Imaging of acute appendicitis and its impact on negative appendectomy and perforation rates: the St. Paul's experience.

PURPOSE: Preoperative imaging of acute appendicitis is widely practised. The aim of this study is to determine the prevalence of preoperative imaging of acute appendicitis in our institution and its effect on the negative appendectomy rate and perforation rates. METHODS: We undertook a retrospective review of all patients who underwent appendectomy from January 2000 to December 2004. All available preoperative ultrasound (US), computed tomography (CT), and pathology results were reviewed. RESULTS: A total of 380 appendectomies were performed over this time period for the preoperative diagnosis of acute appendicitis. Fifty-nine patients had histologically normal appendices, giving an overall negative appendectomy rate of 15.5%. Overall, patients who had preoperative imaging showed a lower negative appendectomy rate (11.4%) than did those without imaging (22.2%). Without preoperative imaging, women had a higher negative appendectomy rate (34.3%) than did men (17.4%). Reduction in the negative appendectomy rate was demonstrated with preoperative imaging in both sexes (16.7% and 5.7%, respectively). Also demonstrated is a definite trend toward increased use of preoperative CT and away from US as the sole preoperative imaging modality. This is associated with a reduced negative appendectomy rate. CONCLUSIONS: The increased use of preoperative imaging, particularly CT, is associated with a decreased negative appendectomy rate and a decreased perforation rate at our institution.

Clinical and histological predictors of response to medical therapy in collagenous colitis.

OBJECTIVES: Collagenous colitis (CC) is an uncommon form of inflammatory bowel disease. The response to typical medical therapies (antimotility agents, 5-aminosalicylic acid [5-ASA], and corticosteroids) is variable. We aimed to determine if there are clinical or histological variables that can predict response to medical therapy. METHODS: All cases of CC were identified in three tertiary care medical centers. All charts of included patients were reviewed and clinical variables (age, gender, duration of symptoms, frequency of bowel movements, and the use of nonsteroidal anti-inflammatory drugs [NSAIDs]) were recorded. Available histology slides were reviewed by one GI pathologist. Intraepithelial inflammation, epithelial loss or detachment, inflammation in the lamina propria, presence of eosinophilia, crypt inflammation, Paneth's cell metaplasia, and collagen layer thickness were recorded. Depending on their response to therapy, patients were divided into three groups: 1) spontaneous recovery or response to antidiarrheal agents alone, 2) response to 5-ASA agents, and 3) response to corticosteroids after failure of antidiarrheal agents and 5-ASA. RESULTS: Ninety-four patients with CC were identified. Of these, 62 patients were included. The median age was 58 (range = 20-85), and 88% were female. Among the histological parameters only the degree of inflammation in the lamina propria significantly differed between the three response groups (p = 0.007). Patients who required corticosteroids had greater inflammation. Among the clinical parameters age at presentation and use of NSAIDs significantly differed between groups. In the antidiarrheal group, patients tended to be more elderly, and in the corticosteroid group, more patients were on NSAIDs. CONCLUSIONS: 1) The degree of lamina propria inflammation can be used as a histological predictor to guide treatment in patients with CC. 2) Patients who responded to antidiarrheal agents or had spontaneous remissions were significantly older than those patients requiring 5-ASA compounds or corticosteroids. 3) Patients who were taking NSAIDs were more likely to require corticosteroid therapy, presumably reflecting more severe disease.

Familial microscopic colitis.

Collagenous and lymphocytic colitis are two inflammatory conditions of the colon that are often collectively referred to as microscopic colitis. The present report describes what is believed to be the third published case of familial microscopic colitis. A 55-year-old woman who suffered from chronic diarrhea was diagnosed with lymphocytic colitis on colonic biopsy. Subsequently, her 36-year-old daughter was diagnosed with collagenous colitis. The familial occurrence of these diseases may support an immunological hypothesis for their etiology. In addition, it supports the assumption that collagenous and lymphocytic colitis are two manifestations of the same disease process rather than two completely separate entities. The familial tendency of this disease may make a case for early colonoscopy and biopsy in relatives of patients diagnosed with microscopic colitis if they present with suggestive symptoms.

CT appearance of microcystic meningioma.

Microcystic meningioma is an unusual variant, which has recently been proposed for inclusion in the WHO Classification of Central Nervous System Tumors. Its unique structure produces findings that may be confusing to radiologist and pathologist alike. A case is reported and the English language literature reviewed.

Primary adrenal leiomyosarcoma in a man with acquired immunodeficiency syndrome (AIDS). Further evidence for an increase in smooth muscle tumors related to Epstein-Barr infection in AIDS.

We report a rare primary adrenal leiomyosarcoma in a 30-year-old, human immunodeficiency virus--positive man. This is, we believe, the third documented case in the English literature of this tumor in this site, and the first to be reported in an adult male with acquired immunodeficiency syndrome. The smooth muscle origin of this tumor was apparent by routine microscopy and confirmed by positive immunostaining for smooth muscle actin. The patient is presently well and shows no evidence of recurrence 20 months after surgery. The present findings are discussed with reference to the reported rising incidence of smooth muscle tumors in human immunodeficiency virus--infected patients and the associated etiologic role of Epstein-Barr virus in the pathogenesis of these tumors.