Objective: To determine the association between Alvarado score and the severity of acute appendicitis in an East Coast Hospital, Malaysia. Methods: The cross-sectional study involved reviewing the record of all 177 Patients operated for suspected acute appendicitis in the hospital. Data were collected using a proforma. The severity of appendicitis was divided into perforated or non-perforated from the histo-pathological examination reports. Alvarado score recorded during the presentation to hospital was recorded. Simple and multiple logistic regression analysis were used to determine the association between Alvarado score and the severity of acute appendicitis. Results: Prevalence of perforated appendicitis was 25.1%. The mean of Alvarado score was 7.5 (SD: 1.35). Multiple logistic regression analysis showed a significant association between Alvarado score and severity of acute appendicitis after adjusting for age, gender and duration of pain before presentation. Conclusion: Higher Alvarado score is associated with higher odds of perforation. Therefore, Alvarado score could be used not just for diagnostic purpose, but also for predicting the severity of appendicitis.

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Introduction: We aim to report an uncommon case of post ERCP perforation that effectively managed conservatively in non-hepatobiliary surgery centre. Case report: A 46-year-old man diagnosed to have obstructive jaundice secondary to distal common bile duct (CBD) stone. He underwent ERCP at a private centre, sphincterotomy was performed, but, the operator had failed to insert the stent and complicated with post ERCP perforation evidenced by contrast extravasation beyond 1/3rd of the CBD and referred to our centre. Patient was subjected for re ERCP. There were difficulties in cannulating the CBD and stent was inserted. Cholangiogram revealed contrast leak around the pancreatic duct and bifurcation of hepatic duct. There was no evidence of CBD stone. Computed Tomography (CT) of the abdomen revealed extensive subcutaneous emphysema on the right side of the abdomen to right inguinal region, extensive retroperitoneal free air and pneumoperitoneum, but there were no free fluid or contrast extravasation. The patient subjected for non-operative management (NOM) for the complication and kept fasting with total parenteral nutrition and intravenous antibiotic. He recovered well with the opted management. Patient was programmed with Gastrograffin study after 10 days that showed no evidence of contrast leak to suggest free bowel injury. He was allowed orally after that and was discharged well after 15 days with stent in situ. During follow up, he was well, and the stent removed after 3 months. Patient planned for laparoscopic cholecystectomy and on table cholangiogram. Conclusion:  Post ERCP perforation is uncommon but lethal. Early recognition of the complication is crucial hence appropriate management can be arranged to avoid death. To date, surgery is not the only choice available to manage this complication.

Background: Appendicitis is common and delayed presentation results in complicated appendicitis with increased morbidity. This study investigates the effect of the Movement Control Order (MCO) during the COVID-19 pandemic on the presentation and severity of appendicitis. Methods: A cross-sectional study including 193 patients diagnosed with appendicitis was conducted at four hospitals in Pahang, Malaysia. Those who presented between 1 February 2020 and 17 March 2020 were included in the pre-MCO group and those between 18 March 2020 and 30 April 2020 in the MCO group. The definitions of simple and complicated appendicitis were based on the Sunshine Appendicitis Grading Score. The primary outcome was the incidence of complicated appendicitis, and the secondary outcomes were length of stay, a composite of surgical morbidities and a composite of organ failure. Results: A total of 105 patients in the pre-MCO group and 88 in the MCO group were analysed. The incidence of complicated appendicitis was 33% and it was higher in the MCO than in the pre-MCO group (44% versus 23%, P = 0.002). The MCO period was independently associated with complicated appendicitis in the logistic regression (P = 0.001). It was also associated with prolonged length of stay (3.5 days versus 2.4 days, P < 0.001) and higher overall surgical morbidity (19% versus 5%, P = 0.002). Conclusion: The MCO imposed during the COVID-19 pandemic was associated with a higher incidence of complicated appendicitis and surgical morbidity.

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