Does warfarin enhance platelet activity?

Salmonella infection can cause appendicitis by direct invasion of the appendix, or can mimic appendicitis by causing mild inflammation of the appendix, ileum, or lymph nodes. Clinical presentation and radiologic and laboratory evaluation may not distinguish the extent of underlying pathology. This case of a child with an atypical presentation of Salmonella who underwent diagnostic laparotomy illustrates the overlap of enteric infections and acute appendicitis. A literature review confirms the variety of clinical scenarios of patients with suspected appendicitis and Salmonella-positive cultures. We conclude that enteric infection should be considered in children with atypical presentations of appendicitis, and that the knowledge that Salmonella can progress to appendicitis should guide management if signs and symptoms of appendicitis develop.     

Should we patch corneal erosions?

This prospective study was performed to investigate epidemiological characteristics in terms of the age- and sex-specific incidence in patients with perforated and nonperforated appendicitis. The study population comprised 1486 consecutive patients who underwent appendectomy for suspected acute appendicitis between 1989 and 1993. Two patient cohorts [n = 544 (37%)] were analyzed with regard to prehospitalization duration of symptoms and in-hospital observation time. The crude incidence of acute appendicitis was 86 per 100,000 per year. Although the incidence of nonperforated appendicitis was highest among adolescents and young adults (13-40 years of age), perforated appendicitis occurred at almost the same incidence in all sex and age groups. The diagnostic accuracy was 76%. Perforated appendicitis occurred in 19%, with higher rates in small children and the elderly, irrespective of gender. A high diagnostic accuracy was not associated with an increased rate of perforation. In small children and the elderly, the diagnostic accuracy was low and the perforation rate high. Patients with perforation had a significantly longer duration of symptoms as well as in-hospital observation time than did patients with nonperforated appendicitis. Perforated appendicitis showed a different incidence pattern than nonperforated appendicitis and was associated with a significantly longer duration of symptoms and in-hospital observation time, probably due to patient-related factors. We suggest this observation deserves attention regarding clinical diagnosis and treatment decision-making for patients with suspected acute appendicitis.     

Does this patient have appendicitis?

Appendicitis is a common cause of abdominal pain for which prompt diagnosis is rewarded by a marked decrease in morbidity and mortality. The history and physical examination are at least as accurate as any laboratory modality in diagnosing or excluding appendicitis. Those signs and symptoms most helpful in diagnosing or excluding appendicitis are reviewed. The presence of a positive psoas sign, fever, or migratory pain to the right lower quadrant suggests an increased likelihood of appendicitis. Conversely, the presence of vomiting before pain makes appendicitis unlikely. The lack of the classic migration of pain, right lower quadrant pain, guarding, or fever makes appendicitis less likely. This article reviews the literature evaluating the operating characteristics of the most useful elements of the history and physical examination for the diagnosis of appendicitis.     

White blood cell count is a poor predictor of severity of disease in the diagnosis of appendicitis

The white blood cell (WBC) count is considered to be a useful test in the diagnosis of appendicitis. The purpose of this study was to examine the clinical features of patients with normal WBC appendicitis and also to determine whether a higher WBC count correlates with a more advanced stage of appendicitis. Patients with pathologically confirmed appendicitis from January 1989 to December 1994 were included in the study (n = 1919). The age, gender, temperature, length of hospital stay, and severity of disease (1 = acute appendicitis; 2 = gangrenous appendicitis; 3 = perforated appendicitis with abscess formation; 4 = appendicitis with diffuse peritonitis) were compared for patients with a normal WBC count (range, 3.8-10.9) versus those who had an elevated WBC count. A normal WBC count was seen in 11 per cent of patients (n = 209). There was no difference in age, temperature, gender, or severity of disease in the patients with a normal WBC count compared with those with an elevated WBC count (P > 0.05). The severity of disease of patients with a normal WBC count were: 1 = 58 per cent; 2 = 13 per cent; 3 = 7 per cent; and 4 = 22 per cent. For patients with an elevated WBC count the scores were: 1 = 57 per cent; 2 = 17 per cent; 3 = 13 per cent; and 4 = 14 per cent. The proportion of gangrenous and perforated appendicitis in the patients with a normal WBC count is the same as in the patients with an elevated WBC count.     

