The diagnostic value of serum hepcidin in acute appendicitis.

BACKGROUND: Acute appendicitis (AA) is the primary cause of acute abdomen in patients presenting to the emergency department with abdominal pain. Limited studies have explored the relationship between serum hepcidin levels and AA. This study aimed to measure serum hepcidin levels in patients undergoing surgery with a preliminary diagnosis of AA and to assess whether these levels can serve as a biochemical marker for diagnosing AA. METHODS: This study included patients aged 18 or older who presented to the emergency department between April 2018 and May 2019 and underwent surgery with a diagnosis of AA. The cohort comprised 94 patients with surgical pathology results compatible with AA (Group A), 16 patients with results not compatible with AA (Group B), and 42 healthy controls. Serum hepcidin levels were measured from venous blood samples. RESULTS: Mean hepcidin levels were 1750±285 pg/mL in Group A, 1349±381 pg/mL in Group B, and 1066±225 pg/mL in the control group. Statistically significant differences in serum hepcidin levels were observed between Group A and the control group (p<0.05). CONCLUSION: Hepcidin levels were significantly higher in patients with AA compared to both the control group and patients with surgically confirmed non-AA pathology. Therefore, hepcidin may serve as a useful adjunct in diagnosing acute appendicitis.

Risk factors for acute complicated appendicitis in children aged three years and younger.

OBJECTIVE: The aim of this study is to identify risk factors associated with acute complicated appendicitis (CA) in children aged three years or younger, providing a theoretical foundation for the management and treatment of acute appendicitis (AA). METHODS: A retrospective analysis was conducted on 135 pediatric patients with AA, admitted to the Department of General Surgery at Anhui Children's Hospital between December 2020 and December 2023, who underwent successful surgical treatment. Based on the intraoperative and postoperative pathological findings, patients were categorized into two groups: complicated appendicitis (CA) (n = 97 cases) and uncomplicated appendicitis (UA) (n = 38 cases). Clinical data including gender, age, weight, disease duration, preoperative white blood cell count (WCC), neutrophil granulocyte (NEUT) count, C-reactive protein (CRP) levels, total bilirubin (TBil) levels, procalcitonin (PCT) levels, calprotectin (Cal) levels, preoperative ultrasound results indicating the presence or absence of fecaliths, maximum appendix diameter, and pediatric appendicitis sore (PAS) were collected and analyzed. Comparative analysis was performed to investigate the differences between the groups and identify risk factors of CA. RESULTS: The CA group exhibited significantly higher values in disease duration, CRP levels, PCT, Cal, presence of appendiceal fecaliths, maximum appendix diameter, and PAS compared to the UA group (P < 0.05). Multivariate analysis identified CRP levels, maximum appendix diameter, and PAS as independent risk factors for CA. Specifically, differences in CRP level (OR = 1.045, 95% CI:1.024 ~ 1.067, P < 0.001), PAS (OR = 1.768, 95% CI:1.086 ~ 2.879, P = 0.022), and maximum appendix diameter (OR = 1.860, 95% CI:1.085 ~ 3.191, P = 0.024) were significant. The area under the receiver operating characteristic curve values were 0.6776 for the PAS, 0.7663 for CRP, and 0.5604 for the maximum appendix diameter. CONCLUSION: CRP levels, PAS, and maximum appendix diameter are independent risk factors for CA in children under three years of age. These parameters are valuable for the early diagnosis of CA.

Utility of thiol/disulphide homeostasis as a biomarker for acute appendicitis: a systematic review and meta-analysis.

The aim of this study was to analyze the role of thiol/disulfide homeostasis (TDH) parameters as an indicator of oxidative stress in acute appendicitis (AA). PubMed, EMBASE, Web of Science, and Scopus databases were systematically searched. Studies reporting on TDH in AA (both complicated and uncomplicated cases) were included. The comparator group were healthy controls. The TDH domain was compared between the groups using anti-oxidant parameters, namely native thiol and total thiol levels, and native thiol/total thiol ratio; and oxidant parameters, namely disulfide level, disulfide/native thiol ratio, and disulfide/total thiol ratio. The statistical analysis was performed using a random-effects model. The methodological quality of the studies was assessed utilizing the Newcastle-Ottawa scale. Eleven studies with a total of 926 subjects, comprising 457 patients with uncomplicated appendicitis, 147 with complicated appendicitis, and 322 healthy controls were included. Our study demonstrated significantly increased oxidative stress in AA as compared to healthy controls in all TDH parameters and significantly lower total thiol levels in complicated AA as compared to uncomplicated AA. Due to a poor methodological quality in five out of eleven studies, future prospective studies with adequate power are essential to validate these observations and refine the diagnostic approaches to AA.

Changes in Levels of Serum Cytokines and Chemokines in Perforated Appendicitis in Children.

Appendicitis is primarily diagnosed based on intraoperative or histopathological findings, and few studies have explored pre-operative markers of a perforated appendix. This study aimed to identify systemic biomarkers to predict pediatric appendicitis at various time points. The study group comprised pediatric patients with clinically suspected appendicitis between 2016 and 2019. Pre-surgical serum interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α), intercellular cell-adhesion molecule-1 (ICAM-1), and endothelial selectin (E-selectin) levels were tested from day 1 to day 3 of the disease course. The biomarker values were analyzed and compared between children with normal appendices and appendicitis and those with perforated appendicitis (PA) and non-perforated appendicitis. Among 226 pediatric patients, 106 had non-perforated appendicitis, 102 had PA, and 18 had normal appendices. The levels of all serum proinflammatory biomarkers were elevated in children with acute appendicitis compared with those in children with normal appendices. In addition, the serum IL-6 and TNF-α levels in children with PA were significantly higher, with an elevation in TNF-α levels from days 1 and 2. In addition, serum IL-6 levels increased significantly from days 2 and 3 (both p < 0.05). Serum ICAM-1 and E-selectin levels were elevated in the PA group, with consistently elevated levels within the first three days of admission (all p < 0.05). These results indicate that increased serum levels of proinflammatory biomarkers including IL-6, TNF-α, ICAM-1, and E-selectin could be used as parameters in the prediction and early diagnosis of acute appendicitis, especially in children with PA.

