Granulomatous Appendicitis Research Articles

APPENDICITIS INFLAMMATORY RESPONSE SCORE FOR DIAGNOSIS OF ACUTE APPENDICITIS AS COMPARED TO ALVARADO SCORE

Background: Acute appendicitis was first described by Reginald. H. Fitz in 1886. It is the most frequent cause of acute abdominal pain requiring surgical intervention. Annually appendectomy is the most common abdominal operation performed on emergency basis. Lifetime risk for developing acute appendicitis is 8.6% in men and 6.7% in women. Acute Appendicitis inciting event in most instances is obstruction of the appendix lumen. Acute Appendicitis is classified as catarrhal phlegmonus, gangrenous and perforated. This classification describes the evolutionary stage of disease. Acute appendicitis is more of a clinical diagnosis present as pain abdomen with classical migration from peri-umbilical region to right iliac fossa in 75% of patient nausea and anorexia. Clinical signs are mostly pyrexia, localized tenderness in the right iliac fossa, muscle guarding and rebound tenderness. Laboratory and radiological investigation are also important tool for the diagnosis. Scoring system have been designed to aid in the clinical assessment of patient with acute appendicitis. The most used scoring is the Alvarado score is best performing in validation studies. Alvarado score doesnt incorporate C reactive protein as a variable, many studies shows the importance of C reactive protein in assessment of patient with appendicitis. Objective: Appendicitis Inflammatory Response score as a diagnostic tool for acute appendicitis in our hospital setting. Study design: A Prospective Study. Study period: October 2016 – September 2018. Study setting: Department of General Surgery, Justice K. S. Hegde charitable hospital. Study population: Patients admitted with signs and symptoms of acute appendicitis at Justice K.S. Hegde charitable Hospital, Mangalore. Sample size: 123 patients using epiinfo software for diagnostic test with PPV 64% with article reference (12) confidence interval of 95% and power of study at 80%. Study group: Patients clinically diagnosed with acute appendicitis and giving consent for the study. Methodology: The present study was conducted in the Department of General surgery, Justice K.S. Hegde charitable Hospital Mangalore, in 123 patients, of any age, who were admitted with complaint of acute appendicitis. Patients included in the study were finally correlate with the histopathological report. Result: The maximum patients were in the age group of 11-20 year compromising around 30.9%. Most of the patients were female around 56.1%. Histopathological report showed around 82.1% as Acute appendicitis, 6.5% acute on chronic, recurrent appendicitis 8.9%, chronic appendicitis, granulomatous appendicitis & lymphoid hyperplasia of appendix were .8% each. AIR classified around 46.3% in low probability, 48% indeterminate and 5.7% in high probability group. Alvarado classified around 3.3% in unlikely, 51.2% in possible diagnosis, 37.4% acute and 8.1% in definite group. On spearman correlation coefficient there was found to be a strong positive correlation between both the scoring system and statistically significant p value of 0.0001. AIR score showed a sensitivity of 56.44% and specificity of 59.09% at score >4. Alvarado had a sensitivity of 98.02 % and specificity of 9.09% at score >4. Alvarado and AIR showed 9.90% and 6.93% at score >8 respectively. The specificity of Alvarado and AIR was 100% respectively. The AIR at a low and higher score had a high PPV and NPV, that may help in correctly diagnosing the patient with acute appendicitis and ruling out from non- appendicitis patient. Conclusion: 1. Alvarado score is better diagnostic tool for acute appendicitis as compared to the AIR score. 2. Alvarado score has higher sensitivity in score of >4 as compared to AIR. 3. AIR score with low sensitivity has low discriminatory power in ruling out patient with acute appendicitis.

P134 Pediatric granulomatous appendicitis, how can it be precursor of Crohn Disease?

