Management of Appendicitis

Abdominal pain and vomiting are the most common presentation of gastrointestinal tract disorders in children that lead to imaging. According to the suspected disease, the age of the child, and the institution's preferences, various imaging modalities, including radiography, US, barium study, or CT or MR have been used for examining the gastrointestinal tract. After the neonatal period, a different set of disorders involves the gastrointestinal tract in infants and children, sometimes producing acute abdomen. Intussusception is the most common cause of acute abdomen in infants and young children. Hypertrophic pyloric stenosis should be ruled out in a young infant with vomiting. A strangulated inguinal hernia, complicated Meckel’s diverticulum or necrotizing enterocolitis, and malrotation with volvulus are other causes of acute abdomen, both in the neonatal period and infancy. Acute appendicitis is the most common surgically treated condition in older children. Appropriate and judicious use of imaging techniques should be made by paying attention to clinical history and physical findings, which, in conjunction with knowledge of imaging findings of pediatric gastrointestinal disorders, will allow an early diagnosis to be made as well as guiding a proper treatment.

Pancreatitis in pregnancy has a prevalence of 1.5/1500-4500 cases, constituting one of the most common acute abdomen wedges, with biliary origin in 70% of cases, triglycerides in 20% and other causes in the remaining 10%, including choledochal cyst (CC) as a rare cause with three previous reports in literature, which may have a fatal outcome with fetal loss in some cases. We report the case of a 25-year-old patient with 30.4 weeks of gestation (WOG) that arrived to emergency room with right upper quadrant and epigastric pain for the last 8 hours, associated with nausea and vomiting. No pathological background referred. At physical examination with jaundice, gravidic abdomen for 30.4 WOG pregnant, fetal movements presents, Murphy (+) and epigastric pain on deep palpation. Laboratories report total bilirubin (TB) 3.9 mg/dl and direct bilirubin (DB) 3.69 mg/dl Alkaline phosphatase (AP) 2038 IU/L Amylase 280 IU/L Lipase 1938 IU/L. Pancreatitis is confirmed and abdominal ultrasound (US) is requested to determine biliar origin. USG reports gallbladder of 9×4 cm, thin walls without filling defects, dilated intrahepatic bile duct and common bile duct cyst. Cholangiopancreatography Resonance Imaging (CPMR) concludes Todani I choledochal cyst of 17×9 cm, with displacement of duodenum, colon and pancreas. Due to gestation ongoing appropriate medical management with fluids and analgesics was started until remission of pancreatitis 72 hours later. After delivery at 34 WOG, cholecystectomy was performed with hepatico-jejunum Roux-Y anastomosis successfully. Histopathologic analisis reports inespecific inflammation without displasia or metaplasia. At four months follow-up patient is asymptomatic. Pancreatitis in pregnancy is a common cause of acute abdomen, rarely associated with choledochal cysts as the cause. Surgical resolution once pregnancy is over must be done as soon as possible by the high risk of adenocarcinoma degeneration and recurrent pancreatitis.

Background: Acute appendicitis is one of the commonest cause of acute abdomen. For more than 100 years, surgeons have been successfully performing appendectomy to treat acute appendicitis. However, there is a recent trend to shift towards a more conservative approach. There has been a wide discussion and controversy on the surgical and non-surgical treatment of acute uncomplicated appendicitis. This work aimed to assess the effectiveness of non-operative conservative management in the treatment of acute uncomplicated appendicitis. Method: This was a single tertiary care level hospital based study done within the duration from 1st September 2016 to 31st January 2018. 180 patients with clinical and radiological features of acute appendicitis presenting within 48 hrs of onset of the symptoms were enrolled. The patients received a broad spectrum antibiotic and symptomatic treatment. The patients were followed up for 6 months. Results: Total 180 patients were enrolled. 108 (60%) of patients were female and 72 (40%) patients were males with mean age of 36 years. 144 (80%) patients successfully responded with the conservative treatment with antibiotics while 36 (20%) patients failed. No mortality was recorded in our study. Out of 36 patients who failed, 13 patients developed appendicular abscess, 12 patients had perforation of appendix while 11 patients had appendicular lump. Conclusions: Conservative management can be established as the first line of management for uncomplicated acute appendicitis patients having first attack successfully, but it should be followed with close monitoring of patients.

