Factors predictive of complicated appendicitis in children

Background: Clinical features of acute appendicitis are often overlapping with other abdominal pathology in children. This increases the risk of complicated appendicitis (CA). It is still difficult to identify CA preoperatively. The study aims to identify pre operative risk factors in children for CA.Methods: A prospective study was conducted in pediatric surgery unit of department of general surgery of a university hospital of Kathmandu, Nepal. All children up to 16 years diagnosed and operated for appendicitis were included in the study. Based on intraoperative findings and histopathological examination (HPE), patients were grouped in simple appendicitis (SA) and CA. Pre-operative clinical and laboratory variables of between simple and CA were compared. P£0.05 was considered as significant.Results: A total of 73 children were included out of which 61 (83.6%) had SA and 12 (16.4%) had CA. Mean age of participants was 12.8±2.9 years. More than half (64.4%) of the participants were male. The median duration of symptoms was 2 days. In bivariate analysis, gender, serum Na, duration of symptoms and rebound tenderness were significantly associated with severity of appendicitis. In multivariate analysis, rebound tenderness (OR-15.36) and duration of symptoms (OR-9.96) were found to be associated with CA.Conclusions: Male patients, rebound tenderness, longer duration of symptoms and hyponatremia can be used to predict CA. Duration of symptoms and rebound tenderness are independent risk factors for CA.

Prediction and Management of Strangulated Bowel Obstruction: A Multiomics Model Analysis

BackgroundDistinguishing strangulated bowel obstruction (StBO) from simple bowel obstruction (SiBO) still poses a challenge for emergency surgeons. We aimed to construct a predictive model that could distinctly discriminate StBO from SiBO based on the degree of bowel ischemia.MethodsA total of 281 patients diagnosed with intestinal obstruction were enrolled. According to pathological confirmation, patients were divided into a simple bowel obstruction (SiBO, n=236) group and a strangulated bowel obstruction (StBO, n=45) group. The clinical characteristics, laboratory tests and radiomics were compared between the groups via univariate analysis. Binary logistic regression was applied to identify independent risk factors, and then predictive models based on radiomics and multiomics models were constructed. Receiver operating characteristic (ROC) curves and the area under the curve (AUC) were calculated to assess the accuracy of the predicted models. Finally, via stratification analysis, we validated the multiomics model in the prediction of transmural necrosis. ResultsOf the 281 patients with SBO, 45 (16.0%) were found to have StBO, while 236(84.0%) with SiBO. Via univariate analysis, clinical characteristics including pain duration (p=0.036), abdominal pain(p=0.018), tenderness (p=0.020), rebound tenderness (p<0.001), bowel sounds (p=0.014), and laboratory parameters like white blood cell (WBC) (p=0.029), neutrophil (NE)% (p=0.007), low levels of sodium (p=0.009), abnormal potassium (p=0.003), high levels of blood urea nitrogen (BUN) (p<0.001) and glucose (p=0.002), as well as the radiomics consisting of mesenteric fluid (p=0.018), ascites (p=0.002), bowel spiral signs (p<0.001) and edema of bowel wall (p=0.037) were closely related to bowel ischemia. The ascites (OR=4.067) and bowel spiral signs (OR=5.506) were identified as independent risk factors of StBO in the radiomics model, the AUC for which was 0.706 (95%CI, 0.617–0.795). In the multivariate analysis, seven risk factors including pain duration≤3days (OR=3.775), rebound tenderness (OR=5.201), low-to-absent bowel sounds (OR=5.006), low levels of potassium (OR=3.696) and sodium (OR=3.753), high levels of BUN (OR=4.349), high radiomics score (OR=11.264) were identified. The area under the receiver operating characteristics (ROC) curve of the model was 0.857(95%CI, 0.793-0.920). The score of the mutiomics model can be calculated as following formula (1.328*Pd+1.649*Rt+1.611*Bs+1.307*K+1.323*Na+1.470*BUN+2.422*Rad-6.009). In the stratification of risk scores, the proportion of patients with transmural necrosis was significantly greater in the high-risk group (24%) than in the medium-risk group (3%). No transmural necrosis was found in the low-risk group.ConclusionThe novel multiomics model consisting of risk factors for pain duration, rebound tenderness, bowel sounds, potassium, sodium, and BUN levels and radiomics offers a useful tool for predicting StBO. Clinical management can be performed according to the multiomics score; for patients with low risk (scores≤ -3.91), conservative treatment is recommended. For the high-risk group (risk scores> -1.472), there was a strong suggestion for detection with laparotomy. For the remaining patients (-3.091< risk scores ≤ -1.472), dynamic observation is suggested.

