, chemokine C-C motif ligand [CCL]-2, serum amyloid A [SAA], matrix metalloproteinase [MMP]-9, and myeloperoxidase [MPO]) were compared with traditional diagnostic variables included in the Appendicitis Inflammatory Response (AIR) score (right iliac fossa pain, vomiting, rebound tenderness, guarding, white blood cell [WBC] count, proportion neutrophils, C-reactive protein and body temperature) in 432 patients with suspected appendicitis by uni- and multivariable regression models. Of the new inflammatory variables, SAA, MPO, and MMP9 were the strongest discriminators for all appendicitis (receiver operating characteristics [ROC] 0.71) and SAA was the strongest discriminator for advanced appendicitis (ROC 0.80) compared with defence or rebound tenderness, which were the strongest traditional discriminators for all appendicitis (ROC 0.84) and the WBC count for advanced appendicitis (ROC 0.89). CCL2 was the strongest independent discriminator beside the AIR score variables in a multivariable model. The AIR score had an ROC area of 0.91 and could correctly classify 58.3 % of the patients, with an accuracy of 92.9 %. This was not improved by inclusion of the new inflammatory markers. The conventional diagnostic variables for appendicitis, as combined in the AIR score, is an efficient screening instrument for classifying patients as low-, indeterminate-, or high-risk for appendicitis. The addition of the new inflammatory variables did not improve diagnostic performance further.

Outcome of appendicectomy in children performed in paediatric surgery units compared with general surgery units

Appendicectomy for acute appendicitis in children may be performed in specialist centres by paediatric surgeons or in general surgery units. Service provision and outcome of appendicectomy in children may differ between such units. This multicentre observational study included all children (aged less than 16 years) who had an appendicectomy at either a paediatric surgery unit or general surgery unit. The primary outcome was normal appendicectomy rate (NAR). Secondary outcomes included 30-day adverse events, use of ultrasound imaging and laparoscopy, and consultant involvement in procedures. Appendicectomies performed in 19 paediatric surgery units (242 children) and 54 general surgery units (461 children) were included. Children treated in paediatric surgery units were younger and more likely to have a preoperative ultrasound examination, a laparoscopic procedure, a consultant present at the procedure, and histologically advanced appendicitis than children treated in general surgery units. The unadjusted NAR was significantly lower in paediatric surgery units (odds ratio (OR) 0.37, 95 per cent confidence interval 0.23 to 0.59; P < 0.001), and the difference persisted after adjusting for age, sex and use of preoperative ultrasound imaging (OR 0.34, 0.21 to 0.57; P < 0.001). Female sex and preoperative ultrasonography, but not age, were significantly associated with normal appendicectomy in general surgery units but not in paediatric surgery units in this adjusted model. The unadjusted 30-day adverse event rate was higher in paediatric surgery units than in general surgery units (OR 1.90, 1.18 to 3.06; P = 0.011). When adjusted for case mix and consultant presence at surgery, no statistically significant relationship between centre type and 30-day adverse event rate existed (OR 1.59, 0.93 to 2.73; P = 0.091). The NAR in general surgery units was over twice that in paediatric surgery units. Despite a more severe case mix, paediatric surgery units had a similar 30-day adverse event rate to general surgery units. Service provision differs between paediatric and general surgery units.

