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1.  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
2.  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
3.  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
4.  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
5.  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
6.  Appendicitis 
BMJ 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
7.  Family History Is a Predictor for Appendicitis in Adults in the Emergency Department 
Introduction:
A family history of appendicitis has been reported to increase the likelihood of the diagnosis in children and in a retrospective study of adults. We compare positive family history with the diagnosis of acute appendicitis in a prospective sample of adults.
Methods:
We conducted a prospective observational study of a convenience sample of 428 patients. We compared patients with surgically proven appendicitis to a group without appendicitis. The latter were further grouped by their presenting symptoms: those presenting with a chief complaint of abdominal pain and those with other chief complaints. Participants answered questions regarding their family history of appendicitis. Family history was then compared for the appendicitis group versus the nonappendicitis group as a whole, and then versus the subgroup of patients without appendicitis but with abdominal pain. The primary analysis was a χ2 test of proportions and the calculation of odds ratio (OR) for the relationship between final diagnosis of appendicitis and family history.
Results:
Of 428 patients enrolled, 116 had appendicitis. Of those with other diagnoses, 158 had abdominal pain and 154 had other complaints. Of all patients with appendicitis, 37.9% (confidence interval [Cl] = 29.1–46.8) had positive family history. Of those without appendicitis, 23.7% (Cl = 19.0–28.4) had positive family history. In the subgroup without appendicitis but with abdominal pain, 25.9% (Cl = 19.1–32.8) had positive family history. Both comparisons were significant (P = 0.003; OR = 1.97; 95% Cl = 1.2–3.1; and P=0.034; OR = 1.74; 95% Cl = 1.04–2.9, respectively). By multivariate logistic regression analysis across the full sample, family history was a significant independent predictor (P = 0.011; OR = 1.883) of appendicitis.
Conclusion:
Adults presenting to the emergency department with a known family history of appendicitis are more likely to have this disease than those without.
doi:10.5811/westjem.2011.6.6679
PMCID: PMC3555584  PMID: 23359540
8.  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
9.  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
10.  The Diagnostic Value of D-dimer, Procalcitonin and CRP in Acute Appendicitis 
BACKGROUND: The early diagnosis of acute abdomen is of great importance. To date, several inflammatory markers have been used for the diagnosis of acute abdominal conditions, including acute appendicitis. The aim of this study was to evaluate the diagnostic utility of D-dimer, Procalcitonin (PCT) and C-reactive protein (CRP) measurements in the acute appendicitis.
METHODS: This prospective study was conducted between March 1st, 2010 and July 1st, 2011. In this period, seventy-eight patients were operated with the diagnosis of acute appendicitis, and D-dimer, PCT and CRP levels of the patients were measured. The patients were grouped as phlegmonous appendicitis (Group 1), gangrenous appendicitis (Group 2), perforated appendicitis (Group 3) and negative appendectomy (Group 4) according to the surgical findings and histopathological results.
RESULTS: Of 78 patients, 54 (69.2 %) were male and 24 (30.8 %) were female, and the mean age was 25.4 ± 11.1 years (range, 18 to 69 years). 66 (84.6 %) patients had increased leukocyte count (white blood cell count). The PCT values were higher than the upper normal limit in 20 (25.6%) patients, followed by D-dimer in 22 (28.2 %) patients and CRP in 54 (69.2 %) patients. The diagnostic value of leukocyte count and CRP in acute appendicitis was higher than that of the other markers, whereas leukocyte count showed very low specificity. CRP values were higher in perforated appendicitis when compared with the phlegmonous appendicitis (p<0.05). However, PCT and D-dimer showed lower diagnostic values (26% and 31%, respectively).
CONCLUSION: An increase in CRP levels alone is not sufficient to make the diagnosis of acute appendicitis. However, CRP levels may differentiate between phlegmonous appendicitis and perforated appendicitis. Due to their low sensitivity and diagnostic value, PCT and D-dimer are not better markers than CRP for the diagnosis of acute appendicitis.
doi:10.7150/ijms.4733
PMCID: PMC3520016  PMID: 23236260
Appendicitis; D-dimer; Procalcitonin; C-reactive protein.
11.  The effect of blunt abdominal trauma on appendix vermiformis 
Emergency Medicine Journal : EMJ  2005;22(12):874-877.
