Diagnosis Of Appendicitis In Patients Research Articles

Predictive values of indirect ultrasound signs for low risk of acute appendicitis in paediatric patients without visualisation of the appendix on ultrasound

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...

Leucocyte count and C-reactive protein cannot be relied upon in the diagnosis of acute appendicitis in HIV-infected patients.

BackgroundSouth Africa has the highest prevalence of human immunodeficiency virus (HIV) infection in the world, and is commonly found in association with appendicitis. Atypical presentation of appendicitis in the presence of HIV infection makes clinical diagnosis of appendicitis unreliable, and inflammatory markers are commonly used as adjuncts. The aim of this study was ascertain the value of inflammatory markers in the diagnosis of appendicitis in patients with and without HIV infection.MethodsPatients with acute appendicitis were studied and divided into HIV-infected and HIV-uninfected groups. Symptoms, and systemic and local signs were recorded. Appendiceal pathology was classified as simple or as complicated by abscess, phlegmon or perforation. Total white cell count (WCC) and C-reactive protein (CRP) were chosen as inflammatory markers. Findings were compared between the two groups.ResultsThe study population consisted of 125 patients, of whom 26 (20.8 per cent) had HIV infection. Clinical manifestations did not differ statistically, and there was no difference in the incidence of simple or complicated appendicitis between the two groups. The mean CRP level was significantly higher in HIV-infected patients (194.9 mg/l versus 138.9 mg/l in HIV-uninfected patients; P = 0.049), and mean WCC (x109/L) was significantly lower (11.07 versus 14.17×109/l respectively; P = 0.010)ConclusionClinical manifestations and pathology did not differ between HIV-infected and HIV-uninfected patients with appendicitis, except that the WCC response was significantly attenuated and CRP levels were generally higher in the presence of HIV infection.

Difficulties in indicating appendectomy; diagnosis of appendicitis in patients with normal white blood cell count

Objectives: Even after 130 years have passed since the first appendectomy, diagnosing acute appendicitis can still be challenging. The objective of this study was to investigate clinical, imaging and laboratory findings of patients diagnosed with acute appendicitis in order to determine whether white blood cell count is helpful in the diagnosis. 
 Materials and Methods: Parameters of Alvarado score, patients’ complaints, physical examination and laboratory findings were recorded. Appendiceal diameters of patients detected with ultrasound (US) were also recorded. 
 Results: Of the 98 patients, 89 patients (91%) had an appendiceal diameter wider than 8 mm and 9 patients (9%) had an appendiceal diameter of 8 mm and smaller in the preoperative US. Pathology was normal in 8 out of 9 patients (89%) with a diameter of 8 mm and below; and 9 out of 89 patients (9%) with a diameter above 8 mm (p

Alvarado Scores Predict Additive Value of Magnetic Resonance Imaging in Workup of Suspected Appendicitis in Children

BackgroundThe presentation of appendicitis in pediatrics is variable, and diagnostic imaging is often used. Magnetic resonance imaging (MRI) is replacing computed tomography in some centers, particularly after a nondiagnostic ultrasound (NDUS). Nonetheless, MRI is not widely used in this setting because of cost, procedure time, institutional capacity, and high rates of negative scans. We hypothesized that the Alvarado Score (AS) could be used to determine the additive diagnostic value of MRI after an NDUS. Materials and methodsRetrospective review of patients aged ≤18 y at a single tertiary care children's hospital who received an ultrasound for suspected appendicitis during 10 consecutive months in 2017. NDUS were defined as nonvisualization of the appendix or secondary signs without radiologic diagnosis. AS were retrospectively calculated from the electronic medical record. Primary outcomes were pathology-confirmed appendicitis, appendectomy, and perforation. ResultsAS was determined for 352 patients out of 463 who met inclusion criteria (76%). Sixty-two percent had an NDUS, and 45% of these patients received MRI. Patients with high-risk AS were significantly more likely to have MRI diagnostic of appendicitis (P = 0.0015), and low-risk AS patients were more likely to have a negative or equivocal MRI (P = 0.0169). Twenty-one MRI scans were required per each additional diagnosis of appendicitis in patients with low AS after NDUS versus 4.2 in intermediate-risk AS patients and 2.1 in high-risk AS patients. ConclusionsRisk stratification with AS can help assess the additive diagnostic utility of MRI after NDUS. MRI may be overutilized for diagnosing acute appendicitis in pediatric patients with low-risk AS.