Modification of an evidence-based protocol for advanced appendicitis in children

IntroductionWe previously developed an evidence-based clinical pathway for children with advanced appendicitis. The pathway standardized the choice and duration of antibiotic therapy and established discharge criteria. Initially, the pathway led to a 50% decrease in the rate of superficial and deep surgical site infections and a significant decrease in hospital length of stay. Four years after implementation, we noted an increase in the infectious complication rate and the emergence of resistant bacteria to commonly used antibiotics. In this study, we prospectively collected peritoneal fluid cultures at the time of appendectomy in an effort to optimize our antibiotic therapy and decrease complication rates. MethodsMicrobiology analysis of peritoneal fluid cultures obtained at the time of appendectomy was performed in patients with an intraoperative diagnosis of advanced appendicitis. Clinical information, including demographics, laboratory data, and postoperative outcomes were collected and compared to the historic cohort. X2, Student’s t-test, and Fisher exact test were used where appropriate. ResultsThe historic and prospective cohorts were similar with respect to clinical and demographic data. The postoperative intra-abdominal abscess rate remained unchanged (28% from 24%, P = 0.603). Escherichia coli and Pseudomonas aeruginosa were the most commonly isolated aerobic bacteria from peritoneal fluid in the prospective cohort. Thirty-two percent of these patients had Pseudomonas spp., and 12% had Enterococcus spp. or Escherichia coli resistant to cefoxitin in their peritoneal fluid cultures. DiscussionA significant proportion (40%) of children with advanced appendicitis had organisms either not susceptible or resistant to our first line antibiotic in their peritoneal fluid cultures. Our clinical pathway now recommends piperacillin-tazobactam as the most effective empiric therapy for advanced appendicitis in children. Microbiologic analysis of peritoneal fluid at appendectomy may be used to tailor antibiotic therapy in advanced appendicitis.

Spontaneous Bacterial Peritonitis Caused by Nontypeable Haemophilus influenzae in a Previously Healthy Child

To the Editors: Spontaneous bacterial peritonitis (SBP) is an infection of the peritoneum without obvious intra-abdominal cause.1 Most episodes of SBP develop in patients with cirrhosis, but has also been observed in congestive heart failure, nephrotic syndrome, fulminant hepatic failure and alcoholic and viral hepatitis.2 SBP developing in healthy individuals is rare.2Haemophilus influenzae is a rare cause of SBP in normal children and has been assumed to originate from a respiratory source.3 Only 3 cases of SBP caused by H. influenzae have been reported.4–6 However, SBP caused by nontypeable H. influenzae biotype ІІ in otherwise healthy child has never been reported. A 13-year-old previously healthy boy presented to the emergencyroom with 8 days of abdominal pain, fever, diarrhea and vomiting. He reported recent symptoms of upper respiratory tract infection. His temperature was 38°C, the abdomen was tense and tender with signs of peritoneal inflammation. The white blood cell count was 26.9 K/μL (80.8% segmented cells). C-reactive protein was 24.6 mg/L. Ultrasound showed a localized inflammatory mass in the right lower abdomen. The child was considered to have advanced appendicitis taken to surgery. He received preoperatively intravenous amoxicillin and clavulanic acid, metronidazole and netilmicin. Intraoperatively, the abdominal cavity contained 1000 mL of purulent peritoneal fluid, which was Gram stained and cultured for aerobic and anaerobic organisms. The appendix was normal, whereas the omentum was inflamed and edematous with ischemic lesions distally. Appendectomy was performed, and the ischemic portion of the omentum was removed. The peritoneal cavity was irrigated with isotonic crystalloid solution until the returns were clear, and the wound was closed primarily. There were no surgical complications. Histopathology of the appendix and the omentum was normal. The peritoneal fluid culture grew a nontypeable H. influenzae, biotype ІІ, susceptible to amoxicillin and clavulanic acid. The diagnosis of SBP due to H. influenzae was established. The patient received 10 days of antibiotic therapy and recovered completely. The signs and symptoms of SBP are nonspecific. Approximately 10% of the patients are asymptomatic.1 The diagnosis is established by examination of the ascitic fluid. The polymorphonuclear leukocyte count in the fluid exceeds 250 cells/mm³, and peritoneal cultures yield the pathogen.1 Empiric antimicrobial therapy is started, as soon as infection is suspected.2 Preoperatively, diagnosis of SBP in previously healthy children is difficult because of the suspicion of secondary peritonitis undergo laparotomy. The present report demonstrates that SBP due to H. influenzae, although a rare condition in children with no underlying disease, should be considered as a possibility in children with acute abdominal pain, especially if following infection of the respiratory tract. Early diagnosis of SBP, caused by H. influenzae in otherwise normal children, is essential for effective treatment and improved outcome. Anastasia Dimopoulou, MD Department of Pediatric Surgery Children’s Hospital of Penteli Athens, Greece Dimitra Dimopoulou, MD Department of Internal Medicine University Hospital of Heraklion Crete, Greece Efstratios, Christianakis, MD Dimitrios Bourikas, MD Ioannis Alexandrou, MD Department of Pediatric Surgery Children’s Hospital of Penteli Athens, Greece George, Samonis, MD Department of Internal Medicine University Hospital of Heraklion Crete, Greece