Abstract Background Granulomatous appendicitis (GA) in pediatric age is an entity that is difficult to evaluate, diagnose, and may present with unexpected symptoms, and overlap with other diseases. Since there may be many different causes in its etiology, detailed histopathological examination with clinical correlation is very important. Our aims are to analyse detailed histomorphological features of GA in children, understand the etiology and investigate if it may be a precursor of inflammatory bowl disease (IBD) in the follow ups. Methods The detailed histopathology and etiology of pediatric and adult GA’s were evaluated retrospectively in two centers between 2016 and June 2022. All cases diagnosed with granulomatous appendicitis in the given date range were included in the study. Serological, radiological and histomorphological findings of the patients were evaluated within at least 6 months of follow-up and compared with adults. Results Of the 2144 pediatric appendectomy specimens, 25 (0.01%) were GA, 12(48%) of them are female and the mean age was 13.96. While interval appendicitis was the most common cause in GA etiology (n:12, 48%), IBD (n:5, 20%) was the second. 4 pediatric patients were diagnosed with Crohn Disease (CD) and one with Ulcerative Colitis in their follow-ups, none of the adults had IBD. During the follow-ups, mycobacteria was detected in the serology of one case, while actinomycesis was observed in the lumen of another. Crohn's disease may tend to involve the appendix more severely in younger patients. And it may present as the first finding of IBD. It is known that granulomas are more specific for Crohn's disease. In the detailed histopathological examination of cases, non-necrotizing granuloma structure is seen more frequently in CD. Besides, non-necrotizan type granulomas, mucosa involvement of the wall, accompanying exaggerated reactive lymphoid aggregates, and eosinophil count were more common in CD . Conclusion Granulomatous appendicitis may be more associated with IBD, especially in childhood patients than in adults. Detailed histopathological examination of CD-specific features can be alarming. However, when a case with GA is encountered, all conditions that may cause granulomatous inflammation should be ruled out serologically and radiologically, and system scanning should be performed very carefully before considering IBD.

Granulomatous AppendicitisA Rare Case Report

In 1953, Meyerding and Bertram were the first person to report non specific granulomatous inflammation in appendix. Granulomatous appendicitis is a rare condition which usually account to less than 2% of the cases, however idiopathic granulomatous appendicitis is very rare, and diagnosis is usually made by excluding all other conditions. It is challenging to diagnose tuberculous appendicitis based on clinical findings, hence histopathological examination is required. Hereby, authors report a case of 26-year-old male who presented with pain abdomen in the Department of Surgery. On imaging, appendix was thickened, and acute appendicitis was considered as a probable diagnosis. On histopathological examination, it was diagnosed as granulomatous inflammation suggestive of tuberculosis. The present case is presented for its rarity as appendicitis is considered as an abdominal emergency, so prompt management and diagnosis is required by excluding all other causes of granulomatous inflammation in appendix.

S2715 Clinical Correlation Recommended: Appendiceal Crohn’s Masquerading as Acute Appendicitis on CT

Introduction: Granulomatous appendicitis is uncommon, often caused by Crohn’s disease (CD), infiltrative disease (ie sarcoidosis), or infection (ie Yersinia). We report an unusual presentation of CD limited to the appendix. Case Description/Methods: A 46-year-old male with celiac disease presented to clinic for evaluation of intermittent epigastric and right upper quadrant (RUQ) abdominal pain occurring four times per year. When present, the pain was constant, pressure-like and gradually worsened over a three-day period. He denied nausea or vomiting, but reported non-bloody diarrhea with episodes. His symptoms persisted despite a gluten free diet and normalization of celiac serologies. In the clinic, he was afebrile with normal vital signs. Abdominal exam demonstrated mild tenderness to deep palpation of the RUQ. CT enterography demonstrated inflammation around his appendix, terminal ileum, and right ureter concerning for acute appendicitis (Figure). Given incongruity of his mild clinical presentation and chronicity of his symptoms, he underwent colonoscopy which showed inflammation of the appendiceal orifice, surrounding cecum, and distal rectum. Biopsies of the rectum and cecum demonstrated active inflammation without chronicity, with a normal terminal ileum. Due to evidence of active inflammation of unknown etiology, he underwent laparoscopic ileocecectomy with anastomosis. Pathology findings were consistent with moderately active Crohn’s colitis isolated to the appendix. He had no signs or symptoms of extra-intestinal manifestations of inflammatory bowel disease. Following surgery, his symptoms resolved and repeat CT six months later demonstrated resolution of inflammation. The patient remains asymptomatic without CD treatment. Discussion: Isolated appendiceal CD is a rare entity that is most often seen in men in their 20-30s. It typically presents with acute right lower quadrant pain, occasionally with diarrhea, lasting 0-14 days, but can become protracted. Our patient’s history and nontoxic exam did not fit acute appendicitis as initially suspected on CT scan, instead suggesting a chronic process such as CD. There is no consensus regarding surveillance and treatment of isolated appendiceal CD. Recurrence rates after appendectomy are low, suggesting that appendectomy alone is a sufficient treatment for isolated disease. It was therefore recommended that this patient return for further evaluation based on symptoms alone, rather than undergo surveillance.Figure 1.: CT Abdomen Pelvis Enterography with IV Contrast demonstrating appendiceal inflammation.