Review of Appendicitis in Patients With Prolonged Neutropenia

Abstract The diagnosis of appendicitis in patients with prolonged neutropenia is difficult. The range of possible infectious agents includes parasites, bacteria, and fungi, all with various presentations. The choice between medical or surgical interventions for the treatment of patients with appendicitis and prolonged neutropenia can be controversial. We report 3 cases of appendicitis in adult patients with prolonged neutropenia and a literature review outlining the effectiveness of medical management versus surgical treatment for appendicitis in prolonged neutropenic populations. Our 3 cases show that there is potential efficacy of medical management in immunocompromised patients with appendicitis.

Diagnosis of Appendicitis in Patients with a Normal White Blood Cell Count; A Cross-Sectional Study.

To investigate the clinical, imaging and laboratory findings for diagnosis of acute appendicitis (AA) in patients with a normal white blood cell count (WBCC). This retrospective cross-sectional study was conducted in Ankara Numune Training and Research Hospital, Ankara, Turkey, during a 1-year period. To determine diagnostic factors in AA in patients with normal WBCC, medical records of eligible patients were reviewed for demographic and clinical variables, as well as patient outcome. A total of 105 patients that had undergone appendectomy and were found to have a normal WBCC were included in the study. Of these patients, 53 (50.5%) were men and 52 (49.5%) were women. The mean age of the patients was 34.2±12.3 (min 14, max 78). The negative exploration rate was identified as 19%. In the multivariate analysis, only the diameter of appendix was statistically significant (p=0.002). ROC analysis revealed the cut off appendiceal diameter as 8 mm. In patients suspected of AA due to ≥8 mm appendiceal diameter determined by imaging, we recommend surgical treatment even if WBCC and neutrophil count are normal.

A retrospective comparative study to evaluate the accuracy of ultrasound and multidetector abdominal computed tomography in the diagnosis of acute appendicitis

Objectives The aim of this study was to compare the diagnostic accurateness of ultrasound (US) with that of multidetector computed tomography (MDCT) for the diagnosis of appendicitis in patients with doubted acute appendicitis (AA).Patients and methods A retrospective study was carried out on 110 patients of all age groups in the period between November 2014 and January 2016. All patients presented to the emergency department in our institute with suspected diagnosis of AA using sonography and MDCT.Results US diagnosed correctly AA in 70/75 (93.3%) cases confirmed on histopathology. Computed tomography diagnosed correctly AA in 74/75 (98.6%) cases that confirmed on operation and by histopathology.Conclusion MDCT has mild superiority to US in the diagnosis of AA; however, US with expert hands and newer US machines have high sensitivity and specificity in the diagnosis, and without the hazards of radiation.

Diagnosing acute appendicitis using a nonoral contrast CT protocol in patients with a BMI of less than 25.

The objective of this study was to compare the accuracy for the diagnosis of appendicitis in patients presenting to the emergency department (ED) with acute, nontraumatic abdominal pain and a body mass index (BMI) of less than 25 before and after the implementation of a nonoral contrast computed tomography (CT) protocol with intravenous contrast. The IRB approved this HIPAA-compliant retrospective study; informed consent was waived. This study included 736 adult patients with a BMI of less than 25 presenting to our ED with acute, nontraumatic abdominal pain over two distinct 6-month time periods. An oral and intravenous contrast-enhanced protocol was utilized in the first cohort (group A), and an intravenous contrast-enhanced protocol without oral contrast was utilized in the second cohort (group B). Three abdominal fellowship-trained readers retrospectively reviewed all CT studies and electronic medical records, including surgical/pathology reports that served as reference standards. Group A consisted of 359 patients; 41 patients had surgically proven appendicitis. The sensitivity and specificity of the readers for diagnosing appendicitis in group A ranged from 95.2-100 and 98.1-99.5%, respectively. Group B consisted of 372 patients; 39 had surgically proven appendicitis. The sensitivity and specificity of the readers in group B ranged from 92.0-100 and 98.6-100%, respectively. There were no statistically significant differences in sensitivity or specificity for CT scans performed in groups A and B. In patients with a BMI of less than 25, an intravenous contrast-enhanced CT protocol without oral contrast demonstrates similar accuracy to an intravenous contrast-enhanced protocol with oral contrast for diagnosing acute appendicitis.