Acute appendicitis (AA) is the most common cause of acute abdomen during pregnancy. Most of the signs of appendicitis are also found during normal pregnancy period, however, and diagnosis of appendicitis during pregnancy remains challenging. The aim of the current study was to report our clinical experience of AA during pregnancy and investigate optimal management of this difficult situation. Records of 20 pregnant women with diagnosis of AA who underwent appendectomy between 2005 and 2015 were included in this study. Data were collected retrospectively. Patients were evaluated according to age, signs and symptoms, gestational age, physical findings, serum white blood cell count, ultrasound (US) findings, pathology reports, surgical technique, operation time, and complications. Of 20 patients, 16 (80%) underwent open appendectomy and 4 (20%) underwent laparoscopic appendectomy. Mean age of patients was 29.6±5.6 years. Most common symptom was abdominal pain (95%). Six (30%) patients were in first trimester, 9 (45%) patients were in second trimester and 5 (25%) patients in were in third trimester. US findings consistent with AA were found in 12 (60%) patients. Negative appendectomy rate was 30%. Maternal complication was seen in only 1 (5%) patient. No fetal complication was observed. Accurate diagnosis and prompt surgical treatment of AA in pregnant women should be performed due to high rates of maternal and fetal complications.

La apendicitis del muñón es una causa poco común de abdomen agudo quirúrgico en niños, razón por la cual su diagnóstico no se sospecha con frecuencia. Este artículo reporta el caso de un paciente de dos años admitido en el servicio de urgencias por vómito, dolor abdominal y fiebre.Al ingreso, el paciente presentaba taquicardia, taquipnea, distensión abdominal y dolor difuso a la palpación del abdomen; los laboratorios evidenciaban leucocitosis, trombocitosis y elevación de la PCR. Inicialmente, se consideró obstrucción intestinal con base en antecedentes de peritonitis secundaria a una apendicitis perforada; sin embargo, debido al deterioro hemodinámico y al aumento del dolor abdominal, fue llevado a laparotomía exploratoria de urgencia.Durante el procedimiento se encontró peritonitis generalizada con apendicitis de la base, perforación intestinal, múltiples adherencias y, de forma incidental, un divertículo de Meckel. Se realizaron las intervenciones quirúrgicas correspondientes, y por su grave estado, fue hospitalizado en la unidad de cuidados intensivos (UCI), en donde recibió tratamiento con antibiótico de amplio espectro por 14 días y varios lavados peritoneales; por último, el paciente fue dado de alta satisfactoriamente.Aunque la apendicitis del muñón no es una causa frecuente de abdomen agudo, es necesario considerarla en aquellos pacientes con antecedentes de apendicitis y que ingresan por dolor abdominal, ya que la demora en el tratamiento se asocia con mayor morbilidad y aumento en los costos de atención.

