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AbstractIntroduction: Appendicitis is a common cause for emergency operations in the western part of the world, mostly affecting children and young adults. Ultrasound in well-trained hands is an effective imaging tool in making this diagnosis; however, this does not come without its challenges and potential complications. Case report: This is a case of a 19-year-old male with one-day history of severe pain in the right iliac fossa; blood results showed raised inflammatory markers. Ultrasound revealed a large abnormal loop of bowel containing heterogeneously echogenic contents, and two large appendicoliths at the base and fundus, with the presence of free fluid in the right iliac fossa and oedema in the adjacent mesentery. Laparoscopic appendectomy confirmed the presence of severe appendicitis with generalised peritonitis and appendicolith. Histology revealed gangrenous appendicitis with perforation in two places. Discussion: This case demonstrates that making a diagnosis of an inflamed appendix alone on ultrasound is not enough, and conducting a detailed assessment of the inflamed appendix and its surrounding anatomy is essential so that all the associated findings can be reported to aid in the patient management, reduce hospital stay and improve overall diagnosis and prognosis.
CitationBabington E. A. (2022). Complicated appendicitis in an adult patient. Ultrasound (Leeds, England), 30(4), 333–337. https://doi.org/10.1177/1742271X221093727
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Appendicoliths, the little giants: A narrative reviewBabington, Emmanuel (2022-09-27)Objectives: This narrative review aims to collate the data in the existing literature on appendicoliths, by reviewing the available information on appendicoliths that have been previously reported in 24 publications, and providing the information in one article. Key findings: Appendicoliths are frequent culprits in causing luminal obstruction of the appendix, leading to appendicitis. They are calcified masses formed as a result of the aggregation of faecal particulates and inorganic salts within the lumen of the appendix. The presence of appendicoliths in an inflamed appendix influences the patient's treatment, as surgery is usually done to avoid appendix perforation and abscess formation, and also to prevent a future recurrence of the disease. Appendicoliths are mostly imaged using CT, Ultrasound, and plain X-rays; however, CT is the most frequently used modality, particularly in the imaging of complications caused by 'retained' appendicoliths. 'Retained' appendicoliths and their consequential abscesses have been reported in the sub-hepatic and intrahepatic regions, pelvic and tubo-ovarian regions, gluteal region, subcutaneous layer, subphrenic region, and through the diaphragm into the chest cavity. Conclusion: This review provides useful information on the imaging appearances and complications caused by the presence of appendicoliths in an inflamed appendix, and it also provides information on the clinical implications of 'dropped' appendicoliths during appendectomy. Implications for practice: Based on the findings of this review, it is recommended that the appropriate imaging modality (ultrasound and/or CT) should be considered when imaging appendicoliths and its complications. It is also suggested that retained appendicolith be considered a differential diagnosis when imaging patients with a history of appendectomy due to complicated appendicitis/perforation.
The Alvarado score in acute appendicitis: A 3-year audit to evaluate the usefulness in predicting negative appendicectomies in <=16 s at QHBFTAgilinko, Joshua; Waraich, Naseem (2017-11)To evaluate the diagnostic accuracy of the Alvarado score in reducing the rate of negative appendicectomy at Queen's Hospital, a small district general hospital in England. Methodology The retrospective, analytical study included all children who were <=16 years old with a preliminary diagnosis of acute appendicitis undergoing appendicectomy subsequently. Children with other causes of acute abdominal pain were excluded from the study. A total of 118 patients were included. Based on their calculated Alvarado scores, they were stratified into two groups: Group A (Alvarado score <6) and Group B (Alvarado score >=6). Alvarado scores were compared with the histopathology reports, the gold standard for diagnosing acute appendicitis. The data gathered was then subjected to statistical analysis to measure our objective. Results Out of the 118 patients (85 males, 33 females), 46 belonged to Group A and 72 to Group B. Final diagnosis of acute appendicitis from histopathology reports was confirmed in 94 cases (79.6%). The overall sensitivity and positive predictive value of Alvarado score for acute appendicitis were 92% and 94% respectively. The area under the ROC curve was 0.9 indicating a highly accurate test. The sensitivity was only slightly higher for males with a score of <6 than females (94.9% vs. 89.5%, p < 0.05). However, for scores >=6, sensitivity among males was significantly higher than females (79% vs. 62.6%; p < 0.05). A multivariate analysis revealed that anorexia, right iliac fossa tenderness and rebound tenderness are significantly correlated with a correct diagnosis of acute appendicitis (p = 0.025, 0.037 and 0.026 respectively). Conclusion The presence of a high Alvarado score (>=6) is highly predictive of acute appendicitis. In women of childbearing age and Alvarado scores of <6, other pathologies that mimic appendicitis must be considered. An US scan of abdomen and pelvis should be considered in a woman of child-bearing age before proceeding to a surgical intervention.
Peritoneal lavage during laparoscopic appendectomy for complex appendicitis is associated with increased post-operative morbidityPuttock, Darren; Kumbhar, Vikrant; Dagash, Haitham; Patwardhan, Nitin (2022)Aim: Appendicitis is one of the most common paediatric surgical pathologies seen by paediatric surgeons worldwide. Laparoscopic appendectomy is undertaken for all cases of appendicitis in our institute. Intraperitoneal lavage following appendectomy is the conventional way of managing complicated appendicitis; however, some surgeons debate the efficacy of this practice. The aim of this study was to compare outcomes of intraperitoneal lavage versus suction only in children with complicated appendicitis. Methods: Data were collected retrospectively between January 2018 and January 2019. All patients undergoing laparoscopic appendectomy for complex appendicitis were included and divided into two groups, patients who had suction only and those who had lavage and suction. Outcome parameters studied were the length of stay (LOS), number of temperature spikes > 37.7 (TS), operative times (OT) and readmission for intra-abdominal collections. Comparison between the two groups was performed using two sample t-test with unequal variance, significance was set at P < 0.05. Results: A total of 115 patients were included (lavage n = 52, Suction n = 63). The LOS (P = 0.0054), TS (0.0109), OT (P < 0.0001) were significantly higher in the lavage group compared to the suction-only group. Overall rates of readmission were similar between groups, however, readmission for the confirmed intra-abdominal collection was more common in the lavage group. Conclusion: Based on our study, it appears that there is no advantage in performing an intraperitoneal lavage for complex appendicitis. It resulted in a prolonged stay, more post-operative TS and longer operative duration. The likelihood of being readmitted with an intra-abdominal collection following a lavage was higher compared to suction only.