Clinical Significance of Fever and Leukocytosis in Diagnosis of Acute Appendicitis in Children Who Visit Emergency Department With Abdominal Pain

Background: The use of fever in the diagnosis of appendicitis in pediatric patients is unproven. The purpose of this investigation was to determine the value of fever in the diagnosis of acute appendicitis in children presenting to the emergency department (ED) with acute abdominal pain. Methods: Medical records from January-December, 2009, were reviewed for children (age < 18 years) who presented to an ED of one medical center with abdominal pain. Data on initial body temperature, white blood cell count, left shift, and final diagnosis were analyzed. Results: Of 674 children, 119 had appendicitis. The prevalance of initial fever did not differ between those with and without appendicitis, but the prevalence of leukocytosis and left shift were higher in children diagnosed with appendicitis. Despite of stratification by age, leukocytosis, prevalence of fever was not differing. Conclusions: Fever does not help in diagnosing appendicitis in our patients. Leukocytosis and white cell left shifts are on the other hand more common in patients with appendicitis. More studies should follow to investigate their role in diagnosis of appendicitis in patients in emergency department. doi:10.4021/ijcp104e

Diagnosis of Appendicitis in Patients with Abnormal Position of the Appendix due to Mobile Caecum

Acute appendicitis is usually diagnosed on the basis of signs, symptoms, clinical history, physical examination, and results of laboratory tests.The position of the appendix can vary considerably, both in relation to the caecum and because of the inconsistent position of the caecum itself, and may cause variable clinical symptoms. We present the CT findings of surgically proven acute appendicitis associated with atypically located caecum in two patients.

Recurrent Appendicitis Masquerading as Crohnʼs Disease

Purpose: Recurrent appendicitis is the clinical entity in which a patient with pathologically confirmed acute appendicitis describes one or more prior episodes with identical symptoms that resolved without surgical intervention. Although rare, patients report previous episodes of pain and then relief of their symptoms after appendectomy. Methods: A 31-year-old man with a history of HLA-B27 spondyloarthropathy presented to the GI clinic with complaints of two weeks of sharp mid-abdominal pain associated with bloating and cramping. A laboratory evaluation (CBC, Chem 7, LFTs, amylase and sed rate) was within normal limits. A CT scan demonstrated bowel wall thickening and mural stratification in the distal terminal ileum. A colonoscopy showed “nodularity” in the TI to 15 cm but overlying mucosa appeared normal. Small bowel and colonic biopsies were normal. It was thought that the CT abnormalities showed more proximal small bowel disease and, therefore, were not seen on endoscopy. A diagnosis of Crohn's disease was made and the patient's symptoms completely resolved with Infliximab. In 3 months, he returned to the clinic complaining of one week of increasing periumbilical abdominal pain radiating to the RLQ, similar to but not as severe as the prior abdominal pain. Physical exam: +Rovsig's sign. CT enterography was consistent with acute appendicitis. No small bowel abnormalities were seen. Results: The patient underwent a laparoscopic appendectomy that revealed pathologically confirmed acute appendicitis with a large amount of inflammation and adhesions around the appendix. The remainder of the bowel appeared normal. Since appendectomy, the patient has not had recurrent abdominal pain. Conclusion: This case illustrates the importance of correlating endoscopic and CT findings as well as recognizing the existence of recurrent appendicitis. Although this diagnosis is rare, identifying this entity is critical to the institution of appropriate treatment and the prevention of possible peritonitis. This case serves as a reminder not to discount the diagnosis of appendicitis in patients with prior episodes of similar abdominal pain.

