Differential Diagnosis Of Acute Appendicitis Research Articles

Neuroendocrine tumor of the appendix masquerading as acute appendicitis with a mucocele on CT scan: a rare finding

IntroductionNeuroendocrine tumors (NETs) of the appendix are rare and are often discovered incidentally during surgery for acute appendicitis or other unrelated conditions (Modlin et al. in Gastroenterology 128:1717–1751, 2005, Alsaad et al. in Oncol Rep 16:1105–1109, 2006, Frilling et al. in Lancet Oncol 15:e8–e21, 2014). These tumors can range from asymptomatic incidental findings to clinically significant tumors with metastases (Alsaad et al. in Oncol Rep 16:1105–1109, 2006, Gomes et al. in World J Emerg Surg 10:60, 2015, Paiva et al. in Eur J Cancer 38:702–705, 2002, Burke et al. in Am J Surg Pathol. 9:661–674, 1985). This case report presents a rare case of a NET of the appendix presenting as acute appendicitis.Case descriptionA 23-year-old male presented with right lower quadrant abdominal pain, nausea, and vomiting for 2 days. A CT scan revealed a mucocoele of the appendix. The patient underwent laparoscopic appendectomy, and the appendix was sent for histopathological examination. The final pathological report confirmed a NET of the appendix with a Ki-67 index of 1% and no lymphovascular invasion. Due to tumor invasion to the cecum and its large size (3–4 cm), the patient underwent right hemicolectomy. The final histopathology report of the resected specimen confirmed the diagnosis of NET of the appendix.DiscussionThe clinical diagnosis of NETs of the appendix can be challenging due to their rarity and non-specific presentation. Symptoms of NETs of the appendix can mimic those of acute appendicitis, making it difficult to differentiate between the two conditions. Imaging studies, such as CT scans, can provide valuable information about the size and location of the tumor (Gomes et al. in World J Emerg Surg 10:60, 2015, Maggard et al. in Ann Surg 240:117–122, 2004, Burke et al. in Am J Surg Pathol. 9:661–674, 1985, Frilling et al. in Lancet Oncol 15:e8–e21, 2014). However, the definitive diagnosis is made through histopathological examination of the resected specimen. The treatment of NETs of the appendix depends on factors such as the size, location, and grade of the tumor. Small tumors confined to the appendix with no lymph-vascular invasion can be treated with appendectomy alone, while larger tumors or those that have spread beyond the appendix may require more extensive surgery, such as right hemicolectomy (Gomes et al. in World J Emerg Surg 10:60, 2015, Mestier et al. in Dig Liver Dis 52:899–911, 2020, Maggard et al. in Ann Surg 240:117–122, 2004, Burke et al. in Am J Surg Pathol. 9:661–674, 1985, Frilling et al. in Lancet Oncol 15:e8–e21, 2014, Pavel et al. in Neuroendocrinology 103:172–185, 2016). In some cases, additional treatments such as chemotherapy or radiation therapy may be recommended.ConclusionThis case report emphasizes the importance of considering NETs of the appendix in the differential diagnosis of acute appendicitis. Imaging studies can provide valuable information, but the definitive diagnosis is made through histopathological examination. The treatment approach for NETs of the appendix depends on various factors and requires a multidisciplinary approach for optimal management.

Validation of the modified Alvarado score on patients attending A&E units with suspected appendicitis

