Utility of biomarkers in predicting complicated appendicitis: can immature granulocyte percentage and C-reactive protein be used?

BACKGROUND: Acute appendicitis is the most common reason for abdominal surgery in children. The aim of this study was to evaluate the utility of biomarkers in predicting complicated appendicitis (CA). METHODS: Patients having a diagnosis of acute appendicitis who underwent operations were retrospectively determined, and the utility of biomarkers in predicting CA was evaluated. RESULTS: A total of 251 patients were included in the study. The mean age was 130.9 ± 48.8 months, 148 of the cases (59%) were simple appendicitis, and 103 (41%) were CA. The C-reactive protein (CRP) levels, immature granulocyte (IG) percentage, white blood cell counts, and absolute neutrophil counts were significantly higher in the CA patients. The bilirubin levels and neutrophil to lymphocyte ratios were not useful for predicting CA. The best area under the curve (AUC) values to predict CA were with the IG percentage and CRP level (0.82), the IG percentage [odds ratio (OR) 9.36, 95% CI (4.94-17.75), p < 0.001] and CRP [OR 8.42, 95% CI (4.72-15.02), p < 0.001] were the best marker in predicting CA. The sensitivity of the IG percentage and CRP level were higher than other markers. CONCLUSION: To predict CA, the best AUC values were associated with the IG percentage and the CRP level. Because it is easy, fast to measure, does not require taking extra blood, and does not lead to additional costs, IG percentage may be preferred in the diagnosis of patients with CA.

Comparison of non-invasive physiological assessment tools between simple and perforated appendicitis in children.

PURPOSE: The role of non-invasive measures of physiologic reserve, specifically the Compensatory reserve index (CRI) and the Shock index pediatric age-adjusted (SIPA), is unknown in the management of children with acute appendicitis. CRI is a first-in-class algorithm that uses pulse oximetry waveforms to continuously monitor central volume status loss. SIPA is a well-validated, but a discontinuous measure of shock that has been calibrated for children. METHODS: Children with suspected acute appendicitis (2-17 years old) were prospectively enrolled at a single center from 2014 to 2015 and monitored with a CipherOx CRI™ M1 pulse oximeter. CRI values range from 1 (normovolemia) to 0 (life-threatening hypovolemia). SIPA is calculated by dividing heart rate by systolic blood pressure and categorized as normal or abnormal, based on age-specific cutoffs. Univariate and multivariable regression models were developed with simple versus perforated appendicitis as the outcome. RESULTS: Almost half the patients (45/94, 48%) had perforated appendicitis. On univariate analysis, the median admission CRI value was significantly higher (0.60 versus 0.33, p < 0.001) and the ED SIPA values were significantly lower (0.90 versus 1.10, p = 0.002) in children with simple versus perforated appendicitis. In a multivariable model, only CRI significantly detected differences in the physiologic state between patients with simple and perforated appendicitis. CONCLUSIONS: CRI is a non-invasive measure of physiologic reserve that may be used to accurately guide early management of children with acute simple versus perforated appendicitis.

Pediatric COVID-19 and Appendicitis: A Gut Reaction to SARS-CoV-2?

BACKGROUND: We describe the temporal pattern of COVID-19 admissions to a tertiary care children's hospital in central New Jersey during the SARS-CoV-2 surge, covering the time period from March 29 to July 26, 2020. METHODS: Medical charts were reviewed for the date of admission, past medical history, and demographic variables, presenting signs and symptoms, admitting laboratory values, diagnostic imaging, diagnosis, treatment modalities, and outcomes including length of stay and disease severity. RESULTS: Patients with symptomatic SARS-CoV-2 infection tended to present with pneumonia early during the study period, which coincided with the early surge in New Jersey cases. Approximately 2 weeks after the peak in reported SARS-CoV-2 cases in New Jersey, we began to see fewer pneumonia cases and an increase in admissions for Multi-Inflammatory Syndrome in Children and cases of acute appendicitis in association with a diagnosis of SARS-CoV-2 infection. CONCLUSIONS: We present a novel association of acute appendicitis in children infected with SARS-CoV-2 and postulate that it may represent a postinfectious hyperinflammatory complication of SARS-CoV-2 infection occurring 2 weeks after the early manifestation of acute pneumonia disease in children.

