Gangrenous Appendicitis Research Articles

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.

Treatment of Superior Mesenteric and Portal Vein Thrombosis with Direct Thrombolytic Infusion via an Operatively Placed Mesenteric Catheter

Acute superior mesenteric vein (SMV) and portal vein (PV) thrombosis can be a complication of hypercoagulable, inflammatory, or infectious states. It can also occur as a complication of medical or surgical intervention. Management of mesenteric and portal vein thrombosis includes both operative and nonoperative approaches. Operative interventions include thrombectomy with thrombolysis; this is often employed for patients who present with signs of peritoneal irritation. Nonoperative approaches can be either noninvasive or invasive. Treatment with anticoagulation has been shown to be efficacious, though its rate of recanalization is not as high as with intravascular infusion of thrombolytics. Intravenous catheterization and thrombolytic infusion has the advantage of direct pharmacologic thrombolysis of clot, with decreased infusion required and the possibility to carry out dilation or thrombectomy concurrently. We report the use of recombinant tissue-plasminogen activator (rt-PA) infusion via an operatively placed multi side-hole catheter/5-Fr introducer sheath into the right portal and superior mesenteric vein clot, inserted through a small jejunal vein, in a patient who presented with acute gangrenous appendicitis and thrombosis of the main portal trunk and superior mesenteric vein. A temporary abdominal closure was maintained until 36 hours after the start of infusion of the rt-PA. At this time venous system had normal flow, with complete recanalization of the right portal and superior mesenteric veins.

Investigation and treatment of myocardial ischaemia in critical care.

A 49-year-old man required a prolonged intensive care unit (ITU) stay for sepsis and multiorgan failure (MOF) following a laparotomy for gangrenous appendicitis. He had a history of myocardial infarction and previous coronary stent insertion. During attempts to wean from mechanical ventilation during his second week in ITU, he developed unstable angina associated with bradyarrhythmias and complete heart block.

The value of 5-hydroxy indole acetic acid measurement in spot urine diagnosis of acute appendicitis

To assess the role of 5-Hydroxy Indole Acetic Acid (5-HIAA) levels in spot urine in diagnosis of acute appendicitis. A prospective, controlled study. Ankara Numune Teaching and Research Hospital, Ankara, Turkey. Twenty six patients with histologically proven acute appendicitis following appendectomy were included in the study. Control group with consisted of patients prepared for hernia repair in the same duration. In the preoperative period, urine samples were collected from every patient for measurement of 5-HIAA. The study group comprised 26 patients; 15 of those had high urine 5-HIAA levels, whereas 11 patients had values within normal range. None of ten control patients displayed positive test result. The test had 58% sensitivity and 48% specificity. In histopathological examination only two of ten patients with gangrenous appendicitis showed positive test result, whereas 13 of 16 patients with no histopathological gangrenous changes had high values. Urine 5-HIAA measurement has low sensitivity and specificity. The value of the test is even clearly lower in gangrenous appendicitis. This may be misleading in management of patients in late phase of appendicitis and in cases with perforation which is mainly responsible for morbidity.

Septicémie à Streptocoque du groupe milleri et appendicite aiguë de l'enfant

The authors report a post-appendectomy septicemia due to Streptococcus milleri group occurring with metronidazole antibiotherapy diagnosis delay is possible with diarrhoea observed in childhood complicated appendicitis Streptococcus milleri group can develop postoperative sepsis despite antibiotherapy. They recommend associative and synergetic antibiotherapy in childhood gangrenous appendicitis to prevent a possible septicaemia due to Streptococcus milleri group.

