Nodular image in the appendix observed on ultrasound: endometriosis or neuroendocrine neoplasia?

Objective: To evaluate the association between clinical and imaging with surgical and pathological findings in patients with suspected neuroendocrine tumor of appendix and/or appendix endometriosis. Methods: Retrospective descriptive study conducted at the Teaching and Research Institute of Hospital Israelita Albert Einstein, in which medical records and databases of patients with suspected neuroendocrine tumor of appendix and/or endometriosis of appendix were analyzed by imaging. Results: Twenty-eight patients were included, all of which had some type of appendix alteration on the ultrasound examination. The pathological outcome of the appendix found 25 (89.3%) lesions compatible with endometriosis and three (10.7%) neuroendocrine tumors. The clinical findings of imaging and surgery were compared with the result of pathological anatomy by means of relative frequency. Conclusion: It was possible to observe a higher prevalence of appendix endometriosis when the patient presented more intense pain symptoms. The image observed on ultrasound obtained a high positive predictive value for appendicular endometriosis.

Ultrasound Assessment in Children With Suspected Appendicitis: Time to Revise Diagnostic Criteria: A Prospective Cohort Study.

Background: Although ultrasound is considered the gold standard for the evaluation of children with suspected appendicitis, there is still much debate about the most accurate ultrasound findings. The purpose of this study was to define the best ultrasound signs that could ultimately improve the diagnostic accuracy of ultrasound for diagnosing pediatric acute appendicitis, and to differentiate between simple appendicitis and complicated appendicitis. Patients and Methods: After approval by our Institutional Review Board, a prospective study was carried out from January 1, 2022, to July 31, 2023, in a pediatric emergency department. We included all patients aged under 14 years with suspected appendicitis and ultrasound-visualized appendix. Results: A total of 550 patients presented with suspected appendicitis during the study period. Of these children, 411 had an ultrasound-visualized appendix. Our patients' mean age was 9.4 years. The best positive predictive value of ultrasound was found for appendiceal diameter ≥7.5 mm. The combination of an appendiceal diameter <6 mm and the lack of peri-appendiceal free fluid on ultrasound rules out the diagnosis of appendicitis. The best diagnostic accuracy of ultrasound, which was 92%, was achieved for appendix diameters ≥6.5 mm. The sonographic sign giving the best ultrasound accuracy for diagnosing complicated appendicitis was an appendix diameter ≥9 mm. Conclusions: In conclusion, our present study demonstrated that appendiceal diameter ≥6.5 mm is the gold standard for diagnosing appendicitis in pediatric patients. The combination of an appendiceal diameter <6 mm and the lack of peri-appendiceal free fluid on ultrasound would rule out appendicitis.

Acute diverticulitis of the appendix.

Acute diverticulitis of the appendix (ADA), though uncommon, often presents similarly to acute appendicitis but carries a higher risk of complications such as perforation and malignancy. We report the case of a male patient in his 50s with acute right iliac fossa abdominal pain, diagnosed via CT scan with ADA. Urgent laparoscopic appendicectomy was performed, and the patient was discharged without further issues. This case highlights the importance of promptly identifying and managing such conditions to minimise complications and improve outcomes. Despite the overlap in symptoms between appendiceal diverticulitis and acute appendicitis, accurate diagnosis is crucial for appropriate treatment. Healthcare providers should maintain a high index of suspicion, particularly in older patients presenting with an acute appendicitis, like clinical picture to ensure timely intervention and optimal patient care.

Atypical Duplex appendix arising from the ascending colon: a case report.

BACKGROUND: Duplex or vermiform appendix refers to the presence of an appendix beside the naturally occurring one. Although, duplex appendix emerges from the caecum most of the time, yet it is encountered in other parts of the colon. Inflammation of duplex appendix may represent not only a clinical, but also a surgical dilemma, and this would be confusing further among patients who already had prior appendectomy. CASE PRESENTATION: We present a case of 29-years old Egyptian male patient with history of appendectomy one and half year before presenting to the emergency department with recurrent acute abdominal pain that was linked to duplex appendicitis abnormally emerged from the mid-ascending colon. The first episode was treated conservatively considering atypical right colon diverticulitis as a potential differential diagnosis. Seven months later the patient was treated by laparoscopic appendectomy and experienced an uneventful pot-operative course. CONCLUSION: Duplex appendicitis, though rare, should be considered in the differential diagnosis of recurrent acute abdomen even after appendectomy.