COVID-19 lockdown impact on common general surgical acute presentations to a regional centre in New Zealand.

AIM: New Zealand's stated goal of eradicating COVID-19 included the enforcement of a national lockdown. During this time, a perceived decrease in hospital presentations nationwide was noted. This was also the experience of the Department of General Surgery, Bay of Plenty District Health Board (BOPDHB). We sought to quantify this reduction by analysing the frequency and severity of three common acute general surgical presentations; appendicitis, cholecystitis and diverticulitis. METHODS: Data on presentations of patients with appendicitis, cholecystitis and diverticulitis were retrospectively collected for the national lockdown period (25 March 2020-27 April 2020) and the immediate pre-lockdown period (21 February 2020-25 March 2020). Data collected included patient demographics, duration of symptoms, method of diagnosis, treatment, severity of disease, length of stay and complications. RESULTS: A reduction of 62.2% was noted in the frequency of appendicitis during the lockdown period compared to the pre-lockdown period. Patients presented later during lockdown and had a higher complication rate (5.4% versus 42.8%). Similarly, a 39.2% reduction in presentations of cholecystitis during lockdown was found. The lockdown group of patients had a longer length of stay (6.9 versus 4 days) and only one patient (9.1%, 1/11) was managed with laparoscopic cholecystectomy during the lockdown period, compared to 52.9% of patients (9/17) over the pre-lockdown period. No difference in frequency or severity of acute diverticulitis presentations between the two periods was found. CONCLUSIONS: The COVID-19 lockdown led to fewer presentations, but these were often delayed, with more complications and a longer length of stay. This could be partly explained by patient fear around exposure to the virus and reluctance to attend hospital. More research is needed to study the flow-on effects of the COVID-19 lockdown on surgical presentations.

The importance of laboratory tests and Body Mass Index in the diagnosis of acute appendicitis.

<b>Background:</b> Acute appendicitis is the most common cause of acute abdomen. Delay in diagnosis increases the mortality and morbidity. <br><b>Aim: </b>In this study, we aimed to investigate whether the body mass index is useful in diagnosis and whether the neutrophil /lymphocyte and platelet/lymphocyte ratios can help in determining the inflammation level of acute appendicitis. <br><b>Meterial and Methods:</b> Cases of appendectomy performed between June 2012 and December 2018 in our clinic were analyzed retrospectively. Based on the pathology results of the cases included in the study, 4 groups were formed, i.e.: Group 1 (initial stage), Group 2 (catarrhal stage), Group 3 (phlegmonous-gangrenous stage) and Group 4 (perforation). The study compared age, body mass index, leukocyte values, red cell distribution width (RDW), neutrophil/lymphocyte ratio (NLR), platelet /lymphocyte ratio (PLR), and mean platelet volume (MPV) between groups. <br><b> Results:</b> 828 cases were included in the study. When compared between groups, the values of Group 3 and Group 4 were higher than those of Group 1 and Group 2 for PLR and NLR. There was no difference in RDW and MPV values in the blood. When Body Mass Index (BMI) was compared between groups, it was found to be significantly higher with increasing histopathological stage. <br><b>Conclusion:</b> In acute appendicitis, the blood leukocyte value, elevated PLR and NLR are helpful in diagnosis. We aimed to emphasize that the diagnosis of acute appendicitis is delayed in patients with a BMI above 30 and/or at age of over 40 years, with the perforation rate being determined more frequently.

Computed tomography scan usage when US results are non-diagnostic for suspected acute appendicitis in children.

