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Appendicitis
Published in Stephen M. Cohn, Peter Rhee, 50 Landmark Papers, 2019
Today, the risk of appendicitis is about 10% in the US population, with a mean age of 31. About 20% of patients present with perforation. The appendix is retrocecal in 65% of cases, and pelvic in location in 31%, a fact which certainly contributes to its confusing and often atypical clinical presentation. While abdominal pain is universal, fever and leukocytosis are variable findings. Of note, pain medications have been proven to reduce patient discomfort without obscuring physical findings or delaying intervention (Attard et al., 1992). The Alvarado score has aided in stratifying patients at risk (Alvarado, 1986). CT is the preferred diagnostic imaging technique in adults, with an accuracy rate of about 95% (Rao et al., 1998) (similar to that found with surgeon evaluation alone). There has been a reduction in the removal of normal appendices in the CT era, but the appendiceal perforation rates have actually increased over the last 20 years. In addition, many patients who may have been observed prior to CT scanning are now undergoing removal of very “early” appendicitis. MRI is valuable during pregnancy, and studies have demonstrated that the appendix does not move cephalad (i.e., remains in the same position) during gestation, contrary to previously held beliefs. Fetal mortality is much higher with perforated appendicitis, but nontherapeutic appendectomy is not as dangerous. Therefore, early open appendectomy (laparoscopy doubles the fetal loss rate) is preferred during pregnancy when appendicitis is suspected.
Colorectal Surgery
Published in Gozie Offiah, Arnold Hill, RCSI Handbook of Clinical Surgery for Finals, 2019
Alvarado Score:Score 0-3: Low risk.Score 4-6: Observe / may need interventionScore 7-9: Male: Proceed to appendectomy. Female: Diagnostic laparoscopy.Best employed as a tool in excluding appendicitis
The vermiform appendix
Published in Professor Sir Norman Williams, Professor P. Ronan O’Connell, Professor Andrew W. McCaskie, Bailey & Love's Short Practice of Surgery, 2018
Professor Sir Norman Williams, Professor P. Ronan O’Connell, Professor Andrew W. McCaskie
can lead to the removal of a normal appendix in 15-30% of cases. The premise that it is better to remove a normal appendix than to delay diagnosis does not stand up to close scrutiny, particularly in the elderly. A number of clinical and laboratory-based scoring systems have been devised to assist diagnosis. The most widely used is the Alvarado score (Table72.2). A score of 7 or more is strongly predictive of acute appendicitis.
Low intra-operative diagnostic accuracy does not affect postoperative treatment of acute appendicitis
Published in Acta Chirurgica Belgica, 2020
Eric E. Vinck, Ricardo A. Villarreal, Carlos Luna-Jaspe, Luis F. Cabrera, Tim F. Peterson, Felipe Bernal, Carmen L. Roa
Acute appendicitis continues to be a presurgical diagnostic challenge, and criteria for determining complex versus noncomplex appendicitis still vary among surgeons. Although risk scores such as the Alvarado score and imaging studies help approximate the diagnosis, confirmation is done intra-operatively, followed by histological confirmation. Once acute appendicitis is classified as complicated or noncomplicated by the surgeon, the postoperative conduct is chosen. Because many surgeons have varying opinions as to which characteristics should be globally considered as complicated in the absence of perforation, antibiotic use and hospital stay/discharge vary [5]. A proposed laparoscopic appendicitis score system using 6 criteria in order to accurately classify the appendix has shown a positive and negative predictive value of 99% and 100%, respectively: Grado 0 – normal looking, Grade 1 – redness and edema, Grade 2 – superficial fibrin, Grade 3a – segmental necrosis, Grade 3b – base necrosis, Grade 4A – abscess, Grade 4B – localized peritonitis, Grade 5 – diffuse peritonitis. This grading system helps defining postoperative management such as antibiotics and intra-hospital duration, however errors tend to occur in Grades 0 and 1 [5,6,23,24].