Evaluating the effectiveness of a discharge protocol for children with advanced appendicitis

BackgroundIn 2006, an evidence-based protocol for the management of children with appendicitis was established at our institution. Discharge criteria for patients with advanced appendicitis were based on a combination of clinical parameters and laboratory values. The purpose of this study is to evaluate the utility of laboratory values in guiding patient management with a discharge protocol for advanced appendicitis. Materials and methodsWe reviewed charts of patients with advanced appendicitis as defined by the surgeon intraoperatively from 2008–2009. We evaluated the sensitivity and specificity of the laboratory values at discharge for predicting postoperative intra-abdominal abscess (IAA) formation using a receiver operator curve. A logistic regression analysis was performed to identify predictors of IAA formation. ResultsWe identified 450 patients (mean age 8.9 ± 3.9 y). The postoperative IAA rate was 25%. The sensitivity and specificity for developing an abscess with a white blood cell count >12,000/UL were 52% and 82%, respectively (AUC 0.72, 95% CI 0.67–0.78, P < 0.001). The sensitivity and specificity for bands >3% were 47% and 70% (AUC 0.60, 95% CI 0.53–0.67, P = 0.002), respectively. On logistic regression analysis, an elevated white blood cell count was independently associated with an increased likelihood of a postoperative IAA (OR 1.27, 95% CI 1.19–1.35, P < 0.001). ConclusionsThe absence of leukocytosis is useful for identifying children with a decreased risk of postappendectomy IAA formation who otherwise meet clinical discharge parameters. A band count is not as predictive of risk. The use of laboratory evaluation as a component of discharge criteria in advanced appendicitis can stratify a subset of patients who are at increased IAA risk and may benefit from continued antibiotic therapy.

Evaluating the Effectiveness of a Discharge Protocol for Advanced Appendicitis at a Children's Hospital

Evaluating the Effectiveness of a Discharge Protocol for Advanced Appendicitis at a Children's Hospital

Appendicectomy is Associated With Increased Pregnancy Rate

This study was carried out to determine whether pregnancy rate is reduced after appendicitis or appendicectomy. The association between appendicectomy, appendicitis, and subsequent fertility is controversial. A cohort study was carried out in the Medicines Monitoring database. The cohort of women who underwent appendicectomy and appropriate comparators were followed up until first pregnancy after appendicectomy date. Pathology of the appendix was verified manually. The association between appendicectomy, appendicitis, and pregnancy was determined by Cox regression models. The age and social deprivation score-matched analyses included 2935 patients who had appendicectomy with 5870 comparators. There were 1277 (43.5%) pregnancies in the appendicectomy cohort and 2319 (39.5%) in the comparator cohort during a mean follow-up of 12.4 (standard deviation: 7.3) years. The adjusted hazard ratios (HRs) for pregnancy rates were 1.20 (95% confidence interval [CI]: 1.10-1.31). In an unmatched cohort analysis (3009 in the appendicectomy cohort and 122,912 in the comparator cohort), the adjusted HRs for pregnancy rates were 1.65 (95% CI: 1.55-1.75). Within the histologically proven appendicitis subset, the adjusted HR was 1.21 (95% CI: 1.08-1.37) in comparison with the matched comparator cohort. In comparison with the group of participants who had appendicectomy for a normal appendix, the HRs were 0.98 (95% CI: 0.83-1.15) for mucosal and catarrhal appendicitis, 0.72 (95% CI: 0.64-0.82) for suppurative appendicitis, and 0.64 (95% CI: 0.50-0.80) for gangrenous appendicitis. Appendicectomy and early appendicitis were associated with increased pregnancy rates. Young women with early appendicitis had better pregnancy rates than those with advanced appendicitis. Early referral for laparoscopy and appendicectomy is advocated.

