Tenderness In Right Lower Quadrant Research Articles

An Unusually Long Appendix: A Case Report and Literature Review

BACKGROUND: Acute appendicitis is one of the most common conditions in emergency surgery and appendectomy is the most frequently performed surgical procedure. The complexity of this pathology is reflected in the numerous congenital malformations and anatomical variations of the vermiform appendix. Anatomical variations are mainly related to its length and position. The average length of the appendix was found to be 9.5 cm in the male and 8.7 cm in the female, but different length has been reported, from 1 cm to even a 33 cm on the cadaver. CASE PRESENTATION: A 34-year-old man was admitted to the general surgery department due to symptoms that began the previous day. The patient complained of lumbar pain which later migrated to the periumbilical region and the right lower quadrant (RLQ) of the abdomen followed by fever, nausea, and vomiting. On clinical examination, he had a tenderness in RLQ with abdominal guarding. Laboratory analyzes showed leukocytosis and high markers of inflammation. Urinalysis and abdominal ultrasound were normal. Taking into consideration the clinical presentation and laboratory parameters, a decision was made to proceed for an open appendectomy. Intraoperatively, the appendix was inflamed, very long, partly retrocaecal, and partly paracolic in position, with two coils, extending upward. After dividing the mesoappendix, it measured 20 cm in length. The appendectomy was performed. Post-operative recovery was without complications. The patient was discharged from the hospital on the 3rd post-operative day. CONCLUSION: Although acute appendicitis is very frequent condition in emergency surgery, making the diagnosis could be challenging due to numerous differential diagnostic dilemmas. The position of the appendix and direction of its extension could lead to misdiagnosis. The synthesis of clinical examination, laboratory analyzes, and diagnostic procedures should lead clinicians to the right diagnosis and surgical treatment, avoiding possible complications and additional costs.

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.

Factors affecting utilization of CT scan following ultrasound evaluation of suspected appendicitis.

When evaluating a pediatric patient in the emergency department for suspected appendicitis, a provider is often faced with the dilemma of deciding if a computed tomography (CT) scan is warranted when-as is most often the case-ultrasound results do not yield a definitive diagnosis. The potential risks of radiation must be weighed against numerous aspects of a patient's background, physical exam, and already-obtained workup. This study aims to aid in future decision making of providers in their evaluation of patients with suspected appendicitis, to help facilitate a more comprehensive answer to the "next-steps" in the question of equivocal ultrasound, and to create a pathway utilizing lab results, physical exam findings, and pertinent positives and negatives in patient history to facilitate a more objective decision-making process for ordering a CT scan. A retrospective chart review was performed for patients who were evaluated for possible appendicitis at our institution between October 2016 and October 2017 and whose ultrasound results were equivocal. We determined what factors led to increased frequency of obtaining CT scans. Statistical analysis showed that several factors were independently associated with the increased likelihood of having a CT scan performed. When considered in combination with the other parameters, it was found that older children, males, report of right lower quadrant (RLQ) pain, and presence of RLQ tenderness on physical exam were all associated with a significantly higher likelihood of having a CT scan performed. When combined with present algorithms and protocols already in use, this information can assist the provider in making prudent decisions for their patients with the potential for reduced provider bias.

An Unusual Case of Right Lower Quadrant Pain: A Case Report.

IntroductionThe perforation of a cecal diverticulum is a rare and challenging condition for the emergency physician.Case ReportA 47-year-old man with a past surgical history of bilateral inguinal hernia repair presented to the emergency department (ED) with acute abdominal pain of three days’ duration. Pain was localized to the right lower quadrant (RLQ), with anorexia as the only associated symptom. Upon arrival to the ED, his exam demonstrated focal RLQ tenderness to palpation, rebound tenderness, and guarding. Labs did not show any elevation in inflammatory markers, liver enzymes, or lipase. Computed tomography showed no evidence of acute appendicitis, colitis, or hernia recurrence. After morphine and reassessment, the patient still had a focal peritoneal exam in the RLQ. Surgical consultation was obtained and recommended additional non-opioid analgesia as well as serial abdominal exams. After several repeat abdominal exams, there was no change in the focality of the patient’s pain. Surgery was reconsulted and opted to take the patient to the operating room for exploratory laparoscopy with “appendicitis” as the presumptive diagnosis. Pathology report revealed a perforated cecal diverticulum that was adherent to the abdominal wall. The patient did well and was discharged on his third postoperative day.ConclusionThis case further underlines that even in the era of sensitive imaging tools, the diagnostic value of a targeted physical exam with clinical re-evaluation can never be overestimated.

