Validation of the Modified Alvarado Score in Patients Attending A&E Unit With Suspected Appendicitis – Prospective Clinical Study

BackgroundThe aim of our prospective study was to confirm the validity, diagnostic accuracy of the modified Alvarado score developed in the Department of Surgery, University of Szeged.Methods138 patients were enrolled in our study between 01 January 2019 and 01 January 2020. The patient’s modified Alvarado score was calculated in the Emergency Department before surgical consultation and decision of further therapy. The score was validated based on the final histology finding of the removed appendix. Additionally, potential correlation was examined between the frequency of drain usage, hospital stay, antibiotic use and the severity of the inflammation. ResultsComparing the scores with the histological findings, specificity of the modified Alvarado score was 84.78%, its sensitivity was 97.83% (with cutoff value of 5.5). Spearman's rank correlation (0.796) and ROC analysis (area under the curve 0.968) confirmed that the modified Alvarado score has an excellent predictive value in the diagnosis of acute appendicitis. Based on the result of the Fisher's exact test, cross tabulation and Spearman’s rank correlation correlation was found between the severity of the inflammation determined by the histology finding, the selected antibiotic and the duration of the antibiotic therapy, the average duration of hospitalization and drain insertion. ConclusionsBased on the results of our study, predictive value of the new, modified score system is excellent, using this score system is safe in the differential diagnosis of acute appendicitis as an aid for non-surgical consultants in emergency care. This new score system may decrease the number of unnecessary surgical consultations, decrease waiting time of the patients and some unnecessary examinations can be avoided. Trial RegistrationValidation of the modified Alvarado score in patients presenting in the Emergency Department with right lower abdominal complaints, ethical license number: 248/2018/SZTE, date of registration: 2018.11.04., name of ethics committee: SZTE SZAKK Regionális és Intézményi Humán Orvosbiológiai Kutatásetikai Bizottság- Clinical Research Coordination Office of the University of Szeged

A Curious “Appendicitis”, Magnetic Foreign Bodies Ingestion In a Five Year Old Girl With Ileal Perforation. Case Report and Review of Literature.

BackgroundForeign body ingestion is common in children. Ingestion of multiple magnetic foreign bodies poses a significant risk of complications as they are unlikely to pass spontaneously. Case presentationWe present our interesting case of a 5 Year old girl, complaining of right iliac fossa pain not relieved with paracetamol, associated with 2 episodes of vomiting and one episode of loose bowel motion. Abdominal examination revealed tender right iliac fossa with weak rebound and mild guarding with no rigidity. WBC was 16.9, with 12.68 neutrophils, with normal urea, creatinine, amylase, CRP and liver function tests. Patient was admitted for suspected appendicitis versus gastroenteritis. Abdominal ultrasound showed free fluid in the pelvis, appendix was not seen and there was a mass in the right iliac fossa. The patient was started on intravenous co-amoxiclav and diagnostic laparoscopy revealed a normal appendix with free fluid in pelvis. The omentum was stuck to terminal ileum with two necrotic patches and a perforation in the terminal ileum with magnetic foreign bodies protruding from the perforation site.There was no peritoneal contamination. Laparotomy was performed via right lower transverse incision with resection & anastomosis of necrotic perforated bowel segment and removal of three magnetic foreign bodies from the terminal ileum. Patient had smooth postoperative recovery. ConclusionThe Ingestion of multiple magnets, or a magnet with a metallic object should be considered an impending surgical emergency as it is unlikely to pass spontaneously and complications are more likely. There are no reports where more than one magnet was passed spontaneously. The possibility of foreign body ingestion should always be considered in a young child presenting with abdominal symptoms. Early intervention is indicated if the history, clinical findings and imaging are suggestive of multiple magnetic ingestion to prevent serious life threatening complications.

Analysis of intraoperative findings with clinico-pathological features in appendicitis-an observational study

Background: Appendectomy is the most common abdominal surgery performed today. Appendicitis consists of vast spectrum ranging from acute to chronic to recurrent forms however existence of recurrent and chronic appendicitis is still doubted by many. In spite of various scoring systems and appendectomy being the ultimate treatment, its timing remains still controversial especially in chronic and recurrent variants of appendicitis.Methods: A total of 100 consecutive cases of suspected appendicitis who were admitted investigated and treated at our centre were taken up for this observational study. Data pertaining to clinical, operative and histopathological findings were collected and tabulated. Mean and SD were used for continuous data and for categorical data, frequency and percentages were calculated. A chi-square test was used for categorical data to find statistical significance.Results: Per operatively the appendix appeared non-inflamed in 57% of patients suggestive of chronic (recurrent) form and inflamed in 43% of patients suggestive of an acute form of appendicitis. The histopathological studies revealed chronic inflammatory cells in 63% of the resected specimens, suggestive of chronic appendicitis and acute inflammatory cells in 37% of the specimens, suggestive of acute appendicitis.Conclusions: We conclude that the correlation of clinical findings, operative findings and the histopathological findings correlate with one another (p<0.001). The surgeon’s clinical and operative findings have specificity of around 87.30% and 90.47% respectively. Hence the diagnostic accuracy of the surgeon is directly dependent on the surgeons’ expertise and there is no substitution for an experienced surgeon’s judgement.

