The role of Ultrasound in Diagnosis of Acute Appendicitis: A Review Article

Acute appendicitis (AA) is a frequent abdominal infection that affects 7% of people at some time in their lives. As a result, any delay in diagnosis might lead to complications such as perforation and abscesses in the incision. Ultrasound (U/S) plays an essential role in the diagnosis and management of acute appendicitis, which improves patient outcomes. Recent technological advances have brought profound changes to diagnostic ultrasound imaging. Acute appendicitis is a frequent abdominal condition that affects many people at their lives acute appendicitis is a difficult diagnosis based on clinical and laboratory data. Abnormal US findings during appendiceal scan indicate a greater chance of having recurrent appendicitis, US scan play an important role in the pre-surgical evaluation and planning of patients with appendicitis. In this review, different US techniques and their applications in diagnosis of appendicitis and early and accurate diagnosis are discussed.

TP10.2.2Adherence to the new Royal College of Surgeons (RCS) guidance pertaining to acute appendicitis management during COVID-19

Aims The mainstay of acute appendicitis treatment is a surgical approach. However, in the tumultuous COVID-19 era, the approach to acute appendicitis management has altered. We sought to assess the applicability of the new RCS COVID-19 guidance after resolution of the global pandemic. Methods A retrospective study was conducted on 244 patients presenting between 01/03/2020 and 17/07/2020. Three sources of data were sought: patients presenting to A&E with signs of appendicitis, operative logs for patients who underwent removal of their appendix and all CT/US scans where the clinician had queried appendicitis in the request. Results 139 patients were treated conservatively with antibiotics (57.0%). 35 (25.2%) represented within 6 months. Conservative treatment was successful in 92.1% of cases. 65 appendectomies were completed during that time. 45 cases presented acutely whereby the surgical management of acute appendicitis was the primary choice. The decision to operate was due to: 13 (20%) because the patient was 16 or younger. 4 cases presenting with signs of severe sepsis. 4 cases had a complicated appendicitis on their imaging results. 22 (33.8%) cases were completed without initial conservative management. 9 (3.7%) cases failed conservative treatment thus requiring surgical management. 11 (4.5%) cases represented within 6 months due to recurrent appendicitis despite successful antibiotic treatment. Therefore, the recurrence rate following conservative treatment was 7.9%. Conclusions There was mixed adherence to the new guidance. Surgical management remains the best approach towards acute appendicitis. However, excellent results can still be achieved with appropriately targeted antibiotic therapy.

MUCOSECTOMY IN COMPLICATED APPENDICITIS

Objective: To describe the technique and results of mucosectomy; A surgical technique that is easy to perform, and has a lower morbidity and complication rate as compared to standard appendectomy in cases of complicated appendicitis. Study Design: Quasi-experimental study. Place and Duration of Study: Surgical - A Unit, Ayub Teaching Hospital, in Abbottabad, from Mar 2017 to Mar 2019. Methodology: Patients included were those who presented with appendicular mass, phlegmon, recurrent appendicitis, appendicitis in uncommon locations, presence of adhesions, those cases of appendicular mass and phlegmon which was either not responding to medical treatment, or diagnosed per operatively being clinically not palpable or not seen on ultrasound. Per operative and post-operative variables were documented and analyzed. In mucosectomy, thesubserosal portion of the appendix i-emuscularis and mucosa of the appendix was dissected out from the serosa after ligation of the appendicular base, or ligation done after delivering the appendix out of the serosa. The serosa that was adherent to the surrounding gut, omentum or other viscera was left intact. Results: A total of 192 patients were included in this study, half of which underwent standard appendectomy and a mucosectomy was performed on the rest. The mean time of surgery was 30 ± 1.2min as compared to the standard appendectomy group (55min ± 3.6). More than half of the patients undergoing standard appendectomy required extension of the incision (56.2%), only 8% required so from those on whom mucosectomy was performed. Per operative hemorrhage was seen in 32.2%, however inmucosectomy group only 1%.