Risk Factors Associated with Acute Appendicitis in Pregnancy

Backgrounds:: Acute appendicitis has been considered as the most common non-obstetric indication that requires surgical intervention in pregnant women. Objective: The aim of this study is to compare clinical manifestations and para-clinical indices between pregnant and non-pregnant patients who have undergone appendectomy. Methods:: In this prospective cohort study, 57 pregnant and non-pregnant women presenting appendicitis were compared in terms of diagnostic indicators, histopathological characteristics and laboratory findings. Results:: Periumbilical region was the point of initiation of the pain; however, it was more prominent in non-pregnant women. Similarly, tenderness in RLQ (right lower quadrant) of the abdomen was more detectable in the non-pregnant group, and some of the cases showed no rebound tenderness. Pregnant women with appendicitis presented an abnormal increase in the WBC count. Conclusion:: Pregnancy and appendicitis-related signs and symptoms have similarity among them. Due to pregnancy, the physical examination might not present an exact diagnosis; therefore, pregnant women susceptible to have appendicitis must undergo a complete and careful on-time examination that includes ultrasound and labs.

THORACOABDOMINAL AORTIC DISSECTION: ATYPICAL PRESENTATION AND MULTIORGAN DAMAGE

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Acute Aortic Dissection (AoD) is the disruption of the tunica intima and tunica media of the aortic wall forming a blood-filled dissection plane dividing into "true" and "false" lumen. We categorize AoD as Type A and Type B (Stanford classification) based on the part of the aorta involved. However, an accurate diagnosis is difficult due to inconsistent clinical presentations (typically present with tearing chest pain radiating to the back). This is a unique clinical case of an atypical presentation with a complicated clinical course. CASE PRESENTATION: A 53-year-old man with untreated hypertension presented to the emergency room (ER) with worsening right lower extremity (RLE) pain and numbness for 6 days, aggravated with ambulation along with right lower quadrant (RLQ) abdominal pain. He endorses extensive tobacco, alcohol, marijuana, and cocaine use. In the ER, the blood pressure was 275/142 mmHg, biventricular hypertrophy on the EKG. He also had RLQ tenderness and diminished pulses in the RLE. The abdominal computed tomography (CT) discovered a distal abdominal aortic division. The larger false lumen dissected the left renal artery, left common iliac artery, with thrombosis of the left internal iliac artery. The narrow true lumen minimizes perfusion to the RLE and the right kidney. CT angiography of the chest confirmed a Stanford Type B aortic dissection with the intimal tear distal to the left subclavian artery. Intravenous Nicardipine and Esmolol drip controlled the blood pressure, followed by a femorofemoral bypass to improve RLE perfusion. Post-operative contrast nephropathy improved on day 10. Subsequently, a persistent ileus due to poor intestinal perfusion was corrected by transverse loop colostomy on day 15. On day 20, the patient was discharged with oral antihypertensive medications. DISCUSSION: The incidence of AoD is 5-30 per million people per year. 38% of ER presentations are missed; 28% are diagnosed at autopsy. Hypertension, atherosclerosis, cocaine abuse, cardiac surgeries, and systemic inflammatory syndromes can increase risk. Sullivan et al. suggest that a physician suspects AoD in 86% of patients with chest and back pain, 45% with only chest pain, and only 8% with abdominal pain. Our case is a unique combination of an atypical presentation (abdominal pain, leg numbness) with significant malperfusion of RLE, small bowel, and the right kidney (IRAD registry). For Type B dissection, medical management is preferred followed by surgical techniques to improve perfusion. Estimated inpatient mortality is 30% in proximal dissection and 10% in distal dissection. After the acute phase, the 10-year survival rate for AoD is <50%. CONCLUSIONS: Even with atypical symptoms, AoD and associated complications were successfully diagnosed and treated. Even with current surgical and medical advancements, controversies regarding diagnosis, the timing of repair, and type of repair still exist. REFERENCE #1: Cebicci, Huseyin & Salt, Omer & Gurbuz, Sukru & Sahin, Taner & Cumaoglu, Mustafa & Koyuncu, Serhat. (2014). Atypical presentations of aortic dissections: A case series. Acta Medica Mediterranea. 30. 85-90. REFERENCE #2: Sullivan PR, Wolfson AB, Leckey RD, Burke JL. Diagnosis of acute thoracic aortic dissection in the emergency department. Am J Emerg Med. 2000 Jan;18(1):46-50. doi: 10.1016/s0735- 6757(00)90047-0. PMID: 10674531 REFERENCE #3: Crawford, Todd C, et al. "Malperfusion Syndromes in Aortic Dissections." Vascular Medicine, vol. 21, no. 3, 2016, pp. 264–273., doi:10.1177/1358863x15625371 DISCLOSURES: No relevant relationships by Saurabh Chokshi, source=Web Response No relevant relationships by David Goldgrab, source=Web Response No relevant relationships by Devansh Patel, source=Web Response no disclosure on file for Jorge Perez

