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1.  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
2.  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
3.  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
4.  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
5.  Acute abdominal pain in children1 
During a twelve-month period, 416 children with acute abdominal pain required emergency admission to Southampton General Hospital; 46% had operations. Appendicitis was the commonest organic cause of acute abdominal pain identified (31%). Constipation (9%) can present as acute abdominal pain simulating appendicitis. All children should have a urine sample examined microscopically and the finding of significant pyuria is suggestive, but not diagnostic, of a urinary tract infection (7%). Mesenteric adenitis, which can only be diagnosed with certainty at laparotomy, was less common (4%). Despite careful clinical assessment and follow up, 45% of children in this series remained undiagnosed. Sedation but not analgesia may assist in the diagnosis of the acute abdomen in children.
PMCID: PMC1438202  PMID: 7241473
6.  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
7.  An unusual case in surgical emergency: Abdominal cocoon and its laparoscopic management 
Small bowel obstruction associated with abdominal cocoon (AC) is a rarely encountered surgical emergency. This condition is characterised by a thick fibrous membrane which encases the small bowel partially or completely. It is usually difficult to be able to make a definitive diagnosis in the presence of obscure clinical and radiological findings. Diagnosis is usually made at laparotomy when the encasement of the small bowel within a cocoon-like sac is visualised. Here, we report on a 29-year-old male patient who presented with acute small bowel obstruction and was eventually diagnosed with AC at laparoscopy. In this case, laparoscopic excision of the fibrous sac and extensive adhesiolysis resulted in complete recovery. Although rare, the diagnosis of AC should be kept in cases of patients with intestinal obstruction combined with relevant imaging findings. Laparoscopy should also be considered for the management of this condition in suitable patients.
doi:10.4103/0972-9941.83511
PMCID: PMC3193760  PMID: 22022102
Abdominal cocoon; laparoscopy; management; small bowel obstruction
8.  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
9.  L-sign in appendicitis: a case series 
Cases Journal  2009;2:8117.
Introduction
Clinical signs have been always of significant value in the diagnosis of appendicitis. Specific clinical signs are elicited coupled with routine laboratory and radiological investigations in making the diagnosis of acute appendicitis. L-sign in appendicitis is similar to the well known Rovsing’s sign and is based on the same principle but is elicited on right side on the lateral abdominal wall.
Case presentation
A case series of 3 patients is presented here who had the L-sign in acute appendicitis. All had Rovsing’s sign positive and the histopathological evidence of appendicitis.
Conclusion
L-sign in appendicitis is similar to the Rovsing’s sign in diagnosis of appendicitis but elicited on right side.
doi:10.4076/1757-1626-2-8117
PMCID: PMC2769404  PMID: 19918454
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.  An unusual and difficult diagnosis of intestinal obstruction: The abdominal cocoon. Case report and review of the literature 
Abdominal cocoon is a rare cause of intestinal obstruction. The abdominal cocoon is probably a developmental abnormality, largely asymptomatic, and is found incidentally at laparotomy or autopsy. Pre-operative diagnosis cannot be often made correctly. This rare entity of intestinal obstruction has been described in the whole literature as a thick fibrotic sac covering the small bowel partially or completely. The etiology of abdominal cocoon is unknown and most often it is found in adolescent girls from tropical or subtropical countries. Complete recovery is generally expected after the removal of the membrane surgically. This paper reports a male patient who has had intestinal obstruction symptoms and has per-operatively been diagnosed as abdominal cocoon.
doi:10.1186/1749-7922-1-8
PMCID: PMC1459267  PMID: 16759404
12.  Laparoscopic management of abdominal cocoon 
“Peritonitis fibrosa incapsulata”, first described in 1907, is a condition characterized by encasement of the bowel with a thick fibrous membrane. This condition was renamed as “abdominal cocoon” in 1978. It presents as small bowel obstruction clinically. 35 cases of abdominal cocoon have been reported in the literature over the last three decades. Abdominal cocoon is more common in adolescent girls from tropical countries. Various etiologies have been described, including tubercular. It is treated surgically by releasing the entrapped bowel. We report a laparoscopic experience of tubercular abdominal cocoon and review the literature.
doi:10.4103/0972-9941.40992
PMCID: PMC2699059  PMID: 19547673
Abdominal cocoon; intestinal obstruction; laparoscopy
13.  Traumatic appendicitis: a case report and literature review 
Appendicitis and trauma may exist together, which causes an interesting debate whether trauma has led to appendicitis. We report a case of appendicitis after an abdominal trauma. Our patient developed acute appendicitis following a stab wound in the right iliac fossa. Surgical exploration confirmed the traumatic origin of appendicitis, appendectomy was performed and our patient made an excellent recovery. In non operative management of abdominal trauma, physical examinations and radiological explorations should be repeated in order to diagnose traumatic appendicitis.
doi:10.1186/1749-7922-8-31
PMCID: PMC3750490  PMID: 23937952
Appendicitis; Abdominal trauma
14.  Unusual case of acute appendicitis with left upper quadrant abdominal pain 
INTRODUCTION
Acute appendicitis is one of the most frequent causes of surgical abdominal pain presenting to the Emergency Department. The diagnosis is confirmed by a set of clinical signs, blood tests and imaging.