Interval appendicitis shows histological differences from acute appendicitis and may mimic Crohn disease and other forms of granulomatous appendicitis.

While patients presenting with clinical signs and symptoms of acute appendicitis (AA) often receive surgical intervention shortly after presentation, certain patients may instead receive non-operative management initially, with appendectomy later. The histology of such interval appendicitis (IA) has only been described in small series. Also, we have noticed a recent increase in the incidence of IA specimens at our institution. We identified appendectomy specimens in our department during 2018 with available haematoxylin and eosin slides and electronic clinical data, and evaluated multiple histological findings. Cases were then divided into AA and IA, based on clinical history (AA if the patient presented to the hospital within 1 week of symptom onset and underwent appendectomy within 48 h; IA if appendectomy was delayed at least 1 week). Changes between groups were compared. The cohort included 165 cases (125 AA, 40 IA). Findings significantly more common in AA included mucosal acute inflammation, mural acute inflammation and acute serositis. Findings significantly more common in IA included Crohn-like mural inflammation, mural fibrosis, goblet cell hyperplasia, granulomas, xanthogranulomatous inflammation, haemosiderin-laden macrophages and granulation tissue. The rate of IA in 2018 (24%) was noticeably higher than in previous years. Acute inflammatory changes are more common in AA but can remain present in IA. Mural fibrosis, serosal adhesions, haemosiderin-laden macrophages and granulation tissue suggest IA. Granulomas and xanthogranulomatous inflammation can also be seen in IA, and Crohn-like mural inflammation is not uncommon. These histological patterns can guide signout and prevent diagnostic errors, particularly when clinical information is unavailable.

EP.TU.435A Rare Case of Granulomatous Appendicitis

Abstract Granulomatous appendicitis is a rare form of appendicitis due to a variety of causes such a foreign body, fungi, parasites, mycobacteria, Yesinia, Crohn's pathology and delayed appendicectomy. Definitive diagnosis necessitates histopathological analysis. We present an unusual case of granulomatous appendicitis in a young gentleman, incidentally detected at histopathology, along with a brief literature review. Patient presented with a classical clinical history and examination findings suggestive of acute appendicitis and underwent an emergency laparoscopic appendicectomy, followed by an uneventful post-operative recovery. Histopathological examination showed features of acute on chronic transmural inflammation with epithelioid granuloma, confirming diagnosis of granulomatous appendicitis. We hereby, aim to emphasize the significance of increased awareness required among general surgeons and pathologists, as patients with granulomatous appendicitis needs to be investigated further due to the likelihood of them having an underlying Crohn’s disease or developing it in future.

English

BACKGROUND Appendix is considered as a vestigial organ in medical history. But recent studies reveal its importance in immunological function. Appendicectomy is one of the most common surgeries performed and acute appendicitis being the most frequent pathology noted. Various less common pathologies like parasitic infestation, granuloma, diverticulum, neoplasms are also described. In our institute, we have seen an increased rate of acute appendicitis and a relative increase in neoplastic conditions. The purpose of this study was histopathological evaluation of lesions of appendix over a period of five years and its association with demographic data. METHODS This cross-sectional study included all specimens received in the department of pathology with primary pathology in appendix. Appendix removed as a part of other surgical procedures were excluded. Relevant clinical data, gross findings and histopathological diagnoses were retrieved from pathology records and computer databases and statistical analysis was done using Statistical Package for Social Sciences (SPSS 16.0). RESULTS Out of the 576 cases, 485 (84 %) patients showed findings consistent with acute appendicitis on histopathological examination. Perforation rate was 4.86 % and was higher in male patients. Other pathologies include chronic appendicitis in 58 cases (10.06 %), eosinophilic appendicitis in one case (0.17 %), appendix with lymphoid hyperplasia in 14 cases (2.43 %), periappendicitis in 4 cases (0.69 %), fibrous obliteration of appendix in 2 cases (0.34 %), granulomatous appendicitis in 4 cases (0.69 %), appendix with lymphoid hyperplasia in 14 cases (2.43 %), diverticulitis in one case (0.17 %), tubular adenoma with low grade dysplasia in one case (0.17 %), neuroendocrine tumour in one case (0.17 %) and mucinous neoplasms in 5 cases (0.86 %). CONCLUSIONS The study supports routine histological examination of all the appendicectomy specimens to avoid missing of any clinically important condition which has significant impact on treatment and prognosis. Also noted an increased number of mucinous neoplasms suggesting the importance of future studies in this field. KEYWORDS Appendix, Acute Appendicitis, Chronic Appendicitis, Mucinous Neoplasms of Appendix, Diverticulitis

Crohn Disease Infrequently Affects the Appendix and Rarely Causes Granulomatous Appendicitis.

