Signs Of Appendicitis Research Articles

Stratified computed tomography findings improve diagnostic accuracy for appendicitis.

To improve the diagnostic accuracy in patients with symptoms and signs of appendicitis, but without confirmative computed tomography (CT) findings. We retrospectively reviewed the database of 224 patients who had been operated on for the suspicion of appendicitis, but whose CT findings were negative or equivocal for appendicitis. The patient population was divided into two groups: a pathologically proven appendicitis group (n = 177) and a non-appendicitis group (n = 47). The CT images of these patients were re-evaluated according to the characteristic CT features as described in the literature. The re-evaluations and baseline characteristics of the two groups were compared. The two groups showed significant differences with respect to appendiceal diameter, and the presence of periappendiceal fat stranding and intraluminal air in the appendix. A larger proportion of patients in the appendicitis group showed distended appendices larger than 6.0 mm (66.3% vs 37.0%; P < 0.001), periappendiceal fat stranding (34.1% vs 8.9%; P = 0.001), and the absence of intraluminal air (67.6% vs 48.9%; P = 0.024) compared to the non-appendicitis group. Furthermore, the presence of two or more of these factors increased the odds ratio to 6.8 times higher than baseline (95%CI: 3.013-15.454; P < 0.001). Appendiceal diameter and wall thickening, fat stranding, and absence of intraluminal air can be used to increased diagnostic accuracy for appendicitis with equivocal CT findings.

The prevalence and patterns of intraluminal air in acute appendicitis at CT

The purpose of this study is to investigate if the presence and distribution of intraluminal air in the appendix contributes to the computed tomography (CT) diagnosis of appendicitis. We identified 100 consecutive patients (57 men and 43 women; mean age, 38) with CT prior to appendectomy for acute appendicitis over a 5-year period and a control group of 100 consecutive patients (29 men and 71 women; mean age, 39) who underwent CT for acute abdominal pain without appendicitis. Patients were scanned using multidetector row CT scanners at 1.25 or 5-mm slice thickness, peak tube voltage of 120 kVp, and milliamperse automatically adjusted to attain a noise index of 12. Ninety-two of 100 study patients and 95 of 100 controls received 150 mL intravenous contrast. Two independent readers noted the presence and distribution pattern of intraluminal air in the appendix, appendiceal diameter, wall hyperemia, wall thickening (>3 mm), and wall stratification and presence of any secondary signs of appendicitis including fat stranding and free fluid. Data were compared between groups using Fisher's exact test and Student's t test. Intraluminal air in the appendix was more common in control patients versus patients with appendicitis (66 of 100 versus 27 of 100, p < 0.001). No significant differences in the patterns of intraluminal air were found between cases and controls. Among appendicitis cases, there was no significant difference in mean appendiceal diameter (12.8 versus 12.0, p = 0.20) or number of CT signs of appendicitis (1.93 versus 1.86, p = 0.78) in cases with intraluminal air versus without. No case of appendicitis demonstrated intraluminal air without secondary signs of appendicitis. Although intraluminal air is sometimes assumed to exclude a diagnosis of appendicitis, it is actually a common finding seen in up to 27 % of cases at CT. The pattern of intraluminal air was not helpful in differentiating a normal appendix from appendicitis.

Endometriosis with salpingitis simulating acute appendicitis

Right iliac fossa (RIF) pain is a common clinical problem. Acute appendicitis is the commonest cause for RIF pain and emergency abdominal surgery. Clinical symptoms and signs of appendicitis are often non-specific and can mimic a variety of commonly encountered disease processes leading to false negative diagnosis. Prompt and accurate diagnosis with early surgical intervention is essential to minimise morbidity. Despite advances in various investigative modalities, diagnosis of appendicitis may still remain difficult in sizeable number of patients. Misdiagnosis of appendicitis is maximal in women of child bearing age because of frequent clinical overlap of appendicitis with various gynaecological conditions. We report a rare case of pelvic endometriosis with involvement of the right fallopian tube simulating acute appendicitis in a young female.

Perforated diverticulitis of the appendix: ultrasonographic diagnosis.

