Unusual complications of a common disease in COVID times: a case series

Acute appendicitis is the most common abdominal surgical emergency worldwide. 20-30% of cases of appendicitis can complicate which is defined as perforation, purulent peritoneal collection, abscess formation and generalized peritonitis. The risk of perforated appendicitis increases when appropriate treatment for acute appendicitis is delayed. There has been an avoidance of both urgent or emergency and routine medical care because of Coronavirus disease 2019 (COVID-19) concerns all over the world. In our study, the delayed presentation of the patients with acute appendicitis to the hospital prevented appropriate management leading to a much more morbid disease course. Increasing accessibility of medical and telehealth services might help prevent delay of needed care. Even during the COVID-19 pandemic, persons experiencing a medical emergency should seek and be provided care without delay.

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Perforated Appendicitis: An Unintended Consequence During the Coronavirus-19 Pandemic

Military Medicine ◽

10.1093/milmed/usaa527 ◽

2020 ◽

Author(s):

Andrew W Wang ◽

James Prieto ◽

Daniel S Ikeda ◽

Paul R Lewis ◽

Emily M Benzer ◽

...

Keyword(s):

Acute Appendicitis ◽

Disease Process ◽

Perforated Appendicitis ◽

The United States ◽

Military Hospital ◽

Symptom Duration ◽

Delayed Presentation ◽

Historical Cohort ◽

Surgical Conditions ◽

The Impact

ABSTRACT Background The coronavirus disease 2019 (COVID-19) pandemic has had major clinical impact across the globe. Delayed presentation for medical emergencies has been noted by the medical community. There has been limited reporting on the impact for the care for emergent surgical conditions. We sought to describe the effect of the global pandemic on the presentation and outcomes for the most common urgent general surgery disease process, acute appendicitis. Methods We performed a retrospective review of patients admitted to the United States Naval Hospital Okinawa during the COVID-19 pandemic, from January 2020 to May 2020 (COVID cohort), and compared them to a historical cohort (pre-COVID cohort) over the prior 2 years. Demographics, clinical presentation data, and interventions were collected. Results Of the 80 patients with appendicitis, 20% presented perforated. Most patients were male (71%), presented with 1 day of symptoms and had a length of stay of 1 to 2 days. Comparing groups, 13% of the pre-COVID group vs. 31% of the COVID cohort presented perforated (P = .04), with a symptom duration of 1.6 vs. 2.7 days before presentation (P = .075), respectively. Conclusions The COVID-19 pandemic and the global systematic response has impacted unrelated medical and surgical conditions. At our overseas military hospital with minimal disease burden, we observed a delay in presentation for acute appendicitis with a higher incidence of perforation. Patients should be empowered to continue to seek care for urgent and emergent medical and surgical conditions so that they are not harmed by fear of COVID-19 rather than by COVID-19 itself.

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Appendicular perforation and its contributing factors

International Surgery Journal ◽

10.18203/2349-2902.isj20172401 ◽

2017 ◽

Vol 4 (6) ◽

pp. 2007

Author(s):

Anandaravi B. N. ◽

Ramaswami B.

Keyword(s):

Risk Factors ◽

Acute Appendicitis ◽

Elderly Patients ◽

Perforated Appendicitis ◽

Clinical History ◽

The Elderly ◽

Morbidity And Mortality ◽

Delayed Presentation ◽

Contributing Factors ◽

Steroid Dependent

Background: The objective was to study of different risk factors contributing in appendicular perforation and effective management of patients by knowing risk factors.Methods: This study was conducted in the department of general surgery K. R. Hospital Mysore medical college and research institute, Mysore, Karnataka, India from January 2015 to June 2016. Patients of age above 18 years and both sexes operated for acute appendicitis were included in present study. The clinical history, clinical features, investigations, intraoperative findings, were noted and surgical procedure done and all perforated appendicitis cases were operated lower midline incision, through wash given with normal saline drain in situ. Post operatively antibiotics were given and all patients follow up done for one month.Results: Present study duration is one and half year we operated total 100 patients for acute appendicitis. In this study 55 patients were male (55%) and 45 patients were females (45%). According to our study acute appendicitis is more common in males. Appendicular perforation has noticed in 23 female patients. The incidence of perforated appendicitis is low in males 12 out of 35 as compared to females 23 out of 35. The incidence of appendicular perforation is higher in the extreme of ages. In the elderly patients it is 58.33%. Thus, according to present study findings age above (>40 years) is strongly associated with the perforated appendicitis (p<0.001 chi squared test). Delayed presentation shows 77.41% appendicular perforation and faecolith associated with 64.51%.Conclusions: The morbidity and mortality rates are higher in elderly patients, diabetics, steroid dependent and immunocompromised patients. We should be aggressive in the treatment of acute appendicitis associated with high risk factors. So once acute appendicitis is diagnosed, the expedient surgery and appropriate use of perioperative antibiotics can help in reducing the morbidity and mortality.

