Diagnosis Of Complicated Appendicitis Research Articles

DIAGNOSING CASES OF COMPLICATED APPENDICITIS USING NEUTROPHIL-LYMPHOCYTE RATIO: A PROSPECTIVE STUDY

This study aimed to investigate the significance of the neutrophil-lymphocyte ratio (NLR) in the diagnosis of complicated appendicitis and distinguish it from uncomplicated appendicitis. Acute appendicitis is a typical surgical emergency, with a lifetime probability of 8.6% for males and 6.7% for females. It is crucial to diagnose and treat this condition promptly to prevent complications such as perforation, peritonitis, and fluid collection, which can lead to extended hospital stays, morbidity, and mortality. The prospective observational study lasted for three months at Ruth K.M. Pfau Civil Hospital, Karachi. Patients between the ages of 16 and 40 who were diagnosed with acute appendicitis using clinical and/or radiological evidence and underwent appendectomy were included in the study. Pre-operative assessments and laboratory results, including NLR, were recorded and compared to operative findings. The study found that NLR values greater than 8.0 were indicative of complicated appendicitis, with a sensitivity of 90.9% and a specificity of 100%. Therefore, NLR has a high predictive value for identifying complicated appendicitis in our local population.

The predictive value of the C-reactive protein/albumin ratio in adult patients with complicated appendicitis

Abstract Objectives The purpose of this study was to analyze the role of C-reactive protein/albumin ratio (CRP/ALB) in the diagnosis of complicated appendicitis in adults. Methods A retrospective analysis of 202 patients with acute appendicitis admitted to the Emergency Department of Weifang People’s Hospital between January 2021 and December 2022 was conducted. Patients were classified into complicated appendicitis group (CA) and non-complicated appendicitis group (NCA) based on postoperative pathological diagnosis, and the two groups were compared in terms of preoperative age, gender, white blood cell count (WBCC), C-reactive protein/albumin ratio (CRP/ALB), serum sodium (Na), and fibrinogen (FIB). Results The 202 cases of acute appendicitis in this study, 36.6 % (n=74) were CA. Multivariate logistic regression analysis showed that CPR/ALB (p≤0.001), FIB (p<0.001), and Na (p=0.011) were risk factors for complicated appendicitis. The results of receiver operating characteristic (ROC) analysis, conducted to evaluate the role of CRP/ALB, Na, and FIB in detecting CA, showed that the area under the curve (AUC) of CRP/ALB was 0.871, which was higher than that of FIB and Na. CRP/ALB ratio ≥1.04 was an important indicator for predicting complicated appendicitis, with a sensitivity of 78.2 % and specificity of 84.7 %. Conclusions CRP/ALB ratio can serve as a good indicator for predicting complicated appendicitis.

Comparison of the Laparoscopic Appendicitis (LAPP) score with the Alvarado and Appendicitis Inflammatory Response(AIR) scores and computed tomography and pathology results

Background: Acute appendicitis is the most commonly encountered and operated group among general surgery emergency patients. Various scoring and algorithms are used in diagnosis and treatment. This study aimed to compare the Laparoscopic Appendicitis (LAPP) score, which is used to reduce negative appendectomy, according to the pathology and preoperative computed tomography results and investigate its correlation with other clinical scoring systems. Methods: Patients who underwent appendectomy in our clinic between June 2020 and March 2021 were retrospectively reviewed. The obtained LAPP scores were compared with the preoperative imaging results, Alvarado score, appendicitis inflammatory response (AIR) score, and pathology results. Results: The study included a total of 109 patients, of whom 22 (20.18%) had a pathology result that was not consistent with appendicitis. The LAPP score was determined as 1.41 for this 22 patients who underwent negative appendectomy (p<0.001), 2.45 for 74 patients with suppurative appendicitis (p<0.001), and 3.54 for 13 patients with gangrenous or perforated appendicitis (p<0.001). Conclusions: The purpose of the LAPP score is to reduce the rate of negative appendectomy. Appendectomy is also performed in some patients who may have spontaneous resolution if they present to the hospital in the early period. We also consider that the frequency of familial Mediterranean fever in Turkey may be another reason for the high rate of negative appendectomy. In addition, the correlation of high Alvarado and AIR scores with a high LAPP score indicates that it is more reliable in the diagnosis of complicated appendicitis.