This retrospective study was aimed to determine the factors suggesting the need for computed tomography (CT) scanning when ultrasound (US) imaging results are negative or non-diagnostic in children suspicious for acute appendicitis in the emergency department.Patients less than 18 years old who underwent abdominal ultrasound and CT to rule out acute appendicitis were enrolled. Patients were classified into 2 groups: the false-negative group, in which patients had negative or non-diagnostic results on the initial US and a final diagnosis of acute appendicitis on the following abdominal CT, and the true-negative group, in which patients had negative or non-diagnostic US results and were negative on abdominal CT. Logistic regression and propensity score matching with the predicting factors were performed.The presence of vomiting (odds ratio (OR), 7.78; 95% confidence interval (CI), 1.92-41.04) and poor oral intake (OR, 4.67; 95% CI, 1.21-21.15) with a high white blood cell (WBC) count (OR 1.26; 95% CI, 1.09-2.37), segmented neutrophil ratio (OR, 1.09; 95% CI, 1.03-1.16), and C-reactive protein (CRP) (OR, 1.49; 95% CI, 1.09-2.37) were suggestive of the false-negative group. The propensity-matched population also showed significant associations with vomiting (OR, 7.86; 95% CI, 1.65-37.40) and poor oral intake (OR, 5.50; 95% CI, 1.28-23.69) with an elevated WBC count (OR, 1.27; 95% CI, 1.08-1.50), segmented neutrophil ratio (OR, 1.09; 95% CI, 1.03-1.16), and CRP (OR, 1.51; 95% CI, 1.03-2.22).A CT scan should be considered in children with suspected acute appendicitis if they have vomiting, high CRP, and high WBC count, despite negative or non-diagnostic US results.

Acute Appendicitis in Children Younger than Five Years of Age: Diagnostic Challenge for Pediatric Surgeons.

Background: The aim of this study is the evaluation of clinical signs and outcomes of treatment in children under five years of age who underwent appendectomy because of acute appendicitis. Patients and Methods: From January 2009 until December 2018, 90 patients (54 boys and 36 girls) younger than five years of age, treated with appendectomy because of acute appendicitis, were included in this study. Patients were divided into two groups, depending on the intra-operative finding of non-perforated (Group I; n = 32) or perforated (Group II; n = 58) appendicitis. The groups were compared regarding demographic, clinical, and laboratory data and outcomes of treatment. Results: Of 1687 appendectomies in this period, 90 (5.3%) of them were performed in patients aged five years or younger. There were 58 (64.4%) patients with perforated appendix. Positive correlation between the rate of perforation and the age of patients was found. Perforation rates were significantly higher in younger patients (100%, <1 year; 100%, 1-2 y; 83.3%, 2-3 y; 71.4%, 3-4 y; 78.6%, 4-5 y, and 47.3%, 5 y) (p = 0.037). Vomiting and diarrhea were found more commonly in the group of perforated appendix (p < 0.002, p < 0.001), while constipation was found more often in the patients whose appendix was not perforated (p < 0.001). The median duration of symptoms (48 h vs. 16 h; p < 0.001) and median duration of hospitalization (7.5 d vs. 5 d; p < 0.001) were notably longer for the group of patients with perforated than the group of patients with non-perforated appendix. All complications occurred in the group of perforated appendix with total incidence of 4.4%. Conclusion: The clinical presentation of acute appendicitis for children aged five years or younger is often unusual, and establishing the proper diagnosis is often delayed. Patient age is tied closely to the stage of acute appendicitis, so the youngest patients present with more advanced stages of disease and are at greater risk of perforation. Acute appendicitis should be considered in all cases where a child is having abdominal pain, fever, and diarrhea, which has been shown to be present significantly more often in children with perforated appendix.

Tomoelastography for non-invasive detection and treatment monitoring in acute appendicitis.

Acute appendicitis is the most common cause of the acute abdomen syndrome and can be treated either surgically or conservatively with antibiotics. This case demonstrates the first time use of mechanics based MRI by tomoelastography with generation of quantitative maps of tissue stiffness (shear wave speed in m/s) and tissue fluidity (shear modulus loss angle, in rad) in a case of uncomplicated acute appendicitis with antibiotic treatment at (i) baseline, (ii) the end of treatment (EOT) and (iii) the 10 day follow-up after EOT. Baseline maps of stiffness and fluidity revealed to the naked eye the extent of intestinal inflammation by markedly increased values of stiffness and fluidity (2.56±0.12 m/s, 1.37±0.24 rad) compared with normal values, indicating the immediate response to antibiotic treatment at EOT (1.47±0.28 m/s, 0.80±0.11 rad) and persistent normalisation at follow-up (1.54±0.22 m/s, 0.92±0.22 rad). Tomoelastography is a non-invasive, quantitative imaging method for mechanics based characterisation and follow-up of acute appendicitis.

