Clinical Diagnosis Of Appendicitis Research Articles

Caecal Perforations: Anatomoclinical Aspects and Management in the General Surgery Department at the CHU Donka

Introduction: the aim of this study was to analyze the management of 45 cases of caecal perforations in the general surgery department at CHU Donka Conakry. Methodology: This was a descriptive retrospective study lasting 10 years, from January 1, 2013 to December 31, 2022 performed in the general surgery department at CHU Donka, Conakry. Results: We have recorded in 10 years, 45 cases of caecal perforations or 9.45% compared to other cecal pathologies. The age groups from 50 to 64 years accounted for 35.5% or 16 cases. The average age was 53.2 years and the extremes were from 6 years to 86 years. The male sex represented 27 patients or 60% with a sex ratio of 1.5. Abdominal pain and fever were the reasons for consultation in all our patients and the clinical diagnosis of appendicitis was made in 20 patients or 44%. Luberkunian adenocarcinoma was histologically evoked in 15 cases, i.e. 33.33%, and benign behavior was visualized in 25 patients, i.e. 56%. Conclusion: The anatomopathological examination constitutes a means of evaluation of the lesion assessment but also of the etiological diagnosis.

Treatment outcome of appendicitis in Azare

Objectives: Appendicitis is and has remained one of the most common abdominal surgical emergencies the world over. Its procedure and appendectomy is also a very common and regularly done surgical procedure and, thus, a very important disease to describe in totality. Hence, we set out to describe the pattern of presentation and management outcome of this condition in our environment. Materials and Methods: Data were collected retrospectively of all patients with the clinical diagnosis of appendicitis during the study period and analyzed. Results: A total of 62 patients had a clinical diagnosis of appendicitis over the period under review. M: F was 1:1.1. Age ranged from 3 years to 47 years with a mean of 21.50 ± 10.07. All (100%) patients presented with right iliac fossa pain. Other symptoms were anorexia (45.2%), nausea (61.3%), and vomiting (40.3%). All (100%) of patients went on to have an appendectomy. Twelve (19.40%) patients had surgical site infection and 2 (3.20%) developed enterocutaneous fistula. Duration of hospital stay ranged from 1 to 30 days. One patient who had uncontrolled diabetes mellitus died giving a mortality rate of 1.6. Conclusion: Typical clinical features of acute appendicitis were lower abdominal quadrant pain associated with nausea, anorexia, and vomiting. It goes without saying that diagnosis can still be made comfortably on clinical grounds and treatment outcome is generally good.

The Rate of Negative Appendicectomy and Perforated Appendicitis As Quality Indicators of the General Surgical Service in a District General Hospital in Cavan, Republic of Ireland.

Introduction Appendicitis is a common surgical condition that can be difficult to diagnose due to its varied clinical presentations. Surgical removal of the inflamed appendix is often necessary, and the appendix is sent for histopathological assessment to confirm the diagnosis. However, in some cases, the analysis may return a negative result for acute inflammation, known as a negative appendicectomy (NA). The definition of NA varies among experts. While negative appendicectomies are not ideal, they are accepted by surgeons to reduce the rate of perforated appendicitis, which can have severe consequences for patients. A study was conducted to investigate the rates of negative appendicectomies and their impact at a local district general hospital in Cavan, Republic of Ireland. Methods The study was conducted retrospectively from January 2014 to December 2019 on patients who were admitted with suspected appendicitis and underwent appendicectomy for appendicitis, regardless of age and sex. The researchers excluded patients who underwent elective, interval, and incidental appendicectomies. Data were collected on patient demographics, duration of symptoms prior to presentation, the intraoperative appearance of the appendix, and the histology results of the appendix specimens. Descriptive statistics and the Chi-squared test were used for data analysis with the help of IBM Statistical Package for the Social Sciences (SPSS) Version 26. Results The study retrospectively reviewed 876 patients who underwent an appendicectomy for suspected appendicitis between January 2014 and December 2019. The age distribution of patients was non-uniform, with 72% presenting before the third decade. The overall perforated appendicitis rate was 7.08%, and the overall negative appendicectomy (NA) rate was 21.3%. A subset analysis showed a statistically significant lower NA rate in females than in males. The NA rate decreased significantly over time and has been sustained since 2014 at around 10%, which is consistent with other published studies. The majority of the histology findings were uncomplicated appendicitis. Discussion This article discusses the challenges of diagnosing appendicitis and the need to reduce unnecessary surgeries. Laparoscopic appendectomy is the standard treatment, with an average cost of £2222.53 per patient in the UK. However, patients with negative appendicectomies (NA) have longer hospital stays and higher morbidity than uncomplicated cases, making it crucial to reduce unnecessary surgeries. The clinical diagnosis of appendicitis is not always straightforward, and the rate of perforated appendicitis increases with a longer duration of symptoms, particularly pain. The selective use of imaging in suspected appendicitis could reduce NA rates, but a statistical difference has not been proven. Scoring systems like the Alvarado score have limitations and cannot be relied upon alone. Retrospective studies have limitations, and biases and confounding variables must be considered. Conclusion The study found that a thorough investigation of patients, particularly with preoperative imaging, can decrease the rate of unnecessary appendectomies without increasing the rate of perforation. This could save costs and reduce harm to patients.

