Notes in Chapter 42

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Published	11/02/2024	Appendicitis is a version of {{c1::diverticulitis}} in which the {{c2::appendix}} represents a long diverticulum with a narrow lumen.
Published	11/02/2024	The appendix serves as a reservoir for normal intestinal flora and has the highest concentration of {{c1::gut-associated lymphoid tissue (GALT)}} in t…
Published	11/02/2024	Appendectomy is associated with a {{c1::reduced}} risk of developing {{c2::ulcerative colitis}}.
Published	11/02/2024	Appendectomy is linked to an increased risk of developing severe {{c1::Clostridium difficile}}–associated {{c2::colitis}}.
Published	11/02/2024	Inflammation of the appendix is often caused by an {{c1::obstructive process}} such as stool or {{c2::fecaliths}}.
Published	11/02/2024	It is suggested that only half of appendicitis cases arise from {{c1::luminal obstruction}}, such as stool or {{c2::neoplasm}}.
Published	11/02/2024	Appendicitis shows increased incidence in {{c1::summer}} and varies with {{c2::barometric pressure}}.
Published	11/02/2024	Genetic factors account for {{c1::30%}} of the risk of developing {{c2::appendicitis}}.
Published	11/02/2024	A family history increases the risk of appendicitis by {{c1::threefold}}.
Published	11/02/2024	Bacteria such as {{c1::Yersinia}} and viruses such as {{c2::Coxsackie B}} have been implicated in appendicitis.
Published	11/02/2024	The association between fecaliths and appendicitis is stronger in {{c1::developed countries}} with low-{{c2::fiber diets}}.
Published	11/02/2024	Perforation rates of appendicitis in children under 5 years old can be as high as {{c1::82%}} and nearly {{c2::100%}} in 1-year-olds.
Published	11/02/2024	The risk of appendicitis perforation varies greatly, with rates reported between {{c1::20%}} and {{c2::76%}} in pediatric hospitals.
Published	11/02/2024	{{c1::Nonperforated appendicitis}} may resolve without treatment, as seen in cases of {{c2::chronic appendicitis}}.
Published	11/02/2024	The classic presentation of appendicitis begins with {{c1::anorexia}} and vague {{c2::periumbilical pain}}.
Published	11/02/2024	Periumbilical pain is of {{c1::visceral nerve origin}} and is referred to the common dermatome of the {{c2::8th–10th thoracic dorsal ganglia}}.
Published	11/02/2024	Pain localizes to the right lower abdomen when inflammation irritates the local {{c1::peritoneum}}, which has potent {{c2::somatic sensation}}.
Published	11/02/2024	The McBurney point is located {{c1::1.5 to 2 inches}} from the anterior superior iliac process along a line drawn to the {{c2::umbilicus}}.
Published	11/02/2024	The {{c1::Rovsing sign}} is RLQ pain resulting from palpation of the {{c2::left lower abdomen}}.
Published	11/02/2024	The {{c1::psoas sign}} is RLQ pain when the patient is in the left decubitus position and the {{c2::right leg is extended}}.
Published	11/02/2024	A positive psoas sign is often suggestive of {{c1::retrocecal appendicitis}}.
Published	11/02/2024	The {{c1::Dunphy sign}} is increased RLQ pain with {{c2::coughing}}.
Published	11/02/2024	The {{c1::Markle (heel jar) test}} is RLQ pain with {{c2::dorsiflexion of the right foot}}.
Published	11/02/2024	Vomiting typically follows RLQ pain, but it is not a reliable finding in {{c1::children}}.
Published	11/02/2024	Diarrhea is more common with {{c1::perforated appendicitis}} and in {{c2::infants and toddlers}}.
Published	11/02/2024	Only {{c1::36%}} of children presenting to the emergency department with abdominal pain are diagnosed with {{c2::appendicitis}}.
Published	11/02/2024	Rebound tenderness is the only physical finding that increases the likelihood of {{c1::appendicitis}}, whereas the absence of RLQ tenderness decreases…
Published	11/02/2024	High fever in appendicitis is more common after {{c1::rupture}} due to {{c2::peritoneal contamination}}.
