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1.  Appendicitis epiploicae: a rare cause of acute abdomen 
BMJ Case Reports  2010;2010:bcr08.2009.2171.
Acute appendicitis is one of the most common causes of right lower quadrant acute abdominal pain in adults. Some other conditions, including appendicitis epiploicae, can simulate an acute abdomen. Appendicitis epiploicae or epiploic appendicitis usually originates in the sigmoid colon and rarely from other parts of colon. We report a case of a 20-year-old man with appendicitis epiploicae of the caecum, who underwent surgery for acute appendicitis. Analysis of this uncommon condition, together with a review of the pertinent literature, are presented.
doi:10.1136/bcr.08.2009.2171
PMCID: PMC3047281  PMID: 22736317
2.  Cecal epiploica appendix torsion in a female child mimicking acute appendicitis: a case report 
Cases Journal  2009;2:8023.
Acute appendicitis is the most common cause of the right lower quadrant acute abdominal pain in children. Some other conditions including cecal epiploica appendix torsion, can simulate acute abdomen. Epiploica appendix torsion usually occurs in the sigmoid colon and rarely in the cecum of adult males. In children, this entity is extremely rare and may represent a diagnostic and therapeutic dilemma. We report a case of an 8-year-old Greek girl, presented with signs and symptoms mimicking acute abdomen. Our patient is the younger one among the other four with cecal epiploica appendix torsion that had been reported in the literature.
doi:10.1186/1757-1626-2-8023
PMCID: PMC2740296  PMID: 19830045
3.  Appendicitis in Children: Evaluation of the Pediatric Appendicitis Score in Younger and Older Children 
Surgery Research and Practice  2014;2014:438076.
Background. This study aimed to evaluate Pediatric Appendicitis Score (PAS), diagnostic delay, and factors responsible for possible late diagnosis in children <4 years compared with older children who were operated on for suspected appendicitis. Method. 122 children, between 1 and 14 years, operated on with appendectomy for suspected appendicitis, were retrospectively analyzed. The cohort was divided into two age groups: ≥4 years (n = 102) and <4 years (n = 20). Results. The mean PAS was lower among the younger compared with the older patients (5.3 and 6.6, resp.; P = 0.005), despite the fact that younger children had more severe appendicitis (75.0% and 33.3%, resp.; P = 0.001). PAS had low sensitivity in both groups, with a significantly lower sensitivity among the younger patients. Parent and doctor delay were confirmed in children <4 years of age with appendicitis. PAS did not aid in patients with doctor delay. Parameters in patient history, symptoms, and abdominal examination were more diffuse in younger children. Conclusion. PAS should be used with caution when examining children younger than 4 years of age. Diffuse symptoms in younger children with acute appendicitis lead to delay and to later diagnosis and more complicated appendicitis.
doi:10.1155/2014/438076
PMCID: PMC4276704  PMID: 25574500
4.  Idiopathic sclerosing encapsulating peritonitis (abdominal cocoon) in adult male. A case report 
INTRODUCTION
Abdominal cocoon (sclerosing encapsulating peritonitis) (SEP) is a rare condition, mostly affecting adolescent girls living in tropical/subtropical region. Its etiology is unknown. It may cause acute or sub-acute intestinal obstruction.
PRESENTATION OF CASE
We report here a 39 year old male who complained of long standing colicky abdominal pain, with significant weight loss. Abdomen CT scan showed clumping of ileal loops at the level of umbilicus, with a thin capsule surrounding it. Laparoscopy revealed abdominal cocoon, biopsy of which showed dense hypocellular fibro-collagenous tissue with no neoplastic or granulomatous process. Excision of fibrous tissue and release of adhesions was done. Patient was symptoms free after five months follow up.
DISCUSSION
Abdominal exploration is usually needed for the diagnosis and treatment of abdominal cocoon. A thick fibrotic peritoneal wrapping of the bowel is usually found. Complete recovery is the result in majority of cases after surgical removal of the wrap causing the cocoon.
CONCLUSION
Primary sclerosing encapsulating peritonitis (cocoon abdomen) diagnosis needs a high index of suspicion, as signs and symptoms are nonspecific and imaging findings are not always conclusive. Careful excision of the accessory peritoneal sac and lysis of adhesions between bowels is the best treatment. Prognosis is generally good.
doi:10.1016/j.ijscr.2014.07.017
PMCID: PMC4189066  PMID: 25217877
Idiopathic; Sclerosing; Encapsulating peritonitis; Abdominal cocoon
5.  Abdominal cocoon—A rare cause of intestinal obstruction☆ 
INTRODUCTION
Abdominal cocoon syndrome is characterized by small bowel encapsulation by a fibro-collagenous membrane or “cocoon”. It is a rare cause of intestinal obstruction.
PRESENTATION OF CASE
A 42-year old man presented with sub-acute intestinal obstruction. Intra-operatively, the entire small bowel was found to be encapsulated in a dense fibrous sac. The peritoneal sac was excised, followed by lysis of the inter-loop adhesions. Postoperative recovery was unremarkable.
DISCUSSION
Most patients with abdominal cocoon syndrome present with features of recurrent acute or chronic small bowel obstruction secondary to kinking and/or compression of the intestines within the constricting cocoon. An abdominal mass may also be present due to an encapsulated cluster of dilated small bowel loops.