The use of C-reactive protein to predict uncomplicated appendicitis and increase uptake of laparoscopy in low resource hospitals-A retrospective cohort study.

BACKGROUND: Acute appendicitis remains the most common surgical emergency worldwide. There has been a low uptake of laparoscopic appendicectomy in the South African public sector. Preoperative identification of cases of uncomplicated appendicitis that are amenable to a laparoscopic approach may facilitate the implementation of laparoscopic appendicectomy programs in training hospitals. With limited access to preoperative imaging, alternative strategies for this preoperative prediction are needed. METHODS: A retrospective audit of patients over the age of 12 years with a histologically confirmed diagnosis of acute appendicitis over a 5-year period was performed. Patients were categorized as uncomplicated or complicated appendicitis and C-reactive protein (CRP) and white cell count (WCC) reviewed. Receiver operating characteristics curves were constructed for these blood tests and acute appendicitis severity. Youden's J statistic was used to determine optimal cut off values for diagnosing complicated appendicitis. RESULTS: 358 patients had confirmed appendicitis and complete blood results. Of these, 189 (52.79%) had complicated appendicitis with a 40.22% perforation rate. Median CRP in uncomplicated and complicated groups were 68 mg/L (IQR 19-142) and 216 mg/L (IQR 103-313) with an area under the curve (AUC) of 0.75 (95% CI: 0.70-0.80). The median WCC in the two groups were 12.6 × 109 cells/L (IQR 9.9-15.6) and 14.4 × 109 cells/L (IQR 11.5-18.28) with an AUC of 0.61 (95% CI: 0.56-0.67). The optimal cut off value for CRP was found to be 110 mg/L with a sensitivity of 74.74% and specificity of 69.23%. CONCLUSION: A cutoff value of 110 mg/dl CRP can distinguish patients with early appendicitis from those with complicated disease and when used in conjunction with clinical assessment may help identify patients in whom laparoscopic appendicectomy is appropriate.

Diagnostic performance of serum CA-125 for overall and complicated acute appendicitis: a systematic review and meta-analysis.

This study aimed to analyze the diagnostic performance of serum CA-125 in acute appendicitis (AA). This review was registered in PROSPERO (CRD42023450988). We included prospective and retrospective original clinical studies evaluating the diagnostic performance of serum CA-125 in AA. A search was conducted in PubMed, Web of Science, Scopus, and OVID. Search terms and keywords were: (appendicitis OR appendectomy) AND (CA-125 OR CA125). Two independent reviewers selected the articles and extracted relevant data. Methodological quality was assessed using the QUADAS-2 index. A synthesis of the results, standardization of the metrics, and three random-effect meta-analyses were performed. Five studies with data from 533 participants (including 219 patients with a confirmed diagnosis of AA and 107 controls) were included in this review. The random-effect meta-analysis of serum CA-125 (AA vs controls) included 3 articles (125 AA and 70 controls) and resulted in a non-significant mean difference [95% CI] of - 6.80 [- 20.51, 6.92] U/mL (p = 0.33). The meta-analysis by subgroups that included only male patients resulted in a significant mean difference [95% CI] of 3.48 [0.46, 6.49] U/mL (p = 0.02). Although serum CA-125 does not appear to be a good overall marker for the diagnosis of AA, our subgroup analyses show that this marker could be useful for diagnosing AA in males. It also appears to be a potentially useful tool for discriminating complicated and uncomplicated AA. However, the limited number of included studies precludes drawing generalizable conclusions. Future prospective studies focused on males and in its potential ability to discriminate between complicated and uncomplicated AA are required.Registration. PROSPERO (CRD42023450988).

Usefulness of extended inflammatory parameters related to neutrophil activation reported by Sysmex XN-1000 hematology analyzer for predicting complicated acute appendicitis. Comparison with canonical inflammatory laboratory tests.

AIM: Accurate diagnosis of complicated appendicitis is of importance to ensure that patients receive early and effective treatment, minimizing the risk of postoperative complications to promote successful recovery. Biochemical markers are a promising tool to identify complicated appendicitis. We aimed to evaluate the potential role of novel parameters related with neutrophil activation, known as "Extended Inflammation Parameters" (EIP), included in blood cell count reported by Sysmex XN-Series analyzers, compared to other canonical biomarkers in identifying complicated appendicitis. METHOD: Prospective observational study including patients with confirmed diagnosis of acute appendicitis. C-reactive protein (CRP), procalcitonin, cell blood count, including white blood cell (WBC), absolute neutrophil (ANC) and immature granulocyte (IG) count and EIP (neutrophil reactivity [NEUT-RI] and granularity intensity [NEUT-GI]) were analyzed before surgery. Their accuracy to diagnose complicated appendicitis was tested in an ROC curve analysis. RESULTS: Our population study included 119 patients, and appendicitis was complicated in 58 (48.7%). NLR, CRP and procalcitonin levels, ANC and IG count and NEUT-RI and NEUT-GI were higher in patients with complicated appendicitis. Regarding accuracy for complicated appendicitis, CRP was the biomarker with the highest performance (ROC AUC: 0.829), with an optimal cutoff of 73.1 mg/L (sensitivity: 63.8%, specificity: 88.5%). NEUT-RI and NEUT-GI achieved both significant but poor accuracy, with ROC AUC of 0.606 and 0.637, respectively. CONCLUSIONS: Novel laboratory tests reported by Sysmex XN-Series analyzers have poor accuracy for identifying complicated appendicitis. In this study, CRP was the biomarker with the highest performance and may be useful as predictor of the severity of acute appendicitis.

