ArticlePDF Available

Ultrasound features and the diagnostic strategy of subhepatic appendicitis

Authors:

Abstract and Figures

Background: This study aimed to compare the differences of ultrasound findings between subhepatic appendicitis and appendicitis at a normal position, then discuss the diagnostic strategies and improve the accuracy of diagnosis. Methods: A retrospective analysis was performed in our hospital. One thousand five hundred ninety-one patients with appendicitis were diagnosed from January 2014 to January 2018. Eighteen patients with subhepatic appendicitis and 25 patients with appendicitis with regular positions were selected randomly as the control group. The difference in ultrasound features between the two groups was studied. Comparisons between the two groups showed statistically significant differences in the frequencies of the fishbone sign, enlarged appendix, appendicoliths, and hyperechoic omental cap (P<0.05). Results: Statistical significance was not observed with the difference in the frequency of whether there was lymphadenectasis (P>0.05) in the abdominal cavity between the two groups. The Pareto chart was drawn to look for the main factors associated. The results of interpretation on the critical points of diagnosis for subhepatic appendicitis: (I) the fishbone sign of a dilated ileum in the right lower abdomen; and (II) the fishbone sign of a dilated ileum in the right lower abdomen + presence of an enlarged appendix in the right upper abdomen. Conclusions: An abnormally dilated ileum in the right lower abdomen - the fishbone sign, is a vital sign leading to the diagnosis of subhepatic appendicitis. The fishbone sign of a dilated ileum in the right lower abdomen + whether there is a vermiform structure is an important diagnostic indicator for subhepatic appendicitis.
Page 1 of 11
© Annals of Translational Medicine. All rights reserved. Ann Transl Med 2020;8(17):1083 | http://dx.doi.org/10.21037/atm-20-5265
Ultrasound features and the diagnostic strategy of subhepatic
appendicitis
Dong Yu1#, Chenyao Gu2#, Shuchen Zhang2, Hui Yang3, Taotao Yao4
1Department of Radiology, Jizhong Energy Fengfeng Group Hospital, Handan, China; 2Department of Radiology, Yancheng No. 1 People’s
Hospital, Yancheng, China; 3Department of Orthopaedic, Jizhong Energy Fengfeng Group Hospital, Handan, China; 4Rehabilitation Center, the
First Afliated Hospital of Guangzhou University of Traditional Chinese Medicine, Guangzhou, China
Contributions: (I) Conception and design: D Yu; (II) Administrative support: S Zhang; (III) Provision of study materials or patients: C Gu; (IV)
Collection and assembly of data: H Yang; (V) Data analysis and interpretation: T Yao; (VI) Manuscript writing: All authors; (VII) Final approval of
manuscript: All authors.
#These authors contributed equally to this work.
Correspondence to: Dr. Shuchen Zhang. Department of Radiology, Yancheng No. 1 People’s Hospital, 166 Yulong Road, Tinghu District, Yancheng,
China. Email: 2220099999@qq.com.
Background: This study aimed to compare the differences of ultrasound findings between subhepatic
appendicitis and appendicitis at a normal position, then discuss the diagnostic strategies and improve the
accuracy of diagnosis.
Methods: A retrospective analysis was performed in our hospital. One thousand five hundred ninety-
one patients with appendicitis were diagnosed from January 2014 to January 2018. Eighteen patients with
subhepatic appendicitis and 25 patients with appendicitis with regular positions were selected randomly as
the control group. The difference in ultrasound features between the two groups was studied. Comparisons
between the two groups showed statistically significant differences in the frequencies of the fishbone sign,
enlarged appendix, appendicoliths, and hyperechoic omental cap (P<0.05).
Results: Statistical significance was not observed with the difference in the frequency of whether there was
lymphadenectasis (P>0.05) in the abdominal cavity between the two groups. The Pareto chart was drawn
to look for the main factors associated. The results of interpretation on the critical points of diagnosis for
subhepatic appendicitis: (I) the fishbone sign of a dilated ileum in the right lower abdomen; and (II) the
fishbone sign of a dilated ileum in the right lower abdomen + presence of an enlarged appendix in the right
upper abdomen.
Conclusions: An abnormally dilated ileum in the right lower abdomen – the fishbone sign, is a vital sign leading
to the diagnosis of subhepatic appendicitis. The fishbone sign of a dilated ileum in the right lower abdomen +
whether there is a vermiform structure is an important diagnostic indicator for subhepatic appendicitis.
Keywords: Subhepatic appendicitis; the fishbone sign; hyperechoic omental cap; diagnostic strategy; 20/80 rule;
the Pareto principle
Submitted Jun 17, 2020. Accepted for publication Aug 25, 2020.
doi: 10.21037/atm-20-5265
View this article at: http://dx.doi.org/10.21037/atm-20-5265
Introduction
EAES and WSES guidelines recommended to make
a combination of “ultrasound” and comprehensive
clinical indicators” to form a clinical-imaging score
could significantly improve the sensitivity and specificity
of appendicitis diagnosis, and reduce the need for CT
examinations in the diagnosis of acute appendicitis.
Although the clinical-imaging score could significantly
improve the accuracy and specificity of appendicitis
diagnosis, the diagnosis of appendicitis remained to be a
1083
Original Article
Yu et al. Ultrasound features of subhepatic appendicitis
© Annals of Translational Medicine. All rights reserved. Ann Transl Med 2020;8(17):1083 | http://dx.doi.org/10.21037/atm-20-5265
Page 2 of 11
challenge and the clinical management of appendicitis was
also in dispute (1). After review of the appendicitis surgery
data in our hospital from January 2014 to January 2018,
we found that the main reason for the missed diagnosis
of appendicitis was the abnormal location of the appendix
(the appendix located far away from the McBurney point).
Subhepatic appendicitis is a common type of variation in
the position of the appendix, with low morbidity and a high
rate of missed diagnosis (2). The common type of abnormal
appendicitis was subhepatic appendicitis. In this review and
analysis, the diagnostic accuracy of subhepatic appendicitis
in our hospital was only 11.1%. Due to the overhigh rate
of missed diagnosis, we focused on the ultrasound diagnosis
in subhepatic appendicitis. For open appendectomy
(OA), the accurate diagnosis of subhepatic appendicitis by
ultrasound and body surface positioning could help the
surgeon find the best surgical incision in the upper right
abdomen. For LA and SLA, the ultrasound could help the
surgeon select a more easy-to-operate “hole”. This was a
retrospective cohort study on the ultrasound features of
subhepatic appendicitis. Combining the 20/80 rule and
the Pareto principle, this study made logical judgments
on the combination of direct ultrasonic images with
indirect ultrasonic images of subhepatic appendicitis and
explored the diagnostic strategy of subhepatic appendicitis
(3-5). The effective combination of statistical method and
logical judgment method was an exploration of a whole
new diagnostic mode in clinical study. The improvement
of accuracy in the diagnostic of subhepatic appendicitis by
ultrasound provided a basis for selection of surgical timing
and surgical methods.
