Iliac Fossa Tenderness Research Articles

EP376 - Portal Pyaemia and Fungal Septicaemia Associated with Mesenteric Venous Pneumatosis - Improving Patient Outcomes

Abstract An 82 year old female presented to A&E with a 1 week history of lower abdominal pain, fever, and nausea. She had a known history of sigmoid diverticulosis, however had not had any previous abdominal surgery, and had no other past medical history of note. At presentation she was in septic shock, requiring vasopressor support to maintain her blood pressure. Her abdominal examination revealed left iliac fossa tenderness, however no features of peritonism. Initial investigations revealed a White Cell Count (WCC) 49.3x10^9/L, a C-Reactive Protein (CRP) 191mg/L, and an ALP of 434IU/L. A CT scan of the abdomen and pelvis confirmed acute sigmoid diverticulitis, with radiological features suggesting gas tracking along the inferior mesenteric vein (IMV). An emergency Hartmann’s procedure was performed, and intra-operatively pus was evidence draining directly from the IMV. Pre-operative blood cultures and intra-operative tissue cultures grew Escherichia coli, for which the patient was treated with intravenous meropenem post-operatively. She was transferred to Intensive Care Unit and stepped down to the ward on post-operative day 5. Within the first 48 hours post-operative, the WCC had risen to 64x10^9/L, however within 72 hours of commencing anti-fungals, this dramatically decreased to 16x10^9/L. After this, her recovery was swift, and was discharged shortly after. In the context of acute diverticulitis, any radiological evidence of gas within the portal venous system is likely secondary to portal pyaemia. Urgent operative intervention for source control remains the mainstay of management, with consideration of anti-fungals imperative.

Different Recent Scoring Systems for Better Diagnosis of Acute Appendicitis

Abstract Background Acute appendicitis is one of the most common surgical emergencies, with a lifetime prevalence rate of approximately one in seven. Aim of the Work to compare RIPASA score, (AIR) score and Modified Alvarado Score widely and easily used scoring systems, in order to identify which one is the best in sensitivity, specificity, positive predictive value, negative predictive value and accuracy, So which one leads to the most accurate diagnosis of acute Appendicitis. Patients and Methods A randomized prospective study that was conducted in Ain-Shams University Hospitals. The study started in February 2022 till the number of cases is fulfilled. 50 patients presented with RT iliac fossa tenderness. Each patient was scored by the three scoring systems using history, examination, clinical labs. Results 66.0% of cases were positive confirmed histology and (34.0%) cases were negative confirmed histology. There were highly statistically significant difference between Negative Confirmed histology and Positive Confirmed histology regarding RIPASA score, (AIR) score and Modified Alvarado Score. In this study, receiver operating characteristic curve (ROC) shows that the best cut off point of Modified Alvarado Score to detect Positive Modified Alvarado Score group was found >5 * with sensitivity of 87.88%, specificity of 64.71%, PPV of 82.9%, NPV of 73.3% and total accuracy of 77.0%. Conclusion the Appendicitis Inflammatory Response score and Raja Isteri Pengiran Anak Saleha Appendicitis score have high discriminating powers and outperform the Modified Alvarado score. They could aid in selecting patients who require timely surgery or those who require further evaluation. Both these scores have the potential to turn out into scoring systems of choice if future research can substantiate our study findings.

Low-grade Appendiceal Mucinous Neoplasm in a Middle-aged Female: A Case Report

Mucinous Appendiceal Neoplasms (MANs) are rare tumours where more than 50% of the tumour volume is composed of extracellular mucin. Low-grade Appendiceal Mucinous Neoplasm (LAMN) is a rare condition with symptoms that vary depending on clinical manifestations. It can manifest as an unruptured mucin-filled appendix, transmural invasion of the primary tumour, or present with peritoneal metastases post-rupture. The prognosis of LAMN depends on the presence or absence of neoplastic epithelium outside the appendix. Here, the authors describe a case of 35-year-old female who visited the OPD of Emergency Medicine with only complain of pain in abdomen for three days. She exhibited right iliac fossa tenderness with no guarding during the abdominal examination. She underwent an open appendectomy and was diagnosed with LAMN upon histopathological examination. She was advised to follow up after six months post-discharge to monitor for any metastatic spread. Due to its malignant potential, mucinous lesions of the appendix are uncommon yet significant entities. They are more prevalent in women and can range from mucinous adenocarcinomas to straightforward retention cysts. This case illustrates the need for extreme caution when dealing with appendiceal tumours and the importance of selecting the appropriate course of action, be it surgical or medical.