Imaging findings in patients with-right lower quadrant pain: alternative diagnoses to appendicitis

Patients with right lower quadrant (RLQ) pain referred for imaging studies with a clinical diagnosis of appendicitis may have other pathologic conditions mimicking appendicitis. Appropriate diagnostic imaging may establish other specific diagnoses and thereby play a significant role in determining proper medical or surgical treatment. In this pictorial essay, we present a spectrum of imaging findings in patients whose clinical features were suggestive of appendicitis, but the diagnoses of a broad spectrum of other diseases were established with the imaging studies. The differential diagnoses of diseases mimicking appendicitis are reviewed.     

Autocatalytic processing of pro-papaya proteinase IV is prevented by crowding of the active-site cleft

BACKGROUND: To establish the value of saline-filled appendiceal ultrasonography in the the diagnosis of clinically equivocal acute appendicitis. METHODS: Saline-filled ultrasonography was performed in 43 patients with an equivocal clinical diagnosis of acute appendicitis. RESULTS: Sonography diagnosed 31 of 32 patients without acute appendicitis (97%). A normal appendix was visualized in 15 patients (47%), and we identified a normal appendix in 15 of 22 patients (68%) in whom the colon was cleansed with Golytely(R). Sonography diagnosed 10 of 11 patients with acute appendicitis (91%). In three of 10 patients, the findings corresponded to sonographic pitfalls. CONCLUSION: Saline-filled appendiceal ultrasonography enables the detection of a normal appendix and may overcome sonographic pitfalls in acute appendicitis.     

Allopurinol blocks shock-wave-induced rises in cytosolic calcium levels in MDCK cells

OBJECTIVE: To evaluate physicians' probability estimates of acute appendicitis based on structured collection of clinical data. DESIGN: Open prospective study. SETTING: District hospital, Norway. SUBJECTS: 304 patients admitted with suspected acute appendicitis. INTERVENTIONS: Initial diagnostic accuracy of physicians was compared with corresponding results from a computer model. MAIN OUTCOME MEASURES: The estimated probabilities of appendicitis in different testing groups were analysed using receiver operating characteristic (ROC) curves. RESULTS: Physicians' estimates had a mean area under ROC-curve of 0.81 (95% CI 0.79 to 0.82), not significantly different from the computer model. Both correlated well with the actual rate of appendicitis, but the physicians tended to overestimate the probability by 10%. CONCLUSION: Physicians' probability estimates perform rather well. Further attempts to implement a probabilistic approach in the diagnostic process of acute appendicitis therefore seem justified.     

Is there a role for abdominal computed tomographic scans in appendicitis?

OBJECTIVE: To better define the effectiveness of abdominal computed tomographic scanning (ACTS) in adult patients with suspected appendicitis. DESIGN: Retrospective analysis. SETTING: A community teaching hospital. PATIENTS: Ninety-seven patients with appendicitis in the differential diagnosis, whose clinical findings were insufficient to perform surgery or to discharge from the hospital, during a 14-month period. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Accuracy of ACTS, rate of appendectomies that show no appendicitis (negative appendectomy rate), and frequency of ACTS as a definitive diagnostic test. RESULTS: Forty-nine of the 50 patients with appendicitis were correctly diagnosed by ACTS. Forty-three of the 47 patients without appendicitis were correctly diagnosed by ACTS. Positive predictive value was 92%, negative predictive value was 98%, and accuracy was 96%. The ACTS group had a negative appendectomy rate of 5.8% (3/52), lower than the hospital rate of 14% for the preceding 3 years. The ACTS established an alternative diagnosis in 16 patients, allowed 10 other patients to be discharged early or not admitted, and was the critical diagnostic test in 30 of the patients with appendicitis. Therefore, the ACTS played a definitive role in the treatment of 56 (57.7%) of the 97 patients. CONCLUSIONS: The ACTS was an accurate test in the diagnosis of appendicitis and was of significant benefit in 57.7% of the patients studied. However, it was difficult to predict which patients were most likely to benefit. Expanded selective use of ACTS for patients with clinically indeterminate appendicitis may result in a lower negative appendectomy rate and fewer patient admissions for observation.     