A Case of Necrotizing Fasciitis Caused by Acute Gangrenous Appendicitis

A Case of Necrotizing Fasciitis Caused by Acute Gangrenous Appendicitis

Contrast-enhanced power Doppler US in the diagnosis of acute appendicitis

Introduction/ objective: To determine the value of power Doppler (PD) ultrasonography (US) and contrast-enhanced power Doppler (CEPD) US in the diagnosis of acute appendicitis and the prediction of histopathologic stages. Methods and material: 50 patients with suspected acute appendicitis were evaluated by the same radiologist with PD US and CEPD US. Air micro bubbles stabilized by a granulate of “galactose and palmitic acid” were used as a contrast medium for sonography with the concentration of 400 mg/ml. PD US and CEPD US results were later correlated with the surgical and histopathologic findings. PD US and CEPD US findings were considered positive for appendicitis; if there was depiction of hyperemia in the wall of the appendix or if there was depiction of prominent peripheral vascularity when compared with normal soft tissues; and negative if both hyperemia and peripheral hyperemia were not prominent. Results and discussions: Of the 50 patients, 35 patients had histopathologically proven acute appendicitis. CEPD US showed prominent hyperemia in the appendiceal vessels or feeding vessels of the inflamed appendix, and resistance index (RI) calculations were easier. There was statistically significant difference between mean RI values of the normal appendix, suppurative appendicitis and gangrenous appendicitis. PD US has accuracy of 80%, sensitivity of 74% and CEPD US has 98%, and 100% in the diagnosis of acute appendicitis. CEPD US identified 100% of suppurative appendicitis and gangrenous appendicitis. Conclusion: CEPD US is a promising method in the diagnosis of acute appendicitis and determination of the inflammation stage.

Transvaginal sonography in the diagnosis of acute appendicitis.

To evaluate transvaginal sonography with power Doppler capacity in the diagnosis of acute appendicitis and in discriminating appendicitis from pelvic inflammatory disease. We describe transvaginal sonographic findings of six women with acute appendicitis selected from 31 women seen in an emergency room setting for clinically suspected pelvic inflammatory disease. The study population underwent gray-scale transvaginal sonography, and specific sonographic landmark findings for acute appendicitis and pelvic inflammatory disease were used. Hyperemia of any infectious complex was identified by power Doppler. Laparoscopy was performed after transvaginal sonography and was used as the gold standard. Laparoscopy showed acute appendicitis in six (19%) of the 31 patients. A thick walled non-compressible gas-containing tubular structure with a diameter exceeding 6 mm was seen by transvaginal sonography in four of the six cases, consistent with uncomplicated appendicitis. A heterogeneous complex with surrounding hyperechogenic soft tissue was seen in two cases with gangrenous appendicitis. Power Doppler detected hyperemia in all six cases. Normal adnexal structures were imaged next to the inflamed appendix. The sonographic criteria consistent with acute appendicitis were clearly different from those of acute pelvic inflammatory disease. Transvaginal sonography provides an opportunity to distinguish between appendicitis and acute pelvic inflammatory disease. Prospective trials are needed in order to evaluate the impact of transvaginal sonography in the diagnosis of acute appendicitis.

Identification by 16S ribosomal RNA gene sequencing of Arcobacter butzleri bacteraemia in a patient with acute gangrenous appendicitis

Aims: To identify a strain of Gram negative facultative anaerobic curved bacillus, concomitantly isolated with Escherichia coli and Streptococcus milleri, from the blood culture of a 69 year old woman...

Helicobacter pylori infection in patients undergoing appendectomy.

Helicobacter pylori has been found in the upper gastrointestinal tract; it is incriminated as aetiological factor in various pathological conditions. This prospective study assesses the presence of this microorganism in the appendix flora and the possible role of its infection in the pathogenesis of acute appendicitis. H. pylori was investigated in 46 consecutive patients undergoing emergent appendectomy for presumed acute appendicitis. Blood sample for serological test of H. pylori infection was drawn before operation. The removed appendix specimen was stained for H. pylori; confirmation was made by PCR (Polymerase Chain Reaction) analysis. The intensity of inflammation was determined pathologically grading from no inflammation to gangrenous appendicitis. Statistical analysis was made using the chi-square test. Seropositivity for H. pylori infection was found in 18 patients (39%), but the microbe was detected in just two appendix specimens (4%). In all seropositive patients acute appendicitis was confirmed by the pathology study; serous (33%) and purulent or gangrenous (67%). The latter incidence in the seronegative patients was 50%. There were found eight specimens (17%) negative for inflammation dealing all with seronegative patients. It seems that H. pylori colonizes the appendix in small proportion and is unlikely to be associated in direct correlation with acute appendicitis. However, seropositive patients with acute inflammation are likely to suffer from purulent or gangrenous form.