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.

A Case of Torsion in an Otherwise-Normal Ovary in a 22-years old nulliparous women: Utilization of Diagnostic Laparoscopy for the Accurate Diagnosis

Ovarian torsion can be seen in the otherwise-normal ovary and is a challenging issue in the emergency department. Definitive diagnosis is sometimes difficult to establish because of clinical symptoms similar to other abdominal diseases. We report a 22-year-old woman, nullipara, with acute lower right abdominal pain for 14 hours before coming to an emergency room. On examination, the abdomen was soft but tender over the right iliac fossa and rebound tenderness were present.Ultrasound radiological examination showed that the right ovary is grossly enlarged (volume- 98.4cc) with hyperechoic central stoma. On colour, doppler twisted pedicel was noted. Mild collection is also seen in the pouch of Doglus. During laparoscopy, we found a blackish-red cystic mass of about 12 × 11 cm experiencing torsion. Then salpingooophorectomy was done. This is an interesting case of torsion in an otherwise-normal ovary with a huge hematosalpinx. J Bangladesh Coll Phys Surg 2023; 41(4): 342-347

Performance and diagnostic accuracy of scoring systems in adult patients with suspected appendicitis.

This study aims to determine the most accurate appendicitis scoring system and optimal cut-off points for each scoring system. This single-centred prospective cohort study was conducted from January-to-June 2021, involving all patients admitted on suspicion of appendicitis. All patients were scored according to the Alvarado score, Appendicitis Inflammatory Response (AIR) score, Raja Isteri Pengiran Anak Saleha (RIPASA) score and Adult Appendicitis score (AAS). The final diagnosis for each patient was recorded. Sensitivity and specificity were calculated for each system. Receiver operating characteristic (ROC) curve was constructed for each scoring system, and the area under the curve (AUC) was calculated. Optimal cut-off scores were calculated using Youden's Index. A total of 245 patients were recruited with 198 (80.8%) patients underwent surgery. RIPASA score had higher sensitivity and specificity than other scoring systems without being statistically significant (sensitivity 72.7%, specificity 62.3%, optimal score 8.5, AUC 0.724), followed by the AAS (sensitivity 60.2%, specificity 75.4%, optimal score 14, AUC 0.719), AIR score (sensitivity 76.7%, specificity 52.2%, optimal score 5, AUC 0.688) and Alvarado score (sensitivity 69.9%, specificity 62.3%, optimal score 5, AUC 0.681). Multiple logistic regression revealed anorexia (p-value 0.018), right iliac fossa tenderness (p-value 0.005) and guarding (p-value 0.047) as significant clinical factors independently associated with appendicitis. Appendicitis scoring systems have shown moderate sensitivity and specificity in our population. The RIPASA scoring system has shown to be the most sensitive, specific and easy-to-use scoring system in the Malaysian population whereas the AAS is most accurate in excluding low-risk patients.

Valentino’s Syndrome in Acute Pancreatitis Female Patient: A Case Report with Literature Review

Introduction: Valentino’s syndrome is an unusual right iliac fossa pain due to perforation of a duodenal peptic ulcer through the paracolic sulcus leading to local irritation. The aim of this study is to report a case of Valentino’s syndrome from acute pancreatitis with a brief literature report. Case Presentation: A 50-year-old lady presented with diffuse irradiated abdominal pain and swelling of about 6 h duration, associated with nausea, vomiting, and inability to flatus. There was positive upper abdominal and right iliac fossa tenderness. The abdominal computed tomography (CT) scan showed acute pancreatitis appearance with fat stranding and fluid collection from the peripancreatic to the right lower quadrant. Serum amylase and lipase were elevated. Therefore, the initial diagnoses were acute pancreatitis and appendicitis. Conservative management was done because of poor hemodynamics, laboratory work-up, and the lack of medical speciality to perform surgery. The patient was then transferred to another hospital with adequate facilities. Conclusion Valentino’s syndrome from acute pancreatitis is an extremely rare case, presented with vague symptoms, diagnosed by abdominal CT scan. Clinical diagnosis could be challenging for clinicians.

