آپاندیسیت و غیره

Axial CT images through the lower abdomen

apandis — Sun, 25 Sep 2005 14:39:10 GMT

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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APPENDICITIS is the most common surgical emergency seen in hospitals. Six of every hundred persons w

apandis — Sun, 25 Sep 2005 14:35:17 GMT

Symptom of Appendicitis

"Ouch! Must be the Mustard"

APPENDICITIS is the most common surgical emergency seen in hospitals. Six of every hundred persons will get it at some point in their life.

The appendix is a small pouch like a finger connected to your main gut. It's use is unknown but sometimes it gets blocked by stool passing by. Once this happens bacteria in the stool start to multiply and cause an infection of the appendix. It's like having a river of stool passing by. If it stops it gets stagnant just like a real pool of water allowing bacteria to grow - which is why stagnant water starts to smell bad.

The symptoms of Appendicitis are:

Fever.
Bad breath and no appetite.
Heart racing.
Coughing hurts your tummy.
Pain in your tummy that starts around your navel and later drops into your right lower side like in the cartoon guy above.

Appendicitis is diagnosed by your doctor from a history of the above symptoms and by pressing with his/her hand on your tummy. If there is pain over the right lower abdomen, especially if worse on jerking the area, appendicitis is strongly suspected - except in females where ovaries and other structures can also lead to pain in this area.

We'll look next at treatment.

Next!

آپاندیس گانگرنه

apandis — Sun, 25 Sep 2005 14:24:42 GMT

Acute Appendicitis: Gastrointestinal Imaging

apandis — Sun, 25 Sep 2005 14:11:18 GMT

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

Gastrointestinal Imaging

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 onthe diagnostic performance of ultrasonography (US) and on theappropriateness of the surgical decision.

MATERIALS AND METHODS: A prospective randomized, double-blindplacebo-controlled trial with morphine was conducted. A visualanalog scale was used to evaluate pain in 340 patients aged16 years or older. US was performed with a standardized protocol.Diagnosis was confirmed at histologic analysis or, in the patientsreleased without surgery, at follow-up.

RESULTS: One hundred seventy-five patients were injected withmorphine, and 165 were injected with the placebo. Pain reliefwas stronger in the morphine group. In the morphine group, UShad 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 predictivevalue (64.6%) and a lower negative predictive value (71.4%),but the differences between this group and the placebo groupwere not statistically significant. Among female patients, thedecision to operate was appropriate more often in the morphinegroup (75.8%), but the difference between this group and theplacebo group was not statistically significant (5.1%; 95% CI,-7.4%, 17.6%). In male patients and overall, opiate analgesiadid not influence the appropriateness of the decision. The appropriatenessto discharge patients without surgery was 100% in all groups.

CONCLUSION: Morphine does not improve US-based diagnosis ofappendicitis.

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 investigatingpain in the right lower part of the abdomen that they suspectis due to appendicitis. They fear that the analgesia will maskthe symptomatology and delay the diagnosis. However, in 1979,an editorial in the British Medical Journal (1) suggested theuse of opiate analgesia for abdominal pain. Then, the resultsof the studies by Zoltie and Cust in 1986 (2), Attard et alin 1992 (3), and Pace and Burke in 1996 (4) showed that theuse of opiate analgesia for acute abdominal pain did not causeeither a delay in diagnosis or drug-related adverse effects.

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

We therefore conducted a prospective randomized, double-blind,and placebo-controlled trial on early pain relief with intravenousadministration of morphine in patients admitted to an emergencydepartment for pain in the right lower part of the abdomen.The objectives of the trial were to determine the influenceof opiate analgesia on the diagnostic performance of US andon 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 yearsor older who consulted the emergency department of a universityhospital for pain in the right lower part of the abdomen betweenApril 1993 and October 1995. The hospital ethical committeeapproved the protocol. Exclusion criteria were a previous appendectomy;a clinical presentation highly suggestive of a nonappendicularpathologic condition (eg, renal colic or extrauterine pregnancy);the presence of renal, hepatic, or respiratory insufficiency;and the use of psychotropic medication. Patients who were admittedseveral times during the study were eligible to participateonly once. Of the 488 eligible patients, 350 (72%) participatedin the study. They all gave written informed consent.

The medical history was taken and a clinical examination wasperformed by the emergency department resident who checked theinclusion criteria. All patients were asked to assess theirpain by using a 10-cm visual analog scale, or VAS, during thefirst examination (pain score 1). After providing signed informedconsent, the patients were then randomized to receive one of440 vials specially prepared by the hospital pharmacy for thestudy. These vials contained either 10 mg of morphine (1 mg/mL)or a placebo (sodium chloride 0.9%). The dose of morphine administeredfor analgesia was 0.1 mg per kilogram of body weight, whichwas administered intravenously (50% in 3 minutes, then 50% in2 minutes). About 45 minutes after the administration of eithersubstance—the morphine or the placebo—the patientswere asked to give a second assessment of their level of painby using the visual analog scale (pain score 2).