Introduction The neutrophil-to-lymphocyte ratio (NLR) has emerged in recent years as a predictor of inflammation in various infectious pathologies. Among them, its value in predicting severity or complications in acute appendicitis has been studied and validated in adults and children. Although these studies are clear about its usefulness, it’s still unclear what value is optimal as a cut-off point. However, there is a knowledge gap in whether this evidence can be extrapolated to pregnant women with acute appendicitis. Gestation is a physiological situation that causes an intrinsic alteration of the immune system, altering white blood cell counts, and making the pregnant woman vulnerable to infection. Among these, acute appendicitis is the most frequent cause of acute abdomen in pregnancy. The aim of this study is to analyse whether NLR can play a predictive role in the severity of acute appendicitis in pregnant women. Methods We reviewed medical records for all consecutive pregnant patients admitted for acute appendicitis from 2018 to 2023 in our tertiary care university hospital. Results Fourteen patients were analysed, mean age was 29 years. Five (35.7%) were in the first trimester, 4 in the second trimester and 5 in the third trimester. The mean evolution time from the onset of symptoms to diagnosis was 2.4 days. The most used diagnostic technique was abdominal ultrasound (13 cases) and only in one patient MRI was performed for diagnosis. Four appendectomies had an open approach, and the others were laparoscopic. During surgery, peritonitis was observed in 9 cases (64%), and in 4 of them there was generalized peritonitis. In 2 cases acute appendicitis triggered birth, both in the third trimester, and both presented peritonitis. The mean hospital stay was 4 days, and 11 patients (78.5%) received empirical antibiotic therapy after surgery. Of the 14 cases, 6 presented complicated acute appendicitis in the pathological study, which did not correlate with intraoperative findings. CPR was significantly elevated in cases with peritonitis (mean 163 mg/l in cases with peritonitis versus 52 mg/l in non-peritonitis). We found the same correlation between NLR and peritonitis, significantly higher with a mean of 15.84% in the peritonitis group versus 7.31% in cases without peritonitis, However, we did not find a correlation between the anatomopathological diagnosis and the NLR. Conclusions In 5 years, only 14 pregnant women presented acute appendicitis in our tertiary hospital, despite being the most common cause of acute abdomen during pregnancy. Due to the small sample we cannot draw conclusions, but we can observe trends. It seems that the NLR behaves similarly as a predictor of complication or severity, especially if there is peritonitis. In published literature, it seems that the average NLR in pregnant women is higher than that of the non-pregnant population. We also observed that more than half of appendicitis in pregnant women presented peritonitis, whether localized or generalized, which is higher than in the general population. It seems that the NLR may behave similarly in pregnant women with peritonitis as in the non-pregnant population, so it could help predict the presence of peritonitis to provide early care in this vulnerable population.

The evaluation of acute appendicitis (AA), the most common cause of acute abdomen, in conscripts is important, specifically when it seems that the probability of malingering for secondary gains (such as exemption) is high, and surgeons may lose some cases of AA through this assumption. In this analytic cross-sectional study, 455 male conscripts with suspected AA were compared with 142 male individuals between 14 and 26 years of age who had already been selected for appendectomy. The mean age (+/-SE) was 20.4+/-0.08 years. There were no statistically significant differences between the case and control groups in terms of age, rates of different symptoms and signs, quality and duration of pain, vital signs, and laboratory findings. There was no significant difference between conscripts and others in terms of the presentation of AA and its accurate diagnosis. Therefore, it is recommended that military physicians approach conscripts with suspected AA like other patients.

Background: Appendicitis is the most common cause of acute abdomen and appendectomy is the most frequent surgical procedure performed in the world in recent times. In the last few years the number of laparoscopic appendectomies performed around the world has dramatically increased. Objective: The aim of the work is to study the acceptance and satisfaction of the patients as regards the laparoscopic approach for management of acute appendicitis and evaluation the results. Patients and methods: It was a comparative study included 100 consecutive patients with acute appendicitis. They were given the options to accept the approach for appendectomy whether open or laparoscopic after discussion the advantages and disadvantages of each approach and the last decision were left to the patient. The study was approved by the medical ethics committee of Aswan University Hospital and a written informed consent was obtained from all patients. Results: The consecutive patients of age ranging from 15-45 years with features suggestive of acute appendicitis were divided into laparoscopic appendectomy group (LA) 70 cases and open appendectomy group (OA) 30 cases, after taking informed consent. LA was done with the help of three trocar/cannulae creating pneumoperitoneum with CO2 whereas OA was performed by McBurney incision. The operating times in OA and LA were 20-70 minutes (mean 30) and 25-95 minutes (mean 55) respectively. Increased doses of analgesics, antibiotics and antiemetics were required in OA, as compared to LA. The mean postoperative hospital stay in LA group was 1.4 days (range 1-3 days) whereas it was in OA group, it was 3.5 days (range 2- 6 days). Conclusion: LA is safe and has major benefits like less postoperative pain, decreased wound infection, early hospital discharged, early return to work and a better cosmetic scar than OA.