Various unusual presentation of acute appendicitis in adult. A case series

Acute appendicitis is common abdominal condition in our day to day surgical practice. Classical features include periumbilical pain that migrates to the right iliac fossa, anorexia, fever, and tenderness and guarding in the right iliac fossa. However, in our present study, three atypical presentation of acute appendicitis is demonstrated in clinical practice. These three cases do not have classical features of murphy’s triad, that is, nausea, vomiting, fever, and cardinal sign of positive Mcburney’s tenderness. Our three atypical cases are: (1) A 38 year old obese male patient who presented with features of umbilical inflammation with serous discharge due to presence of acute inflamed appendix in pre-existing small umbilical hernial sac. (2) A 49-year-old male medicine seller presented right sided scrotal pain with same sided inguino-scrotal swelling for short duration due to presence of inflamed swollen tip of appendix at bottom of right hemi-scrotum in pre-existing inguinal hernia. (3) A 81-years-male gentleman presented with anorexia, weakness, abdominal fullness, and bilateral pedal edema. He did not have pain abdomen, fever, and right iliac fossa tenderness. Imaging modalities confirmed the acute appendicitis in three cases. Diagnosis of appendicitis in absence of typical features is to be made from pre-occupied knowledge and with help of imaging studies.

Laparoscopic Approach to a Patient with Omental Infarction: A Case Report

Background: Omental infarction is an entity that seldom manifests with gastrointestinal symptoms and often presents a diagnostic challenge. Due to its nonspecific presentation, it is usually not included as a differential diagnosis of acute abdomen, especially in an emergency setting. Case Presentation:: We present the case of a 38-year-old overweight female, seen in the emergency department, with a complaint of sudden onset of worsening epigastric abdominal pain for four days. The pain became more localized at the right iliac fossa two days before the admission. A physical examination revealed severe right iliac fossa tenderness and positive rebound tenderness. : A computed tomography of the abdomen was done and showed a localized area of mesenteric fat stranding in the right lumbar region reaching up to the inferior border of the right lobe of the liver with adjacent peritoneal fold thickening, likely suggesting inflammatory etiology. However, the appendix was visualized normally with a mild enhancement of the distal part suggesting secondary mild acute appendicitis. : A decision for diagnostic laparoscopy was made, where we found a 4x4 cm infarcted greater omental segment, which was excised and sent for histopathology. Conclusion:: Idiopathic omental infarction is a rare cause of acute abdomen in adults and needs to be considered as a potential differential diagnosis, especially if the clinical finding does not correspond with common conditions, like acute appendicitis.

Perforation of ileum by unnoticed toothpick ingestion presenting as acute appendicitis: A case report

Many distinct pathologic disorders can cause acute abdomen, and it can be challenging for doctors to distinguish between them. Appendicitis and small bowel perforation are two examples. This case is being reported to highlight a rare instance in which acute appendicitis can be mistaken for ileal perforation by sharp solid objects. We discuss the case of a 9-year-old boy who arrived at our hospital complaining of right iliac fossa abdominal pain that started two days earlier with no other associated symptoms. Physical examination revealed right iliac fossa tenderness and rebound tenderness. The results of the imaging and laboratory tests were inconclusive; therefore, the patient was admitted for observation and further assessment. Re-evaluation 4h after admission found no clinical improvement, and abdominal examination revealed guarding and rebound tenderness, prompting the surgical team to opt for an appendectomy. During surgery, an elliptical incision was made to remove a sharp foreign body penetrating the ileum. Even during surgery, diagnosing acute appendicitis is difficult. Some cases of small bowel perforation caused by foreign body ingestion have been linked to a clinical picture similar to acute appendicitis, while others present with acute peritoneal signs. This report describes a sealed ileal perforation by a sharp solid object, manifested as acute appendicitis. Perforation of the small bowel by sharp solid objects may easily be missed on imaging, probably related to their ability to seal off the resulting perforation. A sharp solid object's perforation seems to cause localized tenderness mimicking appendicitis.