Pre-appendectomy hyponatremia is associated with increased rates of complicated appendicitis.

BackgroundAcute appendicitis is one of the most common surgical emergencies worldwide. Preoperative assessment of the risk of complicated appendicitis may aid in treatment planning. We sought to investigate the association between pre-appendectomy hyponatremia and diagnosis of complicated appendicitis. MethodsThe TriNetX platform, a federated health research network that aggregates de-identified electronic health record data of over 90 million patients across the United States, was queried for patients who underwent appendectomy starting January 2019 and who had at least one sodium value from the preoperative period. The study population was stratified into three age groups: pediatric (age < 18), adult (age 18–64), and older adult (age ≥ 65). These groups were subdivided into patients with preoperative hyponatremia (<135 mmol/L) and normonatremia (135–145 mmol/L). ResultsAmong the 61,245 patients who met inclusion criteria, 17,546 were included for analysis following propensity score matching. The odds of complicated appendicitis were highest in pediatric patients (age < 18) with pre-appendectomy hyponatremia (odds ratio [OR] = 2.91, 95 % CI [2.53, 3.35]). Patients age 18–64 and aged ≥ 65 with preoperative hyponatremia also demonstrated increased odds of a complicated appendicitis diagnosis, but to a lesser extent (OR = 2.11, 95 % CI [1.92, 2.32] (OR = 1.49, 95 % CI [1.25, 1.77], respectively). ConclusionsIn a large analysis of matched patients with acute appendicitis, we found an association between immediate preoperative hyponatremia and complicated appendicitis. Future studies are indicated to further evaluate the role of hyponatremia as a potential diagnostic marker for complicated appendicitis in all age groups. Key messageThis study suggests a role of hyponatremia as one of multiple variables to incorporate into future clinical decision tools for complicated acute appendicitis.

Comparison of ileocecal resection and right hemicolectomy in the surgical treatment of complicated appendicitis.

Simple appendectomy with a complicated appendicitis diagnosis could prove difficult, sometimes requiring ex-tended resection. Hence, we aimed to compare two procedures that are preferred for extended resection, ileocecal resection, and right hemicolectomy, in terms of patients' demographic data, preoperative laboratory values (white blood cell [WBC], Neutrophil-to-lymphocyte ratio [N/L], C-reactive protein [CRP]), operation times, postoperative complications, length of hospital stay, and 1-month mortality rates. We retrospectively reviewed patients who underwent extended resection with the diagnosis of complicated appen-dicitis in our clinic from February 2015 to December 2020. We divided the patients into two groups those who underwent right hemicolectomy and those who underwent ileocecal resection. Among the 55 patients who underwent extended resection with the diagnosis of complicated appendicitis, 32 (58.1%) underwent right hemicolectomy and 23 underwent ileocecal resection (41.8%). The groups did not differ statistically significantly in terms of demographic characteristics, preoperative laboratory values (WBC, N/L, CRP), Clavien-Dindo classification scores, mean hospital stay, or 1-month mortality rates (p>0.005). However, there was a statistically significant difference between the groups in terms of operation time (p<0.001). Ileocecal resection is a safe procedure for patients diagnosed with complicated appendicitis who are scheduled for extended resection.

Validity of Machine Learning in Detecting Complicated Appendicitis in a Resource-Limited Setting: Findings from Vietnam.

