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Saturday, 26 October 2013

Appendicitis


Appendicitis is defined as a condition of inflammation of Appendix. It is classified  as an emergency, in many required the removal of the appendix. If burst, or perforate, spilling infectious materials into the abdominal cavity can be life threatening.

I. Signs and Symptoms
1. Abdominal pain and upper respiratory tract infection
Although appendicitis is the condition that most commonly requires emergent abdominal surgery in the paediatric population, less than 2% of the disease occurs in infants and it is even more uncommon in neonates. There is report of a  rare case of a 14-month-old child presenting with abdominal pain first diagnosed with upper respiratory tract infection and then admitted to our Paediatric Surgery Department with a final diagnosis of acute appendicitis, according to the  FONDAZIONE IRCCS CA' GRANDA - Ospedale Maggiore Policlinico(1).

2. Vomiting,fever,  pain, anorexia, diarrhea, abdominal tenderness, peritonitis, temperature 38.0 degrees C or more, abdominal distension, Leukocytosis, small-bowel obstruction (SBO), Contrast enemas and Perforated appendicitis
In the study to identify the presenting symptoms and signs in this age group and examine their subsequent management and outcome, by the The Scarborough Hospital, indicated that in 27 children less than 3 years old (mean 23 months) comprised 2.3% of all children with appendicitis in the series, the most common presenting symptoms were vomiting (27), fever (23), pain (21), anorexia (15), and diarrhea (11). The average duration of symptoms was 3 days, with 4 or more days in 9 children. Eighteen children were seen by a physician before the correct diagnosis was made; 14 were initially treated for an upper respiratory tract infection, otitis media, or a urinary tract infection. The most common presenting signs were abdominal tenderness (27), peritonitis (24), temperature 38.0 degrees C or more (21), abdominal distension (18), Leukocytosis (<12.0 x 10(3)/mm(3)) was found in 18, tenderness was localized to the right lower quadrant (RLQ) in 14 and was diffuse in 10. Abdominal radiographs demonstrated findings of a small-bowel obstruction (SBO) in 14 of 21 patients, a fecalith in 2, and a pneumoperitoneum in 1. Contrast enemas were performed in 6 children, 5 of whom had a phlegmon or an abscess. Perforated appendicitis was found in all 27 patients. An appendectomy was performed in 25 and a RLQ drain was placed in 18(2).

3. An abdominal mass, guarding, rebound tenderness, rigidity, diffuse or focal tenderness, diarrhea, emesis, fever, pain, and anorexia
According to the Children's Hospital of Philadelphia, the common physical signs of an abdominal mass, guarding, rebound tenderness, rigidity, and diffuse or focal tenderness and  common symptoms are  diarrhea, emesis, fever, pain, and anorexia with the most common presenting symptom was abdominal pain (94%); the most common sign was abdominal tenderness (95.8%)(3)
 
II. Causes ans risk factors
A. Causes
The cause of appendicitis is the result of blockage by stool, a foreign body, or cancer of that can lead to infection.
1, Bacterial, viral and parasitic infiection 
According to the study by the, the pathologic spectrum of the inflamed appendix encompasses a wide range of infectious entities, some with specific histologic findings, and others with nonspecific findings that may require an extensive diagnostic evaluation. The appendix is exclusively involved in some of these disorders, and in others may be involved through extension from other areas of the gastrointestinal tract(4). Other sin the study to investigate the role of parasitic infestation in the etiology of acute pediatric appendicitis, indicated that parasites were present in 5.5% (88 patients), and of those 88 parasitic infestations, 45 (51.1%) were Enterobaisis, 8 (9.1%) were Schistosomiasis, 23 (26.1%) were Ascariasis, 7 (8%) Trichuriasis, and 5 (5.7%) were Teania Saginata. The percentage of patients with suppurative, gangrenous or perforated appendicitis was similar in both groups with no statistical significance, irrespective of the presence or absence of parasitic infestation(5).