Accuracy Evaluation of Pediatric Appendicitis Scoring (PAS) Method in Differentiating Nonspecific Abdominal Pain from Appendicitis

Background: This study aimed at evaluating the accuracy of the pediatric appendicitis scoring method in differentiating nonspecific abdominal pain (NSAP) from appendicitis. Methods: This cross-sectional study was conducted on 391 children who were hospitalized in the emergency ward due to acute abdominal pain suspected of appendicitis. Pediatric Appendicitis Score (PAS), C-reactive protein (CRP), and appendicitis pathology results of patients undergoing surgery were recorded. Results: The results showed that the no significant difference was found among patients in the three experimental groups (appendicitis, specific abdominal pain except appendicitis, and NSAP) with respect to temperature (p = 0.212), but the other variables were significantly different. Findings showed that high CRP frequency, pain migration to right lower quadrant (RLQ), tenderness in right iliac fossa (RIF), anorexia, leukocytosis, high neutrophil, and mean tenderness in RLQ in the appendicitis group were higher than those in the other two groups (p = 0.001). The PAS questionnaire can also be used as a reliable questionnaire with appropriate sensitivity (0.929) and specificity (0.993), and this questionnaire along with detailed clinical examinations could reduce the rate of negative appendectomy to less than 1%. Conclusions: This study showed high accuracy of PAS in diagnosing children with appendicitis and differentiating appendicitis from cases of NSAP and specific abdominal pain other than appendicitis. The PAS system could also significantly reduce cases of negative appendicitis. Although high CRP had an excellent ability to diagnose appendicitis, its accuracy was lower than PAS.

Clinical profile of acute appendicitis at the National Referral Hospital in Bhutan

Introduction: Acute appendicitis poses a diagnostic challenge in a low-resource setting like ours. Without timely and appropriate management, acute appendicitis can lead to prolonged morbidity and mortality. We describe the clinical profile of acute appendicitis at the national referral hospital in Bhutan. Method: This was a cross-sectional descriptive study of all cases of acute appendicitis managed at the National Referral Hospital, Bhutan from 1st January-31st December 2016. Data related to patients’ symptoms, clinical examination and ultrasonographic findings, treatment details, length of hospital stay, and histopathology report were analyzed. Results: Of the 3291 surgical admissions, there were 173 patients with acute appendicitis contributing to 5.3% of the total surgical burden. The median age was 27 years (IQR 20, 39), 60.1% were males. 96.5% and 91.9% of the patients presented with right iliac fossa pain and tenderness respectively. While 74.6%(n=129) had primary surgery, 18.9%(n=32) were managed conservatively. Of the 32 patients, 37.5%(n=12) had surgery after failed conservative management. Seventy-five percent presented with intraoperative features of complicated appendicitis. The negative appendectomy rate was 2.2%. The median length of hospital stay was three days (range 3–60). Ultrasonographic diagnosis compared to histopathological confirmation had a sensitivity of 87.8%, kappa agreement of 87.3%, and specificity of 66.7%. Conclusion: Acute appendicitis is a common surgical emergency. Ultrasonography in the diagnosis of acute appendicitis was useful in a low-resource setting. A high proportion of complicated acute appendicitis in our setting needs effective interventional strategies.

EP-66 Omental infarct – A rare cause of Right iliac fossa pain in a child

Abstract Introduction Idiopathic omental infarction is a very rare cause of abdominal pain in the pediatric age group. We report a case of suspected acute appendicitis in an 8-year-old child, noted to have omental infarct on diagnostic laparoscopy. Case presentation An 8-year-old male child with no other medical issues presented to the acute surgical take with a 2-day history of right iliac fossa pain. The pain was of sudden onset and there were no other associated urinary or bowel symptoms. On clinical examination, there was right iliac fossa tenderness. There were mildly raised inflammatory markers. An ultrasound scan performed showed a possible blind-ending tubular structure measuring 7mm in the right iliac fossa with a small amount of free fluids. A presumptive diagnosis of acute appendicitis was made and the patient was taken to theatre. Upon diagnostic laparoscopy, we noted blood in the RIF with a normal-looking appendix and area of omental infarction adjacent to the appendix. We proceeded to excise the area of mesenteric infarction using an energy device. The appendix was removed to avoid future diagnostic confusion. Conclusion Idiopathic omental infarction is an extremely rare cause of abdominal pain in children and may mimic acute appendicitis. Ultrasound imaging may be misleading. Laparoscopic exploration allows for accurate diagnosis as well as treatment.