Objectives: Trauma and appendicitis are the most common conditions of childhood for which surgical consultation is sought in emergency departments. Occasionally, appendicitis and trauma exist together, which causes an interesting debate whether trauma has led to appendicitis. We aimed to evaluate our patients with traumatic appendicitis and to discuss their properties in the light of the literature.
Methods: We retrospectively reviewed the charts of children of blunt abdominal trauma accompanied by appendicitis.
Results: Of 29 cases of blunt abdominal trauma that had required surgical exploration, five were found to have gross findings of acute appendicitis and underwent appendicectomy. Appendicitis was confirmed histopathologically.
Conclusion: It should be kept in mind that children managed for severe blunt abdominal trauma may develop appendicitis. If clinical outlook suggests appendicitis in cases conservatively managed for blunt abdominal trauma, physical examinations, abdominal ultrasonography and/or abdominal computed tomography should be repeated for diagnosis of traumatic appendicitis. This approach will help to protect the patients against the complications of appendicitis that are likely to develop.
doi:10.1136/emj.2004.018895
PMCID: PMC1726629  PMID: 16299198
12.  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
13.  Normal inflammatory markers in appendicitis: evidence from two independent cohort studies 
JRSM Short Reports  2011;2(5):43.
Objectives
Acute appendicitis is a common surgical condition which can lead to severe complications. Recent work suggested that patients experiencing right lower abdominal pain, with normal white cell count (WCC) and C-reactive protein (CRP) are unlikely to have acute appendicitis and can be discharged. We present two independent data-sets that suggest that this strategy may not be risk-free.
Design
Retrospective cohort study of consecutive patients from two district general hospitals. Sensitivity and specificity of CRP, WCC and neutrophil count (NC) in predicting appendicitis were calculated. Markers were analysed using Fisher's exact test and Kruskul-Wallace test.
Setting
Two district general hospitals in the UK.
Participants
Patients undergoing appendicectomy for suspected appendicitis.
Main outcome measures
Inflammatory markers and appendix histology.
Results
A total of 297 patients were included. Appendicitis occurred in four patients with normal CRP, WCC and NC in centre A and 13 patients in centre B. The sensitivity of all three markers combined was 94% (centre A) and 92% (centre B). The specificity was 60% (centre A) and 64% (centre B). No single marker could differentiate uncomplicated and complicated appendicitis, but a raised NC or a CRP >35.5 mg/l predicted complicated appendicitis. CRP, WCC and NC combined differentiated between patients with a normal appendix, uncomplicated appendicitis and complicated appendicitis.
Conclusions
Appendicitis in the presence of normal inflammatory markers is not uncommon. We disagree with the view of Sengupta et al. who suggest that patients with normal WCC and CRP are unlikely to have appendicitis, and recommend that clinicians be wary of normal inflammatory markers in patients with a high clinical suspicion of appendicitis.
doi:10.1258/shorts.2011.010114
PMCID: PMC3105453  PMID: 21637404
14.  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
15.  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
16.  Clinical presentation of acute appendicitis in adults at the Chris Hani Baragwanath academic hospital 
Background
Acute appendicitis is the most common surgical abdominal emergency. Delayed treatment increases the incidence of complications. The aim of this study was to investigate the presentation, incidence, and predictors of complications, and histological findings in adult patients with clinical diagnosis of acute appendicitis.
Methods
The study was a prospective observational study and included patients aged 12 years and older diagnosed with acute appendicitis. Data collected included demographic data, clinical presentation, duration of symptoms and reasons for presentation delay, diagnostic investigations, operative and histology findings, length of hospital stay, and mortality.
Results
A total of 146 patients were admitted with a mean age of 26 years (SD = 12 years). The male to female ratio was 1.6:1. Predominant presenting symptoms were right iliac fossa pain (95%), nausea (80%), and vomiting (73%), with 63% of patients presenting 2 days after onset of symptoms. Fever was present in 15% and only 31% of patients gave a typical history of acute appendicitis of vague peri-umbilical pain. The negative predictive values of white cell count and C-reactive protein for acute appendicitis were 28% and 50%, respectively. Sensitivity of the ultrasound to detect acute appendicitis was 60% with a negative predictive value of 31%; 30% of patients had complicated appendicitis. Histology results showed a normal appendix in 11% of patients. The 30-day mortality rate was 1.4%.
