Appendicitis

Axial CT images through the lower abdomen show a small fecalith in the right lower quadrant with dilatation of the appendix, thickening of its wall and periappendiceal inflammation.

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Radiology. 1999;210:639-643.)
© RSNA, 1999

Acute Appendicitis: Influence of Early Pain Relief on the Accuracy of Clinical and US Findings in the Decision to Operate—A Randomized Trial

Bernard Vermeulen, MD¹, Alfredo Morabia, MD², Pierre-François Unger, MD¹, Catherine Goehring, MD², Christian Grangier, MD³, Igor Skljarov, MD³ and François Terrier, MD³

¹ Emergency Department (B.V., P.F.U.)
² Clinical Epidemiology Division (A.M., C. Goehring)
³ Radiology Department (C. Grangier, I.S., F.T.), Hôpitaux Universitaires de Genève, Rue Micheli-de-Crest 24, CH-1211 Genève 14, Switzerland.

	Abstract

TOP Abstract Introduction MATERIALS AND METHODS RESULTS DISCUSSION References

 
PURPOSE: To determine the influence of early pain relief on the diagnostic performance of ultrasonography (US) and on the appropriateness of the surgical decision.

MATERIALS AND METHODS: A prospective randomized, double-blind placebo-controlled trial with morphine was conducted. A visual analog scale was used to evaluate pain in 340 patients aged 16 years or older. US was performed with a standardized protocol. Diagnosis was confirmed at histologic analysis or, in the patients released without surgery, at follow-up.

RESULTS: One hundred seventy-five patients were injected with morphine, and 165 were injected with the placebo. Pain relief was stronger in the morphine group. In the morphine group, US had lower (71.1%) sensitivity (difference, -9.5%; 95% CI, -18.5%, -0.5%) and higher (65.2%) specificity (difference, 11.4%; 95% CI, 1.0%, 21.8%). This group had also a higher positive predictive value (64.6%) and a lower negative predictive value (71.4%), but the differences between this group and the placebo group were not statistically significant. Among female patients, the decision to operate was appropriate more often in the morphine group (75.8%), but the difference between this group and the placebo group was not statistically significant (5.1%; 95% CI, -7.4%, 17.6%). In male patients and overall, opiate analgesia did not influence the appropriateness of the decision. The appropriateness to discharge patients without surgery was 100% in all groups.

CONCLUSION: Morphine does not improve US-based diagnosis of appendicitis.

Index terms: Anesthesia • Appendicitis, 751.291, 752.291 • Appendix, US, 751.1298, 752.1298 • Ultrasound (US), utilization, 751.1298, 752.1298

	Introduction

TOP Abstract Introduction MATERIALS AND METHODS RESULTS DISCUSSION References

 
Surgeons are reluctant to use opiate analgesia while investigating pain in the right lower part of the abdomen that they suspect is due to appendicitis. They fear that the analgesia will mask the symptomatology and delay the diagnosis. However, in 1979, an editorial in the British Medical Journal (1) suggested the use of opiate analgesia for abdominal pain. Then, the results of the studies by Zoltie and Cust in 1986 (2), Attard et al in 1992 (3), and Pace and Burke in 1996 (4) showed that the use of opiate analgesia for acute abdominal pain did not cause either a delay in diagnosis or drug-related adverse effects.

Pain relief may have beneficial aspects in the diagnosis of appendicitis. Ultrasonography (US) has become a major tool for investigating and diagnosing many abdominal pathologic entities. The reported accuracy of US in diagnosing appendicitis varies between 75% and 90% in sensitivity and between 95% and 100% in specificity (5–8). Technically, the examination of the cecum requires a graded compression of the right lower region of the abdomen, as described by Puylaert (9) or others (10,11). It is reasonable to expect that localized peritonitis may hamper the compression and therefore lower the quality and interpretation of US images. On the other hand, it can also be argued that the presence of pain tends to indicate a positive diagnosis of acute appendicitis and that morphine could mask and therefore decrease the sensitivity of this technique. The problem is that, to our knowledge, no scientific evidence of whether pain can alter the accuracy of US in the right lower region of the abdomen has been reported yet.

We therefore conducted a prospective randomized, double-blind, and placebo-controlled trial on early pain relief with intravenous administration of morphine in patients admitted to an emergency department for pain in the right lower part of the abdomen. The objectives of the trial were to determine the influence of opiate analgesia on the diagnostic performance of US and on the appropriateness of the decision of whether to operate.

	MATERIALS AND METHODS

TOP Abstract Introduction MATERIALS AND METHODS RESULTS DISCUSSION References

 
Eligible patients were male and female patients aged 16 years or older who consulted the emergency department of a university hospital for pain in the right lower part of the abdomen between April 1993 and October 1995. The hospital ethical committee approved the protocol. Exclusion criteria were a previous appendectomy; a clinical presentation highly suggestive of a nonappendicular pathologic condition (eg, renal colic or extrauterine pregnancy); the presence of renal, hepatic, or respiratory insufficiency; and the use of psychotropic medication. Patients who were admitted several times during the study were eligible to participate only once. Of the 488 eligible patients, 350 (72%) participated in the study. They all gave written informed consent.

The medical history was taken and a clinical examination was performed by the emergency department resident who checked the inclusion criteria. All patients were asked to assess their pain by using a 10-cm visual analog scale, or VAS, during the first examination (pain score 1). After providing signed informed consent, the patients were then randomized to receive one of 440 vials specially prepared by the hospital pharmacy for the study. These vials contained either 10 mg of morphine (1 mg/mL) or a placebo (sodium chloride 0.9%). The dose of morphine administered for analgesia was 0.1 mg per kilogram of body weight, which was administered intravenously (50% in 3 minutes, then 50% in 2 minutes). About 45 minutes after the administration of either substance—the morphine or the placebo—the patients were asked to give a second assessment of their level of pain by using the visual analog scale (pain score 2).

US was performed at the latest within the 4 hours after the intravenous injection of morphine or the placebo by the radiologist in the emergency department, who was a second- or third-year resident. A US scanning unit (Acuson, Mountain View, Calif) with 3.5- (convex sectorial for the entire abdomen) and 7.5-MHz (linear for local examination of the appendix) probes was used. The examination was performed by using a standard protocol established by the radiology department. The radiologist had to answer specific questions about the position, diameter, length, and deformability of the appendix and more general questions about the bladder, cecum, distal ileum, pericecal fat, presence of pericecal liquid, and influence of pain on the examination. He or she then had to classify the diagnosis of appendicitis as sure, probable, or absent.

After US, all patients presented to a surgeon for clinical examination, analysis of the radiologic and laboratory results, and therapeutic decision. The decision of the surgeon was not analyzed. Laparoscopic surgery was performed if no major contraindication was present within 24 hours after admission. A histologic diagnosis was obtained in all patients who underwent surgery. Patients who were not operated on and stayed in the ward 24 hours or more for observation were examined again by a surgeon before leaving the hospital. All of these patients were contacted after 30 days for follow-up. The randomization code was broken and communicated to the authors only after all of the data had been collected.

The Student t test for paired and unpaired data was used to compute differences in pain score within the groups (ie, morphine group and placebo group) and between the groups. The heterogeneity of proportions between the two groups was assessed by using probability differences and 95% CIs (12). The analyses were performed with SAS, version 6 software (SAS Institute, Cary, NC). The sensitivity of US was the proportion of histologically confirmed cases of appendicitis that were classified as sure or probable by the radiologist. The specificity of US was the proportion of all patients who were discharged without undergoing surgery, who were not readmitted during the following month, and in whom appendicitis was ruled out by the radiologist. The positive predictive value of US was the proportion of histologically confirmed cases of appendicitis in patients whose US findings were classified as sure or probable for the presence of appendicitis by the radiologist. The negative predictive value was the proportion of non–histologically confirmed cases of appendicitis in patients in whom appendicitis had been ruled out by the radiologist.

Reasons for refusal to participate in the study were no consent from the parents of patients younger than 20 years (n = 22) and communication problems due to foreign language (n = 5).

As shown in the Figure, 350 patients were able to participate in the study, and the medical files of 340 patients could be analyzed. Ten files could not be used because clinical or radiologic information was missing (seven patients), there was no follow-up at 1 month (two patients), or the operation took place before the protocol procedure was completed (one patient).

 

 
One hundred seventy-five patients received an injection of morphine, and 165 received an injection of the placebo. The two groups of patients were comparable with respect to age, sex, leukocytosis, fever, and duration of symptoms.

Overall, 205 patients underwent surgery; in 181 (88%) of these patients, the surgery was laparoscopy. One hundred thirteen (65%) patients in the morphine group and 92 (56%) patients in the placebo group were operated on. Overall, appendicitis (acute, phlegmonous, or perforated) was confirmed histologically in 155 (76%) patients. The corresponding frequencies were 83 (73%) patients in the morphine group who underwent surgery and 72 (78%) patients in the placebo group who underwent surgery. None of the 135 patients who did not undergo surgery and left the hospital after 24 hours of observation was readmitted or operated on at another local hospital.

A normal appendix was diagnosed in 34 patients who underwent surgery (28 [26%] of 107 female patients and six [6%] of 98 male patients). Sixteen patients (13 [12%] of 107 female patients and three [3%] of 98 male patients) had other diagnoses, which included gynecologic pathologic conditions, appendicular carcinoids, peritoneal carcinosis, spontaneous adhesion, appendicular cancer, Crohn disease, or omental infarcts. No adverse effects after the morphine or placebo injection that necessitated the use of naloxone were reported.

The data in Table 1 show that in all the groups the pain score diminished significantly (P = .001) after the injection of morphine or the placebo. The pain relief was, however, stronger in the morphine group (minus about 2 points) than in the placebo group (minus about 1 point). The numbers of patients with positive and with negative diagnoses, as determined at US and at final diagnosis, are shown in Table 2. These numbers were used to compute the statistics presented in Tables 3 and 4.

 

 

 

 
Table 3 shows the sensitivity and specificity of US for the diagnosis of appendicitis in patients with right lower abdominal pain. The diagnostic standards were the histologic diagnosis of appendicitis in patients who underwent surgery and no readmission in those who did not undergo surgery. Surgical findings other than appendicitis were classified as false-positive findings. The sensitivity of US was lower in the female patients who received morphine (65.9%) than in the female patients who received the placebo (84.0%); the difference was statistically significant (-18.1%; 95% CI, -30.0%, -6.2%). The specificity of US was higher in the male patients who received morphine (74.2%) than in the male patients who received the placebo (57.7%); the difference was statistically significant (16.5%; 95% CI, 1.4%, 31.6%). In the total sample, the sensitivity of US was lower (71.1%) and the specificity was higher (65.2%) in the morphine group than in the placebo group; both sets of results were statistically significant (P < .05).

The data in Table 4 show that the prevalence of appendicitis was lower in the female patients (40.2% in the morphine group and 27.2% in the placebo group) than in the male patients (57.5% in the morphine group and 64.4% in the placebo group). Because of the higher prevalence of appendicitis in the male patients, the positive predictive value of US was substantially better in these patients than in the female patients; in both the morphine and the placebo groups, the negative predictive value tended to be higher in the female patients (not statistically significant in the morphine group). In the female patients, morphine injection resulted in a lower negative predictive value (72.6%) than that in the placebo group (89.7%) (difference, -17.1%; 95% CI, -27.8%, -6.4%); this suggests that morphine had masked the US-based diagnosis. On the other hand, the positive predictive value was better in the morphine group (52.9%) than in the placebo group (39.6%), but the difference was not statistically significant. In male patients, both the positive and the negative predictive values were better in the morphine group, but the differences did not reach statistical significance.

The proportion of surgical findings and the appropriateness of the decision of whether to undergo surgery, based on the data in the Figure, are presented in Table 5. Surgical findings included the histopathologic diagnosis of appendicitis or of another pathologic entity. The surgical findings were more frequent in the male patients than in the female patients. The decision to operate was considered to be appropriate when it resulted in surgical findings. The highest probability of an appropriate decision was observed among the male patients in the morphine group (93.6%; 95% CI, 86.6%, 100%). The lowest probability of an appropriate decision was observed among the female patients in the placebo group (70.7%; 95% CI, 56.8%, 84.7%). Among the female patients, the decision to operate was more often appropriate in the morphine group (75.8%), but the difference between this group and the placebo group was not statistically significant (5.1%; 95% CI, -7.4%, 17.6%). In the male patients and overall, opiate analgesia did not influence the appropriateness of the decision to operate.

 
The decision to discharge without surgery was considered to be appropriate when it was not followed by readmission for abdominal pain. Because no patient had to be readmitted after it was decided not to operate, the appropriateness of the decision to discharge without surgery was 100% in all groups (Table 5).

	DISCUSSION

TOP Abstract Introduction MATERIALS AND METHODS RESULTS DISCUSSION References

 
The results of our study show that use of a major analgesic substantially reduces pain in patients. This result is comparable to that of Pace and Burke (4), who, with the same doses of morphine, observed a substantial reduction in pain as measured on a visual analog scale for all types of abdominal pain.

The diagnostic accuracy of US was more contrasted. Morphine tended to decrease sensitivity but increase specificity. This is consistent with the surgeon's concern that analgesia may mask the symptomatology of appendicitis. This was paradoxical; we expected morphine to improve sensitivity because it facilitated the maneuvers of the radiologist and reduced the proportion of false-negative findings. The explanation may be that pain also influences radiologic diagnosis (11,13–15). On the other hand, analgesia appears to be beneficial for specificity, that is, for reducing the proportion of false-positive US-based diagnoses of appendicitis.

As a result, analgesia tended to improve the positive predictive value but worsen the negative predictive value of US. It is of note, however, that the overall differences between the morphine group and the placebo group were not statistically significant. The results of this study could then be interpreted as being basically negative for the influence of morphine on the accuracy of US in the diagnosis of right lower abdominal pain.

But these results confirm those of three other studies (2–4) that showed that the use of a major analgesic (ie, morphine) for abdominal pain does not hinder the diagnostic process. This may be because morphine influences the perception of pain and the affective reaction to it more than it confers complete analgesia.

The most important finding of the present study is that pain relief does not modify the appropriateness of the decision of whether to operate on or discharge the patient. The decision not to operate on a patient with pain in the right lower part of the abdomen has always been appropriate for patients who received morphine as well as for those who did not. The appropriateness of the decision to perform surgery, which is essentially laparoscopy (16), has not been as good, probably because this procedure is relatively noninvasive and because clinicians want a visual diagnosis and thus accept a large proportion of null explorations. With 26% of null laparoscopic explorations in women and 9% in men reported, our results do not differ from those reported in the current literature (17–19).

In conclusion, the results of our study do not demonstrate that the use of analgesia improves the diagnostic performance of US. However, they do not indicate that major analgesia used with a strictly applied protocol for pain in the right lower part of the abdomen has a deleterious effect on the diagnosis of appendicitis or on the decision to perform laparoscopy. Thus, surgeon fear that analgesia will bias the decision is not warranted. This conclusion, however, may not be generalized to other abdominal pathologic entities such as pancreatitis or toxic megacolon, in which opiate analgesia is usually not recommended.

	Acknowledgments

 
We thank Mr. Ba-Lau Luong for the management of the data and the nurses and physicians of the Emergency Department at Hôpitaux Universitaires de Genève for participating in the study.

CASE REPORT

Duodenal obstruction due to appendicular abscess (a case report).

::  Abstract

The obstruction to the third part of duodenum due to appendicular abscess is reported here. The abscess had tracked behind the mesocolon and obstructed the duodenum. The case was treated by drainage of abscess and anterior gastrojejunostomy.