Diagnostic value of c-reactive protein and the influence of visceral fat in patients with obesity and acute appendicitis / Valor diagnóstico da proteína c-reativa e a influência da gordura visceral em pacientes com obesidade e apendicite aguda

ABSTRACT Background: The C reactive protein (CRP) is one of the most accurate inflammatory markers in acute appendicitis (AA). Obesity leads to a pro-inflammatory state with increased CRP, which may interfere with the interpretation of this laboratory test in AA. Aim: To assess sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of CRP in patients with AA and their correlation to body mass index (BMI) and body fat composition. Method: This is a retrospective study based on clinical records and imaging studies of 191 subjects with histopathologically confirmed AA compared to 249 controls who underwent abdominal computed tomography (CT). Clinical and epidemiological data, BMI, and CRP values were extracted from medical records. CT scans were assessed for AA findings and body composition measurements. Results: CRP values increased according to patients' BMI, with varying sensitivity from 79.78% in subjects with normal or lean BMI, 87.87% in overweight, and 93.5% in individuals with obesity. A similar pattern was observed for NPV: an increase with increasing BMI, 69.3% in individuals with normal or lean BMI, 84.3% in overweight, and 91.3% in individuals with obesity. There was a positive correlation between CRP and visceral fat area in patients with AA. Conclusions: Variations exist for sensitivity, specificity, PPV, and NPV values of CRP in patients with AA, stratified by BMI. An increase in visceral fat area is associated with elevated CRP across the BMI spectrum.

RESUMO Racional: A proteína C reativa (PCR) é um dos marcadores inflamatórios com maior acurácia na apendicite aguda (AA). A obesidade leva a um estado pró-inflamatório com PCR aumentada, o que pode interferir na interpretação deste teste de laboratório na AA. Objetivo: Avaliar a sensibilidade, especificidade, valor preditivo positivo (VPP) e valor preditivo negativo (VPN) da PCR em pacientes com AA e sua correlação com o índice de massa corporal (IMC) e a composição da gordura corporal. Métodos: Este é um estudo retrospectivo baseado em registros clínicos e estudos de imagem de 191 indivíduos histopatologicamente confirmados com AA em comparação com 249 controles que foram submetidos à tomografia computadorizada abdominal (TC). Dados clínicos e epidemiológicos, valores de IMC e PCR foram extraídos de registros médicos. As TC foram avaliadas para achados de AA e medidas de composição corporal. Resultados: Os valores da PCR aumentaram de acordo com o IMC dos pacientes, com sensibilidade variável de 79,78% em indivíduos com IMC normal ou magro, 87,87% em excesso de peso e 93,5% em indivíduos com obesidade. Um padrão semelhante foi observado para o VPN: um aumento com o aumento do IMC, 69,3% em indivíduos com IMC normal ou magro, 84,3% em excesso de peso e 91,3% em indivíduos com obesidade. Houve uma correlação positiva entre a PCR e a área de gordura visceral em pacientes com AA. Conclusão: Existem variações quanto à sensibilidade, especificidade, VPP e valores VPN da PCR em pacientes com AA, estratificados pelo IMC. Um aumento na área de gordura visceral está associado à PCR elevada em todo o espectro do IMC.

Apendicitis aguda. Criterios de atención médica / Acute appendicitis. Health care criteria

INTRODUCCIÓN. La apendicitis aguda es la causa más frecuente de dolor abdominal agudo o dolor abdominal quirúrgico. El examen clínico usando la escala de Alvarado para su diagnóstico permite realizar una práctica evaluación de su condición. OBJETIVO. Unificar criterios en la atención médica ambulatoria, en emergencias y servicios de cirugía para lograr una adecuada y eficaz atención. MATERIAL Y MÉTODOS. Se realizó un estudio observacional y el análisis de varios estudios, siendo las variables más consideradas la edad, presentación clínica, anatomopatología, antibioticoterapia y complicaciones del posoperatorio. RESULTADOS. Predomina el grupo de edad comprendido entre los 10 a 30 años, sexo masculino, el análisis anatomopatológico indica mayor número de la forma supurativa, la profilaxis antibiótica preoperatoria y la antibioticoterapia posoperatoria disminuyen las complicaciones posoperatorias. CONCLUSIONES. Una adecuada utilización de medios diagnósticos y terapéuticos redunda en beneficios para el paciente y la institución.

INTRODUCTION. Acute appendicitis is the most common cause of acute abdominal pain or surgical abdominal pain. The clinical examination using the Alvarado scale for its diagnosis allows a practical evaluation of its emergencies and surgical services to achieve adequate and effective care. MATERIAL AND METHODS. An observational study and analysis of several studies were carried out, being the variables most considered the age, clinical presentation, anatomopathology, antibiotic therapy and postoperative complications. RESULTS. Prevalence of the age group between 10 and 30 years old, male, anatomopathological analysis indicates the highest number of suppurative form, preoperative antibiotic prophylaxis and postoperative antibiotic therapy reduce postoperative complications. CONCLUSIONS. An adequate use of diagnostic and therapeutic means benefits the patient and the institution.

Apendicetomía no terapéutica: revisión de 1 año en el Centro Hospitalario Pereira Rossell, Montevideo, Uruguay / Non-therapeutic appendectomy: 1-year review at the Pereira Rossell Hospital Center, Montevideo, Uruguay / Apendicectomia não terapêutica: revisão de 1 ano no Centro Hospitalar Pereira Rossell, Montevidéu, Uruguai

Objetivos: La apendicitis aguda es una de las patologías quirúrgicas más frecuentes en pediatría y la apendicectomía un procedimiento históricamente probado para su tratamiento. Sin embargo, se ha llamado la atención sobre la morbilidad y costos que implican los casos de apendicectomías no terapéuticas (ANT). Realizamos un estudio para determinar la proporción de ANT en nuestro hospital, analizar sus características y plantear hipótesis de trabajo que nos permitan disminuir su incidencia. Métodos: Se realizó un análisis retrospectivo incluyendo todos los pacientes que fueron intervenidos quirúrgicamente desde el 1/1/13 hasta el 31/12/13 con diagnóstico clínico presuntivo de apendicitis aguda, en el Hospital Pediátrico del Centro Hospitalario Pereira Rossell. Se analizaron la edad, el sexo, la vía de abordaje, los hallazgos intra-operatorios, el diagnóstico anátomo-patológico y el uso y los resultados del hemograma y la ecografía. Resultados: En el período mencionado se realizaron 287 apendicectomías en pacientes con diagnóstico de apendicitis aguda, de los cuales 146 (50,87%) fueron operados por medio de un abordaje convencional y 141 (49,13%) por abordaje laparoscópico. El índice de ANT fue de 10,1% siendo similares las tasas para ambas vías de abordaje (10,27% convencional vs 9,92% laparoscópica). Por otra parte, se evidenció una mayor incidencia de ANT en el sexo femenino (16,6% vs 5,8%). Respecto a la franja etaria, la tasa de ANT fue mayor entre los pacientes de 11-15 años(12,19%), mientras que para las edades comprendidas entre 6-10 años fue de 8,08% y para los pacientes de 0-5 años fue de 4,16%. De los 29 pacientes que presentaron apéndice sano, 12 presentaban adenitis mesentérica, una paciente presentaba una rotura folicular y una paciente presentaba una peritonitis de causa médica. En 15 pacientes no se encontraron otras alteraciones. Conclusiones: El índice de apendicectomías no terapéuticas en nuestro hospital fue del 10,10% en el año 2013. La experiencia internacional y algunos trabajos nacionales demuestran que este resultado es mejorable. Se plantea la utilización de algoritmos clínicos para mejorar la presunción diagnóstica y hacer el mejor uso de los recursos diagnósticos disponibles, así como la instauración de un sistema de registro y análisis prospectivo de los resultados clínicos en apendicitis aguda.