Lymphadenopathy as a prodrome for systemic lupus erythematous

: A 41-year-old woman presented to the hospital with one month of fever, chills, lymphadenopathy, abdominal pain, a bilateral upper extremity rash, and malaise. The patient had no significant prior medical history and was physically active, kickboxing twice a week and working 16-hour days. She reported increased difficulty getting out of bed over the span of one month. Physical exam was notable for tender, palpable posterior cervical lymph nodes that were mobile and about 1 cm in maximum diameter. There was mild abdominal tenderness to deep palpation without guarding or rebound tenderness. A computerized tomography (CT) scan of the abdomen and pelvis was notable for diffuse mesenteric fat stranding and prominent right retroperitoneal lymph nodes. The patient was readmitted two months later with worsening fatigue, abdominal pain, subjective fever, night sweats, and swelling and tenderness of her wrists and fingers despite ibuprofen. After extensive infectious, hematologic and autoimmune evaluations, a diagnosis of systemic lupus erythematous (SLE) was made and treatment with high-dose steroids and hydroxychloroquine, which resulted in gradual improvement in symptoms. This report highlights fevers and generalized lymphadenopathy as a subtle prodrome of SLE.

A Retrospective Analysis of Acute Appendicitis in Children Treated with Laparoscopic Appendectomies at a Single Center in Dubai, UAE

<b><i>Background:</i></b> Appendicitis is one of the most common emergency conditions that occur in the pediatric population. The condition is usually suspected clinically, and the diagnosis is confirmed by radiological investigations such as ultrasound, CT scan, or MRI. This study was conducted to contribute to global databases by presenting data from the Middle East with an objective of identifying the clinical characteristics of children who were diagnosed with acute appendicitis and underwent laparoscopic appendectomy at a single pediatric surgery center in Dubai. <b><i>Methods:</i></b> A 2-year hospital-based retrospective cohort study was conducted at Mediclinic Parkview Hospital, Dubai, enrolling all patients younger than 14 years who were diagnosed with acute appendicitis and who underwent laparoscopic appendectomy. Demographic data, clinical presentation, laboratory, radiological and pathology findings, postoperative complications, and readmission rates were analyzed. <b><i>Results:</i></b> Fifty-six patients were operated on and enrolled in this study. All patients (56/56) presented with abdominal pain, while an associated fever was present in 44.6% (25/56); 78.5% (44/56) of the patients had nausea but 64.3% (36/56) had vomiting. On examination, all patients had abdominal tenderness, while rebound tenderness in the right iliac fossa (RIF) was found in 92.8% (52/56) of the patients. Laboratory investigations showed elevated leukocyte count in 76.7% (43/56) of patients. Appendicitis was diagnosed on ultrasound in 57.4% (31/54) of the patients, and free fluid was visualized in 40.7% (22/54) of the patients. Appendicitis was diagnosed on CT scan in all 25 patients, and free fluid was visualized in 64% (16/25) of the patients. The number of admission days ranged from 1 to 5 days, with a median of 2 days. And 62.5% (35/56) of patients were discharged in the first 2 days from admission. Major and minor complications after surgery were documented in 4 and 14 patients, respectively. Pathology reports showed features of acute appendicitis in all the resected appendices. <b><i>Conclusions:</i></b> Acute appendicitis in children should be suspected in all children with acute abdominal pain. This study can help guide the management of pediatric appendicitis and allow proper and standardized documentation of findings and judicious use of laboratory and radiological investigations.

A Case of Tuberculous Spondylitis in Child with Undernourish

Tuberculous spondylitis accounts for around 2% of all cases of Tuberculosis (TB) and around 15% of extrapulmonary TB cases. It has been reported that a 17 years old boy with a complaint of a bump on the lumbar region and felt low back pain since two years before admission with a history of back trauma. There was a decrease of body weight. There was no paraesthesia nor paralysis. Defecation and micturition were normal. Basic immunization was incomplete. On physical examination found palpable lymph nodes 0,5x0,5x0,5 cm, multiple et regio colli. There was no BCG scar. Impression nutritional status was undernourished. There was fixed palpable mass at back size about 5x4x5 cm, hard, no fluctuations, no rebound tenderness. Lung examination was normal. Tuberculin test showed induration sized 20 mm. Gene Xpert result Micobacterium Tuberculosis (MTB) not detected. On chest X-ray examination found L1-2 corpus destruction. MRI Spine was suggestive of compressive fractures and suggestive of a bilateral psoas abscess. Decompression and lumbar stabilization surgery were performed. The histopathology examination results were consistent to spondylitis TB characteristics. The patient was discharged on 6th hospitalization and given anti-tuberculous drug.Keywords: bump, extrapulmonary, fracture, spondylitis, tuberculosis

Acute appendicitis coexisting with acute pyelonephritis causing diagnostic dilemma: a case report