Pregnancy and appendicitis: a systematic review and meta-analysis on the clinical use of MRI in diagnosis of appendicitis in pregnant women.

Background: The aim of this systematic review and meta-analysis was to evaluate the clinical use of MRI for the evaluation of acute appendicitis during pregnancy. Methods: The searches were conducted by two independent researchers (MK, MS) to find the relevant studies published from 1/1/2009 until end of 30/12/2018. We searched for published literature in the English language in MEDLINE via PubMed, EMBASETM via Ovid, The Cochrane Library, and Trip database. For literature published in other languages, we searched national databases (Magiran and SID), KoreaMed, and LILACS. The keywords used in the search strategy are Pregnancy [MeSH], Pregnant [MeSH] OR-Magnetic resonance imaging [MeSH] OR-Appendicitis [MeSH] OR-Ultrasound, [MeSH] OR, imaging, MRI [MeSH] OR"،" and Right lower quadrant pain [MeSH]. The risk of bias of every article was evaluated by using QUADAS-2. On the basis of the results from the 2 × 2 tables, pooled measures for sensitivity, specificity, diagnostic odds ratio (DOR), and area under the curves (AUC) along with their 95% confidence intervals (CIs) were calculated using the DerSimonian Lair methodology. Results: As many as 1164 studies were selected. After analyzing the correspondence of the studies with the required criteria, 19 studies were selected for the final review. For appendicitis in pregnancy, the MRI sensitivity was 91.8% at the 95% confidence interval of (95% CI 87.7-94.9%). At the confidence interval of 95%, the specificity was 97.9% (95% CI 0.97.2-100%). The risk of bias in the studies conducted was measured using the QUADAS-2 tool. Conclusion: MRI has high sensitivity and specificity (91.8%, 97.9% respectively) for the diagnosis of acute appendicitis in pregnant patients with clinically suspected appendicitis. It is an excellent imaging technique in many instances, which does not expose a fetus, or the mother, to ionizing radiation, making it an excellent option for pregnant patients with suspected acute appendicitis.

Preoperative assessment of complicated appendicitis through stress reaction and clinical manifestations.

This study assessed the severity of the disease through the preoperative clinical manifestations and inflammatory reaction indicators of acute appendicitis, and established a score table to predict complicated appendicitis (CA).The clinical data of 238 patients with acute appendicitis in our hospital were retrospectively analyzed, which included 18 patients with acute simple appendicitis (7.6%), 170 patients with acute purulent appendicitis (72.0%), and 48 patients with acute gangrene and perforation (20.3%). The clinical manifestations and inflammatory reaction indicators were analyzed by univariate logistic regression. Multivariate logistic regression analysis was performed to screen out the independent risk factors of CA. The ß coefficients of independent risk factors entering the multivariate model were assigned by rounding, and the total score was the sum of values of all factors. Finally, verification and analysis were performed for the predictive model, and the operating characteristic curve (ROC) curve was drawn. Then, the area under the curve (AUC) was compared with the THRIVE scale, and the Hosmer-Lemeshow method was used to evaluate whether the model fitted well.The multivariate logistic regression analysis of independent risk factors was performed, and the values were rounded to the variable assignment based on the ß coefficient values. The plotted ROC and AUC was calculated as 0.857 (P < .001). Using the Hosmer-Lemeshow method, the X-value was 12.430, suggesting that the prediction model fitted well.The scoring system can quickly determine whether this is a CA, allowing for an earlier and correct diagnosis and treatment. Furthermore, the scoring system was convenient, economical, and affordable. Moreover, it is easy to popularized and promote.

