1158. Pediatric Group A Streptococcal Peritonitis: A Single-Center Eleven Patient Case Series

Background Pediatric group A streptococcal peritonitis (GASP) is a rare but serious infection, with few cases reported in the literature. Utah has an unusually high incidence of invasive GAS (iGAS) disease, but the frequency and characteristics of pediatric GASP are unknown. Methods We performed a retrospective chart review to identify GASP in Utah children from 2000-2019. GASP was defined as isolation of GAS from peritoneal fluid or blood and clinical signs of peritonitis. Results : Eleven children with GASP were identified, with slight female predominance (n=6). Median age was 6 years; males were significantly younger than females (1.4 versus 7.2 years, p=0.01). GAS was isolated from 4 of 8 blood and 8 of 11 peritoneal cultures obtained. Peritoneal fluid PCR was positive for GAS in one patient. Ten patients underwent laparotomy. Peri-appendiceal inflammation prompted appendectomy in 7 patients; only one had pathologic findings of acute appendicitis. Four patients developed streptococcal toxic shock syndrome and 7 required intensive care. Non-white race (n=4) and lack of appendectomy (n=5) were associated with more severe outcomes. Median antibiotic duration was 27 days. Median hospitalization was 8 days. All patients survived. Figure 1. Schematic representation of GAS peritonitis patient clinical course. Each patient is represented by a single line. Duration of symptoms prior to hospitalization, as well as duration of hospitalization (day 0 representing admission), intensive care, antibiotic administration, and timing of procedural interventions are noted. Duration of antibiotics after discharge for patient 3 was unable to be verified, as indicated by a question mark. Hospitalization, general pediatric hospital care. PICU, pediatric intensive care unit. IR, interventional radiology. Conclusion We present the largest pediatric case series of GASP to date. Diagnostic hallmarks included gastrointestinal symptoms, fever, systemic inflammation, and peritoneal enhancement without an abdominal source. Peri-appendiceal inflammation was common, although acute appendicitis was rare, and appendectomy was associated with a less severe course. GASP should be considered in patients with acute abdominal processes given increasing incidence of iGAS infections. Disclosures All Authors: No reported disclosures

P083 High prevalence of ulcerative appendicitis in UC patients without colonic disease activity

Background The aim of the current study was to assess histological features of appendices from patients with UC and its clinical relevance. Methods Patients with UC in remission and active UC (therapy refractory) that underwent an appendectomy in the frame of clinical trials between 2012–2019 were included. Histological features of UC appendices were compared to those of patients with acute appendicitis and colon carcinoma. The Robarts Histopathology Index score (RHI) was used to assess appendiceal inflammation. In patients with active UC, clinical and histological characteristics were compared between patients with and without endoscopic response after appendectomy. Results In total, 140 appendix specimens were assessed (n=35 UC remission, n=35 active UC, n=35 acute appendicitis, n=35 colon carcinoma). Histological features of appendices from UC patients looked like UC rather than acute appendicitis. The incidence of active appendiceal inflammation was not different between UC patients in remission versus active disease (53.7% versus 46.3%, p=0.45) and limited versus extensive disease (58.5% versus 41.5%, p=0.50). Endoscopic response, assessed in 28 therapy refractory patients, was more frequently seen in patients with higher RHI scores (RHI>9 81.8% versus RHI≤9 9.1%, p=0.004) and limited disease (proctitis/left sided 63.6% versus pancolitis 36.4%, p=0.02). Conclusion The presence of active appendiceal inflammation is common in UC and not related to disease activity in the colon. More than 50% of UC patients in remission show active histological disease in the appendix. Favorable response to appendectomy for refractory UC was seen in cases with ulcerative appendicitis. These findings might support the role of the appendix as a driving force in UC.

DOP15 Clinical relevance of endoscopic peri-appendiceal red patch in Ulcerative Colitis patients

Background Recently, increasing evidence is suggesting appendectomy as an alternative treatment approach for ulcerative colitis (UC), especially in case of pathological inflammation of the appendix. Therefore, pre-operative identification of appendiceal inflammation could be of clinical importance to predict efficacy of therapeutic appendectomy. This study assessed the incidence of peri-appendiceal red patch (PARP) on colonoscopy, with the aim to correlate PARP to patient and disease characteristics. In addition, the prognostic relevance of PARP on course of disease, and more specifically, histopathological findings of inflammation in resection specimens of the appendix were assessed, to analyze if PARP could potentially be used to identify patients eligible for appendectomy. Methods All consecutive patients with UC undergoing colonoscopy in 2014 or 2015 were included to determine the incidence of PARP in a cross-sectional study. Findings were correlated to patient and disease characteristics, upscaling of treatment during disease course and colectomy rates. Degree of inflammation of the appendix in case of subsequent appendectomy/colectomy was determined and results were compared between patients with and without PARP. Histological inflammation was scored by an independent pathologist using the Robarts histopathology index (RHI). Results In total, 249 patients with an eligible endoscopy report were included. The incidence of PARP was 17.7% (44/249). Patients with PARP were significantly younger and had a shorter disease course. PARP patients with active disease had proctitis more frequently, although not significant (29.4% vs 11.4%, p= 0.19). Out of 44 PARP patients, 27 (61.4%) were found in colonoscopies showing endoscopic Mayo score 0 or 1. Patients with PARP required significantly more upscaling of medical therapy (81.8% vs 58.0%, p= 0.03), and during the median follow up of 71 months the PARP patient group underwent colectomy more frequently (13.6% vs 4.9%, p=0.04). Eighteen appendices were available for histological analysis, of which 8 showed a PARP pre-operatively. Patients with PARP had a higher median Robarts Histology Index (RHI) score compared to patients without a PARP (13.5 vs 6.5 p< 0.01). Conclusion PARP was predominantly found in UC patients with younger age and shorter disease duration and were demonstrated to have a more severe course of UC. Patients with PARP had a higher histopathological inflammation score. Since pathological inflammation of the appendix has been associated with improved efficacy of therapeutic appendectomy, it could be attractive to analyze if the presence of PARP might help in selecting patients more likely to respond to therapeutic appendectomy.