Objectives: Acute appendicitis is one of the most frequent pediatric surgical diseases and appendectomy is a historically proved treatment. However, attention has been directed at morbidity and costs of negative appendectomy (NA). Here we analyze the incidence of NA at our hospital and its characteristics in order to propose a working hypothesis that allows a decrease in its incidence. Methods: A retrospective analysis including all patients who underwent surgery from 01/01/13 to 31/12/13, with presumptive clinical diagnosis of acute appendicitis, in the Pediatric Hospital of the Pereira Rossell Hospital Center, was done. Age, sex, surgical approach, operative findings, pathologic diagnosis and the use and results of laboratory and ultrasound, were analyzed. Results: In the referred period, appendectomies were performed in 287 patients with diagnosis of acute appendicitis, of which 146 (50.87%) were operated by a conventional approach and 141 (49.13%) by laparoscopic approach. The NA were 10.10%, with similar rates for both approaches (10.27% vs 9.92%, conventionalvs laparoscopic).A higher incidence of of NA was evident in girls, (16,6% vs 5,8% conventionalvs. laparoscopic ).With respect to the age group, the rate of NA was higher among 11-15 years old patients (12,19%), while for those aged between 6-10 years it was 8.08 % and for patients aged 0-5 years it was 4.16%. Of the 29 patients who had a healthy appendix, 12 had mesenteric adenitis, one patient had a follicular rupture and other had a medical peritonitis. In 15 patients no other abnormalities were found. Conclusions: The NA rate at our Hospital was 10.10% during 2013. The international experience and some national works prove that this result is improvable. We propose the utilization of clinical scores in order to improve clinical diagnostic and rational use of ancillary resources and the installation of a prospective registry and analysis system of results in acute appendicitis.

Objetivos: A apendicite aguda é uma das patologias cirúrgicas mais frequentes em pediatria e apendicectomia, um procedimento historicamente comprovado para seu tratamento. Entretanto, a atenção e a morbidade e os custos envolvidos em casos de apendicectomias não terapêuticas (ANT) chamaram a atenção. Realizamos um estudo para determinar a proporção de ANT em nosso hospital, analisamos suas características e propomos hipóteses de trabalho que nos permitem reduzir sua incidência. Métodos: Realizamos uma análise retrospectiva, incluindo todos os pacientes submetidos à cirurgia de 1/1/13 a 12/31/13 com diagnóstico clínico presumível de apendicite aguda no Hospital Pediátrico do Centro Hospitalar Pereira Rossell. Analisamos a idade, sexo, abordagem, achados intra-operatórios, diagnóstico anatomopatológico e o uso e resultados de hemograma e ultra-som. Resultados: no período mencionado, foram realizadas 287 apendicectomias em pacientes com apendicite aguda, dos quais 146 (50,87%) foram operados por abordagem convencional e 141 (49,13%) por abordagem laparoscópica. O índice ANT foi de 10,1% com taxas semelhantes para ambas as abordagens (10,27% versus 9,92% laparoscópicas). Por outro lado, houve maior incidência de ANT no sexo feminino (16,6% vs 5,8%). Em relação à faixa etária, a taxa de ANT foi maior entre os pacientes com idades entre 11-15 anos (12,19%), enquanto que para as idades 6-10 anos foi de 8,08% e para pacientes de 0 -5 anos foi de 4,16%. Dos 29 pacientes com apêndice saudável, 12 apresentavam adenite mesentérica, um paciente apresentava ruptura folicular e um paciente apresentava peritonite de grau médico. Não foram encontradas outras alterações em 15 pacientes. Conclusões: A taxa de apendicectomias não terapêuticas em nosso hospital foi de 10,10% no ano de 2013. A experiência internacional e alguns estudos nacionais mostram que esse resultado pode ser melhorado. O uso de algoritmos clínicos para melhorar a presunção diagnóstica e fazer o melhor uso dos recursos diagnósticos disponíveis, bem como o estabelecimento de um sistema de registro e análise prospectiva dos resultados clínicos em apendicite aguda.

Obstrucción intestinal en pacientes con apendicitis / Intestinal obstruction in appendicitis

Introducción: La apendicitis aguda como causa de obstrucción intestinal es una situación clínica infrecuente. Los objetivos de este estudio son los de definir la incidencia de obstrucción intestinal de acuerdo con la clasificación de obstrucción intestinal en apendicitis y la caracterización de su severidad. Métodos: Se diseñó un estudio de cohorte retrospectiva analizando todos los pacientes operados por obstrucción intestinal secundaria a apendicitis durante un periodo de 15 años. Se incluyeron variables continuas y categóricas tales como edad, sexo, periodo de tiempo entre el inicio de los síntomas y el diagnóstico, valores de proteína C reactiva, recuento de leucocitos, tipo de obstrucción intestinal y la puntuación del WSES Sepsis Severity Score. Resultados: Durante el periodo de estudio, un total de 3.626 pacientes fueron operados por apendicitis; en 44 casos se encontró una obstrucción intestinal asociada (1,2%). De acuerdo con la clasificación de obstrucción intestinal en apendicitis, la mayoría de estos pacientes presentaron un íleo mecánico con estrangulación del intestino (48%). La mayor parte de los pacientes (77%) presentaron una puntuación de 3 puntos o menos en el WSES Sepsis Severity Score. Conclusiones: La incidencia de obstrucción intestinal en apendicitis fue mayor de lo esperado. Estos pacientes presentaron una respuesta inflamatoria severa, con una puntuación en el WSES Sepsis Severity Score de 3 puntos. De acuerdo con la clasificación de obstrucción intestinal, la mayoría de los casos presentaron obstrucción mecánica con estrangulación.