Laparoscopic appendectomy in children: A favorable alternative in simple and complicated appendicitis

Background/Purpose: The laparoscopic treatment of pediatric appendicitis remains controversial, particularly in complicated cases (gangrene and perforation). This study evaluates outcomes of open (OA) and laparoscopic appendectomy (LA). Methods: The 391 cases of pediatric appendectomy performed between January 1998 and January 2001 were reviewed for age, sex, weight, type and length of intervention, operative description, antimicrobial therapy, analgesia, complications, length of hospitalization, and histopathology. Results: A total of 126 patients were operated on by laparoscopy, 262 by laparotomy, and there were 3 conversions (LA + OA). LA patients were older (11.9 v 9.6 years; P <.001) and more frequently girls (57.1% v 38.2%; P =.0004). LA took longer to perform (45.7 v 40.6 minutes; P =.0014). Operatively, 24.6% of LAs were described as complicated compared with 22.5% in OA. Narcotic use was equivalent in both groups (1.16 v 1.29 days; P =.434), as was the incidence of complications, either operative (1.6% v 0.4%; P =.20) or postoperative (10.3% v 8.02%; P =.32). Hospitalization was shorter in LA (2.38 v 2.94 days; P =.0131). Histopathology was negative in 21.4% of LAs compared with 13% of OAs (P =.032). Conclusions: Laparoscopic appendectomy does not increase the incidence of complications, even with gangrenous or perforated appendicitis. The length of intervention is prolonged by 5 minutes on average. This technique allows for a shorter hospitalization. J Pediatr Surg 37:695-698. Copyright 2002, Elsevier Science (USA). All rights reserved.

ASC, which is composed of a PYD and a CARD, is up-regulated by inflammation and apoptosis in human neutrophils

ASC is an adaptor protein that is composed of two protein–protein interaction domains, a PYRIN domain (PYD), and a caspase-recruitment domain (CARD). Recently, ASC was identified as a binding partner of pyrin, which is the product of MEFV, a gene causing familial Mediterranean fever (FMF). Mutations in MEFV result in defects in control of neutrophil-mediated inflammation. Thus we focused on the expression of ASC in neutrophils. Immunohistochemical study showed that ASC is increased in neutrophils in severe inflammatory sites of gangrenous appendicitis. We, then, tested whether proinflammatory mediators induce ASC using peripheral blood neutrophils in vitro. ASC expression was transiently up-regulated by IL-1α, IL-1β, IFN-α, IFN-γ, TNFα, and LPS. ASC was also increased by incubation with either anti-Fas antibody or recombinant soluble Fas ligand. The Fas-mediated induction of ASC was inhibited by a general caspase inhibitor, z-VAD-fmk, and an immunocytochemical study showed that ASC was increased in neutrophils exhibiting characteristic phenotypes for apoptosis. These findings suggest that up-regulation of ASC is closely associated with inflammation and apoptosis in neutrophils.

Comparison of open and laparoscopic treatment of acute appendicitis

Background: Appendectomy can be performed using either a laparoscopic or an open technique. This study compares the outcome of patients treated for acute appendicitis by open appendectomy with the outcome of those undergoing laparoscopic appendectomy. Methods: Patients undergoing appendectomy at The Mount Sinai Hospital between 1994 and 1998 were studied. Outcome of patients having open appendectomy was compared with that of patients having laparoscopic appendectomy. Results: Seven hundred fifty-eight patients underwent appendectomy for acute appendicitis during the 5-year study period. Two hundred seventy-one (36%) had open appendectomy and 487 (64%) had laparoscopic appendectomy. Patients subsequently found to have a normal appendix had the highest rate of laparoscopic appendectomy, whereas those with gangrenous appendicitis were most likely to have open appendectomy ( P <0.05). There was a significant decline in the postoperative length of stay for open cases during the length of the study. In the final year, the difference in length of stay between open and laparoscopic appendectomy was only 1 day. Patients with gangrenous appendicitis had a significantly longer length of stay than did patients with a normal appendix or suppurative appendicitis. The hospital cost of laparoscopic appendectomy was greater than that for open appendectomy but the extra expenditure in the operating room was offset by the longer length of stay of the patients having open surgery. Conclusions: Differences in outcome between open and laparoscopic appendectomy are minor. In this study, more difficult cases with gangrenous appendicitis were more likely to require open appendectomy whereas milder forms of appendicitis, especially in women, were more likely to be treated by laparoscopy. Savings from the slightly shorter hospital stay after laparoscopic appendectomy are offset by the higher surgical cost of the laparoscopic equipment.