How to cite this article: Hardikar JV. Duodenal obstruction due to appendicular abscess (a case report). J Postgrad Med 1990;36:169-70

How to cite this URL: Hardikar JV. Duodenal obstruction due to appendicular abscess (a case report). J Postgrad Med [serial online] 1990 [cited 2005 Sep 25];36:169-70. Available from: http://www.jpgmonline.com/article.asp?issn=0022-3859;year=1990;volume=36;issue=3;spage=169;epage=70;aulast=Hardikar

::   Introduction

The mortality and morbidity following perforated appendix is unacceptably high. Postoperative complications like intra-abdominal abscesses, septicemia are well known. In the present case, I wish to report the case of intraabdominal abscess causing obstruction to the third part of duodenum.

::   Case report

Mr. D, 25-year-old man previously in good health presented with abdominal pain and fever of 8 days duration. On admission, he was very toxic. The pulse rate was 130/min. and B.P. of 100 mm of Hg. Abdominal examination revealed generalised tenderness, guarding and rigidity. Peristaltic sounds were absent. A clinical diagnosis of perforative peritonitis was made. His investigations were as follows: Hb-9.5 gm %, WBC-14800/cmm, serum Na-130 mEq% and serum K-3.6 mEq%.
Plain X-ray abdomen did not show any characteristic findings except for generalised around glass appearance and few dilated loops of bowel. After initial resuscitation with ringer lactate solution and administration of gentamicin, ampicillin and metronidazol, the patient was explored.
The operative findings were as follows: Peritoneal cavity contained 300 ml of thin purulent fluid-Terminal ileum, caecum and omentuni had formed a mass in right iliac fossa. After separating these adhesions gently, the abscess cavity was found behind the terminal ileal mesentry. The distal portion of appendix was sloughed out and lying free in abscess cavity.
The remaining proximal portion of appendix was removed and the stump was buried in caecal wall. A drain was inserted into abscess cavity. After peritoncal lavage, the abdomen was closed. Early post-operative period was uneventful. After 5th post-operative day when patient was already oil liquid diet, lie started vomiting. At this stage, the oral intake was witliheld. The nasogastric tube was re-inserted and intravenous fluids given. Nasogastric aspirate remained high for nearly 72 hours. A thin barium was ordered to rule out mechanical obstruction which showed obstruction to third pait ot duodenum (see [Figure - 1]). The patient was reexplored. The findings were as follows: 1. Caecum, terinitial ileum and the site of buried appendicular stump were normal. 2. Previous abscess cavity was already contracted. 3. There was an abscess located bellind gastrocolic ligament in front of 3rd part of duodenum. When the abscess was drained after opening the gastrocolic ligament, the cavity was found to be connecting with, the previous abscess through a very small opening. A drain was inserted to abscess cavity and anterior gastrojejunostomy was carried out, Subsequently paticiii made a smooth recovery.

::   Discussion

The incidence of Post-operative complications following appendicectomy is under 5% provided the operation is performed before perforation of appendix. The mortality rate of generalised peritonitis following perforated appendix is still over 5%. Intra-abdominal abscesses do occur following perforated appendix. They occur within 7-14 days after the onset of infection. They are often located in pelvis. They can extend to right subplirenic space, lift paracolic gutter and so on. The clinical manifestations include persistent fever, localised tenderness, a dynamic ilcus, displacement of viscera etc. The downward displacement of fundus and widening the space between fundus and diaphragm has been reported[1].
In present case third part of duodenum was obstructed due to extension of appendicular abscess. This was treated by drainage of abscess and gastrojejunostomy. Since this is a rare complication of intraabdominal abscess, I wish to report this case.

::   Acknowledgment

I wish to thank the Dean, Seth GS Medical College and King Edward Memorial Hospital for allowing me to publish this report.

::   References

1.	Hardy JD. In: "Complications in Surgery and their Management." Philadelphia, London, Toronto and Sydney: WB Saunders Company; 1981, pp 610-614.

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	INTUSSUSCEPTION
>	SIGMOID VOLVULUS

Acute appendicitis results from bacterial invasion usually distal to an obstruction of the lumen. The obstruction is caused by faecaliths, seeds or worms in the lumen or by invasion of the appendix wall by parasites, such as amoeba or schistosomes. Lymphoid hyperplasia following a viral infection has also been implicated. Untreated, the infection progresses to:

::	Local peritonitis with formation of an appendicular mass
::	Abscess formation
::	Gangrene of the appendix
::	Perforation
::	General peritonitis.

Clinical features

Symptoms include:

::	Central abdominal colic, which settles to a burning pain in the right iliac fossa
::	Anorexia, nausea, vomiting and fever.

Physical findings include:

::	Tenderness with localized rigidity in the right lower quadrant over McBurney’s point
::	Rebound tenderness, or tenderness to percussion, in the right lower quadrant
::	Pain in the right lower quadrant after pressing deeply in the left lower quadrant
::	Right sided tenderness on rectal examination.

The differential diagnosis includes:

::	Gastroenteritis
::	Ascariasis
::	Amoebiasis
::	Urinary tract infection
::	Renal or ureteric calculi
::	Ruptured ectopic pregnancy
::	Pelvic inflammatory disease (salpingitis)
::	Twisted ovarian cyst
::	Ruptured ovarian follicle
::	Mesenteric adenitis.

Appendicular mass

This is caused by inflammation and swelling of the appendix, caecum, omentum and distal part of the terminal ileum. Treat conservatively with rest, antibiotics, analgesics and fluids. If the patient’s pain and fever either continue or recur, the mass probably includes an abscess which should be incised and drained.

Technique

Emergency appendectomy

::	With the patient in the supine position, place an 8–10 cm incision over McBurney’s point or the point of maximum tenderness you have previously marked (Figure 7.15). Note that this incision should be smaller in a child. Deepen the incision to the level of the external oblique aponeurosis and cut through this in line with its fibres (Figure 7.16). Split the underlying muscles along the lines of their fibres using blunt dissection with scissors and large straight artery forceps (Figure 7.17). Use a “gridiron” technique by splitting and retracting the muscle layers until the extraperitoneal fat and the peritoneum are exposed. Lift the peritoneum with two pairs of artery forceps to form a tent and squeeze this with your fingers to displace the underlying viscera. Incise the peritoneum between the two pairs of artery forceps.
Figure 7.15
Figure 7.16
Figure 7.17
::	Aspirate any free peritoneal fluid and take a specimen for bacteriological culture. If the appendix is visible, pick it up with a non-toothed or a Babcock forceps. The appendix may be delivered by gently lifting the caecum with the anterior taeniae coli. An inflamed appendix is fragile so deliver it into the wound with great care. The position of the appendix is variable (Figures 7.18 and 7.19). Locate it by following the taeniae coli to the base of the caecum and lifting both the caecum and the appendix into the wound (Figure 7.20).
Figure 7.18
Figure 7.19
Figure 7.20
::	Divide the mesoappendix (containing the appendicular artery) between artery forceps close to the base of the appendix. Ligate it with 0 absorbable suture (Figures 7.21–7.23). Clamp the base of the appendix to crush the wall and reapply the clamp a little further distally (Figures 7.24 and 7.25). Ligate the crushed appendix with 2/0 absorbable suture. Cut the ends of the ligature fairly short and hold them with forceps to help invaginate the appendix stump. Insert a 2/0 absorbable, purse-string suture in the caecum around the base of the appendix (Figure 7.26). Divide the appendix between the ligature and the clamp and invaginate the stump as the purse-string is tightened and tied over it (Figure 7.27). The purse-string is traditional, but optional. Simple ligation is adequate and the preferred technique if insertion of a purse-string is at all difficult.
Figure 7.21
Figure 7.22
Figure 7.23
Figure 7.24
Figure 7.25
Figure 7.26
Figure 7.27
::	Close the abdominal wound using: • Continuous 2/0 absorbable suture for the peritoneum • Interrupted 0 absorbable sutures for the split muscle fibres • Interrupted or continuous 0 absorbable for the external oblique aponeurosis • Interrupted 2/0 monofilament non-absorbable for the skin. If there is severe inflammation or wound contamination, do not close the skin, but pack the skin and subcutaneous layers with damp saline gauze for delayed primary closure.

Intraoperative problems

Intraoperative problems include:

::	Adherent and retrocaecal appendix
::	Appendicular abscess.

Adherent and retrocaecal appendix

Mobilize the caecum by dividing its retroperitoneal attachment and then excise the appendix in a retrograde manner. Ligate and divide the base of the appendix, then invaginate the stump, ligate the vessels in the mesoappendix, and finally remove the appendix.

Appendicular abscess

Treat the abscess with incision and drainage. Consider interval appendectomy if symptoms recur.

>	INTUSSUSCEPTION
>	SIGMOID VOLVULUS

HBO IN COMPLEX TREATING OF INFANTILE PERITONITIS. Practical recommendations. Appendicular peritonitis still remains one of the principle reasons for complications and lethality. That is caused by specifications of infantile body as well as by the complicity of diagnosis and too late start of treating. Application of operations; antibiotics and other medicines isn't enough effective: lethality can be from 2,5% to 20,7%; complications - 4,2 - 85%. In literature of the latest time hypoxia (first - circulatory; then ­tissue one) is mentioned as a compulsory element of peritonitis pathogenesis. It deals with metabolism transgressions; function of paremchymatous organs; intoxication; reduction of hemodynamics; shifts of acid-alkaline balance; intestine paresis; etc. The sicks of infantile age suffer from all of these diseases more severely; the pathology is developing more quickly - this is caused by greater necessity in oxygen (by 3 times) of a young body. Inclusion of  HBO in complex therapy of peritonitis is acquitted for its tremendous abilities of supplying of body with oxygen - this results in diminishment of oxygental deficiency; improvement of metabolism and micro circulation; prevention of vascular thrombosis and inflation; activation of parenchymatous organs and intestine. All this normalizes the homeostasis and improves the results of treating of peritonitis. Clinical observation of 152 sicks of age less than 14 years in Lvov Medical Institution can confirm the efficiency of HBO in treating of infantile peritonitis. Indications  and method of treating. HBO can be beneficial in prophylaxis or treating therapy of peritonitis. It could be applied  in pre-operational and early after-operational period of II and III degrees of disease; especially for young people. HBO is applied in early after-operational period of I degree of disease; application in case of limited peritonitis is permitted individually. The conditional contraindications for its application are otorhinolaryngologic diseases; caverns in lung; epilepsy; hypertension. In case of pneumonia, which often accompanies peritonitis, the approach to the indication of HBO would be individual. The success of application of HBO directly depends on the optimal selection of values of parameters of procedure. These depend on many characteristics of sick; age is one of them. The average clinical figures for HBO are: pressure - 0,8-1,2ATI (for sicks younger 3 years) and 1,5-2ATI for older ones; period - 60 min.; 2 procedures in first day and one -next 1-4 days. The preparation to procedure also depends on many values: indications; kind of hypoxia; complications after the operation; accompanying diseases and individual sensitivity. Preparation of sick to the procedure. The otorhinolaryngologist's consultation is compulsory. For the very little children nose would be cleaned by the stuff. For prophylaxis application of boro-adrenaline drops or 2-3% ephedrine is desirable. Gastric tube can be applied in case of I degree; if the pathology is harder, tube is compulsory to prevent the aspiration; especially in period of compression and decompression. If the chamber is constructed with oxygental mask, the existence of tube violates the isolation; sequenty a special hole would be done in mask. III degree of peritonitis often requires parenteral inlets; this would be done with low frequency of dropping; especially in compression and decompression periods to avoid transgressions of that frequency. If normal regime of parenteral inputting can't be provided, the inlet would be temporary interrupted. Any oil and creams would be cleaned off; when selecting the dress frequent uresis and defecation of such sicks of that age would be taken into account. The improved temperature, if any, would be reduced in ordinary way: during HBO the temperature usually additionally improves. The sedatives are required for children during the procedure; for this sodium oxybutyrate can be used: usually the dose of 80-120 mg/kg of body in 30-40 ml. of 10% glucose solution is enough for the whole time of procedure. If doctor wishes to contact with sick, the dose would be 60 mg/kg. Aminasine or pipolphen  can also be used. Older children would be instructed on their behavior in chamber. Gauges are used for control of patient during the procedure. The most important are: cardiogram; encephalogram; respiratory frequency; phonoentherography and temperature of body. All of them would be checked each 10 min. The values for micro climate in chamber would also be permanently controlled. The patient would be placed horizontally; if the stomach is enlarged, the head would be posed upper than legs. PERSUING OF PROCEDURES. The rules of security would be permanently fulfilled. For younger children the speed of compression would be 0,05 ATI/min.; if pressure above 0,5ATI is permitted, the speed after that level can be improved to 0,1ATI/min. At pressure above 1ATI the shape of breath can change to tachypnea; this phenomena disappears after reduction of pressure to 0,5-0,8ATI. The sicks with III degree of disease often represent the change of respiration on restrictive type; the respiratoric deficiency takes place. These sicks are more sensitive to the compression; the pressure for them wouldn't be above 0,8-1ATI. With recreation the loyalty to hyperpressure improves. Decompression for younger children would be done with the speed of 0,05ATI/min.; for older - 0,1ATI/min., when the pressure is lower 1ATI, and 0,2ATI/min., when the pressure is above 1ATI. For sicks with the III degree it would be done with the speed of 0,05 - 0,03 ATI/min. Switching of oxygen takes place at 0,8-1ATI for younger children; 2ATI for older. About micro climate during the procedure: the moisture would steadily improve at 30-35% and achieve the 100% level at the end of procedure; temperature would improve only during the isopression period at 5 C and achieve 28 C. For younger children the climate changes are less sharp: 1-2 C and about 15% of moisture. The regularity of procedures depends on the state of sick and the achieved effects: usually that is twice in first day (as an exclusion - 3 times!); second day and later on ­once a day. HBO is applicable when the compensatory systems are yet repairable and functional changes are reversible. Later application is less useful. Absence of bettering after 2-3 procedures displays the unreversible violations of immunosystem. Further worthening of state displays the existence of complications (purulent foci; commisural ileus), to be treated operationally.   CONTROL OF THE EFFICIENCY OF HBO. Previous therapy, age, degree of disease would be taken into account during the HBO. Treating is efficient if the intoxication significantly reduces in first 2-3 days and majority of functional violations are mastered in 3-5 days. Already in the process of procedure the bettering can be observed: after 15-20 min. skin becomes pale; respiration -deep and regular; pulse index lessens. Arterial pressure doesn't change significantly. the diameter of stomach lessens by 5-6 sm.; frequent uresis and defecation appear; bile is outputted through the gastric tube. The sick becomes more still and less excited. Kidney investigations present the improvement of diuresis; filtration and stream; these are completely normalized after the course for sicks of I and II degree. HBO prevents sharp kidney deficiency in early after-operation period. Reograms of liver present the improvement of circulation - that supplies the regularity in functioning of the whole body. Phonoenterogram would present the normalization of acoustic activity of intestine 1 day after; sometimes - 3 days after first procedure. This is the result of reduction of hypoxia in intestine, bettering of circulation and lessening of pressure there. HBO restores acid-alkaline balance already in the process of procedure; but steady normalization of this can be the result of only the whole course. Tension in venose circulation normalizes already after the first procedure. To estimate the efficiency of HBO in complex treating of peritonitis the analysis of far-off sequences of application are also required.   Professor       A. Troshkov, Doctor      V. Grochovsky.

Acute Appendicitis: Review and Update

D. MIKE HARDIN, JR., M.D.,

Texas A&M University Health Science Center, Temple, Texas

Appendicitis is common, with a lifetime occurrence of 7 percent. Abdominal pain and anorexia are the predominant symptoms. The most important physical examination finding is right lower quadrant tenderness to palpation. A complete blood count and urinalysis are sometimes helpful in determining the diagnosis and supporting the presence or absence of appendicitis, while appendiceal computed tomographic scans and ultrasonography can be helpful in equivocal cases. Delay in diagnosing appendicitis increases the risk of perforation and complications. Complication and mortality rates are much higher in children and the elderly. (Am Fam Physician 1999;60:2027-34.)

