Concurrent Appendicitis Research Articles

Relative CT number of periappendiceal fat stranding may be an applicable index for estimating the severity of acute appendicitis.

Objectives:To investigate the feasibility of relative CT numbers to periappendiceal fat attenuation as an applicable index for estimating the severity of acute appendicitis.Methods:In total, 308 consecutive surgery-confirmed acute appendicitis patients and 243 controls with available preoperative CT were analyzed retrospectively. The radiological parameters were appendix diameter, length, and wall thickness as concurrent appendicitis signs. CT numbers of periappendiceal fat, mesenteric fat, subcutaneous fat in the anterior and posterior abdominal wall, retroperitoneal fat, gluteal subcutaneous fat and psoas major muscle were measured, as well as the relative CT numbers of periappendiceal fat compared with other locations.Results:There were 287 suppurative acute appendicitis (SAA) and 21 gangrenous or perforated acute appendicitis (GPAA) cases confirmed by pathology. The CT number of periappendiceal fat was significantly higher in patients than in controls (P＜0.01) although there was a wide overlap (−72.33 HU–117.43 HU). Significant differences in relative CT numbers were observed between the groups in gluteal subcutaneous fat (RCTgl) and psoas major muscle (RCTps) (P＜0.01). The AUCs of RCTgl and RCTps showed high accuracy to discriminate acute appendicitis from controls (AUC = 0.803, 0.761; 0.854, 0.847) and GPAA from SAA (AUC = 0.905, 0.851).Conclusions:Attenuation of periappendiceal fat on CT is related to the severity of appendicitis, and relative CT numbers (RCTgl and RCTps) could be an applicable index for severity determination.Advances in knowledge:Periappendiceal fat infiltration is related to the severity of acute appendicitis (especially relative CT number). Other clinical and CT features also need to be considered in the evaluation of inflammation.

Carcinoid tumours of the appendix: an analysis of emergency appendicectomies over a 24-year period and outcomes of laparoscopic versus open resection.

Carcinoid tumours of the appendix are the most common primary malignant lesion of the appendix. However, the overall incidence remains low; found in as few as 0.3-0.9% appendicectomy specimens. Almost all appendiceal carcinoids are found incidentally during surgery for suspected appendicitis. A retrospective review of all appendiceal carcinoids was performed in six hospitals from January 1990 until December 2013. Demographic data, operative technique, histopathological characteristics, clinic reviews and need for further treatment were recorded and compared with literature. Appendiceal carcinoids were identified in 175 specimens. The mean age is 32 years (range 8-87 years), with 69 (39.4%) males and 106 (60.6%) females (P < 0.0001). Of these, 106 underwent open surgery with standard McBurney incision, nine underwent full laparotomy and 60 underwent laparoscopic surgery. Six of the laparoscopic surgeries were converted to open procedures. We recorded 159 (90.75%) classical carcinoids and 16 (9.25%) goblet cell carcinoids. Overall, 131 (75.7%) had concurrent appendicitis; classical carcinoid 72.6% versus goblet cell carcinoid 93.8%. The median size of the goblet cell carcinoids was significantly larger than classical carcinoids. Classical carcinoids were mostly distal to the base, while goblet cell carcinoids had equal distribution. It appears that the involvement of resection margins was not influenced by the surgical technique. Thirty patients required further right hemicolectomy as treatment for high-risk features; open 19 (15.9%) versus laparoscopic 11 (20.4%). Laparoscopic appendicectomy did not seem to adversely influence the margin clearance in appendiceal carcinoid, though we recommend that all appendicectomies should include the mesoappendix.

Concurrent Streptococcal Pharyngitis and Appendicitis in a Boy with Neurodevelopmental Disorder

Acute appendicitis is the most common surgical emergency in children. A Japanese 8-year-old boy with attention deficit hyperactivity (ADHD) and comorbid autism spectrum disorder (ASD) exhibited fever, anorexia, and frequent vomiting. Gastrointestinal symptoms were initially regarded as associated with streptococcal pharyngitis and adverse effects of ADHD medication. Empirical antibiotic therapy did not improve his clinical condition. Absence of abdominal distension and tenderness led to a misled diagnosis and delayed diagnosis and treatment of acute appendicitis. Surgical intervention was made eventually for perforated appendicitis. He recovered without sequelae. Streptococcal pharyngitis with concurrent appendicitis is rare. Children with ASD sometimes have difficulty explaining their signs because of communication problems and insensitivity to pain. Special consideration is necessary when examining children with neurodevelopmental disorders, especially in emergency surgical conditions.