Accuracy Of the Gynecology Imaging Reporting And Data System Based Upon Ultrasound Evaluation Of Adnexal Lesions

Background: Globally as growing occurrence ratio of ovarian cancer as well as efficacy of Gynecologic-Imaging Reporting-and-Data-System GI-RADS to diagnose pathologies like ovaries cancer, we designed for evaluating the presentation of diagnosis of this system to differentiate among the adnexal benign and malignant lesions. For routine gynecologic examinations, pelvic ultrasound is generally used, consequential in analysis of adnexal lesions, main stream of which are benign or functional. Though, because of probable difficulties including benign adnexal cyst (i.e. pelvic pain and adnexal torsion) as well as ultimate significance of initial analysis as well as cure of ovarian cancer, precise ultrasound analysis of adnexal lesions is important in clinical run through Methods: We searched google scholar and pubmed form 2000 to December 2019. Selection criteria reporting on the accuracy of GI-R-A-D-S system in ultrasound. Results: In this study, we evaluated 197 women with suspected appendicitis. The proportions of GI-RADS II, III, IV and V were 34.5 (69 cases), 38.0 (76 cases), 19.5 (39 cases) and 6.5 (13 cases). For the high-risk and low-risk GI-RADS subtypes, 72.5% were classified as GI-RADS II and III, and 26 were classified as GI-RADS IV and V, respectively. Conclusive histopathologic analysis was testified for 158 cases. Histopathologic assessment designated that 12(7.6%) of were malignant masses as well as 146(92.6%) were benign. Associating by histopathologic analysis, the GIRADS system specificity, sensitivity, negative predictive value and positive predictive value, as well as negative LR were 91.6, 80.82, 28.2, 99.1, 4.77, and 0.10, correspondingly. The accurateness of the scoring system was 81.64%. Conclusion: This systemic review concluded that by Gynecologic-Imaging-Reporting-Data System, we could measure the possibility of malignant stage through such an organized along with modest recording system thus that system could be valuable in clinician to perform a suitable clinical organization Keywords: Adnexal Diseases, Ovarian Neoplasms, Ultrasonography.

Nematode as a Cause of Appendicular–Cutaneous Fistula

BackgroundCutaneous fistula may develop spontaneously as a complication of an perforating appendicitis. However, intestinal fistula caused by parasites is a rare report.Case presentationIn the operation, we found that expanded appendix was perforated from its distal part and was fistulized to the right lateral abdominal wall. The complications of postoperative was intestinal fistula. Colonoscopy was performed revealing some nematode around the appendiceal orifice. The development of fistula after bowel resection and anastomosis can be devastating. Immediate drainage and establishment of enteral nutrition can lead to spontaneous healing of fistula.ConclusionsTesting for nematode infection in a patient with suspected appendicitis is not routine, it still stands as a challenge in clinical practice. In view of this situation, killing parasites is necessary, otherwise it is difficult to cure.

Does Serum Bilirubin Add Value in the Diagnosis of Appendicitis? A Multi-Institution Analysis of 2024 Patients

BACKGROUNDEven with modern diagnostics, appendicitis can be difficult to diagnose accurately. Negative appendicectomies (NA) and delayed diagnosis of complicated appendicitis (CA, i.e. perforation or abscess) remain common. Serum bilirubin has been proposed as an additional biomarker to assist with the diagnosis of appendicitis. In this large series, we assessed the value of bilirubin in the diagnosis of appendicitis.METHODS A retrospective review of patients with suspected appendicitis at three hospitals over a three year period was performed. All consecutive patients with appendicectomy were included. In addition, a “discharged” sub-group of consecutive patients who were admitted with suspected appendicitis but discharged without an operation was also identified.Demographic data, presence of fever, tachycardia, total white cell count (WCC), neutrophil count, total serum bilirubin, operative findings and final histology were recorded. Multivariate logistic regression was performed to determine independent predictors of appendicitis and CA. Receiver-operator analysis was performed to compare bilirubin to WCC and neutrophil count.RESULTS There were 2024 patients: 1167 had uncomplicated appendicitis, 355 had CA and 303 underwent NA. 200 non-surgical "discharged" patients were included for comparison. Compared to those without appendicitis (NA and discharged groups), increased serum bilirubin was associated with an increased likelihood of appendicitis (OR 1.030 (1.013, 1.048), p<0.0001) and increased likelihood of CA (OR 1.035, 95% CI (1.021, 1.050), p<0.001). These results remained significant when the discharged group, NA group and uncomplicated appendicitis groups were analyzed separately.The sensitivity and specificity of bilirubin was inferior to neutrophil count for the diagnosis of appendicitis (AUC 0.657 versus 0.725, p<0.0001). Bilirubin, WCC and neutrophils each were all relatively insensitive and non-specific over a variety of cut-off values and combinations did not improve their accuracy.CONCLUSION Hyperbilirubinaemia was independently associated with an increased likelihood of both uncomplicated and complicated appendicitis, however had similar sensitivity and specificity when compared to WCC or neutrophils. Bilirubin, neutrophil count and WCC alone are not discriminatory enough to be used in isolation but may be incrementally useful adjuncts in pre-operative assessment of patients with suspected appendicitis.