Appendiceal diverticulitis is an uncommon condition, mimicking appendicitis, but with greater risk of perforation and complications. Preoperative diagnosis is rare, but can be achieved by ultrasonography as identification of the diverticulum and classical signs of appendicitis. We report a case of ultrasonographic diagnosis of a perforated appendiceal diverticulitis in an adult male and discuss this condition.

Computed Tomography Diagnosis of Acute Appendicitis—Pictorial Essay

Acute appendicitis is a common surgical emergency with varied clinical presentations. Early diagnosis is absolutely necessary to minimize morbidity whereas delayed or missed diagnosis can cause adverse consequences. Computed tomography is a highly accurate imaging technique for diagnosing appendicitis. Hence it plays a valuable role in selected patients with suspected appendicitis; [1]. In this essay, we review the normal Computed tomography anatomy of the appendix and the right lower quadrant and illustrate the Computed tomography signs of appendicitis and important differential diagnostic entities. The Computed tomography appearance of complications of acute appendicitis is also presented, as are issues concerning clinical presentation and duration of the symptoms. Computed tomography signs can be varied and overlooked as they say what is easy to see is also easy to miss.

Acute Appendicitis

The term ‘appendicitis’ was first described by Reginald H. Fitz in 1886 and has since become the most common surgical emergency that can affect people of any age. Appendicitis is usually a clinical diagnosis so it is important for GPs to have a good understanding of the symptoms and signs of appendicitis in order to differentiate it from other causes of lower abdominal pain. GPs can play an invaluable role in the outcome of this condition as early referral can result in timely surgical intervention that leads to reduced morbidity.

An Occult Presentation of Appendicitis in a Patient with Tetraplegia

A 26-yr-old man with a C4 American Spinal Injury Association impairment scale B spinal cord injury was admitted due to a left calf pressure ulcer. The patient's initial laboratory results and physical examination findings were unremarkable, except for a stage IV pressure ulcer. On day 7, the patient developed fever and leukocytosis. A complete culture workup performed did not yield abnormalities. A computed tomography scan of the abdomen and pelvis revealed retrocecal appendicitis with a retrocecal abscess containing an appendicolith. The abscess was drained percutaneously, and the patient was given a 6-wk course of intravenous antibiotics. The patient returned to the hospital 30 days later for an appendectomy. Typical signs of appendicitis can be masked in patients with a spinal cord injury. It is crucial to include appendicitis in the differential diagnosis of this population, even though the presentation is as nonspecific as fever and leukocytosis.

′PEN′ appendicitis

We report a three-year-old boy who ingested the tip of a pen and presented with signs of appendicitis. Plain abdominal radiographs showed the foreign body in the right iliac fossa. Surgical exploration revealed perforated appendix and the foreign body in its lumen. Appendectomy resulted in satisfactory recovery.

Computed tomography findings mimicking appendicitis as a manifestation of colorectal cancer

The primary computed tomography (CT) signs of appendicitis can also be seen with other inflammatory or neoplastic processes. We report on two cases in which appendiceal dilatation and peri-appendiceal fluid or stranding were the dominant imaging manifestations of colorectal carcinoma in the ascending colon. This study highlights the need to closely examine the ascending colon in patients with a suspected CT diagnosis of acute appendicitis, since these findings may be secondary to an inconspicuous colorectal carcinoma.

Leukocytes, C-Reactive Protein and Interleukin-6 in Acute Appendicitis in Children: Diagnostic Value and Association with Histological Findings