Introduction: Appendicitis as a cause of intestinal obstruction is an infrequent condition. The purpose of this study was to define the incidence of intestinal obstruction according to the classification of intestinal obstruction secondary to appendicitis, and to characterize their severity. Methods: A retrospective cohort study analyzing all patients operated on for intestinal obstruction secondary to appendicitis within a 15 year period was designed. Continuous and categorical variables including: age, gender, time interval between onset of symptoms and diagnosis, C-reactive protein and white blood cells values, type of intestinal obstruction and WSES Sepsis Severity Score, were included. Results: During the period of study, 3,626 patients were operated on for appendicitis and 44 cases had associated intestinal obstruction (1.2%). According to the classification of intestinal obstruction in appendicitis, most patients had a mechanical ileus with strangulation (48%). Most patients had a WSES Sepsis Severity Score of 3 or less points (77%). Conclusions: The incidence of intestinal obstruction in appendicitis was higher than expected. These patients had a severe inflammatory response with a WSES Sepsis Severity Score of 3 points. According to the classification of intestinal obstruction in appendicitis, most patients had a mechanical obstruction with strangulation.

Apendicitis aguda / Acute appendicitis

Con el uso de las imágenes de creciente sensibilidad, el número de pacientes con diagnóstico de apendicitis ha aumentado, y una significativa proporción de ellos puede no progresar a apendicitis clínicamente relevante o puede resolver espontáneamente y evitar la apendicectomía. Existen reglas de predicción clínica que, sumadas a la tomografía computarizada o la ecografía, pueden tener una sensibilidad y especificidad significativamente altas tanto para descartar como para confirmar el diagnóstico. Los antibióticos deben ser considerados una válida opción terapéutica y su uso, discutido con los pacientes. (AU)

With the use of images of increasing sensitivity, the number of patients diagnosed with appendicitis has increased and a significant proportion of them could not progress to clinically relevant appendicitis or resolve spontaneously and avoid appendectomy. There are clinical prediction rules which combined with computed tomography or ultrasound may have a significantly higher sensitivity and specificity both to rule out as to confirm the diagnosis. Antibiotics should be considered a valid treatment option and its use discussed with patients. (AU)

Achados principais de exames laboratoriais no diagnóstico de apendicite aguda: uma avaliação prospectiva / Main findings in laboratory tests diagnosis of acute appendicitis: a prospective evaluation

RACIONAL: Apendicite aguda é a doença abdominal cirúrgica mais comum nas unidades de emergência. Embora o diagnóstico seja clínico, a realização de exames complementares pode ser útil na dúvida diagnóstica. OBJETIVO: Avaliar as principais alterações de exames laboratoriais em pacientes com apendicite aguda, assim como sua relação com a fase evolutiva da doença. MÉTODOS: Avaliação prospectiva de pacientes com diagnóstico de apendicite aguda submetidos ao tratamento cirúrgico. RESULTADOS: Cento e setenta e nove pacientes participaram deste estudo, a maioria do sexo masculino. A idade média foi de 26 anos. Em relação à contagem de leucócitos, 46,9% apresentavam valores <15.000 mm3. A porcentagem média dos polimorfonucleares foi de 81,7%, de bastões 1,2%, de eosinófilos 1%, de linfócitos 12,8% e de monócitos 2,9%. A proteína C reativa foi solicitada para 54 pacientes. Ela foi <10 mg/dl em 19, entre 10 e 50 mg/dl em 24 e maior ou igual a 50 mg/dl em 11. Com relação à fase evolutiva 64% pacientes apresentaram estágio inicial (fases 1 e 2), 16,2% fase 3 e 35 fase 4. 57% dos pacientes com contagem de leucócitos totais maior ou igual a 20.000/mm3 apresentaram perfuração apendicular (p<0,05). A porcentagem de leucócitos polimorfonucleados de pacientes com fases iniciais foi menor em relação às avançadas (79,8% e 85,1%, respectivamente), com valor de p<0,05. Pacientes com fases avançadas de apendicite aguda a quantidade de linfócitos foi menor em relação às iniciais (9,3% e 14,8%, respectivamente), com valor de p<0,05. Noventa e quatro porcento dos pacientes com valores de proteína C reativa <10 mg/dl apresentaram fases iniciais de inflamação apendicular (p<0,05). CONCLUSÃO: Houve associações significativas entre contagem total e diferencial de leucócitos, valores de proteína C reativa e fase evolutiva de inflamação apendicular.

BACKGROUND: Acute appendicitis is the most common surgical abdominal disease in the emergency room. Although the diagnosis is clinical the complementary tests may be useful in doubt. AIM: To evaluate the main laboratory tests in patients with acute appendicitis, as well as its relationship with the evolutionary stage of the disease. METHODS: Prospective evaluation of patients with acute appendicitis who underwent surgical treatment. RESULTS: A total of 179 patients participated in this study, most were male. The mean age was 26 years. For leukocyte count 46.9% had values ​​<15.000mm3. The mean percentage of polymorphonuclear cells was 81,7%, 1,2% of sticks, 1% eosinophils, lymphocytes 12,8% and 2,9% monocytes. C-reactive protein was required for 54 patients. It was <10 mg/dl in 19, between 10 and 50 mg/dl in 24 and greater than or equal to 50 mg/dl in 11. Regarding the evolutionary phase 64% patients had early stage (stages 1 and 2), 16,2% stage 3 and 35 stage 4. A total of 57% of patients with white blood cell count greater than or equal to 20.000/mm3 had appendicular perforation (p<0,05). The percentage of polymorphonuclear leukocytes from patients with early stages was lower than the later stages (79,8% and 85,1%, respectively), with p<0,05. Patients with advanced stages of acute appendicitis, the number of lymphocytes was lower than the initial stages (9,3% and 14,8%, respectively), with p<0,05. 94% of patients with C-reactive protein values ​​<10 mg/dl showed early stages of appendicular inflammation (p<0,05). CONCLUSION: A significant association among total and differential leukocyte count, C-reactive protein values ​​and evolutionary phase of appendiceal inflammation was found in this prospective analysis.