Appendiceal Carcinoid Tumor Contained in a Large Inguinal Hernia: A Case Report

We report the first case of a clinically diagnosed incidental appendiceal carcinoid tumor contained in an incarcerated inguinal hernia without inflammation of the appendix. A 67-year-old white man underwent elective open repair of an incarcerated right inguinal hernia containing small bowel, cecum, appendix, and ascending colon. He was found to have a grossly abnormal mass at the tip of his appendix. Appendectomy was performed, and histopathologic analysis confirmed the presence and adequate resection of a neuroendocrine tumor. It is important for general surgeons to be aware that unusual presentations of appendiceal tumors may not be associated with appendiceal inflammation or related symptoms.

Appendectomy for Therapy-Refractory Ulcerative Colitis Results in Pathological Improvement of Colonic Inflammation: Short-Term Results of the PASSION Study

Background and Aims The objective of this study was to examine the modulating effect of an appendectomy on the disease course of therapy-refractory ulcerative colitis [UC] patients, and to analyse appendiceal pathological characteristics predictive of pathological response. Methods Patients with therapy-refractory UC, and referred for proctocolectomy, were invited to undergo laparoscopic appendectomy first. The primary end points were clinical response after 3 and 12 months. Secondary end points were endoscopic remission, failure, and pathologic response. Appendiceal specimens, and pre- and post-operative biopsies were histologically graded according to the validated Geboes score. Results Thirty patients [53% male] with a median age of 40 (interquartile range [IQR], 33–47) underwent appendectomy, with a median preoperative total Mayo score of 9 [IQR, 8–11]. After 12 months, 9 patients [30%] had lasting clinical response, of whom 5 [17%] were in endoscopic remission. Pathological evaluation was possible in 28 patients. After a median of 13.0 weeks [range 7–51], pathological response was seen in 13 patients [46%], with a median decrease of 2 points [range 1–3]. Appendiceal inflammation was highly predictive of pathological response when compared with no inflammation or extensive ulcerations [85% vs 20%, p = 0.001]. Conclusions Appendectomy was effective in one-third of therapy-refractory UC patients, with a substantial proportion of patients demonstrating complete endoscopic remission after 1 year. Pathological response was seen in almost 50% of patients and was related to active inflammation in the appendix, limited disease, and shorter disease duration. These early results suggest that there is a UC patient group that may benefit from appendectomy.

ACUTE APPENDICITIS;

Background: Acute appendicitis is the commonest cause of acute abdomen presenting in emergency room, which is mainly diagnosed on clinical grounds. Objective: To determine the diagnostic accuracy in patient of acute appendicitis and to review the pathological diagnosis. Material and Method: A retrospective study was conducted at PNS SHIFA hospital at Karachi; from May 2012 to April 2013. A total of 120 patients were included in the study who presented with acute abdomen and clinically diagnosed as acute appendicitis. Emergency appendectomy was done in all consecutive subjects and intra operative finding along with histo-pathological reports were compared with clinical diagnosis. Results: A total of 120 patients were included in the study who underwent appendicectomy during this period. The majority of our patients were in the age group between 15-30 years (66.5%) and presented within 24 h of onset of symptoms. The most common symptoms were abdominal pain (100%), vomiting (57.4%) and anorexia (49.0%). Pyrexia was noted in 41.0%.Localized abdominal tenderness with positive release sign was mainly present. The most common incision was gridiron (57.2%) followed by Lanz (37.3%) and in remaining Rutherford Morrison incision was made. Acute appendiceal inflammation and gangrenous appendicitis was present in 67% and 13%, respectively. The perforation rate was 5.0% and there was a direct correlation with time of presentation. There were no patients with carcinoid tumour or adenocarcinoma. Parasites and other associated conditions were seen in 3 % of cases. On the basis of histo-pathological report, 84% were found to have acute appendicitis with negative appendicectomy rate of 16.0%. Conclusions: Clinical surgical skill is good enough to diagnose acute appendicitis but auxiliary diagnostic tools can help to elevate the diagnostic accuracy,but these are not 100% accurate and at times may not be available.So clinial good judgement is essential for proper diagnosis and that can be confirmed by histopathology report.

Case-based review: conservative management of appendicitis – are we delaying the inevitable?

Acute appendicitis is a common surgical presentation for which surgical intervention, an appendicectomy, has remained a largely unchallenged primary treatment modality. Traditionally, it has been felt that the pathophysiological progressive nature of appendicitis ultimately leads to perforation. A number of recent studies, however, suggest that the process of appendiceal inflammation may follow a more remitting nature with evidence indicating spontaneous resolution. It is hypothesised that the treatment of uncomplicated appendicitis may therefore be amenable to conservative management with antibiotics. This article aims to highlight some of the issues and challenges relating to the conservative management of acute appendicitis and further demonstrates potential diagnostic and treatment difficulties involved in managing the more unfamiliar condition of recurrent appendicitis.