Background: Many efforts have been made to find diagnostic tools that would help select children with clinical signs of acute appendicitis that would need immediate appendectomy and to find tools that would reduce the numbers of negative appendectomies. Aim: We aimed to show the association between leukocyte count, level of C-reactive protein and interleukin-6 in peripheral blood on the one side and the degree of histological findings on appendix after appendectomy on the other side in children with high clinical probability for appendicitis (Alvarado score>7). Methods: We analyzed 80 patients of both genders, younger than 15 years, with Alvarado score>7, which underwent open appendectomy with subsequent histological analysis of removed appendices. We sampled 20 consecutive cases without signs of inflammation (group I), 20 cases with pathological signs of incipient inflammation (group II), 20 cases with signs of phlegmonous inflammation (group III) and 20 cases with signs of perforated appendix (group IV). Prior to appendectomy, a peripheral blood was sampled and sent for analysis of leukocyte count and C-reactive protein and interleukine-6 level. We compared values of all 3 measured parameters according to histological findings; we also used Receiver Operating Characteristics (ROC) analysis in order to evaluate diagnostic thresholds for detecting the histological signs of appendicitis. Results: The lowest values of all observed parameters were found in group of negative appendicitis while highest were observed in the group of perforated appendicitis. We have observed a significant between group differences in values of all three parameters according to the degree of histological inflammation (p<0.001). ROC analysis demonstrated that interleukine-6 had the best diagnostic performance in detecting patients with histological signs of appendicitis (AUROC=0.99; 95% CI=0.99-1.00) when compared to CRP and leukocyte count (p<0.05). There was no significant difference in diagnostic performance between CRP and leukocytes counts (p=0.35). Conclusion: Leukocyte count, CRP and interleukine-6 are very useful markers which may help in diagnostics and differentiation of phlegmonous and perforated appendicitis. In patients with high probability of appendicitis, measurement of interleukine-6 may help in better patient selection.

Epiploic Appendagitis in a Female Patient with Situs Ambiguous Abnormality

We report the case of a 23 year-old obese female, with previously diagnosed situs inversus below the diaphragm, who presented with severe left upper quadrant abdominal pain. The patient was believed to have a surgical indication, possibly appendicitis or diverticulitis, and had an emergent abdominal Computed Tomography (CT) scan. The CT was interpreted as epiploic appendagitis with no signs of appendicitis. Epiploic appendagitis is a rare cause of acute abdominal pain, which involves the torsion and eventual necrosis of one of the epiploic appendages. This case was complicated by the fact that the patient had situs inversus below the diaphragm, which made it difficult to relate her localized abdominal pain to the correct anatomic area. The diagnosis allowed the patient to avoid invasive surgery and instead opt for conservative medical management. The utilization of radiologic imaging is of utmost importance in diagnosing this condition, which has characteristic findings on CT, US, and MR, all of which is discussed in this article.

Rechtsseitige Unterbauchschmerzen mit atypischem Befund

We present a 57-year old male patient with symptoms of an acute appendicitis. Surprisingly, preoperative sonography revealed an atypical cystic mass in the right lower quadrant of the abdomen with signs of sedimentation. Laparoscopy showed a ruptured appendiceal mucocele with peritoneal adherent mucus. The patient was treated with ileocecal resection. Histopathological examination revealed an infiltrating mucinous cystadenocarcinoma of the appendix. The patient will be treated with adjuvant intraperitoneal chemotherapy. Despite typical clinical signs of appendicitis a sonographically atypical cystic mass in the right lower abdomen should raise suspicion of a mucocele, eventually on the base of a neoplasm.

Incidence of Appendicitis When the Appendix Can't Be Seen

Signs of appendicitis on helical computed tomography (CT) scans include distended appendix, appendiceal or bowel-wall thickening, abscess formation,

AN APPENDICEAL ADENOMA

A 64 years old African American Male presented after being referred for colorectal screening. Colonoscopy showed the presence of a pedunculated appendiceal and a transverse colon polyp. Biopsy of the appendiceal polyp was performed in addition to polypectomy of the transverse colon polyp. Histological evaluation showed a Tubular adenoma of the appendix. Repeat colonoscopy and snare polypectomy was performed without any complication. The presence of adenomatous polyp of the appendix is an uncommon entity. The reported incidence of appendiceal neoplasms in the available literature is 0.1%. Adenomatous polyps behave in the same manner when it comes to progression to adenocarcinoma as their counterparts in different parts of the colon (1, 2). The majority of adenocarcinomas cause symptoms and signs of appendicitis (3). Other presentations of appendiceal polyps include intussusceptions and spontaneous inversion (4). Treatment of an appendiceal polyp can be a challenge since an inverted diverticulae can have a similar picture and cause peritonitis if polypectomy isperformed. Colonoscopy with polypectomy is an option for the treatment of appendiceal polyps. If the lesion is inaccessible, laparoscopic appendectomy can be performed.