Data from previous studies suggest Crohn disease of the appendix accounts for ∼25% of granulomatous appendicitis cases. However, we have found that granulomatous inflammation in appendectomy specimens rarely heralds Crohn disease. We suspect that appendiceal involvement by Crohn disease is uncommon, even when patients have severe ileocolonic inflammation. We performed this study to determine the prevalence and nature of appendiceal inflammation among patients with Crohn disease. We reviewed 100 ileocolic specimens with strictures and fistulizing Crohn disease for the nature and distribution of inflammatory changes in the appendix and compared them with 100 appendices on colectomy specimens from age-matched and sex-matched patients with ulcerative colitis. We also evaluated 27 additional cases of granulomatous appendicitis in appendectomy specimens to determine the frequency with which this finding represented Crohn disease. The appendix was usually normal (26%) or showed fibrous obliteration (50%) in ileocolic resection specimens from patients with Crohn disease. Mucosal inflammation was much less common in appendices from patients with Crohn disease than ulcerative colitis (6% vs. 28%, P<0.0001); only 4 cases contained epithelioid granulomata, 3 showed mural fibrosis and lymphoid aggregates, and 10 displayed only periappendiceal inflammation. None of the patients with granulomatous appendicitis in appendectomy specimens had, or developed, evidence of Crohn disease. We conclude that Crohn disease infrequently affects the appendix. Interval appendectomy and infection are more important considerations when appendectomy specimens feature granulomatous inflammation and/or mural lymphoid aggregates, especially if there is no history of idiopathic inflammatory bowel disease.

Postoperative complicated appendectomy revealing Crohn’s disease in a pediatric patient

Granulomatous appendicitis is a very rare entity in children. It is related to Crohn’s disease in only 5-10% of the cases. The diagnosis of Crohn’s disease is a real challenge in the pediatric population, especially when its initial manifestation is acute appendicitis. Herein, we present a 13-year-old boy admitted for acute appendicitis. The histopathological examination was conclusive for acute granulomatous appendicitis. The development of an entero-cutaneous fistula has complicated the postoperative evolution. The failure of the conservative management required ileocecal resection. The pathological examination revealed Crohn’s disease. The one-year follow-up on the patient din not reveal any complications. We strongly support the importance of the histopathological examination of the entirely removed appendix. Careful assessment of granulomatous appendicitis is needed in order to establish its possible etiology and to initiate the adequate treatment.

S2909 Granulomatous Appendicitis: Idiopathic or Prospective Crohn’s Disease?

INTRODUCTION: Isolated granulomatous inflammation of the appendix is a rare entity, identified histologically in < 2% of specimens, and typed into idiopathic granulomatous appendicitis (GA) and appendiceal Crohn’s disease (CD). Less than 10% of GA cases develop CD. CASE DESCRIPTION/METHODS: A healthy 26-year-old male was advised to seek care for computed tomography (CT) suggesting acute appendicitis, ordered to assess dysuria and right testicular and abdominal pain of 1-month duration. CT measured a dilated appendix extending to the seminal vesicle, with fecolith and fat stranding. Vitals were stable, abdomen benign, and labs normal. During appendectomy, an inflamed appendix was seen adherent to the bladder. An uneventful post-op period was followed by discharge home. Despite interval recovery, readmission for pain, vomiting, and diarrhea occurred on POD 10. Tachycardia was noted without fever. Abdomen was distended and generally tender. There was leukocytosis. CT found thickened jejunum with proximal dilation and air-fluid-levels. Jejunitis and obstruction resolved with conservative care, but evidence of GA (granuloma with giant cell, negative AFB and GMS stains) on recent pathology prompted testing for a broadened differential. There was denial of travel, ill contacts, personal and family history of CD, but admittance to colonoscopy a decade prior with findings of proctitis. Blood, urine, and stool cultures, as well as C. difficile and O&P were negative. CD, tuberculosis, fungal, and Coccidioides serologies were negative. Ileocolonoscopy found post-op cecal changes. Random ileocolonic biopsies resulted normal mucosa. With clinical stabilization, discharge home was planned. During follow-up visit, the patient declared return to normalcy, and thus declined investigations for CD. DISCUSSION: Causes of GA include infectious, systemic, and local reactions, but often remains elusive, as does a uniform approach to diagnosis and management. Omitted tests limit confidence in diagnosing idiopathic GA, and uncertainty in proper follow-up delays diagnosis of related conditions. Despite idiopathic labeling, we remain vigilant to alternate causes. The patient at first lacked acute infectious features, but as Yersenia is linked to ¼ of cases, serologic testing would be ideal to exclude infection and support idiopathic nature. Sub-acuity lends support to interval appendectomy as a cause. Lastly, a remote history of proctitis, in concert with enteritis on readmit, may hint at chronicity, and begs close follow-up for CD.Figure 1.: Histology showing presence of non-caseating granulomas in a background of lymphocytic inflammation in the appendiceal wall (x10).Figure 2.: Histology showing a giant cell in a granuloma in the appendiceal wall (x10).Figure 3.: Computed tomography of the abdomen and pelvis with IV contrast showing diffuse circumferential thickening of multiple distal jejunal loops.