Calculated decisions: Alvarado score for acute appendicitis

The Alvarado score for acute appendicitis predicts the likelihood of a diagnosis of appendicitis.

Impact of the appendiceal position on the diagnosis and treatment of pediatric appendicitis / Impacto da posição do apêndice sobre o diagnóstico e tratamento de apendicite da infância

ABSTRACT Objective: To investigate how symptoms vary according to the appendiceal position in pediatric patients and to demonstrate that the laparoscopic approach is safe and effective in any appendiceal location by comparing each location to another. Methods: The medical records of 1,736 children aged 14 or younger who underwent laparoscopic appendectomy over a period of 14 years were analyzed retrospectively. Patients were divided according to the position of the appendiceal tip into four groups: anterior, pelvic, retrocecal and subhepatic. The Kruskal-Wallis and chi-square tests were used with the Bonferroni correction, with a significant p<0.05. Results: The appendiceal location was anterior in 1,366 cases, retrocecal in 248 cases, pelvic in 66 cases and subhepatic in 56 cases. There were no significant differences between the groups in terms of patient age and gender. Abdominal pain was the only symptom with statistically significant differences between the groups. The rate of perforated appendicitis was higher in the subhepatic and pelvic positions. Intraoperative complications and conversions were not statistically significant. Technical difficulties and operative time were higher in subhepatic position. The rate of postoperative complications was similar between the different locations, except for bowel obstruction, which was higher in pelvic appendicitis. Conclusions: The clinical symptoms of appendicitis hardly ever change with the position of the appendix. The laparoscopic approach is safe and effective, regardless the appendiceal location.

RESUMO Objetivo: Investigar como os sintomas variam de acordo com a posição do apêndice em pacientes pediátricos e demonstrar que a laparoscopia é segura e eficaz em qualquer posição do apêndice, comparando-as. Métodos: Os prontuários de 1.736 pacientes pediátricos com idade ≤14 anos submetidos à apendicectomia laparoscópica em um período de 14 anos foram analisados retrospectivamente. Os pacientes foram divididos de acordo com a posição do apêndice: anterior, pélvica, retrocecal e sub-hepático. Os testes de Kruskal-Wallis e do qui-quadrado foram usados com a correção de Bonferroni, sendo significante p<0,05. Resultados: A posição do apêndice era anterior em 1.366 casos, retrocecal em 248 casos, pélvica em 66 casos e sub-hepática em 56 casos. Não houve diferenças significativas entre os grupos quanto às variáveis idade e sexo. A dor abdominal foi a única variável com diferenças estatisticamente significantes entre os grupos. A taxa de apêndice perfurado foi superior nas posições sub-hepática e pélvica. As complicações intraoperatórias e a taxa de conversão não foram estatisticamente significativas. As dificuldades técnicas e o tempo cirúrgico foram superiores em posição sub-hepática. A taxa de complicações pós-operatórias foi semelhante entre as diferentes posições, exceto a obstrução intestinal, que foi superior em posição pélvica. Conclusões: Os sintomas da apendicite dificilmente variam com a posição do apêndice. A laparoscopia é segura e eficaz, independentemente da posição do apêndice.

IMPACT OF THE APPENDICEAL POSITION ON THE DIAGNOSIS AND TREATMENT OF PEDIATRIC APPENDICITIS.

OBJECTIVE: To investigate how symptoms vary according to the appendiceal position in pediatric patients and to demonstrate that the laparoscopic approach is safe and effective in any appendiceal location by comparing each location to another. METHODS: The medical records of 1,736 children aged 14 or younger who underwent laparoscopic appendectomy over a period of 14 years were analyzed retrospectively. Patients were divided according to the position of the appendiceal tip into four groups: anterior, pelvic, retrocecal and subhepatic. The Kruskal-Wallis and chi-square tests were used with the Bonferroni correction, with a significant p<0.05. RESULTS: The appendiceal location was anterior in 1,366 cases, retrocecal in 248 cases, pelvic in 66 cases and subhepatic in 56 cases. There were no significant differences between the groups in terms of patient age and gender. Abdominal pain was the only symptom with statistically significant differences between the groups. The rate of perforated appendicitis was higher in the subhepatic and pelvic positions. Intraoperative complications and conversions were not statistically significant. Technical difficulties and operative time were higher in subhepatic position. The rate of postoperative complications was similar between the different locations, except for bowel obstruction, which was higher in pelvic appendicitis. CONCLUSIONS: The clinical symptoms of appendicitis hardly ever change with the position of the appendix. The laparoscopic approach is safe and effective, regardless the appendiceal location.