Comparing the diagnostic accuracy of modified RIPASA and MASS in patients diagnosed with acute appendicitis in Suez Canal University Hospital Emergency Department: a cross-sectional study

IntroductionAcute appendicitis is the most common surgical condition presented in emergency departments globally. It is also the most common cause of abdominal pain treated surgically, with a lifetime risk of 7%. Recent studies show MASS to be easy, simple and cheap diagnostic tool for supporting the diagnosis of acute appendicitis.The modified RIPASA scoring system includes more parameters than MASS and the latter did not contain certain parameters. These parameters are shown to add to the accuracy of modified RIPASA over MASS especially in Asian population.Aim of this studyThe aim of the study was to improve the diagnosis of acute appendicitis in order to lower the negative appendectomy rates.Patients & methodsThis is cross sectional study, the study included 40 patients presented to the emergency department at Suez Canal University hospital with abdominal pain and suspected clinically as acute appendicitis. Then the decision of surgical intervention was made by surgeons, who were blinded for our study, based on their clinical judgment. Then both scores were calculated for all patients and other clinical data were obtained from patients after accepting being included in our study with an informed consent.After operations, the operating theatre records were obtained and cases pathological investigation of the appendices was done. Then the sensitivity, specificity, positive and negative predictive values were calculated and so the diagnostic accuracy for both scoring systems.ResultsClinically, all the patients were suffering acute right iliac fossa tenderness (100%), rebound tenderness (90%), and nausea/ vomiting (70%). Only 45% had elevated White blood count and 55% had negative urine analysis.Histopathological analysis of appendices of the studied patients showed that 40% of the patients had suppurative appendicitis, one quarter of them had catarrhal appendicitis and only 20% had complicated perforated appendicitis. Meanwhile, about 15% had normal (negative) appendix. Modified RIPASA showed a good discriminative ability in our study where the area under the curve for modified RIPASA was 0.902 (95% CI: 0.798 – 1.00) (p = 0.002). Moreover, a value of 8.5 or higher was found to be the best cut-off point to predict acute appendicitis among patient suspected clinically as acute appendicitis with sensitivity = 70.6%, specificity = 100%, positive predictive value of 100%, and negative predictive value of 37.5% and 75% accuracy.The best cut-off score to diagnose acute appendicitis in our sample based on MASS was fixed at 5.5, where the sensitivity of the MASS reached 47.1%, with specificity of 33.3%, positive predictive value of 80%, negative predictive value of 10% and accuracy 45%.ConclusionThe modified RIPASA score is the best diagnostic scoring system for acute appendicitis if compared to the modified Alvarado score, with the former achieving significantly higher sensitivity and diagnostic accuracy. Modified RIPASA was concluded to be a more applicable and useful score. Negative appendicectomy rates can also be avoided by using modified RIPASA score.

Acute appendicitis in pregnant women: A Tunisian center experience.

Acute appendicitis is the most common surgical pathology during pregnancy. It occurs in about 1 in 500 to 1 in 635 pregnancies per year,[1] and appendectomy is the gold standard in the treatment approach.[2] However, its diagnosis represents a challenge to both surgeons and obstetrician-gynecologists. In addition, the role of laparoscopy remains controversial.This study discusses the diagnostic approach and reviews the appropriate surgical approach while evaluating the part of laparoscopy.This is a retrospective descriptive analysis reviewing 36 patients who underwent surgery for acute appendicitis during pregnancy at the “Surgery Department of Jendouba Hospital from January 1, 2005 to December 31, 2019. Data include age, comorbidities, previous abdominal surgery, symptoms, physical examination findings, complementary exams results, operative treatment details, the emergency status of the procedure, associated medical treatment, antibiotics and tocolysis, the pathology reports, and follow-up.The mean age of patients was 27 years. Twenty-one patients (58, 33%) were in the second trimester of pregnancy, 6 patients (16, 66 %) were in the first trimester, and 9 (25%) in the third one. The physical examination reported a right iliac fossa tenderness in 27 patients (75%). The abdominal ultrasound was performed in all cases and guided the diagnosis in 24 cases (66, 66%). 18 patients (50%) underwent laparoscopy, 12 patients (33, 33%) underwent laparotomy. The remaining 6 patients (16, 66%) required a conversion from laparoscopic to open surgery.The clinical presentation of appendicitis in pregnancy is often misguiding. Therefore, an abdominal ultrasound should be performed for all pregnant patients having abdominal pain. The difficulty of operating under laparoscopy increases with the pregnancy term, leading to a higher risk of conversion, which increases the operating time and the doses of anesthetics, causing a maternal and fetal risk.