LAPAROSCOPIC VERSUS OPEN APPENDICECTOMY: A SINGLE CENTER STUDY

INTRODUCTION: Acute appendicitis is one of the commonest causes of acute abdomen encountered in surgical practice, requiring emergency surgery. Open appendicectomy by Grid Iron incision had been gold standard for many years. Laparoscopic technique provided an opportunity to explore new method of management of the suspected cases of the acute appendicitis. AIMS & OBJECTIVES: To compare laparoscopic and open appendicectomy in terms of intra-operative duration, complication of surgery and post operative outcome. MATERIALS AND METHODS: A total of 50 patients with clinical diagnosis of appendicitis were studied. After pre-operative work up, patients were randomly assigned for laparoscopic appendicectomy or open appendicectomy. All cases were observed in the intra- and post-operative period till they were discharged and then later followed up for a period of 4 weeks in the outpatient department. OBSERVATIONS AND RESULTS: A total of 25 patients assigned for laparoscopic appendectomy and 25 patients assigned for open appendectomy were analysed. Majority of patients were male in 3rd or 4th decade of life and had acute appendicitis. There was statistically significant difference of duration of surgery, post-operative pain, duration of hospital stay and return to work in both the groups. There was statistically insignificant difference of post-operative complication in both the groups. CONCLUSION: laparoscopic appendectomy is better than open appendectomy in a properly prepared and selected patient in terms of Duration of surgery, Post operative pain & need of analgesic, Post operative complications like wound infection, Duration of the postoperative hospital stay and Time period to return to work.

UNUSUAL PRESENTATION OF REACTIVE ARTHRITIS AFTER SALMONELLA ENTERITIS IN A 6-YEAR-OLD BOY

ABSTRACT:
 Reactive arthritis, formerly called Reiter’s syndrome is extra-articular oligoarthropathy, which can be due to bacterial infection or genetic predisposition. The infections are either urogenital (chlamydia being most notorious) or gastrointestinal (e.g. salmonella, yersinia, etc.). The human leukocyte antigen (HLA-B27) antigen has been implicated as the most common predisposing factor. Reactive arthritis often involves the joints of the lower limb. Bacterial enteric infections are a potential threat in a Pediatric population that can be due to an acute illness or its sequelae. Reactive arthritis following outbreaks of enteric infections with Salmonella is uncommon in the pediatric population. We report a rare case of a 6 years old boy who came to ER with high-grade fever and severe pain in the right iliac fossa. Clinical diagnosis of appendicitis was made by the physicians on physical exam but after radio-pathological investigation like CBC, ESR, CRP, Blood culture, USG abdomen, CT abdomen, and MRI, diagnosis of reactive arthritis secondary to salmonella enteritis was made and the patient underwent right hip arthrotomy after which he was discharged. Thus, imaging played a pivotal role in the right diagnosis of a patient with proper management guidelines. This also showed that salmonella enteritis can present atypically mimicking septic arthritis or acute appendicitis. Reactive arthritis after salmonella infection is a very rare and one of its kind case reported in Pakistan.

EP.FRI.90 Should laparoscopy be performed before or after appendicectomy in females of reproductive age with a clinical diagnosis of appendicitis?

