JOURNAL CLUB PRESENTATION - APPENDICITIS AN EVIDENCE BASED APPROACH

Journal Club presentation on Appendicitis

1. TOPIC: APPENDICITIS, AN EVIDENCE BASED APPROACH Presenter: KIRENGO T. YGC GEN SURG JOURNAL CLUB

2. APPENDICITIS Inflammation of the vermiform appendix located at the tip of the cecum, usually in the right lower quadrant of the abdomen Acute presentation, usually within 24 hours, may present as a more chronic

3. ETIOLOGY Usually an obstruction of the appendiceal lumen appendicolith Appendiceal tumors such as carcinoid, adenocarcinoma, Intestinal parasites hypertrophied lymphatic tissue

4. PATHOPHYSIOLOGY lumen obstructed >> inc. pressure >> lymphatic and vasc compromise bacteria build up >> acute inflammation >> Localized ischaemia >> perforation >> abscess formation >> Frank peritonitis

5. EPIDEMIOLOGY Ages of 5 - 45, with a mean age of 28 Males have a slightly higher predisposition Incidence is approximately 233/per 100,000 people

6. PRESENTATION Initial generalized or periumbilical abdominal pain (Visceral afferent nerve fibers at T8 through T10) Localizes RIF (appendix becomes inflamed and the adjacent parietal peritoneum is irritated) Anorexia Nausea/vomiting Fever (40% of patients) Diarrhea Generalize malaise Urinary frequency or urgency

7. CLINICAL SIGNS McBurney’s (Right lower quadrant guarding and rebound tenderness at point 1.5 to 2 inches from the anterior superior iliac spine (ASIS) on a straight line from the ASIS to the umbilicus) Rovsing’s (right lower quadrant pain elicited by palpation of the left lower quadrant) Dunphy’s (increased abdominal pain with coughing) Psoas (pain on external rotation or passive extension of the right hip suggesting retrocecal appendicitis) Obturator (pain on internal rotation of the right hip suggesting pelvic appendicitis)

8. DIFFERENTIALS mesenteric adenitis, cecal diverticulum, Meckel’s Gastro: Crohn ileitis, gastroenteritis, irritable bowel disease, Gyne : mittelschmerz, salpingitis, ovarian cyst, ectopic pregnancy, tubo -ovarian abscess, endometriosis, PID musculoskeletal disorders Uro: renal colic, kidney stones, testicular torsion, ovarian torsion

9. EVALUATION LAB: total leucocyte count, neutrophil percentage, and C-reactive protein (CRP) concentration Urinalysis, Pregnancy test CT scan has greater than 95% accuracy USS: limits - obese patients, the operator-dependency MRI: high sensitivity and specificity. Expensive and not readily available

10. CLINICAL SCORING SYSTEMS the Alvarado (or MANTRELS) score Pediatric Appendicitis Score (PAS) Adult Appendicitis Score Appendicitis Inflammatory Response Score

11. TREATMENT kept on clear fluids/ NBM Hydrated IVI Abx +/- post-op Appendectomy – lap +/- open

12. ARTICLE PRESENTED: Title: White cell count and C-reactive protein measurement in patients with possible appendicitis Location of study: Royal Infirmary of Edinburgh Authors: ANSHUMAN SENGUPTA, GEORGE BAX, SIMON PATERSON-BROWN Year of Publication: 2009 Ethics: N/A Conflict of interest: N/A Journal Publication: T he Annals of The Royal College of Surgeons of England Citations: 175

13. LEVEL OF EVIDENCE

14. JOURNAL INTRO The Annals of The Royal College of Surgeons of England The official scholarly research journal of the Royal College of Surgeons and is published eight times a year

15. ARTICLE:

16. METHODS: All patients presenting to the Royal Infirmary of Edinburgh with lower abdominal pain between 31 December 2006 and 6 February 2007 were included in this study No exclusion criteria Clinical collected prospectively using the Lothian Surgical Audit System (LSAS) Patient outcome was ascertained by examining the notes, operative records and pathological reports if appendicectomy was carried out Results were then correlated with WCC and CRP values obtained on admission, working out the sensitivity, specificity and positive and negative predictive values for each laboratory test, individually and in combination with one another

17. METHODS: A positive WCC was taken as being greater than 11 × 109 cells/l A positive CRP level as greater than 10 mg/l. In patients undergoing appendicectomy, the mean and median WCC and CRP values were correlated between those with a normal appendix, acute appendicitis and appendicitis with a complication (peritonitis, gangrene and/or perforation).

18. RESULTS: one patient among the 99 could not be included as his laboratory results could not be found 98 (75 females and 23 males), 28 underwent an operation for suspected appendicitis 6 had a diagnostic laparoscopy with a normal appendix (4 had ovarian cysts and 2 were presumed mesenteric adenitis) 12 had a laparoscopic appendicectomy, 10 open conversion 2 patients had negative appendicectomy on histology Remaining 70 patients discharged

19. RESULTS:

20. RESULTS & CONCLUSION: The most important finding of this study that, to our knowledge, has not previously been demonstrated, is the 100% negative predictive value for acute appendicitis if both WCC and CRP are normal , No patients with both values within the normal range had acute appendicitis. Suggest that WCC and CRP measurements: if used judiciously, they may spare a group of patients not only an unnecessary surgical procedure, or unnecessary admission to hospital

21. CRITICAL APPRAISAL ISSUES WITH THE STUDY WAS THE OBJECTIVE CLEAR & DID THE STUDY ADDRESS IT? BIAS? CONCLUSION MAKE SENSE? APPLICABILITY OF STUDY TO OUR SETTING

22. STUDY LIMITATIONS A single centre study over 2 months Small sample size Stricter inclusion and exclusion criteria - e.g. pregnant women Confounding factors: co-morbidities of the patients, may affect baseline WCC and CRP (e.g. COPD, active cancer, smoking status) More females in this study than there are males; sub-group analysis Pts not followed up

23. THANK YOU ANY QUESTIONS