Complicated appendicitis, a potentially life-threatening condition, is common. However, the diagnosis of this condition is mainly based on physician's experiences and advanced diagnostic equipment. This study built and validated machine learning models to facilitate the detection of complicated appendicitis. A retrospective cohort study was conducted based on medical charts of all patients undergoing a laparoscopic appendectomy at a city hospital during 2016-2020. The synthetic minority over-sampling technique (SMOTE) was used to adjust for the imbalance. Multiple classification approaches were used to train and validate models including support vector machine (SVM), decision tree (DT), K-nearest neighbor (KNN), logistic regression (LR), artificial neural network (ANN), and gradient boosting (GB). Among 1,950 patients included in the data analysis, there were 483 patients identified as having complicated appendicitis (24.8%). Based on data without SMOTE adjustment for imbalance, the accuracy levels and AUCs were high in all models using different parameters, ranging from 0.687 to 0.815. After adjusting for imbalance data using SMOTE, AUC and accuracy levels in the models using imbalance adjusted data were higher. Of these, the GB had all AUC and accuracy values of approximately 0.8 or more in both adjusted and unadjusted data. Machine learning approaches including SVM, DT, logistic, KNN, ANN, and GB have a high level of validity in classifying patients with complicated appendicitis and patients without complicated appendicitis. Among these, GB had the highest level of validity and should be used or further validated. Our study indicates the beneficial potentials of machine learning techniques in a clinical setting in general and in the diagnosis of complicated appendicitis in particular.

Is there a correlation between the diagnostic test results and the histopathological diagnoses of acute appendicitis in a Turkish hospital in Somalia?

Appendicitis is the most common cause of acute abdomen. This study aimed to investigate the demographic and clinical data of the patients diagnosed with acute appendicitis in the emergency department of a Turkish tertiary care center in Somalia. The association between the diagnostic test results and the histopathological diagnoses was also analyzed. Data of the patients diagnosed with acute appendicitis at the emergency department between the 1st of January 2021 and the 31st of December 2021 period were retrospectively reviewed. The demographic data, clinical features, laboratory test results and radiological and histopathological findings of the participants were retrieved from the hospital’s electronic medical records for patients in the database. Overall, 83 patients were included. Among those, 59 (71.1%) were male, and the mean patient age was 22±8.2. The mean values of the leukocyte and neutrophil counts and the C-reactive protein levels were higher than the normal range. The laboratory test, abdominal ultrasonography, and enhanced computerized tomography results were compared with the histopathological findings. Only the neutrophil-lymphocyte ratio was found (to be) significant in the diagnosis of complicated appendicitis. The clinical data, laboratory tests, and radiological imaging findings should be evaluated together to diagnose acute appendicitis. Prompt diagnosis is essential for the prevention of postoperative complications and mortality. A statistically significant difference was found in the comparison of the lymphocyte counts, NLR values, and histopathological findings (p=0.01 and p=0.008).

Using neutrophil-lymphocyte ratio, mean platelet volume, and hyponatremia to diagnose appendicitis in children

Background: Acute appendicitis is one of the common reasons for acute abdominal pain among children. The diagnosis of appendicitis in children is always challenging. There is a failure to improve morbidity and mortality related to appendicitis, even after advancements in imaging modalities. Therefore, there is a need for markers to help in the diagnosis process. This study aimed at finding if neutrophil to lymphocyte ratio (NLR), mean platelet volume (MPV), and hyponatremia are helpful tools to diagnose acute appendicitis and whether they can be beneficial in distinguishing complicated from uncomplicated appendicitis among children. Methods: This cross-sectional study was conducted on the pediatric population who were diagnosed with acute appendicitis and treated as an inpatient in the Ministry of Health Hospitals in Abha and Khamis Mushayt. The data of patients were collected using a data collection sheet. Statistical analysis was conducted using the Statistical Package for the Social Sciences software. Results: Among 384 children with appendicitis; 72.9% had an uncomplicated acute appendectomy, and 27.1% had a complicated condition. NLR significantly increased among complicated cases (p &amp;lt; 0.001), whereas MPV and sodium levels were increased among uncomplicated patients (p &amp;lt; 0.001). The logistic regression model showed that NLR was a predictor for complicated appendicitis (p = 0.031, OR = 1.066; CI 1.006-1.129), whereas regarding increased levels of MPV and sodium, it was found that p = 0.009, OR = 0.794; CI 0.668-0.945 for MPV, and p &amp;lt; 0.001, OR = 0.803; CI 0.735-0.878 for sodium. Conclusion: NLR, low MPV, and hyponatremia have a role in the diagnosis of complicated appendicitis, and they can be predictors of complicated appendicitis.