Published	11/02/2024	A normal {{c1::white blood cell (WBC) count}} does not exclude the diagnosis of {{c2::appendicitis}}.
Published	11/02/2024	Composite appendicitis risk scores estimate risk by combining clinical symptoms, physical examination findings, and {{c1::laboratory data}}.
Published	11/02/2024	The {{c1::Alvarado Score}} is similar to the {{c2::Pediatric Appendicitis Score (PAS)}}, designed for children ages 4–15 years.
Published	11/02/2024	The {{c1::Appendicitis Inflammatory Response (AIR)}} Score uses variables based on {{c2::weighted ordered logistic regression}} analysis.
Published	11/02/2024	The AIR score may be preferable in young children, as the {{c1::Alvarado Score}} requires identifying {{c2::nausea}}, anorexia, and migration of pain.
Published	11/02/2024	The {{c1::PAS}} and Alvarado Score were initially reported to have sensitivity and specificity over {{c2::90%}}.
Published	11/02/2024	Large validation studies have shown sensitivities and specificities for scoring systems in the {{c1::70-90%}} range.
Published	11/02/2024	Scoring systems are less reliable in {{c1::adolescent females}}, requiring investigation beyond the scoring system.
Published	11/02/2024	Appendicitis scoring systems are best used to classify patients into categories of {{c1::discharge}}, further {{c2::imaging}}, or surgical referral.
Published	11/02/2024	Diagnostic imaging minimizes the risk of both {{c1::negative appendectomy}} and a missed diagnosis.
Published	11/02/2024	Plain films show a fecalith in {{c1::5–15%}} of patients, but are not recommended unless bowel {{c2::obstruction}} is suspected.
Published	11/02/2024	{{c1::Ultrasound (US)}} is a bedside modality for appendicitis that requires no {{c2::IV access}} or radiation.
Published	11/02/2024	Common ultrasound signs of appendicitis include a fluid-filled, {{c1::noncompressible appendix}} with a diameter >{{c2::6 mm}}.
Published	11/02/2024	Ultrasound sensitivity and specificity vary widely, ranging from {{c1::44–88%}} and {{c2::90–97%}}, respectively.
Published	11/02/2024	Ultrasound can be challenging in early appendicitis or in {{c1::obese patients}} and is {{c2::operator dependent}}.
Published	11/02/2024	US sensitivity and specificity can increase with {{c1::pediatric ultrasonographers}} and abdominal pain lasting more than {{c2::48 hours}}.
Published	11/02/2024	Standardized categories for US results improve {{c1::reliability}} and decrease variability in {{c2::predictive value}}.
Published	11/02/2024	US Category 1 refers to an {{c1::appendix visualized}} and normal, while Category 4 refers to {{c2::appendicitis with or without abscess}}.
Published	11/02/2024	Nonvisualization of the appendix occurs in {{c1::25-60%}} of cases, with the NPV for Category 1 and 2 studies being around {{c2::95-99%}}.
Published	11/02/2024	{{c1::CT}} provides a 3D image, is not operator dependent, and is generally more {{c2::accurate}} than US for appendicitis.
Published	11/02/2024	CT is more commonly used in {{c1::adult patients}}, but its radiation exposure is a greater concern in {{c2::children}}.
Published	11/02/2024	Three strategies to reduce CT radiation in children include fewer CT scans, reducing {{c1::radiation concentration by 50%}}, and using {{c2::targeted …
Published	11/02/2024	{{c1::MRI}} is a non-radiation alternative with sensitivity and specificity of {{c2::97%}} for diagnosing appendicitis.
Published	11/02/2024	MRI disadvantages include lack of availability, {{c1::motion sensitivity}}, and potential need for {{c2::sedation}}.
Published	11/02/2024	Urgent appendectomy is no longer considered an {{c1::emergency}}, and it can be delayed after {{c2::antibiotics}} are initiated without negative outco…
Published	11/02/2024	Studies show no difference in perforation or {{c1::postoperative complications}} with appendectomy delays of up to {{c2::24 hours}}.