We present the following article in accordance with the
STROBE reporting checklist (available at http://dx.doi.
org/10.21037/atm-20-5265).
Methods
Patients
All procedures performed in this study involving human
participants were in accordance with the Declaration of
Helsinki (as revised in 2013). This study was reviewed
and approved by the Ethics Committee of Jizhong Energy
Fengfeng Group Hospital and informed consent was
taken from all the patients. Totally 1,591 patients with
appendicitis who were treated at Jizhong Energy Fengfeng
Group Hospital between January 2014 and January
2018 were analyzed, and 20 patients with subhepatic
appendicitis, confirmed through an open appendectomy,
or laparoscopic appendectomy, was selected as the
population. Eighteen of the patients had complete clinical
data and preoperative US data.
Inclusion criteria: for the group of patients with
subhepatic appendicitis (Group A), cases with complete
clinical data and ultrasound data were screened. For the
group of patients with appendicitis with normal position
(Group B). Appendicitis cases with complete data were
numbered and entered in the SPSS 21.0 software, and then
25 cases were randomly selected (Figure 1).
Exclusion criteria for the study were: (I) patients without
undergoing ultrasound examination before surgery; (II)
patients with incomplete clinical data; (III) cases without
having been conrmed through surgery; (IV) patients who
are complicated by periappendiceal abscess and not t for
phase I surgical treatment; (V) Crohns disease; (VI) right-
sided diverticulitis; (VII) right-sided segmental omental
infarction; (VIII) appendiceal lesions with appendiceal
mucocele.
Classication: the ultrasound-positive ndings in Group
A and Group B were sorted and classied on the screening
results and clinical experience.
Equipment
Philips IU Elite Ultrasound System with L512 linear array
probes and C15 sector probes, Philips HD15 Ultrasound
System with L312 linear array probes and C1–5 sector
probes, and HITACHI EUB-8500 Ultrasound System with
13-6 linear array probes and 5-2 sector probes were used.
Ultrasound techniques
During the ultrasound examination, the patients were
instructed to lie in a supine position, with the abdomen
exposed and a suitable amount of ultrasound gel applied.
An abdominal ultrasound examination starts with the
right lower abdomen. All the radiologists were trained
on the standard operating procedure for acute abdominal
ultrasound diagnosis.
Variables for observation: (I) the fishbone sign: When
the jejunum dilates in the lower abdomen, the small
intestinal mucosa can be recognized, and jejunal villi can
be recognized, presenting with fishbone-like ultrasound
findings; (II) enlarged appendix: a vermiform structure in
the right lower or upper abdomen, with a lumen diameter
>6 mm and a wall thickness >2 mm (6,7); (III) the presence
Annals of Translational Medicine, Vol 8, No 17 September 2020 Page 3 of 11
© Annals of Translational Medicine. All rights reserved. Ann Transl Med 2020;8(17):1083 | http://dx.doi.org/10.21037/atm-20-5265
Appendicitis with
another position
n=59
Subhepatic
appendicitis had
uncomplete data
n=2
Fish bone
sign
n=16
Vermiform
structure
n=5
The total Ultrasound
features (n=30)
Subhepatic appendicitis
n=20
Subhepatic appendicitis
had complete data
Group A (n=18)
Appendicitis with
abnormal position
n=79
Appendicitis
n=1,591
Vermiform
structure
n=22
Appendicoliths
n=14
Hyperechoic
omental cap
n=13
Fish bone
sign
n=4
Lymphadenect
asis
n=7
The total Ultrasound
features (n=60)
Appendicitis with normal
position
n=1,512
Random sampng
Group B (n=25)
Appendicoliths
n=2
Hyperechoic
omental cap
n=4
Lymphadenect
asis
n=3
Figure 1 Flow diagram for the patients. Data are presented as the number of patients in each category.
of lymphadenectasis in the abdominal cavity, with the ratio
of the long axis-short axis <2 and the short axis >5 mm (8);
(IV) appendicoliths: calcied fecal deposits that are known
as appendicoliths, manifested as strong cloddy echoes with
sound shadows behind on the ultrasound imaging (9-13); (V)
hyperechoic omental cap: thickened oedematous omentum
surrounding the appendix (Figures 2-5).
General clinical data
General clinical data include patient age, sex, body
mass index (BMI), white blood cell (WBC), neutrophil
percentage, body temperature, with or without the irritative
symptoms of peritonitis, with or without signs of metastatic
lower abdominal pain, and course of the disease.
Pareto chart and the Pareto principle
The Pareto principle: factors with a cumulative distribution
of 0% to 80% were primary, factors with a cumulative
distribution of 80% to 90% secondary, and factors with a
cumulative distribution of 90% to 100% general (14).
Pareto chart: a bar chart was drawn with the ultrasound
findings of appendicitis as the X-coordinate and the
number of patients with distinct types of appendicitis on
the ultrasound imaging as the Y-coordinate. A broken line
chart was drawn with the ultrasound ndings of appendicitis
as the X-coordinate and the cumulative percentage as the
Y-coordinate. Afterward, the bar chart and the broken
line chart were integrated with the Y-coordinate as the
benchmark to form a Pareto chart.
Pathological classication of appendicitis
Pathological classification: (I) acute simple appendicitis;
(II) acute phlegmonous appendicitis; (III) acute gangrenous
appendicitis; and (IV) periappendiceal abscess (15,16). As
patients with periappendiceal abscess are not fit for phase
I surgical treatment, this type of patient is not included in
this study.
Statistical methods
SPSS21.0 software was used for statistical analysis.
Measurement variables were expressed in
sx ±
, and
the t-test was used for comparing the differences in the
Yu et al. Ultrasound features of subhepatic appendicitis
© Annals of Translational Medicine. All rights reserved. Ann Transl Med 2020;8(17):1083 | http://dx.doi.org/10.21037/atm-20-5265
Page 4 of 11
Figure 2 The clinical and US features of subhepatic appendicitis. (A) Subhepatic appendicitis in a 40-year-old man. The short axis shows
an enlarged appendix with the target shape (arrow); (B) Long axis showing an enlarged appendix with 9 mm outside diameter (arrows);
(C) Dilated small intestinal showing shbone sign in the right lower abdomen (arrows); (D) enlarged appendix sitting under the liver in
laparoscopic appendectomy; (E) specimen of the appendix here; (F) HE 4×10 Hemorrhage and necrosis in the appendix with neutrophil
inltration; (G) HE 10×10 Marked neutrophilic inltrate within tunica muscularis.