The typical presentation consists of periumbilical pain radiating to the right lower quadrant with peritoneal reaction on palpation (Mac Burney).
PRESENTATION OF CASE
In this article, we report a case of acute appendicitis presenting with a left upper quadrant pain due to intestinal malrotation and we describe the radiologic findings on computed tomography.
DISCUSSION
With an Alvarado score of 4 and a nonconclusive abdominal U/S, the diagnosis of acute appendicitis was a long shot. Persistence of pain and increasing inflammatory parameters in her blood exams pushed the medical team to further investigate and a CT scan revealed intestinal malrotation with acute appendicitis.
CONCLUSION
An examining physician should not be mislead by the atypical presentation of acute appendicitis and should bear in mind the diagnosis to avoid serious complications.
doi:10.1016/j.ijscr.2012.05.002
PMCID: PMC3376725  PMID: 22677782
Acute appendicitis; Intestinal malrotation; Computed tomography
15.  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
16.  Diagnostic value of blood inflammatory markers for detection of acute appendicitis in children 
BMC Surgery  2006;6:15.
Background
Acute appendicitis (AA) is a common surgical problem that is associated with an acute-phase reaction. Previous studies have shown that cytokines and acute-phase proteins are activated and may serve as indicators for the severity of appendicitis. The aim of this study was to compare diagnostic value of different serum inflammatory markers in detection of phlegmonous or perforated appendicitis in children.
Methods
Data were collected prospectively on 211 consecutive children. Laparotomy was performed for suspected AA for 189 patients. Patients were subdivided into groups: nonsurgical abdominal pain, early appendicitis, phlegmonous or gangrenous appendicitis, perforated appendicitis.
White blood cell count (WBC), serum C-reactive protein (CRP), interleukin-6 (IL-6), tumor necrosis factor α (TNF-α), acid α1-glycoprotein (α1GP), endotoxin, and erythrocyte sedimentation reaction (ESR) were estimated ad the time of admission. The diagnostic performance was analyzed using receiver operating characteristic (ROC) curves.
Results
WBC count, CRP and IL-6 correlated significantly with the severity of appendiceal inflammation. Identification of children with severe appendicitis was supported by IL-6 or CRP but not WBC. Between IL-6 and CRP, there were no significant differences in diagnostic use.
Conclusion
Laboratory results should be considered to be integrated within the clinical assessment. If used critically, CRP and IL-6 equally provide surgeons with complementary information in discerning the necessity for urgent operation.
doi:10.1186/1471-2482-6-15
PMCID: PMC1712352  PMID: 17132173
17.  Acute Myeloid Leukemia Presenting as Acute Appendicitis 
Case Reports in Hematology  2013;2013:815365.
Appendicitis in leukemic patients is uncommon but associated with increased mortality. Additionally, leukemic cell infiltration of the appendix is extremely rare. While appendectomy is the treatment of choice for these patients, diagnosis and management of leukemia have a greater impact on remission and survival. A 59-year-old Caucasian female was admitted to the surgical service with acute right lower quadrant pain, nausea, and anorexia. She was noted to have leukocytosis, anemia, and thrombocytopenia. Abdominal imaging demonstrated appendicitis with retroperitoneal and mesenteric lymphadenopathy for which she underwent laparoscopic appendectomy. Peripheral smear, bone marrow biopsy, and surgical pathology of the appendix demonstrated acute myeloid leukemia (AML) with nonsuppurative appendicitis. In the setting of AML, prior cases described the development of appendicitis with active chemotherapy. Of these cases, less than ten patients had leukemic infiltration of the appendix, leading to leukostasis and nonsuppurative appendicitis. Acute appendicitis with leukemic infiltration as the initial manifestation of AML has only been described in two other cases in the literature with an average associated morbidity of 32.6 days. The prompt management in this case of appendicitis and AML resulted in an overall survival of 185 days.
doi:10.1155/2013/815365
PMCID: PMC3693109  PMID: 23840984
18.  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
19.  Goblet cell carcinoid of appendix: A rare case with literature review 
INTRODUCTION
The goblet cell carcinoid, a rare tumor of the appendix, is a separate entity from adenocarcinoma and carcinoid tumors.
PRESENTATION OF CASE
We report a case of goblet cell carcinoid in our institute who presented with acute abdominal symptoms simulating acute appendicitis.
DISCUSSION
Goblet cell carcinoid is a rare neoplasm with distinct histological and clinical features. The diagnosis is essentially made on histological grounds. Still the exact biological behavior of this tumor is uncertain.