Published	11/02/2024	Over {{c1::90%}} of appendectomies today are performed {{c2::laparoscopically}}.
Published	11/02/2024	The risk of postoperative abscess is similar between {{c1::open}} and {{c2::laparoscopic}} appendectomies.
Published	11/02/2024	Laparoscopic appendectomy reduces the risk of {{c1::wound infections}} and {{c2::adhesive small bowel obstruction}}.
Published	11/02/2024	The most common technique for laparoscopic appendectomy is the {{c1::three-port}} approach.
Published	11/02/2024	The single-incision laparoscopic appendectomy offers potential {{c1::cosmetic benefits}} but no major differences in {{c2::outcomes}} compared to the …
Published	11/02/2024	Objective studies on cosmesis have shown no significant long-term advantage with the {{c1::single-site}} approach.
Published	11/02/2024	Current evidence suggests no additional dose of {{c1::antibiotics}} is needed after appendectomy for {{c2::nonperforated}} appendicitis.
Published	11/02/2024	Recent studies found that appendectomy timing, even with a delay up to {{c1::24 hours}}, does not affect {{c2::outcomes}} in appendicitis patients.
Published	11/02/2024	Laparoscopic appendectomy has been shown to decrease the risk of {{c1::wound infections}} and {{c2::adhesive small bowel obstruction}}.
Published	11/02/2024	In a pediatric randomized trial, no differences were found in {{c1::surgical site infections}}, hospital stay, or analgesic use between {{c2::single-i…
Published	11/02/2024	Single-incision laparoscopic appendectomy takes about {{c1::5 minutes}} longer than the {{c2::three-port}} approach.
Published	11/02/2024	Despite early superior cosmetic scores, the {{c1::single-site}} appendectomy approach showed no {{c2::long-term}} advantage in appearance at 18 months…
Published	11/02/2024	For appendicitis patients with no perforation, {{c1::overnight hospital stay}} is no longer routinely {{c2::recommended}} after appendectomy.
Published	11/02/2024	The historical standard for appendicitis management was an {{c1::urgent appendectomy}}, but now it can be safely delayed after {{c2::antibiotic}} init…
Published	11/02/2024	The widespread use of {{c1::laparoscopy}} for appendectomy is over {{c2::90%}} compared to just 20% two decades ago.
Published	11/02/2024	Early studies reported higher postoperative {{c1::abscess rates}} with laparoscopic appendectomy in perforated cases, but recent data shows no differe…
Published	11/02/2024	Single-incision laparoscopic appendectomy’s main proposed advantage is {{c1::cosmesis}}, although trials show no significant difference in {{c2::objec…
Published	11/02/2024	The negative pediatric appendectomy rate is estimated around {{c1::6%}} in Canada and {{c2::4%}} in the United States.
Published	11/02/2024	A major challenge to nonoperative management (NOM) of appendicitis in children is the parental misconception that delaying appendectomy leads to {{c1:…
Published	11/02/2024	Early success of NOM in adults with appendicitis is around {{c1::90%}}, but it decreases to about {{c2::70%}} at 1 year.
Published	11/02/2024	Meta-analyses of adult trials found fewer {{c1::complications}} and better {{c2::pain control}} with NOM compared to initial appendectomy.
Published	11/02/2024	The success rate for NOM in children ranges from {{c1::75–80%}} with no increased risk of {{c2::perforation}}.
Published	11/02/2024	A systematic review found that NOM in children is effective in {{c1::97%}} of cases, with a {{c2::14%}} recurrence rate of appendicitis.
Published	11/02/2024	An appendicolith is considered an {{c1::adverse indicator}} for antibiotic-only treatment in appendicitis.
Published	11/02/2024	Indicators for failure of NOM include abdominal pain for >{{c1::48 hours}}, WBC count >{{c2::18,000}}, and CRP >{{c3::4 mg/dL}}.
Published	11/02/2024	A recent trial in NOM of children with appendicitis found a {{c1::12.3%}} recurrence rate at 1-year follow-up and better {{c2::quality of life scores}…
Published	11/02/2024	NOM of appendicitis in children is cost-effective if the 1-year recurrence rate does not exceed {{c1::40%}}.