The clinical picture of acute appendicitis in children

The authors describe 3860 child patients operated on account of acute appendicitis and analyse the data with regard to age, sex, year of incidence and surgical finding. The highest incidence of acute appendicitis is between 8 and 11 years with a peak at the age of 10 years. It is more frequent in boys (58.3%) than in girls (43.7%), the ratio being 1.3:1. It occurs more often during the cold months (46.5%), in autumn (27.3%) and in winter (25.7%). The number of gangrenous appendicitis is 34.7%-56.7% in boys and 43.5% in girls. The highest rate of missed appendicitis is at the age of the highest incidence (15.2%) with a peak at the age of 10 years (17.8%) and in January (13.3%). The highest incidence of perforated appendicitis is also at the age of the highest incidence (14.9%) with the peak at the age of 8 years (15.6%) and in June (13.5%). Perforation is more frequent in boys (58.1%) than in girls (49.9%). The number of "negative" appendicitis is 15.8%. Prevention of acute appendicitis still remains open due to lack of knowledge of its etiopathogenesis.     

Anaerobic bacteria isolated from appendices and appendicitis cases

Anaerobic bacteria were isolated from 17 of 40 normal appendices and appendicitis cases in Ankara. In both cases gram positive, nonsporulating, and gram negative organisms were isolated. Gram positive cocci were only isolated from appendicitis cases. The bacteria isolated from appendicitis are usually like the anaerobic bacteria of the colon flora. All anaerobic bacteria in appendix flora can cause appendicitis in suitable conditions.     

Diagnostic laparoscopy through the right lower abdominal incision following open appendectomy

BACKGROUND: Diagnostic laparoscopy through the right lower abdominal incision following open appendectomy for suspected acute appendicitis may help in making the correct diagnosis in the absence of pathology of the appendix. METHODS: Fourteen patients with a clinical diagnosis of acute appendicitis underwent diagnostic laparoscopy through the right lower quadrant incision after open appendectomy to exclude further pathology in the case of a noninflamed appendix. RESULTS: In 10 of the 14 patients, laparoscopy helped to correct the diagnosis. In two patients, the etiology of the acute right lower abdominal pain remained unclear. In two others, histological examination showed acute appendicitis despite a normal macroscopic appearance. CONCLUSIONS: Diagnostic laparoscopy through the right lower quadrant incision may help to correct the diagnosis in patients who are operated on for clinically acute appendicitis but in whom no acute appendicitis or other pathological findings are seen.     

Imaging of acute right lower abdominal quadrant pain

This article reviews the clinical diagnosis of appendicitis, indications and options for appendiceal imaging, compares appendiceal CT techniques, and describes the imaging findings with appendicitis and alternative conditions that can clinically mimic appendicitis.     

The significance of appendectomy for appendicitis on subsequent fertility

A study was undertaken to determine fertility in a group of females who as children had been operated on for appendicitis. The 134 women operated on for appendicitis were reviewed. Their ages ranged from 2-18 years at the time of appendectomy. Our data show that perforated appendicitis before puberty has little if any role in the etiology of tubal infertility.     

Menstrual cycle and age: influence on parenchymal contrast medium enhancement in MR imaging of the breast

PURPOSE: To quantify how frequently mesenteric adenitis clinically mimics appendicitis and to determine its appearance at computed tomography (CT). MATERIALS AND METHODS: The medical records of 651 consecutive patients with an admission diagnosis of appendicitis were reviewed to determine how often mesenteric adenitis was the discharge diagnosis. The CT scans of a separate group of 18 patients with a discharge diagnosis of mesenteric adenitis were reviewed. These patients were part of a group of 100 consecutive patients prospectively evaluated with CT of the appendix for clinically suspected appendicitis. RESULTS: Fifty of 651 patients (7.7%) with an admission diagnosis of appendicitis had a discharge diagnosis of mesenteric adenitis. Mesenteric adenitis constituted 50 of the 252 (19.8%) discharge diagnoses other than appendicitis. All 18 CT scans of mesenteric adenitis showed three or more nodes that measured at least 5 mm in shortest axis clustered in the right lower quadrant, with a normal appendix identified. Eight patients had associated ileal or ileocecal wall thickening. CONCLUSION: Mesenteric adenitis is an important clinical mimic of appendicitis. It appears at CT as clustered, enlarged mesenteric lymph nodes with a normal appendix, and there may be associated ileitis or ileocolitis noted.     

