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Radiologia Mar 2023Acute appendicitis is the most common indication for emergency abdominal surgery throughout the world and a common reason for consultation in emergency departments. In... (Review)
Review
Acute appendicitis is the most common indication for emergency abdominal surgery throughout the world and a common reason for consultation in emergency departments. In recent decades, diagnostic imaging has played a fundamental role in identifying acute appendicitis, helping to reduce the rate of blind laparotomies and hospital costs. Given the results of clinical trials supporting the use of antibiotic therapy over surgical treatment, radiologists need to know the diagnostic criteria for complicated acute appendicitis to be able to recommend the best treatment option. This review aims not only to define the diagnostic criteria for appendicitis in different imaging modalities (ultrasonography, computed tomography, and magnetic resonance imaging), but also to explain the diagnostic protocols, atypical presentations, and other conditions that can mimic appendicitis.
Topics: Humans; Appendicitis; Appendectomy; Abdomen; Ultrasonography; Tomography, X-Ray Computed; Acute Disease
PubMed: 37024234
DOI: 10.1016/j.rxeng.2022.09.010 -
American Family Physician Jul 2018Appendicitis is one of the most common causes of acute abdominal pain in adults and children, with a lifetime risk of 8.6% in males and 6.7% in females. It is the most...
Appendicitis is one of the most common causes of acute abdominal pain in adults and children, with a lifetime risk of 8.6% in males and 6.7% in females. It is the most common nonobstetric surgical emergency during pregnancy. Findings from the history, physical examination, and laboratory studies aid in the diagnosis of acute appendicitis. Right lower quadrant pain, abdominal rigidity, and periumbilical pain radiating to the right lower quadrant are the best signs for ruling in acute appendicitis in adults. Absent or decreased bowel sounds, a positive psoas sign, a positive obturator sign, and a positive Rovsing sign are most reliable for ruling in acute appendicitis in children. The Alvarado score, Pediatric Appendicitis Score, and Appendicitis Inflammatory Response score incorporate common clinical and laboratory findings to stratify patients as low, moderate, or high risk and can help in making a timely diagnosis. Recommended first-line imaging consists of point-of-care or formal ultrasonography. Appendectomy via open laparotomy or laparoscopy is the standard treatment for acute appendicitis. However, intravenous antibiotics may be considered first-line therapy in selected patients. Pain control with opioids, nonsteroidal anti-inflammatory drugs, and acetaminophen should be a priority and does not result in delayed or unnecessary intervention. Perforation can lead to sepsis and occurs in 17% to 32% of patients with acute appendicitis. Prolonged duration of symptoms before surgical intervention raises the risk. In moderate- to high-risk patients, surgical consultation should be accomplished quickly to reduce morbidity and mortality resulting from perforation.
Topics: Appendectomy; Appendicitis; Education, Medical, Continuing; Humans; Practice Guidelines as Topic
PubMed: 30215950
DOI: No ID Found -
Scandinavian Journal of Surgery : SJS :... Jun 2021Diagnostic work-up of acute appendicitis remains challenging. While some guidelines advise to use a risk stratification based on clinical parameters, others use standard... (Review)
Review
BACKGROUND
Diagnostic work-up of acute appendicitis remains challenging. While some guidelines advise to use a risk stratification based on clinical parameters, others use standard imaging in all patients. As non-operative management of uncomplicated appendicitis has been identified as feasible and safe, differentiation between uncomplicated and complicated appendicitis is of paramount importance. We reviewed the literature to describe the optimal strategy for diagnosis of acute appendicitis.
METHODS
A narrative review about the diagnosis of acute appendicitis in adult patients was conducted. Both diagnostic strategies and goals were analyzed.
RESULTS
For diagnosing acute appendicitis, both ruling in and ruling out the disease are important. Clinical and laboratory findings individually do not suffice, but when combined in a diagnostic score, a better risk prediction can be made for having acute appendicitis. However, for accurate diagnosis imaging seems obligatory in patients suspected for acute appendicitis. Scoring systems combining clinical and imaging features may differentiate between uncomplicated and complicated appendicitis and may enable ruling out complicated appendicitis. Within conservatively treated patients with uncomplicated appendicitis, predictive factors for non-responsiveness to antibiotics and recurrence of appendicitis need to be defined in order to optimize treatment outcomes.
CONCLUSION
Standard imaging increases the diagnostic power for both ruling in and ruling out acute appendicitis. Incorporating imaging features in clinical scoring models may provide better differentiation between uncomplicated and complicated appendicitis. Optimizing patient selection for antibiotic treatment of appendicitis may minimize recurrence rates, resulting in better treatment outcomes.