Published	11/02/2024	Nonoperative management (NOM) of appendicitis avoids unnecessary {{c1::anesthesia}} for patients who do not have appendicitis.
Published	11/02/2024	Parental misperception about NOM may lead to concerns over a high likelihood of major complications or {{c1::death}}.
Published	11/02/2024	The rate of adverse outcomes from NOM in children with appendicitis includes a variable follow-up interval of usually less than {{c1::1 year}}.
Published	11/02/2024	Indicators for failure of NOM include signs of {{c1::bowel obstruction}}, abscess, or phlegmon on imaging.
Published	11/02/2024	A large patient choice trial is currently assessing children with less than {{c1::48 hours}} of abdominal pain for NOM.
Published	11/02/2024	The effectiveness of antibiotic therapy for appendicitis will be further clarified by ongoing {{c1::randomized trials}}.
Published	11/02/2024	In NOM, a WBC count greater than {{c1::18,000 cells/?L}} is an indicator for potential treatment failure.
Published	11/02/2024	In studies, children managed nonoperatively did not show increased rates of {{c1::perforated appendicitis}}.
Published	11/02/2024	Children in the NOM group reported {{c1::fewer}} days off and overall {{c2::lower costs}} compared to surgical management.
Published	11/02/2024	There is a moderate amount of literature on the NOM of appendicitis in children consisting of cohort studies and a {{c1::pilot}} randomized controlled…
Published	11/02/2024	Retrospective literature on perforated appendicitis is affected by surgeon variability in defining {{c1::perforation}}.
Published	11/02/2024	A survey of APSA members indicated that many base their practices for perforated appendicitis on subjective {{c1::preferences}}.
Published	11/02/2024	Defining perforation as an identifiable hole or a {{c1::fecalith}} in the abdomen can help identify patients at high risk for developing an abscess.
Published	11/02/2024	Patients with perforated appendicitis traditionally require postoperative antibiotic therapy at least until {{c1::clinical resolution}}.
Published	11/02/2024	The traditional antibiotic regimen for perforated appendicitis is {{c1::triple antibiotic therapy}}.
Published	11/02/2024	Monotherapy with {{c1::piperacillin/tazobactam}} has been shown to be as effective as traditional triple antibiotic therapy.
Published	11/02/2024	Once-daily dosing with ceftriaxone has been found to be less costly compared to {{c1::broad-spectrum monotherapeutic agents}}.
Published	11/02/2024	A multicenter case-control study suggests that patients clinically well by postoperative day {{c1::3}} are unlikely to develop an abscess.
Published	11/02/2024	Early transition to oral antibiotics has been found to be as effective as a prolonged course of {{c1::IV antibiotics}}.
Published	11/02/2024	A follow-up study found no further need for oral antibiotic therapy if the patient is eating and has a normal {{c1::WBC count}}.
Published	11/02/2024	Three general strategies for treating perforated appendicitis are {{c1::antibiotics only, antibiotics followed by interval appendectomy,}} and {{c2::a…
Published	11/02/2024	Treating initially with antibiotics aims to avoid a difficult operation during the peak of the {{c1::inflammatory process}}.
Published	11/02/2024	Short-term data suggest the risk of recurrent appendicitis after initial antibiotic treatment is {{c1::8–14%}}.
Published	11/02/2024	In a recent trial comparing initial antibiotic therapy and observation, {{c1::12%}} of patients recurred with appendicitis in one year.
Published	11/02/2024	Studies have shown that delayed appendectomy after antibiotic therapy resulted in fewer overall {{c1::complications}} compared to early appendectomy.
Published	11/02/2024	A prospective randomized trial found the length of hospitalization was {{c1::2 days longer}} in the initial antibiotic group undergoing interval appen…
Published	11/02/2024	Early appendectomy is associated with a lower overall adverse event rate with a relative risk of {{c1::1.86}} when compared to initial antibiotic ther…
Published	11/02/2024	Surgeons who manage perforated appendicitis with antibiotics alone may have concerns about the {{c1::failure rate}} of this approach.