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Risk Factors of Perforation of Appendix and Unfavorable Outcome in Delayed Presentation of Acute Appendicitis: A Cross-Sectional Analysis

TAJ Journal of Teachers Association ◽

10.3329/taj.v30i1.39122 ◽

2018 ◽

Vol 30 (1) ◽

pp. 42-48

Author(s):

Sheikh Mohd A Hakim ◽

Md Habibullah Sarkar ◽

Manzurur Rahman Shah Chowdhury

Keyword(s):

Risk Factors ◽

Acute Appendicitis ◽

Hospital Stay ◽

Abscess Formation ◽

Delayed Presentation ◽

Cross Sectional ◽

Generalized Peritonitis ◽

Operative Complications ◽

Appendiceal Perforation ◽

Post Operative Complications

Background: Perforated or gangrenous appendicitis in patient with a lately presented acute appendicitis remains a challenge for practicing surgeons and continues to be associated with more deadly complications. Results might improve with earlier consideration of the diagnosis followed by prompt surgical intervention. Objective: To identify the risk factors of appendiceal perforation, gangrene and other sequelae in patients with delayed presentation of acute appendicitis and its effects on the prognosis. Patients and Methods: This cross-sectional study was carried out from January, 2015 to July, 2017 (2½ years) in Rajshahi medical college hospital and also it’s neighboring several private hospitals. Those patients of both genders between 12 years to 65 years old, admitted during that period with signs and symptoms of acute appendicitis for more than 48 hours but otherwise healthy (i.e. not having any other comorbidities) were subjected to the present study. The parameters of our study were incidence of appendiceal perforation or gangrene, peri-appendiceal abscess formation, generalized peritonitis, length of hospital stay and post-operative complications. Results: During the study period, a total of 73 patients underwent appendicectomies and 23 patients were excluded, leaving 50 who met the inclusion criteria, 23 males (46%) and 27 females (54%). Of all the risk factors studied, the patient’s pre-hospital time delay was the most important risk factor for perforation (43 patients i.e. 86%) and there were little number of patients with the in-hospital delay (7 patients i.e. 14%). The reasons behind this pre-hospital as well as in-hospital delay were multifactorial. Overall appendiceal perforation occurred in 22 (44%) patients, patients presented with gangrenous appendicitis were 14 (28%), periappendiceal abscess formation was found in 9 (18%) patients, and patients presented with generalized peritonitis were 5 (10%). The duration of hospital stay ranged from several days to several weeks. Post-operative complications occurred in 40 (80%) cases. Post-operative complications were monitored and addressed as: prolonged ileus, wound sepsis as major and minor wound infection, intra-abdominal sepsis as pelvic abscess and faecal fistula. Conclusion: As the time course increases from the initiation of the first symptoms to the definitive management, the complication rate increases and acutely inflamed appendicitis gradually converts to more lethal forms.TAJ 2017; 30(1): 42-48

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Frequency and outcome of complicated appendicitis in toddlers and pre-schoolers

Journal of Pediatric and Adolescent Surgery ◽

10.46831/jpas.v1i1.5 ◽

2020 ◽

Vol 1 (1) ◽

Author(s):

Naseem Khan ◽

Muhammad Ayub Khan ◽

Jehangir Khan ◽

Sajjad Ali ◽

Imran Khattak ◽

...

Keyword(s):

