Appendiceal Intraluminal Gas: A CT Marker for Gangrenous Appendicitis

Introduction. This manuscript aims to investigate the amount of intraluminal gas in acute, nonperforated appendicitis identified on computed tomography (CT) in diagnosing gangrenous appendicitis. Methods. This is a retrospective observational, case-control study with consecutive data collected at a tertiary institution over a two-year period, of patients with CT-diagnosed acute appendicitis who subsequently went on for surgery within 48 hours. Patients who were less than 16 years old, who had an interval between CT and surgery of more than 48 hours, or with CT evidence of appendiceal perforation were excluded. Images were independently assessed by 3 radiologists for intraluminal gas, and the results were then correlated with reference standards obtained from surgical and histopathology reports for the diagnosis of nongangrenous versus gangrenous appendicitis. The sensitivity, specificity, and predictive values of CT intraluminal gas in gangrenous appendicitis were calculated. Results. Our study identified 93 patients with nonperforated acute appendicitis who underwent surgery within the stated timeframe. Intraluminal gas in the appendix was identified in 26 patients (28%), of which 54% had macroscopic and/or microscopic evidence of gangrenous appendicitis. This is in contrast to the subgroup of patients who did not have intraluminal gas (72%), of which only 33% had gangrenous appendicitis. The specificity of intraluminal gas for gangrenous appendicitis is 79%, with a negative predictive value of 86% and likelihood ratio of 1.85. Conclusion. In cases of established acute appendicitis, the presence of intraluminal gas is a moderately specific sign for gangrenous complication. This is worth reporting as it can help prognosticate and triage patients accordingly, for a timelier surgical management and a better outcome.

Increased IgE Deposition in Appendicular Tissue Specimens Is Compatible with a Type I Hypersensitivity Reaction in Acute Appendicitis

Background. IgE mediates type I hypersensitivity reaction and can be found in the mucosa of organs affected by allergy. Acute appendicitis (AA) is a common disease, but its etiology remains poorly understood. Here, we investigated IgE deposition in histological sections of AA samples to test the hypothesis that an allergic reaction may substantially contribute to the pathophysiology of AA. Materials and Methods. In a retrospective study, we assessed the presence of IgE in appendicular specimens of histologically confirmed appendicitis and in the control group, comprised of negative appendicitis and incidental appendectomies, using a monoclonal antibody against human IgE. Samples from 134 appendectomies were included: 38 phlegmonous and 27 gangrenous appendicitis from the study group and 52 incidental appendectomies and 17 negative appendicitis from the control group. The slides were visualized by light microscopy, and a standard procedure was used to manually count the positive IgE staining cells. Results. IgE staining was present in the cells of all but 5 appendicular specimens. We found a significantly increased number of IgE-positive cells in phlegmonous AA ( median = 28 ) when compared to incidental appendectomy ( median = 17 ) ( p = 0.005 ; p < 0.0001 when adjusted for age and gender). No difference was found for gangrenous appendicitis. Discussion. The presence of IgE supports the contribution of an allergic reaction for the pathophysiology of phlegmonous appendicitis. The reduced number of IgE staining cells in gangrenous appendicitis can be due to tissue destruction, or, as been claimed by others, gangrenous appendicitis is a distinct entity, with different etiology. Conclusion. In this study, phlegmonous appendicitis had the highest number of IgE-positive appendicular cells. These findings suggest that an allergic reaction can contribute to the pathophysiology of AA, opening a novel possibility for preventive measures in a disease that typically requires surgery.

SP3.2.18 Reducing the negative appendicectomy rate in children as part of the ‘improving emergency surgery’ quality improvement programme: an assessment of outcomes and balancing measures for unintended consequences

Aim To describe methodology of the quality improvement programme. To assess outcomes and balancing measures. Methods This paper describes how Kotter’s 8-step improvement model was applied in a District General Hospital. The primary outcome (negative appendicectomy rate) was assessed using GIRFT data over 6 years. Reducing negative appendicectomies might conceivably result in delayed surgery (with a potentially increased incidence of perforated/gangrenous appendicitis), increased length of stay (LOS) and increased readmissions due to delay-related complications. These were assessed by a retrospective audit of appendicectomies performed over the same 8-week period in 2016 and 2019. Results The negative appendicectomy rate in children fell from 16% in 2016-2017 (England average 12%) to 4% in 2017-2018. The improvement was sustained at 6% in 2018-2019 (England average 11%). The incidence of perforated/gangrenous appendicitis decreased by 6% from 23% in 2016 to 16% in 2019. Average LOS decreased from 4 days in 2016 to 3 days in 2019. There was 1 (3%) readmission within 7 days in 2016, and 2 (6%) in 2019. Reasons for readmission were postoperative small bowel obstruction due to omental band adhesion(1) and persistent pain (2). None were caused by delayed operation. Conclusions A sustained improvement in negative appendicectomy rate can be achieved by adopting a systematic quality improvement approach. Against expectations, the reduction in negative appendicectomy rate was associated with a slight decrease in average LOS and reduced frequency of perforated/gangrenous appendicitis. There was no significant increase in readmissions, and none were due to delayed operations.