Is Alvarado Score Helpful for Pediatrician in Diagnosis of Acute Appendicitis? Our Center Experience

Background: Many problems in the diagnosis of patients with suspected appendicitis have led to the design of clinical scoring systems. In children, diagnostics tools for appendicitis are more critical. Younger patients, diagnostic challenges become more. Practical scoring systems are useful without any particular material and necessitate novel ability. Objectives: However, in spite of the reported outstanding consequences, these scoring systems are not employed regularly. Methods: In this cross-sectional study performed from October 2016 to October 2017, ten provinces out of the 31 provinces in Iran were randomly selected. A total of 631 patients referring to the hospitals with the suspicion of acute appendicitis were assessed. Related variables such as age, sex, right lower quadrant (RLQ) pain, migration of pain to RLQ, nausea, and presence of vomiting, anorexia, tenderness in RLQ and guarding, presence of rebound tenderness, and degree of fever were taken from recorded files by pediatricians. Alvarado scoring system was used for included cases to assess the accuracy of this test for diagnosis of appendicitis in our centers. Results: The mean age of eligible patients was 9.3 ± 3.21 years ranged from 3 years to 18 years, and 380 (60.5%) were male. Using the Alvarado score system in this study, considering the cut-off point value of 7 to decide for operation, the positive predictive value (PPV) showed 32.6%, and negative predictive value (NPV) was 76.73%, with a sensitivity of 44.05% and, specificity of 66.95%. There were statistically no significant correlations among the scoring of the Alvarado and diagnosis of AA (P &lt; 0.05). Regarding receiver operator characteristic curves (ROC), the area under curve (AUC) was 0.58 (0.54 to 0.63) for Alvarado. The AUC was very low, so there was no value for the diagnosis of appendicitis. According to the findings of the present study, the cut-off point of 4.5 is suggested for the diagnosis of acute appendicitis in children with a sensitivity of 73% and specificity of 58%. Conclusions: Although the Alvarado scores supply obviously practical diagnostic information in the management of pediatric population with supposed appendicitis, this method delivers no adequate PPV for clinical practice as a safe way for determining necessary operation.

S1684 Appendiceal Adenomatous Mucocele Masquerading as Right-Sided Colonic Diverticulitis

INTRODUCTION: Appendiceal mucoceles (AM) are found in 1% of appendiceal specimens. AM are often incidental imaging findings and are often not visible on routine colonoscopy. They are usually asymptomatic, but can present with right lower quadrant (RLQ) pain, palpable mass, weight loss and altered bowel habits- often mimicking appendicitis. We present a rare case of adenomatous AM masquerading as right sided diverticulitis. CASE DESCRIPTION/METHODS: 56 yo man with GERD, chronic constipation, and prior colonic adenomas presents with 48 hrs of non-bloody diarrhea, RLQ pain and fever of 101F; denies chills, nausea, vomiting. Exam: soft, non-distended abdomen, hypoactive bowel sounds, RLQ tenderness with mild rebound. Labs: mild leukocytosis. Imaging: CT A/P shows cecal wall thickening and fat stranding consistent with right sided diverticulitis, no evidence of appendicitis. Patient responded to ciprofloxacin and metronidazole, but presented 2 months later with intermittent RLQ pain, similar but less severe to initial presentation. Colonoscopy revealed an appendiceal rim with a 10 mm adenomatous appearing polyp prolapsing from deep in the orifice; no right sided diverticula were visualized. Patient underwent appendectomy with partial cecectomy and recovered well. Surgical pathology revealed a 1.5 cm adenomatous polyp of the appendix. DISCUSSION: There are various classification systems for AM. The PSOGI consensus criteria describes eight distinct lesion categories: adenoma, serrated polyp, LAMN (low grade neoplasm of the appendix), HAMN (high grade appendiceal mucinous neoplasm), mucinous adenocarcinoma, signet ring cell low differentiated adenocarcinoma, signet ring cell carcinoma and adenocarcinoma. Surgical resection is critical to ascertain lesion type and develop adjunctive therapy and follow up. AM may result in pseudomyxoma peritonei, a fatal condition of copious mucinous or gelatinous ascites. Thus, regardless of classification, surgical resection is indicated for all appendiceal polyps. Initial imaging studies misdiagnosed our patient with right sided diverticulitis. However, colonoscopy with direct mucosal visualization revealing an adenomatous polyp extruding from the appendiceal orifice facilitated the correct diagnosis of AM. Therefore, although rare, appendiceal neoplasms should be considered in cases of RLQ pain and imaging suggestive of acute inflammatory response; colonoscopy is essential for ongoing RLQ pain and presumed right sided diverticulitis to rule out both colonic and appendiceal neoplasms.Figure 1.: Appendiceal polyp.