Figure 3 Subhepatic appendicitis in a 20-year-old, hyperechoic
omental cap (arrows). Figure 4 Appendicolithiasis in 25-year-old women (arrows).
B
D E F
CA
G
measured values between the two groups. A Chi-square test
was used for comparison of count variables between the
two groups. The Contingency Table was used for ordered
categorical variables. Spearmans rank correlation was
used for testing on the correlation of ranked variables, and
P<0.05 showed a statistical difference. Remove cases with
incomplete data. The quality management tools of this
study are the Pareto chart and the Pareto principle. The
Pareto chart was drawn to nd the main diagnostic factors
according to the Pareto principle.
Results
Comparison of general clinical data
Group A: sex (male/female): 11/7; age (42.77±16.34);
BMI (23.78±4.89), WBC (14.39±2.01)×109; neutrophils %
(76.74±4.03); body temperature (8.28±0.60) ; irritative
symptoms of peritonitis (+/): 16/2; and duration from onset
to surgery (7.33±1.78) days. The total of 30 accumulated
ultrasound manifestations.
Group B: sex (male/female): 16/9; age (30.64±15.27);
Annals of Translational Medicine, Vol 8, No 17 September 2020 Page 5 of 11
© Annals of Translational Medicine. All rights reserved. Ann Transl Med 2020;8(17):1083 | http://dx.doi.org/10.21037/atm-20-5265
BMI (24.32±3.88); WBC (13.01±2.71)×109; neutrophils %
(74.49±3.32); body temperature (38.41±0.57) ; irritative
symptoms of peritonitis (+/): 25/1; and duration from onset
to surgery (4.16±1.49) days. The total of 60 accumulated
ultrasound manifestations.
P was greater than 0.05 for comparison between the two
groups, showing that there were no statistically signicant
differences in the clinical data of the patients between the
two groups (Table 1).
Comparison of ultrasound ndings between Group A and
Group B
Comparisons between the two groups showed an χ2=28.135
with a P value <0.05 for the fishbone sign of dilated
ileum in the right lower abdomen, an χ2=16.245 with
a P<0.05 for vermiform structure, an χ2=9.026 with a
P<0.05 for appendicoliths, and an χ2=3.882 with a P<0.05
for hyperechoic omental cap, with statistical significance
observed with differences in frequencies of the samples
between the two groups. For whether there was a presence
of lymphadenectasis, the comparison showed an χ2=0.753
with a P value of 0.386 greater than 0.05, indicating the
difference in the frequency between the two groups was not
statistically signicant (Table 2).
The observed variables of statistical significance are
screened out and ranked by the positive rate from highest to
lowest as follows:
In Group A: the fishbone sign in the right lower
abdomen (88.9%) > vermiform structure (27.8%) in the
right upper abdomen > hyperechoic omental cap (22.2%) >
appendicoliths (11.1%).
In Group B: vermiform structure in the right lower
abdomen (92.0%) > appendicoliths (56.0%) > hyperechoic
omental cap (52.0%) > dilated intestine in the right lower
abdomen (16.0%).
Appendicitis with normal position and subhepatic
appendicitis is divided into A, B, C and D types for
the two groups on the sequences of abnormal positive
ndings screened out using Chi-square test and on clinical
experience
In Group A: Type A: the fishbone sign in the right lower
abdomen; Type B: the fishbone sign in the right lower
abdomen + vermiform structure in the right upper
abdomen; Type C: the fishbone sign in the right lower
abdomen + vermiform structure in the right upper abdomen
+ hyperechoic omental cap; and Type D: the fishbone
sign in the right lower abdomen + vermiform structure
in the right upper abdomen + hyperechoic omental cap +
appendicoliths.
Figure 5 Regular posed appendicitis with panoramic ultrasound
imaging in a 19-year-old woman.
Table 1 Comparison of general clinical data between Group A and Group B
Variable Group A (n=18) Group B (n=25) F/χ2P
Sex (male/female) 11/7 16/9 0.037 0.847
Age (years) 42.77±16.34 30.64±15.27 0.156 0.695
BMI 23.78±4.89 24.32±3.88 1.220 0.276
WBC (×109) 14.39±2.01 13.01±2.71 1.410 0.242
Neutrophils % 76.74±4.03 74.49±3.32 1.834 0.183
Body temperature () 38.28±0.60 38.41±0.57 0.276 0.602
Irritative symptom (+/−) 16/2 25/1 0.088a0.767
Duration from onset to surgery 7.33±1.78 4.16±1.49 2.282 0.139
a, continuity correction.
Yu et al. Ultrasound features of subhepatic appendicitis
© Annals of Translational Medicine. All rights reserved. Ann Transl Med 2020;8(17):1083 | http://dx.doi.org/10.21037/atm-20-5265
Page 6 of 11
Table 3 Association analysis of Group A and Group B
Group Type A Type B Type C Type D Mean rank P
Group A 11 2 2 1 35.389 0.315
Group B 11 8 2 2 41.41
Table 2 Comparison of ultrasound ndings between Group A and Group B (%)
Variables of ultrasound characteristics Group A (n=18) Group B (n=25) χ2P
The fishbone sign 22.348 0.000
+ 16 (88.9) 4 (16.0)
2 (11.1) 21 (84.0)
Enlarge appendix 19.002 0.000
+ 5 (27.8) 23 (92.0)
13 (72.2) 2 (8.0)
Lymphadenectasis 0.252a0.616
+ 3 (16.7) 7 (28.0)
15 (83.3) 18 (72.0)
Appendicoliths 9.026 0.03
+ 2 (11.1) 14 (56.0)
16 (88.9) 11 (44.0)
Hyperechoic omental cap 3.882 0.049
+ 4 (22.2) 13 (52.0)
14 (77.8) 12 (48.0)
a, continuity correction.
In Group B: Type A: vermiform structure in the right
lower abdomen; Type B: vermiform structure in the right
lower abdomen + appendicoliths; Type C: vermiform
structure in the right lower abdomen + appendicoliths
+ hyperechoic omental cap; and Type D: vermiform
structure in the right lower abdomen + appendicoliths +
hyperechoic omental cap + the shbone sign in the right
lower abdomen.
Analysis using the contingency table for the ultrasonic
classification: the mean rank was 41.41 for Group B and
35.389 for Group A, with a P value of 0.315, supporting
the original hypothesis that the classification using the
diagnostic strategy for Group A was consistent to that for
Group B (Table 3).