Appendicitis in children less than 5 years old: influence of age on presentation and outcome

PurposeAppendicitis is the most common emergency surgical condition of the abdomen in children. This study sought to delineate the presentation and the outcome of appendicitis in children younger than 5 years old. MethodsA retrospective review was conducted of all children younger than 5 years of age who underwent appendectomy for acute appendicitis over a 12-year period. ResultsOne thousand eight hundred thirty-six patients younger than 19 years of age underwent appendectomy. Two hundred eighty-one children with an age range of 6 months to 4.9 years were included in this study. Perforation rates were higher in the younger patients (86% <1 year, 74% 1–1.9 years, 60% 2–2.9 years, 64% 3–3.9 years, and 49% 4–4.9 years), but the youngest children had fewer postoperative abscesses. ConclusionsIn children less than 5 years old with appendicitis, age has a direct correlation to the stage of disease. The youngest children present with more advanced appendicitis but are less likely to develop postoperative abscesses.

Risk factors associated with advanced appendicitis and complications after childhood appendectomy

Risk factors associated with advanced appendicitis and complications after childhood appendectomy

Diagnostic power of inflammatory markers in predicting severity of appendicitis.

Severity of inflammation may be a risk factor for negative outcome in non-operative therapy of appendicitis. However, optimal screening test for predicting the pathological severity of appendicitis has not been established. 632 consecutive patients who underwent appendectomy at a single institute were retrospectively reviewed. Clinical parameters are compared among the three pathological grades: simple (G1), gangrenous (G2), and perforated appendicitis (G3). The diagnostic power of inflammatory markers (WBC count and CRP concentration) in discriminating the advanced appendicitis from the milder one was evaluated. CRP concentration was well correlated with the severity of appendicitis (p>0.0001), while WBC count showed only slight increase in advanced pathology (G1 vs. G2-G3). In receiver operating characteristic (ROC) curve analysis, the area under the curve (AUC) was remarkably higher in CRP (AUC 0.809) compared with that in WBC count (AUC 0.617), suggesting that CRP is a more sensitive test in discriminating the pathological severity of appendicitis. Multivariate analysis confirmed that CRP concentration >6.2mg/dL (OR: 5.12; 95% CI: 2.17-12.7) and diameter >12mm (OR: 4.33; 95% CI: 1.98-9.90) were strong predictive factors for advanced appendicitis. CRP concentration may be a potent objective predictor of pathological severity in appendicitis. Combination with the other diagnostic modalities may improve the diagnostic accuracy in predicting the severity of appendicitis.

Transumbilical Laparoscopic-Assisted Appendectomy: An Extracorporeal Single-Incision Alternative to Conventional Laparoscopic Techniques

Recently the use of a single umbilical incision to perform an appendectomy has been described. The purpose of this study was to review our initial experience with transumbilical laparoscopic-assisted appendectomy (TULAA) in the pediatric population. A retrospective review of all pediatric patients treated for appendicitis over a 10-month period was performed. The surgical technique involved using a standard 3-mm or 5-mm trocar for visualization and insufflation. A dissecting/grasping instrument was used adjacent to the trocar through the same incision. Patient demographics, operative findings and time as well as postoperative course were reviewed. Of 21 patients undergoing laparoscopy appendectomy, 18 patients successfully underwent TULAA. Five patients had advanced appendicitis, four had a retrocecal appendix, and three had appendicoliths. The average total operative time was 51 ± 15 minutes. Overall, the average length of stay was 1.2 ± 0.8 days; however, all patients with nonperforated appendicitis were discharged the day after surgery. All patients were followed postoperatively, and none reported postoperative complications of abscess or wound infection. Cost analysis demonstrated a markedly reduced associated cost for TULAA compared with conventional laparoscopy. TULAA is a safe and effective single-incision approach for early appendicitis that incorporates both open and laparoscopic techniques to provide excellent exploration of the abdomen, a short hospital stay, minimal pain, and an excellent cosmetic result. The technique described is cost-effective, because it does not use any special laparoscopes, trocars, or staplers. When performed as described in this study, only a single trocar and a standard laparoscopic setup are required. Cases of advanced appendicitis may require additional trocars or "conversion" to conventional laparoscopic techniques.