Abstract Introduction Females of reproductive age with a clinical diagnosis of appendicitis may undergo laparoscopy prior to appendicectomy. This paper advocates laparoscopy after appendicectomy only if the appendix is macroscopically normal in this patient group. Method A cohort of patients under the care of a single general surgeon is reported. If the appendix was macroscopically normal a laparoscopic port was inserted through the right iliac fossa incision. This single port was used for laparoscopic assessment of the pelvic organs. Results Fourteen females of reproductive age underwent laparoscopy following a macroscopically normal open appendicectomy. No additional laparoscopic ports were required. A benign dermoid ovarian cyst was identified in a 14 year-old which was electively excised following further investigation by a gynaecologist. Two ruptured simple ovarian cysts were also identified. There were no complications reported in this patient group. Conclusions Laparoscopy following a macroscopically normal open appendicectomy allows assessment of the pelvic organs in females of reproductive age and reduces the number of ports required during surgery.

TP10.2.10A Prospective Analysis of Imaging Modalities in Appendicitis during the COVID-19 Pandemic

AimsAcute appendicitis is a common general surgical emergency, occurring in 90-100 per 100,000 patients per year. Clinical practice in the UK involves either a clinical or ultrasound (US) diagnosis, with computed tomography (CT) reserved for cases of suspected complicated appendicitis. Due to the COVID-19 pandemic management pathways were altered, this study sought to capture that.MethodsThis prospective study included adult patients with suspected appendicitis at a single UK centre from March-June 2020. The primary outcome measures were rates of US and CT imaging. Secondary outcomes included subsequent operative and histological findings.ResultsSeventy-five patients were included. A clinical diagnosis of appendicitis was made in 11 (15%). Thirty-five (47%) patients had CT, 22 (29%) had an US and 7 (9%) had both. The appendix was visualised in only 10 patients and a radiological diagnosis of appendicitis was made in 6 cases. Appendicitis was confirmed on histology in 67% of subsequently operated cases.CT evidence of appendicitis correlated with operative appendicitis in 93% (28/30) of cases. There were two cases of appendiceal malignancy not demonstrated on CT. Correlation of complicated appendicitis between CT and operative findings was poor; one third (10/28) of patients had appendiceal perforation not identified on CT.ConclusionsThe use of CT for diagnosing appendicitis was markedly increased during the first wave of the pandemic. The appendix was visualised infrequently on ultrasound, but when seen correlated well with histological findings. CT was superior at detecting appendicitis but failed to differentiate well between complicated and uncomplicated disease.

Endometriosis of the appendix presenting as acute appendicitis

Acute appendicitis is a surgical emergency and accounts for 27.5% of the surgical cases. It is a very common cause of non-gynecologic lower abdominal pain and may occur simultaneously with a variety of gynecologic diseases. We report a case of a 24 years old female, who presented to the surgical emergency department with complaints of acute pain in abdomen for the last 1 day with tenderness in right iliac fossa. Laboratory reports showed leucocytosis with neutrophilia, with presence of toxic granules. A provisional diagnosis of appendicitis was made and the patient was operated. The appendectomy specimen on histopathological examination showed ectopic endometrial glands and stroma in the serosa, based on which a diagnosis of appendiceal endometriosis was given. This case emphasizes the importance of considering the diagnosis of appendiceal endometriosis in a young female of child bearing age with a clinical diagnosis of appendicitis. Keywords: Appendicitis, Endometriosis, Endometrial glands, Stroma.

Eosinophil Count Variation among Histopathological Features of Appendectomy Specimens at Birat Medical College Teaching Hospital