Acute Appendicitis: A prospective study comparing clinical appendicitis with histopathological appendicitis.

Objective: To compare clinical appendicitis with histopathological appendicitis. Study Design: Prospective Cross-sectional study. Setting: Department of Surgery, Lady Reading Hospital, MTI, Peshawar. Period: December 2019 to March 2020. Material & Methods: Out 106 patients with signs and symptoms of acute appendicitis 100 patients were included in the study. 6 patients were excluded because of incomplete data. Patients were examined, ALVARADO score was calculated and routine investigations were done. After open appendectomies all specimens were sent for histopathology. Results: Male to female ratio was 1.7:1, with a mean age of 25 ± 11 year. The most common presenting complain was right iliac fossa pain (98%), followed by nausea/vomiting (86%). The commonest signs elicited were right iliac fossa tenderness (100%), rebound tenderness (100%). Mean ALAVARADO score is 7.39 ± 1.03. Intraoperative findings showed acutely inflamed appendix (90%), perforated appendix (7%) and normal (1%). The histopathology specimens showed acute appendicitis (88%), acute appendicitis with periappendicitis (8%) and normal histology (1%). Conclusion: Our study comparing clinical appendicitis with histological appendicitis with a negative appendectomy rate of only 1% suggests that acute appendicitis remains a clinical diagnosis and that timely accurate clinical diagnosis can prevent many complications associated with delayed/misdiagnosis of acute appendicitis. Laboratory evaluation and imaging especially CT may help in establishing diagnosis in equivocal cases but often leads to delay in diagnosis and also puts extra burden on the health care system.

APPENDICITIS WITH MIDGUT MALROTATION- A RARE CLINICAL ENTITY

Acute appendicitis is a common clinical entity where patient will present mostly with pain abdomen and typical right iliac fossa tenderness. But Acute appendicitis associated with midgut malrotation is a rare entity and patients present with pain in the left side of abdomen which often lead to missing the diagnosis of a surgical emergency unless patient is subjected to further radiological evaluation. Herein we report one such case of a 27yr old male who presented to us with complaints of pain in left upper abdomen and vomiting.

TP9.2.19Factors Associated with Multiple Presentations Prior to Appendicectomy in Children Presenting with Suspected Appendicitis

Abstract Aims Appendicectomy is amongst the most common emergency operations in children. We aim to audit the rate of re-presentation within 30-days prior to appendicectomy in children presenting to the emergency department (ED) with suspected appendicitis and identify the factors associated with re-presentations. Methods Retrospective review of the medical notes of all children that had an emergency appendicectomies between June 2016 and June 2019. Results A total of 231 appendicectomies were performed, all presented through ED, with 8.2%(n = 19) re-presenting within 30-days prior to appendicectomy. Negative appendicectomy rates were similar in those that had appendectomy at initial presentation or when they re-presented (13.2(n = 28)%vs.15.8%(n = 3), p = 0.752), respectively. Of those that re-presented, 84.2%(n = 16) were not reviewed by the surgical team at the index presentation. Female patients accounted for 62.5%(n = 10) of those that re-presented, compared with 31%(n = 57) of those that presented once(p = 0.010). Pyrexia(p = 0.029), Rovsing's sign(p = 0.032), nausea or vomiting(p = 0.012) was associated with histological appendicitis. Absence of migratory pain(p = 0.005), anorexia(p = 0.004), right iliac fossa tenderness(p < 0.001) or guarding(p < 0.001) was associated with higher successful discharge rate. Among those re-presented, there was significant CRP rise between first and second presentation (median(Q1,Q3): 6(1.25,28.5)vs.95.5(27,176.5), p = 0.016) however, white cell count was comparable (median(Q1,Q3): 14.6(11.98,16.05)vs.14.0(11.02,18.58), p = 0.815). Conclusion Clinical symptoms and signs correlated with histological appendicitis. A significant proportion of those that re-presented were not assessed by the surgical team at initial presentation. Early surgical consultation at initial presentation may reduce rates of re-presentation.