A CLINICOPATHOLOGICAL STUDY IN PATIENTS OF ACUTE APENDICITIS AND CORRELATION OF SYMPTOMS WITH DIFFERENT POSITIONS SEEN INTRAOPERATIVELY

INTRODUCTION: The appendix, another named vermiform appendix (from the Latin ward-appendix means “dangling” + “vermis”+ “form” i.e.-dangling worm-shaped thing) is a diverticulum of caecum and marks the beginning of the colon in the conuence of taenias. The appendix is posteromedially attached to the caecum, about 2cm below the ileocecal junction. Taking into account that often the appendix is a mobile structure, the medical 9 importance of its relative position has been questioned by some authors. In general, however some authors describe a signicant relationship between its location and sign and symptoms of acute appendicitis. OBJECTIVES:1.To study the commonest position of appendix seen intraoperatively among the patients with acute appendicitis present in Emergency and OPD of Burdwan Medical College. 2.To identify the commonest position responsible for of gangrenous appendix and appendicular perforation. 3.To identify various signs and symptoms according to their different anatomical position and correlation with intraoperative ndings MATERIALS AND METHODS: This is a Prospective Observational Study in Burdwan Medical college and hospital ,May 2019 to July 2020 on 100 patients. All willing patients in Emergency and OPD of BMCH with acute and recurrent appendicitis who underwent surgery are included in this study. RESULTS: rd th Appendicitis is commonest during 3 decade (43%) followed by 4 decade (36%).Appendicitis is slightly commoner in females with male: female ratio 1:2.4..The most common position of appendix in our study is pelvic position.

Increased Risk of Neoplasms in Adult Patients Undergoing Interval Appendectomy

Purpose: The low rate of recurrent appendicitis after initial nonsurgical management of complicated appendicitis supports the recently implemented strategy of omitting routine interval appendectomy. However, several reports have suggested an increased incidence rate of neoplasms in these patients. We aimed to identify the risk of neoplasms in the population undergoing interval appendectomy.Methods: This study retrospectively analyzed consecutive cases of appendicitis that were treated surgically between January 2014 and December 2018 at a single tertiary referral center. Patients were divided into 2 groups depending on whether they underwent immediate or interval appendectomy. Demographics and perioperative clinical and pathologic parameters were analyzed.Results: All 2,013 adults included in the study underwent surgical treatment because of an initial diagnosis of acute appendicitis. Of these, 5.5% (111 of 2,013) underwent interval appendectomy. Appendiceal neoplasm was identified on pathologic analysis in 36 cases (1.8%). The incidence of neoplasm in the interval group was 12.6% (14 of 111), which was significantly higher than that of the immediate group (1.2% [22 of 1,902], P < 0.001). Conclusion: The incidence rate of neoplasms was significantly higher in patients undergoing interval appendectomy.These findings should be considered when choosing treatment options after successful nonsurgical management of complicated appendicitis.

Ultrasonography findings of appendicular wall thickness in acute appendicitis and recurrent appendicitis with pathological correlation

Background: Appendicitis is among most common cause for acute abdominal pain requiring operative management. This study is to establish relationship between wall thickness of acute appendicitis and recurrent appendicitis with its pathological outcome.Methods: In this prospective study, 24 patients of acute appendicitis and 8 patients of recurrent appendicitis presenting as acute appendicitis were examined by High resolution Ultrasonography within 48 hrs of acute onset of symptoms following a detailed clinical examination. Alvarado scoring was done in all patients. Acute appendicitis and recurrent appendicitis were differentiated on the basis of clinical details and timeline of illness. Post operatively all specimens underwent gross and histopath examination and were divided into subgroups and tabulated as “early acute appendicitis”, “acute suppurative appendicitis” and “acute gangrenous Appendicitis”.Results: Wall thickness of acute appendicitis and recurrent appendicitis (presenting with acute onset of symptoms) were tabulated. Patients with wall thickness of <3mm had statistically significant higher prevalence of acute gangrenous appendicitis on pathological correlation. Patients with recurrent appendicitis had higher incidence of wall thickness <3mm, consequently increased incidence of acute gangrenous appendicitis. The value of z was 6.0715. The value of p is <0.00001. The result was significant at p <0.01 according to SPSS 16, which correlates well with findings.Conclusions: Wall thickness is an important indicator in the management of acute or recurrent appendicitis, wall thickness of <3mm or >3mm was decisive in patient management. Reduced wall thickness of appendix in patients with acute or recurrent appendicitis correlate with higher incidence of acute gangrenous appendicitis therefore are at higher risk of perforation and should be managed aggressively by surgical intervention to avoid complications.