Analysis of correlation between ultrasonic classification
and pathological classification: in Group B, ultrasonic
classification is positively correlated with pathological
classification, with a Spearmans correlation coefficient of
0.716. In Group A, ultrasonic classification is positively
correlated with pathological classication, with a Spearmans
correlation coefcient of 0.747 (Table 4).
Pareto chart and the Pareto principle
Group A: Type A and Type B were the main ultrasound
ndings, with a cumulative percentage of 81.25%. Type A:
the shbone sign of the dilated small intestine in the right
lower abdomen; Type B: the fishbone of the dilated small
intestine in the right lower abdomen + vermiform structure
in the right upper abdomen (Table 5; Figure 6).
Group B: Type A and Type B were the main ultrasound
ndings, with a cumulative percentage of 82.61%. Type A:
vermiform structure in the right lower abdomen; Type B:
vermiform structure + appendicoliths (Table 5; Figure 7).
Annals of Translational Medicine, Vol 8, No 17 September 2020 Page 7 of 11
© Annals of Translational Medicine. All rights reserved. Ann Transl Med 2020;8(17):1083 | http://dx.doi.org/10.21037/atm-20-5265
Table 5 The analysis of the ultrasound categorization of Group A and Group B
Categorization
Group A Group B
n Constituent ratio (%) Cumulative percentiles (%) n Constituent ratio (%) Cumulative percentiles (%)
Type A 11 68.75 68.75 11 47.83 47.83
Type B 2 12.50 81.25 8 34.78 82.61
Type C 2 12.50 93.75 2 8.70 91.30
Type D 1 6.25 100.00 2 8.70 100.00
Table 4 The association analysis on the ultrasound categorization and the pathological classication about subhepatic appendicitis
Group Type A Type B Type C Type D r (P)a
Group A 0.747
Acute simple appendicitis 8
Acute phlegmonous appendicitis 2 2
Acute gangrenous appendicitis 1 2 1
Total 11 2 2 1
Group B 0.716
Acute simple appendicitis 9 1
Acute phlegmonous appendicitis 1 6 1
Acute gangrenous appendicitis 1 1 1 2
Total 11 8 2 2
a, Spearman correlation test.
16
14
12
10
8
6
4
2
0
100.00%
80.00%
60.00%
40.00%
20.00%
0.00%
Group A
n
Cumulative
percentiles (%)
Type A Type B Type C Type D
Figure 6 Group A: Type A and Type B were the main ultrasound
ndings, with a cumulative percentage of 81.25%.
20
15
10
5
0
100.00%
80.00%
60.00%
40.00%
20.00%
0.00%
Group B
n
Cumulative
percentiles (%)
Type A Type B Type C Type D
Figure 7 Group B: Type A and Type B were the main ultrasound
ndings, with a cumulative percentage of 82.61%.
Discussion
Appendicitis is the most common surgical abdominal
emergency in the developed world and developing world
(17-21). Although anatomic variations are less common,
most of the surprises encountered during an appendectomy
are usually due to the various positions of the appendix. It is
of great signicance for surgeons and ultrasonographers to
gain a full understanding of the appendix with an abnormal
Yu et al. Ultrasound features of subhepatic appendicitis
© Annals of Translational Medicine. All rights reserved. Ann Transl Med 2020;8(17):1083 | http://dx.doi.org/10.21037/atm-20-5265
Page 8 of 11
position (22-24).
Subhepatic appendicitis, also called appendicitis with a
high position, refers to the inflamed appendix above the
navel and is the most common type of appendicitis with the
abnormal position (25-27) (Figure 2D). The development
of the appendix is closely related to the development of the
midgut. The primitive gut begins to develop at four weeks
of gestation and can be divided into the foregut, midgut, and
hindgut by the end of the fifth week. The first structures
of the caecum and appendix become visible as bud of the
caecum The appendix becomes visible in the eighth week
of gestation. Colon stretching and elongation results in the
descent of the caecum and vermiform appendix, pushing
the appendix ahead of the caecum. In the postpartum
period, the appendix and the caecum descend to the normal
position. Subhepatic appendicitis primarily results from
midgut malrotation, non-descent of the caecum, or is a
result of free caecum (28-30).
Dilated jejunum is due to the widening of the jejunum
and deposition of intestinal contents, with the intestinal
mucosa displayed clearly against the background of the
intestinal contents. It is primarily manifested as the
fishbone sign on the ultrasound imaging (Figure 2C). It
has a low display rate of only 8% in appendicitis with
the normal position, but a display rate of up to 88.9% in
subhepatic appendicitis. These results could be attributed
to the following: (I) variation in the anatomic position:
in subhepatic appendicitis, the colon moves up, and the
jejunum rotates and aggregates in the right lower abdomen.
The display rate of the ileum is high; (II) inflammatory
stimulation: the inflammatory exudates of subhepatic
appendicitis flow in the direction of gravity into the right
lower abdomen, and paralysis is caused to the ileum due to
inammatory stimulation from the exudates, consequently
resulting in reduced peristalsis and deposition of intestinal
contents; (III) display of the small intestinal mucosa: the
dilated small intestine can be displayed on the ultrasound
imaging. The above factors lead to a high positive rate of
the shbone sign in the right lower abdomen in subhepatic
appendicitis. The shbone sign is also the main lead in the
ultrasonic diagnosis of subhepatic appendicitis.
The vermiform structure is direct evidence for a
diagnosis of appendicitis (Figure 5). When performed by
ultrasonographers properly trained on acute abdominal
ultrasound, appendicitis with the standard position was
displayed by up to 90%. This figure shows the advantage
of ultrasound in the diagnosis of appendicitis in a
normal position. While in Group A, the display rate was
only 27.8%. This difference could be attributed to the
following: (I) the physician performing the examination
was not familiar with subhepatic appendicitis, resulting in
a decreased detection rate of subhepatic appendicitis; (II)
signicant anatomic variation exists with an appendix with
a high position, for it can appear at any position in the
abdominal cavity. The uncertainty of the anatomic position
has increased the difficulty in locating the appendix; (III)
the appendix with the high position is mostly located in
posterior colon/jejunum, and gas present in the colon
interferes with the display of the appendix.
Appendicoliths is the leading cause responsible for
the acute onset of appendicitis (31-35) (Figure 4). In
appendicitis with normal position (Group B), the display
rate of appendicoliths could be up to 56% due to a fixed
position of the appendix. While in subhepatic appendicitis
(Group A), the display rate of appendicoliths was low due to
the different anatomic position and impact of surrounding
tissues. It was only 11.1%.
