Early Diagnosis Of Acute Appendicitis Research Articles

The importance of urine 5-hydroxyindoleacetic acid levels in the early diagnosis of acute appendicitis

Purpose Acute appendicitis is one of the most common surgical emergencies. Diagnosis is usually made depending on the presenting history, clinical evaluation, and laboratory tests. The aim of this study was to investigate the role of urinary 5-hydroxyindoleacetic acid (U-5-HIAA) in the early diagnosis of acute appendicitis. Methods Thirty-five pigmented male rabbits were divided into 5 groups. Group 1 is the control (n = 7); group 2 is the sham (n = 10). The appendix was ligated from its base, and an appendectomy was performed after 12, 24, 36 hours in group 3 (n = 7), group 4 (n = 7), and group 5 (n = 7), respectively. Spot urine samples were obtained for U-5-HIAA determination, and appendectomy tissues were examined histopathologically. Results Acute appendicitis was diagnosed in all animals in group 3, group 4, and group 5, and the mean levels of U-5-HIAA in group 3 were higher than in the other groups. The mean of U-5-HIAA levels between animals with appendicitis and those without showed a significant difference ( P = .003). The U-5-HIAA cutoff point of 4.15 mg/g creatinine had a sensitivity of 85%, a specificity of 64.29%, and an accuracy of 76% (area under curve = 0.805) for acute appendicitis. The probability of acute appendicitis is found to be 10, 2 times more when the U-5-HIAA level is greater than 4.15 mg/g creatinine. Conclusion We have concluded that spot U-5-HIAA level increases significantly in the early stages of acute appendicitis.

Spot urine 5–hydroxyindoleacetic acid levels in the early diagnosis of acute appendicitis

Background/Purpose The significance of spot urine 5–hydroxyindoleacetic acid (5-HIAA) levels in the early diagnosis of acute appendicitis (AA) is questioned. Methods Forty young, pigmented, male rabbits were divided into 4 groups. Groups are summarized as follows: group 1, control (n = 10); group 2, laparotomy, sham (n = 10); group 3, peritonitis with cecal ligation and puncture (n = 10); and group 4, experimental appendicitis (n = 10). Spot urine samples were obtained for 5-HIAA determination, and appendectomy materials were examined histopathologically and peritoneal fluid cultures were obtained after 12 hours in the study groups. The results were analyzed statistically with 1-way analysis of variance and Scheffé and Tukey's HSD tests. Results The mean 5-HIAA levels in the control group was 5.7 ± 0.6 mg/L, whereas it is 5.9 ± 0.9 mg/L, 6.6 ± 0.6 mg/L, 9.4 ± 0.9 mg/L in the sham, peritonitis, and appendicitis groups, respectively. The levels of 5-HIAA in the appendicitis group were higher than those in the other groups, which was statistically significant ( P < .001). Conclusions Spot urine 5-HIAA determination may be a practical, objective, and noninvasive method in the early diagnosis of AA. Because other radiological and laboratory tests can be insufficient, especially in the early period of AA, this test may be used effectively instead. Clinical studies are necessary for further conclusions.

Predictive value of C-reactive protein at different cutoff levels in acute appendicitis

Determining the different cutoff values of C-reactive protein (CRP) on the basis of how long the patient's symptoms were present can be used to early predict acute appendicitis. We analyzed retrospectively from 2001 to 2004 the hospital records of 568 patients who underwent appendectomies for suspected appendicitis. Receiver operating characteristic analysis has shown that CRP measurement can increase the diagnostic accuracy in acute appendicitis. The cutoff values of CRP concentration taken as the first, second, and third days after onset of symptoms that distinguish acute appendicitis from other acute abdominal diseases were 1.5, 4.0, and 10.5 mg/dL, respectively; the values that distinguish perforated appendicitis from other acute abdominal diseases were 3.3 mg/dL (first day), 8.5 mg/dL (second day), and 12.0 mg/dL (third day). The different cutoff values of CRP concentration may serve as a useful predictive parameter in the early diagnosis of acute appendicitis on the first 3 days after the onset of symptoms.

Application of the MANTRELS scoring system in the diagnosis of acute appendicitis in children.

Evaluation of abdominal pain in children poses a major challenge for the pediatrician and pediatric surgeon alike. Acute appendicitis is diagnosed in 1%-8% of children who present with acute abdominal pain in pediatric department. However, initial misdiagnosis rate in childhood is still high, so how to make early and adequate diagnosis of acute appendicitis is still a challenge to pediatrician. Application of the MANTRELS scoring system (Alvarado score) was used in the diagnosis of acute appendicitis in children. We retrospectively collected a total of 111 cases under 14 years who were proven to have acute appendicitis by operative and pathologic reports and 111 cases who were excluded from having acute appendicitis as control subjects from January 2001 to July 2003. We applied the MANTRELS scores to evaluate these patients. Using statistical analysis, the following four parameters: migration pain, rebounding tenderness, right lower quadrant tenderness, shift WBC count and total MANTRELS scores higher than 6 were shown to have discriminatory values (P<0.01). Assessment of the cases in children with suspected acute appendicitis by the MANTRELS scoring system can be an adjuvant method to help us in the early diagnosis of acute appendicitis.