Acute Appendicitis ◽

Pediatric Population ◽

Perforated Appendicitis ◽

Cross Sectional Study ◽

Complicated Appendicitis ◽

Cross Sectional ◽

Generalized Peritonitis ◽

Operative Findings ◽

Study Participants ◽

Emergency Abdominal Surgery

Background: Acute appendicitis is a frequent indication of emergency abdominal surgery in the pediatric population. In younger children, especially toddlers, and preschoolers, the presentation is comparatively late resulting in complicated appendicitis. This study was done to determine the frequency and outcome of complicated appendicitis in toddlers and preschoolers. Methods: This is a cross-sectional study done at the Department of Pediatric Surgery, Lady Reading Hospital Peshawar, during August 2018 and February 2019. The medical records of 144 toddlers and preschoolers who presented with acute appendicitis were reviewed for demography, clinical presentation, operative findings, and outcome. Frequency and types of complicated appendicitis were recorded. Results: The mean age of study participants was 3 years (±2.84), including 46(32%) toddlers and 98(68%) preschoolers. Overall 62% of patients were male while 38% of patients were female. Complicated appendicitis was documented in 75% of patients. The common types of complicated appendicitis were perforation of the appendix with a localized abscess in 68 patients, gangrenous appendicitis in 4 patients, generalized peritonitis in 24 patients, and mass formation in 12 patients. All patients did well after surgery, except one who succumbed to complications of leukemia. Conclusion: In our study, a great deal (75%) of toddlers and preschoolers had complicated appendicitis especially perforated appendicitis with localized peritonitis.

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Delayed presentation and its effects on the prognosis of acute appendicitis

Annals of King Edward Medical University ◽

10.21649/akemu.v11i4.1071 ◽

2016 ◽

Vol 11 (4) ◽

Author(s):

Tariq Waqar, ◽

Irfan Riaz

Keyword(s):

Acute Appendicitis ◽

High Rate ◽

Medical Attention ◽

Delayed Presentation ◽

Perforation Rate ◽

Serious Illness ◽

Generalized Peritonitis ◽

Duration Of Hospitalization ◽

One Year ◽

Operation Results

Objective: To identify the causes of delay in the presentation of the cases of acute appendicitis and its effects on the prognosis. Study design: It was descriptive type of study. Place & duration of study: The study was conducted in Department of Surgery, Nishtar Hospital Multan in one year from February 2004 to January 2005. Patients & methods: The 50 patients of all ages and both sexes were taken from surgical wards of the hospital. They were presented with signs & symptoms of disease for more than 48 hours, but otherwise healthy i.e. not having any other serious illness. The patients were diagnosed as cases of acute appendicitis after history, examination, investigations and operation. Results: There were 4(8%) patients who did not take any treatment. Patients who took the treatment but wrongly diagnosed were 36(72%). Out of these 36 patients, 12(24%) patients were treated by the quacks, in 7(14%) the diagnosis was gastroenteritis, 11(22%) patients took antibiotics and analgesics from the start of the symptoms and in the remaining 6(12%) the presentation of the patients was not typical. 10 patients (20%) were diagnosed as acute appendicitis but they refused for appendicectomy. Out of these 50 cases 24(48%) were complicated. Overall perforation rate was 30%. Patient presenting with gangrenous appendicitis were about 6%. Appendicular mass formation was found in 4% cases. Patients presenting with generalized peritonitis were 6%. Appendicular abscess formation was in 2% cases. The duration of hospitalization was 3 days in uncomplicated cases, while in complicated cases it was 6.5 days. Conclusion: The high rate of complications of appendicitis with its subsequent sequelae of increased morbidity and resource expenditure is the result of patient`s delay in seeking medical attention.

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Acute Appendicitis: After Correct Diagnosis Conservative Treatment or Surgery?

10.5772/intechopen.95870 ◽

2021 ◽

Author(s):

Anestis Charalampopoulos ◽

Nikolaos Koliakos ◽

George Bagias ◽

Georgia Bompetsi ◽

Nikolaos Zavras ◽

...

Keyword(s):

Conservative Treatment ◽

Acute Appendicitis ◽

Correct Diagnosis ◽

Daily Practice ◽

Imaging Data ◽

Review Of The Literature ◽

Generalized Peritonitis ◽

Appropriate Treatment ◽

Correct Estimation ◽

Uncomplicated Acute Appendicitis

Acute appendicitis is the most common surgical disease presented in ED. Ongoing evidence in the literature, in the last 20 years, shows a lot of benefits in favor of conservative treatment. Despite that conservative treatment does not gain the correct position at the daily practice up to day. A large number of parameters related to acute appendicitis, present diversity in their appearance, so the final estimation of the disease may by unclear and the decision for treatment may be incorrect. We analyze these parameters, aiming to clarify their role in correct diagnosis and decision making on appropriate treatment. In the present study a review of the literature is performed, regarding the etiology, pathology, clinical presentation, laboratory, and imaging data of acute appendicitis. The collection and correct estimation of these parameters, is the key for the correct diagnosis of acute appendicitis. Complicated or uncomplicated cases should be diagnosed preoperatively. The next step is the appropriate treatment, conservative or by surgery. At the present time, excluding generalized peritonitis and sepsis, the majority of patients with uncomplicated acute appendicitis and selected complicated cases can by treated successfully by conservative treatment. The majority of patients do not benefit from appendectomy.