Appendicitis is the most common acute surgical condition of the abdomen.¹ Approximately 7 percent of the population will have appendicitis in their lifetime,² with the peak incidence occurring between the ages of 10 and 30 years.³

Despite technologic advances, the diagnosis of appendicitis is still based primarily on the patient's history and the physical examination. Prompt diagnosis and surgical referral may reduce the risk of perforation and prevent complications.⁴ The mortality rate in nonperforated appendicitis is less than 1 percent, but it may be as high as 5 percent or more in young and elderly patients, in whom diagnosis may often be delayed, thus making perforation more likely.¹

Pathogenesis

TABLE 1 Common Symptoms of Appendicitis Common symptoms* Frequency (%) Abdominal pain ~100 Anorexia ~100 Nausea   90 Vomiting   75 Pain migration   50 Classic symptom sequence (vague periumbilical pain to anorexia/nausea/unsustained vomiting to migration of pain to right lower quadrant to low-grade fever)   50 *--Onset of symptoms typically within past 24 to 36 hours. Information from references 3 through 5.

The appendix is a long diverticulum that extends from the inferior tip of the cecum.⁵ Its lining is interspersed with lymphoid follicles.³ Most of the time, the appendix has an intraperitoneal location (either anterior or retrocecal) and, thus, may come in contact with the anterior parietal peritoneum when it is inflamed. Up to 30 percent of the time, the appendix may be "hidden" from the anterior peritoneum by being in a pelvic, retroileal or retrocolic (retroperitoneal retrocecal) position.⁶ The "hidden" position of the appendix notably changes the clinical manifestations of appendicitis.

Obstruction of the narrow appendiceal lumen initiates the clinical illness of acute appendicitis. Obstruction has multiple causes, including lymphoid hyperplasia (related to viral illnesses, including upper respiratory infection, mononucleosis, gastroenteritis), fecaliths, parasites, foreign bodies, Crohn's disease, primary or metastatic cancer and carcinoid syndrome. Lymphoid hyperplasia is more common in children and young adults, accounting for the increased incidence of appendicitis in these age groups.^1,5

History and Physical Examination

Abdominal pain is the most common symptom of appendicitis.³ In multiple studies,^3-5 specific characteristics of the abdominal pain and other associated symptoms have proved to be reliable indicators of acute appendicitis (Table 1). A thorough review of the history of the abdominal pain and of the patient's recent genitourinary, gynecologic and pulmonary history should be obtained.

Anorexia, nausea and vomiting are symptoms that are commonly associated with acute appendicitis. The classic history of pain beginning in the periumbilical region and migrating to the right lower quadrant occurs in only 50 percent of patients.¹ Duration of symptoms exceeding 24 to 36 hours is uncommon in nonperforated appendicitis.¹

TABLE 2 Significant Likelihood Ratios for Symptoms and Signs of Acute Appendicitis Symptom/sign Positive likelihood ratio (LR+) Symptom/sign Negative likelihood ratio (LR-) Right lower quadrant (RLQ) pain 8.0 RLQ pain§ 0 to 0.28† Pain migration 3.2 No similar pain previously|| 0.3 Pain before vomiting 2.8 Pain migration 0.5 Anorexia, nausea and vomiting* Much lower LR+ than RLQ pain, pain migration and pain before vomiting Guarding 0 to 0.54† Rigidity 3.76 Rebound tenderness 0 to 0.86† Psoas sign 2.38 Fever, rigidity and psoas sign¶ Rebound tenderness 1.1 to 6.3† Fever 1.9‡ Guarding and rectal tenderness* Much lower LR+ than rigidity, psoas sign and rebound tenderness NOTE: LR is the amount by which the odds of a disease change with new information, as follows: Likelihood ratio  Degree of change in probability >10 or <0.1  Large (often conclusive) 5 to 10 or 0.1 to 0.2  Moderate 2 to 5 or 0.2 to 0.5  Small (but sometimes important) 1 to 2 or 0.5 to 1  Small (rarely important) *--These symptoms and signs have much lower LR+. †--Ratios are presented in ranges for signs and symptoms that had widely varying results in studies. ‡--Fever had only borderline LR+. §--That is, the absence of RLQ pain significantly lowers the odds of having appendicitis. ||--That is, the history of experiencing a similar pain previously lowers the odds of having appendicitis. ¶--These signs have higher LR-. Information from references 7, 8 and 19

In a recent meta-analysis,⁷ likelihood ratios were calculated for many of these symptoms (Table 2). A likelihood ratio is the amount by which the odds of a disease change with new information (e.g., physical examination findings, laboratory results).⁸ This change can be positive or negative. Symptoms such as anorexia, nausea and vomiting commonly occur in acute appendicitis; however, the presence of these symptoms does not necessarily increase the likelihood of appendicitis nor does their absence decrease the likelihood of the diagnosis. Moreover, other symptoms have more notable positive and negative likelihood ratios (Table 2).

TABLE 3 Common Signs of Appendicitis • Right lower quadrant pain on palpation (the single most important sign) • Low-grade fever (38°C [or 100.4°F])--absence of fever or high fever can occur • Peritoneal signs • Localized tenderness to percussion • Guarding • Other confirmatory peritoneal signs (absence of these signs does not exclude appendicitis) • Psoas sign--pain on extension of right thigh (retroperitoneal retrocecal appendix) • Obturator sign--pain on internal rotation of right thigh (pelvic appendix) • Rovsing's sign--pain in right lower quadrant with palpation of left lower quadrant • Dunphy's sign--increased pain with coughing • Flank tenderness in right lower quadrant (retroperitoneal retrocecal appendix) • Patient maintains hip flexion with knees drawn up for comfort Information from references 3 through 5.

A careful, systematic examination of the abdomen is essential. While right lower quadrant tenderness to palpation is the most important physical examination finding, other signs may help confirm the diagnosis (Table 3). The abdominal examination should begin with inspection followed by auscultation, gentle palpation (beginning at a site distant from the pain) and, finally, abdominal percussion. The rebound tenderness that is associated with peritoneal irritation has been shown to be more accurately identified by percussion of the abdomen than by palpation with quick release.¹

As previously noted, the location of the appendix varies. When the appendix is hidden from the anterior peritoneum, the usual symptoms and signs of acute appendicitis may not be present. Pain and tenderness can occur in a location other than the right lower quadrant.⁶ A retrocecal appendix in a retroperitoneal location may cause flank pain. In this case, stretching the iliopsoas muscle can elicit pain. The psoas sign is elicited in this manner: the patient lies on the left side while the examiner extends the patient's right thigh (Figures 1a and 1b). In contrast, a patient with a pelvic appendix may show no abdominal signs, but the rectal examination may elicit tenderness in the cul-de-sac. In addition, an obturator sign (pain on passive internal rotation of the flexed right thigh) may be present in a patient with a pelvic appendix³ (Figures 2a and 2b).

FIGURE 1A. The psoas sign. Pain on passive extension of the right thigh. Patient lies on left side. Examiner extends patient's right thigh while applying counter resistance to the right hip (asterisk). FIGURE 1B. Anatomic basis for the psoas sign: inflamed appendix is in a retroperitoneal location in contact with the psoas muscle, which is stretched by this maneuver.

FIGURE 2A. The obturator sign. Pain on passive internal rotation of the flexed thigh. Examiner moves lower leg laterally while applying resistance to the lateral side of the knee (asterisk) resulting in internal rotation of the femur. FIGURE 2B. Anatomic basis for the obturator sign: inflamed appendix in the pelvis is in contact with the obturator internus muscle, which is stretched by this maneuver.

The differential diagnosis of appendicitis is broad, but the patient's history and the remainder of the physical examination may clarify the diagnosis (Table 4). Because many gynecologic conditions can mimic appendicitis, a pelvic examination should be performed on all women with abdominal pain. Given the breadth of the differential diagnosis, the pulmonary, genitourinary and rectal examinations are equally important. Studies have shown, however, that the rectal examination provides useful information only when the diagnosis is unclear and, thus, can be reserved for use in such cases.⁵

TABLE 4 Differential Diagnosis of Acute Appendicitis Gastrointestinal Abdominal pain, cause unknown Cholecystitis Crohn's disease Diverticulitis Duodenal ulcer Gastroenteritis Intestinal obstruction Intussusception Meckel's diverticulitis Mesenteric lymphadenitis Necrotizing enterocolitis Neoplasm (carcinoid, carcinoma, lymphoma) Omental torsion Pancreatitis Perforated viscus Volvulus Gynecologic Ectopic pregnancy Endometriosis Ovarian torsion Pelvic inflammatory disease Ruptured ovarian cyst (follicular, corpus luteum) Tubo-ovarian abscess Systemic Diabetic ketoacidosis Porphyria Sickle cell disease Henoch-Schönlein purpura Pulmonary Pleuritis Pneumonia (basilar) Pulmonary infarction Genitourinary Kidney stone Prostatitis Pyelonephritis Testicular torsion Urinary tract infection Wilms' tumor Other Parasitic infection Psoas abscess Rectus sheath hematoma Reprinted with permission from Graffeo CS, Counselman FL. Appendicitis. Emerg Med Clin North Am 1996;14:653-71.

Laboratory and Radiologic Evaluation

If the patient's history and the physical examination do not clarify the diagnosis, laboratory and radiologic evaluations may be helpful. A clear diagnosis of appendicitis obviates the need for further testing and should prompt immediate surgical referral.

Laboratory Tests
The white blood cell (WBC) count is elevated (greater than 10,000 per mm³ [100 3 10⁹ per L]) in 80 percent of all cases of acute appendicitis.⁹ Unfortunately, the WBC is elevated in up to 70 percent of patients with other causes of right lower quadrant pain.¹⁰ Thus, an elevated WBC has a low predictive value. Serial WBC measurements (over 4 to 8 hours) in suspected cases may increase the specificity, as the WBC count often increases in acute appendicitis (except in cases of perforation, in which it may initially fall).⁵

In addition, 95 percent of patients have neutrophilia¹ and, in the elderly, an elevated band count greater than 6 percent has been shown to have a high predictive value for appendicitis.⁹ In general, however, the WBC count and differential are only moderately helpful in confirming the diagnosis of appendicitis because of their low specificities.

A more recently suggested laboratory evaluation is determination of the C-reactive protein level. An elevated C-reactive protein level (greater than 0.8 mg per dL) is common in appendicitis, but studies disagree on its sensitivity and specificity.^4,5 An elevated C-reactive protein level in combination with an elevated WBC count and neutrophilia are highly sensitive (97 to 100 percent). Therefore, if all three of these findings are absent, the chance of appendicitis is low.⁵

In patients with appendicitis, a urinalysis may demonstrate changes such as mild pyuria, proteinuria and hematuria,¹ but the test serves more to exclude urinary tract causes of abdominal pain than to diagnose appendicitis.

FIGURE 3. Ultrasonogram showing longitudinal section (arrows) of inflamed appendix.

Radiologic Evaluation
The options for radiologic evaluation of patients with suspected appendicitis have expanded in recent years, enhancing and sometimes replacing previously used radiologic studies.

Plain radiographs, while often revealing abnormalities in acute appendicitis, lack specificity and are more helpful in diagnosing other causes of abdominal pain. Likewise, barium enema is now used infrequently because of the advances in abdominal imaging.⁵

Ultrasonography and computed tomographic (CT) scans are helpful in evaluating patients with suspected appendicitis.¹¹ Ultrasonography is appropriate in patients in which the diagnosis is equivocal by history and physical examination. It is especially well suited in evaluating right lower quadrant or pelvic pain in pediatric and female patients. A normal appendix (6 mm or less in diameter) must be identified to rule out appendicitis. An inflamed appendix usually measures greater than 6 mm in diameter (Figure 3), is noncompressible and tender with focal compression. Other right lower quadrant conditions such as inflammatory bowel disease, cecal diverticulitis, Meckel's diverticulum, endometriosis and pelvic inflammatory disease can cause false-positive ultrasonography results.¹²

TABLE 5 Comparison of Ultrasound and Appendiceal CT Evaluation of Suspected Appendicitis Comparison graded ultrasound Appendiceal computed tomographic scan Sensitivity 85% 90 to 100% Specificity 92% 95 to 97% Use Evaluate patients with equivocal diagnosis of appendicitis Evaluate patients with equivocal diagnosis of appendicitis Advantages Safe Relatively inexpensive Can rule out pelvic disease in females Better for children More accurate Better identifies phlegmon and abscess Better identifies normal appendix Disadvantages Operator dependent Technically inadequate studies due to gas Pain Cost Ionizing radiation Contrast Information from references 11, 13, 20.

CT, specifically the technique of appendiceal CT, is more accurate than ultrasonography (Table 5). Appendiceal CT consists of a focused, helical, appendiceal CT after a Gastrografin-saline enema (with or without oral contrast) and can be performed and interpreted within one hour. Intravenous contrast is unnecessary.¹² The accuracy of CT is due in part to its ability to identify a normal appendix better than ultrasonography.¹³ An inflamed appendix is greater than 6 mm in diameter, but the CT also demonstrates periappendiceal inflammatory changes¹⁴ (Figures 4 and 5). If appendiceal CT is not available, standard abdominal/pelvic CT with contrast remains highly useful and may be more accurate than ultrasonography.¹²

Treatment

The standard for management of nonperforated appendicitis remains appendectomy. Because prompt treatment of appendicitis is important in preventing further morbidity and mortality, a margin of error in over-diagnosis is acceptable. Currently, the national rate of negative appendectomies is approximately 20 percent.¹⁵ Some studies have investigated nonoperative management with parenteral antibiotic treatment, but 40 percent of these patients eventually required appendectomy.³

Appendectomy may be performed by laparotomy (usually through a limited right lower quadrant incision) or laparoscopy. Diagnostic laparoscopy may be helpful in equivocal cases or in women of childbearing age, while therapeutic laparoscopy may be preferred in certain subsets of patients (e.g., women, obese patients, athletes).¹⁶

While laparoscopic intervention has the advantages of decreased postoperative pain, earlier return to normal activity and better cosmetic results, its disadvantages include greater cost and longer operative time.⁴ Open appendectomy may remain the primary approach to treatment until further cost and benefit analyses are conducted.

FIGURE 4. Computed tomographic scan showing cross-section of inflamed appendix (A) with appendicolith (a).

FIGURE 5. Computed tomographic scan showing enlarged and inflamed appendix (A) extending from the cecum (C).

Complications

The classic history of pain beginning in the periumbilical region and migrating to the right lower quadrant occurs in only 50 percent of patients.

Appendiceal rupture accounts for a majority of the complications of appendicitis. Factors that increase the rate of perforation are delayed presentation to medical care,¹⁷ age extremes (young and old)¹⁸ and hidden location of appendix.⁶ A brief period of in-hospital observation (less than six hours) in equivocal cases does not increase the perforation rate and may improve diagnostic accuracy.¹⁸

Diagnosis of a perforated appendix is usually easier (although immediately after rupture, the patient's symptoms may temporarily subside). The physical examination findings are more obvious if peritonitis generalizes, with a more generalized right lower quadrant tenderness progressing to complete abdominal tenderness. An ill-defined mass may be felt in the right lower quadrant. Fever is more common with rupture, and the WBC count may elevate to 20,000 to 30,000 per mm³ (200 to 300 3 10⁹ per L) with a prominent left shift.³

A periappendiceal abscess may be treated immediately by surgery or by nonoperative management.⁴ Nonoperative management consists of parenteral antibiotics with observation or CT-guided drainage, followed by interval appendectomy six weeks to three months later.¹

Special Considerations

The technique of appendiceal computed tomography is more accurate than ultrasonography in confirming the diagnosis of appendicitis.