CONCLUSION
Abdominal cocoon is a rare condition causing intestinal obstruction and diagnosis requires a high index of suspicion because of the nonspecific clinical picture. CECT of the abdomen is a useful radiological tool to aid in preoperative diagnosis. Peritoneal sac excision and adhesiolysis is the treatment and the outcome is usually satisfactory.
doi:10.1016/j.ijscr.2013.08.004
PMCID: PMC3825929  PMID: 24055916
Sclerosing encapsulating peritonitis; Subacute intestinal obstruction
6.  Systematic review of blunt abdominal trauma as a cause of acute appendicitis 
INTRODUCTION
Acute appendicitis commonly presents as an acute abdomen. Cases of acute appendicitis caused by blunt abdominal trauma are rare. We present a systematic review of appendicitis following blunt abdominal trauma. The aim of this review was to collate and report the clinical presentations and experience of such cases.
SUBJECTS AND METHODS
A literature review was performed using PubMed, Embase and Medline and the keywords ‘appendicitis’, ‘abdominal’ and ‘trauma’.
RESULTS
The initial search returned 381 papers, of which 17 articles were included. We found 28 cases of acute appendicitis secondary to blunt abdominal trauma reported in the literature between 1991 and 2009. Mechanisms of injury included road-traffic accidents, falls, assaults and accidents. Presenting symptoms invariably included abdominal pain, but also nausea, vomiting and anorexia. Only 12 patients had computed tomography scans and 10 patients had ultrasonography. All reported treatment was surgical and positive for appendicitis.
CONCLUSIONS
Although rare, the diagnosis of acute appendicitis must be considered following direct abdominal trauma especially if the patient complains of abdominal right lower quadrant pain, nausea and anorexia. Haemodynamically stable patients who present shortly after blunt abdominal trauma with right lower quadrant pain and tenderness should undergo urgent imaging with a plan to proceed to appendicectomy if the imaging suggested an inflammatory process within the right iliac fossa.
doi:10.1308/003588410X12664192075936
PMCID: PMC3182788  PMID: 20513274
Trauma; Appendicitis
7.  Appendicitis 
Clinical Evidence  2011;2011:0408.
Introduction
Appendicitis is an acute inflammation of the appendix that can lead to an abscess, ileus, peritonitis, or death. Appendicitis is the most common abdominal surgical emergency, with a lifetime risk of approximately 7% to 9% in the USA. Mortality from acute appendicitis is less than 0.3%, but rises to 1.7% after perforation.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical question: What are the effects of treatments for acute appendicitis? We searched: Medline, Embase, The Cochrane Library, and other important databases up to February 2010 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
Results
We found 16 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
Conclusions
In this systematic review we present information relating to the effectiveness and safety of the following interventions: antibiotics, laparoscopic surgery, ligation, open surgery, stump inversion, and surgery.
Key Points
The incidence of acute appendicitis is falling, although the reasons are unclear. Appendicitis is the most common abdominal surgical emergency, with a lifetime risk of approximately 7% to 9% in the USA.Potential causes of appendicitis include faecoliths, lymphoid hyperplasia, fibrous bands, foreign bodies, and caecal carcinoma, all of which can lead to obstruction of the appendix lumen.Mortality from acute appendicitis is <0.3%, but rises to 1.7% after perforation.
Spontaneous resolution of acute appendicitis has been reported in at least 10% of episodes.
Very limited evidence suggests that conservative treatment of acute appendicitis with antibiotics may reduce pain and morphine consumption, but that one third of people are likely to be readmitted with acute appendicitis requiring surgery within 1 year.
Standard treatment for acute appendicitis is appendicectomy. Clinical trials to compare surgery with no treatment would be considered unethical, and have not been done.There is good evidence that laparoscopic surgery in adults reduces wound infections, postoperative pain, duration of hospital stay, and time off work compared with open surgery, but increases the risk of intra-abdominal abscesses.Limited evidence suggests that laparoscopic surgery in children may reduce wound infections and duration of hospital stay compared with open surgery, but it has not been shown to reduce other complications.There is some evidence to suggest that stapling reduces operative time compared with endoloops, but no reliable evidence to suggest that it reduces other complications.We don't know how natural orifice surgery compares with laparoscopic surgery, as we found no RCTs.There is limited evidence to suggest that stump inversion has an increased rate of wound infection compared with simple ligation, and no difference in rate of intra-abdominal abscess formation.
The most common complication of appendicectomy is wound infection, with intra-abdominal abscess formation less common. Treatment with surgery plus antibiotics reduces wound infections and intra-abdominal abscesses compared with surgery alone in adults with simple or complicated appendicitis.However, in children, the benefit of antibiotics may be limited to those with complicated appendicitis.
PMCID: PMC3275312  PMID: 21477397
8.  A rare cause of small bowel obstruction: Abdominal cocoon 
INTRODUCTION
The clinical manifestations of abdominal ‘cocoon’ are non-specific and hence its diagnosis is rarely made preoperatively and the management is often delayed. Surgery remains the main stay of treatment with satisfactory outcome and comprises excision of the fibrous membrane, meticulous adhesionolysis and release of the entrapped small bowel.
