JOURNAL CONFERENCE

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JOURNAL CONFERENCE

• Reporter ?????
• Supervisor?????
• 2003/10/06

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The Anatomy of Appendicitis

• Appendix in a hidden location
• 15 of patients with simple appendicitis or
  without
• appendicitis
• 68 of patients with gangrenous or perforative
• appendicitis
• Complications were more frequent, and hospital
  stays were longer in patients with advanced
  appendicitis
• Anatomic variations in the location of the
  appendix are often responsible for delays in the
  diagnosis of appendicitis.

American Surgeon. 60(1)68-71, 1994 Jan.
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Retrocecal Appendicitis

• 26 noted in a study of 71000 human appendix
  specimens removed
• 4 located at RUQ
• Pain of acute appendicitis may localize to the
  flank rather than RLQ

Am J Epidermal 132910, 1990
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Clinical Course of Retrocecal Appendicitis

• There was no statistical difference between the
  retrocecal or anterior intraperitoneal in
  duration of symptoms, presenting signs and
  symptoms, and initial white blood cell count.
• Retrocecal appendicitis was not associated with a
  higher rate of perforation or increased
  morbidity.

Arch Surg. 1991 May126(5)569-70.
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Case Report of Retrocecal Appendicitis

• A case of right scrotal abscess due to a
  preceding retroperitoneal abscess originating
  from retrocecal appendicitis after appendectomy

Kaohsiung J Med Sci. 2003 May19(5)242-5.
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Case Report of Retrocecal Appendicitis

• Two pediatric patients with retrocecal
  appendicitis that presented with perinephric
  abscess.
• Ruptured retrocecal appendix must be considered
  in cases of perinephric abscess, especially in
  patients with gas bubbles in the abscess and a
  normal urogenital appearance.

Pediatr Nephrol. 2002 Mar17(3)177-80
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Case Report of Retrocecal Appendicitis

• A case of an 8-year-old boy with a 12-hour
  history of right hemiscrotal pain secondary to
  acute retrocecal nonperforated appendicitis.
• Surgical exploration showed a patent "processus
  vaginalis."

J Pediatr Surg. 1998 Sep33(9)1435-6
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N Engl J Med. 2003 Jan 16348(3)236-42
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The MANTRELS Score

• Migration of pain to right lower quadrant
• Anorexia
• Nausea and vomiting
• Tenderness in right lower quadrant
• Rebound pain
• Elevated temperature
• Leukocytosis
• Shift of white blood cell count to left

Ann Emerg Med 1986 15557-564
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Misdiagnosis of Acute Appendicitis

• Approximately 10 of adults who develop
  appendicitis are not diagnosed correctly at the
  first physician encounter
• Special concerns
• Pregnancy
• Non pregnant women of childbearing age
• Children
• Elderly

Emedicine June 19, 2003
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Computed Tomography

• CT had greater sensitivity, greater accuracy than
  abdominal echo, but there were smaller
  differences in specificity.
• Among patients who did not have acute
  appendicitis, the correct alternative diagnosis
  was based on CT studies more frequently than on
  ultrasonographic studies.
• Taking into account the costs of an unnecessary
  appendectomy, one day of inpatient observation,
  and the CT scan, the use of CT resulted in an
  average cost savings of 447 per patient.

N Engl J Med. 2003 Jan 16348(3)236-42
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Whether CT should be performed

• The use of intravenous iodinated contrast
  material or enteric contrast material is a
  controversial matter.
• Intravenous contrast
• Improves the delineation of a thickened appendix
  wall, as well as the detection of inflammation
  within and surrounding the appendix, leading to
  improved diagnostic accuracy.

N Engl J Med. 2003 Jan 16348(3)236-42
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Whether CT should be performed

• Enteric contrast
• Permit definitive identification of the terminal
  ileum and cecum, since terminal ileitis can mimic
  appendicitis both clinically and
  radiographically.
• The spiral CT technique with slice thickness of
  no more than 5 mm is critical for accurate
  imaging of acute appendicitis.
• In addition to the scanning technique, the skill
  and experience of the radiologist influence the
  usefulness of the examination.

N Engl J Med. 2003 Jan 16348(3)236-42
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N Engl J Med. 2003 Jan 16348(3)236-42