Acute Appendicitis: Controversies in Diagnosis and Management

Wray, Curtis J.; Kao, Lillian S.; Millas, Stefanos G.; Tsao, KuoJen; Ko, Tien C.

doi:10.1067/j.cpsurg.2012.10.001

Cited by 91 publications

(79 citation statements)

References 181 publications

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“…In a recent study published in 2013, Wray CJ et al concluded that, the question of whether or not appendectomy should be performed via an open or laparoscopic technique has been inherently difficult to answer because both approaches offer similar advantages, namely, a small incision, low incidence of complications, a short hospital stay, and rapid return to normal activity [25]. At our hospitals, the laparoscopic approach has been adopted for the treatment of appendicitis in the younger age groups but so far, not for the elderly patients.…”

Section: Discussionmentioning

confidence: 99%

Acute appendicitis in the elderly: risk factors for perforation

et al. 2014

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BackgroundAcute appendicitis is the most common surgical emergency and becomes serious when it perforates. Perforation is more frequent in the elderly patients. The aim of this study was to identify the risk factors of perforation in elderly patients who presented with acute appendicitis.MethodologyThe medical records of 214 patients over the age of 60 years who had a pathologically confirmed diagnosis of acute appendicitis over a period of 10 years (2003-2013) were retrospectively reviewed. Patients were grouped into those with perforated and those with nonperforated appendicitis. Comparison was made between both groups in regard to demography, clinical presentation, and time delay to surgery, diagnosis, hospital stay and postoperative complications. Clinical assessment, Ultrasonography and Computerized tomography, in that order, were used for diagnosis. The incidence of perforation was also compared with a previous report from the same region 10 years earlier.ResultsDuring the study period, a total of 214 patients over the age of 60 years had acute appendicitis, 103 males and 111 females. Appendix was found perforated in 87 (41%) patients, 46 (53%) males and 41 (47%) females. Of all patients, 31% were diagnosed by clinical assessment alone, 40% needed US and 29% CT scan. Of all the risk factors studied, the patient’s pre-hospital time delay was the most important risk factor for perforation. Perforation rate was not dependent on the presence of comorbid diseases or in-hospital time delay. Post operative complications occurred in 44 (21%) patients and they were three times more common in the perforated group, 33 (75%) patients in the perforated and 11 (25%) in the nonperforated group. There were 6 deaths (3%), 4 in the perforated and 2 in the nonperforated group.ConclusionAcute appendicitis in elderly patients is a serious disease that requires early diagnosis and treatment. Appendiceal Perforation increases both mortality and morbidity. All elderly patients presented to the hospital with abdominal pain should be admitted and investigated. The early use of CT scan can cut short the way to the appropriate treatment.

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Section: Discussionmentioning

confidence: 99%

Acute appendicitis in the elderly: risk factors for perforation

et al. 2014

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“…Second, equipment and doctors qualified to interpret images are not always available for every patient in all hospitals worldwide. [6][7][8] Leucocytosis and an elevated CRP level have been associated with AA, but there are contradictory results in the literature regarding the contribution of each individual laboratory test or the combination of several values in children. Moreover, the majority of the studies involve small numbers of patients.…”

Section: Researchmentioning

confidence: 93%

“…In a recently published study, the hospital costs of negative appendicectomy in the USA were >USD740 million over a 1-year period. [6] The introduction of ultrasonography and computed tomography (CT) has improved the accuracy of AA diagnosis in recent years. However, heavy reliance on these imaging modalities has some disadvantages.…”

Section: Researchmentioning

confidence: 99%

White blood cell count and C-reactive protein together remain useful for diagnosis and staging of acute appendicitis in children