Diagnostic performance of spectral Doppler in acute appendicitis with an equivocal Alvarado score.

PURPOSE: This study aims to evaluate the added value of duplex Doppler examination to the routinely graded compression grayscale ultrasound (US) for patients with suspected acute appendicitis (AA) in correlation with surgical management outcomes. METHODS: The study lasted from January 2020 to March 2021. Throughout that period, patients who had suspected appendicitis were included with a visible appendix in the grayscale US. These patients were categorized clinically based on Alvarado's score. They underwent graded compression grayscale US of the appendix and duplex Doppler study. Subsequently, they were assigned for non-contrast multislice computed tomography (MSCT) according to Alvarado's score and underwent either emergency appendicectomy or conservative clinical management afterward. A Student's t-test was used to determine if there were significant differences in the mean values between the groups. The diagnostic performance of spectral Doppler US for the diagnosis of AA was depicted. RESULTS: Eighty-four patients with visualized color flow in the appendicular Doppler US were enrolled, with 60 (71.4%) having AA, and 24 (28.6%) not having appendicitis. Spectral Doppler criterion of PSV greater than 8.6 cm/s demonstrated a high sensitivity of 91.67% and specificity of 77.78% for patients with Alvarado score ranging from 4 to 7, and appendiceal MOD ranging from 6 to 8 mm, while a discriminatory criterion of RI greater than 0.51 had a high sensitivity of 100% and a relatively lower specificity of 66.67%. CONCLUSION: The patients with AA have significantly higher point PSV and point RI values than those without AA and are especially useful in equivocal patients whose MODs and Alvarado scores are in the diagnostically equivocal ranges of 6-8 mm and 4-7, respectively, with the point PSV and RI demonstrating negative predictive value 87.5% and 100%.

Left-sided appendicitis managed laparoscopically: a case report.

BACKGROUND: Appendicitis is one of the most common causes of acute abdominal pain and remains the most common abdominal-related emergency seen in emergency room that needs urgent surgery (Yang et al. in J Emerg Med 43:980-2, 2012. 10.1016/j.jemermed.2010.11.056, Wickramasinghe et al. in World J Surg 45:1999-2008, 2021. 10.1007/s00268-021-06077-5). The characteristic presentation is a vague epigastric or periumbilical discomfort or pain that migrates to the lower right quadrant in 50% of cases. Other related symptoms, such as nausea, anorexia, vomiting, and change in bowel habits, occur in varying percentages. The diagnosis is usually reached through comprehensive history, physical examination, laboratory tests, and radiological investigations as needed. Nowadays, computed tomography of the abdomen and pelvis is considered the modality of choice for definitive assessment of patients being evaluated for possible appendicitis. Anatomical variations or an ectopic appendix are rarely reported or highlighted in literature. CASE PRESENTATION: Left-sided appendicitis is a rare (Hu et al. in Front Surg 2022. 10.3389/fsurg.2022.896116) and atypical presentation and has rarely been reported. The majority of these cases are associated with congenital midgut malrotation, situs inversus, or an extremely long appendix (Akbulut et al. in World J Gastroenterol 16:5598-5602, 2010. 10.3748/wjg.v16.i44.5598). This case is of significance to raise awareness regarding an anatomical variation of the appendix that might delay or mislead diagnosis of appendicitis and to confirm safety of a laparoscopic approach in dealing with a left-sided appendicitis case (Yang et al. in J Emerg Med 43:980-2, 2012. 10.1016/j.jemermed.2010.11.056). We report a case of left-sided appendicitis in a 12-year-old child managed successfully via a laparoscopic approach. CONCLUSION: Appendicitis remains the most common abdominal-related emergency that needs urgent surgery (Akbulut et al. in World J Gastroenterol 16:5598-5602, 2010. 10.3748/wjg.v16.i44.5598). Left-sided appendicitis is a rare (Hu et al. in Front Surg 2022. 10.3389/fsurg.2022.896116, Hu et al. in Front Surg 9:896116, 2022. 10.3389/fsurg.2022.896116) and atypical presentation and has rarely been reported. Awareness regarding an anatomical variation of the appendix and diagnostic modalities on a computed tomography scan help avoid delay in diagnosis and management of such a rare entity (Vieira et al. in J Coloproctol 39(03):279-287, 2019. 10.1016/j.jcol.2019.04.003). A laparoscopic approach is a safe approach for management of left-sided appendicitis (Yang et al. in J Emerg Med 43:980-2, 2012. 10.1016/j.jemermed.2010.11.056, Hu et al. in Front Surg 9:896116, 2022. 10.3389/fsurg.2022.896116).