2. Foreign objects
Appendicitis and its complications remain a common problem affecting patients of all age groups. Appendicitis due to foreign bodies is rare and carries an estimated frequency of 0.0005%. But Aaccording to the Department of Surgery, Heilig Hart Tienen, ther is case of a 44-year-old man with appendicitis induced by an appendicolith containing eight steel shotgun pellets. The man was a recreational hunter and for the past 20 years he consumed wild game on a regular basis(6).

B. Risk factors 
1.  Age <20 years, white cell count >10 × 103/mm
In the study to evaluate the impact of timing of appendectomy and other potential risk factors on progression of acute appendicitis, by searching the relevant databases of a tertiary medical center identified 1,604 patients with verified acute appendicitis who underwent appendectomy in 2004-2007with demographic and clinical data and time from symptom onset to emergency room admission ("patient interval") and from emergency room admission to surgery ("hospital interval") and their combination were analyzed by pathological grade, indicated that on multivariate analyses, independent risk factors for appendiceal perforation were age <20 years (OR = 1.58, 95 % CI 1.07-2.35) or >50 years (OR = 2.84, 95 % CI 1.82-4.45) (relative to 20-50 years), white cell count >10 × 103/mm(3) (OR = 4.45, 95 % CI 2.05-9.67), body temperature >37.8 °C (OR = 2.23, 95 % CI 1.45-3.41), hospital interval >24 h (OR = 2.84, 95 % CI 1.49-5.4), patient interval >48 h (OR = 3.84, 95 % CI 2.35-6.29), and combined interval >48 h (OR = 4.29, 95 % CI 2.2-8.36)(7).

2. Gender different, among young
According to study appendicitis is common among young, healthy populations; appendectomy is one of the most common surgical procedures performed in the United States. Among active and reserve component members, there were 31,610 cases of appendicitis and 30,183 appendectomies during 2002 to 2011. The overall incidence rate of appendicitis in the active component was 18.4 per 10,000 person-years (p-yrs). Active component males reported greater rates of perforated appendicitis (2.6 per 10,000 p-yrs). Active component females had higher rates of incidental appendectomies (2.6 per 10,000 p-yrs)(8).

3. Race, increased over time and is higher in the summer months
Appendicitis is most common in whites and Hispanics and less common in African Americans and Asians and incidence has increased over time and is higher in the summer months, according to the study by the University of California San Diego(9).

4. Prior antibiotic administration 
Prior treatment with antibiotics was an independent risk factor for therapeutic delay in pediatric AA, according to the study by the National Center for Child Health and Development, Tokyo(10).

5. Decreased bowel sounds; rebound tenderness; and presence of psoas, obturator, or Rovsing's signs
Factors associated with an increased likelihood of appendicitis included decreased bowel sounds; rebound tenderness; and presence of psoas, obturator, or Rovsing's signs(11).

6. In patients with end-stage renal disease
The independent risk factors were atrial fibrillation (hazard ratio [HR], 2.08), severe liver disease (HR, 1.74), diabetes mellitus (HR, 1.58), and hemodialysis (HR, 1.74), according to the study by the Taipei Medical University(12).

7. Severity of inflammation 
CRP concentration may be a potent objective predictor of pathological severity in appendicitis. Combination with the other diagnostic modalities may improve the diagnostic accuracy in predicting the severity of appendicitis(13).

8. Other risk factors
The principal factors contributing to perforation of appendix are: age of children, delays of surgical intervention, family anamnesis, social group and late recognition of symptoms of appendicitis(14).

9. Appendicolith
Presence of an appendicolith was associated with a 72% rate of recurrent appendicitis compared with a recurrence rate of 26% in those with no appendicolith (chi2 test, P < .004)(15).  


III. Complications and Diseases associated to Appendicitis
A. Complications
1. Pyogenic liver abscess [PLA]
Pyogenic liver abscess [PLA] is a rare and life-threatening disease in children. Appendicitis was the leading source of PLA in the pre-antibiotic era, but it essentially has been eliminated in recent times. There is a report of a 12-year old girl with PLA after laparotomy for perforated appendix. She developed persistent fever and respiratory distress post operatively. Physicians had an impression of pneumonia but abdominal ultrasound showed cystic mass with mobile internal echoes within the right lobe of the liver suggesting an abscess. Patient was successfully managed by percutaneous drainage under ultrasound guidance(16).