IntroductionThe aim of our prospective study was to confirm validity and diagnostic accuracy of the modified Alvarado score, which was developed at the Department of Surgery, University of Szeged, on patients presenting with symptoms suggestive of acute appendicitis (right lower quadrant complaints) at the A&E department.Patient population, methods138 patients were included in our study between 01.01.2019 and 01.01.2020. For patients attending A&E, the first medic calculated and recorded the modified Alvarado score before surgical consultation. The consulting surgeon decided on further treatment without knowing the score. Validation of the score was based on the pathology report of the removed appendix (whether the operation was warranted, and if the score also supported indication for surgery), if there was readmission or surgery due to worsening symptoms after discharge from A&E. We also examined if there was any connection between the value of the Alvarado score and the severity of inflammation. Our aim was to prove that using modified Alvarado score at the A&E Units helps to reduce patient’s waiting time and avoid unnecessary surgical consultations. Furthermore our study included measuring the diagnostic accuracy of the ultrasound examination (specificity, sensitivity).ResultsBased on the results, patients presenting at A&E had a mean modified Alvarado score of 6.5. Comparing the score to histological results showed that the specificity of the modified Alvarado score was 100%, and its sensitivity was 80.7%. Based on Spearman’s rank correlation (0.796) and ROC analysis (AUC 0.968), the modified Alvarado score has an excellent predictive value in diagnosing acute appendicitis. When comparing the patients’ waiting times with the use of modified Alvarado score and without it we found that there was a significant difference in group also in group under 4 points and in group over 7 points when using modified Alvarado score, so the diagnostic and therapeutic algorithm should be much quicker with the help of the score. We found a correlation between the severity of inflammation based on the Fisher’s exact test. Rank correlation of the same question also showed a significant connection. All patients had an US examination during their diagnostic course, its sensitivity was 82.6%, specificity was 87%. Based on this, we can conclude that the predictive value of the imaging method is good.ConclusionsWe can conclude according to our results that the predictive value of the modified score is excellent, and it can be safely applied by non-surgeons in urgent care in the differential diagnosis of acute appendicitis. The new score incorporates the results of an easily obtainable, ionising radiation free imaging method, the ultrasound, which was not included in previous scores. With the help of the new score, the number of unnecessary surgical referrals and waiting times for patients are reduced, excess examinations will become avoidable.

An Evaluation of the Efficacy of Systemic Immune-Inflammation Index in Predicting Enterobius-Associated Appendicitis Preoperatively.

Objective Our study aimed to retrospectively evaluate Enterobius-associated appendicitis cases and compare them with acute appendicitis cases in terms of parameters such as the neutrophil-to-lymphocyte ratio (NLR), C-reactive protein (CRP)-to-lymphocyte ratio (CLR), platelet-to-lymphocyte ratio (PLR), and systemic immune-inflammation index (SII). We primarily aimed to evaluate the utility of SIIin the differential diagnosis of Enterobius-associated appendicitis. Methods The appendectomy specimens of pediatric patients who were operated on for acute appendicitisbetween June 2016 and August 2022 were retrospectively evaluated. Enterobius-associated appendicitis cases wereincluded for analysis. All patients were evaluated regarding age, gender, blood count, surgery, and pathology reports. Pathology reports were evaluated for the presence of histological signs of acute appendicitis. The patients were classified into an Enterobius-associated appendicitis group and a regular acute appendicitis group. CRP, white blood cell (WBC), red cell distribution width (RDW),neutrophils, lymphocytes, NLR, monocytes, eosinophils, platelet (PLT), PLR, CLR, and SII values were compared between the two groups. Results Eleven cases of Enterobius-associated appendicitis were identified out of 430 total cases (2.55%) examined. The mean age of the group with acute appendicitis was 12.83 ±3.16 years, while the mean age of the group with Enterobius-associated appendicitis was 8.55 ±2.54 years. There was no statistically significant difference in terms of CRP, WBC, RDW, lymphocytes, neutrophils, NLR, monocytes, eosinophils, PLT, PLR, and CLR values between the two groups (p>0.05). However, when the SII values of the participants were analyzed, it was observed that the SII values of the participants in the regular appendicitis group were significantly higher than those of the participants in the Enterobius group (p<0.05). Among the 11Enterobius-associated appendicitis patients, seven appendectomy specimens revealed no inflammation and were regarded as negative appendectomy (63.63%). Conclusion This is the first study to demonstrate the utility of preoperative SII evaluation in Enterobius-associated appendicitis. SII is a simple, easy-to-calculate indicator of Enterobius-associated appendicitis and aids in the preoperative differential diagnosis of acute appendicitis.

Neurogenic appendicopathy: A rare differential diagnosis of acute appendicitis

In histologically non-inflamed but clinically suspect appendices, changes described as neurogenic appendicopathy with fibrous or fibrolipomatous obliterations can be observed. The purpose of this study was to analyse the incidence of these entities of the appendix in a longitudinal patient cohort. This is a retrospective single-centre study of 457 patients undergoing laparoscopic appendectomy from 2017 to 2020 due to suspected acute appendicitis. In 72 patients (15.8%) with clinically suspected acute appendicitis, the appendix showed no distinct signs of acute inflammation during the procedure. In 43 patients, histological analysis revealed neurogenic appendicopathy or fibrous and fibrolipomatous obliteration. Female gender (P=0.088), younger age (P<0.0001), longer pain duration (P<0.0001) and repetitive pain episodes were more frequent in these patients than in those with acute appendicitis. Inflammation markers were also decreased in the group of patients with neurogenic appendicopathy (leukocytes 9.8±3.5 vs. 13.0±4.5G/L and C-reactive protein 38.7±60.7 vs. 59.4±70.5mg/L). Neurogenic appendicopathy with fibrous/fibrolipomatous obliteration is a differential diagnosis of acute appendicitis that can only be confirmed by pathology. Female gender, young age, prolonged duration with repetitive episodes of pain, and relatively low inflammatory markers are evocative of this diagnosis.