While appendicitis is uncommon in young children, it poses special difficulties in this age group. Young children are unable to relate a history, often have abdominal pain from other causes and may have more nonspecific signs and symptoms. These factors contribute to a perforation rate as high as 50 percent in this group.¹

In pregnancy, the location of the appendix begins to shift significantly by the fourth to fifth months of gestation. Common symptoms of pregnancy may mimic appendicitis, and the leukocytosis of pregnancy renders the WBC count less useful. While the maternal mortality rate is low, the overall fetal mortality rate is 2 to 8.5 percent, rising to as high as 35 percent in perforation with generalized peritonitis. As in nonpregnant patients, appendectomy is the standard for treatment.³

Elderly patients have the highest mortality rates. The usual signs and symptoms of appendicitis may be diminished, atypical or absent in the elderly, which leads to a higher rate of perforation. More frequent perforation combined with a higher incidence of other medical problems and less reserve to fight infection contribute to a mortality rate of up to 5 percent or more.¹

Final Comment

Prompt diagnosis of appendicitis ensures timely treatment and prevents complications. Because abdominal pain is a common presenting symptom in outpatient care, family physicians serve an important role in the diagnosis of appendicitis. Obvious cases of appendicitis require urgent referral, while equivocal cases warrant further evaluation and, many times, surgical consultation.

The author thanks Glen Cryer, Department of Publications, Scott and White Memorial Hospital, Temple, Tex., for help with the manuscript.

Figures 3 through 5 were provided by Michael L. Nipper, M.D., Department of Radiology, Scott and White Memorial Hospital, Temple, Tex.

---

The Author

D. MIKE HARDIN, JR., M.D.,
is an assistant professor in the Department of Family Medicine at Scott & White Clinic and Memorial Hospital, Bellmead, Tex., affiliated with Texas A&M University Health Science Center in Temple. Dr. Hardin graduated from the University of Texas Medical School at Houston and completed a residency in family practice at the McLennan County Medical Education and Research Foundation, Waco, Tex.

Address correspondence to D. Mike Hardin, Jr., M.D., 556 North Loop 340, Bellmead, TX 76705. Reprints are not available from the author.

Improving the Diagnosis of Appendicitis in Children

Because appendicitis in children frequently mimics other processes, diagnosis can be difficult. Although ultrasound examination can improve diagnostic certainty, its success is operator-dependent, and it does not usually show a retrocecal or noninflamed appendix. Peña and colleagues devised a study to see if use of ultrasonography plus computed tomography with rectal contrast (CT-RC) could improve diagnosis of appendicitis and decrease use of resources in children.

Patients with signs and symptoms of acute appendicitis who were between three and 21 years of age were included as long as they were not pregnant, had no contraindications to rectal contrast medium and had not had an appendectomy. Children with unequivocal presentations underwent appendectomy immediately. Patients with equivocal findings were enrolled in the protocol. Each child initially had a pelvic ultrasound examination.

A positive ultrasound result was defined as visualization of a distended, fluid-filled, noncompressible structure that was at least 6 mm in diameter. This mass also had to have no peristalsis, a stable shape and position, and a location consistent with the appendix (anterior to the psoas muscle or retrocecal). A definitive ultrasound result consistent with the clinical presentation led to a laparotomy. An equivocal ultrasound result, or one in which the appendix was not visualized, led to CT-RC, which was performed as follows: a slow, controlled rectal drip of 200 to 1,000 mL of diatrizoate meglumine (Gastrografin) was administered, followed by CT scanning from the tip of L3 to the acetabular roof. Visualization of an abnormal appendix or pericecal inflammation (or abscess) with a fluid-filled tubular structure more than 6 mm in diameter, or inflammatory changes around the appendiceal area (such as fat stranding, abscess or phlegmon) were defined as positive findings.

The likelihood (on a 1 to 10 scale) of each patient's actually having appendicitis was determined by a surgeon after the ultrasound examination and the CT-RC. Each patient was essentially assigned to one of three treatment plans: discharge, observation or surgery. Those who did not have surgery were followed by telephone two weeks after being seen in the emergency department. In those who had an appendectomy, the diagnosis was confirmed by pathologic examination of the appendix.

Of 177 children initially evaluated, 2.3 percent were discharged, and 19.2 percent went directly to surgery. Most of these (88 percent) had pathologically proven appendicitis (30 percent of these were perforated).

This left 139 patients to be evaluated in the study. Thirty-one of these had ultrasonography only; of these, 19 went directly to surgery after the ultrasound examination. All 19 of these patients had confirmed appendicitis after surgery. The other 11 patients in whom the ultrasound result was negative had the following resolutions: 64 percent of these had resolved symptoms, 18 percent had a normal appendix on ultrasound examination, 9 percent had another diagnosis and 9 percent could not tolerate the rectal contrast (this last child subsequently returned to the hospital with a perforated appendix). In the final group, 108 patients had CT-RC after an equivocal or negative ultrasound result. About one third (29 percent) of these had appendectomy after the CT examination. Appendicitis was found in 90 percent of these patients. One fourth (23 percent) of the children were admitted for observation; only one of these children had appendicitis. The remainder of the group (48 percent) were discharged; none had appendicitis.

The authors conclude that use of CT-RC was more beneficial than ultrasonography in the diagnosis of acute appendicitis in children. That is, there was a beneficial change in management decisions in 18.7 percent of children evaluated with ultrasonography, and a 73.1 percent beneficial change in those evaluated with CT-RC in addition. Although the predictive value of a positive ultrasound result is high (and unnecessary radiation could thus be avoided), the authors conclude that CT-RC can be helpful in children whose diagnosis of appendicitis remains unclear after clinical and ultrasound evaluation.

GRACE BROOKE HUFFMAN, M.D.

Peña BMG, et al. Ultrasonography and limited computed tomography in the diagnosis and management of appendicitis in children. JAMA September 15, 1999;282:1041-6.

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Imaging for Suspected Appendicitis

JERRY L. OLD, M.D., REGINALD W. DUSING, M.D., WENDELL YAP, M.D., and JARED DIRKS, M.D.
University of Kansas School of Medicine, Kansas City, Kansas

Acute appendicitis is the most common reason for emergency abdominal surgery and must be distinguished from other causes of abdominal pain. Family physicians play a valuable role in the early diagnosis and management of this condition. However, the overall diagnostic accuracy achieved by traditional history, physical examination, and laboratory tests has been approximately 80 percent. The ease and accuracy of diagnosis varies by the patient's sex and age, and is more difficult in women of childbearing age, children, and elderly persons. If the diagnosis of acute appendicitis is clear from the history and physical examination, prompt surgical referral is warranted. In atypical cases, ultrasonography and computed tomography (CT) may help lower the rate of false-negative appendicitis diagnoses, reduce morbidity from perforation, and lower hospital expenses. Ultrasonography is safe and readily available, with accuracy rates between 71 and 97 percent, although it is highly operator dependent and difficult in patients with a large body habitus. While there is controversy regarding the use of contrast media and which CT technique is best, the accuracy rate of CT scanning is between 93 and 98 percent. Disadvantages of CT include radiation exposure, cost, and possible complications from contrast media. (Am Fam Physician 2005;71:71-8. Copyright© 2005 American Academy of Family Physicians.)

A PDF version of this document is available. Download PDF now (8 pages /340 KB).   See page 19 for strength-of-recommendation labels.

Appendicitis remains the most common acute surgical condition of the abdomen. In 1997, more than 260,000 new cases occurred in the United States. The overall lifetime occurrence is approximately 12 percent in men and 25 percent in women.1-3

Because abdominal pain is a common presenting complaint in the outpatient setting, family physicians serve an important role in the rapid diagnosis of acute appendicitis. Accurate and timely diagnosis of acute appendicitis is essential to minimize morbidity. Prompt surgical treatment may reduce the risk of appendix perforation. The case-fatality rate of appendicitis jumps from less than 1 percent in nonperforated cases to 5 percent or higher when perforation occurs.4

The diagnosis of appendicitis traditionally has been based on clinical features found primarily in the patient's history and physical examination.5 An elevated white blood cell count has a low predictive value for appendicitis because it is present in a number of conditions.6 While the clinical diagnosis of appendicitis may be straightforward in patients with classic signs and symptoms, atypical presentations can result in delays in treatment, unnecessary hospital admissions for observation, and unnecessary surgery.

Unnecessary surgery for suspected appendicitis exposes patients to increased risks, morbidity, and expense. In 1997, 261,134 patients underwent nonincidental appendectomies in the United States. However, 39,901 (15.3 percent) of the appendixes removed showed no pathologic features of appendicitis.1

Diagnostic accuracy achieved by history and physical examination has remained at about 80 percent in men and women (men are diagnosed accurately 78 to 92 percent of the time, and women 58 to 85 percent of the time).5 Recently, imaging techniques such as ultrasonography, computed tomography (CT), and magnetic resonance imaging (MRI) were evaluated as diagnostic modalities in acute appendicitis and were shown to improve diagnostic accuracy and patient outcomes. However, the routine use of imaging studies in all patients is not well established.

Pathophysiology

The appendix in an adult is a diverticulum arising from the posteromedial wall of the cecum. It averages 10 cm in length. The base of the appendix is fixed to the cecum, while the remainder of the appendix is free. This fact accounts for its variable location (i.e., retrocecal, subcecal, retroileal, pre-ileal, or pelvic) and explains much of the diversity in clinical presentations among patients with acute appendicitis.7

The pathophysiology of appendicitis begins with obstruction of the narrow appendiceal lumen. Obstruction has many sources, including fecaliths, lymphoid hyperplasia (related to viral illnesses such as upper respiratory infections, mononucleosis, or gastroenteritis), gastrointestinal parasites, foreign bodies, and Crohn's disease. Continued secretion of mucus from within the obstructed appendix results in elevated intraluminal pressure, leading to tissue ischemia, over-growth of bacteria, transmural inflammation, appendiceal infarction, and possible perforation.8,9 Inflammation may then quickly extend into the parietal peritoneum and adjacent structures.

Clinical Findings

In a typical presentation, the three clinical findings with the highest predictive value for acute appendicitis are right lower quadrant pain, abdominal rigidity, and migration of pain from the periumbilical region to the right lower quadrant.7 These classic findings occur in about 50 percent of patients,5 however, making missed diagnosis of appendicitis a common successful malpractice claim against family and emergency department physicians.10 Table 16,11 summarizes the prevalence of common signs and symptoms of appendicitis.

TABLE 1 Prevalence of Common Signs and Symptoms of Appendicitis Sign or symptom Frequency (%) Abdominal pain 99 to 100 Right lower quadrant pain or tenderness 96 Anorexia 24 to 99 Nausea 62 to 90 Low-grade fever 67 to 69 Vomiting 32 to 75 Pain migration from periumbilical area to the right lower quadrant 50 Rebound tenderness 26 Right lower quadrant guarding 21 Information from references 6 and 11.

Unusual presentations occur when the appendix is not in its normal location, when the patient is young or elderly, and when the patient is a woman of childbearing age or is pregnant.12-14

The single most important physical finding is right lower quadrant pain on palpation of the abdomen. Other findings include low-grade fever, peritoneal signs, and guarding. In addition, the physical signs (Table 2)8,9,15 resulting from various maneuvers designed to elicit peritoneal pain can be helpful in the diagnosis.15

TABLE 2 Common Signs of Acute Appendicitis Sign Description McBurney sign Localized right lower quadrant pain or guarding on palpation of the abdomen (the single most important sign) Psoas sign Pain on hyperextension of right thigh (often indicates retroperitoneal retrocecal appendix) Obturator sign Pain on internal rotation of right thigh (pelvic appendix) Rovsing sign Pain in the right lower quadrant with palpation of the left lower quadrant Dunphy's sign Increased pain in the right lower quadrant with coughing Hip flexion Patient maintains hip flexion with knees drawn up for comfort Other peritoneal signs Rebound tenderness, hyperesthesia of the skin in the right lower quadrant note: The absence of these signs does not exclude appendicitis. Information from references 8, 9, and 15.

In a recent meta-analysis,5 no single clinical finding was found to effectively rule in or rule out acute appendicitis. Diagnosis is particularly difficult in women of childbearing age because acute gynecologic conditions (e.g., pelvic inflammatory disease) may cause symptoms similar to appendicitis. Therefore, false-negative appendectomy (i.e., removal of a normal appendix) rates have been reported to be as high as 47 percent in female patients who are 10 to 39 years of age.5

Management Options

If the diagnosis of appendicitis is clear from the patient's history and physical examination, no further testing is needed, and prompt surgical referral is warranted.15 When the diagnosis is not clear, management options for suspected appendicitis include observation in a hospital, diagnostic imaging to clarify the diagnosis, laparoscopy, and appendectomy. Imaging studies are cost effective if a definitive diagnosis can be made and observation in a hospital can be avoided.16 Surgical removal of a normal appendix adds to increased morbidity and higher medical costs.

More importantly, imaging studies of patients with an uncertain diagnosis may reduce the rate of perforation, and thus reduce morbidity, mortality, and postoperative hospital stays.5

Radiologic Evaluation

If the diagnosis of appendicitis is suspected, a number of radiologic modalities may improve patient outcomes.12,17-19

Plain radiography (Figure 1) is not specific, generally is not cost effective, and can be misleading in this situation.20 In fewer than 5 percent of patients, an opaque fecalith may be apparent in the right lower quadrant. Plain abdominal films generally are not recommended unless other conditions (e.g., perforation, intestinal obstruction, ureteral calculus) are suspected.8 Likewise, as advanced cross-sectional imaging techniques have become available, barium enema is now used infrequently.9

Figure 1. Plain radiographic image of the abdomen revealing an appendicolith (arrow) in the right lower quadrant.

ultrasonography

Ultrasonography (Figure 2) is inexpensive, safe, and widely available. Diagnostic accuracy, reported to range from 71 to 97 percent,21,22 is highly dependent on operator skill. Ultrasonography is especially useful in women who are pregnant or of childbearing age, and in children. Major advantages to ultrasonography include noninvasiveness, short acquisition time, lack of radiation exposure, and potential for discovering other causes of abdominal pain (e.g., ovarian cysts, ectopic pregnancy, tubo-ovarian abscess).

Figure 2. (Top) Transverse ultrasound image of the right lower quadrant of the abdomen (left view, noncompressed; right view, compressed) revealing a thick-walled, noncompressible tubular structure (an inflamed appendix) with a shadowing appendicolith (arrow), and (bottom) a longitudinal ultrasound image revealing the thick-walled inflamed appendix and appendicolith (arrow) and a small periappendiceal fluid collection.

Criteria for diagnosis of acute appendicitis by ultrasonography are well established and reliable.5,23 The most useful finding on ultrasonography that is suggestive of appendicitis is an outer appendiceal diameter of 6 mm or greater on cross section.24 Periappendiceal findings of inflammatory fat changes frequently are apparent on ultrasonography with acute appendicitis. Findings of appendiceal perforation include loculated pericecal fluid, phlegmon (an ill-defined layer structure of the appendiceal wall) or abscess, prominent pericecal fat, and circumferential loss of the submucosal layer.25

Difficulties with ultrasonography include the fact that a normal appendix must be identified to rule out acute appendicitis.17 Visualization of a normal appendix is more difficult in patients with a large body habitus and when there is an associated ileus, which produces shadowing secondary to overlying gas-filled loops of bowel. Accuracy of ultrasonography also decreases with retrocecal location of the appendix. This is one of the reasons the diagnosis may be in doubt.26

Meckel's diverticulum, cecal diverticulitis, inflammatory bowel disease, pelvic inflammatory disease, and endometriosis can cause false-positive ultrasound results. Patients often complain of discomfort evoked by the transducer pressure during ultrasound evaluation.27

Figure 3. Axial computed tomographic image of an inflamed appendix filled with fluid and an appendicolith (arrow).

