Abstracts

Cholecystitis

In about 95% of patients with cholecystitis the cystic duct is obstructed by a gall stone. The imprisoned bile salts have a toxic action on the gall bladder wall. Acute cholecystitis is liable to be confused with other causes of sudden pain and tenderness in the right hypochondrium. Below the diaphragm, acute retrocecal appendicitis, intestinal obstruction, a perforated peptic ulcer or acute pancreatitis may be confusing factors. The treatment of choice is elective cholecystectomy.

"Acute cholecystitis -- conservative therapy." Forssmann, K. & Singer, M.V. Schweiz-Rundsch. Med. Prax. 1994 Aug 9; 83(32): 877-9. [In German]

Computer

Computer diagnosis

To evaluate physicians' probability estimates of acute appendicitis based on structured collection of clinical data.

Initial diagnostic accuracy of physicians was compared with corresponding results from a computer model.

Physicians' estimates had a mean area under ROC-curve of 0.81, not significantly different from the computer model. Both correlated well with the actual rate of appendicitis, but the physicians tended to overestimate the probability by 10%.

Physicians' probability estimates perform rather well. Further attempts to implement a probabilistic approach in the diagnostic process of acute appendicitis therefore seem justified.

Hallan S et al., Estimating the probability of acute appendicitis using clinical criteria of a structured record sheet: the physician against the computer. Eur J Surg, 1997 Jun, 163:6, 427-32.

Imaging

Patients with right lower quadrant (RLQ) pain referred for imaging studies with a clinical diagnosis of appendicitis may have other pathologic conditions mimicking appendicitis. Appropriate diagnostic imaging may establish other specific diagnoses and thereby play a significant role in determining proper medical or surgical treatment.

The differential diagnoses of diseases mimicking appendicitis are reviewed.

Jain KA et al., Imaging findings in patients with-right lower quadrant pain: alternative diagnoses to appendicitis. J Comput Assist Tomogr, 1997 Sep-Oct, 21:5, 693-8.

Infection

The aetiology of appendicitis, the commonest cause of acute abdomen, is unknown. Infection has been proposed but the evidence has been unconvincing. The purpose of the present study was to investigate if temporo-spatial clustering and outbreaks, characteristics of infectious diseases, could be found in appendicitis cases in a defined Swedish population.

Three outbreaks with a significantly increased number of cases were observed during the 22-year study period.

The finding of temporo-spatial interaction and outbreaks among appendicitis cases supports the concept that appendicitis may be caused by infectious agents.

Andersson R et al., Clusters of acute appendicitis: further evidence for an infectious aetiology. Int J Epidemiol, 1995 Aug, 24:4, 829-33.

Incidence

Incidence (England)

Previous reports have shown a marked decrease in the incidence of acute appendicitis. This study has set out to discover whether this decrease has continued. The pathology records over 15 years have been reviewed to tabulate the frequency of appendicitis in one large district general hospital. The incidence of appendicitis was seen to decrease from approximately 100 to 52 over the 15-year period. This continuing decrease in the incidence of acute appendicitis has implications on acute surgical bed usage, experience for trainee surgeons and referral patterns for general practitioners.

"Continuing fall in the incidence of acute appendicitis." McCahy,P. Ann.R. Coll. Surg. Engl. 1994 Jul; 76(4): 282-3.

Menses

To examine the influence of the menstrual cycle on the incidence and presentation of acute appendicitis.

There were no significant differences in the incidence of acute, gangrenous, or perforated appendicitis in patients operated on during the various phases of the menstrual cycle. During menstruation, however, a normal appendix not accompanied by other disease was found significantly more often. Clinical presentation, physical findings, and laboratory results did not vary throughout the menstrual cycle except for the "classic shifting pain" which was significantly more common during the luteal phase.

Acute appendicitis occurs randomly during the various phases of the menstrual cycle. The incidence of operations for uninflamed appendixes may be higher during the menstrual phase. Significantly more negative laparotomies are done during the menstrual phase, which suggests the existence of a functional disorder that mimics acute appendicitis.

Eldar S et al., The menstrual cycle and acute appendicitis. Eur J Surg, 1995 Dec, 161:12, 897-900.

Minorities

Minority communities

Examined the incidence and epidemiological factors of acute appendicitis in various ethnic groups in an urban minority community.

Acute appendicitis constituted 3.1% of all emergency admissions to the surgical service over the period studied and represented 4.5% of surgical service admissions from the emergency department in Hispanics, 1.9% in African Americans, 1.5% in whites, and 21% in Asians.