The effect of acute complicated appendicitis on liver function test

Objectives: To determine the diagnostic role of hyperbilirubinemia in acute appendicitis like suppurative and gangrenous appendicitis. Methods: This observational study was conducted at Ward-3, Jinnah Postgraduate Medical Center (JPMC), Karachi from 1st June 2019 to 1st June 2020. Males and females above 12 years of age were included. Serum liver function tests and leukocyte counts were carried out. Appendectomies were done, the operative findings and histopathology reports were noted. Hyperbilirubinemia was related with the stages of appendicitis. Results were analyzed by SPSS version 25. Results: There were one hundred twenty patients. Thirty-eight (31.66%) were females and eighty-two (68.33%) were males. Age range was 13 to 60 years. Ten patients (8.33%) were between 13 – 20 years, sixty five (54.16%) were 21 to 30 years, thirty (25%) were 31 – 40 years, ten (8.33%) were 41 – 50 years and five patients (4.17%) were above 50 years of age. Sixty-two (51.66%) patients had simple appendicitis and fifty-four (45%) had complicated appendicitis like suppurative (26.66%) and (16.66%) gangrenous appendicitis. Negative appendectomy was found in four (3.33%). Hyperbilirubinemia was found (100%) in gangrenous, (94.12%) in suppurative and (12.3%) in catarrhal appendicitis. Enzymes like Alanine transaminase and Aspartate transaminase were raised (50%) in gangrenous, (50%) in suppurative and (9.67%) in catarrhal appendicitis. TLC was raised in 112 (96.55%) out of 116 patients and total leukocyte count was normal in negative appendectomies. Conclusions: It is concluded that hyperbilirubinemia is strong diagnostic predictor for complicated appendicitis.\ doi: https://doi.org/10.12669/pjms.37.2.3356 How to cite this:MoulaBux K, Parveen S, Iqbal M, Mehboob A. The effect of acute complicated appendicitis on liver function test. Pak J Med Sci. 2021;37(2):---------. doi: https://doi.org/10.12669/pjms.37.2.3356 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Use of gene expression profiling to identify candidate genes for pretherapeutic patient classification in acute appendicitis

Background Phlegmonous and gangrenous appendicitis represent independent pathophysiological entities with different clinical courses ranging from spontaneous resolution to septic disease. However, reliable predictive methods for these clinical phenotypes have not yet been established. In an attempt to provide pathophysiological insights into the matter, a genomewide gene expression analysis was undertaken in patients with acute appendicitis. Methods Peripheral blood mononuclear cells were isolated and, after histological confirmation of PA or GA, analysed for genomewide gene expression profiling using RNA microarray technology and subsequent pathway analysis. Results Samples from 29 patients aged 7–17 years were included. Genomewide gene expression analysis was performed on 13 samples of phlegmonous and 16 of gangrenous appendicitis. From a total of 56 666 genes, 3594 were significantly differently expressed. Distinct interaction between T and B cells in the phlegmonous appendicitis group was suggested by overexpression of T cell receptor α and β subunits, CD2, CD3, MHC II, CD40L, and the B cell markers CD72 and CD79, indicating an antiviral mechanism. In the gangrenous appendicitis group, expression of genes delineating antibacterial mechanisms was found. Conclusion These results provide evidence for different and independent gene expression in phlegmonous and gangrenous appendicitis in general, but also suggest distinct immunological patterns for the respective entities. In particular, the findings are compatible with previous evidence of spontaneous resolution in phlegmonous and progressive disease in gangrenous appendicitis.

COMPARISON OF SHORT-TERM AND LONG-TERM COURSE OF ANTIBACTERIAL THERAPY FOR INTRA-ABDOMINAL INFECTION CAUSED BY ACUTE GANGRENOUS APPENDICITIS

Intra-abdominal infection and its complications is still remaining a fairly common and urgent global problem. Currently, there are a large number of publications providing guidelines and recommendations for the treatment of infections caused by a certain type of causative agents. However, the appropriate duration of antibiotic therapy is among the most controversial issues. Majority of clinicians tend to prescribe antibiotic therapy until all signs of inflammation disappear, usually for 7-14 days. But, in 1994, Schein M., and co-authors suggested that with adequate treatment of the focus of intra-abdominal infection, the duration of antibiotic therapy can be reduced to 3-4 days that in turn will reduce the resistance to antibacterial drugs. The aim of this study was to investigate the possibility in reducing antibiotic therapy length for patients with intra-abdominal infection caused by acute gangrenous appendicitis. The study included 32 patients aged 18 - 65 years, who were operated on for acute gangrenous appendicitis at the same day when admitted to the hospital at the surgical department of the 3rd Municipal Clinical Hospital of Poltava. The patients were divided into two groups. The first (study) group included 16 patients who received antibiotic therapy within minimum 3 days until the normalization of the leukocytosis and body temperature. The second (control) group included 16 patients who continued to receive antibiotic therapy for at least 2 days following the normalization of these criteria. Based on the results obtained in studying the effect of the length of antibiotic therapy course on intra-abdominal infection in the patients with acute gangrenous appendicitis during the postoperative period, we revealed the duration of antibiotic therapy for 3 ± 0.25 days showed similar results compared to the results of traditional and longer antibiotic therapy. The comparable values included periods of recovery and discharge following the surgery, the incidence of complications in the early and remote postoperative period. Our data confirm the concept that adequate surgical treatment of the infection focus in the abdominal cavity results in the reduction of antibiotic therapy length for several days after the operation without the risk of developing postoperative complications and recurrence of the infectious process.

Acute appendicitis as the first manifestation of HenochSchönlein purpura

Henoch-Schönlein purpura (HSP) is a small vessel systemic vasculitis. Typical symptoms include palpable purpura, joint pain, and abdominal pain. Most cases improve after a few weeks, not requiring any treatments other than symptom control. Acute abdomen resulting from vasculitis is very rare and should be treated as a surgical emergency. We report the case of a 9-year-old boy with acute gangrenous appendicitis as the first manifestation of HSP.