2. A ruptured appendix
Although the finding of appendiceal duplication is uncommon, its misdiagnosis and mismanagement may yield poor clinical outcomes and serious medicolegal consequences. Laparoscopic surgical exploration was performed on a 17-year-old male patient with right lower quadrant pain and a history of a previous appendectomy. Inspection of the cecum revealed a second appendix, which was retrocecal, ruptured, and gangrenous(17). Other study found that appendicitis is the most common abdominal condition leading to urgent surgery in children. With the goal of identifying signs and symptoms that will allow prompt diagnosis of rupture of the appendix and thus decrease associated morbidities, our aim was to determine factors associated with ruptured appendicitis in children diagnosed with appendicitis(17).


B. Diseases associated to Appendicitis
1. Thoracic empyema
Appendicitis and thoracic empyema are rarely presented together. There is a report of  a thoracic empyema due to bacterial translocation in a patient, after she underwent appendicectomy for nonperforated acute appendicitis, according tp the Ankara Training and Research Hospital(18).

2. De Garengeot hernia 
he presence of the appendix within a femoral hernia sac is a rare condition known as De Garengeot hernia. There is a report of a case of De Garengeot hernia with concomitant appendicitis, according to the University of Cagliari(19).

3. Simultaneous Meckel's diverticulitis
There is a report a case of a 24-year-old woman who was delivered via cesarean section at 39 weeks and presented in the puerperium with symptoms of worsening abdominal pain and septicaemia. Preoperative ultrasonography suggested the presence of a pelvic collection. Explorative laparotomy revealed the simultaneous presence of Meckel's diverticulitis and appendicitis without bowel perforation(20).

4. Acute myeloid leukemia
There is a report of a 59-year-old Caucasian female was admitted to the surgical service with acute right lower quadrant pain, nausea, and anorexia. She was noted to have leukocytosis, anemia, and thrombocytopenia. Abdominal imaging demonstrated appendicitis with retroperitoneal and mesenteric lymphadenopathy for which she underwent laparoscopic appendectomy. Peripheral smear, bone marrow biopsy, and surgical pathology of the appendix demonstrated acute myeloid leukemia (AML) with nonsuppurative appendicitis(21).

5.  Leukemia and lymphoma of the appendix
There is a report of a first detailed description of acute myeloid leukaemia involving the appendix, and three cases of lymphomatous infiltration of the appendix presenting with appendicitis(22).

6. Adenocarcinoma 
Acute inflammation of the appendix secondary to luminal obstruction is the chief reason for appendectomy. The rare association of a malignant neoplastic process with the inflammatory process is usually an unexpected finding and is often not diagnosed until the histologic study has been completed. There is a report of two patients with adenocarcinoma of the appendix(23).

 

IV. Misdiagnosis and diagnosis
A. Misdiagnosis
1. Diverticulitis 
According to the study by the Hôpital Saint-Joseph, appendicitis and diverticulitis of the colon are the two main causes of febrile acute abdomen in adults. Diagnosis from imaging (ultrasound and CT) is usually easy. However, an imaging procedure which is not suitable for the clinical situation and an examination performed with the wrong protocol are sources of error and must be avoided. Anatomical variants, inflammatory cancers, complicated forms (perforation, secondary occlusion of the small intestine, peripheral abscesses, fistulae, pylephlebitis, liver abscesses) and associated signs related to a peritoneal inflammatory reaction (reflex ileus, reactive ileitis or salpingitis) can also lead to a wrong diagnosis(24).

2. Visceral myopathy
Visceral myopathy is rare pathological condition of gastrointestinal tract with uncertain clinical presentation and unknown etiology. It is a very rare group of disease and poorly understood condition that may present with chronic or acute intestinal pseudo-obstruction and often mimic other more common gastrointestinal disease. VM should be considered as differential diagnosis whenever the patient presents with acute appendicitis, uncharacteristic abdominal symptoms, recurrent attacks of abdominal distention, and pain with no radiological evidence of intestinal obstruction, according to the First Hospital of Jilin University(25).