Triple presentation of acute appendicitis, Meckel's diverticulum, and hemorrhagic ovarian cyst: A rare case report and literature review.

Introduction and importanceWith 2% prevalence worldwide, Meckel's diverticulum is the most common congenital anomaly of the small intestine, which anatomically results from incomplete obliteration of the vitelline duct. It is usually difficult to differentiate clinically between acute appendicitis and Meckel's diverticulitis, thus in most clinical situations, it is asymptomatic and usually incidentally discovered intraoperatively. On the other hand, Acute appendicitis is one of the most common presentations in a surgical emergency with an 8.6% incidence in males and 6.7% in females. Triple presentation of acute appendicitis, Meckel's diverticulum, and a hemorrhagic ovarian cyst is a rare incidence in literature.Case presentation and clinical discussionA female patient 35 years old with no previous surgical history or known medical disease presented to our ER with right lower quadrant abdominal pain of one-day duration. On physical examination; there was right iliac fossa pain, tenderness, and rebound tenderness indicating acute appendicitis. Intraoperatively we operated appendectomy as usual through Gridiron incision. Upon opening of the parietal peritoneum, there was a hemorrhagic reaction with a catarrhal inflamed appendix. Ileal loops revealed a Meckel's diverticulum. With the peritoneal toilet, there was still a hemorrhagic reaction. Further exploration revealed a ruptured hemorrhagic ovarian cyst, which was managed using bipolar cautery and ligatures.ConclusionIn the operative management of acute appendicitis, we recommend proper assessment for both the right ovary and at least two feet of ileum proximal to the ileocecal valve to exclude any ovarian abnormalities or Meckel's diverticulum respectively especially if the appendix was normal or just was catarrhal inflamed.

A clinico-pathological study of acute appendicitis with management and the role of ultrasound in diagnosis of appendicitis

Background: Acute appendicitis is the most common cause of acute surgical abdomen and appendicectomy is the most commonly done emergency surgery. Its diagnosis remains an enigmatic challenge, plagued by a high rate of negative explorations. There is no single reliable test with satisfactory, sensitivity and specificity. Aim and Objective: The objective of the study is to evaluate the clinical presentations, signs of acute appendicitis and its management. The role of USG in diagnosing acute appendicitis and reducing the rate of negative appendicectomies. Methodology: The present study was conducted in 100 patients who have been clinically diagnosed of having Acute Appendicitis and posted for emergency appendicectomy in General Surgery, Department of MGM, attached to Kakatiya Medical College, Warangal, during the period from January 2018 to June 2020. Preoperatively blood for WBC count, DC and USG abdomen were done. All patients were subjected to histopathological examination postoperatively which was taken as gold standard. Results of Ultrasound were correlated with HPE reports to evaluate their role in diagnosis of acute appendicitis. Results and Observations: In the present study we had 100 cases of which 61 (61%) were males and 39 (39%) were females. The number of patients was highest in the age group 20 to 29years (33%). Migrating Pain to RIF was found in 76% of patients, Anorexia in 87% of patients. Nausea/vomiting were present in 79% patients. Right iliac fossa tenderness was found in 98% of cases. Rebound tenderness was found in 68% of patients. Fever was present in 45% of cases. Total leucocyte count was elevated in 80% of cases in our present study. Shift to let was seen in 42% cases. In our study all the patients were subjected to abdominal ultrasound examination. The sensitivity and specificity of Ultrasonography for acute appendicitis is 94.8% and 80% respectively. Accuracy was 93%. The positive predictive value and negative predictive value of Ultrasonography for acute appendicitis is 98% and 44% respectively. Negative appendectomy rate in this study 5.5%.The majority (60%) is seen in females. Conclusion: Ultrasound is a fast, simple, reliable, non-invasive, repeatable and safe diagnostic modality without any complications. It has greater sensitivity and positive predictive value in diagnosing acute appendicitis and it reduces the rate of negative appendicectomy.