Intra-abdominal abscess after laparoscopic appendectomy for perforated appendicitis.

The incidence of postoperative intra-abdominal abscess is higher after laparoscopic compared with open appendectomy for perforated appendicitis. A historical cohort study of pediatric patients operated on for suspected appendicitis by open appendectomy or laparoscopic appendectomy compares the incidence of postoperative intra-abdominal abscess for each procedure. A tertiary care center. Five hundred thirty-eight pediatric patients were operated on for suspected appendicitis at our institution between 1974 and 1999. Of these, 453 were included in the study. Of the excluded patients, 9 had incomplete medical records, 69 had normal or interval appendectomies, and 7 had appendixes removed by methods other than laparoscopy or right lower quadrant incision. Open appendectomy performed through a right lower quadrant incision or laparoscopic appendectomy performed through a 3-trocar approach by 1 of 3 pediatric surgeons at our institution. The incidence of postoperative intra-abdominal abscess after laparoscopic vs open appendectomy. In perforated appendicitis (170 patients), the incidence of postoperative abscess after laparoscopic appendectomy was 24% vs 4.2% after open appendectomy. The relative risk ratio of developing a postoperative abscess after perforated appendicitis was 5.6 (confidence interval, 2.1-16.0) after laparoscopic vs open appendectomy. The results remained significant when controlled for age, sex, intraoperative irrigation, and preoperative antibiotics. Postoperative abscess in all acute, gangrenous, and perforated appendicitis after laparoscopic appendectomy was 6.4% vs 3.0% after open appendectomy. This was not statistically significant. There is a significant increase in the incidence of postoperative intra-abdominal abscess with perforated appendicitis after laparoscopic compared with open appendectomy in pediatric patients.

Intraabdominal abscess rate after laparoscopic appendectomy

Background: Studies suggest increased intraabdominal abscess (IA) rates following laparoscopic appendectomy (LA), especially for perforated appendicitis. Consequently, an open approach has been advocated. The aim of our study is to compare IA rates following LA performed by a laparoscopic surgery and a general surgical service within the same institution. Methods: Data of LA patients treated at Los Angeles County-University of Southern California (LAC-USC) Medical Center between March 1992 and June 1997 were reviewed. The main outcome measure was postoperative IA. Results: In all, 645 LA were reviewed. A total of 413 LA (285 acute, 61 gangrenous, 67 perforated appendicitis) were performed by three general surgical services (10 attendings). Ten abscesses occurred postoperatively (2.4%), 6 with perforated appendicitis. After the laparoscopic service was introduced, 232 standardized LA (126 acute, 46 gangrenous, 60 perforated) were performed by two attendings. One IA occurred (gangrenous appendicitis). The IA rate for perforated appendicitis was significantly lower on the laparoscopic service ( P = 0.025). There was no difference in IA rates for acute and gangrenous appendicitis. There was no mortality in either group. Conclusion: IA rate following LA for perforated appendicitis was significantly reduced on the laparoscopic service. Mastery of the learning curve and addition of specific surgical techniques explained this improved result. Therefore, laparoscopic appendectomy for complicated appendicitis may not be contraindicated, even for perforated appendicitis.

Complicated Appendicitis: Is There a Minimum Intravenous Antibiotic Requirement? A Prospective Randomized Trial

The proper duration of postoperative intravenous (IV) antibiotics in patients suffering complicated (perforated or gangrenous) appendicitis is debatable. Some advocate a set minimum number of IV antibiotic days whereas others discontinue IV antibiotics depending on the patient's clinical course regardless of the length of therapy. Our objective was to determine whether there are differences in morbidity and resource utilization between the two treatment methodologies. Ninety-four patients with intraoperative findings of complicated appendicitis were included. In all patients IV antibiotics were discontinued on the basis of clinical factors. However, Group 1 patients were given a minimum 5-day IV antibiotic course whereas Group 2 patients had no minimum IV antibiotic requirement. Group 1 patients received more IV antibiotics than Group 2 patients did (5.9 vs 4.3 days; P = 0.014). Infectious complications were not statistically different between the two groups (13.0% in Group 1 and 12.5% in Group 2). Average hospital stay was also not statistically different between the two groups. The data suggest that a protocol with no minimum IV antibiotic requirement in patients with complicated appendicitis does not increase morbidity. Furthermore, the protocol arm with no minimum IV antibiotic requirement led to less IV antibiotic use but did not significantly decrease hospital stay.