Hiperbilirrubinemia en apendicitis: es un factor predictivo de perforación / Hyperbilirubinemia in appendicitis: is a predictive factor of perforation

Background: An elevated total bilirubin level can be a marker for perforated appendicitis. Aim: To assess and compare the predictive value of total bilirubin, C-reactive protein (CRP), white-blood cell count, the lapse of symptoms evolution, and systemic inflammatory response syndrome (SIRS) for the diagnosis of perforated appendicitis. Material and Methods: Prospective study of 134 consecutive patients aged 33 +/- 16 years (63 males) operated for acute appendicitis of whom 49 had a perforated appendix. A preoperative blood sample was obtained to measure total bilirubin, C reactive protein and complete blood count. A systemic inflammatory response score was calculated. Results: The lapse of symptoms before operation was higher in patients with perforated appendicitis compared with their counterparts without perforation (105.2 +/- 79.3 and 38.6 +/- 17.5 hours respectively). C reactive protein values were 176 +/- 82.6 and 80 +/- 76 mg/1 respectively, (p = 0.01). Serum bilirubin values were 0.7 +/- 0.3 and 1.0 +/- 0.5 mg/dl, respectively (p = 0.05). Sixty five percent of patients with perforated appendicitis had a SIRS score between 3 and 4 points. A C reactive protein over 76.7 mg/1, a lapse of symptoms over 34.5 hours and a SIRS score of three or more had the best performance for the prediction of perforated appendicitis. Conclusions: The diagnosis of perforated appendicitis may be suspected based on CRP, SIRS, and the lapse of symptoms before operation. We do not recommend the use of total bilirubin to predict perforation in appendicitis.

Introducción: Se ha propuesto a la hiperbilirrubinemia como un marcador específico de apendicitis perforada. El objetivo del presente estudio es el de comparar el rendimiento para la predicción de perforación de la bilirrubina total (BT) y la proteína C reactiva (PCR), leucocitosis, el tiempo de evolución del cuadro clínico y el síndrome de respuesta inflamatoria sistémica (SIRS). Métodos: Se diseñó un estudio prospectivo y observacional, en el que se aplican curvas Receiver Operating Characteristics para comparar la sensibilidad y especificidad de las variables investigadas, se determinaron los mejores puntos de corte con la mejor sensibilidad y especificidad. Resultados: El período de tiempo de evolución del cuadro clínico se encontraba prolongado en los pacientes con apendicitis perforada (105,2 +/- 79,3 h y 38,6 +/- 17,5 h) y los niveles de PCR se encontraban muy elevados (176 +/- 82,6 mg/1 y 80 +/- 76 mg/1). La mayoría de los pacientes con apendicitis perforada tuvieron una puntuación SIRS entre 3 y 4 puntos. El valor de la PCR mayor a 76,7 mg/1, el tiempo de evolución de los síntomas mayor a 34,5 h y una puntuación SIRS de 3 puntos o más obtuvieron los mejores puntos de corte con el mejor rendimiento para la predicción de apendicitis perforada. Conclusiones: El diagnóstico de apendicitis perforada puede sospecharse cuando la PCR, SIRS y el período de tiempo de evolución del cuadro clínico están elevados. No recomendamos la medición de la BT como factor predictivo de perforación en pacientes con apendicitis.

Rol del recuento de leucocitos y de la proteína C reactiva en niños con apendicitis / White blood cell count and C reactive protein for the diagnosis of acute appendicitis in children

Introducción. Pocos estudios han evaluado el valor predictivo del recuento de leucocitos (RL) y de la proteína C reactiva (PCR) en diferentes puntos de corte en niños con apendicitis. El objetivo de este estudio es el de determinar los puntos de corte para RL y PCR en diferentes periodos de tiempo dentro de la evolución clínica de la apendicitis y establecer su utilidad en el diagnóstico de apendicitis y en la diferenciación entre apendicitis simple y perforada. Material y Método. Estudiamos 198 pacientes operados por apendicitis, dividiéndolos en 4 grupos de acuerdo al periodo de tiempo entre el inicio de los síntomas hasta el diagnóstico. Se construyeron curvas ROC (Receiver Operating Characteristics) para evaluar los valores de RL y PCR, los mejores puntos de corte fueron utilizados en el cálculo de la sensibilidad, especificidad y exactitud diagnóstica de estos exámenes para discriminar entre pacientes con y sin apendicitis y entre pacientes con apendicitis simple y perforada. Resultados. El RL y la PCR individualmente y asociadas, tienen una elevada sensibilidad para diferenciar entre pacientes con y sin apendicitis. La especificidad del RL y la PCR individualmente y asociadas para diferenciar entre pacientes con apendicitis simple y perforada es elevada pero la sensibilidad es baja. Conclusiones. El RL y la PCR pueden utilizarse para apoyar el diagnóstico clínico de apendicitis y dependiendo del tiempo entre el inicio de los síntomas y el diagnóstico, diferenciar pacientes con y sin apendicitis y discriminar entre apendicitis simple y perforada.