Hyperechoic omental cap is a manifestation of extra-
intestinal fat inflammation. Accumulation of purulence
in the appendiceal cavity increases pressure in the cavity,
and the involvement of fats surrounding the appendix by
inflammation leads to lipedema, with fats encapsulating
around the appendix. The occurrence of a hyperechoic
omental cap indicates the worsening of appendicitis. The
display rate of the hyperechoic omental cap was 52.0% in
Group B, and 22.2% in Group A. Hyperechoic omental cap
helps localize inammation. Subhepatic appendicitis is often
complicated by an abnormal distribution of fats around the
appendix, with incomplete fat encapsulation (Figure 3).
After a statistical comparison, the observed variable
lymphadenectasis in the abdominal cavity was not included
as a subject of this study, and it fulfills the diagnostic
thinking. Appendiceal inammation is not an independent
correlation factor for lymphadenectasis. (I) Age is a
confounding factor for the display of lymphadenectasis,
which has a varying rate of display in different age groups,
with a higher rate in the infants than in the adults. (II)
Multiple abdominal disorders can lead to lymphadenectasis,
including inflammatory bowel disease, gastrointestinal
tumor, mesenteric lymphadenitis. The Pareto principle is
also known as the 80/20 rule, the law of the vital few, or
the principle of factor sparsity (36,37). The Pareto chart is
a bar chart of frequencies sorted by frequency. The most
commonly used incarnation of the chart puts the highest
bars on the left and includes a line showing the scores
produced by adding the heights in order from left to right.
Annals of Translational Medicine, Vol 8, No 17 September 2020 Page 9 of 11
© Annals of Translational Medicine. All rights reserved. Ann Transl Med 2020;8(17):1083 | http://dx.doi.org/10.21037/atm-20-5265
This chart is used widely in quality control settings to nd
critical factors leading to failure or defects in a process. The
Pareto chart principle is widely applied in the management,
and applying this principle can show the leading factors
of the problem efficiently and objectively. We applied
this principle in finding the leading factors for ultrasonic
findings of subhepatic appendicitis in this study, which
was a combination of statistics and management. This
principle was used to summarize the diagnosis of subhepatic
appendicitis: only 20% of ultrasound-positive features
were presented in 80% of the patients with subhepatic
appendicitis (38-42).
In subhepatic appendicitis (Group A), the main types of
ultrasound ndings are (I) dilated ileum in the right lower
abdomen, and (II) dilated ileum in the right lower abdomen
+ vermiform structure in the right upper abdomen. Dilated
ileum in the right lower abdomen is the main, leading
to the diagnosis of subhepatic appendicitis. In the case
of clinical data of suspicious appendicitis, the surgeon
and the ultrasonographer should consider the possibility
of subhepatic appendicitis and perform a careful scan
examining whether there are echoes of vermiform structure
in the right upper abdomen when dilated ileum is seen in
the right lower abdomen, to avoid a missed diagnosis of
subhepatic appendicitis.
In appendicitis with normal position (Group B), the main
types of ultrasound findings are as follows: (I) vermiform
structure in the right lower abdomen; and (II) vermiform
structure in the right lower abdomen + appendicoliths
observed in the vermiform structure. Dilated ileum in the
right lower abdomen was a general factor in appendicitis with
a normal position. In other words, the possibility of dilated
ileum occurring in appendicitis with the normal position is
low. It may only exist in cases of serious exudation from the
appendix causing small intestinal paralysis.
Currently, laparoscopic appendectomy (LA) was the
main treatment for acute appendicitis. Mini-incision
open appendectomy (MOA), single port laparoscopic
appendectomy (sLA) and (Natural orifice transluminal
endoscopic surgery (NOTES) via various methods were
also the treatments. The treatments for normal appendicitis
and subhepatic appendicitis were basically in consistency,
for which the surgical excision was recommended. However,
the positions of surgical incisions between the two were
different. For normal appendicitis, generally appendectomy
was conducted at the McBurney point in the right lower
abdomen. For subhepatic appendicitis, the best surgical
approach needed to be in the near location after positioning
of body surface by ultrasound. When selecting LA, for
subhepatic appendicitis, the body surface projection was
needed to be labelled under the guidance of ultrasound.
The surgeon selected the best position of the puncture hole
for the laparoscope according to the projection position
of body surface. The diagnosis of subhepatic appendicitis
could improve the cure rate, select the most suitable surgical
approach, shorten the operation time, and ensure patient’s
safety to the greatest extent.
When it is suspected to be subhepatic appendicitis
through comprehensive clinical indicators, each ultrasound
feature is of great signicance to the diagnosis of subhepatic
appendicitis. The more cumulative positive ultrasound
features, the higher the diagnostic accuracy. Combined
with the 20/80 rule, when comprehensive clinical indicators
support appendicitis with fishbone sign been found by
ultrasound scan of the right lower abdomen, the ultrasound
physician shall consider whether it is subhepatic appendicitis.
At this time, the upper right abdomen needs to be carefully
scanned for evidence of subhepatic appendicitis by the
examiner. The purpose of study on ultrasound features of
subhepatic appendicitis is to improve the diagnosis accuracy
of subhepatic appendicitis and allow patients with subhepatic
appendicitis to receive timely treatment.
Conclusions
This study has summarized the ultrasonic diagnostic
procedure for subhepatic appendicitis. This procedure
can achieve a similar diagnostic effect as the procedure for
appendicitis with a normal position. The presence of an
abnormally dilated ileum in the right lower abdomen the
shbone sign, is the rst lead to the diagnosis of subhepatic
appendicitis.
A specialized diagnostic strategy for subhepatic
appendicitis for patients with clinically suspicious
appendicitis when a vermiform structure is not scanned
in the right lower abdomen and only dilated ileum (the
fishbone sign) should be utilized. A scan focusing on
determining whether there is a presence of vermiform
structure in the right upper abdomen should be performed,
and the possibility of subhepatic appendicitis should not be
ruled out even if the presence of the appendix with the high
position is discovered.
Acknowledgments
Funding: None.
Yu et al. Ultrasound features of subhepatic appendicitis
© Annals of Translational Medicine. All rights reserved. Ann Transl Med 2020;8(17):1083 | http://dx.doi.org/10.21037/atm-20-5265
Page 10 of 11
Footnote
Reporting Checklist: The authors have completed the
STROBE reporting checklist. Available at http://dx.doi.
org/10.21037/atm-20-5265
Data Sharing Statement: Available at http://dx.doi.
org/10.21037/atm-20-5265
Conicts of Interest: All authors have completed the ICMJE
uniform disclosure form (available at http://dx.doi.
org/10.21037/atm-20-5265). The authors have no conicts
of interest to declare.