An Analysis of Factors Influencing Accuracy of the Diagnosis of Acute Appendicitis

The aim of the study was to "refresh" the knowledge about the course of acute appendicitis, to confront the classical clinical picture with the practice, analyze its fluctuations and identify factors influencing these. All patients admitted to the Department of General Surgery in Grudziądz District Hospital with the suspicion of acute appendicitis, who underwent appendectomy and in whom the appendicitis was confirmed in pathologic examination were included in the study. There were 85 patients, 49 men (58%) and 36 women (42%) in a mean age of 30 years (range 10-75). Symptoms, signs and results of biochemical tests (leukocyte rate and CRP) were considered in the analysis. The commonest constellation of symptoms and signs, occurring in at least of 3/4 patients consisted of pain and tenderness localized in right lower quadrant (100%), which exacerbates at movements (98%), felling unwell (93%), loss of appetite (88%), and rebound tenderness in right lower quadrant (74%). No particular fluctuation of clinical features in relation to gender, age, duration of symptoms, biochemical parameters and morphological severity of the inflammation was observed. Relevant findings included relatively fast development (<12 hrs) of advanced appendicitis in 18% of adult patients and more than a half patients with normal body temperature, regardless true appendicitis.

Nitric oxide, lipid peroxidation and total thiol levels in acute appendicitis

The mechanisms involved in the pathology of acute appendicitis (AA) and the factors affecting the progression have still been investigated. Oxidative stress is one of the factors of interest. Nitric oxide (NO) and its role in AA has not been studied previously. Thirty-four patients who underwent operation with a perioperative diagnosis of AA and 16 age and sex-matched controls were included in the study. Serum thiobarbituric acid reactive substances (TBARS), thiol groups (SH), NO metabolites (NO(x)), and conventional inflammation markers were determined. NO(x), TBARS, C-reactive protein (CRP) levels, white blood cell (WBC) count, and erythrocyte sedimentation rate (ESR) were significantly higher, and total SH was significantly lower in AA than in control group. NO(x), TBARS, and SH levels were comparable in acute phlegmonous appendicitis and advanced appendicitis. There was a significant positive correlation between NO(x) and TBARS, CRP, ESR, WBC and a significant negative correlation between NO(x) and SH. Serum NO(x) levels and oxidative stress elevate in AA independent from the extent of the lesion. Increased NO may play a role in the increased oxidative stress in AA.

Acute Purulent Appendicitis

The authors do not include acute purulent appendicitis in their list of differential diagnoses. Clinical experience as well as the issue of medical liability, however, make an addendum necessary. Purulent, usually already perforated, appendicitis is the most common and dangerous differential diagnosis for acute infectious enteritis, in children as well as in adults. Unpublished statistics from the North German arbitration board that relate to acute appendicitis show that some 345 cases were handled between 2000 and 2008; 277 of these were in adults and 68 in children. A complaint because of a delay in diagnosis and therapy was made in the cases of 153 adults (55 %) and 42 children (62 %). The misdiagnosis enteritis was the cause of the diagnostic delay in 56 adults (37 %) and 25 children (60 %). In 37 adults (66 %) and 15 children (60 %), diagnostic errors were confirmed. In all cases the diagnostic delay resulted in severe disease courses; in the case of one adult the outcome was fatal. According to our own estimates the ratio of appendicitis associated diarrhea to infectious enteritis is about 1:100. In spite of this, the differential diagnosis should always be considered. Diarrhea as a symptom does not exclude appendicitis; rather, it is a typical symptom in locally advanced appendicitis, especially in patients with interenteric abscesses. I would recommend subtle palpation of the abdomen, paying attention to regionally different pain reactions and muscular guarding, and taking the patient’s rectal temperature. Rectal examination, especially in young children, is not obligatory but often helpful, because pain symptoms in the pouch of Douglas or the right lower quadrant can be triggered in this way. If the diagnosis is likely to be non-enteritis related diarrhea, control examinations should be performed after 6–12 hours, followed by leukocyte and C-reactive protein tests and ultrasonography. Purulent appendicitis may occasionally occur as a comorbidity in patients with infectious enteritis.