A 15-year-old Boy with Right Lower Quadrant Abdominal Pain and Fever

1. Hira Ahmed, DO† 2. Alicia Kodsi, MD† 3. Christina Gagliardo, MD*,‡ 4. Santina Bruno, DO† 5. Michelle Katzow, MD, MS† 1. *Division of Pediatric Infectious Diseases and 2. †Department of Pediatrics, Maimonides Infants and Children’s Hospital, Brooklyn, NY; 3. ‡Department of Pediatrics, Albert Einstein College of Medicine A 15-year-old previously healthy boy presents to the emergency department (ED) with 1 day of fever, right lower quadrant (RLQ) abdominal pain, and one episode of nonbloody, nonbilious emesis. A clinical diagnosis of acute appendicitis is made, and he undergoes laparoscopic appendectomy and is discharged on postoperative day 1 without any pain. A pathology evaluation of the removed tissue reveals a normal appendix. Two days after discharge, he develops right hip and thigh pain, which progresses over the next 4 days; he again presents to the ED. Physical examination is significant for fever of 40.3°C, RLQ tenderness without rebound or guarding, well-healing surgical …

Retrospective cohort study on clinical predictors for acute abnormalities on CT scan in adult patients with abdominal pain

PurposeIdentification of clinical predictors of acute and surgical pathologies on abdominal CT in patients with non-traumatic abdominal pain (NTAP). MethodsRetrospective chart review cohort study of adults who had abdominal CT scans for investigation of NTAP in the Emergency Department in a tertiary care center in Lebanon. Multivariate analyses were performed to identify predictors of pathologies on CT scan. ResultsThis study included 147 patients who had abdominal CT scans for NTAP. Mean age was 39.8 ± 15.1 years and 58.5 % of patients were females. Less than half (44.9 %) had normal scans. Women had significantly higher rates of normal scans compared to males. Right lower quadrant (RLQ) tenderness was associated with significantly higher odds of having acute abnormalities on CT and of having surgical diagnoses, while epigastric tenderness was negatively associated with these two outcomes. Right and left upper quadrants and diffuse abdominal tenderness, and an abnormal neutrophil count were found to be associated with surgical diagnoses on CT. ConclusionsWomen are less likely to have acute and surgical pathologies on CT ordered for non traumatic abdominal pain. Epigastric tenderness is negatively associated with abnormal and surgical CT results while RLQ tenderness is associated with an abnormal CT that is likely surgical in nature. These findings should help improve diagnostic accuracy of ordering providers and improve resource utilization.

1561 Appendiceal Colic Intussusception Due to Mucocele of Appendix: Is Appendectomy Alone Sufficient?

INTRODUCTION: Mucocele of appendix is a rare clinical entity (0.2-0.3% of appendectomy specimens) with obstruction to drainage of mucus from the appendicular lumen. Rarely, does it manifest as bowel obstruction owing to intussusception of mucocele of appendix (0.01%). Diagnosis of mucocele or its intussusception is radiological, can't differentiate if the cause of obstruction is a benign or a malignant process. CASE DESCRIPTION/METHODS: A 40 year female presented with complaints of right lower quadrant pain since a few days, was dull, aching, intermittent, associated with nausea without any obvious aggravating or relieving factors and history of trauma to the abdomen or previous surgery. Abdominal examination revealed tenderness in right lower quadrant without any guarding or rigidity and lump could be felt in the same quadrant. On auscultation sluggish bowel movement. An abdominal CT: intussusception of mucocele of appendix of 4.5 × 3.1 × 2.5 cm. Open appendectomy was planned to avoid accidental spillage of contents and resected margins and regional nodes were negative for malignancy as per histopathology. The postoperative period was uneventful. DISCUSSION: A Mucocele of appendix (MOA) is an abnormal accumulation of mucus in appendix. A cystadenoma, mucosal hyperplasia, retention cyst or mucinous cystadenocarcinoma may be the cause of this obstruction. Multi-detector CT is imaging of choice, classic appearance of a well circumscribed, fluid-filled, distended appendix. Presence of mural calcification differentiate from appendicular abscess. Further, an intussusception of MOA has been likened to a cup &amp; ball pattern. However, features like enhancing mural nodules within the mucocele/size &gt;2 cm point towards a malignant cause. Definitive management is surgery, a mucocele with compromised base, &gt;2 cm require a primary typhlectomy, otherwise a primary appendectomy suffices. Hence, open surgery is preferred over laparoscopic to prevent spillage. Positive margins and/or lymph node involvement translates into right hemicolectomy. A cystadenoma is followed up like an adenomatous polyp while follow up similar to colonic carcinoma is employed in cases of cystadenocarcinoma of appendix.