Background Acute appendicitis and acute pyelonephritis are the most common diseases admitted to emergency departments. Both conditions have common symptoms such as flank pain, abdominal pain, and fever. Patients’ history, physical examination, laboratory evaluation, and imaging methods are used to differentiate these two conditions. Diverticulitis, colitis, gynecological pathologies, and ureteral stones that mimic acute appendicitis should be kept in mind as differential diagnoses. Cases of pyelonephritis mimicking acute appendicitis have been reported in the literature, but there has not been a reported case in which acute appendicitis occurs during management of acute pyelonephritis. In this article, a case report which can cause such a diagnostic dilemma has been presented. Case presentation A 42-year-old female patient presented with clinical features suggestive of acute appendicitis that developed after a diagnosis of acute pyelonephritis. She underwent laparoscopic appendectomy on account of acute appendicitis during medical treatment for acute pyelonephritis. Physical examination showed only right costovertebral tenderness without any rebound tenderness at McBurney’s point at the first admission, but during treatment rebound tenderness at McBurney’s point was also detected. The Alvarado score of the patient was 5 at the first admission and 7 when acute appendicitis was diagnosed. The patient fully recovered and was discharged after both diseases were completely treated. Conclusions As seen in this case, it should be remembered that both diseases can be seen together which causes a diagnostic dilemma. If clinical or biochemical progression is detected in a patient under treatment, imaging methods should be repeated and additional ones with higher resolutions should be used.

Medical Image of the Month: Perforated Gangrenous Cholecystitis

No abstract available. Article truncated after 150 words. Clinical Scenario: A 47-year-old lady with a past medical history of hypertension, DVT on Xarelto, and methamphetamine use presented with a 3-day history of progressive right upper quadrant pain. Physical examination demonstrated marked right upper quadrant tenderness with palpation and significant rebound tenderness. A CT of the abdomen and pelvis without intravenous contrast demonstrated findings consistent with acute calculus cholecystitis with evidence of perforation and a pericholecystic abscess. The patient was taken emergently to the operating room where she underwent an open cholecystectomy which demonstrated perforated gangrenous cholecystitis with a large abscess in the gallbladder fossa. She was admitted to the ICU post-operatively due septic shock and did well with fluid resuscitation and antibiotic administration. Discussion: Acute cholecystitis is the most common acute complication of cholelithiasis and accounts for 3-9% of hospital admissions for acute abdominal pain. Eight to 95% of cases of acute cholecystitis are the result of a …

Dysuria, Rebound Tenderness, and a Palpable Mass—A Ticking Time Bomb

ABSTRACT A 37-year-old male presented to the emergency department with the complaint of periumbilical abdominal pain, radiating to just above pubic symphysis. The patient reported that the pain was worse with urination and associated with chills and nausea. This case reports discusses the Emergency Department (ED) course and subsequent treatment of a patient found to have an infected urachal cyst, a previously asymptomatic embryological anomaly in an otherwise healthy middle-aged adult male. This is a crucial diagnosis to make in order to avoid the potential for significant morbidity and/or mortality, given the unlikely symptomatic source.

Appraisal of Various Predictors for Complicated Appendicitis in Adults; A Comparative Study Between Complicated and Non-Complicated Appendicitis

Background: Acute appendicitis is the most common non traumatic surgical abdominal emergency, and is the first operation done by most of the general surgeon during their training period. The most important aspect in the management of acute appendicitis, is early diagnosis and intervention to avoid the development of complications.Patients and methods: This prospective study included 184 patients diagnosed with acute appendicitis who were grouped into complicated and non- complicated appendicitis. Both groups were compared to detect predictors for complicated appendicitis to prevent delay management. Results: About 82.6% of our patients were below 30 years (mean: 23.8 years) and 59.2% were females. Histopathology confirmed acute appendicitis in 86.5 %, chronic appendicitis in 12.5%, and normal appendix in 1.1%. About 81.5% have ALVARADO score equal or greater than 7. Complicated appendicitis was diagnosed in 23.37% of patients. There was a significant correlation between complicated appendicitis and gender, rebound tenderness, elevated temperature, elevated WBC, shift to left of WBC and Modified Alvarado Scoring (P values 0.000,0.002,0.001,0.000,0.000, and 0.006), other parameters showed no significant correlations. Conclusion: The rate of complicated appendicitis should be reduced to decrease the associated morbidity, the presence of rebound tenderness, fever, high WBC count and sift to left, a score of 7 or more by modified ALVAADO score, and male sex are highly suggestive. The presence of these factors mandates early and prompt intervention.

Spontaneous Ureteric Rupture and Its Implications in the Emergency Department: A Case Report

Introduction: Spontaneous ureteric rupture is uncommon and has a wide range of presentations. Accurate diagnosis and timely treatment is necessary to avoid potential serious complications. Case Report: We present the case of a 55-year-old female who presented with severe right lower abdominal pain with rebound tenderness, vomiting, and a single episode of hematuria. A computed tomography with intravenous contrast of the abdomen and pelvis showed a 0.3-centimeter right upper ureteric calculus, with hydronephrosis and ureteric rupture. In view of the scan findings, a diagnosis of spontaneous ureteric rupture secondary to urolithiasis was made. The patient underwent a percutaneous nephrostomy and ureteric stenting. Conclusion: Spontaneous rupture of the ureter is an uncommon diagnosis for which clinical and laboratory signs may not always be reliably present. A high index of suspicion is required for diagnosis, which is usually confirmed on advanced imaging. It may occur in serious complications of urinoma and abscess formation. As such, accurate diagnosis and timely treatment is crucial.