PRESENTATION OF CASE
A 45-year-old male patient presented with 6-month history of progressive subacute small bowel obstruction. After initial radiological investigations, he underwent diagnostic laparoscopy and was misdiagnosed as abdominal tuberculosis. He was started on anti-tuberculous therapy, but exploratory laparotomy was carried out after failure to respond to anti-tuberculous therapy. At laparotomy, the abdominal ‘cocoon’ which was encapsulating the entire small bowel was excised, and the adhesions were carefully lysed. The patient remained well and without recurrence at 1-year follow-up.
DISCUSSION
Abdominal ‘cocoon’ is a rare cause of subacute, acute and chronic small bowel obstruction. Its diagnosis is rarely made preoperatively.
CONCLUSION
Abdominal ‘cocoon’ should be thought of as a rare cause of small bowel obstruction. It may be mistaken with abdominal tuberculosis. Surgery remains the mainstay of curative treatment.
doi:10.1016/j.ijscr.2012.03.016
PMCID: PMC3356543  PMID: 22522743
Abdominal cocoon; Intestinal obstruction; Surgery; Adhesionlysis
9.  Appendicitis 
Clinical Evidence  2007;2007:0408.
Introduction
Potential causes of appendicitis include faecoliths, lymphoid hyperplasia, and caecal carcinoma, all of which can lead to obstruction of the appendix lumen. The lifetime risk is approximately 7-9% in the USA, making appendicectomy the most common abdominal surgical emergency. Mortality from acute appendicitis is less than 0.3%, but rises to 1.7% after perforation.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical question: What are the effects of treatments for acute appendicitis? We searched: Medline, Embase, The Cochrane Library and other important databases up to November 2006 (BMJ Clinical evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
Results
We found 10 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
Conclusions
In this systematic review we present information relating to the effectiveness and safety of the following interventions: antibiotics, laparoscopic surgery, ligation, open surgery, stump inversion, surgery.
Key Points
The incidence of acute appendicitis is falling, although the reasons are unclear. The lifetime risk is approximately 7-9% in the USA, making appendicectomy the most common abdominal surgical emergency.Potential causes of appendicitis include faecoliths, lymphoid hyperplasia, and caecal carcinoma, all of which can lead to obstruction of the appendix lumen.Mortality from acute appendicitis is less than 0.3%, but rises to 1.7% after perforation.
Spontaneous resolution of acute appendicitis has been reported in at least 8% of episodes. Very limited evidence suggests that conservative treatment of acute appendicitis with antibiotics may reduce pain and morphine consumption, but that a third of people are likely to be readmitted with acute appendicitis requiring surgery within 1 year.
Standard treatment for acute appendicitis is appendicectomy. Clinical trials to compare surgery with no surgery would be considered unethical, and have not been done.There is some evidence that laparoscopic appendicectomy in adults reduces wound infections, postoperative pain, duration of hospital stay, and time off work compared with open surgery, but may increase the risk of intra-abdominal abscesses.Limited evidence suggests that laparoscopic surgery in children may reduce wound infections and duration of hospital stay compared with open surgery, but it has not been shown to reduce other complications.
The most common complication of appendicectomy is wound infection, with intra-abdominal abscess formation less common. Treatment with surgery plus antibiotics reduces wound infections and intra-abdominal abscesses compared with surgery alone in adults with simple or complicated appendicitis.However, in children, the benefit of antibiotics may be limited to those with complicated appendicitis.
PMCID: PMC2943782  PMID: 19454096
10.  Dengue fever mimicking acute appendicitis: A case report☆ 
INTRODUCTION
Dengue fever is an acute viral disease, which usually presents as a mild febrile illness. Patients with severe disease present with dengue haemorrhagic fever or dengue toxic shock syndrome. Rarely, it presents with abdominal symptoms mimicking acute appendicitis. We present a case of a male patient presenting with right iliac fossa pain and suspected acute appendicitis that was later diagnosed with dengue fever following a negative appendicectomy.
PRESENTATION OF CASE
A 13-year old male patient presented with fever, localized right-sided abdominal pain and vomiting. Abdominal ultrasound was not helpful and appendicectomy was performed due to worsening abdominal signs and an elevated temperature. A normal appendix with enlarged mesenteric nodes was found at surgery. Complete blood count showed thrombocytopenia with leucopenia. Dengue fever was now suspected and confirmed by IgM enzyme-linked immunosorbent assay against dengue virus.
DISCUSSION
This unusual presentation of dengue fever mimicking acute appendicitis should be suspected during viral outbreaks and in patients with atypical symptoms and cytopenias on blood evaluation in order to prevent unnecessary surgery.
CONCLUSION
This case highlights the occurrence of abdominal symptoms and complications that may accompany dengue fever. Early recognition of dengue fever mimicking acute appendicitis will avoid non-therapeutic operation and the diagnosis may be aided by blood investigations indicating a leucopenia, which is uncommon in patients with suppurative acute appendicitis.
doi:10.1016/j.ijscr.2013.08.017
PMCID: PMC3825978  PMID: 24096347
Dengue fever; Acute appendicitis; Acute abdomen; Leucopenia
11.  Large tender abdominal aortic aneurysm presented with concomitant acute appendicitis: a case report 
Cases Journal  2009;2:107.