Figure 4. Axial computed tomographic image of pericecal inflammatory changes (arrow) and mild free fluid in a patient with ruptured acute appendicitis.

computed tomography

CT is more precise than ultrasonography and more reproducible from hospital to hospital (Figures 3 through 5). It has a diagnostic accuracy rate for acute appendicitis of 93 to 98 percent.11 In a recent meta-analysis, findings on CT increased the certainty of diagnosis more than findings on ultrasonography.28 [Strength of recommendation: B, meta-analysis of studies with inconsistent findings] Therefore, consensus in the literature is moving toward an optimal CT scanning technique for acute appendicitis.27 In the past, three major approaches have been advocated: (1) unenhanced CT of the abdomen and pelvis,29 (2) addition of oral and/or intravenous contrast media,30 and (3) focused appendiceal CT (imaging only the right lower quadrant) using rectally administered contrast media,16,31 although this would exclude abdominal pathology outside the field of view.

Figure 5. Axial computed tomographic image of an inflamed appendix with an appendicolith (arrow) and associated periappendiceal and pericecal free fluid.

Recent investigation indicates that abdominopelvic CT is an appropriate initial approach to imaging patients for acute appendicitis.27 Use of intravenous and oral/rectal contrast media and thin cuts optimizes the study.

The accuracy of CT relies in part on its ability to reveal a normal appendix better than ultrasonography. An inflamed appendix revealed on a CT scan is larger than 6 mm in diameter, and has appendiceal wall thickening and wall enhancement after contrast media infusion.32,33 CT scans also can reveal periappendiceal inflammatory changes, which may include inflammatory fat stranding, phlegmon, free fluid, free air bubbles, abscess, and adenopathy.33

Helical CT also has been shown to be an excellent imaging tool for differentiating appendicitis from most acute gynecologic conditions, thus challenging the use of ultrasonography in women.34 Nevertheless, transvaginal ultrasonography remains the standard if a gynecologic diagnosis is in question following CT.

Disadvantages of CT include possible iodinated-contrast-media allergy, patient discomfort from administration of contrast media (especially if rectal contrast media is used), exposure to ionizing radiation, and cost. However, the cost is considerably less than that of removing a normal appendix or hospital observation (which is currently an average of 1.6 days to rule out appendicitis).21

radioisotope and magnetic resonance imaging

Radioisotope imaging with labeled white blood cells (WBCs) is being investigated in patients with acute appendicitis. In the fall of 2004, the U.S. Food and Drug Administration approved a new product that utilizes a monoclonal antibody to label WBCs in vivo quickly and effectively. The product, technetium (99m Tc) fanolesomab (NeutroSpec), is specifically indicated for "scintigraphic imaging of patients with equivocal signs and symptoms of appendicitis who are five years of age or older.”35

The results from a few studies indicate that MRI is helpful in diagnosing acute appendicitis in certain patient populations (e.g., children, pregnant women).5

Indications for Radiologic Modalities

The optimal imaging technique for acute appendicitis should have several key characteristics. It must be accurate, quick, safe, technically nonchallenging, readily available, cost efficient, and capable of being performed with little risk or discomfort for the patient. Imaging procedures, specifically ultrasonography and CT (Table 35,15,21), seem to hold great promise, especially when used in clinically equivocal cases.

TABLE 3 Comparison of Ultrasonography and CT in Suspected Appendicitis Category Ultrasonography CT Accuracy 71% to 97% 93% to 98% Sensitivity 85% to 90% 87% to 100% Specificity 47% to 96% 95% to 99% Negative predictive value 76% 95% Patient types Pregnant women and women of childbearing age, children All types; avoid in pregnant women Approximate cost* $250 $750 Advantages Easily available, noninvasive, no radiation, rapid, no preparation needed, ability to diagnose other sources of pain (especially gynecologic disorders) More accurate, better identification of phlegmon and abscess, may complement ultrasonography when results are suboptimal, better ability to detect normal appendix Disadvantages Operator dependent, not as accurate as CT, difficult with large body habitus, cannot rule out appendicitis if negative appendix is not apparent Radiation exposure, patient discomfort/risk if contrast media used, cost CT = computed tomography. *-Costs include reading. Costs determined December 2004 at the Diagnostic Imaging Center of Kansas City, Mo. Information from references 5, 15, and 21.

However, the routine use of ultrasonography and CT in the diagnosis of appendicitis in all patients is not well established.21 If the diagnosis is apparent from the history, physical examination, and laboratory studies, taking the patient directly to surgery without imaging is justified. The results of several studies show no significant change in misdiagnosis of appendicitis after widespread implementation of ultrasonography and CT.36,37 There is concern that reliance on radiographic studies may distract from careful and timely history and physical examination, and may not be cost effective. In addition, radiographic studies simply are not necessary in all patients. Figure 6 offers guidance on the diagnosis and management of acute appendicitis. The exact role and indications for use of these imaging modalities as diagnostic aids still are being defined.

Diagnosis and Management of Appendicitis

Figure 6. Algorithm for suspected appendicitis. Surgical referral is appropriate at any step. Information from references 8, 12, 15, 17, and 20.

A wide range of results for each imaging modality has been reported in the literature, depending on the study population and study design. Outcome studies are beginning to appear in the literature in which the financial and medical implications of imaging studies in patients with possible acute appendicitis are being assessed. For now, the use of imaging modalities in atypical presentations of suspected cases of appendicitis should complement, but not replace, clinical assessment and judgment.

Strength of Recommendations Key clinical recommendation Label References If the diagnosis of acute appendicitis is clear from the history and physical examination, no further testing is needed. C 15 When the diagnosis of appendicitis is uncertain, computed tomography (CT) and ultrasonography may reduce the rate of perforation. C 5, 17-19 The diagnostic accuracy of ultrasonography for acute appendicitis has been reported to range from 71 to 97 percent. The most useful sign of acute appendicitis on ultrasonography is an outer appendiceal diameter of 6 mm or greater on cross-section. C 21-24 Depending on the technique used, the diagnostic accuracy of CT in acute appendicitis ranges from 93 to 98 percent. On CT, an inflamed appendix is greater than 6 mm in diameter, has appendiceal wall thickening, and wall enhancement after contrast media infusion, and reveals inflammatory changes in the surrounding tissues. C 11, 32, 33 A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, opinion, or case series. See page 19 for more information.

The authors thank Mark Meyer, M.D., Department of Family Medicine, and Louis Wetzel, M.D., Department of Radiology, of the University of Kansas School of Medicine, Kansas City, Kan., for guidance on this article.

The authors indicate that they do not have any conflicts of interest. Sources of funding: none reported.

Figures 1 through 5 used with permission from Jerry L. Old, M.D.

This article is one in a series on radiologic decision making. The series is coordinated by Mark Meyer, M.D., University of Kansas School of Medicine, Kansas City, Kan., and Walter Forred, M.D., University of Missouri-Kansas City School of Medicine, Kansas City, Mo.

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The Authors

JERRY L. OLD, M.D., is clinical assistant professor in the Department of Family Medicine at the University of Kansas School of Medicine, Kansas City, where he also received his medical degree. He completed a residency in family medicine at the University of Kansas Hospital, Kansas City.

REGINALD W. DUSING, M.D., is assistant professor in the Department of Nuclear Medicine at the University of Kansas School of Medicine, Kansas City. He received his medical degree from Baylor College of Medicine, Houston, Tex., completed an internship at the University of Missouri School of Medicine, Columbia, and completed a residency at St. Luke's Hospital, Kansas City, Mo.

WENDELL YAP, M.D., is staff radiologist and assistant professor in the Department of Radiology at the University of Kansas School of Medicine, Kansas City. He received his medical degree from the University of Santo Tomas Faculty of Medicine and Surgery, Manila, Philippines, and completed a residency in radiology at the University of Kansas Hospital, Kansas City.

JARED DIRKS, M.D., is in his second year of residency in the Department of Family Medicine at the University of Kansas School of Medicine, Kansas City. He received his medical degree from the University of Missouri-Kansas City School of Medicine, Kansas City.

Address correspondence to Jerry L. Old, M.D., Department of Family Medicine, University of Kansas School of Medicine, 3901 Rainbow Blvd., Kansas City, KS 66160 (e-mail: jold@kumc.edu). Reprints are not available from the authors.

REFERENCES

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Diagnosis: Acute recurrent appendicitis

Multiple appendicoliths are present on the supine abdominal radiograph.

Click on an image to view a larger one.

Hospital Course:

Surgical consultation was obtained with the presumptive diagnosis of acute appendicitis. The patient was taken to the operating room for an appendectomy and an inflamed appendix was found. There was no evidence of appendiceal perforation. The patient had an uneventful post-operative recovery. Pathologic analysis revealed an appendix that had changes consistent with both acute and chronic appendicitis.

Discussion:

Approximately 250,000 cases of appendicitis occur each year in the United States with 70-80% of the cases occurring in patients less than 30 years of age.1,2,3 Elderly patients (>60 years-old) account for 10% of the cases. The overall mortality is less than 1%,4-6 but increases to 2-6% with perforation,7-9 and 4-23% in the elderly.10-13

Appendicitis can be acute, acute recurrent, or chronic.14 Previous, similar, self-limited symptoms have been reported in 4-30% of patients with acute appendicitis.15-17 In 1028 cases of appendicitis in one study, 25% had a history of previous similar episodes of abdominal symptoms,17 as was seen in the present case. In acute recurrent appendicitis, previous episodes of right lower quadrant pain of an acute, self-limited nature are seen.14 Acute and chronic pathologic changes are found in the appendix. Patients with chronic appendicitis have chronic or multiple, intermittent episodes of right lower quadrant pain with chronic inflammatory changes in the appendix.16,18

The primary pathophysiology of appendicitis is obstruction of the lumen due to lymphoid hyperplasia (60%),3 fecaliths and calculi (up to 30%),19,20 other foreign bodies (4%),3 and tumors or strictures (1%).21 The lumenal obstruction is followed by progressive distention, compromise of the blood supply of the appendiceal wall, and subsequent bacterial invasion beyond the mucosal layer. The appendix becomes gangrenous and usually perforates within 36 hours of the onset of symptoms resulting in localized peritonitis or abscess formation, and less commonly, diffuse peritonitis and disseminated abscess formation.

Plain abdominal radiographs are abnormal in 50% of patients presenting with acute appendicitis.22 Radiographic findings include a dilated cecum and/or terminal ileum with air/fluid levels (most common) referred to as a "sentinel" or "appendiceal" ileus, blurring of the distal psoas shadow, and the presence of a right lower quadrant appendicolith (8-12% of patients). Although a localized ileus is usually seen in the right lower quadrant when present, one retrospective study of 100 cases of surgically proven appendicitis documented a 51% incidence of a focal dilation of a loop of small bowel in the left upper quadrant on supine abdominal radiographs.23 This was thought to be from a localized ileus of the proximal jejunum. Some patients with appendicitis may have evidence of fluid in the right peritoneal cavity manifested by an enlarged right properitoneal flank stripe on a supine abdominal radiograph. An appendiceal abscess may be seen as a large soft-tissue mass-like density in the right lower quadrant, or by loculated or mottled collections of extraluminal gas.

Appendicoliths are formed when fecal material enters the lumen of the appendix and becomes inspissated. This results in an increase in appendiceal mucous gland output leading to the deposition of mineral salts (calcium and phosphorus) contained within the mucous onto the inspissated fecalith. The radiographic characteristics of appendicoliths were first described in 1906.24 Appendicoliths characteristically are usually solitary (70%), oval, laminated (90%) calcified densities from 0.5 - 2.0 cm diameter located in the right lower quadrant. However, they may be found anyplace in the abdomen that the appendix can be situated.14 Unfortunately, appendicoliths may be difficult to distinguish from calcified phleboliths and mesenteric nodes, ureteral calculi, ectopic gallstones, and bone islands. Calcified phleboliths are usually multiple, non-laminated with symmetrical distribution. Calcified mesenteric nodes are mobile, non-laminated, have a dentate border and a granular density, and are usually nearer to the vertebral column. In this patient, the abdominal radiograph shows multiple appendicoliths in a linear fashion in the right lower quadrant which appears to identify the orientation of the appendix. These multiple appendicoliths could be palpated in situ during his laparotomy and where found when the appendix was removed and incised in the operating room prior to submitting it to the pathologist. It is likely from the pathologic changes found in his appendix, and his history of previous symptoms, that he suffered from acute recurrent appendicitis. The presumed etiology of spontaneous resolution in recurrent appendicitis is relief of the luminal obstruction or lymphoid hypertrophy shrinkage.15

Approximately 60% of patients undergoing appendectomy for appendicitis will have an appendicolith found during pathologic examination; however, only 30% of these are calcified.20 In the past, it had been recommended to perform elective appendectomies in asymptomatic patients with radiographs revealing appendicoliths because of the associated higher incidence of gangrene and perforation.20,24 This is especially true in children with appendicoliths, primarily because of their higher incidence of perforation at the time of presentation.14 This recommendation awaits more current confirmation considering the newer diagnostic modalities that may detect acute appendicitis earlier.

Some authors feel that plain abdominal films to search for appendiceal calcifications are indicated in all patients presenting with nonspecific abdominal pain;24,25 however, one should not delay surgical consultation while awaiting abdominal radiography in patients with clinically apparent appendicitis.

Clinical Pearls

1., A supine abdominal radiograph should be considered in patients with right lower quadrant pain to search for appendicoliths.

2. Appendicoliths, although not pathognomonic for acute appendicitis, are distinguished from calcified phleboliths or mesenteric lymph nodes by their number, appearance, size, and location. They are usually solitary, oval, laminated, 0.5 - 2.0 cm in diameter, and located in the right lower quadrant.

3. This case reaffirms that recurrent appendicitis doesoccur.

4. A normal white blood cell count does not rule out appendicitis.

5. The finding of an appendicolith on an abdominal radiograph in a patient with periumbilical abdominal pain or right lower quadrant pain is an indication for an appendectomy.

6. Patients with clinically apparent appendicitis should not have surgery delayed by diagnostic studies.

Photographic Critique:

by Michael A. Morris

The reproduction of radiographs for publication is challenging because of the need to preserve fine detail and subtle shades of gray on the printed photograph. These features are best reproduced using black and white film and traditional black and white prints because of the ability to alter the contrast of the final print during film processing and the use of contrast varying filters or "graded" papers during the printing process. The ability to alter the contrast of the print enables the photographer or lab technician to produce a print that will reproduce well in publication. Generally speaking, it is necessary to produce a print that is slightly "flatter" (one grade less than optimal) in contrast than the original radiograph in order to account for the increase in contrast that is inherent in the offset printing process.

Color slide film is "contrasty" by nature and the use of slide film for copying radiographs for publication usually results in a loss of subtle detail and an overall increase in print contrast that can render the illustration difficult to interpret. Figure 1 would have retained more detail had it been reproduced via the traditional black and white negative/print process.

BISACODYL

 

موارد مصرف‌:

بیساكودیل‌ به‌ عنوان‌ یك‌مسهل‌ محرك‌ برای‌ درمان‌ كوتاه‌ مدت‌یبوست‌ و تخلیه‌ ركتوم‌ و كولون‌ قبل‌ ازانجام‌ آزمونها یا جراحی‌ كولون‌ مصرف‌می‌شود.

 

مكانیسم‌ اثر:

این‌ دارو احتمالا بااثر مستقیم‌بر روی‌ عضلات‌ صاف‌ روده‌ باعث‌ افزایش‌حركات‌ پریستالتیك‌ روده‌ می‌شود.

 

فارماكوكینتیك‌:

اثر این‌ دارو پس‌ از 8ـ6ساعت‌ شروع‌ می‌گردد.

 

موارد منع‌ مصرف‌:

بیساكودیل‌ در صورت‌وجود آپاندیسیت‌ یا نشانه‌های‌ آن‌ یاخونریزی‌ مقعد و نیز در انسداد روده‌باعلت‌ نامشخص‌ نباید مصرف‌ شود. این‌دارو در صورت‌ كولوستومی‌ یاایلئوستومی‌ نباید مصرف‌ شود.