Artificial Neural Networks: Useful Aid in Diagnosing Acute Appendicitis

[corrected] The purpose of the study was to assess the role of artificial neural networks (ANNs) in the diagnosis of appendicitis in patients presenting with acute right iliac fossa (RIF) pain and comparing its performance with the assessment made by experienced clinicians and the Alvarado score. After training and testing an ANN, data from 60 patients presenting with suspected appendicitis over a 6-month period to a teaching hospital was collected prospectively. Accuracy of diagnosing appendicitis by the clinician, the Alvarado score, and the ANN was compared. The sensitivity, specificity, and positive and negative predictive values of the ANN were 100%, 97.2%, 96.0%, and 100% respectively. The ability of the ANN to exclude accurately the diagnosis of appendicitis in patients without true appendicitis was statistically significant compared to the clinical performance (p=0.031) and Alvarado score of >or=6 (p=0.004) and nearly significant compared to the Alvarado score of >or=7 (p=0.063). ANNs can be an effective tool for accurately diagnosing appendicitis and may reduce unnecessary appendectomies.

Acute Abdominal Pain: Diagnostic Impact of Immediate CT Scanning

Computed tomography (CT) has revolutionized the management of patients with acute abdominal pain, but its role in the diagnostic process is still not defined. In this issue Dr. Cecilia Stromberg et al. present the results of immediate and indiscriminate CT scanning in all patients with acute abdominal pain at their hospital. The diagnosis on 2222 CT scans was correct in an impressive 96.8% of the cases. Does this support the idea that early CT should be a part of the routine diagnostic workup in all patients with acute abdominal pain? My main objection is that this is a retrospective study, and we do not know how often the CT scan resulted in a change in management. It is therefore not possible to estimate the effects of this policy in terms of an improved outcome for the patients and its cost efficiency compared to ‘‘conventional’’ management. Early CT scanning was compared with ‘‘conventional’’ management in one randomized trial that included 118 patients with acute abdominal pain [1]. At 24 hours the diagnostic accuracy was the same in both groups. The CT scan sped up detection of the more serious diagnoses but also overstated the seriousness of disease more often than conventional management. It is not clear if the more rapid diagnosis had an impact on the final outcome for the patients. Another randomized study included 182 patients with suspicion of appendicitis [2]. There was no difference in the outcome between the groups, but the operation was significantly delayed in the CT group. In addition to these randomized trials, there are a large number of nonrandomized studies with contradictory results. A less known property of diagnostic tests is that the predictive values are dependent on the prevalence of disease. A CT scan for appendicitis, the most common differential diagnosis for acute abdominal pain, can attain sensitivity and specificity of about 95% in the hands of an experienced radiologist. Even with this accuracy, however, a CT scan is falsely positive or falsely negative in 32% when the prevalence of disease is 10% or 90%, respectively. Appendiceal CT scanning is therefore not recommended as a ‘‘screening’’ instrument in unselected patients with a low probability of appendicitis or for confirming the diagnosis of appendicitis in patients with a high probability of appendicitis [3]. This caution should be applied for other diagnoses as well. Clinical assessment, supported by laboratory examinations and eventual reassessment after a short period of inhospital observation, is often sufficient to make the diagnosis in patients with typical symptoms and signs and to rule out a serious disease in the large group of patients with spontaneously resolving nonspecific abdominal pain. In these situations, a CT scan without a specific question seldom contributes any useful information. It does, however, increase the cost and add exposure to ionizing radiation; and it may lead to incidental findings that eventually turn out to be of no clinical significance—socalled VOMIT (victims of modern imaging techniques) [4]. It causes unnecessary worry and demands new examinations that increase the costs even further. The indiscriminate use of CT scans may also be the cause of an increasing incidence of appendicitis in the United States; that is, this policy may lead to unnecessary operations for diseases that would otherwise resolve undetected [5]. There is a risk that indiscriminate use of CT will lead to impaired diagnostic skills and that diagnostic techniques will be increasingly prescribed by surgeons to cover up this R. E. Andersson (&) Department of Surgery, County Hospital Ryhov, Jonkoping, Sweden e-mail: rollanders@yahoo.com

Review: inflammatory response variables, descriptors of peritoneal irritation, and migration of pain are most discriminatory of appendicitis

Andersson RE. Meta-analysis of the clinical and laboratory diagnosis of appendicitis. Br J Surg 2004;91:28–37. [OpenUrl][1][CrossRef][2][PubMed][3][Web of Science][4] Q In adult patients admitted to hospital with suspected appendicitis, what is...

