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Parental preferences in treatment of acute uncomplicated appendicitis comparing surgery to conservative management with antibiotics and their views on research participation

Kyaw L, Pereira NK, Ang CX, Choo CSC, Nah SA

Eur J Pediatr, 2020 May;179(5):735-742.
PMID: 31897841 DOI: 10.1007/s00431-019-03555-w

Studies show that conservative management in acute uncomplicated appendicitis (AUA) is an alternative to surgery. This study aims to determine factors affecting parental preference in management of AUA and their decision for research participation. We conducted surveys on parents whose children were admitted with suspicion of appendicitis but later confirmed not to have appendicitis. Information on appendicectomy versus conservative treatment with antibiotics was provided using a fixed script and standard information leaflet. Questionnaires covered factors influencing decisions, opinions regarding research, treatment preference and demographic data. We excluded parents not fluent in English. Of 113 respondents, 71(62.8%) chose antibiotics, 39(34.5%) chose appendicectomy, and 3(2.7%) had no preference. Reasons given for choosing antibiotics were fear of surgical risks and preferring less invasive treatment. Those choosing appendicectomy expressed preference for definitive treatment and fear of recurrence. Majority were against randomisation (n = 89, 78.8%) and blinding (n = 90, 79.7%). Over half found difficulty involving their child in research (n = 65, 57.5%). Most thought that research is important (66.4%) and beneficial to others (59.3%). Parents who perceived their child as healthy found research riskier (p = 0.039). Educated parents were more likely to find research beneficial to others (p = 0.012) but less accepting of randomisation (p = 0.001).Conclusion: More parents appear to prefer conservative treatment for acute uncomplicated appendicitis. Researchers must consider parental concerns regarding randomisation and blinding.What is Known:• Conservative management of acute uncomplicated appendicitis in paediatric patients is safe and effective, sparing the child the need for an operation; however, neither conservative nor surgical management is proven to be superior.• Randomised controlled trials provide the highest level of evidence, but it is challenging to recruit paediatric patients as participants in such clinical trials.What is New:• More parents prefer conservative management of uncomplicated appendicitis over surgical management for their children due to fear of surgical risks and complications• Randomisation in trial design is significantly associated with a parent's decision to reject their child's participation in a clinical trial.

Matched MeSH terms: Appendicitis
Disseminated histoplasmosis mimicking an acute appendicitis

Marsilla MM, Khairunisa AA, Azyani Y, Petrick P

Malays J Pathol, 2019 Aug;41(2):223-227.
PMID: 31427560

INTRODUCTION: Histoplasmosis can present in a myriad of clinical manifestations, which often makes its diagnosis difficult and occasionally, deceptive.
CASE REPORT: We describe a case of a 33 years old gentleman who was clinically diagnosed as acute appendicitis at initial presentation in view of a one-week history of fever, right lower quadrant abdominal pain- and guarding at right iliac fossa. He had thrombocytopenia and lymphopenia on presentation. Mesenteric lymphadenitis and small bowel lesion were found intraoperatively, which was respectively biopsied and resected. Histopathological result confirms disseminated histoplasmosis. Retroviral screen was positive. He was treated with amphotericin B for one week, subsequently switched to oral itraconazole, followed by initiation of highly active antiretroviral therapy (HAART).
DISCUSSION: This case illustrates the various nature of histoplasmosis presentation. A high index of suspicion is needed to clinch the diagnosis and subsequently institute prompt treatment as disseminated disease can be fatal if left untreated in an immunosuppressed host.

Matched MeSH terms: Appendicitis
Fulltext Issues in management of acute appendicitis in pregnancy

Nalliah, Sivalingam, Wijesuriya, Lionel, Venugopal, Subramani

International e-Journal of Science, Medicine & Education, 2011;5(1):2-9.
MyJurnal

Acute appendicitis is an infrequent yet the commonest surgical emergency in pregnancy occurring in about 1:1500 pregnancies. The classical abdominal pain in the right lower quadrant of the abdomen is the only reliable clinical sign. Delay in diagnosis is attributed to presence of symptoms commonly seen in pregnancy like nausea and vomiting and difficulty in localizing abdominal pain due to displacement of the appendix with advancing gestation. Perforated appendix and generalized peritonitis impacts adversely on pregnancy contributing to increases in miscarriage, pre-term delivery, fetal loss and even maternal mortality. Imaging studies like abdominal ultrasonogram, helical computerized tomography and magnetic imaging have been utilized to complement clinical suspicion and decrease ‘negative appendectomies’ but robust data on their routine use is awaited. Although the laparoscopic approach is a useful diagnostic and therapeutic tool in early pregnancy, its use as the primary approach for appendicectomy in pregnancy requires further evaluation as increases in the incidence of fetal loss of 5.6% has been reported compared to 3.1% in open access surgery

Matched MeSH terms: Appendicitis
Fulltext The relationship between alvarado score and pain score in managing adult acute appendicitis in the Emergency Department

Ahmad, K.I., Shamsul, A.S., Ismail, M.S.