Antibiotic prophylaxis for appendectomy in children: critical appraisal.

Prophylactic antibiotics are widely used during surgery, above all for clean-contaminated or contaminated procedures. Because factors other than the degree of contamination play a critical role in regard to postoperative infectious complications, it is not evident that recommendations for antibiotic prophylaxis for an adult population can be transferred to children. The aim of the study was to analyze the incidence of postoperative infections in children undergoing appendectomy for suspected appendicitis to evaluate critically the effectiveness of prophylaxis. The charts of all children undergoing appendectomy between 1988 and 1998 were analyzed. In general, appendectomies were performed without antimicrobial prophylaxis. If a perforated appendicitis was found at operation, antibiotics were given intraoperatively. Postoperative infectious complications were defined as wound infections, intraabdominal infections, or prolonged postoperative pyrexia. During the study period of 10 years, 954 patients underwent appendectomy. In 24% of cases the appendix was perforated. Patients received prophylactic antibiotics at the surgeon's discretion. These patients were excluded from further analysis. Among those with non-perforated appendicitis (n = 633), Infectious complications occurred in 19 (3%). Analyzing subgroups according to histologic diagnosis, the incidence was 4.2% (16/382) for gangrenous appendicitis and 1.2% (3/251) for simple appendicitis or normal appendix. These figures are clearly lower than those reported from an adult population, indicating that results from adults cannot a priori be transferred to children, and that general recommendations concerning antimicrobial prophylaxis must be considered carefully for this age group.

Recent Onset of Abdominal Pain in a Patient With Advanced Breast Cancer

Abdominal pain is a frequent complaint heard in medical practice. For palliative care patients, there are numerous causes of abdominal pain. Because of the non-invasive nature of palliative care practice, emphasis is made on minimal investigations. We present a case of a 49-year old patient who developed progressive abdominal pain and was found to have gangrenous appendicitis. The patient underwent surgery and was able to be discharged home. Our findings suggest that any new pain in a cancer patient must be carefully evaluated. Because of the presence of opioid analgesics and corticosteroids, symptoms can be less severe and related to diagnosis in palliative care patients.

Appendicitis during pregnancy

In order to diagnose appendicitis more precisely, and earlier during pregnancy, we reviewed Ž 15 cases in the last 17 years in our hospital Table . 1 . The ratio of appendectomy during pregnancy was approximately 1:1000. Abdominal pain was the only common symptom in all cases. At first, after the onset of pain, the patients visited various doctors, e.g. other clinicians or obstetricians, or came to our obstetrician or emergency department. In the 14 acute cases, body temperature Ž . BT was 37.28C on average. The mean WBC was 16 400rmm. Appendectomy was performed at a mean time of 19 h from the onset of pain. Nine cases were phlegmonous appendicitis without perforation and four were gangrenous appendicitis with perforation. However, there were no differences between the patients in BT, WBC, CRP, or the onset of pain-to-operation time. One report notes that in the case where the

Appendicitis: Why So Complicated? Analysis of 5755 Consecutive Appendectomies

A perceived high rate of complicated (gangrenous or perforated) appendicitis, despite advances in laboratory and radiographic diagnostic modalities, prompted a review of our experience with appendicitis followed by a prospective analysis that examined the time course from presentation to definitive treatment in 218 consecutive patients. In 5755 appendectomies, our overall rate of complicated appendicitis was 32 per cent; higher in males, in the young, and in the elderly; and relatively stable over each year reviewed. Prospectively, we determined that of the various time intervals, the time from the onset of symptoms to first seeking medical attention is the only significant predictor of complicated appendicitis (39.8 vs 16.5 hours for acute appendicitis). On the other hand, the time from surgical evaluation to operative intervention was significantly shorter for complicated appendicitis (3.8 vs 4.7 hours for acute appendicitis). The high rate of complicated appendicitis with its subsequent sequelae of increased morbidity and resource expenditure is primarily the direct result of patient delay in seeking medical attention and not the result of diagnostic dilemma or surgical delay. Public education, specifically targeting those groups at risk, may provide a substantial and significant solution to the complicated appendix.