Association between appendiceal stump closure method and post-operative bowel obstruction after laparoscopic appendectomy

BackgroundLaparoscopic appendectomy is one of the most common urgent pediatric surgical operations. Endoscopic surgical staplers and pre-tied endoloop ligatures are both routinely used for closure of the appendiceal stump in children. Practice patterns vary for a number of reasons, including cost, size, and ease of use. While stapling is standard for some pediatric surgeons, others believe that staples can act as a nidus for small bowel obstruction (SBO). However, studies comparing closure methods have been conflicting in their results and limited in size. Therefore, we aim to determine if there is an association between appendiceal stump closure method and SBO using a national comparative pediatric database. MethodsWe queried the Pediatric Health Information System (PHIS) for patients ages 3–18 years who underwent laparoscopic appendectomy for appendicitis between 1/1/2016 – 12/31/2020. We included hospitals that had greater than 50 patients with billing data and excluded patients with inflammatory bowel disease and simultaneous abdominal operations. We used billing data for the patient's appendectomy to determine if a stapler or a suture ligature was used during the case. Our primary outcome of interest was post-operative SBO or reoperation for lysis of adhesion or intestinal surgery within the first 30 post-operative days. Multivariable regression analyses were used to estimate the association between stump closure method and post-operative SBO or reoperation in addition to cost while adjusting for patient demographics and appendiceal perforation. ResultsIn total, 49,191 patients from 37 hospitals were included, of which, 29,733 (60.44%) were male, 21,403 (43.51%) were non-Hispanic white, and 18,291 (37.18%) had a diagnosis of complicated appendicitis. The median [IQR] age of the cohort was 11 [8–14] years. A surgical stapler was used during laparoscopic appendectomy in 35,788 (72.75%) patients, and early SBO or reoperation occurred in 653 (1.33%) patients. In adjusted analysis controlling for demographics and complicated appendicitis there was no statistically significant difference in the odds of SBO or reoperation between the two groups. (OR 1.17; 99% CI 0.86 – 1.6). Complicated appendicitis was the factor most associated with post-operative SBO or reoperation (OR 4.4; 99% CI 3.01 – 6.44). Median cumulative cost was slightly higher on unadjusted analysis in the stapler group ($10,329.3 vs $9,569.2). However, there was no significant difference on adjusted analysis. ConclusionSBO or reoperation following laparoscopic appendectomy for appendicitis is uncommon. Complicated appendicitis is the most predictive factor of this outcome. Adjusting for available patient, disease, and hospital characteristics, use of a surgical stapler does not appear to be meaningfully associated with the development of acute SBO or reoperation. Surgeon preference remains the mainstay for safe appendiceal stump closure method. Level of evidenceLevel III. Study typeRetrospective Comparative Study.

Hyponatremia-A New Diagnostic Marker for Complicated Acute Appendicitis in Children: A Systematic Review and Meta-Analysis.

Background: Acute appendicitis in the pediatric population remains a diagnostic challenge for clinicians. Despite many biochemical markers, imaging modalities and scoring systems, initial misdiagnosis and complication rates are high in children. This suggests the need for investigations directed towards new diagnostic tools to aid in the diagnosis. Recent studies have shown a correlation between serum sodium levels and complicated appendicitis. Although the exact reasons for hyponatremia in patients with complicated appendicitis are not known, there is persuasive data to support the role of pro-inflammatory cytokines such as IL-6 in the non-osmotic release of antidiuretic hormone. This meta-analysis aims to investigate all available data on hyponatremia as a diagnostic marker of complicated appendicitis in the pediatric population. Methods: The literature search was conducted by two independent investigators according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The scientific databases (PubMed, EMBASE, Web of Science, and Scopus) were systematically searched for relevant studies using the keywords (hyponatremia) AND (appendicitis) AND (children). The methodological quality was assessed using a validated scale, and RevMan 5.4 software was utilized for pooled analysis. Results: Seven studies were included in the final meta-analysis, five of which were retrospective. A total of 1615 and 2808 cases were distributed into two groups: group A with complicated appendicitis and group B with uncomplicated acute appendicitis, respectively. The studies compared serum sodium levels of patients among the groups. Pooling the data demonstrated significantly lower serum sodium levels in children with complicated appendicitis vs. the non-complicated appendicitis (WMD: −3.29, 95% CI = −4.52 to −2.07, p < 0.00001). The estimated heterogeneity among the included studies was substantial and statistically significant (I2 = 98%, p < 0.00001). Conclusion: The results of the present meta-analysis indicate that hyponatremia has potential to be utilized as a biochemical marker in the diagnosis of complicated appendicitis in the pediatric population. However, well designed prospective diagnostic efficiency studies are essential to consolidate the association between hyponatremia and complicated acute appendicitis.

