Tip appendicitis: clinical implications and management. Am J Surg

Department of General Surgery, Hadassash-Hebrew University Medical Center, Jerusalem, Israel.
American journal of surgery (Impact Factor: 2.29). 10/2008; 197(2):211-5. DOI: 10.1016/j.amjsurg.2008.04.016
Source: PubMed


Tip appendicitis describes a rare condition involving inflammatory changes of the distal appendix. We discuss the significance and management of this entity when it is identified on computed tomography (CT) imaging.
CT scans performed at our institution between 2003 and 2007 were reviewed to identify cases of tip appendicitis. Patients were divided into 2 groups, determined by the confirmation of appendicitis on histopathology. Radiological findings and the clinical courses of both groups were documented and compared using univariate analysis.
Of 18 patients with the CT finding of tip appendicitis, appendicitis was ultimately confirmed in 39%. Patients in this group had a higher rate of right lower quadrant (RLQ) tenderness (100% vs 55%, P = .04), leukocytosis (14.2 vs 10.5, P = .03), and clinical suspicion for acute appendicitis (43% vs 0%, P = .02). There were no complications or re-admissions.
The CT finding of tip appendicitis can be managed conservatively in a subset of patients with low clinical suspicion for acute appendicitis.

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    • "Appendiceal obstruction leading to appendicitis can occur anywhere along the appendix [15, 24]. Therefore, if only a small part of the appendix is involved, the inflammation may be limited to the tip [43]. Incomplete visualisation of the whole length of the appendix due to position can lead to a false-negative result if only the tip of the appendix is involved. "
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    ABSTRACT: Acute appendicitis is a common surgical emergency in the paediatric population. Computed tomography (CT) has been shown to have high accuracy and low operator dependence in the diagnosis of appendicitis. However, with increased concerns regarding CT usage in children, ultrasound (US) is the imaging modality of choice in patients where appendicitis is suspected. This review describes and illustrates the step-wise graded-compression technique for the visualisation of the appendix, the normal and pathological appearances of the appendix, as well as the imaging characteristics of the common differentials. • A step-wise technique improves the chances of visualisation of the appendix. • There are often several causes for the non-visualisation of the appendix in children. • A pathological appendix has characteristic US signs, with several secondary features also identified. • There are multiple common differentials to consider in the paediatric patient.
    Insights into Imaging 08/2013; 4(6). DOI:10.1007/s13244-013-0275-3
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    ABSTRACT: Despite many efforts to reduce unnecessary appendectomy for appendicitis, the negative appendectomy rate remains relatively high. Here, we investigated predisposing factors for normal appendix by analyzing the surgical outcomes for patients with equivocal appendicitis. Over a 3-year period, 1516 patients underwent treatment for appendicitis and 148 (10%) were prospectively diagnosed with equivocal appendicitis. We defined equivocal appendicitis as a right lower quadrant pain with tenderness and an apppendiceal diameter of 6 to 9 mm without appendicolith or severe adjacent inflammation as radiological findings. We investigated normal appendix rates in relation to clinical and radiological features. Of the 148 patients, 48 (32%) had a normal appendix and 100 had appendicitis. A higher normal appendix rate was found for low white blood cell count than for leukocytosis (41% vs 23%, odds ratio (OR) = 2.48), and laparoscopic treatment was then open (42% vs 21%, OR = 2.58). Distal appendiceal dilatation, as determined by radiological imaging, was associated with a higher normal appendix rate than whole dilatation (60% vs 27%, OR = 3.96). Low white blood cell count, laparoscopic treatment, and distal appendiceal dilatation were significant predisposing factors for normal appendix after surgery. Radiologically determined distal dilatation of the appendix may be a useful sign for predicting normal appendix.
    The American surgeon 02/2010; 76(2):211-4. · 0.82 Impact Factor
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    ABSTRACT: ABSTRACT Background: Acute appendicitis is the most common surgical emergency of the childhood. Its diagnosis is really challenging. A constellation of through history taking, physical examination, radiographic investigations, and laboratory analysis should be used to balance the risk of delayed operative intervention against the removal of a normal appendix. Here a case with misdiagnosis of acute appendicitis instead of Amanita Phalloides intoxication was presented. Case: A 6-years-girl was referred with history of constant, not-colicky lower quadrant and periumblical abdominal pain from 24 hours ago; associated with nausea and vomiting. In physical examination generalized tenderness particularly in lower quadrants was found. leukocytosis (WBC=22000) with a shift to left (PMN=91%) and hypoglycemia was found too. Alvarado score for diagnosis of acute appendicitis was 7 out of 10. In laparotomy, the appendix appeared normal. Blood study revealed INR>7 during operation which was partially corrected with FFP infusion. The patient developed decreased levels of consciousness and was transferred to ICU. Further history takenfrom her family by the clinical toxicologist revealed that she had eaten wild mushrooms. After examination of the remaining mushrooms by an experienced biologist, the diagnosis of Amanita Phalloides intoxication was established. The patient died tomorrow regardless of appropriate interventions. Conclusion: Mushroom poisoning should be taken into account in evaluation of the patients suspected to have acute appendicitis. If diagnosis of mushroom poisoning was made earlier by proper history taking and a high index of suspicion, the patient would receive the available treatment modalities earlier and her chance of survival would increase.
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