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Acute Perforated Appendicitis: Clinical Profile and Analysis of Risk Factors

Journal of Nepalgunj Medical College ◽

10.3126/jngmc.v16i2.24865 ◽

2018 ◽

Vol 16 (2) ◽

pp. 13-15

Author(s):

Roman Kidwai ◽

Anup Sharma

Keyword(s):

Risk Factors ◽

Renal Function ◽

Acute Appendicitis ◽

Perforated Appendicitis ◽

Male Dominance ◽

Morbidity And Mortality ◽

Delayed Presentation ◽

Number Of Patients ◽

Purulent Peritonitis ◽

The Common

Introduction: The incidence of complicated acute appendicitis, including perforated or gangrenous appendicitis, remains considerably high (28-29%) despite the availability of modern imaging. Acute perforated appendicitis is associated with increased postoperative morbidity and mortality. The aim of the study was to analyze the clinico-pathological profile and outcomes for suspected perforated acute appendicitis and to determine the factors influencing the risk of perforated appendicitis. Materials and Methods: This was a prospective observational study conducted at Nepalgunj Medical College and Teaching Hospital from November 2016 to August 2018. Patients with suspected appendicle perforation were included. The diagnosis was confirmed atlaparotomy. History, physical findings, biochemical and radiological findings were noted. Results: There were 74 patients. The maximum number of patients were in the age group of 0-20 and 21-40 years with a male dominance (M:F 1.9:1). The common presenting features were pain starting in right iliac fossa and becoming generalized with features of peritonitis. Majority presented late to the hospital with the mean duration of 6.35±2.46 days. 17 (22.97%) patients had deranged renal function test at presentation. All patients underwent laparotomy and appendicectomy. The commonest site of perforation was the tip of appendix (58.08%). 27(52.94%) had generalized purulent peritonitis. All had features of acute appendicitis on histological examination. Of the 75 patients only 17 (22.97%) patients had fecolith. 21 (28.37%) had postoperative complications, commonest being surgical site infection (25.67%). Five (6.67%) patients died after surgery. The common cause of death was septic shock with multiorgan failure. Only one patient died due to myocardial infarction. The complications and mortality were common in those patients whose presentation was late i. e after 72 hours from the onset of symptoms, whose renal function was deranged, age > 60, and who had pyoperitoneum. CONCLUSION: Acute perforated appendix is not uncommon. Males are more common with younger people commonly getting affected. Delayed presentation, pyoperitoneum, age >60 are the common risk factors associated with morbidity and mortality.

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Should All Complicated Appendicitis be Treated the Same? the Answer is No

The American Surgeon ◽

10.1177/000313481908501023 ◽

2019 ◽

Vol 85 (10) ◽

pp. 1179-1183

Author(s):

Victoria Wang ◽

Diego Kriger ◽

Elias Fanous ◽

Alfred Lee ◽

Bishoy Zakhary ◽

...

Keyword(s):

Adverse Events ◽

Acute Appendicitis ◽

Conservative Management ◽

Perforated Appendicitis ◽

Late Presentation ◽

Complicated Appendicitis ◽

Fecal Fistula ◽

Delayed Presentation ◽

Radiologic Findings ◽

Uncomplicated Appendicitis

Delayed presentation of acute appendicitis is associated with increased complications. We hypothesized that the outcomes of appendectomy in delayed presentations of acute appendicitis (>72 hours of pain) were dependent on radiologic findings rather than late presentation. We reviewed records from 2009 to 2015 and analyzed delayed presentations of acute appendicitis. We divided patients into three groups based on specific CT findings: uncomplicated appendicitis (UA), phlegmon or abscess (PA), and other perforated appendicitis (PERF, signs of perforation without abscess or phlegmon). One hundred thirty-eight patients were included in this study (58 in the UA, 67 in the PA, and 13 in the PERF groups). Overall, 78 (57%) patients underwent early appendectomy (EA) and 60 (43%) underwent initial conservative management. The incidence of adverse events was lower in EA than that in initial conservative management (17% vs 42%, P = 0.005). EA in the UA group was associated with shorter hospitalization (3.2 vs 5.6 days, P < 0.001) and less adverse events (6% vs 29%, P < 0.05). Severe adverse events (two colectomies and one fecal fistula) were observed in the PA group. In conclusion, in these late presentations of appendicitis, complicated appendicitis was common. EA was safe in selected patients, however, and associated with decreased adverse events.