Differential diagnosis of the granulomatous appendicitis: Retrospective analysis of 16 cases.

This study aims to present the usability of real-time polymerase chain reaction (PCR) and interferon-gamma release assay (IGRA) in the differential diagnosis of granulomatous appendicitis (GAp), especially in areas where tuberculosis (TB) is endemic. Sixteen patients underwent appendectomy with presumed diagnosis of acute appendicitis were retrospectively analyzed for histopathological diagnosis of GAp. Real-time PCR method was used to show the whether presence of DNA of the tubercle bacilli in paraffin-embedded tissue blocks. IGRA test was used to investigate whether tubercle bacilli- specific interferon gamma was present in peripheral blood. Sixteen patients (male: 10 female: 6) aged between 21 and 82 years were included in this study. All patients had acute appendicitis and three of them also had appendiceal perforation. Histopathologically, necrotizing granulomatous inflammation was detected in all appendectomy specimens. Acid-fast bacilli were not detected in any of the pathology slides stained with Ehrlich-Ziehl-Neelsen. Real-time PCR was studied in paraffin-embedded tissue blocks of all patients with GAp, but the TB bacilli DNA was amplified in only three patients. IGRA test was studied in peripheral blood samples of 12 patients with GAp and results were as follows: negative (n=9), positive (n=2) and indeterminate (n=1). We believe that the use of anamnesis, histopathological findings, tissue PCR, blood IGRA and clinical findings together are important for differential diagnosis of GAp, especially where TB is endemic. We also suggest that all appendectomy specimens should be sent to the laboratory for histopathological evaluation even if specimens appear macroscopically normal.

HISTOPATHOLOGICAL SPECTRUM OF APPENDICITIS IN A TERTIARY HEALTH CARE CENTER

INTRODUCTION: Appendix in a nger like projection situated just near the caecum. It is located in the right iliac fossa of the abdomen. The most common pathology which arises is appendicitis and is mostly treated surgically. Although appendix is considered to be a vestigial organ, it accounts for immune function upto some extent. OBJECTIVES: To study and analyse the various histopathological forms of appendicitis MATERIALS AND METHODOLOGY: A descriptive study was undertaken to analyse the different histopathological forms of appendicitis over a period of one year in the Department of Pathology, Government Medical College, Omandurar Government Estate. The acquired data was fed into Microsoft Excel and analysis was done. RESULT: A total of 100 specimens were analysed during the study period. Maximum number of cases (62% of cases) were reported amongst females. The most common age group which was affected was 9 years to 19 years. The most common histopathological form of appendicitis was analysed to be acute appendicitis (76% of cases) The statistical data for various histo pathological types of appendicitis are as follows Subacute appendicitis – 10 cases ; Acute appendicitis – 76 cases ; Chronic appendicitis – 13 cases ; Granulomatous appendicitis – 1 case. CONCLUSION: The incidence of appendicitis is higher in the second decade of life and is remarkably high amongst females. Among the pathological types, incidence of acute appendicitis is the highest and that is seen in the second decade of life

Granulomatous Appendicitis in the Pediatric Population.