Conclusions
Patients with acute appendicitis rarely present with a typical history of vague peri-umbilical pain. The negative predictive values of both white cell count and ultrasound proved that neither of these measurements was accurate in the diagnosis of acute appendicitis. Most of our patients with complicated disease present late, with the most common reasons for this delay being lack of access to a medical clinics and prior treatment by general practitioners. Complications were higher in males and in those aged 45 years and above.
doi:10.1186/1865-1380-7-12
PMCID: PMC3938026  PMID: 24533851
Acute appendicitis; Complications; Delayed presentation; Negative appendicectomy
17.  An evaluation of a superfast MRI sequence in the diagnosis of suspected acute appendicitis 
Background
A lack of typical symptoms in acute appendicitis may delay the appropriate therapy. We hypothesized that a superfast MRI sequence with fat suppression could assist in the diagnosis of acute appendicitis.
Objective
To evaluate the sensitivity and specificity of MRI in the diagnosis of suspected acute appendicitis especially in the early stages and before surgery.
Methods
Subject images were acquired with a 1.5-T clinical MRI scanner (Achieva Nova Dual, Philips, Netherlands) with a four-element phased array abdominal coil with a SENSE factor of 1.8. A total of 41 cases with suspected acute appendicitis were recruited. SENSE-BTFE-SPIR sequence, sensitivity encoding (SENSE) with balanced turbo field echo (BTFE) and spectral presaturation and inversion recovery (SPIR), was adopted in this study.
Results
The sensitivity and specificity were 91.7% and 100%, respectively, in the diagnosis of acute appendicitis by SENSE-BTFE-SPIR in this series. Cases with simple acute appendicitis showed a higher T2 signal in the appendiceal wall, with local fluid surrounding appendix. Cases with purulent appendicitis showed an increased T2 signal within the cavity of the appendix, along with appendiceal wall thickening, or increased T2 signals around effusions in cases with gangrenous appendicitis. A periappendiceal abscess showed a localized, high-signal fluid collection that may have had extensive effects on the adjacent bowel loops, into which the entire appendix may disappear.
Conclusions
The fast SENSE-BTFE-SPIR sequence is capable of demonstrating the location and position of the appendix, the presence of acute appendicitis and its complications, and the clinical stages.
doi:10.3978/j.issn.2223-4292.2012.12.01
PMCID: PMC3533601  PMID: 23289088
Acute appendicitis; magnetic resonance imaging; superfast sequence
18.  Diagnosing Appendicitis: Evidence-Based Review of the Diagnostic Approach in 2014 
Introduction
Acute appendicitis is the most common abdominal emergency requiring emergency surgery. However, the diagnosis is often challenging and the decision to operate, observe or further work-up a patient is often unclear. The utility of clinical scoring systems (namely the Alvarado score), laboratory markers, and the development of novel markers in the diagnosis of appendicitis remains controversial. This article presents an update on the diagnostic approach to appendicitis through an evidence-based review.
Methods
We performed a broad Medline search of radiological imaging, the Alvarado score, common laboratory markers, and novel markers in patients with suspected appendicitis.
Results
Computed tomography (CT) is the most accurate mode of imaging for suspected cases of appendicitis, but the associated increase in radiation exposure is problematic. The Alvarado score is a clinical scoring system that is used to predict the likelihood of appendicitis based on signs, symptoms and laboratory data. It can help risk stratify patients with suspected appendicitis and potentially decrease the use of CT imaging in patients with certain Alvarado scores. White blood cell (WBC), C-reactive protein (CRP), granulocyte count and proportion of polymorphonuclear (PMN) cells are frequently elevated in patients with appendicitis, but are insufficient on their own as a diagnostic modality. When multiple markers are used in combination their diagnostic utility is greatly increased. Several novel markers have been proposed to aid in the diagnosis of appendicitis; however, while promising, most are only in the preliminary stages of being studied.