Background: White blood cell count (WBC) and C-reactive protein (CRP) at different cutoff values may have a predictive value for the diagnosis of appendicitis in children. Aim: To determine the value of WBC and CRP for the diagnosis of appendicitis and for the differentiation of simple from perforated appendicitis. Material and Methods: We studied 198 patients (aged 2 to 14 years, 96 males) operated for appendicitis divided in 4 groups according to the lapse between the onset of symptoms and diagnosis (12 hours or less, 13 to 24 hours, 25 to 48 hours and more than 48 hours). The gold standard for the diagnosis was the pathological study of the surgical piece. Receiver operating characteristic curves were constructed for CRP and WBC; the best cutoff points were used to calculate the sensitivity, specificity and diagnostic accuracy to discriminate patients with and without appendicitis, and patients with simple and perforated appendicitis. Results: At a cut off point ranging from 14600 to 15400 cells/mm³, the sensitivity and specificity of WBC to differentiate children with an without appendicitis ranged from 0.9 to 1 and from 0.2 to 0.4 respectively, in the different groups of children studied. The sensitivity and specificity for CRP, at a cut off point ranging from 4.7 and 9.8 mg/dl, ranged 0.9 to 1 and from 0.2 to 0.4 mg/dl respectively, in the different groups. Sensitivity and specificity values did not change significantly when both WBC count and PCR were considered together. The specificity of WBC and CRP, individually or together, to differentiate patients with simple and perforated appendicitis is high but the sensitivity is low. Conclusions: WBC and CRP have a good sensitivity but a low specificity for the diagnosis of appendicitis. For the differentiation between simple and perforated appendicitis, these laboratory values have a high specificity but a low sensitivity.

Ultrasound and white blood cell counts in suspected acute appendicitis / Ultrasonido y conteo de glóbulos blancos en casos de sospecha de apendicitis aguda

The use of radiological studies as diagnostic tools in patients with suspected acute appendicitis has increased recently. In this setting, abdominal ultrasonography is viewed as a possible means of avoiding unnecessary surgery. This retrospective study of patients who underwent laparotomy for suspected acute appendicitis was undertaken to determine the sensitivity and specificity of ultrasound in diagnosing acute appendicitis and the frequency of leucocytosis in patients in whom the diagnosis was confirmed by histology. The ultrasound and surgery registers were reviewed to identify 254 referrals for abdominal ultrasound between January 2001 and December 2002 because of a clinical suspicion of acute appendicitis. Of these cases, 223 did not proceed to surgery. The study sample comprised 31 patients who had appendectomies after abdominal ultrasonography. The ultrasound reports, pathological diagnoses and white blood cell counts of these patients were obtained and formed the basis for the analysis. A histological diagnosis was available for 30 cases, in 17 of whom appendicitis was confirmed In these patients, positive ultrasound and leucocytosis were present in five (29) and nine (53) respectively. Ultrasound showed 92specificity and 29sensitivity for the pre-operative diagnosis of appendicitis. The positive predictive value of ultrasonography (83) was higher than that of leucocytosis (69). The sensitivity and specificity of ultrasound and leucocytosis in this study indicate limited utility as preoperative diagnostic tools.

El uso de estudios radiológicos como herramientas de diagnóstico en los pacientes con sospecha de apendicitis aguda ha aumentado recientemente. En este escenario, la ultrasonografía abdominal se ve como un posible medio de evitar una cirugía innecesaria. Este estudio retrospectivo de pacientes sometidos a laparotomía por sospecha de apendicitis aguda, fue realizado a fin de determinar la sensibilidad y especificidad del ultrasonido a la hora de diagnosticar la apendicitis aguda así como la frecuencia de leucocitos, en pacientes en quienes el diagnóstico fue confirmado mediante histología. Se revisaron las historias de ultrasonido y cirugía con el propósito de identificar 254 remisiones para la realización de ultrasonido abdominal entre enero de 2001 y diciembre de 2002, debido a una sospecha clínica de apendicitis aguda. De estos casos, 223 no pasaron a cirugía. La muestra del estudio abarcó 31 pacientes a los que se les realizaron apendicectomías tras del ultrasonido abdominal. Se obtuvieron los reportes de los ultrasonidos, los diagnósticos patológicos y los conteos de glóbulos blancos de estos pacientes. Estos reportes constituyeron la base del análisis. Se tuvo a disposición un diagnóstico histológico en 30 casos, en 17 de los cuales se confirmó apendicitis. En estos pacientes, el ultrasonido resultó positivo en cinco casos (29%) y la leucocitosis estuvo presente en nueve (53%). El ultrasonido arrojó un 92% de especificidad y 29% de sensibilidad para el diagnóstico preoperativo de la apendicitis. El valor predictivo positivo de la ultrasonografía (83%) fue mayor que el de la leucocitosis (69%). En este estudio, la sensibilidad y especificidad del ultrasonido y la leucocitosis, indican una limitada utilidad tanto del ultrasonido como del conteo de glóbulos blancos como instrumentos preoperativos de diagnóstico.

Leucograma, proteína C reativa, alfa-1 glicoproteína ácida e velocidade de hemossedimentaçäo na apendicite aguda / Leucocyte count, C reactive protein, alpha-1 acid glycoprotein and erithrocyte sedimmentation rate in acute appendicitis

RACIONAL: O diagnóstico da apendicite aguda é clínico, mas alguns indivíduos podem apresentar sinais e sintomas pouco característicos. As dificuldades diagnósticas ainda conduzem os cirurgiöes à realizaçäo de laparotomias desnecessárias, que atingem índices de 15 por cento a 40 por cento. Os exames laboratoriais, assim, podem se tornar complementos úteis no diagnóstico da apendicite aguda. O leucograma parece ser o de maior valor, mas a dosagem das proteínas de fase aguda, em especial da proteína C reativa, é objeto de vários estudos. CASUíSTICA E MÉTODO: Estudo longitudinal prospectivo, envolvendo 63 pacientes submetidos a apendicectomia por suspeita de apendicite aguda no Hospital das Clínicas da Universidade Federal de Uberlândia, MG, de cujas amostras de sangue foram feitas dosagens das proteínas de fase aguda e leucograma. RESULTADOS: Foram 44 pacientes do sexo masculino e a faixa etária predominante entre 11 e 30 anos. A apendicite aguda foi mais freqüente no sexo masculino (69,8 por cento) e na faixa etária entre 11 e 30 anos. O tipo flegmonoso foi mais freqüente (52,4 por cento). O leucograma mostrou-se aumentado em 74,6 por cento dos casos e a elevaçäo da proteína C reativa foi observada em 88,9 por cento. As dosagens de alfa-1 glicoproteína ácida e velocidade de hemossedimentaçäo foram predominantemente normais. A proteína C reativa esteve aumentada em mais de 80 por cento dos casos em todas as idades. O leucograma e a proteína C reativa alteraram-se em 80 por cento dos pacientes com até 24 horas do início dos sintomas. Com tempo de evoluçäo dos sintomas superior a 24 horas, o leucograma mostrou-se alterado em 69,7 por cento dos casos e a proteína C reativa, em 97 por cento. Sensibilidade e especificidade do leucograma foram de 88,7 por cento e 20 por cento. Para a proteína C reativa, foram de 88,9 por cento e 10 por cento, respectivamente. A dosagem da proteína C reativa apresentou maior sensibilidade (96,9 por cento) para os casos de evoluçäo com mais de 24 horas, sem qualquer especificidade, entretanto, alfa-1 glicoproteína ácida e velocidade de hemossedimentaçäo mostraram-se pouco sensíveis e específicos. CONCLUSÕES: O leucograma e a proteína C reativa apresentam-se alterados de forma significativa nos casos de apendicite aguda, independentemente do sexo ou da faixa etária. O leucograma e, principalmente, a proteína C reativa devem ser exames considerados em indivíduos com tempo de evoluçäo sintomática superior a 24 horas...