Urinary 5-hydroxy indole acetic acid as a test for early diagnosis of acute appendicitis

Objectives: Acute appendicitis (AA) is the most common abdominal emergency. The appendix has abundant serotonin containing cells. Upon inflammation, serotonin is released in the blood and converted into 5-HIAA (5-hydroxy indole acetic acid). Measurement of the urine 5-HIAA (U-5-HIAA) could be a reliable marker of inflammation of the appendix. We have compared the powers of test performance of spot U-5-HIAA and spot U-5-HIAA/creatinin with other routine laboratory tests used for the diagnosis of acute appendicitis. Design and methods: Urine, serum, and blood samples of 110 patients who were admitted and observed in the emergency units of two university hospitals were studied. 5-HIAA was measured using HPLC, C-reactive protein by immunoturbidometry, WBC by electronic cell counting, and urine creatinine by the Jaffe method. Diagnostic accuracy of the various tests was evaluated by receiver operating characteristic (ROC) analysis. Findings: The mean of spot U-5-HIAA in 39 patients with AA (nongangrenous) was 32 ± 2.6 μmol/L, which was much higher than the mean of 40 non-appendicitis patients (NA) (5.5 ± 0.6), 10 follicular hyperplasia (7.5 ± 2.1), and 50 healthy control cases (4.1 ± 0.5) with P < 0.001. The concentration of U-5-HIAA in 21 patients with gangrenous appendicitis (GA) (13.8 ± 2.1) was also higher than NA patients and healthy individuals but lower than AA cases ( P < 0.05). Considering 10 μmol/L as the cutoff point, this test shows 84% sensitivity and 88% specificity, with 90% and 81% positive and negative predictive values, respectively. The area under ROC curve (AUC) of U-5-HIAA in the diagnosis of AA (AUC = 0.903) was much larger than AUCs of U-5-HIAA/Cr (0.787), WBC (0.703), and CRP (0.660). Conclusion: Urinary secretion of 5-HIAA increases significantly in acute appendicitis and measurement of spot U-5-HIAA gives higher diagnostic accuracy than other routine laboratory tests. While the inflammation progresses to necrosis of the appendix, the concentration of 5-HIAA decreases. This decrease could be a warning sign of perforation of the appendix.

Predictive inflammatory parameters in the diagnosis of acute appendicitis in children.

Acute appendicitis is the most common abdominal surgical emergency in children. In order to determine the related factors for early diagnosis of acute appendicitis in children, we analyzed retrospectively from January 2001 to December 2002 the hospital records of 260 consecutive patients under 18 years of age operated on because of suspected acute appendicitis. The patients group comprised 163 males (62.7%) and 97 females (37.3%) with a mean age of 11.1 +/- 4.3 years (range from 0 to 18 years old). The accurate diagnostic rate of acute appendicitis in children was 81.5 percent and negative appendicectomy rate was 18.5 percent. When combining leukocytosis, elevated neutrophil count and elevated C-reactive protein, the specificity and positive predictive value in diagnosing acute appendicitis were increased. According to the application of multivariate logistic regression analysis, the significantly related factors in acute appendicitis were elevated neutrophil count (Odds ratio = 3.79, 95% confidence interval = 1.732-8.293, p < 0.001) and elevated C-reactive protein concentration (Odds ratio = 2.81, 95% confidence interval = 1.231-6.390, p < 0.05). In conclusion, total neutrophil count and C-reactive protein may serve as predictive parameters for early diagnosis of acute appendicitis in children.

Appendicitis in infancy.

Acute appendicitis is the most common cause of abdominal pain requiring surgery in children. But it is an uncommon entity in young children and rare in infants. During a 10-year period, between January 1991 and December 2000, 7 infants (age from 17 days to 8 months) were treated for acute appendicitis at Changhua Christian Hospital. All of the preoperative symptoms and signs, the duration between admission and operation, pathology reports, and laboratory data were reviewed. There were no specific clinical signs and symptoms. The duration between admission and operation ranged from 2 hours to 5 days (mean: 31.4 hours). The pathology reports revealed 3 were gangrenous, 3 were gangrenous with perforation and one was suppurative. There was one death. Pseudomonas aeruginosa was cultured from blood, ascites, bile or stool in 6 cases (85.7%). Early diagnosis of acute appendicitis in infants is still difficult. Although the mortality has declined, the morbidity still remains high. The high percentage of infection by Pseudomonas aeruginosa should be further evaluated in infantile appendicitis.