A rare cause of small bowel obstruction which should always be considered

Introduction Appendicitis has been known to cause acute small bowel obstruction through mechanical and physiological interactions with the ileum. Here a 52 year old male, who, following 3 days of lower abdominal pain, bowels not having opened and vomiting was found on computed tomography (CT) scan to have a mechanical small bowel obstruction. This was operated on via lower midline laparotomy and adhesiolysis. An inflamed appendix was found to have wrapped itself around the terminal ileum causing a focal stricture. After appendectomy the patient was discharged 6 days later and made a full recovery. Case description A 52 year old man with a past history of GORD, hypertension and peripheral vascular disease (with aorto-bifemoral bypass) was admitted onto our Surgical Triage Unit (STU) at 22:10 on a Thursday evening. He complained of a 3 day history of illness consisting of cramping lower abdominal pain, bowels not having opened and recurrent bilious vomiting. Results and Conclusions An urgent CT scan reported “High grade small bowel obstruction, with change of calibre in the distal ileum. This may be secondary to adhesions (previous bilateral femoral bypass) or internal hernia. Incidentally, the appendix also looks inflamed. No perforation or intra-abdominal collections.” At laparotomy, the appendix was inflamed with free pus in the peritoneal cavity and dilated small bowel loops in the vicinity. On closer inspection it could be seen that the inflamed appendix had wrapped itself around the terminal ileum stenosing its lumen and causing the small bowel obstruction. Take home message • Always consider a concurrent appendicitis in cases of small bowel obstruction • Do not exclude an appendicitis in cases of left sided abdominal pain as was the case here • If suspected consider performing computed tomography before proceeding to surgery • The co-existence of these two pathologies may alter operative approach

Streptococcal Pharyngitis and Appendicitis in Children.

Several pathologies, including pharyngitis, are associated with abdominal pain that can mimic appendicitis. We sought to further understand the link between appendicitis-like symptoms and streptococcal (strep) pharyngitis. All patients undergoing ultrasound imaging for appendicitis in our emergency department during 2013 were reviewed (n = 1572). A total of 207 patients were identified who underwent both ultrasound for appendicitis and testing for strep pharyngitis. Demographic and outcomes data between rule out appendicitis patients who underwent strep testing and those who did not were compared. Strep testing was more common in younger patients (mean age = 8.26 vs 10.26 years P < .001) and evenly matched by gender (104 male, 103 female). Of the 207 patients tested for strep pharyngitis, 8 (3.9%) patients had appendicitis and 35 (16.9%) patients tested positive for strep pharyngitis. No cases of concurrent strep pharyngitis and appendicitis were identified. The negative appendectomy rate in the strep pharyngitis tested group was 38.5% (5/13), compared with 7.7% (23/296) ( P = .003) in the nontested group. The appendicitis rate among the strep tested group was 3.8% (8/207) compared with 20% (273/1365) in the nontested group ( P < .001). Patients undergoing testing for strep pharyngitis were younger, had lower rates of appendicitis, and had a higher rate of negative appendectomy. A diagnosis of concurrent appendicitis and strep pharyngitis is rare. In cases of patients with sufficient symptoms to warrant testing for strep pharyngitis a diagnosis of appendicitis is less likely and surgical intervention leads to higher negative appendectomy rates.

A young man with concurrent acute appendicitis and incarcerated right indirect inguinal hernia.