One-year follow-up of conservative management of appendicitis: results from a single centre during extended lockdown in the COVID-19 pandemic.

Conservative management with antibiotics was recommended by the UK Surgical Royal Colleges early in the COVID-19 pandemic as the first-line treatment for acute uncomplicated appendicitis. This is a prospective single-centre cohort study of patients aged 16 years or over, diagnosed clinically and confirmed radiologically with acute appendicitis in a secondary care setting who were initially treated conservatively with antibiotics. The primary outcome was the response to conservative management with antibiotics. Secondary outcomes were: antibiotic duration; operative rates; surgical approach (open, laparoscopic or conversion to open); complication rates; COVID-19 positive rate; rates of readmission within 12 months; and length of hospital stay. A total of 109 patients were included in the study, 67 of whom were male. Median age was 37 (range 17-93) years. A further 28 patients were excluded because of a decision to manage operatively on the index admission or because of other diagnoses. Thirty-three patients (30.3%) had surgery on the index admission after failed conservative management and 15 (13.8%) had surgery on readmission. On histology, 32/48 patients (66.7%) had a diagnosis of complicated appendicitis and 18/48 (37.5%) had a confirmed appendicolith. There was a high readmission rate (47/109; 43.1%) for surgery, a radiological drain or conservative management within the first year following initial conservative management. There is a significant risk of recurrence of symptoms, particularly in the presence of an appendicolith. Laparoscopic appendicectomy should be the first-line treatment, with conservative management reserved for patients with acute uncomplicated appendicitis who are COVID-19 positive or have comorbidities.

Management of Complicated Appendicitis During Pregnancy in the US

Data are sparse regarding the optimal treatment for complicated appendicitis during pregnancy. To compare nonoperative and operative management in complicated appendicitis during pregnancy. This cohort study was conducted using National Inpatient Sample data from between January 2003 and September 2015. This database approximates a 20% stratified sample of US inpatient hospital discharges. Included individuals were pregnant women discharged with the diagnosis of complicated appendicitis. Data were analyzed from February 2020 through February 2022. Study patients were categorized into 3 groups: those with successful nonoperative management, failed nonoperative management with delayed operation, or immediate operation for complicated appendicitis. Clinical outcomes, including maternal infectious complications and perinatal complications, hospital length of stay, and total hospital charges. Among 8087 pregnant women with complicated appendicitis (median [IQR] age, 27 [22-32] years), nonoperative management of complicated appendicitis was successful among 954 patients (11.8%) and failed among 2646 patients (32.7%), who underwent delayed operation; 4487 patients (55.5%) underwent immediate operation. In multivariate analysis, successful nonoperative management was associated with higher odds of amniotic infection (odds ratio [OR], 4.35; 95% CI, 2.22-8.53; P < .001) and sepsis (OR, 1.52; 95% CI, 1.10-2.11; P = .01) compared with immediate operation, while there was no significant difference in preterm delivery, preterm labor, or abortion. However, failed nonoperative management that required delayed operation was associated with higher odds of preterm delivery, preterm labor, or abortion compared with immediate operation (OR, 1.45; 95% CI, 1.24-1.68; P < .001). Immediate operation was associated with decreased hospital charges compared with nonoperative management that was successful (regression coefficient [RC], 0.09; 95% CI, 0.07-0.11; P < .001) and that failed (RC, 0.12; 95% CI: 0.11-0.14; P < .001). In subgroup multivariate logistic regression analysis, each day in delay to surgery was associated with an increase in odds of preterm delivery, preterm labor, or abortion by 23% (OR, 1.23; 95% CI, 1.18-1.29; P < .001). This study found that immediate operation for complicated appendicitis in pregnant women was associated with lower odds of maternal infectious complications without higher odds of perinatal or other maternal complications compared with successful nonoperative management. Failed nonoperative management was associated with worse clinical outcomes.