Introduction: The histopathological examination of appendectomy specimens is the gold standard method for diagnosis. The presence of eosinophil besides other inflammatory cells like neutrophils and mature lymphocytes within different histological layers of appendectomy specimens are common findings for labeling it under various groups. This finding supports the assumption that appendicitis is triggered by Type 1 hypersensitivity reaction. 
 Objective: To evaluate the eosinophil count variation in appendectomy specimens in patients with the clinical diagnosis of appendicitis. 
 Methodology: This is a cross sectional hospital based study of 144 appendectomy specimens obtained in Department of Pathology, Birat Medical College Teaching Hospital from January 2019 to December 2019. Socio-demographic data, association of histopathological patterns with age groups, gender and eosinophil count in various histopathological groups was compared and cross-tabulated using SPSS version 16. 
 Result: Among 144 appendectomy specimens, male gender (50.70%) of 15-24 years age group (36.80%) was predominant. The commonest histopathological diagnosis was acute appendicitis (31.25%) with highest eosinophil count in all of its histological layers. The association of various histopathological patterns with age groups and gender were not statistically significant, whereas it revealed statistically significant correlation between eosinophil counts in all histological layers.
 Conclusion: Findings suggest that the eosinophil count variation in the entire histological layers correlate well among different histopathological patterns of appendectomy specimens. This reflects the high diagnostic value of evaluating the eosinophil count in appendectomy specimens.

ACCURACY OF CLINICAL AND LABORATORY PARAMETERS IN THE DIAGNOSIS OF ACUTE APPENDICITIS

Introduction: The diagnosis of acute appendicitis is generally clinical and once it is diagnosed, operative management ensues. Abdominal pain is the main presenting complaint of patients with acute appendicitis. The diagnostic sequence of colicky central abdominal pain which is followed by vomiting with migration of the pain to the right iliac fossa. The site of maximal tenderness is often said to be over McBurney's point. Specialist investigations are rarely needed to confirm a diagnosis of acute appendicitis, and the diagnosis is predominantly a clinical one. Judicious use of urine and blood tests, for inflammatory response variables, allow exclusion of other pathologies and provide additional evidence to support a clinical diagnosis of appendicitis.
 Material and Methods: Every patient with acute onset of right lower quadrant abdominal pain and without previous history of appendectomy was considered as suspected of having acute appendicitis. Every patient with right iliac fossa pain and without history of appendectomy is suspected of having appendicitis until proven otherwise were included in the study. All Clinical and laboratory tests relevant to acute appendicitis were done among study participants. In Clinical parameters appetite, diarrhea, dysuria, vomiting, signs of localized peritonitis i.e. rebound tenderness and or guarding and pain migration was observed.in laboratory parameters, CRP, complete blood count (CBC) were measured and analysed. Patient’s demographic characteristics were noted.
 Results: A total of 100 patients were included in the study of which 50 were included in the control and 50 in case group. Mean age in control group was 29±7.23 years while in acute appendicetomy group was 29 ±8.77 years. In control group 44% were male and 56 % were female while in acute appendicitis 42% were male and 58 % were female. All clinical presentations were statistically significant in case and control group. CRP was positive in 8 (16%) in control group while in Acute appendicitis group it was 21 (42%) (P=0.0071).
 Conclusion: CRP did not contribute to the overall diagnostic accuracy. The successful diagnosis of acute appendicitis can be done through proper clinical examination and adequate evaluation of laboratory parameters
 Keywords: Acute Appendicitis, CRP, appendicetomy

A Th2 Cytokine Profile in Appendicular Lavage Fluid Suggests Allergy as a Possible Etiology for Acute Appendicitis.

Acute appendicitis is the most frequent surgical abdominal emergency, but its etiology remains poorly understood. Histological examination of the appendix, following its removal due to acute appendicitis, consistently shows features in common with bronchial asthma, suggesting an allergic reaction as a candidate etiologic factor. Here, we propose the concept of appendicular lavage and use it to study the levels of the Th2 cytokines IL-4, IL-5, and IL-9 in patients with a clinical diagnosis of acute appendicitis. The study group included 20 patients with a histological diagnosis of phlegmonous appendicitis, 13 patients with gangrenous appendicitis, and a control group of 8 patients with a clinical diagnosis of appendicitis but with normal histology. Cytokine levels were higher in acute appendicitis. The difference was more pronounced when comparing phlegmonous appendicitis with nonpathological appendicitis (p = 0.01) for IL-4 (48.3 vs. 21.3 pg/mL), IL-5 (29.2 vs. 8.0 pg/mL), and IL-9 (34.1 vs. 16.6 pg/mL). This Th2 cytokine profile is compatible with the hypothesis of allergy as an etiologic factor for acute appendicitis and may have important implications for the diagnosis, prevention, and treatment of this condition.