Objective: To determine the maternal and foetal outcome among the cases of acute appendicitis during pregnancy. D e s i g n :Prospective Study. Setting: Aga Khan Hospital for Women, Kutyana Memon Hospital and Hamdard University Hospital, where authors work.Period: From June 2004 to May 2008. Material a n d M e t h o d s : A total of 21 pregnant females who presented with right sided abdominal painwith clinical diagnosis of acute appendicitis were managed during this study period. All patients were admitted and managed by both surgeonand obstetrician. Detailed 'clinical history and physical examination was performed and all patients were investigated by complete blood picture,urine analysis and ultrasonography of abdomen and pelvis. Appendicectomy was performed through Grid Iron incision. Macroscopic appearanceof appendices and other operative findings were recorded and all specimens were sent for histopathology. All the patients were followed uptill the out come of pregnancy. Results: Twenty one patients were managed during this study period and out of these 21,13 patients wereprimigravida and 8 were multigravida. At presentation most of the patients were in their second trimester of pregnancy. Acute appendicitis wasconfirmed by histopathologically in 16 out of 17 patients with inflamed looking appendices (negative appendicectomy rate was 23.80%). Foetalloss occurred in 2 patients (9.52%) and both were in their second trimester of pregnancy. One patient gave birth to a baby who had low birthweight (4.76%) and one patient who was operated in third trimester had premature labour (4.76%) three weeks prior to expected date.Remaining 17 patients delivered at term without any consequences. Two patients developed wound infection which responded to wound careand antibiotics. C o n c l u s i o n : Acute appendicitis is the commonest cause of acute abdomen during pregnancy. A timely decision and aprofessional liaison among obstetrician and surgeon are key factors for a better outcome.

Background:Acute appendicitis is the most common cause of acute abdomen encountered in general surgical practice, with the life time risk of 7–9 %. While early treatment usually prevent complications, perforated appendicitis remains a serious concern leading to higher morbidity, longer hospital stay .Objectives:To determine clinical, demographic, laboratory, and radiological predictors of perforation in adults with acute appendicitis.Methods:This retrospective cohort study included 200 patients diagnosed with acute appendicitis and treated at a major teaching hospital between January 2018 and December 2022. Patients were categorized into perforated and non-perforated based on intra-operative and histopathological findings. Data on demographics, co-morbidities, symptom duration, laboratory markers, imaging results, complications, and hospital stay were collected. Multivariate logistics regression was applied to identify independent predictors of perforation.Results:Acute appendicitis was more prevalent among patients in their second decade of life (44%) and more common in males (56%) than females (44%). Perforation occurred in 20% of cases. Risk factors significantly associated with perforation include old age, delayed presentation (>48 hours; co-morbidities, particularly diabetes). Elevated WBC count (>18.000\\mm3) with negative shift and increased C-reactive protein level. Ultrasound showed modest diagnostic accuracy, while Computed Tomography (cCT) scan outperformed ultrasound in detecting perforation (sensitivity: 92 vs. 65%). Postoperative complications and hospital stay were significantly higher in patients with perforated appendicitis (P-value < 0. 05).Conclusion:Delayed presentation, elevated inflammatory markers, old age, and co-morbidities are strong, independent predictors of appendiceal perforation. Early diagnosis and prompt surgical intervention, especially in patients with known risk factors, are crucial to prevent complications such as perforation and minimize hospital stay.