'It's just a mucocele': a case report of a massive appendiceal mucocele presenting as a left upper quadrant mass.

Tumours of the appendix are very rare tumours that can and often present with a mucocele. This is a case report highlighting the associated pathology of appendix tumours and the management of a large mucocele. Specifically, how a right hemicolectomy is very rarely needed in these cases regardless of size and local anatomical relationships and some important considerations for the practicing surgeon in the non-tertiary centre that encounters a case like this.

Predictive Factors of Acute Appendicitis in Children With Non-Visualized Appendix on Ultrasound: A Prospective Cohort Study.

Background: Most studies have demonstrated the high accuracy of ultrasound for the diagnosis of acute appendicitis (AA) in children. However, the lack of visualization of the appendix on ultrasound is usually a challenge. The aim of this study was to identify any factors that might help the physician make the right decision when dealing with a child with suspected appendicitis and an appendix not seen on ultrasound. Patients and Methods: After receiving Institutional Review Board approval, we conducted a prospective study in a pediatric emergency department from January 1, 2022, to December 31, 2022. All children under 14 years of age with suspected AA and an appendix not visualized on ultrasound were included. Results: During the study period, 333 children presented with suspected AA. Of these patients, 106 had an appendix not seen on ultrasound. Our patients' median age was 10 years (interquartile range [IQR], 8-11 years), with 54.7% (n = 58) of children being female. Twenty-five (23.6%) were ultimately diagnosed with AA based on pathologic examination. Multivariable logistic regression analysis revealed that Alvarado score ≥6 and increased peri-appendiceal fat echogenicity were predictive for AA. The combination of these two factors provided a positive predictive value of 100%. A white blood cell (WBC) count ≤10 × 109/L and/or a C-reactive protein (CRP) level ≤6 mg/L makes the diagnosis of appendicitis unlikely. Conclusions: In conclusion, our study demonstrated that an Alvarado score at or above six and increased peri-appendiceal fat echogenicity are independent predictive factors of AA in children with non-visualized appendix on ultrasound. The combination of these two factors would confirm the diagnosis of AA in these patients.

Angiodysplasia of the appendix: a diagnostic challenge and the importance of colonoscopy.

The case report discusses the challenges in diagnosing gastrointestinal bleeding of unknown origin, with angiodysplasia (AD) of the appendix being a rare cause. The report presents a case of a man in his late 60s who presented with vomiting, diarrhoea and rectal bleeding. As a result of the bleeding, the patient developed a type II myocardial infarction (MI), which had to be simultaneously managed further complicating the diagnostic process. Despite a normal CT angiogram, ongoing bleeding led to suspicion of AD, which was diagnosed using colonoscopy with limited bowel preparation. The patient underwent an open appendicectomy and was found to have AD of the tip of the appendix as the cause of the bleeding. The case highlights the limitations of CT angiography in haemodynamically unstable patients and subsequent importance of colonoscopy with bowel preparation in diagnosing rare causes of bleeding, even with limited bowel preparation, and the potential life-threatening consequences of untreated AD.

The application value of high-frequency ultrasound in the feasibility assessment of endoscopic retrograde appendicitis therapy in children with appendicitis.

