The Dynamics of Inflammatory Markers in Patients with Suspected Acute Appendicitis

Background: Laboratory tests of inflammatory mediators are routinely used in the diagnosis of acute appendicitis (AA). The aim of this study was to evaluate the differences of dynamics of inflammatory markers of the blood in patients with suspected acute appendicitis between complicated AA (CAA), non-complicated AA (NAA), and when AA was excluded (No-AA). Methods: This was a retrospective analysis of prospectively collected data of patients presented to the Emergency Department (ER) of a tertiary hospital center during a three-year period. All patients suspected of acute appendicitis were prospectively registered from 1 January 2016 to 31 December 2018. The dynamics of inflammatory markers of the blood between different types of AA (No-AA, NAA or CAA) during different periods of time are presented. Results: A total of 453 patients were included in the study, with 297 patients in the No-AA group, 99 in the NAA group, and 57 in the CAA group. White blood cell (WBC) count in the No-AA decreased with time, with a statistically significant difference between the <8 h and 25–72 h group. The neutrophils (NEU) percentage decreased in the No-AA group and was statistically significantly different between the <8 h and 25–72 h and <8 h and >72 h groups. C-reactive protein (CRP) increased significantly in the No-AA group throughout all time intervals, and from the first 24 h to the 25–72 h in the NAA and CAA groups. There was a statistically significant difference between the WBC count between No-AA, NAA, and No-AA and CAA groups during the first 24 and 24–48 h. There was a statistically significant difference between NEU percentage and LYMP percentage and in the NEU/LYMP ratio between No-AA and CAA groups through all time periods. CRP was significantly higher in the first 24 h in the CAA than in the No-AA group, and in the 24–48 h in the CAA group than in the No-AA and NAA groups. The linear logistic regression model, involving inflammatory mediators and clinical characteristics, showed mediocre diagnostic accuracy for diagnosing AA with an AUC of 0.737 (0.671–0.802). Conclusions: Increasing concentrations of inflammatory markers are more characteristic in CAA patients than in No-AA during the first 48 h after onset of the disease. A combination of laboratory tests with clinical signs and symptoms has a mediocre diagnostic accuracy in suspecting AA.

PROBLEMS OF ACUTE APPENDICITIS DIAGNOSTICS AND SURGICAL TREATMENT

Acute appendicitis is a "chameleon disease" that requires in many cases a complex differential diagnosis. Inflammation of the appendix is one of the most common surgical diseases. Difficulties in the verification of acute appendicitis, the severity of complications associated with late diagnosis indicate that the problems of diagnosis and treatment of this pathology has not lost its relevance. The most difficult question for the surgeon is to diagnose acute appendicitis in time and carry out surgical treatment, prevent all possible complications and minimize the frequency of removal of the unaltered appendix. The aim of the study to determine and systematize the causes of difficulties in diagnosing acute appendicitis at the preoperative stage. A retrospective analysis of 586 medical records of inpatients who were treated in the surgical department was performed. Among the operated 511 (87.2%) patients, the diagnosis of acute appendicitis before and after surgery coincided, which was confirmed morphologically. In 75 cases, which is 12.8%, the diagnosis of acute appendicitis had atypical symptoms or was masked by the clinic of another pathology. Observations of atypical cases of acute appendicitis in combination with other pathologies were the following diseases that occurred under the clinic signs, or combined with them: perforation of the small intestine with fish bone - 4 cases; perforation of Meckel's diverticulum - 2. In one case perforation by a fish bone, in another inflammation with its perforation. - terminal ileitis - 1; torsion and necrosis of the fatty suspension of the elongated sigmoid colon - 2; perforation of the diverticulum of the elongated sigmoid colon - 1, rupture of the ovarian cyst - 9 cases, including two children 13 and 17 years; piosalpinx - 2, 1 case of combination of acute calculous cholecystitis with gangrenous appendicitis, which was detected during the audit of the abdominal cavity; inflammatory infiltrate of the omentum - 3; torsion and gangrene of the omentum - 2, a combination of acute appendicitis with omentitis - 8 cases; combination of acute appendicitis with mesoadenitis - 39 cases; rupture of the spleen - 1. Conclusions: Under the clinic of acute appendicitis or in combination with it other acute diseases of the abdominal cavity can mask, up to 12.8%, which are difficult or in some cases impossible to diagnose in the preoperative period. One of the reasons for the difficulties of diagnosis is the omission by patients of anamnesis data regarding the onset and course of the disease, as well as alcohol consumption. Difficulties in diagnosis occur in children, especially young people, which is 61.3% of cases. The combination of acute appendicitis with mesoadenitis was observed in 6.6%. Among these patients, acetonemic syndrome was observed in 87.2% of cases. This group of patients is dominated by children. Gynecological diseases are disguised under the clinic of acute appendicitis in 1.9%, which requires a joint examination by a surgeon and obstetrician-gynecologist of patients with suspected acute appendicitis in the preoperative period. Deciding on surgical treatment for suspected acute appendicitis is a clinic of acute peritonitis, which was observed in 63.3%, requires proper clinical thinking of the surgeon combined with experience, laboratory and instrumental examination.