Journal of Surgical Academia, 2011;1(1):15-24.
MyJurnal

Acute appendicitis is one of the most common differential diagnoses for acute abdominal pain made by emergency doctors. Suspected cases require surgical referral for observation or definitive intervention to prevent complications. A high index of suspicion and good clinical skills with the aid of scoring systems allows early decision making, which includes optimal pain control. The objective of this study was to identify the pain score and is relationship to the cut-off points of the Alvarado scoring system so that justifies early surgical referral or discharge for suspected acute appendicitis from the Emergency Department of Universiti Kebangsaan Malaysia Medical Centre (UKMMC). This was a cross sectional study of acute abdominal pain from June 2007 to September 2008. All patients who fulfilled the criteria and consented to the study were assessed for Alvarado score, verbal numerical pain score (VNRS) and their subsequent management. Patients with an Alvarado score of ≥7 were likely to have acute appendicitis (80.1% sensitivity and 52.63% specificity) and those with the score of ≤3 were unlikely to have acute appendicitis. The median pain score was 7.00 (IQR: 5.00-8.50) but 72.5% did not receive any analgesia. There was no direct relationship between the pain score with Alvarado score. Oligoanalgesia in patients with acute appendicitis still exist in Emergency Department of UKMMC.

Matched MeSH terms: Appendicitis
Gangrenous giant Meckel's diverticulitis masquerading acute appendicitis: a surgical conundrum

Teng WW, Yeap BT, Azizan N, Hayati F, Chuah JA

ANZ J Surg, 2019 09;89(9):E379-E380.
PMID: 29695030 DOI: 10.1111/ans.14503
Matched MeSH terms: Appendicitis
Fulltext The comparative effects of listening to prayer recitation and music therapy intraoperatively on postoperative pain

Farah Syaza Rahman, Nurlia Yahya, Nor Mohammad Md Din, Azarinah Izaham, Wan Rahiza Wan Mat

International Medical Journal Malaysia, 2018;17(2):107-116.
MyJurnal

Introduction: Non-pharmacological interventions are considered as successful adjuncts to manage pain. We are studying the comparative effects of listening to prayer recitation and music therapy intraoperatively as non-pharmacological interventions on postoperative pain and intraoperative haemodynamics. Materials and Methods: Seventy two muslim patients with acute appendicitis requiring open, emergency appendicectomies under general anaesthesia were recruited and randomised into three groups: Group A: patients who listened to prayer recitation, Group B: patients who listened to music, Group C: control group - patients who did not listen to any prayer or music. Intraoperative blood pressure, heart rate and postoperative pain scores were monitored. Results: The demographic data, pre- and post-headphones application haemodynamics were compared. There were significantly lower heart rates at 10, 20, 30, 40, 50, 60 minutes for Group A and at 50 and 60 minutes for Group B patients when compared to Group C. Significant reduction in postoperative pain scores were seen in Group A patients at 30 minutes and 8 hours as compared to Group C patients. No significant differences in pain scores were seen between Group B and C patients. No significant differences in additional analgesic requirements postoperatively were seen in all three groups. Conclusion: Listening to prayer recitation or music intraoperatively significantly lowered intraoperative heart rates, however only prayer recitation significantly reduced postoperative pain scores as compared to the control group.

Matched MeSH terms: Appendicitis
Fulltext Spontaneous bladder perforation: a rare complication of tuberculosis

Kong CH, Ali SA, Singam P, Hong GE, Cheok LB, Zainuddin ZM

Int J Infect Dis, 2010 Sep;14 Suppl 3:e250-2.
PMID: 20117032 DOI: 10.1016/j.ijid.2009.10.006

Spontaneous bladder perforation secondary to tuberculosis (TB) is very rare. Only three cases have been reported so far in the literature. Due to its rarity, the diagnosis of spontaneous bladder perforation is often missed. Confirmation of TB via culture takes a long time and starting empirical treatment for TB is necessary. We relate our experience with a young woman who presented with clinical features of a perforated appendix and was only diagnosed with bladder perforation during laparotomy. She also had distal right ureteral stricture and left infundibular stenosis. The provisional diagnosis of TB was attained via typical histopathological features and a positive Mantoux test. She was started empirically on anti-TB treatment and recovered without any complications. Urine culture after 6 weeks confirmed the diagnosis of TB.