Using unenhanced helical CT with enteric contrast material for suspected appendicitis in patients treated at a community hospital

OBJECTIVE: We evaluated the accuracy of unenhanced helical CT with enteric contrast material in the diagnosis of appendicitis in children and adults treated at a community hospital. SUBJECTS AND METHODS: Over an 8-month period, 100 consecutive patients with right lower quadrant pain and suspected appendicitis were prospectively evaluated. Thin-collimation helical CT scanning was performed after administration of enteric contrast material. CT interpretations were correlated with surgical pathology (45 patients) and clinical follow-up (55 patients). RESULTS: The findings of 33 CT scans were interpreted as positive for appendicitis (29 true-positives and four false-positives), and the findings of 67 were interpreted as negative for appendicitis (66 true-negatives and one false-negative). Sensitivity was 97%, specificity was 94%, accuracy was 95%, positive predictive value was 88%, and negative predictive value was 99%. In the 67 CT scans with negative findings for appendicitis, an alternative diagnosis was made for 36 patients (54%). CONCLUSION: Unenhanced helical CT with enteric contrast material for the evaluation of appendicitis can be implemented in a community hospital. In our study, such imaging achieved excellent accuracy.     

Intra-abdominal abscesses following laparoscopic and open appendectomies

Recent findings in a small number of studies have suggested a trend toward increased infectious complications following laparoscopic appendectomy. The purpose of the present review was to evaluate the incidence of postappendectomy intra-abdominal abscess formation following laparoscopic and open appendectomies. Using the surgical database of the Los Angeles County-University of Southern California Medical Center, we reviewed the records of all appendectomies performed at the center between March 1993 and September 1995. Incidental appendectomies as well as appendectomies in pediatric patients under the age of 18 years were excluded. A total of 2497 appendectomies were identified; indications for these procedures included acute appendicitis in 1422 cases (57%), gangrenous appendicitis in 289 (12%), and perforated appendicitis in 786 (31%). The intraoperative diagnosis made by the surgeon was used for classification. A two-tailed P value of <0.05 was considered significant. There was no significant difference in the rate of abscess formation between the groups undergoing open and laparoscopic appendectomies for acute and gangrenous appendicitis. In patients with perforated appendicitis, a total of 26 postappendectomy intra-abdominal abscesses occurred following 786 appendectomies for an overall abscess formation rate of 3.3%. Eighteen abscesses occurred following 683 open appendectomies (2.6%), six abscesses occurred following 67 laparoscopic appendectomies (9.0%), and the remaining two abscesses occurred following 36 converted cases (5.6%). For perforated appendicitis, however, there was a statistically significant increase in the rate of abscess formation following laparoscopic appendectomy compared to conventional open appendectomy (9.0% vs. 2.6%, P = 0.015). There was no significant difference in the rate of abscess formation between open vs. converted cases or between laparoscopic vs. converted cases. A comparison of the length of the postoperative hospital stay showed no significant difference between open and laparoscopic appendectomy for perforated appendicitis (6.1 days vs. 5.9 days). Laparoscopic appendectomy for perforated appendicitis is associated with a higher rate of postoperative intra-abdominal abscess formation without the benefit of a shortened hospital stay. Given these findings, laparoscopic appendectomy is not recommended in patients with perforated appendicitis.     