The clinical significance of a diagnosis of granulomatous appendicitis (GA) is not well established in the pediatric population. Retrospective review of the etiology and histopathology of pediatric GA at 2 large pediatric institutions. Forty-three (0.4%) patients had GA at a median age of 12.1 years. Twenty-two (51%) had perforated appendicitis that was medically managed prior to interval appendectomy. Sixteen of 21 noninterval appendectomies were performed for clinically suspected acute appendicitis. Among them, 1 had Crohn's disease identified during surgery. None of the other patients had a subsequent diagnosis of inflammatory bowel disease (median follow-up of 4 weeks). There were significantly more cases with mucosal-only granulomas as well as fewer serosal granulomas in the noninterval appendectomy specimens than the interval specimens (P = .014). When performed, special stains for microorganisms did not contribute to clinical care. In the same time period, GA was seen in 6 (6%) of 94 bowel resections for Crohn's disease. GA is rare in pediatric patients, with interval appendectomy being the most common etiology and only rarely associated with Crohn's disease. Granulomas in interval appendectomies tend to be serosal-based. Special stains for infectious organisms in GA are of low diagnostic yield and have little impact on clinical management.

Appendix Bleeding with Painless Bloody Diarrhea: A Case Report and Literature Review.

Appendix bleeding is an uncommon clinical phenomenon. In this article, we reported a case of appendix bleeding with painless bloody diarrhea. With the analysis of clinical features, clinical examination, experimental test and literature review, we diagnosed that the appendix bleeding might be caused by granulomatous appendicitis. This successfully cured case might be a reference for later diagnosis and treatment of appendix bleeding with painless bloody diarrhea.

1618 TB or Not to Be: What’s Truly Going On?

INTRODUCTION: Granulomatous disease of the colon has a constellation of symptoms that is usually attributed to an inflammatory condition such as ulcerative or crohn's colitis. Generally, suspicion for Mycobacterium Tuberculosis (TB) or Mycobacterium Avium (MAC) colitis is low and diagnosis can be difficult. We present a case of abdominal pain in a young individual found to be MAC colitis. CASE DESCRIPTION/METHODS: Our patient was a 29-year-old male with history of hemorrhoids and appendectomy 1 month prior who presented with complaints of recurrent and diffuse abdominal pain. Patient stated the pain had been ongoing for the last two months, denying constitutional symptoms but endorsed alternating constipation and diarrhea with episodic blood in the stool for ten years. He denied any family history of inflammatory bowel disease or malignancy and recently immigrated from Pakistan 4 years ago. Physical examination only exhibited abdominal tenderness upon palpation. Review of pathology report from recent appendectomy showed granulomatous appendicitis suggestive of TB. Investigations revealed a positive beta-quantiferon with mild elevation of fecal calprotein, ASCA, and normal inflammatory markers. Stool studies were negative for infectious organisms but showed growth of acid-fast bacilli with Mycobacterium Avium Complex being isolated. CT scan of abdomen displayed extensive colitis of ascending colon and cecum with dilatation of the terminal ileum. Patient underwent colonoscopy revealing a polypoid mass in the cecum with biopsy consistent with prolapse of mucosa. DISCUSSION: Mycobacterium tuberculosis and Avium Complex are infections predominantly seen in immuno-deficient individuals and in those from developing countries. Diagnosis can be difficult because there are no specific symptoms for colonic infection and less than a quarter of cases have radiological evidence of active or healed pulmonary infection. TB infections of the abdomen comprises roughly 5% of worldwide TB infections with mycobacterium avium being the rarest. Predominatly infections in the GI tract are seen within the terminal ileum due to the bacilli’s affinity for lymphoid tissue with large colon infection being uncommon. Although, TB has been labeled “the great imitator,” other disease states such as MAC colitis may also present as possible IBD versus TB and a broader differential should be considered.