Can Serum Amylase Level Evaluation Facilitate Early Diagnosis of Acute Appendicitis, as an adjunctive biomarker?

Introduction: Acute Appendicitis is considered as a medical emergency, one of the most prevalent etiologies for acute abdominal pain. Perforated cases of acute appendicitis are possible sequences of late diagnosis. One of the biomarkers that can be a potential target in diagnosis of acute appendicitis is serum amylase level evaluation which this study is focused on. Material and Method: 627 patients with acute abdominal pain included in the trial. 125 cases out of these 627,18-65 years old patients with acute abdominal pain whom were suspected of appendicitis were undergone appendectomy surgery due to clinical and paraclinical scoring during standard treatment. At arrival serum amylase evaluation was done for all participants. Macroscopic reports of surgery and histopathologic reports have been recorded. Amylase serum level and its correlation with the acute appendicitis diagnosis and their complications were analyzed with the use of variance test, chi-square tests, ROC curve. Results: Findings showed, in patients with normal appendix, serum amylase level mean was 55.40mg/dl, and in patient with simple acute appendicitis was 33.32mg/dl, and in complicated appendicitis was 62.40mg/dl which had statistically significant differences (P-value=0.003). Data also showed serum amylase level in the diagnosis of complicated appendicitis in the cutting point 34.5, had Sensitivity , specificity,positive predictive value,negative predictive value 100%, 56%, 64.5% and 100%, and the total accuracy of the test is 75.5%. Conclusion: Serum amylase level can be used in more precise diagnosis of acute appendicitis, complicated appendicitis as an adjunctive biomarker. possibly it can help that acute appendicitis and its complication get early diagnosis.

Study of the association of serum procalcitonin with leukocytosis in predicting complicated acute appendicitis

Background: Delay in the diagnosis of complicated appendicitis and its treatment results in an increased rate of postoperative morbidity, mortality and hospital stay. The diagnosis of appendicitis rests on a combination of signs of inflammation such as fever, pain and tenderness; leukocytosis, and elevated C-reactive protein levels, interleukin-6 (IL6) and procalcitonin. Raised level of serum procalcitonin in bacterial infection has been used to further improve the diagnosis of complicated AA.Methods: One-hundred ten patients of appendicitis confirmed by intra-operative findings and final pathologist report, who underwent appendectomy consisting 25 women (22.73%) and 85 men (77.27%) with a mean age of 25 years (age range 15-55 years) were included in this study. Serum procalcitonin value was measured by chemi E411 Cobas method (chemilumiscent immunoassay system) using the B.R.A.H.M.S PCT kit. Serum PCT level &gt;0.5 ng/ml was consider as risk for progression to severe systemic disease.Results: At a 0.5 ng/dl cut-off value of PCT, the sensitivity and specificity of PCT level measurement for acute complicated appendicitis prediction was 90% and 97.14% respectively. Association between WBC count and PCT value shows the sensitivity and specificity in 40 case of acute complicated appendicitis prediction was 86% and 75% respectively.Conclusions: Both the higher PCT values and leukocytosis correlates well with infectious post-operative complications for acute appendicitis and it can help to carry out timely surgical intervention which is highly recommended in complicated appendicitis(correlates PCT &gt;0.5 ng/dl).

A Study to Evaluate the Significance of Sherren’s Triangle Hyperaesthesia in a Treatment of Acute Appendicitis

Background: Acute appendicitis is the most common surgical emergency. In spite of sophisticated new investigations mainstay of diagnosis depends on clinical sign and symptoms, Sherren‘s triangle hyperaesthesia is very important sign with controversial efficacy about it in available literature. The aim of this study was to explore the significance of hyperaesthesia in Sherren’s triangle in a treatment of acute appendicitis. Subjects and Methods: This study was conducted in 418 patients with 186 females and 251 males. Patients were of acute appendicitis operated for appendicectomy included in the study. Results: Sensitivity and specificity of hyperaesthesia in Sherren’s triangle were 47.7% and 42.9% respectively with positive and negative predictive values were 92.1% and 5.56%. Conclusion: Hence it indicates that hyperaesthesia in Sherren’s triangle is important sign to suspect to support diagnosis of acute appendicitis. It has minimal significance to rule out it. This sign plays very important role in a diagnosis of complicated appendicitis like obstructive appendicitis.