Comparative study on surgical outcomes of needle port assisted two port laparoscopic appendicectomy verses conventional three-port laparoscopic appendicectomy

Background: Conventional three port laparoscopic appendicectomy is fast becoming a procedure of choice for appendicitis. Needle port assisted two port laparoscopic appendicectomy is the procedure with similar technique as conventional procedure but has its distinctive advantages. The present study aims to compare the results of needle port assisted two port and conventional three port laparoscopic appendicectomy.Methods: In comparative non-randomized study patients with acute appendicitis, recurrent appendicitis and patients posted for interval appendicectomy of age >18 years, both gender without co-morbidity were enrolled as subjects. Non-consenting patients were excluded. The study factor was needle port assisted two port and conventional three port laparoscopic appendicectomy procedure. The allocation to each procedure was done at random. The outcome factors were compared between both groups.Results: A total of 91 patients with a mean age of 29.77 years and F:M ratio of 1.67:1 were enrolled, of them 31 underwent needle port assisted two port laparoscopic appendicectomy. The mean operative time for two port was 53.38±7.97 min as compared to conventional three port was 44.65±5.86 min which was statistically significant but cosmetic outcome was better as well as statistically significant with two port procedure. The post-operative pain, intra-operative and post-operative complications were compared between these groups but were statistically not significant.Conclusions: Needle port assisted two port laparoscopic appendicectomy appears to give better cosmetic results and can be a good surgical alternative modality for uncomplicated appendicitis.

Endoscopic retrograde appendicitis techniques for the treatment of patients with acute appendicitis

Objective The purpose of this study was to demonstrate the feasibility of endoscopic retrograde appendicitis therapy (ERAT) in treating patients with acute appendicitis. Materials and methods Between January 2014 and December 2014, 22 patients with acute appendicitis underwent ERAT. Patient demographics, colonoscopy findings, endoscopic retrograde appendiceal radiography (ERAR) findings, and treatment outcomes of the ERAT and adverse events associated with ERAT were analyzed. Results In this study, 22 patients with acute appendicitis underwent ERAT. The median age of the patients was 39.5 years. Colonoscopy findings included mucosal hyperemia and swelling of the appendiceal orifice and/or its surrounding mucosa (86.4 %, 19/22) and pus at the appendiceal orifice (40.9 %, 9/22). ERAR findings included irregular contour (76.2 %, 16/21), appendiceal lumen dilation (28.6 %, 6/21), appendiceal lumen stenosis (42.9 %, 9/21), and filling defect of the appendiceal lumen (23.8 %, 5/21). Deep intubation was successfully performed in 21 of the 22 patients (95.5 %). Sixteen patients underwent endoscopic appendiceal stent placement after endoscopic appendiceal irrigation (EAI) due to lumen stenosis of the appendiceal, excessive pus, or appendiceal fecalith, and the remaining 6 patients only underwent EAI. Among the 22 patients who underwent ERAT, their abdominal pain was noticeably relieved following the procedure. The main adverse events associated with ERAT were spontaneous discharge of the stent, recurrent abdominal pain, and recurrent appendicitis. During the follow-up (median 33 months), 2 patients underwent laparoscopic appendectomy. Conclusions ERAT provide a new alternative therapeutic method for patients with acute appendicitis, particularly for certain patients who are unwilling to undergo an appendectomy.