Dear editor We read with great interest the expert opinion of Ditsatham et al1 on an extremely interesting case. Ditsatham describes a patient who presented with both appendicitis and an indirect inguinal hernia. There is very little known on the subject of concurrent appendicitis and hernia throughout the literature. There were some aspects to the history that stood out. The past medical history was particularly revealing. The patient had presented with pectus excavatum, which had been repaired by Nuss procedure. There is little information in the literature on the etiology of pectus excavatum; however, a link between the condition and connective tissue disorders has been made.2 One can infer from Redlinger et al2 that if pectus excavatum is exhibited in over two-thirds of Marfan syndrome patients, it may be linked to the connective tissue, specifically collagen. The presence of a collagen abnormality, even one that may not be synonymous with a diagnosis, can still pose certain health problems. Klinge et al3 present the link between collagen abnormalities and an increased risk of recurrent abdominal hernia. Parallels can be drawn to our patient who presented with a reducible inguinal mass 4 years prior to his described presentation. The risk of such a rare concurrent event may be increased if linked with a connective tissue disorder. Further research should be undertaken in this field to look for a causative relationship. Conditions with unusual presentation of appendicitis have been described; this paper made reference to a rare condition, Amyand hernia, named after an English surgeon. This is relevant since Amyand hernias are often misdiagnosed as a strangulated hernia, and so, the incidence of possible concurrent appendicitis and hernia is higher than reported.4 Concurrent appendicitis and other acute abdomen conditions have also been reported. Eggleston and Afzal5 describe a case of concurrent appendicitis and cecal bascule. In the case reported by Ditsatham, interest diverts to link the two conditions. Could the strangulation of appendix secondary to the traction of omentum in the hernia sac cause appendicitis? The rare presentation of these two conditions makes the viability of an observational study difficult. To conclude, it can be said that this young man may have had a mild underlying collagen abnormality that has led to an increased risk of hernia, thus increasing his 0.0009% risk of developing a concurrent appendicitis and inguinal hernia. The systemic effects of connective tissue disease need to be further explored, with particular attention being paid to the manifestations in the bowel. An important learning point highlighted by this case is that you should always be thorough with your examination and never rule out the possibility of concurrent pathology.

Concurrent Chronic Ectopic Pregnancy and Appendicitis: A Rare Coincidence or Consequence of a Common Etiology

Abstract Background: The simultaneous occurrence of appendicitis and ectopic pregnancy is very rare. It is still not clear whether they are having a common etiology in background or the reported cases have been a mere coincidence. Case: We present a case in which the patient had simultaneous right tubal chronic ectopic pregnancy with appendicitis that was managed successfully by laparoscopic route. Conclusion: Although the combination of ectopic pregnancy and appendicitis is quite rare, it is advisable to rule out concurrent appendicitis in patients of ectopic pregnancy, especially if it is on the right side due to a possible inter-etiological relationship. (J GYNECOL SURG 31:292)

Schistosomose e Apendicite Aguda

Acute appendicitis associated to Schistosoma haematobium and S. mansoni infection has been found in patients submitted to urgent appendectomy at the Hospital Américo Boavida in Luanda. Due to the high prevalence and morbidity caused by schistosomiasis (or bilharziasis) in the country, we suspect that the involvement of Schistosoma infection on appendicular pathology could be very frequent, in particular for those individuals more exposed to the parasite transmission. We report two clinical cases of acute appendicitis whose surgical specimens of the appendix revealed S. haematobium and S. mansoni eggs in histological samples. The reported patients live in endemic areas and have been exposed to schistosome during childhood, which may explain the infection's chronicity. Information of these clinical cases could be relevant, particularly for surgery specialists and clinical pathologists, due to the possibility of finding more patients with concurrent appendicitis and schistosomiasis.

Acute appendicitis mimicking intestinal obstruction in a patient with cystic fibrosis

Cystic fibrosis (CF) is an inherited disease of the secretory glands caused by mutations of the cystic fibrosis transmembrane regulator (CFTR) gene. The clinical manifestations of CF are repetitive lung infections, biliary cirrhosis, pancreatic abnormalities, and gastrointestinal disorders. We report a 21-year-old Taiwanese man with CF who had abdominal pain for 2 days. The diagnosis of CF had been confirmed by peripheral blood analysis of the CFTR gene 5 years before admission. He presented to the emergency department with nausea, vomiting, abdominal distension, and crampy abdominal pain, which is atypical for acute appendicitis. The physical examination and a series of studies revealed intestinal obstruction, but acute appendicitis could not be ruled out. After conservative treatment, together with empiric antibiotics, the refractory abdominal pain and leukocytosis with a left-shift warranted surgical intervention. A diagnostic laparoscopy revealed a swollen, hyperemic appendix, a severely distended small intestine, and serous ascites. The laparoscopic procedure was converted to a laparotomy for open disimpaction and appendectomy. He was discharged on the eighth postoperative day. The histologic examination of the appendix was consistent with early appendicitis. In conclusion, acute abdominal pain in adult CF patients is often associated with intestinal obstruction syndrome. The presentation of concurrent appendicitis may be indolent and lead not only to diagnostic difficulties, but also a number of therapeutic choices.