Conclusion
While CT is the most accurate mode of imaging in suspected appendicitis, the accompanying radiation is a concern. Ultrasound may help in the diagnosis while decreasing the need for CT in certain circumstances. The Alvarado Score has good diagnostic utility at specific cutoff points. Laboratory markers have very limited diagnostic utility on their own but show promise when used in combination. Further studies are warranted for laboratory markers in combination and to validate potential novel markers.
doi:10.5811/westjem.2014.9.21568
PMCID: PMC4251237  PMID: 25493136
19.  Noncontrast and contrast enhanced computed tomography for diagnosing acute appendicitis: A retrospective study for the usefulness 
Abdominal computed tomography (CT) provides great benefits for the differential diagnosis in patients complaining of acute abdominal pain. However, the use of diagnostic X-rays is associated with the cumulative risk of cancer development. In order to determine the relative usefulness of noncontrast and enhanced CT with intravenous contrast material for diagnosing acute appendicitis, the retrospective analysis was performed using 247 patients (46 children and 201 adults) with clinically suspected appendicitis, who were admitted to our hospital from 2002 to 2006 and underwent noncontrast or combined noncontrast and enhanced CT examination. Of 185 patients who were diagnosed to have acute appendicitis with appendiceal thickening (167 cases) or normal-sized appendix (18 cases), 73 cases underwent noncontrast CT alone and these 73 cases could be retrospectively diagnosed to have appendicitis on noncontrast CT. On the other hand, 112 cases of these 185 patients underwent noncontrast CT followed by enhanced CT, and vermiform appendix was detected in 86 cases of them (86/112, 76.8%) on noncontrast CT. These 86 cases could be retrospectively diagnosed to have acute appendicitis on noncontrast CT, whereas enhanced CT was required to detect vermiform appendix and to obtain the final diagnosis of appendicitis in the remaining 26 cases (26/112, 23.2%). Enhanced CT was superior to noncontrast CT in diagnosing appendicitis in all age and any gender groups. We suggest that enhanced, but not noncontrast, CT should be primarily performed for diagnosing acute appendicitis in all patients to minimize the radiation exposure unless intravenous administration of contrast material is contraindicated.
doi:10.3941/jrcr.v3i6.101
PMCID: PMC3303316  PMID: 22470667
Computed tomography; appendicitis
20.  A Comparative Study of Routine Laparoscopic Versus Open Appendectomy 
Objective:
We evaluated the outcomes of routine laparoscopy and laparoscopic appendectomy (LA) in patients with suspected appendicitis. This is a retrospective study of the outcomes of patients undergoing laparoscopic appendectomy compared with outcomes for patients undergoing open appendectomy (OA) during the time that LA came into use.
Method:
Results of patients managed with routine laparoscopy and LA for suspected acute appendicitis were reviewed and analyzed. The preoperative and intraoperative findings were recorded. The clinical outcomes were compared with those of patients undergoing OA in the preceding 10 months.
Results:
During the LA study period, 97 patients (47 men) with the median age of 34 years (range, 18 to 79) presented with clinical features of acute appendicitis. With the exclusion of 5 patients with open operations and 10 patients with other pathologies, 82 patients underwent laparoscopic appendectomy (Group A) for appendicitis. Thirty-one (37.8%) patients had complicated appendicitis (perforated or gangrenous appendicitis). Conversions were required in 6 patients (7.3%). During the OA period, 125 patients (57 men) with the median age of 42 (range, 19 to 79) years were operated on. With the exclusion of 6 patients with other pathologies, 119 underwent OA for acute appendicitis (Group B). Fifty-one (42.9%) had either perforated or gangrenous appendicitis. The median durations of surgery in Group A and Group B were 80 minutes (range, 40 to 195) and 60 minutes (range, 25 to 260), respectively (P<0.005). Postoperative complication rates were comparable between the 2 groups (13.4% in Group A versus 15.8% in Group B). The median hospital stay for patients in Group A and Group B were 3.0 days (range, 1 to 47) and 4.0 days (range, 1 to 47), respectively (P=0.037).
Conclusions:
We conclude that routine laparoscopy and LA for suspected acute appendicitis is safe and is associated with a significantly shorter hospital stay. Other intra-abdominal pathologies can also be diagnosed more accurately with the laparoscopic approach.
PMCID: PMC3016135  PMID: 16882418
Laparoscopic appendectomy
21.  Discriminative Accuracy of Novel and Traditional Biomarkers in Children with Suspected Appendicitis Adjusted for Duration of Abdominal Pain 
Objectives
To assess the accuracy of novel and traditional biomarkers in patients with suspected appendicitis as a function of duration of symptoms.