Role and Incidence of Parasitic Infection in Adult Egyptian Patients with Acute Appendicitis

Background: Appendicitis is the most important acute surgical condition of the abdomen, and appendectomy constitutes one of the most common surgical operations worldwide. Many factors can cause appendicitis but the intestinal parasitic infections are one of the most important causes. Objective: The present study aimed to evaluate and detect the role and incidence of various parasitic infections in appendectomy specimens from Egyptian adult patients with acute appendicitis attending the General Surgery Emergency room at Al-Azhar University Hospitals, Cairo, Egypt (Al-Hussein and Sayed Galal Hospitals). Patients and methods: The present study was carried out on 200 patients undergoing appendectomy with a provisional diagnosis of acute appendicitis during the period from December 2015 to November 2016. The removed appendices were fixed in 10% buffered formalin, sectioned, stained with H&E and examined for histopathological changes and presence of parasites. Stool examination was also done by direct smear, formol ether concentration techniques as well as CBC examination for all patients. Results: Stool examination revealed 120 (60%) out of the total 200 appendectomy patients were positive for parasitic infections, while CBC examination revealed leucocytosis among 167 (83.5%), and eosinophilia in 40 (20%) as well as anemia in 43 (21.5%) in all the studied patients. Histopathological examination revealed parasitic infections in 6 (3%) of appendectomy specimens. The presence of E. vermicularis worms and their eggs as well as Schistosoma ovawere observed in 4 (2%) and 2 (1%) of cases respectively. Features of acute suppurative appendicitis were observed in 143 (71.5%) of cases, of which, 98(49%) cases had luminal obstruction by fecalith and 45 (22.5%) showed patent lumen. Non suppurative appendicitis were presented in 57 cases (28.5%) which included lymphoid hyperplasia in 21 cases (10.5%) and neuronal hyperplasia in 6 cases (3%) as well as granulomatous appendicitis with features consistent with appendiceal Crohn’s disease (CD) in 30 cases (15%). Conclusion: The study concluded that parasitic infections constitute 3% of the surgically removed appendices where Schistosoma eggs and E. vermicularis (adults and eggs) were the parasites recorded. So differential diagnosis of parasitic infections in the etiology of acute appendicitis should be made properly which can save patients from a negative laparotomy, morbidity and even mortality.

Granülomatöz apandisitin basit laboratuar testleriyle ilişkisi. Kontrollü gözlemsel çalışma.

Aim: Granulomatous appendicitis (GA) is evaluated as different clinical situation from specific causes, and very rare. It is defined as the presence of granulomatous inflammation in the appendix. Its etiology can be infectious, or noninfectious. However its differentiation from tumor can be challenging with macroscopic appearance in the operation. In this study, we aimed to present a case series of GA cases, evaluate prediction and association of GA before surgery. Material and methods A descriptive study is designed. All appendectomies between 2007 and 2015 were reviewed. The patients who diagnosed with GA by histopathological evaluation constituted study group. The rest constituted the control group. Demographic data, complete blood count parameters (22 parameters for each) were recorded. Categorical variables were expressed as frequencies and percentages. Baseline characteristics were compared using the t-test and Mann-Whitney U test. Fisher’s exact test was used to compare categorical variables. The differences were considered statistically significant if the p value was less than 0.05 at a 95% confidence interval. Results During study period, 4570 patients were operated for acute abdomen with the presumptive diagnosis of acute appendicitis. Eight (0.2%) patients constituted study group. For control group sample size was calculated as 527 cases (95% power to show a 50% difference in the rate of the primary outcome, with a 2-sided type I error rate of 5%. Additional 142 to decrease errors). Demographic findings like age and gender didn’t show difference between the groups (p=0.499 and p=0.477, respectively). EOS# and EOS% were higher in study group than control group (p<0.0001 and p<0.0001, respectively). Logistic regression analysis showed that EOS% effect was significant with p of <0.0001, odds ratio of 0.522 and Nagelkerke R2 of 0.191. Conclusion Diagnosis of GA with macroscopic appearance in operation is a challenging for a surgeon. We found that EOS# and EOS% are associated with GA.

Incidental Findings in Routine Histopathological Examination of Appendectomy Specimens; Retrospective Analysis of 1970 Patients.

Diseases and tumors of the appendix vermiformis are very rare, except for acute appendicitis. This study aimed to examine rare findings in the histopathologic examinations of specimens of patients undergoing appendectomy due to the diagnosis of acute appendicitis. The files of 1970 patients undergoing appendectomy due to the diagnosis of acute appendicitis between March 2012 and March 2016 were retrospectively investigated. Rare findings were found in 59 (3%) patients, and these were evaluated in detail. Patients' age, gender, pathology reports, and postoperation follow-ups were recorded. The rare histopathological findings of 59 patients were examined. Of these, 31 were female (52.5%) and 28 were male (47.5%). The average age was 33.1±18.2years. The unusual findings were as follows: 16 fibrous obliteration, 11 Enterobius vermicularis, 2 schistosomiasis, 3 appendiceal neuroma, 2 granulomatous appendicitis, 1 Crohn's disease, 3 chronic appendicitis, 1 endometriosis, 2 hyperplastic polyps, 9 mucinous cystadenoma (+mucocele), 8 carcinoid tumors, and 1 lymphoma. All of the malignant tumors were localized in the distal end of the appendix, and all of the patients were treated with appendectomy. Patients with parasitic diseases also underwent anthelmintic treatment, while chemotherapy was administered to the patient with lymphoma. All of the patients diagnosed with malignancy were alive reported no problems at their follow-ups. Although all of the appendectomy samples were normal macroscopically, data from this study suggest that all specimens should be sent for routine investigation.