1667 An Unusual Case of Ileocolonic Intussusception Masquerading as a Colon Mass

INTRODUCTION: Intussusception presents more frequently in the pediatric population versus adults, which only accounts for 5% of all cases. Primary (idiopathic) intussusception make up about 10% of all cases. Secondary causes result from a pathological lesion such as polyps, carcinomas, IBD or postoperative lesions. We describe an unusual case of an adult ileocolonic intussusception masquerading as a colonic mass lesion. CASE DESCRIPTION/METHODS: A 21-year-old female presents with 3 days of intermittent right lower quadrant (RLQ) abdominal pain and constipation. Physical exam revealed RLQ tenderness without peritoneal signs. An abdominal CT scan showed a 7.7 cm mass in the cecum/proximal ascending colon (Figure 1) concerning for malignancy. She underwent a colonoscopy which revealed that the mass was an ileocolonic intussusception into the ascending colon with a prolapsed ileum completely filling the right colonic lumen (Figure 2). The distal ileal lumen was intubated with the colonoscope and showed had severe ileitis with erosions and inflammation (Figure 3) but could not be reduced back endoscopically. An exploratory laparoscopy with reduction of ileocecal intussusception and ileocecectomy with anastomosis was then done. Post procedure, she was pain free and had return of bowel function. The surgical pathology showed ischemic injury to the bowel wall with acute serositis. The patient had a negative workup for IBD, celiac disease, malignancy or polyps, as evaluated with serology, MR enterography, EGD, and video capsule endoscopy for further workup. DISCUSSION: Adult intussusception occurs mainly in the small bowel, with 52% found in the small intestine and 38% in the large intestine (17% ileocecal). Most cases are caused by a structural lesion with neoplasms causing 66% of colonic intussusceptions and 30% of cases in the small bowel. The mechanism is believed due to lesion caught during peristalsis initiating the telescoping process. Those older than the age of 60, bowel resection is recommended given the high incidence of malignancy. Small bowel intussusceptions are more likely to reduce spontaneously and resection is not indicated unless there is ischemia or obstruction. This was a rare presentation of an idiopathic ileocolonic intussusception in an adult presenting as a colonic mass on imaging, diagnosed with colonoscopy and promptly resolved with timely surgical intervention.

Clinical differentiation of acute appendicitis and right colonic diverticulitis: A case-control study.

BACKGROUNDAcute right colonic diverticulitis (ARCD) is an important differential diagnosis of acute appendicitis (AA) in Asian countries because of the unusually high prevalence of right colonic diverticula. Due to qualitative improvement and the high penetration rate of computed tomography (CT) scanning in Japan, differentiation of ARCD and AA mainly depends on this modality. But cost, limited availability, and concern for radiation exposure make CT scanning problematic. Differential findings of ARCD from AA are based on several small studies that used univariate comparisons from Korea and Taiwan. Previous studies on clinical and laboratory differences between AA and ARCD are limited.AIMTo determine clinical differences between AA and ARCD for differentiation of these two diagnoses by creating a logistic regression model.METHODSWe performed an exploratory single-center retrospective case-control study evaluating 369 Japanese patients (age ≥ 16 years), 236 (64.0%) with AA and 133 (36.0%) with ARCD, who were hospitalized between 2012 and 2016. Diagnoses were confirmed by CT images. We compared age, sex, onset-to-visit interval, epigastric/periumbilical pain, right lower quadrant (RLQ) pain, nausea/vomiting, diarrhea, anorexia, medical history, body temperature, blood pressure, heart rate, RLQ tenderness, peritoneal signs, leukocyte count, and levels of serum creatinine, serum C-reactive protein (CRP), and serum alanine aminotrans-ferase. We subsequently performed logistic regression analysis for differentiating AA from ARCD based on the results of the univariate analyses.RESULTSIn the AA and ARCD groups, median ages were 35.5 and 41.0 years, respectively (p=0.011); median onset-to-visit intervals were 1 [interquartile range (IQR): 0-1] and 2 (IQR: 1-3) days, respectively (P < 0.001); median leukocyte counts were 12600 and 11500/mm3, respectively (P = 0.002); and median CRP levels were 1.1 (IQR: 0.2-4.1) and 4.9 (IQR: 2.9-8.5) mg/dL, respectively (P < 0.001). In the logistic regression model, odds ratios (ORs) were significantly high in nausea/vomiting (OR: 3.89, 95%CI: 2.04-7.42) and anorexia (OR: 2.13, 95%CI: 1.06-4.28). ORs were significantly lower with a longer onset-to-visit interval (OR: 0.84, 95%CI: 0.72-0.97), RLQ pain (OR: 0.28, 95%CI: 0.11-0.71), history of diverticulitis (OR: 0.034, 95%CI: 0.005-0.20), and CRP level > 3.0 mg/dL (OR: 0.25, 95%CI: 0.14-0.43). The regression model showed good calibration, discrimination, and optimism.CONCLUSIONClinical findings can differentiate AA and ARCD before imaging studies; nausea/vomiting and anorexia suggest AA, and longer onset-to-visit interval, RLQ pain, previous diverticulitis, and CRP level > 3.0 mg/dL suggest ARCD.