Monsalve

Ellwanger²,

Montedónico

2017

S Afr Med J

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Background. Acute appendicitis (AA) is the most common acute surgical condition of the abdomen, and the most commonly misdiagnosed. Objective. To analyse the white blood cell count (WBCC) and C-reactive protein (CRP) contribution to the diagnosis of AA in children.Methods. This was a retrospective study of 943 consecutive patients operated on with the preoperative diagnosis of AA, in whom preoperative WBCC and CRP had both been measured. Postoperatively, the patients were divided into three groups: normal appendix (no AA), simple AA and complicated AA. Results. Of the 943 patients, 616 (65.3%) had simple AA. The mean (standard deviation (SD)) age for this group was 9.8 (3.2) years (p<0.01 v. complicated AA), the mean WBCC was 16.5 (5.0) × 10 9 /L (p<0.01 v. complicated AA and no AA), and the mean CRP level was 304.8 (409.5) nmol/L (p<0.01 v. complicated AA). The mean age of the patients with complicated AA (283/943, 30.0%) was 7.9 (3.7) years, the mean WBCC was 17.7 (6.2) × 10 9 /L (p<0.01 v. no AA) and the mean CRP level was 1 076.2 (923.8) nmol/L (p<0.01 v. no AA). The mean age of the patients with no AA (44/943, 4.7%) was 8.8 (3.2) years, the mean WBCC was 13.1 (5.3) × 10 9 /L and the mean CRP was 361.9 (447.6) nmol/L. The WBCC was normal in 113/899 patients with appendicitis (12.6%) and CRP in 139 (15.5%). Both the WBCC and CRP were normal in 17 patients with appendicitis (1.9%). The best receiver operating characteristic (ROC) curve was obtained for WBCC when comparing all AA with no AA: cut-off point 15.0 × 10 9 /L, sensitivity 65%, specificity 68%, area under the curve 0.70. The best ROC curve for CRP was obtained when comparing simple AA with complicated AA: cut-off point 361.9 nmol/L, sensitivity 74%, specificity 74%, area under the curve 0.81. Conclusions. The WBCC is helpful in diagnosing simple AA and CRP in diagnosing complicated AA. If both are normal, AA is very unlikely. Together the WBCC and CRP are useful tools in diagnosing and staging AA. RESEARCHPostoperatively, all patients included in the study were divided into three groups according to the intraoperative macroscopic findings, as follows:• Normal appendix (no AA). All patients operated on with the preoperative diagnosis of AA but in whom the appendix was found to be macroscopically normal. The findings on histological analysis of the appendix in this group were recorded. • Simple AA. All non-perforated AA.• Complicated AA. Perforated appendix, peritonitis, appendicular abscess and appendicular mass. Statistical analysisMeans (standard deviations (SDs)) were used to describe the numerical variables. Statistical analysis was performed with parametric tests (Student's t-test or analysis of variance). A cross-sectional analysis of the diagnostic tests was performed where sensitivity, specificity and likelihood ratios were calculated. Receiver operating characteristic (ROC) curves were also elaborated for each test and prediction, calculating the area under the curve with a confidence interval of 95%. The level of significance was set at p<0....

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“…Sample size based on the reported postappendicectomy complication rate of 1.9–8.8%3 4 and negative appendicectomy rate of 6–15%,6 7 we would expect a treatment efficacy of 90% in the control OM group. Based on the reported treatment efficacy of 63–73%15 19 in adults treated with NOM and 58–100% in children,20–32 we would expect a possible difference of treatment efficacy between the control and treatment group to be between 15% and 25%.…”

Section: Discussionmentioning

confidence: 99%

Acute uncomplicated appendicitis study: rationale and protocol for a multicentre, prospective randomised controlled non-inferiority study to evaluate the safety and effectiveness of non-operative management in children with acute uncomplicated appendicitis

Liu

Adams

et al. 2016

BMJ Open

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IntroductionThis article presents an overview of a prospective randomised controlled non-inferiority study designed to evaluate the safety and effectiveness of non-operative management (NOM) with operative management in children with acute uncomplicated appendicitis (AUA). Here, we present the study protocol for this APRES study, a multicentre Australian study. The rationale and details of future analysis, in particular, non-inferiority calculations, cost-effectiveness, feasibility and acceptability of each intervention.DesignA multicentre, prospective randomised controlled clinical trial, conducted in 2 Australian tertiary paediatric hospitals.ParticipantsChildren who meet the inclusion criteria of an age between 5 and 15 years and a clinical diagnosis of AUA will be invited to participate, and after consent will be randomised via a computer-based program into treatment groups. The study started in June 2016, and the target recruitment is 220 patients.InterventionsChildren in the control group will be treated with prophylactic antibiotics and appendicectomy, and those in the intervention group will be treated with antibiotic therapy alone. Primary outcome measures include unplanned or unnecessary operation and complications at 30 days. Secondary outcomes include longer term complications within 1 year, length of stay, time off work and school analgesic requirements and cost.AnalysisData analyses will be on the intention-to-treat principle using non-inferiority analysis. Analysis will include the Pearson χ2 test for categorical variables and independent sample t-test or Mann-Whitney test for continuous variables. Non-inferiority for NOM will be tested using 1-sided Wald tests with an α level of 0.05.Ethics and disseminationThe research has been approved by the Human Research Ethics Committee of the Sydney Children's Hospital Network. In addition, results will be reported through academic journals, seminars and conference presentations.Trial registration numbersNCT02795793; ACTRN12616000788471.

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Acute Appendicitis: Controversies in Diagnosis and Management

Cited by 91 publications

References 181 publications

Acute appendicitis in the elderly: risk factors for perforation

Acute appendicitis in the elderly: risk factors for perforation

White blood cell count and C-reactive protein together remain useful for diagnosis and staging of acute appendicitis in children

Acute uncomplicated appendicitis study: rationale and protocol for a multicentre, prospective randomised controlled non-inferiority study to evaluate the safety and effectiveness of non-operative management in children with acute uncomplicated appendicitis

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