Introduction
The management of concurrently occurring abdominal aortic aneurysm and another intra-abdominal pathology is controversial and represents a difficult management problem for the surgeon. Most surgeons are reluctant to perform a second non vascular procedure at the time of the aneurysm repair because of the risk of graft infection. Some evidence suggests that the one-stage elective surgical treatment in selected patients with concomitant abdominal aortic aneurysm and other pathologies; especially Gastro-Intestinal malignancies, is safe with superior cost effectiveness. However, there is a major dilemma in the management patients with large aneurysm which require an urgent repair and presented with concomitant pathologies that carry a high risk of sepsis. In this case report, we describe an unusual presentation of a large aneurysm with concomitant Acute Appendicitis where both needed an urgent surgical intervention. To our best knowledge, there has been no similar case report published in literature.
Case report
A 66 years old Caucasian male presented with a dual pathology of large abdominal aortic aneurysm and acute appendicitis. The diagnosis was confirmed by Computerized Tomography scan of his abdomen. He underwent a 2-stage operation; open Appendicectomy followed by open repair of his aneurysm to avoid the risk of graft infection. He had an uneventful recovery period with a full return to normal life.
Conclusion
The incidence of patients with abdominal aortic aneurysm and coexistent intra-abdominal surgical pathology is increasing, and the surgical strategy for those patients remains controversial. There are not enough studies that looked directly into the management of large abdominal aortic aneurysm which require an urgent repair and presented with concomitant pathologies that carry a high risk of sepsis. In such situations, simultaneous operations should be avoided because of the risk of prosthetic graft infection and priority should be given to the symptomatic or most life threatening condition. The second pathology should be dealt with as soon as possible; preferably within the same admission. More studies are needed to look into this issue; however, this would be rather difficult because of the uncommon and complex nature of such presentations.
doi:10.1186/1757-1626-2-107
PMCID: PMC2640347  PMID: 19183456
12.  The cost effectiveness of early management of acute appendicitis underlies the importance of curative surgical services to a primary healthcare programme 
Introduction
Appendicitis in the developing world is a cause of significant preventable morbidity. This prospective study from a regional hospital in South Africa constructs a robust cost model that demonstrates the cost effectiveness of an efficient curative surgical service in a primary healthcare-orientated system.
Methods
A prospective audit of all patients with acute appendicitis admitted to Edendale Hospital was undertaken from September 2010 to September 2011. A microcosting approach was used to construct a cost model based on the estimated cost of operative and perioperative interventions together with the associated hospital stay. For cost analysis, patients were divided into the following cohorts: uncomplicated appendicitis, complicated appendicitis with localised intra-abdominal sepsis, complicated appendicitis with generalised intra-abdominal sepsis, with and without intensive care unit admission.
Results
Two hundred patients were operated on for acute appendicitis. Of these, 36% (71/200) had uncomplicated appendicitis and 57% (114/200) had perforation. Pathologies other than appendicitis were present in 8% (15/200) and these patients were excluded. Of the perforated appendices, 45% (51/114) had intra-abdominal contamination that was localised while 55% (63/114) generalised sepsis. The mean cost for each patient was: 6,578 ZAR (£566) for uncomplicated appendicitis; 14,791 ZAR (£1,272) for perforation with localised intra-abdominal sepsis and 34,773 ZAR (£2,990) for perforation with generalised intra-abdominal sepsis without intensive care admission. With intensive care admission it was 77,816 ZAR (£6,692). The total cost of managing acute appendicitis was 4,272,871 ZAR (£367,467). Almost 90% of this total cost was owing to advanced disease with abdominal sepsis and therefore potentially preventable.
Conclusions
Early uncomplicated appendicitis treated appropriately carries little morbidity and is relatively inexpensive to treat. As the pathology progresses, the cost rises exponentially. An efficient curative surgical service must be regarded as a cost effective component of a primary healthcare orientated system.
doi:10.1308/003588413X13511609958415
PMCID: PMC4132504  PMID: 23676814
Appendicitis; Complications; Cost; Model
13.  A case of abdominal cocoon. 
Journal of Korean Medical Science  1995;10(3):220-225.
Abdominal cocoon is a rare disease of the peritoneum and almost invariably presents as an acute or subacute intestinal obstruction with or without a mass. The etiology of this disease is largely unknown and abdominal cocoon of unknown etiology has been limited to the tropical and subtropical zones and primarily affects young adolescent females. In the temperate zone, only one case has been reported from the United Kingdom, but the patient was also born in Pakistan. No case of abdominal cocoon purely developed in the temperate zone has been reported. Recently, we experienced a case of abdominal cocoon in a 34-year-old female patient(Korean) who had never been abroad. The diagnosis was made postoperatively by reviewing the literature. We herein report this rare condition developed in an unusual geographical location with a brief review of the literature.
PMCID: PMC3054113  PMID: 8527051
14.  Accuracy of the new radiographic sign of fecal loading in the cecum for differential diagnosis of acute appendicitis in comparison with other inflammatory diseases of right abdomen: a prospective study  
Journal of Medicine and Life  2012;5(1):85-91.
Rationale: To assess the importance of the new radiographic sign of faecal loading in the cecum for the diagnosis of acute appendicitis, in comparison with other inflammatory diseases, and to verify the maintenance of this radiographic sign after surgical treatment of appendicitis.
