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.