The Incidence of Benign and Malignant Neoplasia Presenting as Acute Appendicitis

Acute appendicitis remains the most common surgical emergency encountered by the general surgeon. It is most often secondary to lymphoid hyperplasia, however it can also result from obstruction of the appendiceal lumen by a mass. We sought to review our experience with neoplasia presenting as appendicitis. We retrospectively reviewed all patients admitted with the diagnosis of appendicitis to our Acute Care Surgery Service from July 1, 2007 to June 30, 2009. Patient demographics, duration of symptoms, lab findings, computed tomography findings, and pathology were all analyzed. Over the 2-year period, 141 patients underwent urgent appendectomy. Ten patients (7.1%) were diagnosed with neoplasia on final pathology, including four women and six men with a mean age of 46.9 years and mean duration of symptoms of 12.6 days. Final pathology revealed four colonic adenocarcinoma; three mucinous tumors; one carcinoid; one endometrioma; and one patient had a combination of a mucinous cystadenoma, a carcinoid tumor, and endometriosis of the appendix. Six patients had concurrent appendicitis. Colonic and appendiceal neoplasia are not unusual etiologies of appendicitis. These patients tend to present at an older age and with longer duration of symptoms.

Unexpected findings at diagnostic laparoscopy: caecal incarceration with concurrent appendicitis in a patient with bilateral broad ligament defects

Internal herniations through broad ligament defects are very rare. We present the first report of the triad of broad ligament defect, internal herniation of the caecum and appendicitis. A 36-year-old woman with phocomelia presented with right iliac fossa pain and vomiting. The patient had no previous history of trauma or surgery. Abdominal ultrasound showed a small amount of free fluid. At laparoscopy, bilateral broad ligament defects were found, with herniation of the caecum and an inflamed appendix through the right-sided defect. A laparoscopic salpingo-oophorectomy was required for reduction of the herniated bowel, and an appendicectomy was performed. Broad ligament defects may be congenital or acquired. In this case, in light of the limb abnormality and absence of previous surgery, a congenital aetiology is more likely. Ultrasound scan is not reliable and, although computed tomography may be of help, a diagnostic laparoscopy is the best investigation.

Incarcerated Amyand’s hernia in a premature infant associated with circumcision: a case report and literature review

Amyand's hernia is a rare presentation of an appendix within an inguinal hernia sac. It is commonly mistaken for an incarcerated or strangulated hernia. Prompt diagnosis requires awareness of this entity, as well as associated radiologic findings on computed tomography (CT) and ultrasound. Treatment includes antibiotics and surgical intervention involving appendectomy and hernia repair. We present a case of a premature infant who developed systemic symptoms after a circumcision and was eventually diagnosed with an Amyand's hernia with concurrent appendicitis.

Right-sided Bochdalek hernia obstructing in an adult: case report and review of the literature

Bochdalek hernias on the right side of the diaphragm are very rarely diagnosed in adults. We review a case of a 35-year-old female who presented acutely with intestinal obstruction. Plain and cross-sectional imaging identified a large right-sided Bochdalek hernia, containing colon, causing a mechanical obstruction and, surprisingly, concurrent appendicitis. The patient underwent an emergency laparotomy. At surgery the colon was reduced and was viable. The diaphragmatic defect was repaired using non-absorbable sutures and an appendicectomy was then performed for purulent appendicitis. She made an uneventful recovery and remains well at 9-month follow-up. We discuss what we believe to be the first reported case of an obstructed right-sided Bochdalek's hernia associated with appendicitis in an adult and review the published literature on this rare condition.