Study of blood count in the validity experimental appendicitis in rabbits

A group of thirty six rabbits was studied, with weight ranging from 2400 to 3100 grams, in order to evaluate the blood test on the validity of experimental acute appendicitis. In order to do that, the animals were distributed amony three groups of 12 rabbits each, that corresponded to observation periods of 24 hours(Group A), 48 hours(Group B) and 72 hours(Group C). The presence of macroscopic appendicitis was verified in all the rabbits of the experiment on the three studied periods. The blood test study showed statistic significance when reading the values of haemoglobin, haematocrit and monocytes in Group C; of total and segmented leucocytes, eosinophiles, limphocytes and monocytes in Group B; when the groups faced each other, however, there was no estatistic significance. So, it was concluded that the values of haemoglobin, red blood, white cells and haematocrit are not suitable markers for experimental appendicitis in rabbits.

Propuesta de una escala práctica para el diagnóstico temprano de apendicitis aguda / Proposal of a practical scale for the early diagnosis of acute appendicitis

Objetivo. Propuesta de una escala práctica, confiable y dinámica para el diagnóstico temprano de apendicitis aguda. Diseño. Estudio longitudinal, prospectivo. Sede. Servicio de Urgencias Médico Quirúrgicas. Hospital de tercer nivel de atención. Pacientes y Método. Se evaluaron 281 casos con dolor abdominal agudo de julio de 1995 a junio de 1996. Ciento cincuenta y seis hombres y 125 mujeres, con edad promedio de 28.4 años. Doscientos treinta presentaron apendicitis con confirmación histopatológica. Análisis estadístico. Prueba F y T. Resultados. Se realizó una escala para el diagnóstico temprano de la pendicitis aguda, basada en 3 signos (dolor a la palpación en cuadrante inferior derecho, rebote en fosa iliaca derecha, McBurney), 3 síntomas (dolor migratorio a fosa iliaca derecha, anorexia, náusea/vómito) y 2 hallazgos de laboratorio (leucocitosis < 10,000 células/mm3, neutrofilia < 7,500 células/mm3) a cada uno de los cuales se les asignó un valor para un total de 10 puntos. Siete puntos o más se consideró como candidato a cirugía por probable apendicitis. Los puntos promedio con la escala en pacientes con apendicitis fue de 8.9 y de 7.1 sin la enfermedad. Existen diferencias estadísticamente significativas (p<0.05) entre los pacientes con y sin apendicitis. Conclusión. La escala propuesta demostró ser útil en el diagnóstico temprano de la apendicitis aguda, puede ser de ayuda cuando exista discrepancia en el tratamiento oportuno

Apendicitis aguda en el anciano: aspectos clínicos y de laboratorio / Acute appendicitis in the ancient: clinical and laboratory aspects

Describir las manifestaciones clínicas, la correlación clínico-patológica y la importancia de los análisis de laboratorio en la definición del cuadro de apendicitis aguda (AA) en el anciano. Material y Métodos: estudio retrospectivo en 100 pacientes de más de 60 años, que fueron hospitalizados en el servicio de emergencia del Hospital Nacional Arzobispo Loayza, durante el periodo 1984-1994. Resultados: En el lapso observado se atendieron un total de 4447 casos de AA en todos los grupos etarios, siendo el 3.89 por ciento constituido por pacientes ancianos. El tiempo de enfermedad promedio fue de 3.5 días, encontrándose que a mayor duración de esta, se incrementaba la probabilidad de perforación apendicular (X²=19.28 p<0.05). Todos los pacientes presentaron dolor abdominal, pero sólo el 43 por ciento tuvo la progresión clásica de este síntoma, se demostró de otro lado, que ha mayor edad, la frecuencia de dolor abdominal atípico se incrementaba, (X²=4, p<0.05). Otros síntomas asociados fueron náuseas (73 por ciento), vómitos (63 por ciento) e hiporexia (52 por ciento). El signo más frecuente fue el Mc Burney (96.5 por ciento), otro signo importante por la frecuencia de presentación fue el signo del Psoas positivo (73.7 por ciento); alza térmica solo se detectó en el 43.8 por ciento. El hemograma fue normal en 28 por ciento y el sedimento de orina fue patológico en 67.2 por ciento. El 56 por ciento tuvo perforación apendicular como diagnóstico intraoperatorio. El tiempo de hospitalización promedio fue de 13 días y la tasa de mortalidad fue 6 por ciento. Conclusiones: En la población anciana bajo estudio, el tiempo de enfermedad fue significativamente mayor al de la poblaciónh general, incrementando la probabilidad de perforación apendicular marcadamente; la presencia de síntomas atípicos con respecto al descrito para otros grupos etarios, molestias urinarias frecuentes, menor prevalencia de fiebre, así como análisis de laboratorio básicos de poca ayuda para definir el cuadro podrían explicar esta observación. No se llega a demostrar que la demora diagnóstica sea debida significativamente a localizaciones apendiculares anormales.