Background: Bowel obstruction is one of the most common causes of acute abdomen and also a common surgical emergency.The causes of IO vary significantly depending on geographical location. The aim of this study was to identify the etiology, clinical presentation, management and outcomes of patients with acute mechanical IO presenting in Jodhpur, Rajasthan.Methods: A prospective study was conducted at Mahatma Gandhi Hospital and Mathura Das Mathur Hospital (associated with Dr. SN Medical College), Jodhpur, Rajasthan. 100 patients with acute intestinal obstruction were admitted and evaluated. Blood routine, X-Ray abdomen, USG abdomen and CECT (if required) were done. A pre-operative diagnosis was made. Intra-operative findings and Post-operative complications were noted and follow up was done till the patient was discharged from the hospital.Results: A total of 69 male and 31 female patients, presented with acute mechanical IO during the period of the study. Mean patient age was 48.5 years with peak incidence in those aged 31-45 years. The foremost signs and symptoms were abdominal distension (88%), obstipation (87%), abdominal pain (81%) and nausea/ vomiting (47%). Adhesions and bands (29%), hernia (13%), neoplasm (9%) and pseudo-obstruction (8%) were the leading causes of intestinal obstruction. The sensitivity of X-ray and USG in present study was 67% and 75% respectively. Most common complication associated was wound infection (17%) followed by paralytic ileus (7%) and respiratory tract infections (6%). Late presentation was associated with poor prognosis. 4 patients expired before surgery. Post-operative mortality was associated with 6 patients and was more common in cases which presented with gangrenous bowel.Conclusions: The most common causes of IO in this study were adhesions and bands, hernia, neoplasm and pseudo-obstruction. Presence of bowel gangrene was associated with higher morbidity and mortality.

Does Right Lower Quadrant Abdominal Ultrasound Accurately Identify Perforation in Pediatric Acute Appendicitis?

Complicated acute appendicitis presenting as an abscess in the abdominal wall in an elderly patient: A case report

Aim: Acute cholecystitis is the most common causes of acute abdomen in elderly population. This study aimed to present the early postoperative period (≤ 30 days) outcomes of elderly patients (≥ 65 years old) with acute cholecystitis who underwent early or delayed cholecystectomy. Methods: Between January 2016 and December 2020, 74 patients aged 65 and over underwent cholecystectomy for acute cholecystitis were included in the study. The patients were divided into two groups as early (time between diagnosis and cholecystectomy 7 days or less, n= 43, 58.1%) or delayed (time between diagnosis and cholecystectomy over 7 days, n= 31, 41.9%) cholecystectomy. Demographic characteristics, preoperative laboratory and radiological findings, and perioperative data of patients were evaluated, and the groups were compared. Results: The median age of patients was 73 (65-90) years, and 39 (52.7%) were male. Sixty-one (82.4%) patients underwent laparoscopic, 8 open (10.8%) and 5 (6.8%) conversion cholecystectomy. The rate of laparoscopic cholecystectomy was higher in the delayed group (n= 29, 93.5%) than in the early group (n= 32, 74.4%), but no statistically significant difference was detected (p=.06). The rate of open cholecystectomy was statistically significantly higher in the early group (n=8, 18.6%) than in the delayed group (n=0) (P=.017), the conversion rate was similar between the groups (p=1). There was no significant difference between the groups in terms of intraoperative complications (p=1). The length of hospital stay was statistically significantly longer in the early compared to the delayed group 5 (1-21) days and 2 (1-12) days, respectively, p&lt; .001). Conclusion: There was no statistical difference regarding intraoperative complications in patients underwent early or delayed cholecystectomy. We believe that the patient's clinical presentation and early or delayed cholecystectomy experience of the team are vital in determining the timing of cholecystectomy, as well as the severity of acute cholecystitis.

BackgroundAcute pancreatitis is one of the most common causes of acute abdomen. It is associated with multiple complications. Gastric perforation and isolated renal vein thrombosis are two infrequent complications. We present a case of acute pancreatitis with gastric perforation and isolated renal vein thrombosis in the same patient.Case presentationA 28-year-old gentleman with chronic alcohol intake presented with complaints of abdominal pain and not responding to analgesics. Biochemical investigations revealed elevated amylase and lipase level. Contrast-enhanced computed tomography (CECT) showed necrotizing pancreatitis with necrotic collection in the lesser sac. On oral contrast, active contrast extravasation from gastric perforation was picked up. Renal vein and splenic vein thrombosis was observed.ConclusionsGastric perforation and renal vein thrombosis are two infrequent complications of acute pancreatitis. High-end radiological suspicion is needed to reduce the associated morbidity and mortality.