A Double Agent in the Cecum

Appendicitis is the most common acute abdominal surgical emergency in the world. Despite its pathophysiology not being understood, appendiceal obstruction has been proposed as the primary cause. In older patients, appendicitis warrants further evaluation as it may be the first symptom of malignancy. This is a 70 year-old-male with medical history of chronic liver disease secondary to alcohol, paroxysmal atrial fibrillation on Warfarin, arterial hypertension and diabetes mellitus type II who presented to the Emergency Department after a call back from the laboratory reporting a hemoglobin drop from a baseline of 13.5 gm/dL to 9.3 gm/dL. Patient complained of a sharp stabbing abdominal pain localized to the right lower quadrant (RLQ) associated to dizziness, loss of appetite and general malaise for a week prior to presentation. Denied changes in bowel habits, bloody stools, dark stools, weight changes, nausea, vomits, diarrhea, constipation, fever or chills. Vital signs were stable. Physical examination was pertinent for a distended abdomen, adequate bowel sounds, soft and depressible, RLQ tenderness to palpation, but no rebound or guarding. Anemia work up revealed iron deficiency anemia. Abdominal CT without contrast revealed a dilated appendix with surrounding fat stranding and a small amount of fluid indicative of appendicitis with several enlarged lymph nodes in the right abdomen. Abdominopelvic CT with IV and PO contrast 3 days later due to progressive abdominal distention and pain revealed a distended appendix with a mass involving the cecum causing appendiceal obstruction and surrounding lymphadenopathy. Gastroenterology service recommended surgical intervention. Surgery service performed a colonoscopy and a large mass was identified at the cecum obstructing approximately 70% of the lumen. The procedure was aborted and biopsies were not taken because patient developed respiratory distress requiring endotracheal intubation. Patient had a prolonged and complicated admission leading to his demise. Autopsy report confirmed a poorly differentiated adenocarcinoma with metastasis. Cecum-Appendix adenocarcinoma is rare and it may mimic symptoms of an acute appendicitis. Therefore, it should raise concern when evaluating patients with physical and radiological findings suggestive of appendicitis in this age group. Management should be surgical due to increased risk of perforation and complications during colonoscopy.

Bedside Sonographic Characteristics of Early and Late Appendicitis

The patients with appendicitis can visit emergency department (ED) either before or after the migration of pain into right lower quadrant (RLQ). The purpose of this study was to determine the characteristics of bedside ultrasound (BUS) and clinical characteristics of the early appendicitis (EA) comparing to the late appendicitis (LA) in ED. A BUS registry of RLQ tenderness for one year was reviewed. Among these cohorts, patients pathologically proven to have appendicitis were selected and divided into two groups: an EA group, patients who complained of a diffuse abdominal pain, and a LA group, patients who complained of a localized right lower quadrant pain. The two groups were compared according to gender, age, BUS findings, inflammatory markers, clinical features, and postoperative pathological findings. A total of 102 patients were enrolled in this study. Among them, 42 patients (41.2%) were in the EA group and 60(58.8%) were in the LA group. Appendiceal diameter and non-compressibility did not differ between the two groups. However, periappendiceal fat infiltration and fluid were less prevalent in the EA group (p=0.031 vs. p=0.022, respectively). Both dilated appendiceal diameter and non-compressibility were visualized in BUS of EA patients. Emergency physicians can detect EA before the localization of pain to RLQ by using BUS.