3. Malignant lymphoma
There is a report of a case of localized malignant lymphoma of the appendix associated with the histological features of acute inflammation that presented clinically as acute appendicitis(26).


4. Herniation pit
herniation pits of the right femoral neck should be considered a potential cause of right lower abdominal pain mimicking acute appendicitis, particularly if the psoas sign and obturator sign are positive and the patient is physically active(27).

5. Acute scrotum
Acute appendicitis presents typically with periumbilical pain that in a few hours settles at the right lower quadrant of the abdomen. Atypical presentations are common but association with acute scrotum is an extreme rarity(28).

6. Testicular mass
There is a report of a case where ultrasound demonstrated an inflamed appendix and a scrotal abscess, allowing the correct surgical management in a difficult clinical situation. In a child presenting with scrotal signs and vague lower abdominal symptoms, an ultrasound assessment of the right iliac fossa should always be performed(29).

7. Cystic lymphangiomas 
There is a report of a case of a 4-year-old boy who was admitted to our hospital because of the right lower quadrant acute abdominal pain suspect of acute appendicitis. At laparotomy, a giant, cystic, encapsulated and lipomatous mesenterial mass was found, 15 x 15 x 10 cm in size, infiltrating the jejunum. The tumor was located 70 cm from Treitz's ligament(30).



V. Preventions
1. A vegetarian diet
Compared with non-vegetarians, Western vegetarians have a lower mean BMI (by about 1 kg/m2), a lower mean plasma total cholesterol concentration (by about 0.5 mmol/l), and a lower mortality from IHD (by about 25%). They may also have a lower risk for some other diseases such as constipation, diverticular disease, gallstones and appendicitis, according to the study by the  University of Oxford(31). 

2. Dietary fiber
In the study of means of food diaries the average daily fiber consumption  in 31 patients with acute appendicitis and in 30 control patients, matched for age and sex with the average daily dietary fiber intake was 17.4 g in the group with appendicitis and 21.0 g in the control group, showed that the difference is statistically significant. Adjustment for the total energy intake in each instance did not change this conclusion. The results support the hypothesis that diet, in particular a lack of fiber, may be an important factor in the pathogenesis of acute appendicitis(32).

3. Less non-potato vegetables and fruit
 In the study of comparison of food consumption between the four countries, and between the health board areas of Eire and regions of Scotland, shows that appendicitis rates are highest in communities that consume more potatoes, sugar, and cereals, and less non-potato vegetables and fruit(33).

4. Green vegetables and tomatoes
In the study to assess the rates of acute appendicitis in 59 areas of England and Wales with consumption of different foods per caput, measured from household food purchases, showed that there was a statistically significant positive correlation with potato consumption and a negative correlation with non-potato vegetables. This negative correlation depended mainly on green vegetables and tomatoes. There was no consistently significant correlation with any other main food group. In particular the correlations with cereal foods, cereal fibre, and total dietary fibre were small and not significant. Green vegetables and tomatoes may protect against appendicitis, possibly through an effect on the bacterial flora of the appendix(34).


VI. Treatments
A. Treatment in conventional medicine perspective 
1. Laparoscopic and Open Appendectomy

In the study using the data from the 2007 to 2009 Taiwan National Health Insurance Research Database. The study sample included 65,339 patients, hospitalized with a discharge diagnosis of acute appendicitis (33.8% underwent laparoscopic appendectomy). A generalized estimated equation (GEE) was performed to explore the relationship between the use of laparoscopy and 30-day re-admission. Hierarchical linear regressions were performed to examine the relationship between the use of laparoscopy, the length of stay (LOS), and the cost per discharge, showed that a significantly lower proportion of patients undergoing laparoscopic appendectomies were re-admitted within 30 days of their index appendectomy, in comparison to patients undergoing open appendectomies (0.66% versus 1.925, p<0.001). Compared with patients undergoing open appendectomies, patients undergoing laparoscopic appendectomies had a shorter LOS (4.01 versus 5.33 days, p<0.001) and a higher cost per discharge (NT$40,554 versus NT$38,509, p<0.001. In 2007, the average exchange rate was US$1 = NT$31.0). GEE revealed that the odds ratio of 30-day readmission for patients undergoing laparoscopic appendectomy was 0.38 (95% CI = 0.33-0.46) that of patients undergoing open appendectomies, after adjusting for surgeon, hospital, and patient characteristics, as well as for the clustering effect of particular surgeons and the propensity score(35).
 