Continuing diagnostic challenge of acute appendicitis: evaluation through modified Alvarado score.

Acute appendicitis with protean manifestations may simulate almost any other acute abdominal illness and in turn may be mimicked by a variety of conditions. Progression of symptoms and signs is usual in contrast to the fluctuating course of some other diseases that lead to heavy morbidity and mortality. A practical score for the early diagnosis of acute appendicitis was established by Alvarado in 1986 and was assessed in this study for its accuracy in pre-operative diagnosis. The usefulness of this scoring system in reducing the evaluated negative appendicectomy rate of acute appendicitis in 91 patients, diagnosed by clinical parameters only, over a period of 12 months is determined. A total of 106 patients underwent Alvarado scoring in emergency surgical service at SK Institute of Medical Sciences, Srinagar Kashmir, India. The high scores in men and children were found to be an easy and satisfactory aid in the early diagnosis of acute appendicitis, but a high false-positive rate for acute appendicitis was found in women.

Concentrations of serotonin in plasma--a test for appendicitis?

We assessed the value of measuring serotonin (5-hydroxytryptamine) in plasma (by HPLC) in the diagnosis of acute appendicitis. Values for patients with subsequently confirmed appendicitis (11-145 nmol/L, median 70 nmol/L) significantly (P congruent to 0.005) exceeded those for patients with abdominal pain in whom appendicitis was only a possible diagnosis (2-45 nmol/L, median 20 nmol/L). The results for appendicitis patients were bimodally distributed, with low results found in patients where surgery revealed gangrenous appendicitis with little viable appendicular tissue. We conclude that measuring serotonin may be of value in confirming or excluding the diagnosis of early acute appendicitis where the physical signs are equivocal, and thus helps reduce unnecessary appendectomies. However, serotonin is of little help in diagnosing gangrenous appendicitis, where physical signs are more likely to be clearcut.

A Practical Score for the Early Diagnosis of Acute Appendicitis

We conducted a retrospective study of 305 patients hospitalized with abdominal pain suggestive of acute appendicitis. Signs, symptoms, and laboratory findings were analyzed for specificity, sensitivity, predictive value, and joint probability. The total joint probability, the sum of a true-positive and a true-negative result, was chosen as a diagnostic weight indicative of the accuracy of the test. Eight predictive factors were found to be useful in making the diagnosis of acute appendicitis. Their importance, according to their diagnostic weight, was determined as follows: localized tenderness in the right lower quadrant, leukocytosis, migration of pain, shift to the left, temperature elevation, nausea-vomiting, anorexia-acetone, and direct rebound pain. Based on this weight, we devised a practical diagnostic score that may help in interpreting the confusing picture of acute appendicitis.

A practical score for the early diagnosis of acute appendicitis

We conducted a retrospective study of 305 patients hospitalized with abdominal pain suggestive of acute appendicitis. Signs, symptoms, and laboratory findings were analyzed for specificity, sensitivity, predictive value, and joint probability. The total joint probability, the sum of a true-positive and a true-negative result, was chosen as a diagnostic weight indicative of the accuracy of the test. Eight predictive factors were found to be useful in making the diagnosis of acute appendicitis. Their importance, according to their diagnostic weight, was determined as follows: localized tenderness in the right lower quadrant, leukocytosis, migration of pain, shift to the left, temperature elevation, nausea-vomiting, anorexia-acetone, and direct rebound pain. Based on this weight, we devised a practical diagnostic score that may help in interpreting the confusing picture of acute appendicitis.

Barium enema: An outpatient procedure in the early diagnosis of acute appendicitis: G. A. Lewin, V. Mikity, and W. A. Wingent. J Pediatr 92:451–453 (March), 1978

Barium enema: An outpatient procedure in the early diagnosis of acute appendicitis: G. A. Lewin, V. Mikity, and W. A. Wingent. J Pediatr 92:451–453 (March), 1978

Barium enema: An outpatient procedure in the early diagnosis of acute appendicitis