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Influence of Covid -19 on the management of Appendicitis

10.53350/pjmhs211571718 ◽

2021 ◽

Vol 15 (7) ◽

pp. 1718-1721

Author(s):

Mahreen Zahra ◽

Muhammad Kashif ◽

Shafiq Ahmed ◽

Saif Rasool ◽

Ikramullah Khan

Keyword(s):

Acute Appendicitis ◽

Conservative Management ◽

Perforated Appendicitis ◽

Pelvic Abscess ◽

Ethical Review ◽

Generalized Peritonitis ◽

Group A ◽

Group B ◽

Operative Findings ◽

Appendicular Mass

Objective: Acute Appendicitis encounters as the frequent problem in surgical pediatric patients leading to Appendectomy, being one of the most common procedures performed in surgical Emergency. During COVID-19 pandemic, the trends in the management of acute appendicitis have changed. Conservative management of appendicitis with antibiotics is being proposed as an alternative to conventional appendectomy. So, this study is conducted to compare the presentation and outcome of Appendicitis managed during pre and post pandemic period in our settings. Methodology: After approval of Ethical Review Committee, a total of 267 patients of age 1-12 years were selected for the study. It was a retrospective Cohort Study. Patients were divided into group A (n=145) which was pre pandemic group. Data was collected retrospectively from charts regarding demographics, presentation, duration of stay operative findings and complications from May-Oct 2019 and Group B (n=122) during covid-19 was collected from the patients presented with appendicitis over a period of six months from May-Oct 2020 . Similar months of the year were selected to remove seasonal variation in the presentation of Appendicitis. All information was collected on a predesigned Performa. Data was compared and analyzed on SPSS 20. Results: Out of 267 patients, 151 (56.56%) were male. Group A patients presented during pre-pandemic period (n=145) were undergone appendectomy for appendicitis in 129 patients (88.96%) with 59 patients (40.68%) having acutely inflamed appendix and 70 patients (48.27%) had complicated appendicitis such as gangrenous, perforated with generalized peritonitis. In Group A only 16 patients (11.03%) were managed conservatively for appendicular mass. In contrast to group B (n=122) presented during pandemic, only 43 patients (35.24%) were operated with findings of acutely inflamed appendicitis while gangrenous/perforated appendicitis with pelvic abscess and/or generalized peritonitis was found in most of the patients with a number of 69 (56.55%), only 10 (8.19%) patient presented as Appendicular mass hence managed conservatively. Conclusion: Delay in presentation and early conservative management during pandemic crisis has resulted in an increase in the complications of Appendicitis. Early referral to specialized centers with vigilant selection for conservative treatment can save patients from developing complications. Keywords: Appendicitis, covid-19, Appendectomy, complications, Pandemic

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Endocrine Dysfunction in Children with Zika-Related Microcephaly Who Were Born during the 2015 Epidemic in the State of Pernambuco, Brazil

Viruses ◽

10.3390/v13010001 ◽

2020 ◽

Vol 13 (1) ◽

pp. 1

Author(s):

Andréia Veras Gonçalves ◽

Demócrito de B. Miranda-Filho ◽

Líbia Cristina Rocha Vilela ◽

Regina Coeli Ferreira Ramos ◽

Thalia V. B. de Araújo ◽

...

Keyword(s):

Optic Nerve ◽

Viral Infections ◽

Case Series ◽

Optic Nerve Hypoplasia ◽

Endocrine Dysfunction ◽

Careful Monitoring ◽

Early Puberty ◽

Growth Impairment ◽

Appropriate Treatment ◽

The Brain

Congenital viral infections and the occurrence of septo-optic dysplasia, which is a combination of optic nerve hypoplasia, abnormal formation of structures along the midline of the brain, and pituitary hypofunction, support the biological plausibility of endocrine dysfunction in Zika-related microcephaly. In this case series we ascertained the presence and describe endocrine dysfunction in 30 children with severe Zika-related microcephaly from the MERG Pediatric Cohort, referred for endocrinological evaluation between February and August 2019. Of the 30 children, 97% had severe microcephaly. The average age at the endocrinological consultation was 41 months and 53% were female. The most frequently observed endocrine dysfunctions comprised short stature, hypothyroidism, obesity and variants early puberty. These dysfunctions occurred alone 57% or in combination 43%. We found optic nerve hypoplasia (6/21) and corpus callosum hypoplasia (20/21). Seizure crises were reported in 86% of the children. The most common—and clinically important—endocrine dysfunctions were pubertal dysfunctions, thyroid disease, growth impairment, and obesity. These dysfunctions require careful monitoring and signal the need for endocrinological evaluation in children with Zika-related microcephaly, in order to make early diagnoses and implement appropriate treatment when necessary.

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