Methods: 470 consecutive patients admitted to the hospital due to acute abdomen were prospectively studied: Group 1 [n=170] – diagnosed with acute appendicitis, subdivided into: Subgroup 1A – [n=100] – submitted to an abdominal radiographic study before surgical treatment, Subgroup 1B – [n=70] – patients who had plain abdominal X-rays done before the surgical procedure and also the following day; Group 2 [n=100] – right nephrolithiasis; Group 3 [n=100] – right acute inflammatory pelvic disease; Group 4 [n=100] – acute cholecystitis. The patients of Groups 2,3 and 4 were submitted to abdominal radiography during the pain episode.
Results: The sign of faecal loading in the cecum, characterized by hypo transparency interspersed with multiple small foci of hyper transparent images, was present in 97 patients of Subgroup 1A, in 68 patients of Subgroup 1B, in 19 patients of Group 2, in 12 patients of Group 3 and in 13 patients of Group 4. During the postoperative period the radiographic sign disappeared in 66 of the 68 cases that had presented with the sign. The sensitivity of the radiographic sign for acute appendicitis was 97.05% and its specificity was 85.33%. The positive predictive value for acute appendicitis was 78.94% and its negative predictive value was 98. 08%.
Discussion: The radiographic image of faecal loading in the cecum is associated with acute appendicitis and disappears after appendectomy. This sign is uncommon in other acute inflammatory diseases of the right side of the abdomen.
PMCID: PMC3307086  PMID: 22574093
Appendicitis; Acute abdomen; Radiography; Cecum; Fecal loading
15.  Left-sided appendicitis in a patient with congenital gastrointestinal malrotation: a case report 
Background
While appendicitis is the most common abdominal disease requiring surgical intervention seen in the emergency room setting, intestinal malrotation is relatively uncommon. When patients with asymptomatic undiagnosed gastrointestinal malrotation clinically present with abdominal pain, accurate diagnosis and definitive therapy may be delayed, possibly increasing the risk of morbidity and mortality. We present a case where CT was crucial diagnostically and helpful for pre-surgical planning in a patient presenting with an acute abdomen superimposed on complete congenital gastrointestinal malrotation.
Case presentation
A 46-year-old previously healthy male with four days of primarily left-sided abdominal pain, low-grade fevers, nausea and anorexia presented to the Emergency Department. His medical history was significant for poorly controlled diabetes and dyslipidemia. His white blood count at that time was elevated. Initial abdominal plain films suggested small bowel obstruction. A CT scan of the abdomen and pelvis was performed with oral and IV contrast to exclude diverticulitis, revealing acute appendicitis superimposed on congenital intestinal malrotation. Following consultation with the surgical team for surgical planning, the patient went on to laparoscopic appendectomy and did well postoperatively.
Conclusion
Atypical presentations of acute abdominal conditions superimposed on asymptomatic gastrointestinal malrotation can result in delays in delivery of definitive therapy and potentially increase morbidity and mortality if not diagnosed in a timely manner. Appropriate imaging can be helpful in hastening diagnosis and guiding intervention.
doi:10.1186/1752-1947-1-92
PMCID: PMC2034390  PMID: 17880685
16.  The NOTA study: non-operative treatment for acute appendicitis: prospective study on the efficacy and safety of antibiotic treatment (amoxicillin and clavulanic acid) in patients with right sided lower abdominal pain 
BMJ Open  2011;1(1):e000006.
Background
Case control studies that randomly assign patients with diagnosis of acute appendicitis to either surgical or non-surgical treatment yield a relapse rate of approximately 14% at one year. It would be useful to know the relapse rate of patients who have, instead, been selected for a given treatment based on a thorough clinical evaluation, including physical examination and laboratory results (Alvarado Score) as well as radiological exams if needed or deemed helpful. If this clinical evaluation is useful, the investigators would expect patient selection to be better than chance, and relapse rate to be lower than 14%. Once the investigators have established the utility of this evaluation, the investigators can begin to identify those components that have predictive value (such as blood analysis, or US/CT findings). This is the first step toward developing an accurate diagnostic-therapeutic algorithm which will avoid risks and costs of needless surgery.
Methods/design
This will be a single-cohort prospective observational study. It will not interfere with the usual pathway, consisting of clinical examination in the Emergency Department (ED) and execution of the following exams at the physician's discretion: full blood count with differential, C reactive protein, abdominal ultrasound, abdominal CT. Patients admitted to an ED with lower abdominal pain and suspicion of acute appendicitis and not needing immediate surgery, are requested by informed consent to undergo observation and non operative treatment with antibiotic therapy (Amoxicillin and Clavulanic Acid). The patients by protocol should not have received any previous antibiotic treatment during the same clinical episode. Patients not undergoing surgery will be physically examined 5 days later. Further follow-up will be conducted at 7, 15 days, 6 months and 12 months. The study will conform to clinical practice guidelines and will follow the recommendations of the Declaration of Helsinki. The protocol was approved on November 2009 by Maggiore Hospital Ethical Review Board (ID CE09079).
Trial Registration
ClinicalTrials.gov identifier: NCT01096927.
Article summary
Article focus
Acute appendicitis can have severe complications including perforation and generalised peritonitis.
The appendix is found to be free of disease in 15–30% of appendectomies.