Diffusion-weighted imaging versus non-contrast magnetic resonance imaging in the diagnosis of acute appendicitis during pregnancy

The aim of this study was to evaluate the diagnostic performance of diffusion-weighted imaging compared to non-contrast magnetic resonance imaging in the differential diagnosis of acute appendicitis in pregnant patients. A total of 72 pregnant patients with the suspicion of acute appendicitis who underwent magnetic resonance imaging combined with diffusion-weighted imaging examinations were enrolled in this retrospective study. Magnetic resonance imaging images (non-contrast and diffusion-weighted imaging sequences) were evaluated. Moreover, apparent diffusion coefficient ratios were estimated. The diagnostic performances of magnetic resonance imaging and diffusion-weighted imaging findings were statistically analyzed on the basis of surgical and follow-up results. Of 72 pregnant patients, 10 (14%) had acute appendicitis on magnetic resonance imaging and diffusion-weighted imaging. Among 10 patients with acute appendicitis, three (3/10) had perforation. diffusion-weighted imaging findings had higher sensitivity (90 versus 60%), negative predictive value (98.41 versus 93.94%), and accuracy (98.61 versus 94.44%) ratios compared to non-contrast magnetic resonance imaging in the diagnosis of acute appendicitis. There was one false-negative result on diffusion-weighted imaging. Diffusion restriction facilitated the detection of appendicitis. The apparent diffusion coefficient ratios were lower in acute appendicitis than in the normal appendix (0.70±0.19 versus 0.96±0.16) (p<0.05). With a shorter scan time and higher diagnostic accuracy, diffusion-weighted imaging can be useful for the early diagnosis of acute appendicitis and for planning appropriate management.

Laparoscopic appendectomy for acute appendicitis in pregnancy

The review is devoted to the role of laparoscopic appendectomy in surgical management of acute appendicitis in pregnancy. We analyzed reviews, prospective and retrospective studies in the PubMed, Google, the Springer Link online library, the Cochrane Systematic Review databases. The results of laparoscopic and traditional treatment of acute appendicitis in pregnant women were assessed. We analyzed clinical, epidemiological features in these patients, differential diagnosis of acute appendicitis in pregnant women, indications and contraindications for endoscopic treatment, features of laparoscopic procedures. Comparative assessment of laparoscopic and open surgeries for acute appendicitis in pregnant women was carried out. We also estimated the influence of surgical treatment of acute appendicitis on subsequent course of pregnancy.

Clinical Value of Abdominal Ultrasonography in the Diagnosis of Acute Abdomen in Children.

In order to study the practical application value of abdominal ultrasonography in the diagnosis and treatment of acute abdomen in children, this study uses the method of collecting clinical actual cases and scientific analysis to estimate the clinical diagnostic value of high-frequency ultrasound and low-frequency ultrasound. In order to further clarify its curative effect and treatment advantages, a retrospective analysis of medical records was conducted, and 95 children with acute abdominal pain and suspected appendicitis who were admitted to a hospital from September 2021 to November 2021 were reviewed. ATIL HD15000 color Doppler ultrasound was used for diagnosis. The results are as follows: the sensitivity, specificity, positive predictive value, and negative predictive value of low-frequency probe in the diagnosis of intussusception in children were 83.61%, 73.33%, 92.73%, and 52.38%, respectively. The sensitivity, specificity, positive predictive value, and negative predictive value in the diagnosis of mesenteric lymphadenitis were 80.00%, 81.97%, 52.17%, and 94.34%, respectively. The sensitivity, specificity, positive predictive value, and negative predictive value of high-frequency probe in the diagnosis of intussusception in children were 93.44%, 80.00%, 95.00%, and 75.00%, respectively. The sensitivity, specificity, positive predictive value, and negative predictive value in the diagnosis of mesenteric lymphadenitis were 93.33%, 95.08%, 82.35%, and 98.31%, respectively. Among the children with appendicitis confirmed by operation and pathology, 69 cases were detected by high-frequency ultrasound and 4 cases were missed (including 3 cases of acute simple appendicitis and 1 case of perforated appendicitis). The false negative was 4%, there was no false positive, and the sensitivity, specificity and accuracy were 95%, 100%, and 96%. In the same cases, 28 cases were detected by low-frequency ultrasound, 45 cases were missed, the false negative was 61%, and there was no false positive. The sensitivity, specificity, and accuracy were 39%, 100%, and 53%. The sensitivity, accuracy, and false negative of high-frequency ultrasound in the diagnosis of acute appendicitis were significantly higher than that of low-frequency ultrasound. This study shows that ultrasound has high accuracy, sensitivity, and specificity in the diagnosis of acute appendicitis. Low-frequency ultrasound can show the whole picture of the disease and the situation in the abdominal cavity, which can better guide the clinical treatment. Color Doppler hemodynamics is a useful supplement to two-dimensional ultrasound, and ultrasound also plays a positive role in the differential diagnosis of acute appendicitis in children.