Normal width of the linea alba, prevalence, and risk factors for diastasis recti abdominis in adults, a cross-sectional study

Aim The prevalence and definition of diastasis recti abdominis (DRA) is under debate. This retrospective cross-sectional study evaluated the interrectal distance and the prevalence of DRA in computed tomography (CT) in an asymptomatic population. Materials and methods Patients undergoing CT scans for suspected appendicitis or kidney stones from 01/2016 to 12/2018 were screened retrospectively to participate. A study population with equal distribution according to gender and age (18–90 years) was generated (n = 329 patients) and the interrectal distance was measured at six reference points. Results DRA (defined as > 2 cm at 3 cm above the umbilicus) was present in 57% of the population. The 80th percentile of the interrectal distance was 10 mm at the xiphoid (median 3 mm, 95% confidence interval (CI) 0–19 mm), 27 mm halfway from xiphoid to umbilicus (median 17 mm, 95% CI 0–39 mm), 34 mm at 3 cm above the umbilicus (median 22 mm, 95% CI 0–50 mm), 32 mm at the umbilicus (median 25 mm, 95% CI 0–45 mm), 25 mm at 2 cm below the umbilicus (median 14 mm, 95% CI 0–39 mm), and 4 mm halfway from umbilicus to pubic symphysis (median 0 mm, 95% CI 0–19 mm). In the multivariate analysis, higher age (p = 0.001), increased body mass index (p < 0.001), and parity (p < 0.037) were independent risk factors for DRA, while split xiphoid, tobacco abuse, and umbilical hernia were not. Conclusion The prevalence of DRA is much higher than commonly estimated (57%). The IRD 3 cm above the umbilicus may be considered normal up to 34 mm. To avoid over-treatment, the definition of DRA should be revised.

TP9.2.24Is preoperative ABO blood typing required in emergency appendicectomies?

Aims Intra-operative bleeding is very rarely a complication of laparoscopic appendicectomy. Despite this, it is often mandatory for any patient undergoing an emergency appendicectomy to have pre-operative ABO blood type sampling. This could be an unnecessary expense and may lead to patients being delayed for theatre. The aim of this study was to see how many patients who underwent an appendicectomy required a blood transfusion intra-operatively or within 30 days of their operation. Methods Data were collected retrospectively for patients of all ages who underwent an appendicectomy for suspected appendicitis at a single centre from March 2018 to May 2020. The primary outcome measure was intra-operative and post-operative blood transfusion up until 30 days after the operation. Results Over 26 months, 698 appendicectomies were performed. Preoperative ABO blood typing was performed in 95% (n = 663) of patients. Collectively, 1,305 blood samples were obtained at a combined total cost of £13,703 to the hospital. None of the patients required blood transfusion intra- or post-operatively. Pre-operative blood transfusion was performed in only three patients, all due to chronic anaemia. 21 (3%) patients were delayed in going to theatre whilst awaiting two valid ABO blood typing results. Conclusions Emergency appendicectomies very rarely experience complications associated with bleeding or requiring blood transfusion. Clinical guidelines should reflect this by avoiding recommendation of such tests in emergency appendicectomies, reducing delays to surgery and resulting in a more efficient allocation of financial and staff resources.

EP.FRI.615 Assessing the reliability of the Adult Appendicitis Score in managing patients with suspected acute appendicitis

Aims To evaluate the effectiveness of using a clinical prediction tool in the management of suspected acute appendicitis Methods Retrospective data was collected on patients undergoing appendicectomy at a single tertiary centre from November 2019 to June 2020. Inclusion criteria were all patients aged 18 and above undergoing diagnostic laparoscopy for suspected appendicitis. Exclusion criteria were all patients that had a pathological finding other than appendicitis at laparoscopy. The pre operative AAS score at first presentation was calculated and patients grouped into low(0-10), intermediate(11-15), and high(16 and above) risk. These groups were then compared to the histological findings. Results A total of 74 patients were included, 44 male and 30 female. The age range was from 18 to 83, with a median age of 36. Of 10 patients in the low risk group, 4 (40%) had appendicitis on histology. 36 out of 40 (90%) patients in the intermediate risk group had appendicitis and 100% of the 24 patients in the high risk group. Pearson’s coefficient showed a significant correlation between the AAS risk (low, intermediate, and high) and the histological diagnosis of appendicitis (r = 0.48, p = 0.000016). Conclusions Our study did show a positive correlation between the AAS risk stratification and histological diagnosis. Based on our findings we would recommend the adoption of this score in assessing patients with suspected acute appendicitis and minimising the negative appendicectomy rate.