 

هشدارها:

استفاده‌ از این‌ دارو در كودكان‌با سن‌ كمتر از 6 سال‌ باید زیرنظر پزشك‌صورت‌ گیرد.

 

عوارض‌ جانبی‌:

از عوارض‌ احتمالی‌ این‌دارو می‌توان‌ از آروغ‌زدن‌، كرامپ‌، اسهال‌،تهوع‌ و تحریك‌ پوستی‌ در اطراف‌ مقعد نام‌برد.

 

تداخل‌های‌ داروئی‌:

مصرف‌ بیش‌ از حد این‌دارو باعث‌ دفع‌ املاح‌ پتاسیم‌ می‌شود و اثرداروهای‌ مدر در كاهش‌ غلظت‌ سرمی‌پتاسیم‌ را كاهش‌ می‌دهد. مصرف‌ همزمان‌داروهای‌ ضداسید و شیر با قرص‌های‌بیساكودیل‌ ممكن‌ است‌ باعث‌ حل‌ شدن‌سریع‌ روكش‌ قرصها و در نتیجه‌ بروزتحریك‌ معده‌ یا دوازدهه‌ شود.

 

نكات‌ قابل‌ توصیه‌:

1 ـ از جویدن‌ یاخردكردن‌ قرصهای‌ بیساكودیل‌ یا ازمصرف‌ آن‌ با داروهای‌ ضداسیدخودداری‌ گردد.

2 ـ در صورت‌ وجود علائم‌ آپاندیسیت‌ و تادو ساعت‌ بعد از مصرف‌ سایر داروها، ازمصرف‌ این‌ دارو خودداری‌ گردد.

3 ـ مصرف‌ طولانی‌ مدت‌ این‌ دارو ممكن‌است‌ سبب‌ وابسته‌شدن‌ كار روده‌ به‌آن‌گردد.

4 ـ احتمال‌ بروز بثورات‌ جلدی‌ و كرامپ‌به‌خصوص‌ در صورت‌ مصرف‌ با معده‌خالی‌ وجود دارد.

 

مقدار مصرف‌:

خوراكی‌:

بزرگسالان‌: برای‌ درمان‌ یبوست‌ مقدار10 - 5 میلی‌ گرم‌ در شب‌ مصرف‌ می‌شودكه‌ در صورت‌ لزوم‌ این‌ مقدار تا 20 ـ 15میلی‌ گرم‌ افزایش‌ می‌یابد. برای‌ تخلیه‌روده‌ها قبل‌ از اعمال‌ رادیولوژی‌ یا جراحی‌10 میلی‌گرم‌ در شب‌ از دو شب‌ قبل‌مصرف‌ می‌شود.

كودكان‌: در درمان‌ یبوست‌ در كودكان‌ باسن‌ كمتر از 10 سال‌ سن‌ مقدار 5 میلی‌گرم‌و برای‌ تخلیه‌ روده‌ نصف‌ مقادیر مصرف‌بزرگسالان‌ مصرف‌ می‌شود.

شیاف‌:

بزرگسالان‌: برای‌ درمان‌ یبوست‌ 10میلی‌گرم‌ در صبح‌ و برای‌ تخلیه‌ روده‌ درصورت‌ لزوم‌، علاوه‌ بر مصرف‌ خوراكی‌دارو 10 میلی‌گرم‌ یك‌ ساعت‌ قبل‌ از عمل‌جراحی‌ یا عكسبرداری‌ استعمال‌ می‌گردد.

كودكان‌: نصف‌ مقدار مصرف‌ بزرگسالان‌مصرف‌ شود.

 

اشكال‌ دارویی‌:

Entric Coated Tablet: 5 mg

Suppository: 10 mg

Pediatric Suppository: 5 mg

 

۲)آيا آنگونه که بعضی از پزشکان عنوان می کنند آپانديس عضوی زائد است؟
آپانديس قسمتی از سيستم لنفاوی و ايمنی بدن است و به هيچ وجه عضو زائدی نيست . اين موضوع که وظائف آپانديس با قسمتهای ديگر سيستم لنفاوی جبران می شودباعث اين تلقی می شود که اين عضو زائد است در صورتيکه به هيچ وجه اينگونه نيست همانطور که يک کليه نيز اضافه نيست گرچه بتوان تنها با يک کليه زندگی کرد. در اين رابطه بايد گفت لوزه ها نيز درست مانند آپانديس از سيستم لنفاوی هستند و زائد نمی باشند
هوميوپاتی برای حمله حاد آپانديسيت نيز درمان دارد که در صورت تشخيص صحيح هوميوپاتی می تواند در مدت بسيار کوتاهی بيماری را درمان کند البته به علت خطرناک بودن تاخير درمان در آپانديسيت معمولا همزمان با تجويز داروی هوميوپاتی بيمار آماده اعزام به بيمارستان می شود که اگر در مدت کوتاهی ( کمتر از يکساعت ) اثر درمانی مشاهده نشد بيمار زمان را از دست نداده باشد. من خود چندين مورد آپانديسيت ( با توجه به علائم کاملا تاييد کننده اين عارضه) را به آسانی با هوميوپاتی درمان نموده ام بدون آنکه عود مجددی مشاهده شود.
در مورد تورم لوزه ها نيز درمان هوميوپاتی به آسانی می تواند مسئله را حل کند و نيازی به جراحی نخواهد بود

ناراحتى سالمندان و كيفيت‏بيمارى آنان

دكتر منصور اشرفى

اگر از علامت‏هاى خزنده بيماريهاى سالمندان ناآگاه باشيم چه‏بسا كار به جائى رسد كه والدين سالخورده ما دچار ناراحتى شديد شوند.

نشانه‏هاى بيمارى والدين سالمند، ممكن است متفاوت از علامت‏هائى باشند كه همان بيماريها در ما پديد مى‏آورند.

به عبارت ديگر: تشخيص بيمارى و شناختن علامت‏هاى آن در سالمندان دقت‏بيشترى مى‏خواهد. پس از آن كه هفت دهه از عمر سپرى شد، اگر به گذشته نظر افكنيم خواهيم ديد كه هركدام از ما در طول حيات خود، تاريخچه بيمارى متفاوت از ديگران دارد. يكى از آثار گذشت ايام، ايجاد تفاوت بيشتر با ديگران است. به عبارت ديگر: هرچه ما پيرتر مى‏شويم با ديگران متفاوت‏تر مى‏گرديم.

يكى از دشواريهائى كه در تشخيص بيماريهاى سالمندان به وجود مى‏آيد در مورد كسانى است كه زود و به‏طور غير عادى به خزان عمر رسيده‏اند و چندين درد باهم دارند. اين نكته قابل ذكر است كه گاهى پيرهاى قوى نيز با كمال تعجب دچار بيماريهائى هستند.

پس در مورد والدين سالمند چه كنيم؟

برخى از بيماريها با علامت‏هاى به اصطلاح خزنده، از نظر ما پنهان مى‏مانند زيرا نشانه‏هاى غير عادى دارند كه ما نمى‏توانيم به موقع از آنها آگاه شده و در صدد چاره‏جوئى برآئيم. حال ببينيم راه‏حل چيست؟ بيماريهائى كه در زير يادآور مى‏كنيم ممكن است در افراد 40 و 50 ساله با علامت‏هائى بروز كنند ولى در اشخاص 70 و 80 ساله با يك رشته نشانه‏هاى كاملا متفاوت ظاهر شوند.

1- حمله قلبى:

تصور كنيد كه پدر 84 ساله شما سرگيجه دارد، دچار آشفتگى ⁽¹⁾ روانى است و تنگى نفس دارد و با وجود اين در ناحيه سينه درد ندارد ولى ممكن است دچار حمله قلبى شده باشد. با اين كه درد شديد قفسه سينه شايع‏ترين نشانه حمله قلبى در سالمندان است، اما گاهى در پيرها به ويژه آنهائى كه بيش از هشتاد سال دارند ممكن است فقط درد جزئى در سينه داشته باشند و يا اصلا احساس درد نكنند. در پيرها غالبا تنگى نفس بارزترين نشانه حمله قلبى است. شگفت‏انگيزتر اين كه گاهى نخستين علامت‏حمله قلبى و از هم‏گسستگى ⁽³⁾ روانى باشد. اغلب از دست دادن تعادل بدن يك علامت مشخصه است چه گاهى به زمين افتادن مى‏تواند يكى از نشانه‏هاى حمله قلبى باشد يعنى اين كه مكانيسم «هومئواستاتيك‏» ⁽⁴⁾ كه باعث نگاهدارى تعادل مى‏شود، غالبا پس از حمله قلبى از بين مى‏رود.

بنابر آنچه كه يادآورى شد، تشخيص حمله قلبى در سالخوردگان دقت‏بسيار و توجه دقيق مى‏خواهد. از خاركتوس (يا به اصطلاح سكته قلبى) پيرها غالبا بى‏سر و صداست. گاهى نوار قلبى پيرها، بر عكس جوانان، حمله قلبى را نشان نمى‏دهد.

2- دات‏الريه يا سينه‏پهلو:

سينه‏پهلو، به ويژه در سالمندان، خطرناك است. در سالخوردگان بيشترين علت مرگ سينه‏پهلوست و يكى از علل آن دير تشخيص داده شدن بيمارى است. يك پير ناتوان هشتاد ساله ممكن است دچار سينه‏پهلو بشود بدون اين كه علامت‏هاى معمولى بيمارى در وى آشكار گردند يعنى اين كه تب، لرز و سرفه نداشته باشد درصورتى كه در جوانان، اين نشانه‏ها به خوبى ظاهر مى‏شوند و وى بيش از سالمندى كه دچار سينه‏پهلوست، بيمار و رنجور به نظر مى‏رسد در صورتى كه در پيرها، تنها علامت ممكن است درهم‏ريختگى روانى باشد.

نخستين آثار سينه‏پهلو، مانند حمله قلبى در پيرها ممكن است تغيير در هوشيارى و فهم مطالب باشد يعنى كم شدن هشيارى و آگاهى از اوضاع، خمارآلودگى و سرگيجه ظاهر شود و يا تغييراتى در اعمال بدنى بروز كند مانند ضعف و خستگى. درهم‏ريختگى روانى نيز به عنوان علامتى در بسيارى از عفونت‏هاى ديگر پيرى داراى اهميت است. در سالمندان عفونت دستگاه ادرارى ممكن است‏به شكل سوزش موقع ادرار بروز كند و غالبا نخستين نشانه آن تغيير در وضع روانى بيمار است.

3- ديابت (بيمارى قند):

درك آغاز بيمارى قند حتى در ميانسالان نيز دشوار است تا چه رسد به سالخوردگان. به هر حال در سالمندان، اين عارضه مرضى است‏خزنده چه فرايند طبيعى سالمندى ممكن است دو علامت مهم و معمولى هشدار دهنده اين بيمارى را، از نظر دور بدارد و آن دو عبارتند از عطش شديد و ادرار كردن پى‏درپى. هرچه پيرتر شويم هم واكنش به تشنگى و هم عمل كليه‏ها كم مى‏شود و اين امرى است طبيعى. يك فرد ديابتى چهل‏ساله كه بيمارى قند او تشخيص داده نشده است، تقريبا هميشه عطش سيراب‏نشدنى و نياز به ادرار كردن پى‏درپى دارد. در صورتى كه پدر ديابتى سالمند 75 ساله وى ممكن است هيچ‏يك از اين علائم را نداشته باشد و اين بيمارى در آنان ناشناخته بماند. از آنجائى كه بيمارى قند تهديدى است‏بر ادامه زندگى و علامت‏هاى آن در سالمندان چندان آشكار نيست پس بهتر است هر سال و يا دست‏كم هر دو سال يكبار قند خون افراد بالاتر از 65 سال اندازه‏گيرى شود.

4- آپانديسيت:

از آنجائى كه معمولا تورم آپانديس در نوجوانان و جوانان ديده مى‏شود، بنابراين، اين بيمارى در افراد سالمند ناديده گرفته مى‏شود. از طرف ديگر درد شديد در ناحيه پائين سمت راست‏شكم مهمترين نشانه تورم آپانديس است. در پيرها شدت اين درد يا كم است و يا كمتر در آن محل متمركز مى‏شود.

تظاهرات و نشانه‏هاى تورم آپانديس ممكن است در سالمندان يك طيف گسترده داشته باشد به طورى كه گاهى نشانه‏هاى تورم بسيار شديد آپانديس فقط منگى، تب مختصر و شكم‏درد جزئى باشد. در سالمندان موارد تورم آپانديس كم است‏به‏طورى كه سالخوردگان بيش از 60 ساله فقط 5درصد بيماران مبتلا به آپانديس را تشكيل مى‏دهند. با وجود اين، تعداد مرگ و مير آنان از اين بيمارى بيش از همه افراد جوان است.

ورم آپانديس (آپانديسيت) نيز مانند سينه‏پهلو، در سالمندان بسيار جدى است چه اين بيمارى در پيرها مانند آپانديسيت جوانان زود تشخيص داده نمى‏شود.

5- پركارى غده درتى يا تيروئيد: ⁽⁵⁾

موقع پركارى تيروئيد، اين غده هورمون بيشترى توليد مى‏كند كه باعث عرق كردن زياد، تپش قلب، لرزش دست‏ها، كوتاهى تنفس (نفس نفس زدن) و تحريك‏پذيرى عصبى مى‏گردد. برآمدگى چشم نيز يكى ديگر از نشانه‏هاى اين عارضه است.

اما در سالمندان غالبا علامت‏هاى پركارى تيروئيد برعكس است‏يعنى اين كه به جاى داشتن علامت‏هاى معمولى افزايش متابوليسم (سوخت و ساز بدن) يعنى عرق كردن، نبض تند شايد اسهال، در افراد سالمند ممكن است درهم‏گسيختگى روانى و ناتوانى بدنى به وجود آيد.

اگر پركارى تيروئيد تشخيص داده شود، خوشبختانه با موفقيت درمان مى‏گردد. اگر مورد توجه قرار نگيرد ممكن است‏بيمار را، بيشتر در معرض حمله قلبى قرار دهد.

• شرح بیماری
• علایم‌ شایع‌
• علل‌
• عوامل تشدید کننده بیماری
• پیشگیری‌
• عواقب‌ مورد انتظار
• عوارض‌ احتمالی‌
• درمان‌
• اصولی‌ کلی‌
• داروها
• فعالیت در زمان ابتلا به این بیماری
• رژیم‌ غذایی‌
• درچه شرایطی باید به پزشک مراجعه نمود؟

شرح بیماری

• آپاندیسیت‌ عبارت‌ است‌ از التهاب‌ زایده‌ کرمی‌ شکل‌ آپاندیس‌ که‌ از اولین‌ قسمت‌ روده‌ بزرگ‌ به‌ نام‌ سکوم‌ منشاء می‌گیرد. آپاندیس‌ هیچ‌ کار شناخته‌شده‌ای‌ ندارد، ولی‌ باعث‌ بیماری‌ می‌شود. هر ساله‌ از هر 500 نفر جمعیت‌ یک‌ نفر دچار آپاندیسیت‌ می‌شود.

علایم‌ آپاندیسیت‌ بسیار متغیر هستند. در مورد هر فردی‌ که‌ درد شکمی‌ تشخیص‌ داده‌ نشده‌ دارد، آپاندیسیت‌ حتماً باید مدنظر باشد.
این‌ بیماری‌ در هر سنی‌ می‌تواند رخ‌ دهد (در مردان‌ بیشتر از زنان‌)، اما در کودکان‌ زیر 2 سال‌ نادر است‌. حداکثر بروز بیماری‌ در سنین‌ 24-15 سالگی‌ است‌.