The value of ischemia-modified albumin and oxidative stress markers in the diagnosis of acute appendicitis in adults.

INTRODUCTION: The present study evaluates the predictive value of such markers as ischemia-modified albumin (IMA), malondialdehyde (MDA) and glutathione peroxide (GSH-Px), in addition to parameters associated with inflammation, oxidative stress and ischemia, playing roles in the pathology of acute appendicitis (AA), including c-reactive protein (CRP), procalcitonin (PCT) and complete blood count (CBC) parameters and their ratios, for the diagnosis of AA in adults. MATERIAL AND METHODS: The study included 51 patients with histologically confirmed appendicitis and 45 healthy controls who referred to the emergency care unit between January and June 2018. The appendicitis cases were classified into two groups, as complicated and non-complicated, based on postoperative pathological investigations. RESULTS: Of all the appendicitis cases, 68.5% (n = 35) were non-complicated and 31.4% (n = 16) were complicated. IMA (positive LR = 3.0, negative LR = 0.1), GSH-Px (positive LR = 0.5, negative LR = 1.8), MDA (positive LR = 1.8, negative LR = 0.6), CRP (positive LR = 7.2, negative LR = 0.2), PCT (positive LR = 0.7, negative LR = 1.3), WBC (positive LR = 2.9, negative LR = 0.3), neutrophil-lymphocyte ratio (positive LR = 3.2, negative LR = 0.1) thrombocyte lymphocyte ratio (positive LR = 1.6, negative LR = 0.5) and IMA/albumin ratio (positive LR = 3.3, negative LR = 0.1) levels in the appendicitis cases were evaluated by a characteristic receiver operating characteristic (ROC) curve. In addition, IMA levels were significantly higher in the complicated cases (0.40 ±â€¯0.05 AbsU) than in the non-complicated cases (0.29 ±â€¯0.04 AbsU) (p < 0.0001). CONCLUSION: Our results showed that IMA (negative LR = 0.1), CRP (positive LR = 7.2, negative LR = 0.2), NLR (negative LR = 0.1) and IMA/albumin ratio (negative LR = 0.1) can serve as important diagnostic biomarkers for AA patients. We therefore believe that before clinically confirming an AA diagnosis, these parameters may be used as diagnostic tools in addition to CBC parameters, CRP levels and radiological imaging studies.

Apuntes históricos y fisiopatológicos sobre apendicitis aguda / Historical and Physiopathological Annotations about Acute Appendicitis

RESUMEN Se realizó un estudio de revisión de corte histórico sobre apendicitis aguda, en el que se profundizó en los aspectos históricos conocidos en mayor o menor grado desde la era Bizantina hasta nuestros días. El objetivo fue actualizar los resultados hallados desde el punto de vista histórico y fisiopatológico y mostrarlos al lector. Para este estudio se realizó una búsqueda a través de las bases de datos Scielo, Medline y PubMed y complementada mediante los buscadores Google, Yahoo y Wikipedia. Se realizó un análisis crítico de los artículos encontrados; se estudiaron también otros artículos de cualquier país, idioma, institución, autor (es) y fecha; de preferencia los nacionales. Se exponen las cuatro teorías relacionadas al origen de esta enfermedad, que son: obstrucción de la luz, ulceraciones mucosas superficiales, la higiene y el rol de la infección, por último, la hipótesis de las fibras dietéticas. Se identificaron aspectos históricos en apendicitis aguda en el tiempo; se aludió a un reporte reciente sobre rasgos gastrointestinales en las distintas especies y las cuatro teorías fisiopatológicas y todas resultaron atractivas(AU)