Management of children with possible appendicitis: a survey of emergency physicians in Australia and New Zealand.

To describe current practice in managing children with possible acute appendicitis in EDs in Australia and New Zealand as the basis for a clinical practice guideline (CPG). An anonymous survey was distributed to consultant emergency physicians working at PREDICT (Paediatric Research in Emergency Departments International Collaborative) sites in Australia and New Zealand in April 2013. A second, site-based survey was distributed to the PREDICT representatives at each of the 13 sites. The response rate was 100% (13/13) for the site-based survey and 82% (145/176) for the physician survey. Most respondents agreed that right lower quadrant (RLQ) tenderness (94%), anorexia (92%), migration of abdominal pain to the RLQ (86%), rebound tenderness in the RLQ (60%) and RLQ tenderness produced on coughing, hopping or percussion (63%) were valuable symptoms and signs in diagnosing appendicitis. The responses regarding nausea and vomiting and fever were less consistent. Less than 50% regarded blood tests (C-reactive protein, white cell count) as relevant for the diagnosis of appendicitis. Most physicians (61%) agreed there was a role for a validated CPG for possible appendicitis in children, although only 3/13 sites reported use of such a CPG. This survey of senior emergency physicians across Australia and New Zealand demonstrated congruence in several clinical markers and disagreements in others in the approach to diagnosing children with possible appendicitis. Whereas emergency physicians would like a validated CPG, this survey has highlighted some critical issues. Particularly, the low regard for blood tests, integral to published diagnostic scoring systems, will be a challenge for the development and introduction of such a CPG in Australia and New Zealand.

Recurrent evisceration from Mcburney’s incision

CASE REPORT A 71­year­old, male presented to emergency room with 24 hr history of right lower quadrant (RLQ) pain, anorexia and low­grade fever. His past medical history included hypertension, asthma, COPD and cerebral palsy. Patient was disabled with severe flexion deformity at the hip joint. On physical examination he was tachycardic, hypotensive and had RLQ tenderness without peritonitis. Blood tests showed white cell count of 7.6x103 cells/mm3 and hemoglobin of 10.4 g/dl. Computed tomography (CT) scan (Figure 1) showed dilated fluid filled appendix (1.1 cm), with fat stranding confirming acute appendicitis (Figure 1). He was resuscitated, given antibiotics and an emergent open appendectomy performed. Post operatively patient was on the surgical floor but was transferred to the ICU for acute exacerbation of COPD and was started on short course steroids in addition to nebulizers. He recovered over the next few days and transferred to the surgical floor. While awaiting placement to a skilled nursing facility on post op day seven he eviscerated bowel through the Mcburney’s incision while having a bowel movement (Figure 2). He was taken to the operating room emergently, bowel was reduced and incision primarily repaired with retention sutures. Patient remained in the hospital and he eviscerated again on the post op day eleven (Figure 3). This time after the bowel was reduced the defect was repaired with a biological mesh and wound approximated with closely placed retention sutures (Figure 4). The patient remained intubated for a week after which tracheostomy was performed due to inability to wean off ventilator. The patient was in the ICU for four days then transferred to a long­term acute care center where he improved over the next four weeks. On follow up his incision healed well. DISCUSSION Evisceration or Burst abdomen via laparotomy incisions is rare. [4] The incidence of evisceration after open appendectomy through a Mcburney’s incision is not clearly known and the recurrence of such evisceration has never been documented in the recent literature. There are multiple layers of fascia and muscles with good blood supply which lead to good healing thus preventing eviseration. The major independent risk factors for evisceration through midline incision are old age, male gender, chronic pulmonary disease, ascites, jaundice, anemia, CLINICAL IMAGES OPEN ACCESS

An Analysis of Factors Influencing Accuracy of the Diagnosis of Acute Appendicitis

The aim of the study was to "refresh" the knowledge about the course of acute appendicitis, to confront the classical clinical picture with the practice, analyze its fluctuations and identify factors influencing these. All patients admitted to the Department of General Surgery in Grudziądz District Hospital with the suspicion of acute appendicitis, who underwent appendectomy and in whom the appendicitis was confirmed in pathologic examination were included in the study. There were 85 patients, 49 men (58%) and 36 women (42%) in a mean age of 30 years (range 10-75). Symptoms, signs and results of biochemical tests (leukocyte rate and CRP) were considered in the analysis. The commonest constellation of symptoms and signs, occurring in at least of 3/4 patients consisted of pain and tenderness localized in right lower quadrant (100%), which exacerbates at movements (98%), felling unwell (93%), loss of appetite (88%), and rebound tenderness in right lower quadrant (74%). No particular fluctuation of clinical features in relation to gender, age, duration of symptoms, biochemical parameters and morphological severity of the inflammation was observed. Relevant findings included relatively fast development (<12 hrs) of advanced appendicitis in 18% of adult patients and more than a half patients with normal body temperature, regardless true appendicitis.