Unusual case of Meckel''s diverticulum: a case report and review of an atypical form of presentation

This is a review of two children who developed acute glomerulonephritis (AGN) following acute gangrenous appendicitis (AGA) with periappendicular collections. The first patient presented with AGN during the course of appendicitis. The second patient developed AGN after appendectomy. Both patients did not have any other predisposing factors. AGN resolved in both patients after massive intravenous antibiotics. This is the first report of acute appendicitis as a predisposing factor for AGN.     

Correlation of peritoneal aspiration cytology with acute appendicitis

Fifty-one patients in whom a clinical diagnosis of acute appendicitis had been made underwent peritoneal aspiration cytology (PAC). Thirty-six had a positive result, 11 had a negative result and aspiration failed in four cases. All patients had an appendicectomy and the histological findings were correlated with the PAC results. Thirty-five of the 36 patients with a positive PAC had histologically proven appendicitis. Seven of the 11 patients with a negative result had normal appendices. The sensitivity of PAC for acute appendicitis was 85% and the specificity was 70%. The positive predictive value was found to be 97% and the negative predictive value 60%. Peritoneal aspiration cytology is a useful aid in the diagnosis of acute appendicitis however, a negative result does not exclude this diagnosis.     

MR imaging in children with nonperforated acute appendicitis: value of unenhanced MR imaging in sonographically selected cases

OBJECTIVE: The aim of this study was to describe the MR appearance of acute appendicitis and to determine the value of MR imaging for diagnosis of acute appendicitis. SUBJECTS AND METHODS: Forty-five children (28 girls, 17 boys), 7-16 years old (mean age, 13 years old), with clinically diagnosed acute appendicitis underwent independently graded compression sonography by two radiologists. MR imaging was performed when sonography revealed acute appendicitis (observer 1, 16 [36%] patients; observer 2, 18 [40%] patients), was inconclusive (observer 1, two [4%] patients; observer 2, one [2%] patient), and was interpreted as normal (observer 1, two [4%] patients; observer 2, one [2%] patient) (n = 20). Axial T1-weighted turbo spin-echo sequences, T2-weighted turbo spin-echo sequences in the axial and coronal planes, and fat-suppressed short inversion time inversion recovery turbo spin-echo sequences in the axial plane (4-mm slice thickness) were obtained and evaluated independently by two radiologists. The ability to see acute appendicitis with MR imaging was evaluated, the appearance and morphologic changes were described, and the most accurate sequence was determined. All children in whom MR imaging was performed underwent surgery. RESULTS: MR imaging revealed acute appendicitis in all cases (100%) by both observers. On T2-weighted ultra turbo spin-echo images, acute appendicitis appeared with a markedly hyperintense center, a slightly hyperintense thickened wall, and markedly hyperintense periappendiceal tissue. Unenhanced axial T2-weighted spin-echo imaging was the most sensitive sequence. CONCLUSION: In this study group, MR imaging was a valuable technique for depiction of acute appendicitis.     

Is there a duty to die?

OBJECTIVE: To review appendectomy cases in children at a small community hospital and to compare with experience at larger centers. DESIGN: A five-year retrospective study. SETTING: Bartlett Regional Hospital, Juneau, Alaska. PATIENTS AND METHODS: Records of children age 14 and younger who underwent appendectomy from 1991 through 1996 were reviewed; 79 charts were found. Cases were grouped as simple appendicitis, advanced appendicitis, and appendectomy without appendicitis. Variables considered included: length of symptoms at first contact, time from onset until surgery, presence or absence of classical symptoms, post-operative complications, length of hospital stay. RESULTS AND CONCLUSION: 51 cases (64.6%) of simple appendicitis, 22 cases (27.9%) of advanced disease, and 6 cases (7.6%) of normal appendix occurred. Advanced disease was high (66.7%) in children less than 5, and low (22.7%) in ages 10-14. Parental delay > 48 hours in seeking care was a significant factor in advanced disease, professional delay (time from first exam until surgery) was not. Post-surgical complications occurred in 7 (31.8%) cases of advanced disease and in none of the cases with simple appendicitis. Advanced disease cases had an average hospital stay of 8.59 days (+/-2.92) vs. 3.86 days (+/-1.46) for simple appendicitis. Review of appendicitis in children at this hospital compared favorably with the experience at larger medical centers.