Ethical Statement: The authors are accountable for all
aspects of the work in ensuring that questions related
to the accuracy or integrity of any part of the work are
appropriately investigated and resolved. All procedures
performed in this study involving human participants were
in accordance with the Declaration of Helsinki (as revised in
2013). This study was reviewed and approved by the Ethics
Committee of Jizhong Energy Fengfeng Group Hospital
and informed consent was taken from all the patients.
Open Access Statement: This is an Open Access article
distributed in accordance with the Creative Commons
Attribution-NonCommercial-NoDerivs 4.0 International
License (CC BY-NC-ND 4.0), which permits the non-
commercial replication and distribution of the article with
the strict proviso that no changes or edits are made and the
original work is properly cited (including links to both the
formal publication through the relevant DOI and the license).
See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
References
1. Gorter RR, Eker HH, Gorter-Stam MA, et al.
Diagnosis and management of acute appendicitis. EAES
consensus development conference 2015. Surg Endosc
2016;30:4668-90.
2. Friday JH. Update on appendicitis: diagnosis
and presurgical management. Curr Opin Pediatr
2006;18:234-8.
3. Thompson GC, Schuh S, Gravel J, et al. Variation in the
Diagnosis and Management of Appendicitis at Canadian
Pediatric Hospitals. Acad Emerg Med 2015;22:811-22.
4. Craner DR, Wexler JI, Nalugo M, et al. Bringing Surgeons
Together Across the World: Diagnosis and Management
of Acute Appendicitis. J Laparoendosc Adv Surg Tech A
2015;25:261-5.
5. Rice-Townsend S, Barnes JN, Hall M, et al. Variation
in Practice and Resource Utilization Associated With
the Diagnosis and Management of Appendicitis at
Freestanding Children's Hospitals: Implications for Value-
Based Comparative Analysis. Ann Surg 2014;259:1228-34.
6. Alter SM, Walsh B, Lenehan PJ, et al. Ultrasound for
Diagnosis of Appendicitis in a Community Hospital
Emergency Department has a High Rate of Nondiagnostic
Studies. J Emerg Med 2017;52:833-8.
7. Franca Neto AH, Amorim MM, Nóbrega BM. Acute
appendicitis in pregnancy: literature review. Rev Assoc
Med Bras (1992) 2015;61:170-7.
8. Sonawane R, Jatkar G, Chaudhari M. Correlation of
ultrasonography ndings of acute appendicitis with
pathological acute appendicitis. Int Surg J 2016;3:1447-50.
9. Dehghan A, Moaddab AH, Mozafarpour S. An unusual
localization of trichobezoar in the appendix. Turk J
Gastroenterol 2011;22:357-8.
10. Robb AL, Ali S, Poonai N, et al. Pain management of
acute appendicitis in Canadian pediatric emergency
departments. CJEM 2017;19:417-23.
11. Horn CB, Tian D, Bochicchio GV, et al. Incidence,
demographics, and outcomes of nonoperative management
of appendicitis in the United States. J Surg Res
2018;223:251-8.
12. GlobalSurg Collaborative. Laparoscopy in management of
appendicitis in high-, middle-, and low-income countries:
a multicenter, prospective, cohort study. Surg Endosc
2018;32:3450-66.
13. Jacob R, Krauss B, Twito G, et al. Emergency department
pain management in children with appendicitis in a
Biethnic population. Clin J Pain 2017;33:1014-8.
14. Qu Z, Dalton C, Blough J, et al. Validation of Pareto
Principle ("20/80 Rule") in Surgical Pathology to Gain
Insight Into Specimen-Diagnosis Prole. Am J Clin Pathol
2015;144:A176.
15. Cho J, Lee D, Sung K, et al. Clinical implication of
discrepancies between surgical and pathologic diagnoses of
acute appendicitis. Ann Surg Treat Res 2017;93:43-9.
16. Carr NJ. The pathology of acute appendicitis. Ann Diagn
Pathol 2000;4:46-58.
17. Aydin D, Turan C, Yurtseven A, et al. Integration of
radiology and clinical score in pediatric appendicitis.
Pediatr Int 2018;60:173-8.
18. Mikaere H, Zeng I, Lauti M, et al. Derivation and
validation of the APPEND score: an acute appendicitis
Annals of Translational Medicine, Vol 8, No 17 September 2020 Page 11 of 11
© Annals of Translational Medicine. All rights reserved. Ann Transl Med 2020;8(17):1083 | http://dx.doi.org/10.21037/atm-20-5265
clinical prediction rule. ANZ J Surg 2018;88:E303-E307.
19. Aceti V, Boscarelli A. Burying the appendiceal stump
during appendicectomy: state of art. Transl Pediatr
2018;7:73-4.
20. Pacharn P, Ying J, Linam LE, et al. Sonography in the
evaluation of acute appendicitis: are negative sonographic
ndings good enough? J Ultrasound Med 2010;29:1749-55.
21. Ahn SE, Moon SK, Lee DH, et al. Sonography of
Gastrointestinal Tract Diseases: Correlation with
Computed Tomographic Findings and Endoscopy. J
Ultrasound Med 2016;35:1543-71.
22. Sanchez TR, Corwin MT, Davoodian A, et al. Sonography
of Abdominal Pain in Children: Appendicitis and Its
Common Mimics. J Ultrasound Med 2016;35:627-35.
23. Xu Y, Jeffrey RB, Chang ST, et al. Sonographic
Differentiation of Complicated From Uncomplicated
Appendicitis: Implications for Antibiotics-First Therapy. J
Ultrasound Med 2017;36:269-77.
24. Xu Y, Jeffrey RB, Shin LK, et al. Color Doppler
Imaging of the Appendix: Criteria to Improve Specicity
for Appendicitis in the Borderline-Size Appendix. J
Ultrasound Med 2016;35:2129-38.
25. Chiapponi C, Jannascha O, Petersena M, et al. A rare case
of perforated "sub-hepatic appendicitis" - a challenging
differential diagnosis of acute abdomen based on the
combination of appendicitis and maldescent of the caecum.
Pathol Res Pract 2017;213:75-8.
26. Singh R. Subhepatic appendicitis: diagnostic dilemma: a
case report. Int Surg J 2016;3:422-4.
27. Sinha A, Cukkemane A, Saini V. Study of different
positions of appendix in operated cases of appendicitis
in rural hospital and its clinical correlation. Journal of
Evidence Based Medicine and Healthcare 2017;4:1420-4.
28. Ahmed I, Asgeirsson KS, Beckingham IJ, et al. The
position of the vermiform appendix at laparoscopy. Surg
Radiol Anat 2007;29:165-8.