Both of our patients, young girls with ulcerative colitis, developed the onset of fever, vomiting, and bloody diarrhea after the ingestion of SAS. We believe that these symptoms were not secondary to the underlying ulcerative colitis because they were reproducible in each patient and resolution was more rapid than could be expected with ulcerative colitis. Patient 1 presented with symptoms characteristic of ulcerative colitis. When treated with SAS her condition deteriorated and did not improve until the SAS was discontinued. Symptoms returned during two subsequent challenges although she was clinically well on both occasions and in complete remission on one. Similarly Patient 2 developed symptoms each time she was treated with SAS. Her colitis was quiescent at the time of each challenge. Both patients tolerate aspirin without evidence of gastrointestinal bleeding or upset. Numerous side effects have been reported with both sulfonamides and salicylates, but the combination of fever, vomiting, and bloody diarrhea has not been among them 8. 9 nor has bloody diarrhea been previously reported with SAS. 1~ We have no explanation for the toxicity observed in our patients. Physicians caring for patients with inflammatory bowel disease should be aware that the onset of fever, vomiting, and bloody diarrhea may be due to SAS and not to a flare-up of the disease. REFERENCES 1. Misiewicz J J, Lennard-Jones JE, Connell AM, Baron JH, and Avery Jones F: Controlled trial of sulfasalazine in maintenance therapy for ulcerative colitis, Lancet 1:185, 1965. 2. Goldman P, and Peppercorn MA: Sulfasalazine, N Engl J Med 293:20, 1975. 3. Das KM, Eastwood MA, McManus JPA, and Sircus W: Adverse reaction during salicylazosulfapyridine therapy and the relation with drug metabolism and acetylator phenotype, N Engl J Med 289:491, 1973. 4. Block MB, Genant HK, and Kirsner JB: Pancreatitis as an adverse reaction to salicylazosulfapyridine, N Engl J Med 282:380, 1970. 5. Lead Article. Sulfasalazine induced lung disease, Lancet 2:504, 1974. 6. Wallace IW: Neurotoxicity associated with a reaction to sulfasalazine, Practitioner 204:850, 1970. 7. Strom J: Toxic epidermal necrolysis (Lyell's Syndrome) Scand J Infect Dis 1:209, 1969. 8. Woodbury DM, and Fingl E: Analgesic, antipyretics, antiinflammatory agents and drugs employed in the therapy of gout, in Goodman A, and Gilman AG, editors: The pharmacological basis of therapeutics, New York, 1975, The Macmillan Company, pp 325-358. 9. Weinstein LS: Antimicrobial agents, sulfonamides and trimethoprimsulfmethoxazole, in Goodman A, and Gilman AG, editors: The pharmacologic basis of therapeutics, New York, 1975, The Macmillan Company, pp 1113-1129. 10. Schinagl EF: Pharmacia Laboratories Inc., Personal communication.

DIAGNOSIS AND TREATMENT: APPENDICITIS IN CHILDHOOD

AS RECENTLY AS 1958, 258 children died in this country as a result of appendicitis. Most of these deaths occurred in young children with perforation. Correct early diagnosis of acute appendicitis and precise and vigorous management of children with advanced appendicitis can prevent these deaths. Particular attention should be paid to the pre-school child with abdominal pain. The historical and physical findings which are generally called classical are more common in older children. The intraluminal pressure of the obstructed appendix of the young child is built up to the same order as in the adult, but the intravascular pressure is lower and the bowel wall thinner. This results in the rapid development of necrosis. These two factors—difficulty in diagnosis and a fulminating course—lead to a high incidence of perforation in children. Combining the statistics of four large series of 551 children, age 4 years and under, with appendicitis, 429 or 77% were found to have perforated appendixes. This high incidence of perforation has not decreased over the years. THE EARLY DIAGNOSIS OF APPENDICITIS Abdominal pain is the prime symptom of appendicitis. Its character and location depend on the anatomic position of the inflamed appendix and the stage of development of the disease process. The young child is often not able to verbalize his complaint of abdominal pain or localize accurately the area of his abdominal discomfiture. Fretfulness, crying, disturbed sleep, and resistance to handling are often the first indications that something is wrong. Anorexia and vomiting are common accompaniments of many childhood illnesses. However, the presence of a good appetite casts some doubt on the diagnosis of appendicitis.

Acute Appendicitis in Children

Early diagnosis of acute appendicitis in the preschool child and management of the child with peritonitis secondary to perforation are the basic clinical problems of this disease in the childhood age group. Although the mortality over the past three decades has progressively decreased to a very low level, the deaths which still occur are almost exclusively in very young children, diagnosed late and with peritonitis. In addition the morbidity, as reflected in the incidence of complications and prolonged hospitalization, is largely confined to patients with perforation. Diagnosis of acute appendicitis in the young child before perforation occurs can be improved by careful and thoughtful appraisal of the child with abdominal symptoms, by hospitalization with frequent evaluation of patients in whom the diagnosis is in doubt, and by expert interpretation of abdominal x-rays in such patients. Successful management of seriously ill children with perforation and peritonitis depends on intensive treatment to

A New Method for the Early Diagnosis of Acute Appendicitis in the Absence of Localization

A New Method for the Early Diagnosis of Acute Appendicitis in the Absence of Localization