Development and Validation of a Differential Diagnosis Model for Acute Appendicitis and Henoch-Schonlein Purpura in Children.

Objective: To study and develop a predictive model for the differential diagnosis of acute appendicitis (AA) and Henoch-Schonlein purpura (HSP) in children and to validate the model internally and externally. Methods: The complete data of AA and HSP cases were retrospectively analyzed and divided into internal and external verification groups. SPSS software was used for single-factor analysis and screening of independent variables, and R software was used for the development and verification of the diagnostic model. Lasso regression analysis was used to screen predictors and Lasso-logistic regression model was constructed, and K-fold cross-validation was used for the internal verification. In addition, nonfever patients were selected for model development and validation in the same way. Receiver operating characteristic (ROC) curves and calibration curves were drawn, respectively, to evaluate the 2 models. Results: Internal development and validation of the model showed that fever, neutrophil ratio (NEUT%), albumin (ALB), direct bilirubin (DBIL), C-reactive protein (CRP), and K were predictive factors for the diagnosis of HSP. The model was presented in the form of a nomogram, and the area under ROC curve of the development group and verification group was 0.9462 (95% confidence interval [CI] = 0.9402-0.9522) and 0.8931 (95% CI = 0.8724-0.9139), respectively. In the model of patients without fever, NEUT%, platelets (PLT), ALB, DBIL, alkaline phosphatase (ALP), CRP, and K were predictive factors for the diagnosis of HSP, and the area under ROC curve of the development group and verification group was 0.9186 (95% CI = 0.908-0.9293) and 0.8591 (95% CI = 0.8284-0.8897), respectively. Conclusion: In this study, 2 diagnostic models were constructed for fever or not, both of which had good discrimination and calibration, and were helpful to distinguish AA and HSP in children.

Comparison Of C-Reactive Protein And High-Sensitivity C-Reactive Protein in Acute Appendicitis Patients With Normal White Blood Cells Counts

Objective: Acute appendicitis is one of the main causes of acute abdominal pain. The main goal of treatment is early diagnosis and emergency surgical intervention. Late diagnosis leads to complex acute appendicitis (gangrene, abscess, and perforation). Although the signs and symptoms of acute appendicitis are well known, it is sometimes difficult to diagnose. Various laboratory markers have been studied for the diagnosis of acute appendicitis, but none showed superiority over physical examination or imaging. In addition, the superiority of high-sensitivity C-reactive protein (hs-CRP) over C-reactive protein (CRP) in patients diagnosed with acute appendicitis has not been evaluated in any study to date. With the current study, we aimed to compare CRP and HsCRP values in patients with acute appendicitis whose white blood cells (WBC) are in the normal range. Materials and methods: In this study, serum levels of CRP and hs-CRP were measured in 45 patients with acute appendicitis (who had normal WBC values) and 42 healthy controls. The results obtained were statistically evaluated in terms of significant differences between the two study groups. In addition, ROC (Receiver Operating Characteristic) analysis was performed to determine the power of CRP and HsCRP in the differential diagnosis of acute appendicitis. Results: CRP and HsCRP levels of the patient group were significantly higher than the control group (0,002 and &lt;0,001 respectively). ROC analysis results revealed that HsCRP has higher diagnostic power than CRP in discriminating between AA patients and healthy people. Conclusion: This study showed that HsCRP may be a more effective biochemical marker in the diagnosis of acute appendicitis instead of CRP.

Are thiol-disulfide homeostasis & neutrophil-to-lymphocyte ratio useful in the differential diagnosis of acute familial Mediterranean fever attacks & acute appendicitis?