As surgery carries various risks, conservative non-surgical treatment with antibiotics for suspected appendix inflammation may avoid needless surgery, in particular as the relapse rate is low and the rate of complications is similar.
Key messages
Case control studies that randomly assign patients with acute appendicitis to either surgical or non-surgical treatment show a relapse rate of approximately 14% at 1 year.
The relapse rate of patients who are treated based on a thorough clinical evaluation should be below 14%.
Once factors predictive of outcome and/or the need of surgery are identified, an accurate diagnostic-therapeutic algorithm which will help avoid the risks and costs of needless surgery can be developed.
Strengths and limitations of this study
This non-randomised controlled study will evaluate the effectiveness and short and long term outcomes of non-operative antibiotic treatment of acute appendicitis.
Amoxicillin and clavulanic acid are common and easily managed low cost drugs, available both for intravenous and oral use.
Better analysis of clinical data might lead to better decision-making in patients with right iliac fossa pain and suspected acute appendicitis.
The study also aims to evaluate the Alvarado score, which is used to diagnose acute appendicitis and discriminate patients needing immediate surgery from patients who may safely undergo observation and antibiotic treatment.
A large sample of patients undergoing non-operative antibiotic treatment will allow a statistically powerful evaluation of safety, efficacy and cost.
An additional objective is to identify clinical, laboratory and imaging findings that are predictive of failure of conservative treatment and/or relapse of appendicitis and need for appendectomy within 1 year.
As efficacy can not be reliably determined in the absence of a control group, a case series observation determining ‘efficacy’ has limited value.
The Alvarado score is used to separate those with acute appendicitis from those with similar symptoms but no appendicitis and there is no evidence that this score can identify those who would benefit from antibiotic treatment.
doi:10.1136/bmjopen-2010-000006
PMCID: PMC3191386  PMID: 22021722
Lower abdominal Pain; right iliac fossa pain; acute appendicitis; antibiotic therapy; conservative Management; appendectomy; recurrence; length of hospital stay; sick leave time; short and long Term abdominal pain evaluation; study protocol; case control study
17.  Acute appendicitis complicated by mass formation occurring simultaneously with serologically proven dengue fever: a case report 
Introduction
Acute abdomen and acute appendicitis are unusual clinical presentations that occur in dengue infection–caused illness. Lymphoid hyperplasia and mesenteric adenitis are possible explanations, although vasculitis in the pathology of dengue infection has not been reported. Authors of previous case reports have described mimicking of acute appendicitis discovered upon surgical treatment. Dengue virus has not been proven to cause acute appendicitis.
Case presentation
We report a case of an 8-year-old Sinhalese boy who developed acute appendicitis during the acute phase of serologically confirmed dengue fever. Although abdominal pain, vomiting and right-sided tenderness were present at the time of admission, a diagnosis of acute appendicitis was considered only 18 hours later, when abdominal guarding and a well-defined mass in the right iliac fossa were detected clinically and ultrasonographically. Conservative management with intravenous antibiotics was successful.
Conclusion
In areas where dengue is endemic, awareness of dengue viral infection as a non-surgical cause of acute abdomen, as well as its ability to mimic acute appendicitis, is important because unnecessary surgery-related morbidity can be decreased. However, delaying or missing the diagnosis of acute appendicitis can result in serious complications. This message is particularly relevant to clinicians, especially pediatricians and surgeons, who encounter large numbers of patients during dengue epidemics and run the risk of missing the diagnosis of acute appendicitis. Likewise, delaying or missing the diagnosis of dengue hemorrhagic fever can lead to dengue shock syndrome and even death. This case highlights the need for careful evaluation of each patient who presents with acute abdomen and dengue infection.
doi:10.1186/1752-1947-8-116
PMCID: PMC4234973  PMID: 24708584
Acute appendicitis; Dengue fever
18.  Gangrenous appendicitis presenting as acute abdominal pain in a patient on automated peritoneal dialysis: a case report 
Introduction
Presentations of abdominal pain in patients on peritoneal dialysis deserve maximal attention and careful differential diagnosis on admittance to medical care. In this case report a gangrenous appendicitis in a patient on automated peritoneal dialysis is presented.
Case presentation
We report the case of a 38-year-old Caucasian man with end-stage renal disease who was on automated peritoneal dialysis and developed acute abdominal pain and cloudy peritoneal dialysate. Negative microbiological cultures of the peritoneal dialysis fluid and an abdominal ultrasonography misleadingly led to a diagnosis of culture negative peritonitis. It was decided to remove the peritoneal catheter but the clinical situation of the patient did not improve. An explorative laparotomy was then carried out; diffuse peritonitis and gangrenous appendicitis were found. An appendectomy was performed. Myocardial infarction and sepsis developed, and the outcome was fatal.
Conclusion
A peritoneal dialysis patient with abdominal pain that persists for more than 48 hours after the usual antibiotic protocol for peritoneal dialysis-related peritonitis should immediately alert the physician to the possibility of peritonitis caused by intra-abdominal pathology. Not only peritoneal catheter removal is indicated in patients whose clinical features worsen or fail to resolve with the established intra-peritoneal antibiotic therapy but, after 72 hours, an early laparoscopy should be done and in a case of correct indication (intra-abdominal pathology) an early explorative laparotomy.
doi:10.1186/1752-1947-6-309
PMCID: PMC3469333  PMID: 22989294
Abdominal pain; Appendicitis; Myocardial infarction; Peritoneal dialysis
19.  Handheld Device Review of Abdominal CT for the Evaluation of Acute Appendicitis 
Journal of Digital Imaging  2011;25(4):492-496.