CONCLUSION
Considering the difficulty of clinical suspicion of this tumor, presenting as appendicitis and incidentally found during appendectomies, we review the goblet cell carcinoid of the appendix using an illustrative case report.
doi:10.1016/j.ijscr.2013.01.007
PMCID: PMC3604658  PMID: 23416502
Goblet cell carcinoid; Appendicular carcinoid; Appendicular tumor
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.  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
22.  Successful laparoscopic management of concomitant ectopic pregnancy and acute appendicitis in a patient of failed tubal ligation – case report with a review of the literature 
Cases Journal  2008;1:412.
Background
The incidence of failed abdominal bilateral tubal ligation (BTL) is quite low. Most often the pregnancy following BTL is ectopic in location. The association of concurrent acute appendicitis with ectopic pregnancy is also very rare. From 1960 till 2008 only 23 such cases of ectopic pregnancy with appendicitis managed by open surgery have been reported in the medical literature.
Case presentation
We present a case in which the patient had concurrent ectopic pregnancy of the right fallopian tube with acute appendicitis after failed BTL and which was managed successfully by laparoscopic approach.
Conclusion
Although the combination of ectopic pregnancy and acute appendicitis is quite rare, it is wise to rule out concurrent acute appendicitis in patients of ectopic pregnancy especially if it is on the right side due to an inter-etiological relationship. Laparoscopic management of both these pathologies can be accomplished quite successfully in properly selected cases.
doi:10.1186/1757-1626-1-412
PMCID: PMC2621128  PMID: 19102771
23.  Combined use of modified Alvarado score and USG in decreasing negative appendicectomy rate 
The Indian Journal of Surgery  2010;72(1):42-48.
Introduction
Appendicitis is notorious in its ability to simulate other conditions and in the frequency it can be mimicked by other pathologies. Despite extraordinary advances in modern radiography imaging and diagnostic laboratory investigations the accurate diagnosis of acute appendicitis remains an enigmatic challenge. Of the various commonly used diagnostic aids for appendicitis, no single test can reduce the rate of negative appendicectomy to zero.
Materials and methods
Fifty admitted cases of suspected appendicitis were subjected to ultrasonography (USG). All the patients were scored out of 9 according to modified Alvarado score. A treatment plan was devised according to which patients with modified Alvarado score ≥7 underwent immediate appendicectomy even if USG was negative for appendicitis and patients with score <7 underwent appendicectomy if USG was positive for appendicitis.
Result
84.3% of males and 44.4% of females admitted as case of suspected appendicitis had confirmed appendicitis. Due to high sensitivity (97.14%) and accuracy (92%) of our diagnostic approach, 85.71% cases of appendicitis were diagnosed in early stage, with only 8.57% perforation and abscess rate, leading to post appendicectomy complication rate of only 5.14% in our study (one wound infection and one urinary retention). We could achieve low negative appendicectomy rate of 7.14% in males and 11.11% in females and overall 8.11% in our study.
Conclusion
Combined use of modified Alvarado score and high frequency USG not only reduces negative appendicectomy rate but also reduces morbidity and postoperative complications.
doi:10.1007/s12262-010-0008-5
PMCID: PMC3452540  PMID: 23133203
Ultrasonography; Acute appendicitis; Alvarado scores
24.  Perforated acute appendicitis resulting from appendiceal villous adenoma presenting with small bowel obstruction: a case report 
BMC Gastroenterology  2011;11:35.
Background
A villous adenoma is an extremely rare benign tumour in the appendix, in contrast to other benign appendiceal lesions. The clinical features are usually asymptomatic. Acute appendicitis is the most common complication with the lesion obstructing the orifice of the appendiceal lumen. Thus, a villous adenoma is usually found during surgical intervention for acute appendicitis. Mechanical obstruction induced by acute perforated appendicitis has been previously reported. Acute appendicitis caused by a villous adenoma presenting with acute intestinal obstruction has not been previously reported.
Case presentation
A 78-year-old woman presented to our Emergency Department with diffuse abdominal pain and tenderness. The abdominal plain film and computed tomography revealed an intestinal obstruction. After surgical intervention, the ruptured appendix was shown to be associated with intestinal obstruction. The post-operative pathologic diagnosis was an appendiceal villous adenoma.
Conclusions
This is the first report describing an appendiceal villous adenoma, which is an occasional cause of perforated acute appendicitis, presenting as a complete intestinal obstruction. We emphasize that in elderly patients without a surgical history, the occult cause of complete intestinal obstruction must be determined. If an appendiceal tumour is diagnosed, an intra-operative frozen section is suggested prior to selecting a suitable method of surgical intervention.
doi:10.1186/1471-230X-11-35
PMCID: PMC3094313  PMID: 21477328
25.  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

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