29. Chauhan S and Anand S. Intracecal appendix: an extremely
rare anatomical variation. A case report and review of
literature. Surg Radiol Anat 2018;40:111-4.
30. Nayak BS. Why the tip of vermiform appendix has variable
position? Med Hypotheses 2010;75:682-3.
31. Resanovic V, Resanovic A, Krstic S, et al. Acute
Appendicitis: Still a Surgical Disease? Results from a
Propensity Score-Based Outcome Analysis of Conservative
Versus Surgical Management from a Prospective Database.
World J Surg 2018;42:903-4.
32. Lipsett SC, Bachur RG. Current Approach to the
Diagnosis and Emergency Department Management
of Appendicitis in Children. Pediatr Emerg Care
2017;33:198-203.
33. Rothrock SG, Pagane J. Acute appendicitis in children:
emergency department diagnosis and management. Ann
Emerg Med 2000;36:39-51.
34. Simillis C, Symeonides P, Shorthouse AJ, et al. A meta-
analysis comparing conservative treatment versus acute
appendectomy for complicated appendicitis (abscess or
phlegmon). Surgery 2010;147:818-29.
35. Slotta JE, Kopsch U, Ghadimi M, et al. Management of
acute appendicitis: evidence for prompt surgical treatment?
Chirurg 2017;88:503-11.
36. Warner CJ, Walsh DB, Horvath AJ, et al. Lean principles
optimize on-time vascular surgery operating room
starts and decrease resident work hours. J Vasc Surg
2013;58:1417-22.
37. Davies P. Time to acknowledge the workings of the 80/20
principle? Br J Gen Pract 2005;55:55-6.
38. Delibegović S, Mehmedovic Z. The inuence of the
different forms of appendix base closure on patient
outcome in laparoscopic appendectomy: a randomized
trial. Surg Endosc 2018;32:2295-9.
39. Lee M, Kim SC. Appendiceal foreign body in an infant.
Medicine (Baltimore) 2017;96:e6717.
40. Müller F, Dormann H, Pstermeister B, et al. Application
of the Pareto principle to identify and address drug-therapy
safety issues. Eur J Clin Pharmacol 2014;70:727-36.
41. Greenwood TJ, Lopez-Costa RI, Rhoades PD, et al. CT
Dose Optimization in Pediatric Radiology: A Multiyear
Effort to Preserve the Benets of Imaging While Reducing
the Risks. Radiographics 2015;35:1539-54.
42. Cruz-Ramírez M, Hervás-Martínez C, Fernández J, et al.
Predicting patient survival after liver transplantation using
evolutionary multi-objective articial neural networks.
Artif Intell Med 2013;58:37-49.
(English Language Editor: J. Chapnick)
Cite this article as: Yu D, Gu C, Zhang S, Yang H, Yao T.
Ultrasound features and the diagnostic strategy of subhepatic
appendicitis. Ann Transl Med 2020;8(17):1083. doi: 10.21037/
atm-20-5265
Article
Full-text available
Abstract Background Appendicitis is the most common abdominal surgical emergency worldwide. Differences between high- and low-income settings in the availability of laparoscopic appendectomy, alternative management choices, and outcomes are poorly described. The aim was to identify variation in surgical management and outcomes of appendicitis within low-, middle-, and high-Human Development Index (HDI) countries worldwide. Methods This is a multicenter, international prospective cohort study. Consecutive sampling of patients undergoing emergency appendectomy over 6 months was conducted. Follow-up lasted 30 days. Results 4546 patients from 52 countries underwent appendectomy (2499 high-, 1540 middle-, and 507 low-HDI groups). Surgical site infection (SSI) rates were higher in low-HDI (OR 2.57, 95% CI 1.33–4.99, p = 0.005) but not middle-HDI countries (OR 1.38, 95% CI 0.76–2.52, p = 0.291), compared with high-HDI countries after adjustment. A laparoscopic approach was common in high-HDI countries (1693/2499, 67.7%), but infrequent in low-HDI (41/507, 8.1%) and middle-HDI (132/1540, 8.6%) groups. After accounting for case-mix, laparoscopy was still associated with fewer overall complications (OR 0.55, 95% CI 0.42–0.71, p < 0.001) and SSIs (OR 0.22, 95% CI 0.14–0.33, p < 0.001). In propensity-score matched groups within low-/middle-HDI countries, laparoscopy was still associated with fewer overall complications (OR 0.23 95% CI 0.11–0.44) and SSI (OR 0.21 95% CI 0.09–0.45). Conclusion A laparoscopic approach is associated with better outcomes and availability appears to differ by country HDI. Despite the profound clinical, operational, and financial barriers to its widespread introduction, laparoscopy could significantly improve outcomes for patients in low-resource environments. Trial registration: NCT02179112. Keywords Appendicitis Appendectomy Global surgery Laparoscopic Operative standards Postoperative care Postoperative complications Surgical site infection Collaborating members are shown in Acknowledgements.
Article
Full-text available
Background: Appendicitis is the most common abdominal surgical emergency worldwide. Differences between high- and low-income settings in the availability of laparoscopic appendectomy, alternative management choices, and outcomes are poorly described. The aim was to identify variation in surgical management and outcomes of appendicitis within low-, middle-, and high-Human Development Index (HDI) countries worldwide. Methods: This is a multicenter, international prospective cohort study. Consecutive sampling of patients undergoing emergency appendectomy over 6 months was conducted. Follow-up lasted 30 days. Results: 4546 patients from 52 countries underwent appendectomy (2499 high-, 1540 middle-, and 507 low-HDI groups). Surgical site infection (SSI) rates were higher in low-HDI (OR 2.57, 95% CI 1.33-4.99, p = 0.005) but not middle-HDI countries (OR 1.38, 95% CI 0.76-2.52, p = 0.291), compared with high-HDI countries after adjustment. A laparoscopic approach was common in high-HDI countries (1693/2499, 67.7%), but infrequent in low-HDI (41/507, 8.1%) and middle-HDI (132/1540, 8.6%) groups. After accounting for case-mix, laparoscopy was still associated with fewer overall complications (OR 0.55, 95% CI 0.42-0.71, p < 0.001) and SSIs (OR 0.22, 95% CI 0.14-0.33, p < 0.001). In propensity-score matched groups within low-/middle-HDI countries, laparoscopy was still associated with fewer overall complications (OR 0.23 95% CI 0.11-0.44) and SSI (OR 0.21 95% CI 0.09-0.45). Conclusion: A laparoscopic approach is associated with better outcomes and availability appears to differ by country HDI. Despite the profound clinical, operational, and financial barriers to its widespread introduction, laparoscopy could significantly improve outcomes for patients in low-resource environments. Trial registration: NCT02179112.