Advances in handheld computing now allow review of DICOM datasets from remote locations. As the diagnostic ability of this tool is unproven, we evaluated the ability to diagnose acute appendicitis on abdominal CT using a mobile DICOM viewer. This HIPAA compliant study was IRB-approved. Twenty-five abdominal CT studies from patients with RLQ pain were interpreted on a handheld device (iPhone) using a DICOM viewer (OsiriX mobile) by five radiologists. All patients had surgical confirmation of acute appendicitis or follow-up confirming no acute appendicitis. Studies were evaluated for the ability to find the appendix, maximum appendiceal diameter, presence of an appendicolith, periappendiceal stranding and fluid, abscess, and an assessment of the diagnosis of acute appendicitis. Results were compared to PACS workstation. Fifteen cases of acute appendicitis were correctly identified on 98% of interpretations, with no false-positives. Eight appendicoliths were correctly identified on 88% of interpretations. Three abscesses were correctly identified by all readers. Handheld device measurement of appendiceal diameter had a mean 8.6% larger than PACS measurements (p = 0.035). Evaluation for acute appendicitis on abdominal CT studies using a portable device DICOM viewer can be performed with good concordance to reads performed on PACS workstations.
doi:10.1007/s10278-011-9431-9
PMCID: PMC3389087  PMID: 22146833
Appendicitis; Computed tomography; Gastrointestinal; Mobile; Teleradiology
20.  Clinical and Laboratory Methods in Diagnosis of Acute Appendicitis in Children 
Croatian medical journal  2007;48(3):353-361.
Aim
To compare the diagnostic accuracy of clinical examination, white blood cell and differential count, and C-reactive protein as routine tests for acute appendicitis with that of interleukin-6 (IL-6) and ultrasonography.
Methods
Eighty-two children were admitted to the Department of Pediatric Surgery and Intensive Care, Ljubljana, Slovenia because of suspected acute appendicitis. Among them, 49 children underwent surgery for acute appendicitis and 33 had abdominal pain but were not treated surgically and were diagnosed with non-specific abdominal pain or mesenteric lymphadenitis on sonography. Clinical signs of acute appendicitis were determined by surgeons on admission. White blood cell count and differential and serum concentrations of C-reactive protein and IL-6 were measured and abdominal ultrasonography was performed.
Results
Ultrasonography showed the highest diagnostic accuracy (92.9%; 95% confidence interval [CI], 84.5%-98.0%, Bayes’ theorem), followed by serum IL-6 concentration (77.6% [67.1-86.1%] receiver-operating characteristic [ROC] curve analysis), clinical signs (69.5% [59.5-79.0%] Bayes’ theorem), white blood cell count (68.4% [57.2-78.3%] ROC curve analysis), and serum C-reactive protein concentration (63.7% [52.1-74.3%] ROC curve analysis). Ultrasonography achieved also the highest specificity (95.2%) and positive (93.8%) and negative (93.3%) predictive values, whereas clinical signs showed the highest sensitivity (93.9%).
Conclusion
Ultrasonography was a more accurate diagnostic method than IL-6 serum concentration, laboratory marker with the highest diagnostic accuracy in our study, and hence it should be a part of the diagnostic procedure for acute appendicitis in children.
PMCID: PMC2080535  PMID: 17589979
21.  The role of high-mobility group box-1 (HMGB-1) in the management of suspected acute appendicitis: useful diagnostic biomarker or just another blind alley? 
Acute abdominal pain is one of the most frequent reasons for admitting patients to the emergency department for surgical evaluation. A wide number of differential diagnoses are available and their pre-test likelihood ratio varies according to the patients' age, gender, duration of symptoms and overall clinical context. While many patients with abdominal pain do not need to be admitted to the hospital wards and even fewer need eventual surgical intervention, the diagnosis of acute appendicitis remains one of the most frequently entertained differential in patients with abdominal pain. In fact, surgery for appendicitis is one of the most frequently performed operations in the Western world. As the authors of the current study point out, the high mobility group box-1 protein (HMGB1) has been known for many years. The study demonstrates in a small pilot that there is a difference in expression of HMGB1 between those with and those without appendicitis. However, is this difference clinically important? Clinically relevant results can only be documented through larger studies comparing its use and expression levels in both healthy subjects, subjects with abdominal pain for other reasons, patients with 'clear-cut' (histopathologically confirmed) appendicitis and in the difficult subgroup of patients with suspected appendicitis and equivocal symptoms.
doi:10.1186/1757-7241-19-28
PMCID: PMC3094253  PMID: 21507211
22.  The consequences of missing appendicitis during pregnancy 
BMJ Case Reports  2011;2011:bcr0520114185.