US was performed at the latest within the 4 hours after theintravenous injection of morphine or the placebo by the radiologistin the emergency department, who was a second- or third-yearresident. 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 establishedby the radiology department. The radiologist had to answer specificquestions about the position, diameter, length, and deformabilityof 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 hadto 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 therapeuticdecision. The decision of the surgeon was not analyzed. Laparoscopicsurgery was performed if no major contraindication was presentwithin 24 hours after admission. A histologic diagnosis wasobtained in all patients who underwent surgery. Patients whowere not operated on and stayed in the ward 24 hours or morefor observation were examined again by a surgeon before leavingthe hospital. All of these patients were contacted after 30days for follow-up. The randomization code was broken and communicatedto the authors only after all of the data had been collected.

The Student t test for paired and unpaired data was used tocompute differences in pain score within the groups (ie, morphinegroup and placebo group) and between the groups. The heterogeneityof proportions between the two groups was assessed by usingprobability differences and 95% CIs (12). The analyses wereperformed with SAS, version 6 software (SAS Institute, Cary,NC). The sensitivity of US was the proportion of histologicallyconfirmed cases of appendicitis that were classified as sureor probable by the radiologist. The specificity of US was theproportion of all patients who were discharged without undergoingsurgery, who were not readmitted during the following month,and in whom appendicitis was ruled out by the radiologist. Thepositive predictive value of US was the proportion of histologicallyconfirmed cases of appendicitis in patients whose US findingswere classified as sure or probable for the presence of appendicitisby the radiologist. The negative predictive value was the proportionof non–histologically confirmed cases of appendicitis inpatients in whom appendicitis had been ruled out by the radiologist.

Reasons for refusal to participate in the study were no consentfrom 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 participatein the study, and the medical files of 340 patients could beanalyzed. Ten files could not be used because clinical or radiologicinformation was missing (seven patients), there was no follow-upat 1 month (two patients), or the operation took place beforethe protocol procedure was completed (one patient).

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Figure 1. There were 340 patients in the study. *App + = number of patients with appendicitis and other diagnoses (eg, gynecologic pathologic entities, appendicular carcinoids, peritoneal carcinosis, spontaneous adhesion, and appendicular cancer) in which surgery was required, **App - = number of patients with a normal appendix at surgery, App + = number of patients who had a reconsultation and eventually underwent surgery in our emergency department or at another facility for suspicion of appendicitis or another diagnosis within 30 days of leaving the emergency department, App - = number of patients who did not have a new consultation for abdominal pain at any facility within 30 days after leaving the emergency department.

	RESULTS

TOP Abstract Introduction MATERIALS AND METHODS RESULTS DISCUSSION References

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

Overall, 205 patients underwent surgery; in 181 (88%) of thesepatients, the surgery was laparoscopy. One hundred thirteen(65%) patients in the morphine group and 92 (56%) patients inthe placebo group were operated on. Overall, appendicitis (acute,phlegmonous, or perforated) was confirmed histologically in155 (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. Noneof the 135 patients who did not undergo surgery and left thehospital after 24 hours of observation was readmitted or operatedon at another local hospital.

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

The data in Table 1 show that in all the groups the pain scorediminished significantly (P = .001) after the injection of morphineor the placebo. The pain relief was, however, stronger in themorphine group (minus about 2 points) than in the placebo group(minus about 1 point). The numbers of patients with positiveand with negative diagnoses, as determined at US and at finaldiagnosis, are shown in Table 2. These numbers were used tocompute the statistics presented in Tables 3 and 4.

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TABLE 1. Pain Scores Obtained before and about 45 Minutes after Morphine or Placebo Injection

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TABLE 2. US Findings and Final Diagnoses in Patients according to Sex and Randomization Arm

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TABLE 3. Sensitivity of US for the Diagnosis of Appendicitis in Patients Complaining of Pain in the Lower Right Part of the Abdomen

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TABLE 4. Frequency of Appendicitis and Predictive Values of US in the Diagnosis of Appendicitis in Patients Complaining of Pain in the Lower Right Part of the Abdomen

Table 3 shows the sensitivity and specificity of US for thediagnosis of appendicitis in patients with right lower abdominalpain. The diagnostic standards were the histologic diagnosisof appendicitis in patients who underwent surgery and no readmissionin those who did not undergo surgery. Surgical findings otherthan appendicitis were classified as false-positive findings.The sensitivity of US was lower in the female patients who receivedmorphine (65.9%) than in the female patients who received theplacebo (84.0%); the difference was statistically significant(-18.1%; 95% CI, -30.0%, -6.2%). The specificity of US was higherin the male patients who received morphine (74.2%) than in themale patients who received the placebo (57.7%); the differencewas 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 groupthan in the placebo group; both sets of results were statisticallysignificant (P < .05).