Continuous subclinical inflammation can be seen in patients with familial Mediterranean fever (FMF) during the attack-free period. The importance of oxidative stress parameters in acute appendicitis (AA) progression has also been shown in previous studies. So, oxidative stress and the oxidant/antioxidant balance may play a role in this persistent subclinical inflammation. With this background the main objective of this study was to investigate the usefulness of combining the thiol-disulfide homeostasis parameters and the neutrophil-to-lymphocyte ratio (NLR) in the differential diagnosis of AA and an acute FMF attack. The present study was conducted prospectively with 84 patients who were admitted to the emergency department between May 1, and December 31, 2018. Another 40 healthy individuals were assigned as the control group. The homeostasis parameters of thiol-disulfide were measured by a spectrophotometric method and NLR was measured in the patient and control groups. Native thiol and total thiol values were lower, while disulfide values were insignificantly higher in patients with AA than in patients with FMF. The white blood cell (WBC), neutrophil and NLR values were significantly higher in the AA group (P<0.001, P<0.001, P<0.001, respectively). When the neutrophil cut-off value for AA was set at 8.55, the calculated sensitivity was 80 per cent, the specificity was 72.2 per cent, and the area under the curve was 0.837. The results of this study suggest that neutrophil, WBC and NLR values can be useful in the differentiation of AA from an acute FMF attack.

Sensitivity and specificity of the Alvarado Score for the timely differential diagnosis of acute appendicitis for a case series in Samoa

BackgroundTimely diagnosis of acute appendicitis (AA) is essential for optimal management of abdominal pain emergency presentations. Improved diagnostic procedures should minimise progression to complicated appendicitis, as well as reduce the number of unwanted surgical interventions. The Alvarado Score is an important tool to assist with the management of AA based on clinically predictive values. The aim of the present study was to evaluate the sensitivity and specificity of the Alvarado Score as an instrument for the diagnosis of AA in our low-resourced context of Samoa. Materials and methodsThe lead investigator performed a retrospective clinical data review design of all patients admitted to the Tupua Tamasese Meaole Hospital Surgical Unit for AA from January 2015 to December 2016. Exclusion criteria were appendiceal abscess and/or mass, and final diagnosis ‘not acute appendicitis’. Age, sex, village, Alvarado Score, Ultrasound Scan Result, surgical management, and histopathology result were the main variables entered into the SPSS statistical software package for analysis. ResultsOf the 225 patients (2–86 years) admitted for AA, 67.1% (N = 151) underwent appendicectomy, and the remaining 32.9% (N = 74) were treated with antibiotics. An Alvarado Score (≥5) showed 91.7% sensitivity and 50% specificity for AA. There was a significant relationship between the Alvarado Score and the Ultrasound Scan for AA (p < 0.05). Histology results showed complicated AA in 68.6% (N = 94) of cases. The negative appendicectomy rate was 2.6%. ConclusionsThe Alvarado Score is an effective tool for the timely differential diagnosis of AA in our Samoan context. The high rate of complicated acute appendicitis warrants investigation to further improve the management of AA in the Pacific Island setting.

Features of Diagnostics and Treatment of Acute Appendicitis in Patients &#x0D; of Infectious Hospital

Introduction. Acute appendicitis occupies one of the leading positions in terms of incidence among urgent surgical diseases of the abdominal organs in Russia and in the world. Despite the accumulated experience in the diagnosis and treatment of the disease, a number of challenges still remain, leading to delayed diagnosis and, as a consequence, the development of destructive and complicated forms and deterioration of treatment outcomes. One of these "stumbling blocks" is the differential diagnosis of acute appendicitis and infectious diseases. In addition, acute appendicitis frequently develops together with existing acute and chronic infectious diseases, and appears to be also their complication. In our opinion, the absence of a specific algorithm of actions when dealing with this category of patients may be one of the reasons for unsatisfactory results. In this regard, there is a need to develop such an algorithm.Aim. Improvement of the therapeutic and diagnostic algorithm in relation to patients with OA admitted to infectious diseases hospitals, as well as evaluation of the results of its application.Materials and methods. The article presents diagnostics and treatment results of patients with acute appendicitis hospitalized in an infectious disease hospital, and compares their outcomes before and after implementation of the developed diagnostic and treatment algorithm. The study included 102 patients. The retrospective group included 55 patients with acute appendicitis, which developed together with acute or chronic infectious diseases, treated before implementation of the algorithm. The prospective group consisted of 47 patients treated using the developed algorithm.Results. . Gangrenous forms developed in 25 (45,5%) patients of the retrospective group, and in 8 (17%) patients of the prospective group. Peritonitis complicated the course of acute appendicitis in 53 (96,4%) patients of the retrospective group, while in patients of the prospective group this complication was noted in 25 (53,5%) cases. Purulent forms of peritonitis were noted in 20 (36,4%) patients of the retrospective group, and only in 3 (6,4%) patients of the prospective group. There was also a significant difference in the incidence of appendicular infiltration / abscess. This complication was registered in 11 (20%) patients of the retrospective group, in the prospective group it was noted in 2 (4,3%) patients. Postoperative complications were recorded in 8 (14.5 %) patients of the retrospective group. There were no postoperative complications in patients of the prospective group.Conclusion. The data obtained allow assuming that use of the proposed treatment and diagnostic algorithm in patients with acute appendicitis admitted to an infectious diseases hospital can positively affect timeliness of diagnosis and treatment and, as a consequence, improve treatment outcomes for this category of patients.