Unexpected pathological lesions of appendix: an analysis of 3000 surgical specimens from Sri Lanka

Background: Unexpected pathological lesions are not infrequent findings in surgical specimens of appendix. Appendiceal malignancies are commonly encountered as incidental lesions. Objective: To analyze the unexpected appendiceal pathological lesions encountered in surgical specimens in a sample of Sri Lankan patients. Methods: A retrospective review of 3000 consecutive appendicectomy specimens and appendices in colectomy specimens received at the Department of Pathology, Faculty of Medicine, University of Peradeniya from 2001 to 2014. Results: There were 2907 appendicectomy specimens and 93 colectomy specimens with an appendix. In appendicectomy specimens, there were 9 (0.3%) primary neoplasms of which 8 were malignant, 2 (0.06%) secondary carcinoma deposits, 7 (0.24%) endometriosis, 7 (0.24%) granulomatous inflammation, 2010 (69.1%) acute appendicitis and the rest (30%) were unremarkable. In the appendices of colectomy specimens, there were 4 (4.3%) primary neoplasms, all of which were malignant, 7 (7.5%) secondary carcinoma deposits, 1 (1.1%) granulomatous inflammation, 11 (11.8%) acute appendicitis and the rest (75.2%) were unremarkable. Of the 3000 specimens, 13 (0.4%) had a primary appendiceal neoplasm: 9 (0.3%) mucinous neoplasms, 3 (0.1%) NET G1 (carcinoids) and 1 (0.03%) sessile serrated adenoma. Of the mucinous neoplasms, 1 was an adenoma, 3 were low grade appendiceal mucinous neoplasms and 5 were adenocarcinomas. Caseous tuberculoid granulomata were present in 5/8 (62.5%) granulomatous appendicitis. Conclusions: The commonest unexpected finding in the appendicectomy sample was primary malignant tumours (0.3%) and the commonest malignant tumour group was mucinous neoplasms. Secondary adenocarcinoma is the commonest pathology in the appendices of colectomy specimens. Most granulomatous appendicitis cases were suggestive of tuberculosis.

Granulomatous appendicitis in children: A single institutional experience

Granulomatous appendicitis (GA) is a rare entity, mostly mentioned in adults. There have been anecdotal case reports describing GA in the paediatric population. This study was aimed at reviewing the cases of appendectomies to assess the incidence and characteristics of GA in children in a tertiary care University hospital. Records of children (<13 years age) with biopsy proven granulomatous lesions in the appendectomy specimen, treated during 1991-2011, were analysed. Data regarding demography, clinical presentation, radiological findings, intra-operative finding, histology, diagnosis and follow-up were recorded and descriptively analysed. Twelve out of 1150 (1.04%) appendectomies were biopsy proven GA. Male to female ratio was 8:4. Four had Yersinia enterocolitis, two had Crohn's disease (CD; one isolated Crohn's Appendicitis, one Ileo-cecal Crohn' with appendicitis) and five were idiopathic. Remaining one case, initially diagnosed as idiopathic GA, developed full blown ileo-cecal CD at 2 nd month post-operative. Age ranged between 4 and 11 years with inflammatory bowel disease (IBD) affecting older children and Yersinia, seen in younger children. Majority (10/12) remained asymptomatic at a maximum of 5 years of follow-up. Two patients had recurrent symptoms; one with sub-acute obstruction (2 years follow-up) and another with flaring of Crohn's ileitis (2 months follow-up). GA in children is a rare entity, with incidence of 1.04% and male preponderance in our series. Idiopathic causes were the most common followed by Yersinia enterocolitis and CD. Although majority remained asymptomatic, IBD should be ruled out in case of recurrence of pain or alteration of bowel habit. Therefore, a long-term follow-up (at least for 5 years) of idiopathic GA is suggested in children.