علایم‌ شایع‌

• دردی‌ که‌ از نزدیک‌ ناف‌ شروع‌ می‌شود و تدریجاً به‌ قسمت‌ تحتانی‌ شکم‌ در سمت‌ راست‌ نقل‌ مکان‌ می‌کند. درد کم‌کم‌ مداوم‌ می‌شود و از حالت‌ مبهم‌ به‌ صورت‌ کاملاً مشخص‌ در می‌آید به‌ طوری‌ که‌ مکان‌ آن‌ دقیق‌تر توسط‌ بیمار نشان‌ داده‌ می‌شود. درد با حرکت‌، تنفس‌ عمیق‌، سرفه‌، عطسه‌، راه‌ رفتن‌، یا لمس‌، بدتر می‌شود.
• تهوع‌ و گاهی‌ استفراغ‌
• یبوست‌ و ناتوانی‌ در دفع‌ گاز
• اسهال‌ (گاهی‌)
• تب‌ کم‌ شدت‌، که‌ پس‌ از سایر علایم‌ آغاز می‌گردد.
• تشدید درد به‌ هنگام‌ لمس‌ ناحیه‌ تحتانی‌ شکم‌ در سمت‌ راست‌، معمولاً در نقطه‌ای‌ حدود یک‌ سوم‌ مسیر ناف‌ به‌ برجستگی‌ بالایی‌ استخوان‌ لگن‌. (توجه‌ داشته‌ باشید که‌ این‌ توصیف‌ فقط‌ زمانی‌ صدق‌ می‌کند که‌ آپاندیس‌ در جای‌ طبیعی‌ خود باشد. در بعضی‌ موارد، نوک‌ آپاندیس‌ در جای‌ دیگر واقع‌ شده‌ است‌، که‌ این‌ باعث‌ مشکل‌ شدن‌ تشخیص‌ می‌شود)
• تورم‌ شکم‌ (در مراحل‌ انتهایی‌)
• افزایش‌ تعداد گلبول‌های‌ سفید خون‌

علل‌

• عفونت‌ به‌ دلیل‌ نامشخص‌، معمولاً توسط‌ باکتری‌های‌ موجود در لوله‌ گوارش‌. آپاندیس‌ ممکن‌ است‌ توسط‌ محتویات‌ در حال‌ عبور در لوله‌ گوارشی‌ یا یک‌ رشته‌ بافتی‌ غیرطبیعی‌ که‌ از بیرون‌ به‌ آن‌ فشار وارد می‌آورد، مسدود شود. زمانی‌ که‌ آپاندیس‌ عفونی‌ می‌شود، متورم‌ و ملتهب‌ گشته‌ و از چرک‌ پر می‌شود.

عوامل تشدید کننده بیماری

• یک‌ بیماری‌ اخیر، به‌ خصوص‌ آلودگی‌ با کرم‌های‌ حلقوی‌، یا عفونت‌ ویروسی‌ دستگاه‌ گوارش‌.

پیشگیری‌

• هیچ‌ روش‌ خاصی‌ برای‌ پیشگیری‌ وجود ندارد

عواقب‌ مورد انتظار

• معمولاً با جراحی‌ قابل‌ درمان‌ است‌. اگر درمان‌ نشود، پاره‌ شدن‌ آپاندیس‌ مرگبار خواهد بود.

عوارض‌ احتمالی‌

• پاره‌ شدن‌ آپاندیس‌، تشکیل‌ آبسه‌، و پریتونیت‌. این‌ عوارض‌ در افراد مسن‌تر بیشتر دیده‌ می‌شود.
• عدم‌ تشخیص‌ درست‌، به‌ علت‌ کم‌ بودن‌ یا نامعمول‌ بودن‌ علایم‌، به‌ خصوص‌ در سنین‌ خیلی‌ *پایین‌ یا خیلی‌ بالا
• تشکیل‌ آبسه‌

درمان‌

اصولی‌ کلی‌

• امکان‌ دارد آزمایش‌ خون‌ (افزایش‌ تعداد گلبول‌های‌ سفید خون‌) و آزمایش‌ ادرار (برای‌ رد عفونت‌ ادراری‌) انجام‌ شوند. عفونت‌ ادراری‌ ممکن‌ است‌ علایمی‌ شبیه‌ آپاندیسیت‌ داشته‌ باشد.
• زمانی‌ که‌ تشخیص‌ هنوز قطعی‌ نیست‌، هر دو ساعت‌ درجه‌ حرارت‌ بدن‌ را با دماسنج‌ مقعدی‌ اندازه‌گیری‌ و ثبت‌ نمایید.
• جراحی‌ برای‌ برداشتن‌ آپاندیس‌ (آپاندکتومی‌). از آنجایی‌ که‌ تشخیص‌ آپاندیسیت‌ مشکل‌ است‌، اغلب‌ تا زمانی‌ که‌ تشخیص‌ قطعی‌ داده‌ نشود، دست‌ به‌ جراحی‌ زده‌ نمی‌شود.
• اگر آبسه‌ تشکیل‌ شود، امکان‌ دارد جراحی‌ به‌ تعویق‌ افتد تا زمانی‌ که‌ آبسه‌ تخلیه‌ شود و فرصت‌ برای‌ التیام‌ آن‌ باشد.

داروها

• هرگز از داروی‌ مسهل‌، تنقیه‌، یا داروی‌ ضددرد استفاده‌ نکنید. داروهای‌ مسهل‌ می‌توانند باعث‌ پارگی‌ آپاندیس‌ شوند، و داروهای‌ تخفیف‌ دهنده‌ درد یا تب‌ نیز باعث‌ مشکل‌تر شدن‌ تشخیص‌ می‌شوند.
• داروهای‌ ضددرد پس‌ از جراحی‌ تجویز می‌شوند.
• اگر عفونت‌ وجود داشته‌ باشد آنتی‌بیوتیک‌ نیز تجویز می‌شود.
• امکان‌ دارد نرم‌کننده‌های‌ مدفوع‌ برای‌ جلوگیری‌ از یبوست‌ توصیه‌ شوند.

فعالیت در زمان ابتلا به این بیماری

• تا وقت‌ عمل‌ در تخت‌ یا صندلی‌ استراحت‌ کنید.
• پس‌ از عمل‌، تدریجاً فعالیت در زمان ابتلا به این بیماری های‌ عادی‌ خود را از سر گیرید.

رژیم‌ غذایی‌

• تا زمانی‌ که‌ آپاندیسیت‌ تشخیص‌ داده‌ نشده‌ است‌ از خوردن‌ و آشامیدن‌ بپرهیزید. وقتی‌ که‌ معده‌ خالی‌ باشد، بیهوشی‌ برای‌ عمل‌ جراحی‌ بسیار بی‌خطرتر خواهد بود. اگر خیلی‌ تشنه‌ هستید، دهان‌ خود را با آب‌ بشویید.
• پس‌ از عمل‌، ابتدا رژیم‌ مایعات‌ و به‌ تدریج‌ رژیم‌ جامدات‌ آغاز می‌شود.

درچه شرایطی باید به پزشک مراجعه نمود؟

• اگر شما یا یکی‌ از اعضای‌ خانواده‌ تان علایم‌ آپاندیست‌ را دارید.
• اگر یکی‌ از موارد زیر قبل‌ یا پس‌ از جراحی‌ رخ‌ دهد:
  • تب‌ مساوی‌ یا بیش‌ از 9/38 درجه‌ سانتیگراد
  • استفراغ‌ مداوم‌
  • افزایش‌ درد شکمی‌
  • غش‌
  • وجود خون‌ در مدفوع‌ یا محتویات‌ استفراغ‌ شده‌
  • منگی‌ یا سردرد

 

اثرات سوء ناشي از استفاده از دستگاه پخت و پز ماكروفر:

ميترا زراتي – كارشناس ارشد تغذيه

 

امروزه استفاده از وسايل پخت سريع غذا نظير ماكروفر گسترش زيادي يافته است.

چرا كه پخت و پز با اين دستگاه بسيار ساده بوده و زمان بسيار اندكي صرف اين فرآيند مي‌شود. ولي بايد توجه داشت كه استفاده از اين دستگاه اثرات بسيار بدي بر روي سلامتي بر جاي مي‌گذارد.

ولي امروزه به دليل افزايش فروش و همچنين افزايش در آمد ناشي از ساخت اين دستگاه، كارخانه‌هاي توليد كننده، مانع از آگاه شدن مصرف كننده‌ها از اثرات مضر اين وسيله مي‌شوند. در نتيجه بسياري از افراد بدون اينكه اطلاعات كافي از اين موضوع داشته باشند به استفاده از اين دستگاه براي پخت و پز مبادرت مي‌ورزند.

اين دستگاه به وسيلة انرژي الكترومغناطيسي عمل مي‌كند. اين امواج شبيه به امواج نوري و يا امواج راديويي مي‌باشد. Microwaves (امواج مورد استفاده در اين دستگاه) طول موج كوتاهي داشته كه سرعت آن 186282 مايل در ثانيه مي‌باشد. در تكنولوژي امروزه از امواج Microwaves در انواع تلفن‌هاي راه دور، برنامه‌هاي تلويزيوني و همچنين سيگنال‌هاي ماهواره‌اي نيز استفاده مي‌گردد. Microwaves موجود در دستگاه مايكروفر با مولكول‌هاي مواد غذايي برخورد كرده و مرتباً ميدان الكتريكي آنها تغيير خواهد كرد. اين تغيير قطبيت ميليون‌ها بار در هر ثانيه اتفاق مي‌افتد. مولكول‌هاي مواد غذايي و به طور عمده مولكول‌هاي آب مرتباً تغيير بار الكتريكي داده و همين امر منجر به ايجاد گرما در مادة‌غذايي و در نهايت پخت آن خواهد شد.

اثرات امواج اين دستگاه به سلامت بدن:

براي گرم كردن  فرمولاي كودكان (شير خشك) استفاده از اين دستگاه نامناسب به نظر مي‌رسد. چراكه امواج الكترو مغناطيسي اسيدهاي آمينه ترانس شير را به ايزومر سيس تبديل خواهد كرد. همچنين به دنبال اين عمل اسيدهاي چرب نوع سيس نيز به فرم ترانس تبديل مي‌شوند اسيدهاي آمينة سيس و اسيدهاي چرب ترانس فعاليت بيولوژيكي ندارند. به علاوه Microwaves اسيد آمينة L پرولين را به D پرولين تبديل مي‌كند. فرم D اين اسيد آمينه خاصيت neurotoxic و nephrotoxic دارد.

مطالعه‌اي كه به دنبال بررسي اثرات امواج اين دستگاه بر روي افراد داوطلب صورت گرفت. نشان داد كه اين امواج بر روي بسياري از شاخص‌هاي خوني نيز تاثير مي‌گذارد. در اين مطالعه 8 فرد داوطلب انتخاب شدند به همة افراديك نوع مادة غذايي خاص داده شد  ولي در اين بين برخي از افراد فقط از مواد غذايي استفاده كردند كه صرفاً در ماكروفر پخته شده بود. در افرادي كه غذاهاي پخته شده در اين دستگاه را استفاده كرده بودند ميزان هموگلوبين كم شده بود به همين علت وقوع آنمي در دراز مدت در اين افراد پيش بيني مي‌شد. همچنين ميزان كل تمام گلبول‌هاي سفيد نيز در اين افراد افزايش يافته بود.

امروزه ثابت شده است كه مصرف مواد غذايي پخته شده به اين روش زمينه را براي ابتلا به انواع سرطان ايجاد مي‌نمايد.

ميزان مادة سرطان زايي به نام d-Nitroso diethanolamines  در گوشتهاي پخته شده در ماكروفر بسيار بالاست. اسيدهاي آمينه موجود در شير و غلاتي كه به اين روش پخته مي‌شوند به نوعي مادة سرطان زا تبديل خواهد شد.

امروزه از ماكروفر جهت ذوب كردن (thawing) مواد غذايي منجمد نيز استفاده مي‌شود. ولي تحقيقات نشان داده‌اند كه در سبزيجات و ميوه‌جاتي كه به اين روش از انجماد خارج مي‌شوند تركيبات گلوكوزيدي و گالاكتوزيدي به تركيباتي تبديل مي‌شوند كه سرطان‌زا هستند. به علاوه وقتي سبزيجات چه به صورت خام، چه پخته و يا به صورت منجمد داخل اين دستگاه مي‌شوند برخي ديگر از تركيبات آنها مانند آلكالوئيدها نيز به مواد سرطان زا تبديل مي‌شوند.

ميزان راديكال‌هاي آزاد در سبزيجات به خصوص سبزيجات غده‌اي به دنبال استفاده از اين روش افزايش مي‌يابد.

ارزش مواد مغذي نيز در اين روش به ميزان %‌90-60 كاهش مي‌يابد. به عنوان مثال زيست دسترسي انواع ويتامين هاي گروه B، ويتامين C، ويتامين E و بسياري از املاح نيز كم مي‌شود. در افرادي كه از مواد غذايي پخته شده در ماكروفر استفاده مي‌كنند اختلالات سيستم لنفاتيكي بسيار بيشتر از ساير افراد مشاهده مي‌شود. همين امر مقاومت بدن را در پيشگيري از ابتلا به انواع سرطان‌ها كاهش مي‌دهد به علاوه در اين افراد ميزان سلول‌هاي سرطاني در خون بسيار بالاست.

تحقيقات نشان مي‌دهند ميزان شيوع سرطان معده و روده در اين افراد بسيار بالاست. به علاوه اين افراد از اختلالاف هضمي نيز رنج مي‌برند چرا كه ترشح آنزيم‌ها و شيره‌هاي گوارشي نيز در دراز مدت مختل مي‌شود.

www.health-science.com

FIndex

 در مورد نمودار ROC  و اینکه محورهایش چه معنی و مفهومی دارند. حالا صحبت سر این است که نموداری که به سمت چپ و بالا کشیده شده باشد در مقام مقایسه با نمودار دیگری که کمتر اینطوری است چه چیزی را می رساند. وقتی نمودار ما به سمت چپ و بالا کشیده شده باشد یعنی این تست ارزش تشخیصی بیشتری دارد در مقایسه با تست دیگری که نمودارش اینطور نیست. به اصطلاح حجم زیر منحنی هر تست وقتی بیشتر باشد این تست ارزش تشخیصی بیشتری دارد! در حقیقت کاربرد اصلی نمودار ROC در همین است که بتواند تستهای مختلف را مقایسه کند!  به عنوان مثال برای تشخیص آپاندیسیت شما می توانید شمارش تعداد گلبولهای سفید خون یا WBC ها را به عنوان یک متغیر در تشخیص آپاندیسیت مورد بررسی قرار دهید. به این معنی که به ازای تغییر مقادیر WBC احتمال آپاندیسیت داشتن فردی که علایم بالینی اش مشکوک به آن است چقدر می باشد. دقیقاٌ اینجا هم مثل مثال قبلی شما به ازای مقادیر مختلف WBC مقادیر حساسیت و ویپگی مختلفی خواهید داشت و می توانید یک نمودار ROC برای آن رسم کنید. از طرف دیگر شما می خواهید بدانید که مثلاٌ اندازه قطر آپاندیس در سونوگرافی شکم این بیماران (این نکته را توجه کنید که گفتم همان بیماران قبلی و نه یک گروه دیگر! این خیلی مهمه!) ارزش تشخیصی بالاتری نسبت به تعداد WBC دارد یا نه؟ اینجا هم می توانید به ازای اندازه های مختلف آپاندیس حساسیت و ویزگی های متفاوتی برای تشخیص آپاندیسیت داشته باشید. با مقایسه ROC ایندو می توانید بفهمید کدامیک در مجموع ارزش تشخیصی بهتری نسبت به آن یکی دارد! خب این خیلی خوب است دیگه!!!!