Methods
This was a prospective cohort study, conducted in a tertiary care emergency department (ED). The authors enrolled children 3 to 18 years old with acute abdominal pain of less than 96 hours, and measured serum levels of Interleukin-6 (IL-6), Interleukin-8 (IL-8), C - reactive protein (CRP), white blood cell count (WBC), and absolute neutrophil count (ANC). Final diagnosis was determined by histopathology or telephone follow-up. Trends in biomarker levels were examined based on duration of abdominal pain. The accuracy of biomarkers was assessed with receiver operating characteristic (ROC) curves. Optimal cut-points and test performance characteristics were calculated for each biomarker.
Results
Of 280 patients enrolled, the median age was 11.3 years (IQR 8.6 to 14.8), 57% were male, and 33% had appendicitis. Median IL-6, median CRP, mean WBC, and mean ANC differed significantly (p < 0.001) between patients with non-perforated appendicitis and those without appendicitis; median IL-8 levels did not differ between groups. In non-perforated appendicitis, median IL-6, WBC, and ANC levels were maximal at less than 24 hrs of pain, while CRP peaked between 24 and 48 hours. In perforated appendicitis, median IL-8 levels were highest by 24 hours, WBC and IL-6 by 24 to 48 hours, and CRP after 48 hours of pain. The WBC appeared to be the most useful marker to predict appendicitis in those with fewer than 24 or more than 48 hours of pain, while CRP was the most useful in those with 24 to 48 hours of pain.
Conclusions
In this population, the serum levels and accuracy of novel and traditional biomarkers varies in relation to duration of abdominal pain. IL-6 shows promise as a novel biomarker to identify children with appendicitis.
doi:10.1111/j.1553-2712.2011.01095.x
PMCID: PMC3117273  PMID: 21676053
22.  Modified Alvarado Scoring System as a diagnostic tool for Acute Appendicitis at Bugando Medical Centre, Mwanza, Tanzania 
BMC Surgery  2011;11:4.
Background
Decision-making in patients with acute appendicitis poses a diagnostic challenge worldwide, despite much advancement in abdominal surgery. The Modified Alvarado Scoring System (MASS) has been reported to be a cheap and quick diagnostic tool in patients with acute appendicitis. However, differences in diagnostic accuracy have been observed if the scores were applied to various populations and clinical settings. The purpose of this study was to evaluate the diagnostic value of Modified Alvarado Scoring System in patients with acute appendicitis in our setting.
Methods
A cross-sectional study involving all patients suspected to have acute appendicitis at Bugando Medical Centre over a six-month period between November 2008 and April 2009 was conducted. All patients who met the inclusion criteria were consecutively enrolled in the study. They were evaluated on admission using the MASS to determine whether they had acute appendicitis or not. All patients underwent appendicectomy according to the hospital protocol. The decision to operate was the prerogative of the surgeon or surgical resident based on overall clinical judgment and not the MASS. The diagnosis was confirmed by histopathological examination. Data was collected using a pre-tested coded questionnaire and analyzed using SPSS statistical computer software.
Results
A total number of 127 patients were studied. Their ages ranged from eight to 76 years (mean 29.64 ± 12.97). There were 37 (29.1%) males and 90 (70.9%) females (M: F = 1:2.4). All patients in this study underwent appendicectomy. The perforation rate was 9.4%. Histopathological examination confirmed appendicitis in 85 patients (66.9%) and the remaining 42 patients had normal appendix giving a negative appendicectomy rate of 33.1% (26.8% for males and 38.3% for females). The sensitivity and specificity of MASS in this study were 94.1% (males 95.8% and females 88.3%) and 90.4% (males 92.9% and females 89.7%) respectively. The Positive Predictive Value and Negative Predictive Value were 95.2% (males 95.5% and females 90.6%) and 88.4% (males 89.3% and females 80.1%) respectively. The accuracy of MASS was 92.9% (males 91.5% and females 87.6%).
Conclusion
The study shows that use of MASS in patients suspected to have acute appendicitis provides a high degree of diagnostic accuracy and can be employed at Bugando Medical Centre to improve the diagnostic accuracy of acute appendicitis and subsequently reduces negative appendicectomy and complication rates. However, additional investigations may be required to confirm the diagnosis in case of atypical presentation.
doi:10.1186/1471-2482-11-4
PMCID: PMC3050681  PMID: 21329493
23.  Profiles of US and CT imaging features with a high probability of appendicitis 
European Radiology  2010;20(7):1657-1666.