Role of serum bilirubin in predicting the severity of acute appendicitis

Background: The aim of the study was to establish the role of hyperbilirubinemia as a new diagnostic tool to predict gangrenous/perforated appendicitis.Methods: A prospective study carried for 9 months (March 2018 to November 2018) at Rajarajeswari Medical College and Hospital. All patients admitted with clinical diagnosis of acute appendicitis and posted for surgery were included in the study. Serum total bilirubin results will be compared with Rajarajeswari Medical College and Hospitals laboratory reference values. These cases will be operated and clinical diagnosis will be confirmed per-operatively and post-operatively by histopathological examination. Final histopathological examination will be considered as a gold standard for diagnosing and categorizing patients as having normal appendix, acute appendicitis and acute appendicitis with perforation and/or gangrene. Based on histopathological examination patients will be categorized as positive (acute appendicitis with perforation and/or gangrene) and negative (acute appendicitis without perforation or gangrene).Results: Sensitivity of serum bilirubin in case of perforated/gangrenous appendicitis was found to be 90%. Specificity of serum bilirubin was found in case of perforated/gangrenous appendicitis was found to be 90.47%. Positive predictive value and negative predicting value of serum bilirubin in perforated/gangrenous appendicitis was found to be 81.8% and 95% respectively with p value of 0.003.Conclusions:Serum total bilirubin is an easily available and cheap and can be estimated from the same blood sample withdrawn for routine investigations, if added to routine investigations, then diagnosis of complicated appendicitis can be made with fair degree of accuracy.

Complicated appendicitis during pregnancy

To analyze incidence, diagnosis and treatment of complicated appendicitis in pregnant women and to determine the optimal surgical approach. Retrospective cohort analysis included 338 pregnant women who underwent appendectomy in 2012-2016. Complicated appendicitis (abscess, local or common peritonitis and their combinations) was diagnosed in 22 cases. The main perioperative variables (duration of the disease, time of surgery, length of hospital-stay, incidence of wound complications, etc.), clinical and laboratory symptoms, results of ultrasound diagnosis and pregnancy outcomes were analyzed. Statistical analysis was carried out in Stata 14.2. Fisher's exact test, Mann-Whitney-Wilcoxon's U-test and multivariate regression analysis were used to compare data. The incidence of complicated appendicitis in pregnant women was 6.51%. There are no clinical symptoms which would be significantly more common in complicated appendicitis during pregnancy. Complicated course prolongs surgery and hospital-stay, however duration of postoperative analgesia depends on surgical technique as a rule. There were 27% of laparoscopic interventions that is lower compared with women with uncomplicated appendicitis. The percentage of conversions was higher too. Clinical diagnosis of complicated appendicitis during pregnancy even by using of ultrasound is not satisfactory and requires the involvement of other objective methods, such as MRI. Laparoscopic intervention is not contraindicated in pregnant women with complicated appendicitis and determine better treatment outcomes than open surgery.