An incidental finding of ANET in a patient with perforated appendix: A case report.

Introduction and importanceAppendiceal neuroendocrine tumors (ANETs) are incidentally found in 0.2–0.7% of appendectomies for suspected appendicitis.Case presentationA 29-year-old female presented with pain in the right lower quadrant of her abdomen for the past 48 h. On emergency appendectomy for suspected acute appendicitis, a perforated appendix was found. Histopathological examination showed grade 1 (low) ANET.Clinical discussionAppendiceal neuroendocrine neoplasms (ANENs) are commonly found at the tip of the appendix and are treated with appendectomy alone. For few ANENs located at the base, or small tumors (≤2 cm) infiltrating the submucosa, the muscularis, the subserosa layer or the mesoappendix, right hemicolectomy is recommended. However, no guidelines have been established concerning patients with appendiceal perforation in case of ANENs.ConclusionAlthough rare, ANETs should be considered in the differential diagnosis of acute appendicitis. Since, ANETs are rarely diagnosed preoperatively, subsequent patient evaluation after appendectomy is crucial for management of the patient.

Difficult cases of differential diagnosis of acute appendicitis

Despite the results of technological progress in medicine, which has made high-resolution methods of medical imaging available, the problem of differential diagnosis of acute appendicitis does not lose its’ relevance. This can be explained by the fact that the symptoms of acute appendicitis are variable, non-specific, and can mimic other diseases with similar symptoms.Three cases of rare diseases of the gastrointestinal tract that simulates acute appendicitis were presented. Those are primary torsion of the greater omentum with necrosis, caecum cancer with lengthy necrosis in a young patient and Crohn's disease that simulates appendicular infiltrate. All patients underwent surgery. Signs of acute appendicitis were indications for surgery. Laparoscopic resection of greater omentum was performed in the first case. In the second case caecum necrosis with peritonitis was revealed by laparoscopy. Conversion laparoscopy to laparotomy was performed. Caecum necrosis with caecum wall perforation and necrosis of terminal part of the ileum was diagnosed. right hemicolectomy with ileo-transverso anastomosis was carried out. Complicated case of Crohn’s disease was suspected. Nevertheless, the diagnosis of colorectal cancer is established by pathomorphology only. This case is interesting because of rare complication of colon cancer – the caecum and the ileum wall necrosis that was manifestation of the disease. In the third case of Crohn’s disease in a young patient the diagnosis of appendicular infiltrate and surgical policy were wrong. At the first laparotomy by McBurney was performed. A dense infiltrate was found in the right iliac fossa. The intervention was finished by local abdominal package. In the early postoperative period an intestinal fistula was formed. The patient underwent relaparotomy and right hemicolectomy with ileo-transversal anastomosis was carried out. Despite the diagnosis of Crohn's disease was questionable patomorphology and was established after half a year only by colonoscopy. The presented cases illustrate the complexity of acute appendicitis and the importance of modern approaches to diagnosis: irreplaceability of laparoscopy and the feasibility of using diagnostic scales. When the right diagnosis is not clear the intervention might be late for using methods of instrumental diagnostics.

Total Leukocyte Count Depicting the Degree of Inflammation in Acute Appendicitis.