Systematic Review Comparing Laparoscopic and Open Appendectomy

Various prospective randomized controlled trials were conducted to compare open and laparoscopic appendectomies. The aim of this systematic review is to compare both the surgical appendectomy interventions and to evaluate the most favored, safe, and effective choice of treatment for appendicitis. In this review, 2462 studies have been retrieved from three major databases: Medline, Scopus, and Cochrane. The inclusion criteria were clinical diagnosis of appendicitis, publication date, and patient’s age. Of these, six studies that met both inclusion and exclusion criteria were chosen. The studies selected were assessed for quality using the CONSORT PRO tool. The data extracted was later analyzed using NCCS 2007 software and Microsoft excel. The means and P values were calculated using the student t test and chi square test provided by the studies. The six studies chosen met the inclusion criteria and achieved an average quality of 15.5 over 25, which is in line with the CONSORT PRO tool. The results indicated that further elaboration on the randomization method should’ve been provided; however, the methodology was the same across the six studies showing a strong correlation and homogeneity in the outcomes. The primary outcomes were all favored in laparoscopic appendectomy (LA) except for intra-abdominal abscesses. The secondary outcomes were all favored by LA except for cost and mortality, which weren’t favored by both the interventions. In conclusion, LA is a safer and more effective surgical procedure than open appendectomy.

The role of MRI in Clinically Suspected Appendicitis During Pregnancy

A 31 years female with approximately 20 weeks of gestation attends the emergency department of the Hospital de Clinicas de Porto Alegre (HCPA) reporting pain in the lower abdomen radiating to the right iliac fossa. After clinical and laboratory examination, the clinical diagnosis of appendicitis was suspected, and then performed magnetic resonance imaging (MRI) of the abdomen for diagnostic reasons. The MRI of the abdomen was performed and revealed signs of appendicitis. The intraoperative findings were purulent fluid in the right iliac fossa and appendix with necrotic appearance without signs of perforation. The pathological diagnosis was acute suppurative appendicitis, with periviscerite signals. In pregnant women the enlarged uterus can alter the position of the abdominal contentes and thus make sonography and clinical diagnosis more difficult. CT can be performed in such cases, but it involves a considerable amount of radiation. A typical dose for an abdominal CT examination is on the order of 10 mSv. The routine use of diagnostic CT for benign diseases, as in appendicitis, raises the question whether the diagnosis can be obtained by other radiologic means, especially in pregnant women and even more when the fetus is in the direct beam. The International Commission on Radiological Protection recently published a report on radiation and pregnancy. They recommended that if the expected dose for the fetus is high, one should question whether the diagnosis could be obtained without using ionizing radiation. MRI has been described as a valuable technique for the evaluation of patients with suspected acute appendicitis.

What clinical presentations and inflammatory markers can be used in the clinical diagnosis of appendicitis in adults?

What clinical presentations and inflammatory markers can be used in the clinical diagnosis of appendicitis in adults?

Manifestations of Acute Appendicitis: A Prospective Study on Acute Abdominal Pain

Background/Aims: The aim of this prospective study was to identify the clinical symptoms and signs most important for the prediction of appendicitis among patients with acute abdominal pain. Methods: Clinical findings in 2,478 patients admitted to the emergency department of Mora Hospital from February 1997 to June 2000, with acute abdominal pain of up to 7 days' duration, were registered in a database. The medical records were reviewed after 1 year. Results: A total of 432 patients were suspected of having appendicitis and in 221 this diagnosis was confirmed. Some 53 patients, with another preliminary diagnosis, were eventually found to suffer from appendicitis, making a total of 274 patients with appendicitis. Appendectomy was performed in 316 patients and was negative in 14%. Clinical diagnosis of appendicitis had a sensitivity of 0.81, a specificity of 0.90, a positive predictive value of 0.51, a positive likelihood ratio of 8.1, and a diagnostic accuracy of 0.89. The highest odds ratios were found for isolated tenderness in the right iliac fossa (3.29), rebound tenderness (3.00), right-sided rectal tenderness (2.53), migration of pain to the right iliac fossa (2.18), and local guarding (2.11). Conclusion: Clinical findings indicating localised inflammation in the right iliac fossa were reliable in predicting acute appendicitis. The patients' history of pain combined with a careful clinical examination still plays an important role in detecting appendicitis among patients with acute abdominal pain.