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.

Omental Infarction in a Child—Conservative Management as an Effective and Safe Strategy in Diagnosis and Treatment

Omental infarction (OI) is a rare disease occurring in children. Important risk factors include overweight and obesity. The clinical presentation is often non-specific, and the main symptom is acute abdominal pain. In addition, infarcted omentum may present with fever, anorexia, nausea, vomiting, diarrhea and dysuria. Due to the localisation of the pain, OI should be differentiated from acute appendicitis. The diagnosis of OI is sometimes made intraoperatively, during appendectomy for suspected acute appendicitis. Hence, it is important to state a correct preoperative diagnosis, which is commonly based on abdominal ultrasound and computed tomography. The treatment of OI is still inconclusive. Both conservative and surgical treatments are used. Both methods have their advantages and disadvantages. The decision of which treatment to follow should be multifactorial and include the patient’s clinical condition at the time of admission, the progression or regression of symptoms during hospitalization and laboratory and imaging findings. We present a clinical case of a 9-year-old overweight girl with OI, whose diagnosis was based on imaging diagnostics and enabled conservative treatment with no complications. The case we have described confirms that the conservative treatment is an effective and safe therapy.

Abdominal Ultrasound and Its Diagnostic Accuracy in Diagnosing Acute Appendicitis: A Meta-Analysis

Background: Acute appendicitis (AA) is a common cause of abdominal pain encountering unnecessary surgeries in emergency departments. The present meta-analysis aims to assess the accuracy of abdominal ultrasound in suspected acute appendicitis cases in terms of sensitivity, specificity, and post-test odds for positive and negative results.Materials and Methods: An extensive and systematic search was conducted in Medline (via PubMed), Cinahl (via Ebsco), Scopus, and Web of Sciences from 2010 till the end of March 2021. Two authors analyzed studies for inclusion, collected results, and conducted analyses separately. Examination of the histopathological tissue collected during appendectomy served as a gold standard for determining the final diagnosis of appendicitis. The accuracy was determined by evaluating sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), diagnostic odds ratio.Results: Out of 3,193 references, a total of 18 studies were selected. Overall sensitivity of 77.2% (95% CI – 75.4–78.9%) and specificity of 60% (95% CI – 58–62%) were observed. The diagnostic odds ratio of 6.88(95% CI 1.99–23.82) was obtained.Conclusion: Abdominal ultrasound shows significant accuracy of diagnosis in patients with suspected acute appendicitis.

Delay in Appendicectomy due to Pre-operative Imaging Results in Increased Complication Rate

Objectives: To determine the frequency of delay in case of suspected acute appendicitis and to determine the frequency of complications in patients of acute appendicitis having delay secondary to pre-operative imaging. Study Design: Descriptive study Place and Duration of Study: Department of General Surgery Unit-2, University of Lahore Teaching Hospital, Lahore 1st January 2020 to 31st March 2021. Methodology: Three hundred and eighty five patients, between 18-40 years of age of both genders presenting with clinically appendicitis were included. All the patients were operated under general anesthesia by a consultant surgeon having minimum of 5 years of experience. Results: The mean age was 28.746±5.25 years. Majority of the patients were between 26-30 years (42.6%). Body mass index of the patients were ˃25kg/m2 in 57.7%. Delay was seen in 155 (40.03%) cases, peri-appendiceal abscess was seen in 10 (2.6%) and peritonitis was seen in 13. Complications due to delay was pri-appendiceal abscess 8 and peritonitis 13 with p value ˂0.05. Conclusion: Delay in the appendectomy due to pre operative imaging has shown significant impact on complications rate and therefore suggests that delaying appendectomy is unsafe. Keywords: Appendectomy, Peri-appendiceal abscess, Peritonitis

Abdominal Ultrasound and its diagnostic accuracy in diagnosing Acute Appendicitis: A Meta-Analysis

Background: Acute appendicitis (AA) is a common cause for abdominal pain encountering unnecessary surgeries in emergency departments. The present meta-analysis aims to assess the accuracy of abdominal ultrasound in suspected acute appendicitis cases in terms of sensitivity, specificity, and post-test odds for positive and negative results. Materials and Methods: An extensive and systematic search was conducted in Medline (via PubMed), Cinahl (via Ebsco), Scopus, and Web of Sciences from 2010 till the end of March 2021. Two authors analyzed studies for inclusion, collected results, and conducted analyses separately. The histopathological study on tissue collected during appendectomy served as the gold standard for determining the final diagnosis. The accuracy was determined by evaluating sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), diagnostic odds ratio. Results: Out of 3193 references, a total of 18 studies were selected. Overall sensitivity of 77.2% (95 % CI – 75.4 – 78.9%) and specificity of 60% (95 % CI – 58% – 62%) were observed. The diagnostic odds ratio of 6.88(95 % CI 1.99 – 23.82) was obtained. Conclusion: Abdominal ultrasound shows significant accuracy of diagnosis in patients with suspected acute appendicitis.