Topics: Acute Disease; Adult; Anti-Bacterial Agents; Appendectomy; Appendicitis; Humans; Treatment Outcome
PubMed: 33851877
DOI: 10.1177/14574969211008330 -
Deutsches Arzteblatt International Nov 2020Acute appendicitis is the most common cause of the acute abdomen, with an incidence of 1 per 1000 persons per year. It is one of the main differential diagnoses of... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Acute appendicitis is the most common cause of the acute abdomen, with an incidence of 1 per 1000 persons per year. It is one of the main differential diagnoses of unclear abdominal conditions.
METHODS
This review is based on pertinent publications that were retrieved by a selective search in the PubMed and Cochrane Library databases.
RESULTS
In addition to the medical history, physical examination and laboratory tests, abdominal ultrasonography should be performed to establish the diagnosis (and sometimes computed tomography [CT] or magnetic resonance imaging [MRI], if ultrasonography is insufficient). Before any treatment is provided, appendicitis is classified as either uncomplicated or complicated. In both types of appendicitis, the decision to treat surgically or conservatively must be based on the overall clinical picture and the patient's risk factors. Appendectomy is the treatment of choice for acute appendicitis in all age groups. In Germany, appendectomy is mainly performed laparoscopically in patients with low morbidity. Uncomplicated appendicitis can, alternatively, be treated conservatively under certain circumstances. A meta-analysis of five randomized, controlled trials has revealed that ca. 37% of adult patients treated conservatively undergo appendectomy within one year. Complicated appendicitis is a serious disease; it can also potentially be treated conservatively (with antibiotics, with or without placement of a drain) as an alternative to surgical treatment.
CONCLUSION
Conservative treatment is being performed more frequently, but the current state of the evidence does not justify a change of the standard therapy from surgery to conservative treatment.
Topics: Acute Disease; Adult; Anti-Bacterial Agents; Appendectomy; Appendicitis; Child; Germany; Humans
PubMed: 33533331
DOI: 10.3238/arztebl.2020.0764 -
Pediatric Surgery International Nov 2022Appendicitis is one of the most common surgical emergencies in children and adults. Appendectomy as the standard care has been challenged in the recent years with... (Review)
Review
Appendicitis is one of the most common surgical emergencies in children and adults. Appendectomy as the standard care has been challenged in the recent years with growing evidence about non-operative treatment as a potential primary treatment in patients presenting with signs and symptoms suggestive of acute appendicitis. This review aims to establish where the recent research stands regarding conservative treatment of acute appendicitis, especially in children. There are several studies that report the potential safety and efficacy of treating acute appendicitis non-operatively. Several studies have challenged the concept of acute appendicitis being a progressive disease that always ends in perforation, rather than a disease that can present as different forms with only a defined number of cases progressing to perforation. The lack of randomized controlled studies is a limitation and well-designed randomized controlled trials are needed to determine the role of non-operative management of acute appendicitis in children.
Topics: Adult; Child; Humans; Appendicitis; Acute Disease; Appendectomy; Conservative Treatment
PubMed: 36441297
DOI: 10.1007/s00383-022-05284-y -
JAMA Surgery Sep 2022Appendectomy remains the standard of care for uncomplicated acute appendicitis despite several randomized clinical trials pointing to the safety and efficacy of... (Meta-Analysis)
Meta-Analysis
IMPORTANCE
Appendectomy remains the standard of care for uncomplicated acute appendicitis despite several randomized clinical trials pointing to the safety and efficacy of nonoperative management of this disease. A meta-analysis of randomized clinical trials may contribute to the body of evidence and help surgeons select which patients may benefit from surgical and nonsurgical treatment.
OBJECTIVE
To assess the efficacy and safety of nonoperative management vs appendectomy for acute uncomplicated appendicitis.
DATA SOURCES
A systematic review was conducted using indexed sources (Embase and PubMed) to search for published randomized clinical trials in English comparing nonoperative management with appendectomy in adult patients presenting with uncomplicated acute appendicitis. To increase sensitivity, no limits were set for outcomes reported, sex, or year of publication. All nonrandomized or quasi-randomized trials were excluded, and validated primers were used.
STUDY SELECTION
Among 1504 studies imported for screening, 805 were duplicates, and 595 were excluded for irrelevancy. A further 96 were excluded after full-text review, mainly owing to wrong study design or inclusion of pediatric populations. Eight studies met the inclusion criteria and were selected for the meta-analysis.
DATA EXTRACTION AND SYNTHESIS
Meta-extraction was conducted with independent extraction by multiple reviewers using the Covidence platform for systematic reviews and in accordance with PRISMA guidelines. Data were pooled by a random-effects model.
MAIN OUTCOMES AND MEASURES
Treatment success and major adverse effects at 30 days' follow-up.