Torsion of an Abdominal-Wall Pedunculated Lipoma: A Rare Differential Diagnosis for Right Iliac Fossa Pain

Pedunculated lipomas arising from the peritoneal wall are a rare finding during abdominal surgery. These benign tumours of mesenchymal origin can arise anywhere in the body and are usually asymptomatic. We present a case of a torted, pedunculated parietal wall lipoma in the right iliac fossa that gave rise to a clinical diagnosis of appendicitis. To our knowledge, such a case has never been reported in the literature previously. We suggest that torsion of a pedunculated parietal lipoma is a rare differential of acute abdominal pain.

Stapled diverticulectomy for solitary caecal diverticulitis

Caecal diverticulitis is an uncommon phenomenon in western countries. The clinical diagnosis is often difficult as it mimics other acute abdominal conditions like appendicitis, colitis or neoplasia. Diagnosis is often made at operation. Operative strategy has been controversial and there is no broad consensus emerging. We report the case of a 71-year-old woman, known to have chronic obstructive pulmonary disease, who presented acutely with right iliac fossa pain. A clinical diagnosis of appendicitis was made. At laparoscopy, a solitary, inflamed, gangrenous caecal diverticulum was found. A laparoscopic stapled diverticulectomy was performed. The patient made a steady post-operative recovery. Histology confirmed diverticulitis. We conclude that stapled diverticulectomy for solitary caecal diverticulitis is a safe and effective surgical strategy when confronted with this scenario.

Acute presentation of a benign cystadenofibroma of the fallopian tube: a case report

IntroductionCystadenofibromas are rare benign tumors of the fallopian tube with only 15 reported cases worldwide. They are usually asymptomatic and are found incidentally. This case is presented on account of its rarity and to the best of our knowledge, is the first reported case of cystadenofibroma of the fallopian tube discovered during an appendicectomy.Case presentationWe report a rare case of cystadenofibroma of the fallopian tube in a 19-year-old Caucasian woman who presented with sudden onset of right iliac fossa pain. A clinical diagnosis of appendicitis was made and she was taken to the operating theater for an appendicectomy. Intraoperatively, the appendix appeared normal. However, the 8 cm cyst contained within the right ovary and the blood in the pelvis warranted a salpingo-oopherectomy. Our patient made an uneventful recovery and was discharged after four days. Histology revealed a benign cystadenofibroma of the fallopian tube. There was no evidence of recurrence in the follow-up period of 12 months.ConclusionCystadenofibromas are benign tumors that may macroscopically and ultrasonographically appear malignant. We recommend that the diagnosis of cystadenofibroma is considered prior to performing radical surgery that may affect the fecundity of these patients. Cystadenofibromas confined to the fallopian tube can be treated curatively with unilateral salpingo-oophorectomy, without the need for any further treatment. However, long-term follow-up of more cases is required to draw more definitive conclusions.

Appendectomy to Remember

A 29‐year‐old Somali women presented with acute right lower quadrant abdominal pain, nausea, and fever. She had migrated as a refugee from Kenya to Minnesota 14 months before presentation. On physical examination, she had periumbilical and right lower quadrant tenderness with signs of peritoneal irritation such as rebound tenderness. Her laboratory investigations revealed leukocytosis (total white blood count 19.3 cells/μL) with a neutrophil predominance (83% neutrophils, 14% lymphocytes, and 3% eosinophils) and an elevated C‐reactive protein. She received the clinical diagnosis of appendicitis and subsequently underwent appendectomy. Pathology study of the surgical specimen is shown in Figures1–3. Figure 1 Histopathology of appendix. The mucosa is ulcerated; the lumen contains red blood cells and inflammatory cells. The submucosa is thickened and displays Schistosoma eggs in various stages of degeneration and calcification (hematoxylin and eosin stain, magnification ×40). Figure 2 Schistosoma eggs are oval, embedded in the submucosa and surrounded by mononuclear and polymorphonuclear inflammatory cells. The internal structure of the eggs reveals miracidia …

Fat-containing lesions revealed by CT in children with right lower quadrant pain

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.