ABSTRACT A historical review about acute appendicitis was carried out, for which the historical aspects known to a greater or lesser degree were studied in depth. This article covers from the Byzantine era to the present day. The objective is to update the results found from the historical and physiopathological viewpoints. For this study, a search was made through the databases Scielo, Medline and PubMed and complemented by the search engines Google, Yahoo and Wikipedia. A critical analysis of the findings was made and other articles from various countries and institutions, written in other languages, by several author(s) and on different dates were also studied; preferably the nationals. The four theories related to the origin of this disease were exposed: obstruction of light, superficial mucosal ulcerations, hygiene and the role of infection, and finally, the hypothesis of dietary fibers. We identified historical aspects in acute appendicitis over time, as well as referred to a recent report on gastrointestinal traits in the different species and the four physiopathological theories, all of which were attractive(AU)

[Acute abdomen - gastrointestinal causes]. / Akutes Abdomen ­ gastrointestinale Ursachen.

CLINICAL/METHODICAL ISSUE: Diagnostic imaging plays a crucial role in the assessment and stratification of pathologic conditions causing acute abdomen. This report provides information on etiology, clinical manifestations and therapeutic options for six common diseases resulting in acute abdomen-appendicitis, cholecystitis, bowel obstruction, diverticulitis, acute pancreatitis, and viscus perforation. PERFORMANCE: Besides initial ultrasound, CT scans often represent the imaging gold standard for the diagnostic evaluation of acute abdomen. PRACTICAL RECOMMENDATIONS: Depending on the underlying pathologic condition, sonography or CT is suitable for the stratification of the gastrointestinal disease causing acute abdomen.

RETROUTERINE PERFORATED GANGRENOUS APPENDICITIS.

We present an atypical case of retrouterine gangrenous perforated appendicitis with Douglas abscess in a 33-year-old woman, with clinical picture developing over two weeks. Laparotomy and appendectomy with abdominal drainage and antibiosis were performed and resulted in complete recovery.

The Karaman score: A new diagnostic score for acute appendicitis.

BACKGROUND: The Karaman score is a novel diagnostic scoring system consisting of 6 parameters. The aim of the present study was to assess the diagnostic performance of the Karaman score in comparison with the Alvarado score. METHODS: A total of 200 patients who underwent an appendectomy were enrolled in the study (research registry number: 2290). RESULTS: The cutoff threshold of the Karaman score in distinguishing acute appendicitis from negative appendectomy was ≥9 with 84.3% sensitivity, 64.7% specificity, 92.1% positive predictive value (PPV), and 45.8% negative predictive value (NPV). The cutoff threshold of the Alvarado score in distinguishing acute appendicitis from negative appendectomy was ≥8 with 72.9% sensitivity, 70.6% specificity, 92.4% PPV, and 34.8% NPV. In multivariate logistic regression analysis, an Alvarado ≥8 score (Odds ratio [OR]:6.644, 95% confidence interval [CI]: 2.854-15.466; p<0.001) and a Karaman ≥9 score (OR:10.374, 95% CI: 4.383-24.558; p<0.001) were each individually predictive in distinguishing acute appendicitis from negative appendectomy when correction was made according to age and gender. However, when both scores were evaluated together, the Alvarado score ≥8 lost its efficacy (OR:1.838, 95% CI: 0.517-6.530; p=0.347), whereas the Karaman score ≥9 retained its predictive power (OR:6.586, 95% CI: 1.893-22.917; p=0.003). CONCLUSION: The Karaman score was more predictive than the Alvarado score in distinguishing acute appendicitis from a negative appendectomy.

Complicated appendicitis and considerations for interval appendectomy.

Acute appendicitis is one of the most common surgical emergencies. Of the 300,000 appendectomies performed each year, 25% are due to complicated appendicitis. This article reviews the incidence and pathophysiology of acute appendicitis, the nonoperative management of complicated appendicitis, and the rationales for and against interval appendectomy.