Published	11/02/2024	Accurate preoperative categorization of appendicitis as perforated or nonperforated is often {{c1::difficult}}.
Published	11/02/2024	A blinded review of CT scans showed that experienced radiologists and surgeons diagnosed perforation with less than {{c1::80% accuracy}}.
Published	11/02/2024	Studies indicate that the use of irrigation during surgery for perforated appendicitis has not shown a {{c1::benefit}}.
Published	11/02/2024	Two retrospective studies found an increase in postoperative abscesses associated with the use of {{c1::irrigation}} during appendectomy.
Published	11/02/2024	A prospective trial comparing irrigation to suction alone showed no difference in postoperative abscess rates, with rates of {{c1::19.1%}} for suction…
Published	11/02/2024	The use of antibiotics alone for perforated appendicitis is intended to avoid a {{c1::difficult operation}} during inflammation.
Published	11/02/2024	The complication rates for initial antibiotic therapy followed by interval appendectomy were found to be similar to those of {{c1::early appendectomy}…
Published	11/02/2024	In cases of perforated appendicitis, a high failure rate for nonoperative management is associated with {{c1::appendicoliths}} seen on imaging.
Published	11/02/2024	Clinical signs indicating a high risk of failure for nonoperative management include abdominal pain lasting over {{c1::48 hours}} and elevated WBC cou…
Published	11/02/2024	Children who undergo early laparoscopic appendectomy for perforated appendicitis have been shown to have {{c1::lower costs}} compared to those receivi…
Published	11/02/2024	The optimal duration of antibiotic therapy for perforated appendicitis has yet to be determined, but transitioning to {{c1::oral antibiotics}} is cons…
Published	11/02/2024	A multicenter case-control study indicates that patients who are clinically well by postoperative day {{c1::3}} are unlikely to develop an abscess.
Published	11/02/2024	Antibiotic monotherapy for perforated appendicitis has been suggested as an alternative to traditional {{c1::triple antibiotic therapy}}.
Published	11/02/2024	A recent study found that once-daily dosing of {{c1::ceftriaxone}} is as effective as traditional antibiotic regimens for intra-abdominal infections.
Published	11/02/2024	In surveys, a significant percentage of pediatric surgeons still routinely use {{c1::irrigation}} during appendectomy despite evidence against its eff…
Published	11/02/2024	The lack of difference in outcomes between irrigation and suction alone suggests that {{c1::irrigation}} does not impact the clinical course.
Published	11/02/2024	A review of literature shows that postoperative abscess rates were similar regardless of the use of {{c1::irrigation}} during laparoscopic appendectom…
Published	11/02/2024	Patients presenting with a well-defined abscess seen on imaging may require {{c1::percutaneous aspiration}} followed by interval appendectomy.
Published	11/02/2024	The approach of treating an abscess with drainage has been an important part of contemporary practice for over {{c1::30 years}}.
Published	11/02/2024	Some studies suggest that patients with abscesses may not benefit from {{c1::drainage}}.
Published	11/02/2024	A study found that there were advantages to not placing a drain for abscesses up to {{c1::17 cm}}.
Published	11/02/2024	Flushing drains with saline is a routine practice to maintain {{c1::patency}}.
Published	11/02/2024	A recent trial showed that instilling {{c1::tPA}} into the abscess drain resulted in longer hospital stays and higher medication charges.
Published	11/02/2024	Quality of life assessments indicated that early operation may be preferable due to reduced stress from ongoing healthcare needs until appendectomy.
Published	11/02/2024	In children presenting with perforated appendicitis and no abscess, early appendectomy significantly reduces the odds of {{c1::adverse events}} and un…
Published	11/02/2024	The overall adverse event rate for children with perforated appendicitis was analyzed in a meta-analysis of two {{c1::randomized controlled trials}}.
Published	11/02/2024	In patients with perforated appendicitis and an abscess, there was no difference between early appendectomy and {{c1::antibiotics followed by interval…
Published	11/02/2024	Despite being common, many unresolved management issues regarding appendicitis require {{c1::future prospective studies}} to address.
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