Objectives
To identify and evaluate profiles of US and CT features associated with acute appendicitis.
Methods
Consecutive patients presenting with acute abdominal pain at the emergency department were invited to participate in this study. All patients underwent US and CT. Imaging features known to be associated with appendicitis, and an imaging diagnosis were prospectively recorded by two independent radiologists. A final diagnosis was assigned after 6 months. Associations between appendiceal imaging features and a final diagnosis of appendicitis were evaluated with logistic regression analysis.
Results
Appendicitis was assigned to 284 of 942 evaluated patients (30%). All evaluated features were associated with appendicitis. Imaging profiles were created after multivariable logistic regression analysis. Of 147 patients with a thickened appendix, local transducer tenderness and peri-appendiceal fat infiltration on US, 139 (95%) had appendicitis. On CT, 119 patients in whom the appendix was completely visualised, thickened, with peri-appendiceal fat infiltration and appendiceal enhancement, 114 had a final diagnosis of appendicitis (96%). When at least two of these essential features were present on US or CT, sensitivity was 92% (95% CI 89–96%) and 96% (95% CI 93–98%), respectively.
Conclusion
Most patients with appendicitis can be categorised within a few imaging profiles on US and CT. When two of the essential features are present the diagnosis of appendicitis can be made accurately.
doi:10.1007/s00330-009-1706-x
PMCID: PMC2882051  PMID: 20119730
Acute appendicitis; Computed tomography; Ultrasonography; Imaging features; Acute abdomen
24.  The Usefulness of Procalcitonin in the Diagnosis of Appendicitis in Children: A Pilot Study 
Objective. To assess the predictive value of procalcitonin in detecting acute appendicitis (AP) in children, and to determine a cutoff value of procalcitonin which can safely include/exclude the diagnosis of acute appendicitis in children with acute abdominal pain. Methods. Prospective cohort study of children aged 5–17 years presenting to the emergency room with right lower quadrant (RLQ) tenderness and strong suspicion for acute AP. In addition to standard diagnostic workup for acute AP, a quantitative procalcitonin level was measured using immunoluminometric assay. Recursive partitioning model was used to assess the usefulness of procalcitonin in the diagnosis of appendicitis. Results. Of the 50 children studied, 48% were diagnosed to have AP. The mean procalcitonin level was higher among the children with appendicitis (P = 0.3). Using the recursive partitioning model, we identified a cutoff value of procalcitonin level of 0.39 with a likelihood ratio presence of appendicitis 3.25 and absence of appendicitis 0.8. None of the study subjects with procalcitonin level <0.39 and WBC count of <6.76 K had appendicitis. Conclusions. In conjunction with the clinical symptoms, a procalcitonin level and WBC count could be a strong predictor of acute appendicitis in children.
doi:10.1155/2012/317504
PMCID: PMC3529464  PMID: 23304513
25.  Idiopathic sclerosing encapsulating peritonitis (or abdominal cocoon): A report of 5 cases 
Sclerosing encapsulating peritonitis (SEP) is a rare cause of intestinal obstruction that is characterized by a thick grayish-white fibrotic membrane encasing the small bowel. SEP can be classified as idiopathic, also known as abdominal cocoon, or secondary. It is difficult to make a definite pre-operative diagnosis. We experienced five cases of abdominal cocoon, and the case files were reviewed retrospectively for the clinical presentation, operative findings and outcome. All the patients presented with acute, subacute and chronic intestinal obstruction. Computed tomography (CT) showed characteristic findings of small bowel loops congregated to the center of the abdomen encased by a soft-tissue density mantle in four cases. Four cases had an uneventful post-operative period, one case received second adhesiolysis due to persistent ileus. The imaging techniques may facilitate pre-operative diagnosis. Surgery is important in the management of SEP.
doi:10.3748/wjg.v13.i26.3649
PMCID: PMC4146810  PMID: 17659721
Sclerosing encapsulating peritonitis; Idiopathic; Abdominal cocoon; Intestinal obstruction; Adhesiolysis

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