Nonhealing Ulcer in an Adolescent with Bloody Diarrhea

Purpose: Case: A 15-year-old previously healthy Caucasian female presented with right lower quadrant (RLQ) cramping pain of one week duration and associated with watery blood-mixed diarrhea, vomiting and subjective fever. On examination, she had RLQ tenderness with deep palpation and a 1.5 cm × 1.5 cm left plantar ulcer with raised erythematous borders. She remembered stepping on a sharp object about 8 days before admission. Blood and stool cultures came back negative. Clostridium difficile stool assay and microscopic examination for ova & parasites were also negative. She later developed hypotension and high-grade fever, thus she was started empirically on broad-spectrum antibiotics. CT of the abdomen showed bowel wall thickening and mucosal enhancement involving the descending and rectosigmoid colon. Colonoscopy showed edematous, erythematous and ulcerated mucosa starting from the rectum and extending continuously to the splenic flexure. Biopsy findings were consistent with ulcerative colitis and she was started on oral mesalamine and hydrocortisone enemas with partial resolution of her gastrointestinal symptoms. Incision and debridement of the foot ulcer was performed, and wound culture grew MSSA for which antibiotic therapy was directed. However, the wound did not improve and appeared to be worsening. The patient also continued to be febrile with increasing leukocytosis. CT of the foot showed an inflammatory plantar mass without extension beyond the plantar fascia. She was taken back to surgery for incision and debridement. Repeat wound cultures did not grow any organism, but the ulcer significantly worsened in size (4 cm × 3 cm) and appearance after the procedure. Histopathology subsequently reported features diagnostic of pyoderma gangrenosum (PG). The patient was placed on intravenous methylprednisolone and her clinical course rapidly improved. She remained stable on oral prednisone and later azathioprine. Discussion: PG is a rare, ulcerative, cutaneous condition which has been reported in 2 to 12% of inflammatory bowel disease patients and may occur at any stage of the disease. Therefore, it should be considered as an important differential diagnosis for nonhealing ulcers. The diagnosis of PG rests entirely on the clinical presentation and course, although biopsy should be carried out in most cases. Our case highlights the phenomenon of pathergy which is the development of new lesions or aggravation of existing ones following trivial trauma. This phenomenon is present in up to 20% of patients with PG and suggests an exaggerated and uncontrolled inflammatory response to nonspecific stimuli. Ergo, invasive surgical debridement should be discouraged.

Omental Infarction: Preoperative Diagnosis and Laparoscopic Management in Children

Omental infarction (OI) is an unusual, poorly characterized cause of abdominal pain in children and is often mistaken for appendicitis preoperatively. We present our experience with this disease process over a 5-year period to identify preoperative factors to aid in timely diagnosis and treatment. We retrospectively reviewed the medical records of all children that had OI and underwent laparoscopic omentectomy from November 2004 to June 2009. Ten patients with the diagnosis of OI were identified. OI occurred in 9 boys and 1 girl, with a median age at presentation of 8.5 years (range, 7-11). Median body mass index at presentation was 23.7 (range, 17-29), with 1 child categorized as healthy weight for age, 1 child as overweight for age, and 5 children as obese for age, based on Centers for Disease Control and Prevention criteria. All patients complained of right-sided abdominal pain; 4 patients complained of predominantly right-upper quadrant (RUQ) pain, 3 patients of right-lower quadrant (RLQ) pain, and 3 of combined RUQ/RLQ pain. On examination, 6 patients had RUQ tenderness and 4 patients had RLQ tenderness. The median duration of symptoms prior to seeking medical attention was 3 days (range, 2-7). All patients underwent computed tomography and the preoperative diagnosis of OI was established in 9 of 10 cases. Operative time was 48 ± 14 minutes. All patients underwent resection of the infarcted omentum; 2 patients underwent concurrent appendectomy. Median length of stay was 2 days (range, 2-4). OI occurs predominantly, but not exclusively, in obese preadolescent males. OI can be reliably distinguished from appendicitis on preoperative history, physical examination, laboratory analysis, and imaging. Laparoscopic omentectomy results in prompt resolution of symptoms and discharge.