Surgical validation of unenhanced helical computed tomography in acute appendicitis.

Surgery for pain in the right lower quadrant of the abdomen remains a clinical dilemma. This prospective study assessed the accuracy of preoperative unenhanced helical computed tomography (CT) in the evaluation of patients with suspected acute appendicitis. One hundred and three adult patients with suspected acute appendicitis underwent unenhanced helical CT of the abdomen. Subsequently, all patients underwent laparoscopic inspection of the abdominal cavity by a surgeon who was blinded to the diagnosis suggested by CT. Patients underwent appropriate surgical therapy accordingly. Follow-up was at least 6 weeks. Appendicitis was diagnosed by CT in 83 patients (80.6 per cent). Acute appendicitis was identified during laparoscopy in 87 patients (84.5 per cent). Prospective interpretation of CT images yielded a sensitivity of 95.4 per cent and a specificity of 100 per cent for the diagnosis of acute appendicitis. There were four false-negative scans. In 12 of 20 patients without signs of appendicitis on CT, the scan established the presence of other pathology. At operation no additional pathology was observed in this group and all other diagnoses proved to be correct. Plain helical CT in patients with suspected acute appendicitis provides an accurate diagnosis without the disadvantages of contrast enhancement.

Imaging in Appendicitis

In Brief OBJECTIVE Acute abdominal pain in women often presents the clinician with a diagnostic dilemma, especially if it is lower abdominal pain. Appendicitis is frequently entertained as a diagnosis, but until recently, the gold standard diagnostic procedure was operation, carrying a high false-negative rate. In recent years, computed tomographic (CT) scan has been advocated as a diagnostic aid. The purpose of this systematic review was to evaluate the accuracy of CT scan in diagnosing appendicitis. DATA SOURCES: Investigators searched PubMed between January and July 2003 using the terms “CT scan” and “appendicitis” with the limits “All adults 19+ years” and “English [language].” In addition, reference lists of all obtained articles were reviewed for other potential citations. METHODS OF STUDY SELECTION: All prospective studies of adults published in English were considered. TABULATION, INTEGRATION, AND RESULTS: Initial searches and reviews yielded 248 citations. Twenty-three of the citations reported prospective studies; only two of these were randomized studies. Prospective studies report sensitivities ranging from 77% to 100%, specificities ranging from 83% to 100%, and accuracies ranging from 88% to 98% for the diagnosis of acute appendicitis. Information gained from CT scans in patients with suspected appendicitis results in alternative diagnosis in 6% to 36%. These values are similar for both men and women. CONCLUSION The data support routine use of CT scan in both men and women for the diagnosis of appendicitis. Computed tomographic scanning is a sensitive and specific diagnostic aid and should be considered in all women presenting with symptoms and signs of appendicitis.

Diagnostic accuracy of focused appendiceal CT in clinically equivocal cases of acute appendicitis.

To determine the diagnostic accuracy of modified focused appendiceal computed tomography (CT) to exclude or confirm appendicitis in patients who presented with equivocal symptoms and signs of appendicitis. One hundred patients (age range, 14-81 years; mean age, 30.6 years) with equivocal symptoms and signs of acute appendicitis were included in this prospective study. Patients were given 30 mL of diatrizoate meglumine and diatrizoate sodium and 60 mL of sorbitol mixed in 1 L of water orally over 1 hour. CT was performed 1.5 hours after the commencement of oral contrast material administration. The criteria used for the diagnosis of appendicitis were (a) appendix greater than 6 mm in maximum diameter, (b) no contrast material in the appendiceal lumen, and (c) inflammatory changes in the periappendiceal fat. CT results were compared with histopathologic findings at appendectomy. Patients with negative CT findings were followed up by telephone or clinically. Of 100 cases, 30 were positive at CT and 70 were negative. There were 28 true-positive cases; two false-positive cases, one cecal diverticulitis and one pelvic peritonitis with periappendicitis; and two false-negative cases, one perforated appendix and one mucosal and submucosal inflammation of the appendix but no transmural inflammation. Sensitivity was 93%, specificity was 97%, and accuracy was 96%. Focused appendiceal CT in which oral contrast material is used alone yields high levels of accuracy in clinically equivocal cases of acute appendicitis.