IntroductionAcute appendicitis (AA) is the most common cause of acute abdomen in young adults. The diagnosis is usually made on various clinical findings. However, a missed case of acute appendicitis is a catastrophe as it later presents with life-threatening complications and results in medicolegal issues. Raised total leukocyte count (TLC) is a frequent finding in patients with acute appendicitis. As a convention, a normal leukocyte count usually rules out the differential diagnosis of acute appendicitis. Recent studies claimed that a substantial proportion of patients with normal TLC also had acute appendicitis and warranted a careful evaluation of such cases before sending them home. However, the reported frequency of acute appendicitis among TLC normal patients varied greatly among studies which necessitated the present study.AimOur aim was to determine the frequency of acute appendicitis in patients of normal TLC.Materials and methodsThis descriptive cross-sectional study was conducted at the Department of Surgery, KRL Hospital Islamabad. This study was carried out from 1 July 2019 to 31 December 2019. This study involved 238 patients of both genders aged between 12 and 70 years suspected of acute appendicitis on physical and ultrasound findings but with a normal TLC (4,500-11,000 WBCs/µL). The outcome variable was the frequency of acute appendicitis among such patients which was diagnosed upon surgery (inflamed appendix with free fluid) and histopathology of excised tissue (mucosal inflammation, neutrophil infiltrates, wall necrosis). Frequency of acute appendicitis was compared across various age and gender groups. Written informed consent was obtained from every patient.ResultsThe mean age of the patients was 27.4±15.5 years. Majority (n = 167, 70.2%) of the patients were aged ≤25 years, followed by 40 (16.8%) patients aged ≥46 years and 31 (13.0%) patients aged between 26 and 45 years. There were 135 (56.7%) male and 103 (43.3%) female patients with a male to female ratio of 1.3:1. All of the patients (100.0%) had pain in the right iliac fossa (RIF) while rebound tenderness, anorexia, nausea/vomiting, fever and dysuria were noted in 83.6%, 79.0%, 73.9%, 63.9% and 15.1% patients, respectively. The diagnosis of acute appendicitis was made in 198 (83.2%) patients with normal TLC and suspicion of acute appendicitis on physical findings and ultrasound. When stratified, there was no statistically significant difference in the frequency of acute appendicitis across various age (p-value = 0.988) and gender (p-value = 0.913) groups.ConclusionIn the present study, contrary to the routine impression that normal TLC rules out the differential diagnosis of acute appendicitis, a substantial proportion of patients with clinical and ultrasound suspicion of acute appendicitis but normal TLC had acute appendicitis which is worrisome as a missed case may later present with complications. The present study thus warrants cautious evaluation of clinically suspected cases with normal TLC count to avoid a missed appendicitis and improve the outcome in future surgical practice.

The Bedel Score: Suggesting a New Scoring System to Avoid Negative Appendectomy

Introduction: Scoring systems are still valuable and valid for differential diagnosis of acute appendicitis (AA). Bedel Score is a new diagnostic tool with 7 parameters that can be easily applied. The aim of this study is to determine the diagnostic performance of the Bedel score in AA and compare it with the Alvarado score. Methods: Our study consisted of 95 patients as a prospective cohort who were admitted to our emergency department due to abdominal pain and were hospitalized with a preliminary diagnosis of AA. Bedel and Alvarado scores were calculated. The patients were categorized into two groups (positive and negative appendectomy) according to their histopathological diagnosis. Results: The study population consisted of 65 (68.4%) male and 30 (31.6%) female patients. The mean age of the patients was 34 (18-87) years. 81 (85.3%) of the patients had histopathologically confirmed AA. Median Alvarado score was significantly higher in patients with positive AA than those with negative AA (7 (range: 3-10) vs. 5 (range 3-7), p&lt;0.001, respectively). Median Bedel score of positive AA patients were also significantly higher than those with negative AA (9 (range: 6-10) vs. 5 (range 2-8) p&lt;0.001, respectively) In separating acute appendicitis from negative exploration, the threshold of the Alvarado score is 63% sensitivity for ?7, 85.7% specificity; The Bedel score had 80.2% sensitivity and 92.9% specificity for the threshold value ?7. Conclusion: Bedel score is fast, simple, easy to learn and apply, as well as an effective and practical scoring system with only 7 parameters. Keywords: Acute appendicitis, Alvarado score, New score, Negative appendectomy

Management of solitary cecum diverticulitis - Single-Center Experience.