Matched MeSH terms: Appendicitis/diagnosis
Ceftazidime/metronidazole versus netilmicin/metronidazole in the treatment of perforated appendicitis in children

Kooi GH, Pit S

Clin Ther, 1990 Jan-Feb;12(1):54-60.
PMID: 2183940

One hundred children with peritonitis resulting from a perforated appendix were treated with ceftazidime or netilmicin. Metronidazole was added to both groups to treat the anaerobic organisms commonly associated with the infecting aerobic organisms in peritonitis. Escherichia coli was the most common aerobe found in peritoneal pus. Wound infection occurred in nine patients of the netilmicin group and in none treated with ceftazidime (P less than 0.01). No bacterial resistance was evident in the ceftazidime group, but gram-positive streptococci found in eight patients were resistant to netilmicin. Thus it is recommended that an antibiotic of the penicillin group be added if netilmicin is used to treat peritonitis. The results indicate that ceftazidime was more effective than netilmicin in the treatment of children with peritonitis resulting from a perforated appendix.

Matched MeSH terms: Appendicitis/complications*
Fulltext Atypical Pelvic Inflammatory Disease (PID) with Empyema and Ascites in A Single Unmarried Lady

Roszaman Ramli, Mokhtar Awang, Ghazali Ismail

International Medical Journal Malaysia, 2006;5(2):1-7.
MyJurnal

Pelvic inflammatory disease (PID) is a common cause of morbidity and accounts for 1 in 60 GP consultations by women under the age of 45 in the UK. Pelvic inflammatory disease encompases a broad category of disease including endometritis, salphingitis, salphingo-oopheritis, tuboovarian abscess and pelvic peritonitis. It most commonly occurs as a result of Chlamydia trachomatis or Nesseria gonorrhea 1,2 infection of the endocervix that eventually spread into the upper genital tract. Direct spread from a nearby infection such as appendicitis and diverticulitis is not that common. Hematogenous spread is rare except in cases of tuberculous pelvic inflammatory disease. This case illustrates atypical presentation of pelvic inflammatory disease in a previously healthy single unmarried lady. The presence of ascites, bilateral ovarian mass and constitutional symptoms closely mimics that of malignant ovarian tumour. This was preceded by empyema which grew E coli.

Matched MeSH terms: Appendicitis
Fulltext A Study on the Clinical Factors Associated with Acute Appendicitis and Perforated Appendicitis among Children in a Secondary Medical Centre in Malaysia

Tan PH, Teng XX, Gan ZY, Tan SQ

Malays J Med Sci, 2020 Jul;27(4):139-146.
PMID: 32863753 MyJurnal DOI: 10.21315/mjms2020.27.4.13

Background: Appendicitis complicated with appendiceal perforation is common among children. The delay in diagnosis of appendicitis is due to children's varied presentations and their difficulty in communicating symptoms. We aimed to identify clinical factors that aid in predicting acute appendicitis (AA) and perforated appendicitis (PA) among children.
Methods: This retrospective study involved 215 children aged 12 years and below with the initial diagnosis of AA and PA. Clinical factors studied were demographics, presenting symptoms, body temperature on admission (BTOA), white cell count (WCC), absolute neutrophil count (ANC), platelet count and urinalysis. Simple and multiple logistic regressions were used to determine the odds ratio of the statistically significant clinical factors. Results: The mean age of the included children was 7.98 ± 2.37 years. The odds of AA increased by 2.177 times when the age was ≥ 8 years (P = 0.022), 2.380 times when duration of symptoms ≥ 2 days (P = 0.011), 2.447 times with right iliac fossa (RIF) pain (P = 0.007), 2.268 times when BTOA ≥ 38 °C (P = 0.020) and 2.382 times when neutrophil percentage was ≥ 76% (P = 0.045). It decreased by 0.409 times with non-RIF pain (P = 0.007). The odds of PA was increased by 4.672 times when duration of symptoms ≥ 2 days (P = 0.005), 3.611 times when BTOA ≥ 38 °C (P = 0.015) and 3.678 times when neutrophil percentage ≥ 76% (P = 0.016). There was no significant correlation between WCC and ANC with AA and PA.
Conclusion: Older children with longer duration of symptoms, RIF pain and higher BTOA are more likely to have appendicitis. The risk of appendiceal perforation increases with longer duration of symptoms and higher BTOA.

Matched MeSH terms: Appendicitis
Pre-emptive intraperitoneal local anaesthesia: an effective method in immediate post-operative pain management and metabolic stress response in laparoscopic appendicectomy, a randomized, double-blinded, placebo-controlled study

Thanapal MR, Tata MD, Tan AJ, Subramaniam T, Tong JM, Palayan K, et al.

ANZ J Surg, 2014 Jan-Feb;84(1-2):47-51.
PMID: 23057502 DOI: 10.1111/j.1445-2197.2012.06210.x

Although laparoscopic surgeries are associated with reduced surgical stress response and shortened post-operative recovery, intense pain and high analgesia requirements in the immediate post-operative period are often the chief complaints.

Matched MeSH terms: Appendicitis/surgery*