Meta-analysis of the clinical and laboratory diagnosis of appendicitis.

The importance of specific elements in the clinical diagnosis of appendicitis is controversial. This review analyses the diagnostic value of elements of disease history, clinical findings and laboratory test results in suspected appendicitis. A systematic Medline search was made of all published studies on the clinical and laboratory diagnosis of appendicitis in patients admitted to hospital with suspected disease. Meta-analyses of receiver-operator characteristic (ROC) areas, and positive and negative likelihood ratios, of 28 diagnostic variables described in 24 studies are presented. Inflammatory response variables (granulocyte count, proportion of polymorphonuclear blood cells, white blood cell count and C-reactive protein concentration), descriptors of peritoneal irritation (rebound and percussion tenderness, guarding and rigidity) and migration of pain were the strongest discriminators, with ROC areas of 0.78 to 0.68. The discriminatory power of the inflammatory variables was particularly strong for perforated appendicitis, with ROC areas of 0.85 to 0.87. Appendicitis was likely when two or more inflammatory variables were increased and unlikely when all were normal. Although all clinical and laboratory variables are weak discriminators individually, they achieve a high discriminatory power when combined. Laboratory examination of the inflammatory response, clinical descriptors of peritoneal irritation, and a history of migration of pain yield the most important diagnostic information and should be included in any diagnostic assessment.

The role of colonoscopy in the diagnosis of appendicitis in patients with atypical presentations

Background: Acute appendicitis is one of the most common causes of acute abdomen. Despite recent advances in radiologic imaging, the diagnosis of acute appendicitis may be difficult on occasion. The aims of this study were to describe the colonoscopic features of appendicitis and to determine whether colonoscopy can be used as an adjunct for the diagnosis of appendicitis in patients with atypical presentations. Methods: The colonoscopic findings in 21 patients (14 men, 7 women; average age 55 years) with a colonoscopic or histopathologic diagnosis of appendicitis were analyzed retrospectively. Colonoscopy was performed because diagnoses suggested by CT were other than acute appendicitis (11 patients), and/or the presenting clinical features were atypical for acute appendicitis with the duration of symptoms being 10 days or longer (17 patients). Results: The colonoscopic diagnosis was acute appendicitis for all 21 patients. Seventeen underwent appendectomy, the diagnosis being verified in all cases. Of the 4 patients whose symptoms improved without appendectomy, 3 were considered to have acute appendicitis because pus was seen to drain from the appendiceal orifice at colonoscopy. A definite diagnosis could not be made in the remaining 1 patient. Therefore, the diagnosis of appendicitis was considered confirmed in 20 of 21 patients. Colonoscopic findings in these 20 patients included hyperemia (15) and bulging (18) at the appendiceal orifice area with surrounding mucosal edema (19), and drainage of pus from the appendiceal orifice (7). Conclusion: Colonoscopy may be useful in the diagnosis of appendicitis when the clinical presentation is atypical for appendicitis and/or imaging studies are nondiagnostic. (Gastrointest Endosc 2002;56:343-8.)

The role of colonoscopy in the diagnosis of appendicitis in patients with atypical presentations

The role of colonoscopy in the diagnosis of appendicitis in patients with atypical presentations

Improving diagnosis of acute appendicitis with atypical findings by Tc-99m HMPAO leukocyte scan