&lt;b&gt; Objective: &lt;/b&gt; Cecal diverticulitis may be encountered as a real etiological factor in 1/300 appendectomies. Differential diagnosis of acute appendicitis and cecal diverticulitis is crucial because of the different treatment methods. Our aim is to reveal the importance of distinguishing acute appendicitis from cecal diverticulitis. &lt;p&gt; &lt;b&gt;Methods: &lt;/b&gt; The data of patients who were admitted to the hospital between 2015 and 2019 with the complaint of abdominal pain and then finally diagnosed with colon diverticular disease, colon diverticulitis, or acute appendicitis, analyzed retrospectively. &lt;p&gt;&lt;b&gt;Results: &lt;/b&gt; A total of 19 cecum diverticulitis patients were detected during surgery for acute appendicitis or during clinical and radiological evaluation. 1247 appendectomies were evaluated; the final diagnosis was observed as cecal diverticulitis in 5 patients (0,4%). One hundred nineteen patients diagnosed with colonic diverticulitis at admission were evaluated, while 105 (88,2%) of them had left-sided diverticulitis, 14 (11,7%) of them had solitary cecal diverticulitis. All of the solitary cecal diverticulitis patients were treated conservatively, except one patient who has Hinchey 3 diverticulitis.&lt;p&gt;&lt;b&gt; Conclusion: &lt;/b&gt; Differential diagnosis of cecum diverticulitis with acute appendicitis is important because cecum diverticulitis can be managed as conservatively in most cases. In order to prevent unnecessary surgical interventions, this importance has increased, especially during the COVID-19 pandemic period.

Acute Mesenteric Lymphadenitis, A Differential Diagnosis of Acute Appendicitis in Adults Also: Case Report

Acute Mesenteric Lymphadenitis, A Differential Diagnosis of Acute Appendicitis in Adults Also: Case Report

Discovery of Urinary Proteomic Signature for Differential Diagnosis of Acute Appendicitis.

Acute appendicitis is one of the most common acute abdomens, but the confident preoperative diagnosis is still a challenge. In order to profile noninvasive urinary biomarkers that could discriminate acute appendicitis from other acute abdomens, we carried out mass spectrometric experiments on urine samples from patients with different acute abdomens and evaluated diagnostic potential of urinary proteins with various machine-learning models. Firstly, outlier protein pools of acute appendicitis and controls were constructed using the discovery dataset (32 acute appendicitis and 41 control acute abdomens) against a reference set of 495 normal urine samples. Ten outlier proteins were then selected by feature selection algorithm and were applied in construction of machine-learning models using naïve Bayes, support vector machine, and random forest algorithms. The models were assessed in the discovery dataset by leave-one-out cross validation and were verified in the validation dataset (16 acute appendicitis and 45 control acute abdomens). Among the three models, random forest model achieved the best performance: the accuracy was 84.9% in the leave-one-out cross validation of discovery dataset and 83.6% (sensitivity: 81.2%, specificity: 84.4%) in the validation dataset. In conclusion, we developed a 10-protein diagnostic panel by the random forest model that was able to distinguish acute appendicitis from confusable acute abdomens with high specificity, which indicated the clinical application potential of noninvasive urinary markers in disease diagnosis.

Tiyol / Disülfit dengesinin değerlendirilmesi çocuklarda apandisitin ayırıcı tanısında yardımcı olabilir mi?

Objective: We aimed to investigate the potential of assessing thiol/disulfide homeostasis as novel oxidative stress markers to improve the challenging diagnosis of acute appendicitis in children. Materials and Methods: A total of 60 pediatric patients (0-18 years) were enrolled in the study, 30 of which were in the control group and 30 in the acute appendicitis group. Native thiol, total thiol, dynamic disulfide, dynamic thiol, ischemia modified albümin, albumin, White blood cell, hemoglobin, hematocrit, and platelet counts of both groups were measured. The results of both groups were compared using the SPSS (Statistical Package for Social Sciences) version 17 (Chicago, USA) program. For all variables, p <0.05 was considered significant. Results: Total thiol (p<0.001), native thiol (p<0.001), and albümin (p<0.001) levels were significantly decreased while dynamic disulfide, dynamic thiol (p=0.003), and ischemia modified albümin (p<0.001) levels those indicating oxidant sides were increased in the acute appendicitis group compared to control. White blood cell counts in acute appendicitis group were higher (p<0.001), and platelet counts were lower (p=0.03) than the control group. Conclusion: In the differential diagnosis of acute appendicitis, especially in cases that are difficult to diagnose , besides a physical examination, imaging, and current laboratory tests, quantification of thiol/disulfide homeostasis may be helpful in diagnosing. In addition, evaluating albumin and IMA levels may increase the specificity of the test. This test can be more helpful in case diagnosis is difficult such as children small in their ages and mental retardation.