A 23-year-old second para was admitted for severe anaemia with abdominal distension in the immediate puerperal period following a preterm delivery. She suffered from acute abdominal pain 3 days back (at 32 weeks of gestation) and was evaluated in the emergency medical department for appendicitis/cholecystitis. Abdominal ultrasound was found to be normal and she received antacids for her pain abdomen. Clinical examination the day after delivery revealed abdominal distension, guarding and rigidity. Ultrasonography revealed a normal puerperal uterus with free fluid in the abdomen which on diagnostic aspiration was pus. Emergency laparotomy showed acute suppurative appendicitis with perforation. Appendecectomy with peritoneal lavage was done. Her postoperative period was stormy with high febrile spikes and evaluation confirmed septicaemia. The organism grown on postoperative blood culture and cervical swab culture was Enterococcus fecalis sensitive to vancomycin and she received the same for 10 days and recovered.
doi:10.1136/bcr.05.2011.4185
PMCID: PMC3158361  PMID: 22688479
23.  Acute Appendicitis Presenting as Unusual Left Upper Quadrant Pain 
Iranian Journal of Radiology  2013;10(3):156-159.
Appendicitis is the most common abdominal disease that requires surgery in the emergency ward. It usually presents as right lower quadrant pain, but may rarely present as left upper quadrant (LUQ) pain due to congenital anatomical abnormalities of the intestine. We report a patient who complained of persistent LUQ abdominal pain and was finally diagnosed by computed tomography (CT) as congenital intestinal malrotation complicated with acute appendicitis. It is important to include acute appendicitis in the differential diagnosis of patients who complain of LUQ abdominal pain. Abdominal CT can provide significant information that is useful in preoperative diagnosis and determination of proper treatment.
doi:10.5812/iranjradiol.6326
PMCID: PMC3857979  PMID: 24348602
Appendicitis; Intestinal Malrotation, Familial; Abdomen, Acute; Abdominal Pain
24.  Outcomes and cost analysis of laparoscopic versus open appendectomy for treatment of acute appendicitis: 4-years experience in a district hospital 
BMC Surgery  2014;14:14.
Background
Laparoscopic appendectomy is not yet unanimously considered the “gold standard” in the treatment of acute appendicitis because of its higher operative time, intra-abdominal abscess risk, and costs compared to open appendectomy. This study aimed to compare outcomes and cost of laparoscopic and open appendectomy in a district hospital.
Methods
A retrospective analysis of 230 patients who underwent appendectomy at the Division of General Surgery of the Civil Hospital of Ragusa, Italy, from May 2008 to May 2012 was performed. The variables analyzed included patients data (age, gender, previous abdominal surgery, preoperative WBC count, duration of symptoms, ASA risk score), rate of uncomplicated or complicated appendicitis, operative time, postoperative complications, length of hospital stay, and total costs. The patients were divided in two groups according to the surgical approach and compared for each variable. The results were analyzed using the t Student test for quantitative variables, and the Chi-square test with Yates correction and Fisher exact test for categorical.
Results
Laparoscopic appendectomy was performed in 139 patients, open appendectomy in 91. Two cases (1.4%) were converted to open procedure and included in the laparoscopic group data. Patient data and rate of complicated appendicitis were similar in the two study groups. There was no statistical difference (p = 0.476) in the mean operative time between the laparoscopic (52.2 min; range, 20–155) and open appendectomy (49.3 min; range, 20–110) groups. The overall incidence of minor and major complications was significantly lower (p = 0.006) after laparoscopic appendectomy (2.9%, 4 cases) than after open appendectomy (13.2%, 12 cases); rate of intra-abdominal abscess were similar. The length of hospital stay was significantly shorter (p = 0.001) in laparoscopic group (2.75 days; range, 1–8) than in open group (3.87 days; range, 1–19). The mean total cost was 2282 Euro in laparoscopic group and 2337 Euro in open group, with a no significant difference of 55 Euro (p = 0.812).
Conclusion
Laparoscopic appendectomy is associated with fewer complications, shorter hospital stay, and similar operative time, intra-abdominal abscess rate, and total costs, compared with open appendectomy. Therefore, laparoscopic appendectomy can be recommended as preferred approach in acute appendicitis.
doi:10.1186/1471-2482-14-14
PMCID: PMC3984427  PMID: 24646120
Laparoscopic appendectomy; Open appendectomy; Costs; Complications; Intra-abdominal abscess; Operative time; Length of hospital stay
25.  White Cell Count and C-Reactive Protein Measurement in Patients with Possible Appendicitis 
INTRODUCTION
Clinical assessment outweighs the use of investigations in the diagnosis of acute appendicitis. Nevertheless, white cell count (WCC) and C-reactive protein (CRP) are regularly measured in patients with suspected appendicitis. The aim of this study was to assess the utility of these markers in patients presenting with acute lower abdominal pain.
PATIENTS AND METHODS
WCC and CRP were measured prospectively in 98 patients presenting with lower abdominal pain, and the results were correlated with each patient's outcome.
RESULTS
No patients with WCC and CRP both in the normal range had acute appendicitis. Raised WCC and CRP were poor positive predictors of appendicitis, both alone and in combination, and correlated poorly with the development of complications.
CONCLUSIONS
This result may have important clinical and economic implications. We suggest that patients experiencing lower abdominal pain, with normal WCC and CRP values, are unlikely to have acute appendicitis and can be safely sent home.
doi:10.1308/003588409X359330
PMCID: PMC2749345  PMID: 19102827
Appendicitis; White cell count; C-reactive protein

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