RESULTS
The main outcome (treatment success proportion at 30 days of follow-up) was not significantly different in the operative and nonoperative management cohorts (risk ratio [RR], 0.85; 95% CI, 0.66-1.11). Likewise, the percentage of major adverse effects was similar in both cohorts (RR, 0.72; 95% CI, 0.29-1.79). However, in the nonoperative management group, length of stay was significantly longer (RR, 1.48; 95% CI, 1.26-1.70), and a median cumulative incidence of 18% of recurrent appendicitis was observed.
CONCLUSIONS AND RELEVANCE
These results point to the general safety and efficacy of nonoperative management of uncomplicated acute appendicitis. However, this strategy may be associated with an increase in duration of hospital stay and a higher rate of recurrent appendicitis. This meta-analysis may help inform decision-making in nonoperative management of uncomplicated acute appendicitis.
Topics: Acute Disease; Adult; Anti-Bacterial Agents; Appendectomy; Appendicitis; Child; Humans; Treatment Outcome
PubMed: 35895073
DOI: 10.1001/jamasurg.2022.2937 -
American Family Physician Jan 2016
Review
Topics: Acute Disease; Anti-Bacterial Agents; Appendectomy; Appendicitis; Diagnosis, Differential; Global Health; Humans; Prevalence
PubMed: 26926413
DOI: No ID Found -
BMJ (Clinical Research Ed.) Apr 2017
Topics: Acute Disease; Appendicitis; Humans
PubMed: 28424152
DOI: 10.1136/bmj.j1703 -
Radiologia 2019To evaluate the accuracy of ultrasonography for the diagnosis of acute appendicitis in adults, to calculate the negative appendicectomy rate in operated patients and the...
OBJECTIVE
To evaluate the accuracy of ultrasonography for the diagnosis of acute appendicitis in adults, to calculate the negative appendicectomy rate in operated patients and the accuracy of pre-defined diagnostic categories and to identify statistically significant signs and symptoms of acute appendicitis in ultrasonography.
MATERIAL AND METHODS
Descriptive prospective study in which we collected the findings of the urgent ultrasonographies ordered in a one-year period for adult patients with pain in the right iliac fossa (RIF), along with their symptoms. We classified them in 5 different diagnostic categories presented in the radiological report: normal appendix, non-visible appendix and no secondary signs, non-conclusive, probable appendicitis, certain appendicitis. By mean of the Stata14 software descriptive analysis, T-test and Chi-square were performed and the data were compared with the final pathological report.
RESULTS
Population: 139 patients (45% men, 55% women), mean age: 32,68 (15-84). Prevalence of acute appendicitis: 50,35% (70/139). Negative appendicectomy rate: 0%. Negative predictive value for the categories 1,2 and 3 taken together: 90,78%. Positive predictive value for the categories 4 and 5 taken together: 100%. Ultrasound sensibility and specificity 90% and 100%, respectively. Statistically significant signs and symptoms (p<0.05): RIF pain, fever, leukocytosis, left shift, visible appendix, non-compressibility, hyperechogenic fat, appendicolith and free fluid.
CONCLUSION
Ultrasound is very accurate for the diagnosis of acute appendicitis in adults.
Topics: Acute Disease; Adolescent; Adult; Aged; Aged, 80 and over; Appendectomy; Appendicitis; Female; Hospitals; Humans; Male; Middle Aged; Prospective Studies; Ultrasonography; Young Adult
PubMed: 30290969
DOI: 10.1016/j.rx.2018.08.007 -
World Journal of Emergency Surgery :... Mar 2020The epidemiology and the outcomes of acute appendicitis in elderly patients are very different from the younger population. Elderly patients with acute appendicitis... (Review)
Review
The epidemiology and the outcomes of acute appendicitis in elderly patients are very different from the younger population. Elderly patients with acute appendicitis showed higher mortality, higher perforation rate, lower diagnostic accuracy, longer delay from symptoms onset and admission, higher postoperative complication rate and higher risk of colonic and appendiceal cancer. The aim of the present work was to investigate age-related factors that could influence a different approach, compared to the 2016 WSES Jerusalem guidelines on general population, in terms of diagnosis and management of elderly patient with acute appendicitis. During the XXIX National Congress of the Italian Society of Surgical Pathophysiology (SIFIPAC) held in Cesena (Italy) in May 2019, in collaboration with the Italian Society of Geriatric Surgery (SICG), the World Society of Emergency Surgery (WSES) and the Italian Society of Emergency Medicine (SIMEU), a panel of experts participated to a Consensus Conference where eight panelists presented a number of statements, which were developed for each of the four topics about diagnosis and management of acute appendicitis in elderly patients, formulated according to the GRADE system. The statements were then voted, eventually modified and finally approved by the participants to the Consensus Conference. The current paper is reporting the definitive guidelines statements on each of the following topics: diagnosis, non-operative management, operative management and antibiotic therapy.
Topics: Acute Disease; Age Factors; Aged; Aged, 80 and over; Appendicitis; Humans
PubMed: 32156296
DOI: 10.1186/s13017-020-00298-0