Results indicate that acute appendicitis is responsible for a higher incidence of emergency admissions among Hispanics than among African Americans. This finding was statistically significant. High white blood cell counts indicated inflammation of the appendix, but had no predictive value for the type of pathology.

Surgical findings were similar in all groups.

Gerst PH et al., Acute appendicitis in minority communities: an epidemiologic study. J Natl Med Assoc, 1997 Mar, 89:3, 168-72.

Neurogenic

Routine exeresis should not be performed if a normal organ is observed during an exploratory procedure, but should be in cases with clinical manifestations of right flank pin since neurogenic appendicitis is not rare. Clinically, neurogenic appendicitis is usually chronic and the appendix appears healthy in situ. Cure is always achieved with resection.

"Neurogenic appendicitis." Aouad,K.; Clotteau, J.E.; Premont, M.; Lemaigre,C. Presse Med. 1994,23(20):940-2. [In French.]

Nutrition & Health

Intensive animal rearing, manipulation of crop production and food processing have altered the qualitative and quantitative balance of nutrients of foods consumed by Western society. Consequently, a rising trend in the incidence of obesity, diabetes, high blood pressure, cardiovascular diseases, dental decay and appendicitis is apparent. Most of these chronic diseases are lifestyle related and are preventable.

"Nutrition and health in relation to food production and processing." Ghebremeskel, M. & Crawford, M.A. Nutr. Health. 1994; 9(4): 237-53.

Ovarian

Ovarian cancer

A retrospective analysis of 136 patients with ovarian carcinoma subjected to appendectomy as a part of surgical procedure was carried out. Of the 136 patients studied, 94 had epithelial and 38 had non-epithelial type of primary ovarian carcinoma. In the remaining 4 patients, the primary operation was performed with an intraoperative diagnosis of ovarian carcinoma but the final pathological examination revealed appendiceal carcinoma metastatic to the ovaries.

The overall appendiceal involvement was 32.5%(43/132). This figure was 15.7% and 39.3% for non-epithelial and epithelial tumors, respectively. Involvement of the appendix ranged from 8.8% for patients with stage I disease to 46% for patients with stage III-IV disease. Routine appendectomy is appropriate for staging early cases and for contributing to maximal cytoreduction in advanced cases.

"Is routine appendectomy beneficial in the management of ovarian cancer?" Ayhan, A. et al., Eur. J. Obstet. Gynecol. Reprod. Biol. 1994 Oct; 57(1): 29-31.

Ultrasound

Evaluated the diagnostic accuracy of clinical judgment and diagnostic ultrasonography (US) used routinely and to create a scoring system to aid diagnosis.

(67%) underwent appendicectomy and the remaining 74 patients were observed. 193 Patients (87%) had a diagnostic US examination. 21 Predictive variables were collected prospectively to create a scoring system.

The decision to operate was made by a junior surgeon solely on the clinical examination, which yielded a diagnostic accuracy of 76%, specificity of 58%, and negative appendicectomy rate of 36%.

193 Patients underwent diagnostic US conducted by the radiologist on call of whom 123 were operated on, 78 for histologically proven appendicitis. US had a diagnostic accuracy of 72%, sensitivity of 49%, and specificity of 88%.

The clinical judgment of a junior surgeon was disappointing, and diagnostic aids are desirable to reduce the negative appendicectomy rate. Diagnostic US performed poorly as a routine procedure. Application of an up to date scoring system might be of some help to patients with a high or low probability of acute appendicitis, but any conclusion about its clinical application cannot be drawn from this study.

Jahn H et al., Comparison of clinical judgment and diagnostic ultrasonography in the diagnosis of acute appendicitis: experience with a score-aided diagnosis. Eur J Surg, 1997 Jun, 163:6, 433-43.

Urbanization

Urbanization (Africa)

In populations in sub-Saharan Africa, transitional changes in patterns of morbidity and mortality are taking place, with decreases in the diseases of poverty and infection, but rises in chronic diseases of prosperity, associated, however, with greater longevity. Remarkably, bowel diseases - appendicitis, diverticular disease, colon cancer - while nearly absent in rural areas, have very low incidences in urban dwellers, despite rises in risk factors, including a decreasing intake of fibre-containing foods.

Currently, there is no explanation for the phenomenon, which stands in marked contrast to the considerable rises which have occurred in dental caries, obesity in women and diabetes.

Walker AR & Segal I: Effects of transition on bowel diseases in sub-Saharan Africans. Eur J Gastroenterol Hepatol, 1997 Feb, 9:2, 207-10.