Acute appendicitis is one of the common acute abdominal diseases in pediatrics. However, the implementation of radiological examination guided endoscopic retrograde appendicitis therapy (ERAT) in adults is limited in children. Our previous research explored the non-invasive guidance of high-frequency ultrasound (HFUS) for ERAT and achieved good therapeutic effects. This study mainly focuses on exploring the application value of HFUS in the feasibility assessment of ERAT in children with appendicitis. 163 children with appendicitis received ERAT guided by HFUS were analyzed retrospectively. According to the parameters evaluated by HFUS before and during ERAT, the results indicated that the distance between the appendix orifice and the ileocecal valve significantly affected the time required for the guidewire to enter the appendix cavity (P < 0.05). The diameter and the texture of the fecalith, the thickness of the intestinal wall of the appendiceal orifice all had significant effects on the successful removal of the fecalith (P < 0.05). The success rate, treatment time and final flushing effect of the guidewire to reach the blind end of the appendix were significantly affected by the tortuosity of the appendix and whether there was adhesion with surrounding tissues (P < 0.05). HFUS can accurately assess the feasibility of ERAT in children with appendicitis.

The human vermiform appendix: morphological and anatomical review.

The article covers aspects of morphological, anatomical, embryological, histological aspects and origin, types, blood supply, innervation, lymph drainage of human vermiform appendix. The purpose of the study is to understand real function and to summarize this information for positive impact on clinical decision in case of appendicitis. Although characteristic features of normal and diseased appendix have been reported for many previous centuries, it still the most common challenge facing every day in operation room. The appendectomy, commonest surgical emergency procedure, may cause little confusion in surgeons due to highly variable situations of it inside the abdominal cavity. However, the recent imaging techniques have increased ability of surgeon for crucial diagnosis of the diseased appendix.

Retro-psoas appendicitis.

The vermiform appendix (VA) is known to exhibit a wide range of anatomic variability, with clinical presentation correlating with certain known anatomic positioning. To the best of our knowledge, we describe the second known case of a retro-psoas muscle VA variant and the first known case of appendicitis in such a location. Retroperitoneal access was obtained, and the appendix was freed from the intermuscular recess between the psoas and iliacus. The peritoneal defect was primarily repaired, and the patient was discharged on postoperative day 1 in good condition.

Diagnosis and treatment of a rare case of an incarcerated bilateral Spigelian hernia with the vermiform appendix and caecum.

Spigelian hernia is a rare form of abdominal wall defect. Bilateral Spigelian hernias are even less common. Surgical repair of Spigelian hernias is recommended due to their high risk of incarceration and strangulation of abdominal contents. A variety of surgical approaches to repair these hernias have been described in the literature including the traditional open approach, laparoscopic transabdominal preperitoneal approach, laparoscopic intraperitoneal repair and laparoscopic totally extraperitoneal repair. Here, we present the case of an elderly female patient with rare bilateral Spigelian hernias, the right side containing incarcerated appendix and caecal pole. The left hernia was unrecognised on preoperative CT imaging. To our knowledge, very few cases have been reported in the literature. The patient underwent bilateral laparoscopic intraperitoneal mesh repair. All technical aspects of the treatment are discussed here, in the context of the current literature, including the surgical technique and the limitations of the CT diagnosis. We aim to summarise the background of these uncommon hernias, the limitations of preoperative investigations and the differences between the available operative approaches.

Strictly-controlled techniques are required in laparoscopic appendectomy for elemental mercury sequestration in the appendix: a case report.

Elemental mercury impaction in the appendix can cause subsequent local and systemic complications. We present a case of a teenage boy who ingested approximately 10 mL of elemental mercury, resulting in residual mercury sequestration in the appendix after conservative management. We performed laparoscopic appendectomy to remove the residual mercury. The patient made a complete clinical recovery without adverse events related to mercury poisoning over the 6-month follow-up. We highlight the advantages of laparoscopic appendectomy, abdominal computed tomography (CT), negative pressure operating rooms, and surgeon protection to improve surgical success rates. This case report adds to the literature on the management of elemental mercury impaction in the appendix and provides valuable insights for clinical decision-making.