Pediatric Advanced Appendicitis

Optimal surgical approach for advanced pediatric appendicectomy remains controversial. We compare the open versus the laparoscopic approach. Retrospective case notes review of children operated on for advanced appendicitis between January 2005 and July 2006 was undertaken for length of hospital stay, operating time, wound complications, need for further surgery, and hospital readmission. Forty children were included, 17 were treated with open approach and 23 with laparoscopic approach. There was no conversion from laparoscopic to open approach. Overall complication rate, length of hospital stay, and need for further surgery were similar in both groups. The mean operative time was longer in the laparoscopic group. Wound complications occurred more in the open group. Readmission for gastrointestinal obstruction was noted in the laparoscopic group. Laparoscopic approach is safe for advanced appendicitis in children. The outcomes are comparable in both study groups.

Early Discharge Following Laparoscopic Appendectomy in Children Utilizing an Evidence-Based Clinical Pathway

The utility of laparoscopic appendectomy (LA) in children remains controversial. The determination of the efficacy of LA in children is complicated by variable postoperative management, duration of antibiotics,and criteria for discharge. The aim of this study was to examine the results of a commitment to LA and the concurrent implementation of an evidence-based clinical pathway (CP) for management appendicitis in a children's hospital. With institutional review board approval, all children presenting with appendicitis (n = 72; age =10.6 +/- 0.1 years) were offered LA and management directed by CP. Data were accrued prospectively for 12 consecutive months (May 2006 to April 2007) and analysis performed at 15 months. Data are reported as the mean +/- standard error of the mean. Children were stratified based on the operative findings: group one - acute 41; group two-suppurative=11; and group 3-gangrenous or perforated 20. Duration of hospital stay differed between the groups:group one= 26 +/- 0.3 hours; group 2 =48 +/- 3 hours; group 3= 127 +/- 6 hours (P <0.05). No patients in groups one or two suffered a complication or were readmitted following discharge. Two patients in group 3 (10%)were readmitted and treated with antibiotic therapy alone. Overall, 66% of the children with acute appendicitis(27/41) and 27% with suppurative appendicitis (3/11) were discharged within 24 hours of admission. Discharge by 24 hours in groups 1 and 2 was not influenced by age, gender, or time of operation (before or after 7 PM). The commitment to LA and use of CP resulted in discharge within 24 hours in 2 of 3 of children with acute appendicitis without readmission or complications being observed. Early discharge was not influenced by age, gender, or time of admission. For advanced appendicitis, length of hospital stay, determined by clinical parameters, resulted in a low rate of complication or readmission.

Retained appendicolith in an inflamed appendix

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.

Receiver operating characteristic analysis of leukocyte counts in operations for suspected appendicitis

Study Objective There has been no clear-cut value of the white blood cell (WBC) count in differential diagnosis of acute appendicitis in emergency medicine. Therefore, the aim of this study was to assess the preoperative WBC counts in 3 groups of patients operated on for a clinical suspicion of acute appendicitis with different findings at appendectomy: uninflamed appendix, uncomplicated acute appendicitis, or complicated acute appendicitis. Methods The medical records of 540 patients who underwent appendectomy for suspected acute appendicitis during a 17-month period were retrospectively reviewed. Data for 3 groups of patients were analyzed to calculate the sensitivity and specificity of the WBC count in the diagnosis of acute appendicitis, and we calculated likelihood ratios for 2 cut-points with either high sensitivity or high specificity. Receiver operating characteristic curves were used to evaluate the WBC count in relation to the true diagnosis and severity of acute appendicitis. Results We were able to identify patients with appendicitis on a statistically significant level using receiver operating characteristic curves of WBC counts (area under the curve = 0.756, P < .001), but the WBC count had no diagnostic value in differentiating between uncomplicated and complicated groups (area under the curve =0.55, P = .086). Likelihood ratio ranged from 1.79 (95% confidence interval, 1.17-2.3) for WBC count of more than 10 500 cells/mm 3 to 3.20 (95% confidence interval, 2.72-3.24) for WBC count of more than 14 300 cells/mm 3. Conclusion White blood cell count is helpful in the diagnosis and exclusion of appendicitis. However, there is no value to differentiate advanced appendicitis.