اما برای کشیدن این نمودار در SPSS به بخش Graphic بروید و آن پایین می بینید نوشته ROC curve! خودشه! همانجا که وارد شوید از شما یک یا چند متغیر کمی می خواهد که در حقیقت مثل WBC و  طول آپاندیس و ... متغیرهای مورد بررسی شما هستند که حتماٌ باید کمی باشند! فقط خواهشمندم نپرسین چرا!!!!! چون اونوقت می فهمم که نوشته این دو نوبت اصلاٌ مفهوم نبوده!!! زیر صفحه هم از شما یک متغیر کیفی می خواهد که در حقیقت همان Gold Standard شماست که تشخیص نهایی را معلوم می کند و باید دو حالتی باشد به معنی تشخیص مثبت/تشخیص منفی. برای تمرین هم که شده بد نیست آزمایش رسم نمودار کنید!

برای این نوبت بیشتر از این سرتان را درد نمی آورم! جلسه آینده جمع بندی می کنیم ارزش تشخیصی را و چند نکته کنکوری اش را برایتان می گویم! از جلسه بعدش می رویم سراغ موضوع دیگری! هر کی هر چی دوست داشت در comment بنویسد اگر بلد بودم آنرا شروع می کنیم! اگر نه هم که در مورد ضریب توافق کاپا صحبت میکنیم!          

     

Appendicitis

URL of this page: http://www.nlm.nih.gov/medlineplus/appendicitis.html

From the National Institutes of Health
• آپاندیسیت  (National Digestive Diseases Information Clearinghouse) - http://digestive.niddk.nih.gov/ddiseases/pubs/appendicitis/index.htm

Overviews
• Appendicitis (Mayo Foundation for Medical Education and Research) - http://www.mayoclinic.com/invoke.cfm?id=DS00274

• تشخیص / علایمAbdominal Pain, Short-Term (American Academy of Family Physicians) - http://familydoctor.org/527.xml

درمان 
• آپاندکتومی  (برداشتن آپاندیس)American College of Surgeons) - http://www.medem.com/medlb/article_detaillb.cfm?article_ID=ZZZAC37TMWC&sub_cat=553

Clinical Trials
• ClinicalTrials.gov: Appendicitis (National Institutes of Health) - http://clinicaltrials.gov/ct/gui/action/FindCondition?ui=D001064&recruiting=true

• آناتومی / فیزیولوژیAtlas of the Body: The Digestive System (American Medical Association) - http://www.medem.com/medlb/article_detaillb.cfm?article_ID=ZZZ7C4T46JC&sub_cat=511

Dictionaries/Glossaries
• Digestive Diseases Dictionary (National Digestive Diseases Information Clearinghouse) - http://digestive.niddk.nih.gov/ddiseases/pubs/dictionary/

Organizations
• American College of Surgeons - http://www.facs.org/
• National Institute of Diabetes and Digestive and Kidney Diseases - http://www.niddk.nih.gov/

Children
• Appendicitis (Nemours Foundation) - http://kidshealth.org/kid/ill_injure/sick/appendicitis.html
• Appendicitis (Nemours Foundation) - http://kidshealth.org/parent/infections/stomach/appendicitis.html
• Appendicitis in Children (Cleveland Clinic Foundation) - http://www.clevelandclinic.org/health/health-info/docs/3000/3055.asp?index=10792
• Pediatric Abdominal Ultrasound Imaging (American College of Radiology, Radiological Society of North America) - http://www.radiologyinfo.org/content/ultra-abdomen-pd.htm

Teenagers
• Appendicitis (Nemours Foundation) - http://kidshealth.org/teen/infections/intestinal/appendicitis.html

You may also be interested in these MedlinePlus related pages:
• Digestive System - http://www.nlm.nih.gov/medlineplus/digestivesystem.html

The primary NIH organization for research on Appendicitis is the National Institute of Diabetes and Digestive and Kidney Diseases - http://www.niddk.nih.gov/

Date last updated: 02 May 2005
Topic last reviewed: 22 February 2005

Appendicitis

Contents of this page: From the NIH Overviews Diagnosis/Symptoms Treatment Clinical Trials Anatomy/Physiology Dictionaries/Glossaries Organizations Children Teenagers Search MEDLINE/PubMed for recent research articles on • Appendicitis You may also be interested in these MedlinePlus related pages: • Digestive System

From the National Institutes of Health Appendicitis (National Digestive Diseases Information Clearinghouse) Overviews Appendicitis (Mayo Foundation for Medical Education and Research) Diagnosis/Symptoms Abdominal Pain, Short-Term (American Academy of Family Physicians) Treatment Appendectomy (Removal of the Appendix) (American College of Surgeons) Clinical Trials ClinicalTrials.gov: Appendicitis (National Institutes of Health) Anatomy/Physiology Atlas of the Body: The Digestive System (American Medical Association) Dictionaries/Glossaries Digestive Diseases Dictionary (National Digestive Diseases Information Clearinghouse) Organizations American College of Surgeons National Institute of Diabetes and Digestive and Kidney Diseases Children Appendicitis (Nemours Foundation) Appendicitis (Nemours Foundation) Appendicitis in Children (Cleveland Clinic Foundation) Pediatric Abdominal Ultrasound Imaging (American College of Radiology, Radiological Society of North America) Teenagers Appendicitis (Nemours Foundation)

Select services and providers for Appendicitis in your area. Select Location IN - Indiana MA - Massachusetts MO - Missouri NC - North Carolina TX - Texas, South Select from map The primary NIH organization for research on Appendicitis is the National Institute of Diabetes and Digestive and Kidney Diseases

 ايدز

 ويروسی به نام ويروس نقض ايمني بدن انسان HIV  وجود دارد كه به روشی عجيب عمل مي كند . اين ويروس در سلول تي  بدن لانه گزينی می كند سلول تی  بخش اصلی دستگاه ايمنی بدن است . اين ويروس در دستگاه توليد مثل  خوب رشد و نمو می كند و تكثير می شود . سيستم ايمنی بدن ميزبان خود را تخريب می كند .

علائم : تب بدون توجيه   -  لرز و عرق شبانه به مدت چندين هفته - احساس خستگی مداوم - كاهش وزن ناگهانی - غدد متورم

ويروس ايدز موجب می شود بدن به سادگی به بيماری های خطرناك مثل ذات الريه مبتلا شود . اين ويروس روی مغز اثر گذاشته و موجب اختلال ذهنی میشود 

درمان : مرحله اول درمان ممكن است با داروی ضد ويروس  زايدوودين AZT  بتوان تا حدی آن را درمان كرد اين دارو موجب تاخير در رشد عفونت ايدز میشود

کم خونی (ناشی از فقر آهن )

علل بروز : کم خونی بیماری نیست . بلکه وضعیتی است که در اثر بیماریها یا اختلالاتجدی ایجاد می شود . علل اصلی کم خونی عبارت است از : تولید ناکافی گلبول های قرمز خون – از دست رفتن خون به مقدار زیاد به علت خونریزی – سوختگی یا منجمد شدن – تخریب بیش از حد گلبول های قرمز خون . علت اصلی کم خونی : کمی گلبول قرمز خون است که ممکن است در اثر عوامل زیر بوجود آیند . رژیم غذایی نا درست – کمبود آهن – کمبود ویتامین c – کمبود ویتامین B – کمبود مس و منگنز یا بروز بعضی عفونت ها .

علائم کم خونی  و کمبود گلبول قرمز خون  باعث می شود که چهره انسان زرد و رنگ پریده شود . احساسخستگی پس از مختصر فعالیتی . نفسهای کوتاه و تپش قلب . عدم توانایی تولید گلبول قرمز به کم خونی آپلازی می انجامد که مغز استخوان را تخریب می کند . درمان بر حسب انواع مختلف کم خونی متفاوت است :

1-     کم خونی گلبول قرمز : بوسیله تغذیه بدن یا قرص و تزریقات

2-     کم خونی آپلازی :با تزریق خون عادی تا مغز استخوان ساخته شود

3-     کم خونی مربوط به تخریب بیش از حدگلبول های قرمز : از طریق داروهای مناسب – تزریق خون یا در آوردن طحال

آپاندیسیت  

علل : باکتری

آپاندیسیت متورم و چرکی می شود که ممکن است آبسه کند و بترکد و عفونت به اندام های دیگر هم سرایت کند

علائم : درد در ناحیه ناف . این درد به سمت راست حرکت می کند . عضلات شکم سفت می شود و شخص تب می کند

درمان : نباید به بیمار مسهل یا ملین داده شود .درمان عادی آپاندیسیت جراحی و در آوردن آپاندیس است . البته درد خفیف آپاندیس اغلب فروکش می کند .

    سرطان 

یک بیماری جدی است که در آن سلول های خاصی از بدن . بدون کنترل افزایش می یابند و سلولها و اندام سالم بدن را از بین می برند.افراد در هر سنی ممکن است مبتلا به سرطان شوند . اما بیشتر اشخاص میان سال و سالخوردگان مبتلا به سرطان می شوند.نسبت ابتلا به سرطان در زنان و مردان تقریبا مساوی است .بیش از صد نوع سرطان تاکنون کشف شده است . از جمله سرطان ریه

در بدن انسان در هر دقیقه سلولهای بیشماری می میرند و به همان تعداد سلول جدید از تقسیم سلولی تولید می شود . اما اگر چیزی در تولید مثل سلول ها تداخل ایجاد کند . این تعادل به هم می خورد .مثلا اگر سلولهای اضافی تکثیر شوند یک برآمدگی تشکیل می دهند به نام تومور

تومور دو نوع است 1- خوش خیم 2- بد خیم

علل اصلی سرطان : 1-تماس شخص با مواد سرطان زا  2- ارث  3  -   مواد شیمیایی خاصی که احتمال ابتلا به سرطان را افزایش می دهند مثل ترکیبات آرسنیک – نیکل – کروم – آهن – بعضی روغن ها – و فر آورده های زغال سنگ 4-     قرار گرفتن در برابر تشعشع مثل اشعه ماورا بنفش 5- سیگار 6- بعضی ویروسها

علائم : اختلال در اجابت مزاج یا عملکرد مثانه  - زخم التیام ناپذیر  - خون ریزی غیر عادی – یک غده در سینه  - سوئ هاضمه مداوم  -  سرفه یا گرفتگی صدا ی مزمن

درمان : 1-  جراحی   2- اشعه درمانی  3- درمان چند جانبه 

افسردگی

 یک اختلال ذهنی است که در آن شخص دوران ناراحتی و احساسات منفی را با رنج می گذراند  . او تمام علایق خود را از دست می دهد و احساس بی کسی  بی پناهی و دلسردی می کند 

علائم : احساس ناراحتی و تنهایی   - بی خوابی -  تغیییر اشتها و وزن – از دست دادن انرژی – حساس شدن – گوشه گیری یا درون گرایی – نداشتن تمرکز و قدرت تصمیم گیری – اندیشیدن به مرگ و خود کشی 

علائم ذهنی به علائم جسمی منجر می شود مثل درد سینه – سردرد – خستگی

درمان : بستگی به نوع آن دارد

ا- نیاز به دارو نداشته باشدو روان درمانی کافی است (افسردگی موقعی)

2- شوک الکتریکی (اگر وضعیت بیمار اجازه استفاده از دارو را ندهد)

3- دارو

    سکته مغزی

 ایست و نرسیدن خون به قسمتی از مغز که ناشی از علل زیر است :

یک لخته خون در قسمتی از بدن و یا انسداد یک سرخ رگ   -   ایجاد لخته درون سرخ رگ – پاره شدن یک رگ –

سکته ی مغزی ممکن است موقتی باشد و بدون از دست دادن هوشیاری

علائم :  نفس کشیدن مشکل می شود و یک طرف بدن فلج می شود و پوست بدن مرطوب و چسبناک می شود و قدرت تکلم مختل می شود (درسکته شدید )

درمان : 

1-     مراقبت های پزشکی دقیق ضروری است

2-     ورزش دادن عضو های صدمه دیده الزامی است تا از سفت شدن و انقباض عضله ها جلوگیری شود (با راهنمایی فیزیوتراپیست )

3-     در صورت مشکل تکلم به متخصص گفتار درمانی مراجعه شود

عوارض سکته به سرعت بهبود نمی یابد و ماه ها و حتی سالها طول می کشد .

سکته های شدید اغلب برای بزرگسالان رخ می دهد

آپاندیسیت به التهاب اپانديس(انشعاب کوچک روده بزرگ) گفته ميشود در مردان شیوع بیشتری نسبت به زنان  دارد . اوج میزان شیوع در اواخر نوجوانی و اوایل ۲۰ سالگی است .

علائم و تظاهرات بالینی :

• با درد کولیکی ( انقباض و گرفتگی ) در اطراف ناف شروع می شود . همزمان با افزایش و پیشرفت التهاب درد بسمت پایین و سمت راست شکم متمایل شده و درست در بالای محل زائده آپاندیس متمرکز میشود . ( نقطه مک بودنی )

• کم شدن و یا از دست رفتن کامل اشتها ( بی اشتهایی ) ، اغلب تهوع و گاهی بهمراه استفراغ میباشد .

• ( علامت ریباندتندرنس + ) اگر بهنگام معاینه سمت راست و پائين شکم  را با دست فشار داده و مدت کوتاهی نگه داریم و بعد دستمان را برداریم . بطور لحظه ای درد بیمار بدتر می شود . این یافته نشانه انتشار التهاب بسمت پرده صفاق است .

• درد اولیه ممکن است مبهم باشد ولی بعداً بطور فزاینده ای تشدید می شود .

• توشه رکتال ( معاینه رکتال ) باعث پیدایش درد سمت راست شکم می شود .

• اگر شخص به پشت دراز بکشد و پای راستش را مستقیم بالا بیاورد در ناحیه  تحتانی سمت راست شکم  درد احساس می شود .

• لمس ناحیه یک چهارم تحتانی سمت چپ شکم منجر به احساس درد در ناحیه مقابل ( سمت راست ) میشود .

• ‌در حالیکه شخص به پشت دراز کشیده . اگر زانو و ران او را به سمت شکم خم کنیم و ساق پا را به سمت داخل و خارج شکم بکشیم اینکار منجر به ایجاد درد میشود.

• اگر پریتونیت ایجاد شده باشد عضله شکم در معاینه بسیار سخت است .

• درد شکمی با راه رفتن و سرفه کردن احتمالاً بدتر می شود .

• تب که معمولاً در طی چندین ساعت اتفاق می افتد .

علائم آزمایشگاهی :

• افزایش تعداد گلبولهای سفید خون در آزمایش CBC

• سونوگرافی و CT اسکن شکمی احتمالاً التهاب آپاندیس را نشان می دهد .

جراحی آپاندیس تشخیص آپاندیسیت را قطعی میکند . این عمل با شکاف کوچکی در ناحیه یک چهارم راست و پائین شکم انجام می شود .

البته همه جراحی ها ،‌ یک آپاندیش غیرطبیعی را نشان نمی دهد . حدود ۱۵-۱۰٪ از موارد اعمال جراحی برای آپاندیسیت مشکلی از آپاندیس را نشان نمی دهد بلکه حکایت از مشکلی فراتر از آپاندیسیت است .

در این موارد جراح آپاندیس را برمی دارد و بقیه شکم را برای پی بردن به علل احتمالی درد بررسی می کند . در بعضی موارد برای اینکار نیاز به شکاف جراحی وسیعتری است .

درمان :

بعد از محرز شدن تشخیص با توجه به علائم بالینی  و یافته های آزمایشگاهی جراحی باید هر چه سریعتر انجام شود . اگر شک به آبسه وجود داشته باشد . ابتدا آنتی بیوتیک تراپی انجام می شود و بعد جراحی صورت می گیرد .

عوارض :

• پارگی روده ها

• گانگرن روده ها ( مردگی بافت روده )

• التهاب پرده صفاق ( پریتونیت )

• آبسه