Why does the clinical diagnosis fail in suspected appendicitis?

To identify systematic errors in surgeons' estimations of the importance of diagnostic variables in the decision to explore patients with suspected appendicitis. Prospective case series. Two emergency departments, Sweden. 496 patients with suspected appendicitis on admission, of whom 194 had a correct operation for appendicitis and 59 had a negative exploration. Predictors of a negative exploration expressed as the odds ratio (OR) for negative exploration. Variables influence on the decision to operate, expressed as the OR for operation, compared with the true diagnostic importance, expressed as the OR for appendicitis. Predictors of negative explorations were high ratings in variables describing pain and tenderness (patient's perceived pain, abdominal tenderness, rebound tenderness, guarding or rectal tenderness), weak or absent inflammatory response, female sex, long duration of symptoms and absence of vomiting, with OR of 1.8-3.0. Pain and tenderness had too strong an influence on the decision to operate whereas the lack of an inflammatory response, no vomiting, and long duration of symptoms were not given enough attention. There was no sex difference in the proportion of patients with non-surgical abdominal pain (NSAP) who were operated on, but NSAP was more common and appendicitis less common among women, leading to a larger proportion of negative appendicectomies among women. Negative explorations in patients with suspected appendicitis are related to systematic errors in the clinical diagnosis with too strong an emphasis on pain and tenderness, and too little attention paid to duration of symptoms and objective signs of inflammation. Rectal tenderness is not a sign of appendicitis. The risk of diagnostic errors is similar in men and women.

Appendiceal and peri-appendiceal air at CT: Prevalence, appearance and clinical significance

Aim: Appendiceal air has been reported as both a sign of appendicitis and of a normal appendix both at plain radiography and computed tomography (CT). It is the aim of this investigation to determine the prevalence, range of appearances, and significance of appendiceal and peri-appendiceal air at CT. Patients and Methods: Appendiceal CT scans of 100 patients with proven appendicitis and 100 patients with a normal appendix were reviewed for the presence of appendiceal and peri-appendiceal air. All cases were correlated with surgical and pathological findings or clinical follow-up. Results: In 100 CT cases of appendicitis, appendiceal and/or peri-appendiceal air was present in one or more forms in 31% of cases. When present, it appeared as intraluminal air bubbles (38.7%) or air-fluid levels (22.6%), appendolith air (41.9%), intramural air (16.1%), peri-appendiceal air bubbles (12.9%), or extraluminal air-fluid level(s) (29.0%). Intramural and extraluminal air correlated with perforation in 60% and 100%, respectively. In 100 CT cases of a normal appendix, air was present in 57%. It was always intraluminal and appeared as small bubbles of air (52.6%), a tubular-shaped air collection (43.9%), or as an air-fluid level (3.5%). The appendiceal lumen was either airless (43%), or minimally (32%), moderately (18%), or completely filled with air (7%). Conclusion: Air is a common finding at appendiceal CT in both the normal and inflamed appendix. Intraluminal air is seen in both appendicitis and normal appendices, and cannot be presumed to indicate a patent lumen and thus a normal appendix. Appendolith, intramural and peri-appendiceal air appear diagnostic of appendicitis.

Self-localization in US of appendicitis: an addition to graded compression.

Graded-compression ultrasound (US) of the right lower quadrant (RLQ) has been a valuable addition to the diagnostic evaluation of acute appendicitis. In an effort to expedite the sonographic evaluation and improve diagnostic accuracy, a method of self-localization was added to the standard graded-compression examination. A total of 236 patients with signs of appendicitis were studied. Eighty-five percent (121 of 142) of the patients with proved appendicitis were able to decisively self-localize their pain. Of the patients without appendicitis who still had significant disease in the RLQ, 88% (29 of 33) were able to self-localize their pain, with an accuracy rate of 86% for significant disease. Among patients without significant disease, only 15% (nine of 61) self-localized their pain. This "sonographic self-localization sign" reduced the time of the examination and was a valuable addition to standard graded-compression US of the appendix.