Even with careful observation, the overall false-positive rate of laparotomy remains 10-15% when acute appendicitis was suspected. Therefore, the clinical efficacy of Tc-99m HMPAO labeled leukocyte (TC-WBC) scan for the diagnosis of acute appendicitis in patients presenting with atypical clinical findings is assessed. Eighty patients presenting with acute abdominal pain and possible acute appendicitis but atypical findings were included in this study. After intravenous injection of TC-WBC, serial anterior abdominal/pelvic images at 30, 60, 120 and 240 min with 800 k counts were obtained with a gamma camera. Any abnormal localization of radioactivity in the right lower quadrant of the abdomen, equal to or greater than bone marrow activity, was considered as a positive scan. 36 out of 49 patients showing positive TC-WBC scans received appendectomy. They all proved to have positive pathological findings. Five positive TC-WBC were not related to acute appendicitis, because of other pathological lesions. Eight patients were not operated and clinical follow-up after one month revealed no acute abdominal condition. Three of 31 patients with negative TC-WBC scans received appendectomy. They also presented positive pathological findings. The remaining 28 patients did not receive operations and revealed no evidence of appendicitis after at least one month of follow-up. The overall sensitivity, specificity, accuracy, positive and negative predictive values for TC-WBC scan to diagnose acute appendicitis were 92, 78, 86, 82, and 90%, respectively. TC-WBC scan provides a rapid and highly accurate method for the diagnosis of acute appendicitis in patients with equivocal clinical examination. It proved useful in reducing the false-positive rate of laparotomy and shortens the time necessary for clinical observation.

LeuTech??

LeuTech is a sterile, lyophilised kit-packaged diagnostic system containing murine anti-CD15 IgM monoclonal antibody proprietary radiolabelled with technetium 99m ((99m) Tc) for infection imaging. After intravenous injection of LeuTech, diagnostic imaging can be obtained within 1h with conventional planar gamma camera techniques. LeuTech binds to neutrophils in vivo at the infection site. LeuTech is a fast (1h to obtain image), convenient (one-step injection), safe, effective (bright, clear images) and cost-effective diagnostic for existing and new nuclear imaging markets including chronic and acute indications such as appendicitis, ischaemic bowel, post-surgical infection and nosocomial infection. Palatin Technologies has successfully completed a Phase III trial with LeuTech in 203 patients at 10 sites in the USA for the detection of equivocal appendicitis. A BLA with the US FDA for LeuTech has been filed for the diagnosis of equivocal appendicitis. The US FDA has recommended LeuTech for approval for the diagnosis of appendicitis in patients with equivocal signs and symptoms. On 28 September 2000 Palatin received a 'complete review' letter from the FDA regarding the BLA for LeuTech. While, there were no further data requested on the safety and clinical efficacy of LeuTech, FDA requested some manufacturing, quality control and validation steps and data to be completed prior the approval of LeuTech. Palatin plans to finalise the amendments to BLA in the H2 of 2002. LeuTech is also being investigated in Phase II clinical trials for the diagnosis of osteomyelitis in 45 patients at four sites. Positive interim results from a Phase II clinical study conducted in 19 patients with diabetic foot ulcers and suspected osteomyelitis were announced at the Society of Nuclear Medicine Annual Meeting, Toronto, Canada, in June 2001. Imaging with LeuTech provided a diagnostic image within 1 hour compared with the 24 hours required to obtain an image using standard-of-care diagnostic, Indium oxide-labelled white blood cells. Walter Reed Army Medical Center is evaluating LeuTech for early detection of inhalation anthrax. LeuTech is planned to be evaluated for the detection of osteomyelitis secondary to joint replacements (such as hip replacement), postoperative abscesses, ulcerative colitis and other intra-abdominal infections (colitis, spleen or urinary tract). Palatin Technologies has exclusive rights to murine anti-CD15 IgM monoclonal antibody from The Wistar Institute of Biology and Anatomy. LeuTech has been licensed to Mallinckrodt worldwide, except for Europe. In October 2000, Mallinckrodt was acquired by Tyco International. On 15 May 2002, Palatin Technologies announced that its agreement with Tyco/Healthcare/Mallinckrodt regarding LeuTech marketing was amended to require Mallinckrodt to pay an additional $3.2 million to cover half of Palatin's expenses for the completion of the FDA's review. The additional funding is conditional upon reaching of certain milestones with Palatin receiving $800,000 within ten days of the signing of the amendment. Under the terms of the original agreement (1999), Palatin received a licensing fee of $500,000 and $13 million for the stock. All expenses prior to FDA approval were equally shared. Palatin will manufacture LeuTech and will receive a transfer price per unit and also royalties on net sales.

The diagnosis of appendicitis in patients with acquired immunedeficiency syndrome-four case reports: [formula omitted]. Department of Gastroenterology

The diagnosis of appendicitis in patients with acquired immunedeficiency syndrome-four case reports: [formula omitted]. Department of Gastroenterology