2. Draining an abscess before appendix surgery 
If in case if your appendix has burst and an abscess has formed around it. In the study to analyze retrospectively our experience with this disease to value the results of drainage of the abscess and appendectomy in one stage in presence of appendiceal abscesses, showed that preoperative ultrasonography showed an accuracy of 85.7% in detecting the presence of an abscess. Mean size of the abscesses were 5 cm (from a minimum of 3 cm to a maximum of 9 cm). The mean duration of surgical operation was 48 minutes (min 35'-max 95'), with a mean in-hospital stay of 6.2 days. Morbidity rate was 9% and was due in 75% of cases to wound infection and in 25% of cases to wound dehiscence. Neither major morbidity nor mortality were observed. In consideration of the results the authors conclude that even in presence of an appendiceal abscess, appendectomy with abscess drainage is not only a safe operation with a low morbidity rate but the procedure of choice allowing a significative reduction of hospitalization and health cost(36).

B. Treatment in Herbal medicine perspective 
1. Phaseolus angularis Wight (adzuki bean)
Phaseolus angularis Wight (adzuki bean) is an ethnopharmacologically well-known folk medicine that is prescribed for infection, edema, and inflammation of the joints, appendix, kidney and bladder in Korea, China and Japan. According to the study by the, Pa-EE dose-dependently suppressed the release of PGE(2) and NO in LPS-, Poly(I:C)-, and pam3CSK-activated macrophages. Phaseolus angularis ethanol extract (Pa-EE) strongly down-regulated LPS-induced mRNA expression of inducible NO synthase (iNOS) and cyclooxygenase (COX)-2. Interestingly, Pa-EE markedly inhibited NF-κB, activator protein (AP)-1, and cAMP response element binding protein (CREB) activation; further, according to direct kinase assays and immunoblot analyses, Pa-EE blocked the activation of the upstream signaling molecules spleen tyrosine kinase (Syk), p38, and transforming growth factor β-activated kinase 1 (TAK1). Finally, orally administered Pa-EE clearly ameliorated EtOH/HCl-induced gastritis in mice(37).

2. Cinnamomum cassia 
Cinnamomum cassia Blume (Aceraceae) has been traditionally used to treat various inflammatory diseases such as gastritis. According to the study by the Sungkyunkwan University,  95% ethanol extract (Cc-EE) of Cinnamomum cassia exerts strong anti-inflammatory activity by suppressing Src/Syk-mediated NF-κB activation, which contributes to its major ethno-pharmacological role as an anti-gastritis remedy. Future work will be focused on determining whether the extract can be further developed as an anti-inflammatory drug(38).


 
C. Treatment in Traditional Chinese medicine perspective 
Traditional Chinese medicine on a weight basis, includes 190-210 parts of gentrin knotweed, 190-210 parts of sargentodoxa cuneata, 190-210 parts of common reed rhizome, and 140-160 parts of licorice. The medication  has the effects of clearing heat clearing and removing toxicity, antibiosis and antiphlogosis, dispelling wind and expelling parasites, dispersing blood stasis and relieving pain, removing edema and dissipating binds on acute and chronic appendicitis patients, can gradually restore the appendix tissue and the functions, causes less recurrence after a patient is cured, is convenient for use, can reduce pain, has no toxic or side effect, and is cheap and highly-effective, according to the Abstract of study (English, CN 102266504 B) posted in Ip.com(39). 

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