Article
Full-text available
Background: The efficacy of ultrasonography (US) and abdominal X-ray in combination with Pediatric Appendicitis Score (PAS) is complicated in the diagnosis of acute appendicitis. Abdominal X-ray is as useful as US with clinical assessment when evaluated by experienced pediatric radiologist in acute appendicitis. The aim of this study was to determine the value of US and abdominal X-ray for appendicitis in children when combined with clinical assessment based on PAS, and to establish a practical pathway for acute appendicitis in childhood. Methods: A prospective, observational cohort study was conducted at an urban, academic pediatric emergency department. Patients were classified at low (PAS 1-4), intermediate (PAS 5-7), or high (PAS 8-10) risk for appendicitis. Low-risk patients were discharged with telephone follow-up in ≤10 days; those at intermediate risk underwent X-ray and US. High-risk patients received immediate surgical consultation. Patients were grouped on histopathology as having either proven acute appendicitis or no appendicitis. Results: A total of 288 children were analyzed. Surgery was performed in 134 patients (46.5%), and 128 (95.5%) had positive histopathology. Mean PAS in the patients with and without appendicitis was 7.09 ± 1.42 and 4.97 ± 2.29, respectively (P = 0.00). The rate of missed cases was 6/288 (2%), and the negative appendectomy rate was 6/134 (4.4%). When the score cut-off was set at 6, the sensitivity and specificity of PAS was 86.7% and 63.1%, respectively. The diagnostic performance of daytime US had a sensitivity of 91.1% and specificity of 71.1%. Also, positive US or PAS >6 or both, had sensitivity and specificity 96.7% and 59.9%, respectively. Conclusion: US or abdominal X-ray in children with possible appendicitis should be integrated with PAS to determine the next steps in management. In the case of discordance between the clinical findings and radiology, prolonged observation or further imaging are recommended.
Article
Full-text available
Background: During laparoscopic appendectomy, the base of the appendix is usually secured by loop ligature or stapling device. Hem-o-lok and DS clips have been shown as alternative techniques. The aim of this study was to compare the clinical outcomes of various forms of securing the base of the appendix, in order to find the most suitable method. Patients and methods: The study included 120 patients with acute appendicitis randomly divided into four groups with 30 patients in each. In the first group, the base of the appendix was secured using an Endoloop, in the second group using a stapling device, in the third group using Hem-o-lok, and in the fourth group using a DS clip. The primary outcome was overall morbidity following securing the base of the appendix. Secondary outcomes were time of application and operative procedure, total length of stay, and surgical outcome. Results: No morbidity was recorded in any group. The time of application was significantly longer in the Endoloop group than in the Stapler (P < 0.0001), Hem-o-lok (P < 0.0001), and DS clips (P < 0.0001) groups. The time of application in the Stapler group was significantly shorter than in the Hem-o-lok (P < 0.0001) and the DS clips (P < 0.0001) groups. The time of the operative procedure was significantly longer in the Endoloop than in the Stapler group (P < 0.0001). The time of the operative procedure in the Stapler group was significantly shorter than in the DS clips group (P < 0.0001) but did not differ significantly from the Hem-o-lok group (P = 0.199). The time of the operative procedure in the Hem-o-lok group was significantly shorter than in the DS clips group (P = 0.044). Conclusion: All forms of closure of the appendix base are acceptable, but Hem-o-lok and DS clips have the best potential for further development, and will probably become the method of choice in securing the base of the appendix.
Article
Full-text available
Purpose The postoperative treatment after appendectomy is usually decided on the basis of the surgeons' intraoperative findings. Comparatively, the pathologic diagnosis of appendicitis is confirmed several days after the surgery; therefore, it usually does not affect the postoperative treatment strategy. The aim of this study was to investigate the discrepancies between the surgical and pathologic diagnoses of appendicitis and to identify their clinical implication. Methods A retrospective observational study was performed in 1,817 patients who underwent 3-port laparoscopic appendectomy for the final diagnosis of appendicitis. The clinical variables that could estimate the severity of appendicitis and the intensity of postoperative treatment were analyzed and compared according to the surgical and pathologic diagnoses. Results Of 1,321 cases of surgically simple appendicitis, 254 (29.3%) were pathologically complicated appendicitis. On the other hand, 221 of 496 cases (44.5%) of surgically complicated appendicitis were pathologically simple. Neither the surgical nor the pathologic diagnosis of appendicitis affected the development of postoperative intra-abdominal abscess (P = 0.079 for surgical diagnosis; P = 0.288 for pathologic diagnosis); however, the surgical diagnosis showed more correlation with the severity of disease and the intensity of the treatment pathway than did the pathologic diagnosis. Conclusion There were discrepancies between the surgeons' intraoperative assessment and the pathologists' final histologic diagnosis of appendicitis. The surgeon's classification might be more predictive of the outcome than the pathologist's because only the surgeon's findings are available immediately after surgery.
Article
Full-text available
Appendicitis is the most common surgical abdominal emergency in the developed world. Most of the surprises encountered during an appendectomy are usually due to the various positions of the appendix tip. Anatomical variations are an extremely rare phenomenon, with only a few case reports scattered among volumes of literature on the vermiform appendix. A new variation is described in which the appendix was intracecal and cause for surprise during surgery. A review of literature of rare anatomical variations of the appendix is also presented.
Article
Background: Appendicitis is the most common intraabdominal surgical emergency in the United States, with over 250,000 cases each year. Several recent studies have evaluated the efficacy of nonoperative management of appendicitis. We measured changes in the treatment of appendicitis in the United States from 1998 to 2014 and evaluated outcomes in the contemporary cohort of appendicitis cases from 2010 to 2014. Methods: The National Inpatient Sample was queried for cases with a principal diagnosis of appendicitis. Cases with peritoneal abscesses were excluded. We determined trends in management and then compared cases managed nonoperatively versus those managed with early operation for demographics and outcomes including mortality, total charges, and length of stay using univariate analysis, binary logistic regression analysis, and case-control matching. Results: Although early operation remains the dominate treatment for acute appendicitis in the United States, there is an accelerating trend in nonoperative management. Nonoperative management is associated with increased age, number of comorbidities, and inpatient diagnoses. In univariate, multiple regression, and case-control analysis, nonoperative management is associated with decreased total charges but significantly increased risk of mortality. Conclusions: Elderly patients and patients with medical comorbidities are more likely to be treated nonoperatively for appendicitis than younger patients. Although previously published data support nonoperative management of appendicitis in low-risk surgical patients, we suggest that elderly or medically complex patients may benefit from early operative treatment of appendicitis and are potentially at risk of poor outcomes from nonoperative management.