HYPERBILIRUBINEMIA AS AN INDICATOR OF COMPLICATED APPENDICITIS

Introduction: Appendicitis is a common presentation in the surgical emergency. Of these 34.7% are perforated or gangrenous. Delay in diagnosis of complicated appendicitis can lead to increase in operative burden and ensuing morbidity. Hyperbilirubinemia is a non invasive and cost effective diagnostic tool for complicated appendicitis. Prioritization of patients on operating lists and reduction in unnecessary investigations may be possible with accurate and timely diagnosis of the disease. Objectives: To determine the diagnostic accuracy of Hyperbilirubinemia in diagnosing complicated appendicitis keeping histopathology as gold standard. Study design:Descriptive, cross-sectional. Study duration:21st November 2015 to 20th May 2016 Settings:Surgical Unit 1 Holy Family Hospital Rawalpindi Pakistan Materials & Methods: A total of 185 suspected cases of acute appendicitis undergoing appendectomy between ages of 12-60 years of either gender were recruited. Total bilirubin levels were sent preoperatively. Appendectomy was performed and specimen sent in formalin bottles, histopathological diagnosis was traced. Results: Mean age was 24.16 ± 11.69 years. Out of 185 patients, 100 (54.05%) were male and 85 (45.95%) were females.In Hyperbilirubinemia positive patients, 30 (True Positive) had complicated appendicitis and 06 (False Positive) had simple appendicitis on histopathology. Among 149 patients with normal total bilirubin, 23 (False Negative) had complicated appendicitis whereas 126 (True Negative) did not have complicated appendicitis on histopathology(p=0.0001).Overall sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of Hyperbilirubinemia in diagnosing complicated appendicitis was 56.60%, 95.45%, 83.33%, 84.56% and 84.32% respectively. Conclusion: Hyperbilirubinemia at presentation is an accurate and specific indicator of complicated appendicitis.

Sherren`s triangle hyperaesthesia a tool to rule out complicated appendicitis

Background: Acute appendicitis is the most common surgical emergency. In spite of sophisticated new investigations mainstay of diagnosis depends on clinical sign and symptoms, Sherren`s triangle hyperaesthesia is very important sign with controversial efficacy about it in available literature. Hence this study was undertaken to prove its efficacy of it.Methods: This study was conducted in 418 patients with 186 females and 251 males. Patients were of acute appendicitis operated for appendicectomy included in the study. Data analysis was done by data statistic software.Results: Sensitivity and specificity of hyperaesthesia in Sherren’s triangle were 47.7% and 42.9% respectively with positive and negative predictive values were 92.1% and 5.56%.Conclusions: Hence it indicates that hyperaesthesia in Sherren’s triangle is important sign to suspect to support diagnosis of acute appendicitis. It has minimal significance to rule out it. This sign plays very important role in a diagnosis of complicated appendicitis like obstructive appendicitis.

Hyperbilirubinemia as a predictor of the severity of acute appendicitis - an observational study

Background: Appendicitis is the most common acute abdominal condition requiring emergency surgery, with a lifetime risk of 6%. Appendectomy continues to be one of the commonest procedures in general surgery, accounts for approximately 1% of all surgical operation. Despite the increased use of ultrasonography, computed tomography scanning and laparoscopy, the rate of misdiagnosis of appendicitis has remained constant (15.3%). The aim of this study was to whether Serum Bilirubin can be considered as a new laboratory marker to aid in the diagnosis of acute appendicitis and if so, does it have the predictive capacity to warn us about complicated appendicitis.Methods: This was prospective observational study done in Mahatma Gandhi Medical College and Research Institute, Pondicherry between November 2014 and August 2016. About 110 patients of acute appendicitis who had undergone appendicectomy were studied. Data was collected and analyzed critically.Results: Males 66 (60%) outnumbered females 44 (40%) and overall mean age was 26.61±12.37 years. Of the 110 patients, 9% were normal appendix, 59.09% were confirmed as acute appendicitis while 31.81% were diagnosed with complicated appendicitis on biopsy. The Sensitivity and Specificity of serum bilirubin as a marker in predicting Acute appendicitis and complicated appendicitis was 47.6% and 90.9% respectively. Similarly, the Positive predicative value and Negative predicative value for the same was 88.5% and 61.5% respectively with odds ratio 12.4 with significant p value &lt;0.0001.Conclusions: Serum bilirubin is easily available test and cheap and can be estimated from the sample of blood drawn for routine blood investigations. Patients with clinical signs and symptoms of appendicitis and with hyperbilirubinemia should be identified as having a higher probability of complicated appendicitis. Hence, serum bilirubin levels have a predictive potential for the diagnosis of severity of acute appendicitis and need for early appendicectomy. If total serum bilirubin is added to already existing laboratory tests, then the diagnosis of complicated appendicitis in clinically suspected cases can be made with fair degree of accuracy, the need for CECT and MRI can be reduced and unnecessary delay in appendicectomy can be avoided.