The data in Table 4 show that the prevalence of appendicitiswas lower in the female patients (40.2% in the morphine groupand 27.2% in the placebo group) than in the male patients (57.5%in the morphine group and 64.4% in the placebo group). Becauseof the higher prevalence of appendicitis in the male patients,the positive predictive value of US was substantially betterin these patients than in the female patients; in both the morphineand the placebo groups, the negative predictive value tendedto be higher in the female patients (not statistically significantin the morphine group). In the female patients, morphine injectionresulted in a lower negative predictive value (72.6%) than thatin the placebo group (89.7%) (difference, -17.1%; 95% CI, -27.8%,-6.4%); this suggests that morphine had masked the US-baseddiagnosis. On the other hand, the positive predictive valuewas better in the morphine group (52.9%) than in the placebogroup (39.6%), but the difference was not statistically significant.In male patients, both the positive and the negative predictivevalues were better in the morphine group, but the differencesdid not reach statistical significance.

The proportion of surgical findings and the appropriatenessof the decision of whether to undergo surgery, based on thedata in the Figure, are presented in Table 5. Surgical findingsincluded the histopathologic diagnosis of appendicitis or ofanother pathologic entity. The surgical findings were more frequentin the male patients than in the female patients. The decisionto operate was considered to be appropriate when it resultedin surgical findings. The highest probability of an appropriatedecision was observed among the male patients in the morphinegroup (93.6%; 95% CI, 86.6%, 100%). The lowest probability ofan appropriate decision was observed among the female patientsin the placebo group (70.7%; 95% CI, 56.8%, 84.7%). Among thefemale patients, the decision to operate was more often appropriatein the morphine group (75.8%), but the difference between thisgroup 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 thedecision to operate.

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TABLE 5. Appropriateness of the Decision to Operate Correlated with Final Diagnosis

The decision to discharge without surgery was considered tobe appropriate when it was not followed by readmission for abdominalpain. Because no patient had to be readmitted after it was decidednot to operate, the appropriateness of the decision to dischargewithout 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 analgesicsubstantially reduces pain in patients. This result is comparableto that of Pace and Burke (4), who, with the same doses of morphine,observed a substantial reduction in pain as measured on a visualanalog scale for all types of abdominal pain.

The diagnostic accuracy of US was more contrasted. Morphinetended to decrease sensitivity but increase specificity. Thisis consistent with the surgeon's concern that analgesia maymask the symptomatology of appendicitis. This was paradoxical;we expected morphine to improve sensitivity because it facilitatedthe maneuvers of the radiologist and reduced the proportionof false-negative findings. The explanation may be that painalso influences radiologic diagnosis (11,13–15). On theother hand, analgesia appears to be beneficial for specificity,that is, for reducing the proportion of false-positive US-baseddiagnoses of appendicitis.

As a result, analgesia tended to improve the positive predictivevalue but worsen the negative predictive value of US. It isof note, however, that the overall differences between the morphinegroup and the placebo group were not statistically significant.The results of this study could then be interpreted as beingbasically negative for the influence of morphine on the accuracyof 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. Thismay be because morphine influences the perception of pain andthe affective reaction to it more than it confers complete analgesia.

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

In conclusion, the results of our study do not demonstrate thatthe use of analgesia improves the diagnostic performance ofUS. However, they do not indicate that major analgesia usedwith a strictly applied protocol for pain in the right lowerpart of the abdomen has a deleterious effect on the diagnosisof 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 abdominalpathologic 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 andthe nurses and physicians of the Emergency Department at HôpitauxUniversitaires de Genève for participating in the study.

CASE REPORT

apandis — Sun, 25 Sep 2005 14:06:21 GMT

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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Acute appendicitis

apandis — Sun, 25 Sep 2005 13:57:06 GMT

	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

Appendicular peritonitis

apandis — Sun, 25 Sep 2005 13:52:51 GMT

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.

آسیب شناسی آپاندیسیت http://img.villagephotos.com/p/2004-12/909460/KHAJEH-KHMD83.JPG

apandis — Sun, 25 Sep 2005 13:35:18 GMT

Acute Appendicitis: Review

apandis — Tue, 16 Aug 2005 21:09:01 GMT

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.⁶The "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.³In 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.¹Duration 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.⁹Unfortunately, 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.

apandis — Tue, 16 Aug 2005 21:03:35 GMT

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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